Dr Nicole Coupe. SPINZ Symposium, Dunedin, 28 November 2006. http://www.spinz.org.nz

1. Kainamu Whakamomori: Attempted
Suicide in Aotearoa
Dr Nicole M. C oupe KÄI TAH U , TE ATIAWA
Pos t Doctoral Fellow
N ga P ae o te Maram atanga
n.m.coupe@mas s ey.ac.nz

2. Summary
 Aotearoa contemporary context
 Maori attempted suicide medical record review
 Maori attempted suicide case control study
 Translating research into suicide prevention

3. Definitions
 Changes in coding
 Differences in DHB reporting and patient management
 Hospitalisations are numbers of episodes rather than
individual people
 Readmissions same condition counted as additional
discharges
 People transferred between hospitals are counted each time

4. Intentional self harm rates
A otearoa Non-Mäori Mäori
100,000 No. 100,000 No. 100,000 No.
Total 1 31 .5 5292 1 34.1 4573 1 1 5.1 71 9
Fem ale 1 78.6 361 0 1 85.0 31 43 1 43.9 467
M ale 84.2 1 682 83.3 1 430 85.0 252

5. Suicide & Intentional Self Harm Rates
Age standardised
rate (per 100,000)
450
400 Male
350 Female
300
250
200
150
100
50
0
10- 15- 20- 25- 30- 35- 40- 45- 50- 55- 60- 65- 70- 75- 80- 85+
Age groups (years)
 Total 20-24 years (300.0/100,000)
 Males 25-29 years (201.6/100,000)
 Females 15-19 years (425.4/100,000)
 Mäori 20-24 years (277.5/100,000)
 Males 20-25 years (210.0/100,000)
 Females 20-24 years (343.4/100,000)

6. Suicide & Intentional Self Harm Rates
Age standardised
rate (per 100,000)
450
400 Male
350 Female
300
250
200
150
100
50
0
5-14 15-24 25-44 45-64 65+
Age groups (years)
 15-24 years both males and females
 Rates decrease with life style age group

7. DHB intentional self harm
 West Coast (250.3) &
Canterbury (218.7)
 Waitemata, Auckland,
Counties, Waikato, Hutt
Valley, Nelson
Marlborough, Otago
 125-187/100,000
 Capital & Coast (61.9) &
Southland (63.1)

8. Hospitalisation & Deprivation
 Increase
hospitalisations Age standardised
rate (per 100,000)
with increased 180
160
deprivations 140
120
100
 Least deprived 80
60
areas 83/100,000 40
20
0
 Most deprived 1 2 3
NZDep2001 quintile
4 5
areas
154.7/100,000

9. Other researchers of suicide attempts
 Bennett – Päkeh ä youth suicid e
 Tiatia – Pacific youth suicid e
 Beautrais – Serious suicid e attem pts
 H atcher – Problem solving therapy after suicid e
attem pt
 N ad a-Raja, C ollings, C oggan

10. Mäori attempted suicide
 M äori M ed ical Record Review
 M äori Attem pted Suicid e C ase C ontrol

11. Study zone

12. Mäori Medical Record Review
 R e cord s from E m e rge ncy D e p artm e nts b e twe e n Ju ly 1 s t 1 999 –
D e ce m b e r 31 s t 2000
 N = 252 ind ivid u als / 0 p re s e ntations - 1 8m th s
31
 61 % fe m ale ; 85% s ole M äori, 43% C ou ntie s M anu kau , 25% e m p loye d ,
21 % u ne m p loye d , 1 7% b e ne ficiarie s , 56% living with wh änau
 70% P ois oning (53% p re s crip tion m e d ications , 20% analge s ics ), 1 5%
cu tting or p ie rcing
 H om e , 1 800-2400 h ou rs , 37% p re s e ntations alcoh ol (fe m ale s
you nge r), 1 5% M arij ana
u
 71 % firs t tim e rs – re p e at p re s e ntations (74% 2x, 1 7% 3x, 9% 5x)
 E D s e rvice 53 % m e d ications , 88% p s ych iatric, 1 6% cu ltu ral
inform e d , 1 3% ab s cond e d or re fu s e d s e rvice s
 87% with p os t d is ch arge p lans , 67% h om e , 1 8% p s ych iatric care ,
 F ollow u p C M H S , H os p ital p s ych s e rvice s G P , C u ltu ral S e rvice s 4%

13. Conclusion
 1 M äori e ve ry 2 d ays p re s e nts to
Au ckland E D for D S H
 20% p re s e nte d following O D analge s ics
 50% p re viou s ly b e e n to E D and 33%
m ore th an twice
 O ve rnigh t ad m is s ions allow cu ltu rally
ap p rop riate as s e s s m e nt and follow u p

14. Kaupapa Mäori Methodology
 C om m u nity d rive n S e lf id e ntification
re s e arch
P articip ant
 M äori p rincip al
controlle d inte rvie w
inve s tigator
Tim e
 M äori re s e arch te am
P lace
 M äori d e cis ion
Koh a
m aking
 P artne rs h ip s with D is s e m ination
non-M äori

15. Mäori case control study
 C AS E S : C O N TR O LS :
 n= 250 n= 250
 M äori (s e lf M äori (s e lf
Id e ntification) id e ntification)
 1 6 – 50 ye ars
1 6 – 50 ye ars
 Atte m p te d s u icid e
P op u lation b as e d
(d iagnos e d )
Au ckland R e gion
 Au ckland re gion
227 s ite s ; 3045
 3 h os p itals (Au ckland ,
h ou s e h old s
M id d le m ore , N orth
S h ore )

16. Method Mäori case control study
 Q u e s tionnaire (> 400 qu e s tions )
 C u ltu ral Ind icators
 D e m ograp h ic & s ocio-e conom ic factors
 G e ne ral H e alth Q u e s tionnaire (G H Q – 28)
 H os p ital Anxie ty & D e p re s s ion S cale (H AD S ) & M e ntal H e alth
F actors
 S u b s tance U s e (C AG E )
 H e alth s e rvice acce s s ib ility
 S ocial s u p p orts
 E nvironm e ntal factors
 S u icid ality (C ID I)
 Be ck’s S cale of S u icid e Inte nt (S IS – 1 4)

17. Results
 C as e s e le ction
 1 s t Au gu s t 2000 to 1 3th Janu ary 2002 (1 5m th s )
 Inte rvie ws com p le te N ov 2002 (27m th s )
 21 4 (85.5% ) cas e s & 203 (81 .2% ) controls

18. Culture & Mäori attempted suicide
C ulture All ages 16-24
Identity & whakapapa (family tree) OR CI OR CI
S ole Mäori identity 2.4 1 .59, 3.63 2.6 1 .23, 5.68
Knowledge 4+ generations 0.25 0.1 4, 0.44 0.4 0.1 1 , 1 .08
Name Iwi (tribe) 0.35 0.1 8, 0.67 0.3 0.1 1 , 0.94
Marae (village common) 0.09 0.04, 0.21 0.1 0.01 , 0.27
Tikanga (Mäori protocols ) 1.8 1 .1 8, 2.75 1.3 0.6, 2.8
Whänau (family) links 0.16 0.09, 0.29 0.3 0.09, 0.72
Whenua (Mäori land) 0.22 0.1 3, 0.36 0.3 0.1 2, 0.66
Kai (Mäori food) 0.26 0.1 7, 0.40 0.2 0.08, 0.43
Te Reo Mäori (Mäori language) 0.19 0.1 0, 0.35 1.9 0.74, 5.03

19. Measuring culture
Identity Profiles
Cultural indicators Secure Positive Notional Compromised
2: Identify as Mäori Yes Yes Yes No
4: No. of Mäori generations 3+ 2 1 Any response
8.1: Times to own marae 5+ 2-4 0-1 Any response
9.4: Role whänau plays in life > large Small <small Any response
10: Interest Mäori land Yes Yes/dk No Any response
basic -
15: Te reo Mäori ability adv - native learner No ability Any response
Q.2 = yes + Q.2 = yes + Q.2 = yes
3 other 2 other + 3 other Q.2 = no
positive positive negative + any other
Minimum criteria responses responses responses response

20. Te Ao Mäori Model
A+G + A+G + A+G + A+G + A+G +
Cultural Indicators A+G SES GHQ HADS Drugs Abuse
Cultural identity
profile X23=33.62 X23=19.09 X23=3.06 X23=2.76 X23=24.15 X23=18.79
0.28 0.4 1.1 0.5 0.2 0.2
Secure (0.1, 0.7) (0.1, 1.1) (0.2, 6.7) (0.2, 0.3) (0.1, 0.7) (0.1, 0.8)
3.1
1.0 1.2 (0.7, 1.1 1.0 0.9
Positive (0.5, 2.4) (0.4, 3.2) 14.4) (0.3, 3.7) (0.4, 2.6) (0.2, 3.6)
1.8
4.4 3.7 (0.2, 1.2 2.9 3.3
Notional (1.5, 13.3) (1.04, 13.) 15.3) (0.3, 6.1) (0.8, 10.2) (0.6, 18.0)
Compromised 1 1 1 1 1 1

21. Whakamomori: Mäori suicide prevention model
Variable OR C onfidenc e P value
D e m o graphics Age 0.99 Intervals
0.95 -1 .04 0.8
G e nd e r F e m al e 0.75 0.31 -1 .80 0.5
Mal e 1
C ultural Id e ntity S e cure 1 0.2
P o s itive 3.31 1 .1 0-9.95
No tio nal 1 .56 0.1 9-1 9.95
C o m pro m is e d 1 .7 0.23-1 2 .38
Health S tatus GHQ–28 1.28 1.20-1.35 <0.0001
Inte rpe rs o nal At l as t o nce
e 2 .04 0.69-5.88 0.2
Abus e No 1
Al ho l (C AG E )
co Two ite m s 1 .51 0.61 -1 .64 0.4
Le s s than 2 1
Marij
uana Us e 1 .55 0.68-3.85 0.3
D o n’t us e 1
E d ucatio n S cho o l l ave r ≤
e 1 .84 0.75 -4.51 0.2
S cho o l l ave r >
e 1
E m pl ym e nt
o Ye s 1 .03 0.36-2.93 0.96
No 1
Inco m e U nd e r$2 0,000 0.84 0.31 -2.28 0.7
At l as t $2 0,000
e 1

22. Whakamomori: Mäori suicide prevention model
Variable OR C onfidenc e P value
D e m o graphic Age Intervals
0.99 (0.96-1 .03) 0.8
G e nd e r F e m al
e 0.88 (0.43-1 .81 ) 0.7
Mal e 1
C ul
tural Id e ntity S ec ure 1 0.003
P o s itive 2.48 (1 .21 -5.08)
No tio nal 8.32 (2.51 -27.61 )
C o m pro m is e d 4.3 (1 .31 -1 4.1 )
Inte rpe rs o nal A t leas t onc e 2.27 ( 1.15-4.35) 0.02
Abus e No 1
S ubs tance U s e
Al ho l (C AG E )
co Two items 1.85 ( 1.00-3.45) 0.05
Mo re than two 1
Marij
uana Us e 2.27 ( 1.24-4.16) 0.008
D o n’t us e 1
E d ucatio n S cho o l l ave r ?
e 1 .69 (0.77-3.71 ) 0.07
S cho o l l ave r > 1
e
E m pl ym e nt
o Ye s 0.77 (0.37-1 .60) 0.5
Inco m e Le s s than 1 .73 (0.88-3.40) 0.1
At l as t $20,000 1
e

23. Translation research - implementation
 Whakawhanaungatanga – Self Harm & Suicide
Prevention Collaborative
 Case Finding Assessment Tool – Early
detection and management of people at risk of
suicide in primary care setting

24. Whakawhanaungatanga
 Implementation of
guidelines into
 Emergency
Departments
 Mental Health
Services
 Maori Health Services

25. Methodology
 Tools
 National targets
 Mapping an individual clients pathway
through secondary care
 Plan – Do – Study – Act Cycles

26. National Targets
 90% of people attending the ED identified with self-harm
or suicidality are seen within 1 hour
 100% of people presenting with self-harm or suicidality
will have documented assessment.
 100% of people presenting with self-harm or suicidality
will be provided with a written copy of their care plan on
discharge (also significant others/ whänau if appropriate)
 100% of people presenting with self harm or suicidality
will have a follow up appointment within 48-hours of
discharge.
 90% of people who do not attend that appointment will be
contacted within 48 hrs.

27. Client Pathway Map
 What is a typical problem at each point of the process?
 Are there examples of best practice?
 Identify measures to monitor improved processes
 Test changes

28. Plan – Do – Study – Act
 What are we trying to
accomplish?
 An aim with a clear outcome
target is essential to assign
resources & garner support
 What changes can we make
to result in improvement?
 The hypothesis generation
step…where we test ideas
before implementing changes
 How will we know that a
change is an improvement?
 Measurement to demonstrate
improvement

29. Who’s In
 Emergency departments, mental health & Maori health
services in DHB’s
 Northland
 Waitemata
 Counties Manukau
 Waikato
 Lakes
 Taranaki
 Mid Central
 Hutt Valley
 West Coast
 Southland

30. Primary Care tool development
 Detection & Management of people at risk of
suicide in the primary care setting
 Depression
 Anxiety
 Interpersonal abuse
 Substance use (alcohol & drugs)
 Gambling
 Smoking
 Eating Disorder

31. Methodology
 Kaupapa Epidemiology
 Randomised control trial
− Raukura Hauora o Tainui (PHO), West Auckland PHO,
North Shore PHO and Tairawhiti PHO
− N=1000 face validity
− N=1200 content validity
 Kaupapa
− Maori co-leadership, data collection & analysis,
participants