Skip to main content

Diabetes podiatry services for Māori in Aotearoa: a step in the right direction?

Abstract

Māori with diabetes are at a 65% greater risk of amputation compared to non-Māori with diabetes. Despite evidence to support the role of podiatrists in reducing diabetes-related lower limb amputations; the effectiveness of diabetes podiatry services at the community and secondary level to achieve this for Māori is largely unknown. Diabetes podiatry services need to be reorientated and be culturally applicable to Indigenous communities. Transforming diabetes podiatry services and practice may reduce Indigenous amputation rates and improve quality of life for an unserved community.

Peer Review reports

Background

Globally, Indigenous people disproportionately carry the burden of disease, which constitutes a breach of the Declaration on the Rights of Indigenous Peoples [1]. Māori are the Indigenous people of Aotearoa. It is not certain where the title Māori came from (i.e., natives, ordinary) but Māori consider themselves the ‘tangata whenua’ the people of the land. Te Tiriti o Waitangi (Māori text) was negotiated by Māori and British Crown in 1840 and outlines the terms of British settlement. Te Tiriti affirmed Māori tino rangatiratanga (unfettered authority) and granted the Crown limited governorship over their (non-Māori) people. It also granted Māori the same rights as privileges as British subjects and recognised the importance of religious and cultural freedom. The subsequent breaches of Te Tiriti have had disastrous inter-generational effects on Māori health [2].

Several government inquiries have determined systemic ethnic health inequities [3]. A major theme of these reports is institutional racism and prejudice which are modifiable determinants of Māori health and wellbeing. Health care practitioners, including podiatrists are responsible for confronting and acting upon these issues [4]. The Health Practitioners Competency Assurance Act [2003] is the main driver for ensuring culturally competent and safe practices in recognition of Te Tiriti. This is a unique competency for podiatry registration in Aotearoa. The Podiatrist Board of New Zealand is the regulatory body operating who determine how this competency is promoted and reviewed. Podiatrists currently must demonstrate cultural competency in a 2-year cycle for a minimum of 3 h [4].

Māori philosophy around health is holistic with various models that capture no separation from the physical, social, emotional or spirituality of an individual or their whānau (extended family [5,6,7,8]. When these domains are in harmony, and Māori have full cultural autonomy, health and wellbeing improve.

Despite this worldview, the measurement of Māori wellbeing often centres on Western worldviews [9]. For Māori, “data encapsulates stories, kāranga (calling, invitation), whakairo (carvings), waiata (song) and the knowledge shared in wānanga (open discussion including reflection for collective decision-making)” and hence, measuring Māori wellbeing needs to be considered through a Māori lens [10]. Wellbeing measures need to incorporate Indigenous aspirations including cultural practices such as “land use, traditional livelihoods and customary activities, language and culture” [11]. The purpose of this commentary is to admit the need to improve diabetes podiatry services for Māori through Māori worldviews. Critical evaluation can determine if diabetes podiatry services are doing what is intended, and asks the question, “Is this the best way of doing things?” [12].

Podiatry management of diabetes for Māori

Podiatrists are considered the gatekeepers of diabetic foot management in the prevention of lower limb amputations [13]. Diabetes-related lower limb amputation is preceded by diabetic foot ulceration which is the net effect of clinical and social variables [14, 15]. The podiatrist’s role is to review diabetes related symptoms and signs of which change the function and structure of the lower limb, through objective vascular and neurological assessment. This assessment allows the podiatrist to triage the threat of risk of ulceration and manage these consequences through means such as off-loading devices, self-management for health education in partnership with the person, or referral to secondary level (hospital based) podiatrists for ulcer management or surgical review [16]. However, unhelpful social and political factors that impinge on wellbeing of Indigenous populations include location of health services, infrastructure, educational and employment disadvantage; and cultural and language difficulties [17]. Focussing on biomedical risk factors alone as per the current triaging tools do little to curb the social injustices experienced by Indigenous people.

In Aotearoa, funding is available to podiatrists in the community including private practice to assess and manage people with diabetes or consider referral to secondary level podiatrists which is publicly funded. Ethnicity as an inclusion for diabetes podiatry services was based primarily on a sixfold relative risk of amputation as well as addressing the need for culturally appropriate and comprehensive services [18, 19]. However, since funded diabetes podiatry services have been available, Māori, pose a 65% greater risk of amputation compared to non-Māori, [15, 16].

These findings highlight a fragmented health system where the quality of the resources available differ nationally and regionally [20]. Furthermore, a recent report highlights inconsistency of the level of quality of diabetes services in Aotearoa [21]. One such concerning theme was limited podiatry and retinal screening services and inconsistent diabetes self-management education and support. Māori identified barriers and enablers to diabetes podiatry services over ten years ago, yet culturally appropriate services and resources are still inadequate [22]. More recent findings of systemic racism have led to a major health reform in Aotearoa, with the disestablishment of district health boards and the formation of a Māori Health Authority. There is an opportunity to transform current diabetes podiatry services to meet Māori aspirations and improve lower limb outcomes.

The emergence of Te Tiriti-led decolonising praxis is crucial to addressing the inter-generational trauma that Māori have endured for little under 200 years. A Critical Tiriti Analysis [23] of current services show less then favourable equity results, levels of self-determination, leadership for mutual benefit and cultural freedom. With this current knowledge and a restructure of the health sector, podiatrists aligned in this field will be challenged to improve clinical outcomes for Māori. Whilst indicated earlier that Māori health and wellbeing encompasses more than just the physical, podiatrists will have to rethink the socio-political factors that impinge on health outcomes of Māori. Podiatrists (Māori and non-Māori) will be able to access support through iwi (tribal), hapū (sub-tribe) and Māori communities to partner an approach to mitigate inequity and empower cultural autonomy. These collaborations will also be considered when informing cultural competency requirements by the Podiatrists Board of New Zealand [24].

In conclusion, despite support for diabetes podiatry in preventing lower limb amputations the effectiveness of these services is largely unknown for Māori. Given the current health reforms, evaluation of diabetes services for Māori through wānanga (open discussions) allows opportunity for engagement and collective decisions which is a better reflection of a Te Tiriti partnership.

Availability of data and materials

The data utilised in this commentary is readily accessible from an academic library.

Abbreviations

AUT:

Auckland University of Technology

PHO:

Primary Health Organisation

References

  1. UN General Assembly. United Nations Declaration on the Rights of Indigenous Peoples: resolution / adopted by the General Assembly, 2 October 2007, A/RES/61/295. Available from: https://www.refworld.org/docid/471355a82.html. Accessed 11 Jan 2022.

  2. Reid P, Robson B. Understanding health inequities. In: Te Rōpū Rangahau Hauora a Eru Pōmare, editor. Hauora: Māori standards of health IV. A study of the years 2000–2005. Wellington: University of Otago; 2007. p. 3–4.

    Google Scholar 

  3. Ministry of Health. Wai 2575 Māori Health Trends Report. Wellington, New Zealand. 2019. https://www.health.govt.nz/publication/wai-2575-maori-health-trends-report. Accessed 24 May 2021.

  4. Podiatrists Board of New Zealand: Principles and standards for the practice of podiatry in New Zealand. 2019. https://podiatristsboard.org.nz/news-resources-forms/board-publications/. Accessed 24 May 2021.

  5. Durie M. Te pae mahutonga: a model for Māori health promotion. Health Promotion Forum Newsletter. 1999;49:2–5.

    Google Scholar 

  6. R Pere. Te Wheke: a celebration of infinite wisdom. Gisborne: Ao Ako; 1991.

    Google Scholar 

  7. Pitama S, Robetson P, Cram F, Gillies M, Huria T, Dallas-Katoa W. Meihana Model: a clinical assessment framework. New Zeal J Psychol. 2007;36(3):118–225.

    Google Scholar 

  8. Durie M. Whaiora: Māori health development. 2nd ed. Auckland: Oxford University Press; 1998.

    Google Scholar 

  9. Came H, Doole C, McKenna B, McCreanor T. Institutional racism in public health contracting: findings of a nationwide survey from New Zealand. Soc Sci Med. 2017;199:132–9.

    Article  Google Scholar 

  10. Independent Māori Statutory Board. Data issues of signficance. 2019. https://www.imsb.maori.nz/assets/sm/upload/pa/0z/vq/ww/IMSB%20Data%20Issues%202019_d.pdf?k=8451bdff4e. Accessed 12 May 2021

    Google Scholar 

  11. McDonald C, Moreno-Monroy A, Springare L. Indigenous economic development and well-being in a place-based context. London: OECD Publishing; 2019.

    Google Scholar 

  12. Moewaka Barnes H. The evaluation hikoi: A Māori overview of programme evaluation. Auckland: Te Rōpū Whāriki; 2009.

    Google Scholar 

  13. Frykberg RG. Team approach toward lower extremity amputation prevention in diabetes. J Am Podiatr Med Assoc. 1997;87(7):305–12.

    CAS  Article  Google Scholar 

  14. Alexidou K, Doupis J. Management of diabetic foot ulcers. Diabetes Ther. 2012;3(4):1–15.

  15. Gurney JK, Stanley J, York S, Rosenbaum D, Sarfati D. Risk of lower limb amputation in a national prevalent cohort of patients with diabetes. Diabetologia. 2018;61(3):626–35.

    Article  Google Scholar 

  16. New Zealand Society for the Study of Diabetes Diabetic foot special interest group. Updated foot screening referral pathways. 2017. Available from: https://www.nzssd.org.nz/special-interest-groups/group/3/diabetic-foot-special-interest-group. Cited 2021, 13/04.

  17. West M, Chuter V, Munteanu S, Hawke F. Defining the gap: a systematic review of the difference in rates of diabetes-related foot complications in Aboriginal and Torres Strait Islander Australians and non-Indigenous Australians. J Foot Ankle Res. 2017;10(1):1–10.

    Article  Google Scholar 

  18. Ministry of Health. Tatau Kahukura: Maori health chart book. 2010. https://www.health.govt.nz/system/files/documents/publications/maori-hth-cbk-2010.pdf. Accessed 11 Jan 2022.

    Google Scholar 

  19. Robinson TE, Kenealy T, Elley CR, Garrett M, Bramley D, Drury PL. Ethnicity and risk of lower limb amputation in people with Type 2 diabetes: a prospective cohort study. Diabetic Med. 2016;33(1):55–61.

    CAS  Article  Google Scholar 

  20. Health and Disability System Review. Health and Disability System Review – Final Report – Pūrongo Whakamutunga. Wellington, New Zealand. 2020. https://www.hqsc.govt.nz/assets/Health-Quality-Evaluation/PR/Window_2019_web_final.pdf. Accessed 4 Jan 2022.

  21. Pricewaterhouse Coopers. The Economic and Social Cost of Type 2 Diabetes. https://healthierlives.co.nz/wp-content/uploads/Economic-and-Social-Cost-of-Type-2-Diabetes-FINAL-REPORT.pdf. Accessed 11 January 2022. Cited 2021, 28/04.

  22. Browne J, Garrett N. An intervention trial for Māori at risk of diabetes-related lower limb pathology. 2010. Available from: http://eds.b.ebscohost.com.ezproxy.aut.ac.nz/eds/detail/detail?vid=1&sid=d03d5958-4a40-4568-aff6-119444dc4473%40sessionmgr103&bdata=JnNpdGU9ZWRzLWxpdmU%3d#AN=aut.b13007713&db=cat05020a. Accessed 24 Aug 2018. Cited 2018, 19/04.

    Google Scholar 

  23. Came H, O’Sullivan D, McCreanor T. Introducing Critical Tiriti Analysis through a retrospective review of the New Zealand Primary Health Care Strategy. Ethnicities. 2020;20(3):434.

    Article  Google Scholar 

  24. Came H, Kidd J, Heke D, McCreanor T. Te Tiriti o Waitangi compliance in regulated health practitioner competency documents in Aotearoa: a Critical Tiriti Analysis. NZ Med J. 2021;134(1535):35–43.

    Google Scholar 

Download references

Acknowledgements

The author would like to acknowledge those who support Indigenous research space.

Funding

Not applicable.

Author information

Authors and Affiliations

Authors

Contributions

BI is the lead author and sourced much of the literature and formed the substance of the argument. KR provided literature and was involved in the drafting of the argument. HC made a minor contribution to the drafting of the paper and is acting as corresponding author for the team. The author(s) read and approved the final manuscript.

Corresponding author

Correspondence to B Ihaka.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

Keith Rome is the editor-in-chief of this journal. Belinda Ihaka is the Deputy Chair of the Podiatrists Board of New Zealand.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Ihaka, B., Rome, K. & Came, H. Diabetes podiatry services for Māori in Aotearoa: a step in the right direction?. J Foot Ankle Res 15, 59 (2022). https://doi.org/10.1186/s13047-022-00564-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13047-022-00564-1

Keywords

  • Indigenous
  • Māori
  • Diabetes
  • Amputation