title: Epidemiological evidence that can help to improve timely diagnosis of colorectal cancer in New Zealand.

authors: Hirsz, Malgorzata

subjects: Colorectal cancer

abstract: Incidence rates of colorectal cancer (CRC) in New Zealand (NZ) are among the highest in the world. The long-term survival rates in NZ are poor, which has partially been attributed to late diagnosis. Considering that CRC is a curable disease if diagnosed early, conducting research targeted at the improvement of early diagnosis is therefore important. This thesis provides statistical models for the calculation of CRC incidence rates in the entire NZ population and population strata defined by age, gender, ethnicity and diabetes status, and a model for CRC risk in individual patients referred to the secondary care. The models presented here could assist health professionals in the selection of patients for further investigation to facilitate earlier diagnosis. The empirical part consists of three independent observational studies, briefly described below.

Sub-study 1. The objectives were, first, to describe trends in CRC incidence in the NZ population and, second, to investigate whether there are any strata defined by gender and ethnicity with especially increased incidence rates of CRC. To address these objectives, I analysed data from the New Zealand Cancer Registry (years 1994–2018) using an age- period-cohort (APC) model. The overall CRC incidence rates in NZ decreased between 1994 and 2018 by an average of 1.31% per year. However, the decrease was observed only in patients 50 years and older. In those 30-<50 years old, the incidence rates increased between 1994 and 2018 regardless of gender and ethnicity. The increase was similar for proximal, distal and rectal cancers. The APC analyses revealed very strong cohort effects that could explain nearly the entire trends in CRC incidence, pointing out generations born in the 1970s and 80s being affected by the increased incidence rates, rather than individuals 30-<50 years old. The cohort effects were different in Ma ̄ori and non-Ma ̄ori populations. In non-Ma ̄ori born between approximately 1939 and 1955, incidence rates decreased sharply. By contrast, those Ma ̄ori generations have not benefitted from the sharp decrease in rates. However, CRC incidence increased substantially in both M ̄aori and non-M ̄aori groups born in the 1970s and 80s.

Sub-study 2. The objective was to estimate the IRR for CRC in patients with diabetes compared to those without diabetes, with relation to diabetes duration and use of insulin for diabetes control. Registration in the Virtual Diabetes Register (VDR) in the years 2014–2018 was used as a marker of a diabetes diagnosis. Tables with counts of the entire NZ population stratified by age, gender, and ethnicity were obtained from Statistics NZ. In total, data from 310,710 patients with diabetes, corresponding to 1,277,284 person- years and 2512 incident CRC cases were analysed using a Poisson regression model. Diabetes was associated with an overall increased CRC incidence of 13% compared to non-diabetes [IRR=1.13 (95% CI: 1.08, 1.18)]. The IRR was especially high in the first three months after diabetes diagnosis [IRR=2.55 (95% CI 2.02, 3.21)], likely due to detection bias. The association was equally strong in males and females. However, in the analysis by ethnicity, the incidence of CRC was increased only in non-Ma ̄ori patients and restricted only to those younger than 75 years.

Sub-study 3. The objective was to develop a predictive model for CRC risk in individual patients referred to secondary care. To develop such a model, I extracted information from free text included in e-referrals from GPs’ to the Gastroenterology and General Surgery departments in the Waikato Hospital from 2015-2018, including: symptoms; test results; and family history of CRC. The reference test was a full colonoscopy with visualisation of the cecum. Data from 3015 patients, 20-<90 years old were analysed using a logistic regression model. The final model included the following predictors associated with increased CRC risk: anaemia, rectal bleeding, palpable mass in abdomen or rectum, weight loss, age and gender, and a decreased CRC risk: family history of CRC, abdominal pain, and inflammatory bowel disease. The model discriminates patients with low CRC risk well. According to the final cross-validated model, around 20% of patients from our cohort had performed colonoscopy despite a very low CRC risk (less than 1.5%).

In conclusion, the APC analysis revealed an alarming pattern. According to the fitted APC model, the combination of increasing age and cohort effect in generations born in the 1970s and 80s will bring a wave of CRC diagnoses in the near future when the young generations with high CRC incidence rates will replace the old generations with low CRC incidence. The results from this study could therefore help policy-makers to plan the needs for gastroenterology services.
Secondly, CRC incidence rates in diabetes have been found to be slightly increased com- pared to non-diabetes but only in non-Ma ̄ori individuals younger than 75 years.
Third, the results suggest that males underutilise health services. As shown in sub- study 3, males underwent fewer colonoscopies than females, despite having a higher risk of CRC. The higher detection bias in males than in females (sub-study 2) could also suggest underuse of health services by males, but the difference was not statistically significant.
Finally, based on the fitted models for CRC incidence in sub-studies 1 and 2, population- wide CRC screening for Ma ̄ori and patients with diabetes, based on the incidence, instead of age alone, would be proposed to start at age 57.5 years if the screening in the general population starts at age 60 years.

text: Epidemiological evidence that can help to improve timely diagnosis of colorectal cancer in New Zealand. Incidence rates of colorectal cancer (CRC) in New Zealand (NZ) are among the highest in the world. The long-term survival rates in NZ are poor, which has partially been attributed to late diagnosis. Considering that CRC is a curable disease if diagnosed early, conducting research targeted at the improvement of early diagnosis is therefore important. This thesis provides statistical models for the calculation of CRC incidence rates in the entire NZ population and population strata defined by age, gender, ethnicity and diabetes status, and a model for CRC risk in individual patients referred to the secondary care. The models presented here could assist health professionals in the selection of patients for further investigation to facilitate earlier diagnosis. The empirical part consists of three independent observational studies, briefly described below.

Sub-study 1. The objectives were, first, to describe trends in CRC incidence in the NZ population and, second, to investigate whether there are any strata defined by gender and ethnicity with especially increased incidence rates of CRC. To address these objectives, I analysed data from the New Zealand Cancer Registry (years 1994–2018) using an age- period-cohort (APC) model. The overall CRC incidence rates in NZ decreased between 1994 and 2018 by an average of 1.31% per year. However, the decrease was observed only in patients 50 years and older. In those 30-<50 years old, the incidence rates increased between 1994 and 2018 regardless of gender and ethnicity. The increase was similar for proximal, distal and rectal cancers. The APC analyses revealed very strong cohort effects that could explain nearly the entire trends in CRC incidence, pointing out generations born in the 1970s and 80s being affected by the increased incidence rates, rather than individuals 30-<50 years old. The cohort effects were different in Ma ̄ori and non-Ma ̄ori populations. In non-Ma ̄ori born between approximately 1939 and 1955, incidence rates decreased sharply. By contrast, those Ma ̄ori generations have not benefitted from the sharp decrease in rates. However, CRC incidence increased substantially in both M ̄aori and non-M ̄aori groups born in the 1970s and 80s.

Sub-study 2. The objective was to estimate the IRR for CRC in patients with diabetes compared to those without diabetes, with relation to diabetes duration and use of insulin for diabetes control. Registration in the Virtual Diabetes Register (VDR) in the years 2014–2018 was used as a marker of a diabetes diagnosis. Tables with counts of the entire NZ population stratified by age, gender, and ethnicity were obtained from Statistics NZ. In total, data from 310,710 patients with diabetes, corresponding to 1,277,284 person- years and 2512 incident CRC cases were analysed using a Poisson regression model. Diabetes was associated with an overall increased CRC incidence of 13% compared to non-diabetes [IRR=1.13 (95% CI: 1.08, 1.18)]. The IRR was especially high in the first three months after diabetes diagnosis [IRR=2.55 (95% CI 2.02, 3.21)], likely due to detection bias. The association was equally strong in males and females. However, in the analysis by ethnicity, the incidence of CRC was increased only in non-Ma ̄ori patients and restricted only to those younger than 75 years.

Sub-study 3. The objective was to develop a predictive model for CRC risk in individual patients referred to secondary care. To develop such a model, I extracted information from free text included in e-referrals from GPs’ to the Gastroenterology and General Surgery departments in the Waikato Hospital from 2015-2018, including: symptoms; test results; and family history of CRC. The reference test was a full colonoscopy with visualisation of the cecum. Data from 3015 patients, 20-<90 years old were analysed using a logistic regression model. The final model included the following predictors associated with increased CRC risk: anaemia, rectal bleeding, palpable mass in abdomen or rectum, weight loss, age and gender, and a decreased CRC risk: family history of CRC, abdominal pain, and inflammatory bowel disease. The model discriminates patients with low CRC risk well. According to the final cross-validated model, around 20% of patients from our cohort had performed colonoscopy despite a very low CRC risk (less than 1.5%).

In conclusion, the APC analysis revealed an alarming pattern. According to the fitted APC model, the combination of increasing age and cohort effect in generations born in the 1970s and 80s will bring a wave of CRC diagnoses in the near future when the young generations with high CRC incidence rates will replace the old generations with low CRC incidence. The results from this study could therefore help policy-makers to plan the needs for gastroenterology services.
Secondly, CRC incidence rates in diabetes have been found to be slightly increased com- pared to non-diabetes but only in non-Ma ̄ori individuals younger than 75 years.
Third, the results suggest that males underutilise health services. As shown in sub- study 3, males underwent fewer colonoscopies than females, despite having a higher risk of CRC. The higher detection bias in males than in females (sub-study 2) could also suggest underuse of health services by males, but the difference was not statistically significant.
Finally, based on the fitted models for CRC incidence in sub-studies 1 and 2, population- wide CRC screening for Ma ̄ori and patients with diabetes, based on the incidence, instead of age alone, would be proposed to start at age 57.5 years if the screening in the general population starts at age 60 years.

year: 2021

title: Culture and climate change: A study of future-proofing Māori tourism businesses

authors: Tawhai, Crystal Candace

subjects: culture

abstract: This thesis explores how prepared Māori tourism businesses are to adapt to climate change and how Māori values may influence the business's perception of responses to climate change. As climate impacts are growing in New Zealand, as a result of increasing extreme weather events, how can Māori tourism businesses protect their taonga (resources)? Taonga in the context of this study includes Māori values, lands, seas and their businesses. Furthermore, the literature indicates that Māori tourism significantly contributes to the economic, social and cultural wellbeing for Māori and wider New Zealand (NZ Māori Tourism, 2018). 
At a specific level, the study focuses on three Māori tourism businesses. Two of the businesses are North Island-based whānau-owned enterprises, one on Kāpiti Island and the other in Napier. The third is a hapū-owned business located in Kaikoura in the South Island. Drawing on kaupapa Māori frameworks built on Māori struggles for tino rangatiratanga and mana motuhake (self-determination), the study adheres to kaupapa Māori principles of carrying out research by Māori to benefit Māori. The primary data for the study was collected through semi-structured interviews with each of the businesses, taking care to ensure the cultural safety of the participants and using appropriate tikanga (protocol) in each interview. 

The findings of the study show that Māori tourism businesses are adapting to environmental changes but are unsure about the pace of climate change. The uncertainties are due to a lack of access to information and competing priorities within their businesses. The research also shows how decisions made by local government as well as business perceptions of local and central government institutions negatively impacts on the ability of businesses to adapt to climate change. While there were differences in the businesses’ treatment of science and scientific information, all of them prioritised Māori cultural values. Significantly, these values underpin all the activities of the businesses, including, environmental enhancement and protection. An emphasis on Māori values in facilitated partnerships between tourism businesses, government bodies, and other community stakeholders on co-designing climate change adaptation strategies can help the tourism sector to prepare for a changing climate.

text: Culture and climate change: A study of future-proofing Māori tourism businesses This thesis explores how prepared Māori tourism businesses are to adapt to climate change and how Māori values may influence the business's perception of responses to climate change. As climate impacts are growing in New Zealand, as a result of increasing extreme weather events, how can Māori tourism businesses protect their taonga (resources)? Taonga in the context of this study includes Māori values, lands, seas and their businesses. Furthermore, the literature indicates that Māori tourism significantly contributes to the economic, social and cultural wellbeing for Māori and wider New Zealand (NZ Māori Tourism, 2018). 
At a specific level, the study focuses on three Māori tourism businesses. Two of the businesses are North Island-based whānau-owned enterprises, one on Kāpiti Island and the other in Napier. The third is a hapū-owned business located in Kaikoura in the South Island. Drawing on kaupapa Māori frameworks built on Māori struggles for tino rangatiratanga and mana motuhake (self-determination), the study adheres to kaupapa Māori principles of carrying out research by Māori to benefit Māori. The primary data for the study was collected through semi-structured interviews with each of the businesses, taking care to ensure the cultural safety of the participants and using appropriate tikanga (protocol) in each interview. 

The findings of the study show that Māori tourism businesses are adapting to environmental changes but are unsure about the pace of climate change. The uncertainties are due to a lack of access to information and competing priorities within their businesses. The research also shows how decisions made by local government as well as business perceptions of local and central government institutions negatively impacts on the ability of businesses to adapt to climate change. While there were differences in the businesses’ treatment of science and scientific information, all of them prioritised Māori cultural values. Significantly, these values underpin all the activities of the businesses, including, environmental enhancement and protection. An emphasis on Māori values in facilitated partnerships between tourism businesses, government bodies, and other community stakeholders on co-designing climate change adaptation strategies can help the tourism sector to prepare for a changing climate.

year: 2020

title: Maldivian primary teachers activate and shape their Social Studies pedagogies through reflection

authors: Saeed, Sharuda

subjects: social studies

abstract: This study emerges from a deep-seated concern about the potential erosion of Maldivian cultural heritage and identity, reflected in the diminishing prominence of traditional cultural practices, language, beliefs, which are often threatened by tourism and foreign influences. The research investigates how Maldivian primary teachers perceive and teach social studies, a subject crucial for preserving cultural identity and for promoting sustainable development. As a Maldivian social studies educator, I view social studies education as an empowering force for fostering critical thinking, empathy, and global citizenship among future leaders.   

The research explores how primary teachers activate and shape their social studies pedagogy through reflection, with a focus on Key Stage 1 and 2 levels. Some findings indicate that teachers face challenges due to limited access to specialised professional learning, resulting pedagogical approaches that are often teacher-led and exam focused, rather than being inquiry-based and student-centred. This thesis sheds light on these dynamics and contributes to critical need for educational reform conversations in the Maldives on the quality of social studies education.   

Conducted during the COVID-19 pandemic, this largely qualitative study initially adopted a Participatory Action Research [PAR] methodology and later transitioned to Online Participatory Action Research [OPAR]. Data was collected from ten participants via a Qualtrics questionnaire and online workshops, with four teachers contributing reflective narrative texts and participating in online interviews. Thematic analysis and grounded theory guided the analysis, which uncovered key themes and generating theoretical insights drawn from the firsthand experiences of the participants within the realm of social studies education in the Maldives.  

The findings highlight the crucial role of reflective practice in shaping pedagogy and fostering professional growth. Analysis of teachers’ experiences suggested how reflective practice influences their social studies teaching, helping them adapt to the evolving educational landscape in the Maldives. The study also highlights strategies teachers employ to navigate challenges, and illustrated the practical impact of reflective practice on improving teaching, learning, and ongoing professional development for Maldivian social studies teachers.  

Four key implications arise from this study. First, the study highlights the importance of understanding teachers’ perceptions of social studies within the National Curriculum Framework, and the need for more targeted exploration of its significance. Second, it underscores the need to address challenges in professional learning, with recommending tailored interventions to enhance teachers’ social studies pedagogy being necessary. Third, the research emphasises the role of reflective practice in shaping teaching methods and urges educational institutions, including the Maldives National University, to integrate reflective strategies into teacher training. Finally, the findings advocate for policy initiatives and support structures to create an environment that fosters reflective practices, enhancing social studies education in primary schools.

text: Maldivian primary teachers activate and shape their Social Studies pedagogies through reflection This study emerges from a deep-seated concern about the potential erosion of Maldivian cultural heritage and identity, reflected in the diminishing prominence of traditional cultural practices, language, beliefs, which are often threatened by tourism and foreign influences. The research investigates how Maldivian primary teachers perceive and teach social studies, a subject crucial for preserving cultural identity and for promoting sustainable development. As a Maldivian social studies educator, I view social studies education as an empowering force for fostering critical thinking, empathy, and global citizenship among future leaders.   

The research explores how primary teachers activate and shape their social studies pedagogy through reflection, with a focus on Key Stage 1 and 2 levels. Some findings indicate that teachers face challenges due to limited access to specialised professional learning, resulting pedagogical approaches that are often teacher-led and exam focused, rather than being inquiry-based and student-centred. This thesis sheds light on these dynamics and contributes to critical need for educational reform conversations in the Maldives on the quality of social studies education.   

Conducted during the COVID-19 pandemic, this largely qualitative study initially adopted a Participatory Action Research [PAR] methodology and later transitioned to Online Participatory Action Research [OPAR]. Data was collected from ten participants via a Qualtrics questionnaire and online workshops, with four teachers contributing reflective narrative texts and participating in online interviews. Thematic analysis and grounded theory guided the analysis, which uncovered key themes and generating theoretical insights drawn from the firsthand experiences of the participants within the realm of social studies education in the Maldives.  

The findings highlight the crucial role of reflective practice in shaping pedagogy and fostering professional growth. Analysis of teachers’ experiences suggested how reflective practice influences their social studies teaching, helping them adapt to the evolving educational landscape in the Maldives. The study also highlights strategies teachers employ to navigate challenges, and illustrated the practical impact of reflective practice on improving teaching, learning, and ongoing professional development for Maldivian social studies teachers.  

Four key implications arise from this study. First, the study highlights the importance of understanding teachers’ perceptions of social studies within the National Curriculum Framework, and the need for more targeted exploration of its significance. Second, it underscores the need to address challenges in professional learning, with recommending tailored interventions to enhance teachers’ social studies pedagogy being necessary. Third, the research emphasises the role of reflective practice in shaping teaching methods and urges educational institutions, including the Maldives National University, to integrate reflective strategies into teacher training. Finally, the findings advocate for policy initiatives and support structures to create an environment that fosters reflective practices, enhancing social studies education in primary schools.

year: 2024