Pacific secondary school students’ access to primary health care in New Zealand

Over the past decade, reducing health inequalities through improving Pacific peoples access to and through primary health services has been a key focus of the Primary Health Care Strategy (PHCS).1 Access, in this context, means the capacity to obtain health care when needed. National data shows Pacific populations in New Zealand experience unmet health needs in primary care and there are variations in the quality of care experienced.2-5A stocktake of health needs brought together information on more than 150 health and social indicators of relevance to Pacific peoples.6 It identified poorer health status, greater exposure to risk factors for poor health and access barriers to health care for Pacific people. Whilst this study reports on a wide range of indicators, its weaknesses included a lack of indepth analysis and analysis for Pacific youth.A key point of difference between Pacific and non-Pacific groups in New Zealand, is the youthful demography of Pacific People, with 38% of the Pacific population under the age of 15, which is much higher than the NZ general population overall at 22%.7The median age for New Zealands Pacific population is 21.1 years, which is considerably lower than the median age of the New Zealand population overall at 35.9 years. It should be noted here, that in terms of demography, Pacific young people account for the majority of the Pacific population in New Zealand (56% under the age of 24 years).Good access and utilisation of primary care services is an important resource of preventable health for Pacific young people.8 Current Ministry of Health targets prioritises effective primary health services that can be delivered Better, Sooner, More Convenient .9 The factors that affect access to health services and the delivery of quality of care need to be better understood in order to improve healthcare-related outcomes of an important burgeoning group of young New Zealanders. This study undertook secondary analysis of the Youth 2007 data set to define any barriers in primary health and dental care access, utilisation and unmet need for Pacific youth. It identified factors impacting on access and defined disparities between Pacific and New Zealand European students. This information will be vital in addressing the goals of the Better, Sooner, More Convenient Primary Health Care Strategy.10 Method Survey background Data for the current study were collected as part of Youth07, a nationally representative sample of the health and wellbeing of secondary school students in New Zealand. First, 115 schools were randomly selected and 96 agreed to participate in the survey, representing an 84% response rate for schools. The participating schools reflected the general characteristics of secondary schools in New Zealand.11 From the participating schools, students (n=12,355) were randomly selected from the school roll and invited to participate. Of these, a total of 9107 students formed the final Youth07 sample, representing a 74% response rate. On the day of the survey, students were asked to come to a designated room. Upon arrival students were given an anonymous login code to access the survey. The survey included a 622-item multimedia questionnaire administered on a Nokia Internet tablet and identification of their census meshblock number (based on their residential address) to determine the extent of their neighbourhood deprivation. The multimedia nature of the questionnaire meant that all students could read each question and response options themselves, while listening to the questions and responses being read aloud through headphones. The University of Auckland Human Subject Ethics Committee granted ethical approval for the study. School principals consented to participation in the survey on behalf of the Boards of Trustees. Students and their parents were provided with information sheets about the survey. Students consented themselves to participate in the study on the day of the survey. A more detailed description of the research methodology can be obtained elsewhere.11 Secondary analysis of the data provided by Pacific students (13% of the total sample) was undertaken. Ethnicity was recorded using New Zealand 2006 Census ethnicity question whereby participants select all of the ethnic groups that they identified with.12 All students who self-identified any of their ethnic groups as Samoan, Cook Islands, Tongan, Niue, Tokelauan, Fijian, or Other Pacific Peoples are included in these analyses (n=1178). New Zealand European students identified through ethnic prioritisation (i.e., students that are non-Maori, non-Pacific, non-Asian) were included in the analyses (n=4797). Intra-Pacific ethnicity analyses could not be completed as findings may be confounded by small sample numbers. Outcome measures To assess the level of healthcare access amongst students, the question When was the last time you went for health care? was used for analysis. This question had 4 response options: 0-6 months. 7-12 months. 13-24 months ago. More than 2 years ago. These four responses were dichotomised into two categories, with the first two options classed as; accessing healthcare in the last 12 months and the last two options classed as; not accessing healthcare in the last 12 months. To find out what types of healthcare services students were accessing, students were asked Which of the following places for health care have you used in the last 12 months? (pick as many or as few as apply to you). Students were presented with 10 choices, 8 of which were used in this study: Family doctor, medical centre or GP clinic. School health clinic. After-hours or 24-hour accident and medical centre. Hospital accident and emergency. Youth centre. Family planning or sexual health clinic. Traditional healer (e.g. tohunga, fofo). Alternative health worker (e.g. naturopath, homeopath, acupuncturist). (The last two response options Other and None were excluded from the analyses.) Foregone healthcare was assessed using the question In the last 12 months, has there been any time when you wanted or needed to see a doctor or nurse (or other health care worker) about your health, but you werent able to? Students were able to indicate by choosing a Yes or No response. If students chose a Yes response to not accessing healthcare in the last 12 months, they were asked a further branching question on reasons for not accessing healthcare when needed. The question they answered was Here are some reasons people dont get health care even though they need to. Have any of these ever applied to you? (you can answer as many or as few as you want.) Table 4 presents the 10 reasons (response options) students were offered to choose from using a Yes or No response. The last response option to this question was other reason(s) which has been excluded from the analyses. All students were asked to indicate the types of health issues they may have had difficulty getting help for. The question was In the last 12 months have you had any difficulty getting help for any of the following? (you can answer as many as apply to you). Table 3 presents the eight reasons (response options) included in the analyses. The last two response options; something else and I havent had difficulty getting help were excluded from the analyses. Dental care access was measured using the question How long has it been since you last visited a dentist, dental nurse or other dental health worker (such as dental therapists or orthodontists). There were 6 response options available: Within the past year (less than 12 months ago). Within the past 2 years (more than 1 year but less than 2 years ago). Within the past 5 years (more than 2 years but less than 5 years ago). 5 or more years ago. I have never seen a dentist or any other dental health worker. Dont know/not sure. ((click here to view Tables 2-4)) These 6 responses were dichotomised into two categories, with the first option classed as; accessing dental healthcare in the last 12 months, and all other options classed as; not accessing dental healthcare in the last 12 months. Foregone dental healthcare was assessed using the question In the last 12 months, has there been any time when you needed to see a dentist or dental nurse about your teeth or gums, but werent able to? Students were able to choose from three responses; Yes or No or dont know. These three options were collapsed into two categories, with the last two options combined as a No category. The quality of health care received by young people was assessed with a question on personal interactions with a health professional (e.g. doctor, nurse, dentist etc.). Students were asked Have you ever been treated unfairly (e.g. treated differently, kept waiting) by a health professional (e.g. doctor, nurse, dentist etc.) because of your ethnicity or ethnic group? Students were able to choose from 4 options: Yes, within the past 12 months. Yes, more than 12 months ago. No. Dont know/unsure. These responses were dichotomised into two categories with the first two options combined to a yes category and the last two options combined as a no category. Demography Age, gender and ethnicity were determined by self-report. Small area deprivation(NZDep) was determined using the 2006 New Zealand Deprivation Index.13 For descriptive purposes, the NZDep Index deciles were categorised into three groups reflecting low deprivation (1-3), middle levels of deprivation (4-7), and high deprivation (8-10). Analysis Frequencies and percentages were used to describe the characteristics of students. Chi-squared tests were used to investigate the bivariate associations between ethnicity and outcome variables. Adjusted relative risk (aRR) was estimated using a log-binomial regression model controlling for age, sex and socioeconomic deprivation. All analyses were conducted using the procedures in the SAS v9.2 software (Cary, NC) and accounted for the clustered design of the data. Results Table 1 shows the demographic characteristics of the students included in this study. Information was available for 5975 students; 1178 Pacific and 4797 NZ European students. There were no gender differences across the two groups of students, but there were differences by age and by socioeconomic status. Pacific youth were younger and had much higher levels of social deprivation than NZ European students. Types of healthcare services utilised A question on the types of healthcare services that Pacific students accessed in the previous 12 months, showed that the family doctor, medical centre or GP clinic was rated the most used by Pacific students (91.4% compared to NZ European students 93.9% p = 0.01), followed by school health clinic (32.9% compared to NZ European students 20.1% p < 0.001); the hospital accident and emergency (18.1% compared to NZ European students 19.1% p = 0.45); an after-hours or 24-hour accident and medical centre (13.4% compared to NZ European students 16.8% p = 0.09); an alternative health worker (e.g. naturopath, homeopath, acupuncturist (9.1% compared to NZ European students 12.6% p = 0.002); family planning or sexual health clinic (6.1% compared to NZ European students 5.0% p = 0.17); a traditional healer (e.g. tohunga, fofo) (5.1% compared to NZ European students 0.1% p < 0.001); youth centre (4.0% compared to NZ European students 1.8% p = 0.002). Table 1. Demographic characteristics of Pacific and NZ European secondary school students Variables Pacific NZ European n % n % p-value Total n 1178 19.9 4797 80.1 Gender Males 548 46.5 2166 45.0 Females 630 53.5 2631 55.0 0.77 Age 13 and under 292 24.8 959 19.8 14 267 22.6 1139 23.7 15