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The aim of this study was to explore the experience and perceptions of a diagnosis of prediabetes among a demographically diverse sample of New Zealanders who had, and had not, regressed to normoglycaemia following participation in a primary care nurse-delivered intervention for 6 months. The sample included Indigenous Māori who have high rates of diabetes and associated co-morbidities.A purposefully selected sample of 58 people with prediabetes and BMI25 kg/mMost participants recalled being shocked when told they had prediabetes, but they did not perceive the diagnosis to be a label in a negative sense, and some, described the diagnosis as helpful. Participants appreciated knowing that prediabetes could be reversed, and the opportunity to be able to take supported action and make lifestyle changes through the nurse-delivered prediabetes lifestyle intervention. Participants' clear preference was to take control and make dietary changes, not to take Metformin.Prediabetes was not considered a negative label, but an opportunity, when coupled with a primary care nurse-delivered dietary intervention.

Objective: In 2020, a government-funded school lunch program was introduced in a quarter of New Zealand schools selected based on high levels of socio-economic barriers. We report family (whānau), student and principal perspectives on the impact of the first two years of this healthy school lunch program. Methods: We conducted five focus groups (2 with secondary students and 3 with family members) and four school principal interviews. Thematic analysis was carried out to develop themes describing the health, wellbeing and nutritional impact of the program. Participating schools represent a range of contexts: primary and secondary, and schools using on-site kitchens and cooks or schools choosing to receive meals delivered by external caterers. Results: Family participants were 82% Indigenous Māori and self-identified as having ‘borderline’ (73.5%) or no financial security (8.8%). Seven positives themes were identified: improved food security, enhanced equity, increased appreciation of healthy foods for students, enhanced mana (wellbeing) for all, reduced financial hardship and stress for families, opportunities for nutritional learning and that appreciation and uptake happen over time. Four negative impact themes were identified: low uptake that created food waste, perception that healthy food is not palatable for students, lack of knowledge of the program and loss of agency for students. Conclusions: This is the largest intervention in nutrition and food security for children ever to be introduced in New Zealand. The first two years have resulted in important wellbeing and financial benefits for students and families involved, particularly when the school environment promotes uptake. More involvement of students and family members is essential.

People with chronic kidney disease (CKD) living in rural communities have increased risks of death, morbidity, hospitalization and poorer quality of life compared with people with CKD living in urban areas. This study explores the experiences and perceptions of rural and remote patients and families in relation to accessing health services for kidney disease in Aotearoa New Zealand.We conducted an In-depth interview study. We purposively sampled adult patients with CKD and their caregivers who lived further than 100 km (62 miles) or more than 1 h drive from their nearest dialysis or transplant centre. Qualitative data were analyzed inductively to generate themes, subthemes and a conceptual framework.Of 35 participants, including 26 patients and nine caregivers, 51% were female, 71% travelled between 1 and 3 h to their nearest renal unit, and the remainder, between 3 and 6 h. We identified five themes and related subthemes: intense psychological impact of rurality; pressure of extended periods away from home; services not designed for rural and remote living; suffering from financial losses; and poor communication.Rural and remote patients with CKD and their caregivers face the added challenges of separation from family, social and community support and financial burden, which can have profound consequences on their psychological and physical well-being and that of their families.

The strict nationwide Covid-19 lockdown that began in March 2020 in Aotearoa New Zealand required staff from tertiary education institutions to immediately adapt and move their teaching and professional activities online, as well as maintain social contact remotely. The aim of our study was to explore the impact of the lockdown and restrictions on working life and personal wellbeing for staff at five Institutes of Technology and Polytechnics (ITPs) across Te Pūkenga national network. Participants were invited to complete an online survey at five time points, corresponding to different alert levels and decreasing social restrictions. They responded to questions about changes to work and personal life, activities to maintain wellbeing, adequacy and trustworthiness of information sources, and provided qualitative comment. Overall, 2250 responses were collected from 1240 individuals over the five time points. They show that participants made higher levels of adjustments in their working lives than in their personal lives or their efforts to maintain social contact. Levels of adjustment decreased over time, despite an increase in alert level (increased social restrictions) in September 2020. Attention to wellbeing also dropped off over time, with an increasing proportion of staff becoming at risk of poor wellbeing (below the cut-off of the WHO-5 depression index). Qualitative comments show innovative and creative ways of maintaining wellbeing despite the requirements for considerable adjustments to participants’ daily working and personal lives.

Objective:To understand motivators, facilitators and challenges to dietary change amongst a diverse sample of New Zealanders with prediabetes participating in a primary care nurse-led individualised dietary intervention.Design:A qualitative study involving semi-structured, face-to-face interviews with a stratified sample of adults with prediabetes and BMI ≥ 25 kg/m2, purposefully selected from a larger 2-year primary care-based prediabetes dietary intervention study. Thematic analysis was undertaken. A socio-ecological model guided interpretation.Setting:Hawke’s Bay, Aotearoa/New Zealand, April 2018–March 2020.Participants:Fifty-eight people aged 28–69 years, with similar numbers of men and women, indigenous Māori and non-Māori, and those who had and had not regressed to normoglycaemia at 6 months.Results:Motivators for wanting to make dietary changes were determination not to progress to diabetes; wanting to be healthy and contribute to others and encouragement by others. Facilitators for adopting and maintaining changes were a strong desire to be healthy; personal determination and feeling supported. Challenges were compromised control over life and environmental factors; feeling unsupported by others; social occasions; financial constraints and living with other health conditions. Developing their own strategies to overcome challenges was empowering, enabling a sense of control. These factors were similar across demographic and glycaemic outcome groups.Conclusions:Influences on dietary change involved personal, interpersonal, organisational, environmental and policy factors. Although findings appeared similar across groups, dietary interventions need to address the specific ways motivators, facilitators and challenges manifest for individuals and social groups and be tailored accordingly within the context of the wider obesogenic and socio-economic environment.

Choosing Wisely seeks to prevent harm by reducing the number of unnecessary tests, treatments and procedures, and by promoting shared decision-making. This article scopes perspectives of Māori patients/consumers and Māori health practitioners around Choosing Wisely and explores shared decision-making between Māori and their medical practitioners.Eight Māori consumers and seven Māori health practitioners participated in a qualitative, semi-structured, in-depth interview study with an inductive thematic analysis.Participant feedback spanned issues from lack of Māori participation in programme governance through to practical issues like meaningful and literacy-appropriate health messaging, traversing consumer, practitioner, organisational and health-system aspects. Feedback further focused on the patient having trust in the practitioner, a sense of autonomy and the availability of advocacy and support in the consultation.Despite a late campaign collaboration with Māori, Choosing Wisely New Zealand is the first of the international programmes to acknowledge the possibility that their initiative might increase inequity for Indigenous populations. This enquiry highlights the need to consult Māori early and to infuse Treaty principles and Māori knowledge and custom at every stage of the programme.

The school food environment plays an important role in shaping students’ dietary choices, which often influence future dietary behaviours. We surveyed primary and secondary schools in Hawke’s Bay, New Zealand, to measure the comprehensiveness and strength of food policies, describe the culture of food provision, and identify barriers to improving school food environments. Fifty-one schools were included in the final analysis, with 58.8% having a food policy, most of which used a generic template. Schools with food policies and those participating in the free and healthy lunch programme were more likely to have a strong culture around healthy eating. Common barriers to healthy eating were food outlets near school and resistance from students. Secondary schools reported facing more barriers to implementing healthy eating cultures, were more likely to use food as classroom rewards and to sell food to students, most of which was unhealthy. Hawke’s Bay schools participating in food provision programmes are successfully improving their food environments through improved culture and delivery of healthy food; however, more action is needed to strengthen the wording and guidance in food policies and reduce the provision of unhealthy food in schools before effective change can be achieved.

Healthy food environments in early childhood play an important role in establishing health-promoting nutritional behaviours for later life. We surveyed Early Learning Services (ELS) in the Hawke’s Bay region of New Zealand and describe common barriers and facilitators to providing a healthy food environment, through descriptive survey analysis and thematic analysis of open-ended questions. We used a policy analysis tool to assess the strength and comprehensiveness of the individual centre’s nutrition policies and we report on the healthiness of menus provided daily in the centres. Sixty-two centres participated and 96.7% had policies on nutrition compared to 86.7% with policies on drinks. Of the 14 full policies provided for analysis, identified strengths were providing timelines for review and encouraging role modelling by teachers. The main weaknesses were communication with parents and staff, lack of nutrition training for staff and absence of policies for special occasion and fundraising food. With regard to practices in the ELS, food for celebrations was more likely to be healthy when provided by the centre rather than brought from home. Food used in fundraising was more likely to be unhealthy than healthy, though

Our current food system is failing to deliver on equitable health outcomes, wellbeing and food security and the Hawke’s Bay region of New Zealand has high inequities and one the highest levels of childhood obesity nationally. This articlereports baseline quantitative data from 2087 students (aged 9 or 13) from 41 primary and secondary schools, including schools participating in the Ka Ora, Ka Ako Healthy School Lunch programme. Students answered an online survey covering food security, general wellbeing (WHO-5), eating behaviours and physical activity and were measured/weighed for body size. 16.8% of students experienced food insufficiency in the home and 31.3% of 13-yr-olds did not eat breakfast. Overall, only 12.9% met the national vegetable intake guidelines and 39.6% met fruit intake guidelines. Students in high advantage schools (decile 8–10) were twice as likely to meet the vegetable intake guidelines. 47.1% of 13-year old girls were at risk of reduced wellbeing. 54.6% of students had a healthy weight and 44.5% experienced overweight or obesity; in low advantage (decile 1–3) schools 64.4% experienced overweight or obesity. The data form a baseline for an evaluation of multiple public health initiatives underway in Hawke’s Bay to improve food environments and nutritional wellbeing.

Background Reported experiences of racism in Aotearoa New Zealand are consistently associated with negative measures of health, self-rated health, life satisfaction, and reduced access to high-quality healthcare with subsequent poor health outcomes. In this paper, we report on perceptions and experiences of prejudice and racism by Indigenous Māori with kidney disease and their family members and donors who took part in a wider study about experiences of kidney transplantation. Methods We conducted semi-structured interviews with 40 Māori between September and December 2020. Participants included those with kidney disease who had considered, were being worked up for, or who had already received a kidney transplant as well as family members and potential or previous donors. We examined the data for experiences of racism using a theoretical framework for racism on three levels: institutionalised racism, personally mediated racism, and internalised racism. Results We identified subthemes at each level of racism: institutional (excluded and devalued by health system; disease stigmatization; discriminatory body weight criteria, lack of power), personally mediated (experiencing racial profiling; explicit racism), and internalized racism (shame and unworthiness to receive a transplant). Conclusions The wide-reaching experiences and perceptions of racism described by participants with kidney disease and their families in this research point to an unfair health system and suggest that racism may be contributing to kidney transplantation inequity in Aotearoa New Zealand. Addressing racism at all levels is imperative if we are to address inequitable outcomes for Māori requiring kidney transplantation. Supplementary Information The online version contains supplementary material available at 10.1007/s40615-021-01212-3.

BackgroundReported experiences of racism in Aotearoa New Zealand are consistently associated with negative measures of health, self-rated health, life satisfaction, and reduced access to high quality healthcare with subsequent poor health outcomes. In this paper we report on perceptions and experiences of prejudice and racism by Indigenous Māori with kidney disease, their family members and donors who took part in a wider study about experiences of kidney transplantation.MethodsWe conducted semi-structured interviews with 40 Māori. Participants included those with kidney disease who had considered, were being worked up for, or who had already received a kidney transplant as well as family members and potential or previous donors. We examined the data for experiences of racism using a theoretical framework for racism on three levels: institutionalised racism, personally mediated racism, and internalised racism.ResultsWe identified subthemes at each level of racism: institutional (excluded and devalued by health system; disease stigmatisation; discriminatory body weight criteria, lack of power), personally-mediated (experiencing racial profiling; explicit racism) and internalized racism (shame and unworthiness to receive a transplant).ConclusionsThe wide-reaching experiences and perceptions of racism described by participants with kidney disease and their families in this research point to an unfair health system and suggests that racism may be contributing to kidney transplantation inequity in Aotearoa New Zealand. Addressing racism at all levels is imperative if we are to address inequitable outcomes for Māori requiring kidney transplantation.

Background The prevalence of smoking during pregnancy among indigenous women approaches 50% and is associated with sudden infant death, pregnancy loss, preterm delivery, low birth weight, and anatomical deformity. This study aims to synthesise qualitative studies by reporting experiences, perceptions, and values of smoking cessation among pregnant indigenous women to inform potential interventions. Method A highly-sensitive search of MEDLINE, Embase, PsychINFO, and CINAHL, in conjunction with analysis of Google Scholar and reference lists of related studies was conducted in March 2018. We utilised two methods (thematic synthesis and an indigenous Māori analytical framework) in parallel to analyse data. Completeness of reporting in studies was evaluated using the Consolidated Criteria for Reporting Qualitative Studies (COREQ) framework. Results We included seven studies from Australia and New Zealand involving 250 indigenous women. Three themes were identified. Realising well-being and creating agency included giving the best start to baby, pride in being a healthy mum, female role models, and family support. Understanding the drivers for smoking included the impact of stress and chaos that hindered prioritisation of self-care, the social acceptability of smoking, guilt and feeling judged, and inadequate information about the risks of smoking. Indigenous women strongly preferred culturally responsive approaches to smoking cessation, placing value on programs designed specifically for and by indigenous people, that were accessible, and provided an alternative to smoking. Conclusion Future interventions and smoking cessation programmes might be more effective and acceptable to indigenous women and families when they harness self-agency and the desire for a healthy baby, recognise the high value of indigenous peer involvement, and embed a social focus in place of smoking as a way to maintain community support and relationships. Development and evaluation of smoking cessation programs for pregnant indigenous women and families is warranted.

As part of the COVID-19 economic recovery package, the Aotearoa New Zealand Government rolled out a universal free and healthy lunch programme to the 25% least advantaged schools nationwide. This study explored experiences of school lunch providers in the Hawke’s Bay region. The aim was to create a systems map identifying points of intervention through which the lunch programme could be improved to meet the goal of reducing child food insecurity. Twelve lunch providers were interviewed to generate casual loop diagrams which were examined and integrated to form a single systems map. Seven themes arose during analysis: teacher support, principal support, nutrition guidelines and government support, supply chain, ingredient suppliers, student feedback and food waste. Teacher support was important for getting students to try new foods and eat the nutritious lunches. Principal support was a strong theme impacting opportunities for broader student engagement. This study employed systems science to highlight the importance of support from different stakeholders within the lunch programme to achieve the goal of reduced child food insecurity. Further work is needed to ensure the programme meets the wider goals of the government and community, and to determine the potential broader benefits of the programme.

In Aotearoa/New Zealand, Indigenous Māori experience inequitable delivery of kidney transplantation despite disproportionately higher rates of kidney failure. This study describes Māori patients' and families' values, perspectives, and experiences related to kidney transplantation.Qualitative interview study.We conducted 40 in-depth interviews of 40 Māori: 8 who had received a transplant, 20 with chronic kidney disease (which included 10 on the deceased donor transplant list, 9 who were interested in transplantation and not currently waitlisted or who were ineligible for waitlisting, and 1 who was not interested in transplantation), 4 live-kidney donors, and 8 family members including 6 who had experiences with donor assessment.Data were analyzed inductively to generate themes and a conceptual framework.We identified 5 major themes: actively seeking a kidney transplant; evolving attitudes toward traditional values and practices; being confronted by interpersonal and systemic racism; poor information and communication; and challenged by social determinants of health.Participants were recruited nationally through patient advocacy organizations and 1 regional kidney service. Potential participants unrelated to these groups or region could not be included.Māori participants were highly motivated to seek kidney transplantation and were inspired by positive experiences through donating and receiving a kidney. However, they faced barriers including social determinants, racism, and lack of information that impacted both direct experiences of transplantation and access to transplantation services.

Rationale & Objective: Community house hemodialysis is a submodality of home hemodialysis that enables patients to perform hemodialysis independent of nursing or medical supervision in a shared house. This study describes the perspectives and experiences of patients using community house hemodialysis in New Zealand to explore ways this dialysis modality may support the wider delivery of independent hemodialysis care. Study Design: Qualitative semi-structured in-depth interview study. Setting & Participants: 25 patients who had experienced community house hemodialysis. Participants were asked about why they chose community house hemodialysis and their experiences and perspectives of this. Analytical Approach: Thematic analysis using an inductive approach. Results: 25 patients were interviewed (14 men and 11 women, aged 31-65 years). Most were of Māori or Pacific ethnicity and in part- or full-time employment. More than two-thirds dialyzed for 20 hours a week or more. We identified 4 themes that described patients’ experiences and perspectives of choosing and using community house hemodialysis: reducing burden on family (when home is not an option, minimizing family exposure to dialysis, maintaining privacy and self-identity, reducing the costs of home hemodialysis, and gaining a reprieve from home), offering flexibility and freedom (having a normal life, maintaining employment, and facilitating travel), control of my health (building independence and self-efficacy, a place of wellness, avoiding institutionalization, and creating a culture of extended-hour dialysis), and community support (building social inclusion and supporting peers). Limitations: Non-Māori and non-Pacific patient experiences of community house hemodialysis could not be explored. Conclusions: Community house hemodialysis is a dialysis modality that overcomes many of the socioeconomic barriers to home hemodialysis, is socially and culturally acceptable to Māori and Pacific people, and supports extended-hour hemodialysis and thereby promotes more equitable access to best practice services. It is therefore a significant addition to independent hemodialysis options available for patients. Index Words: End-stage kidney disease, home hemodialysis, patient preference, decision-making, semi-structured interviews

Children’s nutrition is highly influenced by community-level deprivation and socioeconomic inequalities and the health outcomes associated, such as childhood obesity, continue to widen. Systems Thinking using community-based system dynamics (CBSD) approaches can build community capacity, develop new knowledge and increase commitments to health improvement at the community level. We applied the formal structure and resources of a Group Model Building (GMB) approach, embedded within an Indigenous worldview to engage a high deprivation, high Indigenous population regional community in New Zealand to improve children’s nutrition. Three GMB workshops were held and the youth and adult participants created two systems map of the drivers and feedback loops of poor nutrition in the community. Māori Indigenous knowledge (mātauranga) and approaches (tikanga) were prioritized to ensure cultural safety of participants and to encourage identification of interventions that take into account social and cultural environmental factors. While the adult-constructed map focused more on the influence of societal factors such as cost of housing, financial literacy in communities, and social security, the youth-constructed map placed more emphasis on individual-environment factors such as the influence of marketing by the fast-food industry and mental wellbeing. Ten prioritized community-proposed interventions such as increasing cultural connections in schools, are presented with the feasibility and likely impact for change of each intervention rated by community leaders. The combination of community-based system dynamics methods of group model building and a mātauranga Māori worldview is a novel Indigenous systems approach that engages participants and highlights cultural and family issues in the systems maps, acknowledging the ongoing impact of historical colonization in our communities.

Aim The aim of this study was to identify the potential risks and benefits of sleeping infants in a Pēpi-Pod distributed to families with high risk of sudden unexpected death in infancy compared to a bassinet. Methods Forty-five mostly indigenous Māori mothers who were referred by local health providers to receive a Pēpi-Pod were surveyed at recruitment, 1 and 3 months. A sleep study at 1 month included infrared video, oximetry and temperature measures. Results When compared with 89 historical bassinet controls, an intention-to-treat analysis of questionnaires showed no increase in direct bed sharing but demonstrated significantly less sharing of the maternal bedroom at both interviews, with the majority of those not sleeping in the maternal bedroom, actually sleeping in the living room. The 1 month 'as-used' analysis showed poorer maternal sleep quality. The 'as-used' analysis of video data (24 Pēpi-Pod and 113 bassinet infants) also showed no increase in direct bed sharing, head covering or prone/side sleep position. Differences in oxygen saturation were not significant, but heart rate was higher in the Pēpi-Pod infants by 8.37 bpm (95% confidence interval 4.40, 12.14). Time in the thermal comfort zone was not different between groups despite Pēpi-Pod infants being situated in significantly warmer rooms. Conclusions Overall, we found that most differences in infant risk behaviours in a Pēpi-Pod compared to a bassinet were small, with confidence intervals excluding meaningful differences. We noted poorer maternal sleep quality at 1 month. Higher infant heart rates in the Pēpi-Pod group may be related to higher room temperatures. The Pēpi-Pod appears physiologically safe but is associated with lower reported maternal sleep quality.

ObjectiveTo compare overnight oxygen saturation, heart rate and the thermal environment of infants sleeping in an indigenous sleep device (wahakura) or bassinet to identify potential risks and benefits.DesignRandomised controlled trial.SettingFamily homes in low socio-economic areas in New Zealand.Patients200 mainly Māori mothers and their infants.InterventionsParticipants received a wahakura or bassinet from birth.Main outcome measuresOvernight oximetry, heart rate and temperature at 1 month.ResultsIntention-to-treat analysis for 83 bassinet and 84 wahakura infants showed no significant differences between groups for the mean time oxygen saturation (SpO2) was less than 94% (0.54 min, 95% CI -1.36 to 2.45) or less than 90% (0.22 min, 95% CI -0.56 to 1.00), the mean number of SpO2dips per hour >5% (-0.19, 95% CI -3.07 to 2.69) or >10% (-0.41, 95% CI -1.63 to 0.81), mean heart rate (1.99 beats/min, 95% CI -1.02 to 4.99), or time shin temperature >36°C (risk ratio (RR): 0.63, 95% CI 0.13 to 2.99) or ConclusionsThis indigenous sleep device is at least as safe as the currently recommended bassinet, which supports its use as a sleep environment that offers an alternative way of bed-sharing.Trial registration numberAustralian New Zealand Clinical Trials Registry: ACTRN12610000993099.

Background Kidney transplantation is considered best practice treatment for end stage kidney disease (ESKD), however Indigenous patients are substantially less likely to receive either a deceased or live donor kidney transplant than non-Indigenous patients. We describe Indigenous peoples’ experiences and perspectives including traditional values around kidney transplantation to inform international transplant programs. Methods We conducted a systematic review of qualitative studies involving Indigenous adults who have experience with or perceptions of kidney transplantation. We searched MEDLINE, Embase, PsychINFO, and CINAHL, in conjunction with analysis of Google Scholar and reference lists of related studies till July 2019. We utilised thematic synthesis to analyse data. Completeness of reporting in studies was evaluated using the Consolidated Criteria for Reporting Qualitative Studies (COREQ) framework. Results Eight studies involving 225 Indigenous participants were included. Five themes were identified: strong desire for transplantation (seeking normality and freedom from dialysis, wanting to reduce burden of disease within community); lack of partnership in shared decision-making (receiving inadequate information, ineffective communication); barriers to live kidney donation (difficulty asking, apprehension about impact on donor, avoiding additional financial burden and fear of complications); cultural considerations (influence of traditional values and beliefs, reconciling traditional values with pragmatic need); and experiencing lack of cultural competence in clinical care (struggling with prejudice and ignorance, mistrust of clinicians and health system). Conclusion Indigenous participants had a strong desire for a kidney transplant and recognised the need for more readily available kidney transplants for others in their communities with ESKD. However, they faced prejudice and a lack of cultural competence by health workers as well as wider barriers to transplantation in systems that did not support effective and culturally appropriate delivery of information and care. Traditional cultural values also influenced decisions regarding kidney transplantation but such values were moderated when considering transplantation. Transplantation programs need to identify and mitigate barriers, such as the financial burden, promote cultural safety and incorporate traditional values into the promotion of transplantation in order to address inequitable transplantation rates. Registration Not applicable.

IntroductionPre-diabetes is a high-risk state for the development of type 2 diabetes mellitus (T2DM) and cardiovascular disease. Regression to normoglycaemia, even if transient, significantly reduces the risk of developing T2DM. The primary aim of this mixed-methods study is to determine if there are clinically relevant differences among those with pre-diabetes and excess weight who regress to normoglycaemia, those who have persistent pre-diabetes and those who progress to T2DM following participation in a 6-month primary care nurse-delivered pre-diabetes dietary intervention. Incidence of T2DM at 2 years will be examined.Methods and analysisFour hundred participants with pre-diabetes (New Zealand definition glycated haemoglobin 41–49 mmol/mol) and a body mass index >25 kg/m2 will be recruited through eight primary care practices in Hawke’s Bay, New Zealand. Trained primary care nurses will deliver a 6-month structured dietary intervention, followed by quarterly reviews for 18 months post-intervention. Clinical data, data on lifestyle factors and health-related quality of life (HR-QoL) and blood samples will be collected at baseline, 6 months, 12 months and 24 months. Sixty participants purposefully selected will complete a semi-structured interview following the 6-month intervention. Poisson regression with robust standard errors and clustered by practice will be used to identify predictors of regression or progression at 6 months, and risk factors for developing T2DM at 2 years. Qualitative data will be analysed thematically. Changes in HR-QoL will be described and potential cost savings will be estimated from a funder’s perspective at 2 years.Ethics and disseminationThis study was approved by the Northern A Health and Disability Ethics Committee, New Zealand (Ethics Reference: 17/NTA/24). Study results will be presented to participants, published in peer-reviewed journals and presented at relevant conferences.Trial registration numberACTRN12617000591358; Pre-results.

Background Eliminating indigenous and ethnic health inequities requires addressing the determinants of health inequities which includes institutionalised racism, and ensuring a health care system that delivers appropriate and equitable care. There is growing recognition of the importance of cultural competency and cultural safety at both individual health practitioner and organisational levels to achieve equitable health care. Some jurisdictions have included cultural competency in health professional licensing legislation, health professional accreditation standards, and pre-service and in-service training programmes. However, there are mixed definitions and understandings of cultural competency and cultural safety, and how best to achieve them. Methods A literature review of 59 international articles on the definitions of cultural competency and cultural safety was undertaken. Findings were contextualised to the cultural competency legislation, statements and initiatives present within Aotearoa New Zealand, a national Symposium on Cultural Competence and Māori Health, convened by the Medical Council of New Zealand and Te Ohu Rata o Aotearoa – Māori Medical Practitioners Association (Te ORA) and consultation with Māori medical practitioners via Te ORA. Results Health practitioners, healthcare organisations and health systems need to be engaged in working towards cultural safety and critical consciousness. To do this, they must be prepared to critique the ‘taken for granted’ power structures and be prepared to challenge their own culture and cultural systems rather than prioritise becoming ‘competent’ in the cultures of others. The objective of cultural safety activities also needs to be clearly linked to achieving health equity. Healthcare organisations and authorities need to be held accountable for providing culturally safe care, as defined by patients and their communities, and as measured through progress towards achieving health equity. Conclusions A move to cultural safety rather than cultural competency is recommended. We propose a definition for cultural safety that we believe to be more fit for purpose in achieving health equity, and clarify the essential principles and practical steps to operationalise this approach in healthcare organisations and workforce development. The unintended consequences of a narrow or limited understanding of cultural competency are discussed, along with recommendations for how a broader conceptualisation of these terms is important.

The bassinet-like wahakura is an Indigenous initiative for the prevention of Sudden Unexpected Death in Infancy (SUDI). It was developed by New Zealand Māori in 2005 when Māori were rejecting the ‘stop bedsharing’ SUDI prevention message and the SUDI disparity between Māori and non-Māori had become entrenched. Made of native flax, the wahakura was promoted as a culturally resonant, in-bed safe sleep device that would disrupt the SUDI risk associated with ‘bedsharing where there was smoking in pregnancy’ without relying on smoking cessation. A significant movement of weavers and health professionals grew around the wahakura program. A body of research, including infant care surveys, retrospective case review, qualitative enquiry and a randomised controlled trial comparing wahakura and bassinet safety demonstrated the device’s public health plausibility, acceptability to Māori women and its essential safety. This facilitated the distribution, by District Health Boards, of safe sleep devices, including a related device called the Pēpi-Pod, and safe sleep education to high-risk, mainly Māori, mothers. Infant mortality in New Zealand fell by 29%, primarily among Māori infants, over the period 2009–15, suggesting that Māori cultural concepts, traditional activities and community engagement can have a significant effect on ethnic inequities in infant mortality.

AIM: Post-neonatal mortality rates changed very little from 2000 until recently. There has been a decrease in mortality in New Zealand from 2009 to 2015. This paper describes an infant Safe Sleep programme and postulates it is the cause for the recent decrease in deaths. METHODS: The Safe Sleep programme involved: a focus on preventing accidental suffocation, a blitz approach to SUDI education, the targeted provision of portable infant safe sleep devices (ISSD) and the development of safe sleep policy across all district health boards (DHBs). RESULTS: Participation in the 'blitz approach' education by health professionals exceeded 1 in 23 live births, distribution of Safe Sleep leaflets exceeded 2 for every live birth, and over 16,500 ISSDs have been distributed to vulnerable infants. Post-perinatal mortality fell 29% from 2009 to 2015 (2.8 to 2.0/1000 live births). The fall has been greatest for Māori and in regions with the most intensive programmes. CONCLUSION: The recent fall in post-perinatal mortality has not happened by chance. It is likely that the components of end-stage prevention strategy, a focus on preventing accidental suffocation, the education blitz, the targeted supply of ISSDs, and strengthened health policy, have all contributed to varying degrees. This article is protected by copyright. All rights reserved.This article is protected by copyright. All rights reserved. Language: en

Background Although breastfeeding duration in New Zealand’s indigenous Māori is shorter than in non-Māori, we know little about barriers or motivators of breastfeeding in this community. The aim of this analysis was to identify predictors for extended duration of breastfeeding amongst participants drawn from predominantly Māori communities in regional Hawke’s Bay. Methods Mother/baby dyads were recruited from two midwifery practices serving predominantly Māori women in mostly deprived areas, for a randomised controlled trial comparing the risks and benefits of an indigenous sleeping device (wahakura) and a bassinet. Questionnaires were administered at baseline (pregnancy) and at one, three and six months postnatal. Several questions relating to breastfeeding and factors associated with breastfeeding were included. The data from both groups were pooled to examine predictors of breastfeeding duration. Results Māori comprised 70.5% of the 197 participants recruited. The median time infants were fully breastfed was eight weeks and Māori women were more likely to breastfeed for a shorter duration than New Zealand European women with an odds-ratio (OR) of 0.45 (95% CI 0.24, 0.85). The key predictors for extended duration of breastfeeding were the strong support of the mother’s partner (OR = 3.64, 95% CI 1.76, 7.55) or her mother for breastfeeding (OR = 2.47, 95% CI 1.27, 4.82), longer intended duration of maternal breastfeeding (OR = 1.02, 95% CI 1.00, 1.03) and being an older mother (OR = 1.07, 95% CI 1.02, 1.12). The key predictors for shorter duration of breastfeeding were pacifier use (OR = 0.28, 95% CI 0.17, 0.46), daily cigarette smoking (OR = 0.51, 95% CI 0.37, 0.69), alcohol use (OR = 0.54, 95% CI 0.31, 0.93) and living in a more deprived area (OR 0.40, 95% CI 0.22, 0.72). Conclusions Breastfeeding duration in this group of mainly Māori women was shorter than the national average. Increasing the duration of breastfeeding by these mothers could be further facilitated by ante and postnatal education involving their own mothers and their partners in the support of breastfeeding and by addressing pacifier use, smoking and alcohol use.

Māori demand on New Zealand mental health services is out of proportion to the size of the Māori population, and the psychiatric service response is limited by lack of capacity. But there is also an inherent lack of capability, that is, the ability of a Western paradigm psychiatric service to meet the needs of an indigenous community. The Mahi a Atua narratives-based programme established in the primary mental healthcare services of the Tairāwhiti/Gisborne area has created a new approach to psychiatric assessment, diagnosis and therapy that is appropriate, but not confined, to the Māori community.

The aim of this study was to identify the potential risks and benefits of sleeping infants in a Pēpi-Pod distributed to families with high risk of sudden unexpected death in infancy compared to a bassinet.Forty-five mostly indigenous Māori mothers who were referred by local health providers to receive a Pēpi-Pod were surveyed at recruitment, 1 and 3 months. A sleep study at 1 month included infrared video, oximetry and temperature measures.When compared with 89 historical bassinet controls, an intention-to-treat analysis of questionnaires showed no increase in direct bed sharing but demonstrated significantly less sharing of the maternal bedroom at both interviews, with the majority of those not sleeping in the maternal bedroom, actually sleeping in the living room. The 1 month 'as-used' analysis showed poorer maternal sleep quality. The 'as-used' analysis of video data (24 Pēpi-Pod and 113 bassinet infants) also showed no increase in direct bed sharing, head covering or prone/side sleep position. Differences in oxygen saturation were not significant, but heart rate was higher in the Pēpi-Pod infants by 8.37 bpm (95% confidence interval 4.40, 12.14). Time in the thermal comfort zone was not different between groups despite Pēpi-Pod infants being situated in significantly warmer rooms.Overall, we found that most differences in infant risk behaviours in a Pēpi-Pod compared to a bassinet were small, with confidence intervals excluding meaningful differences. We noted poorer maternal sleep quality at 1 month. Higher infant heart rates in the Pēpi-Pod group may be related to higher room temperatures. The Pēpi-Pod appears physiologically safe but is associated with lower reported maternal sleep quality.

OBJECTIVES: To compare an indigenous sleep device (wahakura) for infants at high risk for sudden unexpected death with a bassinet, for measures of infant sleep position, head covering, breastfeeding, bed-sharing, and maternal sleep and fatigue. METHODS: A total of 200 mainly Māori pregnant women were recruited from deprived areas of New Zealand. They were randomized to receive a bassinet or wahakura and asked to sleep the infant in this device from birth. Questionnaires at 1, 3, and 6 months and an overnight infrared video in the home at 1 month were completed. RESULTS: An intention-to-treat and an “as-used” analysis of questionnaires showed no group differences at 1, 3, and 6 months in infant-adult direct bed-sharing (7% vs 12%, P = .24 at 1 month), and at the 6-month interview, the wahakura group reported twice the level of full breastfeeding (22.5% vs 10.7%, P = .04). Maternal sleep and fatigue were not significantly different between groups. Video identified no increase in head covering, prone/side sleep position, or bed-sharing in the wahakura group, either from intention-to-treat analysis, or when analyzed for actual sleep location. CONCLUSION There were no significant differences in infant risk behaviors in wahakura compared with bassinets and there were other advantages, including an increase in sustained breastfeeding. This suggests wahakura are relatively safe and can be promoted as an alternative to infant-adult bed-sharing. Policies that encourage utilization are likely to be helpful in high-risk populations.

Aim: To review autopsy reports of all SUDI deaths in the Auckland region, New Zealand, from October 2000 to December 2009. Methods: Information on all SUDI cases from 2000 to 2009 was extracted from autopsy and police reports from the National Forensic Pathology Service at Auckland Hospital. Results: Of the 332 post-mortems in this period, 221 were classified as SUDI. Of these, 83% were Māori or Pacific infants. The median age at death was 11 weeks and 11% occurred in 7- to 28-day-olds. At the time of death, 64% overall were bedsharing; this was more common in 7–28 day olds (92%). Bedsharing infants were significantly younger at death than non-bedsharing infants (p = 0.008). Where sleep position was known, 57% were placed in non-supine at the last sleep. There was no evidence of diagnostic shift and the prevalence of bedsharing did not change over the decade. Conclusions: Bedsharing was associated with a high proportion of SUDI cases, especially in the youngest infants, and non-supine sleep positions were common. There is a need to enhance SUDI prevention messages and consider innovative ways of promoting safe sleeping environment and supine sleep position in Māori and Pacific communities.

Background: The suggestion that body mass index (BMI) cutoffs to define obesity should differ in persons of Polynesian descent compared with Europeans is based principally on the observation that persons of Polynesian descent have a relatively higher propor- tion of lean body mass for a given BMI. Objectives: The objectives were to determine whether the relation between BMI, waist circumference, and metabolic comorbidity dif- fers in the 2 major ethnic groups in New Zealand and to ascertain whether ethnicity-specific BMI and waist circumference cutoffs for obesity are justified for Maori (indigenous New Zealanders). Design: Subjects included a convenience sample of 1539 men and women aged 17-82 y (47% Maori, 53% white) with measures of BMI, waist circumference, blood pressure, fasting insulin, glucose, and lipids. The sensitivity and specificity of BMI (in kg/m 2 ; 30 and 32), waist circumference (80 and 88 cm in women, 94 and 102 cm in men), and waist-to-height ratio (WHtR 0.6) in relation to in- sulin sensitivity, insulin resistance, and the metabolic syndrome were determined. Receiver operating characteristic curves and areas under the curve (AUCs) were also calculated. Results: No ethnic or sex differences in AUCs were observed for BMI, waist circumference, or WHtR, which showed that these an- thropometric measures perform similarly in Maori and European men and women and correctly discriminate between those with and without insulin resistance or the metabolic syndrome 79-87% of the time. Any increase in specificity from a higher BMI cutoff of 32 in Maori was offset by appreciable reductions in sensitivity. Conclusion: These findings argue against having different BMI or waist circumference cutoffs for people of Polynesian descent. Am J Clin Nutr doi: 10.3945/ajcn.2010.29317.

Maori babies in Aotearoa/New Zealand die of Sudden Infant Death Syndrome (SIDS) at over five times the rate of their non-Maori peers. Research and health promotion around modifiable risk factors has produced only a small improvement in this situation since the mid-1990s. This paper reports on life story interviews, conducted between 2002 and 2004, with nineteen mothers of Maori infants who have died of SIDS. Potential participants were identified and accessed with the support of the national Maori SIDS Prevention Programme care-workers, in both urban and rural locations throughout both main islands of New Zealand. The paper articulates, in a thematic fashion, the bereaved mothers' experiences of alienation, marginalisation and exclusion, as a testimony of lives lived under conditions of serious deprivation in an affluent society. Constructing these experiences as non-modifiable risk factors hinders the development of policy and health promotion interventions that could improve the conditions in which Maori mothers live and raise their babies. It is argued that new approaches that target those whose lives are described here and build on the WHO Social Determinants of Health framework are vital to the efforts of New Zealanders to attain health equity and stem the tide of devastating and preventable loss of Maori babies to SIDS.

The loss of a baby is always hard to cope with and the grieving process is likely to be difficult. Interventions to work with Sudden Infant Death Syndrome (SIDS) families have improved grieving outcomes for many but the needs of Maori fathers are not well understood or catered to by existing services. This article presents narrative data from Maori fathers who have lost a baby to SIDS and analyzes these narratives in the context of the literature and of traditional Maori constructs about grief. The authors document a rarely discussed Maori concept, "the attainment of mauri tau," as the desired outcome of the grieving process; and begin a discussion around the changing face of the Maori grieving process and its implications for the grieving practices of Maori men.

The wahakura (flax bassinet) is presently being distributed as a safe infant sleeping device amongst New Zealand Māori, where sudden unexpected deaths in infancy (SUDI) rates are high. It is promoted as mitigating bedsharing risk by providing a separate infant sleeping surface. This study aimed to understand exactly what factors determine the apparent acceptability of the wahakura as an infant sleeping device to Māori mothers and other key Māori community stakeholders.The qualitative study used face-to-face, semi-structured interviews, following Māori cultural protocols, to explore the experiences and views of 12 Māori mothers and 10 key informants who had wahakura experience. We employed purposeful sampling of participants and thematic analysis of data.The practical appeal of the wahakura related to its portability, the enabling of bedsharing and easier breastfeeding. Considerable cultural and spiritual appeal was related to its native flax composition and traditional origin. Health professionals found it useful to engage Māori women antenatally.The study affirmed the acceptance of the wahakura as a culturally initiated endeavour, meaningfully engaging Māori mothers and families in SUDI risk mitigation. It has the potential to capitalise on the benefits of bedsharing to enhance infant wellbeing while also safeguarding them from harm.

We sought to identify lifestyle behaviours which influence risk of impaired glucose metabolism, IGM (newly diagnosed type 2 diabetes, impaired glucose tolerance [IGT] or impaired fasting glycemia [IFG]) or insulin resistance (IR) in a predominantly Maori community, and applied the McAuley formula to determine whether it predicts high risk individuals amongst this community. Three hundred and seventy one participants completed a lifestyle and dietary behaviour questionnaire and oral glucose tolerance test. Clinical variables, microalbuminuria, fasting glucose, insulin and lipids were measured. Diabetes, IFG and IGT were defined according to WHO criteria. IR was defined using the McAuley formula. Those with IGM and those with IR showed similar risk factor attributes. Odds ratios (95% CI) for development of IGM and IR were 0.43 (0.21-0.88) and 0.51 (0.33-0.80), respectively, for regular physical activity, and 0.55 (0.26-1.15) and 0.59 (0.37-0.96), respectively, for two or more dietary behaviours characterized by a high intake of fibre. Regular physical activity and a diet characterized by a high intake of dietary fibre were found to reduce risk of newly diagnosed IGM or IR. The McAuley formula appears to predict high-risk individuals in a predominantly Maori population as it does in European populations.

Background Sudden Unexpected Death in Infancy (SUDI) has persistent high rates in deprived indigenous communities and much of this mortality is attributable to unsafe sleep environments. Whilst health promotion worldwide has concentrated on avoidance of bedsharing, the indigenous Māori community in New Zealand has reproduced a traditional flax bassinet (wahakura) designed to be used in ways that include bedsharing. To date there has been no assessment of the safety of this traditional sleeping device. Methods/Design This two arm randomised controlled trial is being conducted with 200 mother-baby dyads recruited from Māori communities in areas of high deprivation in the Hawkes Bay, New Zealand. They are randomised to wahakura or bassinet use and investigation includes questionnaires at baseline (pregnancy), when baby is 1, 3, and 6 months, and an overnight video sleep study at 1 month with monitoring of baby temperature and oxygen saturation, and measurement of baby urinary cotinine and maternal salivary oxytocin. Outcome measures are amount of time head covered, amount of time in thermal comfort zone, number of hypoxic events, amount of time in the assigned sleep device, amount of time breastfeeding, number of parental (non-feed related) touching infant events, amount of time in the prone sleep position, the number of behavioural arousals and the amount of time infant is awake overnight. Survey data will compare breastfeeding patterns at 1, 3, and 6 months as well as data on maternal mind-mindedness, maternal wellbeing, attachment to baby, and maternal sleep patterns. Discussion Indigenous communities require creative SUDI interventions that fit within their prevailing world view. This trial, and its assessment of the safety of a wahakura relative to a standard bassinet, is an important contribution to the range of SUDI prevention research being undertaken worldwide. Trials registration Australian New Zealand Clinical Trials Registry: ACTRN12610000993099 Registered 16th November 2010

Maori have high SIDS rates and relevant information is needed to craft appropriate prevention strategies. The aim of the study was to determine what Maori mothers know about SIDS prevention, and to determine their SIDS-related child care practices.Maori mothers who gave birth in the Counties Manukau District Health Board area were surveyed about their SIDS related knowledge, and infant care practices and their reasons for using and their concerns about these practices. Results were compared with a similar 2005 survey of a largely European sample.Knowledge of Maori mothers about SIDS prevention was much lower than for European mothers. More Maori infants slept prone and Maori mothers stopped breastfeeding significantly earlier. Although co-sleeping rates were similar, bedsharing increased to 65% for some part of the night. In addition, more than half of the Maori mothers had smoked in pregnancy and 21% of them were sharing a bed with their infant. Potentially unsafe soft objects such as rolled blankets or pillows were used by a third of mothers to help maintain the sleep position.Maori mothers have a poorer knowledge of SIDS prevention practices. The high rate of maternal smoking, the early cessation of breastfeeding, and co-sleeping where there was smoking in pregnancy were also areas of concern. Appropriate health promotion measures need to be developed for the high-risk Maori community.

To determine the prevalence of insulin resistance, impaired fasting glycaemia, impaired glucose tolerance, and diabetes mellitus in a rural Maori community, and to compare different methods for identifying individuals with insulin resistance.589 randomly selected individuals from the Ngati Porou Hauora Register aged 25 years and over and resident on New Zealand's East Coast north of Gisborne were invited to participate in the study. A questionnaire was administered, anthropometric measures made, and blood samples taken for an oral glucose tolerance test and biochemical analysis. Impaired fasting glycaemia, impaired glucose tolerance, and diabetes mellitus were defined according to World Health Organization (WHO) diagnostic criteria, and among those persons with normal glucose tolerance, insulin resistance was calculated according to the McAuley formula and three other recognised methods for calculating insulin sensitivity.The overall age-standardised prevalence of diabetes (both known and newly diagnosed) was 10.6% and the age-standardised prevalence of insulin resistance was 37.0%. Age-specific diabetes rates were high among the older age groups, peaking at 34.1% for 60-69 year olds, whereas age-specific insulin resistance rates were high among the young age groups with the highest rate (44.3%) occurring among 30-39 year olds. Persons identifying as insulin-resistant reported higher rates of gout and family history of diabetes--and were found to have a higher waist circumference, blood pressure, and lower high-density lipoprotein (HDL) cholesterol than those without a glucose metabolism disorder.Diabetes is a common disorder among this population, but insulin resistance is even more prevalent, especially among young age groups. This is considerable cause for concern given that insulin resistance is believed to be the underlying cause of most cases of type 2 diabetes mellitus, and is confirmed by these data to be associated with a high degree of cardiovascular risk.

This paper describes and compares the infant care practices and beliefs of Maori, Tongan, Samoan, Cook Islands, Niuean and Pakeha (European) caregivers residing in Auckland, New Zealand. Focusing on four areas--sources of support and advice; infant feeding; infant sleeping arrangements; and traditional practices and beliefs--it explores inter-ethnic similarities and differences and intra-ethnic tensions. The international literature indicates that there can be significant cultural variation in infant care practices and in the meanings attributed to them. There is, however, little New Zealand literature on this topic, despite its importance for effective health service and health message delivery. Participants were primary caregivers of infants under 12 months. An average of six focus groups were conducted within each ethnic group, resulting in a total of 37 groups comprising 150 participants. We found similarities across all ethnic groups in the perceived importance of breastfeeding and the difficulties experienced in establishing and maintaining this practice. The spectrum of behaviours ranged widely with differences most pronounced between Pacific caregivers, especially those Island-raised, and Pakeha caregivers, especially those in nuclear families. Amongst the former, norms included: the family as central in providing support and advice; infant bedsharing; abdominal rubbing during pregnancy; baby massage; and the importance of adhering to traditional protocols to ensure infant well-being. Amongst the latter, norms included: strong reliance on professional advice; looser family support networks; the infant sleeping in a cot; and adherence to Western biomedical understandings of health and illness. Maori caregivers bridged the spectrum created by these groups and exhibited a diverse range of practices. Intra-cultural differences were present in all groups indicating the dynamic nature of cultural practices. They were most evident between Pacific-raised and New Zealand-raised Pacific caregivers, with the latter attempting to marry traditional with Western beliefs and practices.

EDITOR,—Charles Essex implies that the cot death rate has failed to fall in the Maori community because “advice not to share the bed has alienated leaders of some ethnic groups, who claim that it goes against traditional infant care practices.”1 Essex seems to be placing the blame directly on to the Maori community and absolving the public health system for its failure to deal with cot death among Maori. The higher cot death rate in Maori than non-Maori since the …