Ethnic inequalities in breast cancer and breast cancer survival 

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Chapter 2. Background – People and health services in Aotearoa New Zealand and the Waikato region

People of New Zealand:

Māori are the Indigenous people of New Zealand. They are Polynesian people who settled in New Zealand about 1000 years ago. Subsequent immigrations, initially by Europeans starting from 1800’s and later by Pacific Islanders and Asians, have created the present day dynamic multicultural society of New Zealand. According to the latest population census in 2013, NZ Europeans (Pākehā) make the numeric majority (74%), while Māori comprise approximately 15% of the population. Asian (11.8%) and Pacific (7.4%) comprise the other two main ethnic groups (17). Māori were the sole inhabitants of Aotearoa New Zealand for several hundred years until the arrival of the British and subsequent colonization which started in the early 1800s. Through a combination of colonization, the Treaty of Waitangi and military suppression of Māori resistance, the British settlers managed to make New Zealand a part of the British Empire (18). Although the Treaty granted Māori equal rights, acquisition of Māori land by the British led to the New Zealand land wars in 1860’s. Following these wars, over 100,000 hectares of Māori land was confiscated by the government under the New Zealand Settlements Act in 1863,purportedly as punishment for Māori rebellion. Loss of land, illnesses and after effects of tribal wars led to a rapid decline in the Māori population with many scientists and politicians predicting an imminent extinction in the late 1800s (19). A major resurgence in the Māori population was observed after the Second World War. Many Māori migrated to larger towns and cities during the depression and post-world war periods in search of employment, leaving rural communities depleted and disconnecting many urban Māori from their traditional ways of life (20). While standards of living improved among Māori during this time, they continued to lag behind Pākehā in areas such as health, income, skilled employment and access to higher education. Māori leaders and government policymakers alike have struggled to deal with social issues stemming from increased urban migration, including a shortage of housing and jobs, and a rise in crime, poverty and health problems.

Indigenous Māori, British colonization, the Treaty and evolution into present day New Zealand

Māori

Māori are the Indigenous people in NZ and are considered tangata whenua –people of the land. They are descendants of Polynesians who had arrived approximately 1000 years ago (18, 21). Iwi (tribes) formed the largest social groups of Māori who trace their ancestry to original Polynesian migrants. Each iwi comprised of a structure for ruling and leadership was based on a system of chieftainship. Important units of pre-European Māori society were the whānau or extended family, and the hapū or group of whānau. After these came the iwi or tribe, consisting of groups of hapū. Traditional Māori society preserved history orally through narratives, songs, and chants; skilled experts could recite the tribal genealogies (whakapapa) back for hundreds of years.
Traditional Māori belief systems, such as views about reliance on the whānau, individual mana (prestige), death and dying, and practices associated with tapu (sacred), continue to influence health behaviour. These views may influence preferences for care, individual help-seeking behaviour and responses to health care providers (22).

British colonization

The first significant contact between Māori and Europeans occurred in 1769, at the time of James Cook’s expedition to New Zealand from Britain (23). Subsequently, by early 1800s many Europeans traders, missionaries, convicts escaped from Australia, and deserting seamen began to settle in the country. From about 1800 to about 1830, the Europeans lived in New Zealand on Māori sufferance. During this period a rapid decline in Māori population was observed partly because thousands were killed in their musket wars in the 1820s and 1830s, but mainly because the Europeans brought a battery of new germs and viruses. Measles, some forms of influenza, typhoid, small pox and other diseases reduced the Māori population from perhaps 200,000 in 1769, when James Cook arrived, to less than 40,000 by 1870.With the growing British population in New Zealand and due to the threat from the French, the British Crown intended to annex New Zealand into the British Empire. The authority of New Zealand was taken by the British Crown through the signing of the Treaty of Waitangi in 1840 (24).

CHAPTER 1. INTRODUCTION
CHAPTER 2. BACKGROUND – PEOPLE AND HEALTH SERVICES IN AOTEAROA NEW ZEALAND AND THE WAIKATO REGION
2.1. People of New Zealand:
2.2. Māori, British colonization, the Treaty and evolution into present day New Zealand 
2.2.1 Māori
2.2.2 British colonization
2.2.3 Treaty of Waitangi (Te Triti o Waitangi)
2.2.4 Present day New Zealand
2.3. Health care system in New Zealand
2.3.1 Health care structure, organization and delivery
2.4. Waikato Region and the Waikato District Health Board 
2.5. Breast Cancer 
2.5.1 Breast cancer
2.5.2 Management of breast cancer
2.5.3 Management guidelines
CHAPTER 3. LITERATURE REVIEW
3.1. Ethnic inequalities in breast cancer and breast cancer survival 
3.1.1 Ethnic inequalities in breast cancer and breast cancer survival in New Zealand
3.1.2 Ethnic inequalities in breast cancer and breast cancer survival in other countries
3.2. Reasons for ethnic disparities in breast cancer outcomes
3.2.1 Patient level factors
3.2.2 Tumour factors
3.2.3 Healthcare service factors
3.3. Understanding key drivers behind ethnic inequities in breast cancer outcomes
3.3.1 Healthcare structure (System level)
3.3.2 Physician level factors (Provider level)
3.3.3 Patient level factors
3.4. Conceptual framework Ethnic differences in breast cancer outcomes in Aotearoa New Zealand
CHAPTER 4. DESIGN AND METHODS 
4.1. Study population 
4.2. Data sources:
4.2.1 The Waikato Breast Cancer Register:
4.2.2 Retrospective data collection:
4.2.3 Other data sources:
4.3. Data collection: 
4.3.1 Ethics approval
4.3.2 The Waikato Breast Cancer Register
4.3.3 Retrospective data collection:
4.3.4 Data preparation:
4.4. Variables: 
4.4.1 Exposure variable – Ethnicity:
4.4.2 Tumour characteristics
4.4.3 Patient characteristics
4.4.4 Health care access
4.5. Outcome data 
4.6. Sample size estimation
4.7. Data analyses
CHAPTER 5. RESULTS
5.1. How valid are the data used in this study?
5.2. What risk factors contribute to ethnic inequities in breast cancer? A preliminary analysis
5.3. Is breast cancer screening contributing to ethnic inequity in outcomes?
5.4. Are there ethnic differences in breast cancer biology? 
5.5. Are there ethnic differences in delay in surgical treatment?
5.6. Are there ethnic differences in delay in chemotherapy and radiation therapy?
5.7. Are there differences in the use of adjuvant therapy for breast cancer by ethnicity
5.8. Does patient adherence with treatment contribute to inequity? 
5.9. Are there ethnic differences in quality of surgical care provided for breast cancer?
5.10. How things add up: quantitative impact of factors on ethnic inequity 
CHAPTER 6. DISCUSSION AND CONCLUSIONS 
6.1. Interpretation of results
6.1.1 Differences between Māori and NZ European women with breast cancer
6.2. Why do these disparities exist?
6.2.1 Provider and healthcare system characteristics
6.2.2 Patient factors including socioeconomic factors
6.3. How can we provide Māori women with better and equitable healthcare? 
6.3.1 Identifying the problem and its underlying reasons
6.3.2 Providing equitable and acceptable care
6.4. Strengths and Limitations – How valid are the findings? 
6.4.1 Study design
6.4.2 Internal validity / Bias
6.4.3 Confounding and estimating effects.
6.4.4 Chance and variability
6.4.5 External validity
6.5. Conclusions
APPENDICES
REFERENCES

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Ethnic differences in breast cancer outcomes in Aotearoa New Zealand