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. Māori 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 Māori 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.

What is affirmative action in tertiary education? An overview of affirmative action policies in health professional programmes, drawing on experience from Aotearoa and overseas

Both the universities of Auckland and Otago have had affirmative selection policies for entry into health profession programmes for a number of decades. These policies have been created and strengthened as a result of the leadership and advocacy of Māori leaders, academics and communities. The aims of this paper are to: 1) define affirmative action and outline the rationale for affirmative policies, 2) give examples of how affirmative action policies have been implemented in Aotearoa, and 3) give examples of legal challenges to affirmative action drawing on international experience. Affirmative action policies for health professional programmes are a strategy for improving equity in health through raising the participation of members of population groups that have been historically excluded or under-represented. There are a range of arguments in favour of affirmative policies: constitutional obligations related to Te Tiriti o Waitangi; health professionals from under-represented communities are more likely to serve their communities; they help address biases in healthcare delivery, thereby improving the quality of care; they contribute to health equity through the impact their careers have on the education of others; they are more likely to focus their research on communities they serve and engage with; and their leadership has the potential to benefit the entire system. Legal challenges to affirmative action have been common in some overseas jurisdictions and have resulted in some instances in weaker, or absent, affirmative action policies. We conclude that strong affirmative action policies in tertiary health profession programme admissions contribute to achieving health equity. While much of the literature focusses on admissions to medical programmes, the principles of affirmative action apply equally to all health profession (and other) programmes in Aotearoa.

The ownership elephant is becoming a mammoth: a policy focus on ownership is needed to transform Aotearoa New Zealand's health system

Explicit government policy about ownership of health services is an important yet missing element in Aotearoa New Zealand's health system. Policy has not systematically addressed ownership as a health system policy tool since the late 1930s. It is timely to revisit ownership amid health system reform and increasing reliance on private provision (for-profit companies), notably for primary and community care, and also as an integral part of digitalisation. Simultaneously, policy should recognise the importance and potential of both the third sector (NGOs, Pasifika, community-owned services), Māori ownership and direct government provision of services to address health equity. Iwi-led developments over recent decades, along with the establishment of the Te Aka Whai Ora (Māori Health Authority), and Iwi Māori Partnership Boards provide opportunities for emerging Indigenous models of health service ownership, more consistent with Te Tiriti o Waitangi and mātauranga Māori. Four ownership types relevant to health service provision and equity are briefly explored: private for-profit, NGOs and community, government and Māori. These ownership domains operate differently in practice and over time, influencing service design, utilisation and health outcomes. Overall, the New Zealand state should take a deliberate strategic view of ownership as a policy instrument, in particular because of its relevance to health equity.

Inclusive medical education for students with disabilities: a new guidance document from Medical Deans Australia and New Zealand

This paper outlines: 1) the work undertaken by Medical Deans Australia and New Zealand (MDANZ) to review and update its 2017 guidelines related to selecting and supporting students with disabilities, and 2) the resulting new recommendations. The review group considered common approaches to supporting medical students with a disability through an inclusive, strengths-based lens. The outcome was a guidance document that centres the importance of a strengths-based and inclusive culture within medical schools, and emphasises an individualised, context-specific and inclusive approach based on early, open dialogue. Strong project governance and broad consultation were critical to achieving this outcome. As social norms and technologies evolve, regular re-examination of guidance on how to support potential or current medical students with a disability will be necessary.

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 Māori and Pacific, and students who come from low socioeconomic and rural backgrounds. The enrolment rate for Māori 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 Māori 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, Māori and the British Crown signed in 1840) and have a strong pro-equity focus.

Assessing need for primary care services: analysis of New Zealand Health Survey data

Introduction The 2001 Primary Health Care Strategy provided significant new government funding for primary care (general practice and related services) via capitation funding formulas. However, there remain important unanswered questions about how capitation funding formulas should be redesigned to ensure equitable and sustainable service provision to all population groups. Aim To compare levels of chronic illness, utilisation, and unmet need in patients categorised as 'high-need' with those categorised as non-'high-need' using the definitions that are used in the current funding context, in order to inform primary care funding formula design. Methods Respondents of the New Zealand Health Survey (2018-19) were categorised into 'high-need' and non-'high-need', as defined in current funding formulas. We analysed: (i) presence, and number, of chronic diseases; (ii) self-reported primary care utilisation (previous 12 months); and (iii) self-reported unmet need for primary care (previous 12 months). Analyses used integrated survey weights to account for survey design. Results In total, 29% of respondents were 'high-need', of whom 50.2% reported one or more chronic conditions (vs 47.8% of non-'high-need' respondents). 'High-need' respondents were more likely than non-'high-need' respondents to: report three or more chronic conditions (14.4% vs 13.7%); visit a general practitioner more often (seven or more visits per year: 9.9% vs 6.6%); and report barriers to care. Discussion There is an urgent need for further quantification of the funding requirements of general practices serving high proportions of 'high-need' patients in order to ensure their viability, sustainability and the provision of quality of care.

Selection of Māori students into medicine: re-imagining merit. Exploring some of the sociological reasons that might explain the exclusion of Māori from the medical workforce

This paper aims to describe a number of sociological and theoretical foundations that underpin selection into tertiary health education in New Zealand and that have historically served to limit the participation of Māori students in restricted-entry health professional programmes. It further describes practical steps that can be taken to promote pro-equity changes within tertiary institutions. First, we discuss the sociological concept of meritocracy as a dominant approach to student selection and pedagogy in universities, and we describe the consequences of this approach for Māori students. Second, we discuss the concepts of white supremacy and privilege as two organising sets of values that interplay with each other and shape the tertiary environment. Third, we discuss possible alternative theoretical and ethical approaches based on Rawls' theory of justice, mana motuhake and strengths-based assumptions. Finally, we illustrate these alternative approaches, which are fundamentally committed to Te Tiriti o Waitangi, with an example of their successful application.

Empowering equity: Striving for socio-economic equity in the Aotearoa New Zealand health workforce

BACKGROUND

The lack of diversity in the health workforce is partly due to selection criteria for health professional programmes that have not selected students from a wide range of backgrounds. Consequently, health care professionals from minority groups and lower socio-economic backgrounds are under-represented in the workforce.

APPROACH

The Socioeconomic Equity (EQ) support programme aims to increase the participation, retention and academic success of students from low socio-economic communities studying in health professional programmes at the University of Otago. At the start of the academic year, students who had attended a secondary school from a low socio-economic community were invited to take part in the EQ Programme. This includes group workshops on study skills, guidance from peer mentors, subject specific academic support, one-on-one course advice and pastoral support and activities to enhance self-esteem and self-efficacy.

EVALUATION

Comparing the first two years of the EQ project with the previous year, there was an increase in the percentage of students from schools in low socio-economic communities that passed HSFY. It was also found that more EQ students were offered places in health professional programmes than in the previous year.

IMPLICATIONS

The percentage of students passing HSFY has increased, and importantly, the percentage of students from low socio-economic backgrounds entering professional health programmes has doubled. This is a small start to building a health workforce that fairly reflects people from all communities.

Emergency COVID-19 funding to general practices in early 2020: lessons for future allocation to support equity

AIM

To (1) describe the distribution of Ministry of Health (MOH) COVID-19 emergency funding to general practices in March and April 2020 and (2) consider whether further funding to general practices should be allocated differently to support equity for patients.

METHODS

Emergency funding allocation criteria and funding amounts by general practice were obtained from the MOH. Practices were stratified according to their proportion of high-needs enrolled patients (Māori, Pacific or living in an area with the highest quintile of socioeconomic deprivation). Funding per practice was calculated for separate and total payments according to practice stratum of high-needs enrolled patients.

RESULTS

The median combined March and April funding for general practices with 80% high-needs patients was 28% higher per practice ($36,674 vs $28,686) and 48% higher per patient ($10.50 vs $7.11) compared with the funding received by general practices with fewer than 20% high-needs patients. Although the March allocation did increase funding for high-needs patients, the April allocation did not.

CONCLUSIONS

Emergency support funding for general practices was organised by the MOH at short notice and in exceptional circumstances. In the future, the MOH should apply pro-equity resource allocation in all emergencies, as with other circumstances.

Health workforce planning under conditions of uncertainty: identifying supportive integrated care policies using scenario analysis

Purpose

Integrated care presents health workforce planners with significant uncertainty. This results from: (1) these workforces are likely in the future to be different from the present, (2) integrated care's variable definitions and (3) workforce policy and planning is not familiar with addressing such challenges. One means to deal with uncertainty is scenario analysis. In this study we reveal some integration-supportive workforce governance and planning policies that were derived from the application of scenario analysis.

Design/methodology/approach

Through a mixed methods design that applies content analysis, scenario construction and the policy Delphi method, we analysed a set of New Zealand's older persons health sector workforce scenarios. Developed from data gathered from workforce documents and studies, the scenarios were evaluated by a suitably qualified panel, and derived policy statements were assessed for desirability and feasibility.

Findings

One scenario was found to be most favourable, based on its broad focus, inclusion of prevention and references to patient dignity, although funding changes were indicated as necessary for its realisation. The integration-supportive policies are based on promoting network-based care models, patient-centric funding that promotes collaboration and the enhancement of interprofessional education and educator involvement.

Originality/value

Scenario analysis for policy production is rare in health workforce planning. We show how it is possible to identify policies to address an integrated care workforce's development using this method. The article provides value for planners and decision-makers by identifying the pros and cons of future situations and offers guidance on how to reduce uncertainty through policy rehearsal and reflection.

Rethinking workforce planning for integrated care: using scenario analysis to facilitate policy development

BACKGROUND

A goal of health workforce planning is to have the most appropriate workforce available to meet prevailing needs. However, this is a difficult task when considering integrated care, as future workforces may require different numbers, roles and skill mixes than those at present. With this uncertainty and large variations in what constitutes integrated care, current health workforce policy and planning processes are poorly placed to respond. In order to address this issue, we present a scenario-based workforce planning approach.

METHODS

We propose a novel mixed methods design, incorporating content analysis, scenario methods and scenario analysis through the use of a policy Delphi. The design prescribes that data be gathered from workforce documents and studies that are used to develop scenarios, which are then assessed by a panel of suitably qualified people. Assessment consists of evaluating scenario desirability, feasibility and validity and includes a process for indicating policy development opportunities.

RESULTS

We confirmed our method using data from New Zealand's Older Persons Health sector and its workforce. Three scenarios resulted, one that reflects a normative direction and two alternatives that reflect key sector workforce drivers and trends. One of these, based on alternative assumptions, was found to be more desirable by the policy Delphi panel. The panel also found a number of favourable policy proposals.

CONCLUSIONS

The method shows that through applying techniques that have been developed to accommodate uncertainty, health workforce planning can benefit when confronting issues associated with integrated care. The method contributes to overcoming significant weaknesses of present health workforce planning approaches by identifying a wider range of plausible futures and thematic kernels for policy development. The use of scenarios provides a means to contemplate future situations and provides opportunities for policy rehearsal and reflection.

The ongoing evolution of capitation funding for primary care: the December 2018 PHO capitation funding changes for Community Services Card holders

AIM

To 1) consider the possible impact on equity of the recent policy to support people on low incomes to access primary care using the Community Services Card (CSC), and 2) identify questions that will need to be answered in order for the policy and funding changes to be evaluated.

METHODS

Review of publicly accessible reports, papers, media releases and websites to detail and examine the funding changes made in December 2018 to implement the CSC policy.

RESULTS

CSC possession is an important new determinant of eligibility to low-cost access to primary care for many people. As the funding changes are complex, the equity effects cannot be fully understood until further detailed modelling is carried out, and specific questions are answered.

CONCLUSIONS

The December 2018 PHO capitation funding policy changes represent a further step towards universal low-cost primary healthcare. The effects of those funding changes should now be evaluated in order to understand their effects on equity. It is the responsibility of the Ministry of Health to ensure that an evaluation of the changes takes place.

The 'elephants in the room' for New Zealand's health system in its 80th anniversary year: general practice charges and ownership models

The 2018 year signalled the 80th anniversary of the Social Security Act 1938. In order to implement this legislation, a historic compromise between the government and the medical profession created institutional arrangements for the New Zealand health system that endure to this day. The 2018 year also marked the commencement of a Ministerial review of the New Zealand health system. This article considers two intertwined arrangements which stem from the post-1938 compromise that the Ministerial review will need to address if goals of equity and, indeed, the original intent of the 1938 legislation are to be delivered upon: general practice patient charges; and ownership models. It describes the problems patient charges create, and options for ownership that the Ministerial review might contemplate.

Proposal for a National Interprofessional School of Rural Health

Shortages of health professionals persist in much of rural New Zealand despite a range of targeted university and professional college initiatives. In response to this a collective of universities, professional colleges and sector groups have put a proposal to Government for a National Interprofessional School of Rural Health. If adopted, this proposal would embed rural health professional education and research in rural communities around New Zealand, empowering them to organise the education that occurs in their community, in a coherent and coordinated way. What is being proposed is not a new or separate education provider but rather an 'enabling body' that would lever off the expertise and resources of the existing tertiary institutions, colleges and rural communities. It calls for an 'all of systems' approach that encompasses all the health professions that practise in rural areas, undergraduate education and postgraduate training, and rural health research. Although modelled on successful Australian rural clinical schools, it is a uniquely New Zealand solution that is cognisant of the New Zealand context and resources.

New Zealand's health workforce planning should embrace complexity and uncertainty

Concerns over New Zealand's health workforce sufficiency, distribution and sustainability continue. Proposed solutions tend to focus on supplying medical professionals to meet predicted numbers or to resolve distributional problems. This is despite quantitative forecasts being known to have poor reliability. A recent study on New Zealand's health workforce planning, which focused less on medical workforce numbers and more on the system's organisation and constituent interrelations, highlights the use of complementary methods to define the problems and design a range of policy responses. Core to deciding on suitable interventions is the use of analysis tools, such as judgement-based approaches, which are commensurate with the actual levels of uncertainty being experienced, and which complement quantitative predictive forecasting.

Holding a mirror to society? Progression towards achieving better sociodemographic representation among the University of Otago's health professional students

AIM

1) To describe the sociodemographic characteristics of students accepted into eight health professional programmes at the University of Otago in 2016. 2) To provide an update on an earlier (2012) paper to illustrate progress towards increasing diversity within the health professional student cohort.

METHODS

Student data were obtained from the University of Otago's central student records system. Data were obtained in anonymous, summary form. New Zealand population data were obtained from Statistics New Zealand. Descriptive statistics were calculated.

RESULTS

Between 2010 and 2016 there was: a marked increase in the proportion of Māori (124% increase) and Pacific students (121% increase) in health professional programmes, more pronounced in medicine and dentistry (increases of 179% and 133% respectively); an increase in the proportion of students from rural areas from 19.2% to 22.5%; an increase in the proportion of female students from 59.6% to 61.3%; and little overall change in the overall socioeconomic profile.

CONCLUSION

Between 2010 and 2016 there was an overall increase in diversity in the health professional student body, with strong growth in Māori, Pacific and rural students. The recent introduction of new affirmative categories will hopefully result in an increase in socioeconomic diversity and in the number of refugee students.

The promise of complementarity: Using the methods of foresight for health workforce planning

Health workforce planning aims to meet a health system's needs with a sustainable and fit-for-purpose workforce, although its efficacy is reduced in conditions of uncertainty. This PhD breakthrough article offers foresight as a means of addressing this uncertainty and models its complementarity in the context of the health workforce planning problem. The article summarises the findings of a two-case multi-phase mixed method study that incorporates actor analysis, scenario development and policy Delphi. This reveals a few dominant actors of considerable influence who are in conflict over a few critical workforce issues. Using these to augment normative scenarios, developed from existing clinically developed model of care visions, a number of exploratory alternative descriptions of future workforce situations are produced for each case. Their analysis reveals that these scenarios are a reasonable facsimile of plausible futures, though some are favoured over others. Policy directions to support these favoured aspects can also be identified. This novel approach offers workforce planners and policy makers some guidance on the use of complimentary data, methods to overcome the limitations of conventional workforce forecasting and a framework for exploring the complexities and ambiguities of a health workforce's evolution.

How Other Countries Use Deprivation Indices-And Why The United States Desperately Needs One

Integrating public health and medicine to address social determinants of health is essential to achieving the Triple Aim of lower costs, improved care, and population health. There is intense interest in the United States in using social determinants of health to direct clinical and community health interventions, and to adjust quality measures and payments. The United Kingdom and New Zealand use data representing aspects of material and social deprivation from their censuses or from administrative data sets to construct indices designed to measure socioeconomic variation across communities, assess community needs, inform research, adjust clinical funding, allocate community resources, and determine policy impact. Indices provide these countries with comparable data and serve as a universal language and tool set to define organizing principles for population health. In this article we examine how these countries develop, validate, and operationalize their indices; explore their use in policy; and propose the development of a similar deprivation index for the United States.

Proposed new industry code on unhealthy food marketing to children and young people: will it make a difference?

Reducing the exposure of children and young people to the marketing of unhealthy foods is a core strategy for reducing the high overweight and obesity prevalence in this population. The Advertising Standards Authority (ASA) has recently reviewed its self-regulatory codes and proposed a revised single code on advertising to children. This article evaluates the proposed code against eight criteria for an effective code, which were included in a submission to the ASA review process from over 70 New Zealand health professors. The evaluation found that the proposed code largely represents no change or uncertain change from the existing codes, and cannot be expected to provide substantial protection for children and young people from the marketing of unhealthy foods. Government regulations will be needed to achieve this important outcome.

Is cost-related non-collection of prescriptions associated with a reduction in health? Findings from a large-scale longitudinal study of New Zealand adults

OBJECTIVE

To investigate whether cost-related non-collection of prescription medication is associated with a decline in health.

SETTINGS

New Zealand Survey of Family, Income and Employment (SoFIE)-Health.

PARTICIPANTS

Data from 17 363 participants with at least two observations in three waves (2004-2005, 2006-2007, 2008-2009) of a panel study were analysed using fixed effects regression modelling.

PRIMARY OUTCOME MEASURES

Self-rated health (SRH), physical health (PCS) and mental health scores (MCS) were the health measures used in this study.

RESULTS

After adjusting for time-varying confounders, non-collection of prescription items was associated with a 0.11 (95% CI 0.07 to 0.15) unit worsening in SRH, a 1.00 (95% CI 0.61 to 1.40) unit decline in PCS and a 1.69 (95% CI 1.19 to 2.18) unit decline in MCS. The interaction of the main exposure with gender was significant for SRH and MCS. Non-collection of prescription items was associated with a decline in SRH of 0.18 (95% CI 0.11 to 0.25) units for males and 0.08 (95% CI 0.03 to 0.13) units for females, and a decrease in MCS of 2.55 (95% CI 1.67 to 3.42) and 1.29 (95% CI 0.70 to 1.89) units for males and females, respectively. The interaction of the main exposure with age was significant for SRH. For respondents aged 15-24 and 25-64 years, non-collection of prescription items was associated with a decline in SRH of 0.12 (95% CI 0.03 to 0.21) and 0.12 (95% CI 0.07 to 0.17) units, respectively, but for respondents aged 65 years and over, non-collection of prescription items had no significant effect on SRH.

CONCLUSION

Our results show that those who do not collect prescription medications because of cost have an increased risk of a subsequent decline in health.

Is change in global self-rated health associated with change in affiliation with a primary care provider? Findings from a longitudinal study from New Zealand

AIMS

To investigate the association of self-rated health and affiliation with a primary care provider (PCP) in New Zealand.

METHODS

We used data from a New Zealand panel study of 22,000 adults. The main exposure was self-rated health, and the main outcome measure was affiliation with a PCP. Fixed effects conditional logistic models were used to control for observed time-varying and unobserved time-invariant confounding.

RESULTS

In any given wave, the odds of being affiliated with a PCP were higher for those in good and fair/poor health relative to those in excellent health. While affiliation for Europeans increased as reported health declined, the odds of being affiliated were lower for Māori respondents reporting very good or good health relative to those in excellent health. No significant differences in the association by age or gender were observed.

CONCLUSIONS

Our data support the hypothesis that those in poorer health are more likely to be affiliated with a PCP. Variations in affiliation for Māori could arise for several reasons, including differences in care-seeking behaviour and perceived need of care. It may also mean that the message about the benefits of primary health care is not getting through equally to all population groups.

Equity in statin use in New Zealand

INTRODUCTION

Preventive medications such as statins are used to reduce cardiovascular risk. There is some evidence to suggest that people of lower socioeconomic position are less likely to be prescribed statins. In New Zealand, Maori have higher rates of cardiovascular disease.

AIM

This study aimed to investigate statin utilisation by socioeconomic position and ethnicity in a region of New Zealand.

METHODS

This was a cross-sectional study in which data were collected on all prescriptions dispensed from all pharmacies in one city during 2005/6. Linkage with national datasets provided information on patients' age, gender and ethnicity. Socioeconomic position was identified using the New Zealand Index of Socioeconomic Deprivation 2006.

RESULTS

Statin use increased with age until around 75 years. Below age 65 years, those in the most deprived socioeconomic areas were most likely to receive statins. In the 55-64 age group, 22.3% of the most deprived population received a statin prescription (compared with 17.5% of the mid and 18.6% of the least deprived group). At ages up to 75 years, use was higher amongst Maori than non-Maori, particularly in middle age, where Maori have a higher risk of cardiovascular disease. In the 45-54 age group, 11.6% of Maori received a statin prescription, compared with 8.7% of non-Maori.

DISCUSSION

Statin use approximately matched the pattern of need, in contrast to other studies which found under-treatment of people of low socioeconomic position. A PHARMAC campaign to increase statin use may have increased use in high-risk groups in New Zealand.

Government funding of health research in New Zealand

An analysis of levels of government health research funding carried out in 2008 demonstrated that funding in New Zealand, after adjustment for population size, was less than one-third of that in Australia, less than one-fifth of that in the United Kingdom, and about 10% of that in the United States. This was perceived to be a major obstacle to the recruitment and retention of clinical and academic staff in our hospitals and universities. We have now repeated these analyses to determine the current state of these comparisons. From 2009 to the present funds for direct funding of research through the Health Research Council (HRC) have remained static at $54m. As a result of inflation of research costs (principally salaries) this represents a decrease of approximately one-quarter in the quantum of research funded by the HRC over the last 4 years. Current funding rates in the comparator countries, population-adjusted and converted to NZ$, are 3.4-fold higher in Australia, 4.5-fold higher in the United Kingdom, and 9.7-fold higher in the United States. Urgent and sustained action is needed to correct these major disparities in government health research funding if the quality of academic and clinical staff in our public institutions is to be maintained.

Equity in statin use in New Zealand

INTRODUCTION: Preventive medications such as statins are used to reduce cardiovascular risk. There is some evidence to suggest that people of lower socioeconomic position are less likely to be prescribed statins. In New Zealand, Maori have higher rates of cardiovascular disease. AIM: This study aimed to investigate statin utilisation by socioeconomic position and ethnicity in a region of New Zealand. METHODS: This was a cross-sectional study in which data were collected on all prescriptions dispensed from all pharmacies in one city during 2005/6. Linkage with national datasets provided information on patients’ age, gender and ethnicity. Socioeconomic position was identified using the New Zealand Index of Socioeconomic Deprivation 2006. RESULTS: Statin use increased with age until around 75 years. Below age 65 years, those in the most deprived socioeconomic areas were most likely to receive statins. In the 55–64 age group, 22.3% of the most deprived population received a statin prescription (compared with 17.5% of the mid and 18.6% of the least deprived group). At ages up to 75 years, use was higher amongst Maori than non-Maori, particularly in middle age, where Maori have a higher risk of cardiovascular disease. In the 45–54 age group, 11.6% of Maori received a statin prescription, compared with 8.7% of non-Maori. DISCUSSION: Statin use approximately matched the pattern of need, in contrast to other studies which found under-treatment of people of low socioeconomic position. A PHARMAC campaign to increase statin use may have increased use in high-risk groups in New Zealand. KEYWORDS: Ethnic groups; New Zealand; prescriptions; socioeconomic status; statins

Holding a mirror to society? The sociodemographic characteristics of the University of Otago's health professional students

AIM

To describe the sociodemographic characteristics of students accepted into eight health professional programmes at the University of Otago.

METHODS

Student data were obtained from the University of Otago's central student records system. Data were obtained in anonymous, summary form. New Zealand population data were obtained from Statistics New Zealand. Descriptive statistics were calculated.

RESULTS

In 2010 health professional students at the University of Otago were largely from outside the Otago region (88.1%). 59.6% were female and 84.8% were either New Zealand citizens or permanent residents. Within the domestic student cohort, 65.0% of students self-identified as being within the New Zealand European and Other category (compared with 75.3% of the national population), 34.2% as Asian (compared with 11.1%), 6.3% as Maori (compared with 15.2%), and 2.3% as Pacific (compared with 7.7%). A large proportion of students came from high socioeconomic areas and only 3.4% of students had attended secondary schools with a socioeconomic decile of less than 4.

CONCLUSION

Schools and Faculties within the University of Otago's Division of Health Sciences do not achieve the sociodemographic mirror of society we hope for, and we strive to improve both our selection processes, within the constraints and limitations of the available selection tools, and our student support mechanisms. We will continue to refine these policies and work with other key stakeholders in better preparing school leavers for health professional programmes.

Gender differences in financial barriers to primary health care in New Zealand

INTRODUCTION

Gender differences in health status and use of health care services have been established in the developed world with less attention paid to gender differences in financial barriers to primary care. Such barriers represent potentially avoidable mortality and morbidity.

AIM

To examine gender differences in financial barriers to New Zealand primary health care.

METHODS

Data from SoFIE-health, an add-on to Statistics New Zealand-led Survey of Family, Income and Employment (SoFIE), analysed using logistic regression, controlling for demographic, socioeconomic, health behaviour and health variables. Access to primary health care includes general practitioner and dental care and prescription drugs.

RESULTS

Odds of deferring seeing their doctor(s), dentist and buying a prescription respectively at least once during preceding 12 months, because they could not afford the cost of a visit or prescription, were greater for women compared to men (Odds Ratio (OR) 1.82, 95% CI: 1.67-1.99; OR 2.05, 95% CI: 1.78-2.34; and OR 1.58, 95% CI: 1.47-1.71; respectively). Adjusting for demographic, socioeconomic, health behaviour and health status attenuated OR to 1.45 (1.31-1.61) for deferring medical visit, 1.47 (1.26-1.71) buying prescription, and 1.35 (1.24-1.46) for deferring dental visit, although confidence intervals still excluded the null.

DISCUSSION

Gender significantly associated with reporting cost barriers to primary health care, regardless of individual deprivation or income levels, suggesting that primary health care policies targeting gender-specific factors are warranted. Policy measures to reduce co-payments may improve access to care for both women and men, and may have positive health implications.

Development of New Zealand's deprivation index (NZDep) and its uptake as a national policy tool

OBJECTIVES

To outline the development and uses of the census-based New Zealand small-area index of relative socio-economic deprivation, NZDep.

METHODS

NZDep has been created from four 5-yearly censuses using theory developed from international deprivation research, a standard statistical procedure (principal component analysis) and both construct and criterion validation.

RESULTS

The latest index was based on nine socio-economic deprivation variables available for just over 4 million people. It was calculated from a basis of 24,000 small areas containing a median of approximately 90 people. The deprivation index has a value from 1 (low) to 10 (high). It is mapped to standard administrative areas and is available free of charge. The index is easy to visualize, and deprivation maps are widely used. The index is used in many applications in research and social epidemiology, and routinely by the country's Ministry of Health, both to explore health variations across the country and to allocate central government funds to local health care providers. Geographers in local government were quick to recognize the index as a good tool for visualizing the diversity and neediness of local communities, and hence as a tool for town and service planning.

CONCLUSION

The national NZDep index of small-area deprivation has been used widely in research on mortality, morbidity and determinants of ill health, and in needs assessment, resource allocation and advocacy.

Funding community medicines by exception: a descriptive epidemiological study from New Zealand

AIMS

To assess rates of approval and identify factors associated with successful applications for funding to the New Zealand Community Exceptional Circumstances (CEC) scheme.

METHOD

Descriptive quantitative analysis of data in CEC applications database. The main outcome was initial application approval rate. Analysis included calculation of unadjusted and adjusted associations between potential determinants (for example patient age, gender) and outcomes using logistic regression analysis. All CEC applications with a decision about approval or decline 1 October 2001 to 30 September 2008 were included.

RESULTS

Application numbers were high, but had reduced since 2001. A small number of medicines (11) and indications comprised about a third of the applications to the scheme. While some common applications were clearly outside the remit of the scheme, many applications were for patients who fitted the scheme's eligibility criteria. The overall initial application approval rate was 16% and the renewal application approval rate was 88%. Approval rates varied widely by type of medicine, therapeutic group and indication. After adjusting for other potential determinants there were no statistically significant differences in initial approval rates by gender, ethnicity or socioeconomic status of the patient. There were however, significant differences in initial application approval by age of the patient, type of applicant doctor and by geographical location of the applicant doctor.

CONCLUSIONS

There was no evidence that gender, ethnicity and socioeconomic status of patients were factors associated with successful applications. However, applications for younger patients, those made by specialists, and those made by applying clinicians from the Auckland District Health Board area were more likely to be successful. It is possible that this may to some degree be appropriate, but requires further research.

Measuring socioeconomic position in New Zealand

INTRODUCTION: Measures of socioeconomic position (SEP) are widely used in health research. AIM: To provide future researchers with empirically based guidance about the relative utility of five measures of SEP in predicting health outcomes. METHODS: Data from 12 488 adults were obtained from the 2006 New Zealand Health Survey. Seven health-related outcome measures with expected variations by SEP are modelled using five measures of SEP: a census-based small-area index of relative socioeconomic deprivation, NZDep2006; a questionnaire-based individual-level index of socioeconomic deprivation, NZiDep; an index of living standards, ELSI; education, measured by highest qualification; and equivalised household income. RESULTS: After including the individual measure of deprivation, the area-based measure of deprivation adds useful explanatory power, and, separately, the broader spectrum provided by the living standards index adds only a small amount of extra explanatory power. The education and household income variables add little extra explanatory power. DISCUSSION: Both NZiDep and ELSI are useful health-outcome predictors. NZiDep is the cheapest data to obtain and less prone to missing data. The area index, NZDep, is a useful addition to the arsenal of individual SEP indicators, and is a reasonable alternative to them where the use of individual measures is impracticable. Education and household income, using commonly used measurement tools, may be of limited use in research if more proximal indicators of SEP are available. NZDep and NZiDep are cost-effective measures of SEP in health research. Other or additional measures may be useful if costs allow and/or for topic-related hypothesis testing. KEYWORDS: Deprivation; inequalities; living standards; New Zealand; socioeconomic position

Gender differences in financial barriers to primary health care in New Zealand

INTRODUCTION: Gender differences in health status and use of health care services have been established in the developed world with less attention paid to gender differences in financial barriers to primary care. Such barriers represent potentially avoidable mortality and morbidity. AIM: To examine gender differences in financial barriers to New Zealand primary health care. METHODS: Data from SoFIE-health, an add-on to Statistics New Zealand–led Survey of Family, Income and Employment (SoFIE), analysed using logistic regression, controlling for demographic, socioeconomic, health behaviour and health variables. Access to primary health care includes general practitioner and dental care and prescription drugs. RESULTS: Odds of deferring seeing their doctor(s), dentist and buying a prescription respectively at least once during preceding 12 months, because they could not afford the cost of a visit or prescription, were greater for women compared to men (Odds Ratio (OR) 1.82, 95% CI: 1.67–1.99; OR 2.05, 95% CI: 1.78–2.34; and OR 1.58, 95% CI: 1.47–1.71; respectively). Adjusting for demographic, socioeconomic, health behaviour and health status attenuated OR to 1.45 (1.31–1.61) for deferring medical visit, 1.47 (1.26–1.71) buying prescription, and 1.35 (1.24–1.46) for deferring dental visit, although confidence intervals still excluded the null. DISCUSSION: Gender significantly associated with reporting cost barriers to primary health care, regardless of individual deprivation or income levels, suggesting that primary health care policies targeting gender-specific factors are warranted. Policy measures to reduce co-payments may improve access to care for both women and men, and may have positive health implications. KEYWORDS: Gender; primary health care; access barriers; New Zealand

Too much and too little? Prevalence and extent of antibiotic use in a New Zealand region

OBJECTIVES

Although antibiotic use in the community is a significant contributor to resistance, little is known about social patterns of use. This study aimed to explore the use of antibiotics by age, gender, ethnicity, socio-economic status and rurality.

METHODS

Data were obtained on all medicines dispensed to ambulatory patients in one isolated town for a year, and data on antibiotics are presented in this paper. Demographic details were obtained from pharmacy records or by matching to a national patient dataset.

RESULTS

During the study year, 51% of the population received a prescription for one or more antibiotics, and on average people in the region received 10.15 defined daily doses (DDDs). Prevalence of use was higher for females (ratio, 1.18), and for young people (under 25) and the elderly (75 and over), and the amount in DDDs/person/year broadly followed this pattern. Māori (indigenous New Zealanders) were less likely to receive a prescription (48% of the population) than non-Māori (55%) and received smaller quantities on average. Rural Māori, including rural Māori children, received few prescriptions and low quantities of antibiotics compared with other population groups.

CONCLUSIONS

The level of antibiotic use in the general population is high, despite campaigns to try to reduce unnecessary use. The prevalence of acute rheumatic fever is high amongst rural Māori, and consequently treatment guidelines recommend prophylactic use of antibiotics for sore throat in this population. This makes the comparatively very low level of use of antibiotics amongst rural Māori children very concerning.

Continuity of care with general practitioners in New Zealand: results from SoFIE-Primary Care

Continuity of care has been defined as seeing the same health care provider over time, and has been shown to be associated with positive health outcomes, high quality care, high patient satisfaction with care and with lowering health care costs. While the benefits of continuity of care with a primary care provider are well documented, relatively little is known about those patients who receive or do not receive continuity of care. Using data from SoFIE-health, which is an add-on to the Statistics New Zealand-led Survey of Family, Income and Employment, this paper aims to construct a summary measure of continuity of care and to contribute to an enhanced understanding of the prevalence of continuity of care in New Zealand. We used the Primary Care Assessment Tools (PCAT) to create a mean score of continuity of care. We found continuity of care is high in New Zealand. Overall, our data provide some support for the hypothesis that people with high health needs have higher mean continuity of care scores (e.g. the elderly, Pacific and Asian ethnic groups, those in the low income tertile, and those with one or more chronic conditions). The authors propose that continued incentives to develop and sustain affiliation with a primary care provider and continuity of care are important for maintaining the quality and cost-effectiveness of primary health care.

Leadership for health: developing a canny nanny state

Health leadership comes from government, non-governmental organisations (NGOs), commercial organisations, and the community as a whole. Government has an obligation to act to protect the health of its citizens, both in respect of traditional threats to health, such as infectious diseases, and in response to newer threats, such as diet. Leadership requires the recognition and rejection of strategies that attempt to replace evidence with rhetoric. We recommend that health policy decisions have a clear evidence base and equity rationale, where the proposed interventions have been balanced against the freedom of individuals to act on their own account without undue influence from marketing. We recommend that government draws on the experience and expertise of the NGO and public health sectors, and communities to promote responsiveness to local priorities and needs. We recommend that public health practitioners strengthen their links with communities and build constituencies so public health decision-making does not occur predominantly in the bureaucratic domain.