What predicts regression from pre-diabetes to normal glucose regulation following a primary care nurse-delivered dietary intervention? A study protocol for a prospective cohort study

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 \u3e25 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

Narratives of deprivation: Women's life stories around Maori sudden infant death syndrome

Maori babies in Aotearoa/New Zealand die of Sudden Infant Death Syndrome (SIDS) at over five times the rate of their non-Maori peers. Research and health promotion around modifiable risk factors has produced only a small improvement in this situation since the mid-1990s. This paper reports on life story interviews, conducted between 2002 and 2004, with nineteen mothers of Maori infants who have died of SIDS. Potential participants were identified and accessed with the support of the national Maori SIDS Prevention Programme care-workers, in both urban and rural locations throughout both main islands of New Zealand. The paper articulates, in a thematic fashion, the bereaved mothers' experiences of alienation, marginalisation and exclusion, as a testimony of lives lived under conditions of serious deprivation in an affluent society. Constructing these experiences as non-modifiable risk factors hinders the development of policy and health promotion interventions that could improve the conditions in which Maori mothers live and raise their babies. It is argued that new approaches that target those whose lives are described here and build on the WHO Social Determinants of Health framework are vital to the efforts of New Zealanders to attain health equity and stem the tide of devastating and preventable loss of Maori babies to SIDS.New Zealand/Aotearoa Maori Sudden infant death syndrome (SIDS) Socio-economic deprivation Narratives Ethnic disparities Mothers

Systems Mapping of the New Zealand Free and Healthy School Lunch Programme: Perspectives from Lunch Providers

As part of the COVID-19 economic recovery package, the Aotearoa New Zealand Government rolled out a universal free and healthy lunch programme to the 25% least advantaged schools nationwide. This study explored experiences of school lunch providers in the Hawke’s Bay region. The aim was to create a systems map identifying points of intervention through which the lunch programme could be improved to meet the goal of reducing child food insecurity. Twelve lunch providers were interviewed to generate casual loop diagrams which were examined and integrated to form a single systems map. Seven themes arose during analysis: teacher support, principal support, nutrition guidelines and government support, supply chain, ingredient suppliers, student feedback and food waste. Teacher support was important for getting students to try new foods and eat the nutritious lunches. Principal support was a strong theme impacting opportunities for broader student engagement. This study employed systems science to highlight the importance of support from different stakeholders within the lunch programme to achieve the goal of reduced child food insecurity. Further work is needed to ensure the programme meets the wider goals of the government and community, and to determine the potential broader benefits of the programme

Community Co-Design of Regional Actions for Children’s Nutritional Health Combining Indigenous Knowledge and Systems Thinking

Children’s nutrition is highly influenced by community-level deprivation and socioeconomic inequalities and the health outcomes associated, such as childhood obesity, continue to widen. Systems Thinking using community-based system dynamics (CBSD) approaches can build community capacity, develop new knowledge and increase commitments to health improvement at the community level. We applied the formal structure and resources of a Group Model Building (GMB) approach, embedded within an Indigenous worldview to engage a high deprivation, high Indigenous population regional community in New Zealand to improve children’s nutrition. Three GMB workshops were held and the youth and adult participants created two systems map of the drivers and feedback loops of poor nutrition in the community. Māori Indigenous knowledge (mātauranga) and approaches (tikanga) were prioritized to ensure cultural safety of participants and to encourage identification of interventions that take into account social and cultural environmental factors. While the adult-constructed map focused more on the influence of societal factors such as cost of housing, financial literacy in communities, and social security, the youth-constructed map placed more emphasis on individual-environment factors such as the influence of marketing by the fast-food industry and mental wellbeing. Ten prioritized community-proposed interventions such as increasing cultural connections in schools, are presented with the feasibility and likely impact for change of each intervention rated by community leaders. The combination of community-based system dynamics methods of group model building and a mātauranga Māori worldview is a novel Indigenous systems approach that engages participants and highlights cultural and family issues in the systems maps, acknowledging the ongoing impact of historical colonization in our communities

Infant care practices in New Zealand: a cross-cultural qualitative study

This paper describes and compares the infant care practices and beliefs of Maori, Tongan, Samoan, Cook Islands, Niuean and Pakeha (European) caregivers residing in Auckland, New Zealand. Focusing on four areas -- sources of support and advice; infant feeding; infant sleeping arrangements; and traditional practices and beliefs -- it explores inter-ethnic similarities and differences and intra-ethnic tensions. The international literature indicates that there can be significant cultural variation in infant care practices and in the meanings attributed to them. There is, however, little New Zealand literature on this topic, despite its importance for effective health service and health message delivery. Participants were primary caregivers of infants under 12 months. An average of six focus groups were conducted within each ethnic group, resulting in a total of 37 groups comprising 150 participants. We found similarities across all ethnic groups in the perceived importance of breastfeeding and the difficulties experienced in establishing and maintaining this practice. The spectrum of behaviours ranged widely with differences most pronounced between Pacific caregivers, especially those Island-raised, and Pakeha caregivers, especially those in nuclear families. Amongst the former, norms included: the family as central in providing support and advice; infant bedsharing; abdominal rubbing during pregnancy; baby massage; and the importance of adhering to traditional protocols to ensure infant well-being. Amongst the latter, norms included: strong reliance on professional advice; looser family support networks; the infant sleeping in a cot; and adherence to Western biomedical understandings of health and illness. Maori caregivers bridged the spectrum created by these groups and exhibited a diverse range of practices. Intra-cultural differences were present in all groups indicating the dynamic nature of cultural practices. They were most evident between Pacific-raised and New Zealand-raised Pacific caregivers, with the latter attempting to marry traditional with Western beliefs and practices.Infant care practices Cross-cultural New Zealand Maori Pacific Focus groups

Proximal and distal influences on dietary change among a diverse group with prediabetes participating in a pragmatic, primary care nurse-led intervention: A qualitative study

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 body mass index ≥ 25kg/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\u27s 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. Facilitators for adopting and maintaining changes were a strong desire to be healthy; personal determination; and feeling supported. Challenges were compromised control over life and environmental factors; feeling unsupported by others; social occasions; financial constraints; and living with other health conditions. Developing their own strategies to overcome challenges was empowering, enabling a sense of control. These factors were similar across demographic and glycaemic outcome groups. Conclusions: Influences on dietary change involved personal, interpersonal, organisational, environmental, and policy factors. Although findings appeared similar across groups, dietary interventions need to address the specific ways motivators, facilitators and challenges manifest for individuals and social groups, and be tailored accordingly within the context of the wider obesogenic and socioeconomic environment

Ngati and healthy: translating diabetes prevention evidence into community action

Introduction: Type 2 diabetes mellitus (T2DM) is a major health issue in New Zealand Maori. Clinical trials have demonstrated potential for the prevention of T2DM, but whether community public health programmes aiming to prevent diabetes are effective is untested. Objective: To describe the planning and design of an intervention aiming to translate T2DM prevention clinical trial evidence into a community-wide population health intervention in a high risk predominantly Maori community. Approach: Community concerns about the diabetes burden were heard by the local diabetes nurse, herself a tribal member, and discussed with a locally raised academic. Project planning ensued. The intervention and its evaluation were designed using a participatory community development model. The planned intervention had three components: community-wide health promotion initiatives conveying healthy lifestyle messages, community education and monitoring for identified high-risk individuals and their extended families, and a structural strategy aimed at adapting local environments to support lifestyle changes. The evaluation plan involved interrupted time series surveys coupled with formative and process evaluations rather than a randomised control trial design. Discussion: Consulting communities, validating community concerns and prioritising cultural and ethical issues were key steps. Time spent developing good relationships amongst the health provider and academic research team members at the outset proved invaluable, as the team were united in addressing the project planning and implementation challenges, such as funding obstacles that arose because of our ethically and culturally appropriate non-randomised control trial evaluation design. The pre-intervention survey demonstrated high rates of diabetes (13%), insulin resistance (33%) and risk factors, and provided evidence for positive, as opposed to negative, lifestyle intervention messages. Conclusion: Community-wide lifestyle interventions have the potential to reduce rates of type 2 diabetes and other chronic diseases in high-risk communities, but require a high level of commitment from the health sector and buy-in from the community. Adequate commitment, leadership, planning and resources are essential

Predictors of breastfeeding duration in a predominantly Māori population in New Zealand

Abstract 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