Receipt of mastectomy and adjuvant radiotherapy following breast conserving surgery (BCS) in New Zealand women with BCS-eligible breast cancer, 2010-2015: an observational study focusing on ethnic differences.

BACKGROUND: Women with early breast cancer who meet guideline-based criteria should be offered breast conserving surgery (BCS) with adjuvant radiotherapy as an alternative to mastectomy. New Zealand (NZ) has documented ethnic disparities in screening access and in breast cancer treatment pathways. This study aimed to determine whether, among BCS-eligible women, rates of receipt of mastectomy or radiotherapy differed by ethnicity and other factors. METHODS: The study assessed management of women with early breast cancer (ductal carcinoma in situ [DCIS] and invasive stages I-IIIA) registered between 2010 and 2015, extracted from the recently consolidated New Zealand Breast Cancer Registry (now Te Rehita Mate Utaetae NZBCF National Breast Cancer Register). Specific criteria were applied to determine women eligible for BCS. Uni- and multivariable analyses were undertaken to examine differences by demographic and clinicopathological factors with a primary focus on ethnicity (Maori, Pacific, Asian, and Other; the latter is defined as NZ European, Other European, and Middle Eastern Latin American and African). RESULTS: Overall 22.2% of 5520 BCS-eligible women were treated with mastectomy, and 91.1% of 3807 women who undertook BCS received adjuvant radiotherapy (93.5% for invasive cancer, and 78.3% for DCIS). Asian ethnicity was associated with a higher mastectomy rate in the invasive cancer group (OR 2.18; 95%CI 1.72-2.75), compared to Other ethnicity, along with older age, symptomatic diagnosis, advanced stage, larger tumour, HER2-positive, and hormone receptor-negative groups. Pacific ethnicity was associated with a lower adjuvant radiotherapy rate, compared to Other ethnicity, in both invasive and DCIS groups, along with older age, symptomatic diagnosis, and lower grade tumour in the invasive group. Both mastectomy and adjuvant radiotherapy rates decreased over time. For those who did not receive radiotherapy, non-referral by a clinician was the most common documented reason (8%), followed by patient decline after being referred (5%). CONCLUSION: Rates of radiotherapy use are high by international standards. Further research is required to understand differences by ethnicity in both rates of mastectomy and lower rates of radiotherapy after BCS for Pacific women, and the reasons for non-referral by clinicians.

Indigenous Cultural Identity of Research Authors Standard: research and reconciliation with Indigenous Peoples in rural health journals.

The Indigenous Cultural Identity of Research Authors Standard (ICIRAS) is based on a gap in research publishing practice where Indigenous peoples' identity is not systematically and rigorously recognised in rural health research publications. There are widespread reforms, in different research areas, to counter the reputation of scientific research as a vehicle of racism and discrimination. Reflecting on these broader movements, the editorial teams of three rural health journals - Rural and Remote Health, the Australian Journal of Rural Health, and the Canadian Journal of Rural Medicine - adopted a policy of 'Nothing about Indigenous Peoples, without Indigenous Peoples'. This meant changing practices so that Indigenous Peoples' identity could be embedded in authorship credentials - such as in the byline. An environmental scan of literature about the inclusion of Indigenous Peoples in research revealed many ways in which editorial boards of journals could improve their process to signal to readers that Indigenous voices are included in rural health research publication governance. Improving the health and wellbeing of Indigenous peoples worldwide requires high-quality research evidence. This quality benchmark needs to explicitly signal the inclusion of Indigenous authors. The ICIRAS is a call to action for research journals and institutions to rigorously improve research governance and leadership to amplify the cultural identity of Indigenous peoples in rural health research.

Re-imagining anti-racist theory for the health sector.

Ethnic health inequities between Maori and other New Zealanders continue to manifest systemically across the health sector. They are unjust, unfair, and are a breach of Te Tiriti o Waitangi. Institutional racism is a key modifiable driver of these disparities. Historically, health sector responses to racism could be characterised as ad hoc or in-action. Efforts have included investment in Maori health providers, Maori representation in governance, equity initiatives, kawa whakaruruhau-cultural safety and Te Tiriti training. Most anti-racist interventions have been educational and focused on individual change-especially for operational staff and students, rather than decision-makers. These historic contributions have been insufficient to address entrenched problems of systemic and societal racism.This paper examines three anti-racism initiatives currently occurring across Aotearoa; i) the Matike Mai Constitutional Transformation report/movement, ii) the development of the National Action Plan Against Racism, and iii) Ao Mai Te Ra currently being developed within the health sector.Drawing on long-time involvement in anti-racism praxis and scholarship, the Maori and non-Maori authors of this paper are making the case to re-imagine anti-racism theory. Such re-imagining needs to centre engagement with Te Tiriti. In addition, we argue it needs to involve both tangata whenua and Tauiwi.

‘Look, wait, I’ll translate’: refugee women’s experiences with interpreters in healthcare in Aotearoa New Zealand.

This study aimed to explore refugee women's experiences of interpreters in healthcare in Aotearoa, New Zealand (NZ). Semi-structured interviews were conducted with nine women who arrived in NZ as refugees. Analysis involved a 'text in context' approach. An iterative and interpretive process was employed by engaging with participant accounts and field notes. The various meanings behind participants' experiences were unpacked in relation to the literature and the broader socio-cultural contexts in which these experiences occurred. Findings highlighted issues with professional and informal interpreters. These issues included cost, discrepancies in dialect, translation outside appointments, and privacy. Findings indicate ethical and practical implications of using interpreters in healthcare for refugee women. A step to achieving equitable healthcare for refugee women in New Zealand entails putting in place accessible and robust communicative infrastructure.

Smashing the patriarchy to address gender health inequities: Past, present and future perspectives from Aotearoa (New Zealand).

The second wave feminist dream of smashing the patriarchy remains a task yet to be completed on a complex to do list. Women, particularly able-bodied cis-gendered white women however do enjoy the privilege of living longer than men. But our longer lives take place within patriarchal-capitalist systems where many women's social and cultural rights continue to be compromised. How do we ensure that all women can exercise our right to health and wellbeing? In this paper, the authors examine, critique, review and re-vision the dynamics of power and patriarchy over three distinct time periods - 1999, 2019 and 2039. We look to the past to track progress; we look to the present to see what we have achieved and look to the future for what might be. This conceptual paper is informed by the authors' expert knowledge, a review of the literature and the novel use of speculative ethnography. The authors conclude that patriarchy remains not only a negative determinant of women's health that needs to be smashed, but is also a threat to all people and to planetary health.

A critical analysis of te Tiriti o Waitangi application in primary health organisations in Aotearoa New Zealand: Findings from a nationwide survey.

Primary health is at the forefront of efforts to address health inequities. Effective primary health care keeps people well and improves longevity and quality of life. The persistence of health inequities, particularly between Indigenous peoples and non-Indigenous peoples globally, suggests that there is a need to strengthen policy and practise. Unique to Aotearoa (New Zealand) is te Tiriti o Waitangi, a treaty negotiated in 1840 between the British Crown and hapu (Maori [Indigenous] subtribes). This treaty is foundational to public policy in Aotearoa and requires the Crown (New Zealand government) to uphold a set of responsibilities around protecting and promoting Maori health. This paper examines to what extent Primary Health Organisations are upholding te Tiriti o Waitangi. The study utilises data from a nationwide telephone survey of public health providers conducted in 2019-2020 recruited from a list on the Ministry of Health website. This paper focuses on data about te Tiriti application from 21 Primary Health Organisations from a sample size of thirty. Critical te Tiriti analysis, an emerging methodology, was used to assess to what extent the participating primary health organisations were te Tiriti compliant. The critical te Tiriti analysis found poor to fair compliance with most elements of te Tiriti but good engagement with equity. Suggestions for strengthening practise included examining relationships with Maori, utilising a planned approach, structural mechanisms, normalising Maori world views and consistency in application. The onus needs to be on non-Maori to contribute to the cultural change and power-sharing required to uphold te Tiriti. Critical te Tiriti analysis is a useful methodology to review te Tiriti compliance and could be used in other contexts to review alignment with Indigenous rights and aspirations.

Patient-reported diagnostic intervals to colorectal cancer diagnosis in the Midland region of New Zealand: a prospective cohort study.

BACKGROUND AND OBJECTIVES: New Zealand (NZ) has high rates of colorectal cancer (CRC) but low rates of early detection. The majority of CRC is diagnosed through general practice, where lengthy diagnostic intervals are common. We investigated factors contributing to diagnostic delay in a cohort of patients newly diagnosed with CRC. METHODS: Patients were recruited from the Midland region and interviewed about their diagnostic experience using a questionnaire based on a modified Model of Pathways to Treatment framework and SYMPTOM questionnaire. Descriptive statistics were used to describe the population characteristics. Chi-square analysis and logistic regression were used to analyse factors influencing diagnostic intervals. RESULTS: Data from 176 patients were analysed, of which 65 (36.9%) experienced a general practitioner (GP) diagnostic interval of >120 days and 96 (54.5%) experienced a total diagnostic interval (TDI) > 120 days. Patients reporting rectal bleeding were less likely to experience a long TDI (odds ratio [OR] 0.34, 95% confidence interval [CI]: 0.14-0.78) and appraisal/help-seeking interval (OR, 0.19, 95% CI: 0.06-0.59). Patients <60 were more likely to report a longer appraisal/help-seeking interval (OR, 3.32, 95% CI: 1.17-9.46). Female (OR, 2.19, 95% CI: 1.08-4.44) and Maori patients (OR, 3.18, 95% CI: 1.04-9.78) were more likely to experience a long GP diagnostic interval. CONCLUSION: NZ patients with CRC can experience long diagnostic intervals, attributed to patient and health system factors. Young patients, Maori, females, and patients experiencing change of bowel habit may be at particular risk. We need to increase symptom awareness of CRC for patients and GPs. Concentrated efforts are needed to ensure equity for Maori in access to screening, diagnostics, and treatment.

New Zealand has high rates of colorectal cancer but low rates of early detection. We interviewed newly diagnosed patients about their diagnostic experience to identify factors influencing time to diagnosis. More than half of patients experienced a long diagnostic interval. Young patients, Maori, females, and patients experiencing changes of bowel habit may be at particular risk for long intervals. With the diagnostic difficulty of colorectal cancer (CRC), we need to increase CRC symptom awareness for patients and general practitioners.

Outcomes from colonoscopy following referral from New Zealand general practice: a retrospective analysis.

BACKGROUND: New Zealand has high rates of colorectal cancer (CRC) but poor outcomes. Most patients with CRC are diagnosed following referral from general practice, where a general practitioner (GP) assesses symptoms according to national guidelines. All referred patients are then re-prioritised by the hospital system. The first objective of this study was to identify what proportion of patients referred by general practice to surgical/gastroenterology at Waikato District Health Board (DHB) had a colonoscopy. The second objective was to determine what proportion of these referrals have an underlying CRC and the factors associated with the likelihood of this diagnosis. METHODS: This study is a retrospective analysis of e-referral data for patients aged 30-70+ who were referred from 75 general practices to general surgery, gastroenterology or direct to colonoscopy at Waikato DHB, 01 January 2015-31 December 2017. Primary and secondary outcome measures included the proportion and characteristics of patients who were having colonoscopy, and of those, who were diagnosed with CRC. Data were analysed using chi square and logistic regression. RESULTS: 6718/20648 (32.5%) patients had a colonoscopy and 372 (5.5%) of these were diagnosed with CRC. The probability of having CRC following a colonoscopy increased with age (p value < 0.001). Females (p value < 0.001), non-Maori (p value < 0.001), and patients with a high suspicion of cancer (HSCan) label originating from their GP were more likely to have a colonoscopy, while the odds ratio of Maori having a colonoscopy was 0.66 (95% CI 0.60-0.73). The odds ratio of a CRC diagnosis following colonoscopy was 1.67 (95% CI 1.35-2.07) for men compared to women, and 2.34 (95% CI 1.70-3.22) for those with a GP HSCan label. Of the 585 patients referred with a GP HSCan, 423 (72.3%) were reprioritised by the hospital and 55 patients had their diagnosis unnecessarily delayed. CONCLUSIONS: If a GP refers a patient with an HSCan, and the patient receives a colonoscopy, then the likelihood of having CRC is almost 15.0%. This would suggest that these patients should be routinely prioritised without further triage by the hospital. Further research is needed to understand why Maori are less likely to receive a colonoscopy following referral from general practice.

Te Tiriti o Waitangi compliance in regulated health practitioner competency documents in Aotearoa.

Within Aotearoa (New Zealand) there are systemic health inequities between Maori (the Indigenous people of Aotearoa) and other New Zealanders. These inequities are enabled in part by the failure of the health providers, policy and practitioners to fulfil treaty obligations to Maori as outlined in our foundational document, te Tiriti o Waitangi (te Tiriti). Regulated health professionals have the potential to play a central role in upholding te Tiriti and addressing inequities. Competency documents define health professionals' scope of practice and inform curriculum in health faculties. In this novel study, we critically examine 18 regulated health practitioners' competency documents, which were sourced from the websites of their respective professional bodies. The competencies were reviewed using an adapted criterion from Critical te Tiriti Analysis, a five-phase analysis process, to determine their compliance with te Tiriti. There was considerable variation in the quality of the competency documents reviewed. Most were not te Tiriti compliant. We identified a range of alternative competencies that could strengthen te Tiriti engagement. They focussed on (i) the importance of whanaungatanga (the active making of relationships with Maori), (ii) non-Maori consciously becoming an ally with Maori in the pursuit of racial justice and (iii) actively engaging in decolonisation or power-sharing. In the context of Aotearoa, competency documents need to be te Tiriti compliant to fulfil treaty obligations and policy expectations about health equity. An adapted version of Critical te Tiriti Analysis might be useful for those interested in racial justice who want to review health competencies in other colonial settings.

Women, Patriarchy and Health Inequalities: The Urgent Need to Reorient Our Systems.

This Special Issue is entitled "Women, patriarchy, and health inequalities: an unresolved issue" [...].

How do colorectal cancer patients rate their GP: a mixed methods study.

BACKGROUND: New Zealand (NZ) has a high incidence of colorectal cancer (CRC) and low rates of early diagnosis. With screening not yet nationwide, the majority of CRC is diagnosed through general practice. A good patient-general practitioner (GP) relationship can facilitate prompt diagnosis, but when there is a breakdown in this relationship, delays can occur. Delayed diagnosis of CRC in NZ receives a disproportionally high number of complaints directed against GPs, suggesting deficits in the patient-GP connection. We aimed to investigate patient-reported confidence and ratings of their GP following the diagnostic process. METHODS: This study is a mixed methods analysis of responses to a structured questionnaire and free text comments from patients newly diagnosed with CRC in the Midland region of NZ. A total of 195 patients responded to the structured questionnaire, and 113 patients provided additional free text comments. Descriptive statistics were used to describe the study population and chi square analysis determined the statistical significance of factors possibly linked to delay. Free text comments were analysed using a thematic framework. RESULTS: Most participants rated their GP as 'Very good/Good' at communication with patients about their health conditions and involving them in decisions about their care, and 6.7% of participants rated their overall level of confidence and trust in their GP as 'Not at all'. Age, gender, ethnicity and a longer diagnostic interval were associated with lower confidence and trust. Free text comments were grouped in to three themes: 1. GP Interpersonal skills; (communication, listening, taking patient symptoms seriously), 2. Technical competence; (speed of referral, misdiagnoses, lack of physical examination), and 3. Organisation of general practice care; (appointment length, getting an appointment, continuity of care). CONCLUSIONS: Maori, females, and younger participants were more likely to report low confidence and trust in their GP. Participants associate a poor diagnostic experience with deficits in the interpersonal and technical skills of their GP, and health system factors within general practice. Short appointment times, access to appointments and poor GP continuity are important components of how patients assess their experience and are particularly important to ensure equal access for Maori patients.

The Simpson-led health sector review: a failure to uphold te Tiriti o Waitangi.

The Health and Disability System Review (the 'Simpson Review') was an opportunity for health sector transformation, particularly in light of the recent damning WAI 2575 Waitangi Tribunal report released during the review process. There appears to have been a concerted effort to engage with the sector, an impressive Maori Expert Advisory Group and an extensive body of available scholarship documenting where improvements could be made. In this viewpoint, the authors, tangata whenua (Indigenous people of the land) and tangata Tiriti (people of te Tiriti) and health scholars and leaders undertook a high-level review of the Simpson Review report and analysed it against key elements of te Tiriti o Waitangi. The Simpson Review was an opportunity to share power, commit to Maori health and embed structural mechanisms, such as the proposed Maori health authority, to uphold te Tiriti o Waitangi. It was also an opportunity to recommit to health equity and eliminate institutional racism. We conclude that the Simpson Review did not take up these opportunities, but instead perpetuated further breaches of te Tiriti.

Ha Ora: secondary care barriers and enablers to early diagnosis of lung cancer for Maori communities.

BACKGROUND: Lung Cancer is the leading cause of cancer deaths in Aotearoa New Zealand. Maori communities in particular have higher incidence and mortality rates from Lung Cancer. Diagnosis of lung cancer at an early stage can allow for curative treatment. This project aimed to document the barriers to early diagnosis and treatment of lung cancer in secondary care for Maori communities. METHODS: This project used a kaupapa Maori approach. Nine community hui (focus groups) and nine primary healthcare provider hui were carried out in five rural localities in the Midland region. Community hui included cancer patients, whanau (families), and other community members. Healthcare provider hui comprised staff members at the local primary healthcare centre, including General Practitioners and nurses. Hui data were thematically analysed. RESULTS: Barriers and enablers to early diagnosis of lung cancer were categorised into two broad themes: Specialist services and treatment, and whanau journey. The barriers and enablers that participants experienced in specialist services and treatment related to access to care, engagement with specialists, communication with specialist services and cultural values and respect, whereas barriers and enablers relating to the whanau journey focused on agency and the impact on whanau. CONCLUSIONS: The study highlighted the need to improve communication within and across healthcare services, the importance of understanding the cultural needs of patients and whanau and a health system strategy that meets these needs. Findings also demonstrated the resilience of Maori and the active efforts of whanau as carers to foster health literacy in future generations.

Indigenous perspectives on breaking bad news: ethical considerations for healthcare providers.

Most healthcare providers (HCPs) work from ethical principles based on a Western model of practice that may not adhere to the cultural values intrinsic to Indigenous peoples. Breaking bad news (BBN) is an important topic of ethical concern in health research. While much has been documented on BBN globally, the ethical implications of receiving bad news, from an Indigenous patient perspective in particular, is an area that requires further inquiry. This article discusses the experiences of Maori (Indigenous peoples of New Zealand) lung cancer patients and their families, in order to investigate the ethical implications of receiving bad news. Data collection occurred through 23 semistructured interviews and nine focus groups with Maori lung cancer patients and their families in four districts in the Midland Region of New Zealand: Waikato, Bay of Plenty, Lakes and Tairawhiti. The findings of this study were categorised into two key themes: communication and context. Avenues for best practice include understanding the centrality of the HCP-patient relationship and family ties in the healthcare journey, and providing patients with the full range of viable treatment options including hope, clear advice and guidance when the situation calls for it. Overall, the findings of this study hold implications for providing culturally safe and humanistic cancer care when BBN to Maori and Indigenous patients.

The nature of police shootings in New Zealand: A comparison of mental health and non-mental health events.

The use of firearms by police in mental health-related events has not been previously researched in New Zealand. This study analysed reports of investigations carried out by the Independent Police Conduct Authority between 1995 and 2019. We extracted data relating to mental health state, demographics, setting, police response, outcome of shooting, and whether the individual was known to police, mental health services, and with a history of mental distress or drug use. Of the 258 reports analysed, 47 (18%) involved mental health-related events compared to 211 (82%) classified as non-mental health events. Nineteen (40.4%) of the 47 mental health events resulted in shootings, compared to 31 (14.8%) of the 211 non-mental health events. Of the 50 cases that involved shootings 38% (n = 19) were identified as mental health events compared to 62% (n = 31) non-mental health events. Over half of the mental health events (n = 11, 57.9%) resulted in fatalities, compared to 35.5% (n = 11) of the non-mental health events. Cases predominantly involved young males. We could not ascertain the ethnicity of individuals from the IPCA reports. Across all shooting events, a high proportion of individuals possessed a weapon, predominantly either a firearm or a knife, and just under half were known to police and had known substance use. Of the 19 mental health events, 47.4% (n = 9) of individuals were known to mental health services and in 89.5% (n = 17) of cases whanau (family) were aware of the individual's current (at the time of the event) mental health distress and/or history. These findings suggest opportunities to prevent the escalation of events to the point where they involve shootings. Lack of ethnicity data limits the accountability of the IPCA and is an impediment to informed discussion of police response to people of different ethnicities, and Maori in particular, in New Zealand.

Ha Ora: Barriers and enablers to early diagnosis of lung cancer in primary healthcare for Maori communities.

OBJECTIVE: The objective of this research was to document the barriers to early presentation and diagnosis of lung cancer within primary healthcare, identified by Maori whanau (families) and primary healthcare providers in the Midland region of Aotearoa New Zealand. METHODS: This project used a kaupapa Maori approach. Nine community hui (focus groups) and nine primary healthcare provider hui were carried out in five rural localities in the Midland region. Each community hui included cancer patients, whanau, and other community members. Each healthcare provider hui comprised staff members at the local primary healthcare centre, including General Practitioners and nurses. Hui data were thematically analysed. RESULTS: Barriers and enablers to early diagnosis of lung cancer were categorised into three key themes: GP relationship and position in the community, health literacy and pathways to diagnosis. CONCLUSION: This study demonstrates that culturally responsive, patient-centred healthcare, and positive GP-patient relationships are significant factors for Maori patients and whanau serving as barriers and enablers to early diagnosis of lung cancer.