Preceding group A streptococcus skin and throat infections are individually associated with acute rheumatic fever
A large study of throat and skin swab data from the Auckland region has demonstrated that group A streptococcus (GAS) skin infections are strongly associated with subsequent acute rheumatic fever. A total of 1,866,981 throat and skin swabs collected between 2010 and 2017 were analysed, as well as antibiotic dispensing data for the same period and hospitalisations for acute rheumatic fever between 2010 and 2018. Māori and Pacific individuals had the highest risk of acute rheumatic fever in the 8- to 90-day period following a GAS-positive throat (relative risk 4.8; 95% CI 3.6-6.4) or skin (relative risk 5.1; 95% CI 1.8-15.0) swab. Antibiotic dispensing was not associated with a reduction in the risk of acute rheumatic fever following either a GAS-positive throat or skin swab.
Although some have hypothesised that GAS skin infections are associated with subsequent acute rheumatic fever, this study provides clear evidence for it, including its risk compared with traditional throat infections, and the increased risk for Māori and Pacific peoples.
Reference: BMJ Glob Health. 2021;6(12):e007038.
He Tamariki Kokoti Tau: Tackling preterm incidence and outcomes of preterm births by ethnicity in Aotearoa New Zealand
European women are significantly less likely to give birth to extremely or very preterm infants compared with Māori women, and their infants are at lower risk of early neonatal or post-neonatal death, according to a Kaupapa Māori research study. The study analysed maternity, mortality and hospital data for women and their infants born in New Zealand between 1 January 2010 and 31 December 2014. The adjusted relative risk of having an extremely or very preterm infant was 0.86 (95% CI 0.76-0.95) for European women compared with Māori women. Corresponding adjusted relative risks of early neonatal death and post-neonatal death were 0.65 (95% CI 0.45-0.93) and 0.41 (95% CI 0.26-0.64), respectively. In addition to ethnicity, the risk of preterm birth was also influenced by maternal age, body mass index, smoking status and small for gestational age status. The study authors concluded that the New Zealand maternity system privileges whiteness, and that evidence-based medical care is not delivered systemically and equitably for all.
Another important paper from this excellent team. Interesting that they have chosen to focus on New Zealand European rates, demonstrating inequities by focussing on how an ethnic group is privileged. I’m still in two minds about this approach as I’m not sure that it will drive the necessary changes in our system. Interested to hear others’ thoughts.
Reference: Int J Gynaecol Obstet. 2021;155(2): 239-246.
Outcomes from colonoscopy following referral from New Zealand general practice
In a study of Waikato DHB data, the likelihood of colorectal cancer in patients undergoing colonoscopy following GP referral with a high suspicion of cancer (HSCan) was almost 15%. The study authors suggested that such patients should be routinely prioritised without further triage by the hospital. They assessed e-referral data for patients aged at least 30 years referred from 75 general practices to general surgery, gastroenterology or direct to colonoscopy between 1 January 2015 and 31 December 2017. A total of 6718/20648 (32.5%) patients underwent colonoscopy, of whom 372 (5.5%) were diagnosed with colorectal cancer. Females, non-Māori, and patients with a HSCan label originating from their GP were more likely to have a colonoscopy. Among the 585 patients with a GP HSCan label who underwent colonoscopy, the odds ratio of a colorectal cancer diagnosis 2.34 (95% CI 1.70-3.22). However, 423 of these patients were reprioritised by the hospital and 55 had their diagnosis unnecessarily delayed.
Given our recent lockdowns, and now long waiting lists for investigations, I agree with the recommendation to prioritise GP referred patients without further hospital triaging. And given the significant disparities in colon cancer survival between Māori and non-Māori, an equity approach must also be prioritised.
Reference: BMC Gastroenterol. 2021;21(1):471.
Creating an indigenous Māori-centred model of relational health
The importance and relevance of relational approaches to engaging Māori and their whānau accessing health services has been highlighted in a qualitative literature review. Health and wellbeing for Māori is a holistic and relational concept, and building relationships that include whānau is a cultural imperative. Key elements for a Māori-centred model of relational care include whakawhanaungatanga (the process of building relationships) using tikanga (cultural protocols and processes) and informed by cultural values of aroha (compassion and empathy), manaakitanga (kindness and hospitality), mauri (binding energy), and wairua (importance of spiritual wellbeing).
Tā Mason himself would argue that we should continue to build, revise and grow models of hauora Māori. For me, the elements aligned with Kaupapa Māori Theory (particularly Linda Smith’s Decolonising Methodologies) and Vision Matauranga and Charles Royal’s idea that such models can revitalise our cultural ways of knowing, as well as achieve social justice, in ways that generate new knowledge.
Reference: J Clin Nurs. 2021;30(23-24):3539-3555.
Exploring indigenous perspectives on tobacco tax: how some Māori families are responding in Aotearoa New Zealand
A qualitative study informed by Kaupapa Māori theory has demonstrated that although Māori are concerned about the rising cost of tobacco, this has generally not translated into quit attempts. The study involved interviews with 72 Māori individuals, most of whom were smokers, from 15 whānau units in two geographical regions – one rural/provincial and one urban. The study showed that whānau have developed innovative tobacco-related practices to continue smoking, albeit in a modified fashion, despite the rising costs of tobacco. The study authors concluded that hypothecated taxes should be used to scale up Māori-specific cessation and uptake prevention programmes, including restricting the availability and appeal of tobacco.
Great to see attention being given to this important kaupapa. Lockdowns may have also impacted on access to tobacco and therefore smoking?
Reference: Tob Control. 2021;30(e2):e144-e149.
Rates of Māori women receiving surgical treatment for urinary incontinence and pelvic organ prolapse in Southern District Health Board
Although rates of surgery for urinary incontinence and pelvic floor prolapse were similar between Māori and non-Māori in a New Zealand study, the greater prevalence of these conditions in Māori women means this likely represents inequity of access. The study reviewed women who underwent gynaecological surgery between 2015 and 2019 in the Southern DHB area. Unadjusted results suggested that there was a difference in access to gynaecological surgery for Māori and non-Māori. However, standardisation for differences in the age structures of the two populations showed that Māori and non-Māori women access this surgery at very similar rates.
There is some interesting work coming from Southern DHB – the strong Iwi Māori leadership there may be driving the focus on research that is responsive to Māori. I’ve included this paper as a good reminder on how to report that equal process does not necessarily translate as equity.
Reference: N Z Med J. 2021;134(1546):38-46.
Cyberbullying Toward Māori Is Rife in New Zealand: Incidences and Demographic Differences in Experiences of Cyberbullying Among Māori
A large New Zealand study has highlighted the prevalence of cyberbullying in Māori adults. Individuals aged 18-83 years (n = 6,529) who completed the questionnaire-based Māori Identity and Financial Attitudes Study in 2017 were included in the present study. On average, 19.3% of participants reported ever experiencing cyberbullying, and 4.1% reported experiencing cyberbullying within the past month. When analysed by age group, young adults (aged 18-25 years) experienced the highest rates of cyberbullying. Rates of cyberbullying were also higher among women and those identifying as a minority sexual orientation compared with men and heterosexuals. Individuals who identified as Māori as one of their multiple ethnicities experienced higher rates of cyberbullying than those who identified as Māori only. The study discusses practical and theoretical implications in light of Māori mental health outcomes.
This research is close to my heart, as my 10-year-old experienced online bullying from ‘friends’ last year. Our young people will become increasingly exposed to cyberbullying with online learning and reduced opportunities for social interactions. Thankfully the school was incredible in its response, but we’ve had to take action as a whānau too. There are some great practical tips outlined in this paper.
Reference: Cyberpsychol Behav Soc Netw. 2021;24(12):822-830.
The Choosing Wisely campaign and shared decision-making with Māori
Choosing Wisely is an international health quality improvement campaign designed to prevent harm by reducing the number of unnecessary tests, treatments and procedures, and by promoting shared decision-making. In this study, 8 Māori consumers and 7 Māori health practitioners were interviewed about the Choosing Wisely New Zealand campaign and its messages. Study participants highlighted issues ranging from lack of Māori participation in programme governance through to practical issues like meaningful and literacyappropriate health messaging, traversing consumer, practitioner, organisational and health-system aspects. Participant feedback also indicated the need for patients to have trust in the practitioner, a sense of autonomy and availability of advocacy and support in the consultation. The study authors noted that Choosing Wisely New Zealand is the first of the international programmes to acknowledge the possibility that their initiative might increase inequity for indigenous populations. They stressed the need to consult Māori early and to infuse Treaty principles and Māori knowledge and custom at every stage of the programme.
A key message here – it’s never too late to bring the Treaty principles into your project. As a reminder these are Partnership, Equity, Active protection, Tino Rangatiratanga and Options. Kia kaha koutou!
Reference: N Z Med J. 2021;134(1547):26-33.
