Evidence of inequitable use of chemotherapy in New Zealand colorectal cancer patients
Variations in the use and timeliness of chemotherapy were explored in 24,217 patients diagnosed with colon cancer and 8,170 patients diagnosed with rectal cancer in New Zealand between 1 January 2006 and 31 December 2016. The uptake and timeliness of chemotherapy was reported to improve over time. Overall, publicly funded chemotherapy was received by 27.8% of patients with colon cancer and 43.8% of patients with rectal cancer. Māori patients were among the three ethnic groups least likely to receive chemotherapy, coming second to Pacific patients and ahead of Asian patients. Initiation of chemotherapy within 10 weeks of diagnosis was more likely in patients who were younger, New Zealand European, resident in the Southern Cancer Network region and with metastatic disease. Age ≥80 years or a short life expectancy accounted for more than half of the patients with advanced colorectal cancer who did not receive chemotherapy.
Timely given the recent calls to address equity in the Bowel Screening Programme. Further reasons provided here to ensure that early diagnosis is considered as part of systematic shake-up of bowel cancer treatment pathways.
Reference: N Z Med J. 2020;133(1520):15-26.
Severe early childhood caries: a modern (neglected) epidemic?
The rate of severe early childhood dental caries was investigated in a retrospective analysis of routine oral health data collected from 10,766 children aged 5 years attending the Canterbury DHB child oral health services between 1 January 2018 and 31 December 2019. Overall, 18.4% of children were classified as having severe early childhood caries. Rates were significantly different across ethnic groups with 26.2% in Māori children, 40.1% in Pacific children and 15.4% in non-Māori /non-Pacific children (p<0.001). The authors commented that the heavy oral health burden is unequally shared and the consequences have significant health and wellbeing implications, both now and in the future.
The long-standing evidence of poor oral health for children in Aotearoa, and the significant inequities by ethnicity, level of neighbourhood deprivation and location, would suggest the need for focussed effort in dental services. Therefore it was extremely disappointing to see dental care missing from the recent health and disability sector review. Hopefully this is an area the proposed Māori Health Authority will prioritise.
Reference: N Z Med J. 2020;133(1518):10-18.
Ethnic inequality in non-steroidal anti-inflammatory drug-associated harm in New Zealand
Ethnic disparities in the risk of NSAID-associated complications were assessed in a retrospective cohort study of the primary care population in New Zealand who were dispensed NSAIDs between 2008 and 2015. The risk of hospital admission for upper GI bleeding, heart failure and acute kidney failure in the 90-day period following NSAID dispensing was assessed using national pharmaceutical dispensing and hospital admissions data. NSAIDs were dispensed to 3,023,067 patients between 2008 and 2015 with a total intended duration of treatment of 2,353,140 patient-years. Māori patients dispensed NSAIDs were significantly younger than European patients (p<0.001). Māori patients were more likely than European patients to be hospitalised for NSAID-associated complications with rate ratios of 2.54 for upper GI bleeding, 2.48 for heart failure and 1.46 for acute kidney failure. The higher risk of upper GI bleeding and heart failure in Māori patients was most evident in males and patients aged <60 years. The authors commented that interventions promoting safer use of NSAIDS are needed to reduce the inequity in serious complications across ethnic groups.
This is concerning but perhaps most worrying was the fact that there was higher risk for upper GI bleeds and heart failure when NSAIDs were prescribed in young Māori and Pacific men. Although there may be health reasons to consider NSAIDs (i.e. acute gout or musculoskeletal injuries), the evidence presented here suggests we need to look at other options so that we ‘do no harm’.
Reference: Pharmacoepidemiol Drug Saf. 2020;29(8):881-889.
Are we all in this together? Longitudinal assessment of cumulative adversities by socioeconomic position in the first 3 weeks of lockdown in the UK
The effects of the COVID-19 pandemic on the changing patterns of adversity relative to socioeconomic position were explored in a social study during the first 3 weeks of lockdown in the UK. Data from 12,527 adults, who participated in an online weekly panel as part of the University College London COVID-19 Social Study, were analysed to assess 10 different types of adverse experiences. There were clear inequalities in adverse experiences by socioeconomic position, particularly for adversities relating to finances (e.g. loss of employment and reduced income) and basic needs (e.g. access to food and medications), which did not change over time.
I’ve included this as a reminder that we can’t just focus on the ‘infection’ numbers, and that we must monitor, and address, other potential adverse experiences for whānau.
Reference: J Epidemiol Community Health. 2020;74(9):683-688.
Enhancing Māori and Pasifika graduate interest in ophthalmology surgical training in New Zealand/Aotearoa
Māori and Pasifika medical graduates were found to have low interest in ophthalmology training in a mixed-methods study using retrospective analysis and prospective semi-structured interviews. Retrospective analysis of Medical Schools Outcomes Database and Longitudinal Tracking Project for 2012–2017 found that only 64 (6.7%) medical graduates from the University of Auckland and the University of Otago ranked ophthalmology among their top three preferred training specialties; six graduates (9.3%) identified as Māori/Pasifika. Intellectual content, procedural skills, specialty exposure and mentorship were ranked as highly influential factors irrespective of ethnicity. Additional insights to improve the representation of Māori/Pasifika ophthalmologists in New Zealand were gained from semi‐structured qualitative interviews with six Māori/Pasifika medical postgraduates. These insights included promoting Māori/Pasifika connections and clarifying training pathways for future graduates.
Of particular relevance given the outcry from health leaders, workers and students about the proposed end to the Māori and Pacific pathways at Otago medical school. As one student raised – have we achieved equity already? In speaking with Māori surgical trainees, racism is a major issue for them, and the idea of working in a toxic environment is not attractive to anyone!
Reference: Clin Exp Ophthalmol. 2020;48(6): 739-748.
Indigenous engagement in health: lessons from Brazil, Chile, Australia and New Zealand
This review examined the national policies and legislation in Brazil, Chile, Australia and New Zealand to support Indigenous engagement in identifying and addressing the differential health needs of Indigenous peoples. Although all four countries have adopted international agreements regarding the engagement of Indigenous peoples in health, national policy, legislation and practice vary significantly. Comparatively, New Zealand has established policies to facilitate Indigenous engagement and significant initiatives and policy structures to address Indigenous health. However, such policies may not necessarily translate into practice and New Zealand policies have been reported as insufficient and potentially contributing to health inequity for Māori.
An excellent review of the barriers to developing and implementing kaupapa Māori health interventions; and the need for multi-level policy and legislation to effect change for Indigenous peoples. I often remind funders that Māori have a right to be part of decision-making (including funding decisions) and the solution.
Reference: Int J Equity Health. 2020;19(1):47.
Acknowledging and acting on racism in the health sector in Aotearoa New Zealand
This editorial highlights some of the false beliefs that persist, and contribute to, ongoing racism within the health sector in New Zealand, including those encountered through the academic peer review process. It includes recommendations for the NZMJ and Pākehā health professionals and researchers to support culturally safe research and equitable outcomes for Māori and other groups experiencing inequities.
I wish to acknowledge NZMJ for having an entire issue dedicated to examining inequities and racism in the health system. Although this an editorial, it has links to all the other papers in it. We look forward to working with NZMJ to address our recommendations.
Reference: N Z Med J. 2020;133(1520):7-13.
Ethnic (pay) disparities in public sector leadership from 2001–2016 in Aotearoa New Zealand
This paper examined the distribution of ethnic pay disparities within the public sector and DHBs by analysing the population proportions of Māori, Pasifika and Other ethnicities earning over $NZ100,000 over 5-year intervals between 2001 to 2016. Data were obtained by a series of official information act requests. Linear regression analysis showed a statistically significant pattern of ethnic pay disparities across the public sector with fewer Māori and Pasifika staff employed in DHBs than their population proportion. Māori and Pasifika workers were less likely to be promoted or appointed to roles in the upper tiers of the public sector and DHBs. The authors commented that the data present an example of institutional racism and highlighted the need for more research to understand the dynamics and drivers of ethnic pay disparity.
The results presented in this paper align with recent calls for pay parity across disciplines (primary health care GPs and nurses with their DHB-employed colleagues), confirming that our system appears to value, and therefore pay, some more than others. Many of us may think it is not within our remit to address these. Remember that the average annual income for Māori in 2013 was $22.5k; the minimum wage pays $34.3k/year; and the minimum living wage was calculated at $46.5k/year in 2017. In my experience, ensuring that our workers receive at least the minimum living wage has made a huge difference to our staff and their whānau.
Reference: Int J Crit Indig Stud. 2020;13(1): 70-85.
Indigenous nurses’ practice realities of cultural safety and socioethical nursing
The realities of culturally safe care were explored in a qualitative narrative inquiry involving interviews with 12 Māori registered nurses and nurse practitioners providing direct care in either primary or secondary health services. The analysis highlighted that clinical care was too easily prioritised over cultural needs and demonstrated that nurses need to consider the broader equity issues that impact Māori disengagement from healthcare in order to deliver culturally safe care. The retention of Indigenous nurses was considered essential for advocating culturally safe care and contributed to positive healthcare outcomes for Māori. Support from leadership was also found to be important to ensure workplace efficiencies did not override culturally safe care.
An excellent summary of the key components to a framework supporting the development of a culturally safe health workforce.
Reference: Nurs Ethics. 2020; doi:10.1177/0969733020940376. [Epub ahead of print]
