Assessing the gaps in cardiovascular disease risk assessment and management in primary care for Māori and Pacific peoples in Aotearoa New Zealand— a systematic review

Abstract

Background

Māori and Pacific peoples carry the highest burden of cardiovascular disease in New Zealand (NZ). This systematic review aimed to determine access to evidence-based cardiovascular disease risk assessment (CVDRA) and management in primary care for Māori and Pacific peoples compared with other ethnicities in NZ, as well as factors contributing to reduced access.

Methods

In this systematic review with a narrative synthesis, keywords related to Māori and Pacific peoples, cardiovascular disease, and primary care were used to search MEDLINE (OVID), EMBASE, Scopus, CINAHL, NZresearch.org, National Library Catalogue (Te Puna), Index New Zealand (INNZ), and Australia/New Zealand Reference Centre, grey literature and hand search sources from 1 January 2000 to 31 December 2024. Two reviewers screened texts and three reviewers extracted data and assessed quality. High quality was defined using Western (Mixed Methods Appraisal Tool, MMAT, ≥80% compliance) and Indigenous (CONSolIDated critERtia for strengthening the reporting of health research involving Indigenous Peoples, CONSIDER) research tools. The protocol for this systematic review was registered at: https://doi.org/10.17605/OSF.IO/VUDE9.

Findings

A total of 2765 texts were identified of which 69 were included. This review identified inadequate levels of CVDRA in Māori and Pacific peoples when measured against the 90% national target. While the provision of primary prevention medications was higher (antihypertensives) or similar (lipid-lowering) compared to that for other ethnic groups, adherence was lower for Māori and Pacific peoples compared to other groups. Māori and Pacific peoples were less likely than others to receive antiplatelets and lipid-lowering therapy for secondary prevention. Evidence for antihypertensives in secondary prevention and combination therapy (in primary or secondary prevention) was mixed. Māori and Pacific peoples experienced reduced access to revascularisation compared with other ethnic groups, an inequity that persisted over time. Factors contributing to CVDRA and management were provision of adequate health literacy, relationships with providers and whānau, access to care, and cultural safety. While 64% of studies were ≥80% compliant with the MMAT, suggesting high quality from a Western research perspective, 71% of studies had an adapted CONSIDER score ≤2, suggesting low quality from an Indigenous perspective. The CONSIDER domains with the highest levels of reporting were Prioritisation, and Analysis and interpretation, while Capacity and Dissemination were the least reported domains. Qualitative studies had generally higher levels of CONSIDER reporting than mixed methods and quantitative studies. Kaupapa Māori Research was of the highest quality, followed by studies focused on Māori and/or Pacific peoples, while studies not focused on Māori and/or Pacific peoples had the lowest levels of CONSIDER reporting.

Interpretation

Extensive and inequitable gaps in CVDRA and management for Māori and Pacific peoples were identified. Opportunities for reducing these gaps include providing adequate CVD literacy, involvement of whanāu, patient-provider relationships, access to care, and enhancing cultural safety. Our findings will contribute to the development of a cardiovascular care equity roadmap in NZ. There are opportunities to improve reporting against the adapted CONSIDER criteria, which involves critical inquiry and a strength-based approach inclusive of Māori and Pacific values, particularly in quantitative research and research including but not focusing on Māori and Pacific peoples.

Funding

The Heart Foundation of New Zealand and Healthier Lives National Science Challenge, grant number 1819.