The Right to Equal Health: Best Practice Priorities for Maori with Bipolar Disorder from Staff Focus Groups.

Bipolar disorder (BD) is a serious mental health condition that is clinically complex to monitor and manage. While best practice guidelines exist, they vary internationally lacking consensus. Indigenous peoples, including Maori in New Zealand, experience higher community rates of BD. While New Zealand practice guidelines recommend providing culturally responsive care to Maori, studies show that Maori do not receive best practice. This qualitative study aimed to share the evidence about patterns of health service use and Maori patient experiences with focus group participants involved in the design and delivery of BD services, to discuss and develop guidelines for best practice for Maori with BD and address areas of unmet need. Three focus groups were conducted with 22 participants involved in the delivery of services to Maori with BD across three sites. Willing participants were sent background information and three focus group questions framed to elicit priority solutions to improve clinical, structural and organisational features of mental health service delivery for Maori patients with BD and their whanau (family). The nominal group technique was used to synthesise responses, and then develop a prioritised list of proposed solutions. Results identified system-level changes required at the clinical, structural and organisational levels of healthcare. Findings further evidence the need for healthcare reform in New Zealand, to be responsive to Maori with BD.

Racism, early psychosis, and institutional contact: A qualitative study of Indigenous experiences.

BACKGROUND: There is evidence of Indigenous and ethnic minority inequities in the incidence and outcomes of early psychosis. Racism has been implicated as having an important role. AIM: To use Indigenous experiences to develop a more detailed understanding of how racism operates to impact early psychosis outcomes. METHODS: Critical Race Theory informed the methodology used. Twenty-three Indigenous participants participated in four family focus group interviews and thirteen individual interviews, comprising of 9 Maori youth with early psychosis, 10 family members and 4 Maori mental health professionals. An analysis of the data was undertaken using deductive structural coding to identify descriptions of racism, followed by inductive descriptive and pattern coding. RESULTS: Participant experiences revealed how racism operates as a socio-cultural phenomenon that interacts with institutional policy and culture across systems pertaining to social responsiveness, risk discourse, and mental health service structures. This is described across three major themes: 1) selective responses based on racial stereotypes, 2) race related risk assessment bias and 3) institutional racism in the mental health workforce. The impacts of racism were reported as inaction in the face of social need, increased use of coercive practices and an under resourced Indigenous mental health workforce. CONCLUSION: The study illustrated the inter-related nature of interpersonal, institutional and structural racism with examples of interpersonal racism in the form of negative stereotypes interacting with organizational, socio-cultural and political priorities. These findings indicate that organizational cultures may differentially impact Indigenous and minority people and that social responsiveness, risk discourse and the distribution of workforce expenditure are important targets for anti-racism efforts.

Reimagining eating disorder spaces: a qualitative study exploring Maori experiences of accessing treatment for eating disorders in Aotearoa New Zealand.

BACKGROUND: Health, illness, and the body are conceptualized within the cultural context of a society. The values and belief systems of a society, including media portrayals, shape how health and illness present. Traditionally, Western portrayals of eating disorders have been prioritized over and above Indigenous realities. This paper explores the lived experiences of Maori with eating disorders and their whanau (family/support system) to identify the enablers and barriers to accessing specialist services for eating disorders in New Zealand. METHOD: Kaupapa Maori research methodology was used to ensure the research supported Maori health advancement. Fifteen semi-structured interviews were completed with Maori participants including; those with an eating disorder diagnosis (anorexia nervosa, bulimia nervosa, and binge eating disorder), and/or their whanau. Structural, descriptive, and pattern coding was undertaken within the thematic analysis. Low's spatializing culture framework was used to interpret the findings. RESULTS: Two overarching themes identified systemic and social barriers to accessing treatment for Maori with eating disorders. The first theme, was space, that described the material culture within eating disorder settings. This theme critiqued eating disorder services, including idiosyncratic use of assessment methods, inaccessible service locations, and the limited number of beds available in specialist mental health services. The second theme, place, referred to the meaning given to social interactions created within space. Participants critiqued the privileging of non-Maori experiences, and how this makes a place and space of exclusion for Maori and their whanau in eating disorder services in New Zealand. Other barriers included shame and stigma, while enablers included family support and self-advocacy. CONCLUSION: More education is needed for those working in the space of primary health settings about the diversity of those with eating disorders to enable them to look beyond the stereotype of what an eating disorder looks like, and to take seriously the concerns of whaiora and whanau who present with disordered eating concerns. There is also a need for thorough assessment and early referral for eating disorder treatment to ensure the benefits of early intervention are enabled for Maori. Attention given to these findings will ensure a place for Maori in specialist eating disorder services in New Zealand.

Eating disorders are at least as common in Maori (Indigenous people of New Zealand) when compared to their non-Maori counterparts, however, a recent study investigating specialist service use data identified lower-than-expected service use for Maori. This paper explores the lived experiences of Maori with eating disorders and their whanau (family/support network) to understand the barriers and enablers to accessing treatment. Participants in this study identified both systemic and social barriers to accessing treatment for eating disorders; Systemic barriers included the idiosyncratic use of assessment methods by health practitioners, and inaccessible service locations, including the number of available inpatient beds. While social barriers included the stereotype of what an eating disorder looks like, shame, stigma, and discrimination; support networks were described as both an enabler and barrier to accessing specialist treatment for eating disorders. The findings from this study suggest thorough assessment and early referrals are needed for Maori presenting with disordered eating concerns. Moreover, more education is needed for those working in primary healthcare settings about the diversity of eating disorders to ensure they move beyond the stereotype of what an eating disorder looks like.

Mortality after release from incarceration in New Zealand by gender: A national record linkage study.

Background: People who enter and leave places of incarceration experience considerable health inequities and are at increased risk of premature death compared to the general population. Causes of premature death in this population vary markedly between countries and so country-specific information is needed. Additionally, there is a lack of large population-based studies which can disaggregate mortality risk based on person and incarceration factors. This study is the first examination of mortality in the period following release from incarceration in New Zealand. Methods: We linked deidentified administrative data on incarceration and release between 1 January 1998 and 31 December 2016 with national mortality data for the same period to examine mortality after release in those who had been incarcerated for at least 1 day. Age standardised mortality rates and mortality ratios compared to the general New Zealand population were calculated separately for men and women, for releases from remand compared with prison, and by cause of death and time since release. Results: 90,195 individuals (13% women, 49% Maori) were followed up for 9.4 years after release from incarceration, with 4,764 deaths over the follow-up period. The overall standardised mortality ratio was 3.3 (95% CI 3.2, 3.4) compared to the general population, and higher for women (3.8) than men (2.7). The most common causes of death were cardiovascular disease, cancer and suicide. Rates of death were similar following release from remand versus prison, however suicide rates were highest following release from remand. Regardless of the type of incarceration, mortality was highest in the first month after release. Conclusion: Experience of incarceration in New Zealand is associated with high rates of mortality from both chronic conditions and external causes. There are urgent policy imperatives to recognise and actively address the increased health and mortality risks faced by people released from New Zealand prisons.

Addressing structural discrimination: prioritising people with mental health and addiction issues during the COVID-19 pandemic.

Structural discrimination worsens physical health inequities and significantly reduces life expectancy for people with mental health and addiction issues. Aotearoa has recently made some notable changes in health policy by formally recognising the physical health needs of people with mental health and addiction issues. The COVID-19 vaccination sequencing framework provides an important opportunity to protect and promote the health of people with addiction and mental health issues. An expert advisory group, convened as part of the Aotearoa Equally Well collaborative, considered findings of a literature review on the vulnerability of people with mental health and addiction issues of contracting and dying from COVID-19. Evidence indicates an association between mental health and addiction issues and infection risk and worse outcomes. The group concluded mental health and addiction issues should be recognised as underlying health conditions that increase COVID-19 vulnerability, and that people with these issues should be prioritised for vaccination. For too long the health system has failed to address the life expectancy gap of people with addiction and mental health issues. Now is an opportunity to change the korero. People with mental health and addiction issues experience significant physical health inequities. Addressing these inequities must be integral in modern health policy-including our COVID-19 pandemic response.

The physical health of Maori with bipolar disorder.

AIMS: There is very little empirical evidence about the relationship between severe mental illness and the physical health of Indigenous peoples. This paper aims to compare the physical health of Maori and non-Maori with a diagnosis of bipolar disorder in contact with NZ mental health services. METHODS: A cohort of Maori and non-Maori with a current bipolar disorder diagnosis at 1 January 2010 were identified from routine mental health services data and followed up for non-psychiatric hospital admissions and deaths over the subsequent 5 years. RESULTS: Maori with bipolar disorder had a higher level of morbidity and a higher risk of death from natural causes compared to non-Maori with the same diagnosis, indicating higher levels of physical health need. The rate of medical and surgical hospitalisation was not higher among Maori compared to non-Maori (as might be expected given increased health needs) which suggests under-treatment of physical health conditions in this group may be a factor in the observed higher risk of mortality from natural causes for Maori. CONCLUSION: This study provides the first indication that systemic factors which cause health inequities between Maori and non-Maori are compounded for Maori living with severe mental illness. Further exploration of other diagnostic groups and subgroups is needed to understand the best approach to reducing these inequalities.

Revolutionized Public Health Teaching to Equip Medical Students for 21st Century Practice.

Medical graduates increasingly need public health skills to equip them to face the challenges of healthcare practice in the 21st century; however, incorporating public health learning within medical degrees remains a challenge. This paper describes the process and preliminary outcomes of the transformation, between 2016 and 2019, of a 5-week public health module taught within an undergraduate medical degree in New Zealand. The previous course consisted of a research project and standalone lectures on public health topics. The new course takes an active case-based learning approach to engage student interest and stimulate a broadening of perspective from the individual to the population while retaining relevance to students. A combination of individual- and population-level case scenarios aim to help students understand the context of health, think critically about determinants of health and health inequities, and develop skills in disease prevention, health promotion, and system change that are relevant to their future clinical careers. The new module is based on contemporary medical education theory, emphasizes reflective practice, and is integrated with other learning in the degree. It challenges students to understand the relevance of public health to every aspect of medicine and equips them with the skills needed to act to improve population health and reduce inequities as health professionals and leaders of the future.

Ethnic disparities in the use of seclusion for adult psychiatric inpatients in New Zealand.

AIM: This study aims to investigate disparities in seclusion between Maori and non-Maori non-Pacific (nMnP) adults in mental health inpatient units in New Zealand. METHOD: This study uses data on 7,239 inpatient psychiatric admissions and 782 seclusion events for nine district health boards (servicing 39% of the New Zealand population) for the period 1 July 2008 to 30 June 2010, from a New Zealand Ministry of Health dataset (PRIMHD). We calculate the age-standardised rates of seclusion per monthly inpatient admissions. Regression modelling of seclusion event rate ratios for Maori compared to nMnP adjusted for age, gender, socioeconomic deprivation (NZDep2006), legal status, referral pathway and diagnosis. RESULTS: Maori psychiatric inpatients are 39% more likely to experience a seclusion episode than nMnP adults in New Zealand. Important contributors to the disparity in seclusion rates between Maori and nMnP were age and legal status on admission. Adjustment for a range of demographic and admission variables accounted for part of the measured disparity between Maori and nMnP (RR 1.33, fully adjusted). CONCLUSIONS: To reduce seclusion use for Maori, community mental health services responsive to Maori needs are required to prevent the need for inpatient admission, and reduce the acuity of illness where admission is required.

Incidence and management of hepatocellular carcinoma among Maori and non-Maori New Zealanders.

OBJECTIVE: To investigate time trends in hepatocellular carcinoma (HCC) incidence disparities, and ethnic differences in risk factors, comorbidity and treatment pathways among HCC patients. METHODS: Cohorts of the NZ population (1981-2004) were created and probabilistically linked to cancer registry records to investigate trends in incidence by ethnicity over time. Hospital notes of 97 Maori and 92 non-Maori HCC patients diagnosed between 01/01/2006 and 31/12/2008 in NZ's North Island were reviewed. RESULTS: Liver cancer incidence was higher among Maori for all time periods. Compared with non-Maori, Maori males had nearly five times the rate of liver cancer (pooled RR=4.79, 95% CI 4.14-5.54), and Maori females three times the rate (pooled RR= 3.02, 95% CI 2.33-3.92). There were no significant differences in tumour characteristics or treatment of Maori and non-Maori patients with HCC. Maori more commonly had hypertension (51% versus 25%) while more non-Maori had cirrhosis recorded (62% versus 41%). The prevalence of hepatitis B among Maori patients (56%; 95% CI 45%-67%) was more than double that of non-Maori (27%; 95% CI 19%-36%). The hazard ratio for cancer-specific death for Maori compared with non-Maori was 1.36 (95% CI 0.96-1.92). CONCLUSIONS AND IMPLICATIONS: HCC remains an important health problem particularly for Maori men. Efforts to improve coverage of screening for hepatitis B and surveillance of those with chronic hepatitis should be a priority to address the large inequalities found in liver cancer epidemiology.

Social inequalities or inequities in cancer incidence? Repeated census-cancer cohort studies, New Zealand 1981-1986 to 2001-2004.

BACKGROUND: We examine incidence trends for 18 adult cancers, by ethnicity and socioeconomic position in New Zealand. METHODS: The 1981 to 2001 censuses were linked to subsequent cancer registrations, giving 47.5 million person-years of follow-up. RESULTS ETHNICITY: Pooled over time, differences were marked: Pacific and Maori rates of cervical, endometrial, stomach and pancreatic cancers were 1.5-2.5 times European/Other rates; Maori, Pacific and Asian rates of liver cancer were 5 times European/Other; European/Other rates of colorectal, bladder and brain cancers were 1.5-2 times the rates of other groups and melanoma rates 5-10 times higher; Pacific and Asian kidney cancer rates were half those of Maori and European/Other. Over time, Maori and Pacific rates of cervical cancer fell faster and Maori rates of colorectal and breast cancer increased faster, than European/Other rates. Male lung cancer rates decreased for European/Other, were stable for Maori and increased for Pacific. Female lung cancer rates increased for all ethnic groups. INCOME: Other than lung (rate ratio 1.35 men, 1.56 women), cervical (1.35) and stomach cancer (1.23), differences in incidence by income were modest or absent. CONCLUSIONS: Tobacco explains many of the social group trends and differences and constitutes an inequity. Cervical cancer trends are plausibly explained by screening and sexual practices. Faster increases of colorectal and breast cancer among Maori are presumably due to changes in dietary and reproductive behaviour, but the higher Maori breast cancer rate is unexplained. Ethnic differences in bladder, brain, endometrial and kidney cancer cannot be fully explained.

Ethnic and socioeconomic trends in breast cancer incidence in New Zealand.

BACKGROUND: Breast cancer incidence varies between social groups, but differences have not been thoroughly examined in New Zealand. The objectives of this study are to determine whether trends in breast cancer incidence varied by ethnicity and socioeconomic position between 1981 and 2004 in New Zealand, and to assess possible risk factor explanations. METHODS: Five cohorts of the entire New Zealand population for 1981-86, 1986-1991, 1991-1996, 1996-2001, and 2001-2004 were created, and probabilistically linked to cancer registry records, allowing direct determination of ethnic and socioeconomic trends in breast cancer incidence. RESULTS: Breast cancer rates increased across all ethnic and socioeconomic groups between 1981 and 2004. Maori women consistently had the highest age standardised rates, and the difference between Maori and European/Other women increased from 7% in 1981-6 to 24% in 2001-4. Pacific and Asian women had consistently lower rates of breast cancer than European/Other women over the time period studied (12% and 28% lower respectively when pooled over time), although young Pacific women had slightly higher incidence rates than young European/other women. A gradient between high and low income women was evident, with high income women having breast cancer rates approximately 10% higher and this difference did not change significantly over time. CONCLUSIONS: Differences in breast cancer incidence between European and Pacific women and between socioeconomic groups are explicable in terms of known risk factors. However no straightforward explanation for the relatively high incidence amongst Maori is apparent. Further research to explore high Maori breast cancer rates may contribute to reducing the burden of breast cancer amongst Maori women, as well as improving our understanding of the aetiology of breast cancer.

Survival disparities in Indigenous and non-Indigenous New Zealanders with colon cancer: the role of patient comorbidity, treatment and health service factors.

BACKGROUND: Ethnic disparities in cancer survival have been documented in many populations and cancer types. The causes of these inequalities are not well understood but may include disease and patient characteristics, treatment differences and health service factors. Survival was compared in a cohort of Maori (Indigenous) and non-Maori New Zealanders with colon cancer, and the contribution of demographics, disease characteristics, patient comorbidity, treatment and healthcare factors to survival disparities was assessed. METHODS: Maori patients diagnosed as having colon cancer between 1996 and 2003 were identified from the New Zealand Cancer Registry and compared with a randomly selected sample of non-Maori patients. Clinical and outcome data were obtained from medical records, pathology reports and the national mortality database. Cancer-specific survival was examined using Kaplan-Meier survival curves and Cox hazards modelling with multivariable adjustment. RESULTS: 301 Maori and 328 non-Maori patients with colon cancer were compared. Maori had a significantly poorer cancer survival than non-Maori (hazard ratio (HR)=1.33, 95% CI 1.03 to 1.71) that was not explained by demographic or disease characteristics. The most important factors contributing to poorer survival in Maori were patient comorbidity and markers of healthcare access, each of which accounted for around a third of the survival disparity. The final model accounted for almost all the survival disparity between Maori and non-Maori patients (HR=1.07, 95% CI 0.77 to 1.47). CONCLUSION: Higher patient comorbidity and poorer access and quality of cancer care are both important explanations for worse survival in Maori compared with non-Maori New Zealanders with colon cancer.