Te Rongoā Kākāriki: Kanohi-ki-te-kanohi, e pai ana? A mixed methods randomized trial of two approaches to the Green Prescription
In Aotearoa New Zealand the prevalence of Type 2 diabetes mellitus (T2DM) is three times higher for Māori than New Zealand European and is increasing. Participation of Māori newly diagnosed with T2DM with the Te Rongoā Kākāriki (Green Prescription, GRx) health service is lower than for New Zealand European. This thesis has four linked aims: i) to examine differences in the engagement and active participation (adherence) (Chapter 4), ii) to compare changes in physical and metabolic measures (Chapter 5) using a kanohi-ki-te-kanohi (face-to-face) mode of delivery or waea (telephone) for Māori and New Zealand European, iii) to better understand the perceptions, knowledge and activities of the participants that enabled them to participate (Chapter 6) and iv) to understand better how participants make and maintain lifestyle changes through the GRx health service.
This GRx research study was a randomised trial (ACTRN012605000622606) using a kaupapa Māori framework and research principles, with a mixed methods approach, in which Māori and New Zealand European women and men newly diagnosed with T2DM were randomised to either kanohi-ki-te-kanohi (face-to-face) mode of delivery or waea (telephone) for six months. Physical and metabolic measurements were made, questionnaires completed and interviews undertaken at baseline, six and 12 months. After 12 months medical records were accessed for glycated haemoglobin (HbA1c) and lipid measures associated with metabolic risk. Analysis of variance (ANOVA) was used to examine for differences among the categorical variables of ethnicity, mode of delivery and gender.
A total of 152 (96 women, 56 men) participants aged 30-86 years consented to participate and completed baseline measurements. Recruitment was less than the target (240), but equal numbers of Māori and New Zealand European were recruited, from GRx referrals that were predominantly non-Māori. The participants included 68 Māori, 70 New Zealand European and 14 ‘Other’ (neither Māori nor New Zealand European). The main findings excluded the ‘Other’ group. More New Zealand European than Māori remained in the randomised trial at six (74% vs. 51%) and 12-months (56% vs. 30%), respectively. There was a trend for more participants to remain in the kanohi-ki-te-kanohi (face-to-face) (68%) compared with the waea (telephone) (58%) mode of delivery at six months.
The physical and metabolic data revealed that at the end of the 6-month GRx intervention, for 88 participants, body weight was reduced by 1.6 kg (95% CI, 0.3 to 2.8) and waist circumference by 3.6 cm (95% CI, 2.4 to 4.9). At six months, of the 63 who had HbA1c measured there was a reduction of 1.3% (95% CI, 0.3 to 2.4). No differences by GRx mode of delivery, ethnicity or gender were observed in these analyses. At the 12-month follow-up, for the 59 participants measured (20 Māori and 39 New Zealand European), the body weight and waist circumference measures were reduced from baseline by 2.3 kg (95% CI, 0.5 to 4.0) and 5.5 cm (95% CI, 3.4 to 7.6), respectively. In 36 participants (12 Māori and 24 New Zealand European) the HbA1c was reduced by 0.6% (95% CI, 0.0 to 1.3). No differences for GRx mode of delivery, ethnicity or gender were observed. In general, improvements in physical characteristics were associated with improvements in HbA1c concentrations. The greatest improvement was in those who had higher HbA1c (worse glycaemic control) at baseline.
Data from the questionnaires showed that most participants were inactive at baseline (≤ 30 min/day) and 25% reportedly increased their participation in walking activities at six and 12 months with no differences noted between mode of delivery, ethnic groups or gender. Overall, no changes in intensity and time spent in physical activity were found between six and 12 months. Optimism and positive self-belief in ability to manage their diabetes did not change. However, a small association was found between the changes in the perceived need for special training and changes in body weight, waist circumference and the diabetes empowerment score.
Five key themes from the interviews, in relation to improved self-management of T2DM, were found. The themes involved: whānaungātanga: strengthening relationships; pātaka mātauranga: sharing knowledge; whakamana: empowerment; manaakitanga: giving and receiving support and assistance from others and pikitia ngā maunga: overcoming barriers. A shared responsibility of the participants, the researcher and Māori GRx kaiwhakahaere, including the general practitioner and/or practice nurse to communicate better and overcome barriers, was identified. Kanohi-ki-te-kanohi (face-to-face) was the preferred approach to GRx even though there were no differences in metabolic/physical outcomes with mode of delivery. Overall, participants endorsed that the initial kanohi-ki-te-kanohi (face-to-face) contact was instrumental to their understanding and participation.
To conclude, the GRx health service delivered by Sport Waikato Regional Sports Trust was associated with comparable improvements in HbA1c and weight among Māori and New Zealand European with no difference between the two modes of delivery. Kanohi-ki-te-kanohi (face-to-face) contact was the preferred approach to GRx. Participation by Māori once referred was relatively high and probably higher than New Zealand European, but with high drop-out. Understanding of GRx was poor prior to entering the service. The major hurdle to GRx uptake among Māori appears to be in primary care. Primary care needs to improve their explanation of GRx and their linkage with the GRx programme. New strategies are required to maintain participation.