Health Inequality in Eight Adverse Outcomes Over a 25-Year Period in a Multi-Ethnic Population in New Zealand Population with Impaired Glucose Tolerance and/or Impaired Fasting Glucose: An Age-Period-Cohort Analysis.

Purpose: We aimed to examine socioeconomic inequality (SI) in cause-specific outcomes among adults with impaired glucose tolerance (IGT) and/or Impaired fasting glucose (IFG) in New Zealand (NZ) over 25 years. Patients and Methods: A population-based open cohort was derived from Diabetes Care Support Service in NZ with national databases linkage. Patients aged ≥18 years with IGT and/or IFG were enrolled between 01/01/1994 and 31/07/2018 and followed up until death or 31/12/2018. Incident outcomes (all-cause, premature, cardiovascular, and cancer death; cardiovascular, myocardial infarction, stroke, heart failure, and end-stage kidney disease hospitalization) by demographic, anthropometric, socioeconomic status, clinical measurements, enrol-time-periods, and IGT/IFG were evaluated. Adjusted incidence rate ratios, absolute risk difference, and SI measurements (slope and relative index of inequality) were estimated using Age-Period-Cohort models. Results: 29,894 patients (58.5 (SD 14.3) years mean age; 52.2% female) were enrolled with 5.6 (IQR: 4.4-7.4) years of median follow-up. Mortality rates decreased, whereas hospitalization (except myocardial infarction) rates increased. SI was significant for each outcome. Higher mortality and hospitalization rates and worsened SI were common in men, older, the most deprived, and Maori patients, as well as patients with obesity, current smoking, with both IFG and IGT, and greater metabolic derangement (higher systolic blood pressure, lipids, and HbA1c, and lower level of mean arterial pressure). Conclusion: Enhanced management strategies are necessary for people with IGT and/or IFG to address persisting SI, especially for men, older people, current smokers, NZ European and Maori patients, patients with obesity, or with any abnormal metabolic measurements.

Adverse Clinical Outcomes Attributable to Socioeconomic and Ethnic Disparities Among People with Type 2 Diabetes in New Zealand Between 1994-2018: A Multiple Linked Cohort Study.

Purpose: The study aimed to examine the separate population-level contributions of the ethnic and socioeconomic disparities among people with type 2 diabetes mellitus (T2DM) and residence in New Zealand (NZ). Patients and Methods: A prospective cohort enrolled T2DM patients from 01/01/1994 into the Diabetes Care Support Service, a primary care audit program in Auckland, NZ. The cohort was linked to national registry databases (socioeconomic status, pharmaceutical claim, hospitalization, and death registration). Each cohort member was followed up till death or the study end time (31/12/2019), whichever came first. Incident clinical events (stroke, myocardial infarction (MI), heart failure (HF), end-stage renal disease (ESRD), and premature mortality (PM)) were used as outcomes. The attributable fractions (AFs) were estimated for the whole population and for specific population with NZ Europeans (NZE) and/or least deprived population as reference, both unadjusted and with adjustment for covariables by Cox Regression models. Results: Among 36,267 patients, adjusted population AFs indicated 6.6(-30.8-33.3)% of PM, 17.1(5.8-27.0)% of MI, 35.3(22.6-46.0)% of stroke, 14.3(3.2-24.2)% of HF, and 15.9(6.7-24.2)% of ESRD could be attributed to deprivation; while 14.3(3.3-25.4)% of PM, -3.3(-8.3-1.5)% of MI, -0.5(-6.7-5.3)% of stroke, 4.7(0.3-8.8)% of HF, 13.3(9.9-16.6)% of ESRD could be attributed to ethnicity. Deprivation contributed a significant AF to stroke, while ethnicity was important for ESRD. Gradient of AF for deprivation indicated NZE and Asians were most affected by deprivation across outcomes. Conversely, Maori, with the highest AFs for ethnicity of PM and ESRD, were unaffected by deprivation. At same deprivations, the AFs of MI and stroke were greatest among NZE compared with other ethnic groups; the AF of ESRD was greatest among Maori and Pasifika. Conclusion: Both socioeconomic deprivation and ethnicity are strongly associated with outcomes in patients with T2DM in NZ, although the extent of the deprivation gradient is greatest among NZE and Asians, and least among Maori.

Rugby Fans in Training New Zealand (RUFIT-NZ): protocol for a randomized controlled trial to assess the effectiveness and cost-effectiveness of a healthy lifestyle program for overweight men delivered through professional rugby clubs in New Zealand.

BACKGROUND: A healthy lifestyle program that appeals to, and supports, obese New Zealand (NZ) European, Maori (indigenous) and Pasifika men to achieve weight loss is urgently needed. In Scotland, Football Fans in Training (FFIT), a weight management and healthy lifestyle program for overweight and obese men aged 35-65 years , delivered by community coaching staff at professional football clubs, has been shown to be beneficial and cost-effective. A pilot program inspired by FFIT but delivered by professional rugby clubs in NZ (n = 96) was shown to be effective in weight loss, improved physiological outcomes, and adherence to healthy lifestyle behaviors in overweight and obese men. The objective of this trial is to determine the effectiveness and cost-effectiveness of the Rugby Fans in Training New Zealand (RUFIT-NZ) program. METHODS: A pragmatic, two-arm, multi-center, randomized controlled trial involving 308 overweight and obese men aged 30-65 years, randomized to either an intervention group (n = 154) or a wait-list control group (n = 154). The intervention-group participated in the 12-week RUFIT-NZ program, a gender-sensitized, healthy lifestyle intervention adapted to the environment and cultural diversity of NZ and delivered through professional rugby clubs. Participants in the intervention group undergo physical training sessions, in addition to workshop-based sessions to learn about nutrition, physical activity, sleep, sedentary behavior, and a range of behavior-change strategies for sustaining a healthier lifestyle. The control group receives the program after 52 weeks. The primary outcome is change in body weight from baseline to 52 weeks. Secondary outcomes include change in body weight at 12 weeks; waist circumference, blood pressure, fitness, and lifestyle behaviors at 12 and 52 weeks; and cost-effectiveness. A process evaluation informed by the RE-AIM framework will evaluate potential implementation of RUFIT-NZ as an ongoing program in NZ after the trial. DISCUSSION: This trial will investigate the effectiveness and cost-effectiveness of the RUFIT-NZ program in overweight and obese NZ men. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry, ACTRN12619000069156. Registered on 18 January 2019, according to the World Health Organization Trial Registration Data Set. Universal Trial Number, U1111-1245-0645.

Effectiveness of recruitment to a smartphone-delivered nutrition intervention in New Zealand: analysis of a randomised controlled trial.

OBJECTIVES: Delivery of interventions via smartphone is a relatively new initiative in public health, and limited evidence exists regarding optimal strategies for recruitment. We describe the effectiveness of approaches used to recruit participants to a smartphone-enabled nutrition intervention trial. METHODS: Internet and social media advertising, mainstream media advertising and research team networks were used to recruit New Zealand adults to a fully automated smartphone-delivered nutrition labelling trial (no face-to-face visits were required). Recruitment of Maori and Pacific participants was a key focus and ethically relevant recruitment materials and approaches were used where possible. The effectiveness of recruitment strategies was evaluated using Google Analytics, monitoring of study website registrations and randomisations, and self-reported participant data. The cost of the various strategies and associations with participant demographics were assessed. RESULTS: Over a period of 13 months, there were 2448 registrations on the study website, and 1357 eligible individuals were randomised into the study (55%). Facebook campaigns were the most successful recruitment strategy overall (43% of all randomised participants) and for all ethnic groups (Maori 44%, Pacific 44% and other 43%). Significant associations were observed between recruitment strategy and age (p<0.001), household size (p<0.001), ethnicity (p<0.001), gender (p=0.005) and interest in healthy eating (p=0.022). Facebook campaigns resulted in the highest absolute numbers of study registrations and randomisations (966 and 584, respectively). Network strategies and Facebook campaigns cost least per randomised participant (NZ$4 and NZ$5, respectively), whereas radio advertising costs most (NZ$179 per participant). CONCLUSION: Internet and social media advertising were the most effective and least costly approaches to recruiting participants to a smartphone-delivered trial. These approaches also reached diverse ethnic groups. However, more culturally appropriate recruitment strategies are likely to be necessary in studies where large numbers of participants from specific ethnic groups are sought. TRIAL REGISTRATION: ACTRN12614000644662; Post-results.

Initiation and maintenance of cardiovascular medications following cardiovascular risk assessment in a large primary care cohort: PREDICT CVD-16.

AIM: To examine whether use of a standardized cardiovascular disease (CVD) risk assessment recommended by national guidelines is associated with appropriate initiation and maintenance of medication in a large primary care cohort. METHODS AND DESIGN: A total of 90,631 people aged 30-80 years were followed for up to 3 years after a formal CVD risk assessment was undertaken between January 2006 and October 2009, during routine primary care visits in New Zealand. Patients either had prior CVD or had their CVD risk estimated using a modified Framingham prediction equation for fatal or non-fatal CVD events. The individual risk profiles were anonymously linked to national dispensing data for blood-pressure-lowering and lipid-lowering medications in the 6-month period before and in consecutive 6-month blocks after the baseline CVD risk assessment. RESULTS: At baseline, a combination of blood-pressure-lowering and lipid-lowering therapy was already being used by about two-thirds of patients with prior CVD, one-quarter with a 5-year CVD risk greater than 10% (approximately 20% 10-year risk), and one-tenth with CVD risk below this level. Among these previously treated patients, dispensing rates for blood-pressure-lowering, lipid-lowering, or both medications together declined by only 4⊟16% up to 3 years after baseline assessment, irrespective of risk category. Among patients untreated at baseline, combination therapy was initiated within 6 months for 21% with prior CVD, 16% with 5-year CVD risk greater than 15% (approximately 30% 10-year risk and the national drug-treatment threshold), 10% with 5-year CVD risk between 10 and 14% (approximately 20⊟29% 10-year risk), and 3% in the lowest risk category. Across the study population, patients with prior CVD had the highest dispensing rates for each category of medication, and incrementally higher dispensing rates were noted as CVD risk group increased. CONCLUSIONS: In this primary care cohort, most patients already using CVD medications at the time of the baseline CVD risk assessment maintained treatment over a maximum of 3 years follow up, irrespective of their estimated baseline risk. Among patients untreated at baseline, subsequent dispensing rates were strongly related to estimated CVD risk group. Around 15⊟20% of untreated patients meeting national drug-treatment criteria commenced combination pharmacotherapy within 6 months of CVD risk assessment.

Impacts of inter- and intra- ethnic partnerships/relationships on traditional gift giving in a cohort of Pacific mothers.

Traditional gift-giving (TGG) is an important element of familial obligations among Pacific families. Migration from Pacific homelands to New Zealand and other countries has had an impact on participation in TGG., Many anecdotal accounts have suggested that TGG diminishes when Pacific persons marry outside their ethnic groups. While TGG is an indicator of social cohesion TGG can have direct influence on disposable income. The practice of TGG impacts on health as Income and social cohesion are key determinants of health. Thus TGG Health and social cohesion are closely interrelated and interdependent. The data for this paper is taken from a longitudinal cohort study of 1,398 Pacific children and their families in South Auckland, New Zealand. The study sought participants' responses to questions pertaining to the amounts gifted, the frequency of giving, recipients of the gifting and their reasons for participating and not participating in TGG. The assumption explored in this paper is that as Pacific peoples move outside their social sphere and become more acculturated with other ethnic groups, TGG was more likely to diminish rather than increase. This paper addresses the TGG participation rates among Pacific peoples in inter-ethnic relationships and intra-ethnic relationships. It argues that couples in an intra-ethnic intimate relationship are more likely to participate in traditional gift-giving than those who are in inter-ethnic intimate relationships. While this is true for most PI inter ethnic relationships the level of participation increases further with inter-ethnic intimate relationships among Tongans and Samoans who are also the largest participators of all ethnic groups in traditional gift-giving.

Utilisation of Traditional Pacific Healers by mothers and children of the Pacific Islands Families Study.

AIM: This research explores data on the mother's willingness to use, and children's use of Traditional Pacific Healers (TPH) from the first five waves of the Pacific Islands Families study (PIFS). Specific aims were: to report the prevalence of, and describe factors associated with, (1) the willingness of Pacific mothers to use the health services of Traditional Pacific Healers, (2) the use of Traditional Pacific Healers to treat children within the cohort and (3) to assess whether the use of Traditional Pacific Healers was a substitute or a supplement for western medicine. METHODS: Mothers were asked whether they would use a Traditional Pacific Healer if sick (willingness) and how often their child had seen a Traditional Pacific healer in the previous 12 months (use). These questions were asked at multiple measurement waves consisting of 6 week, 4 and 6 year for mothers, and 6 weeks, 1, 2, 4, and 6 year measurement waves for children. RESULTS: At 6 weeks 48% of mothers were willing to use TPH and this decreased to 36% at year 4 and 24% at year 6. Pacific born mothers, Samoan and Tongan mothers, and religious mothers were significantly more willing to use a TPH. Varied patterns of use were observed by children based on ethnicity and measurement wave. Like mothers--use by children declined as they aged. At 6 weeks 18% of children saw a TPH whilst 8% saw a TPH at age 6 years. Mothers amenable to using traditional healers are using them as supplemental to western medicine, rather than as a substitute. CONCLUSIONS: There is a steady reduction observed in mother's willingness and children's use of TPH in the PIFS over time. This raises the question of the whether provision of TPH is sustainable in NZ. There are significant differences in use of TPH by ethnicity. Further research that assesses reasons for visits, treatments provided, and costs may help explain the observed variations shown in this study.

'From Kava to Lager'--alcohol consumption and drinking patterns for older adults of Pacific ethnic groups, and Europeans in the Diabetes Heart and Health Study (DHAHS) 2002-2003, Auckland New Zealand.

AIM: This paper describes and compares alcohol consumption and drinking patterns for Pacific ethnic groups (Samoan, Tongan, Niue, Cook Islands) and European New Zealanders by gender participating in the 2002-03 Diabetes Heart and Health Study (DHAHS). METHODS: The DHAHS was a cross-sectional population based study of people age 35-74 years carried out in Auckland between 2002-03. A total of 1011 Pacific people comprising of 484 Samoan, 252 Tongan, 109 Niuean, 116 Cook Islanders and 47 'Other Pacific' (mainly Fijian) and 1745 European participants took part in the survey Participants answered a self-administered questionnaire to assess whether they consumed alcohol, their drinking patterns and consumption levels and reasons for stopping drinking. RESULTS: Approximately half (51.3%) of all Pacific people did not currently drink compared to 6.2% of the European population. Of 'non-drinkers'--never Drinking'was significantly more common in Pacific (40%) compared to Europeans (13%) p < 0.0001. Ex-drinkers comprised 6.3% of the 'ever-drank' population for European compared to 27.6% for Pacific. The majority of Pacific men and women drinkers (>60%) consumed alcohol 'weekly' or 'less than weekly'. In contrast the majority of European men and women drinkers (>60%) consumed alcohol '2-3 days per week' or 'daily'. European men were significantly more likely to drink wine and spirits, and European women were significantly more likely to drink wine than their Pacific counterparts. Pacific drinkers consumed an average of 6.9 drinks on a typical occasion and 82 mls of pure alcohol per week, compared to 3.6 drinks and 126 mls per week for Europeans. CONCLUSION: Middle-aged and older Pacific adults are less likely to consume alcohol than Europeans however those who drink consume more on a typical occasion but drink less regularly resulting in lower weekly consumption of pure alcohol. Drinking patterns in these Pacific adults tend to show substantial diversity by age (older are less likely to drink), sex (women less likely to drink), and financial deprivation (middle groups consume more than least and most financially deprived). For Europeans a more homogenous drinking style prevailed by age, sex, and deprivation. Pacific drinkers were also approximately five times more likely to stop drinking compared to Europeans, citing family and social reasons as their main motivation for stopping drinking.

Differences in health-related socioeconomic characteristics among Pacific populations living in Auckland, New Zealand.

AIM: To describe, compare and contrast the health-related socioeconomic characteristics of the different Pacific ethnic groups surveyed in the Auckland Diabetes, Heart and Health Survey (DHHS). METHODS: The DHHS was carried out in Auckland in 2002-2003. Electoral roll based sampling and cluster sampling strategies were used to recruit a representative sample of Auckland Pacific populations. Participants answered a self-administered questionnaire about their demographic and socioeconomic position. RESULTS: The study surveyed 1011 Pacific people aged between 35-74 years of age. Of the 1011 Pacific participants, 484 were of Samoan, 255 Tongan, 116 Cook Island, 109 Niuean, 26 Fijian, and 21 were of 'Other Pacific' ethnic groups. Samoans were least likely to have no children, and most likely to hold a certificate qualification. Tongans were least likely to be born in New Zealand (NZ) and had the shortest residence time in NZ. Tongans were most likely to be married and had the largest families. Cook Islanders were most likely to be NZ-born and had the highest household income. Niueans were most likely to be in paid employment, to hold a diploma qualification, to own their own homes, and have the smallest families. CONCLUSIONS: In conclusion, a distinct pattern (continuum) emerged from the results. The Cook Island and Niuean ethnic groups generally had a similar and more favourable socioeconomic profile compared to the Samoan and Tongan ethnic groups. These differences are most likely to be related to the length of residence in NZ. As differences existed, each Pacific ethnic group should be investigated separately when there are sufficient numbers.