Background: Eliminating indigenous and ethnic health inequities requires addressing the determinants of health inequities which includes institutionalised racism, and ensuring a health care system that delivers appropriate and equitable care. There is growing recognition of the importance of cultural competency and cultural safety at both individual health practitioner and organisational levels to achieve equitable health care. Some jurisdictions have included cultural competency in health professional licensing legislation, health professional accreditation standards, and pre-service and in-service training programmes. However, there are mixed definitions and understandings of cultural competency and cultural safety, and how best to achieve them. Methods: A literature review of 59 international articles on the definitions of cultural competency and cultural safety was undertaken. Findings were contextualised to the cultural competency legislation, statements and initiatives present within Aotearoa New Zealand, a national Symposium on Cultural Competence and Māori Health, convened by the Medical Council of New Zealand and Te Ohu Rata o Aotearoa-Māori Medical Practitioners Association (Te ORA) and consultation with Māori medical practitioners via Te ORA. Results: Health practitioners, healthcare organisations and health systems need to be engaged in working towards cultural safety and critical consciousness. To do this, they must be prepared to critique the 'taken for granted' power structures and be prepared to challenge their own culture and cultural systems rather than prioritise becoming 'competent' in the cultures of others. The objective of cultural safety activities also needs to be clearly linked to achieving health equity. Healthcare organisations and authorities need to be held accountable for providing culturally safe care, as defined by patients and their communities, and as measured through progress towards achieving health equity. Conclusions: A move to cultural safety rather than cultural competency is recommended. We propose a definition for cultural safety that we believe to be more fit for purpose in achieving health equity, and clarify the essential principles and practical steps to operationalise this approach in healthcare organisations and workforce development. The unintended consequences of a narrow or limited understanding of cultural competency are discussed, along with recommendations for how a broader conceptualisation of these terms is important.

Aotearoa/New Zealand (Aotearoa/NZ) and the United States (U.S.) suffer inequities in health outcomes by race/ethnicity and socioeconomic status. This paper compares both countries' approaches to health equity to inform policy efforts. We developed a conceptual model that highlights how government and private policies influence health equity by impacting the healthcare system (access to care, structure and quality of care, payment of care), and integration of healthcare system with social services. These policies are shaped by each country's culture, history, and values. Aotearoa/NZ and U.S. share strong aspirational goals for health equity in their national health strategy documents. Unfortunately, implemented policies are frequently not explicit in how they address health inequities, and often do not align with evidence-based approaches known to improve equity. To authentically commit to achieving health equity, nations should: 1) Explicitly design quality of care and payment policies to achieve equity, holding the healthcare system accountable through public monitoring and evaluation, and supporting with adequate resources; 2) Address all determinants of health for individuals and communities with coordinated approaches, integrated funding streams, and shared accountability metrics across health and social sectors; 3) Share power authentically with racial/ethnic minorities and promote indigenous peoples' self-determination; 4) Have free, frank, and fearless discussions about impacts of structural racism, colonialism, and white privilege, ensuring that policies and programs explicitly address root causes.

Permanent hypopituitarism is rare after both inflicted and accidental structural TBI in early childhood. Precocious puberty was the only pituitary hormone abnormality found, but the prevalence did not exceed that of the normal population.

BackgroundProgress Tests (PTs) draw on a common question bank to assess all students in a programme against graduate outcomes. Theoretically PTs drive deep approaches to learning and reduce assessment-related stress. In 2013, PTs were introduced to two year groups of medical students (Years 2 and 4), whereas students in Years 3 and 5 were taking traditional high-stakes assessments. Staged introduction of PTs into our medical curriculum provided a time-limited opportunity for a comparative study. The main purpose of the current study was to compare the impact of PTs on undergraduate medical students’ approaches to learning and perceived stress with that of traditional high-stakes assessments. We also aimed to investigate the associations between approaches to learning, stress and PT scores.MethodsUndergraduate medical students (N = 333 and N = 298 at Time 1 and Time 2 respectively) answered the Revised Study Process Questionnaire (R-SPQ-2F) and the Perceived Stress Scale (PSS) at two time points to evaluate change over time. The R-SPQ-2F generated a surface approach and a deep approach score; the PSS generated an overall perceived stress score.ResultsWe found no significant differences between the two groups in approaches to learning at either time point, and no significant changes in approaches to learning over time in either cohort. Levels of stress increased significantly at the end of the year (Time 2) for students in the traditional assessment cohort, but not in the PT cohort. In the PT cohort, surface approach to learning, but not stress, was a significant negative predictor of students’ PT scores.ConclusionsWhile confirming an association between surface approaches to learning and lower PT scores, we failed to demonstrate an effect of PTs on approaches to learning. However, a reduction in assessment-associated stress is an important finding.

The determinants of health inequities between Indigenous and non-Indigenous populations include factors amenable to medical education’s influence—for example, the competence of the medical workforce to provide effective and equitable care to Indigenous populations. Medical education institutions have an important role to play in eliminating these inequities. However, there is evidence that medical education is not adequately fulfilling this role and, in fact, may be complicit in perpetuating inequities. This article seeks to examine the factors underpinning medical education’s role in Indigenous health inequity, to inform interventions to address these factors. The authors developed a consensus statement that synthesizes evidence from research, evaluation, and the collective experience of an international research collaboration including experts in Indigenous medical education. The statement describes foundational processes that limit Indigenous health development in medical education and articulates key principles that can be applied at multiple levels to advance Indigenous health equity. The authors recognize colonization, racism, and privilege as fundamental determinants of Indigenous health that are also deeply embedded in Western medical education. To contribute effectively to Indigenous health development, medical education institutions must engage in decolonization processes and address racism and privilege at curricular and institutional levels. Indigenous health curricula must be formalized and comprehensive, and must be consistently reinforced in all educational environments. Institutions’ responsibilities extend to advocacy for health system and broader societal reform to reduce and eliminate health inequities. These activities must be adequately resourced and underpinned by investment in infrastructure and Indigenous leadership.

The concept of cultural competence has become reified by inclusion as an accreditation standard in the US and Canada, in New Zealand it is demanded through an Act of Parliament, and it pervades discussion in Australian medical education discourse. However, there is evidence that medical graduates feel poorly prepared to deliver cross-cultural care (Weissman et al. in J Am Med Assoc 294(9):1058-1067, 2005) and many commentators have questioned the effectiveness of cultural competence curricula. In this paper we apply Hafferty's taxonomy of curricula, the formal, informal and hidden curriculum (Hafferty in Acad Med 73(4):403-407, 1998), to cultural competence. Using an example across each of these curricular domains, we highlight the need for curricular congruence to support cultural competence development among learners. We argue that much of the focus on cultural competence has been in the realm of formal curricula, with existing informal and hidden curricula which may be at odds with the formal curriculum. The focus of the formal, informal and hidden curriculum, we contend, should be to address disparities in health care outcomes. In conclusion, we suggest that without congruence between formal, informal and hidden curricula, approaches to addressing disparity in health care outcomes in medical education may continue to represent reform without change.

Climate change poses a serious threat to the health and well-being of Indigenous peoples around the world. Despite living in diverse contexts, Indigenous peoples face a number of common challenges. Disproportionate threats from climate change exist due to a range of factors including unique relationships with the natural environment, socioeconomic deprivation, a greater existing burden of disease, poorer access to and quality of health care, and political marginalization. Responses to climate change at global, national, and local levels also threaten Indigenous people’s rights. While climate action presents many opportunities to improve health and reduce inequities, there is also significant potential for climate mitigation and adaptation policies to inflict harm on Indigenous peoples. An important aspect of this is the impact on traditional lands, which are acknowledged as a fundamental determinant of Indigenous health and well-being. This article seeks to elucidate the relationships between climate change and Indigenous health and to inform health promotion solutions to achieve climate justice for Indigenous peoples. The underpinning analysis is founded on a Kaupapa Māori positioning, which seeks transformative change and involves critiquing Western knowledges and structures that undermine Indigenous rights. A central theme is that anthropogenic climate change is intimately connected to the ideologies, systems and practices of colonialism, and that the impacts on Indigenous peoples can be conceptualized as an intensification of the process of colonization. It is not possible to understand and address climate-related health impacts for Indigenous peoples without examining this broader context of colonial oppression, marginalization and dispossession. The challenge for health promotion is to engage in a process of decolonization. This involves deconstructing its own systems and practices to avoid reinforcing colonialism and perpetuating inequities. It also requires health promotion practitioners to support Indigenous self-determination and recognize Indigenous knowledges as a critical foundation for climate change and health solutions.

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