Optimal medication therapy in Indigenous populations

Abstract

The overarching topic of this thesis is optimal medication therapy in Indigenous populations with a focus on Māori. Medicines are a foundational element of western health systems. They have the potential to cure, control, prevent, or cause illness. The goal, therefore, is to ensure optimal use. Throughout the world, Indigenous peoples experience inequities in health outcomes compared with non-Indigenous people, in part due to inequitable access to medicines optimisation. To obtain an insight into opportunities to transform this situation, a targeted approach was identified by focusing on gout – a health condition prevalent in Māori and treatable with medicines. Underpinned by Kaupapa Māori research theory, this thesis aimed to investigate how gout medication therapy for Māori can be optimised. The study was undertaken in seven phases: contextualising the medicines system in Aotearoa New Zealand; identifying initiatives involving two or more components to address medicines optimisation through a scoping review; developing and implementing a decision-support tool for gout management at the point of prescribing medicines; developing and implementing a multi-level care initiative to improve gout management in a predominantly Māori primary care setting; identifying the barriers to and enablers of implementing these initiatives; developing advice on promoting equitable gout management; and identifying the barriers to medicines optimisation from a medicines environment perspective, and therefore opportunities for transformation in the approach to medicines use in Aotearoa New Zealand. Findings: The systems around medicines are complex, and Māori are still impacted by legislation, especially the Tohunga Suppression Act. The scoping review identified a gap in focused research demonstrating outcomes for Indigenous people; the decision-support tool and multi-level care initiatives met multiple barriers, including at patient, provider, and system levels; there was misalignment in the definition of ‘optimal’ between the community and providers. The complexity of problems and solutions were drawn together in Ngā Rau o Kawakawa –a diagrammatic representation of the gaps in the medicines environment in Aotearoa New Zealand. There are times when Indigenous researchers need to get on with advocating for transformation. A coherent, strategised, holistic, mātauranga inclusive approach to the medicines environment does not exist in Aotearoa New Zealand. In conclusion, there is an urgent need: • for a national gout strategy led by those with gout and their families • to establish an entity (a Centre of Medicines Optimisation) with delegated responsibility for oversight of the medicines environment, equally inclusive of Indigenous perspectives and values.