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).

An innovative Indigenous-led model for integrated COVID-19 case management in Auckland, New Zealand: lessons from implementation.

In Aotearoa/New Zealand (NZ), the Indigenous Maori population have been more severely impacted than non-Maori throughout the COVID-19 pandemic, and less well served by NZ's COVID-19 response. This case-study describes an innovative Indigenous-led service delivery model, which was designed and implemented to improve the case and contact management of Maori with COVID-19 in Auckland. We outline the context in which the conventional public health case and contact management was failing Maori and the factors which enabled Indigenous innovation and leadership. We describe the details of the model and how the approach fundamentally differed to the conventional approach to care. Qualitative and quantitative data on impact of the model are shared, along with the key barriers and enablers in the implementation of the model. The Maori Regional Coordination Hub (MRCH) model offers a valuable alternative to the conventional public health case and contact management approach, and this case study highlights lessons which may be applicable to improving the design and delivery of public health services to other Indigenous and marginalized groups.

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.

Inequities in colonoscopy access: a retrospective audit of accepted referrals in Te Whatu Ora Counties Manukau.

AIM: Maori are more likely to have colorectal cancer (CRC) diagnosed in the emergency setting.[[1]] CRC patients diagnosed in the emergency setting have a higher stage, increased surgical complications and worse survival than those diagnosed elsewhere.[[2]] Access to colonoscopy is crucial to diagnosing CRC prior to an emergency presentation. This study aims to assess inequities in access to symptomatic and surveillance colonoscopies. METHODS: A retrospective audit of all accepted referrals for symptomatic and surveillance colonoscopies made in Te Whatu Ora Counties Manukau in 2018 (n=7,184) with analysis by multivariate logistic regression. RESULTS: Of the 751 Maori patients, 33.4% were removed off the waiting list and therefore did not have their colonoscopy performed, compared to 24.1% of the 4,047 NZ European patients. Maori patients were significantly more likely to be removed off the waiting list than NZ European patients with an adjusted odds ratio of 1.68 (95% confidence interval [CI] 1.40-2.02). Pasifika patients were significantly more likely to be removed off the waiting list than NZ European patients with an adjusted odds ratio of 2.30 (95% CI 1.92-2.75). CONCLUSIONS: Maori have significantly less access to colonoscopies than NZ Europeans. We suggest improvements to referral systems locally and nationally to facilitate equitable access.

Using Days Alive and Out of Hospital to measure inequities and possible pathways for them after cardiovascular surgery in Aotearoa New Zealand: study protocol for a secondary data analysis.

INTRODUCTION: In Aotearoa New Zealand (NZ), socioeconomic status and being of Maori ethnicity are often associated with poorer health outcomes, including after surgery. Inequities can be partially explained by differences in health status and health system biases are hypothesised as important factors for remaining inequities. Previous work identified inequities between Maori and non-Maori following cardiovascular surgery, some of which have been identified in studies between 1990 and 2012. Days Alive and Out of Hospital (DAOH) is an emerging surgical outcome metric. DAOH is a composite measure of outcomes, which may reflect patient experience and longer periods of DAOH may also reflect extended interactions with the health system. Recently, a 1.1-day difference in DAOH was observed between Maori and non-Maori at a hospital in NZ across a range of operations. METHODS AND ANALYSIS: We will conduct a secondary data analysis using data from the National Minimum Data Set, maintained by the Ministry of Health. We will report unadjusted and risk-adjusted DAOH values between Maori and non-Maori using direct risk standardisation. We will risk adjust first for age and sex, then for each of deprivation (NZDep18), levels of morbidity (M3 score) and rurality. We will report DAOH values across three time periods, 30, 90 and 365 days and across nine deciles of the DAOH distribution (0.1-0.9 inclusive). We will interpret all results from a Kaupapa Maori research positioning, acknowledging that Maori health outcomes are directly tied to the unequal distribution of the social determinants of health. ETHICS AND DISSEMINATION: Ethics approval for this study was given by the Auckland Health Research Ethics Committee. Outputs from this study are likely to interest a range of audiences. We plan to disseminate our findings through academic channels, presentations to interested groups including Maori-specific hui (meetings), social media and lay press.

National cross-sectional study of the sociodemographic characteristics of Aotearoa New Zealand's regulated health workforce pre-registration students: a mirror on society?

OBJECTIVES: To provide a sociodemographic profile of students enrolled in their first year of a health professional pre-registration programme offered within New Zealand (NZ) tertiary institutions. DESIGN: Observational, cross-sectional study. Data were sought from NZ tertiary education institutions for all eligible students accepted into the first 'professional' year of a health professional programme for the 5-year period 2016-2020 inclusive. VARIABLES OF INTEREST: gender, citizenship, ethnicity, rural classification, socioeconomic deprivation, school type and school socioeconomic scores. Analyses were carried out using the R statistics software. SETTING: Aotearoa NZ. PARTICIPANTS: All students (domestic and international) accepted into the first 'professional' year of a health professional programme leading to registration under the Health Practitioners Competence Assurance Act 2003. RESULTS: NZ's health workforce pre-registration students do not reflect the diverse communities they will serve in several important dimensions. There is a systematic under-representation of students who identify as Maori and Pacific, and students who come from low socioeconomic and rural backgrounds. The enrolment rate for Maori students is about 99 per 100 000 eligible population and for some Pacific ethnic groups is lower still, compared with 152 per 100 000 for NZ European students. The unadjusted rate ratio for enrolment for both Maori students and Pacific students versus 'NZ European and Other' students is approximately 0.7. CONCLUSIONS: We recommend that: (1) there should be a nationally coordinated system for collecting and reporting on the sociodemographic characteristics of the health workforce pre-registration; (2) mechanisms be developed to allow the agencies that fund tertiary education to base their funding decisions directly on the projected health workforce needs of the health system and (3) tertiary education funding decisions be based on Te Tiriti o Waitangi (the foundational constitutional agreement between the Indigenous people, Maori and the British Crown signed in 1840) and have a strong pro-equity focus.

The student narrative of undergoing academic difficulty and remediation in a medical programme: Indigenous Maori and Pacific Admission Scheme (MAPAS) and international student perspectives at The University of Auckland.

AIMS: To understand the medical student perspective and experiences of academic difficulty and remediation in years' 2-6 at The University of Auckland (UoA), Aotearoa New Zealand, who were admitted via the Indigenous Maori and Pacific Admission Scheme (MAPAS) and international student pathways. METHODS: A qualitative study which undertook one-on-one, semi-structured interviews using case study as the research method within Kaupapa Maori and Pacific research frameworks. Two student groups were interviewed during 2017: MAPAS and international medical students. An email invitation was sent to all students, inviting those who had failed a year, or at least one examination, assessment, module or domain in UoA Medical Programme during 2014-2016 to participate in the study. Interview transcripts were thematically analysed with an inductive approach. RESULTS: Fourteen medical students at UoA were included in the study, with ten from MAPAS and four from the international student admission pathway. There were six major themes identified. Three themes related to academic difficulty: the set curriculum, the hidden clinical curriculum and life complexities. Three related to the student perspectives of remediation: the impact of MAPAS support, enhanced resilience (particularly the MAPAS cohort) and stigmatisation from failing. CONCLUSIONS: This study has investigated the MAPAS and international medical student experience of academic difficulty and remediation at UoA. The student dialogue offered a rich insight to deepen our understanding into the remediation process to ensure it is not only culturally safe but also fit for purpose. Tertiary institutions that offer undergraduate medical education can (and should) better support their at-risk medical student cohorts.

Examining emergency department inequities in Aotearoa New Zealand: Findings from a national retrospective observational study examining Indigenous emergency care outcomes.

OBJECTIVE: There is increasing evidence that EDs may not operate equitably for all patients, with Indigenous and minoritised ethnicity patients experiencing longer wait times for assessment, differential pain management and less evaluation and treatment of acute conditions. METHODS: This retrospective observational study used a Kaupapa Maori framework to investigate ED admissions into 18/20 District Health Boards in Aotearoa New Zealand (2006-2012). Key pre-admission variable was ethnicity (Maori:non-Maori), and outcome variables included: ED self-discharge; ED arrival to assessment time; hospital re-admission within 72 h; ED re-presentation within 72 h; ED length of stay; ward length of stay; access block and mortality (in ED or within 10 days of ED departure). Generalised linear regression models controlled for year of presentation, sex, age, deprivation, triage category and comorbidity. RESULTS: Despite some ED process measures favouring Maori, for example arrival to assessment time (mean difference -2.14 min; 95% confidence interval [CI] -2.42 to -1.86) and access block (odds ratio [OR] 0.89, 95% CI 0.87-0.91), others showed no difference, for example self-discharge (OR 0.98, 95% CI 0.97-1.00). Despite this, Maori mortality (OR 1.60, 95% CI 1.50-1.71) and ED re-presentation (OR 1.11, 95% CI 1.09-1.12) were higher than non-Maori. CONCLUSION: To our knowledge, this is the most comprehensive investigation of acute outcomes by ethnicity to date in New Zealand. We found ED mortality inequities that are unlikely to be explained by ED process measures or comorbidities. Our findings reinforce the need to investigate health professional bias and institutional racism within an acute care context.

Barriers and facilitators for Maori in accessing hospital services in Aotearoa New Zealand.

AIM: This paper reports the findings of a literature review to answer the research question, "What are the barriers and facilitators of access to hospital services for Maori?" METHOD: MEDLINE (Ovid) and PsycINFO were searched using keywords to identify relevant literature published between 2000 and 2020. The data analysis was informed by a Kaupapa Maori positioning and the CONSIDER statement on reporting of health research involving Indigenous peoples. RESULTS: Twenty-three papers met the inclusion criteria. We identified five themes that captured the barriers for Maori accessing hospital services (practical barriers, poor communication, hostile healthcare environment, primary care barriers and racism) and five facilitatory themes were identified (practical facilitators, whakawhanaungatanga, whanau, manaakitanga and cultural safety). CONCLUSION: This article confirms existing knowledge about practical barriers and facilitators to healthcare access for Maori and contributes to an emerging body of evidence about the impact of racism and culturally unsafe services in preventing Maori from accessing healthcare services. The facilitators identified provide a potential roadmap for the redesign of services so they are accessible and effective for Maori. Improving services in this way would support district health boards, the Ministry of Health and professional organisations to comply with their commitments to providing culturally safe services and health professionals.

Hearing loss and hearing service experiences among older Maori and whanau: a scoping review.

AIM: Older Maori have higher rates of self-reported disabling hearing loss in Aotearoa New Zealand (NZ). However, have greater unmet need for special equipment than non-Maori. This review aims to analyse current literature on the experiences of hearing loss and hearing services among older Maori and whanau. METHOD: This scoping review was undertaken using a Kaupapa Maori approach and PRISMA guidelines. Databases were explored to identify literature focused on older Maori and whanau experiences of hearing loss and hearing services. Inclusion criteria included: literature set in the NZ context; published between 1985 and 2020; English language; focus on hard-of-hearing Maori and whanau experiencing sensorineural hearing loss. RESULTS: A total of eight sources were identified. Hearing loss is a detriment to daily functioning, partaking in conversations and retaining Maori culture. Cost and poor patient-provider interactions created barriers to hearing services for Maori with hearing loss and whanau. CONCLUSION: The last analysis of literature regarding hearing loss and hearing services for Maori was written in 1989. Inequities in hearing loss and access to hearing services remain. Research that is Maori-led and uses a Kaupapa Maori approach is needed to further understand the realities of hearing loss and hearing services for older Maori and whanau.

Examining emergency department inequities: Descriptive analysis of national data (2006-2012).

OBJECTIVE: Internationally, Indigenous and minoritised ethnic groups experience longer wait times, differential pain management and less evaluation and treatment for acute conditions within emergency medicine care. Examining ED Inequities (EEDI) aims to investigate whether inequities between Maori and non-Maori exist within EDs in Aotearoa New Zealand (NZ). This article presents the descriptive findings for the present study. METHODS: A retrospective observational study framed from a Kaupapa Maori positioning, EEDI uses secondary data from emergency medicine admissions into 18/20 District Health Boards in NZ between 2006 and 2012. Data sources include variables from the Shorter Stays in ED National Research Project database and comorbidity data from NZ's National Minimum Dataset. The key predictor of interest is patient ethnicity with descriptive variables, including sex, age group, area deprivation, mode of presentation, referral method, Australasian Triage Scale and trauma status. RESULTS: There were a total of 5 972 102 ED events (1 168 944 Maori, 4 803 158 non-Maori). We found an increasing proportion of ED events per year, with a higher proportion of Maori from younger age groups and areas of high deprivation compared to non-Maori events. Maori also had a higher proportion of self-referral and were triaged to be seen within a longer time frame compared to non-Maori. CONCLUSION: Our findings show that there are different patterns of ED usage when comparing Maori and non-Maori events. The next level of analysis of the EEDI dataset will be to examine whether there are any associations between ethnicity and ED outcomes for Maori and non-Maori patients.

Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition.

BACKGROUND: Eliminating indigenous and ethnic health inequities requires addressing the determinants of health inequities which includes institutionalised racism, and ensuring a health care system that delivers appropriate and equitable care. There is growing recognition of the importance of cultural competency and cultural safety at both individual health practitioner and organisational levels to achieve equitable health care. Some jurisdictions have included cultural competency in health professional licensing legislation, health professional accreditation standards, and pre-service and in-service training programmes. However, there are mixed definitions and understandings of cultural competency and cultural safety, and how best to achieve them. METHODS: A literature review of 59 international articles on the definitions of cultural competency and cultural safety was undertaken. Findings were contextualised to the cultural competency legislation, statements and initiatives present within Aotearoa New Zealand, a national Symposium on Cultural Competence and Maori Health, convened by the Medical Council of New Zealand and Te Ohu Rata o Aotearoa - Maori Medical Practitioners Association (Te ORA) and consultation with Maori medical practitioners via Te ORA. RESULTS: Health practitioners, healthcare organisations and health systems need to be engaged in working towards cultural safety and critical consciousness. To do this, they must be prepared to critique the 'taken for granted' power structures and be prepared to challenge their own culture and cultural systems rather than prioritise becoming 'competent' in the cultures of others. The objective of cultural safety activities also needs to be clearly linked to achieving health equity. Healthcare organisations and authorities need to be held accountable for providing culturally safe care, as defined by patients and their communities, and as measured through progress towards achieving health equity. CONCLUSIONS: A move to cultural safety rather than cultural competency is recommended. We propose a definition for cultural safety that we believe to be more fit for purpose in achieving health equity, and clarify the essential principles and practical steps to operationalise this approach in healthcare organisations and workforce development. The unintended consequences of a narrow or limited understanding of cultural competency are discussed, along with recommendations for how a broader conceptualisation of these terms is important.

Medical electives: exploring the determinants of placement and access variables between 2010 and 2016 at the University of Auckland.

BACKGROUND: Medical electives undertaken during sixth year at medical school provide an opportunity for students to work in an overseas or New Zealand health facility to gain exposure to a health system outside their training facility. Previous work suggests that the elective experience can be profound, exposing global health inequities, or influencing future career decisions. This study assessed patterns within elective choice by students' socio demographic and programme entry characteristics. METHODS: A retrospective analysis of student elective records from 2010 to 2016 was undertaken using a Kaupapa Maori research framework, an approach which prioritises positive benefits for Maori (and Pacific) participants and communities. A descriptive analysis of routinely collected de-identified aggregate secondary data included demographic variables (gender, age group, ethnicity, secondary school decile, year and route of entry), and elective site. Route of entry (into medical school) is via general, MAPAS (Maori and Pacific Admissions Scheme) and RRS (Regional and Rural Scheme). Multivariable logistic regression analysis determined the odd ratios for predictors of going overseas for elective and electives taking place in a "High" (HIC) compared to "Low- and middle-income countries" (LMIC). RESULTS: Of the 1101 students who undertook an elective (2010-2016) the majority undertook their elective overseas; the majority spent their elective within a high-income country. Age (younger), route of entry (general) and high school decile (high) were associated with going overseas for an elective. Within the MAPAS cohort, Pacific students were more likely (than Maori) were to go overseas for their elective; Maori students were more likely to spend their elective in a HIC. CONCLUSION: The medical elective holds an important, pivotal opportunity for medical students to expand their clinical, professional and cultural competency. Our results suggest that targeted support may be necessary to ensure equitable access, particularly for MAPAS students the benefit of an overseas elective.

Examining emergency department inequities: Do they exist?

OBJECTIVES: Ethnic inequities in health outcomes have been well documented with Indigenous peoples experiencing a high level of healthcare need, yet low access to, and through, high-quality healthcare services. Despite Maori having a high ED use, few studies have explored the potential for ethnic inequities in emergency care within New Zealand (NZ). Healthcare delivery within an ED context is characterised by time-pressured, relatively brief, complex and demanding environments. When clinical decision-making occurs in this context, provider prejudice, stereotyping and bias are more likely. The examining emergency department inequities (EEDI) research project aims to investigate whether clinically important ethnic inequities between Maori and non-Maori exist. METHODS: EEDI is a retrospective observational study examining ED admissions in NZ between 2006 and 2012 (5 976 126 ED events). EEDI has been designed from a Kaupapa Maori Research position. RESULTS: The primary data source is the existing Shorter Stays in Emergency Department National Research Project (SSED) dataset that will be combined with clinical information extracted from NZ's National Minimum Dataset. The key predictor variable is patient ethnicity with other covariates including: sex, age-group, area deprivation, mode of presentation, referral method, Australasian Triage Scale and the Multimorbidity Measure (M3 Index) for co-morbidities. Generalised linear regression models will be used to investigate the associations between pre-admission variables and the measures of ED care, and to examine the contribution of each measure of ED care on ethnic inequities in mortality. CONCLUSION: The present study will provide the largest, most comprehensive investigation of ED outcomes by ethnicity to date in NZ.

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.

Ethnic bias amongst medical students in Aotearoa/New Zealand: Findings from the Bias and Decision Making in Medicine (BDMM) study.

Although health provider racial/ethnic bias has the potential to influence health outcomes and inequities, research within health education and training contexts remains limited. This paper reports findings from an anonymous web-based study examining racial/ethnic bias amongst final year medical students in Aotearoa/New Zealand. Data from 302 students (34% of all eligible final year medical students) were collected in two waves in 2014 and 2015 as part of the Bias and Decision Making in Medicine (BDMM) study. Two chronic disease vignettes, two implicit bias measures, and measures of explicit bias were used to assess racial/ethnic bias towards New Zealand European and Maori (indigenous) peoples. Medical students demonstrated implicit pro-New Zealand European racial/ethnic bias on average, and bias towards viewing New Zealand European patients as more compliant relative to Maori. Explicit pro-New Zealand European racial/ethnic bias was less evident, but apparent for measures of ethnic preference, relative warmth, and beliefs about the compliance and competence of Maori patients relative to New Zealand European patients. In addition, racial/ethnic bias appeared to be associated with some measures of medical student beliefs about individual patients by ethnicity when responding to a mental health vignette. Patterning of racial/ethnic bias by student characteristics was not consistent, with the exception of some associations between student ethnicity, socioeconomic background, and racial/ethnic bias. This is the first study of its kind with a health professional population in Aotearoa/New Zealand, representing an important contribution to further understanding and addressing current health inequities between Maori and New Zealand European populations.

Time to CT head in adult patients with suspected traumatic brain injury: Association with the 'Shorter Stays in Emergency Departments' health target in Aotearoa New Zealand.

A national health target for length of stay in emergency departments (ED) was introduced in 2009 to reduce crowding and improve quality of care. We aimed to determine whether the target was associated with changes in time to CT and appropriateness of CT imaging, as markers of care quality for suspected acute traumatic brain injury (TBI). We undertook a retrospective review of the case records of a random sample of people aged ≥15 years presenting to the ED with TBI from 2006 to 2013. General linear models were used to investigate changes in outcomes along with routine process times before and after the introduction of the target. Among 501 eligible cases the median (IQR) time to CT was 136 (76-247) pre target versus 119 (59-209) minutes post target, p = 0.014. The proportion of appropriate imaging was similar between periods: 77.9% (95% CI 71-83%) versus 76.6% (95%CI 72-81%), p = 0.825. Interactions suggested that the time to CT and appropriateness of imaging before and after the introduction of the target varied by ethnicity, although the changes were not clinically important. Time to assessment and length of stay did not change importantly. We found no evidence of a clinically important change in time to CT or appropriateness of imaging for suspected TBI in association with the introduction of the SSED time target. Additional research with larger cohorts of Maori and Pacific participants is recommended to understand our observed patterns by ethnicity.

Ethnic bias and clinical decision-making among New Zealand medical students: an observational study.

BACKGROUND: Health professional racial/ethnic bias may impact on clinical decision-making and contribute to subsequent ethnic health inequities. However, limited research has been undertaken among medical students. This paper presents findings from the Bias and Decision-Making in Medicine (BDMM) study, which sought to examine ethnic bias (Maori (indigenous peoples) compared with New Zealand European) among medical students and associations with clinical decision-making. METHODS: All final year New Zealand (NZ) medical students in 2014 and 2015 (n = 888) were invited to participate in a cross-sectional online study. Key components included: two chronic disease vignettes (cardiovascular disease (CVD) and depression) with randomized patient ethnicity (Maori or NZ European) and questions on patient management; implicit bias measures (an ethnicity preference Implicit Association Test (IAT) and an ethnicity and compliant patient IAT); and, explicit ethnic bias questions. Associations between ethnic bias and clinical decision-making responses to vignettes were tested using linear regression. RESULTS: Three hundred and two students participated (34% response rate). Implicit and explicit ethnic bias favoring NZ Europeans was apparent among medical students. In the CVD vignette, no significant differences in clinical decision-making by patient ethnicity were observed. There were also no differential associations by patient ethnicity between any measures of ethnic bias (implicit or explicit) and patient management responses in the CVD vignette. In the depression vignette, some differences in the ranking of recommended treatment options were observed by patient ethnicity and explicit preference for NZ Europeans was associated with increased reporting that NZ European patients would benefit from treatment but not Maori (slope difference 0.34, 95% CI 0.08, 0.60; p = 0.011), although this was the only significant finding in these analyses. CONCLUSIONS: NZ medical students demonstrated ethnic bias, although overall this was not associated with clinical decision-making. This study both adds to the small body of literature internationally on racial/ethnic bias among medical students and provides relevant and important information for medical education on indigenous health and ethnic health inequities in New Zealand.

Achieving health equity in Aotearoa: strengthening responsiveness to Maori in health research.

Excellent health research is essential for good health outcomes, services and systems. Health research should also build towards equity and in doing so ensure that no one is left behind. As recipients of government funding, researchers are increasingly required to demonstrate an understanding of their delegated responsibilities to undertake research that has the potential to address Maori health needs and priorities. These requirements form the basis of responsiveness to Maori in health research, and several research institutions have implemented systems to support their organisational approach to this endeavour. However, many health researchers have a narrow view of responsiveness to Maori and how it might be relevant to their work. In this viewpoint paper we provide an overview of existing frameworks that can be used to develop thinking and positioning in relation to the Treaty of Waitangi and responsiveness to Maori. We also describe an equity-based approach to responsiveness to Maori and highlight four key areas that require careful consideration, namely: (1) relevance to Maori; (2) Maori as participants; (3) promoting the Maori voice, and; (4) human tissue. Finally, we argue for greater engagement with responsiveness to Maori activities as part of our commitment to achieving equitable health outcomes.