Māori Health Review Issue 38

Outcomes are presented from an evaluation of primary care investment measured through the Capital and Coast District Health Board’s (DHB) Primary Health Care Framework. The Framework was developed in 2002/2003 to guide funding decisions at a DHB level, and to provide a transparent basis for evaluation of the implementation of the Primary Health Care Strategy in this district. Analyses of quantitative and qualitative data revealed a link between investment in primary health care, increased access to primary care for high-need populations, workforce redistribution, and improved health outcomes. Among enrolled populations, ambulatory sensitive hospitalisations and emergency department use reduced and the District’s immunisation coverage improved markedly. Funding and contracting initiatives enhanced both ‘mainstream’ and ‘niche’ providers and together with community-based health initiatives, had a measurable impact on a range of health indicators and inequalities. Māori primary care providers improved access for Māori as well as their enrolled populations of Pacific and Other ethnicity. There was growth and redistribution in the primary care workforce, which improved the availability of general practitioners, nurses, and community workers in poorer communities.

These researchers compared epidemiology data on serious skin infections among children in the Gisborne (Tairawhiti) region on the East Coast of New Zealand’s North Island with equivalent national data, in an attempt to identify factors contributing to the consistently greater than average infection rates and significantly larger ethnic disparities in the Tairawhiti region. Hospitalisation data were reviewed for 0–14-year-old children in the Tairawhiti region discharged from hospital with a serious skin infection between 1990 and 2007; several demographic variables were compared to equivalent data for New Zealand cases over the same period. In Tairawhiti the age-adjusted incidence of serious skin infections increased from 641.1/100 000 in 1990–1999 to 988.4/100 000 in 2000–2007, while the New Zealand incidence increased from 354.3/100 000 to 531.7/100 000. In all regions, the highest infection rates were among preschool-aged children, Māori children, and those living in deprived neighbourhoods. The disparity between Māori and non-Māori children was significantly greater in Tairawhiti than nationally. The standardised ratio of observed to expected discharges in Tairawhiti compared with New Zealand was 1.42 (95% CI, 1.32 to 1.52) in 1990–1999 and 1.28 (95% CI, 1.19 to 1.36) in 2000–2007.

Hospital charts were reviewed of all children aged 0–14 years in the Tairawhiti (Gisborne) region admitted with a serious skin infection to Gisborne Hospital between 1 January 2006 and 31 December 2007. Of the 163 documented cases, 83% occurred in Māori children. The most common types of infection were cellulitis (38%) and subcutaneous abscesses (36%), and the most frequent sites of infection were the head, face and neck (32%) and lower limbs (32%). A previous episode of skin infection was recorded in 34% of children, with previous hospitalisation in 12%. A skin injury preceded infection in 37% of cases, more than reported in the Auckland and Wellington regions. Of the 77% of children who saw a GP 60% required immediate hospital admission. Compared with figures from the Auckland region, there were longer delays to medical care with a mean duration of symptoms of 2.5 days prior to visiting a GP. The most frequently isolated organisms were Staphylococcus aureus (48%) and Streptococcus pyogenes (20%) with similar proportions and resistance patterns to other New Zealand settings.

This article describes the epidemiology of childhood skin infections presenting to primary care in the Tairawhiti (Gisborne) region, compared to hospitalised cases during the same period. The 9 participating general practitioners recorded 110 incident cases of skin infections in 0–14 year old children over a 10-week period in 2008, equivalent to an annual incidence rate of 106.7 (95% CI, 85.2 to 127.2) cases per 1000 children in the region. For every one hospitalisation there were an estimated 14 primary care cases. Three-quarters of skin infections in both primary care and hospital settings occurred in Māori children. Hospitalised cases of serious skin infections were more likely to occur in the preschool age group whereas the majority of cases at the primary care level consisted of children aged 5–9 years.

These researchers used a Kaupapa Māori Research (KMR) methodological approach to review the literature, with the aim of identifying ‘best practice’ for recruitment of indigenous secondary school students into tertiary health programmes with particular relevance to recruitment of Māori within a New Zealand context. While the current body of published literature remains scant as to Māori-specific recruitment, data are growing as to other indigenous and underrepresented minority populations. Of the 70 articles included in this review, few provided evidence of effectiveness. However, data indicate recruitment activity is occurring across a pipeline that extends from secondary through to tertiary education contexts and in some instances vocational (post-graduate) training. The study authors conclude that “achieving equity in health workforce representation should remain both a political and ethical priority”.

This theme issue of the American Journal of Public Health focuses on links between racial/ethnic discrimination and health outcomes. The themed section opens with an article that reviews current measures, research approaches, data resources, and results of research on race/ethnicity-based health care discrimination. Subsequent articles centre on issues of measurement, implicit bias, perception of discrimination and institutional racism. The issue illustrates the state of the field, describes current methodology, identifies research gaps and suggests areas that should be considered for future research. It is intended to serve as a valuable resource for researchers in this topic area and will help position researchers, policy makers, and professionals at all levels of health care to address the effects of discrimination in the evolving health care environment. The full text of the articles may be accessed free of charge at http://healthservices.cancer.gov/areas/disparities/supplement.html. A single printed copy of the issue may be ordered online from the NCI Publications Locator (https://pubs.cancer.gov/ncipl/home.aspx?js=1).

National-level health data sets were examined to determine the prevalence of gout in the entire Aotearoa New Zealand population. Hospitalisation and drug dispensing claims for allopurinol and colchicine were obtained from the Aotearoa New Zealand Health Tracker (ANZHT) to estimate the prevalence of gout in 2009, stratified by age, gender, ethnicity and socioeconomic status (n=4,295,296), then compared with data from an independent large primary care data set (HealthStat, n=555,313). The all-ages crude prevalence of diagnosed gout in the ANZHT population was 2.69%. Similarly, the prevalence was 2.89% in the HealthStat population after standardising the data to the ANZHT population for age, gender, ethnicity and deprivation. The ANZHT data revealed that gout occurred more frequently in Māori and Pacific people (relative risk [RR] 3.11 and 3.59, respectively), in males (RR 3.58), in those living in the most socioeconomically deprived areas (RR 1.41) and in those aged >65 years (RR >40; p-value for all <0.0001). Notably, >25% of elderly Māori and Pacific men with diagnosed with gout.

In this 12-month pilot investigation into the cultural acceptability of home-based remote telemonitoring among patients with chronic health conditions, there were no clear differences in quality of life at the end of the trial among those in the control group, whereas the telehealth group showed a consistent trend towards improved quality of life on several instruments, including the SF-36, the St George Respiratory Questionnaire and the K10 questionnaire; the improvement in the latter was significant. Hospitalisations were reduced in both the control (–19%) and telehealth group (–25%). Patient interviews indicated that the technology was acceptable to most patients and their families, including Māori.

This paper reports outcomes of an evaluation into the self-administered Te Tomokanga survey, designed to determine the cultural acceptability of Child and Adolescent Mental Health Services (CAMHS) for indigenous populations. It incorporates questions that examine CAMHS delivery in light of the Whare Tapa Whā,1 a Māori comprehensive model of health with a focus on whānau involvement and culturally responsive services. This mail or telephone survey was completed by a cohort of 168 Māori whānau, whose children had been referred to one of the three types of CAMHS, mainstream, bicultural, and kaupapa Māori,2 of the District Health Board in the Midland health region, an area with a large Māori population with high levels of social deprivation. The Te Tomokanga instrument was shown to have a similar factor structure to the North American questionnaire from which it had been derived. It identified issues relevant to Māori whānau satisfaction with CAMHS. The work supports the concept that Māori desire therapeutic methods consistent with the Whare Tapa Whā, such as whānau involvement and the importance of recognising culture and spirituality. Participants were generally positive about the services they received from the three different CAMHS types, which shows good acceptability of CAMHS for Māori. Satisfaction with CAMHS was related to whānau involvement and culturally delivered services. 1. The Whare Tapa Whā framework relies on a Māori worldview of health, a holistic approach advocating a balance between the four dimensions of the Taha Whānau (family), the Taha Tinana (physical), the Taha Hinengaro (cognitive or intellectual) and the Taha Wairua (spiritual). It is believed if one aspect is in distress then it impacts on the others causing tension and increased risk of poor health. Optimal health requires balance between all four dimensions. 2. Kaupapa Māori mental health services provide Māori dedicated clinical and cultural workforce for Māori service users.