Lorna Dyall

Ethnic disparities in incidence of stroke subtypes: Auckland Regional Community Stroke Study, 2002-2003

BACKGROUND Limited population-based data exist on differences in the incidence of major pathological stroke types and ischaemic stroke subtypes across ethnic groups. We aimed to provide such data within the large multi-ethnic population of Auckland, New Zealand. METHODS All first-ever cases of stroke (n=1423) in a population-based register in 940 000 residents (aged 15 years) in Auckland, New Zealand, for a 12-month period in 2002-2003, were classified into ischaemic stroke, primary intracerebral haemorrhage (PICH), subarachnoid haemorrhage, and undetermined stroke, according to standard definitions and results of neuroimaging/necropsy (in over 90% of cases). Ischaemic stroke was further classified into five subtypes. Ethnicity was self-identified and grouped as New Zealand (NZ)/European, Maori/Pacific, and Asian/other. Incidence rates were standardised to the WHO world population by the direct method, and differences in rates between ethnic groups expressed as rate ratios (RRs), with NZ/European as the reference group. FINDINGS In NZ/European people, ischaemic stroke comprised 73%, PICH 11%, and subarachnoid haemorrhage 6%, but PICH was higher in Maori/Pacific people (17%) and in Asian/other people (22%). Compared with NZ/European people, age-adjusted RRs for PICH were 2.7 (95% CI 1.8-4.0) and 2.3 (95% CI 1.4-3.7) among Maori/Pacific and Asian/other people, respectively. The corresponding RR for ischaemic stroke was greater for Maori/Pacific people (1.7 [95% CI 1.4-2.0]), particularly embolic stroke, and for Asian/other people (1.3 [95% CI 1.0-1.7]). The onset of stroke in Maori/Pacific and Asian/other people began at significantly younger ages (62 years and 64 years, respectively) than in NZ/Europeans (75 years; p<0.0001). There were ethnic differences in the risk factor profiles (such as age, sex, hypertension, cardiac disease, diabetes, hypercholesterolaemia, smoking status, overweight) for the stroke types and subtypes. INTERPRETATION Compared to NZ/Europeans, Maori/Pacific and Asian/other people are at higher risk of ischaemic stroke and PICH, whereas similar rates of subarachnoid haemorrhage were evident across ethnic groups. The ethnic disparities in the rates of stroke types could be due to substantial differences found in risk factor profiles between ethnic groups. This information should be considered when planning prevention and stroke-care services in multi-ethnic communities.

Cultural Icons and Marketing of Gambling

A number of different countries and states have or are in the process of developing formal or informal guidelines to govern gambling advertising and marketing of gambling. There is a growing consensus that gambling advertising should not mislead the public, be fair, provide information on the odds of wining and there should be provisions in place to protect vulnerable groups, such as, children. In the development of these guidelines by different countries or states there has been no real consideration of the need to engage with different indigenous and ethnic populations to ensure that they are protected as vulnerable populations. Further there is a need to engage with these populations within countries and across countries to ensure that indigenous and ethnic minority cultural icons, values, religious practices and music are not used without their permission or exploited in the business of promoting and marketing different forms of gambling products. New Zealand’s experience of marketing and advertising of gambling is discussed in this paper. It is outlined the development of casinos in New Zealand and how Maori were actively encouraged to participate in the opening of these establishments and therefore, legitimate their existence as a safe place for Maori, the indigenous population of New Zealand to frequent on a regular basis. Since then other ethnic minority populations have been targeted to engage in different forms of gambling by recognising their significant cultural events, importance of family events and celebrating and promoting the success of important sport role models. Gambling advertising can be direct or subtle, however, little research has focussed on the third person effect associated with gambling advertising. New Zealand has adopted a public health approach to reduce gambling related harm. One of the key strategies introduced to reduce gambling related harm has been the development and implementation of harm minimisation regulations. Research conducted in New Zealand regarding individuals’ attitudes and behaviour to gambling, highlights that Maori have a high recall of gambling advertisements alongside other ethnic populations. The paper suggests that as part of a public health approach to reduce gambling related harm that it is now timely in New Zealand, for consideration to be given as to how much exposure, if any, New Zealanders should be subjected to gambling advertising.

Culture, ethnicity, and sport management: a New Zealand perspective.

There is a growing recognition of the need to understand the impacts of culture and ethnicity on sport consumption, and to identify the consequent implications for sport management and marketing. Styles and patterns of sport involvement vary across cultures, sometimes requiring that associated rules, rituals, and ceremonies be modified or adapted to fit particular cultural settings. Patterns and styles of interpersonal communication also vary across cultures. Two dimensions of cultural difference in interpersonal communication - inclusion versus exclusion and egalitarianism versus respect - have particular potential to affect sport participation negatively if they are not accommodated appropriately. Depending on their sensitivity to cultural differences, the policies and practices of sport managers in multicultural settings can enhance or worsen inter-ethnic relations, recruitment, turnover, motivation, and involvement. Needed research and implications for the management of sport are highlighted.

Quality of hospital care for Māori patients in New Zealand: retrospective cross-sectional assessment

BACKGROUND New Zealand has a substantial indigenous minority--the Māori--that has considerably worse health status than the majority population. We aimed to assess possible disparities in quality of hospital care for Māori with data on preventable adverse events as an indicator of suboptimum treatment. METHODS We undertook a nationally representative cross-sectional survey of admissions to general public hospitals with more than 100 beds providing acute care. A sample of 6579 patients admitted in 1998 to 13 hospitals was selected by stratified systematic list sample. We did a two-stage retrospective assessment of records by structured implicit review. Outcome measures were occurrence, effect, and preventability of adverse events. FINDINGS Māori accounted for just greater than 15% of admissions and were on average younger, were more likely to be from from deprived areas, had a different case mix, and were in hospital for a shorter stay compared with patients of non-Māori/non-Pacific origin. Overall, after age standardisation, 14% of admissions for Māori were associated with an adverse event, compared with 11% for non-Māori/non-Pacific patients (p=0.01 for difference between groups). For preventable, in-hospital events, this disparity persisted after controlling for age, other sociodemographic factors, and case mix (adjusted odds ratio 1.47; p=0.05). Analysis of potential causal factors showed no markedly or consistently different pattern between the groups. INTERPRETATION Despite a predominantly publicly funded hospital system, our findings suggest that hospital care received by Māori is marginally poorer than that received by New Zealand citizens of non-Māori/non-Pacific origin. Although no cause specific to Māori was evident, various policy and system issues can be addressed.

Life and Living in Advanced Age: A Cohort Study in New Zealand -Te Puāwaitanga o Nga Tapuwae Kia Ora Tonu, LiLACS NZ: Study protocol

BackgroundThe number of people of advanced age (85 years and older) is increasing and health systems may be challenged by increasing health-related needs. Recent overseas evidence suggests relatively high levels of wellbeing in this group, however little is known about people of advanced age, particularly the indigenous Māori, in Aotearoa, New Zealand. This paper outlines the methods of the study Life and Living in Advanced Age: A Cohort Study in New Zealand. The study aimed to establish predictors of successful advanced ageing and understand the relative importance of health, frailty, cultural, social & economic factors to successful ageing for Māori and non-Māori in New Zealand.Methods/designA total population cohort study of those of advanced age. Two cohorts of equal size, Māori aged 80–90 and non-Māori aged 85, oversampling to enable sufficient power, were enrolled. A defined geographic region, living in the Bay of Plenty and Lakes District Health Board areas of New Zealand, defined the sampling frame. Rūnanga (Māori tribal organisations) and Primary Health Organisations were subcontracted to recruit on behalf of the University. Measures - a comprehensive interview schedule was piloted and administered by a trained interviewer using standardised techniques. Socio-demographic and personal history included tribal affiliation for Māori and participation in cultural practices; physical and psychological health status used standardised validated research tools; health behaviours included smoking, alcohol use and nutrition risk; and environmental data included local amenities, type of housing and neighbourhood. Social network structures and social support exchanges are recorded. Measures of physical function; gait speed, leg strength and balance, were completed. Everyday interests and activities, views on ageing and financial interests complete the interview. A physical assessment by a trained nurse included electrocardiograph, blood pressure, hearing and vision, anthropometric measures, respiratory function testing and blood samples.DiscussionA longitudinal study of people of advanced age is underway in New Zealand. The health status of a population based sample of older people will be established and predictors of successful ageing determined.

No effect of ultraviolet radiation on blood pressure and other cardiovascular risk factors.

Objectives Recent epidemiological studies have reported inverse associations between vitamin D status and blood pressure. The study aim is to determine if exposure to ultraviolet B radiation, which synthesizes vitamin D, lowers blood pressure, compared with ultraviolet A radiation. Methods Men and women (n = 119) with low vitamin D levels [serum 25-hydroxyvitamin D [25(OH)D] <50 nmol/l], completed a randomized clinical trial carried out during winter. Blood pressure was measured for 12–14 h with an ambulatory monitor at baseline and 12 weeks. In between, participants received 24 whole body exposures of either ultraviolet B (n = 58) or ultraviolet A (n = 61) over 12 weeks. Results Mean (SD) 25(OH)D increased from 43.7 (9.7) to 92.6 (16.9) nmol/l in the ultraviolet B arm after 12 weeks, and from 45.4 (9.2) to 64.9 (11.3) nmol/l in the ultraviolet A arm. However, mean blood pressure, which was similar for the ultraviolet B and ultraviolet A at baseline (134.9/79.2 vs. 132.9/77.8 mmHg; P = 0.59 and 0.56, respectively), did not change from baseline to 12 weeks in either group. The mean change [95% confidence interval (CI)] in blood pressure over this period in the ultraviolet B group compared with the ultraviolet A group was −2.2 (−7.8, 3.3) mmHg for systolic (P = 0.42) and −2.7 (−6.5, 1.0) mmHg for diastolic (P = 0.15). Conclusion Exposure to ultraviolet B did not lower blood pressure. Our results suggest that if vitamin D protects against cardiovascular disease, it involves some mechanism other than blood pressure.

Health equity in the New Zealand health care system: a national survey

IntroductionIn all countries people experience different social circumstances that result in avoidable differences in health. In New Zealand, Māori, Pacific peoples, and those with lower socioeconomic status experience higher levels of chronic illness, which is the leading cause of mortality, morbidity and inequitable health outcomes. Whilst the health system can enable a fairer distribution of good health, limited national data is available to measure health equity. Therefore, we sought to find out whether health services in New Zealand were equitable by measuring the level of development of components of chronic care management systems across district health boards. Variation in provision by geography, condition or ethnicity can be interpreted as inequitable.MethodsA national survey of district health boards (DHBs) was undertaken on macro approaches to chronic condition management with detail on cardiovascular disease, chronic obstructive pulmonary disease, congestive heart failure, stroke and diabetes. Additional data from expert informant interviews on program reach and the cultural needs of Māori and Pacific peoples was sought. Survey data were analyzed on dimensions of health equity relevant to strategic planning and program delivery. Results are presented as descriptive statistics and free text. Interviews were transcribed and NVivo 8 software supported a general inductive approach to identify common themes.ResultsSurvey responses were received from the majority of DHBs (15/21), some PHOs (21/84) and 31 expert informants. Measuring, monitoring and targeting equity is not systematically undertaken. The Health Equity Assessment Tool is used in strategic planning but not in decisions about implementing or monitoring disease programs. Variable implementation of evidence-based practices in disease management and multiple funding streams made program implementation difficult. Equity for Māori is embedded in policy, this is not so for other ethnic groups or by geography. Populations that conventional practitioners find hard to reach, despite recognized needs, are often underserved. Nurses and community health workers carried a disproportionate burden of care. Cultural and diversity training is not a condition of employment.ConclusionsThere is a struggle to put equity principles into practice, indicating will without enactment. Equity is not addressed systematically below strategic levels and equity does not shape funding decisions, program development, implementation and monitoring. Equity is not incentivized although examples of exceptional practice, driven by individuals, are evident across New Zealand.

Dietary intakes of European, Māori, Pacific and Asian adults living in Auckland: the Diabetes, Heart and Health Study.

Objective: To compare dietary intakes of European, Māori, Pacific, and Asian men and women living in Auckland.

Engagement and recruitment of Māori and non-Māori people of advanced age to LiLACS NZ

Objectives : Life and Living in Advanced Age: A Cohort Study in New Zealand (LiLACS NZ) aims to determine the predictors of successful advanced ageing and understand the trajectories of wellbeing in advanced age. This paper reports recruitment strategies used to enrol 600 Māori aged 80–90 years and 600 non‐Māori aged 85 years living within a defined geographic boundary.

Why People Gamble: A Qualitative Study of Four New Zealand Ethnic Groups

In multicultural countries such as New Zealand, it is particularly important that gambling research take into account possible cultural differences. Many New Zealanders come from cultures that do not have a history of gambling, including the Mäori (New Zealand indigenous people), Pacific Islanders, and recent migrants. Little research has examined the reasons why people start and continue to gamble, especially among different ethnic groups. This research project thus aimed to develop a framework to explain how environmental, cultural, and social factors interact with personal attributes to determine gambling behaviors. In a qualitative study, 131 people broadly representative of Mäori, Pacific, Asian, and Päkehä/New Zealand European groups residing in New Zealand were interviewed individually or in focus groups. They included social and problem gamblers, families of problem gamblers, and professionals. Different personal, socioeconomic, environmental, and cultural factors were identified, summarized in a developmental framework, and compared to factors found for ethnic groups in other countries. Public health policy issues were raised, including greater control of gambling promotion.