Implementing new forms of collaboration and participation in primary health care: leveraging past learnings to inform future initiatives.

Introduction Within primary health care policy, there is an increasing focus on enhancing involvement with secondary health care, social care services and communities. Yet, translating these expectations into tangible changes frequently encounters significant obstacles. As part of an investigation into the progress made in achieving primary health care reform in Aotearoa New Zealand, realist research was undertaken with those charged with responsibility for national and local policies. The specific analysis in this paper probes primary health care leaders' assessments of progress towards more collaboration with other health and non-health agencies, and communities. Aim This study aimed to investigate how ideas for more integration and joinedup care have found their way into the practice of primary health care in Aotearoa New Zealand. Methods Applying a realist logic of inquiry, data from semi-structured interviews with primary health care leaders were analysed to identify key contextual characteristics and mechanisms. Explanations were developed of what influenced leaders to invest energy in joined-up and integrated care activities. Results Our findings highlight three explanatory mechanisms and their associated contexts: a willingness to share power, build trusting relationships and manage task complexity. These underpin leaders' accounts of the success (or otherwise) of collaborative arrangements. Discussion Such insights have import in the context of the current health reforms for stakeholders charged with developing local approaches to the planning and delivery of health services.

Cohort profile: Nga Kawekawe o Mate Korona | Impacts of COVID-19 in Aotearoa - a prospective, national cohort study of people with COVID-19 in New Zealand.

PURPOSE: The COVID-19 pandemic has had significant health, social and economic impacts around the world. We established a national, population-based longitudinal cohort to investigate the immediate and longer-term physical, psychological and economic impacts of COVID-19 on affected people in Aotearoa New Zealand (Aotearoa), with the resulting evidence to assist in designing appropriate health and well-being services for people with COVID-19. PARTICIPANTS: All people residing in Aotearoa aged 16 years or over, who had a confirmed or probable diagnosis of COVID-19 prior to December 2021, were invited to participate. Those living in dementia units were excluded. Participation involved taking part in one or more of four online surveys and/or in-depth interviews. The first wave of data collection took place from February to June 2022. FINDINGS TO DATE: By 30 November 2021, of 8735 people in Aotearoa aged 16+ who had COVID-19, 8712 were eligible for the study and 8012 had valid addresses so were able to be contacted to take part. A total of 990 people, including 161 Tangata Whenua (Maori, Indigenous peoples of Aotearoa) completed one or more surveys; in addition, 62 took part in in-depth interviews. Two hundred and seventeen people (20%) reported symptoms consistent with long COVID. Key areas of adverse impacts were experiences of stigma, mental distress, poor experiences of health services and barriers to healthcare, each being significantly more pronounced among disabled people and/or those with long COVID. FUTURE PLANS: Further data collection is planned to follow-up cohort participants. This cohort will be supplemented by the inclusion of a cohort of people with long COVID following Omicron infection. Future follow-ups will assess longitudinal changes to health and well-being impacts, including mental health, social, workplace/education and economic impacts of COVID-19.

Impact of removing prescription co-payments on the use of costly health services: a pragmatic randomised controlled trial.

OBJECTIVES: To determine whether exempting people (with high health needs and living in areas of high deprivation) from a $5 prescription charge reduces hospital use. DESIGN: Two-group parallel prospective randomised controlled trial. SETTING: People living in the community in various regions of New Zealand. PARTICIPANTS: One thousand sixty one people who lived in areas of high socioeconomic deprivation, and either took medicines for diabetes, took antipsychotic medicines, or had chronic obstructive pulmonary disease (COPD). Of the 1053 who completed the study, just under half (49%) were Maori. INTERVENTIONS: Participants were individually randomized (1-1 ratio) to either be exempted from the standard $5 charge per prescription item for one year (2019-2020) (n = 591) or usual care (n = 469). Those in the intervention group did not pay the standard NZ$5 charge, and pharmacies billed the study for these. Participants continued to pay any other costs for prescription medicines. Those in the control group continued to pay all prescription charges for the year although they may have received one-off assistance from other agencies. MAIN OUTCOME MEASURES: The primary outcome was length of stay (hospital bed-days). Secondary outcomes presented in this paper included: all-cause hospitalisations, hospitalisations for diabetes/mental health problems/COPD, deaths, and emergency department visits. RESULTS: The trial was under-powered because the recruitment target was not met. There was no statistically significant reduction in the primary outcome, hospital bed-days (IRR = 0.68, CI: 0.54 to 1.05). Participants in the intervention group were significantly less likely to be hospitalised during the study year than those in the control group (OR = 0.70, CI: 0.54 to 0.90). There were statistically significant reductions in the number of hospital admissions for mental health problems (IRR = 0.39, CI: 0.17 to 0.92), the number of admissions for COPD (IRR = 0.37, CI: 0.16 to 0.85), and length of stay for COPD (IRR 0.20, CI: 0.07 to 0.60). Apart from all-cause mortality and diabetes length of stay, all measures were better for the intervention group than the control group. CONCLUSIONS: Eliminating a small co-payment appears to have had a substantial effect on patients' risk of being hospitalised. Given the small amount of revenue gathered from the charges, and the comparative large costs of hospitalisations, the results suggest that these charges are likely to increase the overall cost of healthcare, as well as exacerbate ethnic inequalities. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618001486213 registered on 04/09/2018.

Experiences of New Zealand public health messaging while in lockdown.

OBJECTIVE: The COVID-19 pandemic has led to greater societal divides based on alignment with vaccine mandates and social distancing requirements. This paper briefly lays out the experiences of individuals in Aotearoa New Zealand related to public health messaging. METHODS: Adults in Aotearoa New Zealand participated in a mixed-methods study involving a survey (n=1,010 analysed results) and then semi-structured interviews with a subset of surveyed participants (38 participants). Results were thematically analysed. RESULTS: Participants highlighted two key areas related to public health messaging, these related to message consistency and the impact of messaging on wellbeing. Conclusions and public health implications: As the COVID-19 pandemic continues and further disrupts health service delivery and normal societal functioning, forward planning is needed to deliver more targeted messaging.

COVID-19 Pandemic Lockdown and Wellbeing: Experiences from Aotearoa New Zealand in 2020.

In 2020, in the first COVID-19 pandemic lockdown, Aotearoa New Zealand consistently maintained stringent public health measures including stay-at-home lockdowns and distancing responses. Considering the widespread disruption to social functioning caused by the pandemic, this paper aimed to explore environmental and social factors that influenced the wellbeing of individuals during the first lockdown in Aotearoa New Zealand. Our mixed-methods study involved a survey (n = 1010) and semi-structured interviews of a subset of surveyed individuals undertaken at the tail end of the first 2020 lockdown. Survey participants were recruited through social media-driven snowball sampling, less than 50% were aged under 45 years and 85% identified as female. Of those interviewed, 63% identified as female. Qualitative interview findings and open-ended survey results were analysed thematically. Participants described a variety of factors influencing wellbeing, largely related to the community and household; physical, behavioural, and lifestyle factors; access to health services; and social and economic foundations. While much of the focus of COVID-19 recovery was on reversing the economic and physical toll of the pandemic, our findings emphasise the need to empower individuals, families, and communities to mitigate the pandemic's negative implications on wellbeing.

Impact of removing prescription charges on health outcomes: protocol for a randomised controlled trial.

INTRODUCTION: Prescription charges prevent many people from accessing the medicines they need to maintain or improve their health. In New Zealand, where most people pay $5 per prescription item, Maori and Pacific peoples, those living in most deprived areas and those with chronic health conditions are the most likely to report that cost prevents them from accessing medicines. METHODS AND ANALYSIS: This randomised controlled trial (RCT) will evaluate the effect of removing prescription charges on health outcomes and healthcare utilisation patterns of people with low income and high health needs. We will enrol 2000 participants: half will be allocated to the intervention group and we will pay for their prescription charges for 12 months. The other half will receive usual care. The primary outcome will be hospital bed-days. Secondary outcomes will be: all-cause and diabetes/mental health-specific hospitalisations, prescription medicines dispensed (number and type), deaths, emergency department visits and quality of life as measured by the 5-level EQ-5D version. Costs associated with these outcomes will be compared in an economic substudy. A qualitative substudy will also help understand the impact of free prescriptions on participant well-being using in-depth interviews. DISCUSSION: Being unable to afford prescription medicines is only one of many factors that influence adherence to medicines, but removing prescription charges is relatively simple and in New Zealand would be cheap compared with other policy changes. This RCT will help identify the extent of the impact of a simple intervention to improve access to medicines on health outcomes and health service utilisation. ETHICS AND DISSEMINATION: This study was approved by the Central Health and Disability Ethics Committee (NZ) in July 2019 (19/CEN/33). Findings will be reported in peer-reviewed publications, as well as in professional newsletters, mainstream media and through public meetings. TRIAL REGISTRATION NUMBER: ACTRN12618001486213p.

Recruiting people facing social disadvantage: the experience of the Free Meds study.

BACKGROUND: Researching access to health services, and ways to improve equity, frequently requires researchers to recruit people facing social disadvantage. Recruitment can be challenging, and there is limited high quality evidence to guide researchers. This paper describes experiences of recruiting 1068 participants facing social disadvantage for a randomised controlled trial of prescription charges, and provides evidence on the advantages and disadvantages of recruitment methods. METHODS: Those living in areas of higher social deprivation, taking medicines for diabetes, taking anti-psychotic medicines, or with COPD were eligible to participate in the study. Several strategies were trialled to meet recruitment targets. We initially attempted to recruit participants in person, and then switched to a phone-based system, eventually utilising a market research company to deal with incoming calls. We used a range of strategies to publicise the study, including pamphlets in pharmacies and medical centres, media (especially local newspapers) and social media. RESULTS: Enrolling people on the phone was cheaper on average than recruiting in person, but as we refined our approach over time, the cost of the latter dropped significantly. In person recruitment had many advantages, such as enhancing our understanding of potential participants' concerns. Forty-nine percent of our participants are Maori, which we attribute to having Maori researchers on the team, recruiting in areas of high Maori population, team members' existing links with Maori health providers, and engaging and working with Maori providers. CONCLUSIONS: Recruiting people facing social disadvantage requires careful planning and flexible recruitment strategies. Support from organisations trusted by potential participants is essential. REGISTRATION: The Free Meds study is registered with the Australian and New Zealand Clinical Trials Registry ( ACTRN12618001486213 ).

Telehealth consultations in general practice during a pandemic lockdown: survey and interviews on patient experiences and preferences.

BACKGROUND: During the first COVID-19 pandemic 'lockdown' in Aotearoa/New Zealand (March-May 2020, in which strict 'stay at home' measures were introduced), general practices were advised to use telephone and video consultations (telehealth) wherever possible instead of the usual in-person visits. This was a sudden change for most practices and patients. This research aimed to explore how patients accessed general practice during lockdown and evaluate their experiences with telehealth, to inform how telehealth could be most effectively used in the future. METHODS: Using a mixed-method approach, we undertook an online survey and in-depth interviews with adults (> 18 years) who had contact with practices during lockdown, recruited through social media and email lists. We present descriptive statistics from the survey data (n = 1010) and qualitative analysis of interview data (n = 38) and open-ended survey questions, using a framework of access to health care, from the patient's perspective. RESULTS: In general, patients reported high satisfaction with telehealth in general practice during lockdown. Telehealth was convenient and allowed patients to safely access health care without having to weigh-up the fear of COVID-19 infection against the need to be seen. Telehealth worked best for routine and familiar health issues and when rapport was established between patients and clinicians. This was easier with a pre-existing clinical relationship, but not impossible without one. Telehealth was less suitable when a physical examination was needed, when the diagnosis was unknown or for patients who had a strong preference to be seen in-person. CONCLUSIONS: Even in this disruptive lockdown period, that prompted an unexpected and rapid implementation of telehealth services in general practices, most patients had positive experiences with telehealth. In the future, patients want the choice of consultation type to match their needs, circumstances, and preferences. Technological issues and funding barriers may need to be addressed, and clear communication for both patients and clinicians is needed about key aspects of telehealth (e.g. cost, appropriateness, privacy). Maintaining telehealth as an option post-lockdown has the potential to increase timely and safe access to primary health care for many patients.

School nursing in New Zealand: a study of services.

There are universal concerns about youth health and recognition of the potential of school health services but little consensus internationally as to how these are best configured. Limited information about nursing services in New Zealand secondary schools, changing patterns of youth health needs and expanding roles for nurses in primary health care indicated a need to research school nursing services. This study found that within New Zealand schools there was wide variation in the types of health services and their funding; that nurses are well qualified and highly experienced, although some lack clinical supervision; that students present most commonly for sexual health and injuries or sickness; and that they choose school health services for accessibility and confidentiality. It concludes that one way forward would be to develop a national-level policy for nurse-led school health centers, with appropriate funding, that allows for local flexibility and includes a career pathway for school nurses.

Pain, infection, and colds and flu: Samoan people's views about antibiotics.

BACKGROUND: Samoan people have access to and use both Western and traditional forms of healing. Little is known about their perceptions and use of healing agents. OBJECTIVES: To explore Samoan people's interpretation and use of a subset of Western medicines, namely, antibiotics, in Samoa and in New Zealand. METHODS: Semi-structured interviews were held with a purposeful sample of 31 Samoans, recruited through informal networks. Thematic analysis focused on understanding participants' perspectives on antibiotics using a phenomenological approach. Results from these interviews were used to develop a questionnaire administered to 232 Samoans recruited in health care facilities in Samoa and New Zealand. RESULTS: Participants were mostly females (57% of structured interview participants), and most (88%) were born in Samoa. Nearly half the sample had tertiary education. In Western terms, confusion about what antibiotics do and lack of clarity about which medicines are antibiotics were very common among the Samoan population. Antibiotics are commonly believed to be useful for colds and flu (75% of respondents) and were frequently used for these conditions. The distinctive features of the responses were the belief that antibiotics are pain killers (50%) and confusion between infection and pain. The confusion between antibiotics and pain killers may reflect a conflict between Samoan and Western concepts of illness. In the Samoan view, the lived experience of illness appears to be conflated with the illness itself; that is, pain is seen as an illness. CONCLUSIONS: The findings have implications for attempts to promote rational use of antibiotics either with individuals or as a part of public education campaigns. Such efforts may fail in some communities if they are based on the assumption that people share Western beliefs about what antibiotics are; what they do; and which illness have microbial, bacterial, or viral causes.

Navigating between illness paradigms: treatment seeking by Samoan people in Samoa and New Zealand.

There are substantial Samoan communities in New Zealand. Most Samoan people use both palagi (Western) and traditional Samoan health care. Western practitioners sometimes comment on Samoan patients' seemingly erratic patterns of seeking and using health care. Within a larger study on knowledge and the use of antibiotics, we carried out semistructured interviews with 31 Samoan people in Samoa and New Zealand.Accounts of participants' responses to illness and patterns of treatment seeking reveal how Samoan people draw on traditional and Western models of treatment and healing resources. Samoan people are very active interpreters of illness symptoms, using (at least) the two illness paradigms they know of to make sense of symptoms.These paradigms and systems of treatment are sometimes used experimentally, to determine whether illnesses are Samoan or Western. Symptom interpretation and decision making about treatment are done at the family level as well as the individual level. The individual might hold a particular view of what symptoms mean and what to do about them, but might not act on this if overruled or persuaded by other family members.

Understanding and use of antibiotics amongst Samoan people in New Zealand.

INTRODUCTION: Use of antibiotics is high in Samoa and this may affect the expectations and patterns of antibiotic use of Samoans in New Zealand. AIM: This study examined the understanding and reported use of antibiotics amongst Samoans in New Zealand. METHODS: In-depth interviews were held with 13 Samoans in New Zealand. These interviews were analysed and used to develop a questionnaire that was administered to 112 Samoans attending health care facilities in New Zealand. RESULTS: Many participants had little understanding of antibiotics. Less than 2% identified the correct purpose for antibiotics, and 66% thought they were used to relieve pain. Respondents regarded a wide range of medicines (including some which they regularly took) as antibiotics. They frequently attributed colds and flu to environmental conditions (96%), and regarded antibiotics as a useful treatment for them (81%). They reported stopping taking antibiotics before finishing the course. Very few (8%) were aware of antibiotic resistance. DISCUSSION: Health care practitioners cannot assume that patients share a Western scientific understanding of which illnesses are caused by microbes, or what antibiotics are or do. People may have significant confusion about the medicines they take. Samoans, whether they are born in New Zealand or not, may hold traditional Samoan views about health and illness.