Type 2 diabetes is a major long-term condition in New Zealand. Importantly, for every type 2 diabetes indicator, there are significant ethnic inequities with Māori, the indigenous people of New Zealand, and Pacific and Indian peoples, most affected.1 Type 2 diabetes incidence, hospitalisation and mortality rates are increasing in New Zealand,2 as are ethnic disparities.1 Of note, Māori, Pacific peoples and people living in areas of high deprivation are at increased risk for poorly controlled type 2 diabetes (defined here as HbA1c >65), have higher hospital admission rates with diabetes complications and have more severe diabetes-related illnesses.1,3
Achieving equity in Type 2 diabetes outcomes requires a comprehensive and determined approach to ensure we “measure it, understand its risk factors, develop valid and efficient approaches to screening and diagnosis, and develop and implement culturally specific interventions for prevention and treatment”.2 Primary healthcare is key but to date much of the focus for primary care funders, planners and providers has been on doctor and nurse-led prevention, screening and diagnosis, education and starting medical management including initiation of insulin.4 Importantly, there are few proven effective interventions in the community for managing poorly controlled type 2 diabetes.5 Most research to date has focused on tailoring the medical management model6 with mixed results for Māori and Pacific peoples.1,2
Development of an evidence-based kaupapa Māori programme for diabetes in primary care—Mana Tū
In 2010 the National Hauora Coalition (NHC), a Māori-led Primary Health Organisation (PHO) based in Auckland, convened an expert advisory group including consumers to develop an evidence-based kaupapa Māori programme for people and their whānau living with complex LTCs—the Oranga ki Tua (OKT) Advisory Roopu. Members included primary and secondary clinicians, rehabilitation and kaupapa Māori researchers and providers, health literacy experts and people living with long-term conditions including diabetes. Their remit was to design a primary care programme to support Māori and their whānau to ‘live well’ with a long-term condition.
Given the burden, and what appeared to be inertia in service development, a kaupapa Māori programme for type 2 diabetes—Mana Tū—was prioritised by the group. Mana Tū, meaning ‘to stand with authority’, is a mana-enhancing programme that supports people with poorly controlled type 2 diabetes to ‘take charge’ of it and its associated conditions. The OKT group designed a programme that aligned with recommendations in the Equity of Health Care for Māori: A Framework.7 Based upon literature in the field of quality improvement and research on improving access to health services for Māori, indigenous peoples and minority ethnic groups, the Framework provides guidance on key actions to be taken at health system and health service levels to achieve equitable healthcare for Māori. It is focused on long-term conditions including diabetes. Mana Tū was further informed by He Korowai Oranga’s aspiration for ‘Rangatiratanga’ or people’s right to participate in making decisions about their health and to have meaningful ways to decide how health services might be provided for their benefit.8
Mana Tū is based in primary care and has three major components: a Network Hub, Kai Manaaki (skilled case managers who work with whānau with poorly controlled diabetes) and a cross-sector network of services to whom whānau can be referred to address the wider determinants of health. The Network Hub supports the delivery of the intervention through training of Kai Manaaki, referrals management, cross-sector network development and quality improvement of the programme. Mana Tū works across the three—system, service and individual/whānau—levels described above. More detail about the specific elements for each of the three levels is provided below and although we have attempted to ascribe elements to one level, as set out in the Framework7 and He Korowai Oranga8, many will sit across two or three system level elements, including Māori leadership, a focus on health equity and addressing wider determinants including discrimination. Service level features for Mana Tū are the Network Hub, its workforce of Kai Manaaki, integrated primary care and information management. Individuals and whānau are empowered in the ‘taking charge’, whānau ora and ‘the journey’ factors of Mana Tū that impact on the whānau’s ability to ‘mana tū’.
Māori leadership, defined as “championing the provision of high-quality healthcare that delivers equity of health outcomes for Māori”,7 is a key factor in successful health programmes.9,10 At the system level, Mana Tū has demonstrated Māori leadership by engaging Māori governors, developers and providers; setting health equity as a clear expectation; putting in place monitoring and evaluation mechanisms7 including kaupapa Māori research methodologies,11 and training its workforce to be responsive to the needs and aspirations of Māori.7 Importantly, optimal health outcomes will not be achieved unless there is a system-wide commitment to supporting it. Therefore, Mana Tū promotes Māori leadership and system responsibility.7
Mana Tū also aligns with the Government’s priorities for health research and service development that contributes to Māori health and eliminates health inequities.12 Achieving health equity requires a primary healthcare system that is committed to mitigating rather than extending diabetes inequities.11 Evidence suggests that health interventions designed specifically for those ‘currently missing out’ will ultimately achieve health gain and equitable outcomes for all.13 Those currently ‘missing out’ in terms of receiving quality type 2 diabetes care that achieves equitable outcomes are Māori, Pacific peoples and people living in communities with markers of socio-economic disadvantage; and people with pre-diabetes.1 Therefore, Mana Tū was designed by and for these people. The potential benefits of achieving health equity, when realised by our people, our health system and our society, are clear.
However, achieving health equity requires more than just addressing the immediate cause of disease. A focus on the socially determined conditions in which people grow, live, work and age,14 also known as the wider determinants for health, is required. All societies have social hierarchies in which resources, power and privilege are distributed unequally. However, the idea that this is inevitable or immutable not only harms the nation’s population and its economy,14 but is unjust and discriminatory. Mana Tū specifically asks people about the wider determinants that impact on their wellbeing, and provides a Network Hub for relevant sectors (eg, education, housing, justice) to engage with people and their whānau. In doing so it attempts to address the wider determinants in ways that support people’s freedom to lead lives in which they feel valued.14
In hui held with whānau, clinicians, funders, researchers and policy makers during the development and implementation of Mana Tū, stakeholders were clear that improved outcomes for Māori and Pacific people require identifying and addressing discrimination in the health and social care system. Stakeholders’ reports align with the literature: discrimination occurs at policy, funding and service levels in both health and social settings.15,16 This creates a context in which the social issues are often not addressed, where Māori and Pacific peoples do not feel safe when engaging with the health or social services, further compounded by a system with no clear commitment to sustainable funding for approaches to LTC management that target these issues. Mana Tū seeks to tackle discrimination by working with decision-makers and providers at regular and formal meetings, building evidence, providing ongoing education and working through examples of better practice.
Mana Tū’s Network Hub stemmed from previous NHC experience leading and implementing successful large-scale whānau ora programmes and initiatives such as Mana Kidz and AWHI.17 In these programmes, care is delivered by a diverse range of providers within a network of contributing stakeholders and the Hub’s role is to provide equal access to quality clinical care, population health activity and services that address social determinants in a connected way.18 The Mana Tū Hub has a critical organising function which supports the delivery of the intervention across multiple providers, including general practice clinics and district health boards, education, housing and social programmes. It also operationally supports Mana Tū delivery through the provision of Kai Manaaki workforce training and development, programme design and implementation, clinical leadership, project management, service quality improvement and data management. The Hub is supported by a network lead manager along with information management and analytical support.
The evidence for case managers or community health workers working with individualson clinical indicators and in geographically isolated areas to improve health outcomes is well established.19–21 Mana Tū has engaged Kai Manaaki to provide case management via the person’s GP clinic. Kai Manaaki are unique in that they also undertake case management with family/whānau; and in ways that support people to take charge of the clinical conditions and the social determinants of wellbeing.22 The six Kai Manaaki have a range of diabetes-related backgrounds including nursing, social work, educators and community workers. In addition to the ‘usual’ training about diabetes and its management, KM are trained in motivational interviewing, cultural safety and health literacy. Kai Manaaki live and contribute in the local communities with whom they are working, currently across metro-Auckland and in Whangaroa in Te Tai Tokerau. Importantly, they meet regularly for peer support and review,23 quality improvement activities and mentorship with qualified health professionals24,25 and are provided with other capacity building opportunities (ie, conferences, report writing).
Patients receive regular home visits from Kai Manaaki over a period of 12 months. During these visits, patients have ample time and support by Kai Manaaki to express any clinical issues related to their condition, as well as social or psychological issues. This information informs the next steps in which the Kai Manaaki work with the person’s primary care clinician to refer onto appropriate services. The Kai Manaaki manages the referral process, supporting the patient into and through it. The patient receives both clinical and social support that otherwise may not have been identified or offered in standard care.22
Key to the success of Mana Tū is its integration in primary care clinics rather than being co-located or coordinated.26 Although studies have shown that a greater degree of integration between primary and secondary healthcare improves patient outcomes,26 evidence has also highlighted issues with, and therefore lack of, integration of horizontal care necessary to manage the spectrum of clinical, psychological and social determinants of LTCs with patients and their families.27 The whānau ora approach in the title speaks to Mana Tū’s role in cutting across multiple sectors, services, providers and settings to enhance quality of care and quality of life for people with complex, long-term health issues and their whānau/families.28 Integration of the Kai Manaaki into GP clinics has the added benefit of ensuring that the relationships between Kai Manaaki and health and social care professionals are maintained and nurtured.29
Mana Tū utilises a sophisticated information platform to allow innovative data capture in general practice and patient home visits. Mōhio is a clinical platform developed by the NHC and is designed to support general practice and PHO information management, claims, referrals, compliance reporting, budget management and clinical decision support and analysis. The Mōhio system has been further developed specifically for the Mana Tū programme to allow Kai Manaaki to regularly capture patient progress on a mobile tablet device. All data is stored in a secure server, with live reporting enabled to feedback to practices. Mōhio is efficient and innovative in the way it collects, analyses and views patients’ data and progress.
Individual and whānau
Self-management or taking charge is fundamental to supporting people live well with diabetes;1 yet SM is difficult for people with type 2 diabetes to sustain. Successful self management programmes with indigenous people are culturally safe, relevant, community-based and focused on small changes over longer periods of time.5 Previous research with Māori and Pacific peoples living with another long-term condition (stroke) tested the effectiveness of a programme with these elements and found that the ability to direct aspects of one’s life with a long-term condition or to ‘take charge’ was highly valued and associated with a better quality of life.22 Mana Tū has incorporated features of the Taking Charge intervention, including a full initial assessment and prioritised self-directed goal setting based on the assessment. The assessment includes clinical, social, health literacy and whānau-wellbeing related questions that are validated and reliable; and specifically seek whānau participation.30 Importantly, by going through a checklist, listening and facilitating the process where the person and their whānau identify opportunities to take charge, people take ownership and are more engaged about living with their long-term condition.22 Feedback on goals is provided at regular, agreed-to intervals including blood test results, which are reported back to patients and their clinician every three months in keeping with best practice.5
‘Patient’ factors include family/whānau and community engagement, as the evidence is overwhelming that this will enhance diabetes outcomes.31 As a result, there are calls to introduce interventions that address family support and functioning in diabetes management plans.1 Involving whānau is also a great opportunity to engage others, particularly those at risk, in activities to prevent type 2 diabetes, including slowing the progression of pre-diabetes to diabetes.
Finally living well with a long-term condition such as type 2 diabetes is a journey1 over time. The duration of navigator-type interventions for long-term conditions reported in the literature ranges from 1–18 months.32 Careful consideration was given to the duration of Mana Tū and 12 months was deemed suitable to see changes in clinical indicators.29 Mana Tū seeks to commence discharge planning at nine months, well within the 12-month limit. It also provides for patient-led exits at any point in the 12-month programme and possible re-entry and/or support to access other services. Therefore, it is important that all (patient, whānau, Kai Manaaki and health and social providers) have a clear expectation of Mana Tū and its role in setting people up with tools and skills for life. As Figure 1 shows, Mana Tū is a series of pragmatic steps to support the person’s journey across all three levels.
Figure 1: The Mana Tū Journey.
A framework for change
Notably, the overarching programme goal for Mana Tū is change. A Mana Tū framework for change was developed which brings all three levels (individual/whānau, service, system) together (Table 1) to improve a set of short- and longer-term outcomes. In the short term (12 months), improved engagement from general practice with Mana Tū will improve their understanding about addressing the wider determinants. This leads to the patient feeling they are understood better, leading to an improved experience of their clinical engagement and subsequently improved clinical outcomes.In the longer term (1–3 years) Mana Tū is designed to have impacts for the whānau of the patient, with increasing levels of trust of the general practice environment, and improvements in social determinants (eg, employment, education, housing). The programme aims to have broadened attitudes and understanding in general practice, particularly with regard to its responsibilities to meet the rights of Māori and Pacific peoples to excellent healthcare and outcomes. Finally, as a result of whānau meeting goals there will be a reduction in hospital resource utilisation.
Table 1: Mana Tū framework for change.
Evaluation and next steps
In 2017 the NHC was awarded a Long-Term Conditions Partnership Research grant (Healthier Lives National Science Challenge Health Research Council and Ministry of Health33) to test the effectiveness of Mana Tū. The study is registered with the Australia and New Zealand Clinical Trials Register (ANZCTR registration number 12617001276347) and has ethical approval (HDEC 17/NTB/249). The research is part-way through—recruitment commenced in March 2018 and full results will not be available until 2020.
The funded research project is also distinctive and has four separate studies: (1) a cluster randomised controlled trial with 400 participants across 10 GP clinics, the primary clinical outcome being a reduction in HbA1c at 12 months; (2) qualitative research that explores the implementation process from an indigenous perspective,34 including acceptability, adoption, fidelity, penetration and sustainability; (3) an investigation of the efficiency and cost effectiveness of Mana Tū; (4) qualitative interviews with clients and their whānau regarding their aspirations and how well Mana Tū met them. Each study is conducted over the programme’s timeframe of 12 months, and outputs from each inform the other. Additional research regarding the Kai Manaaki, to be undertaken by a PhD student, will provide important information about how they work. With multiple requests to replicate aspects of Mana Tū in other services and programmes around New Zealand, it seemed timely to describe Mana Tū including its rationale and the key components of its unique model of care. However, the implementation of Mana Tū elsewhere is not recommended until the findings from its evaluation are available. The potential to report on wider benefits including a focus on the health of the population, enhanced patient experience and control of rising costs is worth noting. The tensions associated with these principles have been raised in a number of programmes for the management of long-term conditions and diabetes across New Zealand and with other indigenous populations,35,36 and though many pilots are successful,37 challenges are faced in scaling them up or transferring them to other contexts. The researchers plan to contribute to these critical knowledge gaps by gaining a better understanding of the features that make Mana Tū successful; and leading the development of strategies for scaling them up. We look forward to reporting the outcomes in 2020.