Cultural Assessment for Suicide
Prevention with Māori
Dr Nicole Coupe
Whakapapa Rangahau
Past Research
• Hine Titama – Hine nui te Po
• 1848 Tiramorehu wrote of his partners
whakamomori and mate
• 1995 Kia Piki Te Ora o Te Taitamariki
• 2000 Needs assessments for sites
• 2005 Whakamomori: Māori Suicide Prevention
• 2009 Te Ira Tangata: Cultural Assessment for
suicide prevention
Whakapapa Rangahau
Past Research
Maori Suicide
– ~80-100 /year
– Males
– 15-35 years
– Hanging 67%
Maori Attempted Suicide
–
–
–
–
~700 / year
Females
Median age 30 years
Overdose
Whakapapa Rangahau
Maori Medical Record Review
(CMDHD, ADHB, WDHB)
n = 252 Mäori
n = 310 Mäori DSH presentations
n = 93 repeat presentations
Females accounted for 61%
Sole Mäori identity – 86%
CMDHB – 43%
Occupational Status
•
25% employed
•
21% unemployed
•
17% receiving government benefit
– 70% sickness or invalids
Methods
•
70% Poisoning by solid or liquids
•
53% took prescription medications
•
20% Analgesics
Circumstances
•
Home, 1800-2400 hours injury period and presentation,
Alcohol 37%
Living arrangements
•
10% alone
•
56% with family/whänau
Previous ED contact
71% first timers
Repeaters (74% twice before, 17% 3x, 9% >5x)
ED Service Provision
•
53 % Medications, 88% Psychiatric interventions
•
16% cultural informed
•
13% absconded or refused services
Discharge Summary
•
87% with post discharge plans
 67% went home
Follow up
•
Community Mental Health Services
•
Hospital Psychiatric / Psychological Services
•
General Practitioners
•
Cultural Services minimal 4%
Summary
•
1 Mäori every 2days presents ED for DSH
•
1/5 presented following OD analgesics
•
½ previously been to ED and 1/3 more than twice
•
Overnight admissions allow culturally appropriate
treatment and follow up arrangements
Whakapapa Rangahau
Maori Attempted Suicide Case
Control Study
214 (85.5%) cases & 203 (81.2%) controls
–
–
–
–
–
–
–
Cultural Indicators
Demographic & Socio-economic Factors
General Health Questionnaire (GHQ–28)
Health Service Accessibility
Social Supports
Environmental Factors
Hospital Anxiety & Depression Scale (HADS) & Mental Health
Factors
– Substance Use (CAGE)
– Suicidality (CIDI)
– Beck’s Scale of Suicide Intent (SIS–14) & Event Characteristics
Whakapapa Rangahau
Maori Attempted Suicide Case
Control Study
214 (85.5%) cases & 203 (81.2%) controls
Whakapapa Rangahau
Maori Attempted Suicide Case
Control Study
Whakapapa Rangahau
Maori Attempted Suicide Case
Control Study
Whakapapa Rangahau
Maori Attempted Suicide Case
Control Study
Variable
Demographics
Gender
Cultural Identity
Health Status
Interpersonal
Abuse
Alcohol (CAGE)
Marijuana
Education
Employment
Income
OR
Age
Female
Male
Secure
Positive
Notional
Compromised
GHQ–28
At least once
No
Two items
Less than 2
Use
Don’t use
School leaver ≤
School leaver >
Yes
No
Under$20,000
At least $20,000
0.99
0.75
1
1
3.31
1.56
1.7
1.28
2.04
1
1.51
1
1.55
1
1.84
1
1.03
1
0.84
1
Confidence
Intervals
0.95-1.04
0.31-1.80
P value
0.8
0.5
0.2
1.10-9.95
0.19-19.95
0.23-12.38
1.20-1.35
0.69-5.88
<0.0001
0.2
0.61-1.64
0.4
0.68-3.85
0.3
0.75-4.51
0.2
0.36-2.93
0.96
0.31-2.28
0.7
Whakapapa Rangahau
Past Research
Roopu
Te Ira Tangata Team
Investigation Team
– Simon Hatcher, Nicole Coupe, Mason Durie, Rees Tapsell,
Hinemoa Elder
Advisory Group (past and present)
– Maria Baker, Sharon Baillie, Tuwhakairiori Williams, Phyllis
Tangitu, Materoa Mar, Mel Robson, Ministry of Health,
Counties Manukau, Northland and Waitemata (DHB reps)
Project Team (past and present)
– Nicole Coupe, Ruth Herd, Karen Wikiriwhi, Alice Walker,
Moana Pene-Prokopis, Te Ami Henare-Toka, Mihiteria King,
Waiora Pene-Hare
Evaluation
– Tania Wolfgramm
Huarahi –
Methodology
Recruitment
– Counties Manukau, Northland and Waitemata
DHBs
Eligibility
– >17, not at school and cognitively able to consent,
Maori
Randomisation
– Treatment as Usual (controls) and Powhiri: Model
of Engagement (intervention)
Person Identified Presenting To Emergency Department with an Episode of Deliberate
Self Harm
Project Staff determine eligibility and ethnicity from psychosocial assessment and discharge summary
Eligible Non Maori
Project staff gathers information required
Person randomised
Control Group
 Consent Form
 Rating Scales
 Treatment as Usual
INELIGIBLE
Unable To Give Informed Consent or Still At School Collect
information from DHB and NZHIS
Eligible Maori
(Age, Gender, Ethnicity, DSH details)
Person randomised
Experimental Group







Consent Form
Rating Scales
Patient Support
Problem Solving Therapy
Vouchers GP visit
Cultural Assessment
Risk Assessment
Control Group
• Consent Form
• Rating Scales
• Treatment as Usual
3 and 12 months post index
presentation
rating scales
 telephone interview
 DHB Records interrogated
 NZHIS information collected
3 and 12 months post index
presentation
rating scales
 telephone interview
 DHB Records interrogated
 NZHIS information collected
Postcards 1, 2,
3, 4, 6, 8, 10 &
12 months post
index
presentation
Experimental Group
• Consent Form
•
Rating Scales
•
Patient support
•
Problem Solving Therapy
•
Vouchers GP visit
•
Cultural Assessment
•
Risk Assessment
3 and 12 months post index presentation
•
•
•
•
Rating scales
Telephone interview
DHB Records interrogated
NZHIS information collected
Postcards 1, 2, 3, 4,
6, 8, 10 & 12 months
post index
presentation
Powhiri – Process of
Engagement
– Taki/Wero
– Karanga
– Karakia
– Whaikorero
– Waiata
– Koha
– Hongi
– Hakari
– Poroporoaki
Consent
Patient support
Prayer (coming together)
Problem solving therapy
PST homework
Reciprocity
End of Patient support
Food & drink closure
Dissemination
Taki / Wero
(challenge)
• Consent
Karanga (Call)
Karakia (Prayer)
Whaikorero
(Speech)
Waiata (Song)
Koha (Gift)
Hongi
(coming together)
Hakari (Feast)
Poroporoaki
(Farewell)
Tukunga Iho
Outcome measures
The primary outcome is:
1. Beck Hopelessness Scale.
Secondary outcomes are:
1. The proportion of Māori who repeat self harm (3 months and one
year).
2. Anxiety and depression measured by the Hospital Anxiety and
Depression Scale (HADS)
3. Cultural Identity Profile (Durie et al, 1995) & Sense of Belonging
(SOBI)
4. Quality of life as measured by the (EQ-5D) and the (SF36)
5. Overall mortality at 3 months, one year, five years and ten years
6. Health service use at three months, one year, five years and ten years
Nā Reira
So far
As at 21 June 2012 Te Ira Tangata has:
• Recruitment statistics for Te Ira Tangata since November 2009
– 582 participants completed form A, 217 ineligible
– 365 participants eligible for the study
• 182 participants randomised into the intervention group,
95 consented
• 183 participants randomised into the control group, 72
consented
– N=167 (19 months), 5 withdraws,
• Twelve month follow ups: 116 of the 162 All forms (71%)
• Three month follow ups: 97 of the 166 All Forms (58%)
Ā Tērā
Next
Process evaluation will help determine whether Powhiri: model of
engagement improves outcomes for Māori who self harm
Te Ira Tangata finished 15 June 2012 all 12 month follow ups
Te Ira Tangata finishes 15 June 2016 all 5 year follow ups
Role out training in Powhiri: Model of Engagement into DHBs,
Primary care, and community services
Whoatu
What you can do!
Keep
• Improving Māori cultural identity by
– Improving te reo Māori
– Increasing access to
• Whakapapa
• Whanau
• Whenua
• Marae
• Those things Māori
Huarahi hou
New Plan!
1. Promote mental health and wellbeing, and prevent mental
health problems
2. Improve the care of people who are experiencing mental
disorders
3. Improve the care of people who make non-fatal suicide attempts
4. Reduce access to means of suicide
5. Promote safe reporting and portrayal of suicidal behaviour by
media
6. Support whanau, friends and others affected by suicide or
suicide attempt
7. Expand the evidence about rates, causes and effective
intervention
Huarahi hou
Promote Maori mental health and wellbeing, and
prevent mental health problems
1. Secure cultural Identity
a)
b)
c)
d)
e)
f)
Childhood abuse and neglect
Alcohol and drug
Life stress (relationships, employment, finance, health)
Socio-economic inequalities
Social cohesion and support (whakapapa, collective vs
individual)
Discrimination
2. Policy to Prevention
1.
2.
3.
Strengthen linkages - intersectoral collaboration
Address needs of Maori
Reduce inequalities
Huarahi hou
Improve the care of people who are experiencing
mental disorders assoc with suicidal behaiour
1. Population based initiative
a)
b)
c)
Improved access for Maori, increased help seeking behaviour
Improved public awareness, destigmatisation
Depression awareness campaigns, destigmatisation, telephone
counselling eg NDI, LMLM, Lifelines
2. Community Approaches
a)
b)
Programmes support CHW to improve understanding recognition mental
health problems & suicidal behaviour to improve help seeking
Living Works ASIST Prog, Mental Health Literacy, Gatekeeper Initiatives
3. Health Services approaches (Primary, Secondary, Mental Health,
Youth)
a)
Service need to be effective, appropriate, accessible and user friendly
Huarahi hou
Improve the care of people who make non-fatal
suicide attempts
1. Improving acute management of Maori
a)
b)
c)
Whakawhanaungatanga: Self harm & Suicide Prevention Collaborative
Te Ira Tangata: Powhiri: Model of Engagement
Problem Solving Therapy – addressing non-secure identity
2. Improving long-term management for Maori
a)
b)
PST – addressing non-secure identity
Innovation approaches
3. Improving management in institutional settings (CYFS, Schools,
Police, Prisons) – best practice guidelines
Huarahi hou
Reduce access to means of suicide
1. Hanging
a)
Control physical environment
I.
Whanau informed about reducing access
2. Overdose
a)
b)
Control and restricting access to prescription drugs
Paracetamol, blister packets with restricted points of sale
3. Firearms
a)
Fire arms regulations focused on licensing and safe storage
4. Jumping
a)
Barriers installed popular jumping sites
Huarahi hou
Promote safe reporting and portrayal of suicidal
behaviour by media
1. Rationale – imitation, contagion, normalisation
2. Legislative response in Coroners Act 2006 limiting publication of
details of deaths of individual suicides
3. Media guidelines and protocols supported by education
Huarahi hou
Support whanau, friends and others affected by
suicide or suicide attempt
Postvention
1. Support whanau bereaved by suicide
a)
Recognise variation in cultural attitudes to death, dying and suicide
2. Support whanau after suicide attempt
a) Family psycho-education programmes to reduce stress
b) Written information
c) Liaison between carers and providers
3. Minimise contagion
a)
b)
c)
d)
e)
Unified community response utilising community resources
Defuse tension
Accurate timely information
Media management
Identify susceptible individuals
Huarahi hou
Expand the evidence about rates, causes and
effective intervention
1. Improving the quality and timeliness of suicide data
a) Coroners investigations systematic and accessible
b) Improved intentional self harm data collection
c) Improved ethnicity recording
2. Expanding the research base
a)
Kaupapa Maori research required
3. Improve the dissemination of research and information