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Presents the first theoretical and methodological shift in the measurement of area deprivation in NZ since the 1990s and describes the development of the New Zealand Index of Multiple Deprivation (IMD). Describes briefly the development of Data Zones, an intermediary geographical scale, before outlining the development of the New Zealand Index of Multiple Deprivation (IMD), which uses routine data sets and methods comparable to current international deprivation indices. Identifies 28 indicators of deprivation from national health, social development, taxation, education, police databases, geospatial data providers and the 2013 Census, all of which represented seven domains of deprivation : employment; income; crime; housing; health; education; and geographical access Source: National Library of New Zealand Te Puna Matauranga o Aotearoa, licensed by the Department of Internal Affairs for re-use under the Creative Commons Attribution 3.0 New Zealand Licence.

Background Transport is fundamental to support older Māori (kaumātua) wellbeing, facilitating ageing in place, social inclusion and access to cultural sites and practices – there is minimal research on transport practices of Indigenous populations and no published quantitative studies on the transport practices of kaumātua. Considering this data gap, we describe kaumātua transport practices and driving cessation planning in the context of a sample of older drivers from Aotearoa New Zealand. Methods Cross-sectional descriptive analysis of baseline data from New Zealand Prospective Older Adult Transport and Health Study (NZPATHS) of 1181 older drivers (65–96 years), 15% of whom identified as Māori. Data were gathered via computer assisted structured telephone interviews, including socio-demographic, health, transport and driving practice measures. Statistical tests performed were Mann Whitney, chi-square and Fisher’s exact tests, to provide contextual ethnic comparisons between categorical variables. Results Participants reported transport modes used in the previous three months. Similarly to non- Māori, kaumātua (driving at baseline) relied heavily on the private car for transport, as drivers (solely, 99%; or with passengers, 90%) and as passengers (87%). Compared to non-Māori, fewer Māori walked for transport (41% vs. 53%), and fewer used public transport (18% vs. 26%, bus/tram; 10% vs. 16%, train). Few kaumātua (4%) had made plans for not driving, a smaller proportion than for non-Māori (11%). Conclusions Kaumātua rely heavily on private cars for transport, yet when they can no longer drive, this dependence may present barriers to daily living and to maintaining cultural practices, health, and wellbeing. Increased transport infrastructure including public and community transport is needed to allow transport options beyond driving. Transport stakeholders must incorporate wider perspectives, including Indigenous peoples’ voices. This study provides data that can be used to inform and support improvements within the transport sector that reduce transport and health disadvantage and inequities.

Background Inequities in implementation contribute to the unequal benefit of health interventions between groups of people with differing levels of advantage in society. Implementation science theories, models and frameworks (TMFs) provide a theoretical basis for understanding the multi-level factors that influence implementation outcomes and are used to guide implementation processes. This study aimed to identify and analyse TMFs that have an equity focus or have been used to implement interventions in populations who experience ethnicity or ‘race’-related health inequities. Methods A scoping review was conducted to identify the relevant literature published from January 2011 to April 2022 by searching electronic databases (MEDLINE and CINAHL), the Dissemination and Implementation model database, hand-searching key journals and searching the reference lists and citations of studies that met the inclusion criteria. Titles, abstracts and full-text articles were screened independently by at least two researchers. Data were extracted from studies meeting the inclusion criteria, including the study characteristics, TMF description and operationalisation. TMFs were categorised as determinant frameworks, classic theories, implementation theories, process models and evaluation frameworks according to their overarching aim and described with respect to how equity and system-level factors influencing implementation were incorporated. Results Database searches yielded 610 results, 70 of which were eligible for full-text review, and 18 met the inclusion criteria. A further eight publications were identified from additional sources. In total, 26 papers describing 15 TMFs and their operationalisation were included. Categorisation resulted in four determinant frameworks, one implementation theory, six process models and three evaluation frameworks. One framework included elements of determinant, process and evaluation TMFs and was therefore classified as a ‘hybrid’ framework. TMFs varied in their equity and systems focus. Twelve TMFs had an equity focus and three were established TMFs applied in an equity context. All TMFs at least partially considered systems-level factors, with five fully considering macro-, meso- and micro-level influences on equity and implementation. Conclusions This scoping review identifies and summarises the implementation science TMFs available to support equity-focused implementation. This review may be used as a resource to guide TMF selection and illustrate how TMFs have been utilised in equity-focused implementation activities.

IntroductionInequities in health status exist in New Zealand across the rural–urban spectrum. In parallel, rural–urban differences in health service utilisation vary by service type. Despite the New Zealand public health system being based on principles of universal access, equity and fairness, levels of health expenditure on rural and urban populations are not well understood. The purpose of the study is to undertake a rural–urban analysis of public health system expenditure, based on individual-level service utilisation and national pricing of health service events.Methods and analysisIndividual-level service utilisation and pricing will be collated from national collection databases for all eligible users of publicly funded services. The analysis will include calendar years 2017–2024. Descriptive analysis and a two-part generalised linear regression model will be used to identify if rural–urban differences in expenditure exist, and what the association of rurality is with expenditure (if any). The model will also be used to identify geographic regions with expenditure levels that vary from those predicted using regression model weights. As the specific statistical approach will be determined by data attributes, this protocol outlines the intended approach to construct the analytical model.Ethics and consultationEthics approval was obtained from the University of Otago Human Research Ethics Committee (HD23/052). Māori consultation has been undertaken with the Ngāi Tahu Research Consultation Committee and will continue throughout the research process.

Equity in healthcare is the ideal state where everyone shares equal rights and opportunities. To date, research methodologies are limited in their scope to translate into more equitable healthcare policies and practices. We present a re-interpreted grounded theory methodology to contribute to active dialogue toward optimizing equity through research. This re-interpreted research methodology is presented within a study investigating why ethnic disparities in infant survival from critical congenital heart disease occur in a multi-ethnic national setting in New Zealand. Using dialectical pluralism, we developed an innovative Multi-ethnic, Multisource Grounded Theory methodological concept by deliberately integrating Indigenous and multi-ethnic intersectional perspectives on health inequities from diverse data sources (literature reviews, retrospective case studies, and interview transcripts). Central to the process was the uplifting and centralizing of Indigenous voices. Conceptually, Multi-ethnic, Multisource Grounded Theory could reframe an existing research domain to equip researchers with a framework to intentionally integrate cultural considerations when building information from diverse data in the health equity space. Theoretically, this approach could enhance methodological rigour and support the translation of responsible, ethical, and equitable healthcare models.

ObjectiveThere are large inequities in the lung cancer burden for the Indigenous Māori population of New Zealand. We model the potential lifetime health gains, equity impacts and cost-effectiveness of a national low-dose CT (LDCT) screening programme for lung cancer in smokers aged 55–74 years with a 30 pack-year history, and for formers smokers who have quit within the last 15 years.DesignA Markov macrosimulation model estimated: health benefits (health-adjusted life-years (HALYs)), costs and cost-effectiveness of biennial LDCT screening. Input parameters came from literature and NZ-linked health datasets.SettingNew Zealand.ParticipantsPopulation aged 55–74 years in 2011.InterventionsBiennial LDCT screening for lung cancer compared with usual care.Outcome measuresIncremental cost-effectiveness ratios were calculated using the average difference in costs and HALYs between the screened and the unscreened populations. Equity analyses included substituting non-Māori values for Māori values of background morbidity, mortality and stage-specific survival. Changes in inequities in lung cancer survival and ‘health-adjusted life expectancy’ (HALE) were measured.ResultsLDCT screening in NZ is likely to be cost-effective for the total population: NZ$34 400 per HALY gained (95% uncertainty interval NZ$27 500 to NZ$42 900) and for Māori separately (using a threshold of gross domestic product per capita NZ$45 000). Health gains per capita for Māori females were twice that for non-Māori females and 25% greater for Māori males compared with non-Māori males. LDCT screening will narrow absolute inequities in HALE and lung cancer mortality for Māori, but will slightly increase relative inequities in mortality from lung cancer (compared with non-Māori) due to differential stage-specific survival.ConclusionA national biennial LDCT lung cancer screening programme in New Zealand is likely to be cost-effective, will improve total population health and reduce health inequities for Māori. Attention must be paid to addressing ethnic inequities in stage-specific lung cancer survival.

Background Māori (Indigenous) youth of Aotearoa New Zealand are experiencing widening inequities in mental health when compared to Pākehā (New Zealand European/other European/“White”; cultural majority) youth. This study used an ecological approach to investigate key risk and protective factors for Māori to help prioritise actions. Methods A subsample of Māori participants ( N  = 1,528) from a large representative cross-sectional secondary dataset on secondary school students’ health and wellbeing (Youth’19) were used to examine the effects of explanatory variables selected from five domains (individual, and their wider social ecosystem, including whānau/family, school, and community) on four mental health outcomes (wellbeing, depressive symptoms, suicide thoughts, suicide attempts). Descriptive statistics (percentages and 95% CIs) were used to examine the equity of these variables between Māori and Pākehā/White youth. Results Overall, individual risk factors included female sex, functional disability, and sexual abuse. Wider adverse social ecosystems included housing precarity, household deprivation, bullying, and racial discrimination. Key protective factors included the Indigenous concept of whanaungatanga (relationships/connection) with whānau (family), and feelings of safety in social ecosystems including home, school, and neighbourhoods. These risk and protective factors were broadly similar across the four mental health outcomes. Compared to Pākehā/White youth, Māori youth were exposed to greater risk-conferring ecosystems, including socioeconomic deprivation, discrimination, and violence-related harms. Conclusions Addressing inequitable mental health harm requires not only intervening at the individual level, but also addressing the wider social ecosystems that disproportionately harm Māori youth, including colonial systems that consistently impact Indigenous youth mental health, particularly housing precarity, poverty, violence, bullying, and racism. Culturally and developmentally appropriate approaches with a focus on creating safe and inclusive societies are urgently required to reduce Indigenous youth mental health inequity.

ObjectivesExamine the impact of two generic—urban–rural experimental profile (UREP) and urban accessibility (UA)—and one purposely built—geographic classification for health (GCH)—rurality classification systems on the identification of rural–urban health disparities in Aotearoa New Zealand (NZ).DesignA comparative observational study.SettingNZ; the most recent 5 years of available data on mortality events (2013–2017), hospitalisations and non-admitted hospital patient events (both 2015–2019).ParticipantsNumerator data included deaths (n=156 521), hospitalisations (n=13 020 042) and selected non-admitted patient events (n=44 596 471) for the total NZ population during the study period. Annual denominators, by 5-year age group, sex, ethnicity (Māori, non-Māori) and rurality, were estimated from Census 2013 and Census 2018.Primary and secondary outcome measuresPrimary measures were the unadjusted rural incidence rates for 17 health outcome and service utilisation indicators, using each rurality classification. Secondary measures were the age-sex-adjusted rural and urban incidence rate ratios (IRRs) for the same indicators and rurality classifications.ResultsTotal population rural rates of all indicators examined were substantially higher using the GCH compared with the UREP, and for all except paediatric hospitalisations when the UA was applied. All-cause rural mortality rates using the GCH, UA and UREP were 82, 67 and 50 per 10 000 person-years, respectively. Rural–urban all-cause mortality IRRs were higher using the GCH (1.21, 95% CI 1.19 to 1.22), compared with the UA (0.92, 95% CI 0.91 to 0.94) and UREP (0.67, 95% CI 0.66 to 0.68). Age-sex-adjusted rural and urban IRRs were also higher using the GCH than the UREP for all outcomes, and higher than the UA for 13 of the 17 outcomes. A similar pattern was observed for Māori with higher rural rates for all outcomes using the GCH compared with the UREP, and 11 of the 17 outcomes using the UA. For Māori, rural–urban all-cause mortality IRRs for Māori were higher using the GCH (1.34, 95% CI 1.29 to 1.38), compared with the UA (1.23, 95% CI 1.19 to 1.27) and UREP (1.15, 95% CI 1.10 to 1.19).ConclusionsSubstantial variation in rural health outcome and service utilisation rates were identified with different classifications. Rural rates using the GCH are substantially higher than the UREP. Generic classifications substantially underestimated rural–urban mortality IRRs for the total and Māori populations.

Background Lung cancer screening reduces lung cancer mortality by at least 20%. If implemented equitably, it has the potential to reduce inequities for Māori (the Indigenous people of Aotearoa New Zealand), whose rates of lung cancer are significantly higher than non-Māori. Our aim was to inform the equitable implementation of potential future lung cancer screening in Aotearoa by understanding the acceptability, decision making processes and design preferences for Māori and their whānau. Methods In 2020, Māori potentially eligible for lung cancer screening ( n  = 388) and their whānau/family members ( n  = 103) completed separate cross-sectional surveys about how a future screening programme could be designed and delivered. The focus of the surveys was to determine the level of support for a lung screening programme and to explore decision making and design preferences for Māori and their whānau. The two surveys were analysed separately with pre-defined responses reported as frequencies and percentages. Fisher’s exact tests were used to compare responses between gender, region, age-group and smoking status. Significant differences were further explored using pairwise comparisons with Bonferroni correction. Free text comments were analysed thematically. Results There was a very high level of support for a lung screening programme. When deciding whether to take part in screening, the strongest preferences were to follow doctors’ advice, followed by deciding alone, or with their whānau. An almost equal proportion of participants preferred to receive an invitation from their GP, or from a screening programme. Preferences for receiving information about the programme varied, with the most common being talking directly to a doctor, followed by reading a brochure, or receiving information via email. The results showed clear differences in preferences between demographic groups, particularly between regions and age-groups. Conclusions Surveys of potentially eligible Māori participants and their whānau have revealed support for screening, but diverse preferences regarding decision making and programme design. These findings have informed a randomised controlled trial on lung cancer screening invitation approaches and will guide the development of a national lung screening programme.

Lung cancer screening can significantly reduce mortality from lung cancer. Further evidence about how to optimize lung cancer screening for specific populations, including Aotearoa New Zealand (NZ)’s Indigenous Māori (who experience disproportionately higher rates of lung cancer), is needed to ensure it is equitable. This community-based, pragmatic cluster randomized trial aims to determine whether a lung cancer screening invitation from a patient’s primary care physician, compared to from a centralized screening service, will optimize screening uptake for Māori. Participating primary care practices (clinics) in Auckland, Aotearoa NZ will be randomized to either the primary care-led or centralized service for delivery of the screening invitation. Clinic patients who meet the following criteria will be eligible: Māori; aged 55–74 years; enrolled in participating clinics in the region; ever-smokers; and have at least a 2% risk of developing lung cancer within six years (determined using the PLCO M2012 risk prediction model). Eligible patients who respond positively to the invitation will undertake shared decision-making with a nurse about undergoing a low dose CT scan (LDCT) and an assessment for Chronic Obstructive Pulmonary Disease (COPD). The primary outcomes are: 1) the proportion of eligible population who complete a risk assessment and 2) the proportion of people eligible for a CT scan who complete the CT scan. Secondary outcomes include evaluating the contextual factors needed to inform the screening process, such as including assessment for Chronic Obstructive Pulmonary Disease (COPD). We will also use the RE-AIM framework to evaluate specific implementation factors. This study is a world-first, Indigenous-led lung cancer screening trial for Māori participants. The study will provide policy-relevant information on a key policy parameter, invitation method. In addition, the trial includes a nested analysis of COPD in the screened Indigenous population, and it provides baseline (T0 screen round) data using RE-AIM implementation outcomes.