Asian health trends in New Zealand from 2002 to 2021, and the case for dedicated research funding

Aotearoa New Zealand is currently in the middle of a profound change in the demographic composition of its people. The main change over the last 20 years has been in its ethnic composition. Data from the New Zealand census (Table 1) show that while the total population increased from 2006 by 24% to nearly 5 million in 2023, larger increases have occurred in non-European ethnic groups. For Māori, the increase over this period has been 57%, and for Pacific 66%. However, the largest increase has been in the Asian community, which has increased from being 9% of the total population in 2006 to 17% in 2023—a relative increase of 143% from 2006. This increase is expected to continue so that 26% of the New Zealand population by 2043 will be Asian.¹

View Table 1–3, Figure 1–2.

Because of its increasing size, the health of the Asian community is of great importance for New Zealand, not only for individual Asian people but also for funding health services at the population level. Evidence has emerged over the last decade showing that some diseases remain elevated in the Asian community.⁴ Failure to address the causes of these diseases will impact adversely on the New Zealand health budget in the long term. In this paper, we describe key findings from a major report we have co-authored on the health of the Asian community in New Zealand, and the trends in health research funding by ethnicity. Together, these document a mismatch between the level of Asian health research funding and the disease burden affecting the Asian community.

1.    Asian health report

We have recently prepared a major report on the health of the Asian community in New Zealand.⁵ It is based on data collected in the New Zealand Health Survey from 2002/2003 up to the recent data release for 2020/2021. Briefly, the method used in the New Zealand Health Survey is as follows.

Methods

All New Zealand Health Surveys have used a three-stage, stratified complex sampling method to over-sample Māori, Pacific and Asian participants to allow for ethnic-specific analyses of all three ethnicities, along with European and Other participants.^6,7 Face-to-face interviews were carried out in the homes of participants. Information was collected on the following topics: demographic status, health behaviours, health conditions and health service utilisation.⁸ This was done separately for children aged 0–14 years and adults aged ≥15 years, although only results for adults are reported in this paper.

Ethnicity was self-defined, and participants were allowed to choose their affiliation with more than one ethnic group, in which case the following priority for categorising ethnicity was applied: Asian, followed by Māori, then Pacific, and lastly European and Other. The Asian sample was further categorised, based on the coding available from the Ministry of Health – Manatū Hauora, into three groupings, with the following order of priority: South Asian (Indian, Fiji-Indian, Pakistani, Sri Lankan, Bengali, Nepali and Afghani), Chinese, and Other Asian.⁴ The ethnic-specific sample sizes for the two recent survey periods (2019–2021) for adults were: South Asian 805, Chinese 573, Other Asian 708, Māori 3,790, Pacific 1,000 and European and Other 12,532.

Participants are weighted by the inverse of their sampling probability so that collectively those surveyed represent the total resident New Zealand population.⁵ For the difference across all ethnic groupings, the combined data from the 2019 to 2020 and 2020 to 2021 surveys were analysed to compare: All Asian (as reference, combined South Asian, Chinese, Other Asian), Māori, Pacific and European and Other, after controlling for age and gender (as appropriate). Mantel–Haenszel common relative risks (RRs) for binary disease and prevention service variables were also calculated for selected two-ethnic grouping comparisons (European and Other as reference), adjusting for age and gender (as appropriate).

For trend analyses, comparisons among Asian were made using available data between the 2002 to 2003 and 2019 to 2021 (as reference) surveys for adults aged 15 years and older. All p-values have been adjusted for age and gender as appropriate. Data were analysed using SUDAAN (version 11.0.4, Research Triangle Park, North Carolina, United States of America) and SAS 9.4 (SAS Institute Inc, Cary, North Carolina, United States of America).

Results

Table 2 summarises selected adult data from the main report. It compares the four main ethnic groups (Asian, Māori, Pacific and European and Other) in the 2019–2020 and 2020–2021 surveys combined, using Asian as the reference, and changes over time among Asian only since their first inclusion in the 2002–2003 New Zealand Health Survey.

Demographic variables

The Asian community in New Zealand has aged over the last two decades, with the proportion of Asian people aged ≥65 years increasing between 2002 to 2003 and 2019 to 2021 (p=0.01), and is now similar to that for Pacific (p=0.13), but below that for Māori and European and Other (p<0.01). The length of time lived in New Zealand by Asian people has increased, with the proportion who have lived in New Zealand for ≥10 years, or who were born here, nearly doubling between 2002 to 2003 and 2019 to 2021. The Asian community is very highly educated, with the proportion of Asian people with a university degree increasing between 2002 to 2003 and 2019 to 2021, and it is currently much higher than in the other main ethnic groups. Over the same period, the proportion of Asian people on government support (e.g., unemployment benefit) has decreased such that it is a much lower proportion than the other main ethnic groups, indicating that Asian people overall are net contributors to the government purse. Of concern, the proportion of Asian people who report being a victim of an ethnically motivated verbal or physical attack has increased during the period from 2011 to 2012 (the first year this was measured in the New Zealand Health Survey) to 2020 to 2021, and is now similar to that for Māori (but higher than that for Pacific and European and Other).

Health behaviours

The trends in health behaviours since 2002–2003 are mixed, with some improving and others worsening. Pleasingly, the proportion of current smokers among Asian people has decreased during this period and currently is the lowest of the main ethnic groups. The pattern for physical activity itself is mixed, with no significant change between 2002 to 2003 and 2019 to 2021 in the proportion of Asian people who are active, although the proportion who are sedentary declined over this period.

Of concern, the proportion of Asian people consuming the recommended five+ serves of fruit and vegetables each day has decreased between 2002 to 2003 and 2019 to 2021, and currently is much lower than for Māori and European and Other groups. Alcohol consumption has also increased among the Asian community between 2002 to 2003 and 2019 to 2021, based both on the proportion who drank alcohol in the last 12 months and also the proportion reporting hazardous drinking (Alcohol Use Disorders Identification Test [AUDIT] score ≥8⁹): however, their current percents for these are both lower than those of other ethnic groups. In addition, the proportion of Asian people with obesity (based on internationally accepted ethnic-specific definitions^10,11) has doubled between 2002 to 2003 and 2019 to 2021, so that it is only slightly lower currently than for Pacific but higher than for Māori (and European and Other).

Diseases

The above adverse behaviour profiles among Asian people for fruit and vegetable intake, physical activity and obesity are being manifested by increased risk of some chronic diseases. Table 3 shows RR of disease separately for three Asian groupings (South Asian, Chinese and Other Asian) because of their different patterns, and for Māori and Pacific, in comparison with European and Other, adjusted for age and gender to remove confounding effects from these variables. The adjusted RRs of hypertension and high blood cholesterol are elevated by a similar amount in South Asian, Māori and Pacific, as is diabetes in South Asian and Other Asian (RR >3.0). In contrast, the risks of all of the above diseases are similar in Chinese to those for European and Other. In addition, the risk of cardiovascular disease is also lower in Chinese, as are asthma, arthritis and depression in all three Asian groupings.

Prevention services

The level of prevention services provided in the last 12 months is a measure of the degree to which clinical services are responding to the adverse cardiometabolic disease profile of Asian people. Table 3 shows that South Asian people, along with Māori and Pacific, were more likely to be offered weight/height measurements, cholesterol testing and advice regarding exercise and physical health, compared with European and Other. Appropriately, increased testing for diabetes was also offered to South Asian, Other Asian, Māori and Pacific. Of concern, South Asian people were not more likely to be offered a blood pressure test in the last 12 months than European and Other, despite having a higher risk of hypertension. Also, all three Asian groupings were no more likely to be offered green prescriptions (advice to be physically active and eat healthily) or advice on weight than European and Other, in contrast to the situation for Māori and Pacific, who were, despite all three Asian groupings having elevated levels of obesity.⁵ These latter findings point to gaps in the prevention services offered to Asian people.

In summary, the data in Table 2–3 on trends in health behaviours among Asian adults since 2002–2003—with a worsening in the situation for fruit and vegetable intake, obesity and alcohol and no improvement in activity levels, along with the current elevated risk of cardiometabolic disease, particularly for South Asian, at levels similar to those for Māori and Pacific—indicate a societal and health system failure to improve the health of the Asian community, a need that was identified nearly 20 years ago.¹² These findings are consistent with the report on Asian health in New Zealand in 2011–2013,⁴ and many are supported by additional New Zealand¹³ and international studies.^14,15

2.    Health research funding

One important area that has the potential to identify possible factors contributing to worse health outcomes or preventing improvements is research—particularly government-funded health research. The Ministry of Health – Manatū Hauora eventually recognised the need to collect separate data from Asian people in the 2002 New Zealand Health Survey, 10 years after the first survey conducted in collaboration with Stats NZ in 1992–1993. It is the monitoring of the health status of Asian people in the New Zealand Health Surveys that has provided the data for our report⁵ and this article.

However, the main government funder of health research in New Zealand is the Health Research Council of New Zealand (HRC). What have they done over the last 10 years or so, during a period when the Asian community has become a major part of the New Zealand population, and after the publication of our previous report in 2016,⁴ which found very similar findings to our current report?

Methods

In order to explore the allocation of health research funding by ethnicity and track their trends, we extracted information on funded health research projects from the HRC Research Repository¹⁶—the main government funder of health research—for the period between 2010 and 2023. The extracted data included the study title, year, approved budget, lead investigator, host organisation, proposal type and lay summary.

We then searched the study titles and lay summaries, and categorised all funded studies into Asian-, Māori- and Pacific-focussed studies using the following keywords: Asian = Asian, Asia, Chinese, India; Māori = Maori, Māori, Mäori, Rongoā, Hauora, Whakatōhea, Wahine, Tangata Whenua, Tāne, Ngāti Rangitihi; and Pacific = Pacific, Pasifika, Tonga, Samoa, Cook Island, Fiji, Niue, Niuean, Tokelau, Ni-Vanuatu. Trends in the number of funded studies, and approved budget, by ethnicity and year were analysed. If a study mentioned more than one ethnic group, it was allocated to each one.

Results

Over the 14-year period from 2010 to 2023, a total of 2,685 studies were funded with an approved budget of NZ$1.55 billion. Around 1.2% (n=32) of these studies were Asian-focussed (had Asian-related keywords in the title or abstract), accounting for 1.1% (NZ$16.9 million) of the total approved budget.

Figure 1 and Appendix Table 1 show the annual number of HRC-funded studies during 2010–2023, by ethnicity of the study participants, based on key words in the titles or lay summaries of these studies. Over this period the total number of studies increased by over 60% (from 183 to 300 per year), as did the number of studies where Māori or Pacific ethnicity was mentioned in the title or lay summary. In contrast, there has been no discernible increase in the number of studies with “Asian” in the title or lay summary. Further, the number of such studies is very low—far lower than the proportion that Asian people contribute to the total New Zealand population (Table 1). A similar pattern is seen for the approved budgets of funded studies (Figure 2, Appendix Table 2). We acknowledge there are limitations with the method we used to identify studies with Asian participants. By relying on titles and lay summaries, we may have missed some studies that did have an Asian focus. The HRC has much more extensive data about funded studies that could be used to confirm or refute our findings.

3.    Discussion

Given the mismatch between health needs, population size and health research funding, in our view the time has come for the main government funder of health research (i.e., HRC) to ring-fence funding for Asian researchers who submit grant applications focussing on Asian health. The HRC has twice in its past ring-fenced ethnic-specific funding. The first was for Māori, with the creation by the Health Research Council Act 1990 of the Māori Research Committee, which was provided with money ring-fenced for Māori researchers. This resulted in a flowering of research by and for Māori, which up until then had been blocked by the relative inexperience of Māori researchers operating in an openly competitive environment. This experience was repeated in 2017 when the HRC finally implemented a policy to ring-fence project funding (up to NZ$1.2 million) for research by and for Pacific.¹⁷ Since then, the number and funding of Pacific research has increased (Figure 1–2). The ring-fencing of funds for Māori and Pacific researchers are both excellent examples of the benefits from such a strategy.

The same arrangement is now needed for Asian researchers, e.g., starting with summer studentships, master’s scholarships, PhD scholarships and postdoctoral fellowships, as a recent review has found that the evidence base on Asian health in New Zealand is weak.¹⁸ Increasing the number of and funding for research by and for Asians is more likely to identify factors that are preventing improvements in health outcomes than the current situation that has remained or worsened over the last 20 years. This is also highlighted in the recently submitted petition for a National Health and Well-Being Policy/Strategy for Asian and MELAA Communities.¹⁹ Over time, the continuing increase in the size of the Asian population will require research on other subpopulations, such as Filipinos and those who are gender diverse. The earlier decision by the Ministry of Health – Manatū Hauora to recruit sufficient Asian participants in the 2002–2003 New Zealand Health Survey is an example of the benefits that flow from a policy that allows for the carrying out of ethnic-specific analyses.

4.    Conclusion

The health of the Asian community has not improved over the last 20 years. Given its rapidly increasing size in New Zealand, and the limited funding currently awarded for Asian health research, funding agencies such as the HRC need to ring-fence and increase funding for Asian researchers so that they can identify solutions within their communities to rectify this situation.

View Appendix.