Financial barriers to primary health care in Aotearoa New Zealand.

BACKGROUND: In Aotearoa New Zealand, co-payments to see a general practitioner (GP, family doctor) or collect a prescription are payable by virtually all adults. OBJECTIVE: To examine the extent to which these user co-payments are a barrier to accessing health care, focussing on inequities for indigenous Maori. METHODS: Pooled data from sequential waves (years) of the New Zealand Health Survey, 2011/12 to 2018/19 were analysed. Outcomes were self-reported cost barriers to seeing a GP or collecting a prescription in the previous year. Logistic regression was used to estimate odds ratios (ORs) of barriers to care for Maori compared with non-Maori, sequentially adjusting for additional explanatory variables. RESULTS: Pooled data included 107,231 people, 22,292 (21%) were Maori. Across all years, 22% of Maori (13% non-Maori) experienced a cost barrier to seeing a GP, and 14% of Maori (5% non-Maori) reported a cost barrier to collecting a prescription. The age- and wave-adjusted OR comparing Maori/non-Maori was 1.71 (95% confidence interval [CI]: 1.61, 1.81) for the cost barrier to primary care and 2.97 (95% CI: 2.75, 3.20) for the cost barrier to collecting prescriptions. Sociodemographics accounted for about half the inequity for both outcomes; in a fully adjusted model, age, sex, low income, and poorer underlying health were determinants of both outcomes, and deprivation was additionally associated with the cost barrier to collecting a prescription but not to seeing a GP. CONCLUSIONS: Maori experience considerable inequity in access to primary health care; evidence supports an urgent need for change to system funding to eliminate financial barriers to care.

Developing principles of social change as a result of a Pasifika Youth Empowerment Program: A qualitative study.

ISSUE: Empowerment is a concept over-used in health promotion, yet it is an important process that can used in developing the capacity and capability of young people for creating social change to improve healthier lives. METHODS: The Youth Empowerment Program (YEP), a pilot study aimed at empowering 15 youth (18-24 years) to lead healthier lives. We present secondary outcomes of the original YEP study, using focus groups and mobile-mentary approaches to capture the impact of the YEP through the youths' understanding of the program. Thematic analyses to examine the pragmatic usefulness of the empowerment program. RESULTS: We identified three major themes: (aa) Knowledge: education and awareness of healthy living and understanding of the wider social health issues, compound the health complexities of obesity; (b) Youth as catalysts for change: the youth viewed themselves as agents of social change; and (c) Transformation: the youth recognised themselves as catalysts for change that can positively transform communities into action. CONCLUSION: This study contributes new insights and depth of understanding about how the empowerment program can strengthen the process of individual capacity in an effort to mobilise social change for the betterment of the whole community, particularly among indigenous Pasifika population groups. SO WHAT?: Developing empowerment principles will enable others to consider "how apply" empowerment more practically when working with young people and not use it flippantly with no real action-oriented outcome.

A Comparison of Midwife-Led and Medical-Led Models of Care and Their Relationship to Adverse Fetal and Neonatal Outcomes: A Retrospective Cohort Study in New Zealand.

BACKGROUND: Internationally, a typical model of maternity care is a medically led system with varying levels of midwifery input. New Zealand has a midwife-led model of care, and there are movements in other countries to adopt such a system. There is a paucity of systemic evaluation that formally investigates safety-related outcomes in relationship to midwife-led care within an entire maternity service. The main objective of this study was to compare major adverse perinatal outcomes between midwife-led and medical-led maternity care in New Zealand. METHODS AND FINDINGS: This was a population-based retrospective cohort study. Participants were mother/baby pairs for all 244,047 singleton, term deliveries occurring between 1 January 2008 and 31 December 2012 in New Zealand in which no major fetal, neonatal, chromosomal or metabolic abnormality was identified and the mother was first registered with a midwife, obstetrician, or general practitioner as lead maternity carer. Main outcome measures were low Apgar score at five min, intrauterine hypoxia, birth-related asphyxia, neonatal encephalopathy, small for gestational age (as a negative control), and mortality outcomes (perinatal related mortality, stillbirth, and neonatal mortality). Logistic regression models were fitted, with crude and adjusted odds ratios (ORs) generated for each outcome for midwife-led versus medical-led care (based on lead maternity carer at first registration) with 95% confidence intervals. Fully adjusted models included age, ethnicity, deprivation, trimester of registration, parity, smoking, body mass index (BMI), and pre-existing diabetes and/or hypertension in the model. Of the 244,047 pregnancies included in the study, 223,385 (91.5%) were first registered with a midwife lead maternity carer, and 20,662 (8.5%) with a medical lead maternity carer. Adjusted ORs showed that medical-led births were associated with lower odds of an Apgar score of less than seven at 5 min (OR 0.52; 95% confidence interval 0.43-0.64), intrauterine hypoxia (OR 0.79; 0.62-1.02), birth-related asphyxia (OR 0.45; 0.32-0.62), and neonatal encephalopathy (OR 0.61; 0.38-0.97). No association was found between lead carer at first registration and being small for gestational age (SGA), which was included as a negative control (OR 1.00; 0.95-1.05). It was not possible to definitively determine whether one model of care was associated with fewer infant deaths, with ORs for the medical-led model compared with the midwife-led model being 0.80 (0.54-1.19) for perinatal related mortality, 0.86 (0.55-1.34) for stillbirth, and 0.62 (0.25-1.53) for neonatal mortality. Major limitations were related to the use of routine data in which some variables lacked detail; for example, we were unable to differentiate the midwife-led group into those who had received medical input during pregnancy and those who had not. CONCLUSIONS: There is an unexplained excess of adverse events in midwife-led deliveries in New Zealand where midwives practice autonomously. The findings are of concern and demonstrate a need for further research that specifically investigates the reasons for the apparent excess of adverse outcomes in mothers with midwife-led care. These findings should be interpreted in the context of New Zealand's internationally comparable birth outcomes and in the context of research that supports the many benefits of midwife-led care, such as greater patient satisfaction and lower intervention rates.

Cancer incidence in indigenous people in Australia, New Zealand, Canada, and the USA: a comparative population-based study.

INTRODUCTION: Indigenous people have disproportionally worse health and lower life expectancy than their non-indigenous counterparts in high-income countries. Cancer data for indigenous people are scarce and incidence has not previously been collectively reported in Australia, New Zealand, Canada, and the USA. We aimed to investigate and compare, for the first time, the cancer burden in indigenous populations in these countries. METHODS: We derived incidence data from population-based cancer registries in three states of Australia (Queensland, Western Australia, and the Northern Territory), New Zealand, the province of Alberta in Canada, and the Contract Health Service Delivery Areas of the USA. Summary rates for First Nations and Inuit in Alberta, Canada, were provided directly by Alberta Health Services. We compared age-standardised rates by registry, sex, cancer site, and ethnicity for all incident cancer cases, excluding non-melanoma skin cancers, diagnosed between 2002 and 2006. Standardised rate ratios (SRRs) and 95% CIs were computed to compare the indigenous and non-indigenous populations of each jurisdiction, except for the Alaska Native population, which was compared with the white population from the USA. FINDINGS: We included 24 815 cases of cancer in indigenous people and 5 685 264 in non-indigenous people from all jurisdictions, not including Alberta, Canada. The overall cancer burden in indigenous populations was substantially lower in the USA except in Alaska, similar or slightly lower in Australia and Canada, and higher in New Zealand compared with their non-indigenous counterparts. Among the most commonly occurring cancers in indigenous men were lung, prostate, and colorectal cancer. In most jurisdictions, breast cancer was the most common cancer in women followed by lung and colorectal cancer. The incidence of lung cancer was higher in indigenous men in all Australian regions, in Alberta, and in US Alaska Natives than in their non-indigenous counterparts. For breast cancer, rates in women were lower in all indigenous populations except in New Zealand (SRR 1·23, CI 95% 1·16-1·32) and Alaska (1·14, 1·01-1·30). Incidence of cervical cancer was higher in indigenous women than in non-indigenous women in most jurisdictions, although the difference was not always statistically significant. INTERPRETATION: There are clear differences in the scale and profile of cancer in indigenous and non-indigenous populations in Australia, New Zealand, Canada, and the USA. Our findings highlight the need for much-improved, targeted programmes of screening, vaccination, and smoking cessation, among other prevention strategies. Governments and researchers need to work in partnership with indigenous communities to improve cancer surveillance in all jurisdictions and facilitate access to cancer data. FUNDING: International Agency for Research on Cancer-Australia Fellowship.

Indigenous inequities in the presentation and management of stomach cancer in New Zealand: a country with universal health care coverage.

BACKGROUND: Maori in New Zealand have markedly higher incidence and poorer survival from stomach cancer than non-Maori. We investigated the presentation, management and survival of stomach cancer in a cohort of newly diagnosed Maori and non-Maori patients. METHODS: A clinical notes review of all Maori from the North Island diagnosed between 2006 and 2008, and a random equivalent sample of non-Maori, was conducted (final cohort n = 335). Patient characteristics, tumour characteristics, receipt and timing of treatment and cancer-specific survival were compared. RESULTS: Compared to non-Maori, Maori patients had a younger average age at diagnosis, higher prevalence of congestive heart failure and renal disease, and were more likely to be diagnosed with distal disease (43 % Maori, 26 % non-Maori, p = 0.004). Stage and grade distributions were similar between ethnic groups. Two-thirds (66 %) of stage I-III patients had definitive surgery, with similar rates for Maori (71 %) and non-Maori (68 %). Maori were less likely to have surgery performed by a specialist upper gastrointestinal surgeon (38 % Maori, 79 % non-Maori, p < 0.01) and less likely to be treated in a main centre (44 % Maori, 87 % non-Maori, p < 0.01). After adjusting for age, sex, stage, tumour site and comorbidity, Maori had nonsignificant 27 % poorer survival (hazard ratio 1.27, 95 % CI 0.96-1.68). CONCLUSIONS: There was evidence of differential presentation and access to specialised surgical services, as well as differential survival, for Maori stomach cancer patients compared to non-Maori. These findings support the development of the national stomach cancer treatment standards and highlight the need for an equity focus within these guidelines.

Barriers to and delays in accessing breast cancer care among New Zealand women: disparities by ethnicity.

BACKGROUND: Unequal access to health care contributes to disparities in cancer outcomes. We examined the ethnic disparity in barriers to accessing primary and specialist health care experienced by New Zealand women with breast cancer. METHODS: Women diagnosed with a primary invasive breast cancer between 2005 and 2007 were eligible. There were 1,799 respondents, n = 302 Maori (the indigenous population of NZ), n = 70 Pacific and n = 1,427 non-Maori/non-Pacific women. Participants completed a questionnaire listing 12 barriers grouped into three domains for analysis: personal; practical; and health care process factors, and reported the number of days between seeing a primary and a specialist care provider. Chi-squared, Fisher exact tests and logistic regression were used to assess uni- and multivariable differences in prevalence between ethnic groupings. RESULTS: The prevalence of reporting three or more barriers was 18% among Pacific, 10% among Maori and 3% among non-Maori/non-Pacific women (P <0.001). The most commonly reported barriers were fear (Maori women) and cost (Pacific and non-Maori/non-Pacific women). Ethnic differences in reported barriers were not explained by deprivation or diabetes prevalence. Women with diabetes reported a two-fold higher risk of experiencing barriers to care compared to those without diabetes (odds ratio [OR]: 2.06, 95%CI 1.20 to 3.57). Maori and Pacific women were more likely to face delays (median 14 days) in seeing a specialist than non-Maori/non-Pacific women (median 7 days); these differences were not explained by the reported barriers. CONCLUSIONS: Patterns of reported barriers to care differed according to ethnicity and were not explained by deprivation, or presence of co-morbidity. Maori and Pacific women are more likely to experience barriers to breast cancer care compared to non- Maori/non-Pacific women. We identified two key barriers affecting care for Maori and Pacific women; (a) delays in follow-up, and (b) the impact of co-morbid conditions. Future New Zealand work needs to focus attention on health care process factors and improving the interface between primary and secondary care to ensure quality health care is realised for all women with breast cancer.

Cancer care decision making in multidisciplinary meetings.

Little research has been undertaken on the actual decision-making processes in cancer care multidisciplinary meetings (MDMs). This article was based on a qualitative observational study of two regional cancer treatment centers in New Zealand. We audiorecorded 10 meetings in which 106 patient cases were discussed. Members of the meetings categorized cases in varying ways, drew on a range of sources of authority, expressed different value positions, and utilized a variety of strategies to justify their actions. An important dimension of authority was encountered authority-the authority a clinician has because of meeting the patient. The MDM chairperson can play an important role in making explicit the sources of authority being drawn on and the value positions of members to provide more clarity to the decision-making process. Attending to issues of process, authority, and values in MDMs has the potential to improve cancer care decision making and ultimately, health outcomes.

Exploring Maori cancer patients', their families', community and hospice views of hospice care.

BACKGROUND: Despite poor cancer survival statistics, Maori do not readily access hospice services. This study aims to explore how hospice services respond to Maori by investigating the different influences and interactions between three perspectives of hospice care. METHOD: The authors conducted a Maori-centred, cross-sectional qualitative study by undertaking semi-structured interviews with hospice patients and whanau (families) (n=8), hospice representatives (n=4), and representatives from three Maori health provider organisations (n=5). CONCLUSIONS: The study found that negative perceptions of hospice are being changed by hospices' relationships with other organisations and positive stories from whanau. Involvement from whanau, continuity of care and after-hours care with a greater Maori workforce and a further emphasis on culturally safe care are critical for this work to gain momentum. Findings can be of use to further develop quality of care indicators that reflect the perspectives of patients and whanau, and those who provide their care.

The burden of stomach cancer in indigenous populations: a systematic review and global assessment.

OBJECTIVE: Stomach cancer is a leading cause of cancer death, especially in developing countries. Incidence has been associated with poverty and is also reported to disproportionately affect indigenous peoples, many of whom live in poor socioeconomic circumstances and experience lower standards of health. In this comprehensive assessment, we explore the burden of stomach cancer among indigenous peoples globally. DESIGN: The literature was searched systematically for studies on stomach cancer incidence, mortality and survival in indigenous populations, including Indigenous Australians, Maori in New Zealand, indigenous peoples from the circumpolar region, native Americans and Alaska natives in the USA, and the Mapuche peoples in Chile. Data from the New Zealand Health Information Service and the Surveillance Epidemiology and End Results (SEER) Program were used to estimate trends in incidence. RESULTS: Elevated rates of stomach cancer incidence and mortality were found in almost all indigenous peoples relative to corresponding non-indigenous populations in the same regions or countries. This was particularly evident among Inuit residing in the circumpolar region (standardised incidence ratios (SIR) males: 3.9, females: 3.6) and in Maori (SIR males: 2.2, females: 3.2). Increasing trends in incidence were found for some groups. CONCLUSIONS: We found a higher burden of stomach cancer in indigenous populations globally, and rising incidence in some indigenous groups, in stark contrast to the decreasing global trends. This is of major public health concern requiring close surveillance and further research of potential risk factors. Given evidence that improving nutrition and housing sanitation, and Helicobacter pylori eradication programmes could reduce stomach cancer rates, policies which address these initiatives could reduce inequalities in stomach cancer burden for indigenous peoples.

Healthy lifestyle and risk of breast cancer for indigenous and non-indigenous women in New Zealand: a case control study.

BACKGROUND: The reasons for the increasing breast cancer incidence in indigenous Maori compared to non-Maori New Zealand women are unknown. The aim of this study was to assess the association of an index of combined healthy lifestyle behaviours with the risk of breast cancer in Maori and non-Maori women. METHODS: A population-based case-control study was conducted, including breast cancer cases registered in New Zealand from 2005-2007. Controls were matched by ethnicity and 5-year age bands. A healthy lifestyle index score (HLIS) was generated for 1093 cases and 2118 controls, based on public health and cancer prevention recommendations. The HLIS was constructed from eleven factors (limiting red meat, cream, and cheese; consuming more white meat, fish, fruit and vegetables; lower alcohol consumption; not smoking; higher exercise levels; lower body mass index; and longer cumulative duration of breastfeeding). Equal weight was given to each factor. Logistic regression was used to estimate the associations between breast cancer and the HLIS for each ethnic group stratified by menopausal status. RESULTS: Among Maori, the mean HLIS was 5.00 (range 1-9); among non-Maori the mean was 5.43 (range 1.5-10.5). There was little evidence of an association between the HLIS and breast cancer for non-Maori women. Among postmenopausal Maori, those in the top HLIS tertile had a significantly lower odds of breast cancer (Odds Ratio 0.47, 95% confidence interval 0.23-0.94) compared to those in the bottom tertile. CONCLUSION: These findings suggest that healthy lifestyle recommendations could be important for reducing breast cancer risk in postmenopausal Maori women.

Consequences of cost barriers to prescriptions: cohort study in Aotearoa New Zealand.

AIMS: A NZ$5 co-payment prescription charge was removed in July 2023 but may be reinstated. Here we quantify the health impact and cost of not being able to afford this charge. METHODS: We linked New Zealand Health Surveys (2013/2014-2018/2019) to hospitalisation data using data available in Integrated Data Infrastructure (IDI). Cox proportional-hazards models compared time to hospitalisation between those who had faced a cost barrier to collecting a prescription and those who had not. RESULTS: Of the 81,626 total survey respondents, 72,243 were available for analysis in IDI. A further 516 were excluded to give an analysis dataset of 71,502. Of these, 5,889 (8.2%) reported not collecting a prescription due to cost in the previous year. Among people who faced a cost barrier, 60.0% (95% confidence interval [CI] 58.7-61.2%) were admitted to hospital during the study period, compared to 43.9% (95% CI 43.6-44.3%) of those who did not. Having adjusted for socio-demographic variables, people who faced a cost barrier were 34% (hazard ratio 1.34; 95% CI 1.29-1.39) more likely to be admitted to hospital than those who did not. Annual avoidable hospitalisation costs-were prescription co-payments to remain free-are estimated at $32.4 million per year based on the assumption of a causal relationship between unmet need for prescription medicines and subsequent hospitalisation. CONCLUSIONS: The revenue to the health system from co-payments may be offset by the costs associated with avoidable hospitalisations.

Building a systems-thinking community workforce to scale action on determinants of health in New Zealand.

This article describes findings from the evaluation of Healthy Families NZ (HFNZ), an equity-driven, place-based community health initiative. Implemented in nine diverse communities across New Zealand, HFNZ aims to strengthen the systems that can improve health and well-being. Findings highlight local needs and priorities including the social mechanisms important for reorienting health and policy systems towards place-based communities. Lessons encompass the importance of local lived experience in putting evidence into practice; the strength of acting with systems in mind; the need for relational, learning, intentional, and well-resourced community organisation; examples of how to foster place-based 'community-up' leadership; and how to enable responsiveness between communities and local and national policy systems. A reconceptualisation of scaling in the context of complexity and systems change is offered, which recognises that relationships and agency are key to making progress on the determinants of health.

A multi-ethnic breast cancer case-control study in New Zealand: evidence of differential risk patterns.

PURPOSE: To investigate whether the relationships between established risk factors and breast cancer risk differ between three ethnic groups in New Zealand, namely Maori, Pacific, and non-Maori/non-Pacific women. METHODS: The study is a multi-ethnic, age-, and ethnicity-matched population-based case-control study of breast cancer in women. Women with a primary, invasive breast cancer registered on the New Zealand Cancer Registry between 1 April 2005 and 30 April 2006, and Maori or Pacific women diagnosed to 30 April 2007 were eligible. Control women were identified from the New Zealand Electoral Roll, stratified by ethnicity, then frequency matched on age to the cases. Logistic regression was used to estimate odds ratios (OR) and 95 % confidence intervals (CI) between exposures and breast cancer risk in three ethnic groups separately. Likelihood ratio tests were used to test for modification of the effects by ethnicity. Post-stratification weighting of the controls was used to account for differential non-response by deprivation category. RESULTS: The study comprised 1,799 cases (302 Maori, 70 Pacific, 1,427 non-Maori/non-Pacific) and 2,543 controls (746 Maori, 194 Pacific, 1,603 non-Maori/non-Pacific), based on self-identified ethnicity. Maori women were more likely to have ER and PR positive breast cancer compared to other ethnicities. There were marked differences in exposure prevalence between ethnicities and some differing patterns of risk factors for breast cancer between the three main ethnic groups. Of interest was the strong relationship between number of children and lower breast cancer risk in Pacific women (OR for 4 or more vs. 1 child OR 0.13, 95 % CI 0.05-0.35) and a higher risk of breast cancer associated with smoking (OR 1.76, 95 % CI 1.25-2.48) and binge drinking (5 or more vs. 1-2 drinks per occasion, OR 1.55, 95 % CI 1.07-2.26) in Maori women. Some of the documented results were attenuated following post-stratification weighting. CONCLUSIONS: The findings of this study need to be interpreted with caution, given the possibility of selection bias due to low response rates among some groups of women. Reducing the burden of breast cancer in New Zealand is likely to require different approaches for different ethnic groups.

Cohort profile: Nga Kawekawe o Mate Korona | Impacts of COVID-19 in Aotearoa - a prospective, national cohort study of people with COVID-19 in New Zealand.

PURPOSE: The COVID-19 pandemic has had significant health, social and economic impacts around the world. We established a national, population-based longitudinal cohort to investigate the immediate and longer-term physical, psychological and economic impacts of COVID-19 on affected people in Aotearoa New Zealand (Aotearoa), with the resulting evidence to assist in designing appropriate health and well-being services for people with COVID-19. PARTICIPANTS: All people residing in Aotearoa aged 16 years or over, who had a confirmed or probable diagnosis of COVID-19 prior to December 2021, were invited to participate. Those living in dementia units were excluded. Participation involved taking part in one or more of four online surveys and/or in-depth interviews. The first wave of data collection took place from February to June 2022. FINDINGS TO DATE: By 30 November 2021, of 8735 people in Aotearoa aged 16+ who had COVID-19, 8712 were eligible for the study and 8012 had valid addresses so were able to be contacted to take part. A total of 990 people, including 161 Tangata Whenua (Maori, Indigenous peoples of Aotearoa) completed one or more surveys; in addition, 62 took part in in-depth interviews. Two hundred and seventeen people (20%) reported symptoms consistent with long COVID. Key areas of adverse impacts were experiences of stigma, mental distress, poor experiences of health services and barriers to healthcare, each being significantly more pronounced among disabled people and/or those with long COVID. FUTURE PLANS: Further data collection is planned to follow-up cohort participants. This cohort will be supplemented by the inclusion of a cohort of people with long COVID following Omicron infection. Future follow-ups will assess longitudinal changes to health and well-being impacts, including mental health, social, workplace/education and economic impacts of COVID-19.

Ethnic differences in disease presentation of uterine cancer in New Zealand women.

OBJECTIVES: Little is known about the ethnic differences in disease presentation of uterine cancer in New Zealand women. The objectives of this study were two-fold: (1) to estimate the incidence and mortality of uterine cancer among women in New Zealand and (2) to examine the association of ethnicity and socioeconomic status with tumour stage and grade, at presentation of uterine cancer. METHODS: Retrospective survey of cancer cases identified from the New Zealand Cancer Registry. The authors analysed all 3203 uterine cancer cases registered with the New Zealand Cancer Registry during the period 1 January 1997 to 31 December 2006. Ethnic groups were defined based on the self-identified ethnicity recorded on the cancer registry: Ma-ori, Pacific and non-Maori non-Pacific women. Socioeconomic status was categorised as quintiles of the New Zealand Deprivation Index 2006. The mortality to incidence ratio was used as a measure of prognosis. Logistic regression was used to estimate age, ethnic and deprivation adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Pacific and Maori women have higher incidence (32.4 and 17.7 per 100 000 women, respectively) and mortality rates of uterine cancer (12.1 and 7.4 per 100 000 women, respectively). Women in the most deprived areas are more likely to present with an advanced stage of uterine cancer (OR 1.64, 95% CI 1.09-2.48). Maori and Pacific women are less likely to present with well-differentiated tumours (OR 0.69, 95% CI 0.52-0.92 and OR 0.72, 95% CI 0.52-0.99, respectively). CONCLUSIONS: Maori and Pacific women, and those from lower socioeconomic areas, are more likely to present with advanced uterine cancer.

A longitudinal linkage study of occupation and ischaemic heart disease in the general and Maori populations of New Zealand.

OBJECTIVES: Occupation is a poorly characterised risk factor for cardiovascular disease (CVD) with females and indigenous populations under-represented in most research. This study assessed associations between occupation and ischaemic heart disease (IHD) in males and females of the general and Maori (indigenous people of NZ) populations of New Zealand (NZ). METHODS: Two surveys of the NZ adult population (NZ Workforce Survey (NZWS); 2004-2006; n = 3003) and of the Maori population (NZWS Maori; 2009-2010; n = 2107) with detailed occupational histories were linked with routinely collected health data and followed-up until December 2018. Cox regression was used to calculate hazard ratios (HR) for IHD and "ever-worked" in any of the nine major occupational groups or 17 industries. Analyses were controlled for age, deprivation and smoking, and stratified by sex and survey. RESULTS: 'Plant/machine operators and assemblers' and 'elementary occupations' were positively associated with IHD in female Maori (HR 2.2, 95%CI 1.2-4.1 and HR 2.0, 1.1-3.8, respectively) and among NZWS males who had been employed as 'plant/machine operators and assemblers' for 10+ years (HR 1.7, 1.2-2.8). Working in the 'manufacturing' industry was also associated with IHD in NZWS females (HR 1.9, 1.1-3.7), whilst inverse associations were observed for 'technicians and associate professionals' (HR 0.5, 0.3-0.8) in NZWS males. For 'clerks', a positive association was found for NZWS males (HR 1.8, 1.2-2.7), whilst an inverse association was observed for Maori females (HR 0.4, 0.2-0.8). CONCLUSION: Associations with IHD differed significantly across occupational groups and were not consistent across males and females or for Maori and the general population, even within the same occupational groups, suggesting that current knowledge regarding the association between occupation and IHD may not be generalisable across different population groups.

Ischaemic Heart Disease and Occupational Exposures: A Longitudinal Linkage Study in the General and Maori Populations of New Zealand.

OBJECTIVES: This study assessed associations between occupational exposures and ischaemic heart disease (IHD) for males and females in the general and Maori populations (indigenous people of New Zealand). METHODS: Two surveys of the general adult [New Zealand Workforce Survey (NZWS); 2004-2006; n = 3003] and Maori population (Maori NZWS; 2009-2010; n = 2107), with information on occupational exposures, were linked with administrative health data and followed-up until December 2018. Cox proportional hazards regression (adjusted for age, deprivation, and smoking) was used to assess associations between organizational factors, stress, and dust, chemical and physical exposures, and IHD. RESULTS: Dust [hazard ratio (HR) 1.6, 95%CI 1.1-2.4], smoke or fumes (HR 1.5, 1.0-2.3), and oils and solvents (HR 1.5, 1.0-2.3) were associated with IHD in NZWS males. A high frequency of awkward or tiring hand positions was associated with IHD in both males and females of the NZWS (HRs 1.8, 1.1-2.8 and 2.4, 1.1-5.0, respectively). Repetitive tasks and working at very high speed were associated with IHD among NZWS females (HRs 3.4, 1.1-10.4 and 2.6, 1.2-5.5, respectively). Maori NZWS females working with vibrating tools and those exposed to a high frequency of loud noise were more likely to experience IHD (HRs 2.3, 1.1-4.8 and 2.1, 1.0-4.4, respectively). Exposure to multiple dust and chemical factors was associated with IHD in the NZWS males, as was exposure to multiple physical factors in males and females of the NZWS. CONCLUSIONS: Exposures associated with an elevated IHD risk included dust, smoke or fumes, oils and solvents, awkward grip or hand movements, carrying out repetitive tasks, working at very high speed, loud noise, and working with tools that vibrate. Results were not consistently observed for males and females and between the general and Maori populations.

Assessing youth empowerment and co-design to advance Pasifika health: a qualitative research study in New Zealand.

OBJECTIVES: The Pasifika Prediabetes Youth Empowerment Programme (PPYEP) was a community-based research project that aimed to investigate empowerment and co-design modules to build the capacity of Pasifika youth to develop community interventions for preventing prediabetes. METHODS: This paper reports findings from a formative evaluation process of the programme using thematic analysis. It emphasises the adoption, perceptions and application of empowerment and co-design based on the youth and community providers' experiences. RESULTS: We found that the programme fostered a safe space, increased youth's knowledge about health and healthy lifestyles, developed their leadership and social change capacities, and provided a tool to develop and refine culturally centred prediabetes-prevention programmes. These themes emerged non-linearly and synergistically throughout the programme. CONCLUSIONS: Our research emphasises that empowerment and co-design are complementary in building youth capacity in community-based partnerships in health promotion. Implications for public health: Empowerment and co-design are effective tools to develop and implement culturally tailored health promotion programmes for Pasifika peoples. Future research is needed to explore the programme within different Pasifika contexts, health issues and Indigenous groups.

Consequences of barriers to primary health care for children in Aotearoa New Zealand.

Inequities in the provision of accessible primary health care contribute to poor health outcomes and health inequity. This study evaluated inequities in the prevalence and consequences of barriers that children face in seeing a general practitioner (GP) in Aotearoa New Zealand. We analysed data on 5,947 children from the Growing Up in New Zealand longitudinal study cohort on barriers to seeing a GP in the previous year, reported by mothers when their children were aged 24 months and 54 months (in 2011/12 and 2013/14 respectively); and maternal-reported hospitalisations in the year prior to age 54 months. We used logistic regression to estimate odds ratios (OR) and 95% confidence intervals (CIs) for consequences of these barriers. Overall, 4.7% (n = 279) of children experienced barriers to seeing a GP in the year to 24 months and 5.5% (n = 325) in the year to 54 months. At each age, and for each specific barrier studied, barriers were more prevalent among Maori (the indigenous people of Aotearoa New Zealand), and among Pacific, compared to New Zealand European, children. Children facing barriers in the year to age 24 months were twice as likely to be hospitalised in the year to 54 months (OR 2.18, 95%CI: 1.38 to 3.44). When this relationship was analysed by ethnicity, the association was strongest for Maori (OR: 2.92, 95%CI: 1.60 to 5.30), less strong for Pacific (OR 2.01, 95%CI: 0.92 to 4.37) and not present for New Zealand European (OR 1.27, 95%CI 0.39 to 4.12) families. Barriers that children face to seeing a GP have social and cost implications for families and the health system. Changes to the health system, and future health policy, must align with the New Zealand government's obligations under Te Tiriti o [The Treaty of] Waitangi, to ensure that health equity becomes a reality for Maori.