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Kainamu Whakamomori: Maori Attempted Suicide in Aotearoa
1. Kainamu Whakamomori: Attempted
Suicide in Aotearoa
Dr Nicole M. C oupe KĂI 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. Summary
ï” Aotearoa contemporary context
ï” Maori attempted suicide medical record review
ï” Maori attempted suicide case control study
ï” Translating research into suicide prevention
3. Definitions
ï” Changes in coding
ï” Differences in DHB reporting and patient management
ï” Hospitalisations are numbers of episodes rather than
individual people
ï Readmissions same condition counted as additional
discharges
ï People transferred between hospitals are counted each time
4. Intentional self harm rates
A otearoa Non-MĂ€ori MĂ€ori
100,000 No. 100,000 No. 100,000 No.
Total 1 31 .5 5292 1 34.1 4573 1 1 5.1 71 9
Fem ale 1 78.6 361 0 1 85.0 31 43 1 43.9 467
M ale 84.2 1 682 83.3 1 430 85.0 252
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)
ï” Total 20-24 years (300.0/100,000)
ï” Males 25-29 years (201.6/100,000)
ï” Females 15-19 years (425.4/100,000)
ï” MĂ€ori 20-24 years (277.5/100,000)
ï Males 20-25 years (210.0/100,000)
ï Females 20-24 years (343.4/100,000)
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)
ï” 15-24 years both males and females
ï” Rates decrease with life style age group
7. DHB intentional self harm
ï” West Coast (250.3) &
Canterbury (218.7)
ï” Waitemata, Auckland,
Counties, Waikato, Hutt
Valley, Nelson
Marlborough, Otago
ï 125-187/100,000
ï” Capital & Coast (61.9) &
Southland (63.1)
8. Hospitalisation & Deprivation
ï” Increase
hospitalisations Age standardised
rate (per 100,000)
with increased 180
160
deprivations 140
120
100
ï” Least deprived 80
60
areas 83/100,000 40
20
0
ï” Most deprived 1 2 3
NZDep2001 quintile
4 5
areas
154.7/100,000
9. Other researchers of suicide attempts
ï” Bennett â PĂ€keh Ă€ youth suicid e
ï” Tiatia â Pacific youth suicid e
ï” Beautrais â Serious suicid e attem pts
ï” H atcher â Problem solving therapy after suicid e
attem pt
ï” N ad a-Raja, C ollings, C oggan
12. MĂ€ori Medical Record Review
ï” 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 â
D e ce m b e r 31 s t 2000
ï” N = 252 ind ivid u als / 0 p re s e ntations - 1 8m th s
31
ï 61 % fe m ale ; 85% s ole M Ă€ori, 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 Ànau
ï 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
ï” 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
ï” 71 % firs t tim e rs â re p e at p re s e ntations (74% 2x, 1 7% 3x, 9% 5x)
ï” 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
ï” 87% with p os t d is ch arge p lans , 67% h om e , 1 8% p s ych iatric care ,
ï” 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. Conclusion
ï” 1 M Ă€ori e ve ry 2 d ays p re s e nts to
Au ckland E D for D S H
ï” 20% p re s e nte d following O D analge s ics
ï” 50% p re viou s ly b e e n to E D and 33%
m ore th an twice
ï” 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. Kaupapa MĂ€ori Methodology
ï” C om m u nity d rive n ï”S e lf id e ntification
re s e arch
ï”P articip ant
ï” M Ă€ori p rincip al
controlle d inte rvie w
inve s tigator
ïTim e
ï” M Ă€ori re s e arch te am
ïP lace
ï” M Ă€ori d e cis ion
ïKoh a
m aking
ï” P artne rs h ip s with ï”D is s e m ination
non-M Àori
15. MĂ€ori case control study
ï” C AS E S : ï”C O N TR O LS :
ï n= 250 ïn= 250
ï M Ă€ori (s e lf ïM Ă€ori (s e lf
Id e ntification) id e ntification)
ï 1 6 â 50 ye ars
ï1 6 â 50 ye ars
ï Atte m p te d s u icid e
ïP op u lation b as e d
(d iagnos e d )
ïAu ckland R e gion
ï Au ckland re gion
ï227 s ite s ; 3045
ï 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. Method MĂ€ori case control study
ï” Q u e s tionnaire (> 400 qu e s tions )
ï C u ltu ral Ind icators
ï D e m ograp h ic & s ocio-e conom ic factors
ï G e ne ral H e alth Q u e s tionnaire (G H Q â 28)
ï 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
ï S u b s tance U s e (C AG E )
ï H e alth s e rvice acce s s ib ility
ï S ocial s u p p orts
ï E nvironm e ntal factors
ï S u icid ality (C ID I)
ï Be ckâs S cale of S u icid e Inte nt (S IS â 1 4)
17. Results
ï” C as e s e le ction
ï 1 s t Au gu s t 2000 to 1 3th Janu ary 2002 (1 5m th s )
ï” Inte rvie ws com p le te N ov 2002 (27m th s )
ï” 21 4 (85.5% ) cas e s & 203 (81 .2% ) controls
19. Measuring culture
Identity Profiles
Cultural indicators Secure Positive Notional Compromised
2: Identify as MĂ€ori Yes Yes Yes No
4: No. of MĂ€ori generations 3+ 2 1 Any response
8.1: Times to own marae 5+ 2-4 0-1 Any response
9.4: Role whÀnau plays in life > large Small <small Any response
10: Interest MĂ€ori land Yes Yes/dk No Any response
basic -
15: Te reo MĂ€ori 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 other
Minimum criteria responses responses responses response
21. Whakamomori: MĂ€ori suicide prevention model
Variable OR C onfidenc e P value
D e m o graphics Age 0.99 Intervals
0.95 -1 .04 0.8
G e nd e r F e m al e 0.75 0.31 -1 .80 0.5
Mal e 1
C 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 .38
Health S tatus GHQâ28 1.28 1.20-1.35 <0.0001
Inte rpe rs o nal At l as t o nce
e 2 .04 0.69-5.88 0.2
Abus e No 1
Al ho l (C AG E )
co Two ite m s 1 .51 0.61 -1 .64 0.4
Le s s than 2 1
Marij
uana Us e 1 .55 0.68-3.85 0.3
D o nât us e 1
E d ucatio n S cho o l l ave r â€
e 1 .84 0.75 -4.51 0.2
S cho o l l ave r >
e 1
E m pl ym e nt
o Ye s 1 .03 0.36-2.93 0.96
No 1
Inco 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. Whakamomori: MĂ€ori suicide prevention model
Variable OR C onfidenc e P value
D e m o graphic Age Intervals
0.99 (0.96-1 .03) 0.8
G e nd e r F e m al
e 0.88 (0.43-1 .81 ) 0.7
Mal e 1
C 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) 0.02
Abus e No 1
S ubs tance U s e
Al ho l (C AG E )
co Two items 1.85 ( 1.00-3.45) 0.05
Mo re than two 1
Marij
uana Us e 2.27 ( 1.24-4.16) 0.008
D o nât us e 1
E 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
e
E m pl ym e nt
o Ye s 0.77 (0.37-1 .60) 0.5
Inco m e Le s s than 1 .73 (0.88-3.40) 0.1
At l as t $20,000 1
e
23. Translation research - implementation
ï” Whakawhanaungatanga â Self Harm & Suicide
Prevention Collaborative
ï” Case Finding Assessment Tool â Early
detection and management of people at risk of
suicide in primary care setting
24. Whakawhanaungatanga
ï” Implementation of
guidelines into
ï Emergency
Departments
ï Mental Health
Services
ï Maori Health Services
25. Methodology
ï” Tools
ï National targets
ï Mapping an individual clients pathway
through secondary care
ï Plan â Do â Study â Act Cycles
26. National Targets
ï” 90% of people attending the ED identified with self-harm
or suicidality are seen within 1 hour
ï” 100% of people presenting with self-harm or suicidality
will have documented assessment.
ï” 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/ whÀnau if appropriate)
ï” 100% of people presenting with self harm or suicidality
will have a follow up appointment within 48-hours of
discharge.
ï 90% of people who do not attend that appointment will be
contacted within 48 hrs.
27. Client Pathway Map
ï” What is a typical problem at each point of the process?
ï” Are there examples of best practice?
ï” Identify measures to monitor improved processes
ï” Test changes
28. Plan â Do â Study â Act
ï” What are we trying to
accomplish?
ï An aim with a clear outcome
target is essential to assign
resources & garner support
ï” What changes can we make
to result in improvement?
ï The hypothesis generation
stepâŠwhere we test ideas
before implementing changes
ï” How will we know that a
change is an improvement?
ï Measurement to demonstrate
improvement
29. Whoâs In
ï” Emergency departments, mental health & Maori health
services in DHBâs
ï Northland
ï Waitemata
ï Counties Manukau
ï Waikato
ï Lakes
ï Taranaki
ï Mid Central
ï Hutt Valley
ï West Coast
ï Southland
30. Primary Care tool development
ï” Detection & Management of people at risk of
suicide in the primary care setting
ï Depression
ï Anxiety
ï Interpersonal abuse
ï Substance use (alcohol & drugs)
ï Gambling
ï Smoking
ï Eating Disorder
31. Methodology
ï” Kaupapa Epidemiology
ï Randomised control trial
â Raukura Hauora o Tainui (PHO), West Auckland PHO,
North Shore PHO and Tairawhiti PHO
â N=1000 face validity
â N=1200 content validity
ï Kaupapa
â Maori co-leadership, data collection & analysis,
participants
Hinweis der Redaktion
Not possible to compare to previous years as the definition of intentional self harm has been extended
Area of high concentration MĂ€ori suicide and suicidal behaviours
Epidemiology driven by kaupapa MĂ€ori 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 MĂ€ori
Cultural identity indicators 6 items identity genealogy marae access whanau (family) access whenua (land) access MĂ€ori 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
MĂ€ori 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 MĂ€ori attempted suicide
Removing general health status from the model reveals more significant factors that may affect the level of MĂ€ori attempted suicide cultural identity abuse marujuana