THE WAHAKURA LENS AND

David Tipene-Leach

29 July, 2018

GP18

A N U P D A T E O N C U L T U R A L C O M P E T E N C E

GP (WITH A PUBLIC HEALTH DEGREE)

Whakatane

Te Teko

Matatā

Ruatoki

East Coast

Gisborne

Hastings

PUB HEALTH DR (WITH A HX OF GENERAL PRACTICE)

1974

The Year of 74

1974

The Year of 74

1974

The Year of 74

1977

Community Forum

Sept 77

1981

1987

Dept Community Health

Teaching Māori Health

CULTURAL SENSITIVITY

Teaching students/doctors ABOUT what Māori

believe, Māori how behave …

… so that the doctor

might do a better job

CULTURAL COMPETENCE 2003

The Health Practitioners Competence Assurance Act 2003

“protect the health and safety of the public

by providing mechanisms to ensure

that doctors are competent and fit to practice”

CULTURAL COMPETENCE

... an awareness of cultural diversity and the ability to

function effectively, and respectfully, when working with

and treating people of different cultural backgrounds.

Cultural competence means a doctor has the attitudes, skills and knowledge needed to achieve this. ..

CULTURAL COMPETENCE

2017 UPDATE ON CULTURAL COMPETENCE

Medical Council and Te ORA

• A culturally competent workforce

• Improved health outcomes and reduced health inequities for Mā̄ori

• Standards for College accreditation around cultural

competence

2017 UPDATE ON CULTURAL COMPETENCE

Equitable outcomes

for Māori and

Pacific peoples

2018 UPDATE ON CULTURAL COMPETENCE

THINKING ABOUT INEQUITIES

inequities

THINKING ABOUT INEQUITIES

The conditions in which

people are born, grow up,

live, work and age.

THINKING ABOUT INEQUITIES

Cultural incompetence is where a

practitioner lacks the cultural

attitudes, skills and knowledge

needed to achieve

outcomes for his/her client.

THINKING ABOUT INEQUITIES

Where social, political or

health institutions

consistently produce inequitable outcomes …

… that systematically put disadvantaged

groups at further disadvantage

with respect to health

INEQUITIES

inequities

THIS PRESENTATION IS ABOUT

A 34x 72 cm

flax bassinet

A Māori

inspired

intervention

Designed

to combat

the SUDI

inequity• .

.

MAINTAINING THE CONNECTION

MAKING NIGHT BREASTFEEDING EASIER

A CONSISTENT SLEEPING SPACE FOR ALL CAREGIVERS

THAT IS PORTABLE AND GOES ANYWHERE AND EVERYWHERE

FOR BEDSHARING

A GREAT CONTRACEPTIVE

SO WHAT WAS THE PROBLEM?

• .

SIDS RATES AND THEN SUDI RATE IN NZ

0

2

4

6

8

10

12

Death

s p

er

1000 b

irth

s

SIDS/SUDI Rate NZ 1978 - 2012

SIDS rate Maori SIDS rate Non-Maori SIDS rate

Health

care

inequity

NZ COT DEATH STUDY, 1987-90

Non-modifiable RFs

Maori, low SES

Young,

unmarried, pooreducation

Access to antenatal

care and clasess

Birth outcomes

LBW, prematurity, NICU

NZ COT DEATH STUDY, 1987-90

Non-modifiable RFs

Maori, low SES

Young,

unmarried, pooreducation

Access to antenatal

care and clasess

Birth outcomes

LBW, prematurity, NICU

NZ COT DEATH STUDY, 1987-90

Modifiable RFs

Prone sleep position

Maternal cigarette

Not breast feeding

Bed-sharing

NZ COT DEATH STUDY, 1987-90

Modifiable RFs

Prone sleep position

Maternal cigarette

Not breast feeding

Bed-sharing

Are they really

modifiable

risk factors?

NZ COT DEATH STUDY, 1987-90

Modifiable RFs

Prone sleep position

Maternal cigarette

Not breast feeding

Bed-sharing

Not good for a

behaviour

change

programme

THE NATIONAL COT DEATH PREVENTION CAMPAIGN (1991)

Māori

National

5%

64%

THE NATIONAL COT DEATH PREVENTION CAMPAIGN (1991)

Māori

National

5%

64%

Health

care

inequity

MĀORI SIDS PREVENTION PROGRAMME

.

SIDS RATES DOWN

0

2

4

6

8

10

12

Death

s p

er

1000 b

irth

s

SIDS/SUDI Rate NZ 1978 - 2012

SIDS rate Maori SIDS rate Non-Maori SIDS rate

5%

The Māori SIDS Prevention programme

A SUDI RATE PLATEAU

0

2

4

6

8

10

12

Death

s p

er

1000 b

irth

s

SIDS/SUDI Rate NZ 1978 - 2012

SIDS rate Maori SIDS rate Non-Maori SIDS rate

SO WHAT’S THE PROBLEM?

• .

Bedsharing

where there was

smoking in

pregnancy

Scragg et all NZMJ 108(1001): 218-222

Independent

of smoking

cessation

SO WHAT’S THE STRATEGY?

• .

Independent

of smoking

cessation

SO WHAT’S THE STRATEGY?

• .

Separate sleeping surface

Independent

of smoking

cessation

SO WHAT’S THE STRATEGY?

• .

Separate sleeping surface

in a shared bed

A WAHAKURA FOR EVERY MĀORI INFANT

• .

A WAHAKURA FOR EVERY MĀORI INFANT

• .

wahakura and Pēpi-Pod are appropriate and safe

A WAHAKURA FOR EVERY MĀORI INFANT

• . DHB Safe Sleep

Programme

2010

Christchurch

earthquake

Hawkes Bay 2011

DHB Safe Sleep

program

A WAHAKURA FOR EVERY MĀORI INFANT

after supplying a SSD to ¼ of the SUDI risk group

Post perinatal mortality by ethnicity

THE WAHAKURA STRATEGY WORKED

2009-2015 The infant mortality rate fell by 29%

THE WAHAKURA STRATEGY WORKED

THE WAHAKURA STRATEGY WORKED

THE WAHAKURA STRATEGY WORKED

THE WAHAKURA STRATEGY WORKED

.

THE WAHAKURA STRATEGY WORKED

.

THE WAHAKURA STRATEGY WORKED

.“…to invest in Pēpi-Pods the ministry

would need "a greater level of

evidence of effectiveness and

safety than is currently available."

INSTITUTIONAL RACISM?

INSTITUTIONAL RACISM?

"If those were Pakeha babies dying the Ministry

would be going to extraordinary lengths to

find an innovative way of saving them”

INSTITUTIONAL RACISM?

The Ministry of Health “may consider” funding …

THE WAHAKURA STRATEGY WORKED

Its going to be rolled out nationally

THE MCNZ & TE ORA & MINISTER OF HEALTH STRATEGY

.

Equitable outcomes

for Māori and

Pacific peoples

A culturally

competent workforce

Equitable health outcomes for Mā̄ori

THE MCNZ & TE ORA & MINISTER OF HEALTH STRATEGY

.

Cultural

sensitivity

Informative

Not systematic

Nice to know

Not directive

Cultural

competence

Instructive

Systematic

Resourced

Not monitored

THE MCNZ & TE ORA & MINISTER OF HEALTH STRATEGY

.

Cultural

sensitivity

Cultural

competence

Absolutely nowhere!

THE MCNZ & TE ORA (& MAYBE THE MINISTER OF HEALTH) STRATEGY

• Reviewed the ‘Cultural Competence’

strategy

• Current literature suggests we we should be

moving towards ‘Cultural Safety’

THE MCNZ & TE ORA (& MAYBE THE MINISTER OF HEALTH) STRATEGY

• The key difference between the two is the

notion of ‘power’ imbalance

• practitioners to examine themselves and the

potential impact of their own culture on clinical

interactions.

• our own biases, attitudes, assumptions,

stereotypes and prejudices that may be

contributing to a lower quality of healthcare for

some patients

THE MCNZ & TE ORA (& MAYBE THE MINISTER OF HEALTH) STRATEGY

Personally reflective and critical

• “understand one’s own assumptions, biases,

and values”

• “social justice, equity and respect”

THE MCNZ & TE ORA (& MAYBE THE MINISTER OF HEALTH) STRATEGY

Systematic throughout the organisation

• Ethnicity classification and collection

• Māori health workforce

• Supporting a culture of equity

• Tools to Support Individual Cultural Safety

• Understanding Bias and How to Reduce It

• Māori specific tools

THE WAHAKURA IS ENTRENCHED WHEN …

• .

Your

pregnant

PM sheds

a tear

when she

gets given

one

THE EQUITY STRATEGY IS ENTRENCHED WHEN …

Your Minister

of Health

sheds a tear

of joy when

equity starts

to emerge

in primary

care

PS ON SAFE SLEEP

• .

PS ON SAFE SLEEP

• .

PS ON SAFE SLEEP

• .

PS ON SAFE SLEEP

• .

Problems with this problem:

The numbers are small

The more recent numbers are ‘provisional’

The ‘increase’ is unlikely to be significant

So if we use postperinatal figures …

PS ON SAFE SLEEP

• .

PS ON SAFE SLEEP

• .

PS ON SAFE SLEEP

• .

What might be happening to PPN mortality after

2013?

The lower risk decreasing slowly until 2017/18

The higher risk have plateau’ed again until in 2017-18

PS ON SAFE SLEEP

• .

Why might this be happening?

The ‘old’ Safe Sleep programme covered only 27% of

risk group

We have picked the last of the ‘low hanging fruit’ in

2012/13?

The MoH rollout of ‘Safe Sleep’ is taking a while to get

going

HOW DO YOU MONITOR SUCCESS?