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He Kitenga: Health Sciences Research Highlights 2011

 

The He Kitenga Māori 2011 edition recognises the University’s commitment to kaupapa Māori research, and research into aspects of Te Ao Māori, on a national and international scale. This edition featured many Health Sciences stories:         

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Dental Partnerships

University of Otago researchers seeking to develop ways to reduce chronic dental disease among Māori children will be doing so as part of an international initiative.

The project is a partnership between Māori, Indigenous Australians and First Nations Canada, under the umbrella of the International Collaborative Indigenous Health Research Partnership. The Health Research Council (HRC) is putting more than $2.3 million in funding into the New Zealand part of the project.

Associate Professor John Broughton (Department of Preventive and Social Medicine), who is director of the University-based Ngāi Tahu Māori Health Research Unit, is lead investigator for the New Zealand research and is working closely with Professor Murray Thomson and Kate Morgaine at the Faculty of Dentistry.

"Oral health disparities between indigenous populations and the rest of the population are a global thing," says Broughton. "The cause is multifactorial. Diet, oral health behaviours, fluoridation, social determinants of health - those sorts of things."

Early childhood caries can become the focus of disease, pain and discomfort in the body, he says. "It can compromise their eating, their diet, and their behaviour. It can impact upon the quality of their life and impact on other members of the family."

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The New Zealand research is being conducted in partnership with Tainui through their health provider, Raukura Hauora O Tainui, and the Waikato Tainui College for Research and Development, established by the late Sir Robert Mahuta.

"They are leading the project on the ground so it is all being done within their tribal area. They have the clinical facilities, while the college has the strong research kaupapa."

Broughton points to some startling statistics when putting the case for such research in New Zealand. For example, Waikato District Health Board data on preventable hospital admissions for 2007 indicate that 12.8 per cent of admissions involving children aged up to four years were for dental reasons, making it the second highest cause. In the next age group (five–14 years) the figure for admissions due to dental problems jumped to 30.8 per cent, making it the highest cause in that age group.

The project is looking at New Zealand Māori mothers and their babies, and to safeguard the oral health of the mothers as well as that of the children.

"The thing about it is that all dental disease is preventable. And if you have a parent with poor oral health, and if you have a parent who has a high caries rate and a virulent strain of bacteria in their mouths they can infect their babies – just by kissing them."

By restoring and maintaining the oral health of the parents, and then other interventions along the way, it is hoped the babies can grow up without any oral pathology.

The researchers are currently recruiting 200 pregnant mothers for the five-year study who will be split into two randomised groups – an intervention group and a delayed intervention group so that all participants get the benefits of the interventions.

The intervention has two components: dental treatments for mothers and motivational interventions.

"It is called motivational and participatory guidance. It's not telling the participants what they should and shouldn't do; it's leading them into the position where they make those decisions themselves," says Broughton.

"This is a good example of whānau ora. It's not just focused on the individual; it's focused on the family and the environment as well."

FUNDING
Health Research Council of New Zealand

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The Rural Heart

Using kaupapa Māori methodology, University of Otago, Christchurch researchers are exploring risk factors in the prevalence of cardiac disease amongst rural Māori.

Half a century ago researchers travelled into the misty heart of Tūhoe country to study the heart health of a rural iwi. They gathered data on adults from the isolated Ruatahuna Valley in the Urewera region, central North Island, and found exceptionally high rates of coronary heart disease, obesity, smoking, high cholesterol, clinical gout and diabetes.

Since then, a lot of information has been collected on the cardiovascular health of Māori and non-Māori living in urban areas, but the 50-year-old Tūhoe study remained the most up-to-date, intensive research on rural Māori’s cardiovascular health. Until now.

Researchers from the University of Otago, Christchurch have recently published a paper titled “Community screening for cardiovascular risk factors and levels of treatment in a rural community”, summing up the findings for 252 Māori participants living in the rural area of Wairoa, Hawke’s Bay. It shows that little has changed in the past 50 years. Rural Māori participants still have worryingly high rates of cardiovascular disease and a lot of undetected cardiac risk factors.

The rural study is just one part of the Hauora Manawa Community Heart Study, which aims to look at the full range of cardiac risk factors of Māori within two community settings.

Māori comprise 15 per cent of New Zealand’s population, but are three times more likely to die of heart disease than non-Māori. While this disparity is recognised, no New Zealand studies have explored how the prevalence of heart disease risk factors differs in diverse communities across New Zealand.

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The Hauora Manawa Community Heart Study was established by the Māori and Indigenous Health Institute (MIHI), in collaboration with the Christchurch Cardioendocrine Research Group (CCERG), more than five years ago. MIHI director Suzanne Pitama, who is from Ngāti Kahungunu on the North Island’s East Coast, says there is great opportunity for her team to improve the statistics for Māori.

“Current data does not yet present us with the full story on Māori cardiac disease. The aim of this project is to see if we can find new information that might contribute to Māori health gain.”

The study compares randomly-selected populations from two Māori communities (one in rural Hawke’s Bay, and Mana Whenua ki Waitaha in urban Christchurch) with a non-Māori community in Christchurch. Researchers have documented cardiovascular risk factors in Māori and are currently monitoring the implementation of treatment programmes, interventions and outcomes.

The project has a kaupapa Māori methodology, including Māori leadership and control of the project, and researchers are working alongside two tribal authorities. Questionnaires, clinical protocols and recruitment approaches have been designed to be culturally appropriate.

Project co-leader Associate Professor Vicky Cameron (CCERG) says the study is unique in that it strives to understand a wide range of risk factors – from social factors and lifestyle to the role of genetics – in the prevalence of heart disease in Māori.

“The study will cover a much wider range of biochemical and social factors out in the community and, perhaps most importantly, how these interact with one another in relation to early onset of heart disease, or not.”

“Community screening for cardiovascular risk factors and levels of treatment in a rural community” is one of the first major papers to be published from the study.
Rural participants provided information on demographics, personal and family medical history, current medications, smoking status, alcohol consumption, physical activity levels and socioeconomics. Their blood pressure was taken and blood tested for glucose and insulin levels. Their Body Mass Index (BMI) was also calculated.

Significantly, the data identified high numbers of people with clear, but previously undetected, risk factors for cardiovascular disease. Twenty-five per cent of the sample had previously been diagnosed with hypertension. The study uncovered an additional 22 per cent of participants who had hypertension, but were not aware of it.

Dyslipidaemia (high blood cholesterol) had been previously diagnosed in 14 per cent of participants; high blood cholesterol was found in an additional 43 per cent of participants. Type-2 diabetes had been previously diagnosed in 11 per cent of the participants, but only 21 per cent of this group had their blood sugar levels under control (an indication of whether they were managing their diabetes, or not).

These “surprising” levels of treatable risk factors were identified despite almost 70 per cent of participants having visited their GP within the past six months. Cameron says this suggests that additional opportunities for GPs to conduct cardiovascular disease screening should be taken when patients attended their doctor for illness or minor injury. Management of risk factors could be intensified further to achieve target levels within this rural Māori population.

Some cardiovascular disease risk factors were evident in much younger participants than the medical profession would usually screen. Government guidelines currently recommend Māori males be screened at five-year intervals from the age of 35, and Maori women from age 45. Pitama says the findings indicate screening should begin at an earlier age in Māori, particularly for those living in rural areas.

The study found that about 70 per cent of the rural sample was physically active at the level recommended by national guidelines – a much higher level of physical activity than the national average of about 51 per cent. However, despite being active, 80 per cent of participants were classified as having a BMI above the healthy range, compared with 63 per cent of the general population.

Smoking rates were high, with 43 per cent of participants reporting being a current smoker. Since these findings were presented to the local District Health Board, two smoking cessation facilitators have been employed in the Wairoa district, just one example of the impact the study on not just participants, but all Māori.

Pitama describes the opportunity to work on a project which will impact on such an important kaupapa as a “privilege’” She and Cameron hope that in 50 years Māori heart health will be in far better shape, thanks in part to the Hauora Manawa Community Heart Study, and the input of its participants.

FUNDING

Health Research Council of New Zealand
Heart Foundation of New Zealand

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Māori cohort for POIS

Ensuring that a large sample of Māori was included in the Prospective Outcomes of Injury Study (POIS) should provide researchers with meaningful insight into Māori experience of health services, ACC and recovery (or not) after injury.

The larger study, led by Dr Sarah Derrett (Injury Prevention Research Unit), followed an earlier Health Research Council (HRC) developmental grant awarded to Professor John Langley. The Māori arm of POIS is driven by Associate Professor Brendan Hokowhitu (School of Māori, Pacific and Indigenous Studies – Te Tumu), Dr Emma Wyeth (Ngāi Tahu Māori Health Research Unit) and Derrett.

They consulted closely with Māori around the country to see how the study could best work and suggested measures such as having questions in te reo and having interviewers located in different regions to allow face-to-face interviews.

The aim was to have a quantitative component to the study, built around mainly telephone interviews of 2,856 participants (including 566 Māori) alongside a qualitative component involving in-depth interviews with 15 Māori. The latter are the focus of Wyeth's HRC Eru Pōmare Research Fellowship.

"I have done two interviews with each participant: around six months after injury and again 12 months after injury," she says. "It gives participants an opportunity to provide an update on how things have been going and they can also talk through issues that were raised in the first interview. It has allowed more of a rapport to be built."

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Derrett says they extended recruitment to ensure that 20 per cent of their cohort was Māori to allow meaningful, stand-alone analysis of Māori health and disability outcomes.

"One of the main aims of the study is to look at predictors of disability following injury and it is possible that the predictors for Māori are not the same as the predictors for non-Māori, so it was really important that we recruited enough Māori."

Study participants are answering more than 600 questions over two-years. Derrett says Māori they consulted at the beginning of the study believed that having a meaningful level of quantitative information, backed up by the qualitative study, would be valuable to policymakers and communities alike.

"If there are different factors influencing Māori recovery then health-service providers, ACC and other groups need to be aware of those factors when dealing with newly-injured Māori to ensure their recovery is better," she says.

Analyses are now underway.

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Health Research Council of New Zealand
ACC

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Medicine meets Māori

“He was the first doctor that ‘got me’.” – Māori patient and high user of the New Zealand health services for 30 years.

The comment above is not about a senior clinician, but a fourth-year medical student from Christchurch. What sets this medical student apart from other medics is his use of a novel teaching method developed at the University of Otago, Christchurch (UOC).

The “Hui Process” aims to increase medical professionals’ range of skills so they can better engage with Māori patients – and to improve Māori patients’ impression of the medical profession.

Dr Cameron Lacey is a senior lecturer at the UOC and, along with its Māori Indigenous Health Institute (MIHI) team, is researching the use of the Hui Process as both a teaching tool and, potentially, a way for all clinicians to interact with Māori patients.
Lacey says that it is increasingly recognised that teaching cultural competence is critical in medical education. However, there is a lack of agreement about the best means of achieving this.

“It is a challenge to develop and teach cultural competencies which extend beyond tokenistic or over-simplified stereotypes,’’ he says.

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The Hui Process has been developed over that past eight years by MIHI. It draws on traditional cultural practices and marries them with the UOC’s model for interviewing in a clinical setting.

A hui is a central ritual of encounter in the Māori world (Te Ao Māori). This coming-together of parties offers the chance to talk and, ideally, gain a better understanding of the other’s perspective.

The Hui Process contains four key elements of Te Ao Māori:

Mihi. The medical student clearly identifies themself, their role and the specific reason for their visit. They also acknowledge that the patient identifies as Māori.

Whakawhanaungatanga. This is a step further than building rapport. It is about reaching a point of shared experience, with a focus on the patient's connection to Te Ao Māori. The conversation may traverse the patient’s whenua (land connections), whānau involvement and use of te reo. Ideally, the medical student shares something of his experience of these things. The process encourages students to move beyond the usual avoidance of self-disclosure.

Kaupapa. This is when the clinical “interview” takes place. The UOC teaches its students to extend the typical history-taking process with Māori patients to include factors such as migration, colonisation, racism, marginalisation and Māori beliefs.

Poroporoaki. The student concludes the interview by checking they have understood what the patient has said, checking the patient understands what they have said and clarifying what happens next, such as a follow-up appointment.

Lacey says Christchurch medical students are introduced to the Hui Process in their fourth year through role-play with simulated patients. They are then shown videos of clinicians using the process. After becoming familiar with the process, students are encouraged to use it in all their clinical rotations when they encounter Māori patients.

A practical test of the Hui Process comes in the form of the Hauora Māori health day, where medical students provide health checks for people at the Rehua Marae. Students also visit the Māori community at Ōnuku on the Banks Peninsula.

Lacey and the MIHI team have undertaken initial research into the success of the Hui Process and is now doing further work to validate its use. He hopes this may lead to the Hui Process being adopted by other medical school campuses and, eventually, by the majority of clinicians.

“Evaluations are still in the early stages and limited conclusions can be drawn, but it seems the Hui Process meets requirements of an effective cultural competence. It is firmly grounded in Māori culture, aligns well with standard medical practice and, above all, we have had positive feedback from both students and patients, saying it has had a positive impact on patient experience.’’

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University of Otago
Canterbury District Health Board
Partnership Health

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Prescriptive Insights

Professor Pauline Norris and Dr Simon Horsburgh: “The people who have the best reasons for needing antibiotics are the ones who get the least.”

Inequalities in the levels of prescription medicines accessed by Māori have been highlighted by a School of Pharmacy study based in the Tairāwhiti region.

All prescriptions written in the region are dealt with through Gisborne pharmacies. Those that cannot be picked up directly from the pharmacy are sent to depots in outlying rural areas.

Professor Pauline Norris (School of Pharmacy) says being able to get data from the Gisborne pharmacies gives them a complete picture of all the medicines used region-wide. So far they have published two papers – one on antibiotics and the other on psychotropic drugs for the elderly – showing that the rates of use are much lower amongst Māori.

Norris and Dr Simon Horsburgh (Department of Preventive and Social Medicine) identified a particularly low use of antibiotics by rural Māori.

"This is very worrying because rates of infectious diseases are higher amongst Māori and, in particular, rheumatic fever is really high amongst the Māori population in Tairāwhiti,” Norris says. “The people who have the best reasons for needing antibiotics are the ones who get the least.

"I think this is a really important measure of access to health care."

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Many rural Māori live in small, remote communities, so they are not just a long way from a pharmacy, they can also be a long way from the depot and along poor roads.

"People face a lot of practical problems in actually accessing health care and medicines. The combination of geographic distance and poverty is really a significant barrier."

Horsburgh says that in urban Gisborne antibiotics use was about the same for non-Māori and Māori. "That's not what you would expect if everyone got equal access to health care, because Māori tend to suffer from higher rates of infectious disease than non-Māori."

The causes have not yet been investigated, but Norris says it seems likely that factors such as poverty, not being able to afford health care and medicines, as well as not being able to get to the health centre and depot are likely to be part of the problem.

"Relying on people to go and get medical attention and get their medicines in remote locations is just placing too many barriers in their way. You've got to be much more proactive about targeting high risk communities and really trying to eradicate diseases like rheumatic fever."

Norris says a school-based programme in Flaxmere is a good example of what can be done. Throat swabs are taken from the children at school, medicine is delivered to the children’s homes and stickers are given as rewards for taking medicine. At the same time, it is ensured that their families are getting all the social welfare help they are entitled to and arrangements are made to have houses insulated.

"I think our research really suggests that the approach of just hoping that it will work, and relying on people getting to the doctor and picking up the medicines themselves is just not working – it's just not leading to the pattern of antibiotic use that you'd want."

FUNDING
Health Research Council of New Zealand
University of Otago School of Pharmacy

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Working for mothers and babies

Dr Beverly Lawton: “We’ll be looking at Māori women to see if the reasons for their problems are any different from non-Māori mothers.”

Dr Beverly Lawton is on a personal crusade. Raised in Wellington with her father from Ngāti Porou on the East Coast, she is now head of the Women’s Health Research Centre on the University of Otago, Wellington campus and involved in several significant research studies to improve maternal and infant health care.

“This is really an interesting time for us with multiple new studies on the go,” she says. “As the only centre of its kind in the country, our mission is to make a real difference to the health of mothers and babies in New Zealand.

“We’re looking at improving the differences in health outcomes for all women and their infants, including Māori, and particularly Māori mothers under the age of 20, whose babies are more likely to have serious health problems.”

In the coming year the centre will be extending a pilot study that looked at why mothers are admitted to intensive care units (ICU) with acute health problems before, during or after giving birth. The initial severe acute maternal morbidity (SAMM) study undertaken in one district health board area showed about one third of the 29 pregnant women admitted to ICU in one year had a “preventable event” within the health system, such as haemorrhaging, blood clots or life-threatening blood poisoning.

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The extended study will examine maternal admissions to ICU in four district health boards. “We’ll be looking at Māori women to see if the reasons for their problems are any different from non-Māori mothers,” she says. “This kind of audit has never been done in New Zealand and we’re using a well established international model for the analysis.

“Negative outcomes associated with having a baby have considerable personal and public health costs. If we can determine some of the causes or indicators of maternal morbidity, this will benefit all mothers who are admitted to ICU,” she says. However, Lawton points out admission rates for mothers to ICU in New Zealand are not high and match international rates, with only one to two per cent of pregnancies having a “severe event” and 33 per cent of those women being admitted to ICUs.

Concurrently, the Women’s Health Research Centre is undertaking a wide-ranging retrospective investigation of the health of 55,000 women and infants in the first year after birth. “We’re focusing here on avoidable hospitalisation, asking what are those things, such as vaccination rates, which keep infants and mothers out of hospital in the first year after birth?

“This large sample will give us robust data on how we can improve maternal and infant care in the first year. It’ll also improve care for mothers under the age of 20, who often have more health problems with their babies.”

This will be extended in the “E Hine” study, researching the health journey of young Māori women under the age of 20, from pregnancy, through birth, to the first year of looking after their baby. This project, funded by the Health Research Council, will interview 40 pregnant under-20-year-old Māori women in Hawke’s Bay and Wellington over two years.

“We know that children of young women have higher infant mortality rates and we need to look closely at the needs of this group. This study aims to find out what works in the system and what doesn’t, the barriers that young Māori mothers experience, and how best to support them and their children.”

Lawton says the findings will assist all young mothers in New Zealand. At the same time, she says, some of the factors that influence the health of babies of young Māori women may be different from non-Māori women of similar socio-economic groups.

“This is not just a socio-economic question,” she says. “We believe the differences may well lie in provider and service issues.”

All these projects are being carried out under a kaupapa Māori model, with Māori at the centre and research decisions flowing from their needs.

“We have local kaumātua advising us all the way through these studies and are fortunate enough to have strong support from local Māori communities wherever we carry out our research.”

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Ministry of Health
Health Research Council of New Zealand

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Equality and quality: a health-care debate

Bridget Robson: “Māori with acute coronary syndrome appear to be less likely to get the same treatment as non-Māori and are more likely to die earlier.”

Anecdotal debate within the health system and amongst researchers regarding poor outcomes for Māori patients has, for some time, revolved around whether there are systemic reasons for these inequalities, or differences.

Although the wider social, economic and environmental determinants of health play a large part in variations in health status, timely access to high quality health care is important if you are unwell.

More recently research groups, such as Te Rōpū Rangahau Hauora a Eru Pōmare, at the University of Otago, Wellington, have focused attention on whether Māori are receiving unequal treatment in some areas of the health system and why this might be so.

Bridget Robson, who heads the centre, has been interested research in the United States showing that improvements in cardiovascular disease mortality have been due to more effective treatments. However, the strongest evidence of unequal treatment between ethnic groups was also found in studies of cardiovascular disease.

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“Māori in New Zealand also have high heart disease mortality rates so this is one area where we focused our research: to see if there were differences in treatment that may affect Māori health outcomes compared to non-Māori,” she explains.

The Unequal Treatment study looked at the receipt of cardiac procedures such as coronary bypass and graft, angioplasty and angiography. It selected a cohort of Māori and non-Māori first admissions to hospital, identifying their procedures and how long it took to have them. The study also controlled for a range of other factors that might affect whether people received these procedures: co-morbidity, type of hospital, socio-economic deprivation levels.

“We found a gap in outcomes for Māori. There’s inequality of treatment that can’t be fully explained by other factors such as co-morbidity,” she says.

“It seems that Māori with acute coronary syndrome appear to be less likely to get the same treatment as non-Māori and are more likely to die earlier. Indeed, this gap becomes apparent in the first few days after admission.”

Robson says it was an interesting – and somewhat stressful – moment when she presented the results to cardiologists. Some found it difficult to accept that Māori receive unequal hospital treatment and suggested a range of other reasons why treatment rates are worse, over and above the factors for which the study had controlled.

“However, we believe our study is robust. For instance, outcome differentials were seen in both secondary and tertiary hospitals, so it’s not just an issue of hospital size or location.”

The Unequal Treatment study did not look at the reasons why there might be problems in how hospitals treat Māori. However, Robson is encouraged by the fact that the results have been taken on board by clinicians. A clinical cardiac equity group has been established in Auckland and there will be an ongoing audit of cardiac care in Hawke’s Bay. The Taranaki District Health Board is also starting to investigate its provision of cardiac revascularisation procedures for Māori.

“I’m hoping that these developments will encourage similar actions in other district health boards,” says Robson.

Other areas being investigated with regard to unequal treatment are obstetrics and cervical cancer, with the former focusing on higher rates of caesarean section for non-Māori compared to Māori.

“This study is looking at whether adverse outcomes in a cohort of Māori mothers and babies are related to differences in the rates of obstetric interventions. We’re also carrying out interviews with clinicians and patients.”

The results from the cervical cancer study are more positive, showing that both the rate and mortality levels of cervical cancer in Māori women have dropped, and there are no inequalities in treatment for this disease.

“We think this is due to the great job Māori providers have done in raising awareness and supporting Māori women to be screened with a follow-up colposcopy, if necessary. Mainstream cervical cancer services have also made efforts to better respond to Māori women and their whānau. Essentially, there’s now standardised treatment for cervical cancer across the country,” she says.

“However, there’s still a problem for Māori women in terms of survivability, but this relates to being diagnosed at a later stage rather than unequal treatment.”

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Health Research Council of New Zealand

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Oral health agendas

Bridget Robson and research assistant Ruruhira Rameka of the Te Rōpū Rangahau Hauora a Eru Pōmare look at ways to improve the poor oral health of many Māori.

The costs of accessing dental care have been identified as a significant contributor to the poor oral health among Māori and their whānau. This hidden, but serious health problem is now being addressed through research by the University of Otago’s Te Rōpū Rangahau Hauora a Eru Pōmare, in Wellington.

This year it published an assessment and research agenda regarding the pressing needs of Māori for better access to oral health. Oranga Waha - Oral Health Research Priorities for Māori details wide-ranging ways to improve the poor oral health of many Māori and to determine the best strategies for reaching this goal.

“This really is an urgent health problem in New Zealand,” explains lead author Associate Dean Māori Bridget Robson. “Cost is a huge factor in dental care for many, possibly the majority of Māori. Although around $1 billion a year is spent on oral health in New Zealand, only $178 million is publicly funded and only $9 million of that goes to low-income adults.”

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As a result, Robson says, many Māori never go to a dentist after leaving school and some resort to drastic measures to deal with pain from rotten teeth. Poor oral health is also linked to other health problems such as diabetes, lung and heart disease. Others complain of drugs drying out their mouth which increases their risk of tooth and gum disease.

Using the input and experience of several Māori health providers, NGOs and Te Ao Marama (the New Zealand Māori Dental Association), the Oranga Waha report recommends further research priorities and strategies needed to combat poor oral health in the Māori community.

Its key recommendations focus on increasing Māori providers of oral health services; upskilling dental services to manage patients who have disabilities or chronic conditions; the development of new models to make dental care more accessible to Māori; encouraging dentists to work in low-income or rural areas; and investigating how to increase Māori community control over environmental factors such as alcohol outlets, fluoride, and the marketing of food and tobacco.

“We now need to promote the findings to the dental community and then to carry out further detailed investigation into what are the most achievable priorities for the health system in the short term,” says Robson.

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Ministry of Health
Health Research Council of New Zealand

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Diabetes: the new "pandemic"

Research by Māori for Māori has become an important focus of diabetes studies at Otago.

Earlier this year the highly respected medical journal The Lancet began calling diabetes a pandemic.

"It used to be a disease, then it became an epidemic and now it's qualified as a pandemic," says Professor Jim Mann (Edgar National Centre for Diabetes and Obesity Research).

That change in status resonates particularly strongly in New Zealand which has the world's fourth highest rate of type 2 or adult onset diabetes, with Māori, Pacific and Asian – particularly those from the Indian subcontinent – figuring prominently in the statistics.

Although rates amongst Māori are the lowest of those three population groups, they still make sobering reading. Figures drawn from research involving Ngāti Porou on the North Island's East Coast show that amongst Māori over the age of 25 almost half have either diabetes or pre-diabetes: that is, showing signs of insulin resistance, impaired glucose tolerance, impaired fasting glucose.

Mann and his team have conducted extensive research into a variety of dietary and lifestyle interventions to tackle diabetes in its earliest stages. Research by Māori for Māori has been an important part of that process and has led to the development of a new generation of researchers such as Dr Lisa Te Morenga.

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After leaving the forestry industry Te Morenga headed to Otago where she studied nutrition, gaining her PhD and moving into postdoctoral research. She says she did not set out to do kaupapa Māori research as such, but still wanted to pursue research relevant to Māori, particularly in areas such as diabetes and cardiovascular disease.

One of her first pieces of research was a dietary intervention study using off-the-shelf products and easy recipes to find a simple dietary intervention to reduce key risk factors associated with increase diabetes and cardiovascular disease. As it worked out, the high protein, high fibre diet was fairly similar to the traditional Māori diet.

"I showed that people following that diet, without strict dietary or weight-loss advice, experienced a little bit of weight loss and improvement in body composition and lipids – a general improvement in all factors that are associated with increased risk for diabetes."

A second study, comparing high fibre and high protein diets, showed that the latter appeared to have benefits for people at high risk of developing diabetes. That study echoed earlier work from the department that suggested that Māori preferred a high protein diet.

Te Morenga has also been working in close collaboration with colleagues at the University of Canterbury, developing a simple test for insulin sensitivity, a precursor to type 2 diabetes where the body becomes resistant to insulin. Mann describes this research as groundbreaking.

"The current tests for measuring insulin sensitivity are very complicated and it takes half a day to do one simple test. The test that we've been working on – and Lisa has been pivotal in this – involves a tiny injection of insulin and a couple of blood tests. So it is a very simple, very easy test to do which has the potential to revolutionise research of this kind in the future."

Te Morenga is also involved in research into the dietary determinants of gout, a condition to which Māori are particularly prone. While the genetic component of gout is recognised, Mann's team is now focusing on the role of sugar in the development of uric acid crystals, which build up in the joints to cause the inflammation associated with gout.

"Now there is a huge interest in sugar and that is terribly relevant to Māori," he says.

Another Māori researcher from the group, Dr Lorraine Brooking, has also compared the effects of a high protein diet compared to a high carbohydrate diet in people who either had diabetes or were pre-diabetic. That research suggested that the high protein diet was infinitely better.

"That's very important because so much emphasis has gone into high carbohydrate and high fibre, but that is not a dietary preference of Māori people," says Mann. "This has practical potential in terms of the advice dietitians give to their Māori patients.”

If any sort of proof of concept was needed to show the potential benefits of lifestyle modification in reducing the risk of diabetes then it was provided by the Ngāti and Healthy Prevent Diabetes Project, a collaborative project involving Ngāti Porou Hauora and the University of Otago.

That project was expanded into a community-based, whole-health approach on the East Coast of the North Island. Mann says the model for successful intervention, regardless of race or culture, has been established through projects such as Ngāti and Healthy. "It just has to be extended. It is a model that could be used anywhere around the country."

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Health Research Council of New Zealand
Riddet Institute (Massey University)
Edgar National Centre for Diabetes and Obesity Research

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Pukapuka Hauora: healthy lungs

Bernadette Jones and Dr Tristram Ingham: “We’re interested in the practical issues that confront Māori parents.”

New Zealand has a high asthma rate, with one in four primary-school age children experiencing asthma symptoms. It is not clear exactly why these rates are so high, nor why Māori children are twice as likely to be admitted to hospital with asthma compared to non-Māori children.

The issues Māori parents face with asthma management raise questions which Bernadette Jones and Dr Tristram Ingham, from Wellington’s Asthma Research Group, have been exploring in their Pukapuka Hauora (Healthy Lungs) study.

“The aim of this longitudinal study has been to interview in-depth a group of Māori parents about their children’s asthma,” says Jones, a Māori researcher with a nursing background. “This involved multiple interviews over several months to develop a comprehensive understanding of how these 32 families are coping and what issues they are facing in managing this chronic disease.”

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Ingham says a lot has been done to describe asthma, particularly the environmental and biomedical factors associated with this condition, including medication compliance. However, relatively little is known about Māori parents’ experiences in managing asthma and the challenges they face on a daily basis, which could have a critical effect on how well their child is doing.

“We’re interested in the practical issues that confront Māori parents. For instance, their understanding and concerns of how and when to use inhalers and steroid medications, their confidence recognising the signs of deterioration and when to take their child to the doctor, as well as environmental factors affecting their asthma, such as housing conditions and allergen triggers.”

Preliminary results of the study show there are a range of issues of concern for Māori parents which could be amenable to intervention. Parents talked about their experiences accessing various health-care services and their interactions with health professionals.

“There are sometimes inconsistencies in messages involving asthma medication and treatment, and parents often noted a lack of continuity in their dealings with health professionals, such as not getting the same GP because of locums or staff shortages.”

Parents also say schools do not always fully understand the needs of children with asthma, with issues such as puffers having to be kept where they are not easily accessible, students being in trouble for disturbing the class by coughing, difficulties doing physical education and asthma plans not being followed while at school.

“This is where boards of trustees need to make sure that there are clear guidelines and protocols to protect the health of these children,” says Ingham.

However, overall Jones and Ingham say Māori parents are doing well with their children’s asthma. They found that community asthma services by nurse educators from the Hutt Valley’s Tu Kotahi Māori Asthma Trust are especially valued and provide clear and consistent information.

“All parents we spoke to have a thirst for knowledge about asthma, so it’s not as though they don’t care. They care deeply about their child’s welfare and are trying to do their best,” says Jones.

One of the additional spin-offs of Pukapuka Hauora is that its findings are informing the Hauora Māori programme which teaches fourth- and fifth-year medical students how to relate more effectively with Māori patients.

Underlying this and other Māori health studies by Jones and Ingham has been the development of their Whānau Tuatahi (Families First) research framework, a practical way of conducting kaupapa Māori research. This means recognising from the outset that Māori culture has different ways of relating, putting participants and their needs at the centre of the research process.

As urban Māori in the Wellington region come from multiple iwi or tribal backgrounds, the researchers believe it is particularly important to have a framework that is Māori-centred throughout the investigatory process.

“We developed a series of principles for engaging with Māori participants and then applied them to the Pukapuka Hauora study, and it worked extremely well,” says Jones. “This meant having a whānau-focused, ‘appreciative’ approach, rather than a deficit model in which Māori feel they are being held to account for ostensible shortcomings in managing their child’s health.”

The researchers say it’s made a big difference in involving the participants. The principles include: whakawhirnaki (trust), whakawhanaungatanga (relationship building), whakamana (empowerment), ngāwari (flexibility), utu (reciprocity) and hurihuringa (reflexivity).

The approach built relationships with Māori parents over some months, involving them from the outset of the project, giving them a chance to ask questions about the research and asthma, and empowering the community as a whole in the research process.

Much of the guidance in developing this framework came through assistance from the Tu Kotahi Māori Asthma Trust which has been working in the Hutt Valley near Wellington for more than a decade.

“I think the fact that we had a 100 per cent retention rate in this study using the Kaupapa Māori framework speaks for itself,” says Jones. “It’s all about engaging and empowering whānau on their terms. Then you find that they’re really involved, interested in taking part in research and in getting their voices heard.”

FUNDING
Health Research Council of New Zealand

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