Te Ngira Papers

Permanent URI for this collectionhttps://researchcommons.waikato.ac.nz/handle/10289/6536

Te Ngira Institute for Population Research is Aotearoa’s only dedicated population research centre. We carry out world-leading research in the areas of Indigenous demography and data sovereignty, temporary migration and Pacific health equity. Our research is widely used by decision-makers in Te Ao Māori, government agencies, communities, and the private sector to help inform choices and responses to the demographic, social and economic interactions that are shaping Aotearoa’s future.

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The elephant in the room: Precarious work in New Zealand’s universities
(University of Auckland, 2022) Simpson, Aimee B.; Jolliffe Simpson, Apriel D.; Soar, Max; Oldfield, Luke; Roy, Rituparna; Salter, Leon A.
Precarious working arrangements, defined by temporary casual and fixed-term employment agreements, are a complex, often hidden feature of academia in Aotearoa New Zealand (Aotearoa hereafter). At present, little is known about the conditions of insecure academic work, the size of this workforce, nor how these workers have been affected by the COVID-19 pandemic. This report provides an insight into the reality of insecure academic work in universities from those who responded to the 2021 Precarious Academic Work Survey. We highlight that in Aotearoa we have a highly trained, casual and fixed-term academic workforce who are engaged in long-term cycles of precarity. Among the 760 participants surveyed, more than one-quarter (28.9%) had been precariously employed for five years or longer. Further, nearly sixty percent (59.2%) had accepted extra work to support themselves or their whānau, even when it jeopardised their other responsibilities (e.g., completing their degrees). Over half (52.7%) of all students, and nearly two-thirds (64.4%) of PhD students surveyed, had held three or more employment agreements at a university in the last 12 months. Financial need (71.6%) was most frequently cited as an important factor in participants’ decisions to engage in precarious work, and over half (52.4%) of participants experienced a rise in their living costs due to working from home during the pandemic. Our report also adds further evidence of inequities present in the academic pipeline. Just one in ten Māori (10.8%) and one in thirteen Pasifika (7.7%) participants were PhD graduates, a smaller proportion than the nearly one-third (31.5%) of New Zealand European/Pākehā. Over two-thirds (66.8%) of international students indicated they were employed in the most insecure forms (Casual or fixed-term contracts of six months or less) of precarious work, compared with 60.5% of domestic students. Of those precarious workers completing a PhD, domestic students in our survey were far more likely to be receiving a stipend (73.9%) compared to international students (50%). Further, 63.2% of participants who were international students without a stipend reported that they lacked confidence in having sufficient ongoing academic work in the next 12 months. Instances of discrimination, bullying, and harassment were also reported by survey participants, with 33.7% citing that they had been impacted by such issues. Other workplace safety concerns were evident: nearly half of participants (45.7%) described their workloads as always or often unsustainable and negatively impacting their health and wellbeing. Meanwhile, one-quarter (23.9%) of precarious staff rated their current stress level as an eight, on a scale of zero (no stress) to ten (completely stressed). Two-thirds (66.3%) of participants were not confident they would receive adequate support from their employer in the event of a future crisis (e.g., a natural disaster or outbreak of infectious disease). On this basis, we encourage universities to do better for their casual and fixed-term employees through increasing job security, reducing inequities for Māori and Pasifika precarious staff, and improving conditions for postgraduate students, both domestic and international. In our final recommendations, we implore the government to work alongside universities to realise this change by investigating workloads, increasing, and rebalancing sector funding, and reinstating the postgraduate student allowance.
The Geographic Classification for Health: Methodology and classification report
(Otago University, 2021) Whitehead, Jesse; Davie, Gabrielle; de Graaf, Brandon; Crengle, Sue; Smith, Michelle; Lawrenson, Ross; Fearnley, Dave; Farrell, Noella; Nixon, Garry
The GCH is based on population and drive time data that was used in the development of the Urban Accessibility (UA) classification (Statistics New Zealand, 2020). The UA is in turn based on the Statistical Standard for Geographic Areas 2018 (SSGA18) which includes the urban rural 2018 (UR2018) classification (Statistics New Zealand, 2018). The authors of this report have applied a framework to the UA classification that considers a health services discourse to determine appropriate population and drive time thresholds. We have tested both the quantitative and ‘on-the-ground’ validity of the GCH, in partnership with the Ministry of Health’s National Rural Health Advisory Group (NRHAG). The GCH is comprised of five categories, two urban and three rural, that reflect degrees of reducing urban influence and increasing rurality. The GCH applies these categories to all of New Zealand’s Statistical Area 1s (SA1s, small statistical areas which are the output geography for population data) on a scale from ‘Urban 1’ to ‘Urban 2’ based on population size, and from “Rural 1’ to ‘Rural 3’ based on drive time to their closest major, large, medium, and small* (*As defined in the Statistical Standard for Geographic Areas 2018 (Statistics New Zealand, 2018)) urban areas. Like the UA, the GCH is based on population size and density, with drive time used to indicate increasing rurality. Unlike the UA, which is a generic classification, the population and drive time thresholds used in the GCH have been developed from a health perspective, in consultation with more than 300 individuals from 20 organisations. The nature of the functional relationships between urban areas and rural surrounds have also been considered through a health lens. In this paper we discuss concepts and issues with previous ‘generic’ urban-rural classifications being used in health research in Aotearoa New Zealand. We also describe the GCH methodology and classification, discuss limitations, and illustrate the GCH with maps.
How differing methods of ascribing ethnicity and socio-economic status affect risk estimates for hospitalisation with infectious disease
(Cambridge University Press (CUP), 2019) Hobbs, Mark R.; Atatoa Carr, Polly; Fa'alili-Fidow, Jacinta; Pillai, Avinesh; Morton, Susan M. B.; Grant, Cameron C.
Significant ethnic and socio-economic disparities exist in infectious diseases (IDs) rates in New Zealand, so accurate measures of these characteristics are required. This study compared methods of ascribing ethnicity and socio-economic status. Children in the Growing Up in New Zealand longitudinal cohort were ascribed to self-prioritised, total response and single-combined ethnic groups. Socio-economic status was measured using household income, and both census-derived and survey-derived deprivation indices. Rates of ID hospitalisation were compared using linked administrative data. Self-prioritised ethnicity was simplest to use. Total response accounted for mixed ethnicity and allowed overlap between groups. Single combined ethnicity required aggregation of small groups to maintain power but offered greater detail. Regardless of the method used, Māori and Pacific children, and children in the most socio-economically deprived households had a greater risk of ID hospitalisation. Risk differences between self-prioritised and total response methods were not significant for Māori and Pacific children but single-combined ethnicity revealed a diversity of risk within these groups. Household income was affected by non-random missing data. The census derived deprivation index offered a high level of completeness with some risk of multicollinearity and concerns regarding the ecological fallacy. The survey-derived index required extra questions but was acceptable to participants and provided individualised data. Based on these results, the use of single-combined ethnicity and an individualised survey-derived index of deprivation are recommended where sample size and data structure allow it.
Telomere length in early childhood is associated with sex and ethnicity
(Springer Nature, 2019) Ly, Kien; Walker, Caroline; Berry, Sarah; Snell, Russell; Marks, Emma; Thayer, Zaneta; Atatoa-Carr, Polly; Morton, Susan M. B.
Telomeres are repetitive DNA sequences at the end of chromosomes that function to protect chromosomes from degradation. Throughout the life course, telomere length decreases with age and is influenced by environmental factors and health conditions. This study aimed to determine the relative telomere lengths in a diverse cohort of about 4000 four-year-old children in New Zealand. Linear regression was used to investigate the relationship between telomere length, child gender, ethnicity, paternal age and deprivation. We observed substantial variation in telomere length according to sex and self-identified ethnicity. Telomere length was longer in females compared to males (coefficient of 0.042, 95% confidence interval (CI) 0.024–0.060). European children had shorter telomere than both the indigenous Māori (coefficient of 0.03, CI 0.007–0.055) and Pacific children (coefficient of 0.15, CI 0.12–0.18). The data suggest that telomere lengths are highly variable and variability between individuals arise from early age, influenced partly by sex and ethnicity. Longer telomeres in indigenous Māori and Pacific children may reflect the heritability of telomere length in genetically less complex populations. This study increases our understanding of telomere dynamics in young children since the majority of telomere studies are conducted in adults.
Critical reflection for researcher–community partnership effectiveness: The He Pikinga Waiora process evaluation tool guiding the implementation of chronic condition interventions in Indigenous communities
(CSIRO Publishing, 2019) Rarere, Moana; Oetzel, John G.; Masters-Awatere, Bridgette; Scott, Nina; Wihapi, Ray; Manuel, Carey; Gilbert, Rewa
Critically reflecting on researcher–community partnerships is a key component in implementing chronic condition interventions in Indigenous communities. This paper draws on the results and learnings from a process evaluation that measures how well two research–community partnerships have followed the He Pikinga Waiora (HPW) Implementation Framework while co-designing chronic condition interventions in primary care. The HPW framework is centred on Indigenous self-determination and knowledge surrounded by community engagement, cultural centredness, systems thinking and integrated knowledge translation. The evaluation included in-depth interviews and online surveys with 10 team members. The findings demonstrate that the HPW framework was followed well, with strengths particularly in community engagement and relationship building. Areas for improvement included systems thinking and integrated knowledge translation to support sustainability of the interventions. The need for partnerships to use process evaluation results to support critical reflection is asserted, which helps build strong trust and synergy, power sharing and effective and sustainable implementation practices. It is concluded that the HPW framework is well suited to evaluating implementation of health interventions in primary care as it assists in the facilitation of better collaboration between researchers and Indigenous communities, and encourages the implementation team to reflect on power and privilege.
Māori data governance model
(Te Kāhui Raraunga, 2023) Kukutai, Tahu; Campbell-Kamareira, Kyla; Mead, Aroha Te Pareake; Mikaere, Kirikowhai; Moses, Caleb; Whitehead, Jesse; Cormack, Donna
This report describes the Māori Data Governance Model that has been designed by Māori data experts for use across the Aotearoa New Zealand public service. Māori data is a taonga that requires culturally grounded models of protection and care. The Model provides guidance for the system-wide governance of Māori data, consistent with the Government’s responsibilities under te Tiriti o Waitangi. The Model is intended to assist all agencies to undertake Māori data governance in a way that is values-led, centred on Māori needs and priorities, and informed by research. This is important because existing government data processes and practices are failing to meet Māori informational needs. The Vision, Tuia te korowai o Hine-Raraunga – Data for self-determination, enables iwi, hapū and Māori organisations, businesses and communities to pursue their own goals for cultural, social, economic and environmental wellbeing. Eight Data Pou or pillars define critical areas of data governance and specify the actions that should be undertaken to realise six desired outcomes. The Model does not cover every element of data governance; instead, it focuses on key priorities and actions, against which agencies can assess their level of data maturity. The Model explicitly recognises the need for changes to system leadership, policies and legal settings so that Māori can exercise authority over Māori data to reduce unethical data use and strengthen outcomes for individuals, whānau and communities. The report also identifies the need for strategic investment in a Mana Motuhake data system that sits outside of the public sector to ensure iwi and hapū sovereignty over iwi and hapū data.
The estimation and interpretation of coefficients in panel gravity models of migration
(Springer Nature, 2019) Cameron, Michael Patrick; Poot, Jacques
In this paper, we demonstrate that the conventional ordinary least squares and fixed effects estimators of classical gravity models of migration are biased, and that the interpretation of coefficients in the fixed effects gravity model is typically incorrect. We then present a best linear unbiased (BLU) estimator for gravity models of migration, and illustrate its application with inter-regional data from New Zealand. The results demonstrate that the standard ordinary least squares and fixed effect models lead to biased coefficients on population. Alternative estimates that are BLU are provided for a data generating process with fixed origin and destination effects. The coefficients on population must be interpreted in this model as growth rate effects rather than level effects. Our findings also have significance for other types of spatial interaction modelling.
He Pikinga Waiora Kimi Ora lifestyle programme: Case study of a successful community-based indigenous diabetes intervention
(Pasifika Medical Association Group (PMAG), 2021) Masters-Awatere, Bridgette; Cassim, Shemana; Tamatea, Jade; Scott, Nina; Simpson, Chae; Paekau, Cherie
AIM: To co-design and implement a whānau-centred, community-based lifestyle programme (Kimi Ora) intended to ensure no worsening of HbA1c and to improve wellbeing for Māori whānau and communities with diabetes or pre-diabetes. METHODS: Māori healthcare providers, community members, research advisors and wider stakeholders used a co-design process underpinned by He Pikinga Waiora to collaboratively develop and implement Kimi Ora Control group comparisons and participants were recruited from Te Kōhao Health. Multi-method monitoring and collection captured individual, whānau and community data. RESULTS: Kimi Ora was run in two communities in Aotearoa New Zealand. In total, there were 35 participants who took part in an eight-week programme offered five times alongside a comparison group comprising 21 participants. Kimi Ora resulted in significant improvements on all biomedical measures compared to baseline, and participants had gains relative to the comparison group for variables including weight, BMI, blood pressure and waist measurement. Of particular note was the 100% retention rate and sustained community support for Kimi Ora. CONCLUSIONS: Outcomes from Kimi Ora demonstrate this programme, which was actively tailored for and worked with Māori communities in a responsive and flexible manner, resulted in successful biomedical outcomes, high engagement and high retention.
The alienation of the Opuatia block: A GIS case study report written for Counting our Tūpuna
(Te Ngira: Institute for Population Research, the University of Waikato, 2021) Whitehead, Jesse
This report provides an analysis and visualisation of the fragmentation and alienation of the Opuatia block (Opuatia hereafter), as well as changes in its ownership and geographic structure since 1866. The three main aims are to quantify the amount of Opuatia remaining in Ngāti Tiipa ownership at the end of each decade, identifying critical moments in time, and highlighting the processes through which Opuatia was alienated and fragmented. These questions are addressed through a bespoke method that was developed to link data from several sources. These include (but are not limited to) historic records of land alienation, held by the Māori Land Court, and geospatial information available through Land Information New Zealand. The key findings show that approximately 94% of the original Opuatia has been alienated, with only small parcles of land remaining in Ngāti Tiipa ownership. The late 1890s and early 1900s were a criticial period where over 80% of alienations were carried out. The results inidcate that the Crown was a key driver of this process, directly alienating more than 18,000 acres from Opuatia, much of which was taken on a single day in 1896. Individual settlers were responsible for most other alienations, and some of the same names appear several times in the historical record as settler families alienated clusters of land to build up significant stakes in the area. Finally, another result of this report is the method itself, which outlines an approach for tracing a defined block of land through the Native Land Court and linking this information to geospatial datasets. The limitations of this report include the poor interoperability of key data sources, and the barriers that this presents to other hapū or organisations who may want to replicate this work. A more detailed investigation of archival records is required to examine the specific reasons behind why each parent block, and the subdivisions with them, was alienated from Ngāti Tiipa ownership.
Protecting hapū data privacy: A Ngāti Tiipa case study of technology considerations
(Te Ngira Institute for Population Research, 2025-02-11) Clark, Vanessa; Teague, Vanessa
This brief is a part of a series, produced for the Tikanga in Technology (TiNT) research programme, that provides a hapū perspective on data sovereignty, data governance, and data privacy. In this brief we focus on the Ngāti Tiipa ‘layer cake’ technology approach and assess it against the values of the TiNT Māori Data Privacy Framework. This brief should be read in conjunction with TiNT Brief #3 The Māori Data Privacy Framework: How useful is it for hapū?
Hapū data sovereignty: Tips for getting started
(Te Ngira Institute for Population Research, 2025-02-11) Clark, Vanessa; Kukutai, Tahu; Kani, Heeni; Pēpi Tarapa-Dewes, Ella; Teague, Vanessa
This brief is a part of a series, produced for the Tikanga in Technology (TiNT) research programme, that provides a hapū perspective on data sovereignty, data governance, and data privacy. The purpose is to provide practical advice for individuals, whānau, marae and hapū who are embarking on their own hapū data sovereignty kaupapa, with a particular focus on whakapapa data.
The Māori Data Privacy Framework: How useful is it for hapū?
(Te Ngira Institute for Population Research, 2025-02-11) Clark, Vanessa; Kukutai, Tahu; Teague, Vanessa; Kani, Heeni; Pēpi Tarapa-Dewes, Ella
This brief is a part of a series, produced for the Tikanga in Technology (TiNT) research programme, that provides a hapū perspective on data sovereignty, data governance, and data privacy. In this brief we focus on the Māori Data Privacy Framework developed by the TiNT team and assess how useful it is for hapū. To do so, we draw on a case study with Ngāti Tiipa, one of the 33 iwi and hapū of the Waikato confederation (Kukutai, Whitehead & Kani, 2022). This brief should be read in conjunction with TiNT Brief #2 Protecting hapū data privacy: A Ngāti Tiipa case study of technology considerations.
Māori data sovereignty and privacy
(Te Ngira Institute for Population Research, 2023) Kukutai, Tahu; Cassim, Shemana; Clark, Vanessa; Jones, Nicholas; Mika, Jason; Morar, Rhianna; Muru-Lanning, Marama; Pouwhare, Robert; Teague, Vanessa; Tuffery Huria, Lynell; Watts, David; Sterling, Rogena
Privacy is a fundamental human right. One of its most important aspects is information privacy – providing individuals with control over the way in which their personal data is collected, used, disclosed and otherwise handled. Existing information privacy regulation neither recognises nor protects the collective privacy rights of Indigenous peoples. This paper explores Indigenous data privacy, and the challenges and opportunities, in the context of Aotearoa. It has two aims: to identify gaps in existing data privacy approaches with regards to Indigenous data, and to provide a foundation for progressing alternative privacy paradigms. We argue that while personal data protection is necessary, it is insufficient to meet the needs of Māori and Aotearoa more broadly. In so doing, we draw on three areas of research: Indigenous and Māori data sovereignty; data and information privacy, including collective privacy; and Māori and Indigenous privacy perspectives. We examine key features of the Aotearoa privacy context – including the Privacy Act 2020 (NZ) – and consider the implications of te Tiriti o Waitangi and tikanga Māori for alternative privacy approaches. Future options, including legal and extra-legal measures, are proposed.
Te Pūtahitanga: A Tiriti-led science-policy approach for Aotearoa New Zealand
(Ngā Pae o te Māramatanga, 2021-04-28) Kukutai, Tahu; McIntosh, T; Durie, M; Boulton, A; Foster, M; Hutchings, J; Mark-Shadbolt, M; Moewaka Barnes, H; Moko-Mead, TT; Paine, S-J; Pitama, S; Ruru, J
This paper examines the interface between science and policymaking and calls for a policy approach that is enabled by, and responsive to, Te Tiriti o Waitangi and Mātauranga Māori. For a science sector to have its greatest reach and impact for all citizens, it must demonstrate relevance, accessibility and inclusion. In Aotearoa, there has been concern about the exclusion of Māori and Pacific expertise from science advice and key decision-making roles. Te Tiriti offers a powerful framework for connecting systems and communities of knowledge in ways that are mutually beneficial and future focused.
Prevalence of gestational diabetes in the Waikato region of New Zealand
(Wiley, 2022) Chepulis, Lynne Merran; Morison, Brittany; Lawrenson, Ross; Paul, Ryan G.
Gestational diabetes mellitus (GDM) during pregnancy is associated with health complications for both mother and infant, but patient numbers in the Waikato District Health Board region of New Zealand have not been well characterised. This study reviewed the full 2018 cohort of Waikato District Health Board hospital births (n = 4970) to report on GDM prevalence by ethnicity and age. The overall prevalence of GDM was 5.7% and is more likely to affect Asian, Pacific and Māori women as well as those of advanced maternal age.
The COVID-19 domestic vaccine pass: Implications for Māori
(National Institute of Demographic and Economic Analysis, 2021-11-30) Kukutai, Tahu; Clark, Vanessa; Mika, Jason; Muru-Lanning, Marama; Pouwhare, Robert; Sterling, Rogena; Teague, Vanessa; Watts, David; Cassim, Shemana
The New Zealand government has introduced a COVID-19 domestic vaccine pass to be used in conjunction with the COVID-19 Protection Framework. The Framework is likely to be activated soon after Cabinet meets on 29 November 2021. The pass will be necessary to access places and events that require proof of vaccination under the Framework. This brief does not argue for or against the introduction of a domestic vaccine pass, but rather discusses key issues that it raises for Māori, and suggests actions to address them. We see four key issues: • the lack of Māori involvement, as a Tiriti partner, on either the design or implementation of the COVID-19 domestic vaccine pass; • disproportionate restriction on Māori mobility due to lower Māori vaccination rates; • privacy and data security concerns; • uneven implementation that could increase discrimination against Māori and other groups considered to pose a risk to others’ safety. To respond to these issues we recommend that the implementation of the pass be designed in partnership with Māori and comply with Māori data sovereignty requirements. As Tiriti partners, Māori should expect that the pass will keep their communities safe, while providing opportunities to enact manaakitanga in the matrix of care, and the mana to manage their own affairs.
Initial report of the 2018 Census external data quality panel
(Stats NZ, 2019) Bedford, Richard; Reid, Alison; Milne, Barry; Cormack, Donna; Cope, Ian; Cook, Len; Kukutai, Tahu; Lumley, Thomas
One in six New Zealand residents did not complete a questionnaire for the 2018 New Zealand Census of Population and Dwellings. This was largely due to operational failures that made it difficult for a significant number of individuals and households to access census questionnaires, and to fulfill their statutory duty to participate.
Barriers to diabetes self-management in a subset of New Zealand adults with Type 2 diabetes and poor glycaemic control
(Hindawi Ltd, 2021) Chepulis, Lynne Merran; Morison, Brittany; Cassim, Shemana; Norman, Kimberley; Keenan, Rawiri; Paul, Ryan G.; Lawrenson, Ross
Background. Despite the fact that there is an increasingly effective armoury of medications to treat diabetes, many people continue to have substantially elevated blood glucose levels. The purpose of this study was to explore what the barriers to diabetes management are in a cohort of people with diabetes and poor glycaemic control. Methods. Qualitative semistructured interviews were carried out with 10 people with diabetes who had known diabetes and a recent HbA1c of >11.3% (100 mmol/mol) to explore their experiences of barriers to diabetes self-management and glycaemic control. Results. Barriers to diabetes management were based around two key themes: biopsychosocial factors and knowledge about diabetes. Specifically, financial concerns, social stigma, medication side effects, and cognitive impairment due to hyperglycaemia were commonly reported as barriers to medication use. Other barriers included a lack of knowledge about their own condition, poor relationships with healthcare professionals, and a lack of relevant resources to support diet and weight loss. Conclusion. People with diabetes with poor glycaemic control experience many of the same barriers as those reported elsewhere, but also experience issues specifically related to their severe hyperglycaemia. Management of diabetes could be improved via the increased use of patient education and availability of locally relevant resources.
Will access to COVID-19 vaccine in Aotearoa be equitable for priority populations?
(New Zealand Medical Association, 2021) Whitehead, Jesse; Scott, Nina; Atatoa-Carr, Polly; Lawrenson, Ross
AIM: This research examines the equity implications of the geographic distribution of COVID-19 vaccine delivery locations in Aotearoa New Zealand under five potential scenarios: (1) stadium mega-clinics; (2) Community Based Assessment Centres; (3) GP clinics; (4) community pharmacies; and (5) schools. METHOD: We mapped the distribution of Aotearoa New Zealand’s population and the location of potential vaccine delivery facilities under each scenario. Geostatistical techniques identified population clusters for Māori, Pacific peoples and people aged 65 years and over. We calculated travel times between all potential facilities and each Statistical Area 1 in the country. Descriptive statistics indicate the size and proportion of populations that could face significant travel barriers when accessing COVID-19 vaccinations. RESULTS: Several areas with significant travel times to potential vaccine delivery sites were also communities identified as having an elevated risk of COVID-19 disease and severity. All potential scenarios for vaccine delivery, with the exception of schools, resulted in travel barriers for a substantial proportion of the population. Overall, these travel time barriers disproportionately burden Māori, older communities and people living in areas of high socioeconomic deprivation. CONCLUSION: The equitable delivery of COVID-19 vaccines is key to an elimination strategy. However, if current health services and facilities are used without well-designed and supported outreach services, then access to vaccination is likely to be inequitable.
“We’re trying to heal, you know?” A mixed methods analysis of the spatial equity of General Practitioner services in the Waikato District Health Board region
(New Zealand Demographic Society, 2020) Whitehead, Jesse; Pearson, Amber L.; Lawrenson, Ross; Atatoa-Carr, Polly
Inequitable access to health services can cause and exacerbate inequities in health outcomes and should therefore be monitored regularly to ensure that service distributions match population needs. Health service accessibility includes several factors and can be monitored using both quantitative and qualitative methods. We present an exploratory analysis of the spatial equity of general practice services in the Waikato District Health Board region using a mixed methods approach. Geographic Information Systems are used to assess the spatial accessibility of GP services, and in-depth qualitative interviews provide a better understanding of not only where inequities exist, but why they occur.

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