Access to advanced-level hospital care: differences in prehospital times calculated using incident locations compared with patients' usual residence.

Studies estimate that 84% of the USA and New Zealand's (NZ) resident populations have timely access (within 60 min) to advanced-level hospital care. Our aim was to assess whether usual residence (ie, home address) is a suitable proxy for location of injury incidence. In this observational study, injury fatalities registered in NZ's Mortality Collection during 2008-2012 were linked to Coronial files. Estimated access times via emergency medical services were calculated using locations of incident and home. Using incident locations, 73% (n=4445/6104) had timely access to care compared with 77% when using home location. Access calculations using patients' home locations overestimated timely access, especially for those injured in industrial/construction areas (18%; 95% CI 6% to 29%) and from drowning (14%; 95% CI 7% to 22%). When considering timely access to definitive care, using the location of the injury as the origin provides important information for health system planning.

Evaluating the impact of prehospital care on mortality following major trauma in New Zealand: a retrospective cohort study.

BACKGROUND: Injury is a leading cause of death and health loss in New Zealand and internationally. The potentially fatal or severe consequences of many injuries can be reduced through an optimally structured prehospital trauma care system that can provide timely and appropriate care. OBJECTIVE: To investigate the relationship between emergency medical services (EMS) care and survival to hospital for major trauma cases in New Zealand. METHODS: This project is a retrospective cohort study of New Zealand major trauma cases attended by EMS providers over a 2-year period. Outcomes include survival to hospital and survival in hospital for at least 24 hours. The project has three phases: (1) identification of the cohort and assembling a bespoke longitudinal dataset linking EMS, New Zealand Major Trauma Registry and Coronial data; (2) describing the pathways and processes of care to inform an investigation of the relationships between types of EMS care and survival using propensity score modelling to adjust for case-mix differences; (3) assessment of the implications for future practice, policy and research. DISCUSSION: The study findings will help identify opportunities to optimise the delivery of EMS care in New Zealand by informing the development or revision of existing major trauma EMS policies and guidelines, and to provide a baseline for monitoring the impact of future initiatives. Establishing an evidence-base will support a whole-of-system appraisal that could include broader complex variables relating to healthcare services throughout the continuum of trauma care.

Mapping a route to Indigenous engagement in cancer genomic research.

Precision oncology guided by genomic research has an increasingly important role in the care of people with cancer. However, substantial inequities remain in cancer outcomes of Indigenous peoples, including Indigenous Maori in Aotearoa New Zealand (New Zealand). These inequities will be perpetuated unless deliberate steps are taken to include Indigenous peoples in all parts of cancer research-as research participants, in research leadership, and in research governance. This approach is especially important when there have been historical breaches of trust that have discouraged their participation in health research. This Personal View describes a precision oncology research roadmap for neuroendocrine tumour research, which seeks to reflect the values of New Zealand's Indigenous Maori people. This roadmap includes facilitating ongoing dialogue, Maori leadership, reciprocity, agreed kawa (guiding principles), tikanga (cultural protocols), and honest monitoring of what is and what is not being achieved. We challenge cancer researchers worldwide to generate locally appropriate roadmaps that honestly assess their practices to benefit Indigenous people internationally.

Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition.

BACKGROUND: Eliminating indigenous and ethnic health inequities requires addressing the determinants of health inequities which includes institutionalised racism, and ensuring a health care system that delivers appropriate and equitable care. There is growing recognition of the importance of cultural competency and cultural safety at both individual health practitioner and organisational levels to achieve equitable health care. Some jurisdictions have included cultural competency in health professional licensing legislation, health professional accreditation standards, and pre-service and in-service training programmes. However, there are mixed definitions and understandings of cultural competency and cultural safety, and how best to achieve them. METHODS: A literature review of 59 international articles on the definitions of cultural competency and cultural safety was undertaken. Findings were contextualised to the cultural competency legislation, statements and initiatives present within Aotearoa New Zealand, a national Symposium on Cultural Competence and Maori Health, convened by the Medical Council of New Zealand and Te Ohu Rata o Aotearoa - Maori Medical Practitioners Association (Te ORA) and consultation with Maori medical practitioners via Te ORA. RESULTS: Health practitioners, healthcare organisations and health systems need to be engaged in working towards cultural safety and critical consciousness. To do this, they must be prepared to critique the 'taken for granted' power structures and be prepared to challenge their own culture and cultural systems rather than prioritise becoming 'competent' in the cultures of others. The objective of cultural safety activities also needs to be clearly linked to achieving health equity. Healthcare organisations and authorities need to be held accountable for providing culturally safe care, as defined by patients and their communities, and as measured through progress towards achieving health equity. CONCLUSIONS: A move to cultural safety rather than cultural competency is recommended. We propose a definition for cultural safety that we believe to be more fit for purpose in achieving health equity, and clarify the essential principles and practical steps to operationalise this approach in healthcare organisations and workforce development. The unintended consequences of a narrow or limited understanding of cultural competency are discussed, along with recommendations for how a broader conceptualisation of these terms is important.

The experience of gestational diabetes for indigenous Maori women living in rural New Zealand: qualitative research informing the development of decolonising interventions.

BACKGROUND: Although early detection and management of excess rates of gestational diabetes mellitus (GDM) among Indigenous women can substantially reduce maternal and offspring complications, current interventions seem ineffective for Indigenous women. While undertaking a qualitative study in a rural community in Northland, New Zealand about the complexities of living with diabetes, we observed a common emotional discourse about the burden of diabetic pregnancies. Given the significance of GDM and our commitment to give voice to Indigenous Maori women in ways that could potentially inform solutions, we aimed to explore the phenomenon of GDM among Maori women in a rural context marked by high area-deprivation. METHOD: A qualitative and Kaupapa Maori methodology was utilised. A sub-sample of women (n = 10) from a broader study designed to improve type 2 diabetes mellitus (T2DM) who had experienced GDM or pre-existing diabetes during pregnancy and/or had been exposed to diabetes in utero were interviewed. Participants in the broader study were recruited via the local primary care clinic. Experiences of GDM, in relation to their current T2DM, was sought. Narrative data was analysed for themes. RESULTS: Intergenerational experiences informed perceptions that GDM was an inevitable heritable illness that "just runs in the family." The cumulative effects of deprivation and living with GDM compounded the complexities of participant' lives including perceptions of powerlessness and mental health deterioration. Missed opportunities for health services to detect and manage diabetes had ongoing health consequences for the women and their offspring. Positive relationships with healthcare providers facilitated management of GDM and helped women engage with self-management. CONCLUSION: Maori women living with T2DM were clear that health providers had failed to intervene in ways that would have potentially slowed or prevented progression of GDM to T2DM. Participants revealed missed opportunities for appropriate diagnostic testing, treatment and health promotion programmes for GDM. Poor collaboration between health services and social services meant psychosocial issues were rarely addressed and the cycle of intergenerational poverty and disadvantage prevailed. These data highlight opportunities for extended case management to include whanau (family) engagement, input from social services, and evidence-based medicine and/or long-term management and prevention of T2DM.

Predictors of academic success for Maori, Pacific and non-Maori non-Pacific students in health professional education: a quantitative analysis.

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 Maori and Pacific research methodologies were used to conduct a quantitative analysis using data for 2686 health professional students [150 Maori, 257 Pacific, 2279, non-Maori 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 Maori (p = 0.0002, 95% CI 0.22, 0.69), 0.70 points for Pacific (p < 0.0001, CI 0.52, 0.87), and 0.55 points for nMnP (p < 0.0001, CI 0.51, 0.58) students. For the total cohort, ethnic grouping was consistently the most significant predictor of academic outcomes. This study demonstrated clear differences in academic outcomes between both Maori and Pacific students when compared to nMnP students. Some (but not all) of the disparities between ethnic groupings could be explained by controlling for admission variables.

Effectiveness of the YourCall™ text message intervention to reduce harmful drinking in patients discharged from trauma wards: protocol for a randomised controlled trial.

BACKGROUND: Behavioural brief interventions (BI) can support people to reduce harmful drinking but multiple barriers impede the delivery and equitable access to these. To address this challenge, we developed YourCall™, a novel short message service (SMS) text message intervention incorporating BI principles. This protocol describes a trial evaluating the effectiveness of YourCall™ (compared to usual care) in reducing hazardous drinking and alcohol related harm among injured adults who received in-patient care. METHODS/DESIGN: Participants recruited to this single-blind randomised controlled trial comprised patients aged 16-69 years in three trauma-admitting hospitals in Auckland, New Zealand. Those who screened positive for moderately hazardous drinking were randomly assigned by computer to usual care (control group) or the intervention. The latter comprised 16 informational and motivational text messages delivered using an automated system over the four weeks following discharge. The primary outcome is the difference in mean AUDIT-C score between the intervention and control groups at 3 months, with the maintenance of the effect examined at 6 and 12 months follow-up. Secondary outcomes comprised the health and social impacts of heavy drinking ascertained through a web-survey at 12 months, and further injuries identified through probabilistic linkage to national databases on accident insurance, hospital discharges, and mortality. Research staff evaluating outcomes were blinded to allocation. Intention-to-treat analyses will include assessment of interactions based on ethnicity (Maori compared with non-Maori). DISCUSSION: If found to be effective, this mobile health strategy has the potential to overcome current barriers to implementing equitably accessible interventions that can reduce harmful drinking. TRIAL REGISTRATION: Universal Trial Number (UTN) U1111-1134-0028. ACTRN12612001220853 . Submitted 8 November 2012 (date of enrolment of first participant); Version 1 registration confirmed 19 November 2012. Retrospectively registered.

Time to cranial computerised tomography for acute traumatic brain injury in paediatric patients: Effect of the shorter stays in emergency departments target in New Zealand.

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 <15 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. RESULTS: 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). CONCLUSION: 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.

Patterns of privilege: A total cohort analysis of admission and academic outcomes for Maori, Pacific and non-Maori non-Pacific health professional students.

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 Maori 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 Maori, Pacific, and non-Maori non-Pacific (nMnP) students. Statistical tests were used to identify significant differences between the three ethnic groupings. RESULTS: Maori and Pacific students were more likely to attend low decile schools (27 % Maori, 33 % Pacific vs. 5 % nMnP, p < 0.01); complete bridging foundation programmes (43 % Maori, 50 % Pacific vs. 5 % nMnP, p < 0.01), and received lower secondary school results (Rank Score 197 Maori, 178 Pacific vs. 231 nMnP, p < 0.01) when compared with nMnP students. Patterns of privilege were seen across all academic outcomes, whereby nMnP students achieved higher first year GPA (3.6 Maori, 2.8 Pacific vs. 4.7 nMnP, p < 0.01); were more likely to pass all first year courses (61 % Maori, 41 % Pacific vs. 78 % nMnP, p < 0.01); to graduate from intended programme (66 % Maori, 69 % Pacific vs. 78 % nMnP, p < 0.01); and to achieve optimal completion (9 % Maori, 2 % Pacific vs. 20 % nMnP, p < 0.01) when compared to Maori and Pacific students. CONCLUSIONS: To meet health workforce and health equity goals, tertiary institution staff should understand the realities and challenges faced by Maori and Pacific students and ensure programme delivery meets the unique needs of these students. Ethnic disparities in academic outcomes show patterns of privilege and should be alarming to tertiary institutions. If institutions are serious about achieving equitable outcomes for Maori and Pacific students, major institutional changes are necessary that ensure the unique needs of Maori and Pacific students are met.

The effect of the Shorter Stays in Emergency Departments health target on the quality of ED discharge summaries.

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.

A tertiary approach to improving equity in health: quantitative analysis of the Maori and Pacific Admission Scheme (MAPAS) process, 2008-2012.

INTRODUCTION: Achieving health equity for indigenous and ethnic minority populations requires the development of an ethnically diverse health workforce. This study explores a tertiary admission programme targeting Maori and Pacific applicants to nursing, pharmacy and health sciences (a precursor to medicine) at the University of Auckland (UoA), Aotearoa New Zealand (NZ). Application of cognitive and non-cognitive selection tools, including a Multiple Mini Interview (MMI), are examined. METHODS: Indigenous Kaupapa Maori methodology guided analysis of the Maori and Pacific Admission Scheme (MAPAS) for the years 2008-2012. Multiple logistic regression models were used to identify the predicted effect of admission variables on the final MAPAS recommendation of best starting point for success in health professional study i.e. 'CertHSc' (Certificate in Health Sciences, bridging/foundation), 'Bachelor' (degree-level) or 'Not FMHS' (Faculty of Medical and Health Sciences). Regression analyses controlled for interview year, gender and ancestry. RESULTS: Of the 918 MAPAS interviewees: 35% (319) were Maori, 58% (530) Pacific, 7% (68) Maori/Pacific; 71% (653) school leavers; 72% (662) females. The average rank score was 167/320, 40-80 credits below guaranteed FMHS degree offers. Just under half of all interviewees were recommended 'CertHSc' 47% (428), 13% (117) 'Bachelor' and 38% (332) 'Not FMHS' as the best starting point. Strong associations were identified between Bachelor recommendation and exposure to Any 2 Sciences (OR:7.897, CI:3.855-16.175; p < 0.0001), higher rank score (OR:1.043, CI:1.034-1.052; p < 0.0001) and higher scores on MAPAS mathematics test (OR:1.043, CI:1.028-1.059; p < 0.0001). MMI stations had mixed associations, with academic preparation and career aspirations more consistently associated with recommendations. CONCLUSIONS: Our findings raise concerns about the ability of the secondary education sector to prepare Maori and Pacific students adequately for health professional study. A comprehensive tertiary admissions process using multiple tools for selection (cognitive and non-cognitive) and the provision of alternative entry pathways are recommended for indigenous and ethnic minority health workforce development. The application of the MMI within an equity and indigenous cultural context can support a holistic assessment of an applicant's potential to succeed within tertiary study. The new MAPAS admissions process may provide an exemplar for other tertiary institutions looking to widen participation via equity-targeted admission processes.

Development of a text message intervention aimed at reducing alcohol-related harm in patients admitted to hospital as a result of injury.

BACKGROUND: Screening for alcohol misuse and brief interventions (BIs) for harm in trauma care settings are known to reduce alcohol intake and injury recidivism, but are rarely implemented. We created the content for a mobile phone text message BI service to reduce harmful drinking among patients admitted to hospital following an injury who screen positive for hazardous alcohol use. The aim of this study was to pre-test and refine the text message content using a robust contextualisation process ahead of its formal evaluation in a randomised controlled trial. METHODS: Pre-testing was conducted in two phases. First, in-depth interviews were conducted with 14 trauma inpatients (16-60 years) at Auckland City Hospital and five key informants. Participants were interviewed face-to-face using a semi-structured interview guide. Topics explored included: opinions on text message ideas and wording, which messages did or did not work well and why, interactivity of the intervention, cultural relevance of messages, and tone of the content. In a second phase, consultation was undertaken with Maori (New Zealand's indigenous population) and Pacific groups to explore the relevance and appropriateness of the text message content for Maori and Pacific audiences. RESULTS: Factors identified as important for ensuring the text message content was engaging, relevant, and useful for recipients were: reducing the complexity of message content and structure; increasing the interactive functionality of the text message programme; ensuring an empowering tone to text messages; and optimising the appropriateness and relevance of text messages for Maori and Pacific people. The final version of the intervention (named 'YourCall(™)') had three pathways for people to choose between: 1) text messages in English with Te Reo (Maori language) words of welcome and encouragement, 2) text messages in Te Reo Maori, and 3) text messages in English (with an option to receive a greeting in Samoan, Tongan, Cook Island Maori, Niuean, Tokelauan, Tuvaluan, or Fijian). CONCLUSIONS: We have developed a text message intervention underpinned by established BI evidence and behaviour change theory and refined based on feedback and consultation. The next step is evaluation of the intervention in a randomised-controlled trial.

Quantitative analysis of a Maori and Pacific admission process on first-year health study.

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 Maori and Pacific students on their best starting point for academic success towards a career in medicine, nursing, health sciences and pharmacy. METHODS: All Maori 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< 0.0001); MAPAS Advice Followed (1.26, CI: 0.18-1.34, p = 0.0002); Exposure to Any 2 Sciences (0.651, CI: 0.15-1.15, p = 0.012); and MAPAS Mathematics Test (0.14, CI: 0.02-0.26, p = 0.0186) variables were strongly associated with an increase in First Year Tertiary GPA. The odds of passing all courses in First Year Tertiary study was 5.4 times higher for students who Followed MAPAS Advice (CI: 2.35-12.39; p< 0.0001) and 2.3 times higher with Exposure to Any Two Sciences (CI: 1.15-4.60; p = 0.0186). First Year Bachelor students who Followed MAPAS Advice had an average GPA that was 1.1 points higher for all eight (CI: 0.45-1.73; p = 0.0009) and Core 4 courses (CI: 0.60-2.04; p = 0.0004). CONCLUSIONS: The MAPAS admissions process was strongly associated with positive academic outcomes in the first year of tertiary study. Universities should invest in a comprehensive admissions process that includes alternative entry pathways for indigenous and ethnic minority applicants.

Examining the impact of COVID-19 on Maori:non-Maori health inequities in Aotearoa, New Zealand: an observational study protocol.

INTRODUCTION: The COVID-19 pandemic has had both direct and indirect impacts on the health of populations worldwide. While racial/ethnic health inequities in COVID-19 infection are now well known (and ongoing), knowledge about the impact of COVID-19 pandemic management on non-COVID-19-related outcomes for Indigenous peoples is less well understood. This article presents the study protocol for the Health Research Council of New Zealand funded project 'Ma te Mohio ka Marama: Impact of COVID-19 on Maori:non-Maori inequities'. The study aims to explore changes in access to healthcare, quality of healthcare and health outcomes for Maori, the Indigenous peoples of Aotearoa New Zealand (NZ) and non-Maori during the COVID-19 outbreak period across NZ. METHODS AND ANALYSIS: This observational study is framed within a Kaupapa Maori research positioning that includes Kaupapa Maori epidemiology. National datasets will be used to report on access to healthcare, quality of healthcare and health outcomes between Maori and non-Maori during the COVID-19 pandemic in NZ. Study periods are defined as (a) prepandemic period (2015-2019), (b) first pandemic year without COVID-19 vaccines (2020) and (c) pandemic period with COVID-19 vaccines (2021 onwards). Regional and national differences between Maori and non-Maori will be explored in two phases focused on identified health priority areas for NZ including (1) mortality, cancer, long-term conditions, first 1000 days, mental health and (2) rheumatic fever. ETHICS AND DISSEMINATION: This study has ethical approval from the Auckland Health Research Ethics Committee (AHREC AH26253). An advisory group will work with the project team to disseminate the findings of this project via project-specific meetings, peer-reviewed publications and a project-specific website. The overall intention of the project is to highlight areas requiring health policy and practice interventions to address Indigenous inequities in health resulting from COVID-19 pandemic management (both historical and in the future).

Informed consent for medical student involvement in patient care: an updated consensus statement.

Enabling patients to consent to or decline involvement of medical students in their care is an essential aspect of ethically sound, patient-centred, mana-enhancing healthcare. It is required by Aotearoa New Zealand law and Te Kaunihera Rata o Aotearoa Medical Council of New Zealand policy. This requirement was affirmed and explored in a 2015 Consensus Statement jointly authored by the Auckland and Otago Medical Schools. Student reporting through published studies, reflective assignments and anecdotal experiences of students and teachers indicate procedures for obtaining patient consent to student involvement in care remain substandard at times. Between 2020 and 2023 senior leaders of Aotearoa New Zealand's two medical schools, and faculty involved with teaching ethics and professionalism, met to discuss these challenges and reflect on ways they could be addressed. Key stakeholders were engaged to inform proposed responses. This updated consensus statement is the result. It does not establish new standards but outlines Aotearoa New Zealand's existing cultural, ethical, legal and regulatory requirements, and considers how these may be reasonably and feasibly met using some examples.

Addressing indigenous health workforce inequities: a literature review exploring 'best' practice for recruitment into tertiary health programmes.

INTRODUCTION: Addressing the underrepresentation of indigenous health professionals is recognised internationally as being integral to overcoming indigenous health inequities. This literature review aims to identify 'best practice' for recruitment of indigenous secondary school students into tertiary health programmes with particular relevance to recruitment of Maori within a New Zealand context. METHODOLOGY/METHODS: A Kaupapa Maori Research (KMR) methodological approach was utilised to review literature and categorise content via: country; population group; health profession focus; research methods; evidence of effectiveness; and discussion of barriers. Recruitment activities are described within five broad contexts associated with the recruitment pipeline: Early Exposure, Transitioning, Retention/Completion, Professional Workforce Development, and Across the total pipeline. RESULTS: A total of 70 articles were included. There is a lack of published literature specific to Maori recruitment and a limited, but growing, body of literature focused on other indigenous and underrepresented minority populations.The literature is primarily descriptive in nature with few articles providing evidence of effectiveness. However, the literature clearly frames recruitment activity as occurring across a pipeline that extends from secondary through to tertiary education contexts and in some instances vocational (post-graduate) training. Early exposure activities encourage students to achieve success in appropriate school subjects, address deficiencies in careers advice and offer tertiary enrichment opportunities. Support for students to transition into and within health professional programmes is required including bridging/foundation programmes, admission policies/quotas and institutional mission statements demonstrating a commitment to achieving equity. Retention/completion support includes academic and pastoral interventions and institutional changes to ensure safer environments for indigenous students. Overall, recruitment should reflect a comprehensive, integrated pipeline approach that includes secondary, tertiary, community and workforce stakeholders. CONCLUSIONS: Although the current literature is less able to identify 'best practice', six broad principles to achieve success for indigenous health workforce development include: 1) Framing initiatives within indigenous worldviews 2) Demonstrating a tangible institutional commitment to equity 3) Framing interventions to address barriers to indigenous health workforce development 4) Incorporating a comprehensive pipeline model 5) Increasing family and community engagement and 6) Incorporating quality data tracking and evaluation. Achieving equity in health workforce representation should remain both a political and ethical priority.

The cost of child health inequalities in Aotearoa New Zealand: a preliminary scoping study.

BACKGROUND: Health inequalities have been extensively documented, internationally and in New Zealand. The cost of reducing health inequities is often perceived as high; however, recent international studies suggest the cost of "doing nothing" is itself significant. This study aimed to develop a preliminary estimate of the economic cost of health inequities between Maori (indigenous) and non-Maori children in New Zealand. METHODS: Standard quantitative epidemiological methods and "cost of illness" methodology were employed, within a Kaupapa Maori theoretical framework. Data were obtained from national data collections held by the New Zealand Health Information Service and other health sector agencies. RESULTS: Preliminary estimates suggest child health inequities between Maori and non-Maori in New Zealand are cost-saving to the health sector. However the societal costs are significant. A conservative "base case" scenario estimate is over $NZ62 million per year, while alternative costing methods yield larger costs of nearly $NZ200 million per annum. The total cost estimate is highly sensitive to the costing method used and Value of Statistical Life applied, as the cost of potentially avoidable deaths of Maori children is the major contributor to this estimate. CONCLUSIONS: This preliminary study suggests that health sector spending is skewed towards non-Maori children despite evidence of greater Maori need. Persistent child health inequities result in significant societal economic costs. Eliminating child health inequities, particularly in primary care access, could result in significant economic benefits for New Zealand. However, there are conceptual, ethical and methodological challenges in estimating the economic cost of child health inequities. Re-thinking of traditional economic frameworks and development of more appropriate methodologies is required.