I have undertaken qualitative health research and evaluation for a number of years in both academic and community settings in Auckland, Tairāwhiti and Hawke’s Bay, New Zealand. My particular research interest areas are Māori infant health, inequities in health services and prediabetes Address: Napier, Hawke's Bay, New Zealand
Objective:To understand motivators, facilitators and challenges to dietary change amongst a diver... more 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. Facilitat...
RATIONALE AND OBJECTIVE In Aotearoa/New Zealand, Indigenous Māori experience inequitable delivery... more RATIONALE AND OBJECTIVE 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. STUDY DESIGN Qualitative interview study: Setting and participants: We conducted 40 in-depth interviews of 40 Māori: eight who had received a transplant, twenty with chronic kidney disease which included ten on the deceased donor transplant list, nine who were interested in transplantation and not currently waitlisted or who were ineligible for waitlisting, and one who was not interested in transplantation. We interviewed four live kidney donors and eight family members including six who had experiences with donor assessment. ANALYTICAL APPROACH Data were analyzed inductively to generate themes and a conceptual framework. RESULTS We identified five 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. LIMITATIONS Participants were recruited nationally through patient advocacy organisations and one regional kidney service. Potential participants unrelated to these groups or region could not be included. CONCLUSIONS 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.
The aim of this study was to explore the experience and perceptions of a diagnosis of prediabetes... more 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 BMI >25 kg/m2, stratified by male/female, Māori/non-Māori, and those who had/had not regressed to normoglycaemia, after completing 6-months of a prediabetes intervention were interviewed. Interviews were audio-recorded and transcribed. Data were analysed by thematic analysis. Most 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.
BackgroundReported experiences of racism in Aotearoa New Zealand are consistently associated with... more 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 (exc...
Background: Kidney transplantation is considered best practice treatment for end stage kidney dis... more 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.
Introduction Pre-diabetes is a high-risk state for the
development of type 2 diabetes mellitus (T... more Introduction Pre-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 analysis Four 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 dissemination This 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 number ACTRN12617000591358; Pre-results.
Abstract. The bassinet-like wahakura is an Indigenous initiative for the prevention of Sudden Une... more Abstract. 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. Additional keywords: bassinet, bedsharing, Māori, Sudden Unexpected Death in Infancy (SUDI), Sudden Infant Death Syndrome (SIDS), traditional.
Aim To explore the experiences of people recently diagnosed with prediabetes and overweight or ob... more Aim To explore the experiences of people recently diagnosed with prediabetes and overweight or obese in making dietary changes following a six-month primary care nurse-delivered dietary intervention pilot. Methods Semi-structured interviews were conducted with 20 participants, purposefully selected to ensure a mix of ethnicity, gender and glycaemic outcome. Thematic analysis of interview data was undertaken. Results Participants described feeling shocked when they received the diagnosis of prediabetes. Three core themes, each containing subthemes, emerged: (i) supportive factors - determination not to develop diabetes, clear information and manageable strategies, and supportive relationships; (ii) barriers - lack of family support, financial constraints, social expectations around food, and chronic health issues; and (iii) overcoming challenges - growing and sharing food, using frozen vegetables and planning. Challenges related to cultural expectations around providing and partaking of food were more evident for indigenous Māori participants Conclusions A diagnosis of prediabetes provides a window of opportunity for healthcare professionals to work with those diagnosed and their families to make healthful dietary changes. Dietary guidance is likely to be most effective when individuals’ life circumstances are taken into account. Clear information and supportive relationships to facilitate lifestyle change are extremely important. (Clinical Trials Registry No; ANZCTR ACTRN1261500080656)
Background: Primary care nurse-led prediabetes interventions are seldom reported. We examined the... more Background: Primary care nurse-led prediabetes interventions are seldom reported. We examined the implementation and feasibility of a 6-month multilevel primary care nurse-led prediabetes lifestyle intervention compared with current practice in patients with prediabetes, with weight and glycated haemoglobin (HbA1c) as outcomes. Methods: This study used a convergent mixed methods design involving a 6-month pragmatic non-randomised pilot study with a qualitative process evaluation, and was conducted in two neighbouring provincial cities in New Zealand, with indigenous Māori populations comprising 18.2% and 23.0%, respectively. Participants were non-pregnant adults aged ≤ 70 years with newly diagnosed prediabetes (HbA1c 41-49 mmol/mol), body mass index (BMI) ≥ 25 kg/m2 and not prescribed Metformin. A structured dietary intervention tool delivered by primary care nurses with visits at baseline, 2–3 weeks, 3 months and 6 months was implemented in four intervention practices. Four control practices continued to provide usual care. Primary quantitative outcome measures were weight and HbA1c. Linear and quantile regression models were used to compare each outcome between the two groups at follow-up. Qualitative data included: observations of nurse training sessions and steering group meetings; document review; semi-structured interviews with a purposive sample of key informants (n = 17) and intervention patients (n =20). Thematic analysis was used. Results: One hundred fifty-seven patients with prediabetes enrolled (85 intervention, 72 control), 47.8% female and 31.2% Māori. Co-morbidities were common, particularly hypertension (49.7%), dyslipidaemia (40.1%) and gout (15.9%). Baseline and 6 month measures were available for 91% control and 79% intervention participants. After adjustment, the intervention group lost a mean 1.3 kg more than the control group (p < 0.001). Mean HbA1c, BMI and waist circumference decreased in the intervention group and increased in the control group, but differences were not statistically significant. Implementation fidelity was high, and it was feasible to implement the intervention in busy general practice settings. The intervention was highly acceptable to both patients and key stakeholders, especially primary care nurses. Conclusions: Study findings confirm the feasibility and acceptability of primary care nurses providing structured dietary advice to patients with prediabetes in busy general practice settings. The small but potentially beneficial mean weight loss among the intervention group supports further investigation. Trial Registration: ANZCTR ACTRN12615000806561. Registered 3 August 2015 (Retrospectively registered). Keywords: Prediabetes, Dietary modification, Weight loss, Structured intervention implementation, General practice, Primary care nursing, Indigenous population, Pragmatic clinical trial, Outcome and process assessment, Qualitative evaluation
Abstract
Aims The wahakura (flax bassinet) is presently being distributed as a safe infant sleepi... more Abstract Aims 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. Methods 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. Results 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. Conclusions 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.
Abstract
Background: Sudden Unexpected Death in Infancy (SUDI) has persistent high rates in depri... more Abstract 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 Keywords: Sudden Unexpected Death in Infancy, Sudden Infant Death Syndrome, Infant, Sleep, Prevention, Culture, Protocol, Indigenous, Bedsharing, Co-sleeping
Background: Although breastfeeding duration in New Zealand’s indigenous Māori is shorter than in ... more 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. Keywords: Infant nutrition, Lactation, Maternal knowledge, Pacifier
Objective:To understand motivators, facilitators and challenges to dietary change amongst a diver... more 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. Facilitat...
RATIONALE AND OBJECTIVE In Aotearoa/New Zealand, Indigenous Māori experience inequitable delivery... more RATIONALE AND OBJECTIVE 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. STUDY DESIGN Qualitative interview study: Setting and participants: We conducted 40 in-depth interviews of 40 Māori: eight who had received a transplant, twenty with chronic kidney disease which included ten on the deceased donor transplant list, nine who were interested in transplantation and not currently waitlisted or who were ineligible for waitlisting, and one who was not interested in transplantation. We interviewed four live kidney donors and eight family members including six who had experiences with donor assessment. ANALYTICAL APPROACH Data were analyzed inductively to generate themes and a conceptual framework. RESULTS We identified five 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. LIMITATIONS Participants were recruited nationally through patient advocacy organisations and one regional kidney service. Potential participants unrelated to these groups or region could not be included. CONCLUSIONS 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.
The aim of this study was to explore the experience and perceptions of a diagnosis of prediabetes... more 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 BMI >25 kg/m2, stratified by male/female, Māori/non-Māori, and those who had/had not regressed to normoglycaemia, after completing 6-months of a prediabetes intervention were interviewed. Interviews were audio-recorded and transcribed. Data were analysed by thematic analysis. Most 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.
BackgroundReported experiences of racism in Aotearoa New Zealand are consistently associated with... more 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 (exc...
Background: Kidney transplantation is considered best practice treatment for end stage kidney dis... more 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.
Introduction Pre-diabetes is a high-risk state for the
development of type 2 diabetes mellitus (T... more Introduction Pre-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 analysis Four 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 dissemination This 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 number ACTRN12617000591358; Pre-results.
Abstract. The bassinet-like wahakura is an Indigenous initiative for the prevention of Sudden Une... more Abstract. 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. Additional keywords: bassinet, bedsharing, Māori, Sudden Unexpected Death in Infancy (SUDI), Sudden Infant Death Syndrome (SIDS), traditional.
Aim To explore the experiences of people recently diagnosed with prediabetes and overweight or ob... more Aim To explore the experiences of people recently diagnosed with prediabetes and overweight or obese in making dietary changes following a six-month primary care nurse-delivered dietary intervention pilot. Methods Semi-structured interviews were conducted with 20 participants, purposefully selected to ensure a mix of ethnicity, gender and glycaemic outcome. Thematic analysis of interview data was undertaken. Results Participants described feeling shocked when they received the diagnosis of prediabetes. Three core themes, each containing subthemes, emerged: (i) supportive factors - determination not to develop diabetes, clear information and manageable strategies, and supportive relationships; (ii) barriers - lack of family support, financial constraints, social expectations around food, and chronic health issues; and (iii) overcoming challenges - growing and sharing food, using frozen vegetables and planning. Challenges related to cultural expectations around providing and partaking of food were more evident for indigenous Māori participants Conclusions A diagnosis of prediabetes provides a window of opportunity for healthcare professionals to work with those diagnosed and their families to make healthful dietary changes. Dietary guidance is likely to be most effective when individuals’ life circumstances are taken into account. Clear information and supportive relationships to facilitate lifestyle change are extremely important. (Clinical Trials Registry No; ANZCTR ACTRN1261500080656)
Background: Primary care nurse-led prediabetes interventions are seldom reported. We examined the... more Background: Primary care nurse-led prediabetes interventions are seldom reported. We examined the implementation and feasibility of a 6-month multilevel primary care nurse-led prediabetes lifestyle intervention compared with current practice in patients with prediabetes, with weight and glycated haemoglobin (HbA1c) as outcomes. Methods: This study used a convergent mixed methods design involving a 6-month pragmatic non-randomised pilot study with a qualitative process evaluation, and was conducted in two neighbouring provincial cities in New Zealand, with indigenous Māori populations comprising 18.2% and 23.0%, respectively. Participants were non-pregnant adults aged ≤ 70 years with newly diagnosed prediabetes (HbA1c 41-49 mmol/mol), body mass index (BMI) ≥ 25 kg/m2 and not prescribed Metformin. A structured dietary intervention tool delivered by primary care nurses with visits at baseline, 2–3 weeks, 3 months and 6 months was implemented in four intervention practices. Four control practices continued to provide usual care. Primary quantitative outcome measures were weight and HbA1c. Linear and quantile regression models were used to compare each outcome between the two groups at follow-up. Qualitative data included: observations of nurse training sessions and steering group meetings; document review; semi-structured interviews with a purposive sample of key informants (n = 17) and intervention patients (n =20). Thematic analysis was used. Results: One hundred fifty-seven patients with prediabetes enrolled (85 intervention, 72 control), 47.8% female and 31.2% Māori. Co-morbidities were common, particularly hypertension (49.7%), dyslipidaemia (40.1%) and gout (15.9%). Baseline and 6 month measures were available for 91% control and 79% intervention participants. After adjustment, the intervention group lost a mean 1.3 kg more than the control group (p < 0.001). Mean HbA1c, BMI and waist circumference decreased in the intervention group and increased in the control group, but differences were not statistically significant. Implementation fidelity was high, and it was feasible to implement the intervention in busy general practice settings. The intervention was highly acceptable to both patients and key stakeholders, especially primary care nurses. Conclusions: Study findings confirm the feasibility and acceptability of primary care nurses providing structured dietary advice to patients with prediabetes in busy general practice settings. The small but potentially beneficial mean weight loss among the intervention group supports further investigation. Trial Registration: ANZCTR ACTRN12615000806561. Registered 3 August 2015 (Retrospectively registered). Keywords: Prediabetes, Dietary modification, Weight loss, Structured intervention implementation, General practice, Primary care nursing, Indigenous population, Pragmatic clinical trial, Outcome and process assessment, Qualitative evaluation
Abstract
Aims The wahakura (flax bassinet) is presently being distributed as a safe infant sleepi... more Abstract Aims 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. Methods 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. Results 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. Conclusions 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.
Abstract
Background: Sudden Unexpected Death in Infancy (SUDI) has persistent high rates in depri... more Abstract 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 Keywords: Sudden Unexpected Death in Infancy, Sudden Infant Death Syndrome, Infant, Sleep, Prevention, Culture, Protocol, Indigenous, Bedsharing, Co-sleeping
Background: Although breastfeeding duration in New Zealand’s indigenous Māori is shorter than in ... more 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. Keywords: Infant nutrition, Lactation, Maternal knowledge, Pacifier
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Papers by Sally Abel
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 analysis Four 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 dissemination This 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 number ACTRN12617000591358; Pre-results.
‘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.
Additional keywords: bassinet, bedsharing, Māori, Sudden Unexpected Death in Infancy (SUDI), Sudden Infant Death Syndrome (SIDS), traditional.
Methods Semi-structured interviews were conducted with 20 participants, purposefully selected to ensure a mix of ethnicity, gender and glycaemic outcome. Thematic analysis of interview data was undertaken.
Results Participants described feeling shocked when they received the diagnosis of prediabetes. Three core themes, each containing subthemes, emerged: (i) supportive factors - determination not to develop diabetes, clear information and manageable strategies, and supportive relationships; (ii) barriers - lack of family support, financial constraints, social expectations around food, and chronic health issues; and (iii) overcoming challenges - growing and sharing food, using frozen vegetables and planning. Challenges related to cultural expectations around providing and partaking of food were more evident for indigenous Māori participants
Conclusions A diagnosis of prediabetes provides a window of opportunity for healthcare professionals to work with those diagnosed and their families to make healthful dietary changes. Dietary guidance is likely to be most effective when individuals’ life circumstances are taken into account. Clear information and supportive relationships to facilitate lifestyle change are extremely important.
(Clinical Trials Registry No; ANZCTR ACTRN1261500080656)
Methods: This study used a convergent mixed methods design involving a 6-month pragmatic non-randomised pilot study with a qualitative process evaluation, and was conducted in two neighbouring provincial cities in New Zealand, with indigenous Māori populations comprising 18.2% and 23.0%, respectively. Participants were non-pregnant adults aged ≤ 70 years with newly diagnosed prediabetes (HbA1c 41-49 mmol/mol), body mass index (BMI) ≥ 25 kg/m2 and not prescribed Metformin. A structured dietary intervention tool delivered by primary care nurses with visits at baseline, 2–3 weeks, 3 months and 6 months was implemented in four intervention practices. Four control practices continued to provide usual care. Primary quantitative outcome measures were weight and HbA1c. Linear and quantile regression models were used to compare each outcome between the two groups at follow-up. Qualitative data included: observations of nurse training sessions and steering group meetings; document
review; semi-structured interviews with a purposive sample of key informants (n = 17) and intervention patients (n =20). Thematic analysis was used.
Results: One hundred fifty-seven patients with prediabetes enrolled (85 intervention, 72 control), 47.8% female and 31.2% Māori. Co-morbidities were common, particularly hypertension (49.7%), dyslipidaemia (40.1%) and gout (15.9%). Baseline and 6 month measures were available for 91% control and 79% intervention participants. After adjustment, the intervention group lost a mean 1.3 kg more than the control group (p < 0.001). Mean HbA1c, BMI and waist circumference decreased in the intervention group and increased in the control group, but differences were not statistically significant. Implementation fidelity was high, and it was feasible to implement the intervention in busy general practice settings. The intervention was highly acceptable to both patients and key stakeholders, especially primary care nurses.
Conclusions: Study findings confirm the feasibility and acceptability of primary care nurses providing structured dietary advice to patients with prediabetes in busy general practice settings. The small but potentially beneficial mean weight loss among the intervention group supports further investigation.
Trial Registration: ANZCTR ACTRN12615000806561. Registered 3 August 2015 (Retrospectively registered).
Keywords: Prediabetes, Dietary modification, Weight loss, Structured intervention implementation, General practice, Primary care nursing, Indigenous population, Pragmatic clinical trial, Outcome and process assessment, Qualitative
evaluation
Aims 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.
Methods 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.
Results 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.
Conclusions 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.
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
Keywords: Sudden Unexpected Death in Infancy, Sudden Infant Death Syndrome, Infant, Sleep, Prevention,
Culture, Protocol, Indigenous, Bedsharing, Co-sleeping
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.
Keywords: Infant nutrition, Lactation, Maternal knowledge, Pacifier
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 analysis Four 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 dissemination This 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 number ACTRN12617000591358; Pre-results.
‘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.
Additional keywords: bassinet, bedsharing, Māori, Sudden Unexpected Death in Infancy (SUDI), Sudden Infant Death Syndrome (SIDS), traditional.
Methods Semi-structured interviews were conducted with 20 participants, purposefully selected to ensure a mix of ethnicity, gender and glycaemic outcome. Thematic analysis of interview data was undertaken.
Results Participants described feeling shocked when they received the diagnosis of prediabetes. Three core themes, each containing subthemes, emerged: (i) supportive factors - determination not to develop diabetes, clear information and manageable strategies, and supportive relationships; (ii) barriers - lack of family support, financial constraints, social expectations around food, and chronic health issues; and (iii) overcoming challenges - growing and sharing food, using frozen vegetables and planning. Challenges related to cultural expectations around providing and partaking of food were more evident for indigenous Māori participants
Conclusions A diagnosis of prediabetes provides a window of opportunity for healthcare professionals to work with those diagnosed and their families to make healthful dietary changes. Dietary guidance is likely to be most effective when individuals’ life circumstances are taken into account. Clear information and supportive relationships to facilitate lifestyle change are extremely important.
(Clinical Trials Registry No; ANZCTR ACTRN1261500080656)
Methods: This study used a convergent mixed methods design involving a 6-month pragmatic non-randomised pilot study with a qualitative process evaluation, and was conducted in two neighbouring provincial cities in New Zealand, with indigenous Māori populations comprising 18.2% and 23.0%, respectively. Participants were non-pregnant adults aged ≤ 70 years with newly diagnosed prediabetes (HbA1c 41-49 mmol/mol), body mass index (BMI) ≥ 25 kg/m2 and not prescribed Metformin. A structured dietary intervention tool delivered by primary care nurses with visits at baseline, 2–3 weeks, 3 months and 6 months was implemented in four intervention practices. Four control practices continued to provide usual care. Primary quantitative outcome measures were weight and HbA1c. Linear and quantile regression models were used to compare each outcome between the two groups at follow-up. Qualitative data included: observations of nurse training sessions and steering group meetings; document
review; semi-structured interviews with a purposive sample of key informants (n = 17) and intervention patients (n =20). Thematic analysis was used.
Results: One hundred fifty-seven patients with prediabetes enrolled (85 intervention, 72 control), 47.8% female and 31.2% Māori. Co-morbidities were common, particularly hypertension (49.7%), dyslipidaemia (40.1%) and gout (15.9%). Baseline and 6 month measures were available for 91% control and 79% intervention participants. After adjustment, the intervention group lost a mean 1.3 kg more than the control group (p < 0.001). Mean HbA1c, BMI and waist circumference decreased in the intervention group and increased in the control group, but differences were not statistically significant. Implementation fidelity was high, and it was feasible to implement the intervention in busy general practice settings. The intervention was highly acceptable to both patients and key stakeholders, especially primary care nurses.
Conclusions: Study findings confirm the feasibility and acceptability of primary care nurses providing structured dietary advice to patients with prediabetes in busy general practice settings. The small but potentially beneficial mean weight loss among the intervention group supports further investigation.
Trial Registration: ANZCTR ACTRN12615000806561. Registered 3 August 2015 (Retrospectively registered).
Keywords: Prediabetes, Dietary modification, Weight loss, Structured intervention implementation, General practice, Primary care nursing, Indigenous population, Pragmatic clinical trial, Outcome and process assessment, Qualitative
evaluation
Aims 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.
Methods 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.
Results 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.
Conclusions 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.
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
Keywords: Sudden Unexpected Death in Infancy, Sudden Infant Death Syndrome, Infant, Sleep, Prevention,
Culture, Protocol, Indigenous, Bedsharing, Co-sleeping
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.
Keywords: Infant nutrition, Lactation, Maternal knowledge, Pacifier