Drivers of access to cardiovascular health care for rural Indigenous Peoples: a scoping review.

INTRODUCTION: Māori (the Indigenous Peoples of Aotearoa New Zealand) are disproportionately represented in cardiovascular disease (CVD) prevalence, morbidity and mortality rates, and are less likely to receive evidence-based CVD health care. Rural Māori experience additional barriers to treatment access, poorer health outcomes and a greater burden of CVD risk factors compared to Non-Māori and Māori living in urban areas. Importantly, these inequities are similarly experienced by Indigenous Peoples in other nations impacted by colonisation. Given the scarcity of available literature, a systematic scoping review was conducted on literature exploring barriers and facilitators in accessing CVD health care for rural Māori and other Indigenous Peoples in nations impacted by colonisation. METHODS: The review was underpinned by Kaupapa Māori Research methodology and was conducted utilising Arksey and O'Malley's (2005) methodological framework. A database search of MEDLINE (OVID), PubMed, Embase, SCOPUS, CINAHL Plus, Australia/New Zealand Reference Centre and NZResearch.org was used to explore empirical research literature. A grey literature search was also conducted. Literature based in any healthcare setting providing care to adults for CVD was included. Rural or remote Indigenous Peoples from New Zealand, Australia, Canada, and the US were included. Literature was included if it addressed cardiovascular conditions and reported barriers and facilitators to healthcare access in any care setting. RESULTS: A total of 363 articles were identified from the database search. An additional 19 reports were identified in the grey literature search. Following screening, 16 articles were included from the database search and 5 articles from the grey literature search. The literature was summarised using the Te Tiriti o Waitangi (Treaty of Waitangi) Framework principles: tino rangatiratanga (self-determination), partnership, active protection, equity and options. Themes elucidated from the literature were described as key drivers of CVD healthcare access for rural Indigenous Peoples. Key driver themes included input from rural Indigenous Peoples on healthcare service design and delivery, adequate resourcing and support of indigenous and rural healthcare services, addressing systemic racism and historical trauma, providing culturally appropriate health care, rural Indigenous Peoples' access to family and wellbeing support, rural Indigenous Peoples' differential access to the wider social determinants of health, effective interservice linkages and communication, and equity-driven and congruent data systems. CONCLUSION: The findings are consistent with other literature exploring access to health care for rural Indigenous Peoples. This review offers a novel approach to summarising literature by situating the themes within the context of equity and rights for Indigenous Peoples. This review also highlighted the need for further research in this area to be conducted in the context of Aotearoa New Zealand.

Development of a rural strategy for an urban-based medical program: a pragmatic reality.

INTRODUCTION: Health disparities between rural and urban areas in Aotearoa New Zealand are exacerbated by rural workforce issues. Traditionally, undergraduate medical programs are urban-based, and reconfiguring the curriculum to meet the needs of rural communities is challenging. The aim of this project is explore how urban-located universities might develop and implement a rural strategy. Evaluation of a rural strategy may lead to the strategy's ongoing improvements designed to increase the rural workforce. METHODS: This is a qualitative study involving semi-structured interviews with purposively selected key stakeholders. Enquiry included the systematic identification of processes required to develop a rural strategy, including possible facilitators and challenges to be addressed. Qualitative analysis of de-identified data was conducted using a thematic approach. RESULTS: Fourteen stakeholders were interviewed: four rural GPs, two rural hospital doctors, four administrators involved in placing students, and four senior medical academics with involvement in the regional and rural programs. Five overarching themes were identified: (1) developing rural pathways into medical school, (2) improving and expanding rural exposures, (3) developing rural GP pathways, (4) implementing interprofessional education and (5) having a social mission. CONCLUSION: These findings align with the literature relating to developing rural strategies for universities. However, this study also suggested that rural health interprofessional programs may have a role. A key finding was that the social mission of a university may not be visible to rural stakeholders. Reorientating an urban-located university to having a rural strategy requires moving past having policy around social accountability to operationalising it.

Socio-demographic profile of medical students in Aotearoa, New Zealand (2016-2020): a nationwide cross-sectional study.

OBJECTIVE: To determine the socio-demographic profile of all students enrolled to study medicine in Aotearoa New Zealand (NZ). DESIGN AND SETTING: Observational, cross-sectional study. Data were sought from the Universities of Auckland and Otago, the two NZ tertiary education institutions providing medical education, for the period 2016-2020 inclusive. These data are a subset of the larger project 'Mirror on Society' examining all regulated health professional enrolled students in NZ. VARIABLES OF INTEREST: gender, citizenship, ethnicity, rural classification, socioeconomic deprivation, school type and school socioeconomic scores. NZ denominator population data (18-29 years) were sourced from the 2018 census. PARTICIPANTS: 2858 students were enrolled to study medicine between 2016 and 2020 inclusive. RESULTS: There were more women (59.1%) enrolled to study medicine than men (40.9%) and the majority (96.5%) were in the 18-29 years age range. Maori students (rate ratio 0.92; 95% CI 0.84 to 1.0) and Pacific students (rate ratio 0.85; 95% CI 0.73 to 0.98) had lower overall rates of enrolment. For all ethnic groups, irrespective of rural or urban origin, enrolment rates had a nearly log-linear negative relationship with increasing socioeconomic deprivation. Enrolments were lower for students from rural areas compared with those from urban areas (rate ratio 0.53; 95% CI 0.46-0.61). Overall NZ's medical students do not reflect the diverse communities they will serve, with under-representation of Maori and Pacific students and students who come from low socioeconomic and rural backgrounds. CONCLUSIONS: To meaningfully address these issues, we suggest the following policy changes: universities commit and act to Indigenise institutional ways of knowing and being; selection policies are reviewed to ensure that communities in greatest need of doctors are prioritised for enrolment into medicine (specifically, the impact of low socioeconomic status should be factored into selection decisions); and the government fund more New Zealanders to study medicine.

Envisioning a Tiriti-responsive New Zealand Health Plan: lessons from district health boards' annual plans.

AIMS: Over recent decades, a body of research has established the presence of pervasive health inequities experienced by Maori. Work to identify the root causes of inequities has focused on the unequal distribution of the determinants of good health, access to healthcare, and racism. This study contributes to a small but growing field of work which engages with Te Tiriti o Waitangi to critique key health documents, focusing on district health boards' (DHBs) annual plans. METHODS: A qualitative, directed content analytical approach was used to investigate whether DHBs' 2019/2020 annual plans were consistent with the principles of Te Tiriti o Waitangi, as identified by the Wai 2575 Waitangi Tribunal inquiry. RESULTS: While annual plans contained actions that aligned with the principles of active protection and equity, comparatively few related to the principles of options, partnership, and tino rangatiratanga. Overall, DHB actions operated to constrain options available to Maori and efforts to exercise the Tiriti-guaranteed right of tino rangatiratanga in the provision of health services. CONCLUSION: While DHBs' annual plans expressed commitment to Te Tiriti o Waitangi, their content did not give effect to these commitments. Significant shifts are necessary if future New Zealand Health Plans are Tiriti-responsive documents that deliver Tiriti-responsive health services.

Understanding and experience of climate change in rural general practice in Aotearoa-New Zealand.

BACKGROUND: Climate change is already affecting Aotearoa New Zealand (Aotearoa-NZ). The public health effects are varied and complex, and rural primary care staff will be at the front line of effects and responses. However, little is known about their understanding and experience. OBJECTIVES: To determine understanding, experiences and preparedness of rural general practice staff in Aotearoa-NZ about climate change and health equity. METHODS: A mixed-methods national cross-sectional survey of rural general practice staff was undertaken that included Likert-style and free-text responses. Quantitative data were analysed with simple descriptive analysis and qualitative data were thematically analysed using a deductive framework based on Te Whare Tapa Wha. RESULTS: A proportion of survey respondents remained unsure about climate science and health links, although many others already reported a range of negative climate change health impacts on their communities, and expected these to worsen. Twenty to thirty percent of respondents lacked confidence in their health service's capability to provide support following extreme weather. Themes included acknowledgement that the health effects of climate change are highly varied and complex, that the health risks for rural communities combine climate change and wider environmental degradation and that climate change will exacerbate existing health inequities. CONCLUSIONS: The study adds to sparse information on climate change effects on health in rural primary care. We suggest that tailored professional education on climate change science and rural health equity is still needed, while urgent resourcing and training for interagency disaster response within rural and remote communities is needed.

Making sure the New Zealand border is not our Achilles heel: repeated cross-sectional COVID-19 surveys in primary care.

AIM: Quick COVID-19 Surveys are an international collaboration designed to rapidly analyse and disseminate a primary care perspective on the pandemic and associated health response. In this paper we present results from surveys relating to opening the New Zealand border. METHOD: Three surveys were distributed to primary care practices between May and December 2020. A range of primary care member organisations distributed the survey augmented by snowballing. Quantitative data were analysed using descriptive statistics and qualitative data through an inductive process and grouped into themes. RESULTS: Respondents became increasingly supportive of opening a trans-Tasman border but not internationally. Two broad themes were evident: (1) making sure that the border is not an Achilles heel and (2) effective strategies to reduce local transmission. These themes highlight primary care's concerns around management of the border and the management of local spread respectively. CONCLUSION: The results highlight concerns around border control from a primary care perspective. The border control issues raised by primary care have proven to be prophetic at times and reflect the role that primary care has as observers of society. The survey mechanism provides a template for rapidly eliciting a primary care voice for future health issues.

Ngatiwai Whakapakari Tinana: strengthening bodies through a Kaupapa Maori fitness and exercise programme.

INTRODUCTION Activity based weight loss programmes may result in modest reductions in weight. Despite the small successes demonstrated by these interventions, there are few examples that specifically address the disparity of obesity for Maori compared to non-Maori. AIM This research highlights the results of a Kaupapa Maori fitness and exercise programme that aimed to assist mainly Maori adults, to lose weight. The programme was designed to support participants by using Maori cultural values. METHODS A Muay Thai kickboxing exercise programme was developed with community involvement. Kaupapa Maori principles underpinned the programme, such as whanaungatanga and tino rangatiratanga. Ninety-three participants were followed for at least 3 months. Participants' blood pressure, weight, body mass index, mental wellbeing scores, and waist and hip circumferences were collected at regular intervals. Multiple linear models were used to calculate estimated changes per 100 days of the programme. RESULTS The mean duration of participation was 214 days. The estimated weight loss per participant per 100 days was 5.2 kg. Statistically significant improvements were noted in blood pressure, waist and hip circumference, systolic blood pressure and mental wellbeing. DISCUSSION The improvements in physical and mental wellbeing are thought to have stemmed, in part, from the use of Kaupapa Maori principles. The success of this programme strengthens the argument that programmes aiming to address the precursors of chronic disease need to be designed for Maori by Maori in order to reduce health inequities.

Impact of Gaps in Merit-Based Incentive Payment System Measures on Marginalized Populations.

As the United States enters a new era of value-based payment heavy in emphasis on primary care measurement, careful examination of selected measures and their potential impact on outcomes and vulnerable populations is essential. Applying a theoretical model of health care quality as a coding matrix, we used a directed content analysis approach to categorize individual Merit Based Incentive Payment System (MIPS) measures. We found that most MIPS measures related to aspects of clinical effectiveness, whereas few, if any, related to aspects of access, patient experience, or interpersonal care. These gaps suggest that MIPS may fail to measure the broader aspects of health care quality and even risk worsening existing disparities.

The impact of a point-of-care testing device on CVD risk assessment completion in New Zealand primary-care practice: A cluster randomised controlled trial and qualitative investigation.

OBJECTIVES: To assess the effect of a point of care (POC) device for testing lipids and HbA1c in addition to testing by community laboratory facilities (usual practice) on the completion of cardiovascular disease (CVD) risk assessments in general practice. METHODS: We conducted a pragmatic, cluster randomised controlled trial in 20 New Zealand general practices stratified by size and rurality and randomised to POC device plus usual practice or usual practice alone (controls). Patients aged 35-79 years were eligible if they met national guideline criteria for CVD risk assessment. Data on CVD risk assessments were aggregated using a web-based decision support programme common to each practice. Data entered into the on-line CVD risk assessment form could be saved pending blood test results. The primary outcome was the proportion of completed CVD risk assessments. Qualitative data on practice processes for CVD risk assessment and feasibility of POC testing were collected at the end of the study by interviews and questionnaire. The POC testing was supported by a comprehensive quality assurance programme. RESULTS: A CVD risk assessment entry was recorded for 7421 patients in 10 POC practices and 6217 patients in 10 control practices; 99.5% of CVD risk assessments had complete data in both groups (adjusted odds ratio 1.02 [95%CI 0.61-1.69]). There were major external influences that affected the trial: including a national performance target for CVD risk assessment and changes to CVD guidelines. All practices had invested in systems and dedicated staff time to identify and follow up patients to completion. However, the POC device was viewed by most as an additional tool rather than as an opportunity to review practice work flow and leverage the immediate test results for patient education and CVD risk management discussions. Shortly after commencement, the trial was halted due to a change in the HbA1c test assay performance. The trial restarted after the manufacturing issue was rectified but this affected the end use of the device. CONCLUSIONS: Performance incentives and external influences were more powerful modifiers of practice behaviours than the POC device in relation to CVD risk assessment completion. The promise of combining risk assessment, communication and management within one consultation was not realised. With shifts in policy focus, the utility of POC devices for patient engagement in CVD preventive care may be demonstrated if fully integrated into the clinical setting. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12613000607774.

Reliability of Mini-CEX Assessment of Medical Students in General Practice Clinical Attachments.

BACKGROUND AND OBJECTIVES: Mini Clinical Evaluation eXercise (mini-CEX) involves observation of routine clinical encounters, initially developed to assess clinical competencies of postgraduate doctors. This study aimed to measure its inter-rater reliability in assessment of medical students in general practice settings. METHODS: General practitioners (GPs) supervising medical students were invited to complete online teaching on how to conduct a mini-CEX. This included three randomly presented scripted films of clinical scenarios representing different levels of student performance. Consenting participants completed an online mini-CEX. Mean marks were calculated for each case, Intraclass Correlation Coefficients (ICC) for overall clinical and four individual competencies, one-way analysis of variance to compare scores, and internal consistency measured by Cronbach's alpha. RESULTS: RESULTS were collated for the first 100 completing GPs, majority aged 40-59 years (71%), male (59%), New Zealand European (58%). Forty-four percent were in rural practice, with 21 mean years in practice. Mean mini-CEX grades increased as standardized performance increased, indicating that GPs reliably agreed about ranking of student performance from poor to very good. The intraclass correlation coefficient (ICC) for overall clinical competency was 0.78 (95% confidence interval 0.48-0.99), indicating good reliability regarding their agreement with each other. A Cronbach's alpha calculated with the overall scores was 0.85, indicating good internal consistency. CONCLUSIONS: Mini-CEXs in undergraduate general practice attachments provide a reliable measure of assessing performance. However, they may be less useful in identifying exceptional performance or weaknesses in key competencies. In addition, caution must be applied in relying upon mini-CEXs to supply a summative assessment.

What makes Care Plus effective in a provincial Primary Health Organisation? Perceptions of primary care workers.

INTRODUCTION: Care Plus is a New Zealand chronic care initiative. It provides funding for extra primary care visits for patients with chronic diseases and aims to improve chronic care management, primary health care team work and reduce inequalities in health care. This mixed methodology study aimed to explore characteristics within practices that may contribute to improved clinical outcomes for Care Plus. METHODS: A focus group interview was conducted with a group of health professionals involved in Care Plus in a North Island Primary Health Organisation (PHO). Participants were selected because of their 'expert status'. Interview analysis used a general inductive approach. A questionnaire was sent to all practice nurses to determine prevalence of characteristics derived from the focus group. FINDINGS: Seven primary care workers involved in Care Plus participated in a focus group from which three major themes emerged: nursing factors, practice organisation factors and general practitioner (GP) factors. Sub-themes identified as patient-centredness, assertive follow-up, nursing knowledge, referral to other health professionals, dedicated appointment times, long consultation time, low cost, GP commitment and teamwork were all considered to be characteristics that could lead to improved clinical outcomes. Questionnaire responses from 18 practice nurses suggest that GPs are under-involved with Care Plus. DISCUSSION: Patients with chronic conditions have complex needs. Care Plus is a nationwide initiative providing funding for chronic care. Some characteristics of nurses, practice organisation and GPs may lead to improved clinical outcomes in Care Plus. A number of these characteristics are supported in the literature.