Whiti ki Te Ao Session 1: International medical education video-conference: Keynote Address
(Matire Harwood) Te ORA were privileged to have Professor Mason Durie open the conference with his perspective (as tangata whenua and a doctor) on future opportunities and challenges for Māori health. This was in keeping with the theme ‘Whiti ki Te Ao Mārama – Determining our future’. But as we know, to look forward you must also look back and Mason opened his ko – rero with a chronicle of ‘transformational’ Māori doctors and their individual legacies; people like Maui and Eru Pōmare and more recently Paratene Ngata. Significant developments over the past 25 years in Māori health were presented along with the pathways to such change/improvements. These have included the development of Māori models of health, nationally-led policies, an indigenisation of health services, support for independent and specialised Māori providers and increased capacity in the Māori health workforce. Mason suggested that 2010 is an apppropriate time to look forward and identify ways to sustain these improvements. He proposed 5 key steps for the next 25 years (2010–2035): learning from our past; predicting the profile of Māori (projected number in 2035 estimated at 800,000!); scanning our ‘environment’ (looking at current Māori capabilities and possible benefits of technologies); understanding life course epidemiology (that what happens in utero and as pe – pi/tamariki will have long-term impacts. Examples include poor management of glue ear by health services and the impacts this has on education, later employment etc); and development of ‘scenarios’ (where do we see Māori, Māori doctors, whānau ora and health care in 25 years time). The presentation concluded with a frank discussion about the need for Māori doctors to ‘step up’ to the demand for leadership in Māori health. Mason suggested that we are ideally placed to undertake and work with others in this role given the potential of our ‘distinctive’ characteristics. As he sees it, Māori doctors should aspire to be exemplary practitioners (clinicians and researchers) and be participants in indigenous health networks. He inspired the audience to be proud of the unique skills and knowledge we have, our whakapapa, access to mātauranga Māori and iwi relationships, and our commitment to whānau ora.
Ngāti Porou Health Disparities Report
In support of the Wai 1184 claim filed with the Waitangi Tribunal for and on behalf of Ngāti Porou Hauora and Ngāti Porou whanau and hapu, a report has been written within the process related to Treaty claim settlements. The research for this report draws upon data from the latest Hauora report i.e., for the 2000–2005 period. The report also includes a series of case studies for: cardiovascular disease; cancer; diabetes; mental health; acute rheumatic heart disease; ambulatory sensitive hospitalisations; childhood immunisations; and, smoking. The report discusses differences between Māori and non-Māori within the Tairāwhiti/ Ngāti Porou rohe especially in relation to life expectancy; mortality, morbidity; hospital procedures; and, years of life lost.
(Matire Harwood) An extremely moving and poignant presentation of the work Tania has undertaken on behalf of Dr Patarene Ngata and Ngāti Porou. Tania described the privilege and honour she felt when Dr Pat handed the task of writing the Claim to her in his last year but also the issues she faced when undertaking the mahi. She also had some useful tips for those people considering a similar project (including ‘don’t accept invitations for a cup of tea with kaumātua’ and ‘you need lots of friends and networks’)! As Dr Pat has said, Ngāti Porou are dying before their time and this was confirmed by the data; life expectancy for Māori is lower in the Tairāwhiti DHB region compared to most other DHBs and the disparity between Māori and non-Māori greater there than at other DHBs. Ngaroma, Pat’s wife, advised the hui that “Pat’s wish was that the Claim would address the inequalities in quality of health care provided to Māori and Ngāti Pororu”. Tania suggested the structural causes of disease require structural solutions and that Treaty Claims provide an ideal framework within which we can negotiate such changes.
Māori experiences of care: He ritenga whakaaro
This session discussed findings from research undertaken by Mauri Ora Associates into Māori patient experiences of health services. A telephone survey gathered information from 651 Māori on 1400 service encounters in the previous 6 months. According to quantitative analyses, while most respondents reported mostly good experiences, about 20% reported significantly different attitudes and perceptions based on their experiences. Many of this group expressed concerns about interactions with health professionals and hospital staff and were more likely to report they would avoid care in the future. The research indicates that the quality of interaction with health professionals can affect the patient’s experience.
(Matire Harwood) Many of you will have heard Peter talk about, or have read, this report. I picked up a few new points from his presentation including the advantages of choosing appropriate methods (the value of telephone interviews particularly for follow-up surveys and ease/ability to monitor changes over time); that the concept of the ‘patient experience’ as a health outcome, although acknowledged by most, is not captured well and requires more work; and that stigmas and negative attitudes from health providers are cumulative. And as always, the presentation was infused with Peter’s personality including his own anecdotes and unique sense of humour!
Survival and treatment of cervical cancer among Maori and non-Maori women in New Zealand
These researchers sought to determine if ethnic disparities in treatment and survival exist among a cohort of Māori (n=344) and non-Māori women (n=1567) with cervical cancer, who were retrospectively identified from the New Zealand Cancer Register between 1 January 1996 and 31 December 2006. Inequalities in incidence and mortality decreased over time. Over the entire cohort period, Māori women were more likely to be diagnosed at a later stage of disease and have poorer survival than non-Māori (stage-adjusted hazard ratio 1.64). However, survival disparities were also found to be decreasing over time. Māori women with cervical cancer had a slightly higher receipt of total hysterectomies, and similar receipt of radical hysterectomies and brachytherapy (age and stage adjusted).
(Matire Harwood) Another quality research project from the team at Te Ro – pu – Rangahau Hauora a Eru Pōmare. Ricci and Mel presented findings from one of the ‘Unequal Treatment’ projects – cervical cancer. The audience was pleased to see, and commented on, the improvements over time. Interim results from the qualitative aspect of the study have informed a number of excellent recommendations including a need to set national standards and the provision of free cervical smears. The authors highlighted the fact that many of the improvements in cervical cancer rates and outcomes are the result of significant work undertaken by Māori health providers and that this mahi should be acknowledged.
Ethnicity data: current issues and challenges
This presentation discussed some key current and future issues in ethnicity data and potential implications for the Māori health sector in regard to the collection, classification and output of ethnicity data in the health sector, the ability to monitor ethnicity data over time, the barriers and facilitators to ethnicity data collection, and the intersection of ethnicity data with genetic discourses in relation to Māori health and ethnic disparities.
(Rhys Jones) Ethnicity is a complex and contested term, and the social and political contexts are constantly changing. In this presentation Donna gave an historical overview and outlined some of the current issues in Aotearoa. Ethnicity data can be used for good or evil: it should facilitate a better understanding of inequalities and provide for more effective interventions, but it is often linked to outdated notions of race and genetic explanations for inequalities. There was an interesting discussion about the ‘New Zealander’ response, which comprised 11.1% of the ethnicity responses in the 2006 Census. It is unclear how much of this is actual ethnic identification and how much is a protest response (or a response to being an ‘unmarked’ category). There is a risk that changes to ethnicity data policies and practices could compromise Māori rights and undermine the ability of the Crown to meet its obligations, so we need to continue to be vigilant in this area.
Te Ara Whakapiki Taitamariki Youth’07: The health and wellbeing of secondary school students in New Zealand
Key findings were presented for the 2059 students who reported Māori ethnicity in two national surveys of secondary school youth health and well-being; the Adolescent Health Research Group in 2001 (Youth2000) and 2007 (Youth’07). The data collected yield important information about health and wellbeing topics as well as factors that may increase or decrease the likelihood of young people experiencing positive health outcomes.
(Matire Harwood) Sue presented findings from this impressive research. The innovative methods for recruitment of taitamariki at both mainstream secondary schools and wharekura resulted in 73% response rates. Three important messages for health providers were presented. Firstly, over 80% of the Māori students interviewed said that they had seen a GP in the previous 12 months; this confirms the need to ensure appropriate services/care at practices. Secondly, Māori students found it more difficult to access health care when it was needed compared to Pākehā (23% compared with 14%). And so a focus on development of strategies to improve access to acute health care for Māori youth is also required. Finally, the researchers acknowledged the limitations of the study, the most significant being the fact that there was no voice from those taitamariki who are NOT at schools. Further research to identify their health needs/issues is a priority.
Reference: For more information about the study/results, check out the website: www.youth2000.ac.nz
Why don’t patients with diagnosed diabetes attend a free “Get Checked” annual review?
To determine why many patients with diagnosed diabetes do not attend the free annual review provided by the New Zealand “Get Checked” programme (and specifically why ethnic minorities, in particular Māori, are under-represented), a cohort of 68 patients with diabetes was identified who had not attended an annual review in the previous 2 years. They were surveyed by questionnaire as to barriers surrounding attendance. Thematic analysis of the responses from 26 patients (a return rate of 38% for the questionnaire) identified key issues including difficulty with transport, conflict with work and lack of motivation. There were differences in responses between Māori and non-Māori.
(Rhys Jones) This was the first of two excellent presentations by medical students at the conference. The study examined explanations for non-attendance at diabetes annual review. Māori and Pacific respondents were more likely to identify difficulty with transport and family commitments as reasons for non-attendance. For European respondents, the most common reasons were having forgotten or believing they could manage their own diabetes. Another important issue for all participants was the lack of out-of-hours services. This identifies the need for services to better meet the needs of patients, particularly in relation to offering more flexible services.
Reference: This study was published in the September issue of the Journal of Primary Health Care (2009;1(3):222-5).
Hazardous drinking among Māori university students: impacts and approaches
Julia reported outcomes from a survey undertaken in 2007 of eight New Zealand university campuses investigating the level and pattern of alcohol use and its consequences among Māori students. Of a total of 3858 students surveyed, “equal explanatory power” in the sampling identified 1182 as Māori. Both male and female Māori students had high rates of alcohol consumption and hazardous drinking. During or following drinking, students experienced high levels of negative impacts on health, such as having blackouts and hangovers. There were also high levels of second-hand effects, the results of someone else’s drinking, with more than 10% of students reporting having been assaulted. The survey also investigated possible modifying factors including prior drinking history and involvement with social and community groups. Julia discussed these findings and made some suggestions as to other potential means of reducing alcohol-related harm.
(Rhys Jones) Julia is also a medical student and her presentation generated a lot of discussion at the hui. While many of us could relate to the findings the extent of hazardous drinking behaviour is concerning. The survey found that consumption of alcohol among Māori students was very common and was associated with a range of adverse impacts for drinkers and those around them. Involvement in recreational, university, cultural and religious groups was considered likely to encourage responsible drinking, which suggests some possible approaches to reduce the harm from alcohol. However, this is a complex issue which will require a long-term, multi-sector approach to address. Reinstating the legal drinking age to 20 would be a good start.
LIME Network
Odette Mazel is the Programme Manager for the Leaders in Indigenous Medical Education (LIME) Network, a Medical Deans Australia and New Zealand Project hosted by Onemda VicHealth Koori Health Unit within the Melbourne School of Population Health at The University of Melbourne. Odette’s presentation sought to promote the activities of the LIME Network and to get those interested in improving Indigenous health through better medical education better engaged.
(Rhys Jones) LIME is an important network as we consider the dual challenges of developing the Māori medical workforce and improving the responsiveness of the medical workforce as a whole to Māori health. Odette’s presentation aimed to build the network’s links on this side of the Tasman and to support the mahi that is being done in Aotearoa. If you are committed to improving Indigenous health through better health professional education I would encourage you to become involved with LIME. A great opportunity to do so is coming up – the LIME Connection III conference is being held in Melbourne on 3–4 December 2009.
Reference: For more information go to www.limenetwork.net.au/
