Pae Ora (Disestablishment of Maori Health Authority) Amendment Act 2024: further Crown breaches of Te Tiriti o Waitangi.

The Waitangi Tribunal in their Wai 2575 Report recommended the establishment of Te Aka Whai Ora (the Maori Health Authority) to remedy some of the contemporary breaches of Te Tiriti o Waitangi (Te Tiriti). Te Aka Whai Ora was the culmination of decades of Maori advocacy for the establishment of independent Maori health leadership, policymaking and commissioning. Under urgency, the new National-led coalition Government passed the Pae Ora (Disestablishment of Maori Health Authority) Amendment Act 2024 in February. In this paper we use Critical Tiriti Analysis (CTA), a five-stage process, to review the extent to which the Act is compliant with the five elements of Te Tiriti (the authoritative Maori text), the preamble, the three written articles and the oral article. We found that the Act had very limited Tiriti compliance and the potential to do great harm. We offered practical suggestions how this could have been avoided.

Preventing suicide in indigenous communities.

PURPOSE OF REVIEW: To provide an update on recent studies on suicide prevention in indigenous populations with a focus on recently colonised indigenous peoples in Canada, the United States, Australia and New Zealand. RECENT FINDINGS: There have been several recent reviews on suicide prevention in indigenous populations with high suicide rates. However most of them describe the problem and there is little new that is available on effective interventions. One randomized controlled trial of a package of measures focusing on cultural identity in Maori who had recently self-harmed compared to usual care found little effect on suicidal behavior but it did significantly reduce presentations to hospital for any reason after one year. SUMMARY: The reasons for the limited evidence include a lack of ring fenced funding and a lack of research infrastructure; the problem of high rates of suicide but small numbers; and the difficulty in creating effective collaborations between researchers and communities. Potential solutions include identifying specific research funding; improving capacity in indigenous research; putting effort into accurate identification and recording of ethnicity; and thinking about the problem of suicide in recently colonised populations as a global problem to enable large scale high quality studies to take place.

Te Ira Tangata: a Zelen randomised controlled trial of a culturally informed treatment compared to treatment as usual in Maori who present to hospital after self-harm.

PURPOSE: Indigenous people have high rates of suicide and self-harm compared to other population groups. AIM: The aim of this trial was to see if a package of interventions delivered in a culturally appropriate way improved outcomes at one year in Maori who presented with intentional self-harm to emergency departments. METHODS: Participants were Maori who presented with intentional self-harm to emergency departments in New Zealand. The study design was a double consent Zelen randomised controlled trial. The intervention included regular postcards, problem solving therapy, patient support, risk management, improved access to primary care and cultural assessment in addition to usual care. The control group received usual care. The main outcome measure was the self-rated change in scores on the Beck Hopelessness Scale at one year. RESULTS: 182 people were randomized to the intervention group 95 of whom consented to take part in the study. 183 people were randomized to the control group 72 of whom consented to take part in the study. For those who consented comparing the intervention group with the control group there was a statistically significant greater change in hopelessness scores at 3 months (difference -1.7 95 % CI -3.4 to -0.01, p = 0.05) but not at one year (difference -1.6 95 % CI -3.4 to 0.3, p = 0.11). Maori who consented and received the intervention were also significantly less likely to present to hospital for non-self-harm reasons in the year after the index episode (44.2 vs. 61.1 %, p = 0.03). Those participants randomised to the intervention were less likely to re-present with self-harm at 3 months (10.4 vs. 18 %, p = 0.04) but not at 12 months compared to the control group. CONCLUSIONS: In Maori who presented to hospital with intentional self-harm a culturally informed intervention had an effect on hopelessness and re-presentation with self-harm in the short term but not at 12 months. There was a significant decrease in hospital presentations for non-self harm over the next year. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registry ACTRN12609000952246.

Te Ira Tangata: a Zelen randomised controlled trial of a treatment package including problem solving therapy compared to treatment as usual in Maori who present to hospital after self harm.

BACKGROUND: Maori, the indigenous people of New Zealand, who present to hospital after intentionally harming themselves, do so at a higher rate than non-Maori. There have been no previous treatment trials in Maori who self harm and previous reviews of interventions in other populations have been inconclusive as existing trials have been under powered and done on unrepresentative populations. These reviews have however indicated that problem solving therapy and sending regular postcards after the self harm attempt may be an effective treatment. There is also a small literature on sense of belonging in self harm and the importance of culture. This protocol describes a pragmatic trial of a package of measures which include problem solving therapy, postcards, patient support, cultural assessment, improved access to primary care and a risk management strategy in Maori who present to hospital after self harm using a novel design. METHODS: We propose to use a double consent Zelen design where participants are randomised prior to giving consent to enrol a representative cohort of patients. The main outcome will be the number of Maori scoring below nine on the Beck Hopelessness Scale. Secondary outcomes will be hospital repetition at one year; self reported self harm; anxiety; depression; quality of life; social function; and hospital use at three months and one year. DISCUSSION: A strength of the study is that it is a pragmatic trial which aims to recruit Maori using a Maori clinical team and protocol. It does not exclude people if English is not their first language. A potential limitation is the analysis of the results which is complex and may underestimate any effect if a large number of people refuse their consent in the group randomised to problem solving therapy as they will effectively cross over to the treatment as usual group. This study is the first randomised control trial to explicitly use cultural assessment and management. TRIAL REGISTRATION: Australia and New Zealand Clinical Trials Register (ANZCTR): ACTRN12609000952246.

Asking for help is helpful: validation of a brief lifestyle and mood assessment tool in primary health care.

PURPOSE: The short, validated, self-administered, Case-finding and Help Assessment Tool (CHAT) for lifestyle and mental health assessment of adult patients in primary health care addresses inactivity, tobacco use, alcohol and other drug misuse, problem gambling, depression, anxiety and stress, abuse, and anger problems. For each issue patients are asked whether they would like help, either during the consultation or at a later date. This study aims to assess the value of the help question. METHODS: Validation of the CHAT was conducted according to the STAndards for Reporting of Diagnostic accuracy studies statement for diagnostic tests. The setting was Auckland primary care practices with populations ranging from socioeconomically advantaged to deprived. Participants were 755 consecutive primary care patients who completed the CHAT plus the help question and reference standards. Sensitivity, specificity, and likelihood ratios with and without the addition of help the question were calculated. RESULTS: Sensitivity ranged from 80% to 98% for the more-common conditions (depression, nicotine dependency, anxiety, problematic drinking). For each condition, specificity increased with the addition of the help question: depression increased from 73% to 98%; anxiety 77% to 99%; drinking 85% to 99%; verbal anger 92% to 99%; verbal abuse 97% to 99%; problematic drinking and gambling 98% to 99%. CONCLUSIONS: The help question increased specificity without compromising sensitivity and reduced false positives, thereby increasing the positive predictive value. It allowed patients with comorbidities to prioritize issues they wished to address, indicate their readiness to change, promote self-determination, and give the clinician an indication of which topics to pursue.

Case finding of lifestyle and mental health disorders in primary care: validation of the 'CHAT' tool.

BACKGROUND: Primary care is accessible and ideally placed for case finding of patients with lifestyle and mental health risk factors and subsequent intervention. The short self-administered Case-finding and Help Assessment Tool (CHAT) was developed for lifestyle and mental health assessment of adult patients in primary health care. This tool checks for tobacco use, alcohol and other drug misuse, problem gambling, depression, anxiety and stress, abuse, anger problems, inactivity, and eating disorders. It is well accepted by patients, GPs and nurses. AIM: To assess criterion-based validity of CHAT against a composite gold standard. DESIGN OF STUDY: Conducted according to the Standards for Reporting of Diagnostic Accuracy statement for diagnostic tests. SETTING: Primary care practices in Auckland, New Zealand. METHOD: One thousand consecutive adult patients completed CHAT and a composite gold standard. Sensitivities, specificities, positive and negative predictive values, and likelihood ratios were calculated. RESULTS: Response rates for each item ranged from 79.6 to 99.8%. CHAT was sensitive and specific for almost all issues screened, except exercise and eating disorders. Sensitivity ranged from 96% (95% confidence interval [CI] = 87 to 99%) for major depression to 26% (95% CI = 22 to 30%) for exercise. Specificity ranged from 97% (95% CI = 96 to 98%) for problem gambling and problem drug use to 40% (95% CI = 36 to 45%) for exercise. All had high likelihood ratios (3-30), except exercise and eating disorders. CONCLUSION: CHAT is a valid and acceptable case-finding tool for most common lifestyle and mental health conditions.

Primary care patients reporting concerns about their gambling frequently have other co-occurring lifestyle and mental health issues.

BACKGROUND: Problem gambling often goes undetected by family physicians but may be associated with stress-related medical problems as well as mental disorders and substance abuse. Family physicians are often first in line to identify these problems and to provide a proper referral. The aim of this study was to compare a group of primary care patients who identified concerns with their gambling behavior with the total population of screened patients in relation to co-morbidity of other lifestyle risk factors or mental health issues. METHODS: This is a cross sectional study comparing patients identified as worrying about their gambling behavior with the total screened patient population for co morbidity. The setting was 51 urban and rural New Zealand practices. Participants were consecutive adult patients per practice (N = 2,536) who completed a brief multi-item tool screening primary care patients for lifestyle risk factors and mental health problems (smoking, alcohol and drug misuse, problem gambling, depression, anxiety, abuse, anger). Data analysis used descriptive statistics and non-parametric binomial tests with adjusting for clustering by practitioner using STATA survey analysis. RESULTS: Approximately 3/100 (3%) answered yes to the gambling question. Those worried about gambling more likely to be male OR 1.85 (95% CI 1.1 to 3.1). Increasing age reduced likelihood of gambling concerns - logistic regression for complex survey data OR = 0.99 (CI 95% 0.97 to 0.99) p = 0.04 for each year older. Patients concerned about gambling were significantly more likely (all p < 0.0001) to have concerns about their smoking, use of recreational drugs, and alcohol. Similarly there were more likely to indicate problems with depression, anxiety and anger control. No significant relationship with gambling worries was found for abuse, physical inactivity or weight concerns. Patients expressing concerns about gambling were significantly more likely to want help with smoking, other drug use, depression and anxiety. CONCLUSION: Our questionnaire identifies patients who express a need for help with gambling and other lifestyle and mental health issues. Screening for gambling in primary care has the potential to identify individuals with multiple co-occurring disorders.

Ethnic differences in mental health and lifestyle issues: results from multi-item general practice screening.

AIM: To determine ethnic differences in response, acceptance and desire to address problems identified by the multi-item screening tool (MIST). METHODS: Patients were assessed using the MIST in urban Auckland. Fifty consecutive adult patients from 20 randomly selected practices completed the MIST and evaluation sheet before their consultation. All patients and general practitioners (GPs) completed feedback forms. Analysis adjusted for the clustered nature of the data. RESULTS: Participants were 1000 patients and 20 urban GPs. The participation rate was 87% of GPs and 97.75% of patients. Compared with New Zealand Europeans, Pacific Island people were significantly more likely to be concerned about abuse and anger control. Maori were significantly more likely to want help with cutting down their alcohol use. The screening tool was accepted by all patients (<1% objection rate) regardless of ethnicity. DISCUSSION: This is the first study to examine possible ethnic differences between primary care patients' response to screening on lifestyle behaviours and mental health issues.