Kainamu Whakamomori: Attempted      Suicide in Aotearoa       Dr Nicole M. C oupe KÄI TAH U , TE ATIAWA                 Po...
Summary   Aotearoa contemporary context   Maori attempted suicide medical record review   Maori attempted suicide case ...
Definitions   Changes in coding   Differences in DHB reporting and patient management   Hospitalisations are numbers of...
Intentional self harm rates            A otearoa         Non-Mäori            Mäori          100,000   No.      100,000   ...
Suicide & Intentional Self Harm Rates          Age standardised          rate (per 100,000)    450    400                 ...
Suicide & Intentional Self Harm Rates          Age standardised          rate (per 100,000)    450    400                 ...
DHB intentional self harm         West Coast (250.3) &          Canterbury (218.7)         Waitemata, Auckland,         ...
Hospitalisation & Deprivation   Increase    hospitalisations         Age standardised                             rate (p...
Other researchers of suicide attempts   Bennett – Päkeh ä youth suicid e   Tiatia – Pacific youth suicid e   Beautrais ...
Mäori attempted suicide   M äori M ed ical Record Review   M äori Attem pted Suicid e C ase C ontrol
Study zone
Mäori Medical Record Review   R e cord s from E m e rge ncy D e p artm e nts b e twe e n Ju ly 1 s t 1 999 –    D e ce m ...
Conclusion   1 M äori e ve ry 2 d ays p re s e nts to    Au ckland E D for D S H   20% p re s e nte d following O D anal...
Kaupapa Mäori Methodology   C om m u nity d rive n   S e lf id e ntification    re s e arch                             ...
Mäori case control study   C AS E S :                         C O N TR O LS :      n= 250                            n...
Method Mäori case control study   Q u e s tionnaire (> 400 qu e s tions )        C u ltu ral Ind icators        D e m o...
Results   C as e s e le ction       1 s t Au gu s t 2000 to 1 3th Janu ary 2002 (1 5m th s )   Inte rvie ws com p le te...
Culture & Mäori attempted suicideC ulture                                 All ages                   16-24Identity & whaka...
Measuring culture                                                   Identity Profiles       Cultural indicators       Secu...
Te Ao Mäori Model                                     A+G +            A+G +          A+G +            A+G +            A+...
Whakamomori: Mäori suicide prevention modelVariable                                     OR      C onfidenc e   P valueD e ...
Whakamomori: Mäori suicide prevention modelVariable                                    OR        C onfidenc e      P value...
Translation research - implementation   Whakawhanaungatanga – Self Harm & Suicide    Prevention Collaborative   Case Fin...
Whakawhanaungatanga   Implementation of    guidelines into       Emergency        Departments       Mental Health      ...
Methodology   Tools     National targets     Mapping an individual clients pathway      through secondary care     Pla...
National Targets   90% of people attending the ED identified with self-harm    or suicidality are seen within 1 hour   1...
Client Pathway Map   What is a typical problem at each point of the process?   Are there examples of best practice?   I...
Plan – Do – Study – Act   What are we trying to    accomplish?       An aim with a clear outcome        target is essent...
Who’s In   Emergency departments, mental health & Maori health    services in DHB’s       Northland       Waitemata    ...
Primary Care tool development   Detection & Management of people at risk of    suicide in the primary care setting      ...
Methodology   Kaupapa Epidemiology       Randomised control trial         −   Raukura Hauora o Tainui (PHO), West Auckla...
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Kainamu Whakamomori: Maori Attempted Suicide in Aotearoa

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Dr Nicole Coupe. SPINZ Symposium, Dunedin, 28 November 2006. http://www.spinz.org.nz

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  • Not possible to compare to previous years as the definition of intentional self harm has been extended
  • Area of high concentration Mäori suicide and suicidal behaviours
  • Epidemiology driven by kaupapa Mäori processes
  • Identification of case and controls
  • Several validated questionnaires employed Over 400 questions in total
  • 15 months selection 27 months interviewing High response rates for Mäori
  • Cultural identity indicators 6 items identity genealogy marae access whanau (family) access whenua (land) access Mäori language ability Production of 4 discrete identity profiles
  • Cultural identity profiles with respect to possible confounders age & gender SES GHQ-28 HADS Substances Abuse Only significant factors secure identity protective wrt age, gender, substances & abuse Notional identity increases risk by age, gender and SES
  • Mäori Suicide prevention model combining demographics, cultural identity, health status, abuse, substances and SES Having a poor general health status is the only significant factor to affect the level of Mäori attempted suicide
  • Removing general health status from the model reveals more significant factors that may affect the level of Mäori attempted suicide cultural identity abuse marujuana
  • Kainamu Whakamomori: Maori Attempted Suicide in Aotearoa

    1. 1. Kainamu Whakamomori: Attempted Suicide in Aotearoa Dr Nicole M. C oupe KÄI TAH U , TE ATIAWA Pos t Doctoral Fellow N ga P ae o te Maram atanga n.m.coupe@mas s ey.ac.nz
    2. 2. Summary Aotearoa contemporary context Maori attempted suicide medical record review Maori attempted suicide case control study Translating research into suicide prevention
    3. 3. Definitions Changes in coding Differences in DHB reporting and patient management Hospitalisations are numbers of episodes rather than individual people  Readmissions same condition counted as additional discharges  People transferred between hospitals are counted each time
    4. 4. Intentional self harm rates A otearoa Non-Mäori Mäori 100,000 No. 100,000 No. 100,000 No.Total 1 31 .5 5292 1 34.1 4573 1 1 5.1 71 9Fem ale 1 78.6 361 0 1 85.0 31 43 1 43.9 467M ale 84.2 1 682 83.3 1 430 85.0 252
    5. 5. Suicide & Intentional Self Harm Rates Age standardised rate (per 100,000) 450 400 Male 350 Female 300 250 200 150 100 50 0 10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85+ Age groups (years) Total 20-24 years (300.0/100,000) Males 25-29 years (201.6/100,000) Females 15-19 years (425.4/100,000) Mäori 20-24 years (277.5/100,000)  Males 20-25 years (210.0/100,000)  Females 20-24 years (343.4/100,000)
    6. 6. Suicide & Intentional Self Harm Rates Age standardised rate (per 100,000) 450 400 Male 350 Female 300 250 200 150 100 50 0 5-14 15-24 25-44 45-64 65+ Age groups (years) 15-24 years both males and females Rates decrease with life style age group
    7. 7. DHB intentional self harm  West Coast (250.3) & Canterbury (218.7)  Waitemata, Auckland, Counties, Waikato, Hutt Valley, Nelson Marlborough, Otago  125-187/100,000  Capital & Coast (61.9) & Southland (63.1)
    8. 8. Hospitalisation & Deprivation Increase hospitalisations Age standardised rate (per 100,000) with increased 180 160 deprivations 140 120 100 Least deprived 80 60 areas 83/100,000 40 20 0 Most deprived 1 2 3 NZDep2001 quintile 4 5 areas 154.7/100,000
    9. 9. Other researchers of suicide attempts Bennett – Päkeh ä youth suicid e Tiatia – Pacific youth suicid e Beautrais – Serious suicid e attem pts H atcher – Problem solving therapy after suicid e attem pt N ad a-Raja, C ollings, C oggan
    10. 10. Mäori attempted suicide M äori M ed ical Record Review M äori Attem pted Suicid e C ase C ontrol
    11. 11. Study zone
    12. 12. Mäori Medical Record Review R e cord s from E m e rge ncy D e p artm e nts b e twe e n Ju ly 1 s t 1 999 – D e ce m b e r 31 s t 2000 N = 252 ind ivid u als / 0 p re s e ntations - 1 8m th s 31  61 % fe m ale ; 85% s ole M äori, 43% C ou ntie s M anu kau , 25% e m p loye d , 21 % u ne m p loye d , 1 7% b e ne ficiarie s , 56% living with wh änau  70% P ois oning (53% p re s crip tion m e d ications , 20% analge s ics ), 1 5% cu tting or p ie rcing H om e , 1 800-2400 h ou rs , 37% p re s e ntations alcoh ol (fe m ale s you nge r), 1 5% M arij ana u 71 % firs t tim e rs – re p e at p re s e ntations (74% 2x, 1 7% 3x, 9% 5x) E D s e rvice 53 % m e d ications , 88% p s ych iatric, 1 6% cu ltu ral inform e d , 1 3% ab s cond e d or re fu s e d s e rvice s 87% with p os t d is ch arge p lans , 67% h om e , 1 8% p s ych iatric care , F ollow u p C M H S , H os p ital p s ych s e rvice s G P , C u ltu ral S e rvice s 4%
    13. 13. Conclusion 1 M äori e ve ry 2 d ays p re s e nts to Au ckland E D for D S H 20% p re s e nte d following O D analge s ics 50% p re viou s ly b e e n to E D and 33% m ore th an twice O ve rnigh t ad m is s ions allow cu ltu rally ap p rop riate as s e s s m e nt and follow u p
    14. 14. Kaupapa Mäori Methodology C om m u nity d rive n S e lf id e ntification re s e arch P articip ant M äori p rincip al controlle d inte rvie w inve s tigator Tim e M äori re s e arch te am P lace M äori d e cis ion Koh a m aking P artne rs h ip s with D is s e m ination non-M äori
    15. 15. Mäori case control study C AS E S : C O N TR O LS :  n= 250 n= 250  M äori (s e lf M äori (s e lf Id e ntification) id e ntification)  1 6 – 50 ye ars 1 6 – 50 ye ars  Atte m p te d s u icid e P op u lation b as e d (d iagnos e d ) Au ckland R e gion  Au ckland re gion 227 s ite s ; 3045  3 h os p itals (Au ckland , h ou s e h old s M id d le m ore , N orth S h ore )
    16. 16. Method Mäori case control study Q u e s tionnaire (> 400 qu e s tions )  C u ltu ral Ind icators  D e m ograp h ic & s ocio-e conom ic factors  G e ne ral H e alth Q u e s tionnaire (G H Q – 28)  H os p ital Anxie ty & D e p re s s ion S cale (H AD S ) & M e ntal H e alth F actors  S u b s tance U s e (C AG E )  H e alth s e rvice acce s s ib ility  S ocial s u p p orts  E nvironm e ntal factors  S u icid ality (C ID I)  Be ck’s S cale of S u icid e Inte nt (S IS – 1 4)
    17. 17. Results C as e s e le ction  1 s t Au gu s t 2000 to 1 3th Janu ary 2002 (1 5m th s ) Inte rvie ws com p le te N ov 2002 (27m th s ) 21 4 (85.5% ) cas e s & 203 (81 .2% ) controls
    18. 18. Culture & Mäori attempted suicideC ulture All ages 16-24Identity & whakapapa (family tree) OR CI OR CI S ole Mäori identity 2.4 1 .59, 3.63 2.6 1 .23, 5.68 Knowledge 4+ generations 0.25 0.1 4, 0.44 0.4 0.1 1 , 1 .08 Name Iwi (tribe) 0.35 0.1 8, 0.67 0.3 0.1 1 , 0.94Marae (village common) 0.09 0.04, 0.21 0.1 0.01 , 0.27Tikanga (Mäori protocols ) 1.8 1 .1 8, 2.75 1.3 0.6, 2.8Whänau (family) links 0.16 0.09, 0.29 0.3 0.09, 0.72Whenua (Mäori land) 0.22 0.1 3, 0.36 0.3 0.1 2, 0.66Kai (Mäori food) 0.26 0.1 7, 0.40 0.2 0.08, 0.43Te Reo Mäori (Mäori language) 0.19 0.1 0, 0.35 1.9 0.74, 5.03
    19. 19. Measuring culture Identity Profiles Cultural indicators Secure Positive Notional Compromised2: Identify as Mäori Yes Yes Yes No4: No. of Mäori generations 3+ 2 1 Any response8.1: Times to own marae 5+ 2-4 0-1 Any response9.4: Role whänau plays in life > large Small <small Any response10: Interest Mäori land Yes Yes/dk No Any response basic -15: Te reo Mäori ability adv - native learner No ability Any response Q.2 = yes + Q.2 = yes + Q.2 = yes 3 other 2 other + 3 other Q.2 = no positive positive negative + any otherMinimum criteria responses responses responses response
    20. 20. Te Ao Mäori Model A+G + A+G + A+G + A+G + A+G +Cultural Indicators A+G SES GHQ HADS Drugs AbuseCultural identity profile X23=33.62 X23=19.09 X23=3.06 X23=2.76 X23=24.15 X23=18.79 0.28 0.4 1.1 0.5 0.2 0.2Secure (0.1, 0.7) (0.1, 1.1) (0.2, 6.7) (0.2, 0.3) (0.1, 0.7) (0.1, 0.8) 3.1 1.0 1.2 (0.7, 1.1 1.0 0.9Positive (0.5, 2.4) (0.4, 3.2) 14.4) (0.3, 3.7) (0.4, 2.6) (0.2, 3.6) 1.8 4.4 3.7 (0.2, 1.2 2.9 3.3Notional (1.5, 13.3) (1.04, 13.) 15.3) (0.3, 6.1) (0.8, 10.2) (0.6, 18.0)Compromised 1 1 1 1 1 1
    21. 21. Whakamomori: Mäori suicide prevention modelVariable OR C onfidenc e P valueD e m o graphics Age 0.99 Intervals 0.95 -1 .04 0.8G e nd e r F e m al e 0.75 0.31 -1 .80 0.5 Mal e 1C ultural Id e ntity S e cure 1 0.2 P o s itive 3.31 1 .1 0-9.95 No tio nal 1 .56 0.1 9-1 9.95 C o m pro m is e d 1 .7 0.23-1 2 .38Health S tatus GHQ–28 1.28 1.20-1.35 <0.0001Inte rpe rs o nal At l as t o nce e 2 .04 0.69-5.88 0.2Abus e No 1Al ho l (C AG E ) co Two ite m s 1 .51 0.61 -1 .64 0.4 Le s s than 2 1Marij uana Us e 1 .55 0.68-3.85 0.3 D o n’t us e 1E d ucatio n S cho o l l ave r ≤ e 1 .84 0.75 -4.51 0.2 S cho o l l ave r > e 1E m pl ym e nt o Ye s 1 .03 0.36-2.93 0.96 No 1Inco m e U nd e r$2 0,000 0.84 0.31 -2.28 0.7 At l as t $2 0,000 e 1
    22. 22. Whakamomori: Mäori suicide prevention modelVariable OR C onfidenc e P valueD e m o graphic Age Intervals 0.99 (0.96-1 .03) 0.8G e nd e r F e m al e 0.88 (0.43-1 .81 ) 0.7 Mal e 1C ul tural Id e ntity S ec ure 1 0.003 P o s itive 2.48 (1 .21 -5.08) No tio nal 8.32 (2.51 -27.61 ) C o m pro m is e d 4.3 (1 .31 -1 4.1 )Inte rpe rs o nal A t leas t onc e 2.27 ( 1.15-4.35) 0.02Abus e No 1S ubs tance U s eAl ho l (C AG E ) co Two items 1.85 ( 1.00-3.45) 0.05 Mo re than two 1Marij uana Us e 2.27 ( 1.24-4.16) 0.008 D o n’t us e 1E d ucatio n S cho o l l ave r ? e 1 .69 (0.77-3.71 ) 0.07 S cho o l l ave r > 1 eE m pl ym e nt o Ye s 0.77 (0.37-1 .60) 0.5Inco m e Le s s than 1 .73 (0.88-3.40) 0.1 At l as t $20,000 1 e
    23. 23. Translation research - implementation Whakawhanaungatanga – Self Harm & Suicide Prevention Collaborative Case Finding Assessment Tool – Early detection and management of people at risk of suicide in primary care setting
    24. 24. Whakawhanaungatanga Implementation of guidelines into  Emergency Departments  Mental Health Services  Maori Health Services
    25. 25. Methodology Tools  National targets  Mapping an individual clients pathway through secondary care  Plan – Do – Study – Act Cycles
    26. 26. National Targets 90% of people attending the ED identified with self-harm or suicidality are seen within 1 hour 100% of people presenting with self-harm or suicidality will have documented assessment. 100% of people presenting with self-harm or suicidality will be provided with a written copy of their care plan on discharge (also significant others/ whänau if appropriate) 100% of people presenting with self harm or suicidality will have a follow up appointment within 48-hours of discharge.  90% of people who do not attend that appointment will be contacted within 48 hrs.
    27. 27. Client Pathway Map What is a typical problem at each point of the process? Are there examples of best practice? Identify measures to monitor improved processes Test changes
    28. 28. Plan – Do – Study – Act What are we trying to accomplish?  An aim with a clear outcome target is essential to assign resources & garner support What changes can we make to result in improvement?  The hypothesis generation step…where we test ideas before implementing changes How will we know that a change is an improvement?  Measurement to demonstrate improvement
    29. 29. Who’s In Emergency departments, mental health & Maori health services in DHB’s  Northland  Waitemata  Counties Manukau  Waikato  Lakes  Taranaki  Mid Central  Hutt Valley  West Coast  Southland
    30. 30. Primary Care tool development Detection & Management of people at risk of suicide in the primary care setting  Depression  Anxiety  Interpersonal abuse  Substance use (alcohol & drugs)  Gambling  Smoking  Eating Disorder
    31. 31. Methodology Kaupapa Epidemiology  Randomised control trial − Raukura Hauora o Tainui (PHO), West Auckland PHO, North Shore PHO and Tairawhiti PHO − N=1000 face validity − N=1200 content validity  Kaupapa − Maori co-leadership, data collection & analysis, participants
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