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.

It's not special treatment That's part of the Treaty of Waitangi! Organisational barriers to enhancing the Aged Residential Care environment for older Maori and Whanau in New Zealand.

BACKGROUND: New Zealand's older Indigenous Maori people experience poorer health and reduced access to healthcare than their older non-Maori counterparts. Organisational factors (such as leadership or workforce) may influence the attitudes and perceptions of older Maori and their family (whanau) to use aged residential care services. Currently, there is a paucity of research surrounding the organisational barriers that impact the experiences of older Maori people who seek care in aged residential care (ARC) services. METHODS: This study used a Kaupapa Maori qualitative research approach that legitimises Maori knowledge and critiques structures that subjugate Maori autonomy and control over their wellbeing. Interviews regarding their experiences of care were carried out with older Maori (n = 30) and whanau (family) members (n = 18) who had used, or declined to use an aged residential care facility. Narrative data were analysed inductively for themes that illustrated organisational barriers. RESULTS: The key organisational theme was 'Culturally safe care', within which there were three barriers: 'Acceptability and Adequacy of Facility', 'Interface Between Aged Residential Care and Whanau Models of Care', and 'Workforce'. Collectively, these barriers emphasise the importance of an organisational approach to improving the quality of care delivered to older Maori and whanau in ARC. CONCLUSION: Fostering a collective culture of equity within ARC provider services and equipping healthcare leaders and staff with the skills and knowledge to deliver culturally safe care is critical to addressing organisational barriers to ARC.

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.

Acute aortic syndrome: nationwide study of epidemiology, management, and outcomes.

BACKGROUND: Epidemiological studies on acute aortic syndrome (AAS) have relied largely on unverified administrative coding, leading to wide-ranging estimates of incidence. This study aimed to evaluate the incidence, management, and outcomes of AAS in Aotearoa New Zealand. METHODS: This was a national population-based retrospective study of patients presenting with an index admission of AAS from 2010 to 2020. Cases from the Ministry of Health National Minimum Dataset, National Mortality Collection, and the Australasian Vascular Audit were cross-verified with hospital notes. Poisson regression adjusted for sex and age was used to investigate trends over time. RESULTS: During the study interval, 1295 patients presented to hospital with confirmed AAS, including 790 with type A (61.0 per cent) and 505 with type B (39.0 per cent) AAS. A total of 290 patients died out of hospital between 2010 and 2018. The overall incidence of aortic dissection including out-of-hospital cases was 3.13 (95 per cent c.i. 2.96 to 3.30) per 100 000 person-years, and this increased by an average of 3 (95 per cent c.i. 1 to 6) per cent per year after adjustment for age and sex adjustment on Poisson regression, driven by increasing type A cases. Age-standardized rates of disease were higher in men, and in Maori and Pacific populations. The management strategies used, and 30-day mortality rates among patients with type A (31.9 per cent) and B (9.7 per cent) disease have remained constant over time. CONCLUSION: Mortality after AAS remains high despite advances over the past decade. The disease incidence and burden are likely to continue to increase with an ageing population. There is impetus now for further work on disease prevention and the reduction of ethnic disparities.

Interviews with Indigenous Maori with type 1 diabetes using open-source automated insulin delivery in the CREATE randomised trial.

Purpose: Open-source automated insulin delivery (AID) is used by thousands of people with type 1 diabetes (T1D), but has unknown generalisability to marginalised ethnic groups. This study explored experiences of Indigenous Maori participants in the CREATE trial with use of an open-source AID system to identify enablers/barriers to health equity. Methods: The CREATE randomised trial compared open-source AID (OpenAPS algorithm on an Android phone with a Bluetooth-connected pump) to sensor-augmented pump therapy. Kaupapa Maori Research methodology was used in this sub-study. Ten semi-structured interviews with Maori participants (5 children, 5 adults) and whanau (extended family) were completed. Interviews were recorded and transcribed, and data were analysed thematically. NVivo was used for descriptive and pattern coding. Results: Enablers/barriers to equity aligned with four themes: access (to diabetes technologies), training/support, operation (of open-source AID), and outcomes. Participants described a sense of empowerment, and improved quality of life, wellbeing, and glycaemia. Parents felt reassured by the system's ability to control glucose, and children were granted greater independence. Participants were able to use the open-source AID system with ease to suit whanau needs, and technical problems were manageable with healthcare professional support. All participants identified structures in the health system precluding equitable utilisation of diabetes technologies for Maori. Conclusion: Maori experienced open-source AID positively, and aspired to use this therapy; however, structural and socio-economic barriers to equity were identified. This research proposes strength-based solutions which should be considered in the redesign of diabetes services to improve health outcomes for Maori with T1D.Trial Registration: The CREATE trial, encompassing this qualitative sub-study, was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12620000034932p) on the 20th January 2020. Supplementary Information: The online version contains supplementary material available at 10.1007/s40200-023-01215-3.

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.

'It absolutely needs to move out of that structure': Maori with bipolar disorder identify structural barriers and propose solutions to reform the New Zealand mental health system.

OBJECTIVES: This paper synthesises critique from Maori patients with Bipolar Disorder (BD) and their whanau to identify barriers and propose changes to improve the structure and function of the New Zealand mental health system. DESIGN: A qualitative Kaupapa Maori Research methodology was used. Twenty-four semi-structured interviews were completed with Maori patients with BD and members of their whanau. Structural, descriptive and pattern coding was completed using an adapted cultural competence framework to organise and analyse the data. RESULTS: Three key themes identified the impact of structural features of the New Zealand mental health system on health equity for Maori with BD. Themes involved the accessibility, delivery and scope of the current health system, and described how structural features influenced the quality, utility and availability of BD services for Maori patients and whanau. Structural barriers in the existing design, and potential changes to improve the accessibility, delivery and scope of BD services for Maori, were proposed including a redesign of operational, environmental, staffing, and navigation points (information, transition, fatigue) to better meet the needs of Maori with BD. CONCLUSION: A commitment to equity when implementing structural change is needed, including ongoing evaluation and refinement. This paper provides specific recommendations that should be considered in health service redesign to ensure the New Zealand mental health system meets the needs of Maori patients with BD and their whanau.

"If we can just dream " Maori talk about healthcare for bipolar disorder in New Zealand: A qualitative study privileging Indigenous voices on organisational transformation for health equity.

OBJECTIVES: This paper identifies barriers to equity and proposes changes to improve the organisation of healthcare in New Zealand for Maori with bipolar disorder (BD) and their families. DESIGN: A qualitative Kaupapa Maori methodology was used. Twenty-four semi-structured interviews were completed with Maori with BD and members of their family. Structural and descriptive coding was used to organise and analyse the data, including an analytic frame that explored participants' critique of attributes of the organisation of healthcare and alignment with Maori health policy. RESULTS: Transformation to the organisation of healthcare is needed to achieve health equity. Executive management must lead changes to organisational culture, deliver an equity partnership model with Maori, embed cultural safety and redesign the organisation of healthcare to improve wellbeing. Healthcare incentive structures must diversify, develop and retain a culturally competent health workforce. Information management and technology systems must guide continued whole system improvements. CONCLUSION: This paper provides recommendations that should be considered in planned reforms to the organisation of healthcare in New Zealand. The challenge remains whether resourcing for an equitable healthcare organisation will be implemented in partial fulfilment of promises of equity in policy.

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.

Reported Maori consumer experiences of health systems and programs in qualitative research: a systematic review with meta-synthesis.

BACKGROUND: Persistent inequities in health experiences and outcomes are observed for Maori compared to non-Maori in Aotearoa New Zealand. We conceptualised factors associated with Maori consumer experiences of health programs and services and characterise how the recommendations arising from qualitative research inform strategies to address inequities. METHODS: In this systematic review, electronic literature searching was conducted in February 2018. Qualitative studies reporting Maori consumer experiences of health services and programs in Aotearoa New Zealand were eligible. Maori consumer experiences of health services were mapped to the WHO Commission of Social Determinants of Health (CSDH) conceptual framework on health inequities as related to: (i) the socioeconomic and political context; (ii) socioeconomic positioning; or (iii) intermediary factors that increase exposure to health-compromising conditions. Recommendations to improve consumer experiences were mapped to the CSDH framework for tackling social determinants of health inequities as policy directions on: (i) unequal consequences of illness (individual interaction); (ii) risks of exposure to health-damaging factors (community); (iii) exposures to health-damaging factors (public policies); and (iv) mitigating effects of socioeconomic and political stratification (environment). RESULTS: Fifty-four studies were included. Maori consumer experiences mapped to social determinants of health inequities were most frequently related to direct interactions with health services and programs, particularly patient-clinician interactions (communication, relationships) and cultural competencies of clinicians and the system. Key recommendations by researchers mapped to potential strategies to address inequity were identified at all levels of the political, social and health system from individual interactions, community change, and broader public and system-level strategies. Recommendations were predominantly focused on actions to reduce risks of exposure to health-damaging factors including health literacy interventions, increased resources in cultural competencies and Maori capacity in health service development and workforce. CONCLUSIONS: Maori consumer experiences of health services and programs are an important informer of variables that impact health inequity. Strategies to tackle health inequities informed by Maori consumer experiences can be drawn from existing empirical research. Future qualitative exploration of how socioeconomic, political and public policies influence Maori consumer experiences of health services and programs could inform a broader range of structural policies to address health inequities.

Consolidated criteria for strengthening reporting of health research involving indigenous peoples: the CONSIDER statement.

BACKGROUND: Research reporting guidelines are increasingly commonplace and shown to improve the quality of published health research and health outcomes. Despite severe health inequities among Indigenous Peoples and the potential for research to address the causes, there is an extended legacy of health research exploiting Indigenous Peoples. This paper describes the development of the CONSolIDated critERtia for strengthening the reporting of health research involving Indigenous Peoples (CONSIDER) statement. METHODS: A collaborative prioritization process was conducted based on national and international statements and guidelines about Indigenous health research from the following nations (Peoples): Australia (Aboriginal and Torres Strait Islanders), Canada (First Nations Peoples, Métis), Hawaii (Native Hawaiian), New Zealand (Maori), Taiwan (Taiwan Indigenous Tribes), United States of America (First Nations Peoples) and Northern Scandinavian countries (Sami). A review of seven research guidelines was completed, and meta-synthesis was used to construct a reporting guideline checklist for transparent and comprehensive reporting of research involving Indigenous Peoples. RESULTS: A list of 88 possible checklist items was generated, reconciled, and categorized. Eight research domains and 17 criteria for the reporting of research involving Indigenous Peoples were identified. The research reporting domains were: (i) governance; (ii) relationships; (iii) prioritization; (iv) methodologies; (v) participation; (vi) capacity; (vii) analysis and findings; and (viii) dissemination. CONCLUSIONS: The CONSIDER statement is a collaborative synthesis and prioritization of national and international research statements and guidelines. The CONSIDER statement provides a checklist for the reporting of health research involving Indigenous peoples to strengthen research praxis and advance Indigenous health outcomes.

Sociodemographic, environmental characteristics and comorbidities of older adults with schizophrenia who access community health service support: A national cross-sectional study.

OBJECTIVES: Schizophrenia is a serious and chronic mental illness known to have broad ranging impacts for individuals across the lifespan, yet research on the disease in older adults is sparse. This study provides a profile of the sociodemographic, environmental and diagnostic characteristics of older community residents with schizophrenia using a national database. METHODS: A cross-sectional sample of individuals who underwent community needs assessment using the standardised Home Care International Residential Assessment Instrument between 1 September 2012 and 31 January 2016 was utilised. Sociodemographic, diagnostic, and social and environmental variables were measured for individuals with a diagnosis of schizophrenia and compared to those without a diagnosis of schizophrenia. Statistical investigations employed bivariable and multivariable logistic regression models. RESULTS: A total sample of 71,859 was eligible and 517 (0.7%) had a diagnosis of schizophrenia. The majority of the sociodemographic variables were statistically associated with schizophrenia in the adjusted analysis, except for ethnicity ( p = 0.35). Nearly all the measured social and environmental variables were adversely associated with having a diagnosis of schizophrenia, such as living in squalid conditions (adjusted odds ratio = 2.16; 95% confidence interval = [1.42, 3.28]). Participants with schizophrenia were significantly more likely to be diagnosed with all assessed psychiatric comorbidities ( p < 0.001) and diabetes mellitus ( p = 0.002), whereas coronary heart disease ( p = 0.001) and other physical comorbidities ( p = 0.001) were found at significantly lower rates. CONCLUSION: The profile of schizophrenia found here suggests some subtle differences in the demographic profile and distribution of medical comorbidities in the older population with schizophrenia. The results also suggest that this group continues to experience social disadvantage into old age. This requires the attention of policy-makers to ensure that services are tailored to the high social needs of these individuals.

Educating for Indigenous Health Equity: An International Consensus Statement.

The determinants of health inequities between Indigenous and non-Indigenous populations include factors amenable to medical education's influence-for example, the competence of the medical workforce to provide effective and equitable care to Indigenous populations. Medical education institutions have an important role to play in eliminating these inequities. However, there is evidence that medical education is not adequately fulfilling this role and, in fact, may be complicit in perpetuating inequities.This article seeks to examine the factors underpinning medical education's role in Indigenous health inequity, to inform interventions to address these factors. The authors developed a consensus statement that synthesizes evidence from research, evaluation, and the collective experience of an international research collaboration including experts in Indigenous medical education. The statement describes foundational processes that limit Indigenous health development in medical education and articulates key principles that can be applied at multiple levels to advance Indigenous health equity.The authors recognize colonization, racism, and privilege as fundamental determinants of Indigenous health that are also deeply embedded in Western medical education. To contribute effectively to Indigenous health development, medical education institutions must engage in decolonization processes and address racism and privilege at curricular and institutional levels. Indigenous health curricula must be formalized and comprehensive, and must be consistently reinforced in all educational environments. Institutions' responsibilities extend to advocacy for health system and broader societal reform to reduce and eliminate health inequities. These activities must be adequately resourced and underpinned by investment in infrastructure and Indigenous leadership.

Implementation and impact of indigenous health curricula: a systematic review.

CONTEXT: The effectiveness of cultural competency education in improving health practitioner proficiency and addressing health inequities for minoritised patient groups is uncertain. Identification of institutional factors that shape or constrain development of indigenous health curricula may provide insights into the impact of these factors on the broader cultural competency curricula. METHODS: We undertook a systematic review using actor-network theory to inform our interpretive synthesis of studies that reported indigenous health curricula evaluated within medical, nursing and allied health education. We searched the MEDLINE, OVID Nursing, Educational Resources Information Center (ERIC), PsycINFO, EMBASE, Web of Science and PubMed databases to December 2017 using exploded MeSH terms 'indigenous' and 'medical education' and 'educational professional' and 'health professional education'. We included studies involving undergraduate or postgraduate medical, nursing or allied health students or practitioners. Studies were eligible if they documented indigenous health learning outcomes, pedagogical practices and student evaluations. RESULTS: Twenty-three studies were eligible for the review. In an interpretive synthesis informed by actor-network theory, three themes emerged from the data: indigenous health as an emerging curriculum (drivers of institutional change, increasing indigenous capacity and leadership, and addressing deficit discourse); institutional resource allocation to indigenous health curricula (placement within the core curriculum, time allocation, and resources constraining pedagogy), and impact of the curriculum on learners (acceptability of the curriculum, learner knowledge, and learner behaviour). CONCLUSIONS: Systemic barriers acting on and within educational networks have limited the developmental capacity of indigenous health curricula, supported and sustained hidden curricula, and led to insufficient institutional investment to support a comprehensive curriculum. Future research in health professional education should explore these political and network intermediaries acting on cultural competence curricula and how they can be overcome to achieve cultural competency learning outcomes.

Putting action into the revised Australian Medical Council standards on Aboriginal and Torres Strait Islander and Maori health.

Since 2006 the Australian Medical Council (AMC) accreditation standards have required medical schools to comprehensively address issues related to the health of Aboriginal and Torres Strait Islander peoples in Australia, and Maori in New Zealand. This has spanned areas of staff expertise, staff and student recruitment, curriculum and institutional leadership. These Indigenous specific standards have, until now, been absent for specialist medical college accreditation. The AMC revised its accreditation standards for specialist medical colleges in 2015, and for the first time included Indigenous specific standards. This commentary presents a guideline to support Australasian medical colleges' responsiveness to these Indigenous specific standards.

Maori Indigenous Health Framework in action: addressing ethnic disparities in healthcare.

There has been a steady increase in cultural competency training in medical education programmes worldwide. To provide high-quality culturally competent care and reduce health disparities between Maori and non-Maori in New Zealand, several health models have been devised. The Indigenous Health Framework (IHF), currently taught at the University of Otago, Christchurch undergraduate medical programme, is a tool developed to assist health professionals to broaden their range of clinical assessment and communicate effectively with Maori patients and whanau, thereby improving health outcomes and reducing disparities. The authors of this article present a Maori health case study written from the observations of a trainee intern (first author) using components from the IHF to address health disparities between Maori and non-Maori.

Survival Disparity Following Abdominal Aortic Aneurysm Repair Highlights Inequality in Ethnic and Socio-economic Status.

OBJECTIVES: Socio-economic status (SES) and ethnicity have been reported as markers influencing the likelihood of increased mortality. The aim of this study was to investigate how SES and ethnicity impacted patient survival after abdominal aortic aneurysm (AAA) repair. METHODS: Consecutive patients undergoing open and endovascular AAA repair during a 14.5 year period were identified. Ethnicity was defined as recorded on health records and SES (a score of 10, where 1 is least deprived and 10 being most deprived) and was linked to census data. Operative outcomes were reported at 30 days and a medium-term survival analysis used the Cox model to report adjusted hazard ratios (HR). RESULTS: A total of 6239 patients with a median age of 75 years and 78.7% males were included. The majority (5,654) were identified as New Zealand (NZ) Europeans, with 421 identified as NZ Maori, 97 identified as belonging to a Pacific ethnic group, and 67 identified as an Asian ethnic group. The median survival follow-up period was 5 years and after adjusting for confounders, those who identified as NZ Maori had the lowest survival compared with all other ethnic groups with a HR of 1.46 (95% CI 1.23-1.72). Living in areas of high social deprivation ≥ 7 was an independent predictor of short and medium-term overall mortality when compared with living in deprivation deciles 1 or 2. CONCLUSIONS: Low SES was identified as a marker of risk for all ethnic groups in relation to both reduced short and medium-term survival. However, regardless of SES, NZ Maori had worse overall medium-term survival following AAA repair than the other ethnic groups. Therefore it appears that both SES and being Maori were markers of increased exposure to risk that negatively impact upon survival after AAA repair. There is a need to ensure systemic processes support initiatives that reduce this inequality.

Indigenous health: designing a clinical orientation program valued by learners.

BACKGROUND: Indigenous health programs are seen as a curriculum response to addressing health disparities and social accountability. Several interrelated teaching approaches to cultural competency curricula have been recommended, however evidence of the impact of these on learner outcomes including engagement and self-reported competencies is limited. We aimed to explore undergraduate medical student perspectives of an indigenous health orientation program to inform curriculum strategies that promote learning and development of clinical skills. METHODS: We analyzed quantitative and qualitative student evaluations (n = 602) of a three-day immersed indigenous health orientation program between 2006 and 2014 based on Likert-scale responses and open-text comments. We conducted a thematic analysis of narrative student experiences (n = 426). RESULTS: Overall, 509 of 551 respondents (92%) rated the indigenous health orientation program as extremely or highly valuable and most (87%) reported that the course strongly increased their interest in indigenous health. The features of the clinical course that enhanced value for learners included situated learning (learning environment; learning context); teaching qualities (enthusiasm and passion for Maori health; role-modelling); curriculum content (re-presenting Maori history; exploring Maori beliefs, values and practices; using a Maori health framework in clinical practice); teaching methodologies (multiple teaching methods; simulated patient interview); and building relationships with peers (getting to know the student cohort; developing professional working relationships). CONCLUSIONS: Undergraduate medical students valued an indigenous health program delivered in an authentic indigenous environment and that explicitly reframed historical notions of indigenous health to contextualize learning. Content relevant to clinical practice, faculty knowledge, and strengthened peer interactions combined to build learner confidence and self-reported indigenous health competencies. These findings suggest empirical evidence to support a curriculum approach to indigenous health teaching that enhances clinical learning.