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OBJECTIVE There is increasing evidence that EDs may not operate equitably for all patients, with Indigenous and minoritised ethnicity patients experiencing longer wait times for assessment, differential pain management and less evaluation and treatment of acute conditions. METHODS This retrospective observational study used a Kaupapa Māori framework to investigate ED admissions into 18/20 District Health Boards in Aotearoa New Zealand (2006-2012). Key pre-admission variable was ethnicity (Māori:non-Māori), and outcome variables included: ED self-discharge; ED arrival to assessment time; hospital re-admission within 72 h; ED re-presentation within 72 h; ED length of stay; ward length of stay; access block and mortality (in ED or within 10 days of ED departure). Generalised linear regression models controlled for year of presentation, sex, age, deprivation, triage category and comorbidity. RESULTS Despite some ED process measures favouring Māori, for example arrival to assessment time (mean difference -2.14 min; 95% confidence interval [CI] -2.42 to -1.86) and access block (odds ratio [OR] 0.89, 95% CI 0.87-0.91), others showed no difference, for example self-discharge (OR 0.98, 95% CI 0.97-1.00). Despite this, Māori mortality (OR 1.60, 95% CI 1.50-1.71) and ED re-presentation (OR 1.11, 95% CI 1.09-1.12) were higher than non-Māori. CONCLUSION To our knowledge, this is the most comprehensive investigation of acute outcomes by ethnicity to date in New Zealand. We found ED mortality inequities that are unlikely to be explained by ED process measures or comorbidities. Our findings reinforce the need to investigate health professional bias and institutional racism within an acute care context.

To understand the medical student perspective and experiences of academic difficulty and remediation in years' 2-6 at The University of Auckland (UoA), Aotearoa New Zealand, who were admitted via the Indigenous Māori and Pacific Admission Scheme (MAPAS) and international student pathways.A qualitative study which undertook one-on-one, semi-structured interviews using case study as the research method within Kaupapa Māori and Pacific research frameworks. Two student groups were interviewed during 2017: MAPAS and international medical students. An email invitation was sent to all students, inviting those who had failed a year, or at least one examination, assessment, module or domain in UoA Medical Programme during 2014-2016 to participate in the study. Interview transcripts were thematically analysed with an inductive approach.Fourteen medical students at UoA were included in the study, with ten from MAPAS and four from the international student admission pathway. There were six major themes identified. Three themes related to academic difficulty: the set curriculum, the hidden clinical curriculum and life complexities. Three related to the student perspectives of remediation: the impact of MAPAS support, enhanced resilience (particularly the MAPAS cohort) and stigmatisation from failing.This study has investigated the MAPAS and international medical student experience of academic difficulty and remediation at UoA. The student dialogue offered a rich insight to deepen our understanding into the remediation process to ensure it is not only culturally safe but also fit for purpose. Tertiary institutions that offer undergraduate medical education can (and should) better support their at-risk medical student cohorts.

ObjectivesTo provide a sociodemographic profile of students enrolled in their first year of a health professional pre-registration programme offered within New Zealand (NZ) tertiary institutions.DesignObservational, cross-sectional study. Data were sought from NZ tertiary education institutions for all eligible students accepted into the first ‘professional’ year of a health professional programme for the 5-year period 2016–2020 inclusive. Variables of interest: gender, citizenship, ethnicity, rural classification, socioeconomic deprivation, school type and school socioeconomic scores. Analyses were carried out using the R statistics software.SettingAotearoa NZ.ParticipantsAll students (domestic and international) accepted into the first ‘professional’ year of a health professional programme leading to registration under the Health Practitioners Competence Assurance Act 2003.ResultsNZ’s health workforce pre-registration students do not reflect the diverse communities they will serve in several important dimensions. There is a systematic under-representation of students who identify as Māori and Pacific, and students who come from low socioeconomic and rural backgrounds. The enrolment rate for Māori students is about 99 per 100 000 eligible population and for some Pacific ethnic groups is lower still, compared with 152 per 100 000 for NZ European students. The unadjusted rate ratio for enrolment for both Māori students and Pacific students versus ‘NZ European and Other’ students is approximately 0.7.ConclusionsWe recommend that: (1) there should be a nationally coordinated system for collecting and reporting on the sociodemographic characteristics of the health workforce pre-registration; (2) mechanisms be developed to allow the agencies that fund tertiary education to base their funding decisions directly on the projected health workforce needs of the health system and (3) tertiary education funding decisions be based on Te Tiriti o Waitangi (the foundational constitutional agreement between the Indigenous people, Māori and the British Crown signed in 1840) and have a strong pro-equity focus.

Addressing the underrepresentation of Māori in the health workforce is expected to improve Māori health status and contribute to a reduction in Māori health inequities. This research aimed to under...

Objective Internationally, Indigenous and minoritised ethnic groups experience longer wait times, differential pain management and less evaluation and treatment for acute conditions within emergency medicine care. Examining ED Inequities (EEDI) aims to investigate whether inequities between Māori and non‐Māori exist within EDs in Aotearoa New Zealand (NZ). This article presents the descriptive findings for the present study. Methods A retrospective observational study framed from a Kaupapa Māori positioning, EEDI uses secondary data from emergency medicine admissions into 18/20 District Health Boards in NZ between 2006 and 2012. Data sources include variables from the Shorter Stays in ED National Research Project database and comorbidity data from NZ's National Minimum Dataset. The key predictor of interest is patient ethnicity with descriptive variables, including sex, age group, area deprivation, mode of presentation, referral method, Australasian Triage Scale and trauma status. Results There were a total of 5 972 102 ED events (1 168 944 Māori, 4 803 158 non‐Māori). We found an increasing proportion of ED events per year, with a higher proportion of Māori from younger age groups and areas of high deprivation compared to non‐Māori events. Māori also had a higher proportion of self‐referral and were triaged to be seen within a longer time frame compared to non‐Māori. Conclusion Our findings show that there are different patterns of ED usage when comparing Māori and non‐Māori events. The next level of analysis of the EEDI dataset will be to examine whether there are any associations between ethnicity and ED outcomes for Māori and non‐Māori patients., Examining ED Inequities aims to investigate whether inequities between Māori and non‐Māori exist within EDs in Aotearoa New Zealand. This article presents the descriptive findings for this study. Our findings show that there are different patterns of ED usage when comparing Māori and non‐Māori events.

This paper reports the findings of a literature review to answer the research question, "What are the barriers and facilitators of access to hospital services for Māori?"MEDLINE (Ovid) and PsycINFO were searched using keywords to identify relevant literature published between 2000 and 2020. The data analysis was informed by a Kaupapa Māori positioning and the CONSIDER statement on reporting of health research involving Indigenous peoples.Twenty-three papers met the inclusion criteria. We identified five themes that captured the barriers for Māori accessing hospital services (practical barriers, poor communication, hostile healthcare environment, primary care barriers and racism) and five facilitatory themes were identified (practical facilitators, whakawhanaungatanga, whānau, manaakitanga and cultural safety).This article confirms existing knowledge about practical barriers and facilitators to healthcare access for Māori and contributes to an emerging body of evidence about the impact of racism and culturally unsafe services in preventing Māori from accessing healthcare services. The facilitators identified provide a potential roadmap for the redesign of services so they are accessible and effective for Māori. Improving services in this way would support district health boards, the Ministry of Health and professional organisations to comply with their commitments to providing culturally safe services and health professionals.

In this chapter, the health needs and rights of Indigenous peoples are discussed. This discussion covers current challenges beginning with how indigeneity is defined. Within this context, current data on Indigenous health are described with a critique of how Indigenous health is framed. In an attempt to make sense of global patterns of the health of Indigenous peoples, these data are contextualized within our colonial histories, the legacies of historical and intergenerational trauma, differential access to and through health and social services, differential quality of services received by Indigenous peoples, and the under-representation of Indigenous peoples in the health workforce. The latter part of the chapter outlines important considerations for progress towards health equity for Indigenous peoples, especially the foundational right to self-determination and what this means for Indigenous health, from health services, to interventions, research, and Indigenous knowledge. As the world faces significant new health challenges, Indigenous knowledges and ways of being may offer important insights into managing these challenges.

Background Medical electives undertaken during sixth year at medical school provide an opportunity for students to work in an overseas or New Zealand health facility to gain exposure to a health system outside their training facility. Previous work suggests that the elective experience can be profound, exposing global health inequities, or influencing future career decisions. This study assessed patterns within elective choice by students’ socio demographic and programme entry characteristics. Methods A retrospective analysis of student elective records from 2010 to 2016 was undertaken using a Kaupapa Māori research framework, an approach which prioritises positive benefits for Māori (and Pacific) participants and communities. A descriptive analysis of routinely collected de-identified aggregate secondary data included demographic variables (gender, age group, ethnicity, secondary school decile, year and route of entry), and elective site. Route of entry (into medical school) is via general, MAPAS (Māori and Pacific Admissions Scheme) and RRS (Regional and Rural Scheme). Multivariable logistic regression analysis determined the odd ratios for predictors of going overseas for elective and electives taking place in a “High” (HIC) compared to “Low- and middle-income countries” (LMIC). Results Of the 1101 students who undertook an elective (2010–2016) the majority undertook their elective overseas; the majority spent their elective within a high-income country. Age (younger), route of entry (general) and high school decile (high) were associated with going overseas for an elective. Within the MAPAS cohort, Pacific students were more likely (than Māori) were to go overseas for their elective; Māori students were more likely to spend their elective in a HIC. Conclusion The medical elective holds an important, pivotal opportunity for medical students to expand their clinical, professional and cultural competency. Our results suggest that targeted support may be necessary to ensure equitable access, particularly for MAPAS students the benefit of an overseas elective.

Objectives Ethnic inequities in health outcomes have been well documented with Indigenous peoples experiencing a high level of healthcare need, yet low access to, and through, high‐quality healthcare services. Despite Māori having a high ED use, few studies have explored the potential for ethnic inequities in emergency care within New Zealand (NZ). Healthcare delivery within an ED context is characterised by time‐pressured, relatively brief, complex and demanding environments. When clinical decision‐making occurs in this context, provider prejudice, stereotyping and bias are more likely. The examining emergency department inequities (EEDI) research project aims to investigate whether clinically important ethnic inequities between Māori and non‐Māori exist. Methods EEDI is a retrospective observational study examining ED admissions in NZ between 2006 and 2012 (5 976 126 ED events). EEDI has been designed from a Kaupapa Māori Research position. Results The primary data source is the existing Shorter Stays in Emergency Department National Research Project (SSED) dataset that will be combined with clinical information extracted from NZ's National Minimum Dataset. The key predictor variable is patient ethnicity with other covariates including: sex, age‐group, area deprivation, mode of presentation, referral method, Australasian Triage Scale and the Multimorbidity Measure (M3 Index) for co‐morbidities. Generalised linear regression models will be used to investigate the associations between pre‐admission variables and the measures of ED care, and to examine the contribution of each measure of ED care on ethnic inequities in mortality. Conclusion The present study will provide the largest, most comprehensive investigation of ED outcomes by ethnicity to date in NZ.

The determinants of health inequities between Indigenous and non-Indigenous populations include factors amenable to medical education’s influence—for example, the competence of the medical workforce to provide effective and equitable care to Indigenous populations. Medical education institutions have an important role to play in eliminating these inequities. However, there is evidence that medical education is not adequately fulfilling this role and, in fact, may be complicit in perpetuating inequities. This article seeks to examine the factors underpinning medical education’s role in Indigenous health inequity, to inform interventions to address these factors. The authors developed a consensus statement that synthesizes evidence from research, evaluation, and the collective experience of an international research collaboration including experts in Indigenous medical education. The statement describes foundational processes that limit Indigenous health development in medical education and articulates key principles that can be applied at multiple levels to advance Indigenous health equity. The authors recognize colonization, racism, and privilege as fundamental determinants of Indigenous health that are also deeply embedded in Western medical education. To contribute effectively to Indigenous health development, medical education institutions must engage in decolonization processes and address racism and privilege at curricular and institutional levels. Indigenous health curricula must be formalized and comprehensive, and must be consistently reinforced in all educational environments. Institutions’ responsibilities extend to advocacy for health system and broader societal reform to reduce and eliminate health inequities. These activities must be adequately resourced and underpinned by investment in infrastructure and Indigenous leadership.

Older Māori have higher rates of self-reported disabling hearing loss in Aotearoa New Zealand (NZ). However, have greater unmet need for special equipment than non-Māori. This review aims to analyse current literature on the experiences of hearing loss and hearing services among older Māori and whānau.This scoping review was undertaken using a Kaupapa Māori approach and PRISMA guidelines. Databases were explored to identify literature focused on older Māori and whānau experiences of hearing loss and hearing services. Inclusion criteria included: literature set in the NZ context; published between 1985 and 2020; English language; focus on hard-of-hearing Māori and whānau experiencing sensorineural hearing loss.A total of eight sources were identified. Hearing loss is a detriment to daily functioning, partaking in conversations and retaining Māori culture. Cost and poor patient-provider interactions created barriers to hearing services for Māori with hearing loss and whānau.The last analysis of literature regarding hearing loss and hearing services for Māori was written in 1989. Inequities in hearing loss and access to hearing services remain. Research that is Māori-led and uses a Kaupapa Māori approach is needed to further understand the realities of hearing loss and hearing services for older Māori and whānau.

Despite Māori (Indigenous population of New Zealand, NZ) having high Emergency Department (ED) use, few studies have explored for ethnic inequities in ED within NZ. ED healthcare can be time-pressured, complex and demanding. Clinical decision-making in this context may facilitate provider prejudice, stereotyping and bias. The Examining Emergency Department Inequities (EEDI) is a retrospective observational study, designed from a Kaupapa Māori Research position, examining ED admissions in NZ between 2006 and 2012 using the existing Shorter Stays in Emergency Department National Research Project dataset combined with clinical information extracted from NZ’s National Minimum Dataset. The key predictor variable is patient ethnicity with covariates: sex, age-group, area deprivation, mode of presentation, referral method, Australasian Triage Scale and the Multimorbidity Measure (M3 Index) for co-morbidities. Generalised linear regression models investigated the associations between pre-admission variables and the measures of ED care, and mortality. There were a total of 5,972,102 ED events (1,168,944 Māori, 4,803,158 non-Māori). We found an increasing proportion of ED events/year, a higher proportion of Māori ED events from younger age groups and areas of high deprivation compared to non-Māori. Māori had a higher proportion of self-referral and were triaged to be seen within a longer timeframe compared to non-Māori. After controlling for year of ED event, gender, triage category, age at presentation, NZ Deprivation decile and M3 Comorbidity score: Māori had shorter ED arrival to assessment time; shorter ED Length of Stay and less Access Block (>8 hour ED LOS before ward admission). Despite this, Māori mortality within ED or within 10 days of discharge was higher than non-Māori. These findings suggest different patterns in ED usage between Māori and non-Māori. Of concern, inequities in mortality exist despite positive indicators of ED care. Key messages There is evidence of different patterns in emergency department use between Māori and non-Māori in New Zealand. Māori:non-Māori inequities in mortality exist despite positive indicators of emergency department care.

AIM Timely access to computerised tomography (CT) for acute traumatic brain injuries (TBIs) facilitates rapid diagnosis and surgical intervention. In 2009, New Zealand introduced a mandatory target for emergency department (ED) stay such that 95% of patients should leave ED within 6 h of arrival. This study investigated whether this target influenced the timeliness of cranial CT scanning in children who presented to ED with acute TBI. METHODS We retrospectively reviewed a random sample of charts of children

Understanding how to undertake Kaupapa Māori research can be a challenge for emerging health researchers. Unless emerging researchers have exposure to Kaupapa Māori theory or senior Māori health research expertise, the challenge of undertaking Kaupapa Māori research within health research contexts can seem daunting, and for some, too difficult to attempt. This article summarizes what an Indigenous positioning means to me as a health researcher, medical practitioner, academic and Māori community member, and why it is more than just a methodological approach. The theoretical basis of Kaupapa Māori—what it is, how it emerged and what it means for my own research practice—is explored. How Kaupapa Māori interacts with Pacific research methodologies, particularly when health research involves both Māori and Pacific participants, is discussed. It is hoped that this article will assist emerging researchers (both Indigenous and non-Indigenous) to embrace Indigenous-appropriate research approaches within their own work.

Objective Time targets for ED stays are used as a policy instrument to reduce ED crowding. There is debate whether such policies are helpful or harmful, as focus on a process target may divert attention from clinical care. The objective of this study is to investigate whether the Shorter Stays in Emergency Departments target in New Zealand was associated with a change in the quality of ED discharge information provided to primary care providers. Methods The quality of discharge summaries was assessed retrospectively over time using chart review. Logistic regression was used to account for secular trends with adequate or not as the dependent variable. Explanatory variables were: age, ethnicity, deprivation, triage category, year, the step at target introduction (2009) and the change in slope before and after the target. Results Of 500 randomly selected discharge summaries, 491 (98.2%) were included in the analysis. There was evidence of a decrease over time in the proportion of adequate discharge summaries before the introduction of the target (slope estimate (SE) −0.43 (0.20), p=0.02). A step at the target introduction could not be shown (p=0.47). There was evidence of an improvement over time from pre-target to post-target: slope afterwards 0.33, estimate of change in slope (SE) 0.76 (0.27), p=0.006. Conclusions There was no reduction in the quality of discharge summaries following the introduction of the shorter stays in ED target and trends in quality improved. These findings deserve replication in other hospitals which may experience different challenges.

Objective There is debate whether targets for ED length of stay introduced to reduce ED overcrowding are helpful or harmful, as focus on a process target may divert attention from clinical care. Our objective was to investigate the effect of a national ED target in Aotearoa New Zealand on the recommended care for acute asthma as this is known to suffer in overcrowded departments. Methods We conducted a retrospective chart review study across four sites from 2006 to 2012 (target introduced mid 2009). The primary outcome was time to steroids in the ED. The secondary outcomes were other aspects of asthma care in ED. We used general linear models or logistic regression as appropriate to assess care before and after the target. Results Among the 570 (of 1270 randomly selected cases) eligible for analysis, no difference was demonstrated in time to steroids: least square mean (95% CI) = 58.1 (49–67.5) min before and 50.4 (42.9–55.8) min after the target (P = 0.15). More patients received steroids in ED after the target, OR (95% CI) = 2.1 (1.2–4.3). No differences were demonstrated in those receiving steroid prescriptions or re-presentations: OR (95% CI) = 1.3 (0.9–1.96) and 1.1 (0.5–2.3), respectively. Changes in pre-target and post-target ED and hospital length of stay varied between hospitals. Conclusion Introduction of the target was not associated with a change in times to steroids in ED, although more patients received steroids in ED indicating closer adherence to recommended practice.

A national health target for length of stay in emergency departments (ED) was introduced in 2009 to reduce crowding and improve quality of care. We aimed to determine whether the target was associated with changes in time to CT and appropriateness of CT imaging, as markers of care quality for suspected acute traumatic brain injury (TBI). We undertook a retrospective review of the case records of a random sample of people aged ≥15 years presenting to the ED with TBI from 2006 to 2013. General linear models were used to investigate changes in outcomes along with routine process times before and after the introduction of the target. Among 501 eligible cases the median (IQR) time to CT was 136 (76–247) pre target versus 119 (59–209) minutes post target, p = 0.014. The proportion of appropriate imaging was similar between periods: 77.9% (95% CI 71–83%) versus 76.6% (95%CI 72–81%), p = 0.825. Interactions suggested that the time to CT and appropriateness of imaging before and after the introduction of the target varied by ethnicity, although the changes were not clinically important. Time to assessment and length of stay did not change importantly. We found no evidence of a clinically important change in time to CT or appropriateness of imaging for suspected TBI in association with the introduction of the SSED time target. Additional research with larger cohorts of Māori and Pacific participants is recommended to understand our observed patterns by ethnicity.

Widening access to highly competitive and restricted health professional programmes of study such as medicine, pharmacy and optometry remains a challenge for many tertiary institutions. Understanding the role that tertiary institutions can play to increase access for indigenous students remains important. This chapter explores the Vision 20:20 initiative based at the Faculty of Medical and Health Sciences (FMHS) at the University of Auckland, Aotearoa, New Zealand. Based on research findings and programme experience, twelve effective practices for tertiary institutional action are presented within the areas of: recruitment; admission; bridging/foundation education; and, retention. Tertiary institutions can (and should) support indigenous health workforce development via a commitment to tertiary interventions that are aligned to a widening participation and social justice agenda.

Bridging/foundation programmes are often provided by tertiary institutions to increase equity in access and academic performance of students from under-served communities. Little empirical evidence exists to measure the effectiveness of these bridging/foundation programmes on undergraduate academic outcomes. This research identifies the predictive effect of academic outcomes achieved within a bridging/foundation programme, targeted towards indigenous and ethnic minority students, on first-year degree-level outcomes. Overall performance within the bridging/foundation programme was positively associated with increasing Grade Point Average (GPA), ‘Core 4’ GPA and passing all courses in first year. However, mixed associations were identified between feeder bridging/foundation courses and their intended first year course counterparts. These findings support the continued provision of bridging/foundation education; however, curricular reform within the bridging/foundation programme was required. Key development...

Excellent health research is essential for good health outcomes, services and systems. Health research should also build towards equity and in doing so ensure that no one is left behind. As recipients of government funding, researchers are increasingly required to demonstrate an understanding of their delegated responsibilities to undertake research that has the potential to address Māori health needs and priorities. These requirements form the basis of responsiveness to Māori in health research, and several research institutions have implemented systems to support their organisational approach to this endeavour. However, many health researchers have a narrow view of responsiveness to Māori and how it might be relevant to their work. In this viewpoint paper we provide an overview of existing frameworks that can be used to develop thinking and positioning in relation to the Treaty of Waitangi and responsiveness to Māori. We also describe an equity-based approach to responsiveness to Māori and highlight four key areas that require careful consideration, namely: (1) relevance to Māori; (2) Māori as participants; (3) promoting the Māori voice, and; (4) human tissue. Finally, we argue for greater engagement with responsiveness to Māori activities as part of our commitment to achieving equitable health outcomes.

ObjectiveTo determine associations between admission markers of socioeconomic status, transitioning, bridging programme attendance and prior academic preparation on academic outcomes for indigenous Māori, Pacific and rural students admitted into medicine under access pathways designed to widen participation. Findings were compared with students admitted via the general (usual) admission pathway.DesignRetrospective observational study using secondary data.Setting 6-year medical programme (MBChB), University of Auckland, Aotearoa New Zealand. Students are selected and admitted into Year 2 following a first year (undergraduate) or prior degree (graduate).Participants1676 domestic students admitted into Year 2 between 2002 and 2012 via three pathways: GENERAL admission (1167), Māori and Pacific Admission Scheme—MAPAS (317) or Rural Origin Medical Preferential Entry—ROMPE (192). Of these, 1082 students completed the programme in the study period.Main outcome measuresGraduated from medical programme (yes/no), academic scores in Years 2–3 (Grade Point Average (GPA), scored 0–9).Results735/778 (95%) of GENERAL, 111/121 (92%) of ROMPE and 146/183 (80%) of MAPAS students graduated from intended programme. The graduation rate was significantly lower in the MAPAS students (pConclusionsThere were varied associations between admission variables and academic outcomes across the three admission pathways. Equity-targeted admission programmes inclusive of variations in academic threshold for entry may support a widening participation agenda, however, additional academic and pastoral supports are recommended.

The impact of national targets for emergency department (ED) length of stay (LOS) on patient care is unclear. This study aimed to determine the effect of New Zealand's six-hour time target (95% of ED patients discharged or admitted to hospital within six hours) on a range of quality indicators.A nationwide observational study from 2006 to 2012 modelled differences in changes over time before and after target introduction in 2009. The observed model estimates in 2012 were compared to those predicted if pre-target trends had continued. Differences are absolute values except for morality, which is presented as a relative change.There were 5,793,767 ED presentations and 2,082,374 elective admissions from 18 out of a possible 20 district health boards included in the study. There were clinically important reductions in hospital LOS (-0.29 days), EDLOS (-1.1 hours), admitted patients EDLOS (-2.9 hours), ED crowding (-26.8%), ED mortality (-57.8%), elective inpatient mortality (-42.2%) and the proportion not waiting for assessment (-2.8%). Small changes were seen in time to assessment in the ED (-3.4 minutes), re-presentation to ED within 48 hours of the index ED discharge (-0.7%), re-presentation to ED within 48 hours from ward discharge (+0.4%) and acute admissions (+3.9%). An increase was observed in re-admission to a ward within 30 days of discharge (1.0%). These changes were all statistically significant (p0.001).Most outcomes we investigated either improved or were unchanged after the introduction of the time target policy in New Zealand. However, attention is required to ensure that reductions in hospital length of stay are not at the expense of subsequent re-admissions.

Tertiary institutions aim to provide high quality teaching and learning that meet the academic needs for an increasingly diverse student body including indigenous students. Tātou Tātou is a qualitative research project utilising Kaupapa Ma¯ori research methodology and the Critical Incident Technique interview method to investigate the teaching and learning practices that help or hinder Ma¯ori student success in non-lecture settings within undergraduate health programmes at the University of Auckland. Forty-one interviews were completed from medicine, health sciences, nursing and pharmacy. A total of 1346 critical incidents were identified with 67% helping and 33% hindering Ma¯ori student success. Thirteen sub-themes were grouped into three overarching themes representing potential areas of focus for tertiary institutional undergraduate health programme development: Māori student support services, undergraduate programme, and Ma¯ori student whanaungatanga. Academic success for indigenous students requires ...

Background Tertiary institutions are struggling to ensure equitable academic outcomes for indigenous and ethnic minority students in health professional study. This demonstrates disadvantaging of ethnic minority student groups (whereby Indigenous and ethnic minority students consistently achieve academic outcomes at a lower level when compared to non-ethnic minority students) whilst privileging non-ethnic minority students and has important implications for health workforce and health equity priorities. Understanding the reasons for academic inequities is important to improve institutional performance. This study explores factors that impact on academic success for health professional students by ethnic group. Methods Kaupapa Māori methodology was used to analyse data for 2686 health professional students at the University of Auckland in 2002–2012. Data were summarised for admission variables: school decile, Rank Score, subject credits, Auckland school, type of admission, and bridging programme; and academic outcomes: first-year grade point average (GPA), first-year passed all courses, year 2 – 4 programme GPA, graduated, graduated in the minimum time, and composite completion for Māori, Pacific, and non-Māori non-Pacific (nMnP) students. Statistical tests were used to identify significant differences between the three ethnic groupings. Results Māori and Pacific students were more likely to attend low decile schools (27 % Māori, 33 % Pacific vs. 5 % nMnP, p

Background Health provider racial/ethnic bias and its relationship to clinical decision-making is an emerging area of research focus in understanding and addressing ethnic health inequities. Examining potential racial/ethnic bias among medical students may provide important information to inform medical education and training. This paper describes the development, pretesting and piloting of study content, tools and processes for an online study of racial/ethnic bias (comparing Māori and New Zealand European) and clinical decision-making among final year medical students in New Zealand (NZ). Methods The study was developed, pretested and piloted using a staged process (eight stages within five phases). Phase 1 included three stages: 1) scoping and conceptual framework development; 2) literature review and identification of potential measures and items; and, 3) development and adaptation of study content. Three main components were identified to assess different aspects of racial/ethnic bias: (1) implicit racial/ethnic bias using NZ-specific Implicit Association Tests (IATs); (2) explicit racial/ethnic bias using direct questions; and, (3) clinical decision-making, using chronic disease vignettes. Phase 2 (stage 4) comprised expert review and refinement. Formal pretesting (Phase 3) included construct testing using sorting and rating tasks (stage 5) and cognitive interviewing (stage 6). Phase 4 (stage 7) involved content revision and building of the web-based study, followed by pilot testing in Phase 5 (stage 8). Results Materials identified for potential inclusion performed well in construct testing among six participants. This assisted in the prioritisation and selection of measures that worked best in the New Zealand context and aligned with constructs of interest. Findings from the cognitive interviewing (nine participants) on the clarity, meaning, and acceptability of measures led to changes in the final wording of items and ordering of questions. Piloting (18 participants) confirmed the overall functionality of the web-based questionnaire, with a few minor revisions made to the final study. Conclusions Robust processes are required in the development of study content to assess racial/ethnic bias in order to optimise the validity of specific measures, ensure acceptability and minimise potential problems. This paper has utility for other researchers in this area by informing potential development approaches and identifying possible measurement tools. Electronic supplementary material The online version of this article (doi:10.1186/s12909-016-0701-6) contains supplementary material, which is available to authorized users.

Tertiary institutions internationally aim to increase student diversity, however are struggling to achieve equitable academic outcomes for indigenous and ethnic minority students and detailed exploration of factors that impact on success is required. This study explored the predictive effect of admission variables on academic outcomes for health professional students by ethnic grouping. Kaupapa Māori and Pacific research methodologies were used to conduct a quantitative analysis using data for 2686 health professional students [150 Māori, 257 Pacific, 2279, non-Māori non-Pacific (nMnP)]. The predictive effect of admission variables: school decile; attending school in Auckland; type of admission; bridging programme; and first-year bachelor results on academic outcomes: year 2-4 grade point average (GPA); graduating; graduating in the minimum time; and optimal completion for the three ethnic groupings and the full cohort was explored using multiple regression analyses. After adjusting for admission variables, for every point increase in first year bachelor GPA: year 2-4 GPA increased by an average of 0.46 points for Māori (p = 0.0002, 95% CI 0.22, 0.69), 0.70 points for Pacific (p

Timely access to computerised tomography (CT) for acute traumatic brain injuries (TBIs) facilitates rapid diagnosis and surgical intervention. In 2009, New Zealand introduced a mandatory target for emergency department (ED) stay such that 95% of patients should leave ED within 6 h of arrival. This study investigated whether this target influenced the timeliness of cranial CT scanning in children who presented to ED with acute TBI.We retrospectively reviewed a random sample of charts of children15 years with acute TBI from 2006 to 2012. Cases were identified using International Classification of Disease 10 codes consistent with TBI. General linear models investigated changes in time to CT and other indicators before and after the shorter stays in ED target was introduced in 2009.Among the 190 cases eligible for study (n = 91 pre-target and n = 99 post-target), no significant difference was found in time to CT scan pre- and post-target: least squares mean (LSM) with 95% confidence interval = 68 (56-81) versus 65 (53-78) min, respectively, P = 0.66. Time to neurosurgery (LSM 8.7 (5-15) vs. 5.1 (2.6-9.9) h, P = 0.19, or hospital length of stay (LSM: 4.9 (3.9-6.3) vs. 5.2 (4.1-6.7) days, P = 0.69) did not change significantly. However, ED length of stay decreased by 45 min in the post-target period (LSM = 211 (187-238) vs. 166 (98-160) min, P = 0.006).Implementation of the shorter stays in ED target was not associated with a change in the time to CT for children presenting with acute TBI, but an overall reduction in the time spent in ED was apparent.

This study investigates what teaching practices in the ‘non-lecture context of a foundation programme' help or hinder Māori and Pasifika students' success in a New Zealand university. This two-year qualitative project used Kaupapa Māori and Pasifika Research (KM/PR) methodologies conducted in three phases: (1) needs analysis, (2) intervention and (3) evaluation. Twenty-eight Māori or Pasifika students were interviewed using the Critical Incident Technique identifying 798 incidents grouped into four themes for institutional development: (I) use effective practices for teaching and learning, (II) grow independent learners, (III) support the empowerment of the learner and (IV) harness the positive cohort effect. Initially, students reported that intensive support provided by the foundation programme was not preparing students well for success in degree-level study. Following interventions of institutionally-led changes, students reported better preparation for ongoing study. The overall learning environment ...

Objective: Despite the spread of time targets for ED lengths of stay around the world, there have been few studies exploring the effects of such policies on quality of ED care. The Shorter Stays in Emergency Departments (SSED) National Research Project seeks to address this. The purpose of this paper was to describe how the indicators for the SSED study in New Zealand were selected and validated. Methods: A literature review was used to identify potential indicators. A reference group of 25 key stakeholders from across the health system was convened, with the aims of validating the suggested indicators and to ensure that other candidate indicators were not overlooked. A thematic analysis using a general inductive approach was used to analyse focus group discussions. Results: The major themes were communication, access, timeliness, appropriateness and satisfaction. The 12 indicators selected after literature review were confirmed and two further indicators added after the thematic analysis. The indicators are: hospital and ED length of stay; re-presentation within 48 h; mortality; times to reperfusion, antibiotics, asthma treatment, analgesia, CT for head injury and to theatre (appendicitis and fractured neck of femur); triage time compliance; proportion who left without being seen; quality of discharge information; and ED overcrowding/access block. Conclusion: Through literature review and consultation with stakeholders, an evidence-based and clinically relevant set of indicators was compiled with which to measure the effect of the SSED target. This indicator set is consistent with recent international recommendations for measuring quality of care in EDs.

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

The reasons for race/ethnicity (R/E) differences in breast cancer survival have been difficult to disentangle.Surveillance, Epidemiology, and End Results (SEER)-Medicare data were used to identify 41,020 women agedor =68 years with incident breast cancer between 1994-1999 including African American (2479), Hispanic (1172), Asian/Pacific Island (1086), and white women (35,878). A Cox proportional hazards model assessed overall and stage-specific (0/I, II/III, and IV) R/E differences in breast cancer survival after adjusting for mammography screening, tumor characteristics at diagnosis, biologic markers, treatment, comorbidity, and demographics.African American women had worse survival than white women, although controlling for predictor variables reduced this difference among all stage breast cancer (hazards ratio [HR], 1.08; 95% confidence interval [95% CI], 0.97-1.20). Adjustment for predictors reduced, but did not eliminate, disparities in the analysis limited to women diagnosed with stage II/III disease (HR, 1.30; 95% CI, 1.10-1.54). Screening mammography, tumor characteristics at diagnosis, biologic markers, and treatment each produced a similar reduction in HRs for women with stage II/III cancers. Asian and Pacific Island women had better survival than white women before and after accounting for all predictors (adjusted all stages HR, 0.61 [95% CI, 0.47-0.79]; adjusted stage II/III HR, 0.61 [95% CI, 0.47-0.79]). Hispanic women had better survival than white women in all and stage II/III analysis (all stage HR, 0.88; 95% CI, 0.75-1.04) and stage II/III analysis (HR, 0.88; 95% CI, 0.75-1.04), although these findings did not reach statistical significance. There was no significant difference in survival by R/E noted among women diagnosed with stage IV disease.Predictor variables contribute to, but do not fully explain, R/E differences in breast cancer survival for elderly American women. Future analyses should further investigate the role of biology, demographics, and disparities in quality of care.

There is debate whether targets for ED length of stay introduced to reduce ED overcrowding are helpful or harmful, as focus on a process target may divert attention from clinical care. Our objective was to investigate the effect of a national ED target in Aotearoa New Zealand on the recommended care for acute asthma as this is known to suffer in overcrowded departments.We conducted a retrospective chart review study across four sites from 2006 to 2012 (target introduced mid 2009). The primary outcome was time to steroids in the ED. The secondary outcomes were other aspects of asthma care in ED. We used general linear models or logistic regression as appropriate to assess care before and after the target.Among the 570 (of 1270 randomly selected cases) eligible for analysis, no difference was demonstrated in time to steroids: least square mean (95% CI) = 58.1 (49-67.5) min before and 50.4 (42.9-55.8) min after the target (P = 0.15). More patients received steroids in ED after the target, OR (95% CI) = 2.1 (1.2-4.3). No differences were demonstrated in those receiving steroid prescriptions or re-presentations: OR (95% CI) = 1.3 (0.9-1.96) and 1.1 (0.5-2.3), respectively. Changes in pre-target and post-target ED and hospital length of stay varied between hospitals.Introduction of the target was not associated with a change in times to steroids in ED, although more patients received steroids in ED indicating closer adherence to recommended practice.

Background Universities should provide flexible and inclusive selection and admission policies to increase equity in access and outcomes for indigenous and ethnic minority students. This study investigates an equity-targeted admissions process, involving a Multiple Mini Interview and objective testing, advising Māori and Pacific students on their best starting point for academic success towards a career in medicine, nursing, health sciences and pharmacy. Methods All Māori and Pacific Admission Scheme (MAPAS) interviewees enrolled in bridging/foundation or degree-level programmes at the University of Auckland were identified (2009 to 2012). Generalised linear regression models estimated the predicted effects of admission variables (e.g. MAPAS Maths Test; National Certificate in Educational Achievement (NCEA) Rank Score; Any 2 Sciences; Followed MAPAS Advice) on first year academic outcomes (i.e. Grade Point Average (GPA) and Passes All Courses) adjusting for MAPAS interview year, gender, ancestry and school decile. Results 368 First Year Tertiary (bridging/foundation or degree-level) and 242 First Year Bachelor (degree-level only) students were investigated. NCEA Rank Score (estimate 0.26, CI: 0.18-0.34, p

Indigenous health workforce development has been identified as a key strategy to improve Indigenous health and reduce ethnic inequities in health outcomes. Likewise, development of a culturally safe and culturally competent non-Indigenous health workforce must also occur if the elimination of health inequities is to be fully realised. Tertiary education providers responsible for training health professionals must face the challenge of engaging the Indigenous learner within health sciences, exposing the ‘hidden curriculum’ that undermines professional Indigenous health learning and ensuring tertiary success for Indigenous students within their academy. This chapter summarises recent developments, research and interventions within the Faculty of Medical and Health Sciences at the University of Auckland that aims to address these challenges by re-presenting Indigenous student recruitment, selection and support, re-presenting bridging/foundation education and representing Māori health teaching and learning within the curriculum.

Despite the spread of time targets for ED lengths of stay around the world, there have been few studies exploring the effects of such policies on quality of ED care. The Shorter Stays in Emergency Departments (SSED) National Research Project seeks to address this. The purpose of this paper was to describe how the indicators for the SSED study in New Zealand were selected and validated.A literature review was used to identify potential indicators. A reference group of 25 key stakeholders from across the health system was convened, with the aims of validating the suggested indicators and to ensure that other candidate indicators were not overlooked. A thematic analysis using a general inductive approach was used to analyse focus group discussions.The major themes were communication, access, timeliness, appropriateness and satisfaction. The 12 indicators selected after literature review were confirmed and two further indicators added after the thematic analysis. The indicators are: hospital and ED length of stay; re-presentation within 48 h; mortality; times to reperfusion, antibiotics, asthma treatment, analgesia, CT for head injury and to theatre (appendicitis and fractured neck of femur); triage time compliance; proportion who left without being seen; quality of discharge information; and ED overcrowding/access block.Through literature review and consultation with stakeholders, an evidence-based and clinically relevant set of indicators was compiled with which to measure the effect of the SSED target. This indicator set is consistent with recent international recommendations for measuring quality of care in EDs.