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Aim: To ascertain the reasons for and impacts of closed books in general practices in Aotearoa New Zealand and report recommendations for mitigation., Method: A mixed-methods approach was used. A first round of interviews with experts in the primary care sector was conducted, followed by a survey across general practices and, finally, a second round of interviews. Data reported here are qualitative data from the interviews and open-ended questions in the survey. Qualitative data were analysed using a general inductive approach., Results: The key reasons for not enrolling new patients included workforce shortages, high workloads and staff burnout, funding issues, concerns about quality of care and insufficient physical space. These were exacerbated during the COVID-19 pandemic. The impacts included no access or delayed access to primary care, worsening health conditions, undiagnosed or untreated diseases and less or no access to preventive care. Recommendations included recruiting more staff including administrative staff, resolving the pay disparity between general practice and hospital staff, having a longer placement period for students in general practice, utilising a multidisciplinary workforce and revising the funding formula., Conclusion: There is an urgent need to resolve key issues so that general practices can accept all who wish to enrol., Competing Interests: None., (© PMA.)

Introduction Around 5% of the people in Aotearoa New Zealand (NZ) are not enrolled with a general practice. Aim This study aimed to explore the utilisation of general practice by enrolment status and subsequent use of an emergency department. Methods We compared a cohort of respondents from New Zealand Health Surveys (2013/14-2018/19) on self-reported general practice utilisation and their substitutes, according to their enrolment status (enrolled and not enrolled). They were then followed up to examine their subsequent use of an emergency department. Time to an emergency department presentation was modelled with proportional hazards regression models with enrolment status as the explanatory variable. Confounding variables used were sex, age group, prioritised ethnicity, the New Zealand Deprivation Index and self-rated health. Results Those not enrolled were more likely to be young, male, Asian, more socioeconomically deprived and with better health status than those enrolled. Generally, those not enrolledutilised general practice services less. Those not enrolled who had used an emergency department were more likely to have used it as a substitute for general practice (40% vs 26%). Modelling showed that those not enrolled took longer to access an emergency department. Adjusting for confounding variables did not change that interpretation. Discussion Those not enrolled were younger and healthier and may have a perception that enrolment isn't necessary. As a group, they were more likely to be socioeconomically deprived and to use an emergency department, which is free at a public hospital in NZ, as a substitute for primary care which suggests that cost may influence their choices.

Introduction The inability to afford a consultation with a general practitioner may lead to delays in accessing care pathways. Aim This study aimed to explore the characteristics of people by their unmet need for a general practitioner consultation because of cost, and the characteristics of subsequent inpatient hospitalisations. Methods From the New Zealand Health Surveys (2013/14-2018/19), two groups were formed based on their unmet need for a general practitioner consultation due to cost. These groups were compared by socio-demographic factors and subsequent inpatient hospitalisation characteristics during follow-up. Time to an inpatient hospitalisation was the outcome in a proportional hazards regression model with need status as the key variable. The model was expanded to include confounding variables: sex, age group, ethnicity, the New Zealand Deprivation Index and self-rated health. Results The need group, characterised by having a higher proportion of females, younger adults, Māori, increased socioeconomic deprivation and poorer self-rated health experienced a greater chance of hospitalisation, a similar number of visits during follow-up, shorter stays and a quicker time to hospitalisation compared to the no-need group. Proportional hazards survival models gave a 28% higher hazard rate for the time to an inpatient hospitalisation for the need group compared to the no-need group. The inclusion of all the confounders in the model gave a similar hazard ratio. Discussion Although consultation fees vary across general practices, it is evident that this may not eliminate the cost barriers to accessing care for some groups. Needing multiple consultations may contribute to persistent unmet needs.

Introduction The pursuit of health care equity is a fundamental objective for Aotearoa New Zealand, and patient co-payments in primary care challenge this goal. Aim This study aimed to investigate the relationship between primary health care co-payments and the sociodemographic variables in areas where general practices provide health care. Methods Using census data, facilities information from the Ministry of Health, and socioeconomic deprivation indices, linear regression models were used to explore the relationship between weighted average fees charged by general practices and various sociodemographic variables in statistical area 2 regions. Results The study finds that areas with higher proportions of males and economically deprived individuals are associated with lower weighted average fees. Conversely, areas with higher proportions of retirement-aged and European individuals are linked with higher weighted average fees. The inclusion of the Very-Low-Cost-Access variable, indicating a subsidy scheme at the general practice level, made all the sociodemographic variables practically insignificant, suggesting Very-Low-Cost-Access practices are in the right geographical location to target high needs groups. Discussion The findings affirm the complexity of health care inequities in Aotearoa New Zealand, influenced not only by financial factors but also by demographic variables as they play out geographically. While subsidy schemes like the Very-Low-Cost-Access scheme appear to reach groups with greater need, a high level of unmet need due to cost suggests that the fees are still too high. Policymakers need to consider disparities in the on-going health care reforms and make further changes to subsidy schemes to reduce unmet need.

Aims: A NZ$5 co-payment prescription charge was removed in July 2023 but may be reinstated. Here we quantify the health impact and cost of not being able to afford this charge., Methods: We linked New Zealand Health Surveys (2013/2014-2018/2019) to hospitalisation data using data available in Integrated Data Infrastructure (IDI). Cox proportional-hazards models compared time to hospitalisation between those who had faced a cost barrier to collecting a prescription and those who had not., Results: Of the 81,626 total survey respondents, 72,243 were available for analysis in IDI. A further 516 were excluded to give an analysis dataset of 71,502. Of these, 5,889 (8.2%) reported not collecting a prescription due to cost in the previous year. Among people who faced a cost barrier, 60.0% (95% confidence interval [CI] 58.7-61.2%) were admitted to hospital during the study period, compared to 43.9% (95% CI 43.6-44.3%) of those who did not. Having adjusted for socio-demographic variables, people who faced a cost barrier were 34% (hazard ratio 1.34; 95% CI 1.29-1.39) more likely to be admitted to hospital than those who did not. Annual avoidable hospitalisation costs-were prescription co-payments to remain free-are estimated at $32.4 million per year based on the assumption of a causal relationship between unmet need for prescription medicines and subsequent hospitalisation., Conclusions: The revenue to the health system from co-payments may be offset by the costs associated with avoidable hospitalisations., Competing Interests: Nil., (© PMA.)

Aim: In Aotearoa New Zealand, primary care is organised by enrolling patients with a primary care provider. However, the benefits of this arrangement are frustrated when providers "close their books" due to insufficient capacity for new patients. We investigated the extent, evolution and impact of this situation on health access and equity in access to primary healthcare., Method: We distributed a survey for general practice personnel in 2022, yielding 227 valid responses. We examined responses across respondents' practice characteristics, including practice size, rural-urban setting, average co-payments, region and ethnic composition of the catchment population., Results: Most general practices are selectively enrolling their patients. In 2022, only 28% of respondents freely enrolled new people. Since 2019, most respondents (79%) had "closed books" or limited enrolments at some point. The situation worsened between 2019 and 2022, compromising equal opportunity and access in healthcare., Conclusion: Restricted enrolment poses a widespread barrier to health access and equity, and it worsened since the beginning of the COVID-19 pandemic. Addressing closed books and limited enrolments in general practice could significantly improve health services' access and equity. The study aims to inform ongoing health reforms., Competing Interests: The authors declare that they have no competing interests.Ethics approval was obtained from Te Herenga Waka—Victoria University of Wellington Human Ethics Committee on May 3, 2022 (Approval 30193). All survey participants consented to the study., (© PMA.)

Aim: To explore new migrants' access to primary healthcare services in the first 10 years after arrival in Aotearoa New Zealand., Methods: Data come from three New Zealand Health Surveys (2014/2015, 2015/2016 and 2016/2017), which each sampled around 13,500 people, aged 15+ years, who were usual residents of Aotearoa New Zealand. Respondents who said they were born overseas were asked the first year they had come to Aotearoa New Zealand. Those who had arrived in the 10 years before their survey was completed were considered new migrants. The survey data were pooled and around 3,700 respondents were estimated to fit this category. Log-linear models, with adjustments for age, sex, ethnicity and New Zealand Deprivation Index, were used to look at last year use of primary healthcare., Results: Overall, new migrants used primary healthcare similarly to other New Zealanders. They were more likely to have comprehensive health insurance and paid more for GP visits upon arrival but acted similarly to other New Zealanders after 4 years., Conclusion: Generally, new migrants-after adjusting for covariates-appear to be accessing primary healthcare services in a similar manner to other New Zealanders, on average, soon after arrival., Competing Interests: Nil., (© PMA.)

This paper documents the results from the highly successful Lunar flashlight Optical Navigation Experiment with a Star tracker (LONEStar). Launched in December 2022, Lunar Flashlight (LF) was a NASA-funded technology demonstration mission. After a propulsion system anomaly prevented capture in lunar orbit, LF was ejected from the Earth-Moon system and into heliocentric space. NASA subsequently transferred ownership of LF to Georgia Tech to conduct an unfunded extended mission to demonstrate further advanced technology objectives, including LONEStar. From August to December 2023, the LONEStar team performed on-orbit calibration of the optical instrument and a number of different OPNAV experiments. This campaign included the processing of nearly 400 images of star fields, Earth and Moon, and four other planets (Mercury, Mars, Jupiter, and Saturn). LONEStar provided the first on-orbit demonstrations of heliocentric navigation using only optical observations of planets. Of special note is the successful in-flight demonstration of (1) instantaneous triangulation with simultaneous sightings of two planets with the LOST algorithm and (2) dynamic triangulation with sequential sightings of multiple planets., (© The Author(s) 2024.)

Introduction For many countries, primary health care (PHC) serves as the gateway for individuals to access healthcare services. It has been shown to not only improve health but also health equity. To maximise this benefit, a substantial proportion of the population needs to be connected with PHC. The aim here was to assess the degree and evolution of enrolment in light of the coronavirus disease 2019 (COVID-19) pandemic in Aotearoa New Zealand. Methods We examined data on the enrolment of people in PHC organisations between 2016 and 2023. This analysis included breakdowns by sex, age groups, ethnicity, and socioeconomic deprivation levels. Poisson regression models were used to explore whether enrolment changed because of the COVID-19 pandemic. Results In 2016, Māori, young people and the most deprived had lower enrolment rates relative to their peers. Although young people's enrolment rate increased over time, especially during the COVID-19 pandemic, the Māori enrolment rate declined, as did the rate for Pacific people, and those who were the most deprived. The groups who had increases in enrolment rates were those with the lowest levels of socioeconomic deprivation and those in the 'Other' ethnic category, predominantly made up of European New Zealanders. Conclusion Enrolment statistics reveal disparities across sociodemographic lines. The COVID-19 pandemic was associated with changed patterns of enrolment that appear to have consequences for population health.

Introduction In Aotearoa New Zealand, patients can enrol in a general practice for their primary health care. When a general practice no longer enrols new patients this is known as 'closed books'. We examined which District Health Board (DHB) districts were most affected and what characteristics of general practices and DHB districts were associated with closed books. Methods Maps were used to display the distribution of closed books general practices. Linear regression and logistic regression were used to look at the association between DHB or general practice characteristics and closed books. Results There were 347 (33%) general practices that had closed books in June 2022. Canterbury DHB (n  = 45) and Southern DHB (n  = 32) had the greatest number of closed books general practices, while Wairarapa DHB (86%), Midcentral DHB (81%) and Taranaki DHB (81%) had the greatest percentage. Consultation fees (P   Conclusion The problem of closed books is felt across the country but has a larger impact in the middle-lower North Island. This influences access to primary health care enrolment for patients in terms of travel distance, time, and cost. Consultation fees were strongly associated with closed books. This suggests there may be an income threshold above which general practices can afford to close their books if they reach capacity.

Introduction: In Aotearoa New Zealand, being enrolled with a Primary Health Care (PHC) provider furnishes opportunities for lower cost access to PHC, preventative care and secondary health care services, and provides better continuity of care. We examine the characteristics of populations not enrolled, and whether enrolment is associated with amenable mortality., Method: We retrieved records of all deaths registered 2008 to 2017 in Aotearoa New Zealand, which included demographic and primary cause of death information. Deaths were classified as premature (aged under 75 years) or not, and amenable to health care intervention or not. The Primary Health Organisation (PHO) Enrolment Collection dataset provided the PHC enrolment status. Logistic regression was used to estimate the risk of amenable deaths by PHO enrolment status, adjusted for the effects of age, sex, ethnicity and deprivation., Results: A total of 308,628 mortality records were available. Of these, 38.2% were premature deaths, and among them 47.8% were amenable deaths. Cardiovascular diseases made up almost half of the amenable deaths. Males, youths aged 15-24 years, Pacific peoples, Māori and those living in the most socio-economically deprived areas demonstrated a higher risk of amenable mortality compared to their respective reference category. One in twenty (4.3%) people who had died had no active enrolment status in any of the calendar years in the study. The adjusted odds of amenable mortality among those not enrolled in a PHO was 39% higher than those enrolled [Odds Ratio = 1.39, 95% Confidence Interval 1.30-1.47]., Implications: Being enrolled in a PHC system is associated with a lower level of amenable mortality. Given demonstrated inequities in enrolment levels across age and ethnic groups, efforts to improve this could have significant benefits on health equity., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Silwal et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: In Aotearoa/New Zealand, the first nation-wide coronavirus disease 2019 (COVID-19) lockdown occurred from March 23, 2020 to May 13, 2020, requiring most people to stay at home. Health services had to suddenly change how they delivered healthcare and some services were limited or postponed. This study investigated access to healthcare during this lockdown period, whether patients delayed seeking healthcare and reasons for these delays, focusing on the accessibility of primary care services., Methods: Adults (aged 18 years or older) who had contact with primary care services were invited through social media and email lists to participate in an online survey (n = 1010) and 38 people were recruited for in-depth interviews. We thematically analysed qualitative data from the survey and interviews, reported alongside relevant descriptive survey results., Results: More than half (55%) of survey respondents delayed seeking healthcare during lockdown. Factors at a national or health system-level that could influence delay were changing public service messages, an excessive focus on COVID-19 and urgent issues, and poor service integration. Influential factors at a primary care-level were communication and outreach, use of technology, gatekeeping, staff manner and the safety of the clinical practice environment. Factors that influenced patients' individual decisions to seek healthcare were the ability to self-manage and self-triage, consciousness of perceived pressure on health services and fear of infection., Conclusion: In future pandemic lockdowns or crises, appropriate access to primary care services can be improved by unambiguous national messages and better integration of services. Primary care practices should adopt rapid proactive outreach to patients, fostering a calm but safe clinical practice environment. More support for patients to self-manage and self-triage appropriately could benefit over-burdened health systems during lockdowns and as part of business as usual in less extraordinary times., (© 2022 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

In 2020, in the first COVID-19 pandemic lockdown, Aotearoa New Zealand consistently maintained stringent public health measures including stay-at-home lockdowns and distancing responses. Considering the widespread disruption to social functioning caused by the pandemic, this paper aimed to explore environmental and social factors that influenced the wellbeing of individuals during the first lockdown in Aotearoa New Zealand. Our mixed-methods study involved a survey (n = 1010) and semi-structured interviews of a subset of surveyed individuals undertaken at the tail end of the first 2020 lockdown. Survey participants were recruited through social media-driven snowball sampling, less than 50% were aged under 45 years and 85% identified as female. Of those interviewed, 63% identified as female. Qualitative interview findings and open-ended survey results were analysed thematically. Participants described a variety of factors influencing wellbeing, largely related to the community and household; physical, behavioural, and lifestyle factors; access to health services; and social and economic foundations. While much of the focus of COVID-19 recovery was on reversing the economic and physical toll of the pandemic, our findings emphasise the need to empower individuals, families, and communities to mitigate the pandemic's negative implications on wellbeing.

Inequities in the provision of accessible primary health care contribute to poor health outcomes and health inequity. This study evaluated inequities in the prevalence and consequences of barriers that children face in seeing a general practitioner (GP) in Aotearoa New Zealand. We analysed data on 5,947 children from the Growing Up in New Zealand longitudinal study cohort on barriers to seeing a GP in the previous year, reported by mothers when their children were aged 24 months and 54 months (in 2011/12 and 2013/14 respectively); and maternal-reported hospitalisations in the year prior to age 54 months. We used logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CIs) for consequences of these barriers. Overall, 4.7% (n = 279) of children experienced barriers to seeing a GP in the year to 24 months and 5.5% (n = 325) in the year to 54 months. At each age, and for each specific barrier studied, barriers were more prevalent among Māori (the indigenous people of Aotearoa New Zealand), and among Pacific, compared to New Zealand European, children. Children facing barriers in the year to age 24 months were twice as likely to be hospitalised in the year to 54 months (OR 2.18, 95%CI: 1.38 to 3.44). When this relationship was analysed by ethnicity, the association was strongest for Māori (OR: 2.92, 95%CI: 1.60 to 5.30), less strong for Pacific (OR 2.01, 95%CI: 0.92 to 4.37) and not present for New Zealand European (OR 1.27, 95%CI 0.39 to 4.12) families. Barriers that children face to seeing a GP have social and cost implications for families and the health system. Changes to the health system, and future health policy, must align with the New Zealand government's obligations under Te Tiriti o [The Treaty of] Waitangi , to ensure that health equity becomes a reality for Māori., (© 2022 The Authors.)

Background: Changes in pharmacy models of care, services and funding have been occurring internationally, moving away from the traditional dispensing role to more extended patient-facing roles utilising pharmacists' clinical skills. This study aimed to identify the extended services offered by community pharmacy in Aotearoa New Zealand and the barriers and facilitators to extended services provision. The study is unique in that it includes intern (pre-registration) pharmacists., Methods: An online survey, conducted in 2018, of all pharmacists and intern (pre-registration) pharmacists working in a community pharmacy. Data were analysed using descriptive statistics and regression analyses., Results: The results are based on replies from 553 community pharmacists and 59 intern pharmacists (response rate: 19 and 26% respectively). Both pharmacists (83%) and interns (85%) want to work at the top of their scope of practice. Wide variation exists in the specific services individual pharmacists offer. Most pharmacists were accredited to supply the emergency contraceptive pill (95%), sildenafil for erectile dysfunction (86%) and trimethoprim for uncomplicated urinary tract infection (85%). Fewer were able to immunise (34%) or to supply selected oral contraceptives (44%). Just under a quarter could provide a Medicines Use Review (MUR) or Community Pharmacy Anticoagulation Management Service (CPAMS). Of the pharmacists not already accredited, 85% intended to gain accreditation to supply selected oral contraceptives, 40% to become vaccinators, 37% to offer CPAMS and 30% MUR. Interns expressed strong interest in becoming accredited for all extended services. Poisson regression analyses showed key factors supporting the likelihood of providing extended services were owner and management support and appropriate space and equipment. Being excited about the opportunities in community pharmacy, having employer funding and time for training and sufficient support staff were also statistically significant., Conclusions: Pharmacists need time and a supportive management structure to enable them to deliver extended services. Health policy with a greater strategic emphasis on funding services and pharmacist training, and developing technician support roles, will help to minimise or eliminate some of the barriers to role expansion both in Aotearoa New Zealand and internationally., (© 2021. The Author(s).)

Background: Health services internationally have been compelled to change their methods of service delivery in response to the global COVID-19 pandemic, to mitigate the spread of infection amongst health professionals and patients. In Aotearoa/New Zealand, widespread electronic delivery of prescriptions (e-prescribing) was enabled. The aim of the research was to explore patients' experiences of how lockdown, changes to prescribing and the interface between general practices and community pharmacy affected access to prescription medications., Method: The research employed a mixed-method approach. This included an online survey (n = 1,010) and in-depth interviews with a subset of survey respondents (n = 38) during the first COVID-19 lockdown (March-May 2020). Respondents were recruited through a snowballing approach, starting with social media and email list contacts of the research team. In keeping with the approach, descriptive statistics of survey data and thematic analysis of qualitative interview and open-ended questions in survey data were combined., Results: For most respondents who received a prescription during lockdown, this was sent directly to the pharmacy. Most people picked up their medication from the pharmacy; home delivery of medication was rare (4%). Survey and interview respondents wanted e-prescribing to continue post-lockdown and described where things worked well and where they encountered delays in the process of acquiring prescription medication., Conclusions: E-prescribing has the potential to improve access to prescription medication and is convenient for patients. The increase in e-prescribing during lockdown highlighted how the system could be improved, through better feedback about errors, more consistency across practices and pharmacies, more proactive communication with patients, and equitable prescribing costs.

Background: During the first COVID-19 pandemic 'lockdown' in Aotearoa/New Zealand (March-May 2020, in which strict 'stay at home' measures were introduced), general practices were advised to use telephone and video consultations (telehealth) wherever possible instead of the usual in-person visits. This was a sudden change for most practices and patients. This research aimed to explore how patients accessed general practice during lockdown and evaluate their experiences with telehealth, to inform how telehealth could be most effectively used in the future., Methods: Using a mixed-method approach, we undertook an online survey and in-depth interviews with adults (> 18 years) who had contact with practices during lockdown, recruited through social media and email lists. We present descriptive statistics from the survey data (n = 1010) and qualitative analysis of interview data (n = 38) and open-ended survey questions, using a framework of access to health care, from the patient's perspective., Results: In general, patients reported high satisfaction with telehealth in general practice during lockdown. Telehealth was convenient and allowed patients to safely access health care without having to weigh-up the fear of COVID-19 infection against the need to be seen. Telehealth worked best for routine and familiar health issues and when rapport was established between patients and clinicians. This was easier with a pre-existing clinical relationship, but not impossible without one. Telehealth was less suitable when a physical examination was needed, when the diagnosis was unknown or for patients who had a strong preference to be seen in-person., Conclusions: Even in this disruptive lockdown period, that prompted an unexpected and rapid implementation of telehealth services in general practices, most patients had positive experiences with telehealth. In the future, patients want the choice of consultation type to match their needs, circumstances, and preferences. Technological issues and funding barriers may need to be addressed, and clear communication for both patients and clinicians is needed about key aspects of telehealth (e.g. cost, appropriateness, privacy). Maintaining telehealth as an option post-lockdown has the potential to increase timely and safe access to primary health care for many patients.

Background: Haemorrhage in pregnancy may be life-threatening to woman and infant. The impact of severe obstetric haemorrhage can be reduced by detecting high-risk women, implementing guidelines and treatment plans, early detection of hypovolaemia and timely appropriate treatment., Aims: To describe cases of severe maternal morbidity caused by obstetric haemorrhage in New Zealand and investigate the potential preventability of these cases., Materials and Methods: A multidisciplinary expert review panel was established to review cases of obstetric haemorrhage admitted to intensive care or high-dependency units over an 18-month span in New Zealand. Cases were critically analysed by a multidisciplinary team of clinicians to determine the potential preventability., Results: One hundred and twenty cases were identified, most commonly due to postpartum haemorrhage with 36% (n = 43) deemed potentially preventable, mainly due to delay or failure of diagnosis (65%, 28/43) and/or failure or delay in treatment (91%, 39/43). Twenty-three per cent of cases (28/120) resulted in peripartum hysterectomy of which one-third were deemed potentially preventable., Conclusions: Prompt recognition and treatment in accordance with evidence-based guidelines is imperative to decrease the burden of morbidity from obstetric haemorrhage. An emphasis on training clinicians to identify haemorrhage in a timely way may avoid unnecessary obstetric emergencies and can improve maternity and neonatal outcomes., (© 2019 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Aim: To explore associations between tenure and the health service use of older New Zealanders., Methods: Analysis of pooled data for adults aged 55+ from three New Zealand Health Surveys (2013/14, 2014/15, 2015/16) comparing owner-occupiers, private renters and public renters., Results: Public renters, and in some age groups private renters, reported more visits to the GP and a higher proportion reported using a public hospital service in the last year. Renters were less likely than owner-occupiers to have used some privately paid services (visiting a dental health worker or optician). Renters averaged lower co-payments for their last GP visit, but financial barriers to accessing a GP, after-hours medical centre use and not collecting prescriptions were more likely to be reported by renters than owner-occupiers-particularly those that rent publicly., Conclusions: New Zealanders are simultaneously living longer while having declining opportunities to enter home ownership. Older renters are more likely to live in poorer health and, overall, are more likely to use some (public) health services than owner-occupiers yet are more likely to have unmet health needs. The increasing reliance on renting among older people has implications for population health and wellbeing, health service delivery and transitions to residential care., Competing Interests: Access to the data used in this study was provided by Statistic New Zealand under conditions designed to keep individual information secure in accordance with requirements of the Statistics Act 1975. The opinions presented in this article are those of the authors and do not necessarily represent an official view of Statistics New Zealand.

Introduction: Pre-eclampsia and related sequelae are a leading cause of severe maternal and neonatal morbidity and mortality. A significant proportion of these poor outcomes may be preventable with improvements along the continuum of maternal and neonatal care., Aims: The aim of this study was to review cases of pre-eclampsia resulting in severe maternal morbidity, describing the maternal and neonatal outcomes and the potential preventability of severe maternal morbidity (SMM)., Materials and Methods: This was a retrospective cohort study of cases of SMM associated with severe pre-eclampsia - a subset of a national SMM review study. Inclusion criteria for this subset were women who were pregnant or within 42 days of delivery with severe pre-eclampsia as the main reason for admission to an intensive care unit or high dependency unit in New Zealand between 1 August 2013 and 31 January 2015 inclusive. A multidisciplinary expert panel reviewed cases for preventability using a validated preventability tool., Results: Of the 89 severe morbidities that were reviewed, 10 had eclampsia (11%) and there were four neonatal mortalities (4.3%). Multidisciplinary committees assessed the severe morbidity as potentially preventable in 31% (28) of cases with the majority due to delays in diagnosis and suboptimal treatment., Conclusion: We found a high level of preventable morbidity in cases of severe pre-eclampsia with a concerning number of preventable eclampsia. Implementation of evidence-based guidelines reinforced with education would assist clinicians to improve risk recognition, timely diagnosis and treatment and decrease potentially preventable severe morbidity associated with pre-eclampsia., (© 2019 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Objective The aim of the present study was to evaluate the short-term outcomes of two health science academies established by a district health board in South Auckland, New Zealand, to create a health workforce pipeline for local Māori and Pasifika students. Methods A mixed-methods approach was used, involving background discussions with key informants to generate an initial logic model of how the academies work, followed by secondary analysis of students' records relating to retention and academic achievement, a survey of senior academy students' interest in particular health careers and face-to-face interviews and focus groups with students, families and teachers. Results Academy students are collectively achieving better academic results than their contemporaries, although selection decisions are likely to contribute to these results. Academies are retaining students, with over 70% of students transitioning from Year 11 to Years 12 and 13. Senior students are expressing long-term ambitions to work in the health sector. Conclusions Health science academies show promise as an innovative approach to supporting Māori and Pasifika students prepare for a career in the health professions. Evaluating the long-term outcomes of the academies is required to determine their contribution to addressing inequities in the local health workforce. What is known about the topic? Despite progress in health workforce participation for underrepresented indigenous and ethnic minority groups in New Zealand, significant disparities persist. Within this context, a workforce development pipeline that targets preparation of secondary school students is recommended to address identified barriers in the pursuit of health careers. What does this paper add? We provide an evaluation of an innovative district health board initiative supporting high school students that is designed to ensure their future workforce is responsive to the needs of the local community. What are the implications for practitioners? The findings have implications for decision makers in health workforce planning regarding the benefits of investing at an early stage of the workforce development pipeline in order to build an equitable and diverse health professions workforce.

Objective The aim of the present study was to evaluate the short-term outcomes of two health science academies established by a district health board in South Auckland, New Zealand, to create a health workforce pipeline for local Māori and Pasifika students. Methods A mixed-methods approach was used, involving background discussions with key informants to generate an initial logic model of how the academies work, followed by secondary analysis of students' records relating to retention and academic achievement, a survey of senior academy students' interest in particular health careers and face-to-face interviews and focus groups with students, families and teachers. Results Academy students are collectively achieving better academic results than their contemporaries, although selection decisions are likely to contribute to these results. Academies are retaining students, with over 70% of students transitioning from Year 11 to Years 12 and 13. Senior students are expressing long-term ambitions to work in the health sector. Conclusions Health science academies show promise as an innovative approach to supporting Māori and Pasifika students prepare for a career in the health professions. Evaluating the long-term outcomes of the academies is required to determine their contribution to addressing inequities in the local health workforce. What is known about the topic? Despite progress in health workforce participation for underrepresented indigenous and ethnic minority groups in New Zealand, significant disparities persist. Within this context, a workforce development pipeline that targets preparation of secondary school students is recommended to address identified barriers in the pursuit of health careers. What does this paper add? We provide an evaluation of an innovative district health board initiative supporting high school students that is designed to ensure their future workforce is responsive to the needs of the local community. What are the implications for practitioners? The findings have implications for decision makers in health workforce planning regarding the benefits of investing at an early stage of the workforce development pipeline in order to build an equitable and diverse health professions workforce.

Introduction: Not surprisingly given their multi-component nature, initiatives to improve integrated care often evolve to find the best way to bring about change. This paper provides an example of how an evaluation evolved alongside such an initiative designed to better integrate care across primary, community and hospital services in South Auckland, New Zealand., Theory and Methods: Using the explanatory power of a realist evaluative approach, theories of new ways of working that might be prompted by the initiative were explored in: (i) interviews with stakeholders in 2012 and 2015, (ii) online surveys of general practices and local care organisations, and (iii) a purposive sample of ten general practices., Results: The results highlighted the institutional contexts that led to difficulties in implementing population health initiatives. They also revealed that changes in work practices focussed mostly on activities that improved the coordination of care for individuals at risk of hospital admissions., Discussion: Multi-component complex interventions can vary in their delivery and be vulnerable to one or more components not being implemented as originally intended. In the case of this intervention, the move towards strengthening local relationships arose when contractual arrangements stalled. Realist evaluative approaches offer a logic that helps unpick the complexity of the relationships and politics in play, and uncover the assumptions made by those developing, implementing and assessing health service changes., Conclusion: Given the multi-component and evolving nature of initiatives seeking to better integrate care, the realist evaluative emphasis on surfacing early the theories to explain how change is expected to occur helps overcome the challenge of evaluating "a moving target"., Competing Interests: HR is employed by the organisation delivering the Localities initiative, and had direct involvement in aspects of the At Risk Individuals programme. The other authors – LM, MP and JC – were commissioned to deliver an independent evaluation funded by Counties Manukau District Health Board. Approval was sought for the publication of these results as part of the contract for services.

Objective: To explore relationships between the housing tenure of older New Zealanders and their health-related behaviours, and physical and mental health., Methods: Pooled data were analysed for 15,626 older adults (aged 55+) from three consecutive, annual, nationally representative New Zealand Health Surveys to compare owner-occupiers, private renters and public renters., Results: Most in the sample were owner-occupiers (83.2%), with 12.4% private renters and 4.5% public renters. A higher proportion of renters aged 75+ were female. Māori and Pacific people were more likely to be renters. Renters were more likely to be living alone, on lower annual incomes. Overall measures of physical and mental health showed a health gradient, with public renters in the poorest health and owner-occupiers in the best health., Conclusions: Rental tenure is associated with poorer health. Implications for public health: Older renters tend to be economically disadvantaged and in poorer health than owner-occupiers. Over time, the proportion of older renters has been increasing. This will have implications for policy and for services in meeting the diverse care and support needs of older people. Higher rates of renting among Māori and Pacific people and older females means that these groups are particularly vulnerable to any negative impact of renting on health., (© 2019 The Authors.)

Aim: This study investigates non-response bias in an inpatient experience survey with a low response rate by comparing sociodemographic characteristics and response behaviours of initial responders with responders to follow-up, and further explores the factors contributing to non-response. Prior research suggests non-response may be endogenously related to patient characteristics., Method: We re-contacted a convenience sample of non-responders to a nationally representative, cross-sectional inpatient survey conducted in New Zealand. Participants were given a subset of six items drawn from the initial survey and the opportunity to disclose reasons for non-response. Responders to follow-up (n=163) were subsequently compared with responders to the initial survey (n=910) using chi-squared tests of association and logistic regression to assess differences in sociodemographic variables and substantive responses., Results: We find no significant differences in the responses given by initial and follow-up responders. The most common reasons for non-response were "can't remember" (33%), not receiving the survey (25%) or being too busy at the time (25%)., Conclusion: Responders to follow-up have similar experiences of inpatient care in New Zealand to initial responders. Further study is needed to strengthen inferences regarding hard-to-reach patients., Competing Interests: Nil.

Aim: To explore the characteristics of medicinal and non-medicinal cannabis users, and the conditions that were treated with cannabis., Methods: The data comes from the New Zealand Health Survey 2012/2013, which sampled 13,009 people, aged 15+ years, living in private or non-private dwellings in New Zealand. Participants self-reported cannabis use and were put into groups: 1) non-users; 2) ex-users; 3) last year users-non-medicinal; 4) last-year users-medicinal. Prevalence was reported for the major demographic subgroups; sex, age and ethnicity. Regression models were then used to find associations between demographic characteristics and cannabis use for groups 3 and 4., Results/conclusions: About five percent (4.6%, 95% CI 4.1-5.1) of those aged 15+ report using cannabis medicinally. This use was associated with being male, younger, less well-educated and relatively poor. While Māori have the highest prevalence of medicinal use, European NZ/Others make up 67.9% (95% CI 62.7-72.6) of medicinal users. Reported medicinal use was associated with reported conditions that were typically hard to manage: pain, anxiety/nerves and depression. Medicinal users were more likely to report chronic pain and pain interfering, moderately or more, with housework and other work.

Objective: To compare two surveys conducted in 2007 and 2009, of the food and nutrition environment in New Zealand primary schools., Methods: A sample of primary schools was asked about foods and beverages provided or sold to students or used for fundraising, and nutrition-related policies and procedures. Comparisons were made between school decile groups and between years., Results: Of primary schools selling food or beverages, 34% sold 'everyday' items once or more a day (39% in 2007) and 25% sold 'occasional' items once or more a day (36% in 2007). Two-thirds of schools sold food or beverages for fundraising, generally once a term or less. About half the schools had written policies about food (increased from 2007)., Conclusion: There have been some improvements in the food and nutrition environment, with primary schools from lower deciles more likely to be making changes., Implications: The reduction in funding for nutrition-related programs in primary schools may hinder the sustainability of the changes seen, especially in low decile schools., (© 2012 The Authors. ANZJPH © 2012 Public Health Association of Australia.)

Objective: The aim of this study was to assess trends in drinking patterns and alcohol-related problems among age and gender groups in the context of a liberalized alcohol policy environment., Method: Eleven comparable general population alcohol surveys were conducted between 1990 and 2000 in Auckland, New Zealand, during which a substantial number of liberalizing alcohol policy changes occurred. Measurements included typical-occasion quantity and frequency of drinking in the last 12 months. Self-reported alcohol-related problems in the last 12 months were divided into two groups based on risk curve analysis: threshold problems (experienced only once a high level of consumption is reached) and nonthreshold problems (those exhibiting a dose-response relationship). Age groups were 14-19, 20-24, 25-39, and 40-65 years., Results: Significant increases in typical-occasion quantity were found for young men and young women ages 14-19 years and for women 20-24 and 40-65 years. The increase was most marked among those 14-19 years old. Only women ages 25-39 years increased how often they drank. The prevalence of threshold problems significantly increased among male drinkers ages 14-19 and 40-65 years. The proportion of 14- to 19-year-olds experiencing threshold problems was observed to be higher in each year compared with those 40-65 years old, and the 14- to 19-year-olds experienced a greater year-on-year increase. Increases in nonthreshold alcohol-related problems occurred for the youngest and oldest males and for most female age groups (14-19, 25-39, and 40-65 years). The increase was most marked among those 14-19 years old., Conclusions: Increases in quantities consumed and alcohol-related problems were found predominantly among young people and women. The youngest age group, those 14-19 years old, experienced the most marked increases in quantity consumed and problems including, for males, the experience of more serious problems such as "had hands shake in the morning" (experienced only once a high level of consumption is reached).

Unlabelled: Health governance internationally has become more complex, with both hierarchical and network modes of governance explicitly represented within single public systems., Objective: To understand the implementation of new modes and mechanisms of governance under New Zealand health reforms and to assess these in the context of international trends. Research methods sought data from key groups participating in governance policy and implementation. Methods included surveys of board members (N=144, 66% response rate), interviews with chairs (N=14) and chief executives (N=20), and interviews with national policy makers/officials (N=19) and non-government providers and local stakeholders (N=10). Data were collected over two time periods (2001/2002; 2003/2004). Analysis integrated the findings of both qualitative and quantitative methods under themes related to modes and mechanisms of governance. Results indicate that a hierarchical mode of governance was implemented quickly, with mechanisms to ensure political accountability to the government. Over the implementation period the scope of decision-making at different levels required clarification and mechanisms for accountability required adjustment. Non-government provider networks emerged only slowly whereas a network of statutory health organisations established itself quickly., Conclusion: The successful implementation of a mix of governance modes in New Zealand 2001-2004 was characterised by clear government policy, flexibility of approach and the appearance of an unintended network. In New Zealand there is less tendency than in some other some other small countries/jurisdictions towards centralisation, with local elections and community engagement policies providing an element of local participation, and accountability to the centre enhanced through political rather than bureaucratic mechanisms.

Aim: To describe the clinical and demographic characteristics of patients referred by general practitioners (GPs) to both public and private sectors for non-urgent surgical assessment., Method: During 2004, a cohort of 1420 adult patients with the potential to benefit from elective surgery was recruited into the study by their GPs. GPs recorded patient demographics and reasons for referral., Results: 345 out of 828 eligible GPs (42%) agreed to participate in the study and submitted data on 1603 referrals, 2.4 referrals per reporting week. After excluding ACC cases, data on 1420 referrals were analysed. Forty-two percent of those referred were male and 69% were European New Zealanders. The mean age was 55 years. The largest number of referrals were made to general surgery (37%), followed by orthopaedics (19%), gynaecology (12%), and plastic surgery (10%). The modal level of urgency was "routine" and in 24% of cases cancer was a possibility. The GP felt surgery was needed in 47% of cases, while in 73%, assistance with diagnosis and management was sought. In only 3% of eligible cases was no referral made., Conclusion: Elective surgical referral makes up a significant proportion of GP workload. In more than half of cases advice on diagnosis or management, rather than surgery, was sought, and in nearly two-thirds the patient was aged less than 65 years. Cancer control was a relatively frequent goal of referral. The very small number of cases where a desired referral was not made suggests that GP and patient expectations are adjusted to service capacity.

Aim: To assess alcohol-related harms and offences in New Zealand from 1990 to 2003, a period of alcohol policy liberalization, that included the lowering of the purchase age from 20 to 18 years in 1999., Design, Setting and Participants: Time trend analyses were carried out on routinely collected data for prosecutions for driving with excess alcohol; alcohol-involved vehicle crashes (all and fatal) and prosecutions for disorder offences. These were carried out separately for those aged 14-15, 16-17, 18-19, 20-24 and 25 years and over., Measurements: Rates of: prosecutions for driving with excess alcohol (1990-2003); rates of alcohol- involved vehicle crashes (all and fatal) (1990-2003); and rates of prosecutions for disorder offences (1994-2003)., Findings: Effects of alcohol policy liberalization: positive trends were found in the rates of prosecutions for disorder in the 16-17, 18-19, 20-24 and 25 + age groups; with 18-19-year-olds and 16-17-year-olds having the largest rates and largest positive trend in rates. For 16-17-year-olds, there was a positive trend in the rates of prosecutions for excess breath alcohol. Negative trends in rates were found for alcohol-related crashes (all and fatal) among all age groups. Negative trends for those over 16-17 years were found for prosecutions for driving with excess breath alcohol (this was prior to the lowering of the purchase age). Effects of lowering the minimum purchase age: the lowering of minimum purchase age coincided with an increase in the trend of alcohol-related crashes for 18-19-year-olds; the next largest increase was among the 20-24-year-olds (all other age groups also increased but at a much lower rate). A similar result was found for driving with excess alcohol for those aged 18-19 (and those aged 20-24 years). An increase in the rates of prosecutions for disorder offences occurred for the 14-15-year-old group following the lowering of the purchase age., Conclusion: The liberalization of alcohol throughout the 1990s may have influenced younger people more, as reflected in increases in their disorder offences and drink driving. The lowering of the minimum purchase age may have led to an increase in drink-driving among the 18-19-year-olds (those directly affected by the change in purchase age).

Aims: To describe the alcohol consumption patterns and related harms of some Pacific peoples (Samoan, Cook Islands Maori, Tongan, Niuean, Fijian, and Tokelauan) living in Aotearoa (New Zealand), and to draw comparisons with measures from the general New Zealand population., Methods: The Pacific Drugs and Alcohol Consumption Survey (PDACS) was carried out with 1103 randomly selected Pacific peoples aged between 13 and 65 years old who were resident in households throughout New Zealand. The survey used computer-assisted telephone interviewing (CATI) and computer assisted cell-phone interviewing (CACI). The interviews were carried out in 2002/03. We descriptively compare findings from the PDACS with those from the 2000 National Alcohol Survey (NAS)., Results: Fifty-seven percent of Pacific peoples were drinkers (males 61%, females 51%), compared with 85% of the general New Zealand population (males 88%, females 83%). The average annual consumption of absolute alcohol was 21 litres for Pacific drinkers (males 28 litres, females 14 litres) compared with 11 litres for general New Zealand population drinkers (males 16 litres, females 7 litres). The typical occasional quantity consumed by Pacific drinkers was eight drinks (males: nine drinks, females: five drinks) compared with four drinks for drinkers in the general New Zealand population (males: five drinks, females: around four drinks). Thirty-three percent of Pacific drinkers consumed enough to feel drunk at least weekly (males 41%, females 25%) compared with 9% of drinker in the general New Zealand population (males 13%, females 6%). Eighteen percent of Pacific males and 10% of Pacific females reported being physically assaulted by someone who had been drinking compared with 8% and 5% of national males and females respectively. Twenty-three percent of Pacific males and 16% of Pacific females got drunk when there was an important reason to stay sober, compared with 8% and 5% of general New Zealand males and females respectively. Nineteen percent of Pacific males and 21% of Pacific females reported being involved in a serious argument after they had been drinking compared with 12% and 8% of general New Zealand males and females respectively., Conclusions: The proportion of Pacific drinkers is less than the proportion of drinkers in the general New Zealand population. However, Pacific drinkers consume larger annual volumes and typical occasion amounts of absolute alcohol than drinkers in the general New Zealand population. Pacific peoples drinking patterns appear to be more harmful with greater proportions of Pacific peoples reporting violence and injury from other peoples' drinking, and greater proportions of Pacific drinkers reporting problems from violence and serious arguments as a result of their own drinking compared with the general New Zealand population and general New Zealand population drinkers.

This paper describes the evaluation of a regional community action intervention to reduce access to alcohol from off-license premises by minors. The intervention focussed on: (1) monitoring alcohol sales made without age identification from off-licenses; (2) utilizing data on alcohol sales for media advocacy and direct contact with alcohol retailers and (3) working with key enforcement staff to encourage increased monitoring and enforcement of minimum purchase age legislation for off-licenses. Evaluation of this intervention used a case study design. Purchase survey data was obtained before and after intervention. Media items were monitored and included pre- and post-intervention phases. Interviews, with key enforcement staff, and document review were undertaken post-intervention. Purchase survey data showed a significant decrease (p < 0.05) in sales of alcohol made to young people without age identification pre- and post-intervention. Pre-intervention: 60% of visits resulted in a sale made without age identification; post-intervention this proportion was 46%. Principal component analysis of newsprint media indicated increased coverage of items advocating improved age checking for off-licenses following intervention. Interview data and document review indicate that some enforcement staff in the region implemented increased enforcement strategies including, controlled purchase operations and increased visits to off-licenses due to the intervention. Evaluation findings indicate that collaborative and intersectoral community action interventions implemented regionally can be effective in redirecting resources to achieve preventive outcomes at a population level.

New data collected on the procurement and purchase of cannabis in the 2001 New Zealand National Drug Survey are used to estimate the dollar value of the illicit market for cannabis as well conduct other economic analyses of the illicit purchase of cannabis in New Zealand. Eighty-four per cent of last-year cannabis users received at least some of their cannabis 'free', 38% 'bought' at least some of their cannabis, while only 8% grew any of their supply. By proportion of the total dollar value of the cannabis market, sales of 'tinnies' (1.5 g) had the biggest share of the market (30%), followed closely by 50 NZ dollars bags (4 g) (29%) and ounces (28 g) (26%). The average price paid per gram of cannabis fell steadily from 20.50 NZ dollars per gram for a joint to 5.63 per gram for a pound (NZ dollars). The distribution of spending on cannabis was positively skewed (average 1313 NZ dollars, median 400 NZ dollars, mode 100, range 5 - 55,200, interquartile range 100 - 1200) (NZ dollars). The bottom 50% of cannabis buyers spent a median amount on cannabis of 100 NZ dollars a year while the top 5% spent a median amount of 7425 a year (NZ dollars). The dollar value of the illicit cannabis market was estimated to be 190 million (131 - 249 million) (NZ dollars). Three limitations are acknowledged with the market estimate calculated: (i) the truncated age range of the survey data (13 - 45 years); (ii) the likely underestimation of heavy cannabis use in household drug surveys; (iii) a degree of 'double-counting' when the same cannabis is bought and sold a number of times.

Aims: To determine (via a population-based study in Auckland, New Zealand) if there are diurnal, weekly, or seasonal variations in the occurrence of stroke., Methods: All new stroke events in Auckland residents were traced. Time of onset of the stroke was defined as the time when neurological symptoms were first noticed. The day of the week and month of onset were analysed for all strokes., Results: 1711 patients were registered over 1 year. The rate ratios for the onset of stroke in each 6-hourly interval compared with reference interval (1800-2359 hours) were 0.74 (95% CI: 0.61-1.10) for 0000-0559 hours, 2.88 (95% CI: 2.48-3.34) for 0600-1159 hours and 1.74 (95% CI: 1.49-2.05) for 1200-1759 hours. Rate ratios of the seasonal occurrence of stroke compared with spring were 0.75 (95% CI: 0.65-0.86) for summer, 0.83 (95% CI: 0.73-0.95) for autumn and 1.08 (95% CI: 0.96-1.23) for winter. No weekly pattern of stroke occurrence was observed., Conclusions: Strokes were less likely to occur during the summer and autumn than in the winter or spring. There was an increase in the occurrence of stroke in the late morning. The results have implications for the provision of acute stroke services in the community and in hospital.

Aims: This paper aims to compare women's and men's alcohol consumption patterns and alcohol-related problems in New Zealand in 1995 and 2000, by age groups. Secondary aims are to consider the findings in relation to debates on the gender convergence hypothesis regarding the link between gender convergence in alcohol consumption and possible explanations, such as social role convergence and policy changes., Design: Data were collected in two general population surveys conducted in New Zealand in 1995 (n = 4232) and 2000 (n = 5113) using the same questionnaire., Measurements: Quantity consumed on a typical drinking occasion, volume of absolute alcohol consumed per annum, proportions drinking 20+ litres per annum, proportion of total consumption consumed in heavy drinking occasions, frequency of consumption, proportion who drink enough to feel drunk at least once a week, proportions reporting three or more alcohol-related problems and attitudes to intoxication., Findings: Evidence for gender convergence was found across a range of measures of alcohol consumption and alcohol-related problems. In the 20-39-year age group quantities of alcohol consumed on a typical occasion and the related measures of volume, drunkenness and problems all showed convergence. In the groups over 40 years of age convergence occurred in relation to frequency of drinking. In the groups below 20 years, which consumed relatively high quantities and where the differences in consumption between gender groups were relatively small, further convergence did not occur., Conclusions: Gender convergence took place in New Zealand from 1995 to 2000.

Aims: To measure the level of heavy amphetamine use, poly drug use, and intravenous drug use by amphetamine users in New Zealand., Methods: Using a Computer Assisted Telephone Interview (CATI) system, a national sample of approximately 5500 people (aged 15-45 years) were interviewed about their recreational drug use., Results: Five percent of the sample (4.3-5.7) had used stimulants (uppers, speed, amphetamine, methamphetamine) in the last year. Eighty-one percent of these users used stimulants once-a-month or less frequently. Twenty-two percent used half a gram of stimulants or more on a typical occasion. Stimulant users used an average of 6.4 drug types in the last year (range 1-17, standard deviation [SD] 2.8) and 4.2 drug types in the last month (range 0-13, SD 2.1). Three percent of last-year stimulant users (0.7-4.6) had used a needle to inject drugs in the previous year., Conclusions: About one in five amphetamine users used quantities of amphetamine in a single session that have been identified in previous research as being hazardous levels. High levels of poly drug use among amphetamine users indicate users may be at risk of problems from a range of drug types and combinations of drug types, and not just from amphetamine alone. Ongoing monitoring is required to identify if increased amphetamine use is a source of increased intravenous drug use.

Study Objective: To investigate the association between motor vehicle driver injury and socioeconomic status., Design: Cohort study with prospective and retrospective outcomes., Setting: New Zealand., Participants: 10 525 adults (volunteer sample of a multi-industry workforce, n=8008; and a random sample of urban electoral rolls, n=2517)., Outcome Measure: Motor vehicle driver injury resulting in admission of the driver to hospital or the driver's death, or both, during the period 1988-98; hospitalisation and mortality data were obtained by record linkage to national health databases., Main Results: After adjustment for age and sex, driver injury risk was inversely associated with both occupational status (p for linear trend <0.0001) and educational level (p for linear trend =0.007). Participants in the lowest approximate quartile of occupational status were four times as likely (HR 4.17, 95% CI 2.31 to 7.55) to have experienced a driver injury during follow up as participants in the highest approximate quartile. Participants who had been to secondary school for less than two years were twice as likely (HR 2.26, 95% CI 1.34 to 3.81) to have experienced a driver injury as those who had been to university or polytechnic. There was little evidence that driver injury risk was associated with neighbourhood income (p for linear trend =0.12) CONCLUSIONS: Occupational status and educational level seem to be important determinants of driver injury risk. Driver injury countermeasures should be targeted to people in low status occupations, as well as to people with comparatively little formal education.

An intrinsic drawback with the use of a computer-assisted telephone interview (CATI) survey methodology is that people who live in households without a connected landline telephone are excluded from the survey sample. This paper presents a pilot of the feasibility of a computer-assisted cell-phone interview (CACI) methodology designed to survey people living in households without a telephone about alcohol use and be compatible with a larger telephone based alcohol sample. The CACI method was found to be an efficient and cost competitive method to reach non-telephone households. Telephone ownership was found to make a difference to the typical occasion amount of alcohol consumed, with respondents from households without telephones drinking significantly more than those with telephones even when consumption levels were controlled for socio-economic status. Although high levels of telephone ownership in the general population mean these differences may not have any impact on population alcohol measures they may be important in sub-populations where telephone ownership is lower.

Aims: To investigate the relationship between several indicators of socioeconomic status and drinking patterns in young adulthood., Design: Data collected in a longitudinal study of young adults was analysed using repeated-measures models to examine the relationship between income, occupational activity and educational achievement and patterns of drinking., Setting: These data were collected as part of a longitudinal study ofa birth cohort of New Zealanders. They were interviewed for the most part in a central location using a face-to-face method and a computer-assisted alcohol interview., Participants: The participants were members of the Dunedin Multidisciplinary Health and Development study aged 18, 21 and 26 years. Nine hundred and sixty-nine study members contributed to the analysis. Study members have been found to be broadly representative of the New Zealand population and cross national studies suggest findings are generalizable to other similar market economies., Measurements: Three indicators of socioeconomic status were used; educational achievement, occupational activity and income. The educational achievement indicator at age 18 had three levels that ranged from no school qualifications to higher school qualifications. For age 21 two additional categories of tertiary educational achievement were included to make five categories and for age 26 higher tertiary degrees were included in the measure to make six categories. Five categories of occupational activity were used. Income data was also used. Two measures of alcohol consumption were used. These were the frequency of drinking and the typical quantity of alcohol consumed per drinking occasion in the past year., Findings: Frequency of drinking increased over these early adult years and the quantities consumed peaked at age 21 and decreased thereafter for both males and females. Frequency of drinking was influenced by income with the higher income respondents drinking more often and this was persistent overtime. Quantity of drinking was most influenced by educational achievement. The less well-educated young adult drank significantly more during a drinking occasion and at all ages. There was also a relationship between educational achievement and frequency of drinking for males at age 18 and a relationship between women's occupational activity and the quantities they consumed., Conclusions: The finding that the dimensions of drinking operate differently explains the lack of consistency in previous research, which has investigated socioeconomic status and the volumes of alcohol consumed. The findings of higher quantities consumed among those of lower social status may explain some of the reduced life expectancy found among those with lower socioeconomic status.

Objective: To measure the occurrence of shoulder pain after stroke. To identify the factors that predict risk of shoulder pain after stroke., Design: Auckland Stroke Study, population-based case-cohort study., Setting and Subjects: All cases of stroke, including those managed outside hospital, over a 12-month period ending February 1992 were considered in Auckland., Outcome Measures: Self-reported shoulder pain at one week, one month and six months after the onset of stroke for each person., Results: A total of 1,761 stroke events were identified. Self-reported shoulder pain among survivors increased from 256/1474 (17%) at one week, to 261/1,336 (20%) at one month and 284/1,201 (23%) at six months. Shoulder pain was positively associated with motor deficit, side of deficit and severity of deficit. In those surviving to six months after stroke, the risk of shoulder pain was higher in those with severe upper limb motor deficit (odds ratio (OR) 4.94; 95% confidence interval (CI) 3.06-7.98) and in diabetics (OR 1.57, 95% CI 1.15-2.14). Risk of shoulder pain increased with time and was lower for those in institutional care., Conclusion: Shoulder pain after stroke is common, especially in patients with severe sensorimotor deficits, diabetics and those living at home. Appropriate management may reduce the rate of occurrence.

Aims: To examine changes in the use of ecstasy, current conditions of supply, harms resulting from use, and the demographics of users., Methods: National Drug Surveys were conducted in 1998 and 2001. In each survey, a representative national sample of approximately 5500 people aged 15-45 years were asked about their drug use, including ecstasy use, using a Computer Assisted Telephone Interview (CATI) system. Response rates of 79% and 80% respectively were achieved., Results: Last-year use of ecstasy increased from 1.5% in 1998, to 3.4% in 2001. Large increases were found among men aged 20-24 (4.3% to 12.5%), and 25-29 (3.2% to 8.8%). In 2001, 43% of users thought ecstasy was easier to obtain and 29% thought the price was lower compared with a year earlier. About one in ten ecstasy users reported problems related to 'energy and vitality', 'financial position', 'health', and 'outlook on life'. Ecstasy users were predominantly male, aged 20-29, European and single, but were from a broad range of occupational and income-earning groups., Conclusions: The use of ecstasy in New Zealand increased between 1998 and 2001. Conditions of supply became easier. Users reported problems related to use in a range of areas of their lives. There was little evidence to suggest ecstasy use was limited to high-income-earning professionals.

Objective: To identify developmental trajectories of drinking between the ages of 18 and 26 years and to identify variables, amenable to policy influence, which predict these trajectories., Design: Longitudinal data were analysed using latent class mixture modelling., Setting: Participants were interviewed in a central location., Participants: Provincial city birth cohort, cross-national studies suggest findings are generalizable to other similar market economies., Measurements: The frequency of drinking over the past year and the typical quantity consumed per drinking occasion were computed from five location-specific questions. Measures used to predict membership of trajectory groups were ease of access to alcohol, drinking on licensed premises, response to alcohol advertising, educational achievement, parental consumption, age of onset of regular drinking and living arrangements., Results: Three trajectories of quantities consumed showed reduced consumption after age 21 but one trajectory showed marked increases. Three trajectories of frequency of drinking increased or remained stable over time. Access to licensed premises at age 18 had the most significant impact on membership of the trajectory groups and educational achievement had a significant impact on membership of the heavier quantity trajectory groups. Parental alcohol consumption, access to alcohol at 15 years, liking for alcohol advertising, living arrangement and age of onset of regular drinking also influenced trajectory membership., Conclusions: Quantity and frequency of drinking in adolescence and early adulthood had different trajectories. Membership of heavier drinking groups was affected by environmental influences which are subject to policy change, particularly that of earlier access to licensed premises. In a small group high-quantity consumption did not decrease at age 26.

Background: There are two main ways to assess alcohol consumption in a population: per capita estimates, usually derived from data on taxable alcohol available for consumption, and population-based surveys. Population-based survey estimates of alcohol consumption are often compared with estimates based on taxable alcohol available for consumption as a measure of validity. Discrepancies between these two measures occur, with the majority of population-based surveys substantially underestimating taxable alcohol available for consumption., Methods: This article argues, however, that high proportions of taxable alcohol available for consumption can be accounted for by population-based surveys and reports a method of data collection for a national alcohol survey that has accounted for 94% of the taxable alcohol in New Zealand., Results: The ability of the survey methodology to account for this proportion of taxable alcohol is likely due to the within-location beverage-specific alcohol consumption measures used in the survey, the process of recording the quantity of alcohol consumed, the use of a computer-assisted telephone interview system, and the population coverage achieved., Conclusions: Population-based surveys using the methodology outlined in this article may account for, if not exceed, the high proportions of taxable alcohol available for consumption estimates for some populations.

Background and Purpose: Publications on the temporal pattern of the occurrence of subarachnoid hemorrhage (SAH) have produced conflicting results. Variations between studies may relate to the relatively small numbers of SAH cases analyzed, including those in meta-analyses., Methods: We identified all cases of SAH from 3 well-designed population-based studies in Australia (Adelaide, Hobart, and Perth) and New Zealand (Auckland) during 3 periods between 1981 and 1997. The diagnosis of SAH was confirmed with CT, cerebral angiography, cerebrospinal fluid analysis, or autopsy in all cases. Information on the time of occurrence of each event was obtained. Risk ratios (RRs) and 95% CIs were calculated using Poisson regression, with age, sex, smoking status, and history of hypertension entered in the model as covariates., Results: A total of 783 cases of SAH were registered. Age- and sex-adjusted RRs of SAH occurrence were highest in the period between 6 AM and 12 MIDNIGHT (RR 3.2, 95% CI 2.4-4.3) and in winter and spring (RR 1.3, 95% CI 1.1-1.5; RR 1.3, 95% CI 1.1-1.5; respectively). No particular pattern of SAH occurrence was observed according to the day of the week. Restriction of the analyses to proved aneurysmal SAH did not substantially change the point estimates., Conclusions: Circadian and circaseptan (weekly) fluctuations of SAH occurrence in the southern hemisphere are similar to those in the northern hemisphere, but the occurrence of SAH in Australasia exhibits clear seasonal (winter and spring) peaks.