Perceived barriers to self-collected HPV testing for cervical cancer screening, and knowledge of HPV: a survey of primary healthcare smear-takers across Aotearoa New Zealand

AIMS

Cervical cancer remains a burden within Aotearoa New Zealand, with 2022 screening rates sitting 12.7% below target. The National Cervical Screening Programme has changed to primary human papillomavirus (HPV) testing for all screen-eligible people, with the aim for home self-testing. Little is known about the readiness of primary care for the change to self-testing and its associated challenges. A pilot HPV cervical cancer screening programme is being conducted in 17 practice centres. The aim of this study is to explore smear-taker knowledge at these centres about the use of primary HPV testing for cervical cancer screening.

METHODS

This is an ethically approved questionnaire study, with data from a structured web-based questionnaire sent to all smear-takers at the pilot centres.

RESULTS

We achieved a total completion rate of 57.8%. The average score for "Knowledge of HPV" was 56.5% (range=20-100%). The challenges to patient home HPV self-testing were felt to be overall "not at all" to "mildly challenging". Up to 73.3% of participants identified ongoing needs for further education.

CONCLUSIONS

The findings indicate knowledge deficits regarding HPV testing for cervical cancer screening and a desire for the provision of further education. Overall, respondents felt that no major barriers to implementing HPV self-testing would occur.

Developing a model for primary care quality improvement success: a comparative case study in rural, urban and Kaupapa Māori organisations

Introduction Primary care is under pressure to achieve accessible, equitable, quality health care, while being increasingly under resourced. There is a need to understand factors that influence quality improvement (QI) to support a high-performing primary care system. Literature highlights the impact of context on QI but there is little primary care research on this topic. Aim This qualitative case study research seeks to discover the contextual factors influencing QI in primary care, and how the relationships between contextual factors, the QI initiative, and the implementation process influence outcomes. Methods The Consolidated Framework for Implementation Research was used to frame this qualitative study exploring primary care experiences in depth. Six sites were selected to provide a sample of rural, urban and Kaupapa Māori settings. Qualitative data was collected via semi-structured interviews and compared and contrasted with the organisational documents and data provided by participants. Results Cases reported success in achieving improved outcomes for patients, practices, and staff. Strong internal cultures of 'Clan' and 'Adhocracy' typologies supported teamwork, distributed leadership, and a learning climate to facilitate iterative sensemaking activities. To varying degrees, external network relationships provided resources, knowledge, and support. Discussion Organisations were motivated by a combination of patient/community need and organisational culture. Network relationships assisted to varying degrees depending on need. Engaged and distributed leadership based on teamwork was observed, where leadership was shared and emerged at different levels and times as the need arose. A learning climate was supported to enable iterative sensemaking activities to achieve success.

Primary care experiences in the 'Let's test for HPV' study: a qualitative analysis

Introduction The National Cervical Screening Programme (NCSP) will switch from cervical cytology to Human Papillomavirus (HPV) testing as the primary cervical screening modality in 2023. To prepare for rollout an implementation study of HPV testing in primary care commenced in August 2022 in three different geographic regions in NZ. Aims This study explores Primary Care Staff's experience of using the HPV testing pathway in the 'Let's test for HPV' study so that recommendations can be made to improve the testing process before nationwide roll-out. Method Thirty-nine primary care staff were interviewed across all 17 practices in the Capital and Coast, Canterbury and Whanganui region participating in the 'Let's Test For HPV' study. In total 19 interviews took place which followed a semi-structured approach. These interviews were recorded and transcribed. Template analysis was carried out on transcripts to aid in identifying themes. Results Three key themes, with additional subthemes, were identified. Staff were strongly supportive of the new testing regime. Interviewees identified some issues with the new pathway. Educational needs for both patients and clinicians were identified. Conclusion Primary care staff described the experience of using the HPV testing pathway positively; however, there were requests for ongoing additional support and nationwide rollout to be supported by practitioner and patient education programmes. With the right support this new pathway for cervical cancer screening has the potential to improve access for previously underserved and unserved groups.

Developing a national primary care research network: a qualitative study of stakeholder views

Introduction Primary care research is critical to address Aotearoa New Zealand's (NZ) health sector challenges. These include health inequities, workforce issues and the need for evaluation of health system changes. Internationally, primary care data are routinely collected and used to understand these issues by primary care research and surveillance networks (PCRN). NZ currently has no such infrastructure. Aim To explore health sector stakeholders' views on the utility of, and critical elements needed for, a national PCRN in NZ. Methods Twenty semi-structured interviews and a focus group were conducted with key stakeholders, representing different perspectives within the health sector, including Hauora Māori providers. Data were analysed thematically. Results Six themes were identified that included both challenges within current primary care research and ideas for a future network. The themes were: disconnection between research, practice and policy; desire for better infrastructure; improving health equity for Māori and other groups who experience inequity; responding to the research needs of communities; reciprocity between research and practice; and the need for data to allow evidence-informed decision-making. Improving health equity for Māori was identified as a critical function for a national PCRN. Discussion Stakeholders identified challenges in conducting primary care research and translating research into practice and policy in NZ. Stakeholders from across the health sector supported a national PCRN and identified what its function should be and how it could operate. These views were used to develop a set of recommendations to guide the development of a national PCRN.

Contextual antecedents of quality improvement: a comparative case study in rural, urban and Kaupapa Māori general practice

Introduction The impact of contextual factors on primary health-care quality improvement is significant. In-depth research is required to identify the key contextual factors that influence quality improvement initiatives to develop high-performing primary health-care systems. Aim This research seeks to answer two questions; what are the contextual factors influencing primary care improvement initiatives?; and how do contextual factors, the quality improvement initiative and the implementation process influence one another and the overall improvement outcomes? Methods A multi-case study methodology was used to explore the complexities of the phenomena in situ . Three sites where successful quality improvement had occurred were selected by purposeful theoretical sampling to provide a sample of rural, urban and Kaupapa Māori general practice settings typical of the New Zealand environment. Semi-structured interviews were conducted with team members and triangulated with secondary data provided by the organisations. Results The quality improvement topic and the approach taken were intrinsically linked to context. Sites reported success in achieving the desired outcomes benefitting the patients, practice and staff. Teams did not use formal improvement methods, instead relying on established relationships and elements of change management methods. The culture in all three cases was a large component of why and how these initiatives were successful. Discussion Intrinsic motivation was generated by community connections and networks. This combined with a learning climate generated by distributed leadership and teamwork enabled success. Iterative reflection and sensemaking processes were able to deliver quality improvement success in primary care without the use of formal improvement methods.

Electronic transmission of prescriptions in primary care: transformation, timing and teamwork

INTRODUCTION During the coronavirus disease 2019 (COVID-19) pandemic lockdown in New Zealand in March 2020, there was a rapid shift to virtual consultations in primary care. This change was supported by system adjustments to enable electronic transmission of prescriptions without a handwritten signature if they met certain security criteria. International research suggests potential for unintended consequences with such changes, so it is important to understand the effect on professional practice in New Zealand general practice and community pharmacy. AIM The purpose of this study was to undertake a preliminary exploration of the experiences of New Zealand general practitioners and community pharmacists when prescriptions are transmitted electronically directly from prescriber to pharmacy. METHODS Semi-structured interviews with a purposive sample of four pharmacists and four general practitioners gathered qualitative data about their experiences of the shift to electronic transmission of prescriptions. Participants' perceptions of effect on professional workflow, interprofessional interactions between general practitioners and pharmacists, and interactions with patients were explored. Interviews were audio-recorded, and the data analysed thematically using an inductive approach. RESULTS Four themes were identified: workflow transformation; mixed impact on interactions with patients; juggling timing and expectations; and new avenues for interprofessional communication (with some cul-de-sacs). DISCUSSION Both general practitioners and pharmacists experienced transformational changes to workflow. This was positive for general practitioners due to saved time and increased work flexibility. Pharmacists noted potential benefits but also some challenges. To fully reap teamwork benefits, more work is needed on managing the timing issues and patient expectations, and to refine the new modes of communication between health-care practitioners.

Simulating 'that jaw drop moment': challenging heteronormative assumptions in a novel clinical consultation skills session with undergraduate medical students

This article was migrated. The article was marked as recommended. Introduction This paper discusses the design and impact of a clinical consultation skills session for undergraduate medical students in context of diverse sexual orientation, gender identity and expression, and sex characteristics. Existing teaching approaches omit opportunities for application and skills practice. This innovation seeks to address this gap. Methods Senior medical undergraduate students participated in actor-facilitated standardized simulated patient role-play. The scenarios utilized a structure akin to the end of year final observed objective structured clinical examination. Plan-do-study-act cycles involving facilitator observation, verbal and written feedback from students and actors, confidential student evaluations, and peer evaluation contributed to session modification and improvement. Findings The teaching session offered students the opportunity to practice exam-style simulated patient consultations, communication and empathy skills. Improvements made following the first iteration were reflected in positive student evaluations in the second iteration. Discussion and Conclusion Simulated consultations using standardised scenarios represent an accepted format for medical education. We demonstrated it is possible to include topics that frequently give rise to discrimination and stigma from medical professionals whilst maintaining expected learning outcomes. Student evaluations identify the acceptability and value of the topics for medical education. We present a viable option for integration into medical education.

Reducing inappropriate urine testing at Hutt Valley District Health Board using Choosing Wisely principles

AIM

Unnecessary treatment of asymptomatic bacteriuria is a concern. Hutt Valley District Health Board sought to reduce clinically inappropriate urine culture requests through removal of urine dipsticks from wards and education of staff using Choosing Wisely principles. The purpose of this research is to quantitatively evaluate the success of these initiatives.

METHODS

The numbers and results of urine cultures performed for Hutt Valley DHB were analysed, for the period from January 2015 to October 2017. Urinalyses were compared between those designated as 'inpatient' and those as 'outpatient', with the latter being the control of this study. The numbers of primary and secondary coded discharge diagnoses of UTIs were used as a measure of the negative impact of the interventions.

RESULTS

There was a 28% reduction in monthly urine culture requests for inpatients, after staff education and removal of urine dipsticks, with no change in those for outpatients (the negative control). After the intervention, a higher proportion of urine cultures were positive for urinary pathogens (25.2% compared to 23.0%) and the average number of diagnoses of UTI in hospital discharges decreased 17% (from 161 to 134).

CONCLUSION

The removal of urine dipsticks from wards and the education of staff significantly reduced the number of urine culture requests and is a useful strategy to reduce the overuse of antibiotics for asymptomatic bacteriuria without an increase in the number of UTIs. These simple interventions could be used at other hospitals as part of measures to reduce unnecessary care and overdiagnosis.

Quantifying the incidence and burden of herpes zoster in New Zealand general practice: a retrospective cohort study using a natural language processing software inference algorithm

OBJECTIVE

To investigate the incidence of primary care presentations for herpes zoster (zoster) in a representative New Zealand population and to evaluate the utilisation of primary healthcare services following zoster diagnosis.

DESIGN

A cross-sectional retrospective cohort study used a natural language processing software inference algorithm to identify general practice consultations for zoster by interrogating 22 million electronic medical record (EMR) transactions routinely recorded from January 2005 to December 2015. Data linking enabled analysis of the demographics of each case. The frequency of doctor visits was assessed prior to and after the first consultation diagnosing zoster to determine health service utilisation.

SETTING

General practice, using EMRs from two primary health organisations located in the lower North Island, New Zealand.

PARTICIPANTS

Thirty-nine general practices consented interrogation of their EMRs to access deidentified records for all enrolled patients. Out-of-hours and practice nurse consultations were excluded.

MAIN OUTCOME MEASURES

The incidence of first and repeated zoster-related visits to the doctor across all age groups and associated patient demographics. To determine whether zoster affects workload in general practice.

RESULTS

Overall, for 6 189 019 doctor consultations, the incidence of zoster was 48.6 per 10 000 patient-years (95% CI 47.6 to 49.6). Incidence increased from the age of 50 years to a peak rate of 128 per 10 000 in the age group of 80-90 years and was significantly higher in females than males (p<0.001). Over this 11-year period, incidence increased gradually, notably in those aged 80-85 years. Only 19% of patients had one or more follow-up zoster consultations within 12 months of a zoster index consultation. The frequency of consultations, for any reason, did not change between periods before and after the diagnosis.

CONCLUSIONS

Zoster consultations in general practice are rare, and the burden of these cases on overall general practice caseload is low.

Childhood respiratory illness presentation and service utilisation in primary care: a six-year cohort study in Wellington, New Zealand, using natural language processing (NLP) software

OBJECTIVES

To identify childhood respiratory tract-related illness presentation rates and service utilisation in primary care by interrogating free text and coded data from electronic medical records.

DESIGN

Retrospective cohort study. Data interrogation used a natural language processing software inference algorithm.

SETTING

36 primary care practices in New Zealand. Data analysed from January 2008 to December 2013.

PARTICIPANTS

The records from 77 582 children enrolled were reviewed over a 6-year period to estimate the presentation of childhood respiratory illness and service utilisation. This cohort represents 268 919 person-years of data and over 650 000 unique consultations.

MAIN OUTCOME MEASURE

Childhood respiratory illness presentation rate to primary care practice, with description of seasonal and yearly variation.

RESULTS

Respiratory conditions constituted 46% of all child-general practitioner consultations with a stable year-on-year pattern of seasonal peaks. Upper respiratory tract infection was the most common respiratory category accounting for 21.0% of all childhood consultations, followed by otitis media (12.2%), wheeze-related illness (9.7%), throat infection (7.4%) and lower respiratory tract infection (4.4%). Almost 70% of children presented to their general practitioner with at least one respiratory condition in their first year of life; this reduced to approximately 25% for children aged 10-17.

CONCLUSION

This is the first study to assess the primary care incidence and service utilisation of childhood respiratory illness in a large primary care cohort by interrogating electronic medical record free text. The study identified the very high primary care workload related to childhood respiratory illness, especially during the first 2 years of life. These data can enable more effective planning of health service delivery. The findings and methodology have relevance to many countries, and the use of primary care 'big data' in this way can be applied to other health conditions.

Rheumatologists fail to advise people with RA to get immunised, which matters if you are under 65: An audit in a New Zealand rheumatology service

AIM

To assess if yearly-influenza and five-yearly pneumococcal vaccines are recommended to people with rheumatoid arthritis (RA) in a New Zealand rheumatology service in accordance with guidelines and determine patient immunisation status for these respiratory pathogens.

METHODS

Retrospective review of electronic health records of all outpatients with RA attending a regional rheumatology centre in New Zealand over a one-month period immediately after the release of the 2015 influenza vaccination.

RESULTS

The 232 people with RA in the sample had a mean age of 60.4 years with 59% having RA for more than five years. Documented advice was infrequent (<5%) at the index visit and other clinically relevant time points. Despite this, many patients were immunised. People with RA over 65 years of age were more likely to receive influenza vaccination, however, the vaccination rate was similar to the general population over 65 years of age.

CONCLUSIONS

People with RA receive recommended respiratory vaccinations despite infrequent advice for immunisation from rheumatology specialist services. However, immunisation rate in people with RA, particularly those under 65 years, remains suboptimal and multi-level interventions are required to improve this.

Genital examination training: assessing the effectiveness of an integrated female and male teaching programme

BACKGROUND

Learning to undertake intimate female and male examinations is an important part of medical student training but opportunities to participate in practical, supervised learning in a safe environment can be limited. A collaborative, integrated training programme to provide such learning was developed by two university teaching departments and a specialist sexual health service, utilising teaching associates trained for intimate examinations in a simulated clinical educational setting. The objective of this research was to determine changes in senior medical students' self- reported experience and confidence in performing male and female genital examinations, before and after participating in a new clinical teaching programme.

METHODS

A quasi-experimental mixed methods design, using pre and post programme questionnaires and focus groups, was used to assess the effectiveness of the programme.

RESULTS

The students reported greatly improved skill, confidence and comfort levels for both male and female genital examination following the teaching programme. Skill, confidence and comfort regarding male examinations were rated particularly low on the pre-teaching programme self- assessment, but post-programme was rated at similar levels to the female examination.

CONCLUSIONS

This integrated female-male teaching programme (utilising trained teaching associates as simulated patients in a supervised clinical teaching environment) was successful in increasing senior medical students' skills and levels of confidence in performing genital examinations. There were differences between female and male medical students in their learning. Suggestions for improvement included providing more detailed instruction to some clinical supervisors about their facilitation role in the session.

Continuity of cancer patient care in New Zealand; the general practitioner perspective

AIM

As cancer treatments become more effective, increasing numbers of cancer patients seek long-term support from general practice. This study aimed to canvass the perspective of GPs on issues around continuity of care for these patients.

METHODS

In this qualitative study purposive sampling was used to invite a range of New Zealand GPs from urban and rural communities in the Greater Wellington and Otago/Southland areas to participate. A total of 34 GPs took part in three semi-structured individual interviews and six focus groups.

RESULTS

Six main themes emerged; the participating GPs noted they wanted more involvement in their patients' cancer journeys but were not always clear of their place in relation to cancer specialists and other health care providers. They saw cancer as a chronic condition to be managed long term. They mentioned the breast cancer and palliative care models as examples to be followed. Poor communication and barriers for patients in accessing GP care were seen as areas for improvement.

CONCLUSION

Participating GPs felt that the current cancer care pathway could be improved with a better understanding of their own role and through improved communication with patients, cancer specialists and other health professionals.

"I wanted to communicate my feelings freely": a descriptive study of creative responses to enhance reflection in palliative medicine education

BACKGROUND

The recent growth of arts and humanities in medical education shows recognition that these disciplines can facilitate a breadth of thinking and result in personal and professional growth. However creative work can be a challenge to incorporate into a busy curriculum. Offering the option of creative media as a way of reflecting is an example of how this can occur. This study aimed to examine the medical student response to being given this option to explore a visit to a patient in a hospice.

METHODS

This was a mainly qualitative study. In the 2012 academic programme, the class of 86 students were given the option of using a creative medium to explore their responses to both the visit and their developing communication skills. Students were required to write an accompanying commentary if submitting the creative work option. Sixty-four percent of the class chose a creative medium e.g. poetry, visual art, narrative prose, music. These students were asked to take part in research including completing a short on-line survey and consenting for their creative work and commentaries to be further examined. The creative works were categorised by genre and the commentaries analysed using inductive thematic analysis.

RESULTS

Seventeen students completed the on-line survey and fifteen consented to their work being used for this research. Thematic analysis of the student commentaries revealed the following themes: effectiveness for expressing emotion or ideas that are difficult to articulate; engaging and energising quality of the task; time for reflection; flexibility for individual learning styles and therapeutic value.

CONCLUSIONS

Teaching the art of communicating at end-of-life is challenging especially when it involves patients, and teachers want to ensure students gain as much as possible from the experience. Offering the option to use creative media means that students can choose a medium for reflection that best suits them as individuals and that can enable them to benefit as much as possible from their experience.

Identifying influenza-like illness presentation from unstructured general practice clinical narrative using a text classifier rule-based expert system versus a clinical expert

BACKGROUND

We designed and validated a rule-based expert system to identify influenza like illness (ILI) from routinely recorded general practice clinical narrative to aid a larger retrospective research study into the impact of the 2009 influenza pandemic in New Zealand.

METHODS

Rules were assessed using pattern matching heuristics on routine clinical narrative. The system was trained using data from 623 clinical encounters and validated using a clinical expert as a gold standard against a mutually exclusive set of 901 records.

RESULTS

We calculated a 98.2 % specificity and 90.2 % sensitivity across an ILI incidence of 12.4 % measured against clinical expert classification. Peak problem list identification of ILI by clinical coding in any month was 9.2 % of all detected ILI presentations. Our system addressed an unusual problem domain for clinical narrative classification; using notational, unstructured, clinician entered information in a community care setting. It performed well compared with other approaches and domains. It has potential applications in real-time surveillance of disease, and in assisted problem list coding for clinicians.

CONCLUSIONS

Our system identified ILI presentation with sufficient accuracy for use at a population level in the wider research study. The peak coding of 9.2 % illustrated the need for automated coding of unstructured narrative in our study.

Accessing primary care Big Data: the development of a software algorithm to explore the rich content of consultation records

OBJECTIVE

To develop a natural language processing software inference algorithm to classify the content of primary care consultations using electronic health record Big Data and subsequently test the algorithm's ability to estimate the prevalence and burden of childhood respiratory illness in primary care.

DESIGN

Algorithm development and validation study. To classify consultations, the algorithm is designed to interrogate clinical narrative entered as free text, diagnostic (Read) codes created and medications prescribed on the day of the consultation.

SETTING

Thirty-six consenting primary care practices from a mixed urban and semirural region of New Zealand. Three independent sets of 1200 child consultation records were randomly extracted from a data set of all general practitioner consultations in participating practices between 1 January 2008-31 December 2013 for children under 18 years of age (n=754,242). Each consultation record within these sets was independently classified by two expert clinicians as respiratory or non-respiratory, and subclassified according to respiratory diagnostic categories to create three 'gold standard' sets of classified records. These three gold standard record sets were used to train, test and validate the algorithm.

OUTCOME MEASURES

Sensitivity, specificity, positive predictive value and F-measure were calculated to illustrate the algorithm's ability to replicate judgements of expert clinicians within the 1200 record gold standard validation set.

RESULTS

The algorithm was able to identify respiratory consultations in the 1200 record validation set with a sensitivity of 0.72 (95% CI 0.67 to 0.78) and a specificity of 0.95 (95% CI 0.93 to 0.98). The positive predictive value of algorithm respiratory classification was 0.93 (95% CI 0.89 to 0.97). The positive predictive value of the algorithm classifying consultations as being related to specific respiratory diagnostic categories ranged from 0.68 (95% CI 0.40 to 1.00; other respiratory conditions) to 0.91 (95% CI 0.79 to 1.00; throat infections).

CONCLUSIONS

A software inference algorithm that uses primary care Big Data can accurately classify the content of clinical consultations. This algorithm will enable accurate estimation of the prevalence of childhood respiratory illness in primary care and resultant service utilisation. The methodology can also be applied to other areas of clinical care.

A structured, group-based diabetes self-management education (DSME) programme for people, families and whanau with type 2 diabetes (T2DM) in New Zealand: an observational study

BACKGROUND

Group-based diabetes self-management education (DSME) programmes have been shown to be effective. A programme tailored for the unique social and ethnic environment of New Zealand (NZ) was developed using concepts from internationally developed programmes.

AIM

To assess the effectiveness of a 6 week New Zealand specific DSME programme.

METHODS

In this observational study people with type 2 diabetes (aged 18-80 years) from diverse cultural backgrounds were recruited from primary care. Seventeen groups of six education sessions were run. Clinical data were collected from primary care at baseline, 3, 6 and 9 months. Participants also completed a self-administered questionnaire on diabetes knowledge, and self-management behaviours.

RESULTS

107 participants, mean age 56.7±11.3 years and mean duration of diabetes 7.5±7 years (NZ European (44%), Maori (24%), Pacific (16%) and Indian (16%)), were enrolled. Confidence in self-managing diabetes, regular examination of feet, physical activity levels and smoking rates all improved. Glycaemic control improved between baseline and 6 months (HbA1C 64.9±20.0 mmol/mol to 59.9±13.9 mmol/mol (p<0.05) (baseline 8.07%±1.80, 6 months 7.62%±1.25)), but was no different to baseline at 9 months. Systolic BP reduced from 131.9±16.4 to 127.4±18.2 mmHg (p<0.05) at 6 months, but increased to baseline levels by 9 months. Diastolic BP, triglycerides and urine microalbumin:creatinine ratio were significantly reduced at 3, 6 and 9 months.

CONCLUSION

A group-based DSME programme designed specifically for the NZ population was effective at improving aspects of diabetes care at 6 months. The attenuation of these improvements after 6 months suggests a refresher course at that time may be beneficial.

New Zealand general practice nurses' roles in mental health care

AIM

To examine the roles of nurses in general practice interdisciplinary teams caring for people with mild to moderate mental health conditions.

BACKGROUND

Supporting mental health and well-being is an important aspect of primary care. Until now nurses in general practice settings have had variable roles in providing mental health care. The New Zealand Primary Mental Health Initiatives are 26 government-funded, time-limited projects using different service delivery models.

METHODS

An analysis was undertaken of a qualitative data set of interviews, which included commentary about nurses mental health work collected from the different project stakeholders throughout a 29-month external evaluation.

FINDINGS

Two main groups of roles for nurses within the general practice interdisciplinary team were identified: specialist mental health nurses working in newly created roles and practice nurses working in existing roles. Barriers exist to the development of the latter roles.

CONCLUSIONS

Mental health care is a key role in general practice as this is where people frequently present. Internationally, nurses represent a large workforce with the potential to provide effective mental health care. This study found that attitudinal, structural and professional barriers are restricting New Zealand practice nurse role development in the care of those with mild to moderate mental health conditions. There is potential to develop their role within a structured pathway by workforce development and recognition of the value of interdisciplinary care. Given the shortage of mental health professionals this will be an important aspect of the improvement of primary mental health care.

Analysis of a primary care led diabetes annual review programme in a multi ethnic cohort in Wellington, New Zealand

INTRODUCTION

In 2000 a primary care led "Get Checked" programme of free annual diabetes reviews was introduced in New Zealand. This report explores changes in clinical variables over five annual visits in relation to ethnicity.

METHODS

From 19,054 people in the Wellington region all 2967 with Type 2 diabetes completing five visits between 2000 and 2006 contributed data. This included weight, blood pressure, HbA1c, lipids, and urinary albumin:creatinine ratio. Mixed linear models examined changes in clinical variables by visit and the relationships with ethnicity.

RESULTS

Of the 2967, 69.5% were European, 10.0% Maori, 8.6% Pacific and 10.4% Asian. Weight, systolic and diastolic blood pressure declined. HbA1c initially declined with time in Maori, Pacific and Asian and then rose. Total cholesterol decreased and HDL cholesterol rose. Urinary albumin:creatinine ratio fell at first and then rose and the degree of change was dependent on ethnicity. Use of diabetes medications and ACE inhibitor prescription increased in all ethnicities. Statin prescriptions rose from 20 to 61%. Current smoking rates fell from 10.7% to 9.4%.

CONCLUSION

This programme showed improvements in intermediate outcomes of diabetes care across all ethnic groups highlighting the benefit of reducing barriers to, and increasing engagement with, good primary health care.

New Zealand men's health care: are we meeting the needs of men in general practice?

AIM

To describe and compare how men and health professionals perceive men's health and health care.

METHOD

A qualitative study with an inductive thematic analysis of transcripts from three sequential sets of focus groups. The first set included groups totalling 21 general practitioners and 10 practice nurses; the second set with a group of 12 men under 25 years and a group of 10 older men over 35 years; and the third set with the original groups of health professionals. Datasets were analysed individually, sequentially and comparatively for men's and health professionals' beliefs about health and health care.

RESULTS

In the initial focus groups, health professionals reported system, structural, and attitudinal barriers inhibiting men attending general practice. Men reported broad-based health beliefs and, despite reluctance to seek formal health care, men value general practice care and want recognition of their preferred consulting styles. In the final focus groups, researchers fed-back analysis of the health professionals' and men's focus group data with the aim of encouraging further focussed men's health initiatives. However, there was a general lack of enthusiasm from health professionals to do more than what was being done already.

CONCLUSIONS

Despite men and health professionals recognising the importance of men's health, there is general unwillingness on the part of both men and health professionals, for different reasons, to engage with men's health care in general practice. Understanding how men view health and health care delivery has the potential to inform alternative approaches in general practice care.

Teaching and learning about chronic conditions management for undergraduate medical students: utilizing the patient-as-teacher approach

OBJECTIVES

This study was undertaken to evaluate the impact on medical student learning of a revised chronic conditions teaching programme based on the chronic care model utilizing patients-as-teachers.

METHODS

A qualitative questionnaire was completed by students at the start of a primary healthcare rotation to determine existing impressions/understandings about chronic conditions. Following the revised teaching programme, a reflective essay about a home-visit to a person with chronic conditions was completed by students at the end of the rotation.

RESULTS

Analysis of the questionnaire at the start of the rotation showed students have some knowledge of the differences between acute and chronic care, have rather negative impressions of what it means to have chronic conditions and know little of overall patient management including the work of an interdisciplinary team. Analysis of the reflective essays completed by students at the end of the rotation showed an increased understanding of chronic conditions, what it means to have a chronic condition and who supports management.

DISCUSSION

A structured chronic conditions teaching programme including patient-as-teacher is an effective way of building knowledge and changing students' impressions of what it means to have a chronic condition.

New Zealand men’s health care: are we meeting the needs of men in general practice?

AIM: To describe and compare how men and health professionals perceive men’s health and health care. METHOD: A qualitative study with an inductive thematic analysis of transcripts from three sequential sets of focus groups. The first set included groups totalling 21 general practitioners and 10 practice nurses; the second set with a group of 12 men under 25 years and a group of 10 older men over 35 years; and the third set with the original groups of health professionals. Datasets were analysed individually, sequentially and comparatively for men’s and health professionals’ beliefs about health and health care. RESULTS: In the initial focus groups, health professionals reported system, structural, and attitudinal barriers inhibiting men attending general practice. Men reported broad-based health beliefs and, despite reluctance to seek formal health care, men value general practice care and want recognition of their preferred consulting styles. In the final focus groups, researchers fed-back analysis of the health professionals’ and men’s focus group data with the aim of encouraging further focussed men’s health initiatives. However, there was a general lack of enthusiasm from health professionals to do more than what was being done already. CONCLUSIONS: Despite men and health professionals recognising the importance of men’s health, there is general unwillingness on the part of both men and health professionals, for different reasons, to engage with men’s health care in general practice. Understanding how men view health and health care delivery has the potential to inform alternative approaches in general practice care. KEYWORDS: New Zealand; men’s health; general practice; general practitioner; practice nurse

Evaluation of the Palliative Care Partnership: a New Zealand solution to the provision of integrated palliative care

AIMS

This study reports an external evaluation of a funded model of integrated palliative care the Palliative Care Partnership. Care is delivered by a partnership between palliative care coordinators (augmented by specialist hospice clinicians), general practitioners, practice nurses, and supported by community district nurses. Mandatory induction clinician education and other support is a prerequisite.

METHODS

A mixed method approach including in-depth, semi-structured interviews with a purposeful sample of stakeholders and analysis of routinely collected data. The study was undertaken in the MidCentral District Health Board area.

RESULTS

All stakeholders report favourably on the model of care. Data analysis shows the majority of MidCentral general practitioners and many practice nurses have completed training and cared for at least one patient using the funding stream of up to $400 per patient. Clinicians report increased clinical confidence and satisfaction. Patients/family describe best practice palliative care delivery. Funder and management organisation report robust quality and funding procedures.

CONCLUSIONS

The Palliative Care Partnership is an effective model of funded palliative care in primary care. It utilises the enhanced skills of primary and specialist clinicians to provide cost effective palliative care and is a model worthy of replication nationally and internationally.

The treatment of common mental health problems in general practice

BACKGROUND

Previous studies report GPs under-treat mental health disorders, particularly depression, and treatments are non-specific and lack an evidence base. They conclude further training and education of GP's is required.

OBJECTIVE

To describe the treatment of common mental health disorders in relation to the level and severity of psychological problems as defined by the GP and external assessment.

METHODS

Cross sectional survey of General Practice attenders in New Zealand. Fifty consecutive adult patients were recruited from each practice of 70 randomly selected GP's. The psychological status of 773 respondents selected via the General Health Questionnaire (GHQ) was assessed, and details of management provided. Management options were compared with the level of psychological problem identified by the GP.

RESULTS

Treatment varied depending on the level of problem identification, and frequency of consultation, from 93% given treatment when an explicit diagnosis was made to 22.3% in patients with subclinical symptoms. The most commonly given treatment with an explicit diagnosis was psychotropic medication [73% (95% CI 63.6-82.9)] while for those patients with subclinical symptoms the most common form of treatment was discussion and counselling [15.7% (7.1-24.2)]. Only 1.7% (0.3-3.0) of patients with subclinical symptoms received psychotropics.

CONCLUSION

There is a clear association between the level of psychological problem identified and treatment. In contrast to previous views that treatment often appears to be given regardless of diagnosis, these results provide a picture of general practice management of common mental disorders more in line with evidence-based practice than previously described.

Do patients want to disclose psychological problems to GPs?

BACKGROUND

GPs are an accessible health care provider for most patients with mental disorders and are gatekeepers to specialist care. The extent to which patients consider their primary care team as relevant to their mental health problems needs to be explored.

OBJECTIVES

To explore reasons why patients choose not to disclose psychological problems to GPs, and to discuss the implications for the provision of primary mental health care.

METHODS

A cross-sectional survey of consecutive patients attending general practices in New Zealand (part of the MaGPIe study). Patients were screened using the GHQ-12 and a stratified sample participated in a structured in-depth interview to assess their psychological health. Non-disclosure of psychological problems was explored. GPs assessed patients' psychological health using a 5-point scale of severity.

RESULTS

Seventy GPs (90%) and 775 patients (70%) participated. Overall, 29.8% of all patients and 36.9% of patients with current symptoms reported non-disclosure of self-perceived psychological problems. Younger patients, those consulting more frequently and those with greater psychiatric disability were more likely to report non-disclosure. The most frequently given reasons were beliefs that a GP is not the 'right' person to talk to (33.8%) or that mental health problems should not be discussed at all (27.6%).

CONCLUSIONS

Interventions such as screening and GP education may be ineffective in improving primary mental health care unless accompanied by educational programmes for the general public to increase mental health literacy, de-stigmatise mental illness and increase awareness of general practice as an appropriate and effective source of health care.

“What sort of health promotion are you talking about?”: a discourse analysis of the talk of general practitioners

In New Zealand, health promotion is now expected to be an integral part of the work of a general practitioner, and in the recently implemented New Zealand Primary Health Organisation structure, specific funding is available to undertake health promotion activities in primary care. Eighteen general practitioners recruited to take part in two focus groups discussing men's health, talked extensively about health promotion. This talk was analysed through a discourse analysis. This study of the 'talk' of general practitioners suggests that there are problems in transferring the concept, which must be recognised and addressed if health promotion is going to be taken up effectively within general practice. The meaning given to health promotion in the consultation is unclear and general practitioners were unsure about its value in 'health checks' and screening. Lack of time and lack of confidence in the evidence appeared to be barriers to undertaking health promotion within general practice consultations. In the current climate general practitioners are uncertain, to the point of ambivalence, about health promotion in their work. Further work will be required to ensure this ambivalence does not result in covert resistance.

A prospective study of immunisation for a cohort of children

AIMS

To determine rates of immunisation by 24 months of age, the number of times children were recalled and the cost of immunisation for a cohort of children in general practices in Wellington.

METHODS

A prospective study of 979 children registered with 27 general practices. Children in the cohort were followed from 9-24 months old. Data collected included immunisation status, the number of times children were recalled and demographic data.

RESULTS

At the end of the study period (when children reached 24 months of age) 803 (82%) remained with the practices and 176 (18%) had left. At 24 months 724 (74%) of the total cohort and 685 (85.3%) of registered children who stayed with the practice were fully immunised for the early childhood vaccinations. 54% of the cohort were fully immunised after a standard recall process. The average cost per child immunised was $13.33.

CONCLUSION

It is possible to achieve high rates of full immunisation in children registered with a general practice using an effective system of facilitation and support.

Nursing and native peoples in Northern Saskatchewan: 1930s-1950s

The aim of this research is to investigate the role of nurses in northern Saskatchewan Aboriginal communities in Canada between 1930 and the 1950s. During and after the war, the federal government began sharing its responsibilities for delivering health services to Indian communities with a growing system of provincial Public Health nursing stations. In northern Saskatchewan, interaction between Aboriginal peoples and the state health care system occurred primarily through provincial Public Health nurses permanently stationed at these outpost clinics. What was the role of nurses in these communities? How did federal Indian health policy influence nurses' behaviour? Based on the record available for Saskatchewan, it appears the outpost clinics delivered standard nursing care. It also appears that the federal government was eager to devolve its responsibilities for Indian health care to the province, and that its tenuous commitment to providing health care caused confusion in the treatment of patients.