This research examines access to community resources - services, facilities and amenities that are potentially health promoting - in two New Zealand territorial authorities, and the policy and planning frameworks of each regarding community resources. International research evidence indicates that community resource access is potentially beneficial to health and wellbeing, through creating supportive environments for health, and providing venues to facilitate social connections. Review of the urban design and planning literature indicates that community resource access is strongly influenced by the dominant urban design and planning models. Geographic information systems were used to develop a Census meshblock-based indicator of community resource accessibility (the Community Resource Accessibility Index). Quantitative analysis examined associations of resource access with socio-economic and demographic population patterns. Qualitative analysis, using key informant interviews and document analysis, explored policies on community resource access, and the role of health and wellbeing as a policy goal for each territorial authority. Quantitative analysis revealed the socio-economically wealthier city had higher overall levels of community resource access, but within each city, more deprived areas had higher levels of access. The location of community resources within poorer areas reduces the mobility costs of people within these areas to access such resources, and makes more available the general health benefits of community resources. Qualitative analysis indicated community resources are important components of urban strategies. Historic patterns of community resource development, aggregated city wealth and local policies were important determinants of the level of community resource access. In New Zealand, as will be the case internationally to varying degrees, there is considerable scope for territorial authorities to enhance local health and wellbeing, through direct delivery of community resources, and through collaboration with external agencies to develop community resources that are outside the direct responsibilities of territorial authorities. When these findings are considered in the context of the passage of local government legislation in late 2002, there is growing potential for territorial authorities to use a variety of levers to enhance community resource access, and by implication, health and wellbeing. Health promoters have opportunities to engage with local government and contribute to urban development strategies, for the purposes of enhancing population health and reducing health inequalities.

Coeliac disease (CD) is a disorder resulting from interactions between diet, genome and immunity. This research seeks to further our understanding of the pathology of CD in regard to its secondary effects on the diversity of enteral microflora via changes in immune tolerance. It proposes that enteral mucosal pro-inflammatory change in CD is associated with a decrease in microbial diversity whilst remission from inflammation may result in an increase in enteral microbial diversity that could contribute to the restoration of tolerance. The first study analyses whether remission from active CD is associated with change in generic enteral microbial diversity by assessing people at diagnosis and following their response to gluten exclusion. A comparison is made to people without CD consuming a ’normal diet’. DGGE profiling of faecal microflora in subjects with CD at diagnosis (confirmed by serology and by duodenal biopsy) and over three consecutive months on a gluten-free diet (GFD) was performed and profiles were compared with those of age and gender matched control subjects taken at monthly intervals. Diversity of faecal microflora (measured as Simpsons Index ) was significantly lower in people with CD than in control subjects. It was possible to distinguish the profiles of coeliac subjects at diagnosis from those obtained after three months on a GFD but it was not possible to distinguish between the samples from control subjects taken at monthly intervals. The profiles of CD subjects after three months on a GFD were more dissimilar to those of the control subjects than those obtained prior to dietary treatment, chiefly on the basis of three bands that were not found in the faeces of any control subjects. The second study analyses dietary intake to determine if a lack of nutrients at diagnosis (before institution of a GFD) and at monthly intervals for three consecutive months post diagnosis (on a GFD) exists, as it is known that CD is associated with nutrient deficiencies resulting from malabsorption due to intestinal inflammation and damage. Subjects completed a customised food questionnaire at each sampling period. Dietary intake was analysed using Foodworks Professional 2007. Significant differences were identified in gluten, starch and carbohydrate intake but not in other macronutrients. Contrary to established literature, these analyses identified few significant differences in micronutrient intake within coeliac subjects over time, however, significant differences were found in iron and sodium.

This research is about the facilitation of taha wairua (spirituality) in mental health services. This research has been guided by kaupapa Maori frameworks and aimed to answer three questions: · Whether taha wairua, supported by matauranga Maori can be verified as a valid concept for use in mental health services · How Maori cultural and clinical workers facilitate taha wairua within a kaupapa Maori approach, and, · How the use and influence of taha wairua facilitates the inclusion of matauranga Maori. The increasing acceptability of alternative and holistic approaches to healing often with a spiritual component deserves serious consideration, especially within the area of mental health services. The literature shows that indigenous views of health and healing are valid and deserve recognition and acceptance in mental health services. The Treaty of Waitangi, the founding document of New Zealand, underpins Maori rights to the facilitation of taha wairua practices in Western health systems. Current New Zealand mental health policy and legislation provide strategies to progress the facilitation of Maori healing interventions in mental health services. It is noticeable, however, that these strategies are not built on the Treaty of Waitangi but are built on health disparities. The literature also supports the concept that there is a place in the recovery process for both spirituality and religious beliefs, and Western and cultural interventions. The data illustrate how tikanga Maori either practised solely in its natural form or within the framework of Maori models of health is beneficial to health outcomes for tangata whai ora and whanau when supported by the facilitation of taha wairua. The research data provided the foundation for components that can produce a framework for the facilitation of the concept of taha wairua within the scopes of practice of kaimahi Maori in mental health services. Some standards for best practice in supporting taha wairua within the cultural component of all Maori working in mental health have also been proposed. Maori do not have the critical mass to achieve all that has been raised in this research, and the principle of collective responsibility needs to be applied to provide the necessary resources and support to achieve implementation of Maori healing frameworks to facilitate taha wairua in mental health services. It is hoped the knowledge gained from this research will be useful to policy makers and managers in gaining insight into the benefits of healing for tangata whaiora, whanau and kaimahi Maori through the provision of appropriate cultural interventions and in providing an appropriate environment to enable physical and spiritual healing to take place. It is also hoped Maori too will find this research of benefit, particularly to inform scopes of practice, thereby providing potential for new ways to achieve best practice cultural and clinical practice.

Whole document restricted, see Access Instructions file below for details of how to access the print copy. / This exploratory study investigates Traumatic Brain Injury (TBI) rehabilitation processes and outcomes among culturally diverse outpatients in community-based rehabilitation who have sustained a Mild to Moderate TBI. The major aims of this study are twofold: firstly, to determine whether community-based rehabilitation outcomes following TBI differ across Mäori, Pacific and Pakeha cultures; and secondly, to determine and identify any service delivery needs for Mäori and Pacific people in TBI rehabilitation that may be distinct from Pakeha. A fixed comparative non-experimental design was utilised where participants were selected using direct control based on their self-identified ethnic group resulting in sub-samples of 11 Mäori, l1 Pacific and 11 Pakeha (n=33). A "Close Other" from their care-giving support network was selected by the participant to take part in the study (n=20). Each participant completed the Neurobehavioural Cognitive Status Examination (Cognistat), the Brain Injury Community Rehabilitation Outcome Scales (BICRO Scales), the Client Satisfaction Questionnaire (CSQ-31), the Beck Depression Inventory, 2nd Edition (BDI-II), the Impact of Events Scale Revised (IES-R) and a semi-structured qualitative interview, while a "Close Other" completed a BICRO "Carer" questionnaire. Results indicate that all participants were at a homogenous level of overall cognitive functioning but Pacific peoples scored significantly lower than both Mäori and Pakeha on two Language subtests and significantly lower than Pakeha on the Memory subtest. Statistical analysis suggests that both Years of Formal Education and English as a Second Language are important factors contributing to these differences. Individual handicap increased following TBI and decreased following rehabilitation, with no significant difference across cultures and suggesting efficacy of rehabilitation. Of the total sample, 42% scored in the clinically depressed range (half of whom were Pakeha) and 24% of the sample showed mild signs of post-traumatic stress (of whom almost 90% were Mäori or Pacific). Although 97% of participants were generally satisfied with their overall rehabilitation service, Mäori and Pacific people were significantly less satisfied with their Physical Surroundings and the Quantity of Services they received. In conclusion, there appears to be universalities in TBI experience and global rehabilitation outcomes that transcends individual cultures. However, there are micro-level cultural variations that have valuable implications when planning culturally appropriate rehabilitation services for the future. For Mäori and Pacific People, acculturation levels will determine the extent to which these implications apply.

Background Prior to the commencement of this study, gambling was not considered a significant health issue for Maori, even though the first national gambling prevalence study in New Zealand in 1991, identified that Maori had at least three times the risk of problem gambling of non-Maori. In the early 1990s, through the provision of a gambling telephone helpline and gambling counselling services, it was identified that Maori and in particular Maori women, were increasingly seeking help with problems with gambling. Gambling is an integral part of the culture of New Zealand. To understand gambling and problem gambling requires an understanding of the social, economic and cultural context it plays in being Maori. Aim of Study This study investigated whether gambling and problem gambling is an emerging health issue for Maori and if so, the extent of the problem, its effects on Maori and health approaches, and interventions which are likely to be effective for Maori. A public health approach to address problem gambling has been investigated and a plan developed. Methodology This study has been undertaken from a Maori-centered and an action-oriented research approach. It has involved integrating existing and new information from the following sources: Maori patterns of gambling and expenditure, gambling prevalence data, Maori utilisation of gambling treatment services and gambling by indigenous people. Fifteen Maori problem gamblers have been interviewed to understand from the "inside looking out" their experience of problem gambling. Thirty key informants have also been interviewed to understand from the "outside looking in" their perspective as to whether gambling is an emerging health issue for Maori. This research has involved quantitative analysis and qualitative research. Findings This study has found that problem gambling is an emerging public health issue for Maori. The effects of problem gambling for Maori are invisible and masked by other health problems such as alcohol abuse or mental health problems. Maori prevalence of problem gambling is similar to other indigenous populations which have shared similar historical and socio-economic experiences. Problem gambling often leads to crime, imprisonment, development of other health problems and the break down of families. Focusing alone on problem gambling ignores the real issues for Maori, a wider perspective is needed which focuses on Maori and tribal development. A public health strategy is proposed to reduce Maori gambling related harm.

An enhanced notified enteric disease surveillance trial began on 1 July 2007 and continued until 30 June 2008. The aim of the trial was to measure the quality, timeliness and completeness of data collected and submitted by a regional Public Health Service (PHS) to the Institute of Environmental Science and Research Limited (ESR), via the national disease database (EpiSurv) for notified cases of enteric diseases. The trial evaluated two different methods of data collection: postal questionnaires and telephone interviews. Telephone interview techniques were used to improve the contact rate, timeliness and completeness of data gathered from all notified cases of campylobacteriosis in the Manawatu, Horowhenua and Tararua regions. The target set for the project was to achieve a 95% contact rate with 90% full completion of all EpiSurv data fields. For all notified cases of campylobacteriosis a 97% contact rate was achieved in a time frame of between zero to 20 days (three day median) and completeness of all the EpiSurv case report fields ranged between 96 – 100% in the final data. Prior to the commencement of the study, between 1 July 2004 to 30 June 2005, MidCentral PHS (MCPHS) made contact with around 58% of all notified cases of campylobacteriosis and 77% of all other notified enteric disease cases1 . A short pre-screen mail questionnaire, with reply-paid envelope, was sent to all notified cases of cryptosporidiosis, giardiasis, salmonellosis and yersiniosis in the MCPHS regions. EpiSurv case report fields were completed using information supplied in the returned questionnaires. Return rate, timeliness, and completeness were compared with the telephone interview group. Fifty three percent of cases we attempted to contact via mail questionnaire responded within two to 63 days (six day median) and completeness of all the EpiSurv case report fields ranged between 81 – 100%. In addition, we monitored the newly introduced ESR Early Aberration Reporting System (EARS) flags for increased levels of disease compared to historical disease rates, and assessed its usefulness as a tool to identify potential outbreaks in the region. While no outbreaks that had not already been identified by PHS staff were found by monitoring the EARS system, EARS has become an important tool in the MCPHS for comparing our rates of disease with bordering PHSs. EARS also provided a good quick reference tool for media enquiries and the graphs produced in EARS have been well utilised as visual aids for training and seminars presented during the trial period. The results of the surveillance trial initiatives were compared to the rest of New Zealand (NZ) over the same time frame and with a comparable, medium-sized, PHS. While the results of the telephone interviews from the MCPHS trial were close to the comparable PHS, they were significantly higher than for the rest of NZ. The postal questionnaires achieved a lower contact rate than the comparable PHS but similar to the rest of NZ. However, the quality of data gathered in the returned MCPHS postal questionnaire was significantly higher in most fields. Additional analysis was undertaken which indicated that those cases living in higher deprivation and rural areas were less likely to respond to a postal questionnaire. An over-representation of common enteric disease notifications from rural areas in the MCPHS was also highlighted by our research. This trial has shown the effectiveness of utilising telephone interviews and telemarketing techniques for gathering timely and complete data for human enteric disease surveillance within the MCPHS. It has also demonstrated that a short pre-screen questionnaire can be effective in collecting good quality data needed to complete the standard EpiSurv case report form.

The global phenomenon of population ageing has major ramifications for societies and governments around the world. In New Zealand, efforts to address the impacts of population ageing have centred on the Government’s Positive Ageing Strategy. This is a thesis about positive ageing as viewed through Maori eyes. It has been informed by the memories and aspirations of older Maori who have lived through challenging times but have emerged with qualities that enable them to enjoy older age and to contribute to their own whanau, Te Ao Maori (the Maori world) and Te Ao Whanui (wider society). The thesis is philosophically located at the interface between Western science and matauranga Maori, an Indigenous inquiry paradigm. It is argued that Western science and matauranga Maori are relevant to research in the contemporary context, and reflect the realities of older Maori who live in both Te Ao Maori and Te Ao Whanui. The study used research techniques that draw on Western science (literature review), matauranga Maori (review of 42 Maori proverbs) and both inquiry paradigms simultaneously (qualitative study with 20 older Maori people). The research found that Maori positive ageing can be characterised by a two dimensional concept that incorporates a process dimension and an outcome dimension. The process dimension is consistent with a lifecourse perspective and therefore recognises that ageing is a life-long process where circumstances encountered during life may impact cumulatively and manifest in old age. The outcome dimension can be described in terms of complementary ‘universal’ and Maori specific outcome domains. The universal outcome domains are encapsulated in the New Zealand Positive Ageing Strategy and more recently are expressed in the Positive Ageing Indicators 2007 Report. The Maori-specific outcome domains identified in this Study are: kaitiakitanga – stewardship; whanaungatanga – connectedness; taketuku – transmission; takoha – contribution; takatu – adaptability; and, tino rangatiratanga – selfdetermination. The overarching outcome domain is taupaenui – realised potential.

A whanau is a social construct of Maori society in Aotearoa/New Zealand that is likened to an extended family. This thesis describes principles and practice that whanau utilise in decision processes from the findings of a retrospective qualitative case study of three whanau, who decided to participate in genetic research into a medical condition affecting their health. Four elements of whanau decision processes emerged from the data. Hui, rangatiratanga, manaakitanga and kotahitanga are Maori constructs that emphasise the collective nature of whanau decision making, and substantiate philosophical, theoretical and anecdotal evidence that Maori have distinctive ways of reaching decisions, underpinned by unique philosophical conventions. The results of this research place greater significance on the process of decision making than actual decisions, an incidental finding that has not been articulated by previous studies of Maori health and whanau. Contrary to western theoretical knowledge of decision making, whanau decision processes are collective activities. Individual decision making is closely linked to and depends on the collective, because individual identity manifests from the collective, and individual wellbeing is closely linked to that of the collective. When decision processes are familiar to members of a whanau, they are more likely to engage in decision making because they have a greater sense of knowledge and thus control of the processes, and they feel more able to contribute meaningfully to achieving aspirations for their own health. This thesis provides evidence that the New Zealand health sector, health legislation and policies are largely unfavourable for guaranteeing whanau engagement in decision processes. Yet, whanau decision making is an overall objective of the Government’s Maori Health Strategy: He Korowai Oranga, to address inequalities in health between Maori and other New Zealanders that have unacceptably become the norm.

An enhanced notified enteric disease surveillance trial began on 1 July 2007 and continued until 30 June 2008. The aim of the trial was to measure the quality, timeliness and completeness of data collected and submitted by a regional Public Health Service (PHS) to the Institute of Environmental Science and Research Limited (ESR), via the national disease database (EpiSurv) for notified cases of enteric diseases. The trial evaluated two different methods of data collection: postal questionnaires and telephone interviews. Telephone interview techniques were used to improve the contact rate, timeliness and completeness of data gathered from all notified cases of campylobacteriosis in the Manawatu, Horowhenua and Tararua regions. The target set for the project was to achieve a 95% contact rate with 90% full completion of all EpiSurv data fields. For all notified cases of campylobacteriosis a 97% contact rate was achieved in a time frame of between zero to 20 days (three day median) and completeness of all the EpiSurv case report fields ranged between 96 – 100% in the final data. Prior to the commencement of the study, between 1 July 2004 to 30 June 2005, MidCentral PHS (MCPHS) made contact with around 58% of all notified cases of campylobacteriosis and 77% of all other notified enteric disease cases1 . A short pre-screen mail questionnaire, with reply-paid envelope, was sent to all notified cases of cryptosporidiosis, giardiasis, salmonellosis and yersiniosis in the MCPHS regions. EpiSurv case report fields were completed using information supplied in the returned questionnaires. Return rate, timeliness, and completeness were compared with the telephone interview group. Fifty three percent of cases we attempted to contact via mail questionnaire responded within two to 63 days (six day median) and completeness of all the EpiSurv case report fields ranged between 81 – 100%. In addition, we monitored the newly introduced ESR Early Aberration Reporting System (EARS) flags for increased levels of disease compared to historical disease rates, and assessed its usefulness as a tool to identify potential outbreaks in the region. While no outbreaks that had not already been identified by PHS staff were found by monitoring the EARS system, EARS has become an important tool in the MCPHS for comparing our rates of disease with bordering PHSs. EARS also provided a good quick reference tool for media enquiries and the graphs produced in EARS have been well utilised as visual aids for training and seminars presented during the trial period. The results of the surveillance trial initiatives were compared to the rest of New Zealand (NZ) over the same time frame and with a comparable, medium-sized, PHS. While the results of the telephone interviews from the MCPHS trial were close to the comparable PHS, they were significantly higher than for the rest of NZ. The postal questionnaires achieved a lower contact rate than the comparable PHS but similar to the rest of NZ. However, the quality of data gathered in the returned MCPHS postal questionnaire was significantly higher in most fields. Additional analysis was undertaken which indicated that those cases living in higher deprivation and rural areas were less likely to respond to a postal questionnaire. An over-representation of common enteric disease notifications from rural areas in the MCPHS was also highlighted by our research. This trial has shown the effectiveness of utilising telephone interviews and telemarketing techniques for gathering timely and complete data for human enteric disease surveillance within the MCPHS. It has also demonstrated that a short pre-screen questionnaire can be effective in collecting good quality data needed to complete the standard EpiSurv case report form.

An enhanced notified enteric disease surveillance trial began on 1 July 2007 and continued until 30 June 2008. The aim of the trial was to measure the quality, timeliness and completeness of data collected and submitted by a regional Public Health Service (PHS) to the Institute of Environmental Science and Research Limited (ESR), via the national disease database (EpiSurv) for notified cases of enteric diseases. The trial evaluated two different methods of data collection: postal questionnaires and telephone interviews. Telephone interview techniques were used to improve the contact rate, timeliness and completeness of data gathered from all notified cases of campylobacteriosis in the Manawatu, Horowhenua and Tararua regions. The target set for the project was to achieve a 95% contact rate with 90% full completion of all EpiSurv data fields. For all notified cases of campylobacteriosis a 97% contact rate was achieved in a time frame of between zero to 20 days (three day median) and completeness of all the EpiSurv case report fields ranged between 96 – 100% in the final data. Prior to the commencement of the study, between 1 July 2004 to 30 June 2005, MidCentral PHS (MCPHS) made contact with around 58% of all notified cases of campylobacteriosis and 77% of all other notified enteric disease cases1 . A short pre-screen mail questionnaire, with reply-paid envelope, was sent to all notified cases of cryptosporidiosis, giardiasis, salmonellosis and yersiniosis in the MCPHS regions. EpiSurv case report fields were completed using information supplied in the returned questionnaires. Return rate, timeliness, and completeness were compared with the telephone interview group. Fifty three percent of cases we attempted to contact via mail questionnaire responded within two to 63 days (six day median) and completeness of all the EpiSurv case report fields ranged between 81 – 100%. In addition, we monitored the newly introduced ESR Early Aberration Reporting System (EARS) flags for increased levels of disease compared to historical disease rates, and assessed its usefulness as a tool to identify potential outbreaks in the region. While no outbreaks that had not already been identified by PHS staff were found by monitoring the EARS system, EARS has become an important tool in the MCPHS for comparing our rates of disease with bordering PHSs. EARS also provided a good quick reference tool for media enquiries and the graphs produced in EARS have been well utilised as visual aids for training and seminars presented during the trial period. The results of the surveillance trial initiatives were compared to the rest of New Zealand (NZ) over the same time frame and with a comparable, medium-sized, PHS. While the results of the telephone interviews from the MCPHS trial were close to the comparable PHS, they were significantly higher than for the rest of NZ. The postal questionnaires achieved a lower contact rate than the comparable PHS but similar to the rest of NZ. However, the quality of data gathered in the returned MCPHS postal questionnaire was significantly higher in most fields. Additional analysis was undertaken which indicated that those cases living in higher deprivation and rural areas were less likely to respond to a postal questionnaire. An over-representation of common enteric disease notifications from rural areas in the MCPHS was also highlighted by our research. This trial has shown the effectiveness of utilising telephone interviews and telemarketing techniques for gathering timely and complete data for human enteric disease surveillance within the MCPHS. It has also demonstrated that a short pre-screen questionnaire can be effective in collecting good quality data needed to complete the standard EpiSurv case report form.