Hidden figures and misnomers: a case for disaggregated Asian health statistics in Aotearoa New Zealand to improve health outcomes.

People of Asian ethnicity in Aotearoa New Zealand currently constitute 15% of the population. The majority are migrants. The current sources of data to monitor Asian health in New Zealand are routine population surveys and administrative data. This article highlights the effect of "masking" due to the use of a single "Asian" category for reporting health indicators. Issues regarding the use of the "Other Asian" category in administrative data are also discussed. This discourse provides an impetus to raise questions on how we should be developing policies, strategies and investments to make visible the hidden figures of Asian health statistics in New Zealand. Given that Asian population will become the second largest ethnic group in New Zealand, practical steps need to be taken to strengthen the New Zealand health strategy and enable equitable investment in Asian health.

Is ethnicity an appropriate measure of health care marginalization? A systematic review and meta-analysis of the outcomes of diabetic foot ulceration in Aboriginal populations.

BACKGROUND: Aboriginal people have higher prevalence rates of diabetes than non-Aboriginal people in the same geographic locations, and diabetic foot ulcer (DFU) complication rates are also presumed to be higher. The aim of this systematic review and meta-analysis was to compare DFU outcomes in Aboriginal and non-Aboriginal populations. METHODS: We searched PubMed, Embase, CINAHL and the Cochrane Library from inception to October 2018. Inclusion criteria were all types of studies comparing the outcomes of Aboriginal and non-Aboriginal patients with DFU, and studies from Canada, the United States, Australia and New Zealand. Exclusion criteria were patient age younger than 18 years, and studies in any language other than English. The primary outcome was the major amputation rate. We assessed the risk of bias using the ROBINS-I (Risk Of Bias In Non-randomized Studies - of Interventions) tool. Effect measures were reported as odds ratio (OR) with 95% confidence interval (CI). RESULTS: Six cohort studies with a total of 244 792 patients (2609 Aboriginal, 242 183 non-Aboriginal) with DFUs were included. The Aboriginal population was found to have a higher rate of major amputation than the non-Aboriginal population (OR 1.85, 95% CI 1.04-3.31). Four studies were deemed to have moderate risk of bias, and 2 were deemed to have serious risk of bias. CONCLUSION: Our analysis of the available studies supports the conclusion that DFU outcomes, particularly the major amputation rate, are worse in Aboriginal populations than in non-Aboriginal populations in the same geographic locations. Rurality was not uniformly accounted for in all included studies, which may affect how these outcome differences are interpreted. The effect of rurality may be closely intertwined with ethnicity, resulting in worse outcomes.

Letter on an iceberg.

In the public sphere, issues are like icebergs. This somewhat hackneyed metaphor illustrates that, while one facet of an issue is perceived, what is not seen is the hidden substructure of power and culture that form and reinforce it, buoying the issue to prominence above the surface.

Cultural efficacy predicts body satisfaction for Maori.

This paper examines the relationship between body mass index (BMI), self-esteem and self-reported confidence and capability in expressing oneself culturally as Maori (cultural efficacy) for 5,470 Maori who participated in Te Rangahau o Te Tuakiri Maori me Nga Waiaro a-Putea | The Maori Identity and Financial Attitudes Study (MIFAS) in 2017. Adjusting for demographics, self-reported health, education and socio-economic status, we found that a higher BMI was associated with lower body satisfaction and self-esteem. However, higher scores on cultural efficacy were associated with higher levels of body satisfaction and self-esteem for respondents. Furthermore, the negative association between BMI and both body satisfaction and self-esteem was weaker for those with higher cultural efficacy. This held for BMI scores of 25, 30, and 35+. While our data suggest higher cultural efficacy may directly or interactively shield Maori from developing lowered self-esteem typically associated with higher BMI in Western populations, further research, using more comprehensive measures of body satisfaction should explore the extent to which Maori may find the Western "thin ideal" personally desirable for their own bodies.

Rheumatic heart disease in Indigenous young peoples.

Indigenous children and young peoples live with an inequitable burden of acute rheumatic fever and rheumatic heart disease. In this Review, we focus on the epidemiological burden and lived experience of these conditions for Indigenous young peoples in Australia, New Zealand, and Canada. We outline the direct and indirect drivers of rheumatic heart disease risk and their mitigation. Specifically, we identify the opportunities and limitations of predominantly biomedical approaches to the primary, secondary, and tertiary prevention of disease among Indigenous peoples. We explain why these biomedical approaches must be coupled with decolonising approaches to address the underlying cause of disease. Initiatives underway to reduce acute rheumatic fever and rheumatic heart disease in Australia, New Zealand, and Canada are reviewed to identify how an Indigenous rights-based approach could contribute to elimination of rheumatic heart disease and global disease control goals.

Ethnic inequities in screening for diabetes in pregnancy in New Zealand-adherence to national guidelines.

AIM: The aim of this study was to assess adherence to the 2014 Ministry of Health (MoH) screening guidelines for diabetes in pregnancy (DiP) by Maori and non-Maori in the Waikato region. METHODS: Clinical records were reviewed for women without known diabetes before pregnancy who delivered in hospitals or community birth centres in the Waikato region during June-August 2017. Screening rates for DiP were assessed using HbA1c, glucose challenge and/or glucose tolerance tests. RESULTS: Of a total of 807 women, 94% received some form of screening for DiP; 527 (65.3%) underwent HbA1c screening at <20 weeks and 267 (33.1%) underwent testing for gestational diabetes at 24-28 weeks' gestation. However, only 213 (26.4%) received all screening as per the MoH guideline. HbA1c testing was the most common screening performed (83.9% of all pregnancies), and three quarters of women had a glucose load screen at some point during pregnancy. In all measures, screening rates were lower in Maori, with only 17.5% (46 of 263 women) receiving both HbA1c and further glucose load screening in the recommended gestation windows (versus 31.6% (171 of 541) for non-Maori; P<0.0005). CONCLUSIONS: Adherence to screening guidelines for DiP was poor with a marked ethnic inequity. Further work is needed to investigate the barriers to care that drive these differences.

Examining the Impact of Two Dimensions of Precarious Employment, Vulnerability and Insecurity on the Self-Reported Health of Men, Women and Migrants in Australia.

Precarious employment is increasing and adversely affects health. We aimed to investigate how perception of precariousness in current employment impacts gender and migrant workers in Australia. Using cross-sectional interviews of 1292 workers born in Australia, New Zealand, India and the Philippines, data were collected on self-reported health, employment conditions and sociodemographics. Factor analysis of nine questions about perceptions of current employment revealed two dimensions, vulnerability and insecurity. Women had higher vulnerability scores (µ = 6.5 vs. µ = 5.5, t = 5.40, p-value (p) < 0.000) but lower insecurity scores (µ = 8.6 vs. µ = 9.3 t = -4.160 p < 0.0003) than men. Filipino-born workers had higher vulnerability compared with other migrant workers (µ = 6.5 vs. µ = 5.8 t = -3.47 p < 0.0003), and workers born in India had higher insecurity compared with other migrant workers (µ = 9.8 vs. µ = 8.9, t = -6.1 p < 0.0001). While the prevalence of insecurity varied by migrant status, the negative effect on health was higher for Australian-born workers than migrants. Increasing levels of vulnerability and insecurity impacted self-reported health negatively (Coefficient (Coef).0.34 p < 0.0001; Coef.0.25 p < 0.0001, respectively). The combination of high vulnerability and high insecurity had the greatest impact on health (Coef. 2.37 p = 0.002), followed by high vulnerability and moderate insecurity (Coef. 2.0 p = 0.007). Our study suggests that understanding both changes in employment conditions over time as well as knowledge of cultural patterns may offer the best chance of understanding the impact of precarious employment experiences.

Evidence of inequitable use of chemotherapy in New Zealand colorectal cancer patients.

AIMS: To explore variations in the use of and timeliness of chemotherapy in patients diagnosed with colorectal cancer in New Zealand. METHODS: This study included patients diagnosed with colorectal cancer in New Zealand between 1 January 2006 and 31 December 2016. The first chemotherapy regime was identified from Pharmaceutical Collection dataset. Logistic regression model was used to estimate the adjusted odds ratio of having chemotherapy by subgroup after adjustment for other factors. RESULTS: 27.8% (6,737/24,217) of colon cancer patients and 43.8% (3,582/8,170) of rectal cancer patients received publicly funded chemotherapy. The uptake and timeliness of chemotherapy has been improving over time. Pacific people were the least likely to receive chemotherapy, followed by Maori and Asian. Younger patients, New Zealand European, patients with metastatic disease and patients in the Southern Cancer Network were more likely to have chemotherapy in less than 10 weeks post-diagnosis. Over half of the advanced colorectal cancer patients who did not receive chemotherapy were aged 80+ years or had a short life expectancy. CONCLUSIONS: Although the uptake and timeliness of chemotherapy for colorectal cancer has been improving, Maori, Pacific, Asian and older patients were less likely to receive chemotherapy and less likely to receive chemotherapy in a timely manner. There is a variation in use of chemotherapy by Region with patients in the Southern Cancer region appearing to be the most likely to receive chemotherapy and to receive it within a timely period.

A comparison of the clinical features and outcomes of Takotsubo syndrome across five metropolitan hospitals in New Zealand.

AIM: Takotsubo syndrome (TS) mimics acute coronary syndrome but has a distinct pathophysiology. This study aimed to compare and contrast the clinical presentation, management and outcomes of patients with TS in five large New Zealand hospitals. METHODS: We identified 632 consecutive patients presenting to the five major tertiary hospitals in New Zealand (Middlemore Hospital, Auckland City Hospital, North Shore Hospital, Christchurch Hospital and Dunedin Hospital) between January 2006 and June 2018 and obtained clinical, laboratory, electrocardiography, echocardiography, coronary angiography and long-term follow-up data. RESULTS: Six hundred and thirty-two consecutive patients with TS (606 women, mean age 65.0+11.1 years) were included. An associated stressor was identified in two-thirds of patients, and emotional triggers were more frequent than physical triggers (62.9% and 37.1%, respectively). Overall, 12.7% of patient had depression and 11.7% anxiety but this was more common in patients from Christchurch Hospital (20.4% and 23.4%, respectively). The in-hospital mortality among the five hospitals ranges between 0 to 2.0%. The mean follow-up was 4.9+3.4 years (median 4.4 years). Fifty-four people died post-discharge, all but one from a non-cardiac cause. Forty patients had recurrent TS. Mortality post-discharge (p=0.63) and TS recurrence (p=0.38) did not differ significantly among the five hospitals. CONCLUSION: In this large New Zealand TS cohort, the clinical characteristics and presentation were similar among the five hospitals. A subset of patients had a complicated in-hospital course, but late deaths were almost all from non-cardiac causes and recurrence was infrequent. Mortality post-discharge and recurrence was similar between the hospitals.

The epidemiology of patients undergoing meningioma resection in Auckland, New Zealand, 2002 to 2011.

The incidence of meningioma is known to vary by gender and ethnicity. This study aimed to describe the epidemiological characteristics of a 10-year cohort of patients undergoing meningioma resection at Auckland City Hospital, Auckland, New Zealand. Of particular interest was whether there was any difference in meningioma incidence and recurrence rates between New Zealand Maori and Pacific Island patients compared with other ethnic groups. The study was a retrospective analysis of 493 patients with pathologically confirmed meningioma over the period 1 January 2002 to 31 December 2011. Based on this neurosurgical cohort, the minimum incidence of meningioma in the Auckland region was 3.39 per 100,000 population per year (95% C.I. 3.02-3.80) for the study period. Meningioma was significantly more common in women than men by a ratio of 4.2:1. New Zealand Maori and Pacific Island patients had a significantly higher incidence of meningioma than other ethnic groups. New Zealand Maori had a meningioma incidence 2.74 times that of Europeans (95% C.I. 2.01-3.73, p < 0.001). Pacific Island patients had 2.03 times higher incidence of meningioma than Europeans (95% C.I. 1.42 - 2.89, p < 0.001). The overall meningioma recurrence rate was 21.6% with a mean follow-up of 77 months. Recurrence rates for meningioma among Pacific Island patients were significantly higher than for other ethnic groups (hazard ratio 1.73, p = 0.008). Multivariate analysis of clinical variables confirmed the significance of traditional prognostic factors such as WHO tumour grade and Simpson grade of surgical excision in predicting meningioma recurrence.

Indigenous nurses' practice realities of cultural safety and socioethical nursing.

BACKGROUND: Persistent healthcare emphasis on universal moral philosophy has not advantaged indigenous and marginalised groups. Centralising cultural components of care is vital to provide ethical healthcare services to indigenous people and cultural minorities internationally. Woods' theoretical explication of how nurses can integrate cultural safety into a socioethical approach signposts ethical practice that reflects culturally congruent relational care and systemic critique. AIM: To demonstrate the empirical utility of Woods' ethical elements of cultural safety within a socioethical model, through analysis of indigenous nurses' practice realities in Aotearoa New Zealand. RESEARCH DESIGN: The study used a qualitative indigenous narrative inquiry. PARTICIPANTS AND RESEARCH CONTEXT: Participants were recruited nationally. Twelve Maori registered nurses and nurse practitioners were interviewed. All participants provided direct care in either primary or secondary health services. ETHICAL CONSIDERATIONS: Research approval was gained from the Human Ethics Committee of the lead author's tertiary institution. Participation was voluntary, and written informed consent was obtained. FINDINGS: Analysis highlighted the following: (1) cultural needs, which for Maori were integral to care, were easily subsumed by clinical care being prioritised; (2) ethical care by non-indigenous nurses requires critical reflection about broader equity issues that impact Maori disengagement from healthcare; (3) retention of indigenous nurses was seen as essential because their advocacy and the cultural 'fit' for Maori contributed to positive healthcare outcomes; and (4) committed leadership ensured culturally safe care was not eroded through workplace efficiencies. DISCUSSION: The data provide rich representation of Woods' model. The data indicate that nurses must engage reflexively with a relational ethic of care and social justice dimensions in order to deliver culturally safe care. CONCLUSION: Woods' model provides a critical lens for nurses to examine their relational practice and systemic factors that enhance or detract from culturally safe care when caring for members of any indigenous group.

Does exposure to workplace hazards cluster by occupational or sociodemographic characteristics? An analysis of foreign-born workers in Australia.

BACKGROUND: Disparities in exposure to occupational hazards may be linked to social position as well as the type of job a person holds. This study aimed to describe the prevalence of exposure to workplace hazards among three migrant worker groups and to assess whether social disparities in exposure for these groups remain after adjusting for occupational characteristics. METHODS: Data were collected in 2017/2018 from 1630 Australian workers born in New Zealand, India, and the Philippines. Weighted estimated prevalence of exposure to 10 carcinogens and four psychosocial hazards (discrimination, job strain, vulnerability, and insecurity) was calculated for sociodemographics and occupation. Regression estimated the likelihood of exposure by sociodemographics after adjustment for occupational characteristics. RESULTS: Exposure to workplace hazards ranged from 11.7% (discrimination) to 61.2% (exposed to at least one carcinogen). Compared with workers born in India, New Zealand born workers were over twice as likely to be exposed to diesel engine exhaust (adjusted odds ratio [aOR] = 2.60) and 60% more likely to be exposed to at least one carcinogen (aOR = 1.60) but less likely to be exposed to any psychosocial hazard. Social disparities by country of birth, sex, age, education, and number of years in Australia, as well as company size, employment type, and hours, worked remained associated with greater likelihood of reporting one or more workplace hazards after adjusting for occupational characteristics. CONCLUSION: Examining sociodemographic as well as occupational characteristics helps to clarify groups most likely to be exposed to workplace hazards who can be hidden when examining occupational characteristics alone.

Aging in New Zealand: Ka haere ki te ao pakeketanga.

Aotearoa-New Zealand is expecting the number of older adults to double in the next 20 years. Despite publicly funded health and welfare support for older citizens, the aging experience differs across ethnic groups. This creates opportunities and challenges for health and social services to deliver culturally safe and equitable care for all older New Zealanders. Longitudinal and large data sets are pivotal for characterizing the aging experience from birth to advanced age. The New Zealand research funding system responded to predicted demographic changes by increasing funding in order to inform and address key health and well-being issues for older people. In addition, government strategies and policies increasingly focus on social aspects of aging and health inequities and require researchers and organizations to be better connected to end-users. New Zealand needs to continue to fund research that identifies unique and courageous service delivery solutions that result in positive social, financial, psychological, and physical aging for older New Zealanders.

Sarcopenia, as Assessed by Psoas Cross-Sectional Area, Is Predictive of Adverse Postoperative Outcomes in Patients Undergoing Colorectal Cancer Surgery.

BACKGROUND: Frailty and sarcopenia are important concepts in surgical practice because of their association with adverse postoperative outcomes. Radiologically assessed psoas muscle mass has been proposed as a surrogate for sarcopenia and may be predictive of poor postoperative outcomes. OBJECTIVE: This study aimed to determine the association between sarcopenia, as assessed by psoas cross-sectional area, and postoperative outcomes in patients undergoing colorectal cancer surgery. DESIGN: This was a retrospective review of patient records from 2014 to 2016. SETTINGS: This study was conducted at a single tertiary center. PATIENTS: Patients undergoing elective resection of colorectal cancer were included. MAIN OUTCOME MEASURES: Sarcopenia was assessed using the total psoas index, calculated by measuring the cross-sectional area of the psoas muscle at the third lumbar vertebra and normalized for patient height. Preoperative and intraoperative variables, including the presence of preoperative sarcopenia, were evaluated as potential risk factors for adverse postoperative outcomes. RESULTS: Of 350 patients, 115 (32.9%) were identified as sarcopenic. Sarcopenia was associated with a significantly increased length of stay (13 days vs 7 days; OR, 1.31; 95% CI, 1.23-1.42; p < 0.01) and 1-year mortality (13.9% vs 0.9%; OR, 16.2; 95% CI, 4.34-83.4; p < 0.01). Sarcopenia was also associated with a significant increased risk of any complication (85.2% vs 34.5%; OR, 15.4; 95% CI, 8.39-29.7; p < 0.01) and of major complications (30.4% vs 8.9%; OR, 15.1; 95% CI, 7.16-33.2; p < 0.01). LIMITATIONS: This study was limited by its retrospective design and by being conducted in a single institution. Although reduced muscle mass is suggestive of sarcopenia, it does not assess a patient's physical function or other components of the frailty phenotype. CONCLUSION: Radiological sarcopenia is an important predictive risk factor for adverse postoperative outcomes in surgical patients. Computed tomography scans, which are routinely performed as part of staging, provide an opportunity to assess for sarcopenia preoperatively. See Video Abstract at http://links.lww.com/DCR/B201. LA SARCOPENIA, EVALUADA POR EL ÁREA TRANSVERSAL DE PSOAS, PREDICE RESULTADOS POSTOPERATORIOS ADVERSOS EN PACIENTES SOMETIDOS A CIRUGÍA DE CÁNCER COLORECTAL: La fragilidad y la sarcopenia son conceptos importantes en la práctica quirúrgica debido a su asociación con los resultados postoperatorios adversos. La masa muscular del psoas evaluada radiológicamente se ha propuesto como un sustituto de la sarcopenia y puede predecir resultados postoperatorios deficientes.Determinar la asociación entre la sarcopenia, según lo evaluado por el área transversal del psoas, y los resultados postoperatorios en pacientes sometidos a cirugía de cáncer colorrectal.Esta fue una revisión retrospectiva de los registros de pacientes de 2014 a 2016.Este estudio se llevo a cabo en un solo centro terciario.Se incluyeron pacientes sometidos a resección electiva de cáncer colorrectal.La sarcopenia se evaluó utilizando el índice de psoas total (TPI), calculado midiendo el área de la sección transversal del músculo psoas en la tercera vértebra lumbar y normalizado para la altura del paciente.Se evaluaron las variables preoperatorias e intraoperatorias, incluida la presencia de sarcopenia preoperatoria, como posibles factores de riesgo de resultados postoperatorios adversos.De 350 pacientes, 115 (32,9%) fueron identificados como sarcopénicos. La sarcopenia se asoció con un aumento significativo de la duración de la estancia (13 días frente a 7 días, OR 1.31, IC 95% 1.23-1.42, p < 0.01) y de la mortalidad al año (13.9% vs 0.9%, OR 16.2, IC 95% 4.34-83.4, p < 0.01). La sarcopenia también se asoció con un aumento significativo del riesgo de cualquier complicación (85.2% vs 34.5%, OR 15.4, IC 95% 8.39-29.7, p < 0.01) y de complicaciones mayores (30.4% vs 8.9%, OR 15.1 IC 95% 7.16-33,2, p < 0,01).Este estudio estuvo limitado por su diseño retrospectivo y por el hecho de que se realizó en una sola institución. Aunque la reducción de la masa muscular es un indicio de sarcopenia, no evalúa la función física del paciente ni otros componentes del fenotipo de fragilidad.La sarcopenia radiológica es un importante factor de riesgo predictivo para resultados postoperatorios adversos en pacientes quirúrgicos. Las tomografías computarizadas, que se realizan rutinariamente como parte de la estadificación, brindan la oportunidad de evaluar la sarcopenia antes de la operación. Consulte Video Resumen en http://links.lww.com/DCR/B201. (Traducción-Dr. Gonzalo Hagerman).

A decade on: Follow-up findings of indigenous children with bronchiectasis.

OBJECTIVE: The sole prospective longitudinal study of children with either chronic suppurative lung disease (CSLD) or bronchiectasis published in the current era was limited to a single center. We sought to extend this study by evaluating the longer-term clinical and lung function outcomes and their associated risk factors in Indigenous children of adolescents from Australia, Alaska, and New Zealand who participated in our previous CSLD or bronchiectasis studies during 2004-2010. METHODS: Between 2015 and 2018, we evaluated 131 out of 180 (72.8%) children of adolescents from the original studies at a single follow-up visit. We administered standardized questionnaires, reviewed medical records, undertook clinical examinations, performed spirometry, and scored available chest computed tomography scans. RESULTS: Participants were seen at a mean age of 12.3 years (standard deviation: 2.6) and a median of 9.0 years (range: 5.0-13.0) after their original recruitment. With increasing age, rates of acute lower respiratory infections (ALRI) declined, while lung function was mostly within population norms (median forced expiry volume in one-second = 90% predicted, interquartile range [IQR]: 81-105; forced vital capacity [FVC] = 98% predicted, IQR: 85-114). However, 43 out of 111 (38.7%) reported chronic cough episodes. Their overall global rating judged by symptoms, including ALRI frequency, examination findings, and spirometry was well (20.3%), stable (43.9%), or improved (35.8%). Multivariable regression identified household tobacco exposure and age at first ALRI-episode as independent risk factors associated with lower FVC% predicted values. CONCLUSION: Under our clinical care, the respiratory outcomes in late childhood or early adolescence are encouraging for these patient populations at high-risk of premature mortality. Prospective studies to further inform management throughout the life course into adulthood are now needed.

Stage at diagnosis for Maori cancer patients: disparities, similarities and data limitations.

Maori are more likely than non-Maori to get cancer, and once they have cancer they are less likely to survive it. One frequently proposed explanation for this survival disparity is differences between these groups in terms of stage at diagnosis-whereby Maori may be less likely to be diagnosed at an earlier stage, when treatment is more feasible and outcomes are better for the patient. However, this simple explanation ignores the true complexity of the issue of stage at diagnosis as a driver of survival disparities, and makes critical assumptions about the quality of available staging data. In this manuscript we draw on New Zealand Cancer Registry and available clinical audit data to explore this issue in detail. We found that Maori are less likely than European/Other patients to have localised disease and more likely to have advanced disease for several commonly diagnosed cancers; however, we also found that this was not the case for several key cancers, including lung and liver cancer. There is evidence that Maori have more advanced disease at diagnosis for each of the cancers for which we currently have a national screening programme, reinforcing the importance of achieving equity in access to these programmes. Missing stage information on our national registry undermines our ability to both a) monitor progress towards achieving early diagnosis, and b) examine and monitor the role of stage at diagnosis as a driver of survival disparities for several important cancers for Maori, including lung, liver and stomach cancers.

introduce nationwide pulse oximetry screening for the detection of critical congenital heart disease and other hypoxaemic conditions in the newborn.

The mortality risk for infants with critical congenital heart disease (CCHD) unrecognised at the time of birth is high. Pulse oximetry has been utilised as a screening tool for the detection of these anomalies in the newborn as the majority will have a degree of hypoxaemia. This screening strategy has a moderate sensitivity and excellent specificity for the detection of CCHD, and a low false-positive rate. Respiratory and infective diseases are responsible for a large number of positive test results. The early recognition of these diseases can also improve health outcomes. Different approaches have been taken to introduce screening, ranging from hospital-led initiatives to mandatory state-wide policies. A study conducted in New Zealand demonstrated that sector-led screening initiatives are unlikely to result in equitable outcomes. In this midwifery-led maternity setting a nationwide pulse oximetry screening programme with adequate human and material resources should be introduced.