Maori Medical Student and Physician Exposure to Racism, Discrimination, Harassment, and Bullying.

Importance: Discrimination, bullying, and harassment in medicine have been reported internationally, but exposures for Indigenous medical students and physicians, and for racism specifically, remain less examined. Objective: To examine the prevalence of racism, discrimination, bullying, and harassment for Maori medical students and physicians in New Zealand and associations with demographic and clinical characteristics. Design, Setting, and Participants: This cross-sectional study used data from an anonymous national survey of Maori medical students and physicians in New Zealand in late 2021 and early 2022. Data were analyzed from March 2022 to April 2024. Exposures: Age, gender, marginalized status (ie, in addition to being Maori, belonging to other groups traditionally marginalized or underrepresented in medicine), year of medical school, year of graduation, and main work role. Main Outcomes and Measures: Direct and witnessed racism, discrimination, bullying, and harassment were measured as any experience in the last year and ever. Any exposure to negative comments about social groups and witnessing discriminatory treatment toward Maori patients or whanau (extended family). Considering leaving medicine, including because of mistreatment, was measured. Results: Overall, 205 Maori medical students (median [IQR] age, 23.1 [21.6-24.3] years; 137 [67.2%] women) and 200 physicians (median [IQR] age, 36.6 [30.1-45.3] years; 123 [62.8%] women) responded. Direct and witnessed exposure to racism (184 students [91.5%]; 176 physicians [90.7%]) and discrimination (176 students [85.9%]; 179 physicians [89.5%]) ever in medical education, training, or work environments was common. Ever exposure to witnessed and direct bullying (123 students [66.5%]; 150 physicians [89.3%]) and harassment (73 students [39.5%]; 112 physicians [66.7%]) was also common. Most respondents reported witnessing Maori patients or their whanau being treated badly in clinical settings, in direct interactions (67 students [57.8%]; 112 physicians [58.9%]) or behind their backs (87 students [75.0%]; 138 physicians [72.6%]). One-quarter of Maori medical students (45 students), and 37.0% of physicians (61 physicians) had considered leaving or taken a break from medicine because of these experiences. Additional marginalized statuses were significantly associated with any direct experience of mistreatment in the last year for students and physicians. Exposure to some forms of mistreatment were also significantly associated with higher likelihood of thinking about leaving or taking a break from medicine for physicians. Conclusions and Relevance: In this study, Maori medical students and physicians reported high exposure to multiple forms of racism, discrimination, bullying, and harassment in medical education, training, and work environments, requiring an urgent response from medical institutions.

Racism and Health Among Aotearoa New Zealand Young People Aged 15-24 years: Analysis of Multiple National Surveys.

PURPOSE: This Aotearoa New Zealand-based study addresses a gap in literature focusing on individual experiences of racism among adolescents and young adults and its links to health. METHODS: This cross-sectional study uses data from multiple instances of the New Zealand Health Survey (2002/03, 2006/07, 2011/12, 2016/17) and General Social Survey (2008-2016) restricted to participants aged 15-24 years. Prevalence of reported experiences of racism are estimated. Meta-analytic techniques to pool data and multiple regression analyses are used to examine associations between experiences of racism and outcomes measures (mental and physical health, general health and well-being, life satisfaction, inability to access health care, and identity). The study used an ethical co-design process between university researchers and a rangatahi Maori (Maori young people) partnership group. RESULTS: Racism was higher among Maori, Pacific, and Asian young people compared to European young people. Racism was associated with all negative health and well-being measures examined for young people, including negative mental and physical health measures (12-Item Short Form Survey, Kessler Psychological Distress Scale), lower self-rated health, negative life satisfaction, higher unmet need for primary care, and identity measures (feelings of not belonging in New Zealand, less able to express their identity). DISCUSSION: The results of this study are concerning. Non-European young people disproportionately bear the burden of racism in Aotearoa New Zealand with a potentially substantial impact on their health and well-being. This is a breach of Indigenous (for Maori) and other international human rights and should be motivation to act to eliminate racism in all its forms.

Examining the impact of COVID-19 on Maori:non-Maori health inequities in Aotearoa, New Zealand: an observational study protocol.

INTRODUCTION: The COVID-19 pandemic has had both direct and indirect impacts on the health of populations worldwide. While racial/ethnic health inequities in COVID-19 infection are now well known (and ongoing), knowledge about the impact of COVID-19 pandemic management on non-COVID-19-related outcomes for Indigenous peoples is less well understood. This article presents the study protocol for the Health Research Council of New Zealand funded project 'Ma te Mohio ka Marama: Impact of COVID-19 on Maori:non-Maori inequities'. The study aims to explore changes in access to healthcare, quality of healthcare and health outcomes for Maori, the Indigenous peoples of Aotearoa New Zealand (NZ) and non-Maori during the COVID-19 outbreak period across NZ. METHODS AND ANALYSIS: This observational study is framed within a Kaupapa Maori research positioning that includes Kaupapa Maori epidemiology. National datasets will be used to report on access to healthcare, quality of healthcare and health outcomes between Maori and non-Maori during the COVID-19 pandemic in NZ. Study periods are defined as (a) prepandemic period (2015-2019), (b) first pandemic year without COVID-19 vaccines (2020) and (c) pandemic period with COVID-19 vaccines (2021 onwards). Regional and national differences between Maori and non-Maori will be explored in two phases focused on identified health priority areas for NZ including (1) mortality, cancer, long-term conditions, first 1000 days, mental health and (2) rheumatic fever. ETHICS AND DISSEMINATION: This study has ethical approval from the Auckland Health Research Ethics Committee (AHREC AH26253). An advisory group will work with the project team to disseminate the findings of this project via project-specific meetings, peer-reviewed publications and a project-specific website. The overall intention of the project is to highlight areas requiring health policy and practice interventions to address Indigenous inequities in health resulting from COVID-19 pandemic management (both historical and in the future).

The impact of racism on subsequent healthcare use and experiences for adult New Zealanders: a prospective cohort study.

BACKGROUND: Racism is an important determinant of health and driver of racial/ethnic health inequities. Experience of racism has been linked to negative healthcare use and experiences although most studies have been cross-sectional. This study examines the relationship between reported experience of racism and subsequent use and experience of health services. METHODS: This is a prospective cohort study design. The 2016/2017 adult New Zealand Health Survey (NZHS) provided the sampling frame and baseline data on exposures, health status and confounders. This stand-alone study invited all exposed individuals to participate when sampled based on their reported experience of racism (ever), stratified by broad ethnic groupings (Maori, Pacific, Asian, European/Other). Equal numbers of unexposed participants were selected for invitation using propensity score matching (propensity to experience racism, based on key available predictive factors). Follow-up was one to two years after NZHS interview. Outcome variables (last 12 months) were: unmet healthcare need (overall, for mental health, for a general practitioner); satisfaction with usual medical centre; and experiences with general practitioners (explaining care, involvement in decision-making, treated with respect/dignity, confidence and trust). Logistic regression models examining the association between experience of racism (at baseline) and health service use and experience (at follow-up) used doubly-robust estimation to weight for propensity scores used in the sampling with additional adjustment for confounders. RESULTS: The study had 2010 participants. Experience of racism (ever) at baseline was associated with higher overall unmet need at follow-up (adjusted OR (aOR) = 1.71, 95% CI 1.31, 2.23), with similar patterns for other unmet need measures. Experience of racism was associated with higher dissatisfaction with a usual medical centre (aOR = 1.41, 95% CI 1.10, 1.81) and with higher reporting of negative patient experiences. CONCLUSION: In line with how racism structures oppression, exposure to racism is largely felt by non-European groups in Aotearoa New Zealand. Experiences of racism potentially lead to poorer healthcare and healthcare inequities through higher unmet need, lower satisfaction and more negative experiences of healthcare. The health system has a critical role to play in addressing racism within healthcare and supporting societal efforts to eliminate racism and ethnic inequities.

Caregiver experiences of racism and child mental health outcomes: cross-sectional analysis from Aotearoa New Zealand.

AIMS: This study aimed to estimate the prevalence of vicarious racism experienced by children (0-14 years) in Aotearoa New Zealand and investigate the association between vicarious racism and diagnosed child mental health conditions. METHODS: Adult and child 2016/2017 New Zealand Health Survey data were merged to create child-caregiver dyads. Multivariable logistic regression models were used to investigate the association between the caregiver experiences of racism (exposure) and diagnosed child mental health conditions (outcome), adjusting for confounders and exploring potential pathway variables. RESULTS: Looking at 2,989 dyads, the prevalence of "any" vicarious racism was higher for Maori (28.1%; 95% CI 24.2-31.9), Pacific (23.2%; 95% CI 17.9-28.5) and Asian (29%; 95% CI 23.6-34.5) children compared to European/Other children (12.5%; 95% CI 10.2-14.8). A statistically significant association was identified between >2 reports of vicarious racism and the outcome (OR= 2.53, 95% 1.18-5.43). Adding caregiver psychological distress reduced this association (OR= 1.92, 95% 0.91-4.08). CONCLUSIONS: Children in Maori, Pacific and Asian ethnicity groupings experience higher exposure to vicarious racism than those in the European/Other grouping. Multiple experiences of vicarious racism are associated with increased odds of diagnosed child mental health conditions in a dose-response distribution.

We still don't count: the under-counting and under-representation of Maori in health and disability sector data.

AIM: To examine ethnicity data quality; in particular, the representation and potential under-counting of Maori in health and disability sector data, as well as implications for inequities. METHODS: Maori and non-Maori ethnicity data are analysed at: 1) a population aggregate level across multiple 2018 datasets (Estimated Resident Population, Census Usually Resident Population, Health Service User (HSU) population and Primary Health Organisation (PHO) enrolments); and 2) an individual level for those linked in PHO and 2018 Census datasets. Ethnicity is drawn from the National Health Index (NHI) in health datasets and variations by age and gender are explored. RESULTS: Aggregate analyses show that Maori are considerably under-represented in HSU and PHO data. In linked analysis Maori were under-counted on the NHI by 16%. Under-representation in data and under-counting occur across both genders but are more pronounced for Maori men with variations by age. CONCLUSION: High quality ethnicity data are fundamental for understanding and monitoring Maori health and health inequities as well as in the provision of targeted services and interventions that are responsive to Maori aspirations and needs. The continued under-counting of Maori in health and disability sector data is a breach of Te Tiriti o Waitangi and must be addressed with urgency.

Ethnicity data audit in a secondary care gastroenterology service.

AIM: To audit the quality of ethnicity data stored under National Health Index (NHI) in the Hutt Hospital database against a fresh collection of self-identified ethnicity to identify the level of (mis)match present between the datasets. METHOD: Self-identified ethnicity data was collected from 200 consecutive patients presenting to outpatient gastroenterology services and compared to National Health Index (NHI) in the Hutt Hospital database, using the process outlined in the Primary Care Ethnicity Data Audit Toolkit. RESULTS: The overall level of match between the individual's self-identified ethnicity and that recorded in the hospital database was 89% (95% CI [83.8-93.0]). Eighteen patients (9%) self-identified as Maori, 16.7% (95% CI [3.6-41.4]) of whom were not recorded as Maori in the hospital database. Three patients were recorded as Maori in the hospital database but did not self-identify as Maori. CONCLUSION: Ethnicity data are fundamental to the monitoring and provision of equitable health and healthcare, with a range of applications in the health sector. Our findings of poor-quality ethnicity data for Maori in a hospital NHI database are consistent with previous studies. The assessment of ethnicity data quality must be done in multiple ways to reflect its multiple uses.

Co-design for indigenous and other children and young people from priority social groups: A systematic review.

Background: Co-design has increasingly been posited as a useful approach for Indigenous peoples and other social groups that experience inequities. However, the relatively rapid rise in co-design rhetoric has not necessarily been accompanied by increased understanding of whether co-design works for these social groups, and how equity is addressed. Methods: We conducted a systematic review to identify the current state of co-design as theory and praxis within the context of health and/or disability related interventions or services, with a specific focus on equity considerations for Indigenous and other children and young people from priority social groups. Six electronic databases were searched systematically to identify peer-reviewed papers and grey literature (dissertation and theses) published between January 1, 2000 to December 31, 2020, and a hand-search of reference lists for selected full texts was undertaken. Results: Fifteen studies met the inclusion criteria. Although all studies used the term 'co-design', only three provided a definition of what they meant by use of the term. Nine studies described one or more theory-based frameworks and a total of 26 methods, techniques and tools were reported, with only one study describing a formal evaluation. The key mechanism by which equity was addressed appeared to be the inclusion of participants from a social group experiencing inequities within an area of interest. Conclusion: A dearth of information limits the extent to which the literature can be definitive as to whether co-design works for Indigenous and other children and young people from priority social groups, or whether co-design reduces health inequities. It is critical for quality reporting to occur regarding co-design definitions, theory, and praxis. There is an urgent requirement for evaluation research that focuses on co-design impacts and assesses the contribution of co-design to achieving equity. We also recommend culturally safe ethical processes be implemented whenever undertaking co-design.

The economic cost of Indigenous child health inequities in Aotearoa New Zealand-an updated analysis for 2003-2014.

AIMS: This study estimates of the cost of Indigenous child health inequities in New Zealand. METHODS: Standard quantitative epidemiological and cost of illness methodologies were used within a Kaupapa Maori framework. Data for 2003-2014 on children under 15 years were obtained from government datasets. Rates of potentially avoidable hospitalisations and mortality, as well as excess or under-utilisation were calculated. Publicly funded health sector costs, costs to families and costs of premature mortality were used to estimate the costs (or savings) of inequities. RESULTS: Maori children had lower utilisation rates than non-Maori for primary healthcare, outpatient care, medicines, laboratory investigations and care after an accident/injury. Maori children had greater rates of avoidable hospitalisation (RR=1.36, 95% CI 1.35-1.37) and death (RR 1.98, 95% CI 1.84-2.13). Inequalities between Maori and non-Maori children cost in excess of $170 million NZD each year. This includes an annual net savings for the government health sector of $4 million NZD, with an annual cost to society of around $175 million NZD. CONCLUSIONS: The under-serving of Maori children in the health sector saves the government health system money, yet imposes a huge cost on Maori families and society. In addition to avoiding considerable human suffering, reducing child health inequities would result in significant economic benefits.

Bowel cancer screening age range for Maori: what is all the fuss about?

The current New Zealand Bowel Screening Programme (BSP) is inequitable. At present, just over half of bowel cancers in Maori present before the age of 60 years (58% in females and 52% in males), whereas just under a third of bowel cancers in non-Maori are diagnosed before the same age (27% in females and 29% in males). The argument for extending the bowel screening age range down to 50 years for Maori is extremely simple-in comparison to non-Maori, a greater percentage of bowel cancers in Maori occur before the age of 60 years (when screening starts). Commencing the BSP at 50 years of age for Maori with high coverage will help fix this inequity. In this paper we review the current epidemiology of colorectal cancer with respect to the age range extension for Maori.

Racism and health in Aotearoa New Zealand: a systematic review of quantitative studies.

BACKGROUND: Racism is an underlying cause of ethnic health inequities both in Aotearoa New Zealand and internationally. It is timely to synthesise racism and health research within New Zealand particularly given the current policy environment and shift towards addressing the health effects of racism. AIM: To review quantitative research examining self-reported experiences of racial discrimination and associations with measures of health (health conditions, health risk, health status and healthcare) in New Zealand. METHODS: MEDLINE, PsycINFO, Web of Science and CINAHL databases were searched for studies reporting on associations between experiences of racism and health. RESULTS: The systematic review identified 24 quantitative studies reporting associations between self-reported racial discrimination across a wide range of health measures including mental health, physical health, self-rated health, wellbeing, individual level health risks, and healthcare indicators. CONCLUSIONS: Quantitative racism and health research in New Zealand consistently finds that self-reported racial discrimination is associated with a range of poorer health outcomes and reduced access to and quality of healthcare. This review confirms that experience of racial discrimination is an important determinant of health in New Zealand, as it is internationally. There is a pressing need for effectively designed interventions to address the impacts of racism on health.

The impact of racism on the future health of adults: protocol for a prospective cohort study.

BACKGROUND: Racial discrimination is recognised as a key social determinant of health and driver of racial/ethnic health inequities. Studies have shown that people exposed to racism have poorer health outcomes (particularly for mental health), alongside both reduced access to health care and poorer patient experiences. Most of these studies have used cross-sectional designs: this prospective cohort study (drawing on critical approaches to health research) should provide substantially stronger causal evidence regarding the impact of racism on subsequent health and health care outcomes. METHODS: Participants are adults aged 15+ sampled from 2016/17 New Zealand Health Survey (NZHS) participants, sampled based on exposure to racism (ever exposed or never exposed, using five NZHS questions) and stratified by ethnic group (Maori, Pacific, Asian, European and Other). Target sample size is 1680 participants (half exposed, half unexposed) with follow-up survey timed for 12-24 months after baseline NZHS interview. All exposed participants are invited to participate, with unexposed participants selected using propensity score matching (propensity scores for exposure to racism, based on several major confounders). Respondents receive an initial invitation letter with choice of paper or web-based questionnaire. Those invitees not responding following reminders are contacted for computer-assisted telephone interview (CATI). A brief questionnaire was developed covering current health status (mental and physical health measures) and recent health-service utilisation (unmet need and experiences with healthcare measures). Analysis will compare outcomes between those exposed and unexposed to racism, using regression models and inverse probability of treatment weights (IPTW) to account for the propensity score sampling process. DISCUSSION: This study will add robust evidence on the causal links between experience of racism and subsequent health. The use of the NZHS as a baseline for a prospective study allows for the use of propensity score methods during the sampling phase as a novel approach to recruiting participants from the NZHS. This method allows for management of confounding at the sampling stage, while also reducing the need and cost of following up with all NZHS participants.

Self-reported sleep complaints are associated with adverse health outcomes: cross-sectional analysis of the 2002/03 New Zealand Health Survey.

OBJECTIVE: The aim was to investigate the prevalence of self-reported sleep complaints in New Zealand adults and determine the independent association of sleep complaints with adverse health outcomes. DESIGN: We used 2002/03 New Zealand Health Survey data (n = 12,500 adults, ≥15 years). The prevalence of self-reported sleep complaints was estimated by ethnicity. The relationship between sleep complaints and mental health, physical health and health risk behaviors were investigated using multivariable logistic regression models. RESULTS: The prevalence of each sleep complaint measure was highest for the indigenous Maori population (23.6% reported 'any' sleep complaint; 10.3% reported multiple sleep complaints). Reporting 'any' sleep complaint was associated with higher odds of poorer mental health, diagnosed high blood pressure, diagnosed diabetes, diagnosed heart disease, poor/fair self-rated health, obesity, current smoking, and hazardous drinking. CONCLUSION: The higher prevalence of sleep complaints among Maori and the consistent association with poor health suggests a potential role for suboptimal sleep in ethnic health inequities.

Experience of racism and associations with unmet need and healthcare satisfaction: the 2011/12 adult New Zealand Health Survey.

OBJECTIVE: Racism may affect health through differential access to, and quality of, healthcare. This study examined associations between experience of racism and unmet need and satisfaction with healthcare. METHODS: Cross-sectional analysis of the 2011/12 adult New Zealand Health Survey (n=12,596) was undertaken. Logistic regression was used to examine associations between experience of racism (by a health professional and other experiences of racism [ever]) and unmet need for a general practitioner and satisfaction with a usual medical centre in the past year. RESULTS: Experience of racism by a health professional and other forms of racism were higher among Maori, Pacific and Asian groups compared to European/Other. Both racism measures were associated with higher unmet need (health professional racism adjusted OR 3.52, 95%CI 2.42-5.11; other racism OR 2.21, 95%CI 1.78-2.75) and lower satisfaction with a usual medical centre (health professional racism adjusted OR 0.25, 95%CI 0.15-0.34; other racism OR 0.60, 95%CI 0.45-0.79). CONCLUSIONS: Racism may act as a barrier to, and influence the quality of, healthcare. Implications for public health: Addressing racism as a public health issue and major driver of inequities in healthcare and health outcomes is required within the health sector and wider society.

Ethnic bias amongst medical students in Aotearoa/New Zealand: Findings from the Bias and Decision Making in Medicine (BDMM) study.

Although health provider racial/ethnic bias has the potential to influence health outcomes and inequities, research within health education and training contexts remains limited. This paper reports findings from an anonymous web-based study examining racial/ethnic bias amongst final year medical students in Aotearoa/New Zealand. Data from 302 students (34% of all eligible final year medical students) were collected in two waves in 2014 and 2015 as part of the Bias and Decision Making in Medicine (BDMM) study. Two chronic disease vignettes, two implicit bias measures, and measures of explicit bias were used to assess racial/ethnic bias towards New Zealand European and Maori (indigenous) peoples. Medical students demonstrated implicit pro-New Zealand European racial/ethnic bias on average, and bias towards viewing New Zealand European patients as more compliant relative to Maori. Explicit pro-New Zealand European racial/ethnic bias was less evident, but apparent for measures of ethnic preference, relative warmth, and beliefs about the compliance and competence of Maori patients relative to New Zealand European patients. In addition, racial/ethnic bias appeared to be associated with some measures of medical student beliefs about individual patients by ethnicity when responding to a mental health vignette. Patterning of racial/ethnic bias by student characteristics was not consistent, with the exception of some associations between student ethnicity, socioeconomic background, and racial/ethnic bias. This is the first study of its kind with a health professional population in Aotearoa/New Zealand, representing an important contribution to further understanding and addressing current health inequities between Maori and New Zealand European populations.

Racism and health in New Zealand: Prevalence over time and associations between recent experience of racism and health and wellbeing measures using national survey data.

OBJECTIVES: Racism is an important health determinant that contributes to ethnic health inequities. This study sought to describe New Zealand adults' reported recent experiences of racism over a 10 year period. It also sought to examine the association between recent experience of racism and a range of negative health and wellbeing measures. METHODS: The study utilised previously collected data from multiple cross-sectional national surveys (New Zealand Health Surveys 2002/03, 2006/07, 2011/12; and General Social Surveys 2008, 2010, 2012) to provide prevalence estimates of reported experience of racism (in the last 12 months) by major ethnic groupings in New Zealand. Meta-analytical techniques were used to provide improved estimates of the association between recent experience of racism and negative health from multivariable models, for the total cohorts and stratified by ethnicity. RESULTS: Reported recent experience of racism was highest among Asian participants followed by Maori and Pacific peoples, with Europeans reporting the lowest experience of racism. Among Asian participants, reported experience of racism was higher for those born overseas compared to those born in New Zealand. Recent experience of racism appeared to be declining for most groups over the time period examined. Experience of racism in the last 12 months was consistently associated with negative measures of health and wellbeing (SF-12 physical and mental health component scores, self-rated health, overall life satisfaction). While exposure to racism was more common in the non-European ethnic groups, the impact of recent exposure to racism on health was similar across ethnic groups, with the exception of SF-12 physical health. CONCLUSIONS: The higher experience of racism among non-European groups remains an issue in New Zealand and its potential effects on health may contribute to ethnic health inequities. Ongoing focus and monitoring of racism as a determinant of health is required to inform and improve interventions.