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Indigenous children and young peoples live with an inequitable burden of acute rheumatic fever and rheumatic heart disease. In this Review, we focus on the epidemiological burden and lived experience of these conditions for Indigenous young peoples in Australia, New Zealand, and Canada. We outline the direct and indirect drivers of rheumatic heart disease risk and their mitigation. Specifically, we identify the opportunities and limitations of predominantly biomedical approaches to the primary, secondary, and tertiary prevention of disease among Indigenous peoples. We explain why these biomedical approaches must be coupled with decolonising approaches to address the underlying cause of disease. Initiatives underway to reduce acute rheumatic fever and rheumatic heart disease in Australia, New Zealand, and Canada are reviewed to identify how an Indigenous rights-based approach could contribute to elimination of rheumatic heart disease and global disease control goals.

Māori experience barriers to accessing timely, quality healthcare. The March 2020 COVID-19 lockdown in New Zealand required provision of Telehealth consultation options in primary care. Telehealth consultations have the potential to improve access to healthcare for Māori, and thereby reduce health inequities. Conversely, Telehealth may present additional barriers that contribute to inequities overall. This scoping project investigated Māori experiences of Telehealth consultations during the March 2020 COVID-19 lockdown.Semi-structured key informant interviews were completed with five Māori health professionals, six Māori Telehealth patients, and six Māori in-clinic patients, about their healthcare consultation experiences during COVID-19 lockdown. Participants were asked about what worked, what did not work, and for suggestions to improve future Telehealth provision to Māori whānau. Kaupapa Māori methodology underpinned thematic analysis of the interviews.Key findings are presented in three overarching themes: benefits (safety, cost, time, options); challenges (health literacy, access to Information Technology (IT), supply and demand, limited physical assessment); and suggested improvements (systems fit for purpose, supporting IT and health literacy, Telehealth as a routine option, rapport building, and cross system efficiency and information sharing).Telehealth is a viable long-term option that can support Māori whānau access to healthcare.

Addressing the underrepresentation of Māori in the health workforce is expected to improve Māori health status and contribute to a reduction in Māori health inequities. This research aimed to under...

INTRODUCTION Indigenous peoples’ rights include the right to self-determine one’s identity. For Māori, this includes self-assignment of ethnicity, and traditional identities such as Iwi (tribe). New Zealand’s Ministry of Health requires health services to collect ethnicity data using standard protocols. Iwi data are also collected by some health services; however, with no health-specific protocols, little is known about Iwi data collection and quality. The National Hauora Coalition (NHC) Primary Healthcare Organisation (PHO) sought to understand Iwi data collection across its network of primary care providers. AIM To understand Iwi data collection at the NHC PHO; specifically, is it being routinely collected, how is it being collected and what are the results? METHODS In 2017, NHC’s general practice clinics were invited to submit their enrolment forms, which capture ethnicity and potentially Iwi information, by e-mail to the audit team. Forms were reviewed to determine whether Iwi information was being collected and if so, what question was being used. Iwi numbers were collated from the annual data extract. RESULTS Thirty-three of a total of 35 clinics (94%) submitted their enrolment forms to the audit team. Nine of the 33 clinics (27%) sought Iwi name/s with a specific question on their enrolment form. Six different ‘Iwi’ questions were used by the nine clinics. The data extract revealed that the NHC had Iwi data for 13% (2672/20,814) of its Māori enrolments. Ngāpuhi were the largest Iwi group at the NHC. DISCUSSION This is the first study to describe the quantity and quality of Iwi data collection in NZ primary care. Standard procedures for collecting, recording and using Iwi data are being developed by the NHC PHO. These could inform national protocols to optimise the quality of Iwi data.

Transport infrastructure critically influences how people live their lives, structuring mobility and mediating access to the resources central to health and wellbeing. While the links between infra...

Background Prevalence of Type 2 diabetes mellitus (T2DM) is high among Māori and other Pacific Island peoples in New Zealand. Current health services to address T2DM largely take place in primary healthcare settings and have, overall, failed to address the significant health inequities among Māori and Pacific people with T2DM. Culturally comprehensive T2DM management programmes, aimed at addressing inequities in Māori or Pacific diabetes management and workforce development, are not extensively available in New Zealand. Deliberate strategies to improve cultural safety, such as educating health professionals and fostering culturally safe practices must be priority when funding health services that deliver T2DM prevention programmes. There is a significant workforce of community-based, non-clinical workers in South Auckland delivering diabetes self-management education to Māori and Pacific peoples. There is little information on the perspectives, challenges, effectiveness, and success of dietitians, community health workers and kai manaaki (KM) in delivering these services. This study aimed to understand perspectives and characteristics of KM and other community-based, non-clinical health workers, with a focus on how they supported Māori and Pacific Peoples living with T2DM to achieve better outcomes. Methods This qualitative study undertaken was underpinned by the Tangata Hourua research framework. Focus groups with dietitians, community health workers (CHWs) and KM took place in South Auckland, New Zealand. Thematic analysis of the transcripts was used to identify important key themes. Results Analysis of focus group meetings identified three main themes common across the groups: whakawhanaungatanga (actively building relationships), cultural safety (mana enhancing) and cultural alignment to role, with a further two themes identified only by the KM and CHWs, who both strongly associated a multidisciplinary approach to experiences of feeling un/valued in their roles, when compared with dietitians. Generally, all three groups agreed that their roles required good relationships with the people they were working with and an understanding of the contexts in which Māori and Pacific Peoples with T2DM lived. Conclusions Supporting community based, non-clinical workers to build meaningful and culturally safe relationships with Māori and Pacific people has potential to improve diabetes outcomes.

Māori health providers emerged in Aotearoa/New Zealand in the 1980s as a mechanism to achieve self-determination for Māori communities. However, the contracts funding Māori health providers limit expressions of self-determination and fail to reflect Te Tiriti O Waitangi, the founding treaty of Aotearoa/New Zealand. Significant health reforms are proposed in Aotearoa/New Zealand, including the creation of a Māori Health Authority that will commission services from Māori health providers. This paper aims to critique the government contracts provided to Māori health providers in the light of the health reforms. A discourse analysis was undertaken on contracts held by a Māori health provider. The study was informed by a Kaupapa Māori congruent methodology that centralised Māori knowledge. The contractural language utilised a variety of discursive techniques that ultimately limit the power of Māori health providers. These discursive techniques included the redefinition of Māori concepts of self-determination, the use of rhetoric that was not matched by action, reshaping Māori health priorities to reflect the funders' priorities and the application of a deficit lens to Māori health issues. The discursive techniques present in these contracts is consistent with previous work demonstrating a failure of funders to centralise Māori knowledge and ways of being. Success of the proposed health reforms and the Māori Health Authority should require dismantling of non-Māori ways of commissioning and contracting, otherwise there is the continued risk of discriminatory contracting practices limiting the expression of self-determination for Māori health providers.

Objective: Rheumatic fever (RF) recurrence prevention requires secondary prophylaxis for at least ten years. However, recurrences of rheumatic fever (RRF) persist disproportionately affecting Māori and Pacific youth. Reasons for recurrence rates are not well understood and commonly attributed to patient non‐adherence. This research explored Māori and Pacific family experiences of RRF to better understand barriers to accessing secondary prophylaxis to inform health service improvements. Methods: Participants were Māori and Pacific patients who had RRF or unexpected rheumatic heart disease and their family; and health professionals working in RF contexts. Kaupapa Māori, Talanga and Kakala Pacific qualitative methodologies were employed. Data were thematically analysed using a general inductive approach. Results: Data collection included 38 interviews with patients and families (n=80), six focus group interviews and nine interviews with health providers (n=33) from seven geographic regions. Three key themes were identified where mismatches occurred between services and community needs: 1. Model of delivery; 2. Interpersonal approaches to care; and 3. Adolescent care. Conclusions and Public health implications: Successful RRF prevention requires interventions to address structural causes of inequity, appropriate clinical guidelines and quality health services. Service‐delivery models should provide regular prophylaxis in an accessible manner through culturally‐safe, community‐based, age‐appropriate care.

Rheumatic heart disease (RHD) is a large, preventable, global public health burden. In New Zealand (NZ), acute rheumatic fever (ARF) and RHD rates are highest for Māori and Pacific children. This structured review explores the evidence for primary prevention interventions to diagnose and effectively treat group A Streptococcus (GAS) pharyngitis and skin infections to reduce rates of ARF and RHD. Medline, EMBASE and Scopus databases were searched as well as other electronic publications. Included were 50 publications from 1980 onwards. This review has identified that there is little available evidence for effective primary prevention strategies to reduce ARF rates in NZ. However, two primary intervention strategies that should be considered by communities at high-risk of ARF are: the use of school-based clinics to identify and treat GAS pharyngitis and GAS skin infections; and intramuscular benzathine penicillin G with lignocaine analgesia in children who present with a GAS positive throat.

Background: Barriers to accessing perinatal health services in New Zealand remain a significant problem, especially for Māori and rural populations. Information technologies and telehealth can facilitate the distribution of health-related information and promote provider engagement during theperinatal period.Aim: This study explored the perceptions and use of technologies by women and their partners who were pregnant or new mothers/caregivers and who utilised Kaupapa Māori perinatal health services.Method: A Kaupapa Māori consistent methodology was applied. An equal explanatory sampling approach was used for recruitment. Conversational interviews were conducted with a total of nine Northland-residing participants of an antenatal programme. Data were analysed thematically.Findings: Four overarching themes emerged from the interview narratives: communication, information, facilitators and barriers. Participants used a range of online tools to access diverse healthrelated topics and executed autonomous control over the information gained. The credibility andreputability of sources as well as knowledge sharing were valued. Similar technologies were used to communicate with perinatal healthcare providers, including lead maternity carers, and to make in-person appointments. Barriers were related to the technology itself or the experience of usingit, whilst ease of access and emotional elements facilitated engagement. Participants were generally satisfied with the technologies.Conclusion: Technology can play an important role in health literacy and minimising barriers to perinatal healthcare, by facilitating the distribution of information and promoting provider engagement. As the research indicated that online tools and services available in Northland are generally adequate for the population served, perinatal healthcare providers should leverage these to further promote engagement with service users. It is crucial that Māori health values such as whānau (extended family structures) and kanohi ki te kanohi (face-to-face interactions) are incorporated for successful perinatal healthcare delivery via telehealth.Keywords: Māori, perinatal, telehealth, pregnancy, women, Kaupapa Māori

Objectives Type 2 diabetes mellitus (T2DM) and periodontal disease are two highly prevalent, directly and independently associated long-term conditions that disproportionately impact Indigenous Māori in New Zealand (NZ). Although poorly understood, a number of social and biological mechanisms connect these conditions. This qualitative study explored experiences of T2DM and oral and dental (hereafter oral/dental) health; access to oral/dental health care; whether participants' experiences supported or challenged existing evidence; and sought suggestions for improving oral/dental health in a high-deprivation rural area of Northland, NZ. Methods Participants (n = 33) meeting the study criteria: self-identified Māori ethnicity, aged ≥ 18-years with glycated haemoglobin (HBA1c) >65 mmol/L were recruited via the local primary care clinic in September-December 2015; two left the study prior to data collection. During face-to-face semi-structured interviews, participants (n = 31) were asked How does diabetes affect your teeth? and When did you last access dental care? Kaupapa Māori (KM) theory and methodology provided an important decolonizing lens to critically analyse the fundamental causes of Indigenous health inequities. Results Independent analysis of qualitative data by three KM researchers identified four themes: access barriers to quality care; pathways to edentulism; the 'cost' of edentulism; and, unmet need. Results contributed towards informing Mana Tū-an evidence-based KM programme for diabetes in primary care-to be introduced in this and other communities from 2018. Conclusions Oral health is integral to diabetes management, and vice versa. Subsidized specialist referrals for oral-dental health care for Māori with T2DM could improve glycaemic control and diabetes outcomes and reduce diabetes-related complications among this population.

ObjectiveThe present research sought to better understand the barriers, facilitators, attitudes and beliefs that influence the way Māori and Samoan grandparents feed their grandchildren in a deprived urban neighbourhood in New Zealand.DesignThe research adopted a qualitative methodology that was consistent with a Kaupapa Māori research approach. Seven semi-structured interviews were conducted with grandparents to collect narrative data.SettingSampling occurred in one Auckland suburb. The suburb was selected because of its high level of socio-economic deprivation and ethnic diversity.SubjectsSeven grandparents participated in the study (five Māori and two Samoan). Each participant met the inclusion criteria (i.e. they had provided at least five meals per week over the previous three months to grandchildren aged less than 24 months). Marae (i.e. meeting houses and areas used by local Māori tribes/sub-tribes) and community organisations were used to recruit participants.ResultsA general inductive thematic analysis identified four key themes: (i) grandparents’ understanding of optimal feeding practices; (ii) economic and material factors; (iii) previous experiences and customary norms; and (iv) social support and societal pressure.ConclusionsThe study showed that grandparents’ complementary feeding practices in caring for infant grandchildren were influenced by upstream structural elements such as government policies related to welfare and pensions, employment, income and cultural knowledge. Frameworks that seek to achieve social justice and support cultural practices should be employed and promoted in the development of future policy and research in this area.

Large purpose-built retirement complexes including continuing care options are increasingly popular ways to ‘age in place’ for older people in New Zealand and internationally. Promoted by their corporate owners as a lifestyle choice offering a wealth of activities and social interaction in manicured settings along with security and increasing care on site as needed, these entities offer new ways for wealthier older people to age. Applying an ethnographic approach to a case study residential complex in Auckland, New Zealand, we explore how residents experience inclusion and exclusion, and sense of community within such environments with a diversity of fit and frail residents. Data was collected from interviews, walk-about conversations, social site mapping and a selection of media material to gain an understanding of the social issues important to the residents. The twelve participants, aged between 70 and 87, were all independent residents living in the independent part of the complex, which is situated in a socio-economically wealthy suburb of Auckland. We identified that social connections were often fragile, and existing social group membership was key to shared community experiences and a sense of belonging. Residents who found themselves on the social fringes, particularly as newcomers or through health decline, were at risk of marginalisation, stigma, and social exclusion. Further, we identified how the design and layout, and tensions in the structure of the resident-management relationship potentially hinder inclusiveness and sense of community. These findings shed light on alternative experiences at odds with the commercial and populist framing of these places as age-friendly and inclusive communities promoting active lifestyles.

Background Although early detection and management of excess rates of gestational diabetes mellitus (GDM) among Indigenous women can substantially reduce maternal and offspring complications, current interventions seem ineffective for Indigenous women. While undertaking a qualitative study in a rural community in Northland, New Zealand about the complexities of living with diabetes, we observed a common emotional discourse about the burden of diabetic pregnancies. Given the significance of GDM and our commitment to give voice to Indigenous Māori women in ways that could potentially inform solutions, we aimed to explore the phenomenon of GDM among Māori women in a rural context marked by high area-deprivation. Method A qualitative and Kaupapa Māori methodology was utilised. A sub-sample of women (n = 10) from a broader study designed to improve type 2 diabetes mellitus (T2DM) who had experienced GDM or pre-existing diabetes during pregnancy and/or had been exposed to diabetes in utero were interviewed. Participants in the broader study were recruited via the local primary care clinic. Experiences of GDM, in relation to their current T2DM, was sought. Narrative data was analysed for themes. Results Intergenerational experiences informed perceptions that GDM was an inevitable heritable illness that “just runs in the family.” The cumulative effects of deprivation and living with GDM compounded the complexities of participant’ lives including perceptions of powerlessness and mental health deterioration. Missed opportunities for health services to detect and manage diabetes had ongoing health consequences for the women and their offspring. Positive relationships with healthcare providers facilitated management of GDM and helped women engage with self-management. Conclusion Māori women living with T2DM were clear that health providers had failed to intervene in ways that would have potentially slowed or prevented progression of GDM to T2DM. Participants revealed missed opportunities for appropriate diagnostic testing, treatment and health promotion programmes for GDM. Poor collaboration between health services and social services meant psychosocial issues were rarely addressed and the cycle of intergenerational poverty and disadvantage prevailed. These data highlight opportunities for extended case management to include whānau (family) engagement, input from social services, and evidence-based medicine and/or long-term management and prevention of T2DM. Electronic supplementary material The online version of this article (10.1186/s12884-018-2103-8) contains supplementary material, which is available to authorized users.

Interview Schedule for participants. Guide to questions. (DOCX 25 kb)

Excellent health research is essential for good health outcomes, services and systems. Health research should also build towards equity and in doing so ensure that no one is left behind. As recipients of government funding, researchers are increasingly required to demonstrate an understanding of their delegated responsibilities to undertake research that has the potential to address Māori health needs and priorities. These requirements form the basis of responsiveness to Māori in health research, and several research institutions have implemented systems to support their organisational approach to this endeavour. However, many health researchers have a narrow view of responsiveness to Māori and how it might be relevant to their work. In this viewpoint paper we provide an overview of existing frameworks that can be used to develop thinking and positioning in relation to the Treaty of Waitangi and responsiveness to Māori. We also describe an equity-based approach to responsiveness to Māori and highlight four key areas that require careful consideration, namely: (1) relevance to Māori; (2) Māori as participants; (3) promoting the Māori voice, and; (4) human tissue. Finally, we argue for greater engagement with responsiveness to Māori activities as part of our commitment to achieving equitable health outcomes.

In New Zealand, acute rheumatic fever (ARF) remains a significant health problem with persistent ethnic inequities. Māori children 5-15 years of age in Northland have some of the highest ARF rates nationally. This study explored Māori whānau experiences of ARF, including pathways to primary healthcare and barriers and facilitators for diagnosis of ARF.The study applied a qualitative kaupapa Māori approach including eight whānau, two individual interviews and participant observations with 36 participants.Barriers to accessing primary healthcare included: geographic distance, unavailability of appointments, cost, poor trust and rapport between health providers and whānau. Good rapport, communication and trust with health professionals facilitated utilisation of services. Barriers to diagnosis were lack of throat swabbing and inappropriate prescription of antibiotics. Access to primary care, having health professionals follow sore throat guidelines and trust in health professionals facilitated diagnosis.Health services could better support ARF diagnosis through the development of an effective quality improvement strategy for sore throat management, promoting free rapid response throat swabbing for high-risk populations, and exploring options of self-swabbing. Training and evaluation targeted at rapport building should also be established for health professionals to facilitate primary healthcare utilisation.

ABSTRACT BACKGROUND AND CONTEXTRheumatic fever inequitably affects Māori and Pacific children in New Zealand. School-based throat swabbing services, such as the South Auckland Mana Kidz programme, are a key element of rheumatic fever prevention interventions. ASSESSMENT OF THE PROBLEMCounties Manukau has the highest national rates of rheumatic fever (4.7 per 100,000 for first recorded rates). Given these disparities, Mana Kidz undertook an exploratory, community-based initiative to improve its service delivery for Pacific Peoples. RESULTSMana Kidz held a Pacific Leaders’ Fono (meeting) to discuss initiatives to improve rheumatic fever outcomes in South Auckland focused around challenges and solutions for addressing rheumatic fever, effective engagement strategies and leadership qualities needed to drive initiatives. Oral and written responses from 66 attendees were collected and thematically analysed. Four key themes were identified around challenges and solutions for rheumatic fever: social determinants of health; cultural responsiveness; health system challenges; and education, promotion and literacy. Three effective engagement strategies were identified: by Pacific for Pacific; developing a rheumatic fever campaign; improving health services. Three key leadership attributes were identified: culturally responsive leaders; having specific expertise and skills; youth-driven leadership. STRATEGIES FOR IMPROVEMENTMana Kidz has now created Pacific leadership roles in rheumatic fever governance groups, promotes Pacific workforce development and endorses Pacific-led initiatives and partnerships. LESSONSRecognising the value of critical reflection and the importance of good governance and collaborative, right-based partnerships in health services.

Aim: To explore kaumātua attitudes towards physician aid-in dying, to gain a clear understanding of how such attitudes may influence and shape their expectations of medical care at the end of life and to assist health professionals in Aotearoa/New Zealand to address the healthcare needs of older Māori near the end of life. Design: A kaupapa Māori consistent approach was undertaken. A systematic narrative technique was employed for the qualitative data analysis. Data were triangulated through independent data coding by three researchers (two of whom identified as Māori researchers), to ensure a robust and consistent method of analysis as well as adhering to a kaupapa Māori research approach. Setting/participants: Recruitment of participants was through kaumātua of Te Kupenga Hauora Māori (Māori leadership within the Faculty of Medical and Health Sciences), University of Auckland and local Auckland marae. Focus group or individual interviews (as per their preference) were undertaken with 20 Kaumātua from the Auckland region. Results: Five closely interrelated themes were identified from kaumātua narratives regarding physician aid-in dying. These were (1) attitudes and understandings of physician aid-in dying, (2) influence of power, (3) significance of kawa, (4) whānau relationships and the (5) significance of wairua. Conclusion: The study demonstrated that for these kaumātua, medical practices that hasten death such as physician aid-in dying are ‘not all just about the dying’. Tikanga and kawa are important processes and concepts to understand during death and dying, and whānau are central to such processes being respected by those involved in the dying process. These factors are so closely intertwined that they cannot be considered in separation of each other.

Relative deprivation was defined by Townsend (1987, p. 125) as "a state of observable and demonstrable disadvantage, relative to the local community or the wider society or nation to which an individual, family or group belongs". This definition is widely used within social and health sciences to identify, measure, and explain forms of inequality in human societies based on material and social conditions. From a multi-disciplinary social science perspective, we conducted a systematic literature review of published material in English through online database searches and books since 1966. We review the concept and measurement of relative 'deprivation' focussing on area-based deprivation in relation to inequities in health and social outcomes. This paper presents a perspective based in Aotearoa/New Zealand where colonisation has shaped the contours of racialised health inequities and current applications and understandings of 'deprivation'. We provide a critique of Townsend's concept of deprivation and area-based deprivation through a critical, structural analysis and suggest alternatives to give social justice a better chance. Deprivation measures used without critical reflection can lead to deficit framing of populations and maintain current inequities in health and social outcomes. We contend therefore that the lack of consideration of (bio)power, privilege, epistemology and (bio)politics is a central concern in studies of deprivation. Our review highlights the need for the academy to balance the asymmetry between qualitative and quantitative studies of deprivation through trans-disciplinary approaches to understanding deprivation, and subsequently, social and health inequities. We recommend that deprivation research needs be critically applied through a decolonising lens to avoid deficit framing and suggest that there is space for a tool that focuses on measuring the unequal distribution of power and privilege in populations.

Objective: Media portrayals of tuberculosis (TB) in New Zealand are of immigrants who enter the country with active disease and pose a threat to inhabitants, which fosters a popular perception that border control is the best and only response to disease control. This paper reviews both New Zealand and international data on TB rates, causes and transmission among migrant populations to elucidate the precise nature of the link between immigration and TB rates. Methods: Recent information from scholarly journals on immigration and TB was reviewed. Surveillance data from New Zealand and comparable information from other low-incidence countries were reviewed. Conclusions and implications: The importation of active TB is only a minor part of the total TB burden. While effective border control is essential, equally, if not more important, are the circumstances that promote the reactivation of latent TB infection in migrant communities, including migrants' experiences in transit and after arrival, structural conditions, and personal characteristics. For sound prevention strategies, attention needs to be paid to the existence of transnational communities and the conditions for migrants, rather than placing a singular focus on place of birth.