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| Journal of the New Zealand Medical Association,
09-July-2004, Vol 117 No 1197
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A call to action on Maori cardiovascular health
Dale Bramley, Tania Riddell, Sue Crengle, Elana Curtis,
Matire Harwood, Deidre Nehua, Papaarangi Reid
IntroductionMaori have the poorest
cardiovascular health outcomes in Aotearoa (New
Zealand).1–5 Although disparities in
these health outcomes have been documented for many years, progress toward
reducing them has been alarmingly slow.1
Disparities in health are seen as being unjust and
inequitable, avoidable, and potentially detrimental to all members of society.
Furthermore, efforts to reduce disparities may be cost
effective.6
Full recognition of Maori rights as tangata whenua, as
reflected in the Treaty of Waitangi, is an important driver towards the goal of
Maori having at least the same standard of health as non-Maori. Disparities also
reflect the fact that Maori health status has not been afforded the
‘protection’ the crown intends under the Treaty of Waitangi, using
the government’s health framework of the guiding principles of the
Treaty.7
In 2001, the Ministry of Health in association with the New
Zealand Guidelines Group convened a National Cardiovascular Advisory Committee.
The aim of this group was to:
‘advise on the development of an integrated
managed approach to cardiovascular disease, from primary prevention through to
tertiary treatment in Aotearoa, New Zealand. The work of the committee was to
draw upon the best available evidence and was to be conducted in accordance with
the principles of the Treaty of Waitangi’.
A key task of this group was to facilitate the production of
a Maori cardiovascular action plan. To produce this plan, a separate Maori
cardiovascular group was formed.
The aims of this paper are to:
Although many of the determinants of
health lie outside of the realm of the health sector, the sector has a key role
in ensuring that access to procedures is equitable and that healthcare
responsiveness is based on demonstrable
need.8
An overview of Maori cardiovascular health statusMortality rates for cardiovascular
disease in Aotearoa have been declining. However the decline in Maori
cardiovascular mortality has occurred more slowly. This has led to an increase
in disparities.1 For the period 1996–1999
the Maori male cardiovascular mortality was 3.0 times higher than that for
non-Maori, non-Pacific males—and the Maori female mortality rates was 4.2
times higher than that for non-Maori, non-Pacific
females.1
In 2002, 30-day age standardised case fatality rates
following acute coronary syndrome were 158 per 1,000 patients for Maori compared
to 112 per 1,000 patients for
Europeans/Others.9
Maori also have the highest prevalence of many
cardiovascular risk factors. The AC Neilsen Tobacco Survey (2002), found that
44% of Maori males (aged 15+ years) compared to 24% of European males and 51% of
Maori females compared to 24% of European females were
smokers.10 Smoking is the leading modifiable
risk factor causing disease.11
Provisional release data from the 2002/2003 New Zealand
Health Survey (which included over 3,900 Maori) has provided a wealth of
information regarding the prevalence of cardiovascular risk factors in Maori and
non-Maori.12 From this survey, the prevalence
of self reported diabetes in adults over 45 years was 21.4% in Maori males and
13% in Maori females—compared to 8.6% in non-Maori males and 7.5% in
non-Maori females.12
The prevalence of self-reported high blood pressure was
23.2% in Maori males and 22.1% in Maori females—compared to 17.5% and
18.7% respectively in European New
Zealanders.12 Furthermore, the prevalence of
obesity (measured by the interviewer and defined as a BMI ≥30
kg/m2 in non-Maori and ≥32
kg/m2 in Maori) was 31.5% in Maori males
compared to 16.5% in European males, and 26.7% in Maori females compared to
19.1% in European females.12
Given this context of high need, it would be expected that
cardiovascular intervention rates would be substantially higher for Maori.
However, the converse is true. Interventions for coronary artery bypass grafting
(CABG) and percutaneous transluminal coronary angioplasty (PTCA) have been
consistently lower for Maori over many years.
Tukuitonga and Bindman reported that over the period
1990–1999, Maori men had a mean age standardised CABG and PTCA
intervention rate ratio of 0.40 and 0.29 respectively when compared to European
men.13 Although these intervention rates have
been increasing in recent years, they are still far below that which would be
expected given the higher prevalence of risk factors and the higher incidence of
disease in Maori.
Similarly (though data is sparse and is derived from
administrative data-sets) it would appear that Maori have lower utilisation of
diabetes screening. Only 35% of Maori people estimated to have diagnosed
diabetes had a free check in 2002 compared to 51% of all people estimated to
have diagnosed diabetes.14 Compared with
Europeans, Maori diabetic patients were also less likely to be on
cholesterol-lowering medications and ACE inhibitors, and were less likely to
have good glycaemic control (HBA1c
<8%).14
The Maori cardiovascular action planThe overall aim of the Maori
Cardiovascular Action Plan is to improve Maori cardiovascular health and to
remove inequalities in cardiovascular disease outcomes between Maori and
non-Maori. The action plan has six categories. These categories reflect the need
for a multi-level, multi-sector approach to improving cardiovascular outcomes.
The categories for action include the following areas: policy development,
improved information systems, needs assessment, quality standards, Maori
workforce development and a proposed research agenda.
The Treaty of Waitangi and policy developmentThe explicit recognition of the
Treaty of Waitangi is central to the Maori Cardiovascular Action Plan. Indeed,
the Treaty of Waitangi and Whakatataka (the Government’s Maori health
action plan 2002–2005) are to be included in all policy development. The
Maori Cardiovascular Group endorses Jackson’s (2001) comment that the very
reason Maori have high need is because Maori rights under the Treaty of Waitangi
have not been respected.15
Flowing from the recognition of the Treaty of Waitangi is
the need to prioritise Maori health gain in all health policy directives.
Therefore, consultation, engagement, leadership, and representation of Maori in
all areas of policy development and implementation are needed.
It is worth noting here that the Waitangi Tribunal has
recently confirmed that the Treaty of Waitangi assures to Maori:
Information systemsTo monitor disparities and health
status, complete and consistent collection of ethnicity data resulting from
health services encounters is essential. To facilitate this, there is a need to
implement a standardised ethnicity question across the health sector.
Specifically, to ensure consistency between numerators and
denominators within health data-sets, the 2001 census question should be used.
The way in which ethnicity data is coded and stored should also be standardised.
Furthermore, resources and educational material for the training of key health
personnel in the area of ethnicity data collection are also needed. The Maori
Cardiovascular Group endorses the use of regular audits to monitor the accuracy
and completeness of the ethnicity data collected by health providers.
Regarding health provider funding, the amount and level of
health expenditure on Maori cardiovascular health should be monitored. In
particular, expenditure should be consistent with Maori cardiovascular need and
efforts to reduce disparities. In the short term, this will require an
additional investment in Maori cardiovascular health until disparities are
eliminated.
Needs assessmentCardiovascular health needs
assessments for Maori are required in order to identify the level of met and
unmet need in the community. Access barriers to preventive, primary, secondary,
and tertiary services should be identified in partnership with Maori
stakeholders. Creation and implementation of strategies to address identified
barriers will then be required. Access to preventive services including the
promotion of ‘healthy environments’ should be emphasised in order to
reduce the incidence of cardiovascular disease.
A long-term goal of the Action Plan is the need for accurate
Maori cardiovascular disease prevalence and incidence data. Quality indicators
should be developed that measure Maori access to cardiovascular interventions,
and treatments should be based on prevalence and incidence of disease, rather
than calculating access to cardiovascular interventions based only on ethnicity
demographics.
Quality standardsTo improve Maori cardiovascular
health, it is essential that Maori gain access to (and utilise) evidence-based
treatments that have been shown to reduce morbidity and mortality. To achieve
this, quality indicators appropriate for medical care are currently being
developed by the Ministry of Health to monitor cardiovascular health in New
Zealand. Such an approach is consistent with the worldwide trend of an increased
emphasis on the measurement of the quality and outcomes of medical
care.17 The Maori Cardiovascular Advisory Group
has strongly recommended that Maori specific performance indicators in
cardiovascular health be measured. The group has produced a number of indicators
of particular interest for ongoing monitoring of Maori cardiovascular health
gain. These include indicators for cardiovascular disease prevention and care at
primary, secondary and tertiary levels.
Workforce developmentThere is a critical shortage of
Maori involved in cardiovascular healthcare. To adequately document this
shortage, a benchmark audit of the number of Maori working in the field is
needed. After this has been completed, targets should be set for the ongoing
recruitment and training of Maori in the field. Priority areas for Maori
recruitment and training include cardiology specialists, cardiology registrars,
coronary care level III and IV nurses, cardiac rehabilitation nurses, health
researchers, and public health workers (including health promotion staff).
The workforce of Maori specific providers that specialise in
cardiovascular care should also be expanded and their skill mix upgraded.
Specific recommendations regarding Te Hotu Manawa Maori have also been included
in our action plan, as this organisation is the largest Maori specific
cardiovascular health provider in the country.
Regarding non-Maori workforce development, the Group
advocates for health organisations to have service-wide recognition of the
Treaty of Waitangi. Specifically, training courses and educational resources
should be available to all staff—with staff actively encouraged to
participate. For large cardiovascular health organisations, Treaty of Waitangi
audits should be undertaken to measure their responsiveness to Maori.
Innovative ways of delivering care to Maori are needed in
the long term. This may necessitate models of health promotion and care that are
based in the community, and deliver services directly to Maori.
Research agendaKaupapa Maori research is needed.
When research is undertaken from this perspective, Maori cardiovascular health
concerns and needs become self-determined, as well as the research response
needed to address them. Kaupapa Maori research also advocates for the use of
Maori: non-Maori comparisons and produces results that have ‘equal’
meaning and relevance to Maori as non-Maori. The Maori Cardiovascular Advisory
Group supports research that prioritises Maori concerns and that use a Maori
defined analytical framework to address them.
Research findings are currently lacking regarding the
current status of Maori cardiovascular health (including accurate prevalence and
incidence data). Research should be undertaken, both qualitative and
quantitative, regarding access to care (including access barriers), equity of
process along pathways of care, and equity of health outcomes for Maori.
New electronic decision support tools for cardiovascular
health such as PREDICT are currently being developed. They offer the promise of
a better understanding of the relationship between the Maori population’s
cardiovascular risk factors, and mortality and morbidity (in essence a
Framingham-type risk assessment specific to Maori). It is important that these
new tools are used to improve Maori health, and imperative that Maori
researchers are actively involved in their development and
utilisation.
The group also endorses the need to investigate and evaluate
alternative models of service delivery for cardiovascular prevention and care.
To date, the current organisation and delivery of the health system has been
ineffective in reducing disparities. New and innovative methods of delivery (for
example, care delivered in community based settings relevant to Maori) should be
explored and evaluated.
Any discourse on disparities would not be complete without
commenting on the wider determinants of health, in particular, socioeconomic
determinants. Although, discussion of these factors is beyond the scope of our
Action Plan, the Group is aware that the elimination of disparities will require
action on numerous ‘fronts’—including (although not limited
to) employment, education, housing, and welfare. Utilisation of methodological
frameworks that present a broader view of wellbeing (such as Te Pae Mahutonga
and the Ottawa Charter) may assist the development of policy that is more
holistic and better reflects Maori
realities.18
Moving forwardThe next step of the Maori
Cardiovascular Action Plan is the assessment of the above recommendations
(including financial implications) by policy makers. If no specific action is
taken to address the issues identified in this Plan, it is likely that the
current disparities that exist in cardiovascular health for Maori will
continue.
ConclusionDisparities in cardiovascular health
outcomes in Aotearoa continue to negatively impact upon Maori. Little progress
has been made in reducing the size of these disparities. A Maori-specific
Cardiovascular Health Action Plan has been developed that we hope will improve
the responsiveness of the health sector to Maori. This plan is consistent with
the full recognition of Maori rights as tangata whenua—as reflected in the
Treaty of Waitangi. A multi-level, multi-sector approach is needed to address
these disparities. The Maori Cardiovascular Advisory Group hope that this Plan
will go some way in providing the guidance that is needed to address the role
that the health sector can make in reducing these disparities.
Author
information:
Dale Bramley,
Visiting Harkness Fellow and Public Health Physician, Department of Health
Policy, Mt Sinai School of Medicine, New York, USA; Tania Riddell, Public Health
Physician; Sue Crengle, Head of Discipline Maori Health, Department of Maori and
Pacific Health, University of Auckland, Auckland; Elana Curtis, Public
Health Physician, National Screening Unit, Ministry of Health, Wellington;
Matire Harwood, Clinical Research Fellow, MRINZ, Wellington and General
Practitioner Whai Oranga O Te Iwi, Wainuiomata;
Deidre Nehua, CEO, Te
Hotu Manawa Maori (a Maori health promotion organisation), Auckland; Papaarangi
Reid, Public Health Physician, Department of Public Health/Te Ropu Rangahau
Hauora a Eru Pomare, Wellington School of Medicine, University of Otago,
Wellington.
Correspondence: Dr
Dale Bramley, Department of
Health Policy,
Mt Sinai School of Medicine, One Gustave Levy Plaza, Box 1077, New York, USA.
Fax: 212-423-2998; email: dale.bramley@mountsinai.org
References:
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