Evidence Centre Seminar: February 2023

GAIL PACHECO: Kia ora.  Both myself and Nadia will give the presentation today.  But just some context to begin with.  We are part of a much larger team where we are using both quantitative and qualitative methods.  It's part of a funded programme of research for the Health Research Council over the last three and a bit years, as well as funding from the Children and Families Research Fund at MSD and the Health Promotion Agency as well.  So it's part of a much bigger body of work and so, if there is any kind of additional questions, you know, feel free to drop us a line later and there may be things we have also done but just not going to cover today.

What we are going to focus on is three forms of healthcare service uptake, which we have covered over this programme.  Immunisation, GP Services - both the use and experience of GP Services, and dental checks.  But in saying that we are covering those three, we are primarily focusing more on immunisation in part, because there has been, one, lots of interest in that space and lots of end users and stakeholders wanting to know more about that space and that's also where a lot of the data was as well, in terms of data availability.

I'll go first and I'll go through some of the key findings from the quantitative work and then Nadia will talk through her beautiful results in the qualitative work, and then we will join them together a little bit at the end to come and talk through what are some of the practical and policy implications of these findings to kind of bring the academic work into a bit more of a reality lens. 

I think this motivation slide here is probably known to everyone, but I'll just go through it anyway.

Current policy indicates there should be equitable access by ethnicity for these three types of healthcare services.  At least in terms of direct costs.  We have free doctor visits up to the age 14, we've got free vaccines under the National Immunisation Schedule and, of course, free dental care until Year 8 of school. 

But despite these free direct costs, ethnic gaps, we know, persist.  Particularly for Māori and Pacific peoples.  And we also know that if there is underutilisation of these services, then there's going to be future health risks.  There are adverse health outcomes in the long run and there's studies that have shown, for instance, that there's an increase in infectious disease hospitalisations as a result of delayed immunisation uptake. 

So, some of the quantitative work we've done -- I'll present two kind of studies we've done in this space.  So, in the first study, it’s a decomposition analysis and feel free to pose any questions if I use too much economics jargon.  I should say we are from two different disciplines, but that's the beauty of this work that we have managed to kind of complementary put together economics and health in both quantitative and qualitative together to kind of get some end results in terms of policy implications.

Excuse me, I should acknowledge my co-authors in this study.  Terryann Clark, Kaberi Dasgupta, Sonya Lueka and Alexander Plum. And I should also acknowledge the children and families who are part of the Growing Up in New Zealand study, because we use that wonderful data as Valmai alluded to.

So in this particular study, our main aim was to try and understand exactly what are those ethnic differences, in terms of life course trajectories.  So not just at a particular point in time where we get data from one cross section, but what happens to that life course.  What happens, kind of, antenatally when there's a pregnancy, what are the kind of plans in terms of immunisation.  What happens at six weeks, what happens at a year; what happens at 15 months, two years, four years - and follow that life course trajectory. 

And then we wanted to, not just exam the ethnic differences that change over their life course, but try and quantify what was the contribution of different factors, and does that change over the life course.  Does somethings that are more important at six weeks become less important later on and vice versa.  So, we used data from the Growing Up in New Zealand birth cohort study, so this is information on more than 6,000 New Zealand children and their families and it surveys quite a broad range of information about the child, about the health of the family, education of the parents, the neighbourhood, the environment, as well as a lot of cultural questions about identity, and we use, for this particular study, four data waves.  There have been more since then, that Growing Up has collected, but at the time we did this work, there were four data waves: ante natal, at nine months, two years and four years old.  So there is a DCW0, 1, 2, 4, and I just point that terminology out because you might see that in later slides.  And here's just a kind of snap shot of a few of the outcomes of interest.  I haven't put them all in here, there's links at the end of the presentation to the actual papers we've written, so you can go and look at them, but here we've got a mixture of immunisation variables, dental visit variables as well as some around GP use, such as "use of" as well as "experience with".

For immunisation we've got your antenatal intention to fully immunise, whether you did all your first-year immunisations for that child on time, and "on time" is within one month of the due date, whether they received all their 15-month immunisations.  For dental visits we look at whether they've had a dental visit by aged two and aged four, and in the space of doctor visits and GP use et cetera, we look at whether you got your first choice for lead maternity carer as well as had you seen a GP or some health professional since you were pregnant, and then whether you were satisfied with your GP practice at the time the child was aged nine months.  And what's quite interesting, what we have highlighted here in orange is the lowest means.  We have done it by three ethnicities here (there is Asian as well in the report) New Zealand/European, Māori and Pacific peoples, and what's interesting, particularly in the immunisation space, is that New Zealand/European actually have the lowest intention to fully immunise, so 75% relative to 82% for Māori and 94% for Pacific peoples.  But when it comes to the actual immunisation, then Māori have the lowest all first-year immunisations on time and lowest 15-month immunisations on time.  I should note as context, so this is using Growing Up data, and the time these children were these particular ages that we are covering, is pre-COVID, so a different context at that time. 

Dental visits, it's a mixture of Māori and Pacific peoples who have the lowest dental visits, and for choice of LMC, Pasifika have the least likelihood of getting their first choice of lead maternity carer and Māori tend to have the lowest likelihood of being satisfied with their GP practice, and we know that satisfaction leads to less likelihood to uptake other healthcare services.

In terms of the explanatory data we used,  I have kind of put them into categories here.  For instance, we have got quite a wide range of mother and child characteristics: whether this was the first child, what was the mother's age, what was disability status, et cetera.  And then we have a range of socioeconomic variables, which we know are very important, like the employment status of the mother, and the father if we had the data available, educational attainment, household income, et cetera.  For household, whether you are in a sole parent or whether you have a partner, as an example.  And then the last two categories are probably ones that are quite unique in some ways to the Growing Up Survey and you don't tend to get in a lot of other surveys: so mobility, so transport availability, if you had access to personal transport, as well as the number of times you had moved residence in the last - I can't actually quite remember - in the last year or the last three years.  As well as other social aspects, so one, whether you had perceived to be discriminated against in the health system, whether you had been discouraged from immunising, and it was also broken down by who discouraged you, whether it was your family, your friends, whether it was health practitioners, whether it was the media, et cetera, and the flip side, whether you were encouraged to immunise.  So, as you'll see soon, some of those social aspects were really important in determining healthcare service uptake.

Very quickly, the method is a decomposition, which we used a Fairlie decomposition, and all that does is it takes those co-variants that I just described and then tries to quantify how they are associated with ethnic differences in uptake of those various outcomes, whether it's immunisation, dental care or the GP use and experience, and we do comparisons with New Zealand/European.  The other thing it does, not just quantify how much each of those things matter, but it also splits it up into how much of those differences can be explained by those co-variants and how much is left unexplained, which is quite important because that means there is something else we should be looking for if some of the ethnic differences aren't explained by those variables that we just talked through. 

So if you want to look at all the tables and the numbers and the coefficients and marginal effects and all of those sorts of things, have a look at the report, I have just put some of the key findings here in the slide; I will just go through a few of them.

First off, there are several household and individual predictors where the association is time-variant.  What we mean here is that, for instance, I will use the example of socioeconomic status.  It appears socioeconomic status is highly relevant for timely immunisations in the first year, but then it actually becomes statistically insignificant at later immunisation events.  It shows that there isn't a set of factors that necessarily impact each point in time, they change over the life course.

The second point is around, again, timely immunisation, and what we found, that a large proportion of the New Zealand/European-Māori gap in timely immunisation was associated with household characteristics such as single-parent household or size of household.  So what you can think about here is maybe with these kind of characteristics you're juggling a lot of things and getting to timely immunisation events becomes harder to do when you've got a lot more to juggle as a single-parent household or with many children in the household. 

Access to transport and less frequent residential movements were also linked to a number of the healthcare uptake outcomes, as well as employment/education, which often signals lack of choice, potentially.

Now, as I kind of alluded to earlier, social factors played a really key role and it was the largest contributor to the New Zealand/European-Māori difference in GP satisfaction at nine months, particularly whether you were discouraged from immunisation when you were pregnant and also, on the flip side, whether you were encouraged, and when we broke it down, if I remember correctly, it was discouragement from family and friends in terms of source.  Also important was whether you had perceived to have ethnically motivated discrimination by a health professional, this lowered your likelihood of achieving your first choice lead maternity carer and it also reduced your satisfaction level with GPs.

There were some ethnic gaps in this analysis that couldn't be explained despite all these different variables we threw into the model, which means there's more research to do in that space, and the two that couldn’t be, or had high levels of unexplained, were why Pacific mothers, in particular, were less likely to achieve their first-choice LMC, and some of the dental outcomes had a large proportion that were still unexplained as to why there was lower uptake of dental visits by Māori and Pacific.

So that one was looking at a decomposition, and the next study in the quantitative space, before I pass on to my qualitative colleague, we focused in on just immunisation, and here my co-authors are Kabir Dasgupta and Alexander Plum.  And what we really wanted to understand in this study, and it's a very short study but I think really important, some interesting results from it, we want to understand the dependence levels; essentially, how much does immunising at a prior schedule influence your likelihood of vaccinating in the following schedule, so what's that probability difference, if you go to one immunisation event how much more likely are you to go to the next?  And for that we used, specifically, the immunisation data from the Growing Up Study at six weeks, three months, five months, 15 months and 48 months, so quite a few time points.  And our method is this dynamic random effects probit model which I won't go into, except to point out that there's many things that can influence your longitudinal pattern of immunising.  It could be influenced by your first response, your initial response to immunising is a key factor.  It could also be influenced by just your general behavioural effect from one to the next.  And it could also be just unobserved characteristics that constantly influence all immunisation events.  What this particular model does is it tries to hone in on that second one, it accounts for the initial response, it accounts for the unobserved characteristics, and we're trying to hone in on what's left over, what's the genuine behavioural effect of going to the immunisation appointment on your next immunisation appointment?

Very quickly, a transition matrix here, which shows, for instance, your past immunisation on the left-hand side, and on the top, your current immunisation.  So for instance, if you said no in terms of you didn't immunise at the last event, at t - 1,  then 71% of that group were also likely to not immunise at t.  Likewise, if I go to the bottom right corner, if you did immunise, you were yes at t - 1, so yes at the last event, then 95% of that group were yes at the next event.  So that kind of shows there is some dependence, there is some link, what you did at the last event could influence your future behaviour.  This is just raw descriptives.

And here are the main results; the tables, like the other paper, are in the paper.  But the key result is that there is really strong state dependence in child immunisation.  So what that means is, if you immunise at one event, you are 21 percentage points more likely to immunise at the next event, so going into one had a strong impact on your likelihood to go to the next one.   And what I find also interesting here is this effect was exacerbated if you were actually discouraged from having your child immunised in the antenatal period, so if you were discouraged but you somehow went to an immunisation event, that actually had a bigger dependence and so you were even more likely than 21 percentage points to go to following events.  So getting the discouraged people into the immunisation schedule can have a big impact and it can have a lasting impact, a long-term impact, and similarly, that state dependence was also stronger for Māori.  This is where I then pass on to my colleague, Nadia, who is going to talk through some of the qualitative aspects of this study, and then we will join together at the end.

NADIA CHARANIA: Thank you so much and thank you again for the opportunity to speak to you all today.  So, as Gail mentioned, I will be talking through some of the qualitative findings from this piece of research.

So firstly, I also wanted to acknowledge this wonderful qualitative team,  I am presenting on behalf of them, and I also wanted to acknowledge all the participants that contributed their time and ideas for this project, and the members of the advisory group that were really helpful as we developed the study. 

The research aim for this one was to explore the "why" behind the patterns that we were seeing, and I think it's actually really great that we bring qual and quant together, because you will kind of see some stories behind some of the numbers that Gail just went through. 

In the study, we specifically wanted to look at the perceptions and experiences amongst ethnically diverse caregivers.  We used a qualitative description methodology, and it was informed by kaupapa Māori and talanoa principles because we were really keen to ensure that the processes that we used in this research were culturally appropriate for Māori and Pacific.  So, as I said, we focused on caregivers of young children, and we also focused on the same three healthcare services, so immunisations, GP visits and dental checks.  We conducted semi-structured interviews and focus groups, mostly around Northland and Auckland, and in terms of data analysis, we used the six phases of reflexive thematic analysis according the Braun and Clarke.  What was really amazing about this project was our team was linguistically and culturally matched as best as we could to the actual groups and we hoped that this created a comfortable space for caregivers to really share their experiences with us.

So we ended up having 145 caregivers participate in this, which is amazing for a qualitative project, and what was even better was that we had over-representation from Māori.  So, as you can see there, 83 of our caregivers identified as being Māori, most of them were female, and another interesting point, which I'll tie in with some of the results we'll talk about later, about a third of them were born overseas so we do have some interesting experiences from a migrant point of view. 

Among the caregivers that participated in the study, the majority were actually enrolled in GP services and were fully vaccinated so, despite out best efforts to get the hard to reach population, it does indicate that there is some form of engagement amongst the caregivers that we spoke to, but this we saw as a real strength because they were able to speak to their experiences when they accessed services for their children.

So I'll go through the results.  We ended up constructing five themes: hierarchies of knowledge and trust; relational versus transactional health encounters; bad mother vibe; the "slow burn" of waiting; and navigating complexity.  In the next few slides I will spend a little bit more time kind of describing what each of these themes meant.

So in terms of hierarchies of knowledge and trust, the caregivers talked about various sources that they went to for information and support, and they trusted these sources to varying degrees.  Now, while they did talk about, specifically amongst Asian backgrounds, that they did trust healthcare professionals and their points of view, it was really interesting how they talked a lot about how they had "instincts" like their parents and they knew their child the best and they really wanted healthcare professionals to kind of work with them when they were coming up with a treatment plan for their child.  They also talked about resorting to parents that were friends and other family members, and so we called this their informal "parental network", and these are really important sources of information for them, and in some cases it influenced their health seeking behaviour.  So if they talked to friends and family and they were like, "Oh, don't worry about going to the doctors", then that could sometimes influence them seeking healthcare for their child.  And as we can see here in the quote, they say:   

"The parent network provides you with more information sometimes than the midwife.  Experienced mums."

So they really look to people who had children already and they could speak from those experiences.

Caregivers with Indian, Pacific, Chinese and Māori, so basically non-European ethnic backgrounds, they talked about how they did look to traditional healers and medicines, particularly if their child was not in a critical condition.  I just wanted to focus a little bit on Māori in particular because, as I said, we did have an over-representation of Māori in this sample, but it's also really important that we don't kind of group everyone in together, and there are colonial issues that come into play, and we really found that in this study. 

So Māori caregivers were generally less trusting of healthcare professionals, and it was really interesting that they talked about using traditional knowledges and practices as a way to kind of reassure them and provide them comfort and provide a space for them to actively be involved in their child's care.  And what was unfortunate was that, in some cases, they were criticised or made to feel ashamed about using these practices in tandem with Western practices.   And so some Māori caregivers spoke about how they resisted this and they exerted their rangatiratanga, or self-determination, and while this could be perceived as them being aggressive or resistant, they wanted those actions to be perceived as them being fierce kaitiaki, or protectors, of their children.  And so we can see here in this amazing quote that:

"I wouldn’t let them operate until he signed, he would operate as if he was operating on his own child.  I brought the whole operating team into her room, and we did karakia."

So our next theme really focussed on the healthcare encounters.  So caregivers often talked about how there was this very transactional nature of the health appointments but, unfortunately, what caregivers wanted was an opportunity for whakawhanaungatanga, they wanted to build relationships with the healthcare professionals that they were seeing, especially because they were treating their children, they talked about how they really wanted to have inviting health environments and kind healthcare professionals.  It didn't matter per se that the healthcare professionals were linguistically and culturally matched, they just wanted them to be kind and respectful and competent, so those kind of factors trumped, in a sense, having to be exactly matched to their culture and language.

As I alluded to before, before building relationships and that continuity of care was really important for these caregivers, and it was particularly important for mothers when they were postpartum.  So some of the quotes here, it really shows that relationship that can be built and how strong that can be.  So one of the Pacific caregivers said, "I would have lost my youngest son, if it wasn't for her".  So that really shows how strong that bond was.  And a Pākehā caregiver went on to say, "Oh no, I'm alone now…" when the midwife eventually leaves after the postpartum period. 

In general, mothers felt neglected postpartum because a lot of the care then shifted to the newborn and it felt like, once again, going back to that transactional health encounter, it kind of felt like a checklist, like they just wanted to know that you were okay and, in a sense, it didn't really matter if you were not actually doing okay, they kind of just wanted to check through and kind of get the appointment over with, and so creating those relationships, once again, is really important because the mothers or the caregivers might withhold information because it feels like it's just too transactional of an encounter.

The next theme really focused on some of the judgement that caregivers felt in these healthcare encounters.  So a lot of the mothers really opened up about their struggles with motherhood, they talked about feeling overwhelmed, and pressure, and lots of guilt, especially if they were juggling lots of things at home, and in some of the healthcare encounters they had a lot of judgement and fear of being labelled as a "bad mother" and they felt pressure to conform to the exact recommended practices of the healthcare professionals and then felt very disappointed when maybe it didn’t work out for them or it wasn’t the best option for them and their whānau.  So one of the Pākehā caregivers said, "When the lactation consultation called me, and then I told her I had changed from breast feeding to formula,  I felt like I was disappointing her".  

Some of the caregivers also talked about some racist stereotypes, which Gail also spoke to in the quantitative findings.  So one of the Chinese caregivers talked about how the doctor talked to them as if, "You're Chinese and so you always just want to give your child medicine". 

And once again, I just wanted to spend a little bit of time focusing on our Māori whānau.  So they talked about a long history of Māori pēpē and tamariki being policed and really reflecting the historical and ongoing implications of colonisation and the generational trauma faced by Māori whānau.  They described how vulnerable they felt when non-Māori healthcare professionals came into their homes and were interacting with their whānau, and they talked about they were so worried that, if they were judged as being a bad mother, that they might take their baby away.  And so one of the quotes here is saying:

"I had a bad experience when I had my baby.  They said I looked really tired and I might harm my baby."

And here we can see that means that the mother then stopped accessing care and so this then has implications for her pēpē and tamariki.

The next theme really focused on how slow the healthcare system was for the caregivers, so they talked about really, really long times to wait for appointments and referrals and so on and then, paradoxically, the consultations would be very short.  And I think this links in a little bit with the theme about trying to create relationships during these health encounters, and if they are really quick and short and very "check boxy", we can kind of take away from that opportunity to build those trusting relationships. 

Importantly, parents really wanted to be understood, that they were so emotionally distressed and they really wanted their child to be cared for as fast as possible, because, obviously, you don't want to see your child in pain.  But what was really interesting is they were really aware of how overwhelmed the healthcare system was, and once again, sometimes this meant that they withheld information from the healthcare professionals because they didn’t want to burden these professionals, because they knew they were just so overworked.  So in one of the quotes here, an Indian caregiver says:

"My Plunket nurse is my go-to.  I would text her and call her but then, you know, I would only really text her and call if I really, really, really, really had to."

Some of the caregivers also then talked about having limited options for care, and what was interesting was this was internalised as them feeling like they had to feel grateful for at least having some sort of care, so whether it was sub-optimal or didn’t meet their expectations or the consultation was really fast, they should just be so grateful, and they really didn’t want to be perceived as that because they really felt like, once again, that they just were advocating for proper care for their child.

The last theme that I'll go through is "Navigating Complexity".  So caregivers found the health system quite difficult to navigate for their children and they found that there were these certain gatekeepers to care, for example, sometimes a receptionist could be the gatekeeper to book doctors' appointments, for some of our migrant mothers filling out paperwork could be particularly horrendous, especially if your child is sick and needing emergency care.  Caregivers from all of the ethnic backgrounds, particularly those from migrant backgrounds, expressed a lack of awareness about what services and support were available to them, for instance, the concept of a midwife was not necessarily that dominant in their countries of origin so when they came to New Zealand and had to get a midwife, the whole process was very overwhelming for them. 

Participants also talked a lot about transportation costs and language barriers.  Gail talked about those direct costs, but there are some of these indirect costs in terms of transportation and taking time off work, which were at play.  And importantly, what I wanted to talk about here was that caregivers really talked about how assertive and proactive they had to be to access care for their children, and sometimes this could, once again, make them be perceived as being aggressive or obstructive or difficult, which they didn’t want to be judged as, but for them they really felt like they were just being fierce protectors for their children and they really just wanted to advocate for the proper care for their kids. 

One of the Pākehā caregivers used the dental checks as an example of where she had to call and call and say, "Can you see my son, can you see my son, can we book an appointment?" and then went to the appointment, and, unfortunately, the caregiver felt like they didn’t quite get the care that she thought she was going to receive and just kind of sent her on her way.

So I just wanted to go through a couple of ideas as to what some of these results might mean.  So I think in terms of having zero-fee policies, all of the care givers were just so grateful to have, in a sense, free access to healthcare for their child, it did reduce financial barriers, literature has talked about this, so that's a given, but we did see a lot of other barriers and indirect costs to accessing healthcare that can impact child development and health across their lifespan, and so we have just listed some of them here.

The other point I just wanted to bring up, as I said, over half of our participants did come from migrant backgrounds and it was apparent that migrant families had some of these unmet health needs, so in terms of long wait times, difficulty to navigate, limited support postpartum and practices that eroded their trust in healthcare professionals.  Now, this is really interesting because we can see these transnational ties of their expectations of postpartum care and early childhood care that are present in their countries of origin versus what happens here in New Zealand.  For example, in Indian culture it is very common to have a lot of extended family and a lot of support for a mother postpartum, but if you're living away from your family - and it’s a completely different system here and cultural differences here - that support is not necessarily available for mothers postpartum.  So they did often compare the health systems.  Now, what was so interesting, and we kind of talked about this in the results, is just how amazingly assertive and proactive these mothers are, so some of the Asian mothers talked about how they use the health systems in parallel to their advantage for their children's care, so they would access traditional medicines, they would bring them back home, if they were going home and they needed some dental work done they would do it back home, and so that's really fascinating that they are leveraging both of these health systems.  And I think that also goes to how the health systems, particularly in Indian and China, are set up, more private-based.

So we talked about the importance of building relationships and improving those health encounters.  So they didn’t want tick-box  exercises, they wanted to build these trusting relationships, but on the other hand, they also knew how burdened healthcare professionals were, although the importance was it just wasn’t necessary that they were the same ethnic background or shared the values, just that they respected them and they were kind and competent, and this was particularly important for mothers post-partum so that they received the support, and that can transfer into further engagement with the healthcare system for their children.  They also wanted to be seen as shared decision makers in the treatment plans for their children, so they wanted more autonomy and, basically, more decision-making power in those relationships with their healthcare professionals and, hopefully, a little less judgement from the system and providers.

As I said, there was a lot of talk amongst Māori about the ongoing colonial trauma that they're faced with and how our healthcare system, yeah, it needs to do better, and that fear of their children being taken away from them was really front and centre if they didn’t conform to Western ideals of parenting.  So the pressure to conform and the systemic racism present in the health system was very apparent and we could see now that caregivers wanted to exert their mana, their power, their control and they wanted what was best for their children, and so hopefully, with time, and hopefully the new healthcare reforms will be a great opportunity to better weave some of these indigenous healthcare models into our system.

So I will take you through some policy and practice implications before passing it over to Gail for a couple as well.

Overall, additional policies and strategies we think would be helpful to reduce some of those indirect costs of accessing health services for children, and we were particularly interested for the migrant children for whom having to pay did seem like a barrier.  So for immunisations, they're free for all children regardless of your citizenship or migration status, that might be something that we can consider, that's just one idea for all children. 

GAIL PACHECO: And the second point is around developing trusting relationships in delivery of culturally safe care, and even though I presented two studies, there were a couple of common themes that came through and then also matched the qualitative, which is interesting also, I should point out, because our quantitative data is based on children who were growing up from 2009 onwards, so when they were measured at four years old it was 2013, whereas the qualitative data was collected 2019/2020, but yet over that time span, there were still a lot of similarities over that period, and one thing that came through was the importance of encouragement from a range of networks in both the quant and the qual.  In the quantitative, like I mentioned earlier, it came through that the most important was encouragement by family and friends, and what I didn’t mention earlier is that the second most important was encouragement from health professionals.  So those sources of encouragement are really the flip side to the sources of discouragement that also happen through a range of networks and increasingly through social media, et cetera, in the antenatal period. 

Both studies also found the importance of addressing systemic racism and where that may come into play, potentially, in the healthcare system as well.

NADIA CHARANIA: So just at the end there, I just wanted to highlight, once again, that there's an opportunity to provide better support for mothers postpartum, and that this is particularly important, not only to create those relationships, but so that it doesn’t negatively influence their health-seeking behaviour, we don’t want them to be quiet, be silenced and stop accessing care, we want them to be super engaged.  And going to the other point, taking a more whānau-centred approach will be really helpful.

And then lastly, they talk so much about the health system being really complex to navigate and fragmented and very bureaucratic, and so there is an area of opportunity to improve the navigation of the health system and bridge these various amazing support services that are offered, and some of that can be things that we can do structurally, but then because we found some of the migrant parents, in particular, found it a bit challenging to navigate our system, there have been other countries that have orientation sessions for migrant populations as to how to navigate the system, particularly if you are having a child, and so something like that might be helpful, and also better access to interpreter services would be helpful to help overcome some of those language barriers.

So I think that's all from us, but we do have a list here of all of our references so that we can hopefully provide those to anyone who's interested.

GAIL PACHECO: You should be able to receive the slides as well online.

NADIA CHARANIA: Cool.  Thank you.

GAIL PACHECO: Thank you.