STEPPING UP FOR MORI The Asthma Foundation Mori Engagement Strategy - - PowerPoint PPT Presentation

STEPPING UP FOR MĀORI

The Asthma Foundation Māori Engagement Strategy

Dr Tristram Ingham

Strategic Advisor Māori

Ms Cheryl Davies

Board Member

 Our Vision:

Better respiratory health for all New Zealanders

 Our Goal:

Reduce hospital admissions caused by asthma and

• ther respiratory conditions by 25%, by 2025

Introduction

700,000

(individuals with respiratory disease in NZ)

$5.5 billion p.a.

(direct & indirect costs)

3rd highest cause of disability

(Lung Disease by DALY)

3rd highest cause of hospitalisations

The Burden of Respiratory Disease

2.48 1.37 2.09 2.55 5.1 4.64

1 2 3 4 5 6

Asthma Upper Respiratory Tract Infection Influenza & Pneumonia Other Lower Respiratory Tract Infection COPD Lung Cancer

Standardised Relative Rate (Māori vs Non-Māori) Non-Māori Māori

Respiratory Hospitalisations

(Hospitalisations, All DHB’s, 2006-2011)

Data: Asthma Foundation/ University of Otago 2013

non- Māori 65% Māori 35%

Respiratory Hospitalisations

(Hospitalisations, All DHB’s, 2006-2011)

non- Māori 74% Māori 26% non- Māori 73% Māori 27% non- Māori 61% Māori 39% non- Māori 66% Māori 34% non- Māori 70% Māori 30%

ASTHMA UPPER RESP INFECTIONS INFLUENZA/PNEUMONIA OTHER LOWER RESP INFECTIONS

COPD LUNG CANCER

Data: Asthma Foundation/ University of Otago 2013

 Explore ways in which the Asthma Foundation can collaborate with Māori health provider networks & communities to improve Māori respiratory health  Inform the Asthma Foundation’s strategic direction & responsiveness to Māori policies

Strategy Aims

 To enable the Asthma Foundation to establish stronger working relationships with Whānau Ora collectives and Māori health providers to:

 enable closer, more meaningful collaborations at local and regional levels  contribute to improving the access of whānau to services, information and support  reduce the burden of respiratory illnesses for Māori.

Desired Outcomes

SCOPING & NEEDS ASSESSMENT

PROJECT PHASE 1

• 1. Meeting the collectives to introduce the Foundation and what it does
• 2. Outlining its commitment to improving Māori respiratory health conditions
• 3. Outlining how it intends to carry out that commitment
• 4. Finding out what collectives are doing in respiratory health, especially for

Māori

• 5. Identifying the gaps and what is working
• 6. Identifying other areas the Foundation can help with their work in

respiratory care

Phase 1 Objectives

Recommendation One:

Continue to build the Asthma Foundation’s relationship with Māori (via Whānau Ora collectives) to:

• better understand their specific needs;
• raise their awareness of the foundation; and
• collaboratively co-develop a Māori respiratory strategy.

Investigate and explore innovative resources (e.g. multimedia) that will be of more relevance to Māori communities.

Recommendation Two:

Collaboratively develop a Māori respiratory research agenda resulting in improved respiratory health outcomes for Māori. E.g.:

• research to improve health literacy;
• complimentary methods of respiratory wellness
• strategies to mitigate health disparities; and
• innovative service delivery models.

Recommendation Three:

Collaboratively develop best practice support structures that are responsive and relevant to Māori - to support practitioners working with Māori whānau

Recommendation Four:

Understand specific needs of Whānau Ora collectives around workforce training and development and to use these recommendations to broaden and revise the existing Asthma Foundation training programmes.

Recommendation Five:

COLLABORATION & INTERVENTION DEVELOPMENT

PROJECT PHASE 2

Bernadette Jones with Cheryl Davies and whānau

 To continue to engage with three Whānau Ora collectives  To collaboratively develop and pilot ‘best-practice support’ packages for Māori providers (using tamariki asthma as a development model)

Aims

Whānau Ora Collectives

Takiri Mai Te Ata

(Lower Hutt)

• Kokiri Marae Keriana Olsen Trust
• Kokiri Marae Maori Women’s Refuge
• Mana Wahine
• Naku Enei Tamariki
• Tū Kotahi Maori Asthma Trust
• Wainuiomata Marae
• Whai Oranga o Te Iwi Health Centre

Kotahitanga

(South Auckland)

• Papakura Marae
• Te Kaha o Te Rangataki Trust
• Turuki Healthcare Trust

Ngā Mataapuna Oranga

(Tauranga Moana)

• Te Manu Toroa Trust
• Te Rūnanga o Ngāti Tamawhariua
• Pirirākau Hauora Charitable Trust
• Te Puna Hauora Ki Uta Ki Tai
• Whaioranga Trust
• Waitaha Hauoranga Charitable Trust
• Kimioranga Primary Healthcare

Services

 Kaupapa Māori methodology  Participatory Action Research (PAR)  Plan-Do-Study-Act cycles  Embedded capacity (Asthma Champions)

Methodology

Plan Do Study Act

Project Team:

Bernadette Jones (RN) Dr Tristram Ingham Mr Tu Williams Mrs Janice Kuka

AF Project Team

Maraea Nathan (RN)

HUTT

(Takiri Mai Te Ata)

Ms Cheryl Davies Lee Walters (RN)

TAURANGA

(Nga Mataapuna Oranga)

Dr George Gray Atareta Arnold (RN)

AUCKLAND

(Kotahitanga)

Vicky Maiava (RN)

3 Workstreams:

Kotahitanga (Tāmaki Makaurau) Effective community engagement with Māori rangatahi with asthma [Rangatahi Engagement Strategies] Takiri Mai Te Ata (Te Awakairangi) Effective communication with whānau in a healthcare context [Asthma Resources] Ngā Mataapuna Oranga (Tauranga Moana) Effective service delivery for Māori with asthma [Data Quality Indicators]

Workstream 1:

Kotahitanga (Tāmaki Makaurau) Effective community engagement with Māori rangatahi with asthma [Rangatahi Engagement Strategies] Takiri Mai Te Ata (Te Awakairangi) Effective communication with whānau in a healthcare context [Asthma Resources] Ngā Mataapuna Oranga (Tauranga Moana) Effective service delivery for Māori with asthma [Data Quality Indicators]

 Collectives expressed concerns re difficulties in

• bjectively assessing performance in respiratory

health (for Māori)  No established indicators of service effectiveness for asthma in primary health (PHO Enrolment, Smoking cessation, ASH)  No nationally available comparative data available for benchmarking performance

Background

Atlas of Variation

IPIF Performance Dashboard – Non-Māori

IPIF Performance Dashboard – Māori

Aims:

1. Assess data quality in primary care 2. Refine primary care indicator selection 3. Assess indicators for other steps in the patient journey

Patient Journey

Home Primary Care Community/ Home Hospital Quality Diagnosis Pharmaceuticals Admission Rate Heating Education Compliance LOS Prescribing Education Specialist Review Review Spirometry

NICE Quality Standard 25: Asthma (UK, 2013)

11 Quality Statements:

1. Diagnosis 2. Occupational Asthma 3. Written Personalised Action Plans 4. Inhaler Technique 5. Review 6. Assessing Asthma Control 7. Assessing Severity 8. Treatment for Acute Asthma 9. Specialist Review

• 10. Follow-up in Primary Care

11. Difficult Asthma

 Purposive vs. routine data collection

 Practice Management System (PMS) vs Epidemiological survey (ISAAC, NZHS)

 Misclassification of ethnicity

 Patient management systems in primary care have been shown to misclassify the ethnicity of up to 37% of Māori patients. (Bramley 2007)

 Coding of patient information poor

 E.g. smoking status was correctly coded in less than 50% of Māori smokers in a 2006 study (Selak 2006).

 Incentives

 New Zealand's PHO Performance Programme incentivised data quality improvement for smoking status for several years before the measure was sufficiently robust for use as a Health Target contributor.

Barriers to Reliable Primary Care Indicators

Qualitative Interviews were conducted with Clinic Staff across the three collectives:

1. GP’s and nurses agree asthma management is poor – gaps evidential 2. Diagnosis are loosely guided dependent greatly on clinical judgement 3. No monitoring systems or alerts to prompt or recall asthmatics 4. Very little follow-up contact with asthmatics regardless of severity 5. Asthma education is limited by 15 minute time slots: GP vs Nurse

• 6. Very few utilise an array of resources

7. Asthma Management Action Plans not considered useful by many

• 8. Clinical priorities are ‘target’ focused

Interview Themes

 PMS data were made available from 5 participating medical clinics.  Data were extracted by customised Medtech queries and results inspected.  Inclusion criterion were:

 children aged 0-14 years  enrolled in participating clinics  Māori ethnicity on PMS

 Asthma was identified by utilising all asthma-related Read Codes [H33…] (Mukherjee et al. BMJ Open 2014).  Comparison was made with New Zealand Health Survey 2013/14 prevalence estimates for Asthma (Māori, 2-14 years) (i.e. anticipated prevalence of 20.7%)  3,210 children were identified in total  80% were Māori (n=2,552)

Methods

62% 38%

Children with Asthma (by NZHS Prevalence Estimate)

Coded as 'Asthma' Not Coded as 'Asthma'

Results: Diagnostic Coding

N = 2,552

 Provision of asthma education  Provision of asthma action plan  Review: six-month or one-year  Inhaler Technique review  Peak flow monitoring

Results: Downstream Indicators

< 5 out of 3,210 ( i.e. < 1.5%)

 Read-coding within electronic medical records is incomplete (there are no financial or regulatory drivers to perform this task)  38% of Māori asthmatic children may not have been coded with a diagnosis of asthma in the clinics studied in this project.

Conclusion

1. Develop standard diagnostic criteria for asthma across a sample of clinics, 2. Educate clinicians on the importance of read-coding, 3. Monitor observed vs expected asthma prevalence in the clinics, 4. Consider alternate methods to identify asthmatics if read-coding completeness does not improve, 5. When read coding is sufficiently high, finalise a set of asthma indicators for tamariki Māori which have robust intervention logic linking to improved health outcomes, 6. Monitor these indicators over time and provide performance improvement guidance to clinics.

Recommendations

Workstream 2:

Kotahitanga (Tāmaki Makaurau) Effective community engagement with Māori rangatahi with asthma [Rangatahi Engagement Strategies] Takiri Mai Te Ata (Te Awakairangi) Effective communication with whānau in a healthcare context [Asthma Resources] Ngā Mataapuna Oranga (Tauranga Moana) Effective service delivery for Māori with asthma [Data Quality Indicators]

 Hui held with Whānau Ora collective staff, and whānau to identify key areas of interest for the project.

 Resources highlighted as the preferred focus

 Problems with communication between whānau and health professionals seen as critical  Communication problems include:

 lack of time for asthma education,  inconsistent messaging,  difficulty broaching some topics,  inappropriate language,  lack of appropriate resources to support.

 Resources:

 Existing Asthma Resources are…

 not culturally relevant for Māori (no Te Ao Māori worldview),  Not explicitly aimed at rangatahi (youth),  Do not incorporate holistic approaches or ‘wellness’ models (too medication focused),  Deficit focussed (no positive role-modelling evident).

Background

Te Hau Tapu o Tawhirimatea

Talk Cards and complimentary resources:  Focused on “subtle statements” discussed in the DVD  Ensures consistency of information and key messagess  When the nine cards are placed together, they form the whakatauki – “Ehara Taku Toa, He Toa Takatini”  Will be accompanied by an online training programme  Encompasses a Te Ao Māori perspective  Healthy Housing Tips/spacer stickers/posters/auahi kore stickers are included  Will include the “spacer” waiata and a scenario on how to use this resource

The cards are based around a kaupapa Māori framework utilising key Māori principles:  Tautoko/Hononga

(support from a friend)

 Manaakitanga/Hāpori Hauora (Caregiver/Health organisations)  Ōranga/whare

(healthy housing)

 Kaitiakitanga/whānau

(guiding and caring for others)

 Wānanga/Kura

(asthma support in the school environment)

 Tūpuna/Whakapapa

(connecting us to our past, present and future)

 Rangatiratanga/ahau

(self-management)

 Mana/Kaiwhakaako

(support from sports coaches)

 Tikanga/Tākuta

(support from the doctor)

Talking Cards

An Example

Development of a visual resource  A Needs Analysis was completed with 16 rangatahi/teenagers and their parents  The local Maori community indicated they would like to be involved in the production of this resource  “It takes a village to raise a child” was the concept behind the DVD  It was important to have a strong “Te Ao Maori feel”  It needed to be “real”

Visual Resource

This DVD has involved a “whole of community approach” that has included:  a needs analysis  community input in to the development of the resources  community involvement in to the filming process (47 adults and children in total)  Using local Maori talent for the production  Evaluating the finished product in focus groups and utilising an online survey  utilising local Maori graphic designers  a young Maori mother with two asthmatic children designing the posters  two amazing young Maori Film Directors

Community Participatory Approach

Te Hau Tapu o Tawhirimatea

Development of an online Training Programme  Tu Kotahi will develop an online Training Programme that gives tips on how to use the Te Hau Tapu o Tawhirimatea toolkit. Identify other Whanau Ora collectives to work alongside  We envisage sharing this resource with other Whānau Ora collectives over the next 12 months Development of a resource for teenage girls  We will source additional funding to develop another film focused on teenage girls – this will enable educators to have both DVD’s in their toolkit

Where to from here?

 Quantitative Survey Responses

 via Survey Monkey (n= 22)

 3 Qualitative Focus-Groups

 2x rangatahi (n= 15)  1x health & education stakeholders (n= 14)

Evaluation of the Resource

Respondents: Role

Initial Reaction

“What is your first reaction to this new resource?”

Qualities of the Resource

“How well, if at all, does [the term] describe this new resource?”

 INNOVATIVE  WELL-MADE

Confidence: Managing Asthma

“How improved is your confidence managing asthma after seeing this resource?”

Confidence: Talking to Dr or Nurse

“How improved is your comfort talking to a doctor or nurse about asthma after seeing this resource?”

Excludes Health Professionals (n=12)

Balance of Content

“There are a number of themes running through the video. For each, please tell us whether you would have like to seen more or less of that theme in this resource.”

Too Much Too Little

Just right

Workstream 3:

Kotahitanga (Tāmaki Makaurau) Effective community engagement with Māori rangatahi with asthma [Rangatahi Engagement Strategies] Takiri Mai Te Ata (Te Awakairangi) Effective communication with whānau in a healthcare context [Asthma Resources] Ngā Mataapuna Oranga (Tauranga Moana) Effective service delivery for Māori with asthma [Data Quality Indicators]

 What is the problem?

 Poor engagement of Māori rangatahi (youth) with respiratory health  Media strategies and initiatives not reaching rangatahi  Preferences for media conduits unclear (not conventional media)  Need to generate messaging ideas that resonate with rangatahi

 Ideas for engagement activities generated by Kotahitanga collective:

 Competitions  Sports events  School engagement

Background

What strategies did we adopt?

 We developed a radio media campaign focused on promoting an asthma “Breathe Easy” Competition  The “Breathe Easy” Competition was focused on designing a poster, video, song, rap or game that promoted the “Breathe Easy” messages  The Competition was promoted in High Schools and community  Utilised asthma nurse champions and youth workers in the district (who were already well known to the rangatahi)  Facebook and Twitter were also exploited as avenues for promoting this competition

Development of an Asthma Media Campaign for Rangatahi

Innovative entries included:

 Posters  Art  Songs  Raps  Skits  Monologues

“Breathe Easy” Competition Entries

Kōkiri Hauora Holiday Programme (9-17 years)

“Asthma can be managed with medications so that you can continue t0 enjoy your life”

Saneel (11 years old)

Stepping Up for Māori

CONCLUSIONS:

Poutama

Tukutuku Panel, Paruaharanui marae

The stepped pattern

• f

tukutuku panels and woven mats, symbolising genealogies and also the various levels of learning and intellectual achievement.

 Substantial community involvement in each area

 Capacity building within clinics (research)  Supporting local Māori talent (artists, film-makers, weavers)  Rangatahi initiatives (radio)

 Enhanced Medical Clinic buy-in

 Awareness raising with staff  Early changes in behaviour noted (ICS prescribing, referrals)

 Development of Leadership roles

 Clinics within region (Asthma health literacy BOP)  Staff within region (Regional advisory committees)

 Fundraising

 Spin-off fundraising

Other Benefits

 Project Sponsor:  Partner Organisations:

Acknowledgements

Tākiri Mai Te Ata Whānau Ora Collective