Respiratory research with Māori and Pacific children living in Aotearoa, New Zealand: a systematic review and narrative synthesis

Eligibility criteria

The search and screening process identified 29 eligible papers published between 2010 and 2022. Studies were eligible to be included if they investigated any respiratory condition among Māori and Pacific children aged 0–14 in New Zealand.

Search strategy

The initial search strategy was first carried out in June 2020 and repeated in December 2022. Databases searched included Medline, EBSCOHost, Scopus and PubMed. The search strategy used in Medline is provided in Table 1. A combination of controlled vocabulary and Boolean-paired keywords were used, relating to (1) respiratory conditions, (2) Māori or (3) Pacific population group. The keywords, synonyms and various spellings were reviewed and agreed upon by all co-authors before commencement. The authors also conducted a hand search by examining the bibliographies of selected studies for other relevant citations.

Study selection

All articles were imported into RefWorks ProQuest software and duplicate records were removed. Studies were excluded if they were not in English, lacked full text or were conference abstracts, grey literature or not primary research. A search period of 12 years (2010–2022) was used. The quality of studies was assessed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist, which evaluates the methodological quality of quantitative and qualitative studies.²¹ Multiple authors (A. M. I., D. T., D. G., J. N., B. T. and R. H.) independently reviewed the titles and abstracts of the articles for inclusion or exclusion, and further crosschecking and consensus among co-authors were conducted to make the final decisions.

Data extraction

Using the PRISMA checklist, data were extracted from eligible studies into an electronic spreadsheet. The study information extracted comprised authors, year of publication, location, study design, respiratory condition explored, study population (age, gender, ethnicity) and study findings (Table 2). A summary of the characteristics of the studies is also provided (Table 3).

Data synthesis

Four authors (A. M. I., D. T., J. N., D. G.) performed a narrative synthesis of the studies meeting the inclusion criteria. Due to the mix of study designs and research approaches, studies were grouped and summarised under six headings as follows: (1) study characteristics, (2) participants, (3) study design and elements, (4) methods for recruitment or engagement, (5) cultural frameworks used and (6) outcomes.

Study characteristics

Eight studies were based in New Zealand with no specified region. Eleven studies were based in Auckland, with six located explicitly in South Auckland.^27–32 Two studies were conducted across multiple regions of New Zealand; the first was co-located across Porirua, Hutt Valley, Christchurch and Dunedin,³³ and the second across Auckland, Bay of Plenty, Wellington, Nelson and Christchurch.³⁴ Other study locations included Northland,^22,23 the upper North Island,³⁵ the Bay of Plenty³⁶ and Dunedin.³⁷

Most studies reported on respiratory conditions such as asthma (n = 7), group A streptococcal (GAS) and acute rheumatic fever (ARF) (n = 7), lower respiratory tract infections (LRTI) (n = 5), bronchiectasis (n = 3) and upper respiratory tract infections (URTI) (n = 2). Other respiratory conditions included influenza, respiratory syncytial virus (RSV), respiratory tract infection and snoring.

Participants

Most studies included Māori and Pacific children or whānau as part of a multi-ethnic cohort at the Level one ethnicity category.³⁸ Five studies reported multiple ethnicities at the Level two category.^{26,29,31,39,40} Out of the 29 studies, 28 involved Māori children/whānau, while 24 focused on Pacific children/families. Two studies explicitly focused on Māori,^36,41 and only one study had a Pacific-only cohort,²⁶ although one study used the term ‘Polynesian’ to describe their combination of Māori and Pacific participants.³⁵ The remaining studies included a mix of ethnicities such as New Zealand European, Asian, Middle Eastern, Latin American, African (MELAA), and Other ethnicities. Participant numbers varied across studies, ranging from 14 to over 80,000. Most studies had less than 100 participants, with some including less than 39% of Māori or Pacific participants. However, there were also studies with over 40% representation from these groups. Most studies included both male and female participants, while a few focused specifically on females. Some studies did not provide detailed information on participant age or gender, and only a limited number of studies presented comprehensive demographic tables.

Study design and intervention elements

Eleven of the 29 studies were retrospective cohort studies – including two audits – which used datasets from the New Zealand Ministry of Health, the Pharmaceutical Claims Data Mart (PHARMS), New Zealand Health Information Service (NZHIS) or the National Minimum Dataset (Hospital Events) to explore hospitalisation rates, treatment outcomes and prevalence of a range of respiratory conditions.

While four studies were qualitative, two studies were randomised control trials. The first lasted 12 months, where the control group was waitlisted for the intervention.³³ The second was a single-blind trial enrolling children aged less than 2 years hospitalised for lower respiratory tract infections to intervention or control.³² Three were prospective cohort studies. In the first, the association between a pregnant mother’s maternal body fat and the prevalence of infant wheeze was explored,³⁵ the second looked at whether starting school with known asthma contributed to low achievement after the first year of school⁴² and the third reviewed how translated Pacific resources assisted families with managing asthma with their children.²⁶ Four were cross-sectional studies, where one assessed the prevalence of habitual snoring among New Zealand pre-schoolers,³⁷ one explored the pharyngeal GAS prevalence among a cohort of children who attended schools with sore throat clinics,²⁸ one investigated ARF cases’ housing conditions and sore throat treatment to identify opportunities to improve ARF prevention,⁴³ while another described the pharmacological management of children’s asthma to assess whether there were ethnic differences in pharmacological management.²⁵

Three of the four qualitative studies reported on the experiences of families whose children had respiratory infections.^27,29,40 The fourth qualitative study⁴¹ captured the whānau and children’s perspectives of asthma and asthma management and used drawing lung representations as an interactive and fun way to engage with children. Other studies included a non-randomised study where children either received an intervention or placebo,⁴⁴ a case control study that examined the distribution of housing-related risk factors for children with severe acute respiratory infection⁴⁵ and a sero-epidemiologic cohort study which captured influenza infection rates by risk group.⁴⁶ Time frames for each study ranged from 3 months to 6 years.

Methods for recruitment or engagement

Three studies recruited from a tertiary paediatric hospital, two focusing on children^30,32 and the other on parents’ perspectives regarding their child’s respiratory health.²⁹ Another study utilised a public health unit to reach out to families with children who had ARF,⁴⁷ while a different study employed a research nurse and a community health worker to connect with families after their hospital admission.³¹ A similar approach was taken in another study,²⁷ which recruited participants from a tertiary hospital and a paediatric and youth outpatient clinic, relying on clinical staff and flyers placed in waiting rooms. Recruitment challenges prompted this study to expand the age range (from 0–10 to 0–17 years) and adopt snowball sampling as an additional method.

Four studies^26,35,41,45 worked alongside primary care and community organisations to recruit, with one study also advertising in the local newspaper and on the radio.³³ One of these studies, conducted by Jones et al.,⁴¹ worked closely with nurses at a community-based organisation – Tu Kotahi Māori Asthma Trust – known for its work with Māori communities. This partnership used kanohi-ki-te-kanohi (face to face approach), facilitated by the organisation’s nurses, leading to the involvement of other families through snowball sampling. A Māori researcher subsequently met with participants to explain the study and obtain written consent. Ingham’s study,⁴⁵ a sub-study within the Whiti Te Ra Case Control Study, provided a flow diagram outlining the recruitment process. Although it did not provide detailed information on household recruitment, the study involved an advisory group comprising Māori and Pacific community members and local health care organisations, who played a role in recruitment procedures, study design and implementation.

Three studies collaborated with primary and intermediate schools to recruit children.^28,42,44 Two studies directly contacted families through invitation letters and follow-up phone calls.^37,46 Another study, consisting of three cohorts, worked alongside schools, a Māori health provider and a primary care organisation.³⁶ In one study, random residential addresses were used as starting points, with households then being asked about the eligibility of their children, and caregivers were subsequently invited to participate.²⁵ All studies involving direct contact with participants obtained ethics approval. Twelve studies did not require direct recruitment as they utilised previously reported datasets to collect the necessary information. However, two^22,23 of these 12 studies sought approval from their District Health Board assessment committee and Primary Health Organisation clinical governance group before conducting their audits.

Culturally responsive approaches

Out of the 29 studies, only two studies reported utilising a Kaupapa Māori Research framework. The first study emphasised Māori leadership and tikanga (Māori cultural protocols) by involving Māori at all stages of the research, including the formation of an advisory group comprising Māori and Pacific community members and health care organisations.⁴⁵ This partnership supported the development, design, recruitment and implementation phases of the study. In the second study, a qualitative approach was taken, involving interviews with whānau to understand their experiences related to asthma outcomes. Within this study, Kaupapa Māori methods were employed to recruit 32 Māori whānau, achieving a 100% retention rate. The researchers obtained formal ethics approval and sought consultation and permission from kaumātua and kuia (tribal elders) to undertake the research in partnership with their community, accompanied by a launch ceremony and blessing at their local marae.

One study²⁹ reported conducting a cultural consultation to ensure Māori and Pacific perspectives were considered before submitting their ethics application. The study team also included Māori and Samoan researchers who assisted in reviewing research protocols, data analysis and findings. Another study adopted a bilingual approach in their intervention and provided translated asthma resources to families.²⁶ While one study offered the availability of a translator if needed, it was not utilised.²⁷ Several studies incorporated Māori and Pacific researchers or health care professionals in their team, although they were not the primary investigators.

Outcomes

Several studies addressed health disparities experienced by Māori and Pacific children, highlighting areas that require improvement. Two studies^22,23 focused on the inadequate management of sore throats in primary care practices for Māori children, emphasising the need for significant improvements in this setting. Another study examined the ongoing respiratory morbidity 1 year after hospitalisation with pneumonia or severe bronchiolitis among Māori and Pacific children.³¹ Three studies reported disparities in hospitalisation rates for RSV,⁴⁸ non-cystic fibrosis bronchiectasis²⁴ and infectious diseases during the first year of life, comparing Māori and Pacific children with non-Māori/non-Pacific children.⁴⁹

Regarding asthma management, one study²⁵ found no ethnic differences in the use of spacers but revealed that Māori and Pacific children were more likely to receive a nebuliser than European/other children. The same study reported that Māori and Pacific children who experienced severe morbidity were less likely to receive inhaled corticosteroids. In another study,⁵⁰ it was observed that Māori and Pacific children were less likely to have their asthma treatment escalated to a higher step (step one to step three) and were more likely to use oral steroids for asthma exacerbations and not receive prescribed asthma medication in primary care when admitted to the hospital. Other findings included the association between asthma and low reading achievement,⁴² higher prevalence of rhinoconjunctivitis symptoms among Māori and Pacific children,³⁴ higher incidence of habitual snoring among Māori children³⁷ and an association between subcutaneous body fat levels in pregnant women and wheezing in their infants at 18 months.³⁵ The qualitative studies provided a range of participants’ experiences, with one study reporting a 100% retention rate,⁴¹ and another study²⁶ highlighting the positive impact of translated resources on inhaler knowledge and symptom recognition for Pacific families.

The effectiveness of school-based sore throat clinics in reducing ARF hospitalisation rates was demonstrated in three studies.^28,36,51 Two studies focused on housing conditions and found that improvements in housing quality measures such as dampness and mould led to a reduction in hospitalisations for acute respiratory infections,⁴⁵ while another study showed improved school attendance among children with asthma who received a household intervention.³³ Additionally, one study⁴⁷ highlighted the role of environmental conditions in increasing the risk of ARF among families due to high GAS transmission and susceptibility to infection. One study⁴⁴ reported no significant difference in the intervention group receiving treatment for GAS, while another⁴³ reported observing hospitalisations for ARF were not efficient for targeting prevention activities for this condition.