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Abstract Background Racism is an important determinant of health and driver of racial/ethnic health inequities. Experience of racism has been linked to negative healthcare use and experiences although most studies have been cross-sectional. This study examines the relationship between reported experience of racism and subsequent use and experience of health services. Methods This is a prospective cohort study design. The 2016/2017 adult New Zealand Health Survey (NZHS) provided the sampling frame and baseline data on exposures, health status and confounders. This stand-alone study invited all exposed individuals to participate when sampled based on their reported experience of racism (ever), stratified by broad ethnic groupings (Māori, Pacific, Asian, European/Other). Equal numbers of unexposed participants were selected for invitation using propensity score matching (propensity to experience racism, based on key available predictive factors). Follow-up was one to two years after NZHS interview. Outcome variables (last 12 months) were: unmet healthcare need (overall, for mental health, for a general practitioner); satisfaction with usual medical centre; and experiences with general practitioners (explaining care, involvement in decision-making, treated with respect/dignity, confidence and trust). Logistic regression models examining the association between experience of racism (at baseline) and health service use and experience (at follow-up) used doubly-robust estimation to weight for propensity scores used in the sampling with additional adjustment for confounders. Results The study had 2010 participants. Experience of racism (ever) at baseline was associated with higher overall unmet need at follow-up (adjusted OR (aOR) = 1.71, 95% CI 1.31, 2.23), with similar patterns for other unmet need measures. Experience of racism was associated with higher dissatisfaction with a usual medical centre (aOR = 1.41, 95% CI 1.10, 1.81) and with higher reporting of negative patient experiences. Conclusion In line with how racism structures oppression, exposure to racism is largely felt by non-European groups in Aotearoa New Zealand. Experiences of racism potentially lead to poorer healthcare and healthcare inequities through higher unmet need, lower satisfaction and more negative experiences of healthcare. The health system has a critical role to play in addressing racism within healthcare and supporting societal efforts to eliminate racism and ethnic inequities.

Abstract Background Smokefree environments legislation is increasingly being implemented around the world. Evaluations largely find that the legislation is popular, compliance is high and report improved air quality and reduced exposure to secondhand smoke (SHS). The impact of the legislation on disadvantaged groups, including indigenous peoples has not been explored. We present findings from a multifaceted evaluation of the impact of the smokefree workplace provisions of the New Zealand Smokefree Environments Amendment Act on Māori people in New Zealand. Māori are the indigenous people of New Zealand. The Smokefree Environments Amendment Act extended existing smokefree legislation to almost all indoor workplaces in December 2004 (including restaurants and pubs/bars). Methods Review of existing data and commissioned studies to identify evidence for the evaluation of the new legislation: including attitudes and support for the legislation; stakeholders views about the Act and the implementation process; impact on SHS exposure in workplaces and other settings; and impact on smoking-related behaviours. Results Support for the legislation was strong among Māori and reached 90% for smokefree restaurants and 84% for smokefree bars by 2006. Māori stakeholders interviewed were mostly supportive of the way the legislation had been introduced. Reported exposure to SHS in workplaces decreased similarly in Māori and non-Māori with 27% of employed adult Māori reporting SHS exposure indoors at work during the previous week in 2003 and 9% in 2006. Exposure to SHS in the home declined, and may have decreased more in Māori households containing one or more smokers. For example, the proportion of 14–15 year old Māori children reporting that smoking occurred in their home fell from 47% in 2001 to 37% in 2007. Similar reductions in socially-cued smoking occurred among Māori and non-Māori. Evidence for the effect on smoking prevalence was mixed. Māori responded to the new law with increased calls to the national Quitline service. Conclusion The New Zealand Smokefree Environments Amendment Act had a range of positive effects, including reducing SHS exposure among Māori communities. If the experience is replicated in other countries with indigenous populations, it suggests that comprehensive smokefree environments legislation will have beneficial effects on the health of indigenous groups and could contribute to reducing inequalities in health within societies.

We have known for more than 70 years about the harms of commercial tobacco use, as and when used as directed: commercial tobacco use kills.[sup.1,2] Commercial tobacco has been used [...]

: Objectives: To assess support among smokers and recent quitters for the Smokefree New Zealand (NZ) 2025 goal and measures to facilitate its achievement. Methods: Data from CATI interviews with 1,155 (386 Māori) smokers and recent quitters in Wave 1 (August 2016–April 2017) and 1,020 (394 Māori) in Wave 2 (June–December 2018) of the International Tobacco Control (ITC) NZ Survey. Results: (Wave 2 unless stated): Almost all (95%) participants were aware of and more than half (56%) supported the smokefree goal. Support was highest (69–92%) for measures to reduce smoking uptake and protect children from exposure to secondhand smoke. Support was also high for other smokefree policies including mandated denicotinisation of smoked tobacco products (73%) and tobacco retailer licensing (70%, Wave 1). Support was lowest ( Conclusions: There is substantial support among smokers and ex‐smokers for the Smokefree 2025 goal and many measures that could help achieve it. Implications for public health: Implementing a comprehensive strategy to achieve Smokefree 2025 is likely to be acceptable among New Zealand's smokers and ex‐smokers., In October 2010, the Māori Affairs Select Committee of the New Zealand Parliament reported on its Inquiry into the tobacco industry in Aotearoa and the consequences of tobacco use for [...]

In the last decade, reduction in adolescent fertility rates in Indonesia has slowed despite national programmes and policies focused on addressing child marriage. Indonesia currently has the highest number of births to adolescent girls aged 15-19 years in Southeast Asia. There is a need to develop a more nuanced understanding of the drivers of adolescent pregnancy in Indonesia to inform programmes and policies tailored to young people's needs and priorities. This study explored adolescent girls' pathways to pregnancy across two provinces (Central Sulawesi and West Java) in Indonesia. We conducted participatory timeline interviews with 79 girls aged 15-21 years from urban, peri-urban, and rural communities and inquired about their relationships and life experiences leading up to pregnancy. We conducted follow-up interviews with 19 selected participants to validate and clarify preliminary findings. We identified six pathways to adolescent pregnancy which were broadly differentiated by the timing of pregnancy relative to marriage. Three pregnancy pathways within marriage were further differentiated by the main motivation for marriage-financial reasons, protecting the girl and family's reputation, or to progress a romantic relationship. Three pregnancy pathways outside marriage were distinguished by the nature of the sexual relationship preceding pregnancy-consensual sex, unwanted or pressured sex, and forced sex. Drivers of adolescent pregnancy include the acceptability of child marriage and stigma surrounding premarital pregnancy, family and social expectations of pregnancy following marriage, harmful gender-based norms and violence, and lack of sexual and reproductive health information and access to services. Adolescents follow varied pathways to pregnancy in Indonesia. The idealisation and acceptance of child marriage is both a catalyst and outcome of adolescent pregnancy, which is occurring amid stigma surrounding premarital sex and pregnancy, harmful gender-based norms and violence, and barriers to contraceptive access and use. Our findings emphasise that there are many drivers of adolescent pregnancy and different pathways will require intervention approaches that address child marriage alongside other key contributors.

Abstract Objectives: To assess support among smokers and recent quitters for the Smokefree New Zealand (NZ) 2025 goal and measures to facilitate its achievement. Methods: Data from CATI interviews with 1,155 (386 Māori) smokers and recent quitters in Wave 1 (August 2016–April 2017) and 1,020 (394 Māori) in Wave 2 (June–December 2018) of the International Tobacco Control (ITC) NZ Survey. Results: (Wave 2 unless stated): Almost all (95%) participants were aware of and more than half (56%) supported the smokefree goal. Support was highest (69–92%) for measures to reduce smoking uptake and protect children from exposure to secondhand smoke. Support was also high for other smokefree policies including mandated denicotinisation of smoked tobacco products (73%) and tobacco retailer licensing (70%, Wave 1). Support was lowest (

Summary: Background: Rangatahi Māori, the Indigenous adolescents of Aotearoa New Zealand (NZ), have poorer health outcomes than Pākehā (NZ European /other European/“White”) adolescents. We explored the influence of policies for Indigenous youth by presenting health trends, inequities and contrasting policy case examples: tobacco control and healthcare access. Methods: Cross-sectional representative surveys of NZ secondary school students were undertaken in 2001, 2007, 2012 and 2019. Health indicators are presented for Māori and Pākehā adolescents (relative risks with 95% CI, calculated using modified Poisson regression) between 2001–2019 and 2012–2019. Policy examples were examined utilising Critical Te Tiriti Analysis (CTA). Findings: Rangatahi Māori reported significant health gains between 2001 and 2019, but an increase in depressive symptoms (13.8% in 2012 to 27.9% in 2019, RR 2.01 [1.65–2.46]). Compared to Pākehā youth there was a pattern of persistent Māori disadvantage, particularly for racism (RR 2.27 [2.08–2.47]), depressive symptoms (RR 1.42 [1.27–1.59]) and forgone healthcare (RR 1.63 [1.45–1.84]). Tobacco use inequities narrowed (RR 2.53 [2.12–3.02] in 2007 to RR 1.55 [1.25–1.93] in 2019). CTA reveals rangatahi Māori-specific policies, Māori leadership, and political support aligned with improved outcomes and narrowing inequities. Interpretation: Age-appropriate Indigenous strategies are required to improve health outcomes and reduce inequities for rangatahi Māori. Characteristics of effective strategies include: (1) evidence-based, sustained, and comprehensive approaches including both universal levers and Indigenous youth-specific policies; (2) Indigenous and rangatahi leadership; (3) the political will to address Indigenous youth rights, preferences, priorities; and (4) a commitment to an anti-racist praxis and healthcare Indigenisation. Funding: Two Health Research Council of New Zealand Project Grants: (a) Fleming T, Peiris–John R, Crengle S, Parry D. (2018). Integrating survey and intervention research for youth health gains. (HRC ref: 18/473); and (b) Clark TC, Le Grice J, Groot S, Shepherd M, Lewycka S. (2017) Harnessing the spark of life: Maximising whānau contributors to rangatahi wellbeing (HRC ref: 17/315).

The supply of, and demand for, housing in Aotearoa, New Zealand, is in a state of crisis. With all other areas of social deprivation, Māori are impacted disproportionately in the housing space, and have been locked out of the housing market. In order to address this crisis, a range of government, community and iwi initiatives have been established in Tāmaki Makaurau (Auckland) to provide various housing interventions, from emergency housing, accommodation supplements and subsidies to transitional housing, home ownership programmes and papakāinga (Māori settlement, village) development opportunities. Marae Ora, Kāinga Ora (MOKO) is a Kaupapa Māori (Māori approach) research project created to explore the role of marae (cultural centre) and kāinga (village, settlement) in supporting the wellbeing of whānau (family group), hapū (extended kinship grouping), iwi (extended kinship–tribal grouping) and communities, which includes the potential provision of housing. Five marae in the South Auckland landscape are partners in this research and bring to life the prospect of their contribution to housing solutions for their local Māori communities. This article presents some valuable insights into the aspirations of each whānau involved with the five marae with regard to their perspectives and developments with marae-led housing provision.

Dilraj Sokhi,1 Fazal Yakub,1 Karishma Sharma,1 Sheila Waa,2 Peter Mativo1 1Department of Medicine, Aga Khan University Hospital, Aga Khan University Medical College of East Africa, Nairobi, Kenya; 2Department of Radiology, Aga Khan University Hospital, Aga Khan University Medical College of East Africa, Nairobi, KenyaCorrespondence: Dilraj SokhiDepartment of Medicine, Aga Khan University Hospital, Aga Khan University Medical College of East Africa, Room 405, 4th Floor East Tower Block, Third Avenue Parklands, P.O. Box 30270, Nairobi, 00100 GPO, KenyaTel +254 710 559 541Email Dilraj.Sokhi@aku.eduAbstract: Sporadic Creutzfeldt-Jakob disease (sCJD) is a rare prion disease that causes rapidly progressive fatal neurodegeneration. The rarer Heidenhain variant of sCJD presents with visual symptoms and is rarely reported in the literature from sub-Saharan Africa. We report the case of a 57-year-old male with a three-week history of losing direction when driving home and visual hallucinations described as seeing rainbows. Magnetic resonance imaging (MRI) of the brain revealed unilateral parieto-occipital sulcal hyperintensities with restriction on diffusion-weighted imaging (DWI), and electroencephalography (EEG) showed right para-central slowing leading to an initial diagnosis of non-convulsive status epilepticus. He was treated with anti-epileptic medication but was re-admitted less than a month later with worsening spatial memory, aggression, ataxia, dysarthria, myoclonic jerks and a positive startle response, later developing generalised tonic-clonic seizures. Repeat MRI brain scan showed widespread posterior-predominant sulcal DWI restriction in a cortical ribboning pattern pathognomonic for sCJD. EEG showed diffuse slowing, and cerebrospinal fluid was analyzed for abnormal prion protein using real-time quaking-induced conversion but was inconclusive due to suboptimal sample collection. The patient fulfilled the diagnostic criteria for probable sCJD, Heidenhain variant; the family declined brain biopsy for definitive diagnosis. He was subsequently palliated at a local hospice where he died approximately three months after the onset of symptoms. Our case highlights the presence of a rare form of sCJD, and the diagnostic challenges faced in our resource-limited setting.Keywords: Creutzfeldt-Jakob disease, prion, Heidenhain variant, sub-Saharan Africa