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Objective: To identify and describe the attributes of relational care from an Indigenous Māori healthcare consumer perspective., Data Sources: CINAHL Plus, Ovid MEDLINE, ProQuest Nursing & Allied Health, Scopus, New Zealand Index, the Ministry of Health Library, New Zealand Research and Google Scholar were searched between 23 and 30 May 2022., Methods: This scoping review used the Joanna Briggs Institute methodology for scoping reviews, thematic analysis and the Patterns, Advances, Gaps, Evidence for practice and Research recommendations framework for the synthesis of the findings., Results: A total of 1449 records were identified, and 10 sources were selected for final review. We identified five relational attributes that were most important to Māori: (1) the expressive behaviours and characteristics of healthcare professionals (HCPs), (2) communication to facilitate the healthcare partnership, (3) appreciating differing worldviews, (4) the context in which healthcare is delivered and (5) whanaungatanga (meaningful relationships)., Conclusion: The relational attributes identified are inextricably linked. Connecting with HCPs and developing a therapeutic relationship is fundamental to improving consumer experience and engagement with mainstream healthcare services. Whanaungatanga is fundamental to meaningful engagements with HCPs. Future research should explore how relational care is practiced in acute care settings when clinician-consumer interactions are time-limited, examine how the health system influences the capacity for relational care and how Indigenous and Western paradigms can co-exist in healthcare., Implications: This scoping review can inform future projects addressing health equity for Indigenous communities by creating environments that prioritise culturally safe relational care and value Indigenous knowledge systems., Reporting Method: We used the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist., No Patient or Public Contribution: No patient or public contribution., (© 2023 The Authors. Journal of Clinical Nursing published by John Wiley & Sons Ltd.)

Purpose: During the COVID-19 pandemic, the NZ COVID Tracer App (NZCTA) was released as a digital intervention to support contact tracing processes in Aotearoa New Zealand. This paper examines whether NZCTA met the data governance requirements of the Indigenous Māori people. Māori are an interesting case study as they have unique Treaty and data sovereignty rights, and a higher risk of COVID-related mortality. Methods: The NZCTA was assessed against 24 criteria drawn from the Māori Data Governance Model. The assessment drew on documentary sources and the authors' knowledge of NZCTA and contact tracing process. Each criteria was assessed as 'met', 'partially met' or 'not met'. Results: Our retrospective assessment showed a mixed performance against the Māori Data Governance Model, with NZCTA only fulfilling seven of the 24 model criteria and failing to meet nine. Conclusion: There is significant room for improvement in future digital health interventions for Māori. Much work remains to be done in the Aotearoa public sector to uphold Māori data sovereignty and address systemic barriers to genuine partnership with Māori. [ABSTRACT FROM AUTHOR]

This study examines the allocation of COVID-19 funding for Indigenous Peoples in Canada, Australia, New Zealand, and the United States during the pandemic's first wave. Indigenous communities, already facing health disparities, systemic discrimination, and historical forces of colonisation, found themselves further vulnerable to the virus. Analysing the funding policies of these countries, we employed a Health Equity Impact Assessment (HEIA) tool and an Indigenous Lens Tool supplement to evaluate potential impacts. Our results identify three major funding equity issues: unique health and service needs, socioeconomic disparities, and limited access to community and culturally safe health services. Despite efforts for equitable funding, a lack of meaningful consultation led to shortcomings, as seen in Canada's state of emergency declaration and legal disputes in the United States. New Zealand stood out for integrating Māori perspectives, showcasing the importance of consultation. The study calls for a reconciliation-minded path, aligning with Truth and Reconciliation principles, the UN Declaration on the Rights of Indigenous Peoples, and evolving government support. The paper concludes that co-creating equitable funding policies grounded in Indigenous knowledge requires partnership, meaningful consultation, and organisational cultural humility. Even in emergencies, these measures ensure responsiveness and respect for Indigenous self-determination.

Background: People living in rural and remote communities commonly experience significant health disadvantages. Geographical barriers and reduced specialist and generalist services impact access to care when compared with metropolitan context. Innovative models of care have been developed for people living with chronic diseases in rural areas with the goal of overcoming these inequities. The aim of this paper was to describe the characteristics and outcomes of studies investigating innovative models of care for people living with chronic disease in rural areas of developed countries where a metropolitan comparator was included.Methods: An integrative systematic review was undertaken. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) method was used to understand the empirical and theoretical data on clinical outcomes for people living with chronic disease in rural compared with metropolitan contexts and their models of care in Australia, New Zealand, United States, Canada and the United Kingdom.Results: Literature searching revealed 620 articles published in English between 1st January 2000 and 31st March 2019. One hundred sixty were included in the review including 68 from the United States, 59 from Australia and New Zealand (5), 21 from Canada and 11 from the United Kingdom and Ireland. 53% (84) focused on cardiovascular disease; 27% (43) diabetes mellitus; 8% (12) chronic obstructive pulmonary disease; and 13% (27) chronic kidney disease. Mortality was only reported in 10% (16) of studies and only 18% (29) reported data on Indigenous populations.Conclusions: This integrated review reveals that the published literature on common chronic health issues pertaining to rural and remote populations is largely descriptive. Only a small number of publications focus on mortality and comparative health outcomes from health care models in both urban and non-urban populations. Innovative service models and telehealth are together well represented in the published literature but data on health outcomes is relatively sparse. There is significant scope for further directly comparative studies detailing the effect of service delivery models on the health outcomes of urban and rural populations. We believe that such data would further knowledge in this field and help to break the deadly synergy between increased rurality and poorer outcomes for people with chronic disease. [ABSTRACT FROM AUTHOR]

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. 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. 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. 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. [ABSTRACT FROM AUTHOR]

The second wave feminist dream of smashing the patriarchy remains a task yet to be completed on a complex to do list. Women, particularly able-bodied cis-gendered white women however do enjoy the privilege of living longer than men. But our longer lives take place within patriarchal-capitalist systems where many women's social and cultural rights continue to be compromised. How do we ensure that all women can exercise our right to health and wellbeing? In this paper, the authors examine, critique, review and re-vision the dynamics of power and patriarchy over three distinct time periods – 1999, 2019 and 2039. We look to the past to track progress; we look to the present to see what we have achieved and look to the future for what might be. This conceptual paper is informed by the authors' expert knowledge, a review of the literature and the novel use of speculative ethnography. The authors conclude that patriarchy remains not only a negative determinant of women's health that needs to be smashed, but is also a threat to all people and to planetary health. [ABSTRACT FROM AUTHOR]

Background: The emergence of the COVID‐19 and the resulting global pandemic has ushered in far‐reaching changes for countries across the world, not least of which are changes to their education systems. With traditional location‐based exams no longer possible at universities, the uptake of online proctored exams (OPE) has occurred at a pace not seen prior to the pandemic. Students' experiences of online proctored exams during the pandemic are reasonably well‐understood in terms of digital access and ease of use of the technology. However, less is known about students' perceptions of digital confidence and competence to complete an online exam, both of which are important digital equity considerations. Objectives: This study investigates students' digital confidence and competence to undertake online proctored exams to determine whether issues of equity exist for students. Methods: This study reports the results of a survey (N = 761) of one university's students' experiences of end‐of‐semester online proctored exams in New Zealand. Results: Most students were positive about online exams, felt reasonably confident to complete an exam, and had the necessary digital access (i.e., devices, internet) and competence to succeed. However, digital inequalities were found between students' perceptions of digital competence based on ethnicity. While more time learning online equated to increasing self‐reported digital competence for most ethnic groups, this was not the case for Pacific learners. Takeaways: Perceptions of low digital competence can contribute to digital inequalities. Educators can support learners to develop positive perceptions of digital competence by teaching digital literacy skills. Lay Description: What is already known about this topic: Online proctored exams (OPE) have replaced many traditional exams because of the pandemic.Research on the use of online proctored exams during the pandemic suggests some acceptance among students.Apart from access related issues, little is known about digital inequalities associated with online exams. What this paper adds: Most participants were positive about OPE and felt reasonably confident to successfully complete them.Confident students were more likely to report that the exam software was easy to use.Perceptions of digital competence differed based on ethnicity.Marginalized groups were more likely to experience digital inequalities than other groups. Implications for practice and/or policy: Digital inequality is about more than issues of digital access (i.e., devices, internet).Provide differentiated technical support for students who express low digital competence.Teaching online exam digital literacy skills might increase perceptions of digital competence. [ABSTRACT FROM AUTHOR]

In New Zealand, people receiving care from specialist mental health and addiction services experience poorer health outcomes compared to the general population. Māori (Indigenous) specialist mental health and addiction service users experience disproportionate inequities. This study aims to: (1) Describe and understand mental health staff perspectives on the quality of care delivered to specialist mental health and addiction service users in their service – including specifically for Māori; and (2) Identify areas staff report as opportunities for quality improvement. In 2020, Southern District Health Board (now Te Whatu Ora – Southern) mental health staff were invited to participate in a cross‐sectional study assessing their perceptions of a range of service aspects. This paper presents quantitative and qualitative analyses about quality of care. Among the 319 staff who completed the questionnaire; 272 provided quality‐of‐care responses. Among these, 78% reported the quality of care delivered to service users as 'good' or 'excellent'; only 60% reported this for Māori service users. Participants identified individual, service and broader system level factors influencing the quality of care delivered to service users, including factors specific for Māori. This study has identified, for what appears to be the first time, empirical and concerning differences in staff ratings of the quality of care delivered to Māori and SMHAS users overall. Findings highlight the need for institutional and managerial prioritization of hauora Māori, and incorporating tikanga Māori and Te Tiriti into practice. [ABSTRACT FROM AUTHOR]

The current health reforms in Aotearoa New Zealand are being described as "transformational". Political leaders and Crown officials maintain the reforms embed a commitment to Te Tiriti o Waitangi, address racism and promote health equity. These claims are familiar and have been used to socialise previous health sector reforms. This paper interrogates claims of engagement with Te Tiriti by undertaking a desktop critical Tiriti analysis (CTA) of Te Pae Tata: the Interim New Zealand Health Plan. CTA follows five stages from orientation, close reading, determination, strengthening practice, to the Māori final word. The determination was done individually and a consensus was negotiated from the indicators; silent, poor, fair, good, or excellent. Te Pae Tata proactively engaged with Te Tiriti across the entirety of the plan. The authors assessed Te Tiriti elements of the preamble, kāwanatanga and tino rangatiratanga as "fair", ōritetanga as "good" and wairuatanga as "poor". Engaging more substantively with Te Tiriti requires the Crown to recognise that Māori never ceded sovereignty and treaty principles are not equivalent to the authoritative Māori text. Recommendations of the Waitangi Tribunal WAI 2575 and Haumaru reports need to be explicitly addressed to allow monitoring of progress., Competing Interests: Nil, (© PMA.)

This article presents a description of a specific Indigenous research methodology, Kaupapa Māori Research (KMR), followed by a discussion of the potential contribution that KMR and other Indigenous frameworks make toward understanding and addressing widespread mental health inequities affecting the world's Indigenous peoples. The contribution of existing qualitative KMR to the fields of health and mental health in New Zealand is discussed, and innovative approaches employed within these studies will be outlined. This paper describes the utility of KMR methodology which informed the development of qualitative interviews and the adaptation of an analytic framework used to explore the impact of systems on the experiences of Māori (the Indigenous peoples of New Zealand) with bipolar disorder (BD). This paper adds to others published in this journal that describe the value, inherent innovation, and transformative potential of KMR methodologies to inform future qualitative research with Indigenous peoples and to enact systemic change. Transformation is achieved by privileging the voices of Māori describing their experiences of mental health systems; presenting their expert critique to those responsible for the design and delivery of mental health services; and ensuring equal weight is given to exploring the clinical, structural and organizational changes required to achieve health equity. It is proposed that this approach to research praxis is required to ensure that studies do not perpetuate institutional racism, which requires close adherence to Indigenous research priorities and partnership with Indigenous peoples in all steps of the research process. [ABSTRACT FROM AUTHOR]

Purpose: In Aotearoa me Te Waipounamu (New Zealand; NZ) there are considerable inequities in health status and outcomes for Māori, the Indigenous peoples of NZ. It is therefore important that the health status and preferences of Māori are specifically considered in healthcare policy and decision making. This paper describes the health-related quality of life of 390 Māori adults who took part in the NZ EQ-5D-5L valuation study. Methods: Responses on the five dimensions of the EQ-5D-5L were dichotomised into "no problems" and "any problems", summarised and disaggregated by age group. Mean preference weights were reported by age group and overall. Mean utility values (calculated by applying each participant's preference weights to their EQ-5D-5L profile) were summed and respective means and standard deviations reported by age, chronic disease status and disability. Results: The EQ-5D-5L dimensions with the highest proportion of participants reporting any problems were pain/discomfort (61.5%) and anxiety/depression (50%). The most commonly-reported chronic disease was mental illness/distress (24.6%). Anxiety/depression ranked as the most important dimension, with usual activities, the least important. The mean utility value was 0.83 with the lowest value (0.79) found in the 18–24 and 45–54 age groups. For participants with at least one chronic disease the mean utility value was 0.76 compared to 0.91 for those with none. Conclusion: To reduce inequities experienced by Māori it is crucial that the health status of Māori and the values Māori place on health-related quality of life are properly understood. This can only be achieved using Māori-specific data. [ABSTRACT FROM AUTHOR]

Purpose: With global migration, the number of ethnic minority and migrant women receiving maternity health care in dominantly Anglo-European societies has increased significantly but they consistently have among the worst pregnancy and maternal outcomes. This paper aims to analyse gaps in structural (migration-related inequalities) and cultural (responsiveness to ethno-cultural practices) competencies among maternal health practitioners in Aotearoa New Zealand (NZ). Design/methodology/approach: Using a semi-structured interview guide, in-depth interviews were conducted with 13 maternal health practitioners in NZ. Data were analysed using a thematic analysis framework. Findings: The results highlight significant barriers around language and communication, cultural stereotyping by professionals, ethnic women's own constraints around family and cultural expectations and their lack of knowledge about reproductive health. In addition, practitioners' own ethnic differences are inseparable from their approach to structural and cultural competencies; there were instances of 'over-' or 'under-' reading of culture, practitioner constructions of ideal pregnancies and anti-racism concerns that shaped maternal care practices that were sensitive to, but also marginalised, ethnic migrant women who attended maternity services. Originality/value: To the best of the authors' knowledge, this is the only study in NZ that examines the impact of complex dynamics of migration and culture on knowledge, beliefs and values of practitioners, in context of their own personal biographies. Identifying strategies to improve the way diversity is practiced in hospital settings can be transformational in improving maternal outcomes for ethnic migrant women in NZ. [ABSTRACT FROM AUTHOR]

Aims: The combined oral contraceptive (COC) is the most commonly used hormonal contraceptive in Aotearoa New Zealand (Aotearoa/NZ). Currently there is limited data available on who uses COC in Aotearoa/NZ. The aims were to (i) define the population of reproductive‐aged females in Aotearoa/NZ in 2018 and identify the rate of COC use among this group and (ii) describe the sociodemographic and geographic characteristics of the population of COC users compared to the general population of reproductive‐aged females in 2018. Methods: This whole‐of‐population cross‐sectional study used the Integrated Data Infrastructure, a large research database managed by Statistics New Zealand. Females aged 16–50 years with complete sociodemographic and geographic information in 2018 from Aotearoa/NZ's estimated resident population were included. COC dispensing records to this cohort were identified from the national Pharmaceutical Collection. This paper reports descriptive counts of COC use and employs generalised linear regression with a binomial distribution and a log link to estimate adjusted risk ratios (aRR) of COC use for key sociodemographic and geographic subgroups. Results: Of 1 113 750 individuals in the study, 159 789 (14.3%) were dispensed as COC in 2018. European/other individuals were most likely to use COC (aRR: 2.72, 2.67–2.78), and Pacific Peoples were least likely (aRR: 0.56, 0.55–0.58) to use COC. Individuals residing in the most deprived quintile had less COC use than individuals in the least deprived quintile (aRR: 0.73, 0.72–0.74). Conclusion: Our study is able to highlight significant disparities in use by ethnicity, area‐level deprivation, and geographic factors. [ABSTRACT FROM AUTHOR]

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., (© 2022 The Authors. The International Journal of Health Planning and Management published by John Wiley & Sons Ltd.)

Background: Māori have been found to experience marked health inequities compared to non-Māori, including for injury. Accessing healthcare services post-injury can improve outcomes; however, longer-term experiences of healthcare access for injured Māori are unknown. This paper reports on data from the longitudinal Prospective Outcomes of Injury Study – 10 year follow up (POIS-10) Māori study in Aotearoa/New Zealand (NZ), to qualitatively understand Māori experiences of accessing injury-related healthcare services long-term. Methods: Follow-up telephone interviews were conducted with 305 POIS-10 Māori participants, who were injured and recruited 12-years earlier, experiencing a range of injury types and severities. Free text responses about trouble accessing injury-related health services were thematically analysed. Results: Sixty-one participants (20%) reported trouble accessing injury-related health services and provided free text responses. Three related themes describing participants' experiences were connected by the overarching concept that participants were engaging with a system that was not operating in a way it was intended to work: 1) Competing responsibilities and commitments encapsulates practical barriers to accessing services, such as a lack of time and having to prioritise other responsibilities such as work or whānau (family); 2) Disrupted mana refers to the feelings of personal disempowerment through, for example, receiving limited support, care or information tailored to participants' circumstances and is a consequence of patients contending with the practical barriers to accessing services; and 3) Systemic abdication highlights systemic barriers including conflicting information regarding diagnoses and treatment plans, and healthcare provider distrust of participants. Conclusions: Twelve years post-injury, a considerable proportion of Māori reported experiencing barriers to accessing healthcare services. To restore a sense of manaakitanga and improve Māori access to healthcare, Māori-specific supports are required and systemic barriers must be addressed and removed. [ABSTRACT FROM AUTHOR]

Objective: To identify baseline factors associated with outcomes from an inpatient multidisciplinary pain management program (PMP) located in a bicultural area of Aotearoa New Zealand. Methods: A prospective cohort study was undertaken involving 164 people with chronic pain who attended the PMP. Demographic, clinical, and psychosocial measures were obtained at baseline, whereas clinical and psychosocial outcome measures were also obtained at program discharge and 3-month follow up (N = 100). Multivariate analyses were used to determine baseline demographic variables that were associated with outcomes at discharge and follow up. Results: Being male and working full-time were associated with poorer outcomes in select measures at discharge. At the 3-month follow up, Māori ethnicity, working full-time, being retired or unemployed, or having chronic widespread pain were associated with poorer outcomes for some measures, whereas those with rheumatoid arthritis had greater self-efficacy. Conclusions: Sex, ethnicity, employment status, and patient condition impact clinical outcomes from the program and in the time from discharge to follow up. Program content and/or delivery should be altered to promote more equitable outcomes for all patients in the long term. What is known about the topic? Multidisciplinary pain management programs (PMPs) are the best treatment for chronic pain, but not everyone benefits from such programs to the same extent. What does this paper add? Ethnicity, employment status, and pain condition are associated with PMP outcomes, but mainly in the long term. What are the implications for practitioners? Program content, delivery, and follow up should be adapted to facilitate equity in long-term outcomes. [ABSTRACT FROM AUTHOR]

Growing health inequities among the increasingly diverse population in Aotearoa New Zealand have prompted responses in the healthcare system. Diversity-related policies and programmes have been developed in some District Health Boards (DHB) to address the issues. The translation of such policy into practice is, however, convoluted by subjective interests and power differentials and thus the outcomes of policies may deviate from their original objectives. In this paper we examine how staff in one DHB translate and implement health equity and diversity initiatives in their everyday practices in hospital settings. In high-level institutional thinking, Māori health equity policy is dictated by the Treaty of Waitangi which sets it apart from the cultural competence focus of programmes for other ethnic groups. Drawing on interviews with clinical staff in the DHB, we reveal how intersecting subject positions, including personal histories and institutional roles, influence the interpretation and enactment of these policies and programmes in ways that blur their distinct agendas. As a result, the paper demonstrates how the politics that underpin agendas that distinctly address equity and diversity, as well as the potential for change in these areas, can be compromised in everyday practice on the hospital floor., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Te Tiriti o Waitangi was negotiated between the British Crown and Indigenous Māori leaders of Aotearoa New Zealand in 1840. Māori understood the agreement as an affirmation of political authority and a guarantee of British protection of their lands and resources. The Crown understood it as a cession of sovereignty. The tension remains, though legal and political developments in the last 35 years, have established that the agreement places a mandatory obligation on the Crown to protect and promote Māori health. It also requires that Māori may exercise rangatiratanga, or responsibility and authority, in relation to health policy development and implementation. Methods: Te Tiriti is, then, an instrument against which health policy is justly and efficaciously evaluated. This paper introduces critical Tiriti analysis as such an evaluative method. Critical Tiriti analysis involves reviewing policy documents against the Preamble and the Articles of te Tiriti o Waitangi. The review process has five defined phases: (i) orientation; (ii) close reading; (iii) determination; (iv) strengthening practice and (v) Māori final word. Results: We present a working example of critical Tiriti analysis using the New Zealand Government's Primary Health Care Strategy published in 2001. This policy analysis found poor alignment with te Tiriti overall and the indicators of its implementation that we propose. Conclusion: This paper provides direction to policy makers wanting to improve Māori health outcomes and ensure Māori engagement, leadership and substantive authority in the policy process. It offers an approach to analysing policy that is simple to use and, inherently, a tool for advancing social justice. [ABSTRACT FROM AUTHOR]

Aim: To (1) describe the distribution of Ministry of Health (MOH) COVID-19 emergency funding to general practices in March and April 2020 and (2) consider whether further funding to general practices should be allocated differently to support equity for patients., Methods: Emergency funding allocation criteria and funding amounts by general practice were obtained from the MOH. Practices were stratified according to their proportion of high-needs enrolled patients (Māori, Pacific or living in an area with the highest quintile of socioeconomic deprivation). Funding per practice was calculated for separate and total payments according to practice stratum of high-needs enrolled patients., Results: The median combined March and April funding for general practices with 80% high-needs patients was 28% higher per practice ($36,674 vs $28,686) and 48% higher per patient ($10.50 vs $7.11) compared with the funding received by general practices with fewer than 20% high-needs patients. Although the March allocation did increase funding for high-needs patients, the April allocation did not., Conclusions: Emergency support funding for general practices was organised by the MOH at short notice and in exceptional circumstances. In the future, the MOH should apply pro-equity resource allocation in all emergencies, as with other circumstances., Competing Interests: There was no external funding source for preparing this article. The views, opinions, findings and conclusions or recommendations expressed in this paper are strictly those of the authors. They do not necessarily reflect the views of the institution where the authors currently work. The paper is presented not as policy, but with a view to inform and stimulate wider debate. Dr Murton is President of the RNZCGP and she also has an academic appointment at the University of Otago; the views expressed here are her own and not those of the College. Prof Crengle reports other from New Zealand Ministry of Health, personal fees from RNZCGP and other from WellSouth PHN, outside the submitted work.

An introduction is presented in which the editor discusses articles in the issue on topics including uncertainties in New Zealand's health system, challenges in primary care training, and barriers to diabetes management and skin condition treatment.

Background: Rapidly ageing populations means that many people now die in advanced age. This paper investigated public hospital and long-term care home costs in the 12 months before death in Māori and non-Māori of advanced age in New Zealand. Methods: Data from an existing longitudinal study (LiLACS NZ) was used, in which 937 older New Zealanders were enrolled in 2010. At the time of this study, 213 Māori and 241 non-Māori in the cohort had died. National Health Index numbers were linked to the hospitalisation National Minimum Dataset to ascertain public hospitalisation and care home costs in the last year of life. Results: The average total publicly funded hospital and long-term care home costs in the 12 months prior to death were $16,211 and $17,351 for Māori and non-Māori respectively. Non-Māori tended to have long lengths of stay in their last year of life, and non-Māori men had the highest proportion with high costs and long lengths of stay in care homes. Costs in the last year of life were 8.1 times higher in comparison to costs for individuals who did not die in the same time period. Conclusion: Despite New Zealand's commitment to providing an equitable level of healthcare, this study illustrated that ethnic and gender disparities are still apparent at the end of life. This raises questions as to whether money at the end of life is being spent appropriately, and how it could potentially be more equitably targeted to meet the diverse needs of older people and their families. [ABSTRACT FROM AUTHOR]

Between February and May 2020, New Zealand recorded 1504 cases of COVID-19 before eliminating community transmission of the virus in June 2020. During this period, a series of control measures were used including population-wide interventions implemented via a four-level alert system, border restrictions, and a test, trace, and isolate system. Mathematical modelling played a key role in informing the government response and guiding policy development. In this paper, we describe the development of a stochastic mathematical model for the transmission and control of COVID-19 in New Zealand. This includes features such as superspreading, case under-ascertainment, testing and reporting delays, and population-wide and case-targeted control measures. We show how the model was calibrated to New Zealand and international data. We describe how the model was used to compare the effects of various interventions in reducing spread of the virus and to estimate the probability of elimination. We conclude with a discussion of the policy-modelling interface and preparedness for future epidemic outbreaks. [ABSTRACT FROM AUTHOR]

There is a strong body of evidence that supports identifying and managing people according to their risk of a future cardiovascular (CVD) event. Since 2012 the New Zealand public health sector has achieved 90% CVD risk assessment (CVDRA) for each eligible person across New Zealand using a modified version of an overseas risk equation, through incentivising Primary Health Organisation (PHO) performance. In 2018 the New Zealand Ministry of Health endorsed the use of a suite of four new CVDRA equations which were developed using the large NZ Predict cohort (500,000 people). These equations more accurately reflect an individual's CVD risk and incorporate both traditional CVD risk factors, such as smoking and diabetes, but also sociodemographic factors including ethnicity and a deprivation score. The new CVDRA equations are an important tool to address the major inequities in CVD incidence, prevalence and mortality in Aotearoa-New Zealand. However, while the new equations provide more accurate assessment of risk, they are more complicated and therefore more prone to error if not properly validated and systematically implemented. To take advantage of this important opportunity to address equity in heart health we need strategic vision and national leadership. In this paper we make the case that to most safely and cost effectively implement the new equations, the Ministry of Health (MOH) should support a unified national CVD risk generator. A single, electronic, national CVD risk generator would: a) ensure national consistency and quality control-a single set of validated and current equations would be available to both clinicians and patients; b) avoid substantial replication of effort and cost in both developing and validating multiple calculators; c) enable central collection of the encrypted dataset required to develop more accurate risk assessment equations in population subgroups, both now and in the future, as CVD risk evolves; d) provide a platform to facilitate systematic and consistent national CVD risk communication and management; and e) facilitate ease of updating the tool and practice in the future as changes to the algorithm are agreed., Competing Interests: Dr Jackson and Dr Kerr report grants from HRC during the conduct of the study. Dr Wells reports grants from HRC and The Stevenson Foundation during the conduct of the study. Dr Harwood reports grants from HRC and National Science Challenge—Healthier Lives during the conduct of the study.

Aim: This paper describes an initiative facilitating comprehensive assessment and delivery of brief interventions for Māori youth in Northland, New Zealand. Background: The population in Northland is predominantly Māori and is one of New Zealand's most deprived populations. Māori youth have the highest youth suicide rate in the developed world and elevated numbers of youth displaying mental health issues and/or risk behaviours are of grave national concern. Like Indigenous peoples worldwide, inequities persist for Māori youth accessing and engaging with healthcare services. Description: Taking services out to Māori youth in remote and isolated areas, Northland's youth specialist nurses are reducing some barriers to accessing health care. The youth version of the Case‐finding and Help Assessment Tool is a New Zealand‐developed, e‐screening tool for youth psychosocial issues, facilitating comprehensive assessment and brief intervention delivery. Discussion: Early detection of, and timely intervention for, mental health and risk behaviours can significantly improve health outcomes in youth. However, for this to happen barriers preventing youth from accessing appropriate care need to be overcome. Conclusion: Youth specialist nurses could improve access to care for youth from ethnic minorities, rural and isolated regions, and areas of high deprivation without overwhelming the medical profession. Implications for nursing policy: Specialist nurses are trained and empowered to practice at the top of their scope. With general practitioner oversight and standing order sign off specialist nurses can work autonomously to improve access to health services, without increasing the workload of doctors. Implications for nursing practice: Encouraging continuous self‐reflection of the nurse's effectiveness in meeting patient needs, holistically and culturally, facilitates the provision of accessible care that is patient‐centred and culturally safe. [ABSTRACT FROM AUTHOR]

Longitudinal research is needed to better understand the natural history of oral conditions and long-term health and social outcomes. Oral health data has been collected periodically in the Dunedin Multidisciplinary Health and Development Study for over 40 years. To date, 70+ peer-review articles on the Study's oral health-related findings have been published, providing insight into the natural history of oral conditions, risk factors, impacts on quality of life, and disparities in oral health. Some of these report new findings, while others build upon the existing body of evidence. This paper provides an overview of these findings and reflects on their public health implications and policy utility in New Zealand. [ABSTRACT FROM AUTHOR]

Introduction. Evaluating digital health services from an ethical perspective remains one of the more difficult challenges in telemedicine and health technology assessment. We have previously developed a practical ethical checklist comprising 25 questions covering six ethical themes: privacy, security, and confidentiality; equity; autonomy and informed consent; quality and standards of care; patient empowerment; and continuity of care. The checklist makes ethical analysis more easily accessible to a broader audience, including health care providers, technology developers, and patients. Aim. This project applies the previously developed practical ethical checklist to direct-to-consumer virtual primary care consultation services in Aotearoa New Zealand to conduct an ethical assessment. Method. We first mapped the available services. The ethical framework was then applied to assess these services based on publicly available information. Results. Our findings show that the examined virtual consultation services adequately address ethical considerations, particularly regarding patient data privacy and informed consent. We identified areas for improvement in equity, patient empowerment, and continuity of care. Discussion. The application of this framework raises fundamental questions on how continuity of care, equity, and comprehensive care can be protected when virtual care becomes more ubiquitous. The checklist can help virtual consultation services identify areas of improvement and ensure they meet ethical criteria, thus contributing to quality of care. The framework may be adapted to other digital health services and tools, providing ethical guidance to technology developers, clinicians, and patients and their whānau (family). [ABSTRACT FROM AUTHOR]

This paper aims to consider the various parts of what is required to achieve the best possible health outcomes from medicines in partnership with the person for whom they are prescribed. Specifically, it looks to highlight the process from an Indigenous view with respect to Māori in Aotearoa New Zealand, and claims a multi-dimensional approach is imperative. Attaining optimal use of medicines is necessary to help achieve health equity. There is an urgent need to understand and investigate models of care that achieve this optimal state.

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. [ABSTRACT FROM AUTHOR]

This study investigated ethnic disparities in incident HF hospitalisations in NZ. Incident HF hospitalisations in patients aged ≥20 years were identified through International Classification of Diseases, 10th Revision (ICD-10)-coded national hospitalisation records. Of 116,113 incident HF hospitalisations in 2006-2018, 12.8% of patients were Māori, 5.7% were Pasifika, 3.0% were Asian and 78.6% were European/other. Overall, 64% of Māori and Pacific patients were aged <70 years, compared with 37% of Asian and 19% of European/others. In 2018, incidence rate ratios compared with European/others were 6.0, 7.5 and 0.5 for Māori, Pacific people and Asians aged 20-49 years; 3.7, 3.6 and 0.5 for Māori, Pacific people and Asians aged 50-69 years; and 1.5, 1.5 and 0.5 for Māori, Pacific people and Asians aged ≥70 years. Between 2006 and 2018, ethnicity-specific rates diverged in older patients (≥70 years) due to a decline in rates in European/others and Asians, but no change in rates in Māori and Pacific people. [ABSTRACT FROM AUTHOR]

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 decisionmaking 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. [ABSTRACT FROM AUTHOR]

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 enrolled utilised 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. [ABSTRACT FROM AUTHOR]

INTRODUCTION: The New Zealand 2001 Primary Health Care strategy requires primary health organizations (PHOs) to involve communities in their governance and be responsive to communities' needs. it is less clear what the implications of this policy are for general practices. This paper presents key findings from a national study undertaken in the wake of the 2001 primary care reforms on the purpose and process of involving communities in primary health care. METHODS: A three-part qualitative process was employed. Initially, key informant interviews were undertaken with a diverse range of primary care policy makers, funders, practitioners and community stakeholders (n=42). A draft framework for involving communities in primary care was developed, and formed the basis of a consultation phase (n=26). The framework was further developed and then piloted in four PHOs around New Zealand. FINDINGS: Views on community participation varied among different stakeholder groups in the sector. Most described it as a complex process of relationship-building over time, and one that is quite distinct from consumer feedback processes in general practice. For community representatives, it was a process of trust-building and information-sharing between communities and health professionals. These relationships enabled people to feel comfortable seeking care, and professionals to mould services to people's needs. CONCLUSION: This research highlights that community is much more than a setting of care. As citizens, members of disadvantaged communities are partners with general practices and PHOs, working with them to improve health equity by ensuring that services are responsive to their needs. [ABSTRACT FROM AUTHOR]

Objective. This study examines the development of new tools for analysing links between ethnicity and health outcomes. In a New Zealand context, it focuses on (1) how ethnicity is increasingly articulated as a social construct, (2) how individuals belonging to more than one ethnic group have been recorded and reported in research, and (3) health research and policy implications of the growing proportion of New Zealanders who claim multi-ethnic affiliations. Design. New Zealand provides a microcosm in which to consider ethnicity, indigeneity, migration and intermarriage, and their interacting effects on society, culture, identity and health outcomes. Against a backdrop of historical debates about the measurement of race, and then ethnicity, the paper explores recent changes in the recording and reporting of ethnicity in the five-yearly Census of Population and Dwellings, and in death registrations. These changes are then considered in relation to the study of ethnic health disparities and the development of policies to overcome them. Results. In the 2001 Census, of those who responded to the ethnicity question, at a level 1 classification 7.9% gave more than one response. In relation to the indigenous people of New Zealand, of all those who recorded Māori as one or more of their ethnic groups, only 56% recorded Māori only. In the younger age groups, less than half the Māori ethnic group were Māori only. Single ethnic categories disguise considerable within-group diversity in outcomes. Conclusion. While single ethnic group disparity studies have been useful in the past, we suggest that more sophisticated ways of conceptualising and analysing ethnicity data in relation to health disparities are now required in New Zealand. Based on the New Zealand experience, we also suggest that as international migration continues, and as intermarriage becomes more frequent in most countries, there will be pressure to move from single group race-based measures towards culturally-based complex ethnicity measures. [ABSTRACT FROM AUTHOR]

Objectives:The current study aimed to explore if the impact of various risk factors for chronic disease differed for people of Chinese, Indian and New Zealand European and Other (NZEO) ethnicities. Design:Data analysed for this paper was extracted from the 2003–04 and the 2006–07 NZ Health surveys for adults aged 25–70 which used a cross-sectional survey design. Data from both the survey waves were combined and all statistical analysis was done using SAS version 9.2 or 9.3. Ethnicity of participants was coded using a priority-based classification system as (1) Indian, (2) Chinese, (3) Other Asian, (4) NZEO, (5) Maori and (6) Pacific. Only data for Indians, Chinese and NZEO were used for the current study. Prevalence estimates and 95% confidence intervals for chronic disease and the associated risk factors were generated to describe the sample. Logistic regression analysis was used to examine whether the difference in the change in risk of chronic disease with different exposures was different according to ethnicity. Results:Higher deprivation resulted in increased risk of chronic disease in Indian and Chinese males but not in NZEO males (p= .03). There was a weak evidence for a differing effect of physical activity (p = .10) on chronic disease with the protective effect not seen in Indian or Chinese participants. Conclusion:The results of the current study indicate that some factors such as socio-economic deprivation and physical activity may impact differently on the prevalence of chronic disease according to ethnicity. The authors recommend further investigation of these factors using improved and innovative methodology and high-quality ethnicity data to better understand the factors underpinning ethnic disparities in disease prevalence among Asian sub-groups. [ABSTRACT FROM PUBLISHER]

Objectives.New Zealand has a unique tool, Te Tiriti o Waitangi, the Treaty of Waitangi, for addressing health disparities. Indigenous Māori have compromised health status compared to other groups. This paper investigates ways in which public health units (PHUs) and non-governmental organisations (NGOs) use Te Tiriti o Waitangi in service delivery to Māori. Design.A nationwide telephone survey of primary health providers (n=162) was conducted in 2014-15. Participants were asked about effectiveness and monitoring of their service delivery to Māori. Results.PHUs reported actively working with Māori, and Te Tiriti o Waitangi to reduce health disparities. Direct Māori engagement with development and delivery of programmes was viewed as essential. Strategies included designated PHU staff in positions of responsibility, formal partnerships with Māori, and providing operational and strategic guidance. Some PHUs supported development of cultural competencies. NGO responsiveness to Māori was variable. Some NGOs described prioritising service delivery and programmes for Māori. Others reported the focus of their service was European or other non-Māori ethnicities. Lack of resources or past difficulties engaging with Māori were barriers. Conclusion.Public health has an ethical commitment to reduce health disparities. Advancing Te Tiriti obligations in everyday practice has the potential to address inequalities. [ABSTRACT FROM AUTHOR]

Background: Early access to care for carpal tunnel syndrome (CTS) can avoid higher rates of surgery and permanent harm yet is often delayed, particularly for populations more likely to underutilise care. Objective: We sought to explore patient experiences and perspectives of health service access for CTS to inform an equity-focussed co-design of a health service for improving early care access. Methods: In this Normalisation Process Theory (NPT)-informed qualitative study we conducted semistructured in-depth interviews with 19 adults with experience of CTS. Recruitment prioritised New Zealand Māori, Pasifika, low-income, and rural populations. Data were analysed using deductive then inductive thematic analysis. Results: We identified five major themes: (1) the 'Significant Impact of CTS' of the sense-making and relational work to understand the condition, deciding when to get care, compelling clinicians to provide care, and garnering help from others; (2) 'Waiting and Paying for Care'– the enacting, relational, and appraising work to avoid long wait times unless paying privately, particularly where quality of care was low, employment relations poor, or injury compensation processes faltered; (3) circumstances of 'Occupation and CTS Onset' whereby the burden of proof to relate onset of CT symptoms to occupation created excessive relational and enacting work; (4) the 'Information Scarcity' of good information about CTS and the high relational and appraising work associated with using online resources; (5) 'Negotiating Telehealth Perspectives' where telehealth was valued if it meant earlier access for all despite the challenges it held for many. Conclusion: Quality, culturally and linguistically responsive information and communication from clinicians and health services will improve equitable early access to CTS care including realising the potential of telehealth modes of care. Policy changes that reduce individual burden of proof in injury compensation claims processes, enable time off work to attend health appointments, and increase public funding for surgical resources would improve early access to CTS care particularly for Māori and Pacific populations and those in small and rural workplaces. NPT is valuable for understanding where opportunities lie to reduce inequitable delays to accessing care including the impact of racism, particularly for populations more likely to underutilise care. [ABSTRACT FROM AUTHOR]

This paper describes the creation of two new geographical boundary files, known respectively as lower zones and upper zones, for investigating social phenomena and visualising disparities in health outcomes in the Auckland Region of New Zealand. We test the effectiveness of contemporary automated zone design tools before applying an interactive approach which integrated computational power with expert local knowledge and visual interpretation to develop meaningful zones. We demonstrate that an interactive approach addresses multiple zone design criteria (e.g. respecting physical barriers, compactness and homogeneity) more effectively than is possible with an automated approach. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Gout remains a health equity issue; Māori and Pacific peoples are disproportionately afflicted, with increased burden and loss of quality of life, yet are less likely to receive appropriate management, which mainly occurs in primary care. AIM: This study aims to understand the perspectives of the mainly Māori and Pacific clinicians and staff at an urban marae practice about barriers and challenges to delivering effective care to a Māori and Pacific community with high burden of gout. METHODS: Semi-structured interviews were conducted with 10 staff members delivering health care to a mostly Indigenous community. Interviews sought to ascertain staff views of enablers and barriers to optimal gout management and analyse them thematically. RESULTS: Three themes were identified: community disadvantage; demands unique to Indigenous providers; and challenges and opportunities for optimising gout management. High prevalence and heavy impact of gout on wellbeing in the community was intertwined with socioeconomic disadvantage, precariousness of employment and entrenched inaccurate (yet pliable) patient views on gout, to the detriment of focused, effective care. Structural and funding demands on providers inhibited staff focus on the clear community need. Providers saw the culturally safe and competent approach necessary for improvement as requiring community empowerment with appropriate clinical tools and adequate resourcing. DISCUSSION: Despite provider intent to deliver culturally appropriate and safe care and equitable health outcomes for patients suffering from gout, general practice initiatives without aligned resourcing or incentives are inhibited when inequity is pervasive. Simply asking Māori providers to do more for the same amount of resource may not be effective. [ABSTRACT FROM AUTHOR]

Aims: There is very little empirical evidence about the relationship between severe mental illness and the physical health of Indigenous peoples. This paper aims to compare the physical health of Māori and non-Māori with a diagnosis of bipolar disorder in contact with NZ mental health services. Methods: A cohort of Māori and non-Māori with a current bipolar disorder diagnosis at 1 January 2010 were identified from routine mental health services data and followed up for non-psychiatric hospital admissions and deaths over the subsequent 5 years. Results: Māori with bipolar disorder had a higher level of morbidity and a higher risk of death from natural causes compared to non-Māori with the same diagnosis, indicating higher levels of physical health need. The rate of medical and surgical hospitalisation was not higher among Māori compared to non-Māori (as might be expected given increased health needs) which suggests under-treatment of physical health conditions in this group may be a factor in the observed higher risk of mortality from natural causes for Māori. Conclusion: This study provides the first indication that systemic factors which cause health inequities between Māori and non-Māori are compounded for Māori living with severe mental illness. Further exploration of other diagnostic groups and subgroups is needed to understand the best approach to reducing these inequalities. [ABSTRACT FROM AUTHOR]

Census-based deprivation indices have been widely used in Aotearoa/New Zealand, Canada and UK to measure area-based socio-economic inequalities. This paper examines the indicators used in census-based area deprivation indices using a political ecology approach. We question whether the current indicators of deprivation derived from census data are meaningful for the all age groups and minority groups in the population, with a particular focus on deprivation indicators used in New Zealand, Canada and the United Kingdom. We comparatively reviewed methodological papers and reports that describe the indicators of deprivation in Aotearoa/New Zealand, Canada and the UK from 1975 to 2014. We consider the relationship between the notion of standards of living and measurements of deprivation and explore how hegemonic cultural constructs are implicit in measures of deprivation that privilege a Eurocentric, ageist and gender normative construction of statistics. We argue for more political ecological analyses to studying the relationship between social inequalities, geographies, health inequities and political economy to transform structures of oppression and inequality. This requires turning the analytical gaze on the wealthy and privileged instead of defaulting into deficit models to account for inequality. Studies of deprivation and inequality would benefit from understanding the processes and operations of power in the (re)production of socio-economic and health inequities to inform holistic strategies for social justice. [ABSTRACT FROM AUTHOR]

New Zealand is a peaceful nation, but ongoing political tensions and inequities between Māori (the indigenous peoples of New Zealand) and Pākehā (the majority group of Europeans) persist as a result of its colonial history. Identifying ways to redress the enduring legacy of colonialism are therefore of critical importance. Accordingly, this paper examines data from 7017 Māori, as well as 37,233 Pākehā, to examine the impact of regional-level Pākehā warmth towards Māori on Māori support for progressive collective action. Results reveal that Pākehā warmth towards Māori varies markedly across 257 regional wards (regional units created for New Zealand electoral purposes). Moreover, multilevel modelling demonstrates that Pākehā warmth towards Māori at the region-level correlates positively with Māori identity and political efficacy at the individual level which, in turn, both correlate positively with collective action support. Collectively, these results demonstrate the impact of the broader social climate on social change, while identifying a previously-unknown facilitator of collective action support (namely, a broader context of warmth towards structurally disadvantaged groups). [ABSTRACT FROM AUTHOR]

Background: Health intervention implementation in Aotearoa New Zealand (NZ), as in many countries globally, usually varies by ethnicity. Māori (the Indigenous peoples of Aotearoa) and Pacific peoples are less likely to receive interventions than other ethnic groups, despite experiencing persistent health inequities. This study aimed to develop an equity-focused implementation framework, appropriate for the Aotearoa NZ context, to support the planning and delivery of equitable implementation pathways for health interventions, with the intention of achieving equitable outcomes for Māori, as well as people originating from the Pacific Islands. Methods: A scoping review of the literature to identify existing equity-focused implementation theories, models and frameworks was undertaken. One of these, the Equity-based framework for Implementation Research (EquIR), was selected for adaptation. The adaptation process was undertaken in collaboration with the project's Māori and consumer advisory groups and informed by the expertise of local health equity researchers and stakeholders, as well as the international implementation science literature. Results: The adapted framework's foundation is the principles of Te Tiriti o Waitangi (the written agreement between Māori rangatira (chiefs) and the British Crown), and its focus is whānau (extended family)-centred implementation that meets the health and wellbeing aspirations, priorities and needs of whānau. The implementation pathway comprises four main steps: implementation planning, pathway design, monitoring, and outcomes and evaluation, all with an equity focus. The pathway is underpinned by the core constructs of equitable implementation in Aotearoa NZ: collaborative design, anti-racism, Māori and priority population expertise, cultural safety and values-based. Additionally, the contextual factors impacting implementation, i.e. the social, economic, commercial and political determinants of health, are included. Conclusions: The framework presented in this study is the first equity-focused process-type implementation framework to be adapted for the Aotearoa NZ context. This framework is intended to support and facilitate equity-focused implementation research and health intervention implementation by mainstream health services. [ABSTRACT FROM AUTHOR]

Background: Despite three decades of policy initiatives to improve integration of health care, delivery of health care in New Zealand remains fragmented, and health inequities persist for Māori and other high priority populations. An evidence base is needed to increase the chances of success with implementation of large-system transformation (LST) initiatives in a complex adaptive system. Methods: This research aimed to identify key elements that support implementation of LST initiatives, and to investigate contextual factors that influence these initiatives. The realist logic of enquiry, nested within the macro framing of complex adaptive systems, formed the overall methodology for this research and involved five phases: theory gleaning from a local LST initiative, literature review, interviews, workshop, and online survey. NVivo software programme was used for thematic analysis of the interview, workshop, and the survey data. We identified key elements and explained variations in success (outcomes) by identifying mechanisms triggered by various contexts in which LST initiatives are implemented. Results: The research found that a set of 10 key elements need to be present in the New Zealand health system to increase chances of success with implementation of LST initiatives. These are: (i) an alliancing way of working; (ii) a commitment to te Tiriti o Waitangi; (iii) an understanding of equity; (iv) clinical leadership and involvement; (v) involved people, whānau, and community; (vi) intelligent commissioning; (vii) continuous improvement; (viii) integrated health information; (ix) analytic capability; and (x) dedicated resources and time. The research identified five contextual factors that influenced implementation of LST initiatives: a history of working together, distributed leadership from funders, the maturity of Alliances, capacity and capability for improvement, and a continuous improvement culture. The research found that the key mechanism of trust is built and nurtured over time through sharing of power by senior health leaders by practising distributed leadership, which then creates a positive history of working together and increases the maturity of Alliances. Discussion: Two authors (KMS and PBJ) led the development and implementation of the local LST initiative. This prior knowledge and experience provided a unique perspective to the research but also created a conflict of interest and introduced potential bias, these were managed through a wide range of data collection methods and informed consent from participants. The evidence-base for successful implementation of LST initiatives produced in this research contains knowledge and experience of senior system leaders who are often in charge of leading these initiatives. This evidence base enables decision makers to make sense of complex processes involved in the successful implementation of LST initiatives. Conclusions: Use of informal trust-based networks provided a critical platform for successful implementation of LST initiatives in the New Zealand health system. Maturity of these networks relies on building and sustaining high-trust relationships among the network members. The role of local and central agencies and the government is to provide the policy settings and conditions in which trust-based networks can flourish. Other: This study was approved by the Victoria University of Wellington Human Ethics Committee (Ethics Approval Number 27,356). The research was supported by the Victoria University of Wellington research grant (222,809) and from the University of Auckland Department of Medicine research fund (H10779). [ABSTRACT FROM AUTHOR]

Introduction. Manatū Hauora (Aotearoa New Zealand (NZ) Ministry of Health) recognises that respecting and listening to Pacific peoples' knowledge and skills in caring for their communities' wellbeing is a priority, and that novel approaches to care, particularly for chronic health conditions, are necessary. Allied health professionals have the potential to play important roles in primary care design and delivery. Pacific Trust Otago (PTO) provides a weekly seniors' group gathering that has evolved over the years and incorporates exercise, health information and cultural activities. Aim. This study aims to explore what Pacific seniors are learning about their health and wellbeing, and what factors contribute to sustained engagement with this weekly group activity. Methods. The research team conducted a qualitative study using the Kakala Research Framework and the pan-Pacific Talanoa Research Methodology to gather narratives in a relational and comfortable group space. Participants were recruited from the seniors group gathering. Group Talanoa were used to collect data, which were digitally voice-recorded, transcribed, translated, and de-identified. Ethical approval was granted by the University of Otago School of Physiotherapy Ethics Committee. Results. Pacific seniors valued how these gathering The seniors recognised how interconnected and intertwined culture, spirituality, and family were and how this contributed to their sense of individual and collective health and wellbeing. The study highlights the need to consider health beyond the individual to the collective, embracing indigenous perspectives, and authentically nurturing relationships with Pacific health providers. The study recommends primary care funders are supported to understand what is important to Pacific people and partner with Pacific health providers to deliver care in ways that align with indigenous models of care. Discussion. A weekly group gathering for Pacific seniors run by Allied Health professionals provides a welcoming, safe, and culturally meaningful environment where seniors can connect, share, and grow in health and wellbeing together. This study highlights the importance of adopting informed and inclusive approaches to promoting and addressing holistic health for Pacific people, especially in light of ongoing health reforms in Aotearoa NZ. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Introduction. In Aotearoa New Zealand (NZ), there is inequity in rates of neural tube defects (NTDs). Among Maaori, NTD occur in 4.58/10 000 live births, and for Pacific peoples, it is 4.09/10 000 live births; this is compared to 2.81/10 000 live births for non-Maaori, non-Pacific peoples. Aim. To describe self-reported pre-pregnancy folic acid supplementation and to determine the association between pregnancy intendedness, ethnicity, parity, maternal age, care provider and pre-pregnancy folic acid supplementation. Methods. Secondary analysis of postpartum survey data collected at Te Whatu Ora Te Toka Tumai and Counties Manukau birthing facilities in 2020 was conducted. Descriptive analyses explored pregnancy intendedness and self-reported folic acid use by demographic variables. Multivariable logistic regression explored independent associations between demographic variables and folic acid use among intended pregnancies. Results. In total, 398 participants completed the survey. The response rate was (140/149) 94% at Counties Manukau and (258/315) 82% at Te Toka Tumai. Pre-pregnancy supplementation was reported by 182 of 398 participants (46%). Use was higher among those who intended their pregnancy (151/262, 58%) compared to those who were 'pregnancy ambivalent' (9/33, 27%) or did not intend to become pregnant (22/103, 21%). Factors independently associated with supplementation among intended pregnancies included: 'Other ethnicity' (European, Middle Eastern, Latin American, African) compared to Maaori (aOR 5.3 (95% CI 1.3, 21.8)), age =30 years compared to <30 years (aOR 2.1 (1.0, 4.1)), and private obstetrician compared to midwifery care (aOR 4.2 (1.6, 10.9)). Discussion. Low rates of pre-pregnancy folic acid supplementation exist in Auckland with significant ethnic disparity. Mandatory fortification of non-organic wheat is important, but supplementation is still recommended to maximally reduce risk. [ABSTRACT FROM AUTHOR]

Māori, the indigenous people of Aotearoa New Zealand, experience poorer health than non-Māori across a range of health measures. Interventions focused at an individual level have proved largely ineffective; ‘bottom-up’ approaches where communities determine their own priorities may be more sustainable than ‘top-down’ approaches where goals are determined by health authorities. The purpose of this paper is to illustrate an innovative health promotion programme aimed at improving Māori health and to discuss the importance of ownership and control of health initiatives by Māori. Evaluators conducted a comprehensive evaluation of a Healthy Eating Healthy Action programme in six small Māori health agencies, gathering information from programme managers and co-ordinators, participants and wider community members about what changes were occurring at individual, family and community levels. Effective interventions built on cultural values and practices and were delivered by Māori with close connections to the community. Changes in nutrition and physical activity made by participants also benefitted their wider families and community. The changes demonstrated subtle but important shifts in thinking about healthy eating and healthy activity that in the longer term could lead to more measurable change towards improved quality of life for people within communities. [ABSTRACT FROM AUTHOR]

Background: Significant health inequities exist around maternal and infant health for Māori, the indigenous people of New Zealand. The infants of Māori are more likely to die in their first year of life and also have higher rates of hospital admission for respiratory illnesses, with the greatest burden of morbidity being due to bronchiolitis in those under one year of age. Timely immunisations can prevent some respiratory related hospitalisations, although for Māori, the proportion of infants with age appropriate immunisations are lower than for non-Māori. This paper describes the protocol for a retrospective cohort study that linked local hospital and national health information datasets to explore maternal risk factors and obstetric outcomes in relation to respiratory admissions and timely immunisations for infants of Māori and non-Māori women. Methods/Design: The study population included pregnant women who gave birth in hospital in one region of New Zealand between 1995 and 2009. Routinely collected local hospital data were linked via a unique identifier (National Health Index number) to national health information databases to assess rates of post-natal admissions and access to health services for Māori and non-Māori mothers and infants. The two primary outcomes for the study are: 1. The rates of respiratory hospitalisations of infants (⩽1 yr of age) calculated for infants of both Māori and non-Māori women (for mothers under 20 years of age, and overall) accounting for relationship to parity, maternal age, socioeconomic deprivation index, maternal smoking status. 2. The proportion of infants with age appropriate immunisations at six and 12 months, calculated for both infants born to Māori women and infants born to non-Māori women, accounting for relationship to parity, maternal age, socioeconomic deprivation index, smoking status, and other risk factors. Discussion: Analysis of a wide range of routinely collected health information in which maternal and infant data are linked will allow us to directly explore the relationship between key maternal factors and infant health, and provide a greater understanding of the causes of health inequalities that exist between the infants of Māori and non-Māori mothers. [ABSTRACT FROM AUTHOR]

The aim of this paper is to challenge the hypothesis that genetic differences play a significant role in the disparities in health status between Māori and non-Māori. To do so I considered the patterns of these disparities to see if they are consistent with the manifestations of genetic variation. I compared disparities in health between Māori and non-Māori with patterns of disparity across most social sectors (reason one), patterns of disparity across most health indicators (reasons two, three and four) with international experience (reasons five and six) over time (reason seven) and by spatial or kin based clusters (reason eight) over intermarriage (reason nine) and by considering the consensus of modern population genetics (reason ten) and concluded that there appears to be little evidence to suggest genetics to be a major cause of those disparities. [ABSTRACT FROM AUTHOR]