"Back in the Islands": An Investigation of Risk Perception of Tongan People with Pre-Diabetes and Associated Risk Communication of Primary Healthcare Professionals

Abstract

Introduction: Pre-diabetes is a condition of elevated blood sugar levels (HbA1c 41 - 49 mmol/mol), which can increase the risk of type 2 diabetes if not managed effectively. Public health approaches focus on prevention and access to health services, and clinical measures focus on effective care and treatment. Between these two approaches exist Pacific health and health communication. In New Zealand, Pacific peoples have the highest prevalence of pre-diabetes (29.8%) compared to New Zealand/ European and other ethnic groups (24.6%). Lifestyle interventions could delay the onset of type 2 diabetes, which is particularly important for population groups who are at high risk of developing type 2 diabetes. Type 2 diabetes has considerable direct and indirect costs to individuals, their families and the health system. Delaying the onset of type 2 diabetes by better understanding the experiences of Tongan people with pre-diabetes and enabling them to define their preferred communication means and messages for better engagement are essential factors to consider. Health communication between the patient and clinician is an integral part of an individual’s health journey, and understanding health risk information shapes behaviour. The communication of health risks will pose two main features, a probability of an adverse health condition occurring and a negative result if the health condition develops and subsequent protective or maladaptive behaviours. How individuals with prediabetes comprehend risk inevitably informs their health protecting behaviour. This research is Pacific-specific in its application and focuses on the Tongan people in New Zealand. Understanding the perceptions of risk of Tongan people with pre-diabetes may help healthcare services to provide tailored care. This thesis aimed to understand how Tongan people with pre-diabetes conceptualise risk and explore how primary healthcare professionals engage and communicate risk to Tongan patients. Methods: The research was underpinned by the Tongan specific, Kakala and Tālanga methodologies. A sequential exploratory mixed-method study was conducted. First, 12 qualitative in-depth semi-structured interviews with Tongan patients with pre-diabetes from South Seas Healthcare were conducted to understand how they conceptualise risk. Followed by a clinical audit of pre-diabetes at South Seas Healthcare to describe the proportion and characteristics of Pacific-specific patients with pre-diabetes. Then, several stakeholder consultations were conducted with the existing patient, a family member, a Tongan dance choreographer, Tongan anthropologists and members of the Tongan royal family. The stakeholder consultations were conducted to gather insight about the Alamea and the proposed Alamea pre-diabetes risk communication visual tool. Lastly, an online survey was conducted with primary healthcare professionals to describe how they screen, diagnose and manage pre-diabetes. The survey also learned how the respondents communicated risk to Tongan patients and obtained their views on the proposed Alamea pre-diabetes risk communication visual tool. Results: The clinical audit at South Seas Healthcare found that in the years 2015 – 2020, 351 out of a total of 685 patients with pre-diabetes identified as Pacific. About 86% (300/351) of the Pacific patients with pre-diabetes were of Samoan descent, followed by Tongan patients (6%, 22/351). The results showed that some Tongan patients reversed their HbA1c from pre-diabetes to near-normal levels. The majority of Tongan patients were born in Tonga (86%, 19/22). Of the Tongan cohort with pre-diabetes (n = 22) at South Seas Healthcare, 12 patients participated in the qualitative interviews. The one-on-one interviews found that participants’ awareness of pre-diabetes and their risk of developing type 2 diabetes were minimal. Several expressed disbelief at their status of having prediabetes, yet many had familial associations with type 2 diabetes, which may account for their expressions of fear. Participants could not differentiate between pre-diabetes and being at risk for type 2 diabetes, highlighting that the term risk and pre-diabetes require more explanation that is both clinically accurate and culturally appropriate for better understanding for Tongan patients. The findings suggest that the respondents’ awareness of their pre-diabetes status and the broader understanding of pre-diabetes and their risk of developing type 2 diabetes were minimal. As a result, the proposed Alamea pre-diabetes risk communication visual tool was developed. The online survey with primary healthcare professionals (n = 30) demonstrated that pre-diabetes screening, diagnosis and management were aligned with Ministry of Health recommendations. However, there was a lack of use of Tongan (or Pacific) models of health to communicate risk. The use of Pacific-specific visual tools to communicate risk is essential for Pacific peoples, including tailoring risk and health promotion messages. The majority of the primary healthcare professionals were inclined to using visual aids in health risk communication rather than text with Tongan patients. The proposed Alamea pre-diabetes risk communication visual tool contained essential information about pre-diabetes and was considered culturally appropriate by the respondents. Conclusion: Understanding how Tongan people with pre-diabetes conceptualise risk ensures that health services and delivery of care can meet their needs. An HbA1c indicative of pre-diabetes should be communicated to Tongan patients so that they are aware of their high-risk state of developing type 2 diabetes. This will motivate immediate lifestyle changes to reduce the onset of the disease. The proposed Alamea prediabetes risk communication visual tool is designed to engage Tongan people in health, connect Pacific health ideologies, and ensure health messages are salient and understandable to the patient's worldview. With the restructuring of the New Zealand healthcare system, it is important more than ever for healthcare services to acknowledge Pacific worldviews and understand the sociocultural influences and their impact on health and wellbeing. Importantly, having a health workforce reflective of the diverse population groups in New Zealand and for inter-sectorial collaborations in local and national governing bodies to create local environments conducive to healthy living for Pacific peoples to reduce inequities in health. This research is Tongan specific but contributes to Pacific health research.