Donna Cormack

The pervasive effects of racism: experiences of racial discrimination in New Zealand over time and associations with multiple health domains.

Self-reported experience of racial discrimination has been linked to a range of health outcomes in various countries and for different ethnic groups. This study builds on previous work in New Zealand to further investigate the prevalence of self-reported experience of racial discrimination by ethnicity, changes over time and associations with multiple health measures. The study uses data from the 2002/03 (n=12,500) and 2006/07 (n=12,488) New Zealand Health Surveys, nationally representative population-based surveys of adults (15+ years). Reported experience of racial discrimination was measured in both surveys and covered 5 items: experience of an ethnically motivated physical or verbal attack; and unfair treatment because of ethnicity by a health professional, in work, or when gaining housing. Ethnicity was classified as Maori, Pacific, Asian or European. Health indicators included measures of: mental health (SF36 mental health scale, psychological distress, doctor diagnosed mental health condition); physical health (self-rated health, SF36 physical functioning scale, cardiovascular disease); and health risk (smoking, hazardous drinking, excess body fat). Logistic regression was used to examine changes in prevalence of reported experience of racial discrimination over time and associations with health. Reported experience of racial discrimination increased between 2002/03 (28.1% ever) and 2006/07 (35.0% ever) among Asian peoples but remained largely unchanged for other ethnic groupings (Maori 29.5%, Pacific 23.0%, European 13.5%). Experience of racial discrimination was associated with all negative health measures except excess body fat. Where there were significant associations, a dose-response relationship was also evident. We conclude that racial discrimination experienced across a range of settings has the potential to impact on a wide range of health outcomes and risk factors. While ongoing research is needed to understand the multifarious nature of racism and the pathways by which it leads to poor health, it is feasible to monitor experiences of racial discrimination in national surveys.

Survival disparities in Indigenous and non-Indigenous New Zealanders with colon cancer: the role of patient comorbidity, treatment and health service factors

Background Ethnic disparities in cancer survival have been documented in many populations and cancer types. The causes of these inequalities are not well understood but may include disease and patient characteristics, treatment differences and health service factors. Survival was compared in a cohort of Maori (Indigenous) and non-Maori New Zealanders with colon cancer, and the contribution of demographics, disease characteristics, patient comorbidity, treatment and healthcare factors to survival disparities was assessed. Methods Maori patients diagnosed as having colon cancer between 1996 and 2003 were identified from the New Zealand Cancer Registry and compared with a randomly selected sample of non-Maori patients. Clinical and outcome data were obtained from medical records, pathology reports and the national mortality database. Cancer-specific survival was examined using Kaplan–Meier survival curves and Cox hazards modelling with multivariable adjustment. Results 301 Maori and 328 non-Maori patients with colon cancer were compared. Maori had a significantly poorer cancer survival than non-Maori (hazard ratio (HR)=1.33, 95% CI 1.03 to 1.71) that was not explained by demographic or disease characteristics. The most important factors contributing to poorer survival in Maori were patient comorbidity and markers of healthcare access, each of which accounted for around a third of the survival disparity. The final model accounted for almost all the survival disparity between Maori and non-Maori patients (HR=1.07, 95% CI 0.77 to 1.47). Conclusion Higher patient comorbidity and poorer access and quality of cancer care are both important explanations for worse survival in Maori compared with non-Maori New Zealanders with colon cancer.

The effect of comorbidity on the use of adjuvant chemotherapy and survival from colon cancer: a retrospective cohort study

BackgroundComorbidity has a well documented detrimental effect on cancer survival. However it is difficult to disentangle the direct effects of comorbidity on survival from indirect effects via the influence of comorbidity on treatment choice. This study aimed to assess the impact of comorbidity on colon cancer patient survival, the effect of comorbidity on treatment choices for these patients, and the impact of this on survival among those with comorbidity.MethodsThis retrospective cohort study reviewed 589 New Zealanders diagnosed with colon cancer in 1996–2003, followed until the end of 2005. Clinical and outcome data were obtained from clinical records and the national mortality database. Cox proportional hazards and logistic regression models were used to assess the impact of comorbidity on cancer specific and all-cause survival, the effect of comorbidity on chemotherapy recommendations for stage III patients, and the impact of this on survival among those with comorbidity.ResultsAfter adjusting for age, sex, ethnicity, area deprivation, smoking, stage, grade and site of disease, higher Charlson comorbidity score was associated with poorer all-cause survival (HR = 2.63 95%CI:1.82–3.81 for Charlson score ≥ 3 compared with 0). Comorbidity count and several individual conditions were significantly related to poorer all-cause survival. A similar, but less marked effect was seen for cancer specific survival. Among patients with stage III colon cancer, those with a Charlson score ≥ 3 compared with 0 were less likely to be offered chemotherapy (19% compared with 84%) despite such therapy being associated with around a 60% reduction in excess mortality for both all-cause and cancer specific survival in these patients.ConclusionComorbidity impacts on colon cancer survival thorough both physiological burden of disease and its impact on treatment choices. Some patients with comorbidity may forego chemotherapy unnecessarily, increasing avoidable cancer mortality.

Ethnicity and management of colon cancer in New Zealand: do indigenous patients get a worse deal?

Racial and ethnic inequalities in colon cancer treatment have been reported in the United States but not elsewhere. The authors of this report compared cancer treatment in a nationally representative cohort of Maori (indigenous) and non‐Maori New Zealanders with colon cancer.

Ethnic density and area deprivation: Neighbourhood effects on Māori health and racial discrimination in Aotearoa/New Zealand

Some studies suggest that ethnic minority people are healthier when they live in areas with a higher concentration of people from their own ethnic group, a so-called ethnic density effect. To date, no studies have examined the ethnic density effect among indigenous peoples, for whom connections to land, patterns of settlement, and drivers of residential location may differ from ethnic minority populations. The present study analysed the Māori sample from the 2006/07 New Zealand Health Survey to examine the association between increased Māori ethnic density, area deprivation, health, and experiences of racial discrimination. Results of multilevel regressions showed that an increase in Māori ethnic density was associated with decreased odds of reporting poor self-rated health, doctor-diagnosed common mental disorders, and experienced racial discrimination. These associations were strengthened after adjusting for area deprivation, which was consistently associated with increased odds of reporting poor health and reports of racial discrimination. Our findings show that whereas ethnic density is protective of the health and exposure to racial discrimination of Māori, this effect is concealed by the detrimental effect of area deprivation, signalling that the benefits of ethnic density must be interpreted within the current socio-political context. This includes the institutional structures and racist practices that have created existing health and socioeconomic inequities in the first place, and maintain the unequal distribution of concentrated poverty in areas of high Māori density. Addressing poverty and the inequitable distribution of socioeconomic resources by ethnicity and place in New Zealand is vital to improving health and reducing inequalities. Given the racialised nature of access to goods, services, and opportunities within New Zealand society, this also requires a strong commitment to eliminating racism. Such commitment and action will allow the benefits potentially flowing from strong communities to be fully realised.

Self-Reported Experience of Racial Discrimination and Health Care Use in New Zealand: Results From the 2006/07 New Zealand Health Survey

OBJECTIVES We investigated whether reported experience of racial discrimination in health care and in other domains was associated with cancer screening and negative health care experiences. METHODS We used 2006/07 New Zealand Health Survey data (n = 12 488 adults). We used logistic regression to examine the relationship of reported experience of racial discrimination in health care (unfair treatment by a health professional) and in other domains (personal attack, unfair treatment in work and when gaining housing) to breast and cervical cancer screening and negative patient experiences adjusted for other variables. RESULTS Racial discrimination by a health professional was associated with lower odds of breast (odds ratio [OR] = 0.37; 95% confidence interval [CI] = 0.14, 0.996) and cervical cancer (OR = 0.51; 95% CI = 0.30, 0.87) screening among Maori women. Racial discrimination by a health professional (OR = 1.57; 95% CI = 1.15, 2.14) and racial discrimination more widely (OR = 1.55; 95% CI = 1.35, 1.79) were associated with negative patient experiences for all participants. CONCLUSIONS Experience of racial discrimination in both health care and other settings may influence health care use and experiences of care and is a potential pathway to poor health.

Patterns of Disparity: Ethnic and Socio-economic Trends in Breast Cancer Mortality in New Zealand

ObjectiveTo test whether trends in breast cancer mortality varied by ethnicity and socio-economic position during the 1980s and ‘90s in New Zealand.MethodsFour cohorts of the entire New Zealand population for 1981–84; 86–89; 91–94 and 96–99 allowed direct determination of socio-economic trends in breast cancer mortality. For ethnicity, unlinked routine census and mortality data were used with adjustment factors for undercounting of Māori and Pacific deaths.ResultsMāori and non-Māori non-Pacific mortality rates changed little until mid-1990s with Māori experiencing 25% higher mortality. In 1996–99, Māori rates increased notably to become 68% higher than non-Māori non-Pacific (SRR 1.68; 95% CI: 1.49–1.90). Pacific women experienced an approximate three-fold increase in breast cancer mortality over time.There appeared to be reducing mortality among higher income and education groups but trends within socio-economic groups were not statistically significant. Nevertheless, by 1996–99, there was a significant 22% excess mortality (SRR 1.22; 95% CI: 1.01–1.49) for low compared with high-income groups.ConclusionsWidening ethnic, and probably, socio-economic disparities in breast cancer mortality are likely due to both underlying incidence and differential survival trends. Disparities are likely to increase once the full differential mortality benefits of screening impact on the population.

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

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

Improving survival disparities in cervical cancer between Māori and non‐Māori women in New Zealand: a national retrospective cohort study

Objective: Māori women in New Zealand have higher incidence of and mortality from cervical cancer than non‐Māori women, however limited research has examined differences in treatment and survival between these groups. This study aims to determine if ethnic disparities in treatment and survival exist among a cohort of Māori and non‐Māori women with cervical cancer.

Investigating the relationship between ethnic consciousness, racial discrimination and self-rated health in New Zealand.

In this study, we examine race/ethnic consciousness and its associations with experiences of racial discrimination and health in New Zealand. Racism is an important determinant of health and cause of ethnic inequities. However, conceptualising the mechanisms by which racism impacts on health requires racism to be contextualised within the broader social environment. Race/ethnic consciousness (how often people think about their race or ethnicity) is understood as part of a broader assessment of the ‘racial climate’. Higher race/ethnic consciousness has been demonstrated among non-dominant racial/ethnic groups and linked to adverse health outcomes in a limited number of studies. We analysed data from the 2006/07 New Zealand Health Survey, a national population-based survey of New Zealand adults, to examine the distribution of ethnic consciousness by ethnicity, and its association with individual experiences of racial discrimination and self-rated health. Findings showed that European respondents were least likely to report thinking about their ethnicity, with people from non-European ethnic groupings all reporting relatively higher ethnic consciousness. Higher ethnic consciousness was associated with an increased likelihood of reporting experience of racial discrimination for all ethnic groupings and was also associated with fair/poor self-rated health after adjusting for age, sex and ethnicity. However, this difference in health was no longer evident after further adjustment for socioeconomic position and individual experience of racial discrimination. Our study suggests different experiences of racialised social environments by ethnicity in New Zealand and that, at an individual level, ethnic consciousness is related to experiences of racial discrimination. However, the relationship with health is less clear and needs further investigation with research to better understand the racialised social relations that create and maintain ethnic inequities in health in attempts to better address the impacts of racism on health.