Ethnic,socioeconomic and geographical inequalities in road traffic injury rates in the Auckland region

Objective: To describe ethnic, socioeconomic and geographical differences in road traffic injury (RTI) within Auckland, New Zealand's largest city. Methods: We analysed rates of RTI deaths and non‐fatal hospital admissions using the New Zealand Mortality Collection and the National Minimum Data Set 2000–08. Poisson regression examined the association of age, gender, prioritised ethnicity and small area deprivation (New Zealand Index of Deprivation) with RTI rates, and RTI rates were mapped for 21 local board areas within the Auckland region. Results: While RTI rates increased with levels of deprivation in all age groups, the gradient was steepest among children (9% increase/decile) and adults aged 25–64 years (11% increase/decile). In all age groups, RTI risk was highest among Māori. Pacific children had an elevated risk of RTI compared with the NZ European/Other group, but Pacific youth (15–24 years) and adults (25–64 years) had a lower risk. While RTI rates were generally higher for those living in rural local board areas, all but one local board in the southern Auckland urban area had among the highest rates. Conclusions: There are substantial ethnic, socioeconomic and geographic inequalities in RTI risk in the Auckland region, with high rates among Māori (all ages), Pacific children, people living in socioeconomically deprived neighbourhoods, the urban south and rural regions. Implications: To meet the vision of regional plans, road safety efforts must prioritise vulnerable communities at greatest risk of RTI, and implement and monitor the effectiveness of strategies that specifically include a focus on reducing inequalities in RTI rates.     

Inequalities in uptake of influenza vaccine by deprivation and risk group: time trends analysis

The aim of this study was to investigate influenza immunisation rates in the United Kingdom over a 6-year period and examine trends in uptake by deprivation, ethnicity, rurality and risk group. Influenza immunisation rates were determined from 1999/2000 to 2004/2005 using a large general practice database (QRESEARCH). There was a relative increase of 59.5% in the overall influenza vaccination rate over the study period. In 2004/2005, 70.2% of all patients aged 65 and over were vaccinated, compared with 29.3% of patients in a clinical risk group aged less than 65. Males, patients from deprived areas and from areas with a higher proportion of non-White residents had slightly lower vaccination rates overall. This general practice based study suggests that substantial increases in influenza vaccination rates have occurred across all risk groups, but that increased focus should be given to immunising high-risk patients below the age of 65.     

Immunisation of a cohort Pacific children living in New Zealand over the first 2 years of life

Pacific children have had consistently evidenced low rates for routine childhood immunisations. Using the Pacific Islands Families: First 2 Years of Life cohort study, we investigated the immunisation rate of Pacific infants residing in New Zealand at 24-months postpartum. Full immunisation was reported for 89% of infants, substantially increased from the 53% found in the 1992 national survey and closer to the New Zealand Ministry of Health's target of 95%. Increased parity and maternal smoking were associated with incomplete child immunisation status. Initiatives to increase immunisation rates amongst Pacific children appear to be succeeding and warrant continuation.     

Access to chlamydia testing needed for high‐risk groups: patterns of testing and detection in an urban area of New Zealand

Objective : To describe population rates of chlamydia testing and detection by sociodemographic characteristics, and to determine whether testing is reaching those groups most at risk of infection. Methods : Laboratory data for urogenital chlamydia tests in an urban region of New Zealand were collated for the period 1999 to 2005. Census data were used to estimate rates of testing and diagnosis (per 100,000 population). Regression analyses summarised patterns in testing and diagnosis by age, sex, ethnicity and socioeconomic deprivation (controlling for potential confounding factors). Results : Rates of chlamydia testing and detection differed significantly by age, sex, ethnicity and deprivation. Females had lower rates of chlamydia diagnoses than males (OR 0.4, 95% CI 0.39–0.42) but were tested five times more often. When tested, rates of chlamydia detection were significantly higher among Pacific (OR 2.33, 95% CI 2.16–2.5), and Māori (OR 2.01, 95% CI 1.87–2.17) than among European (reference group), and among individuals living in areas of greater socioeconomic deprivation (OR 1.66, 95% CI 1.55–1.77). Chlamydia diagnoses were significantly higher in the under 25 year old age group, with the highest odds of a positive result among the 15–19 year age group (OR 9.06, 95% CI 8.23–9.98). Conclusion : This analysis identified higher‐risk groups who appeared to be underserved by testing relative to their higher rates of infection (including Māori, Pacific, 15–19 year olds and individuals living in areas of high socioeconomic deprivation). Implications : Appropriate chlamydia control programs with testing targeted towards higher‐risk groups are urgently needed in NZ.     

Exploring reasons for ethnic disparities in diet- and lifestyle-related chronic disease for Asian sub-groups in New Zealand: a scoping exercise

Objectives: The current study aimed to explore if the impact of various risk factors for chronic disease differed for people of Chinese, Indian and New Zealand European and Other (NZEO) ethnicities.

Design: Data analysed for this paper was extracted from the 2003–04 and the 2006–07 NZ Health surveys for adults aged 25–70 which used a cross-sectional survey design. Data from both the survey waves were combined and all statistical analysis was done using SAS version 9.2 or 9.3. Ethnicity of participants was coded using a priority-based classification system as (1) Indian, (2) Chinese, (3) Other Asian, (4) NZEO, (5) Maori and (6) Pacific. Only data for Indians, Chinese and NZEO were used for the current study. Prevalence estimates and 95% confidence intervals for chronic disease and the associated risk factors were generated to describe the sample. Logistic regression analysis was used to examine whether the difference in the change in risk of chronic disease with different exposures was different according to ethnicity.

Results: Higher deprivation resulted in increased risk of chronic disease in Indian and Chinese males but not in NZEO males (p =?.03). There was a weak evidence for a differing effect of physical activity (p?=?.10) on chronic disease with the protective effect not seen in Indian or Chinese participants.

Conclusion: The results of the current study indicate that some factors such as socio-economic deprivation and physical activity may impact differently on the prevalence of chronic disease according to ethnicity. The authors recommend further investigation of these factors using improved and innovative methodology and high-quality ethnicity data to better understand the factors underpinning ethnic disparities in disease prevalence among Asian sub-groups.     

No association of income inequality with adult mortality within New Zealand: a multi-level study of 1.4 million 25-64 year olds

STUDY OBJECTIVE: To determine the association of regional income inequality within New Zealand with mortality among 25-64 year olds. DESIGN: Individual census and mortality records were linked over the 1991-94 period. Income inequality (Gini coefficients) and average household income variables were calculated for 35 regions. "Individual level" variables were sex, age, ethnicity, household income, rurality, and small area socioeconomic deprivation. Logistic regression was used for the analyses. Sensitivity analyses for the level of regional aggregation were conducted. PARTICIPANTS: 1.4 million New Zealand census respondents aged 25-64 years followed up for mortality for three years. Main results: Controlling for age, ethnicity, rurality, household income, and regional mean income, there was no association of income inequality with all cause mortality for either men (OR=1.007 for a 0.01 increase in the Gini, 95% confidence intervals 0.989 to 1.024) or women (OR=1.004, 0. 983 to 1.026). By cause of death (cancer, cardiovascular disease, unintentional injury, and suicide) there was some suggestion of a positive association for female unintentional injury (OR=1.068, 0.952 to 1.198) and suicide (OR=1.087, 0.957 to 1.234) but the 95% confidence intervals all included 1.0. Failure to control for ethnicity at the individual level resulted in some association of increasing regional income inequality with increasing mortality risk. Using fewer (n=14) or more (n=73) regional divisions did not substantially change the findings. CONCLUSION: There is no convincing evidence of an association of income inequality within New Zealand with adult mortality. Previous ecological analyses within New Zealand suggesting an association of income inequality with mortality were confounded by ethnicity at the individual level. However, this study does not refute the possibility that income inequality at the national level affects health.     

How much does health care contribute to health inequality in New Zealand?

OBJECTIVE: To quantify the contribution of health care to ethnic and socio-economic inequalities in health in New Zealand in 2000-02, using the concept of 'amenable' mortality (deaths at ages 0-74 years from causes responsive to health care). DATA SOURCES AND METHODS: Mortality data for 2000-02 were provided by the New Zealand Health Information Service and 2001 Census population data were provided by Statistics New Zealand. The classification of ICD-10 codes as amenable or non-amenable used in the Australian and New Zealand Atlas of Avoidable Mortality (2006) was adopted. Ethnicity was categorised as Maori, Pacific or European/Other. Socio-economic position was measured using a Census-based small area deprivation index, the NZDep2001. Mortality rates were standardised for age by the direct method for the ethnic group comparisons, and for both age and ethnicity for the deprivation group comparisons. The contribution of health care to health inequality was then quantified as the ratio of the difference in standardised amenable mortality rates to the difference in standardised total mortality rates (in the age group 0-74 years) between relevant groups. RESULTS: Amenable causes of death were estimated to account for 27%, 34%, 33% and 44% of the total mortality disparity (0-74 years) for Maori males, Maori females, Pacific males and Pacific females respectively, relative to their European/ Other counterparts (adjusting for age). The corresponding proportions for the 'deprived' population relative to the 'non-deprived' population were 26% (males) and 30% (females), adjusting for age and ethnicity. CONCLUSIONS: Amenable causes of death made a substantial contribution to differences in mortality in the 0-74 year age range between ethnic and socio-economic groups in New Zealand in 2000-02, ranging from 26-44% depending on the group.     

Child obesity prevalence across communities in New Zealand: 2010–2016

Objective : To assess community‐level differences in four‐year‐old obesity prevalence in New Zealand (NZ), trends over time, and the extent to which differences can be explained by ethnicity, deprivation and urbanicity. Methods: Obesity measures from the Ministry of Health’s B4 School Check were available for 72–92% of NZ four‐year‐olds for fiscal years 2010/11–2015/16. Ethnicity, deprivation and urbanicity data for the 78 communities were obtained by linking to administrative records. Growth models were used to examine variability in obesity levels and trends over time, and the extent to which ethnicity, deprivation and urbanicity contributed to differences between communities. Results : There were large variations in obesity across communities (range 8.4% to 28.8%). A decline in the prevalence of childhood obesity was observed in most (48 of 78) communities from 2010/11 to 2015/16 (average change=0.2%, range=‐2.0% to 1.9%). Around 50% of the variance in obesity between territorial authorities could be explained by differences in socioeconomic deprivation and ethnic composition. Conclusions : Child obesity varies between NZ communities, but most territorial authorities have experienced a decrease in obesity over the period 2010/11–2015/16. Implications for public health : Addressing deprivation and ethnic inequalities in obesity could substantially reduce community‐level differences in obesity in NZ.     

The role,costs and value for money of external consultancies in the health sector: A study of New Zealand’s District Health Boards

Public spending on external consultancies, particularly within the health sector, is highly controversial in many countries. Yet, despite the apparently large sums of money involved, there is little international analysis surrounding the scope of activities of consultants, meaning there is little understanding of how much is spent, for what purpose and with what result. This paper examines spending on external consultancies in each of New Zealand’s 20 District Health Boards (DHB). Using evidence obtained from DHBs, it provides an insight into the cost and activities of consultants within the New Zealand health sector, the policies behind their engagement and the processes in place to ensure value for money. It finds that DHB spending on external consultants is substantial, at $NZ10–60 million annually. However, few DHBs had policies governing when consultants should be engaged and many were unable to easily identify the extent or purpose of consultancies within their organisation, making it difficult to derive an accurate picture of consultant activity throughout the DHB sector. Policies surrounding value for money were uncommon and, where present, were rarely applied. Given the large sums being spent by New Zealand’s DHBs, and assuming expenditure is similar in other health systems, our findings point to the need for greater accountability for expenditure and better evidence of value for money of consultancies within publicly funded health systems.     

Debunking the 'only 50%' myth: prevalence of established risk factors in New Zealanders with self-reported ischaemic heart disease

OBJECTIVE: To estimate the prevalence of established risk factors for ischaemic heart disease (IHD) in New Zealand adults and compare the prevalence in adults with and without this disease. DESIGN: Data were obtained from the 2002/03 New Zealand Health Survey. Risk factor prevalence was determined by: self-reported doctor diagnosis of high blood pressure, high cholesterol and diabetes; self-report of smoking and physical inactivity; and measurement of obesity. Presence of IHD was based on self-report of heart disease (doctor diagnosed at age 25 years or over) together with current medical or past surgical treatment for this disease. Multiple logistic regression was used to determine prevalence rate ratios (PRRs) for males and females separately, adjusting for age, ethnicity and deprivation. RESULTS: The overall prevalence of IHD was 8%. Overall risk factor prevalences were in the range of 20-25% for each of high blood pressure, high cholesterol, smoking, obesity and physical inactivity, and approximately 5% for diabetes. Overall, 94-97% of adults with IHD had at least one risk factor (depending on how smoking was defined). The PRRs of IHD were highest for cholesterol (about 4.5), followed by blood pressure (about 2.3), with all other risk factors around 1.5. PAF estimates indicate that 80-85% of IHD was attributable to the presence of at least one risk factor for all age, gender and ethnic groups. CONCLUSIONS: Established risk factors account for 80-85% of the non-fatal burden of IHD in New Zealand. Limited research resources would be better used to evaluate which interventions are effective and efficient at reducing exposure of all population groups to known risk factors, rather than on identification of additional risk factors.     

NZDep91: A New Zealand index of deprivation

In New Zealand, existing area-based indices of deprivation were inadequate because of lack of theoretical underpinning and use of comparatively large areas resulting in masking of variation within them. There is growing demand for small area based indices of deprivation for the purposes of resource allocation, research, and community advocacy. This paper describes a new Census-based index of deprivation based on the smallest possible geographical areas using existing Census boundaries. The index uses deprivation variables selected according to established theory, and derived from the 1991 New Zealand Census. Ten age and gender standardised variables were combined using principal components analysis. Each variable is a standardised proportion of people in a small area with a lack of a defined material or social resource. Age/gender standardisation is important to avoid confounding and to improve the performance of indices in resource allocation formulae. The index correlates highly with mortality, hospital discharges, lung cancer registrations and childhood immunisation status.     

Reducing health disparities through primary care reform: the New Zealand experiment

New Zealand experiences significant health disparities related to both ethnicity and deprivation; the average life expectancy for Maori New Zealanders is 9 years less than for other New Zealanders. The government recently introduced a set of primary care reforms aimed at improving health and reducing disparities by reducing co-payments, moving from fee-for-service to capitation, promoting population health management and developing a not for profit infrastructure with community involvement to deliver primary care. Funding for primary care visits will increase by some 43% over 3 years. This paper reviews policy documents and enrollment and payment data for the first 15 months to assess the likely impact on health disparities. The policy has been successfully introduced; over half the New Zealand population (of four million) enrolled in new Primary Health Organizations within 15 months. Over 400,000 people (half of them in vulnerable groups) gained improved access to primary care subsidies in the first 15 months. The combined effect of new payment rules and the deprived nature of the minority populations was that the average per person payment to PHOs on behalf of Maori and Pacific enrollees was more than 70% greater than the per person amount for other ethnicities for the period. The policy is consistent with the principles of the Alma Alta Declaration. Barriers to successful implementation include the risk of middle class capture of the additional funding; the risk that co-payments are not low enough to improve access for the poor; PHO inexperience; and the small size of many PHOs. Transitional equity and efficiency issues with the use of aggregate population characteristics to target higher subsidies are being ameliorated by the introduction of low cost access based on age. A tension between the twin policy goals of low cost access for all, and very low cost access for the most vulnerable populations is identified as a continuing and unresolved policy issue.     

Identifying inequalities in childhood immunisation uptake and timeliness in southeast Scotland, 2008–2018: A retrospective cohort study

BackgroundIn 2018, there was a record incidence of measles and other vaccine-preventable diseases across developed countries. Declining childhood immunisation uptake in southeast Scotland—an area with a large, highly mobile, and socioeconomically diverse population—threatens regional herd immunity and warrants investigation of suboptimal coverage. As deprivation of social and material resources increases risk of non-vaccination, we examined here the relationship between deprivation, uptake, and timeliness for four routine childhood vaccines and identified trends over the past decade.MethodsThis retrospective cohort study analysed immunisation data from the Scottish Immunisation Recall System (SIRS) for four routine childhood vaccines in the UK: the third dose of the primary vaccine (TPV), both doses of measles, mumps, rubella (MMR 1 and MMR 2), and the preschool booster (PSB). Immunisations (N = 329,897) were administered between 2008 and 2018. Deprivation was measured via the Scottish Index of Multiple Deprivation (SIMD), ranking postcodes by deprivation decile. Chi-squared tests and cox proportional hazards models assessed the relationship between uptake, timeliness, and deprivation.ResultsThere is strong evidence for an association between deprivation, uptake, and timeliness. Uptake for all childhood immunisations are very high, especially for TPV and MMR 1 (>98.0%), though certain deprivation deciles exhibit increased risks of non-vaccination for all vaccines. Delay was pronounced for the 40% most deprived population and for immunisations scheduled at later ages. Absolute PSB and MMR 2 uptake has improved since 2008; however, disparities in uptake have increased for all vaccines since the 2006 birth cohort.ConclusionBoth timeliness and uptake are strongly associated with deprivation. While absolute uptake was high for all vaccines, relative uptake and timeliness has been worsening for most groups; the reason for this decline is unclear. Here we identified subgroups that may require targeted interventions to facilitate uptake and timeliness for essential childhood vaccines.     

Investigating technical efficiency and its determinants: The Case of New Zealand District Health Boards

This study investigates the technical efficiency of New Zealand's District Health Boards (DHBs) in providing hospital services, as well as the effect of certain environmental factors on efficiency. This study is the first to use quarterly data on New Zealand DHBs from 2011 to 2017 and apply the two-stage double-bootstrap methodology of Simar and Wilson. The bias-corrected technical efficiency estimates show that on average, DHBs in the areas with high socioeconomic deprivation operate with low technical efficiency. Furthermore, DHB providing secondary hospital services are less efficient than tertiary DHBs. The result from truncated regression indicates that a higher proportion of surgical, elderly, and acute inpatients is associated with increasing levels of technical efficiency. In contrast, the high average length of hospital stay negatively impacts technical efficiency levels. The findings of this study urge policymakers to adopt policies to address the shortages of healthcare staff, barriers to primary healthcare, lack of investment in hospital capacity, and technology to enhance healthcare sector's long-run technical efficiency. In addition, the existing DHB funding formula needs to be revisited as this tends to include perverse incentives for secondary DHBs where patients are kept longer in hospitals, leading to a higher average length of stays in hospitals and is associated with increasing levels of inefficiency.     

Markedly different clustering of CVD risk factors in New Zealand Indian and European people but similar risk scores (PREDICT-14)

Objective: To compare the cardiovascular disease (CVD) risk profiles of Indian and European patients from routine primary care assessments in the northern region of New Zealand. Method: Anonymous CVD risk profiles were extracted from PREDICT (a web‐based decision support program) for Indian and European patients aged 35–74 years. Linear regression models were used to obtain mean differences adjusted for age, gender and deprivation. Results: At recruitment, Indian participants (n=8,830) were younger than Europeans (n=47,091), in keeping with national guidelines that recommend earlier CVD risk assessment for Indians. Compared with Europeans, a greater proportion of Indian participants lived in areas of higher deprivation and had a two to four‐fold greater burden of diabetes in all age groups. Indian participants had a significantly lower proportion of smokers and a lower mean systolic blood pressure. The respective cardiovascular risk factor profiles lead to similar age‐adjusted Framingham five‐year CVD risk scores. Conclusions and implications: National data sources indicate that there are higher rates of hospitalisations and deaths from CVD in Indians compared with Europeans. Our study found similar predicted CVD risk in these two populations despite markedly different clustering of risk factors, suggesting that the Framingham risk equation may underestimate risk in Indians. There is a need for better ethnicity coding to identify all South Asian ethnicities.     

Evidence of suboptimal maternal vaccination coverage in pregnant New Zealand women and increasing inequity over time: A nationwide retrospective cohort study

BackgroundAdequate maternal vaccination coverage is critical for the prevention and control of infectious disease outbreaks such as pertussis, influenza, and more recently COVID-19. To guide efforts to increase vaccination coverage this study examined the extent of vaccination coverage in pregnant New Zealand women over time by area-level deprivation and ethnicity.MethodsA retrospective cohort study was used consisting of all pregnant women who delivered between 01 January 2013 and 31 December 2018, using administrative health datasets. Outcomes were defined as receipt of influenza or pertussis vaccination in any one of the relevant data sources (National Immunisation Register, Proclaims, or Pharmaceutical collection) during their eligible pregnancy. Ethnicity was prioritised as Māori (NZ indigenous), Pacific, Asian, and Other or NZ European and deprivation was defined using New Zealand Index of Multiple Deprivation (IMD).ResultsBetween 2013 and 2018, Asian women had the highest maternal vaccination coverage (36%) for pertussis, while Māori and Pacific women had the lowest, 13% and 15% respectively. Coverage of pertussis vaccination during pregnancy in low deprivation Māori women was 24% and 28% in Pacific women. This is in comparison to 30% and 25% in high deprivation Asian and European/Other women, respectively. Similar trends were seen for influenza.ConclusionBetween 2013 and 2018 maternal vaccination coverage increased for pertussis and influenza. Despite this coverage remains suboptimal, and existing ethnic and deprivation inequities increased. There is an urgent need to focus on equity, to engage and support ethic communities by creating genuinely accessible, culturally appropriate health services.     

Housing tenure as a focus for reducing inequalities in the home safety environment: evidence from Growing Up in New Zealand

Objectives: To determine whether specific demographic characteristics are associated with the presence or absence of household safety strategies. Methods : This study was conducted within Growing Up in New Zealand, a contemporary longitudinal study of New Zealand (NZ) children. Multivariable analyses were used to examine the maternal (self‐prioritised ethnicity, education, age, self‐reported health) and household (area‐level deprivation, tenure, crowding, residential mobility, dwelling type) determinants of household safety strategies being present in the homes of young children. Results : In comparison to family‐owned homes, privately owned rental homes were less likely (OR=0.78; 95%CI 0.65–0.92), and government‐owned rental homes were more likely (OR=1.74, 95%CI 1.25–2.41) to have eight or more household safety strategies present. Conclusions : Living in a privately owned rental home in NZ exposes children to an environment where there are fewer household safety strategies in place. Implications for public health : Housing tenure provides a clear target focus for improving the household safety environment for NZ children.     

Constructing whole of population cohorts for health and social research using the New Zealand Integrated Data Infrastructure

Objectives: To construct and compare a 2013 New Zealand population derived from Statistics New Zealand’s Integrated Data Infrastructure (IDI) with the 2013 census population and a 2013 Health Service Utilisation population, and to ascertain the differences in cardiovascular disease prevalence estimates derived from the three cohorts. Methods: We constructed three national populations through multiple linked administrative data sources in the IDI and compared the three cohorts by age, gender, ethnicity, area‐level deprivation and District Health Board. We also estimated cardiovascular disease prevalence based on hospitalisations using each of the populations as denominators. Results: The IDI population was the largest and most informative cohort. The percentage differences between the IDI and the other two populations were largest for males and for those aged 15–34 years. The percentage differences between the IDI and Census cohorts were largest for people living in the most deprived areas. The ethnic distribution varied across the three cohorts. Using the IDI population as a reference, the Health Service Utilisation population generally overestimated cardiovascular disease prevalence, while the Census population generally underestimated it. Conclusions and implications: The New Zealand IDI population is the most comprehensive and appropriate national cohort for use in health and social research.     

Area level deprivation and drinking patterns among adolescents

ObjectiveTo assess relationships between area level deprivation and drinking patterns among adolescents.MethodThis study uses data from the national New Zealand Alcohol Survey 2004 comprising 1828, age range 12–19 years. A multilevel linear regression was conducted using NZDep2001 (a composite deprivation measure) as the exposure and alcohol use (quantity and frequency) as outcome.ResultsA J-shaped association was observed between area level deprivation and quantity of adolescents’ alcohol use after controlling for age, sex, ethnicity, and individual socioeconomic position; where adolescents living in the most deprived areas consumed the heaviest quantities of alcohol. No association was found for frequency of drinking.ConclusionThis study found a J-shaped relationship between area-level disadvantage and increased quantities consumed, where adolescents living in the most deprived areas typically consumed the heaviest quantities of alcohol. However, our study has also highlighted that future research may better isolate an independent relationship between deprivation and consumption in adolescents by accounting for structural variables related to both deprivation and consumption, such as alcohol outlet density     

Avoidable mortality in New Zealand, 1981-97

Objective : To describe avoidable mortality in New Zealand, including trends and variations between groups by age, gender, ethnicity and degree of deprivation. Method : New Zealand Health Information Service mortality unit records, 1981 to 1997, were classified as ‘avoidable’ or ‘unavoidable’ based on a reassessment of ICD9 codes and an upper age limit of 75 years. ‘Avoidable’ causes of death were further subcategorised according to the level of intervention involved (primary, secondary or tertiary). Deaths were assigned a deprivation score using a Census‐based small area deprivation index, the NZDep96. Mortality rates were age standardised by the direct method, with Segi's world population as the reference. Results : Avoidable mortality declined 38% from 1981 to 1997; unavoidable mortality declined only 9%. In 1996–97 almost 70% of deaths in the 0–74 age range were still considered to be potentially avoidable. Almost 80% of avoidable deaths occur in the 45–74 age group. These deaths are dominated by the emergence of chronic diseases such as ischaemic heart disease, diabetes and smoking‐related cancers. In younger age groups, injury (including suicide) dominates avoidable mortality. Males experience a greater burden of avoidable mortality than females‐a relative excess of 54% (approximately 2,000) in 1996–97. The gender difference is largely attributable to diseases and injuries amenable to primary prevention, with the largest single contribution coming from ischaemic heart disease. The ethnic gap in avoidable mortality remains wide: rates for Maori and Pacific people were 2–2¹/₂ times higher than European rates in 1996–97. Similar gradients are seen with deprivation. Conclusion and implications : Avoidable mortality analysis provides a useful tool for evidence‐based health needs assessment and health policy development.