Using Māori community aspirations to advocate for oral health integration into diabetes care

Māori are the Indigenous people of Aotearoa New Zealand who, as a result of colonisation, experience systematic inequities in health outcomes, access to health and social services and differential exposure to the determinants of health.¹ Māori are disproportionately affected by diabetes—a chronic condition characterised by the inability of the body to produce or effectively use insulin—at rates three times that of non-Māori. Not only do Māori experience an earlier onset of diabetes, but complications are also highest among Māori.² Periodontitis is a chronic condition characterised by inflammation of the supportive structures of the tooth, which if left untreated can cause destruction of the gums and bone, leading to tooth loss. Māori have a greater prevalence of untreated gum disease, periodontal pocketing and tooth loss.³ Diabetes is a known risk factor for periodontitis,⁴ and has been described as increasing the risk and severity of periodontitis.³ Therefore, it is recognised that people with periodontal disease would benefit from interventions focussed on controlling diabetes.⁵

Despite clear oral health inequities between Māori and non-Māori within Aotearoa New Zealand, there are few studies that work directly with Māori communities to identify their aspirations for their own healthcare. One study that explored the experiences of Māori patients with type 2 diabetes in Northland identified key barriers for Māori, including the high costs of dentistry, limited access to services and systemic issues within health service delivery that see oral health separated from diabetes care. They outlined an urgent need for integrated, subsidised and culturally responsive oral health initiatives to improve diabetes outcomes and reduce inequities in diabetes-related complications for Māori.⁶

This research engaged with participants enrolled at the Ora Toa primary health organisation (PHO), an iwi Māori health provider of Te Rūnanga o Toa Rangatira in Porirua. According to the Health Quality & Safety Commission (see: https://public.tableau.com/app/profile/hqi2803/viz/DiabetesPHO2022FINAL/Diabetes2022?publish=yes), in 2022 patients enrolled at the Ora Toa PHO had a significantly greater prevalence of diabetes (10.4%) compared with the rest of Aotearoa New Zealand (6.4%) across all age groups, all genders and all ethnic groups. This study was developed in collaboration with the PHO, who had identified addressing diabetes inequities as a priority. The research aimed to identify if Māori adults impacted by diabetes want oral healthcare provided as part of their diabetes management, including any barriers and opportunities to integrate care.

Methods

Ethics approval

Ethical approval was obtained from the University of Otago Human Ethics Committee (H23/11) and from consultation with Te Rūnanga o Toa Rangatira, including the Clinical Advisory Group and director of health.

Methodology

A Kaupapa Māori research methodology engaged with Māori communities through wānanga (see Appendix for te reo glossary), a traditional method of Māori knowledge transmission.⁷ Wānanga involves engaging in open discussion, reflection and knowledge sharing between researchers and participants. Central to wānanga are the values of mihimihi (greeting and building relationships), whakawhanaungatanga (sharing of whakapapa to connect at a deeper level), kōrero (discussion within the group and sharing on an open floor) and ako (learning and sharing information to strengthen the collective knowledge of the group). Wānanga enabled a safe space for participants to contribute to the research process. Wānanga are useful in Kaupapa Māori research, representing a traditional practice and normal way of life for Māori. Wānanga support the transmission of intergenerational knowledge among whānau, allowing the collective dialogue to address concerns and issues experienced by Māori communities.⁷

Recruitment

Recruitment was carried out over 6 weeks and sought participants from Porirua to engage across two wānanga. As this research was conducted by the Ora Toa PHO, participants were recruited from its four provider locations; together, all providers deliver services to approximately 20,000 people across the wider Wellington Region. As a result, participants come from a convenience sample. Adults diagnosed with any form of diabetes were invited directly by either the Ora Toa PHO diabetes health team or the oral health team by phone call or face-to-face. Poster advertisements for the wānanga were distributed around the Ora Toa PHO health centres, which contained a QR code for participants to register directly. All participants who registered were contacted to confirm their attendance over the phone or by email. Reminders were sent over email before wānanga commenced. A total of 36 participants signed up for either of the two wānanga.

Inclusion criteria

Eligible participants were those who were enrolled at the Ora Toa PHO, who identified as Māori, had a clinical diabetes diagnosis, were over the age of 18 and could provide informed consent. Participants were invited to bring as many whānau members, friends or support persons as they saw fit to support them during the wānanga, to acknowledge that health within the Māori worldview is not separate from the family context.⁸ These whānau members did not need to be enrolled patients or be Māori, but did need to be over the age of 18 to participate in wānanga discussions.

Research design

All wānanga commenced with a karakia, mihimihi and whakawhanaungatanga, with formalities beginning with researcher introductions. The research team were all Māori, and included one researcher with whakapapa to Ngāti Toa Rangatira, and another researcher who is employed by the health provider as a clinical dentist. A short presentation was delivered to explain the relationship between diabetes and periodontitis. Using open-ended question techniques, researchers and participants discussed barriers encountered in accessing oral healthcare, experiences of referral pathways and perspectives on integrating oral health into diabetes management. Participants were asked what oral health support and information they required to support their diabetes health journey. Wānanga concluded with the opportunity for participants to ask questions and closed with kai and a koha. The koha included a supermarket voucher, an oral health pack and a dental voucher to receive treatment from the Ora Toa PHO–based dentist.

Data analysis

The researchers’ analysis included a detailed, iterative review of transcripts from written notes from throughout the wānanga, and transcripts that were initially audio recorded and then transcribed verbatim. These transcripts were thoroughly read to identify the trends of discussion, and the researchers conducted a thematic analysis⁹ to develop a coding matrix from the transcripts. Specific codes that reflected the topics discussed were analysed and re-defined, combining similar codes under the same sub-groups and then themes. The researchers collectively identified and discerned principal themes that highlighted the participants’ priorities for oral healthcare and diabetes management. Participants were invited to a subsequent dissemination wānanga to verify that the analysis accurately reflected their experiences and aspirations regarding diabetes and oral health management. 

Results

While 36 participants signed up for the wānanga, a total of 26 attended and contributed to the data. The research team analysed the data, from which four themes were identified: barriers to dental care, a need for integrating oral health and multidisciplinary care, access to education and information on the impact of diabetes on oral health and connecting to Te Ao Māori.

Barriers to dental care

The cost of dental treatment was a significant barrier to accessing oral healthcare services, with the price a driving force behind avoiding dental care, denying dental care or deferring treatment needs. Many participants expressed that while oral health was considered important, the cost of treatment competed with the cost of living, and ultimately prevented them from attending dental appointments until they experienced pain:

“[Oral health] has always been important, but I guess with the cost of living it hasn’t always been prioritised unless you are feeling the pain or something. It is not really taken as importantly as it probably should, and I’ve never really thought about the link with diabetes. I mean, diabetes just affects everything.”

“When you ring in to make an appointment, it’s always bearing in mind that payment is due on the day. Seeing that straight away is like—forget it. I don't have $500 to come in to get two teeth sorted. And this is half the reason why we don't come here.”

“A lot of payment plans have been pulled, like there used to be a dental plan where I could pay every week, and if I needed something major, I could pay half on the day. And now those have been pulled too and you just have to go in with the cash. Now a lot places have Afterpay and that, but that’s just another thing that is going to get you into trouble.”

Long wait times to be seen by a dentist, or in some instances the complete lack of appointment availability, also contributed to inaccessible dental care. Participants commented on the challenge of accessing the onsite dental service at the Ora Toa PHO, as well as public hospital services at Kenepuru Hospital in Porirua. For the latter, relief of pain appointments were limited and offered on a first in, first served basis. It also prioritised those with urgent needs and required a Community Services Card, which made it difficult to be seen for those who were working full time but were in severe pain:

“You have to ring at eight o’clock in the morning and by five past eight all the appointments are gone.”

“If you’re working full time, unless you’ve got a Community Services Card you can’t go anywhere that’s like Kenepuru or Wellington [hospitals]. You have to actually be at a really bad point, like abscess upon abscesses before they send you in there. Recently, my partner had a toothache and he had to suffer for a couple of days before he could even get an appointment. So we ended up going into Wellington Hospital and that’s when they said, ‘oh no you're really bad so we need to go drain you out’, so it had to get to a really bad point before he even got any help. And like even prior to that they were just giving antibiotics even knowing it wasn’t working ‘cause it had been a whole week of him ringing up saying I’ve got a toothache, I need to get in.”

Integrating oral health and multidisciplinary care

In addition to financial constraints, participants emphasised the lack of integrated services as another barrier to effective oral health management. Most were unaware of the impact of diabetes on oral health and the link between the two chronic diseases. Many expressed that at no point had oral healthcare been discussed as part of their diabetes management, nor had they been asked about their oral health during their diabetes reviews:

“From the start of getting diabetes like 20 years ago, we knew how important feet were, we didn't know the mouth side.”

“But yeah it’s just diabetes in general, you don't learn much about it unless you come to wānanga like these or you actually ask the right questions to your doctors.”

“I don't think I’ve ever talked to my GP [general practitioner] about my mouth. It’s always been about other issues.”

“My GP’s never talked to me since I’ve had diabetes about oral health.”

Annual diabetes reviews were identified as a potential opportunity to discuss oral health. However, participants shared that during diabetes reviews, other areas of the body deemed at risk of complication, such as the eyes and feet, were typically prioritised. They noted that oral health was seldom part of the discussion and advocated for an integrated approach to managing diabetes and oral health, whether through referrals or by having oral health screening integrated into routine diabetic appointments:

“It should be a whole package, you get your feet checked, your eyes checked, everything else checked, so why not your mouth? And having that would motivate people to actually get their teeth looked at.”

“It’s the same with the mouth as well, you get infections there and lose your teeth. It’s ongoing so we need the whole package of care.”

“Referrals, just a quick referral to see how your oral health is. Even if there is a small fee, not an out the gate fee, but you know, something just to make sure your oral healthcare is all good.”

Access to education and information

When asked about the oral health support participants needed to support integrated oral healthcare, they expressed a need for more information regarding the impact of diabetes on oral health and what oral health support is available to them. They touched on the importance of their health provider giving them this information earlier in the disease process, such as during the pre-diabetes stage, and not delaying the sharing of information and resources until they have been diagnosed with diabetes:

“For those that do have it [diabetes], especially in those early stages, it’s important for them to know what’s out there, what they can access and what they are entitled to for free if they have diabetes. I think that's one of the big ones as Māori.”

“I think it [information] would be really good at the pre-diabetic stage… Even if it’s just a dental plan that comes out of it, you know? It’s saying, ‘well your gums are in this state, what we need to do over the next year for you is this…’ and the plan should have that cost in it. This is what it will cost you, so you can prepare yourself for that financial burden.”

Participants felt that in the first instance, information of their health should come from their health practitioner face-to-face. They suggested that these discussions could then be complemented by education and resources shared across social media, television, advertisements and posters being displayed. They believed that more must be done to raise awareness of diabetes and the impact that it has on health:

“Usually when you look at a pamphlet, you’re just reading, and then once you put it down, that information is not retained in your head. Whereas, if you have a one-on-one conversation with your GP or dentist, at least you understand what they’re saying and if you’ve got questions you can ask them straight away. So face-to-face would be the best one.”

“I think one of the biggest barriers is awareness, okay? I mean, if I think about just recently, there’s now new ads about cancer and going to get yourself tested and all that. I’ve learned a lot tonight, and now I’m thinking to myself... If they’ve got that awareness playing nationally, now why isn’t there something about diabetes? Why isn’t there something putting out the awareness? Hey, you might be sitting at home with an abscess and you don’t even know you’ve got diabetes and you’re wondering why your teeth are falling out all the time, you know? Why aren’t we making a bigger noise about it so it’s getting more attention, so it forces the government into making better decisions about the scenario.”

Connecting to Te Ao Māori

To further support oral health education and access to information, connection to Te Ao Māori was identified as important to support integrated oral healthcare. Participants discussed whakapapa and caring for mokopuna, and the future generations throughout both wānanga. Supporting whānau throughout the lifecourse was also emphasised, particularly throughout Kaupapa Māori settings like Kōhanga Reo. Participants suggested information and resources be shared with whānau from all ages and reiterated the importance of healthy messaging to pēpi, their parents and whānau at home:

“So I think the information needs to be sent out to the parents of tamariki, that, you know, diabetes is a really big killer in our whānau at the moment. So information can be handed out at kindergartens and Kōhanga Reo ‘cause I reckon it needs to start there. We’re already teaching them our reo and our tikanga, so why not teach them the proper kai to eat. Because they are gonna be our carriers of everything else later in life, they're gonna be our leaders and that’s where we need to start, with our babies and rangatahi.”

“Teach the rangatahi before they get to our age and you’re already there.”

The value of wānanga and coming together as a community was appreciated by participants. They believed that this platform was important for sharing knowledge and was beneficial since many shared similar experiences regarding their hauora:

“I think just having information nights like this, um ‘cause it brings the community together you know, and not only that, but we also get to hear other people’s stories and how it has affected them, and kind of resonates within yourself a little bit aye, and you reflect on yourself, but also there is a lot of helpful information which you can just discuss in that night, you know?”

“We’re all in the same waka, so you might as well hoe that waka together.”

Discussion

This study has shown that for Māori adults with diabetes in Porirua, there is a disconnect between the delivery of oral health and diabetes management. It also demonstrates that Māori with diabetes do value oral health and want access to the tools and resources that will support them to achieve good oral health as part of their diabetes diagnosis.

Oral health research that worked directly with Māori in Northland⁶ noted there were several barriers to accessing oral healthcare, including financial barriers, wait times and an unmet service need. Our findings confirm that these barriers are not unique to Northland and are experienced by whānau living in Porirua. It is unsurprising that the cost of dentistry, which is an out-of-pocket expense for adults aged 18 years and over,¹⁰ impacts the ability for Māori to access dental services, given the distribution of relative socio-economic deprivation in Aotearoa New Zealand.¹¹ As a result of colonisation, more Māori live in relative deprivation than non-Māori in Aotearoa New Zealand¹² and are more likely to face substantial cost-related barriers when seeking dental treatment.⁶ Financial constraints limit the ability of whānau Māori to afford necessary dental care, leading to deferral or avoidance of treatment. Such cost-related barriers support oral health funding for diabetic patients.

Participants cited long wait times for appointments and in some cases, the complete unavailability of appointments through the public system. This left them suffering through pain for an extended amount of time. Accessing emergency dental care through the public system favours tooth extraction, focussing on symptomatic relief.¹³ This is a downstream measure, with tooth loss from periodontal disease severely impacting on oral health–related quality of life¹⁴ and the ability to eat and drink, all of which are important to maintain diabetic health.

Oral health promotion and prevention are key features of The Strategic Vision for Oral Health in New Zealand.¹⁵ Offering periodontal treatment for diabetic patients as a form of prevention is an upstream attempt to save an individual’s tooth, prevent pain and improve quality of life. To further support this, raising awareness of the impact of diabetes on oral health was recommended by the community. They were concerned that there was little effort to raise awareness of the impact of diabetes on oral health and urged for more resources, information and education about periodontal disease. This is in line with other findings where diabetic participants knew of other medical complications on the eyes, kidneys and feet due to the emphasis by their GP.¹⁶ The literature supports integrating oral health into medical consultations, especially for patients diagnosed with diabetes,¹⁷ with oral health assessments recommended as part of routine diabetes management.¹⁸ While “an examination of the teeth and gums and referral to dental care if presence of significant dental/periodontal disease” is included within the annual diabetes review guidelines (see: https://t2dm.nzssd.org.nz/Section-115-Annual-diabetes-review), participants from our study noted that oral health seldom featured in their diabetes appointments, unless they specifically enquired about it. The participants in our study have confirmed that an integrated, multidisciplinary approach to diabetes management should include oral health.

The Māori Health Action Plan calls for whānau, hapū and iwi Māori to exercise their authority to improve their health and wellbeing.¹⁹ This research engaged with Māori communities through an iwi health provider, an attempt to express tino rangatiratanga and develop Kaupapa Māori services. Investing in Kaupapa Māori services gives expression to Te Tiriti o Waitangi, ensuring research can both clinically and culturally respond to the needs of Māori.²⁰ Participants identified the importance of taking a whānau approach to promoting health, ensuring that people across their lifecourse have access to the tools and knowledge to promote whānau health. These findings reflect Māori values and priorities where health is inseparable from the whānau reality and support the notion that concerns for Māori are driven by factors that affect the community as a whole.²¹

Recommendations

The Government of New Zealand is focussed on accelerating action to address five non-communicable diseases, one of which is diabetes.²² To ensure that diabetic patients have early access to preventative and early interventions, oral health objectives must be explicitly outlined within the broader diabetes policies and strategies to ensure that it is reflected clinically. An action area of The Strategic Vision for Oral Health in New Zealand¹⁵ is to build links between oral health and primary healthcare, which oral health has typically been marginalised from. While the interconnectedness of diabetes and oral health are frequently acknowledged, there are currently no Indigenous or Māori oral health frameworks or guidelines for patients with diabetes, and this is a gap in the current care provided for patients with diabetes. On the other hand, the Ministry of Health and Health New Zealand – Te Whatu Ora have released comprehensive clinical diabetes guidelines for managing retinal pathologies²³ and podiatry risks.²⁴ To meet the needs of Māori communities with diabetes, it is important that oral health receives the same attention, funding, referral processes and awareness as other parts of the body known to experience complications from the diabetes process.

Limitations

As this research was conducted by the Ora Toa PHO, the scope of participants who could be engaged were limited to those who engaged with the service. Therefore, recruitment was from a convenience sample from only one Māori health provider, and the research reflected the views and aspirations of Māori diabetic adults in Porirua only and may not reflect the experiences or aspirations of other population groups living in Aotearoa New Zealand. We hope that our research findings may be useful for other communities and Māori health providers in Aotearoa New Zealand, but we acknowledge that some of the barriers to and opportunities for access may be specific to the Ora Toa community.

Conclusion

Māori adults with diabetes and their whānau want to integrate oral health into their diabetes management and treatment. While there are many barriers to accessing oral health services, there are also many opportunities to improve health outcomes for Māori communities. Future policy and strategy related to diabetes should consider the oral health context and, importantly, should prioritise the relationships and needs of communities who suffer from the chronic disease.

View Appendix.