An innovative Indigenous-led model for integrated COVID-19 case management in Auckland, New Zealand: lessons from implementation.

In Aotearoa/New Zealand (NZ), the Indigenous Maori population have been more severely impacted than non-Maori throughout the COVID-19 pandemic, and less well served by NZ's COVID-19 response. This case-study describes an innovative Indigenous-led service delivery model, which was designed and implemented to improve the case and contact management of Maori with COVID-19 in Auckland. We outline the context in which the conventional public health case and contact management was failing Maori and the factors which enabled Indigenous innovation and leadership. We describe the details of the model and how the approach fundamentally differed to the conventional approach to care. Qualitative and quantitative data on impact of the model are shared, along with the key barriers and enablers in the implementation of the model. The Maori Regional Coordination Hub (MRCH) model offers a valuable alternative to the conventional public health case and contact management approach, and this case study highlights lessons which may be applicable to improving the design and delivery of public health services to other Indigenous and marginalized groups.

Analysis of deprivation distribution in New Zealand by ethnicity, 1991-2013.

AIMS: To compare the distribution of Maori and New Zealand (NZ) European populations in Aotearoa New Zealand by neighbourhood deprivation, for the five censuses between 1991 and 2013, and to identify changes in the distribution pattern over time. METHODS: Geographical meshblock data from the 1991-2013 New Zealand censuses, by NZDep Index deprivation score, and by prioritised ethnic group population, were combined to analyse ethnic population counts by deprivation decile and deprivation score. Trends over time were analysed. RESULTS: Maori were over-represented in the more deprived NZDep deciles and under-represented in the least deprived deciles for all census periods. The NZ European population were over-represented in the least deprived deciles, and under-represented in the more deprived deciles. In each census, over 40% of the Maori population have been living in the two most deprived deciles, compared to less than 15% for NZ European. CONCLUSION: The patterns of inequity in socio-economic deprivation between Maori and NZ Europeans have remained virtually unchanged since 1991, despite various Government commitments to reduce inequity. Socio-economic deprivation for Maori is a key determinant of health inequity, and bolder Government measures prioritised for Maori are needed to change this socio-economic gradient if health equity goals are to be met.

Estimating the economic costs of Indigenous health inequities in New Zealand: a retrospective cohort analysis.

OBJECTIVES: Despite significant international interest in the economic impacts of health inequities, few studies have quantified the costs associated with unfair and preventable ethnic/racial health inequities. This Indigenous-led study is the first to investigate health inequities between Maori and non-Maori adults in New Zealand (NZ) and estimate the economic costs associated with these differences. DESIGN: Retrospective cohort analysis. Quantitative epidemiological methods and 'cost-of-illness' (COI) methodology were employed, within a Kaupapa Maori theoretical framework. SETTING: Data for 2003-2014 were obtained from national data collections held by NZ government agencies, including hospitalisations, mortality, outpatient and primary care consultations, laboratory and pharmaceutical usage and accident claims. PARTICIPANTS: All adults in NZ aged 15 years and above who had engagement with the health system between 2003 and 2014 (deidentified). PRIMARY AND SECONDARY OUTCOME MEASURES: Rates of 'potentially avoidable' hospitalisations and mortality as well as 'excess or underutilisation' of healthcare were calculated, as the difference between actual rates for Maori and the rate expected if Maori had the same rates as non-Maori. These differences were then quantified using COI methodology to estimate the financial cost of ethnic inequities. RESULTS: In this conservative estimate, health inequities between Maori and non-Maori adults cost NZ$863.3 million per year. Direct costs of NZ$39.9 million per year included costs from ambulatory sensitive hospitalisations and outpatient care, with cost savings from underutilisation of primary care. Indirect costs of NZ$823.4 million per year came from years of life lost and lost wages. CONCLUSIONS: Indigenous adult health inequities in NZ create significant direct and indirect costs. The 'cost of doing nothing' is predominantly borne by Indigenous communities and society. The net cost of adult health inequities to the government conceals substantial savings to the government from underutilisation of primary care and accident/injury care.

The economic cost of Indigenous child health inequities in Aotearoa New Zealand-an updated analysis for 2003-2014.

AIMS: This study estimates of the cost of Indigenous child health inequities in New Zealand. METHODS: Standard quantitative epidemiological and cost of illness methodologies were used within a Kaupapa Maori framework. Data for 2003-2014 on children under 15 years were obtained from government datasets. Rates of potentially avoidable hospitalisations and mortality, as well as excess or under-utilisation were calculated. Publicly funded health sector costs, costs to families and costs of premature mortality were used to estimate the costs (or savings) of inequities. RESULTS: Maori children had lower utilisation rates than non-Maori for primary healthcare, outpatient care, medicines, laboratory investigations and care after an accident/injury. Maori children had greater rates of avoidable hospitalisation (RR=1.36, 95% CI 1.35-1.37) and death (RR 1.98, 95% CI 1.84-2.13). Inequalities between Maori and non-Maori children cost in excess of $170 million NZD each year. This includes an annual net savings for the government health sector of $4 million NZD, with an annual cost to society of around $175 million NZD. CONCLUSIONS: The under-serving of Maori children in the health sector saves the government health system money, yet imposes a huge cost on Maori families and society. In addition to avoiding considerable human suffering, reducing child health inequities would result in significant economic benefits.

Reducing inappropriate urine testing at Hutt Valley District Health Board using Choosing Wisely principles.

AIM: Unnecessary treatment of asymptomatic bacteriuria is a concern. Hutt Valley District Health Board sought to reduce clinically inappropriate urine culture requests through removal of urine dipsticks from wards and education of staff using Choosing Wisely principles. The purpose of this research is to quantitatively evaluate the success of these initiatives. METHODS: The numbers and results of urine cultures performed for Hutt Valley DHB were analysed, for the period from January 2015 to October 2017. Urinalyses were compared between those designated as 'inpatient' and those as 'outpatient', with the latter being the control of this study. The numbers of primary and secondary coded discharge diagnoses of UTIs were used as a measure of the negative impact of the interventions. RESULTS: There was a 28% reduction in monthly urine culture requests for inpatients, after staff education and removal of urine dipsticks, with no change in those for outpatients (the negative control). After the intervention, a higher proportion of urine cultures were positive for urinary pathogens (25.2% compared to 23.0%) and the average number of diagnoses of UTI in hospital discharges decreased 17% (from 161 to 134). CONCLUSION: The removal of urine dipsticks from wards and the education of staff significantly reduced the number of urine culture requests and is a useful strategy to reduce the overuse of antibiotics for asymptomatic bacteriuria without an increase in the number of UTIs. These simple interventions could be used at other hospitals as part of measures to reduce unnecessary care and overdiagnosis.

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.

What influences clinicians to choose wisely?

AIM: To evaluate the effectiveness of awareness-raising by the Choosing Wisely campaign in a New Zealand public hospital to reduce routine pre-operative testing and to determine what can be done to bring about change in clinician behaviour. METHODS: Short, semi-structured, one on-one interviews were conducted with 15 doctors of varying seniority from general surgery who were exposed to the campaign between August and October 2018. The interviews covered four general topics including background information, asking about awareness and effectiveness of Choosing Wisely campaign, exploring barriers to changing clinician behaviour around pre-operative testing and exploring potential interventions which may be useful to change behaviour. Data were analysed using Braun and Clarke thematic analysis methodology. RESULTS: Four themes and 17 sub-themes emerged from the interviews. The main themes included awareness of Choosing Wisely, thoughts around pre-operative testing, barriers for changing clinician behaviour and strategies for reducing unnecessary pre-operative testing. CONCLUSION: The findings of this study suggest that a strategy that relies on revising guidelines and raising staff awareness alone is likely to be of limited effectiveness in reducing unnecessary pre-operative testing. In addition to increasing clinician awareness of evidence-based recommendations on unnecessary testing, other strategies may be needed to support behaviour change.

National palliative care capacities around the world: Results from the World Health Organization Noncommunicable Disease Country Capacity Survey.

BACKGROUND: Previous estimates of global palliative care development have not been based on official country data. AIM: The World Health Organization Noncommunicable Disease Country Capacity Survey of World Health Organization member state officials monitors countries' capacities for the prevention and control of noncommunicable diseases. In 2015, for the first time, questions were included on a number of palliative care development metrics to generate baseline data for monitoring global palliative care development. DESIGN: Participants were given instructions, a glossary of terms, and 3 months to complete this closed, non-randomized, online survey. Questions were developed through a consultative process with relevant technical World Health Organization departments. SETTING/PARTICIPANTS: Health ministry officials serving as noncommunicable disease focal points from 177 out of 194 (91%) of World Health Organization Member States completed the voluntary survey. RESULTS: This survey reveals that (a) a minority (37%) of countries have an operational national policy for noncommunicable diseases that includes palliative care, (b) palliative care is least likely to have funding available compared with other core noncommunicable disease services, and (c) there is a large country-income gradient for palliative care funding, oral morphine availability, and integration of palliative care services at the primary levels of the health system. CONCLUSION: Palliative care for noncommunicable disease patients must be strengthened in a majority of countries. These data provide a baseline for trend measurement of official country-level and global palliative care development. A repeat assessment is taking place in the first half of 2017.

Policy approaches to address the social and environmental determinants of health inequity in Asia-pacific.

Asia Pacific is home to over 60% of the world's population and the fastest growing economies. Many of the leadership in the Asia Pacific region is becoming increasingly aware that improving the conditions for health would go a long way to sustaining economic prosperity in the region, as well as improving global and local health equity. There is no biological reason why males born in Cambodia can expect to live 23 years less than males born in Japan, or why females born in Tuvalu live 23 years shorter than females in New Zealand or why non-Indigenous Australian males live 12 years longer than Indigenous men. The nature and drivers of health inequities vary greatly among different social, cultural and geo-political contexts and effective solutions must take this into account. This paper utilizes the CSDH global recommendations as a basis for looking at the actions that are taking place to address the structural drivers and conditions of daily living that affect health inequities in the Asia Pacific context. While there are signs of action and hope, substantial challenges remain for health equity in Asia Pacific. The gains that have been made to date are not equally distributed and may be unsustainable as the world encounters new economic, social and environmental challenges. Tackling health inequities is a political imperative that requires leadership, political courage, social action, a sound evidence base and progressive public policy.

Review article: freedom to lead a life we have reason to value? A spotlight on health inequity in the Asia Pacific region.

The Asia Pacific region is home to more than 60% of the world's population. Life expectancy at birth differs between countries by as much as 27 years. This article suggests that asymmetric economic growth, unplanned urbanization, marked environmental change, unequal improvements in daily living conditions, and the unequal distribution and access to quality health care have contributed to health inequities in the Asia Pacific region. Contextually specific evidence and action are needed. This requires ongoing monitoring of health inequities and systematic evaluation of societal changes and their impact on health inequities. It requires better understanding of how to translate theoretical and empirical demonstrations of the social and environmental impact on health inequities into evidence-informed policies and programs, in diverse geopolitical, socioeconomic, and sociocultural contexts across the Asia Pacific region and the range of associated complex policy processes. A spotlight is needed on health inequities and their causes else the status quo will persist.

Routine vaccination coverage of 11 year olds, by ethnicity, through school-based vaccination in South Auckland.

AIMS: To determine vaccination coverage, by ethnicity, for the routine publicly funded vaccinations for 11 year olds, from school-based vaccination data in South Auckland, New Zealand. METHODS: De-identified aggregate data were obtained with permission from the Counties Manukau District Health Board (CMDHB) Public Health Nurses Database on the 11-year-old tetanus and polio vaccinations from 2005, and analysed to determine percentages of form return, consent and vaccination receipt by ethnicity, including relative risks for Maori compared to non-Maori students. Reasons for vaccination refusal were also analysed. RESULTS: Overall, 48% of Maori and 56% of non-Maori in Year 7 in CMDHB in 2005 (n=8642) were immunised through the school-based programme. Assuming that parents who stated their child had already received these vaccinations were all correct, the estimated overall coverage in this population for the recommended Year 7 tetanus vaccination was 67% (53% for Maori, and 71% for non-Maori). CONCLUSIONS: Vaccination coverage amongst 11 year olds in this population was lower than coverage for other childhood vaccinations in New Zealand, and there was a large Maori:non-Maori disparity.

MeNZB vaccine and epidemic control: when do you stop vaccinating?

New Zealand developed a strain-specific group B meningococcal vaccine to control an epidemic. Following a mass vaccination campaign of three doses to the population under 20 years of age, commencing in July 2004, the vaccine continued to be offered routinely as a four-dose schedule from 6 weeks of age. There is little international data on when to cease epidemic vaccination campaigns. The decision to stop using this vaccine needed to take into account a range of factors. These included epidemiology, vaccine effectiveness and duration of immunity, vaccine coverage, concomitant use with other vaccinations being added to the infant schedule, vaccine supply and cost-benefit criteria. This paper discusses these issues, along with the potential challenges for communication to both health professionals and the public.