Sustainable interprofessional education programmes: What influences teachers to stay involved?

Delivery of interprofessional education (IPE) initiatives for pre-licensure students is increasingly the norm in health and social care training programmes. This collaborative form of education relies on teachers from various disciplines joining together to facilitate IPE. When IPE programmes first start, goodwill often prevails and facilitators are keen to take part. But as time goes on, retaining the IPE facilitator workforce is challenging. Research was undertaken to explore the experience of IPE facilitators who were part of a New Zealand university-based ten year old IPE programme. The research used a qualitative survey approach. Responses were received from 29% of all those invited to participate. Closed questions were collated and free-text survey responses analyzed using Template Analysis. Three themes and one integrative theme were identified. Themes include facilitators who are recognized, facilitators who are confident, and facilitators who are inspired. Themes were mediated by macro, meso and micro level forces. The cross-cutting integrative theme showed IPE facilitators experienced individual tipping points, with the potential to influence their continued involvement. These tipping points need to be recognized and addressed by those in senior level positions (macro-governance and meso-management), to ensure IPE facilitators continue and IPE programmes remain sustainable.

Trusting me, trusting you: Creating conditions for successful pre-registration interprofessional education in rural New Zealand workplace settings.

There is a growing body of evidence supporting the provision of interprofessional education for pre-registration health science students. Furthermore, there is emergent evidence supporting the provision of interprofessional opportunities in rural workplaces. The strategies used by tertiary education providers in establishing and sustaining these rural interprofessional initiatives currently remain unclear, including how to foster authentic engagement with indigenous rural communities. This short commentary seeks to provide some practical guidance on how to successfully implement and maintain rural interprofessional experiences for pre-registration students.

How rural nurses in Southern New Zealand navigate their ethical landscape-A qualitative study.

OBJECTIVE: To explore rural nurse experiences of ethical issues and their management of these as a first step in a programme of work to address rural nurses' ethical needs. DESIGN: This study was qualitative, using mixed qualitative techniques to gather data, which was analysed using a general inductive approach. SETTING: Primary health care in 2 regions of Aotearoa New Zealand. PARTICIPANTS: Eleven nurses working in the West Coast (District Health Board) region and 9 working within the Southern District Health Board region. INTERVENTION: Participants took part in either a focus groups or an interview with members of the research team. MAIN OUTCOME MEASURES: To document ethical issues that confronted these rural nurses and how they navigated these issues. RESULTS: Three themes were identified: 'Signals and Silences,' 'One and Other' and 'Frustrations and Freedoms.' A continuous thread through these themes was the concept of phronesis, or what is sometimes called practical virtue. This practical virtue largely developed through their own experiences, rather than through educational or health system specific support or resources. CONCLUSIONS: We found that rural nurses' deal with specific issues related to the rural setting, such as resourcing and isolation, while maintaining a relationship with the communities they serve and their professional autonomy. Additionally, we discovered the ways in which rural nurses deal with the ethical issues they encounter to be practically focussed. However, rural nurses need supportive leadership not only to sustain the moral agency they demonstrate but also to further develop their ethical decision-making practices. The provision of a clinical ethics tele-service delivering both training opportunities and an on-call consult support service would provide a potential solution.

'I'm still here, that's probably the best part'. Lives of those living rurally with an implantable cardioverter defibrillator: a qualitative study.

INTRODUCTION: The use of implantable cardioverter defibrillators (ICDs) is increasing in both New Zealand and Australia. Also, both countries are experiencing an ageing of their rural populations. Much of the ICD literature focuses on the experience of those living in urban environments, with little known about the experiences of those living in rural contexts. This study aimed to answer the following questions: 'Does living rurally impact the ICD recipient experience and that of their partners?' and 'Can understanding their experiences inform best practice care for those living rurally with an ICD?' METHODS: This qualitative study employed purposive sampling and semi-structured interviews to produce rich narrative data. A general inductive approach was then used to analyse data, producing a series of coded themes through an iterative strategy, to generate an understanding of the rural lived experience after ICD implantation. Interpretations and conclusions were tested with participants at a debriefing meeting at the conclusion of the study. RESULTS: In total 14 ICD recipients and nine partners/carers/whānau (family) were interviewed. One recipient was Māori (indigenous New Zealander) and one female, and overall age range was 57-89 years. The length of time from ICD insertion varied from less than 1 year to 12 years. The final analysis highlighted the substantial role played by partners/carers of recipients. How this recipient-partner/carer dyad managed the post-ICD insertion experience was a major theme in this study. The perennial challenges of advance care planning and ICD deactivation conversation, unmet need for peer support and gaps in the provision of health-related information were all highlighted as challenges to these rural participants. The rural locale, however, posed limited challenges. Loss of a driving licence following receipt of shock therapy was irksome due to the unavailability of public transport but the impediment posed by the device on the practicalities of rural living, such as the need to use power tools and move electric fences, was, for some, more of an issue. CONCLUSION: This is one of the few studies that has considered the influence of rural location on the post-ICD insertion experience of patients and their partners/carers. ICD insertion did not appear to substantially negatively impact on the lives or experiences of rural recipients and their partners/carers. While this study did not set out to explore the role of informal carers who live rurally, the study findings suggest that female partners of rural ICD recipients undertake a significant role in terms of shouldering varying responsibilities including medication management, emotional support and transportation. As the age of ICD recipients increases, so does the age of their partners, therefore, they are also likely to be living with one or more long term conditions. Health professionals need to be aware of this additional burden as research suggests rural informal caregivers are less likely to report associated issues.

Health Care Utilisation and Health Needs of People with Severe COPD in the Southern Region of New Zealand: A Retrospective Case Note Review.

We examined health care utilisation and needs of people with severe COPD in the low-population-density setting of the Southern Region of New Zealand (NZ). We undertook a retrospective case note review of patients with COPD coded as having an emergency department attendance and/or admission with at least one acute exacerbation during 2015 to hospitals in the Southern Region of NZ. Data were collected and analysed from 340 case notes pertaining to: demographics, hospital admissions, outpatient contacts, pulmonary rehabilitation, advance care planning and comorbidities. Geometric mean (95%CI) length of stay for hospital admissions in urban and rural hospitals was 3.0 (2.7-3.4) and 4.0 (2.9-5.4) days respectively. More patients were from areas of higher deprivation but median hospital length of stay for patients from the least deprived areas was 2.0 days longer than others (p = 0.04). There was a median of 4 (range 0-16) comorbidities and 10 medications (range 0-25) per person. Of 169 cases where data was available, 26 (15%) were offered, 17 (10%) declined, and 5 (3%) completed, pulmonary rehabilitation at or in the year prior to the index admission. Patients were less likely to be offered pulmonary rehabilitation if they lived >20km away from the hospital where it took place (odds ratio of 0.12 for those living further away [95%CI 0.02-0.93, p = 0.04]). There were deficits in care: provision and uptake of non-pharmacological interventions was suboptimal and unevenly distributed across the region. Further research is needed to develop and evaluate strategies for delivering non-pharmacological interventions in this setting.

Establishing gold standards for System-Level Measures: a modified Delphi consensus process.

OBJECTIVE: To establish aspirational 'gold standards' for a suite of System-Level Measures (SLMs) being used by Counties Manukau Health (CM Health), a New Zealand (NZ) District Health Board. DESIGN: This study employed a multi-stage, multi-method modified Delphi consensus process. SETTING: The Delphi consensus process involved virtual (email) communication between participants (Round 1) and a structured face-to-face meeting (Round 2) held in Auckland, NZ. PARTICIPANTS: Participants comprised of health professionals, managers, academics and quality improvement experts with an interest in the use of SLMs. INTERVENTIONS: Participants in the first round received a letter requesting their participation in an anonymous Delphi. The second round involved national and international health system experts taking part in a structured, facilitated face-to-face meeting. Participants reviewed 15 SLMs in total. The SLMs all related to the three domains of the Triple Aim: Population Health, e.g. life expectancy at birth; Patient Experience of Care, e.g. rate of adverse events; and Cost and Productivity, e.g. healthcare expenditure per capita. MAIN OUTCOME MEASURES: For a proposed gold standard to be agreed and established for each SLM. RESULTS: Twelve participants took part in Round 1, with 19 participating in Round 2. The process established agreement on a gold standard for each of the 15 reviewed SLMs. CONCLUSION: We demonstrated that the Delphi consensus process can be used to establish gold standards for a suite of SLMs used by a NZ Health Board (CM Health).

Multimorbidity, clinical decision making and health care delivery in New Zealand Primary care: a qualitative study.

BACKGROUND: Multimorbidity is a major issue for primary care. We aimed to explore primary care professionals' accounts of managing multimorbidity and its impact on clinical decision making and regional health care delivery. METHODS: Qualitative interviews with 12 General Practitioners and 4 Primary Care Nurses in New Zealand's Otago region. Thematic analysis was conducted using the constant comparative method. RESULTS: Primary care professionals encountered challenges in providing care to patients with multimorbidity with respect to both clinical decision making and health care delivery. Clinical decision making occurred in time-limited consultations where the challenges of complexity and inadequacy of single disease guidelines were managed through the use of "satisficing" (care deemed satisfactory and sufficient for a given patient) and sequential consultations utilising relational continuity of care. The New Zealand primary care co-payment funding model was seen as a barrier to the delivery of care as it discourages sequential consultations, a problem only partially addressed through the use of the additional capitation based funding stream of Care Plus. Fragmentation of care also occurred within general practice and across the primary/secondary care interface. CONCLUSIONS: These findings highlight specific New Zealand barriers to the delivery of primary care to patients living with multimorbidity. There is a need to develop, implement and nationally evaluate a revised version of Care Plus that takes account of these barriers.

Codesigning a Community Health Navigator program to assist patients to transition from hospital to community.

Background This study aimed to identify the potential roles for Community Health Navigators (CHNs) in addressing problems faced by patients on discharge from hospital to the community, and attitudes and factors which may influence their adoption. Methods Twenty-six qualitative interviews and an online codesign workshop were conducted with patients, nurses, general practice staff, health service managers, community health workers, general practitioners, medical specialists, and pharmacists in the Sydney Local Health District. Qualitative themes from the interviews and workshop transcripts were analysed inductively and subsequently grouped according to a socio-ecological model. Results CHNs could assist patients to navigate non-clinical problems experienced by patients on discharge through assessing needs, establishing trust, providing social and emotional support that is culturally and linguistically appropriate, engaging family and carers, supporting medication adherence, and helping to arrange and attend follow up health and other appointments. Important factors for the success of the CHNs in the performance and sustainability of their roles were the need to establish effective communication and trust with other healthcare team members, be accepted by patients, have access to information about referral and support services, receive formal recognition of their training and experience, and be supported by appropriate supervision. Conclusions This study was unique in exploring the potential role of CHNs in addressing problems faced by patients on discharge from Australian hospitals and the factors influencing their adoption. It informed training and supervision needs and further research to evaluate CHNs' effectiveness and the acceptance of their role within the healthcare team.

Evolution of a health navigator model of care within a primary care setting: a case study.

OBJECTIVE: Patient navigation originated as an approach for reducing disparities in cancer care and consequent health outcomes. Over time navigator models have evolved and been used to address various health issues in differing contexts. This case study outlines the evolution, purpose and effects of a lay-led health navigator model in a deprived, sparsely populated, New Zealand rural setting, where primary care services are frequently understaffed and routinely overstretched. METHODS: Routinely collected service utilisation data, survey results and health navigator interview data were utilised to illustrate the client group the service works with, why primary care refer to the service, as well as lessons learned from implementation to ongoing service provision. RESULTS: Those referred to the navigator service generally represented the most vulnerable in the community. Survey respondents, overall, were highly satisfied with the service. Navigators identified barriers and facilitators to implementation, as well as ongoing obstacles and enablers to service provision. CONCLUSIONS: This lay-led navigator service provided support to a group of unwell individuals, with few resources and multiple barriers to negotiate, and has effectively engaged with health and social care services, while overcoming various barriers and obstacles to its establishment and ongoing operation.

How did New Zealand's regional District Health Board groupings work to improve service integration and health outcomes: a realist evaluation.

OBJECTIVES: In Aotearoa New Zealand (NZ), integration across the healthcare continuum has been a key approach to strengthening the health system and improving health outcomes. A key example has been four regional District Health Board (DHB) groupings, which, from 2011 to 2022, required the country's 20 DHBs to work together regionally. This research explores how this initiative functioned, examining how, for whom and in what circumstances regional DHB groupings worked to deliver improvements in system integration and health outcomes and equity. DESIGN: We used a realist-informed evaluation study design. We used documentary analysis to develop programme logic models to describe the context, structure, capabilities, implementation activities and impact of each of the four regional groupings and then conducted interviews with stakeholders. We developed a generalised context-mechanisms-outcomes model, identifying key commonalities explaining how regional work 'worked' across NZ while noting important regional differences. SETTING: NZ's four regional DHB groupings. PARTICIPANTS: Forty-nine stakeholders from across the four regional groupings. These included regional DHB governance groups and coordinating regional agencies, DHB senior leadership, Maori and Pasifika leadership and lead clinicians for regional work streams. RESULTS: Regional DHB working was layered on top of an already complex DHB environment. Organisational heterogeneity and tensions between local and regional priorities were key contextual factors. In response, regional DHB groupings leveraged a combination of 'hard' policy and planning processes, as well as 'soft', relationship-based mechanisms, aiming to improve system integration, population health outcomes and health equity. CONCLUSION: The complexity of DHB regional working meant that success hinged on building relationships, leadership and trust, alongside robust planning and process mechanisms. As NZ reorients its health system towards a more centralised model underpinned by collaborations between local providers, our findings point to a need to align policy expectations and foster environments that support connection and collegiality across the health system.

Doctors' experiences of providing care in rural hospitals in Southern New Zealand: a qualitative study.

OBJECTIVE: To explore rural hospital doctors' experiences of providing care in New Zealand rural hospitals. DESIGN: The study had a qualitative design, using qualitative content analysis. SETTING: The study was conducted in South Island, New Zealand, and included nine different rural hospitals. RESPONDENTS: Semistructured interviews were conducted with 16 rural hospital doctors. RESULTS: Three themes were identified: 'Applying a holistic perspective in the care', 'striving to maintain patient safety in sparsely populated areas' and 'cooperating in different teams around the patient'. Rural hospital care more than general hospital care was seen as offering a holistic perspective on patient care based on closeness to their home and family, the generalist perspective of care and personal continuity. The presentation of acute life-threatening low-frequency conditions at rural hospitals were associated with feelings of concern due to limited access to ambulance transportation and lack of experience.Overall, however, patient safety in rural hospitals was considered equal or better than in general hospitals. Doctors emphasised the central role of rural hospitals in the healthcare pathways of rural patients, and the advantages and disadvantages with small non-hierarchical multidisciplinary teams caring for patients. Collaboration with hospital specialists was generally perceived as good, although there was a sense that urban colleagues do not understand the additional medical and practical assessments needed in rural compared with the urban context. CONCLUSIONS: This study provides an understanding of how rural hospital doctors value the holistic generalist perspective of rural hospital care, and of how they perceive the quality and safety of that care. The long distances to general hospital care for acute cases were considered concerning.

Implementation of the Diabetes Community Exercise and Education Programme (DCEP) for the management of type 2 diabetes: qualitative process evaluation.

OBJECTIVES: To examine context-specific delivery factors, facilitators and barriers to implementation of the Diabetes Community Exercise and Education Programme (DCEP) for adults with type 2 diabetes (T2D) using the Reach, Effectiveness, Adoption, Implementation and Maintenance framework. DESIGN: A qualitative evaluation embedded within the DCEP pragmatic randomised controlled trial. Data collected via focus groups and interviews and analysed thematically. SETTING: Community-based in two cities (Dunedin and Invercargill) in the lower south island of New Zealand. PARTICIPANTS: Seventeen adults diagnosed with T2D attending DCEP and 14 healthcare professionals involved in DCEP delivery. INTERVENTION: DCEP is a twice weekly session of exercise and education over 12 weeks, followed by a twice weekly ongoing exercise class. RESULTS: While our reach target was met (sample size, ethnic representation), the randomisation process potentially deterred Maori and Pasifika from participating. The reach of DCEP may be extended through the use of several strategies: promotion of self-referral, primary healthcare organisation ownership and community champions. DCEP was considered effective based on perceived benefit. The social and welcoming environment created relationships and connections. People felt comfortable attending DCEP and empowered to learn. Key to implementation and adoption was the building of trusting relationships with local health providers and communities. This takes time and care and cannot be rushed. Training of staff and optimising communication needed further attention. To maintain DCEP, delivery close to where people live and a generic approach catering for people with multiple chronic conditions may be required. CONCLUSIONS: For success, lifestyle programmes such as DCEP, need time and diligence to build and maintain networks and trust. Beyond frontline delivery staff and target populations, relationships should extend to local healthcare organisations and communities. Access and ongoing attendance are enabled by healthcare professionals practicing in a nuanced person-centred manner; this, plus high staff turnover, necessitates ongoing training. TRIAL REGISTRATION NUMBER: ACTRN12617001624370.

What do they get out of it? Considering a partnership model in health service research.

A research study to evaluate the implementation of a long-term conditions model of care provoked questions regarding the potential impact of the researcher's role in health service research. Traditional methods of qualitative interviewing require researchers to be a disembodied presence, objective, and free from bias. When health service research is conducted by health professionals, role conflict may occur if the topic is one they have expertise in, and therefore the ability to provide guidance or information. An alternative perspective to the idea of an independent and objective researcher is the notion of a partnership. In this research collaboration, participants utilised the interview process to reflect and explore different perspectives, and the researcher bracketed their own participation in the phenomenon being studied. Reflexivity was utilised by both participants and the interviewer to ensure transparency and thus bridge the gap between subjectivity and objectivity in qualitative health service research interviewing.

What is the answer to the challenge of multimorbidity in New Zealand?

The increasing prevalence of multimorbidity, a growing ageing population and lack of success in addressing the negative effect of socioeconomic and cultural determinants of health are major challenges for New Zealand's primary care sector. Self-management support strategies, personalised care planning, integrated care and shared health records have all been proposed as mechanisms to address these challenges. The organisation of the health system, however, remains largely unchanged, with limited accommodation and few funding concessions made for the requirements of these different approaches and tools. As a result, the primary care system is no longer a good match for the population it serves. With one in four New Zealanders reporting multimorbidity, and people aged >65 years predicted to double in number by 2050, this article argues that over the next decade, New Zealand requires a health system focused on incorporating self-management support, personalised and integrated care and shared health records. This will require further educating of not only health professionals, but also patients in the purpose behind these approaches. In addition, it will mean transitioning to a primary care system more suited to the needs of people with long-term conditions. The key gain from a radical redesign will be a more equitable health system focused on a broader range of health needs.

Patients' accounts of living with and managing inflammatory bowel disease in rural Southern New Zealand: a qualitative study.

OBJECTIVE: To explore how adults living with inflammatory bowel disease (IBD) in rural New Zealand manage their condition and engage with healthcare providers. DESIGN: Qualitative exploratory design with semi-structured interviews analysed thematically. SETTING AND PARTICIPANTS: Interviews were conducted with 18 people living with IBD in the Otago region of the South Island. RESULTS: Five important constructs were identified: (1) journey to confirming and accepting diagnosis; (2) importance of the relationship with the healthcare team; (3) support from others; (4) learning how to manage IBD and (5) care at a distance-experiences of rurality. Pathways to confirming diagnosis involved two contrasting journeys: a long and slow process where diagnosis remained unclear for a prolonged period, and a more acute process where diagnosis typically came as a shock. Central to the acceptance process was acknowledging the chronicity of the condition, which involved feelings of grief but also the fear of judgement and stigma. Building a strong relationship with the specialist was central to medical management, particularly in the initial stage following diagnosis. Support from others was critical, enabling participants to progress through acceptance of the disease and developing confidence in its everyday management. Participants shared different strategies on how to manage IBD, describing a 'trial and error' process of 'finding what is right' at different stages of the condition. Managing IBD rurally involved challenges of access to specialist care, with perceptions of delayed referrals and concerns about disparities in specialist access compared with urban counterparts. Rural living also had financial implications-cost of time and cost of mobilising resources for long travels to the urban centre for treatments. CONCLUSIONS: Findings from this study provide a rich understanding of the complex health journeys of people living with IBD and the challenges of managing the condition rurally.

'A balancing act'. Living with severe chronic obstructive pulmonary disease in Southern New Zealand: a qualitative study.

INTRODUCTION Chronic obstructive pulmonary disease (COPD) is a common chronic condition managed in primary care. AIM To understand how patients with severe COPD living in the Southern Health Region (Otago and Southland) experience and cope with the condition. METHODS Semi-structured interviews were undertaken with 23 patients with severe COPD (defined using the 2013 GOLD classification). A thematic analysis was conducted. RESULTS Patients' accounts of living with severe COPD revealed four themes: loss, adaptation, isolation and social support. All participants discussed their sense of loss in coming to terms with having COPD and the ongoing restrictions or changes that were associated with breathlessness and fatigue. These losses required adaptation in daily living. Some patients struggled to adjust to new limitations and needed to rely on others for support. Others found ways to adapt their surroundings or ways of doing things while trying to maintain the same activities. Isolation was described in two ways - direct (no longer being able to easily socialize because activities often caused breathlessness) and indirect (the feeling of being isolated from others because they do not understand what it is like to live with COPD). Social support, including support provided by group-based pulmonary rehabilitation, helped to address the problems of social isolation. DISCUSSION Living with severe COPD is a 'balancing act' between insecurity (loss and isolation) and resilience (adaptation and social support). Health-care providers need to be proactive in identifying and managing patients' unmet health needs and promote activities that reduce social isolation.

Supporting ageing well research: Findings from a research priority setting exercise.

OBJECTIVE: This paper describes a workshop process conducted to guide funding priorities for the Ageing Well National Science Challenge in New Zealand (NZ). METHODS: Based on the Checklist for Health Research Priority Setting, stakeholders networking workshops were conducted in five main cities in NZ (n = 133 attendees). Each workshop involved an introductory presentation; small group work exploring the a priori areas of: mind health, social well-being, health services and age-friendly environments; capturing key ideas on flip charts; feedback; and discussion of documented content. RESULTS: Suggested strategies to address these issues incorporated reduction in segregated "villages," delivery of integrated care and provision of age-friendly transport. Proposed examples of monitoring impact included increased tertiary participation by older people and presence of more housing options. CONCLUSION: Actively engaging older adults and community stakeholders in setting research priorities provided a unique opportunity to understand the key areas older adults think important for future research.

Men living with obesity in New Zealand: What does this mean for health care in general practice?

INTRODUCTION: More men than women live with overweight and obesity in New Zealand, yet we know little about their everyday lives or their weight management experiences in primary care. This study sought to link the weight management experiences of these men in primary care, with their experiences of life in general as big men. METHODS: Semi-structured interviews with participants selected purposively based on a priori criteria were conducted. Interviews were either face to face or via telephone. Interviews were digitally recorded and transcribed and text coded into a priori codes where established. RESULTS: Fourteen men were interviewed. Analysis of text data revealed three overarching themes. The first, social experience of life as a big man highlighted the significance of social transitions as times of weight gain. The second theme related to experiences of weight management in primary care, with communication the largest sub-theme. Finally, stigma materialised as a key and widespread issue. CONCLUSION: Scant attention has been paid to the experiences of overweight and obese men in primary care or the impact of their size on their daily lives. Effective, tailored communication by health professionals in primary care is sorely needed. Times of social transition can be exploited as appropriate instances to offer advice on effective strategies to reduce the risk of weight gain. Men also need to be made aware of their vulnerability for weight gain at these times through effective, gender specific health promotion messages. The widespread nature of stigmatising experiences within personal networks was a concerning finding.

Protocol for a randomised controlled trial to evaluate the effectiveness of the diabetes community exercise and education programme (DCEP) for long-term management of diabetes.

INTRODUCTION: Type 2 diabetes is common in Maori and Pacific peoples and in those living in areas of high socioeconomic deprivation in New Zealand (NZ). People with type 2 diabetes often have multimorbidity, which makes their diabetes management more complex. The Diabetes Community Exercise and Education Programme (DCEP) is an interprofessional, patient-centred, whanau (family)-supported package of care specifically developed to engage with Maori and Pacific people and those living in deprived areas. We have previously demonstrated the feasibility and acceptability of the DCEP. This study aims to determine the effectiveness and cost-effectiveness of the DCEP through a pragmatic randomised controlled trial (RCT). METHODS AND ANALYSIS: 220 adults (age ≥35 years) with type 2 diabetes will be recruited from general practices in the lower South Island of NZ (Dunedin and Invercargill) to participate in an RCT. Participants will be randomised to intervention (DCEP) and control (usual care) groups. The DCEP participants will have their exercise goals agreed on with a physiotherapist and nurse and will attend two 90 min exercise and education sessions per week for 12 weeks. The primary outcome measure is blood glucose control (glycated haemoglobin). Secondary outcome measures include quality of life assessed using the Audit of Diabetes-Dependent Quality of Life questionnaire. Data will be collected at four time points: baseline, end of the 12-week intervention (3 months), 6 months postintervention (9 months) and 12 months after the intervention ends (15 months). We will also conduct a cost-effectiveness analysis and a qualitative process evaluation. ETHICS AND DISSEMINATION: The study has been approved by the Health and Disability Ethics Committee, Ministry of Health (HDEC17/CEN/241/AM01). A key output will be the development of an evidence-based training package to facilitate implementation of the DCEP in other NZ regions. TRIAL REGISTRATION NUMBER: ACTRN 12617001624370 p; Pre-results.

Protocol for a mixed methods realist evaluation of regional District Health Board groupings in New Zealand.

INTRODUCTION: Achieving effective integration of healthcare across primary, secondary and tertiary care is a key goal of the New Zealand (NZ) Health Strategy. NZ's regional District Health Board (DHB) groupings are fundamental to delivering integration, bringing the country's 20 DHBs together into four groups to collaboratively plan, fund and deliver health services within their defined geographical regions. This research aims to examine how, for whom and in what circumstances the regional DHB groupings work to improve health service integration, healthcare quality, health outcomes and health equity, particularly for Maori and Pacific peoples. METHODS AND ANALYSIS: This research uses a mixed methods realist evaluation design. It comprises three linked studies: (1) formulating initial programme theory (IPT) through developing programme logic models to describe regional DHB working; (2) empirically testing IPT through both a qualitative process evaluation of regional DHB working using a case study design; and (3) a quantitative analysis of the impact that DHB regional groupings may have on service integration, health outcomes, health equity and costs. The findings of these three studies will allow refinement of the IPT and should lead to a programme theory which will explain how, for whom and in what circumstances regional DHB groupings improve service integration, health outcomes and health equity in NZ. ETHICS AND DISSEMINATION: The University of Otago Human Ethics Committee has approved this study. The embedding of a clinician researcher within a participating regional DHB grouping has facilitated research coproduction, the research has been jointly conceived and designed and will be jointly evaluated and disseminated by researchers and practitioners. Uptake of the research findings by other key groups including policymakers, Maori providers and communities and Pacific providers and communities will be supported through key strategic relationships and dissemination activities. Academic dissemination will occur through publication and conference presentations.