Whole document restricted until August 2010, see Access Instructions file below for details of how to access the print copy. / Abstract Background Asthma is a common problem in New Zealand, and is associated with significant morbidity and costs to children, their families, and wider society. Previously published New Zealand literature suggested that Māori and Pacific children were less likely than NZ European children to receive asthma medications and elements of asthma education, had poorer knowledge of asthma, and experienced greater morbidity and hospitalisations. However, none of the previous literature had been specifically designed to assess the nature of asthma care in the community, or to specifically answer whether there were ethnic disparities in care. A systematic review of studies published in the international literature that compared asthma management among different ethnic groups drawn from community-based samples was undertaken. The results of this review suggested that minority ethnic group children were less likely to receive elements of asthma medication use, asthma education and self-management (action) plans. Objectives The primary objectives of the study were to: • describe the use of medications, medication delivery systems, asthma education, and self-management plans in primary care for Māori, Pacific, and Other ethnic group children • ascertain whether there were any ethnic disparities in the use of medications, medication delivery systems, asthma education, and self-management plans in primary care after controlling for differences in socio-economic position and other potential confounders. Secondary objectives were to: • describe the asthma-related utilisation of GP, after hours medical care, emergency departments, and hospital admissions among Māori, Pacific, and Other ethnic group children with asthma • ascertain whether differences in medication use, the provision of asthma education, and the provision of self-management plans explained ethnic differences in health service utilisation. Methods A cross-sectional survey was conducted in Auckland, New Zealand. The caregivers of 647 children who were aged 2–14 years, had a diagnosis of asthma or experienced ‘wheeze or whistling in the chest’, and had experienced symptoms in the previous 12 months were identified using random residential address start points and door knocking. Ethnically stratified sampling ratios were used to ensure that approximately equal numbers of children of Māori, Pacific and Other ethnicity were enrolled into the study. A face-to-face interview was conducted with the caregivers of these children. Data was collected about: socio-demographic factors; asthma morbidity; asthma medications and delivery devices; exposure to, and experiences of, asthma education and asthma action plans; and asthma-related health services utilisation. Results In this study, the caregivers of 647 eligible children were invited to participate and 583 completed the interview, giving an overall completion rate of 90.1%. There were no ethnic differences in completion rates. The overall use of inhaled corticosteroid medications had increased since previous New Zealand research was published. Multivariable modelling that adjusted for potential confounders did not identify ethnic differences in the use of inhaled corticosteroids or oral steroids. Some findings about medication delivery mechanisms indicated that care was not consistent with guidelines. About 15% of participants reported they had not received asthma education from a primary care health professional. After adjusting for potential confounders there were no ethnic differences in the likelihood of having received asthma education from a health professional. Among those participants who had received education from a primary care health professional, significantly fewer Māori and Pacific caregivers reported receiving education about asthma triggers, pathophysiology and action plans. Lower proportions of Pacific (77.7%; 95% confidence interval (95%CI) 70.3, 85.1) and Māori (79.8%; 95% CI 73.6, 85.9) caregivers were given information about asthma triggers compared to Other caregivers (89.2%; 95% CI 84.9, 93.6; p=0.01). Fewer Māori (63.6%; 95% CI 55.7, 71.4) and Pacific (68.1%; 95% CI 60.1, 76.1) caregivers reported receiving information about pathophysiology (Other 75.9%; 95% CI 69.5, 82.3; p=0.05). Information about asthma action plans had been given to 22.7% (95% CI 15.5, 29.9) of Pacific and 32.9% (95% CI 25.3, 40.6) of Māori compared to Other participants (36.5%; 95% CI 28.6, 44.3; p=0.04). In addition, fewer Māori (64.2%; 95% CI 56.1, 72.3) and Pacific (68.5%; 95% CI 60.1, 77.0) reported that the information they received was clear and easy to understand (Other 77.9%; 95% CI 71.8, 84.1; p=0.03). About half of those who had received education from a health professional reported receiving further education and, after adjustment for potential confounders, Pacific caregivers were less likely to have been given further education (odds ratio 0.57; 95% confidence interval 0.33, 0.96). A minority of participants (35.3%) had heard about action plans and, after adjustment for potential confounders, Pacific caregivers were less likely to have heard about these plans (odds ratio 0.54; 95% confidence interval 0.33, 0.96). About 10% of the sample was considered to have a current action plan. The mean number of visits to a GP for acute and routine asthma care (excluding after-hours doctors and medical services) in the previous twelve months were significantly higher for Pacific (3.89; CI 3.28, 4.60) and Māori (3.56; CI 3.03, 4.16) children than Other ethnic group children (2.47; CI 2.11, 2.85; p<0.0001). Multivariable modelling of health service utilization outcomes (‘number of GP visits for acute and routine asthma care in the previous twelve months’, ‘high use of hospital emergency departments’, and ‘hospital admissions’) showed that adjustment for potential confounding and asthma management variables reduced, but did not fully explain, ethnic differences in these outcomes. Māori children experienced 22% more GP visits and Pacific children 28% more visits than Other children (p=0.05). Other variables that were significantly associated with a higher number of GP visits were: regular source of care they always used (regression coefficient (RC) 0.24; p<0.01); lower household income (RC 0.31; p=0.004) and having a current action plan (RC 0.38; p=0.006). Increasing age (RC -0.04; p=0.003), a lay source of asthma education (RC -0.41; p=0.001), and higher scores on asthma management scenario (RC -0.03; p=0.05) were all associated with a lower number of GP visits. Pacific (odds ratio (OR) 6.93; 95% CI 2.40, 19.98) and Māori (OR 2.60; 95% CI 0.87, 8.32) children were more likely to have used an emergency department for asthma care in the previous twelve months (p=0.0007). Other variables that had a significant effect on the use of EDs in the multivariable model were: not speaking English in the home (OR 3.72; 95% CI 1.52, 9.09; p=0.004), male sex (OR 2.43; 95% CI 1.15, 5.15; p=0.02), and having a current action plan (OR 7.85; 95% CI 3.49, 17.66; p<0.0001). Increasing age was associated with a reduced likelihood of using EDs (OR 0.90; 95% CI 0.81, 1.00; p=0.05). Hospitalisations were more likely in the Pacific (OR 8.94; 95% CI 2.25, 35.62) and Māori (OR 5.40; 95% CI 1.28, 23.06) ethnic groups (p=0.007). Four other variables had a significant effect on hospital admissions in the multivariable model. Participants who had a low income (OR 3.70; 95% CI 1.49, 9.18; p=0.005), and those who had a current action plan (OR 8.39; 95% CI 3.85, 18.30; p<0.0001) were more likely to have been admitted to hospital in the previous 12 months. Increasing age (OR 0.88; 95% CI 0.80, 0.98; p=0.02) and parental history of asthma (OR 0.39; 95% CI 0.18, 0.85; p=0.02) were associated with reduced likelihood of admission. Conclusions The study is a robust example of cross-sectional design and has high internal validity. The study population is representative of the population of children with asthma in the community. The three ethnic groups are also considered to be representative of those ethnic groups in the community. The study, therefore, has good representativeness and the findings of the study can be generalised to the wider population of children with asthma in the Auckland region. The results suggested that some aspects of pharmacological management were more consistent with guideline recommendations than in the past. However, given the higher burden of disease experienced by Māori and Pacific children, the lack of observed ethnic differences in the use of preventative medications may reflect under treatment relative to need. There are important ethnic differences in the provision of asthma education and action plans. Future approaches to improving care should focus on interventions to assist health professionals to implement guideline recommendations and to monitor ethnic disparities in their practice. Asthma education that is comprehensive, structured and delivered in ways that are effective for the people concerned is needed.

Although the effects of noise on children’s learning in school classrooms is well documented, there is very little on the effects of noise on preschool children. There are strict legal requirements for the daily noise exposure an adult worker can received in the workplace but nothing to control the noise children can receive in school and early education. There is also little or no data on how sound affects a child, compared to an adult. The early years of life are critical for the development of speech, hearing and auditory processes, as well as being the most vulnerable time for middle ear infections. This work sets out to determine the typical noise levels in early childhood centres and the effects on a range of children and their teachers. Reverberation times in most centres were found to well exceed the 0.6 seconds prescribed by the Australasian standard for schools and learning spaces. Very high levels of noise were recorded in a number of centres with a significant number of children and staff members, exceeding the maximum daily sound exposure of 100% permitted for workers in industry. A range of special needs children were identified as being particularly at-risk to noise, with the most adverse outcomes reported for those experiencing sensory integration disorder. Yet, even though high levels of noise were recorded, the majority of respondents in a survey of teachers rated the lack of sufficient space for the number of children present as the main issue, and inclement weather as the greatest environmental condition contributing to noise (by confining children indoors, especially over long periods of time). Hearing tests on the children were not permitted under the strict human ethics criteria to which this study had to conform, but simple hearing tests on a small group of teachers, revealed that hearing loss could be a serious occupational health issue. The legal issues of noise control and management in early childhood education have been addressed in this thesis, current legal frameworks reviewed, and recommendations presented for future consideration.

Background Asthma is a common problem in New Zealand, and is associated with significant morbidity and costs to children, their families, and wider society. Previously published New Zealand literature suggested that M��ori and Pacific children were less likely than NZ European children to receive asthma medications and elements of asthma education, had poorer knowledge of asthma, and experienced greater morbidity and hospitalisations. However, none of the previous literature had been specifically designed to assess the nature of asthma care in the community, or to specifically answer whether there were ethnic disparities in care. A systematic review of studies published in the international literature that compared asthma management among different ethnic groups drawn from community-based samples was undertaken. The results of this review suggested that minority ethnic group children were less likely to receive elements of asthma medication use, asthma education and self-management (action) plans. Objectives The primary objectives of the study were to: ��� describe the use of medications, medication delivery systems, asthma education, and self-management plans in primary care for M��ori, Pacific, and Other ethnic group children ��� ascertain whether there were any ethnic disparities in the use of medications, medication delivery systems, asthma education, and self-management plans in primary care after controlling for differences in socio-economic position and other potential confounders. Secondary objectives were to: ��� describe the asthma-related utilisation of GP, after hours medical care, emergency departments, and hospital admissions among M��ori, Pacific, and Other ethnic group children with asthma ��� ascertain whether differences in medication use, the provision of asthma education, and the provision of self-management plans explained ethnic differences in health service utilisation. Methods A cross-sectional survey was conducted in Auckland, New Zealand. The caregivers of 647 children who were aged 2���14 years, had a diagnosis of asthma or experienced ���wheeze or whistling in the chest���, and had experienced symptoms in the previous 12 months were identified using random residential address start points and door knocking. Ethnically stratified sampling ratios were used to ensure that approximately equal numbers of children of M��ori, Pacific and Other ethnicity were enrolled into the study. A face-to-face interview was conducted with the caregivers of these children. Data was collected about: socio-demographic factors; asthma morbidity; asthma medications and delivery devices; exposure to, and experiences of, asthma education and asthma action plans; and asthma-related health services utilisation. Results In this study, the caregivers of 647 eligible children were invited to participate and 583 completed the interview, giving an overall completion rate of 90.1%. There were no ethnic differences in completion rates. The overall use of inhaled corticosteroid medications had increased since previous New Zealand research was published. Multivariable modelling that adjusted for potential confounders did not identify ethnic differences in the use of inhaled corticosteroids or oral steroids. Some findings about medication delivery mechanisms indicated that care was not consistent with guidelines. About 15% of participants reported they had not received asthma education from a primary care health professional. After adjusting for potential confounders there were no ethnic differences in the likelihood of having received asthma education from a health professional. Among those participants who had received education from a primary care health professional, significantly fewer M��ori and Pacific caregivers reported receiving education about asthma triggers, pathophysiology and action plans. Lower proportions of Pacific (77.7%; 95% confidence interval (95%CI) 70.3, 85.1) and M��ori (79.8%; 95% CI 73.6, 85.9) caregivers were given information about asthma triggers compared to Other caregivers (89.2%; 95% CI 84.9, 93.6; p=0.01). Fewer M��ori (63.6%; 95% CI 55.7, 71.4) and Pacific (68.1%; 95% CI 60.1, 76.1) caregivers reported receiving information about pathophysiology (Other 75.9%; 95% CI 69.5, 82.3; p=0.05). Information about asthma action plans had been given to 22.7% (95% CI 15.5, 29.9) of Pacific and 32.9% (95% CI 25.3, 40.6) of M��ori compared to Other participants (36.5%; 95% CI 28.6, 44.3; p=0.04). In addition, fewer M��ori (64.2%; 95% CI 56.1, 72.3) and Pacific (68.5%; 95% CI 60.1, 77.0) reported that the information they received was clear and easy to understand (Other 77.9%; 95% CI 71.8, 84.1; p=0.03). About half of those who had received education from a health professional reported receiving further education and, after adjustment for potential confounders, Pacific caregivers were less likely to have been given further education (odds ratio 0.57; 95% confidence interval 0.33, 0.96). A minority of participants (35.3%) had heard about action plans and, after adjustment for potential confounders, Pacific caregivers were less likely to have heard about these plans (odds ratio 0.54; 95% confidence interval 0.33, 0.96). About 10% of the sample was considered to have a current action plan. The mean number of visits to a GP for acute and routine asthma care (excluding after-hours doctors and medical services) in the previous twelve months were significantly higher for Pacific (3.89; CI 3.28, 4.60) and M��ori (3.56; CI 3.03, 4.16) children than Other ethnic group children (2.47; CI 2.11, 2.85; p<0.0001). Multivariable modelling of health service utilization outcomes (���number of GP visits for acute and routine asthma care in the previous twelve months���, ���high use of hospital emergency departments���, and ���hospital admissions���) showed that adjustment for potential confounding and asthma management variables reduced, but did not fully explain, ethnic differences in these outcomes. M��ori children experienced 22% more GP visits and Pacific children 28% more visits than Other children (p=0.05). Other variables that were significantly associated with a higher number of GP visits were: regular source of care they always used (regression coefficient (RC) 0.24; p<0.01); lower household income (RC 0.31; p=0.004) and having a current action plan (RC 0.38; p=0.006). Increasing age (RC -0.04; p=0.003), a lay source of asthma education (RC -0.41; p=0.001), and higher scores on asthma management scenario (RC -0.03; p=0.05) were all associated with a lower number of GP visits. Pacific (odds ratio (OR) 6.93; 95% CI 2.40, 19.98) and M��ori (OR 2.60; 95% CI 0.87, 8.32) children were more likely to have used an emergency department for asthma care in the previous twelve months (p=0.0007). Other variables that had a significant effect on the use of EDs in the multivariable model were: not speaking English in the home (OR 3.72; 95% CI 1.52, 9.09; p=0.004), male sex (OR 2.43; 95% CI 1.15, 5.15; p=0.02), and having a current action plan (OR 7.85; 95% CI 3.49, 17.66; p<0.0001). Increasing age was associated with a reduced likelihood of using EDs (OR 0.90; 95% CI 0.81, 1.00; p=0.05). Hospitalisations were more likely in the Pacific (OR 8.94; 95% CI 2.25, 35.62) and M��ori (OR 5.40; 95% CI 1.28, 23.06) ethnic groups (p=0.007). Four other variables had a significant effect on hospital admissions in the multivariable model. Participants who had a low income (OR 3.70; 95% CI 1.49, 9.18; p=0.005), and those who had a current action plan (OR 8.39; 95% CI 3.85, 18.30; p<0.0001) were more likely to have been admitted to hospital in the previous 12 months. Increasing age (OR 0.88; 95% CI 0.80, 0.98; p=0.02) and parental history of asthma (OR 0.39; 95% CI 0.18, 0.85; p=0.02) were associated with reduced likelihood of admission. Conclusions The study is a robust example of cross-sectional design and has high internal validity. The study population is representative of the population of children with asthma in the community. The three ethnic groups are also considered to be representative of those ethnic groups in the community. The study, therefore, has good representativeness and the findings of the study can be generalised to the wider population of children with asthma in the Auckland region. The results suggested that some aspects of pharmacological management were more consistent with guideline recommendations than in the past. However, given the higher burden of disease experienced by M��ori and Pacific children, the lack of observed ethnic differences in the use of preventative medications may reflect under treatment relative to need. There are important ethnic differences in the provision of asthma education and action plans. Future approaches to improving care should focus on interventions to assist health professionals to implement guideline recommendations and to monitor ethnic disparities in their practice. Asthma education that is comprehensive, structured and delivered in ways that are effective for the people concerned is needed.

In New Zealand Māori are under-represented in the workforce across multiple sectors. This thesis explores this incongruity with regard to Māori health. A Māori perspective and philosophical foundation formed the basis of the methodological approach, utilising a case study research design to inform the study. This provided the opportunity to explore Māori health workforce development initiatives and their potential to contribute to improvements and gains in Māori health. It was important that this work take into account social and economic factors and their impact on health, as well as the varying political climates of market oriented reform and a fiscal policy focus, because it has not only challenged Māori health development but also provided opportunities for increased Māori involvement and participation in health and New Zealand society. Therefore the thesis, while focused on health takes cognisance of and, coincides with the capacity and capability building efforts that have been a feature of overall Māori development, progress and advancement. In the context of this thesis Māori health workers are seen as leaders within their whānau, hapū, iwi, and Māori communities. Consequently a potential workforce that is strong and powerful can lead to anticipated gains in Māori health alongside other Māori movements for advancement. The potential cannot be under-estimated. This thesis argues that there are critical success factors, specific determinants, influencing Māori health workforce potential, and that these success factors have wider application. Therefore, as this thesis suggests Māori workforce development, especially in relationship to the health workforce, is dependent on effective Māori leadership, the application of Māori values to workplace practices, levels of resourcing that are compatible with training and development, critical mass, and targeted policies and programmes.

Background Hypovitaminosis D is becoming recognised as an emerging threat to health, even in countries like New Zealand which enjoy plentiful sunshine. The evidence for a role for vitamin D deficiency in the aetiology of a plethora of diseases continues to accumulate, including type 2 diabetes, and the preceding insulin resistance. Objectives The primary objective of the Surya Study was to investigate the effect of improved vitamin D status (through supplementation) on insulin resistance. The secondary objectives were to investigate the vitamin D status and bone mineral density of South Asian women living in New Zealand, and to investigate the effect of vitamin D supplementation on bone turnover as measured by biochemical markers of bone resorption and formation. Method Women of South Asian origin, ≥20 years old, living in Auckland (n = 235) were recruited for the study. All were asked to complete a 4-day food diary, invited to have a bone scan, and were screened for entry into the intervention phase which required insulin resistance (HOMA-IR >1.93) and serum 25(OH)D < 50 nmol/L. Eighty-one completed a 6-month randomised controlled trial with 4000 IU vitamin D3 (n = 42) or placebo (n = 39). Primary endpoint measures included insulin resistance, insulin sensitivity (HOMA2%S), fasting C-peptide and markers of bone turnover, osteocalcin (OC) and collagen C-telopeptide (CTX). Ninety-one of the 239 had a bone scan and bone mineral density (BMD) was measured in the proximal femur and lumbar spine. Results Adequate serum 25(OH)D concentrations (>50 nmol/L) were observed in only 16% of subjects screened. Median (25th, 75th percentile) serum 25(OH)D increased significantly from 21 (11,40) to 75 (55,84) nmol/L with supplementation. Significant improvements were seen in insulin sensitivity and insulin resistance (P = 0·003, P = 0·02 respectively), and circulating serum insulin decreased (P = 0·02) with supplementation compared to placebo. There was no change in C-peptide with supplementation. Insulin resistance was most improved when endpoint serum 25(OH)D =80 nmol/L. In post-menopausal women OC and CTX levels increased in the placebo arm but CTX decreased from 0.39±0.15 to 0.36±0.17 (P = 0.012) with supplementation. Osteoporosis (T score <-2.5) was present in 32% of postmenopausal, and 3% of premenopausal women. Women 20 – 29 years (n=10) had very low BMD, calcium intake and serum 25(OH)D Conclusions Improving vitamin D status in insulin resistant women resulted in improved insulin resistance and sensitivity but no change in insulin secretion. Optimal 25(OH)D concentrations for reducing insulin resistance were shown to be ≥80 nmol/L. The prevalence of low 25(OH)D concentrations in this population was alarmingly high, especially in younger women. In post-menopausal women, vitamin D supplementation appeared to ameliorate increased bone turnover attributed to oestrogen deficiency.

This study aimed to understand how Maori women negotiate decisions about alcohol and pregnancy. It was based in the recognition that Maori women?s decisions about drinking alcohol when pregnant are shaped by social and cultural expectations about gender roles, as well as their knowledge about alcohol and pregnancy. Maori attitudes to alcohol have also been influenced by colonisation and Maori responses to it. Alcohol use in pregnancy also exists in the context of potential impacts, including fetal alcohol spectrum disorder. There is little knowledge about how and why women may or may not drink during pregnancy. The research used grounded theory methods. Information was gathered through in-depth interviews with ten Maori women. The information they provided was analysed using constant comparative analysis, and a series of categories was generated. The grounded theory proposes that Maori women manage decisions about drinking alcohol when pregnant using a process of Trading off. Trading off is supported by three key processes: drawing on resources, rationalising, and taking control of the role. Maori women start by learning the rules about alcohol, get messages about alcohol and pregnancy, change their alcohol use while making role transitions, and use alcohol in the processes of fitting in where you are, releasing the pressure, and carrying on as normal. Trading off is an individual process, but exists in a complex social context. The process is fluid, conditional, and continues throughout pregnancy. The theory must be recognised as my interpretation, although I believe it is grounded in the data, accounts for the data, and offers a new, modifiable and potentially useful interpretation. While the body of theory that can be compared to the theory of Trading off is limited, the interpretation is consistent with several models of health behaviour, including Maori health models. This research has implications for future research, and for the development of programmes to support Maori women.

The allergic disease of asthma is characterized by an infiltration of inflammatory cells to the lung, a process co-ordinated by T-helper (TH) cells. The TH2 cytokine Interleukin (IL)-4 promotes infiltration of eosinophils to sites of inflammation. Eosinophil-selective chemoattractant cytokines (eg. eotaxins) are synthesized by lung epithelial cells. Eotaxin-3 is expressed at high levels in the asthmatic lung, predominantly after IL-4 stimulation. Eotaxin-3 is therefore a marker of inappropriate airway inflammation. Polyphenolic (PP) compounds found in high concentrations in berries may have beneficial effects in inflammatory conditions. Plant and Food Research produced high-PP extracts of blackcurrant (BC) cultivars that were tested for inflammation modulating effects. Since high doses of PPs have been shown to cause cell death, we tested two BC cultivars at a range of concentrations in a cell viability (WST-1) assay. While no toxic effects were attributable to the BC extracts (1-50µg/ml), a dose-related trend in cell death was observed and therefore 10µg/ml was chosen for further experiments Ten BC cultivars were compared for efficacy by measuring eotaxin-3 production in IL-4 stimulated human lung epithelial (A549) cells in vitro. Cells were incubated with BC extracts (10µg/ml) and IL-4 (10ng/ml) for 24 hours. The supernatants were then quantified for eotaxin-3 levels by an enzyme-linked immunosorbent assay (ELISA). All ten BC extracts reduced eotaxin-3 levels after stimulation with IL-4, and six BC extracts were effective by statistically significant levels (P<0.05), (BC cultivars -01, -02, -03, -05, -09 & -10). Of those, BC extracts of four cultivars demonstrated a reduction of more than 65% from the IL-4 stimulated control. In addition, a positive trend in inflammation modulation vs. one anthocyanin (ACN) in the BC extracts was shown. This study has demonstrated the beneficial inflammation modulatory effects of polyphenolic BC extracts, which could be related to cyanidin 3-O-rutinoside content. These results may have therapeutic potential for asthma.

Adolescence is a time of great changes, a time where experimentation and exploration is expected and when the values of authority figures are examined and challenged. Adolescents will experiment and push the boundaries of all aspects of their life in order to find their own place and identity in a world that has changed its expectations of them. Use of drugs is one of the ways that they do this. Australian adolescents grow up in a society where alcohol and tobacco is an acceptable part of daily life. Their use of drugs is at least on par with and in some cases exceeds that of the general population. The overall goals of this research were to gain more information on drug use of Australian adolescents, using existing data sets. This research examined, using a number of different age groups, the differences in adolescent drug use between urban and rural Australia for lifetime use, use in the last year and use in the last month using the 2002 edition of the Australian School Student Alcohol and Drug (ASSAD) survey series in conjunction with the 2001 National Drug Strategy Household Survey (NDSHS). It also used these data sets to investigate differences between indigenous adolescents and non-Indigenous adolescents and whether there were any differences in adolescent drug use across socio-economic status groups. Four hypotheses were developed. The first was that rural adolescents are more likely than urban adolescents to use licit drugs and the second was that urban adolescents are more likely than rural adolescents to use illicit drugs. Thirdly, that Indigenous adolescents are more likely than non-Indigenous adolescents to use both licit and illicit drugs and the fourth was that adolescents from low socio-economic status (SES) groups are more likely than adolescents from high SES groups to use licit and illicit substances. The data offered little support for any of the hypotheses. The hypothesis on rural adolescents being more likely to use licit drugs was supported by the ASSAD surveydata but not the NDSHS. All other hypotheses were not supported by either of the data sets. While there are aspects of the information from the two data sets that are contradictory making it difficult to prove or disprove the hypotheses formulated for this research, they highlighted a number of aspects of adolescent drug use. The first of these is that this research supports the premise that rural adolescent drug use rates are converging with urban drug use rates for younger adolescents. It also highlighted that there are a large number of rural school students who are using alcohol and cannabis. The ASSAD data also confirmed other Australian research showing that Indigenous adolescents are less likely than their non-Indigenous counterparts to use alcohol. Both data sets confirmed previous research by indicating that adolescents from the high SES groups are more likely than their counterparts in the lower SES groups to consume alcohol. Further investigation is needed to find out why the data sets did not substantiate each other and to gain further insight into the consumption of alcohol by Indigenous adolescents and adolescents from the higher socio-economic status groups. Increasing the samples of Indigenous people in both of the data sets and lobbying the Australian Bureau of Statistics to increase their sample for the Indigenous Social Survey to include 12-14 year olds should give more information on Indigenous adolescents that could be used in research and prevention activities.

Background Prior to the commencement of this study, gambling was not considered a significant health issue for Maori, even though the first national gambling prevalence study in New Zealand in 1991, identified that Maori had at least three times the risk of problem gambling of non-Maori. In the early 1990s, through the provision of a gambling telephone helpline and gambling counselling services, it was identified that Maori and in particular Maori women, were increasingly seeking help with problems with gambling. Gambling is an integral part of the culture of New Zealand. To understand gambling and problem gambling requires an understanding of the social, economic and cultural context it plays in being Maori. Aim of Study This study investigated whether gambling and problem gambling is an emerging health issue for Maori and if so, the extent of the problem, its effects on Maori and health approaches, and interventions which are likely to be effective for Maori. A public health approach to address problem gambling has been investigated and a plan developed. Methodology This study has been undertaken from a Maori-centered and an action-oriented research approach. It has involved integrating existing and new information from the following sources: Maori patterns of gambling and expenditure, gambling prevalence data, Maori utilisation of gambling treatment services and gambling by indigenous people. Fifteen Maori problem gamblers have been interviewed to understand from the "inside looking out" their experience of problem gambling. Thirty key informants have also been interviewed to understand from the "outside looking in" their perspective as to whether gambling is an emerging health issue for Maori. This research has involved quantitative analysis and qualitative research. Findings This study has found that problem gambling is an emerging public health issue for Maori. The effects of problem gambling for Maori are invisible and masked by other health problems such as alcohol abuse or mental health problems. Maori prevalence of problem gambling is similar to other indigenous populations which have shared similar historical and socio-economic experiences. Problem gambling often leads to crime, imprisonment, development of other health problems and the break down of families. Focusing alone on problem gambling ignores the real issues for Maori, a wider perspective is needed which focuses on Maori and tribal development. A public health strategy is proposed to reduce Maori gambling related harm.

Whole document restricted until August 2010, see Access Instructions file below for details of how to access the print copy. / Abstract Background Asthma is a common problem in New Zealand, and is associated with significant morbidity and costs to children, their families, and wider society. Previously published New Zealand literature suggested that Māori and Pacific children were less likely than NZ European children to receive asthma medications and elements of asthma education, had poorer knowledge of asthma, and experienced greater morbidity and hospitalisations. However, none of the previous literature had been specifically designed to assess the nature of asthma care in the community, or to specifically answer whether there were ethnic disparities in care. A systematic review of studies published in the international literature that compared asthma management among different ethnic groups drawn from community-based samples was undertaken. The results of this review suggested that minority ethnic group children were less likely to receive elements of asthma medication use, asthma education and self-management (action) plans. Objectives The primary objectives of the study were to: • describe the use of medications, medication delivery systems, asthma education, and self-management plans in primary care for Māori, Pacific, and Other ethnic group children • ascertain whether there were any ethnic disparities in the use of medications, medication delivery systems, asthma education, and self-management plans in primary care after controlling for differences in socio-economic position and other potential confounders. Secondary objectives were to: • describe the asthma-related utilisation of GP, after hours medical care, emergency departments, and hospital admissions among Māori, Pacific, and Other ethnic group children with asthma • ascertain whether differences in medication use, the provision of asthma education, and the provision of self-management plans explained ethnic differences in health service utilisation. Methods A cross-sectional survey was conducted in Auckland, New Zealand. The caregivers of 647 children who were aged 2–14 years, had a diagnosis of asthma or experienced ‘wheeze or whistling in the chest’, and had experienced symptoms in the previous 12 months were identified using random residential address start points and door knocking. Ethnically stratified sampling ratios were used to ensure that approximately equal numbers of children of Māori, Pacific and Other ethnicity were enrolled into the study. A face-to-face interview was conducted with the caregivers of these children. Data was collected about: socio-demographic factors; asthma morbidity; asthma medications and delivery devices; exposure to, and experiences of, asthma education and asthma action plans; and asthma-related health services utilisation. Results In this study, the caregivers of 647 eligible children were invited to participate and 583 completed the interview, giving an overall completion rate of 90.1%. There were no ethnic differences in completion rates. The overall use of inhaled corticosteroid medications had increased since previous New Zealand research was published. Multivariable modelling that adjusted for potential confounders did not identify ethnic differences in the use of inhaled corticosteroids or oral steroids. Some findings about medication delivery mechanisms indicated that care was not consistent with guidelines. About 15% of participants reported they had not received asthma education from a primary care health professional. After adjusting for potential confounders there were no ethnic differences in the likelihood of having received asthma education from a health professional. Among those participants who had received education from a primary care health professional, significantly fewer Māori and Pacific caregivers reported receiving education about asthma triggers, pathophysiology and action plans. Lower proportions of Pacific (77.7%; 95% confidence interval (95%CI) 70.3, 85.1) and Māori (79.8%; 95% CI 73.6, 85.9) caregivers were given information about asthma triggers compared to Other caregivers (89.2%; 95% CI 84.9, 93.6; p=0.01). Fewer Māori (63.6%; 95% CI 55.7, 71.4) and Pacific (68.1%; 95% CI 60.1, 76.1) caregivers reported receiving information about pathophysiology (Other 75.9%; 95% CI 69.5, 82.3; p=0.05). Information about asthma action plans had been given to 22.7% (95% CI 15.5, 29.9) of Pacific and 32.9% (95% CI 25.3, 40.6) of Māori compared to Other participants (36.5%; 95% CI 28.6, 44.3; p=0.04). In addition, fewer Māori (64.2%; 95% CI 56.1, 72.3) and Pacific (68.5%; 95% CI 60.1, 77.0) reported that the information they received was clear and easy to understand (Other 77.9%; 95% CI 71.8, 84.1; p=0.03). About half of those who had received education from a health professional reported receiving further education and, after adjustment for potential confounders, Pacific caregivers were less likely to have been given further education (odds ratio 0.57; 95% confidence interval 0.33, 0.96). A minority of participants (35.3%) had heard about action plans and, after adjustment for potential confounders, Pacific caregivers were less likely to have heard about these plans (odds ratio 0.54; 95% confidence interval 0.33, 0.96). About 10% of the sample was considered to have a current action plan. The mean number of visits to a GP for acute and routine asthma care (excluding after-hours doctors and medical services) in the previous twelve months were significantly higher for Pacific (3.89; CI 3.28, 4.60) and Māori (3.56; CI 3.03, 4.16) children than Other ethnic group children (2.47; CI 2.11, 2.85; p<0.0001). Multivariable modelling of health service utilization outcomes (‘number of GP visits for acute and routine asthma care in the previous twelve months’, ‘high use of hospital emergency departments’, and ‘hospital admissions’) showed that adjustment for potential confounding and asthma management variables reduced, but did not fully explain, ethnic differences in these outcomes. Māori children experienced 22% more GP visits and Pacific children 28% more visits than Other children (p=0.05). Other variables that were significantly associated with a higher number of GP visits were: regular source of care they always used (regression coefficient (RC) 0.24; p<0.01); lower household income (RC 0.31; p=0.004) and having a current action plan (RC 0.38; p=0.006). Increasing age (RC -0.04; p=0.003), a lay source of asthma education (RC -0.41; p=0.001), and higher scores on asthma management scenario (RC -0.03; p=0.05) were all associated with a lower number of GP visits. Pacific (odds ratio (OR) 6.93; 95% CI 2.40, 19.98) and Māori (OR 2.60; 95% CI 0.87, 8.32) children were more likely to have used an emergency department for asthma care in the previous twelve months (p=0.0007). Other variables that had a significant effect on the use of EDs in the multivariable model were: not speaking English in the home (OR 3.72; 95% CI 1.52, 9.09; p=0.004), male sex (OR 2.43; 95% CI 1.15, 5.15; p=0.02), and having a current action plan (OR 7.85; 95% CI 3.49, 17.66; p<0.0001). Increasing age was associated with a reduced likelihood of using EDs (OR 0.90; 95% CI 0.81, 1.00; p=0.05). Hospitalisations were more likely in the Pacific (OR 8.94; 95% CI 2.25, 35.62) and Māori (OR 5.40; 95% CI 1.28, 23.06) ethnic groups (p=0.007). Four other variables had a significant effect on hospital admissions in the multivariable model. Participants who had a low income (OR 3.70; 95% CI 1.49, 9.18; p=0.005), and those who had a current action plan (OR 8.39; 95% CI 3.85, 18.30; p<0.0001) were more likely to have been admitted to hospital in the previous 12 months. Increasing age (OR 0.88; 95% CI 0.80, 0.98; p=0.02) and parental history of asthma (OR 0.39; 95% CI 0.18, 0.85; p=0.02) were associated with reduced likelihood of admission. Conclusions The study is a robust example of cross-sectional design and has high internal validity. The study population is representative of the population of children with asthma in the community. The three ethnic groups are also considered to be representative of those ethnic groups in the community. The study, therefore, has good representativeness and the findings of the study can be generalised to the wider population of children with asthma in the Auckland region. The results suggested that some aspects of pharmacological management were more consistent with guideline recommendations than in the past. However, given the higher burden of disease experienced by Māori and Pacific children, the lack of observed ethnic differences in the use of preventative medications may reflect under treatment relative to need. There are important ethnic differences in the provision of asthma education and action plans. Future approaches to improving care should focus on interventions to assist health professionals to implement guideline recommendations and to monitor ethnic disparities in their practice. Asthma education that is comprehensive, structured and delivered in ways that are effective for the people concerned is needed.