Abstract
IntroductionNurse-led programmes play an important role in providing expert education and management in the primary health care (PHC) of people with chronic illnesses. This study examined how a nurse-led diabetes programme set up by Te Hauora 0 Ngati Rârua, a Maori health provider, was effective in addressing the needs of clients. Effectiveness is viewed from a number of perspectives including: cultural appropriateness, integration with the community, accessibility, consumer participation and satisfaction, and health outcomes. The paper is in four sections: A background on health disparities and Maori, then methods, findings generated from a case study of the Te Hauora 0 Ngati Rârua service, and discussion.BackgroundIn Aotearoa/New Zealand, ethnic inequalities between Maori and non-Maori are the most consistent and compelling inequities in health. For example, Maori die on average 8.2 years younger than non-Maori (Statistics NZ, 2009). Of particular concern is the high Maori mortality from diseases that are amenable to treatment, such as diabetes, which affects Maori at a younger age, leading to higher rates of serious diabetic complications and a mortality rate which is four times higher than for non-Maori (Coppell et al., 2013; Statistics NZ).A focus for the New Zealand health system is to develop acceptable and accessible PHC services to keep people well and out of secondary services. To this end the Government funded 264 Maori organisations to provide affordable health services for their people (MOH, 2011). Kaupapa Maori providers attempt to ensure that client access to health services is unimpeded in cultural, financial or social terms, by offering 'by Maori, for Maori' services that incorporate traditional Maori practices and values (Boulton, Tamehana & Brannelly, 2013). As such, the Te Hauora O Ngati Rârua programme was centred on a Diabetes Nurse Educator role, which provided continuity of care across primary and secondary services. While this PHC nursing role has now been replaced by a generalist chronic disease state management role, the insights gained from the evaluation of this diabetes specific programme remain relevant. The findings are important for all nurses working with people (especially Maori) with any chronic condition.Literature ReviewResearch on disparities in health outcomes between Maori and non-Maori has been largely descriptive, identifying and defining the severity of diabetes within communities and different ethnic groups (Coppell et al., 2013; Lim, Chellumuthi, Crook, Rush & Simmons, 2008; Simmons, Rush & Crook, 2009a), and identifying barriers to accessing care (Baxter, 2002; Simmons, Lillis, Swan & Haar, 2007). Some large intervention studies have been undertaken (Coppell et al., 2009; Simmons et al., 2009b), but little is understood about the delivery and experiences of Maori attending targeted diabetes programmes.A number of studies have evaluated Maori health providers including monitoring client utilisation and satisfaction. Maori were found to access such providers because they were cheaper, geographically closer and offered culturally appropriate services (MOH, 2010; Wilson, 2008). Some researchers have considered contractual and organisational issues for Maori providers (Abel, Gibson, Ehau & Tipene Leach, 2005; Boulton, 2007), while others have described aspects of nurse-led PHC services (Hotu et al., 2010; Riley & Crawford, 2010), and found that nurses are able to spend longer with clients and do opportunistic assessments leading to better outcomes. But no studies have focused specifically on nurse-led diabetes programmes.Numerous international studies have explored the reach and effectiveness of diabetes management interventions and nurse-led services (Laws et al., 2012; Pun, Coates & Benzie, 2009; Smide & Hornsten, 2009), including programmes with indigenous populations and ethnic minorities (Ghosh & Spitzer, 2014; Lawrence, 2008). …
Highlights
Diabetes is a direct cause of symptoms, which can lead to death, but the significant burden of the disease relates to the development of complications that typically lead to hospitalisation or death.Diabetes is a health Gain Area for Maori and is one of the thirteen New Zealand Health Strategy action priority objectives for population Health
A test that measures the amount of hemoglobin bound to glucose. It is a measure of how much glucose has been in the blood during the past two to four months. Another perspective comes from Anderson and McDaniel (2000) who propose that health care organisations are best viewed as complex adaptive systems; If we recognise that health care organisations are complex adaptive systems operating in a professional milieu we focus on different things and arrive at different conclusions than if we believe that they are professional bureaucracies begging to be run more effectively and efficiently according to traditional rules of administrative behaviour. p. 84 These comments hold true for Te Hauora O Ngati Rarua (THONR) which values relationships, both with other organisations and clients above traditional business considerations
Other considerations were that THONR staff prefer to work collaboratively rather than appearing to compete with other services, and a significant part of the Maori Diabetes Nurse Educator (MDNE) role involved her working as part of the mainstream service provider at the local hospital
Summary
Diabetes is a direct cause of symptoms, which can lead to death, but the significant burden of the disease (and the majority of costs) relates to the development of complications that typically lead to hospitalisation or death.Diabetes is a health Gain Area for Maori and is one of the thirteen New Zealand Health Strategy action priority objectives for population Health. Future trends for the Tasman, Nelson and Marlborough region suggest that the Maori population will almost double from 9,500 in 1996 to 17,200 in 2021, and a further trend indicates that in twenty years Maori people with Diabetes will nearly double. Jo Janssen is evaluating the programme which means: 1) Describing the programme, 2) Hearing participants’ and staff views on what works well and not so well, and 3) Analysing participants’ clinical and assessment data. What will this mean for you if you decide to participate?. It is entirely your choice whether or not you participate in the study.
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