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Māori health providers emerged in Aotearoa/New Zealand in the 1980s as a mechanism to achieve self‐determination for Māori communities. However, the contracts funding Māori health providers limit expressions of self‐determination and fail to reflect Te Tiriti O Waitangi, the founding treaty of Aotearoa/New Zealand. Significant health reforms are proposed in Aotearoa/New Zealand, including the creation of a Māori Health Authority that will commission services from Māori health providers. This paper aims to critique the government contracts provided to Māori health providers in the light of the health reforms. A discourse analysis was undertaken on contracts held by a Māori health provider. The study was informed by a Kaupapa Māori congruent methodology that centralised Māori knowledge. The contractural language utilised a variety of discursive techniques that ultimately limit the power of Māori health providers. These discursive techniques included the redefinition of Māori concepts of self‐determination, the use of rhetoric that was not matched by action, reshaping Māori health priorities to reflect the funders' priorities and the application of a deficit lens to Māori health issues. The discursive techniques present in these contracts is consistent with previous work demonstrating a failure of funders to centralise Māori knowledge and ways of being. Success of the proposed health reforms and the Māori Health Authority should require dismantling of non‐Māori ways of commissioning and contracting, otherwise there is the continued risk of discriminatory contracting practices limiting the expression of self‐determination for Māori health providers. [ABSTRACT FROM AUTHOR]

This article reports an effective strategy for recruiting patients with asthma to a qualitative study using an animated comic advertised on social media. An ad spend of NZ$432 on Facebook resulted in 101 study enquiries, and 27 participants taking part in the focus groups, of which 16 (56%) were Māori, the Indigenous Peoples of New Zealand. Representation of Māori amongst participants was over five times higher than their proportion in the local population (9.7%), resulting in data fulfilling the principle of equal explanatory power, an approach to research which can help advance Māori health development and address inequity. The success of this campaign is of particular interest for health researchers in New Zealand where Māori continue to be disproportionately affected by poorer health outcomes compared with non-Māori, particularly those with asthma. Approaches that better engage and support participation of under-represented communities in clinical research are of wider global interest. We reflect on the recruitment strategy and outcomes within a Kaupapa Māori framework, explore how this can be applied more widely in healthcare, and suggest direction for future study and implementation. Lay summary We designed an animated comic to advertise a study for patients with asthma. This was shared locally with a Facebook ad. The approach was highly engaging with the public, and resulted in rapid recruitment. Interestingly, participation of Māori (the Indigenous People of New Zealand) was over five times higher than their proportion in the local population. Māori have poorer health outcomes and increased barriers to healthcare access compared with non-Māori, particularly those with asthma. Approaches which can engage and support under-represented communities to participate in clinical research are of wider global interest. In this article, we reflect on the recruitment strategy and outcomes, and suggest direction for future study and implementation. [ABSTRACT FROM AUTHOR]

Background: This paper presents the pilot testing of an online professional development (PD) course for New Zealand (NZ) speech-language therapists (SLTs) working with Māori with stroke-related communication disorders (predominantly aphasia). Taking a public health approach and focusing on the context of Māori as Indigenous peoples in a colonised society, the course lays the foundation for aphasia management for Māori. It consists of two modules. Module One addresses health inequities, social determinants of health, racism, the Treaty of Waitangi, cultural safety and power inherent in the role of the SLT. Module Two includes specific information about providing therapy for Māori stroke patients (particularly those with aphasia) and family members and working with Māori health colleagues. Aim: The primary aim was to ascertain the impact of the course on participants' clinical practice with Māori with aphasia. A secondary aim was to examine participants' assessment of the content and delivery of the course. Methods & Procedures: This was a qualitative longitudinal pilot study. Eleven SLTs completed the online course, immediately followed by a survey in which they gave feedback on the course and named three activities they would do to apply their learning in the following six months. Eight participants were available for interview six months later. Interviews aimed to ascertain what participants learned from the course, how they applied their learning and how the course could be improved. Interview data were analysed using a "general inductive approach", in conjunction with responses to the survey. Outcomes & Results: Interview findings were divided into two main themes – "putting it into practice" which revealed what participants learned and how they applied their learning and "keeping it at the forefront" which focused on maintaining that learning and practice, including reflection on the course content and delivery. All participants were positive about the course and all would recommend it to colleagues. Conclusions: The pilot testing revealed that participants made positive changes to their practice as a result of their learning. Challenges inherent in completing the course and applying learning and suggestions for improvement were also identified. Although the course content is NZ-specific, many of the ideas in the course are relevant to numerous multiethnic contexts across the world in which the speech-language therapy culture in service delivery could be impacted by issues such as power, racism, and inequity. [ABSTRACT FROM AUTHOR]

It is important to understand how consumers (person with stroke/family member/carer) and health workers perceive stroke care services. Consumers and health workers from across New Zealand were surveyed on perceptions of stroke care, access barriers, and views on service centralisation. Quantitative data were summarised using descriptive statistics whilst thematic analysis was used for free-text answers. Of 149 consumers and 79 health workers invited to complete a survey, 53 consumers (36.5%) and 41 health workers (51.8%) responded. Overall, 40/46 (87%) consumers rated stroke care as 'good/excellent' compared to 24/41 (58.6%) health workers. Approximately 72% of consumers preferred to transfer to a specialised hospital. We identified three major themes related to perceptions of stroke care: 1) 'variability in care by stage of treatment'; 2) 'impact of communication by health workers on care experience'; and 3) 'inadequate post-acute services for younger patients'. Four access barrier themes were identified: 1) 'geographic inequities'; 2) 'knowing what is available'; 3) 'knowledge about stroke and available services'; and 4) 'healthcare system factors'. Perceptions of stroke care differed between consumers and health workers, highlighting the importance of involving both in service co-design. Improving communication, post-hospital follow-up, and geographic equity are key areas for improvement. Provision of detailed information on stroke recovery and available services in the community is recommended. Improvements in the delivery of post-hospital stroke care are required to optimise stroke care, with options including routine phone follow up appointments and wider development of early supported discharge services. Stroke rehabilitation services should continue to be delivered 'close to home' to allow community integration. Telehealth is a likely enabler to allow specialist urban clinicians to support non-urban clinicians, as well as increasing the availability and access of community rehabilitation. [ABSTRACT FROM AUTHOR]

Exploring the results of the COVID-19 response in New Zealand (Aotearoa) is warranted so that insights can inform future pandemic planning. We compared the COVID- 19 response in New Zealand to that for the more severe 1918–19 influenza pandemic. Both pandemics were caused by respiratory viruses, but the 1918–19 pandemic was short, intense, and yielded a higher mortality rate. The government and societal responses to COVID-19 were vastly superior; responses had a clear strategic direction and included a highly effective elimination strategy, border restrictions, minimal community spread for 20 months, successful vaccination rollout, and strong central government support. Both pandemics involved a whole-of-government response, community mobilization, and use of public health and social measures. Nevertheless, lessons from 1918–19 on the necessity of action to prevent inequities among different social groups were not fully learned, as demonstrated by the COVID-19 response and its ongoing unequal health outcomes in New Zealand. [ABSTRACT FROM AUTHOR]

Background: Ethnic differences in post-stroke outcomes have been largely attributed to biological and socioeconomic characteristics resulting in differential risk factor profiles and stroke subtypes, but evidence is mixed. Aims: This study assessed ethnic differences in stroke outcome and service access in New Zealand (NZ) and explored underlying causes in addition to traditional risk factors. Methods: This national cohort study used routinely collected health and social data to compare post-stroke outcomes between NZ Europeans, Māori, Pacific Peoples, and Asians, adjusting for differences in baseline characteristics, socioeconomic deprivation, and stroke characteristics. First and principal stroke public hospital admissions during November 2017 to October 2018 were included (N = 6879). Post-stroke unfavorable outcome was defined as being dead, changing residence, or becoming unemployed. Results: In total, 5394 NZ Europeans, 762 Māori, 369 Pacific Peoples, and 354 Asians experienced a stroke during the study period. Median age was 65 years for Māori and Pacific Peoples, and 71 and 79 years for Asians and NZ Europeans, respectively. Compared with NZ Europeans, Māori were more likely to have an unfavorable outcome at all three time-points (odds ratio (OR) = 1.6 (95% confidence interval (CI) = 1.3–1.9); 1.4 (1.2–1.7); 1.4 (1.2–1.7), respectively). Māori had increased odds of death at all time-points (1.7 (1.3–2.1); 1.5 (1.2–1.9); 1.7 (1.3–2.1)), change in residence at 3 and 6 months (1.6 (1.3–2.1); 1.3 (1.1–1.7)), and unemployment at 6 and 12 months (1.5 (1.1–2.1); 1.5 (1.1–2.1)). There was evidence of differences in post-stroke secondary prevention medication by ethnicity. Conclusion: We found ethnic disparities in care and outcomes following stroke which were independent of traditional risk factors, suggesting they may be attributable to stroke service delivery rather than patient factors. [ABSTRACT FROM AUTHOR]

The article discusses the evolving understanding of rehabilitation, emphasizing the need for a broader perspective that includes psychology, sociology, and other behavioral sciences. It challenges the biomedical approach and advocates for the biopsychosocial model of wellness. It recommends for a reevaluation of rehabilitation dogma and a shift towards a person-centered approach.

Context Brown Buttabean Motivation (BBM) is a grassroot Pacific-led organisation aiming to reduce obesity amongst Pasifika (Pacific people in Aotearoa New Zealand) and Indigenous Māori, helping them choose a healthy and active life-style for themselves, their children and their wider family. BBM offers a holistic approach to weight loss, recognising that mental health, family and cultural factors all play essential and critical roles in nutrition and physical activity patterns. Objective To understand how participants experience and engage with BBM. Study Design & Analysis Qualitative study conducted by our co-design research team within a broader BBM research project. Initial inductive thematic approach followed by theoretical deductive analysis of coded data guided by Pacific Fonofale and Māori Te Whare Tapa Whā health models. In this meetinghouse metaphor, the floor is family, roof is culture, house-posts are physical, mental, spiritual and sociodemographic health and well-being, surrounded by environment, time and context. Setting South Auckland, New Zealand 2021 Population Studied BBM participants Instrument Semi-structured interviews Outcome Measures Narrative data Results 22 interviewees (50% female) aged 24-60 years of mixed Pacific and Māori ethnicities. Majority self-reported weight loss (between three and 135kg) since starting BBM. Two researchers independently coded data with adjudication (kappa=0.61) Participants identified the interactive holistic nature of health and wellbeing from BBM. As well as physical, mental and spiritual benefits, BBM helped many reconnect with both their family and their culture. BBM is seen as a new way of life. Participants "immediately belong to BBM family" regardless of culture or size, "with no judgements" and adopt the BBM motto "no excuses". Conclusions Many weight loss studies provide programmes to improve physical exercise and nutrition, but seldom address sustainability and other core factors such as mental health and motivation. BBM is a community-embedded Māori and Pasifika-led intervention, with no reliance on researchers nor external authorities for its ongoing implementation. It addresses factors impacting participants' lives and social determinants of health, including vaccination drives, food parcels and adapting to the COVID-19 pandemic and lockdowns. Our three-year longitudinal cohort study assessing sustained weight loss is ongoing. [ABSTRACT FROM AUTHOR]

Background: Health equity for Indigenous peoples in the context of surgery has recently become topical amongst surgeons in Australasia. Health inequities are amongst the most consistent and compelling disparities between Māori and New Zealand Europeans (NZE) in New Zealand (NZ). We aimed to investigate where ethnic disparities in surgical care may occur and highlight some of the potential contributing factors, over all surgical specialties, between Māori and NZE adults in NZ. Methods: A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement. A series of electronic searches were performed in Medline, Embase, PubMed and CINAHL. Results: Ten studies met the inclusion criteria. All studies employed a range of indicators for surgical care including receipt of surgery following diagnosis, delays to treatment and post‐operative morbidity and mortality. Disparities in the receipt of surgical treatment for several cancers were observed for Māori and remained after adjustment for socioeconomic variables and extent of disease. Māori were more likely to experience delays in treatment and referral to other medical specialties involved in their care. Conclusion: Despite the significant variation in the types of diseases, procedures and indicators of surgical care of the included studies, consistent findings are that disparities in different aspects of surgical care exist between Māori and NZE in NZ. This review highlights the need to better quantify the important issue of health equity for Māori in surgery given the lack of studies over the majority of surgical specialties. [ABSTRACT FROM AUTHOR]

Objective: To assess diabetes eye service use in New Zealand among people aged ≥15 years by estimating service attendance, biennial screening rate, and disparities in the use of screening and treatment services. Methods: We obtained Ministry of Health data from the National Non-Admitted Patient Collection on diabetes eye service events between 1 July 2006 and 31 December 2019 and sociodemographic and mortality data from the Virtual Diabetes Register and linked these using a unique patient identifier (encrypted National Health Index). We 1) summarized attendance at retinal screening and ophthalmology services, 2) calculated biennial and triennial screening rate, 3) summarized treatment with laser and anti-VEGF and used log-binomial regression to examine associations of all of these with age group, ethnicity, and area-level deprivation. Results: In total, 245,844 people aged ≥15 years had at least one diabetes eye service appointment attended or scheduled; half of these (n = 125,821, 51.2%) attended only retinal screening, one-sixth attended only ophthalmology (n = 35,883, 14.6%) and one-third attended both (n = 78,300, 31.8%). The biennial retinal screening rate was 62.1%, with large regional variation (73.9% in Southern District to 29.2% in West Coast). Compared with NZ Europeans, Māori were approximately twice as likely to never receive diabetes eye care or to access ophthalmology when referred from retinal screening, 9% relatively less likely to receive biennial screening and received the fewest anti-VEGF injections when treatment was commenced. Disparities in service access were also present for Pacific Peoples compared to NZ Europeans, younger and older age groups compared to those aged 50–59 years and those living in areas with higher deprivation. Conclusions: Access to diabetes eye care is suboptimal, with substantial disparity between age groups, ethnicity groups, area level deprivation quintile and across districts. Efforts to improve access to and quality of diabetes eye care services must include strengthening data collection and monitoring. [ABSTRACT FROM AUTHOR]

Background: Primary care in Aotearoa New Zealand is largely delivered by general practices, heavily subsidised by government. Te Tiriti o Waitangi (1840) guarantees equal health outcomes for Māori and non-Māori, but differences are stark and longstanding. Seven models of primary care have evolved. We hypothesised that patient health outcomes would differ between models of care; and that Māori, Pacific peoples and those living in material deprivation would have poorer outcomes from primary care. Methods: We conducted a cross-sectional study of patient-level data from national datasets and practices, at 30 September 2018, using multilevel mixed effects regression analyses (patients clustered within practices). Primary outcomes, considered to be measures of unmet need for primary care, were polypharmacy (≥ 65 years), HbA1c testing in adults with diabetes, childhood immunisations (6 months), ambulatory sensitive hospitalisations (0–14, 45–64 years) and emergency department attendances. Explanatory variables adjusted for patient and practice characteristics. Equity, by model of care, ethnicity and deprivation, was assumed if they showed no significant association with patient outcomes. Patient characteristics included: age, ethnicity, deprivation, multi-morbidity, first specialist assessments and practice continuity. Practice characteristics included: size, funding and doctor continuity. Clinical input (consultations and time with nurses and doctors) was considered a measure of practice response. Results: The study included 924 general practices with 4,491,964 enrolled patients. Traditional practices enrolled 73% of the population, but, on average, the proportion of Māori, Pacific and people living with material deprivation was low in any one Traditional practice. Patients with high health needs disproportionately enrolled in Māori, Pacific and Trust/NGO practices. There were multiple associations between models of care and patient health outcomes in fully adjusted regressions. No one model of care out-performed others across all outcomes. Patients with higher health need received more clinical input but this was insufficient to achieve equity in all outcomes. Being a Māori or Pacific patient, or living in material deprivation, across models of care, remained associated with poorer outcomes. Conclusions: Model-level associations with poor patient outcomes suggest inequity in measures that might be used to target investment in primary care. [ABSTRACT FROM AUTHOR]

Māori and Pacific peoples in Aotearoa New Zealand (NZ) face significant inequities in cardiovascular disease (CVD) risk factors, hospitalisations and management rates, compared with non-Māori, non-Pacific peoples. These inequities are intimately linked to factors such as colonisation and the intergenerational impacts of systemic racism. This is the protocol for Manawataki Fatu Fatu for ACCESS (Māori and Pacific hearts in unison for Achieving Cardiovascular Care in Equity StudieS), a mixed-methods programme of research, combining kaupapa Māori and Pacific research methodologies (i.e. incorporating the knowledges, skills and values of Māori and Pacific peoples). In this Māori and Pacific led research programme, we will use qualitative and quantitative methodologies to identify evidence-practice gaps along the healthcare continuum that can be addressed to improve heart health outcomes for Māori and Pacific people in NZ. The programme is built on three foundation projects: (i) the assessment and management of CVD risk in primary care; (ii) pre-hospital delays in accessing care following an acute cardiac event in the community; and (iii) post-discharge and long-term management of heart failure. There are three phases. Phase 1 aims to systematically document research, completed or underway, about equitable access to evidence-based heart health care. We will establish a national collaboration of equity-focused heart health researchers and providers, and undertake systematic reviews relating to the three foundation projects. In Phase 2, we will undertake qualitative and quantitative research in the three foundational projects, to identify interventions to increase access to heart health care that have most potential to improve Māori and Pacific health outcomes and achieve equity. The quantitative and qualitative studies will be undertaken in parallel and will inform each other. Phase 3 will use findings from Phases 1 and 2 to create a Quality-Improvement-Equity Roadmap to inform interventions to improve Māori and Pacific people's access to evidence-based CVD care. [ABSTRACT FROM AUTHOR]

Background: Publicly funded bariatric surgery in New Zealand (NZ) is steadily on the rise to meet the obesity epidemic. Ethnic disparities in obesity rates exist in NZ with Māori and Pacific people having three to five times higher rates than all other ethnic groups within NZ. Ethnic disparities in rates of bariatric surgery have been reported internationally. This research sought to describe rates of publically funded bariatric surgery by self‐identified ethnicity in NZ. Methods: Using reported census and hospitalization discharge data from Statistics NZ and the NZ Ministry of Health, we calculated estimate rates of publicly funded bariatric surgery in the morbidly obese population from June 2009 to July 2014. Results: The average number of publicly funded bariatric procedures performed per 1000 morbidly obese patients from June 2009 to July 2014 was 3.0 for European, 1.4 for Māori and 0.7 for Pacific ethnicities. Conclusion: While these data should be interpreted cautiously due to data limitations, the estimated rates may indicate that bariatric services are currently being provided inequitably across the major ethnic groups within NZ. We suggest that further studies should be performed to explore potential patient, healthcare provider and system‐level factors that may contribute to ethnic disparities in the rates of publicly funded bariatric surgery in NZ. [ABSTRACT FROM AUTHOR]

Efforts to provide accessible eye care must consider the extent to which travel-distance may be a barrier for some communities. This study aimed to determine the distribution of — and geographic access to — eye health services in Aotearoa New Zealand. We further sought to identify communities who might benefit from provision of eye health services that were more geographically accessible. We obtained addresses of optometry and ophthalmology clinics from regulatory bodies and augmented this with online searches. Address locators were created using a Land Information dataset and geocoded using ArcGIS 10.6. A national population was derived using Statistics New Zealand's Integrated Data Infrastructure. We generated population-weighted centroids of each of New Zealand's 50,938 meshblocks and calculated the travel distance along the road network between each clinic and population (meshblock centroid). The proportion of the population living >50 km from each clinic type was calculated; as was the median, inter-quartile range and maximum distance across area-level deprivation quintiles in each district. A national population of 4.88 million was identified, as were addresses for 344 optometry, 46 public ophthalmology and 90 private ophthalmology clinics. Nationally and within each district, travel distance to optometry was shorter than to either type of ophthalmology clinic. The region of Northland — with a high proportion of the population Māori and in the highest quintile of area-level deprivation — had the furthest average distance to travel to optometry and public ophthalmology, while the West Coast region on the South Island had the farthest to travel to private ophthalmology. Several communities were identified where longer distances intersected with higher area-level deprivation. Most New Zealanders live within 10 km of eye health services. However, to achieve equitable eye health, strategies are required that make affordable eye health services accessible to communities for whom large travel distances intersect with high deprivation. [ABSTRACT FROM AUTHOR]

People with cancer have an increased risk of cardiovascular disease. Risk prediction equations developed in New Zealand accurately predict 5-year cardiovascular disease risk in a general primary care population in the country. We assessed the performance of these equations for survivors of cancer in New Zealand. For this validation study, patients aged 30–74 years from the PREDICT open cohort study, which was used to develop the New Zealand cardiovascular disease risk prediction equations, were included in the analysis if they had a primary diagnosis of invasive cancer at least 2 years before the date of the first cardiovascular disease risk assessment. The risk prediction equations are sex-specific and include the following predictors: age, ethnicity, socioeconomic deprivation index, family history of cardiovascular disease, smoking status, history of atrial fibrillation and diabetes, systolic blood pressure, total cholesterol to HDL cholesterol ratio, and preventive pharmacotherapy (blood-pressure-lowering, lipid-lowering, and antithrombotic drugs). Calibration was assessed by comparing the mean predicted 5-year cardiovascular disease risk, estimated using the risk prediction equations, with the observed risk across deciles of risk, for men and women, and according to the three clinical 5-year cardiovascular disease risk groups in New Zealand guidelines (<5%, 5% to <15%, and ≥15%). Discrimination was assessed by Harrell's C statistic. 14 263 patients were included in the study. The mean age was 61 years (SD 9) for men and 60 years (SD 8) for women, with a median follow-up of 5·8 years for men and 5·7 years for women. The observed cardiovascular disease risk was underpredicted by a maximum of 2·5% in male and 3·2% in female decile groups. When patients were grouped according to clinical risk groups, observed cardiovascular disease risk was underpredicted by less than 2% in the lower risk groups and overpredicted by 2·2% for men and 3·3% for women in the highest risk group. Harrell's C statistics were 0·67 (SE 0·01) for men and 0·73 (0·01) for women. The New Zealand cardiovascular disease risk prediction equations reasonably predicted the observed 5-year cardiovascular disease risk in survivors of cancer in the country, in whom risk prediction was considered clinically appropriate. Prediction could be improved by adding cancer-specific variables and considering competing risks. Our findings suggest that the equations are reasonable clinical tools for use in survivors of cancer in New Zealand. Auckland Medical Research Foundation, Health Research Council of New Zealand. [ABSTRACT FROM AUTHOR]

The establishment of a culturally diverse surgical workforce, largely on the basis of gender, has been highly promoted in Australasia in the last decade. Despite this, discussions of gender diversity in surgery have largely excluded Indigenous women. This study presents the experiences of wāhine Māori and Pasifika doctors in Aotearoa, who formed a surgical sisterhood to support them towards applying for advanced surgical training. Utilising mana wāhine and Masi methodologies, semi-structured interpersonal interviews were undertaken with five wāhine who formed the surgical sisterhood. Following transcription and analysis of all interviews, four key themes were identified. These were mana wāhine, unity, our why and change on the horizon. These themes illustrate the complex and varied experiences of wāhine Māori and Pasifika and how they have navigated their surgical pathways amidst multiple layers of discrimination towards being in a position to apply for advanced surgical training. [ABSTRACT FROM AUTHOR]

Māori and Pacific peoples in Aotearoa New Zealand (NZ) face significant inequities in cardiovascular disease (CVD) risk factors, hospitalisations and management rates, compared with non-Māori, non-Pacific peoples. These inequities are intimately linked to factors such as colonisation and the intergenerational impacts of systemic racism. This is the protocol for Manawataki Fatu Fatu for ACCESS (Māori and Pacific hearts in unison for Achieving Cardiovascular Care in Equity StudieS), a mixed-methods programme of research, combining kaupapa Māori and Pacific research methodologies (i.e. incorporating the knowledges, skills and values of Māori and Pacific peoples). In this Māori and Pacific led research programme, we will use qualitative and quantitative methodologies to identify evidence-practice gaps along the healthcare continuum that can be addressed to improve heart health outcomes for Māori and Pacific people in NZ. The programme is built on three foundation projects: (i) the assessment and management of CVD risk in primary care; (ii) prehospital delays in accessing care following an acute cardiac event in the community; and (iii) post-discharge and long-term management of heart failure. There are three phases. Phase 1 aims to systematically document research, completed or underway, about equitable access to evidence-based heart health care. We will establish a national collaboration of equity-focused heart health researchers and providers, and undertake systematic reviews relating to the three foundation projects. In Phase 2, we will undertake qualitative and quantitative research in the three foundational projects, to identify interventions to increase access to heart health care that have most potential to improve Māori and Pacific health outcomes and achieve equity. The quantitative and qualitative studies will be undertaken in parallel and will inform each other. Phase 3 will use findings from Phases 1 and 2 to create a Quality-Improvement-Equity Roadmap to inform interventions to improve Māori and Pacific people's access to evidence-based CVD care. [ABSTRACT FROM AUTHOR]

Background: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) are rare in high-income countries; however, in Aotearoa New Zealand ARF and RHD disproportionately affect Indigenous Māori and Pacific Peoples. This narrative review explores the evidence regarding non-surgical management of patients with clinically significant valve disease or heart failure due to RHD.Methods: Medline, EMBASE and Scopus databases were searched, and additional publications were identified through cross-referencing. Included were 28 publications from 1980 onwards.Results: Of the available interventions, improved anticoagulation management and a national RHD register could improve RHD outcomes in New Zealand. Where community pharmacy anticoagulant management services (CPAMS) are available good anticoagulation control can be achieved with a time in the therapeutic range (TTR) of more than 70%, which is above the internationally recommended level of 60%. The use of pharmacists in anticoagulation control is cost-effective, acceptable to patients, pharmacists, and primary care practitioners. There is a lack of local data available to fully assess other interventions; including optimal therapy for heart failure, equitable access to specialist RHD care, prevention, and management of endocarditis.Conclusion: As RHD continues to disproportionately affect Indigenous and minority groups, pro-equity tertiary prevention interventions should be fully evaluated to ensure they are reducing disease burden and improving outcomes in patients with RHD. [ABSTRACT FROM AUTHOR]

Indigenous experiences of hospitalisation may contribute to maintenance of Indigenous health inequities. We undertook a qualitative systematic review of Māori experiences of hospital care within New Zealand. We performed electronic database searches and used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement to assist study selection. We were guided by Kaupapa Māori (Māori centred) research methodology and used the CONSolIDated critERtia statement to evaluate completeness of reporting against recommended Indigenous ethical guidelines. The Betancourt framework for addressing ethnic disparities in health care was utilised to synthesise findings. Seven studies were included. Studies enlisting Indigenous research expertise and Kaupapa Māori research methodology demonstrated clearer links between participant voices and critique of hospital experiences. Multiple barriers were identified within clinical, organisational and structural loci of practice. Proposed interventions focused on building cultural safety against these barriers. Strategies promoting access to care for Māori and cultural safety training for the workforce are needed. [ABSTRACT FROM AUTHOR]

Objective To describe the dispensing of cardiovascular disease (CVD) preventive medications among older New Zealanders with and without prior CVD or diabetes. Methods New Zealanders aged ≥65 years in 2013 were identified using anonymised linkage of national administrative health databases. Dispensing of blood pressure lowering (BPL), lipid lowering (LL) or antithrombotic (AT) medications, was documented, stratified by age and by history of CVD, diabetes, or neither. Results Of the 593,549 people identified, 32% had prior CVD, 14% had diabetes (of whom half also had prior CVD) and 61% had neither diagnosis. For those with prior CVD, between 79–87% were dispensed BPL and 73–79% were dispensed AT medications, across all age groups. In contrast, LL dispensing was lower than either BPL or AT in every age group, falling from 75% at age 65–69 years to 43% at 85+ years. For people with diabetes, BPL and LL dispensing was similar to those with prior CVD, but AT dispensing was approximately 20% lower. Among people without prior CVD or diabetes, both BPL and AT dispensing increased with age (from 39% and 17% at age 65–69 years to 56% and 35% at 85+ years respectively), whereas LL dispensing was 26–31% across the 65–84 year age groups, falling to 17% at 85+ years. Conclusion The much higher dispensing of BPL and AT compared to LL medications with increasing age suggests a preventive treatment paradox for older people, with the medications most likely to cause adverse effects being dispensed most often. [ABSTRACT FROM AUTHOR]

To investigate the rehabilitation experiences of Māori who were still reporting disability 24 months after an injury resulting in hospitalisation. Participants had been hospitalised for an Accident Compensation Corporation (New Zealand's no-fault injury compensation insurer) entitlement claim injury between 2007 and 2009, and were experiencing disability 24 months post-injury. In-depth kanohi ki te kanohi (face-to-face) qualitative interviews with 12 participants aged between 37 and 71 years at the time of interviews were conducted. Interpretive analyses of interview transcripts, focused on the impacts of injury was conducted with the aid of NVivo software. The overarching theme identified during the analysis was "Impact" with four sub-themes of: Impact on daily life; Impact on relationships, Impact on employment; and, long-term or ongoing impacts. For Māori living with disability 24 months after hospitalisation for injury, adjusting to life after the injury and the rehabilitation process was challenging. Participants discussed frustration with feeling dependent on others, being bored and feeling unfulfilled after their injury, and that many aspects of their lives were impacted on and not always in the expected directions. Many reported longer lasting impacts even after rehabilitation was completed. Implications for rehabilitation programmes e.g., strengthening programmes by taking into account issues discussed by participants, recognising the long-term impacts on both those injured and their whānau (family), and further investigations required are also discussed. Disability after injury can have long term impacts for injured Māori and their relationships. Social impacts can be perceived as more debilitating than the physical impacts after injury. Experiences of employment changes and future prospects are often difficult to navigate for Māori returning to work after an injury. [ABSTRACT FROM AUTHOR]

Objective: To use secondary data from the Taking Charge after Stroke study to explore mechanisms for the positive effect of the Take Charge intervention on physical health, advanced activities of daily living and independence for people after acute stroke. Design: An open, parallel-group, randomised trial with two active and one control intervention and blinded outcome assessment. Setting: Community. Participants: Adults (n = 400) discharged to community, non-institutional living following acute stroke. Interventions: One, two, or zero sessions of the Take Charge intervention, a self-directed rehabilitation intervention which helps a person with stroke take charge of their own recovery. Measures: Twelve months after stroke: Mood (Patient Health Questionnaire-2, Mental Component Summary of the Short Form 36); 'ability to Take Charge' using a novel measure, the Autonomy-Mastery-Purpose-Connectedness (AMP-C) score; activation (Patient Activation Measure); body mass index (BMI), blood pressure (BP) and medication adherence (Medication Adherence Questionnaire). Results: Follow-up was near-complete (388/390 (99.5%)) of survivors at 12 months. Mean age (SD) was 72.0 (12.5) years. There were no significant differences in mood, activation, 'ability to Take Charge', medication adherence, BMI or BP by randomised group at 12 months. There was a significant positive association between baseline AMP-C scores and 12-month outcome for control participants (1.73 (95%CI 0.90 to 2.56)) but not for the Take Charge groups combined (0.34 (95%CI −0.17 to 0.85)). Conclusion: The mechanism by which Take Charge is effective remains uncertain. However, our findings support a hypothesis that baseline variability in motivation, mastery and connectedness may be modified by the Take Charge intervention. [ABSTRACT FROM AUTHOR]

Background: Until recently, most patients with diabetes worldwide have been diagnosed when symptomatic and have high cardiovascular risk, meaning most should be prescribed cardiovascular preventive medications. However, in New Zealand, a world-first national programme led to approximately 90% of eligible adults being screened for diabetes by 2016, up from 50% in 2012, identifying many asymptomatic patients with recent-onset diabetes. We hypothesised that cardiovascular risk prediction equations derived before widespread screening would now significantly overestimate risk in screen-detected patients.Methods: New Zealanders aged 30-74 years with type 2 diabetes and without known cardiovascular disease, heart failure, or substantial renal impairment were identified from the 400 000-person PREDICT primary care cohort study between Oct 27, 2004, and Dec 30, 2016, covering the period before and after widespread screening. Sex-specific equations estimating 5-year risk of cardiovascular disease were developed using Cox regression models, with 18 prespecified predictors, including diabetes-related and renal function measures. Equation performance was compared with an equivalent equation derived in the New Zealand Diabetes Cohort Study (NZDCS), which recruited between 2000 and 2006, before widespread screening.Findings: 46 652 participants were included in the PREDICT-1° Diabetes subcohort, of whom 4114 experienced first cardiovascular events during follow-up (median 5·2 years, IQR 3·3-7·4). 14 829 (31·8%) were not taking oral hypoglycaemic medications or insulin at baseline. Median 5-year cardiovascular risk estimated by the new equations was 4·0% (IQR 2·3-6·8) in women and 7·1% (4·5-11·2) in men. The older NZDCS equation overestimated median cardiovascular risk by three times in women (median 14·2% [9·7-20·0]) and two times in men (17·1% [4·5-20·0]). Model and discrimination performance measures for PREDICT-1° Diabetse equations were also significantly better than for the NZDCS equation (eg, for women: R2=32% [95% CI 29-34], Harrell's C=0·73 [0·72-0·74], Royston's D=1·410 [1·330-1·490] vs R2=24% [21-26], C=0·69 [0·67-0·70], and D=1·147 [1·107-1·187]).Interpretation: International treatment guidelines still consider most people with diabetes to be at high cardiovascular risk; however, we show that recent widespread diabetes screening has radically changed the cardiovascular risk profile of people with diabetes in New Zealand. Many of these patients have normal renal function, are not dispensed glucose-lowering medications, and have low cardiovascular risk. These findings have clear international implications as increased diabetes screening is inevitable due to increasing obesity, simpler screening tests, and the introduction of new-generation glucose-lowering medications that prevent cardiovascular events. Cardiovascular risk prediction equations derived from contemporary diabetes populations, with multiple diabetes-related and renal function predictors, will be required to better differentiate between low-risk and high-risk patients in this increasingly heterogeneous population and to inform appropriate non-pharmacological management and cost-effective targeting of expensive new medications.Funding: Health Research Council of New Zealand, Heart Foundation of New Zealand, and Healthier Lives National Science Challenge. [ABSTRACT FROM AUTHOR]

We describe trends in acute rheumatic fever (ARF), rheumatic heart disease (RHD), and RHD deaths among population groups in New Zealand. We analyzed initial primary ARF and RHD hospitalizations during 2000-2018 and RHD mortality rates during 2000-2016. We found elevated rates of initial ARF hospitalizations for persons of Māori (adjusted rate ratio [aRR] 11.8, 95% CI 10.0-14.0) and Pacific Islander (aRR 23.6, 95% CI 19.9-27.9) ethnicity compared with persons of European/other ethnicity. We also noted higher rates of initial RHD hospitalization for Māori (aRR 3.2, 95% CI 2.9-3.5) and Pacific Islander (aRR 4.6, 95% CI 4.2-5.1) groups and RHD deaths among these groups (Māori aRR 12.3, 95% CI 10.3-14.6, and Pacific Islanders aRR 11.2, 95% CI 9.1-13.8). Rates also were higher in socioeconomically disadvantaged neighborhoods. To curb high rates of ARF and RHD, New Zealand must address increasing social and ethnic inequalities. [ABSTRACT FROM AUTHOR]

This systematic review aimed to determine to what extent and why the care pathways for acute cardiac events in the community might differ for minoritised ethnic populations compared to non-minoritised populations. It also sought to identify the barriers and enablers that could influence variations in access to care for minoritised populations. A multi-database search was conducted for articles published between 1 January 2000 and 1 January 2023. A combination of MeSH terms and keywords was used. Inclusion criteria for papers were published in English, adult population, the primary health condition was an acute cardiac event, and the primary outcomes were disaggregated by ethnicity or race. A narrative review of extracted data was performed, and findings were reported according to the PRISMA 2020 guidelines. Of the 3552 articles identified using the search strategy, 40 were deemed eligible for the review. Studies identified a range of variables in the care pathway that differed by ethnicity or race. These could be grouped as time to care, transportation, event related-variables, EMS interactions and symptoms. A meta-analysis was not performed due to heterogeneity across the studies. The extent and reasons for differences in cardiac care pathways are considerable. There are several remediable barriers and enablers that require attention to achieve equitable access to care for minoritised populations. [ABSTRACT FROM AUTHOR]

Background and purpose: "Take Charge" is a novel, community-based self-directed rehabilitation intervention which helps a person with stroke take charge of their own recovery. In a previous randomized controlled trial, a single Take Charge session improved independence and health-related quality of life 12 months following stroke in Māori and Pacific New Zealanders. We tested the same intervention in three doses (zero, one, or two sessions) in a larger study and in a broader non-Māori and non-Pacific population with stroke. We aimed to confirm whether the Take Charge intervention improved quality of life at 12 months after stroke in a different population and whether two sessions were more effective than one. Methods: We randomized 400 people within 16 weeks of acute stroke who had been discharged to institution-free community living at seven centers in New Zealand to a single Take Charge session (TC1, n = 132), two Take Charge sessions six weeks apart (TC2, n = 138), or a control intervention (n = 130). Take Charge is a "talking therapy" that encourages a sense of purpose, autonomy, mastery, and connectedness with others. The primary outcome was the Physical Component Summary score of the Short Form 36 at 12 months following stroke comparing any Take Charge intervention to control. Results: Of the 400 people randomized (mean age 72.2 years, 58.5% male), 10 died and two withdrew from the study. The remaining 388 (97%) people were followed up at 12 months after stroke. Twelve months following stroke, participants in either of the TC groups (i.e. TC1 + TC2) scored 2.9 (95% confidence intervals (CI) 0.95 to 4.9, p = 0.004) points higher (better) than control on the Short Form 36 Physical Component Summary. This difference remained significant when adjusted for pre-specified baseline variables. There was a dose effect with Short Form 36 Physical Component Summary scores increasing by 1.9 points (95% CI 0.8 to 3.1, p < 0.001) for each extra Take Charge session received. Exposure to the Take Charge intervention was associated with reduced odds of being dependent (modified Rankin Scale 3 to 5) at 12 months (TC1 + TC2 12% versus control 19.5%, odds ratio 0.55, 95% CI 0.31 to 0.99, p = 0.045). Conclusions: Confirming the previous randomized controlled trial outcome, Take Charge—a low-cost, person-centered, self-directed rehabilitation intervention after stroke—improved health-related quality of life and independence. Clinical trial registration-URL: http://www.anzctr.org.au. Unique identifier: ACTRN12615001163594 [ABSTRACT FROM AUTHOR]

Research surrounding access to surgical care between Maori and non-Maori has grown substantially (Fig. Despite a plethora of resources outlining how to conduct safe and responsive research for Maori, non-Maori researchers with little connection to Maori communities and people continue to lead and control research on or about Maori.1 Maori health clinicians and academics tirelessly challenge these researchers and attempt to protect Maori from research that is racist, exploitative and demeaning. Within these discourses, Maori are often framed within a deficit lens in health research.8 Such deficiencies are framed as either biological or cultural, or both, due to mainstream research methodologies lacking critical reflexivity of Western systems that maintain inequities.9 Furthermore, there is limited research examining the impact of sociocultural systems developed by the dominant group on Maori health. [Extracted from the article]

Access to publicly funded bariatric surgery in New Zealand is limited, but privileges patients who identify as New Zealand European or Other European. This example of institutional racism in the New Zealand health system further reiterates that Māori face inequitable access to gold standard medical interventions. This article analyses semi-structured interviews undertaken with Māori who had bariatric surgery at Counties Manukau Health which houses the largest public bariatric service. Thirty-one interviews were conducted, from which six themes were identified in relation to the stages of the bariatric journey. A thematic analysis of transcripts using an inductive approach was undertaken. Using Kaupapa Māori Research–aligned methodology, sites of racism, compassion, clinical barriers to positive health experiences and life-changing experiences were identified along the bariatric journey for Māori patients. [ABSTRACT FROM AUTHOR]

Objectives: Type 2 diabetes mellitus (T2DM) and periodontal disease are two highly prevalent, directly and independently associated long‐term conditions that disproportionately impact Indigenous Māori in New Zealand (NZ). Although poorly understood, a number of social and biological mechanisms connect these conditions. This qualitative study explored experiences of T2DM and oral and dental (hereafter oral/dental) health; access to oral/dental health care; whether participants' experiences supported or challenged existing evidence; and sought suggestions for improving oral/dental health in a high‐deprivation rural area of Northland, NZ. Methods: Participants (n = 33) meeting the study criteria: self‐identified Māori ethnicity, aged ≥ 18‐years with glycated haemoglobin (HBA1c) >65 mmol/L were recruited via the local primary care clinic in September‐December 2015; two left the study prior to data collection. During face‐to‐face semi‐structured interviews, participants (n = 31) were asked How does diabetes affect your teeth? and When did you last access dental care? Kaupapa Māori (KM) theory and methodology provided an important decolonizing lens to critically analyse the fundamental causes of Indigenous health inequities. Results: Independent analysis of qualitative data by three KM researchers identified four themes: access barriers to quality care; pathways to edentulism; the 'cost' of edentulism; and, unmet need. Results contributed towards informing Mana Tū—an evidence‐based KM programme for diabetes in primary care—to be introduced in this and other communities from 2018. Conclusions: Oral health is integral to diabetes management, and vice versa. Subsidized specialist referrals for oral‐dental health care for Māori with T2DM could improve glycaemic control and diabetes outcomes and reduce diabetes‐related complications among this population. [ABSTRACT FROM AUTHOR]