The impact of racism on subsequent healthcare use and experiences for adult New Zealanders: a prospective cohort study

BACKGROUND

Racism is an important determinant of health and driver of racial/ethnic health inequities. Experience of racism has been linked to negative healthcare use and experiences although most studies have been cross-sectional. This study examines the relationship between reported experience of racism and subsequent use and experience of health services.

METHODS

This is a prospective cohort study design. The 2016/2017 adult New Zealand Health Survey (NZHS) provided the sampling frame and baseline data on exposures, health status and confounders. This stand-alone study invited all exposed individuals to participate when sampled based on their reported experience of racism (ever), stratified by broad ethnic groupings (Māori, Pacific, Asian, European/Other). Equal numbers of unexposed participants were selected for invitation using propensity score matching (propensity to experience racism, based on key available predictive factors). Follow-up was one to two years after NZHS interview. Outcome variables (last 12 months) were: unmet healthcare need (overall, for mental health, for a general practitioner); satisfaction with usual medical centre; and experiences with general practitioners (explaining care, involvement in decision-making, treated with respect/dignity, confidence and trust). Logistic regression models examining the association between experience of racism (at baseline) and health service use and experience (at follow-up) used doubly-robust estimation to weight for propensity scores used in the sampling with additional adjustment for confounders.

RESULTS

The study had 2010 participants. Experience of racism (ever) at baseline was associated with higher overall unmet need at follow-up (adjusted OR (aOR) = 1.71, 95% CI 1.31, 2.23), with similar patterns for other unmet need measures. Experience of racism was associated with higher dissatisfaction with a usual medical centre (aOR = 1.41, 95% CI 1.10, 1.81) and with higher reporting of negative patient experiences.

CONCLUSION

In line with how racism structures oppression, exposure to racism is largely felt by non-European groups in Aotearoa New Zealand. Experiences of racism potentially lead to poorer healthcare and healthcare inequities through higher unmet need, lower satisfaction and more negative experiences of healthcare. The health system has a critical role to play in addressing racism within healthcare and supporting societal efforts to eliminate racism and ethnic inequities.

'It absolutely needs to move out of that structure': Māori with bipolar disorder identify structural barriers and propose solutions to reform the New Zealand mental health system

OBJECTIVES

This paper synthesises critique from Māori patients with Bipolar Disorder (BD) and their whānau to identify barriers and propose changes to improve the structure and function of the New Zealand mental health system.

DESIGN

A qualitative Kaupapa Māori Research methodology was used. Twenty-four semi-structured interviews were completed with Māori patients with BD and members of their whānau. Structural, descriptive and pattern coding was completed using an adapted cultural competence framework to organise and analyse the data.

RESULTS

Three key themes identified the impact of structural features of the New Zealand mental health system on health equity for Māori with BD. Themes involved the accessibility, delivery and scope of the current health system, and described how structural features influenced the quality, utility and availability of BD services for Māori patients and whānau. Structural barriers in the existing design, and potential changes to improve the accessibility, delivery and scope of BD services for Māori, were proposed including a redesign of operational, environmental, staffing, and navigation points (information, transition, fatigue) to better meet the needs of Māori with BD.

CONCLUSION

A commitment to equity when implementing structural change is needed, including ongoing evaluation and refinement. This paper provides specific recommendations that should be considered in health service redesign to ensure the New Zealand mental health system meets the needs of Māori patients with BD and their whānau.

Understanding the context of hospital transfers and away-from-home hospitalisations for Māori

In Aotearoa New Zealand, people regularly travel away from their home to receive hospital care. While the role of whānau support for patients in hospital is critical for Māori, there is little information about away-from-home hospitalisations. This paper describes the frequency and patterning of away-from-home hospitalisations and inter-hospital transfers for Māori. Data from the National Minimum Dataset (NMDS), for the 6-year period of 1 January 2009-31 December 2014, were analysed. Basic frequencies, means and descriptive statistics were produced using SAS software. We found that more than 10% of all routine hospitalisations constituted an away-from-home hospitalisation for Māori; that is, a hospitalisation that was in a district health board (DHB) other than the DHB of usual residence for the patient. One quarter (25.19%) of transfer hospitalisations were to a DHB other than the patient's DHB of domicile. Away-from-home hospital admissions increase for Māori as deprivation increases for both routine and transfer admissions, with over half of Māori hospital admissions among people who live in areas of high deprivation. This analysis aids in understanding away-from-home hospitalisations for Māori whānau, the characteristics associated with these types of hospitalisations and supports the development and implementation of policies which better meet whānau Māori needs. The cumulative impact of the need to travel to hospital for care, levels of poverty and a primarily reimbursement-based travel assistance system all perpetuate an unequal cost burden placed upon Māori whānau.

Culturally competent, safe and equitable clinical care for Ma¯ori with bipolar disorder in New Zealand: The expert critique of Ma¯ori patients and Wha¯nau

OBJECTIVE

Research designed to increase knowledge about Māori with bipolar disorder is required to understand how health services support wellbeing and respond to identified levels of community need. This paper synthesises the expert critique of Māori patients with bipolar disorder and their whānau regarding the nuances of cultural competence and safety in clinical encounters with the health system.

METHODS

A qualitative Kaupapa Māori Research methodology was used. A total of 24 semi-structured interviews were completed with Māori patients with bipolar disorder and members of their whānau. Structural, descriptive and pattern coding was completed using an adapted cultural competence framework to organise and analyse the data.

RESULTS

Three themes were evident from participants' critique of clinical components of the health system. Theme 1 established that the efficacy of clinical care for bipolar disorder was dependent on Māori patients and whānau having clear pathways through care, and being able to access timely, consistent care from clinically and culturally competent staff. Theme 2 identified the influence of clinical culture in bipolar disorder services, embedded into care settings, expressed by staff, affecting the safety of clinical care for Māori. Theme 3 focused on the need for bipolar disorder services to prioritise clinical work with whānau, equip staff with skills to facilitate engagement and tailor care with resources to enhance whānau as well as patient wellbeing.

CONCLUSION

The standard of clinical care for Māori with bipolar disorder in New Zealand does not align with practice guidelines, Māori models of health or clinical frameworks designed to inform treatment and address systemic barriers to equity. Research also needs to explore the role of structural and organisational features of the health system on Māori patient and whānau experiences of care.

Co-design for indigenous and other children and young people from priority social groups: A systematic review

Background

Co-design has increasingly been posited as a useful approach for Indigenous peoples and other social groups that experience inequities. However, the relatively rapid rise in co-design rhetoric has not necessarily been accompanied by increased understanding of whether co-design works for these social groups, and how equity is addressed.

Methods

We conducted a systematic review to identify the current state of co-design as theory and praxis within the context of health and/or disability related interventions or services, with a specific focus on equity considerations for Indigenous and other children and young people from priority social groups. Six electronic databases were searched systematically to identify peer-reviewed papers and grey literature (dissertation and theses) published between January 1, 2000 to December 31, 2020, and a hand-search of reference lists for selected full texts was undertaken.

Results

Fifteen studies met the inclusion criteria. Although all studies used the term ‘co-design’, only three provided a definition of what they meant by use of the term. Nine studies described one or more theory-based frameworks and a total of 26 methods, techniques and tools were reported, with only one study describing a formal evaluation. The key mechanism by which equity was addressed appeared to be the inclusion of participants from a social group experiencing inequities within an area of interest.

Conclusion

A dearth of information limits the extent to which the literature can be definitive as to whether co-design works for Indigenous and other children and young people from priority social groups, or whether co-design reduces health inequities. It is critical for quality reporting to occur regarding co-design definitions, theory, and praxis. There is an urgent requirement for evaluation research that focuses on co-design impacts and assesses the contribution of co-design to achieving equity. We also recommend culturally safe ethical processes be implemented whenever undertaking co-design.

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Limited studies report co-design contribution to positive outcomes.

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Evaluatin Evaluation of co-design impacts and contribution to equity is urgently required.

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Culturally safe ethical processes must be implemented in co-design.

"If we can just dream…" Māori talk about healthcare for bipolar disorder in New Zealand: A qualitative study privileging Indigenous voices on organisational transformation for health equity

Objectives

This paper identifies barriers to equity and proposes changes to improve the organisation of healthcare in New Zealand for Māori with bipolar disorder (BD) and their families.

Design

A qualitative Kaupapa Māori methodology was used. Twenty‐four semi‐structured interviews were completed with Māori with BD and members of their family. Structural and descriptive coding was used to organise and analyse the data, including an analytic frame that explored participants' critique of attributes of the organisation of healthcare and alignment with Māori health policy.

Results

Transformation to the organisation of healthcare is needed to achieve health equity. Executive management must lead changes to organisational culture, deliver an equity partnership model with Māori, embed cultural safety and redesign the organisation of healthcare to improve wellbeing. Healthcare incentive structures must diversify, develop and retain a culturally competent health workforce. Information management and technology systems must guide continued whole system improvements.

Conclusion

This paper provides recommendations that should be considered in planned reforms to the organisation of healthcare in New Zealand. The challenge remains whether resourcing for an equitable healthcare organisation will be implemented in partial fulfilment of promises of equity in policy.

Indigenous health equity requires the organisation of healthcare to transform.

Executive management must lead changes to organisational culture.

Change to healthcare culture will then support organisational re‐design.

Evaluation, technologies, and incentives will support continued equity gains.

311Effective prospective study sampling from an existing large-scale national survey using propensity score methods

Focus of Presentation

Cohort study recruitment can be complex, often requiring extensive pre-screening to recruit sufficient numbers of exposed and unexposed participants. We discuss a prospective study of the impact of racism on adult health in New Zealand (NZ), with emphasis on propensity-score based sampling and recruitment methods accessing participants from a national survey (NZ Health Survey 2017/18, n = 12,530 eligible adults).

Discussion will cover sampling design, response rate, and confounder balance in the final sample. Key empirical results will be summarised.

Findings

The NZHS provided a sampling frame with complete baseline exposure and covariate data, giving n = 2,099 exposed individuals (reported racial discrimination on NZHS). A propensity-score model (stratified by ethnicity) allowed invitation of unexposed individuals balanced on key sociodemographic confounders.

Recruitment used postal invitations with telephone follow-up: individuals could respond by paper survey, online questionnaire or telephone interview. Response rate was 54%, with comparable rates in exposed/unexposed individuals, with key sociodemographic factors well-balanced by exposure status.

Conclusions/Implications

Racism is an important determinant of health inequity, with limited prospective research in New Zealand. Our approach enabled appropriate recruitment from a sampling frame with baseline exposure status (NZHS), including allowance for exposure variability by ethnicity. Propensity-score matching on baseline covariates allowed for balance on key confounders at invitation, with balance maintained in the final sample.

Key messages

Secondary sampling from large national surveys can provide efficient recruitment for prospective studies. We achieved a highly satisfactory response rate, and propensity-score based sampling substantially balanced confounders between exposed and unexposed groups, enhancing study validity.

Bowel cancer screening age range for Māori: what is all the fuss about?

The current New Zealand Bowel Screening Programme (BSP) is inequitable. At present, just over half of bowel cancers in Māori present before the age of 60 years (58% in females and 52% in males), whereas just under a third of bowel cancers in non-Māori are diagnosed before the same age (27% in females and 29% in males). The argument for extending the bowel screening age range down to 50 years for Māori is extremely simple-in comparison to non-Māori, a greater percentage of bowel cancers in Māori occur before the age of 60 years (when screening starts). Commencing the BSP at 50 years of age for Māori with high coverage will help fix this inequity. In this paper we review the current epidemiology of colorectal cancer with respect to the age range extension for Māori.

Indigenous Peoples' Data During COVID-19: From External to Internal

Global disease trackers quantifying the size, spread, and distribution of COVID-19 illustrate the power of data during the pandemic. Data are required for decision-making, planning, mitigation, surveillance, and monitoring the equity of responses. There are dual concerns about the availability and suppression of COVID-19 data; due to historic and ongoing racism and exclusion, publicly available data can be both beneficial and harmful. Systemic policies related to genocide and racism, and historic and ongoing marginalization, have led to limitations in quality, quantity, access, and use of Indigenous Peoples' COVID-19 data. Governments, non-profits, researchers, and other institutions must collaborate with Indigenous Peoples on their own terms to improve access to and use of data for effective public health responses to COVID-19.

Racism and health in Aotearoa New Zealand: a systematic review of quantitative studies

BACKGROUND

Racism is an underlying cause of ethnic health inequities both in Aotearoa New Zealand and internationally. It is timely to synthesise racism and health research within New Zealand particularly given the current policy environment and shift towards addressing the health effects of racism.

AIM

To review quantitative research examining self-reported experiences of racial discrimination and associations with measures of health (health conditions, health risk, health status and healthcare) in New Zealand.

METHODS

MEDLINE, PsycINFO, Web of Science and CINAHL databases were searched for studies reporting on associations between experiences of racism and health.

RESULTS

The systematic review identified 24 quantitative studies reporting associations between self-reported racial discrimination across a wide range of health measures including mental health, physical health, self-rated health, wellbeing, individual level health risks, and healthcare indicators.

CONCLUSIONS

Quantitative racism and health research in New Zealand consistently finds that self-reported racial discrimination is associated with a range of poorer health outcomes and reduced access to and quality of healthcare. This review confirms that experience of racial discrimination is an important determinant of health in New Zealand, as it is internationally. There is a pressing need for effectively designed interventions to address the impacts of racism on health.

'…but I just prefer to treat everyone the same…': general practice receptionists talking about health inequities

General practice receptionists are positioned at the beginning of a patient's journey within the healthcare system, yet their influence on a patient's experience is unknown. The limited data on, and research involving, general practice receptionists both in New Zealand and internationally is evidence of this. This research undertook an exploration of the discourses used by a group of general practice receptionists in Wellington, New Zealand to discover how they talk about, and represent, health inequities. Eight in-depth semi-structured interviews were conducted, guided by Social Constructionism and Decolonising Theory. Three reoccurring patterns of discourse were identified: discourses about the social determinants of health; discourses about Māori culture and behaviour; and discourses about egalitarianism. Further, narratives that could be seen as deficit-focussed or victim-blaming were identified. Racism was not directly discussed by participants as a health determinant. The findings support the need for training guided by cultural safety and anti-racism principles to be available for all general practice receptionists.

Colonial histories, racism and health-The experience of Māori and Indigenous peoples

The health of Māori, the Indigenous peoples of Aotearoa, New Zealand, like that of almost all Indigenous peoples worldwide, is characterised by systematic inequities in health outcomes, differential exposure to the determinants of health, inequitable access to and through health and social systems, disproportionate marginalisation and inadequate representation in the health workforce. As health providers, we are often taught that 'taking a history' is a critical component of a patient consultation to ensure that the underlying conditions are treated rather than the often superficial presenting symptoms. In the same way, attempts to make sense of the health and well-being of Indigenous peoples is inadequate unless health providers engage critically with the history of their respective nations and any subsequent patterns of privilege or disadvantage. Understanding this history, within the framework of western imperialism and other similar colonial projects, allows us to make sense of international patterns of Indigenous health status. While health commentators acknowledge the unequal health outcomes of Indigenous people, and an increasing number also link these inequities to Indigenous marginalisation resulting from historic events, very few go further and expose the deep relationship between racism and coloniality and how these continue to be the basic determinants of Indigenous health today. This work includes honest examination of the role that science and the health disciplines have played historically in colonisation through the subjugation of Indigenous ways of knowing and knowledge production, as well as being complicit in the creation and maintenance of a fabricated hierarchy of humankind. Despite the 'science' of this racial hierarchy being discredited, it retains a false validity in our societies. As long as oppressive systems that continue to re-inscribe racism and white privilege remain in communities, including our academic communities, coloniality continues its discrimination. Indigenous voices on migration, ethnicity, racism^a and health will always demand the elimination of inequities in health but to do so will require a parallel commitment to critically interrogating all of our histories and our disciplines, as well as examining how our practice, including research, disrupts or maintains global systems of racism and coloniality.

The impact of racism on the future health of adults: protocol for a prospective cohort study

Background

Racial discrimination is recognised as a key social determinant of health and driver of racial/ethnic health inequities. Studies have shown that people exposed to racism have poorer health outcomes (particularly for mental health), alongside both reduced access to health care and poorer patient experiences. Most of these studies have used cross-sectional designs: this prospective cohort study (drawing on critical approaches to health research) should provide substantially stronger causal evidence regarding the impact of racism on subsequent health and health care outcomes.

Methods

Participants are adults aged 15+ sampled from 2016/17 New Zealand Health Survey (NZHS) participants, sampled based on exposure to racism (ever exposed or never exposed, using five NZHS questions) and stratified by ethnic group (Māori, Pacific, Asian, European and Other). Target sample size is 1680 participants (half exposed, half unexposed) with follow-up survey timed for 12–24 months after baseline NZHS interview. All exposed participants are invited to participate, with unexposed participants selected using propensity score matching (propensity scores for exposure to racism, based on several major confounders). Respondents receive an initial invitation letter with choice of paper or web-based questionnaire. Those invitees not responding following reminders are contacted for computer-assisted telephone interview (CATI).

A brief questionnaire was developed covering current health status (mental and physical health measures) and recent health-service utilisation (unmet need and experiences with healthcare measures). Analysis will compare outcomes between those exposed and unexposed to racism, using regression models and inverse probability of treatment weights (IPTW) to account for the propensity score sampling process.

Discussion

This study will add robust evidence on the causal links between experience of racism and subsequent health. The use of the NZHS as a baseline for a prospective study allows for the use of propensity score methods during the sampling phase as a novel approach to recruiting participants from the NZHS. This method allows for management of confounding at the sampling stage, while also reducing the need and cost of following up with all NZHS participants.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6664-x) contains supplementary material, which is available to authorized users.

Self-reported sleep complaints are associated with adverse health outcomes: cross-sectional analysis of the 2002/03 New Zealand Health Survey

OBJECTIVE

The aim was to investigate the prevalence of self-reported sleep complaints in New Zealand adults and determine the independent association of sleep complaints with adverse health outcomes.

DESIGN

We used 2002/03 New Zealand Health Survey data (n = 12,500 adults, ≥15 years). The prevalence of self-reported sleep complaints was estimated by ethnicity. The relationship between sleep complaints and mental health, physical health and health risk behaviors were investigated using multivariable logistic regression models.

RESULTS

The prevalence of each sleep complaint measure was highest for the indigenous Māori population (23.6% reported 'any' sleep complaint; 10.3% reported multiple sleep complaints). Reporting 'any' sleep complaint was associated with higher odds of poorer mental health, diagnosed high blood pressure, diagnosed diabetes, diagnosed heart disease, poor/fair self-rated health, obesity, current smoking, and hazardous drinking.

CONCLUSION

The higher prevalence of sleep complaints among Māori and the consistent association with poor health suggests a potential role for suboptimal sleep in ethnic health inequities.

The experience of gestational diabetes for indigenous Māori women living in rural New Zealand: qualitative research informing the development of decolonising interventions

Background

Although early detection and management of excess rates of gestational diabetes mellitus (GDM) among Indigenous women can substantially reduce maternal and offspring complications, current interventions seem ineffective for Indigenous women. While undertaking a qualitative study in a rural community in Northland, New Zealand about the complexities of living with diabetes, we observed a common emotional discourse about the burden of diabetic pregnancies. Given the significance of GDM and our commitment to give voice to Indigenous Māori women in ways that could potentially inform solutions, we aimed to explore the phenomenon of GDM among Māori women in a rural context marked by high area-deprivation.

Method

A qualitative and Kaupapa Māori methodology was utilised. A sub-sample of women (n = 10) from a broader study designed to improve type 2 diabetes mellitus (T2DM) who had experienced GDM or pre-existing diabetes during pregnancy and/or had been exposed to diabetes in utero were interviewed. Participants in the broader study were recruited via the local primary care clinic. Experiences of GDM, in relation to their current T2DM, was sought. Narrative data was analysed for themes.

Results

Intergenerational experiences informed perceptions that GDM was an inevitable heritable illness that “just runs in the family.” The cumulative effects of deprivation and living with GDM compounded the complexities of participant’ lives including perceptions of powerlessness and mental health deterioration. Missed opportunities for health services to detect and manage diabetes had ongoing health consequences for the women and their offspring. Positive relationships with healthcare providers facilitated management of GDM and helped women engage with self-management.

Conclusion

Māori women living with T2DM were clear that health providers had failed to intervene in ways that would have potentially slowed or prevented progression of GDM to T2DM. Participants revealed missed opportunities for appropriate diagnostic testing, treatment and health promotion programmes for GDM. Poor collaboration between health services and social services meant psychosocial issues were rarely addressed and the cycle of intergenerational poverty and disadvantage prevailed. These data highlight opportunities for extended case management to include whānau (family) engagement, input from social services, and evidence-based medicine and/or long-term management and prevention of T2DM.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-2103-8) contains supplementary material, which is available to authorized users.

Audit of ethnicity data in the Waikato Hospital Patient Management System and Trauma Registry: pilot of the Hospital Ethnicity Data Audit Toolkit

BACKGROUND

Māori are disproportionately impacted by injury in New Zealand, therefore reliable ethnicity data are essential for measuring and addressing inequities in trauma incidence, care and outcomes.

AIM

To audit the quality of ethnicity data captured by the Waikato Hospital Trauma Registry and Waikato Hospital patient management system against self-identified ethnicity.

METHOD

Self-identified ethnicity using the New Zealand Census ethnicity question was gathered from 100 consecutive trauma patients and compared with ethnicity recorded in their Trauma Registry record and in the hospital's patient management database.

RESULTS

Twenty-nine (29%) participants self-identified as Māori, of whom six were classified as New Zealand European (NZE) only in the Trauma Registry and five as NZE on the hospital patient management database. Over half of Māori (n=18/29) reported more than one ethnicity compared with 4% (n=3/71) of non-Māori. Self-identified ethnicity matched Trauma Registry ethnicity for one quarter (n=7/29) of Māori versus 9% of non-Māori.

CONCLUSIONS

The degree of misclassification of Māori ethnicity data among patients in the Waikato Trauma Registry and the Waikato Hospital patient management system highlights a need for improvements to how ethnicity data is captured within these databases and potentially many other similar entities collecting ethnicity data in New Zealand. The release of revised standardised protocols for the collection of ethnicity data is timely given the recent establishment of a national trauma registry. Without quality data, the opportunity to investigate and address ethnic inequities in trauma incidence and management is greatly compromised.

Perspectives on Linkage Involving Indigenous data

Topic: Perspectives on Linkage Involving Indigenous dataIndigenous populations across the globe are reaffirming their sovereignty rights in the collection and use of Indigenous data. The Indigenous data sovereignty movement has been widely influential and can be unsettling for those who routinely use population-level linked data that include Indigenous identifiers. Ethical policies that stipulate community engagement for access, interpretation and dissemination of Indigenous data create an enabling environment through the critical process of negotiating and navigating data access in partnership with communities. This session will be designed to create space for leading Indigenous voices to set the tone for the discussion around Indigenous population data linkage. Objectives: To provide participants with an opportunity to build on the themes of Indigenous Data Sovereignty presented in the keynote session as they apply to diverse Indigenous populations. To explore approaches to the linkage of Indigenous-identified population data across four countries, including First Nations in three Canadian regions. To share practical applications of Indigenous data sovereignty on data linkage and analysis and discussion. To center Indigenous-driven data linkage and research. Facilitator:Jennifer Walker. Canada Research Chair in Indigenous Health, Laurentian University and Indigenous Lead, Institute for Clinical Evaluative Sciences. Collaborators: Alberta: Bonnie Healy, Tina Apsassin, Chyloe Healy and William Wadsworth (Alberta First Nations Information Governance Centre) Ontario: Carmen R. Jones (Chiefs of Ontario) and Jennifer Walker (Institute for Clinical Evaluative Sciences) British Columbia: Jeff Reading (Providence Health Centre) and Laurel Lemchuk-Favel (First Nations Health Authority) Australia: Raymond Lovett (Australian National University) Aotearoa / New Zealand: Donna Cormack (University of Otago) United States: Stephanie Rainie and Desi Rodriguez-Lonebear (University of Arizona) Session format: 90 minutesCollaborators will participate in a round-table introduction to the work they are doing. Collaborators will discuss the principles underlying their approaches to Indigenous data linkage as well as practical and concrete solutions to challenges. Questions to guide the discussion will be pre-determined by consensus among the collaborators and the themes will include: data governance, community engagement, Indigenous-led linkage and analysis of data, and decision-making regarding access to linked data. Other participants attending the session will be encouraged to listen and will have an opportunity to engage in the discussion and ask questions. Intended output or outcome:The key outcome of the session will be twofold. First, those actively working with Indigenous linked data will have an opportunity for an in-depth and meaningful dialogue about their work, which will promote international collaboration and sharing of ideas. Second, those with less experience and knowledge of the principles of Indigenous data sovereignty and their practical application will have an opportunity to listen to Indigenous people who are advancing the integration of Indigenous ways of knowing into data linkage and analysis. The output of the session will be a summary paper highlighting both the diversity and commonalities of approaches to Indigenous data linkage internationally. Areas where consensus exists, opportunities for collaboration, and challenges will be highlighted.

Caregiver experiences of racism and child healthcare utilisation: cross-sectional analysis from New Zealand

OBJECTIVES

Children's exposure to racism via caregiver experience (vicarious racism) is associated with poorer health and development. However, the relationship with child healthcare utilisation is unknown. We aimed to investigate (1) the prevalence of vicarious racism by child ethnicity; (2) the association between caregiver experiences of racism and child healthcare utilisation; and (3) the contribution of caregiver socioeconomic position and psychological distress to this association.

DESIGN

Cross-sectional analysis of two instances of the New Zealand Health Survey (2006/2007: n=4535 child-primary caregiver dyads; 2011/2012: n=4420 dyads).

MAIN OUTCOME MEASURES

Children's unmet need for healthcare, reporting no usual medical centre and caregiver-reported dissatisfaction with their child's medical centre.

RESULTS

The prevalence of reporting 'any' experience of racism was higher among caregivers of indigenous Māori and Asian children (30.0% for both groups in 2006/2007) compared with European/Other children (14.4% in 2006/2007). Vicarious racism was independently associated with unmet need for child's healthcare (OR=2.30, 95% CI 1.65 to 3.20) and dissatisfaction with their child's medical centre (OR=2.00, 95% CI 1.26 to 3.16). Importantly, there was a dose-response relationship between the number of reported experiences of racism and child healthcare utilisation (eg, unmet need: 1 report of racism, OR=1.89, 95% CI 1.34 to 2.67; 2+ reports of racism, OR=3.06, 95% CI 1.27 to 7.37). Adjustment for caregiver psychological distress attenuated the association between caregiver experiences of racism and child healthcare utilisation.

CONCLUSIONS

Vicarious racism is a serious health problem in New Zealand disproportionately affecting Māori and Asian children and significantly impacting children's healthcare utilisation. Tackling racism may be an important means of improving inequities in child healthcare utilisation.

Ethnic bias amongst medical students in Aotearoa/New Zealand: Findings from the Bias and Decision Making in Medicine (BDMM) study

Although health provider racial/ethnic bias has the potential to influence health outcomes and inequities, research within health education and training contexts remains limited. This paper reports findings from an anonymous web-based study examining racial/ethnic bias amongst final year medical students in Aotearoa/New Zealand. Data from 302 students (34% of all eligible final year medical students) were collected in two waves in 2014 and 2015 as part of the Bias and Decision Making in Medicine (BDMM) study. Two chronic disease vignettes, two implicit bias measures, and measures of explicit bias were used to assess racial/ethnic bias towards New Zealand European and Māori (indigenous) peoples. Medical students demonstrated implicit pro-New Zealand European racial/ethnic bias on average, and bias towards viewing New Zealand European patients as more compliant relative to Māori. Explicit pro-New Zealand European racial/ethnic bias was less evident, but apparent for measures of ethnic preference, relative warmth, and beliefs about the compliance and competence of Māori patients relative to New Zealand European patients. In addition, racial/ethnic bias appeared to be associated with some measures of medical student beliefs about individual patients by ethnicity when responding to a mental health vignette. Patterning of racial/ethnic bias by student characteristics was not consistent, with the exception of some associations between student ethnicity, socioeconomic background, and racial/ethnic bias. This is the first study of its kind with a health professional population in Aotearoa/New Zealand, representing an important contribution to further understanding and addressing current health inequities between Māori and New Zealand European populations.

Multiple forms of discrimination and relationships with health and wellbeing: findings from national cross-sectional surveys in Aotearoa/New Zealand

BACKGROUND

The complex ways in which experiences of discrimination are patterned in society, including the exposure of communities to multiple overlapping forms of discrimination within social systems of oppression, is increasingly recognised in the health sciences. However, research examining the impacts on health and contribution to racial/ethnic health inequities remains limited. This study aims to contribute to the field by exploring the prevalence and patterning of experience of multiple forms of discrimination in Aotearoa/New Zealand, and associations with health and wellbeing.

METHODS

The study's conceptual approach is informed by Kaupapa Māori theory, Ecosocial theory, Critical Race Theory and intersectionality. Data are from the 2008, 2010 and 2012 General Social Surveys (GSS), biennial nationally-representative surveys in Aotearoa/New Zealand. We examined patterning of forms of discrimination in the last 12 months and frequency of experiencing multiple forms of discrimination. We also looked at associations between experience of multiple discrimination and self-rated health, mental health (using SF12), and life satisfaction using logistic regression. We used random effects meta-analysis to produce pooled estimates drawing from all three survey instances.

RESULTS

Māori, and people from Pacific and Asian ethnic groups, reported much higher prevalence of racial discrimination, were more likely to have any experience of discrimination, and were also more likely to experience multiple forms of discrimination, in the last year relative to respondents in the European/Other category. Discrimination was associated with poorer self-rated health, poorer mental health, and greater life dissatisfaction in unadjusted and adjusted estimates. Negative health impacts increased as the number of forms of discrimination experienced increased.

CONCLUSIONS

Discrimination impacts negatively on the health of indigenous peoples and those from minoritised ethnic groups in Aotearoa/New Zealand through higher exposure to racial discrimination, other forms of discrimination, and a greater likelihood of experiencing multiple forms of discrimination. This supports the need for research and interventions that more fully account for the multiple and interlocking ways in which discrimination impacts on health in racialised social hierarchies to maintain systems of privilege and oppression.

Ethnic bias and clinical decision-making among New Zealand medical students: an observational study

BACKGROUND

Health professional racial/ethnic bias may impact on clinical decision-making and contribute to subsequent ethnic health inequities. However, limited research has been undertaken among medical students. This paper presents findings from the Bias and Decision-Making in Medicine (BDMM) study, which sought to examine ethnic bias (Māori (indigenous peoples) compared with New Zealand European) among medical students and associations with clinical decision-making.

METHODS

All final year New Zealand (NZ) medical students in 2014 and 2015 (n = 888) were invited to participate in a cross-sectional online study. Key components included: two chronic disease vignettes (cardiovascular disease (CVD) and depression) with randomized patient ethnicity (Māori or NZ European) and questions on patient management; implicit bias measures (an ethnicity preference Implicit Association Test (IAT) and an ethnicity and compliant patient IAT); and, explicit ethnic bias questions. Associations between ethnic bias and clinical decision-making responses to vignettes were tested using linear regression.

RESULTS

Three hundred and two students participated (34% response rate). Implicit and explicit ethnic bias favoring NZ Europeans was apparent among medical students. In the CVD vignette, no significant differences in clinical decision-making by patient ethnicity were observed. There were also no differential associations by patient ethnicity between any measures of ethnic bias (implicit or explicit) and patient management responses in the CVD vignette. In the depression vignette, some differences in the ranking of recommended treatment options were observed by patient ethnicity and explicit preference for NZ Europeans was associated with increased reporting that NZ European patients would benefit from treatment but not Māori (slope difference 0.34, 95% CI 0.08, 0.60; p = 0.011), although this was the only significant finding in these analyses.

CONCLUSIONS

NZ medical students demonstrated ethnic bias, although overall this was not associated with clinical decision-making. This study both adds to the small body of literature internationally on racial/ethnic bias among medical students and provides relevant and important information for medical education on indigenous health and ethnic health inequities in New Zealand.

Racism and health service utilisation: A systematic review and meta-analysis

Although racism has been posited as driver of racial/ethnic inequities in healthcare, the relationship between racism and health service use and experience has yet to be systematically reviewed or meta-analysed. This paper presents a systematic review and meta-analysis of quantitative empirical studies that report associations between self-reported racism and various measures of healthcare service utilisation. Data were reviewed and extracted from 83 papers reporting 70 studies. Studies included 250,850 participants and were conducted predominately in the U.S. The meta-analysis included 59 papers reporting 52 studies, which were analysed using random effects models and mean weighted effect sizes. Racism was associated with more negative patient experiences of health services (HSU-E) (OR = 0.351 (95% CI [0.236,0.521], k = 19), including lower levels of healthcare-related trust, satisfaction, and communication. Racism was not associated with health service use (HSU-U) as an outcome group, and was not associated with most individual HSU-U outcomes, including having had examinations, health service visits and admissions to health professionals and services. Racism was associated with health service use outcomes such as delaying/not getting healthcare, and lack of adherence to treatment uptake, although these effects may be influenced by a small sample of studies, and publication bias, respectively. Limitations to the literature reviewed in terms of study designs, sampling methods and measurements are discussed along with suggested future directions in the field.

Predictors of academic success for Māori, Pacific and non-Māori non-Pacific students in health professional education: a quantitative analysis

Tertiary institutions internationally aim to increase student diversity, however are struggling to achieve equitable academic outcomes for indigenous and ethnic minority students and detailed exploration of factors that impact on success is required. This study explored the predictive effect of admission variables on academic outcomes for health professional students by ethnic grouping. Kaupapa Māori and Pacific research methodologies were used to conduct a quantitative analysis using data for 2686 health professional students [150 Māori, 257 Pacific, 2279, non-Māori non-Pacific (nMnP)]. The predictive effect of admission variables: school decile; attending school in Auckland; type of admission; bridging programme; and first-year bachelor results on academic outcomes: year 2-4 grade point average (GPA); graduating; graduating in the minimum time; and optimal completion for the three ethnic groupings and the full cohort was explored using multiple regression analyses. After adjusting for admission variables, for every point increase in first year bachelor GPA: year 2-4 GPA increased by an average of 0.46 points for Māori (p = 0.0002, 95% CI 0.22, 0.69), 0.70 points for Pacific (p < 0.0001, CI 0.52, 0.87), and 0.55 points for nMnP (p < 0.0001, CI 0.51, 0.58) students. For the total cohort, ethnic grouping was consistently the most significant predictor of academic outcomes. This study demonstrated clear differences in academic outcomes between both Māori and Pacific students when compared to nMnP students. Some (but not all) of the disparities between ethnic groupings could be explained by controlling for admission variables.

Equity of access to elective surgery: reflections from NZ clinicians

Objectives

To explore factors potentially influencing equitable access to elective surgery in New Zealand by describing clinicians’ perceptions of equity and the factors they consider when prioritising patients for elective surgery.

Methods

A qualitative study in selected New Zealand localities. A purposive sample of 49 general practitioners, specialists and registrars were interviewed. Data were analysed thematically.

Results

General practitioners described unequal opportunities for patients to access primary and secondary care and, in particular, private sector elective surgery. They felt that socio-economically disadvantaged patients were less able to advocate for themselves and were more vulnerable to being lost to the elective surgical booking system as well as being less able to access private care. Both GPs and secondary care clinicians described situations where they would personally advocate for individual patients to improve their access. Advocacy was related to clinicians’ perceptions of the “value” that patients would receive from the surgery and patients” needs for public sector funding.

Conclusions

The structure of the health system contributes to inequities in access to elective care in New Zealand. Subjective decision making by clinicians has the potential to advantage or disadvantage patients through the weighting clinicians place on socio-demographic factors when making rationing decisions. Review of the potential structural barriers to equitable access, further public debate and guidance for clinicians on the relative importance of socio-demographic factors in deciding access to rationed services are required for allocation of services to be fair.

Patterns of privilege: A total cohort analysis of admission and academic outcomes for Māori, Pacific and non-Māori non-Pacific health professional students

BACKGROUND

Tertiary institutions are struggling to ensure equitable academic outcomes for indigenous and ethnic minority students in health professional study. This demonstrates disadvantaging of ethnic minority student groups (whereby Indigenous and ethnic minority students consistently achieve academic outcomes at a lower level when compared to non-ethnic minority students) whilst privileging non-ethnic minority students and has important implications for health workforce and health equity priorities. Understanding the reasons for academic inequities is important to improve institutional performance. This study explores factors that impact on academic success for health professional students by ethnic group.

METHODS

Kaupapa Māori methodology was used to analyse data for 2686 health professional students at the University of Auckland in 2002-2012. Data were summarised for admission variables: school decile, Rank Score, subject credits, Auckland school, type of admission, and bridging programme; and academic outcomes: first-year grade point average (GPA), first-year passed all courses, year 2 - 4 programme GPA, graduated, graduated in the minimum time, and composite completion for Māori, Pacific, and non-Māori non-Pacific (nMnP) students. Statistical tests were used to identify significant differences between the three ethnic groupings.

RESULTS

Māori and Pacific students were more likely to attend low decile schools (27 % Māori, 33 % Pacific vs. 5 % nMnP, p < 0.01); complete bridging foundation programmes (43 % Māori, 50 % Pacific vs. 5 % nMnP, p < 0.01), and received lower secondary school results (Rank Score 197 Māori, 178 Pacific vs. 231 nMnP, p < 0.01) when compared with nMnP students. Patterns of privilege were seen across all academic outcomes, whereby nMnP students achieved higher first year GPA (3.6 Māori, 2.8 Pacific vs. 4.7 nMnP, p < 0.01); were more likely to pass all first year courses (61 % Māori, 41 % Pacific vs. 78 % nMnP, p < 0.01); to graduate from intended programme (66 % Māori, 69 % Pacific vs. 78 % nMnP, p < 0.01); and to achieve optimal completion (9 % Māori, 2 % Pacific vs. 20 % nMnP, p < 0.01) when compared to Māori and Pacific students.

CONCLUSIONS

To meet health workforce and health equity goals, tertiary institution staff should understand the realities and challenges faced by Māori and Pacific students and ensure programme delivery meets the unique needs of these students. Ethnic disparities in academic outcomes show patterns of privilege and should be alarming to tertiary institutions. If institutions are serious about achieving equitable outcomes for Māori and Pacific students, major institutional changes are necessary that ensure the unique needs of Māori and Pacific students are met.

Development and testing of study tools and methods to examine ethnic bias and clinical decision-making among medical students in New Zealand: The Bias and Decision-Making in Medicine (BDMM) study

BACKGROUND

Health provider racial/ethnic bias and its relationship to clinical decision-making is an emerging area of research focus in understanding and addressing ethnic health inequities. Examining potential racial/ethnic bias among medical students may provide important information to inform medical education and training. This paper describes the development, pretesting and piloting of study content, tools and processes for an online study of racial/ethnic bias (comparing Māori and New Zealand European) and clinical decision-making among final year medical students in New Zealand (NZ).

METHODS

The study was developed, pretested and piloted using a staged process (eight stages within five phases). Phase 1 included three stages: 1) scoping and conceptual framework development; 2) literature review and identification of potential measures and items; and, 3) development and adaptation of study content. Three main components were identified to assess different aspects of racial/ethnic bias: (1) implicit racial/ethnic bias using NZ-specific Implicit Association Tests (IATs); (2) explicit racial/ethnic bias using direct questions; and, (3) clinical decision-making, using chronic disease vignettes. Phase 2 (stage 4) comprised expert review and refinement. Formal pretesting (Phase 3) included construct testing using sorting and rating tasks (stage 5) and cognitive interviewing (stage 6). Phase 4 (stage 7) involved content revision and building of the web-based study, followed by pilot testing in Phase 5 (stage 8).

RESULTS

Materials identified for potential inclusion performed well in construct testing among six participants. This assisted in the prioritisation and selection of measures that worked best in the New Zealand context and aligned with constructs of interest. Findings from the cognitive interviewing (nine participants) on the clarity, meaning, and acceptability of measures led to changes in the final wording of items and ordering of questions. Piloting (18 participants) confirmed the overall functionality of the web-based questionnaire, with a few minor revisions made to the final study.

CONCLUSIONS

Robust processes are required in the development of study content to assess racial/ethnic bias in order to optimise the validity of specific measures, ensure acceptability and minimise potential problems. This paper has utility for other researchers in this area by informing potential development approaches and identifying possible measurement tools.

Racial Discrimination and Ethnic Disparities in Sleep Disturbance: the 2002/03 New Zealand Health Survey

STUDY OBJECTIVES

Research on the relationship between racial discrimination and sleep is limited. The aims of this study were to: (1) examine the independent relationship between ethnicity, sex, age, socioeconomic position, experience of racial discrimination and self-reported sleep disturbances, and (2) determine the statistical contribution of experience of racial discrimination to ethnic disparities in sleep disturbances.

METHODS

The study used data from the 2002/03 New Zealand Health Survey, a nationally-representative, population-based survey of New Zealand adults (≥ 15 years). The sample included 4,108 self-identified Māori (indigenous New Zealanders) and 6,261 European adults. Outcome variables were difficulty falling asleep, frequent nocturnal awakenings, and early morning awakenings. Experiences of racial discrimination across five domains were used to assess overall racial discrimination "ever" and the level of exposure to racial discrimination. Socioeconomic position was measured using neighborhood deprivation, education, and equivalized household income.

RESULTS

Māori had a higher prevalence of each sleep disturbance item than Europeans. Reported experiences of racial discrimination were independently associated with each sleep disturbance item, adjusted for ethnicity, sex, age group, and socioeconomic position. Sequential logistic regression models showed that racial discrimination and socioeconomic position explained most of the disparity in difficulty falling asleep and frequent nocturnal awakening between Māori and Europeans; however, ethnic differences in early morning awakenings remained.

CONCLUSIONS

Racial discrimination may play an important role in ethnic disparities in sleep disturbances in New Zealand. Activities to improve the sleep health of non-dominant ethnic groups should consider the potentially multifarious ways in which racial discrimination can disturb sleep.

The significance of relational continuity of care for Māori patient engagement with predominantly non-Māori doctors: findings from a qualitative study

OBJECTIVE

This qualitative study explored self-reported experiences of primary healthcare among a sample of urban Māori adults. This paper specifically focuses on the theme of relational continuity of care identified in participant discussions of access and engagement with their predominantly non-Māori general practitioners (GPs).

METHODS

The study involved a purposively selected subsample (n=42) of the Christchurch Māori cohort of the Hauora Manawa Community Heart Study (n=244). Participants took part in in-depth interviews, which were transcribed and analysed thematically.

RESULTS

Analysis identified compromised access to a preferred GP as a principal barrier to receiving quality and non-discriminatory care from predominantly non-Māori clinicians. In contrast to discussions of healthcare provided by usual GPs, episodic encounters with non-regular clinicians were commonly framed as experiences discouraging utilisation and the perceived value of primary healthcare.

CONCLUSIONS

Facilitating relational continuity of care for Māori patients and their clinicians may contribute towards mediating determinants of inequality at the clinical interface.

IMPLICATIONS

Reducing significant health disparities between Māori and non-Māori was a key goal of the reconfiguration of primary healthcare in the early 2000s. The role of relational continuity of care in achieving equitable inter-ethnic health outcomes in primary healthcare settings is an important consideration.

Investigating the relationship between ethnic consciousness, racial discrimination and self-rated health in New Zealand

In this study, we examine race/ethnic consciousness and its associations with experiences of racial discrimination and health in New Zealand. Racism is an important determinant of health and cause of ethnic inequities. However, conceptualising the mechanisms by which racism impacts on health requires racism to be contextualised within the broader social environment. Race/ethnic consciousness (how often people think about their race or ethnicity) is understood as part of a broader assessment of the 'racial climate'. Higher race/ethnic consciousness has been demonstrated among non-dominant racial/ethnic groups and linked to adverse health outcomes in a limited number of studies. We analysed data from the 2006/07 New Zealand Health Survey, a national population-based survey of New Zealand adults, to examine the distribution of ethnic consciousness by ethnicity, and its association with individual experiences of racial discrimination and self-rated health. Findings showed that European respondents were least likely to report thinking about their ethnicity, with people from non-European ethnic groupings all reporting relatively higher ethnic consciousness. Higher ethnic consciousness was associated with an increased likelihood of reporting experience of racial discrimination for all ethnic groupings and was also associated with fair/poor self-rated health after adjusting for age, sex and ethnicity. However, this difference in health was no longer evident after further adjustment for socioeconomic position and individual experience of racial discrimination. Our study suggests different experiences of racialised social environments by ethnicity in New Zealand and that, at an individual level, ethnic consciousness is related to experiences of racial discrimination. However, the relationship with health is less clear and needs further investigation with research to better understand the racialised social relations that create and maintain ethnic inequities in health in attempts to better address the impacts of racism on health.

General practice ethnicity data: evaluation of a tool

INTRODUCTION

There is evidence that the collection of ethnicity data in New Zealand primary care is variable and that data recording in practices does not always align with the procedures outlined in the Ethnicity Data Protocols for the Health and Disability Sector. In 2010, The Ministry of Health funded the development of a tool to audit the collection of ethnicity data in primary care. The aim of this study was to pilot the Ethnicity Data Audit Tool (EAT) in general practice. The goal was to evaluate the tool and identify recommendations for its improvement.

METHODS

Eight general practices in the Waitemata District Health Board region participated in the EAT pilot. Feedback about the pilot process was gathered by questionnaires and interviews, to gain an understanding of practices' experiences in using the tool. Questionnaire and interview data were analysed using a simple analytical framework and a general inductive method.

FINDINGS

General practice receptionists, practice managers and general practitioners participated in the pilot. Participants found the pilot process challenging but enlightening. The majority felt that the EAT was a useful quality improvement tool for handling patient ethnicity data. Larger practices were the most positive about the tool.

CONCLUSION

The findings suggest that, with minor improvements to the toolkit, the EAT has the potential to lead to significant improvements in the quality of ethnicity data collection and recording in New Zealand general practices. Other system-level factors also need to be addressed.

General practice ethnicity data: evaluation of a tool

INTRODUCTION: There is evidence that the collection of ethnicity data in New Zealand primary care is variable and that data recording in practices does not always align with the procedures outlined in the Ethnicity Data Protocols for the Health and Disability Sector. In 2010, The Ministry of Health funded the development of a tool to audit the collection of ethnicity data in primary care. The aim of this study was to pilot the Ethnicity Data Audit Tool (EAT) in general practice. The goal was to evaluate the tool and identify recommendations for its improvement. METHODS: Eight general practices in the Waitemata District Health Board region participated in the EAT pilot. Feedback about the pilot process was gathered by questionnaires and interviews, to gain an understanding of practices’ experiences in using the tool. Questionnaire and interview data were analysed using a simple analytical framework and a general inductive method. FINDINGS: General practice receptionists, practice managers and general practitioners participated in the pilot. Participants found the pilot process challenging but enlightening. The majority felt that the EAT was a useful quality improvement tool for handling patient ethnicity data. Larger practices were the most positive about the tool. CONCLUSION: The findings suggest that, with minor improvements to the toolkit, the EAT has the potential to lead to significant improvements in the quality of ethnicity data collection and recording in New Zealand general practices. Other system-level factors also need to be addressed. KEYWORDS: Data collection; ethnicity; general practice; primary health care

Improving survival disparities in cervical cancer between Māori and non-Māori women in New Zealand: a national retrospective cohort study

OBJECTIVE

Māori women in New Zealand have higher incidence of and mortality from cervical cancer than non-Māori women, however limited research has examined differences in treatment and survival between these groups. This study aims to determine if ethnic disparities in treatment and survival exist among a cohort of Māori and non-Māori women with cervical cancer.

METHODS

A retrospective cohort study of 1911 women (344 Māori and 1567 non-Māori) identified from the New Zealand Cancer Register with cervical cancer (adenocarcinoma, adenosquamous or squamous cell carcinoma) between 1 January 1996 and 31 December 2006.

RESULTS

Māori women with cervical cancer had a higher receipt of total hysterectomies, and similar receipt of radical hysterectomies and brachytherapy as primary treatment, compared to non-Māori women (age and stage adjusted). Over the cohort period, Māori women had poorer cancer specific survival than non-Māori women (mortality hazard ratio (HR) 2.07, 95% confidence interval (CI): 1.63-2.62). From 1996 to 2005, the survival for Māori improved significantly relative to non-Māori.

CONCLUSION

Māori continue to have higher incidence and mortality than non-Māori from cervical cancer although disparities are improving. Survival disparities are also improving. Treatment (as measured) by ethnicity is similar.

IMPLICATIONS

Primary prevention and early detection remain key interventions for addressing Māori needs and reducing inequalities in cervical cancer in New Zealand.

Ethnic density and area deprivation: neighbourhood effects on Māori health and racial discrimination in Aotearoa/New Zealand

Some studies suggest that ethnic minority people are healthier when they live in areas with a higher concentration of people from their own ethnic group, a so-called ethnic density effect. To date, no studies have examined the ethnic density effect among indigenous peoples, for whom connections to land, patterns of settlement, and drivers of residential location may differ from ethnic minority populations.

The present study analysed the Māori sample from the 2006/07 New Zealand Health Survey to examine the association between increased Māori ethnic density, area deprivation, health, and experiences of racial discrimination. Results of multilevel regressions showed that an increase in Māori ethnic density was associated with decreased odds of reporting poor self-rated health, doctor-diagnosed common mental disorders, and experienced racial discrimination. These associations were strengthened after adjusting for area deprivation, which was consistently associated with increased odds of reporting poor health and reports of racial discrimination. Our findings show that whereas ethnic density is protective of the health and exposure to racial discrimination of Māori, this effect is concealed by the detrimental effect of area deprivation, signalling that the benefits of ethnic density must be interpreted within the current socio-political context. This includes the institutional structures and racist practices that have created existing health and socioeconomic inequities in the first place, and maintain the unequal distribution of concentrated poverty in areas of high Māori density. Addressing poverty and the inequitable distribution of socioeconomic resources by ethnicity and place in New Zealand is vital to improving health and reducing inequalities. Given the racialised nature of access to goods, services, and opportunities within New Zealand society, this also requires a strong commitment to eliminating racism. Such commitment and action will allow the benefits potentially flowing from strong communities to be fully realised.

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Māori ethnic density is associated with improved Māori health and reduced racial discrimination.

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Area deprivation is strongly associated with poorer health and increased racial discrimination.

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The benefits of Māori ethnic density are concealed by the detrimental effect of area deprivation.

Self-reported experience of racial discrimination and health care use in New Zealand: results from the 2006/07 New Zealand Health Survey

OBJECTIVES

We investigated whether reported experience of racial discrimination in health care and in other domains was associated with cancer screening and negative health care experiences.

METHODS

We used 2006/07 New Zealand Health Survey data (n = 12 488 adults). We used logistic regression to examine the relationship of reported experience of racial discrimination in health care (unfair treatment by a health professional) and in other domains (personal attack, unfair treatment in work and when gaining housing) to breast and cervical cancer screening and negative patient experiences adjusted for other variables.

RESULTS

Racial discrimination by a health professional was associated with lower odds of breast (odds ratio [OR] = 0.37; 95% confidence interval [CI] = 0.14, 0.996) and cervical cancer (OR = 0.51; 95% CI = 0.30, 0.87) screening among Maori women. Racial discrimination by a health professional (OR = 1.57; 95% CI = 1.15, 2.14) and racial discrimination more widely (OR = 1.55; 95% CI = 1.35, 1.79) were associated with negative patient experiences for all participants.

CONCLUSIONS

Experience of racial discrimination in both health care and other settings may influence health care use and experiences of care and is a potential pathway to poor health.

Achieving equitable outcomes for Māori women with cervical cancer in New Zealand: health provider views

AIM

This study explored health provider views on changing survival disparities between Māori and non-Māori women, the management of cervical cancer in New Zealand, and achieving equitable outcomes from cervical cancer for Māori women.

METHODS

This research followed on from a cohort study of cervical cancer treatment and survival in New Zealand. Focus groups were undertaken with three provider groups in different regions working across the range of cervical cancer services. Focus group transcripts were analysed to identify key themes.

RESULTS

Providers were encouraged by the reported improvement in survival disparities between Māori and non-Māori women over time. The themes of discussion relating to cervical cancer management included: communication and education; screening; access to treatment; pathways through care; patient factors; and, system standards. Providers also suggested options for further improvements in the management of cervical cancer.

CONCLUSIONS

The focus groups identified that despite improvements over time in cervical cancer disparities between Māori and non-Māori and in the management of cervical cancer, further effort is required to achieve equitable outcomes for Māori, particularly in the areas of prevention and early detection.

The effect of comorbidity on the use of adjuvant chemotherapy and survival from colon cancer: a retrospective cohort study

Background

Comorbidity has a well documented detrimental effect on cancer survival. However it is difficult to disentangle the direct effects of comorbidity on survival from indirect effects via the influence of comorbidity on treatment choice. This study aimed to assess the impact of comorbidity on colon cancer patient survival, the effect of comorbidity on treatment choices for these patients, and the impact of this on survival among those with comorbidity.

Methods

This retrospective cohort study reviewed 589 New Zealanders diagnosed with colon cancer in 1996–2003, followed until the end of 2005. Clinical and outcome data were obtained from clinical records and the national mortality database. Cox proportional hazards and logistic regression models were used to assess the impact of comorbidity on cancer specific and all-cause survival, the effect of comorbidity on chemotherapy recommendations for stage III patients, and the impact of this on survival among those with comorbidity.

Results

After adjusting for age, sex, ethnicity, area deprivation, smoking, stage, grade and site of disease, higher Charlson comorbidity score was associated with poorer all-cause survival (HR = 2.63 95%CI:1.82–3.81 for Charlson score ≥ 3 compared with 0). Comorbidity count and several individual conditions were significantly related to poorer all-cause survival. A similar, but less marked effect was seen for cancer specific survival. Among patients with stage III colon cancer, those with a Charlson score ≥ 3 compared with 0 were less likely to be offered chemotherapy (19% compared with 84%) despite such therapy being associated with around a 60% reduction in excess mortality for both all-cause and cancer specific survival in these patients.

Conclusion

Comorbidity impacts on colon cancer survival thorough both physiological burden of disease and its impact on treatment choices. Some patients with comorbidity may forego chemotherapy unnecessarily, increasing avoidable cancer mortality.