Examining the impact of COVID-19 on Maori:non-Maori health inequities in Aotearoa, New Zealand: an observational study protocol.

INTRODUCTION: The COVID-19 pandemic has had both direct and indirect impacts on the health of populations worldwide. While racial/ethnic health inequities in COVID-19 infection are now well known (and ongoing), knowledge about the impact of COVID-19 pandemic management on non-COVID-19-related outcomes for Indigenous peoples is less well understood. This article presents the study protocol for the Health Research Council of New Zealand funded project 'Ma te Mohio ka Marama: Impact of COVID-19 on Maori:non-Maori inequities'. The study aims to explore changes in access to healthcare, quality of healthcare and health outcomes for Maori, the Indigenous peoples of Aotearoa New Zealand (NZ) and non-Maori during the COVID-19 outbreak period across NZ. METHODS AND ANALYSIS: This observational study is framed within a Kaupapa Maori research positioning that includes Kaupapa Maori epidemiology. National datasets will be used to report on access to healthcare, quality of healthcare and health outcomes between Maori and non-Maori during the COVID-19 pandemic in NZ. Study periods are defined as (a) prepandemic period (2015-2019), (b) first pandemic year without COVID-19 vaccines (2020) and (c) pandemic period with COVID-19 vaccines (2021 onwards). Regional and national differences between Maori and non-Maori will be explored in two phases focused on identified health priority areas for NZ including (1) mortality, cancer, long-term conditions, first 1000 days, mental health and (2) rheumatic fever. ETHICS AND DISSEMINATION: This study has ethical approval from the Auckland Health Research Ethics Committee (AHREC AH26253). An advisory group will work with the project team to disseminate the findings of this project via project-specific meetings, peer-reviewed publications and a project-specific website. The overall intention of the project is to highlight areas requiring health policy and practice interventions to address Indigenous inequities in health resulting from COVID-19 pandemic management (both historical and in the future).

Experience of racism and associations with unmet need and healthcare satisfaction: the 2011/12 adult New Zealand Health Survey.

OBJECTIVE: Racism may affect health through differential access to, and quality of, healthcare. This study examined associations between experience of racism and unmet need and satisfaction with healthcare. METHODS: Cross-sectional analysis of the 2011/12 adult New Zealand Health Survey (n=12,596) was undertaken. Logistic regression was used to examine associations between experience of racism (by a health professional and other experiences of racism [ever]) and unmet need for a general practitioner and satisfaction with a usual medical centre in the past year. RESULTS: Experience of racism by a health professional and other forms of racism were higher among Maori, Pacific and Asian groups compared to European/Other. Both racism measures were associated with higher unmet need (health professional racism adjusted OR 3.52, 95%CI 2.42-5.11; other racism OR 2.21, 95%CI 1.78-2.75) and lower satisfaction with a usual medical centre (health professional racism adjusted OR 0.25, 95%CI 0.15-0.34; other racism OR 0.60, 95%CI 0.45-0.79). CONCLUSIONS: Racism may act as a barrier to, and influence the quality of, healthcare. Implications for public health: Addressing racism as a public health issue and major driver of inequities in healthcare and health outcomes is required within the health sector and wider society.

Racism and health in New Zealand: Prevalence over time and associations between recent experience of racism and health and wellbeing measures using national survey data.

OBJECTIVES: Racism is an important health determinant that contributes to ethnic health inequities. This study sought to describe New Zealand adults' reported recent experiences of racism over a 10 year period. It also sought to examine the association between recent experience of racism and a range of negative health and wellbeing measures. METHODS: The study utilised previously collected data from multiple cross-sectional national surveys (New Zealand Health Surveys 2002/03, 2006/07, 2011/12; and General Social Surveys 2008, 2010, 2012) to provide prevalence estimates of reported experience of racism (in the last 12 months) by major ethnic groupings in New Zealand. Meta-analytical techniques were used to provide improved estimates of the association between recent experience of racism and negative health from multivariable models, for the total cohorts and stratified by ethnicity. RESULTS: Reported recent experience of racism was highest among Asian participants followed by Maori and Pacific peoples, with Europeans reporting the lowest experience of racism. Among Asian participants, reported experience of racism was higher for those born overseas compared to those born in New Zealand. Recent experience of racism appeared to be declining for most groups over the time period examined. Experience of racism in the last 12 months was consistently associated with negative measures of health and wellbeing (SF-12 physical and mental health component scores, self-rated health, overall life satisfaction). While exposure to racism was more common in the non-European ethnic groups, the impact of recent exposure to racism on health was similar across ethnic groups, with the exception of SF-12 physical health. CONCLUSIONS: The higher experience of racism among non-European groups remains an issue in New Zealand and its potential effects on health may contribute to ethnic health inequities. Ongoing focus and monitoring of racism as a determinant of health is required to inform and improve interventions.

The relationship between socially-assigned ethnicity, health and experience of racial discrimination for Maori: analysis of the 2006/07 New Zealand Health Survey.

BACKGROUND: In New Zealand, there are significant and long-standing inequalities in a range of health outcomes, risk factors and healthcare measures between Maori (indigenous peoples) and Pakeha (European). This study expands our understanding of racism as a determinant of such inequalities to examine the concept of socially-assigned ethnicity (how an individual is classified by others ethnically/racially) and its relationship to health and racism for Maori. There is some evidence internationally that being socially-assigned as the dominant ethnic group (in this case European) offers health advantage. METHODS: We analysed data from the 2006/07 New Zealand Health Survey for adult participants who self-identified their ethnicity as Maori (n = 3160). The association between socially-assigned ethnicity and individual experience of racial discrimination, and socially-assigned ethnicity and health (self-rated health, psychological distress [Kessler 10-item scale]) was assessed using logistic and linear regression analyses, respectively. RESULTS: Maori who were socially-assigned as European-only had significantly lower experience of racial discrimination (adjusted odds ratio [OR] = 0.58, 95% confidence interval [CI] = 0.44, 0.78) than Maori who were socially-assigned as non-European. Being socially-assigned as European-only was also associated with health advantage compared to being socially-assigned non-European: more likely to respond with self-rated very good/excellent health (age, sex adjusted OR = 1.39, 95% CI = 1.10, 1.74), and lower Kessler 10 scores (age, sex adjusted mean difference = -0.66, 95% C I = -1.22, -0.10). These results were attenuated following adjustment for socioeconomic measures and experience of racial discrimination. CONCLUSIONS: Results suggest that, in a race conscious society, the way people's ethnicities are viewed by others is associated with tangible health risk or advantage, and this is consistent with an understanding of racism as a health determinant.

Investigating the relationship between socially-assigned ethnicity, racial discrimination and health advantage in New Zealand.

BACKGROUND: While evidence of the contribution of racial discrimination to ethnic health disparities has increased significantly, there has been less research examining relationships between ascribed racial/ethnic categories and health. It has been hypothesized that in racially-stratified societies being assigned as belonging to the dominant racial/ethnic group may be associated with health advantage. This study aimed to investigate associations between socially-assigned ethnicity, self-identified ethnicity, and health, and to consider the role of self-reported experience of racial discrimination in any relationships between socially-assigned ethnicity and health. METHODS: The study used data from the 2006/07 New Zealand Health Survey (n = 12,488), a nationally representative cross-sectional survey of adults 15 years and over. Racial discrimination was measured as reported individual-level experiences across five domains. Health outcome measures examined were self-reported general health and psychological distress. RESULTS: The study identified varying levels of agreement between participants' self-identified and socially-assigned ethnicities. Individuals who reported both self-identifying and being socially-assigned as always belonging to the dominant European grouping tended to have more socioeconomic advantage and experience less racial discrimination. This group also had the highest odds of reporting optimal self-rated health and lower mean levels of psychological distress. These differences were attenuated in models adjusting for socioeconomic measures and individual-level racial discrimination. CONCLUSIONS: The results suggest health advantage accrues to individuals who self-identify and are socially-assigned as belonging to the dominant European ethnic grouping in New Zealand, operating in part through socioeconomic advantage and lower exposure to individual-level racial discrimination. This is consistent with the broader evidence of the negative impacts of racism on health and ethnic inequalities that result from the inequitable distribution of health determinants, the harm and chronic stress linked to experiences of racial discrimination, and via the processes and consequences of racialization at a societal level.

Managing obstructive sleep apnoea and achieving equity: implications for health services.

Sleep occupies a third of life, and poor sleep has wide-ranging consequences for health, safety, and well-being. Recent research suggests significant inequalities in sleep health between Maori and non-Maori adults in New Zealand including self-reported sleeping problems and obstructive sleep apnoea syndrome (OSAS). This paper will outline a series of studies that were designed to assess how many people were affected by OSAS in Aotearoa/New Zealand and specifically sought to prioritise the needs of Maori. It will discuss a number of issues related to the diagnosis and treatment of OSAS in New Zealand and present strategies for reducing inequalities in sleep health.

Changing response rates from Maori and non-Maori in national sleep health surveys.

AIM: To understand declining response rates in New Zealand sleep health surveys by examining contextual changes and specific aspects of the questionnaires and research design that may have contributed. METHOD: From 1999-2008, four population surveys were undertaken, seeking to recruit equal numbers of Maori and non-Maori, consistent with the Kaupapa Maori principle of equal explanatory power; using the electoral roll as a sampling frame and including extensive follow-up. RESULTS: In successive surveys, there were fewer respondents in all age groups. Response rates from Maori were lower in all surveys and the percentage decline was greater than for non-Maori. Between 1999 and 2008, the response rates from the initial mail-out decreased by 50% and the proportion of the sample that were uncontactable increased by 50%. Identified societal trends included decreased currency of electoral roll address information, declining use of listed landline telephone numbers, and possibly declining willingness to participate from increasing respondent burden. Contributing study design features may have included changes in Maori leadership, increasing complexity of questions and saliency of the research topic to potential participants. CONCLUSIONS: The declining response rate in sleep population surveys is likely to be due to a number of factors. The pros and cons of using the electoral roll as a sampling frame in mail surveys should be carefully considered.

Sleep, sleepiness and motor vehicle accidents: a national survey.

OBJECTIVE: To assess the role of sleep-related factors, ethnicity and socioeconomic deprivation in self-reported motor vehicle accidents while driving, after controlling for gender, age and driving exposure. METHODS: Mail survey to a random electoral roll sample of 10,000 people aged 30-60 years, stratified by age decades and ethnicity (71% response rate). The analytical sample included 5,534 current drivers (21.6% Maori men, 21.2% Maori women, 30% non-Maori men, 27.2% non-Maori women). RESULTS: Multiple logistic regression analyses revealed the following independent risk factors for accident involvement while driving (last three years): being younger; higher average weekly driving hours; never/rarely getting enough sleep (OR=1.26, 95% CI 1.06-1.49); reporting any chance of dozing in a car while stopped in traffic (Epworth Sleepiness Scale question 8, OR=1.52, 95% CI 1.15-2.02); and among women, being non-Maori. Total Epworth score was not significantly related to reported accident involvement. CONCLUSIONS: Chronic sleep restriction, and any likelihood of dozing off at the wheel of a motor vehicle, were significant independent predictors of self-reported involvement in all types of motor vehicle accidents, not only those identified as fatigue-related. The Epworth Sleepiness Scale alone is not a reliable clinical tool for identifying individuals at higher risk of crashes. IMPLICATIONS: Factors relating to chronic sleepiness were as important as established demographic risk factors for self-reported motor vehicle accident involvement among 30-60 year-old drivers. The findings reinforce the need for multi-faceted campaigns to reduce sleepy driving.

Prevalence and consequences of insomnia in New Zealand: disparities between Maori and non-Maori.

OBJECTIVE: To investigate the prevalence of self-reported insomnia symptoms among Maori (Indigenous people) and non-Maori adults in the general population of New Zealand. To explore the consequences for health and quality of life experienced by those who report common insomnia complaints and sleeping problems. METHODS: In 2001, a two-page questionnaire was mailed to a stratified random sample of 4,000 adults aged 20-59 years nationwide. Participants were selected from the New Zealand electoral roll. The sample design aimed for equal numbers of Maori and non-Maori participants, men and women, and participants in each decade of age (72.5% response rate). RESULTS: Population prevalence estimates indicate that self-reported insomnia symptoms and sleeping problems are higher among Maori than non-Maori. Multiple logistic regression analyses showed that self-reported insomnia symptoms and/or sleeping problems are significantly associated with reporting poor or fair health and quality of life outcomes. CONCLUSIONS: Approximately one-quarter of adults in New Zealand may suffer from a chronic sleep problem, highlighting insomnia as a major public health issue in New Zealand. IMPLICATIONS: Significant differences in the prevalence of insomnia symptoms and current sleeping problems with respect to ethnicity have implications in the purchase and development of treatment services, with greater need for these services among Maori than non-Maori.