Making Education Easy Issue 17 – 2008
Authors: Tobias M et al
Summary: This study used data from the 1996, 2001 and 2006 New Zealand Census of Population and Dwellings and the corresponding New Zealand Index of Deprivation to describe trends in the distribution of New Zealand’s major ethnic groups (Māori, Pacific, Asian or European/Other) by small area deprivation and trends in the ethnic composition of each deprivation category. Throughout the observation period, Māori and Pacific ethnic groups were over-represented at the more deprived and underrepresented at the less deprived end of the deprivation spectrum. The European ethnic group displayed less marked skewing, and in the opposite direction, while the Asian ethnic group showed close to the expected uniform distribution. Little change occurred in either the deprivation distribution of any ethnic group or the ethnic composition of any deprivation decile between 1996 and 2006.
Comment: The main point to take from this paper is that there has been no change in the distribution of wealth by ethnicity over a 10-year period (from 1996 to 2006). As the authors state, monitoring disparities by ethnicity (in health, wealth, employment, etc) allows us to assess progress toward a socially just NZ. The fact that there is no significant improvement should impel the development of appropriate social policy.
Reference: Aust N Z J Public Health. 2008;32(5):431-6
Abstract
www.maorihealthreview.co.nz a Research Review Publication
Authors: Rubinstein ML et al
Summary: The feasibility and utility of using nicotine nasal spray for adolescent smokers who wanted to quit smoking was examined in a cohort of 40 adolescents aged 15–18 years who smoked ≥5 cigarettes/day for ≥6 months. They were randomly assigned to receive either weekly counselling alone (control) for 8 weeks or 8 weeks of counselling plus 6 weeks of nicotine nasal spray. At 12 weeks, no betweengroup differences were observed in cessation rates, the numbers of cigarettes smoked per day, or salivary cotinine levels. Fifty-seven percent of participants stopped using their spray after only 1 week. The most commonly reported adverse effect was nasal irritation and burning (34.8%) followed by complaints about the taste and smell (13%).
Comment: A useful paper for those of us working with or supporting ‘smoking cessation’ programmes (GPs, nurses, quit coaches, etc). Adolescents in particular should be supported to quit smoking with therapies that they can sustain. It appears that adolescents are most likely to stop a prescribed treatment fairly early (1 week) and so a recommendation would be to check ‘compliance’ with long-term therapies after 1 week, rather than waiting 3 months for this particular population.
Reference: Pediatrics. 2008;122(3):e595-600
Privacy Policy: Research Review will record your email details on a secure database and will not release them to anyone without your prior approval. Research Review and you have the right to inspect, update or delete your details at any time. The views expressed in this Publication are personal to the authors, and do not necessarily represent the views or policy of the Ministry of Health on the issues dealt with in the publication.
Disclaimer: This publication is not intended as a replacement for regular medical education but to assist in the process. The reviews are a summarised interpretation of the published study and reflect the opinion of the writer rather than those of the research group or scientific journal. It is suggested readers review the full trial data before forming a final conclusion on its merits.
Research Review publications are intended for New Zealand health professionals.
Authors: Grembowski D et al
Summary: This study sought to determine whether children who have mothers with a regular source of dental care at baseline have greater dental use in the subsequent year than children with mothers without a regular source, in a cohort of 11,305 children aged 3 to 6 years in low-income families covered by Medicaid. There were 4 racial/ethnic groups: black (3791), Hispanic (2806), white (1902), and other racial/ethnic groups (2806). Approximately 38% of the mothers had a regular source of dental care (RSDC) at baseline. Having a mother with an RSDC at baseline was associated with greater odds of the child’s receiving dental care in the subsequent year, after controlling for potentially confounding variables. Mothers’ RSDC was also associated with children’s receiving more preventive services. These associations were found for children with black and Hispanic mothers; for children with white mothers, the relationships were in the same direction but not statistically significant.
Comment: A significant paper in oral health that also highlights the need to support ‘whānau ora’. Access to dental health services for children, and with anticipation oranga niho, may be improved when mums are supported to access dental services. Financial assistance appears to be particularly important.
Reference: Pediatrics. 2008;122(4):e805-14
Authors: Woolf K et al
Summary: These researchers explored ethnic stereotypes of UK medical students in the context of academic underachievement of medical students from ethnic minorities, in a cohort of Year 3 medical students and their clinical teachers, purposively sampled for ethnicity and sex. They participated in one to one interviews and focus groups. Analyses revealed that the clinical teachers as well as the medical students themselves had negative stereotypes about UK Asian medical students, who were perceived as being over-reliant on book learning and excessively quiet in class. Students also reported being unable to learn from unenthusiastic or intimidating teachers. No evidence of direct discrimination was found.
Comment: A noteworthy paper that was published in a recent BMJ. Interestingly, stereotypes for the ethnic ‘minority’ were not only more negative but also more developed than those for ‘white’ students. The fact that teachers had the same negative ‘stereotypical’ ideas about ‘Asian’ students is somewhat unsettling, particularly if it impacts on knowledge transfer. It also confirms the need for clinical teachers to be culturally safe.
Reference: BMJ. 2008;337:a1220
Authors: Saha S et al
Summary: Outcomes are reported from a Graduation Questionnaire administered to 20,112 graduating medical students (64% of all graduating students in 2003 and 2004) from 118 US-based allopathic medical schools. It sought to determine whether student body racial and ethnic diversity is associated with diversity-related outcomes among US medical students. White students in the highest diversity quintile, as assessed by the proportion of under-represented minority (URM) students, were more likely to rate themselves as highly prepared to care for minority populations than those in the lowest diversity quintile (61.1% vs 53.9%, respectively; p<0.001). This association was strongest in schools in which students perceived a positive climate for inter-racial interaction. White students in the highest URM quintile were also more likely to have strong attitudes endorsing equitable access to care (54.8% vs 44.2%, respectively; p<0.001). No such significant associations were seen between student body URM proportions and diversity-related outcomes for nonwhite students. Intent to practice in an underserved area was greatest among URM students than among white or nonwhite/non-URM students (48.7% vs 18.8% vs 16.2%, respectively).
Comment: The main point I got from this paper is that medical students understand more about equity and access and are more intent on working with high needs communities when the student body with which they train is ethnically diverse. For the NZ context, a rights-based premise for Māori to participate in medical training is corroborated by the positive findings of this study.
Reference: JAMA. 2008;300(10):1135-45
Authors: Howden-Chapman P et al
Summary: These researchers investigated the effects of installing non-polluting, more effective heating (heat pump, wood pellet burner, flued gas) before winter in the homes of 409 children aged 6–12 years with doctor-diagnosed asthma; a control group received a replacement heater at the end of the trial. Although there were no significant improvements in lung function, there were significant reductions in asthma symptoms and time lost from school and reductions in dry cough at night and sleep disturbed by wheeze, among children in the intervention group compared with those in the control group. In addition, the intervention was associated with higher indoor temperatures and lower nitrogen dioxide levels delivered by the heating than measurements taken from the control households.
Comment: Further evidence from the Wellington School of Medicine about the improvements in health outcomes for children when an effective and non-polluting (compared with open fire for example) heating system was introduced in the home.
Reference: BMJ. 2008;337:a1411
Authors: McIlvane JM et al
Summary: These researchers systematically reviewed research published between 1997 and 2008 evaluating the effectiveness of behavioural interventions for arthritis, to determine whether these interventions are effective with, and appropriately utilised by, minority participants. Among 25 randomised intervention studies, only 2 reported on whether the intervention was similarly effective for white and black patients (equal effectiveness was found), and 6 studies reported examining differences in attrition by race (higher attrition in nonwhites was found in 1 study). Most studies did not report the percentage of participants from specific minority groups, and in many studies the percentage of minority participants was small. There were no reports of attempts to make interventions culturally appropriate.
Comment: Hospitalisation rates for arthritis (including gout, osteoarthritis and rheumatoid arthritis) are higher for Māori than non-Māori. As the authors state here, not only is there little evidence about the cultural appropriateness of arthritis treatments, but ethnic minorities do not have access to intervention research. The benefits of participating in such research may include access to expensive treatments (not readily available to all), improved quality of care (with increased follow up and access to investigations) and better information/education about managing the disease.
Reference: Arthritis Care Res. 2008;59(10):1512-8
Authors: Doran T et al
Summary: These researchers examined the relation between socioeconomic inequalities and delivered quality of clinical care under the quality and outcomes framework, a financial incentive scheme that remunerates general practices in the UK for their performance against a set of quality indicators. Overall levels of achievement, defined as the proportion of patients who were deemed eligible by the general practices for whom the targets were achieved, were calculated for 48 clinical activity indicators during the first 3 years of the incentive scheme (from 2004–05 to 2006–07). Median overall reported achievement was 85.1% in year 1, 89.3% in year 2, and 90.8% in year 3. In year 1, median achievement was higher in least deprived areas (quintile 1; 86.8%) than in most deprived areas (quintile 5; to 82.8%). However, between years 1 and 3, median achievement increased by a greater amount in quintile 5 than in quintile 1 (4.4% vs 7.6%), and the gap in median achievement narrowed from 4.0% to 0.8%. A significant inverse association was observed between the increase in achievement during this time and practice performance in previous years (p<0·0001); no such association was seen with area deprivation (p=0.062).
Comment: Many of us working in primary care have watched the UK Quality and Outcomes model with interest, particularly the provision of financial incentives to those practices that meet the clinical indicators. These include things like recording smoking status, the percentage of patients with an MI on ACE inhibitors and so on. The fact that such incentives may be associated with reduced inequalities suggests that it is perhaps something we should be exploring further here in Aotearoa.
Reference: Lancet. 2008;372(9640):728-36
Authors: Lawton BA et al
Summary: Data were analysed from 3616 women aged 49–70 years in a study that enrolled 27 primary care practices and from the multinational WISDOM trial of postmenopausal hormone replacement therapy (HRT), in order to describe menopause symptoms in postmenopausal Māori and non-Māori New Zealand women, and explore relationships between symptoms, sociodemographic profile and postmenopausal HRT use. While Māori and non-Māori differed in demographic and clinical characteristics, few differences were observed in the frequency of menopause-related symptoms. Vasomotor symptoms were reported by 34.4% of women, with no statistically significant difference between Māori and non-Māori (p>0.05). Compared to non-Māori, Māori were less likely to have ever used HRT (24% vs 54%) and to be current HRT users (5% vs 30%; p<0.05).
Comment: An important study reporting on ethnic inequalities for menopausal women in NZ. Often cited by clinicians as the main reason for treatment inequalities, the study has already adjusted for some ‘clinical factors’ and shown that this does not fully explain the disparities between Māori and non-Māori. Other factors to be considered include provider preference (which anecdotally appears to be an issue) and patient preference. Dr Beverley Lawton at the Wellington School of Medicine recommends the following website for women wanting more information about menopausal symptoms and management – www.menopause.org.au.
Reference: Climacteric. 2008;11(6):467-74
Authors: Agban H et al
Summary: This study assessed changes in clinical measures and proportions of patients with type 2 diabetes from different ethnic groups achieving guideline targets within a primary care diabetes annual review programme in New Zealand. A total of 7782 patients had data recorded at baseline in 2002–2003 and at follow-up two years later. A large proportion of Māori (47%) and Pacific (69%) patients had poor glycaemic control at baseline and only small improvements were made over the two years. In contrast, all ethnic groups experienced significant improvements in blood pressure and lipid management at two-year follow-up, at which time over 75% of Māori and Pacific patients received appropriate treatment with antihypertensive and lipid-lowering medication and many of the ethnic disparities in risk factors for complications were reduced.
Comment: Highlights the importance of monitoring services by ethnicity. The study showed that some aspects in the ‘process of care’ were associated with reduced rates in risk factors. However, the desired outcome for a service such as the Diabetes Annual Review is improved diabetes wellbeing, including ‘good’ glycaemic control. Further investigation is required to identify areas in which the DAR can ensure improved diabetes outcomes for Māori and Pacifica people.
Reference: Prim Care Diabetes. 2008 Sep 29. [Epub ahead of print]