A Kaupapa Māori approach to a community cohort study of heart disease in New Zealand

Objective: To report the processes and protocols that were developed in the design and implementation of the Hauora Manawa Project, a cohort study of heart disease in New Zealand and to report the participation at baseline. Methods: This study utilised application of a Kaupapa Māori Methodology in gaining tribal and health community engagement, design of the project and random selection of participants from territorial electoral rolls, to obtain three cohorts: rural Māori, urban Māori and urban non‐Māori. Logistic regression was used to model response rates. Results: Time invested in gaining tribal and health community engagement assisted in the development and design of clear protocols and processes for the study. Response rates were 57.6%, 48.3% and 57.2%. Co‐operation rates (participation among those with whom contact was established) were 74.7%, 66.6% and 71.4%. Conclusions: Use of electoral rolls enables straightforward sampling but results in low response rates because electors have moved. Co‐operation rates highlight the acceptability of this research project to the participants; they indicate the strength of Kaupapa Māori Methodologies in engaging Māori participants and community. Implications: This study provides a model for conducting clinical/biomedical research projects that are compatible with cultural protocols and methodologies, in which the primary aim of the research was Māori health gain.     

Improving survival disparities in cervical cancer between Māori and non‐Māori women in New Zealand: a national retrospective cohort study

Objective: Māori women in New Zealand have higher incidence of and mortality from cervical cancer than non‐Māori women, however limited research has examined differences in treatment and survival between these groups. This study aims to determine if ethnic disparities in treatment and survival exist among a cohort of Māori and non‐Māori women with cervical cancer. Methods: A retrospective cohort study of 1911 women (344 Māori and 1567 non‐Māori) identified from the New Zealand Cancer Register with cervical cancer (adenocarcinoma, adenosquamous or squamous cell carcinoma) between 1 January 1996 and 31 December 2006. Results: Māori women with cervical cancer had a higher receipt of total hysterectomies, and similar receipt of radical hysterectomies and brachytherapy as primary treatment, compared to non‐Māori women (age and stage adjusted). Over the cohort period, Māori women had poorer cancer specific survival than non‐Māori women (mortality hazard ratio (HR) 2.07, 95% confidence interval (CI): 1.63–2.62). From 1996 to 2005, the survival for Māori improved significantly relative to non‐Māori. Conclusion: Māori continue to have higher incidence and mortality than non‐Māori from cervical cancer although disparities are improving. Survival disparities are also improving. Treatment (as measured) by ethnicity is similar. Implications: Primary prevention and early detection remain key interventions for addressing Māori needs and reducing inequalities in cervical cancer in New Zealand.     

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

Objectives : Life and Living in Advanced Age: A Cohort Study in New Zealand (LiLACS NZ) aims to determine the predictors of successful advanced ageing and understand the trajectories of wellbeing in advanced age. This paper reports recruitment strategies used to enrol 600 Māori aged 80–90 years and 600 non‐Māori aged 85 years living within a defined geographic boundary. Methods : Electoral roll and primary health lists of older people were used as a base for identification and recruitment, supplemented by word of mouth, community awareness raising and publicity. A Kaupapa Māori method was used to recruit Māori with: dual Māori and non‐Māori research leadership; the formation of a support group; local tribal organisations and health providers recruiting participants; and use of the Māori language in interviews. Non‐Māori were recruited through local health and community networks. Six organisations used differing strategies to invite older people to participate in several ways: complete full or partial interviews; complete physical assessments; provide a blood sample and provide access to medical records. Results : During 14 months in 2010–2011, 421 of 766 (56%) eligible Māori and 516 of 870 (59%) eligible non‐Māori were enrolled. Participation and contribution of information varied across the recruitment sites. Conclusion : Attention to appropriate recruitment techniques resulted in an acceptable engagement and recruitment for both Māori and non‐Māori of advanced age in a longitudinal cohort study. Implications : There is high potential for meaningful results useful for participants, their whānau and families, health agencies, planners and policy.     

Incidence and management of hepatocellular carcinoma among Māori and non‐Māori New Zealanders

Objective: To investigate time trends in hepatocellular carcinoma (HCC) incidence disparities, and ethnic differences in risk factors, comorbidity and treatment pathways among HCC patients. Methods: Cohorts of the NZ population (1981–2004) were created and probabilistically linked to cancer registry records to investigate trends in incidence by ethnicity over time. Hospital notes of 97 Māori and 92 non‐Māori HCC patients diagnosed between 01/01/2006 and 31/12/2008 in NZ's North Island were reviewed. Results: Liver cancer incidence was higher among Māori for all time periods. Compared with non‐Māori, Māori males had nearly five times the rate of liver cancer (pooled RR=4.79, 95% CI 4.14–5.54), and Māori females three times the rate (pooled RR= 3.02, 95% CI 2.33–3.92). There were no significant differences in tumour characteristics or treatment of Māori and non‐Māori patients with HCC. Māori more commonly had hypertension (51% versus 25%) while more non‐Māori had cirrhosis recorded (62% versus 41%). The prevalence of hepatitis B among Māori patients (56%; 95% CI 45%‐67%) was more than double that of non‐Māori (27%; 95% CI 19%‐36%). The hazard ratio for cancer‐specific death for Māori compared with non‐Māori was 1.36 (95% CI 0.96–1.92). Conclusions and implications: HCC remains an important health problem particularly for Māori men. Efforts to improve coverage of screening for hepatitis B and surveillance of those with chronic hepatitis should be a priority to address the large inequalities found in liver cancer epidemiology.     

Identifying Māori ethnicity for estimating trends in fatal and serious non-fatal injury

Objectives: Counts of mortality and morbidity based on routinely collected national datasets have undercounted Māori, the indigenous people of New Zealand. To correct for the undercount, when estimating fatal and serious non‐fatal injury incidence, the ‘ever‐Māori’ method has been used. This study sought to determine how well the ever‐Māori method corrects for the undercount. Methods: Trends in frequencies and age‐standardised rates for fatal injury indicators were compared using: (a) ever‐Māori classification; (b) New Zealand Census Mortality Study adjustment ratios applied to Total Māori counts from the Mortality Collection; and (c) Total Māori counts from the Mortality Collection. For serious non‐fatal injury, trends using ever‐Māori were compared with Total Māori from hospital discharge data. Results: The absolute number of injuries attributable to Māori varied depending on the method used to adjust for ethnicity status, but trends over time were comparable. Conclusions and implications: At present, there is no optimal method for adjusting for the undercount of Māori in routinely collected health databases. Reassuringly, trends in fatal and serious non‐fatal injury are similar across the methods of adjusting for the undercount.     

Community screening for cardiovascular risk factors and levels of treatment in a rural Māori cohort

Objectives : To document levels of cardiovascular disease (CVD), diagnosed and undiagnosed risk factors and clinical management of CVD risk in rural Māori. Methods : Participants (aged 20–64 years), of Māori descent and self‐report, were randomly sampled to be representative of age and gender profiles of the community. Screening clinics included health questionnaires, fasting blood samples, blood pressure and anthropometric measures. Data were obtained from participants’ primary care physicians regarding prior diagnoses and current clinical management. New Zealand Cardiovascular Guidelines were used to identify new diagnoses at screening and Bestpractice© electronic‐decision support software used to estimate 5‐year CVD risk. Results : Mean age of participants (n=252) was 45.7±0.7, 8% reported a history of cardiac disease, 43% were current smokers, 22% had a healthy BMI, 30% were overweight and 48% obese. Hypertension was previously diagnosed in 25%; an additional 22% were hypertensive at screening. Dyslipidaemia was previously diagnosed in 14% and an additional 43% were dyslipidaemic at screening. Type‐2 diabetes was previously diagnosed in 11%. Glycaemic control was achieved in only 21% of those with type‐2 diabetes. Blood pressure and cholesterol were above recommended targets in more than half of those with diagnosed CVD risk factors. Conclusions : High levels of diagnosed and undiagnosed CVD risk factors, especially hypertension, dyslipidaemia and diabetes were identified in this rural Māori community. Implications : There is a need for opportunistic screening and intensified management of CVD risk factors in this indigenous population group.     

The significance of relational continuity of care for Māori patient engagement with predominantly non‐Māori doctors: findings from a qualitative study

Objective : This qualitative study explored self‐reported experiences of primary healthcare among a sample of urban Māori adults. This paper specifically focuses on the theme of relational continuity of care identified in participant discussions of access and engagement with their predominantly non‐Māori general practitioners (GPs). Methods : The study involved a purposively selected subsample (n=42) of the Christchurch Māori cohort of the Hauora Manawa Community Heart Study (n=244). Participants took part in in‐depth interviews, which were transcribed and analysed thematically. Results : Analysis identified compromised access to a preferred GP as a principal barrier to receiving quality and non‐discriminatory care from predominantly non‐Māori clinicians. In contrast to discussions of healthcare provided by usual GPs, episodic encounters with non‐regular clinicians were commonly framed as experiences discouraging utilisation and the perceived value of primary healthcare. Conclusions : Facilitating relational continuity of care for Māori patients and their clinicians may contribute towards mediating determinants of inequality at the clinical interface. Implications : Reducing significant health disparities between Māori and non‐Māori was a key goal of the reconfiguration of primary healthcare in the early 2000s. The role of relational continuity of care in achieving equitable inter‐ethnic health outcomes in primary healthcare settings is an important consideration.     

Twelve‐month post‐injury outcomes for Māori and non‐Māori: findings from a New Zealand cohort study

Objective : To examine the prevalence of key outcomes among Māori and non‐Māori 12 months post‐injury, and to estimate the risk of these outcomes for Māori compared to non‐Māori. Methods : The Prospective Outcomes of Injury Study recruited 2,856 New Zealand residents from five regions of New Zealand. This paper examines outcomes at 12 months post‐injury for the Māori (n=405) and non‐Māori (n=1,875) groups. Results : High levels of adverse outcomes at 12 months post‐injury were observed in both groups. A greater proportion of Māori than non‐Māori were experiencing disability, problems with mobility and psychological distress 12 months post‐injury. After controlling for pre‐injury and injury‐related characteristics, Māori were found to be at greater risk of disability, problems with mobility, having trouble performing usual activities, psychological distress and reporting ‘barely/not enough’ household income at 12 months compared to non‐Māori. Conclusion : Explanations for higher risk of these poor outcomes are unclear. Future research to identify potential explanations will include experiences with health services and rehabilitation support following injury, subsequent injury and illness, and major life events post‐injury. Implications : Adequate post‐injury care focused on physical and psychological health and financial security is required to reduce the burden experienced by Māori due to injury.     

Response to an indigenous smoking cessation media campaign – It's about whānau

Objective: To assess any effects among Māori (the indigenous people of New Zealand) smokers and their whānau (the traditional Māori family unit) of a campaign designed to support Māori smokers to quit smoking. Method: New Zealand‐wide cross sectional population surveys between 2000 and 2002 of smokers and whānau pre‐ and post‐airing of the campaign. Measures included recall and awareness of the campaign; perceptions of the campaign; and campaign‐attributed changes in quitting‐related attitudes and behaviours. Results: Seventy‐eight per cent of smokers and 73% of whānau were able to recall the campaign one year following its launch. The television commercials (TVCs) were consistently rated very believable or very relevant by over half of the smokers who had seen them. More than half of smokers (54%) stated that the campaign had made them more likely to quit. Conclusion: This nationwide mass media cessation campaign developed to deliver a cessation message to indigenous people was received positively by Māori smokers and their whānau and played a role in prompting quit attempts. Implications: Social marketing campaigns have an important role as part of a tobacco control program to reduce high smoking prevalence among Māori and inequalities in health outcomes between Māori and other New Zealanders.     

How many cancer deaths could New Zealand avoid if five‐year relative survival ratios were the same as in Australia?

Aim: To determine how many Māori and non‐Māori deaths might have been avoidable if cancer survival in New Zealand were as high as in Australia. Methods: Age‐sex‐tumour specific five‐year relative survival ratios were calculated for cancer patients diagnosed with 27 tumour sites (representing about 92% of all cancers) in 2006–10. These were used to estimate the number of Māori, non‐Māori and total deaths (and proportion of excess deaths) that would have been avoidable within five years of diagnosis had New Zealand's relative survival been equivalent to Australia's. Results: A total of 3,631 cancer deaths (726/year; 13.4% of excess deaths) could have been avoidable. Among 25 tumours where ethnic‐specific results were estimated, there were 851 potentially avoidable deaths in Māori (24.9%) and 2,758 in non‐Māori (11.8%). Breast, bowel, lung and prostate tumours made up 64% of avoidable deaths. Those with the highest proportions of avoidable deaths were thyroid (44.7%), prostate (35.5%), breast (30.0%) and uterus (23.5%). More than 50% of Māori melanoma, prostate, testis and thyroid cancer deaths were avoidable. Conclusion: A significant number of cancer deaths could be avoidable if New Zealand achieved Australia's relative survival ratios. The proportion is much higher for Māori than for non‐Māori. Implications: There is considerable scope to improve cancer outcomes in New Zealand.     

Ethnic inequalities in mortality among the elderly in New Zealand

Objectives: To explore the contributions of socio‐economic and demographic factors to ethnic disparity among older adult (65+) all cause and cause‐specific mortality differentials among Māori, Pacific, Asians and non‐Māori, non‐Pacific non‐Asian (nMnPnA) in New Zealand. Methods: We used univariate and multivariable Poisson regression models on linked New Zealand census and mortality data for older adults (65 years and above) (2001 to 2004, 1.3 million person years) with a comprehensive set of socio‐economic indicators (education, income, car access, housing tenure, neighourhood deprivation). Results: After controlling for the differences in age structure, Māori and Pacific males had a higher relative risk of dying than nMnPnA (RR=1.88 (95% Cl: 1.74, 2.04) and RR=1.75 (95% Cl: 1.54, 1.99) respectively) while Asian males had lower risk of dying (RR=0.66, 95% Cl: 0.57, 0.76). For females, the pattern was similar. The mortality gap between ethnic groups was mediated in part by socio‐economic factors. The five socio‐economic factors appear to account for greater than 40% of the excess mortality for Māori and Pacific men and about 34% for Māori females and 48% for Pacific females compared to nMnPnA men and nMnPnA women respectively. However, for Asian people, adjusting for socio‐economic factors actually increases the relative gaps in mortality compared to nMnPnA by 18% for male and 71% for females. Conclusion: The results demonstrate that clear ethnic mortality gradients persist into old age and the mortality level of most groups was influenced by varying distribution of socio‐economic factors. To reduce ethnic differences in old age mortality, inequalities as a result of socio‐economic position should be reduced.     

Predictors of academic success for Māori,Pacific and non-Māori non-Pacific students in health professional education: a quantitative analysis

Tertiary institutions internationally aim to increase student diversity, however are struggling to achieve equitable academic outcomes for indigenous and ethnic minority students and detailed exploration of factors that impact on success is required. This study explored the predictive effect of admission variables on academic outcomes for health professional students by ethnic grouping. Kaupapa Māori and Pacific research methodologies were used to conduct a quantitative analysis using data for 2686 health professional students [150 Māori, 257 Pacific, 2279, non-Māori non-Pacific (nMnP)]. The predictive effect of admission variables: school decile; attending school in Auckland; type of admission; bridging programme; and first-year bachelor results on academic outcomes: year 2–4 grade point average (GPA); graduating; graduating in the minimum time; and optimal completion for the three ethnic groupings and the full cohort was explored using multiple regression analyses. After adjusting for admission variables, for every point increase in first year bachelor GPA: year 2–4 GPA increased by an average of 0.46 points for Māori (p = 0.0002, 95% CI 0.22, 0.69), 0.70 points for Pacific (p < 0.0001, CI 0.52, 0.87), and 0.55 points for nMnP (p < 0.0001, CI 0.51, 0.58) students. For the total cohort, ethnic grouping was consistently the most significant predictor of academic outcomes. This study demonstrated clear differences in academic outcomes between both Māori and Pacific students when compared to nMnP students. Some (but not all) of the disparities between ethnic groupings could be explained by controlling for admission variables.     

Dietary protein intake may reduce hospitalisation due to infection in Māori of advanced age: LiLACS NZ

Objective: To investigate factors related to hospital admission for infection, specifically examining nutrient intakes of Māori in advanced age (80+ years). Method: Face‐to‐face interviews with 200 Māori (85 men) to obtain demographic, social and health information. Diagnoses were validated against medical records. Detailed nutritional assessment using the 24‐hour multiple‐pass recall method was collected on two separate days. FOODfiles was used to analyse nutrient intake. National Health Index (NHI) numbers were matched to hospitalisations over a two‐year period (12 months prior and 12 months following dietary assessment). Selected International Classification of Disease (ICD) codes were used to identify admissions related to infection. Results: A total of 18% of participants were hospitalised due to infection, most commonly lower respiratory tract infection. Controlling for age, gender, NZ deprivation index, diabetes, CVD and chronic lung disease, a lower energy‐adjusted protein intake was independently associated with hospitalisation due to infection: OR (95%CI) 1.14 (1.00–1.29), p=0.046. Conclusions: Protein intake may have a protective effect on the nutrition‐related morbidity of older Māori. Improving dietary protein intake is a simple strategy for dietary modification aiming to decrease the risk of infections that lead to hospitalisation and other morbidities.     

Geographic analysis of infant mortality in New Zealand, 1995–2008: an ethnicity perspective

Objective : To detect spatial clusters of high infant mortality rates in New Zealand for Māori and non‐Māori populations and verify if these clusters are stable over a certain time period (1995–2008) and similar between the two populations. Method : We applied the Kulldorff's spatial scan statistics on data collected by New Zealand Ministry of Health (1995 to 2008) at the territorial local authorities (TLA) level. Kappa coefficient was used to assess the concordance between clusters obtained for Māori and non‐Māori populations. T‐test analyses were conducted to identify associations between spatial clusters and two predictors (population density and deprivation score). Results : There are some significant spatial clusters of infant mortality in New Zealand for both Māori and Non‐Māori. The concordance of the cluster locations between the two populations is strong (kappa=0.77). Unsurprisingly, infant mortality clusters for both Māori and Non‐Māori are associated with the deprivation score. The population density predictor is only significantly and positively associated with clusters obtained for the non‐Māori population. After controlling for deprivation the presence of spatial clusters is all but eliminated. Conclusions : Infant mortality patterns are geographically similar for both Māori and Non‐Māori. However, there are differences geographically between the two populations after accounting for deprivation. Implications : Health services that can affect infant mortality should be aware of the geographical differences across NZ. Deprivation is an important factor in explaining infant mortality rates and policies that ameliorate its effects should be pursued, as it is the major determinant of the geographical pattern of infant mortality in NZ.     

High nutrition risk related to dietary intake is associated with an increased risk of hospitalisation and mortality for older Māori: LiLACS NZ

Objectives : To investigate the association between domains of nutrition risk with hospitalisations and mortality for New Zealand Māori and non‐Māori in advanced age. Methods : Within LiLACS NZ, 256 Māori and 399 non‐Māori octogenarians were assessed for nutrition risk using the Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREEN II) questionnaire according to three domains of risk. Sociodemographic and health characteristics were established. Five years from inception, survival analyses examined associations between nutrition risk from the three domains of SCREEN II with all‐cause hospital admissions and mortality. Results : For Māori but not non‐Māori, lower nutrition risk in the Dietary Intake domain was associated with reduced hospitalisations and mortality (Hazard Ratios [HR] [95%CI] 0.97 [0.95–0.99], p=0.009 and 0.91 [0.86–0.98], p=0.005, respectively). The ‘Factors Affecting Intake’ domain was associated with mortality (HR, [95%CI] 0.94 [0.89–1.00], p=0.048), adjusted for age, gender, socioeconomic deprivation, education, previous hospital admissions, comorbidities and activities of daily living. Conclusion : Improved dietary adequacy may reduce poor outcomes for older Māori. Implications for public health : Nutrition risk among older Māori is identifiable and treatable. Effort is needed to engage relevant community and whānau (family) support to ensure older Māori have food security and cultural food practices are met.     

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.     

The burden of cancer in New Zealand: a comparison of incidence and DALY metrics and its relevance for ethnic disparities

Aim : Cancer burden measured in disability adjusted life years (DALYs) captures survival and disability impacts of incident cancers. In this paper, we estimate the prospective burden of disease arising from 27 cancer sites diagnosed in 2006, by sex and ethnicity; and determine how its distribution differs from that for incidence rates alone. Methods : Using a prospective approach, Markov and cancer disease models were used to estimate DALYs with inputs of population counts, incidence and excess mortality rates, disability weights, and background mortality. DALYs were discounted at 3.5% per year. Results : The age standardised Māori:non‐Māori incidence rate ratios were 1.00 for males and 1.19 for females, whereas for DALYs they were greater at 1.42 for males and 1.68 for females. The total burden of cancer for 2006 incident cases (i.e. not age standardised) was estimated to be approximately 127,000 DALYs. Breast (27%), lung (14%) and colorectal (13%) cancers for females and lung (16%), colorectal (14%), and prostate (16%) cancers for males were the top contributors. By ethnicity, Māori experienced a substantially higher burden from lung cancer (around 25% for both sexes). Conclusions: Due to Māori both having higher rates of cancers with a worse survival (e.g. lung cancer), and tending to have worse survival for each cancer site, ethnic disparities in the age‐standardised DALY burden were greater than those for incidence (rate ratios of 1.52 and 1.07 respectively, sexes pooled).     

Mismatches between health service delivery and community expectations in the provision of secondary prophylaxis for rheumatic fever in New Zealand

Objective : Rheumatic fever (RF) recurrence prevention requires secondary prophylaxis for at least ten years. However, recurrences of rheumatic fever (RRF) persist disproportionately affecting Māori and Pacific youth. Reasons for recurrence rates are not well understood and commonly attributed to patient non‐adherence. This research explored Māori and Pacific family experiences of RRF to better understand barriers to accessing secondary prophylaxis to inform health service improvements. Methods : Participants were Māori and Pacific patients who had RRF or unexpected rheumatic heart disease and their family; and health professionals working in RF contexts. Kaupapa Māori, Talanga and Kakala Pacific qualitative methodologies were employed. Data were thematically analysed using a general inductive approach. Results : Data collection included 38 interviews with patients and families (n=80), six focus group interviews and nine interviews with health providers (n=33) from seven geographic regions. Three key themes were identified where mismatches occurred between services and community needs: 1. Model of delivery; 2. Interpersonal approaches to care; and 3. Adolescent care. Conclusions and Public health implications : Successful RRF prevention requires interventions to address structural causes of inequity, appropriate clinical guidelines and quality health services. Service‐delivery models should provide regular prophylaxis in an accessible manner through culturally‐safe, community‐based, age‐appropriate care.     

Changes in the sexual health behaviours of New Zealand secondary school students, 2001–2012: findings from a national survey series

Objective : To describe trends in self‐reported sexual and reproductive health behaviours among New Zealand secondary school students. Methods : Nationally representative health and wellbeing surveys conducted in 2001 (n=9,699), 2007 (n=9,107) and 2012 (n=8,500) were analysed. Logistic regressions were used to explore variations in sexual health outcomes between 2001 and 2012. Results : ‘Ever had sex’ (?6.9%, p<0.001); ‘currently sexually active’ (? 2.3%, p<0.001); ‘always use condoms’ (?3.3%, p=0.006); ‘condoms at last sex’ (?7.0, p=0.002); ‘contraception at last sex’ (?5.8%, p<0.001) and sexually transmitted infections (?0.3%, p=0.001) have reduced over time. ‘Always use contraception’ did not change significantly (?1.4%, p=0.514) over time. Māori (OR 0.7), Pacific (OR 0.5) and socioeconomically deprived students (OR 0.7) less frequently used condoms. Māori (OR 0.6), Pacific (OR 0.4), Asian (OR 0.5), younger (OR 0.6), and socioeconomically deprived (OR 0.6) students less frequently used contraception. Conclusions : Students in 2012 were more likely to delay sexual activity, but were less likely to use condoms and contraception consistently, compared to students in 2001. Declining contraceptive use over an 11‐year period suggests that current strategies are inadequate, particularly for Māori, Pacific and socioeconomically deprived students. Appropriate and accessible sexual and reproductive health services are urgently required.     

Household crowding associated with childhood otitis media hospitalisations in New Zealand

Objective : To examine the association between hospitalisations for otitis media and area‐level measures of household crowding among children in New Zealand. Methods : Counts of hospital admissions for otitis media by census area unit were offset against population data from the 2006 national census. Area‐level household crowding, exposure to tobacco smoke in the home, equivalised income and individual‐level characteristics age and sex were adjusted for. To examine effect modification by ethnicity, three separate poisson models were examined for the total, Māori and non‐Māori populations. Results : Household crowding was significantly associated with hospital admissions for otitis media after adjustment in all three models. Neighbourhoods with the highest compared to the lowest proportion of crowded homes exhibited incidence rate ratios of 1.25 (95%CI 1.12–1.37) in the total population, 1.59 (95%CI 1.21–2.04) in the Māori restricted model and 1.17 (95%CI 1.06–1.32) in the non‐Māori restricted model. Conclusions : Otitis media hospitalisations are associated with area‐level measures of household crowding and other risk factors in this ecological study. The largest increase in otitis media incidence relative to neighbourhood rates of household crowding was exhibited among Māori cases of otitis media. Implications : This study adds weight to the growing body of literature linking infectious disease risk to overcrowding in the home.