Patient experiences and perspectives of health service access for carpal tunnel syndrome in Aotearoa New Zealand: a normalisation process theory-informed qualitative study.

BACKGROUND: Early access to care for carpal tunnel syndrome (CTS) can avoid higher rates of surgery and permanent harm yet is often delayed, particularly for populations more likely to underutilise care. OBJECTIVE: We sought to explore patient experiences and perspectives of health service access for CTS to inform an equity-focussed co-design of a health service for improving early care access. METHODS: In this Normalisation Process Theory (NPT)-informed qualitative study we conducted semistructured in-depth interviews with 19 adults with experience of CTS. Recruitment prioritised New Zealand Maori, Pasifika, low-income, and rural populations. Data were analysed using deductive then inductive thematic analysis. RESULTS: We identified five major themes: (1) the 'Significant Impact of CTS' of the sense-making and relational work to understand the condition, deciding when to get care, compelling clinicians to provide care, and garnering help from others; (2) 'Waiting and Paying for Care'- the enacting, relational, and appraising work to avoid long wait times unless paying privately, particularly where quality of care was low, employment relations poor, or injury compensation processes faltered; (3) circumstances of 'Occupation and CTS Onset' whereby the burden of proof to relate onset of CT symptoms to occupation created excessive relational and enacting work; (4) the 'Information Scarcity' of good information about CTS and the high relational and appraising work associated with using online resources; (5) 'Negotiating Telehealth Perspectives' where telehealth was valued if it meant earlier access for all despite the challenges it held for many. CONCLUSION: Quality, culturally and linguistically responsive information and communication from clinicians and health services will improve equitable early access to CTS care including realising the potential of telehealth modes of care. Policy changes that reduce individual burden of proof in injury compensation claims processes, enable time off work to attend health appointments, and increase public funding for surgical resources would improve early access to CTS care particularly for Maori and Pacific populations and those in small and rural workplaces. NPT is valuable for understanding where opportunities lie to reduce inequitable delays to accessing care including the impact of racism, particularly for populations more likely to underutilise care.

Non-invasive ventilation for people with neuromuscular disorders in Australia and New Zealand: a qualitative study of clinician perspectives.

OBJECTIVES: To explore the experiences of Australian and New Zealand clinicians with respect to care pathways, their awareness and use of non-invasive ventilation guidelines, and their perspectives on delivering quality non-invasive ventilation services to people with neuromuscular disorders. DESIGN, SETTING, PARTICIPANTS: Qualitative study; semi-structured focus groups and individual interviews with Australian and New Zealand clinicians who provide non-invasive ventilation services to people with neuromuscular disorders, recruited from participants at a 2017 sleep medicine conference. Interviews were conducted during 1 October 2017 - 31 May 2018. MAIN OUTCOME MEASURES: Major themes identified by an iterative, semantic, and inductive analysis. RESULTS: A total of 28 participants attended the four focus group sessions and five individual interviews; fourteen each from New Zealand and Australia, seventeen women and eleven men, eighteen physicians and ten other clinicians. Two major themes were identified: decision making for current practice, and resource constraints. Participants noted variable use of clinical guidelines and limited training to meet the needs of people with neuromuscular disorders who require non-invasive ventilation. They described a lack of dedicated funding, unstructured care pathways, equipment supply levels that do not meet need, low staff-to-patient ratios and staff shortages, and the inability to deliver quality multidisciplinary care. The need for clinical guidelines and service specifications was highlighted as requisite for reducing variation in clinical care. CONCLUSIONS: Systemic factors influence the needs-based provision of non-invasive ventilation for people with neuromuscular disorders. Development of clinical guidelines for Australia and New Zealand, dedicated funding for respiratory services for people with neuromuscular disorders, and specialist clinician training are important for equitable and high quality non-invasive ventilation care.

Noninvasive ventilation in New Zealand: a national prevalence survey.

BACKGROUND: Home-based noninvasive ventilation (NIV) is an effective treatment for a range of conditions that cause respiratory failure which reduces hospitalisation and mortality and improves quality of life. AIMS: To collect NIV prevalence, disease burden and equity data needed for effective national NIV health service planning. METHODS: The authors collected demographics and the primary diagnosis of patients receiving publicly funded NIV in New Zealand in 2018 by surveying all providers. National and regional prevalence rates were calculated using adult population data (aged ≥20 years) for each District Health Board region compared with a 2011 study. A subanalysis of individual-level data was used to calculate age-standardised rates by diagnostic category. RESULTS: A total of 1197 adults were receiving NIV giving a national rate of 32.9 per 100 000; almost twice the 2011 rate (16.7 per 100 000). Significant regional variations in NIV provision (4.5-84.2 per 100 000) were observed. The most frequent indications were obesity hypoventilation syndrome (OHS) (562, 47%), obstructive pathologies (335, 28%) and neuromuscular disorders (175, 15%); all have significantly increased in prevalence since 2011. Maori and Pacific peoples were significantly overrepresented among NIV users (2.24 [95% confidence interval (CI), 1.72-2.93] and 7.03 [95% CI, 5.52-8.94], respectively). The prevalence of NIV-dependent use (>15 h/day) was 4%. CONCLUSIONS: Home-based NIV provision has doubled since the previous survey, reflecting increased burden from OHS and obstructive pathologies and a disproportionate disease burden among Maori and Pacific populations. The large regional variations are concerning and highlight the urgent requirement for national service specifications, education and equipment provision. Further research is needed to address access equity.

Forming inter-institutional partnerships to offer pre-registration IPE: a focus group study.

Interprofessional education (IPE) programs for pre-registration health science students are largely offered within one institution including different schools or faculties. Sometimes in small or regional institutions where there are limited student numbers or few professional training programs, or where larger institutions do not offer particular professional programs, it may be necessary to partner with other institutions to offer IPE. This study sought to explore teacher perspectives of forming inter-institutional partnerships to deliver IPE, in particular, to identify the elements that influence the formation of partnerships. An interpretive descriptive approach was used to thematically analyze data from three focus groups with teachers (n = 21) working in three different partnerships to deliver IPE to students in Wellington, New Zealand. Two main themes were identified which enabled the development of a model of partnership, with a continuum of complexity depending on whether institutions were on the same page and whether the partnership formed to join an existing IPE program or to create a new IPE program. Forming inter-institution partnerships is a pragmatic solution to providing IPE with benefits to all taking part. Our work showed that time, effort, working with complexity, and ability to stay on the same page are necessary elements for building successful partnerships and all need to be taken into account when planning inter-institution partnerships.

Putting Physical Activity While Experiencing Low Back Pain in Context: Balancing the Risks and Benefits.

OBJECTIVE: To analyze attitudes and beliefs about movement and physical activity in people with low back pain (LBP) and compare these beliefs between people with acute and chronic LBP. DESIGN: Qualitative inductive analysis of data collected via face-to-face semistructured interviews. Interviews were audio-recorded and transcribed verbatim. SETTING: Participants were purposively recruited from 1 region of New Zealand. PARTICIPANTS: Persons with LBP (N=23), consisting of individuals with acute LBP (<6wk; n=12) and chronic LBP (>3mo; n=11). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURE: Themes that emerged from participant interview transcripts using analysis based on Interpretative Description. RESULTS: Participants with acute and chronic LBP made judgments about physical activity and rest using the same conceptual model. Concerns about creating more pain, tissue damage, or impairment influenced the physical activity judgments of most participants with acute and chronic LBP. These perceived risks were balanced against the perceived benefits, the most important of which were psychological or social rather than physical. Judgments made by those with acute and chronic LBP were context dependent and influenced by the nature and duration of pain, the type of physical activity, the importance of the activity, and the participant's previous experience. Participants with acute pain who had not experienced back pain previously often expressed more uncertainty, whereas those with chronic LBP appeared to have developed cognitive rules that determined physical activity decisions. CONCLUSIONS: Exploring the perceived risks, benefits, and contextual factors that influence decisions about physical activity and rest may help clinicians to understand the behavior of patients with acute and chronic LBP. Clinicians may best support their patients to engage in physical activity by providing an informed assessment of risks and an explanation about the range of potential benefits.

What makes an interprofessional education programme meaningful to students? Findings from focus group interviews with students based in New Zealand.

It is important to understand what an interprofessional education (IPE) experience means to students and what makes it meaningful so that optimal use can be made of IPE opportunities and resources. This article reports qualitative data from a larger study evaluating an 11-hour IPE programme which focused on long-term condition management. Qualitative analysis aimed to explore students' perspectives of the programme. Forty-one students from dietetics, medicine, physiotherapy, and radiation therapy were invited to participate in interprofessional focus groups. Data gathered from 34 students who participated in two focus groups were analysed inductively using thematic analysis. Three key themes emerged related to (i) learning, (ii) perceived long-term professional benefits, and (iii) the structure and content of the programme. Participants considered the programme to be a valuable learning opportunity with direct relevance to their future clinical careers. Findings indicated that providing students with an opportunity to learn about each other should be prioritised within IPE programmes and that this process should be student-led. This may help students to effectively learn with and from each other. Students perceived active learning activities, including interviewing a patient in their home and presenting findings to their peers, to be particularly valuable.

The positive impact of interprofessional education: a controlled trial to evaluate a programme for health professional students.

BACKGROUND: Collaborative interprofessional practice is an important means of providing effective care to people with complex health problems. Interprofessional education (IPE) is assumed to enhance interprofessional practice despite challenges to demonstrate its efficacy. This study evaluated whether an IPE programme changed students' attitudes to interprofessional teams and interprofessional learning, students' self-reported effectiveness as a team member, and students' perceived ability to manage long-term conditions. METHODS: A prospective controlled trial evaluated an eleven-hour IPE programme focused on long-term conditions' management. Pre-registration students from the disciplines of dietetics (n = 9), medicine (n = 36), physiotherapy (n = 12), and radiation therapy (n = 26) were allocated to either an intervention group (n = 41) who received the IPE program or a control group (n = 42) who continued with their usual discipline specific curriculum. Outcome measures were the Attitudes Toward Health Care Teams Scale (ATHCTS), Readiness for Interprofessional Learning Scale (RIPLS), the Team Skills Scale (TSS), and the Long-Term Condition Management Scale (LTCMS). Analysis of covariance compared mean post-intervention scale scores adjusted for baseline scores. RESULTS: Mean post-intervention attitude scores (all on a five-point scale) were significantly higher in the intervention group than the control group for all scales. The mean difference for the ATHCTS was 0.17 (95 %CI 0.05 to 0.30; p = 0.006), for the RIPLS was 0.30 (95 %CI 0.16 to 0.43; p < 0.001), for the TSS was 0.71 (95 %CI 0.49 to 0.92; p < 0.001), and for the LTCMS was 0.75 (95 %CI 0.56 to 0.94; p < 0.001). The mean effect of the intervention was similar for students from the two larger disciplinary sub-groups of medicine and radiation therapy. CONCLUSIONS: An eleven-hour IPE programme resulted in improved attitudes towards interprofessional teams and interprofessional learning, as well as self-reported ability to function within an interprofessional team, and self-reported confidence, knowledge, and ability to manage people with long-term conditions. These findings indicate that a brief intervention such as this can have immediate positive effects and contribute to the development of health professionals who are ready to collaborate with others to improve patient outcomes.

Acute low back pain management in general practice: uncertainty and conflicting certainties.

BACKGROUND: Low back pain (LBP) is a significant health problem and common reason to visit the GP. Evidence suggests GPs experience difficulty applying evidence-based guidelines. OBJECTIVE: Explore GPs' underlying beliefs about acute LBP and how these influence their clinical management of patients. METHODS: Eleven GPs from one geographical region within New Zealand were recruited by purposive sampling. Audio recordings of semi-structured qualitative interviews were transcribed verbatim. Data were analysed with an Interpretive Description framework. RESULTS: Four key themes emerged related to the causes of acute LBP, GP confidence, communicating diagnostic uncertainty and encouraging movement and activity. Acute LBP was seen as a direct representation of tissue injury, consequently the assessment and management of patients' attitudes and beliefs was not a priority. Participants' confidence was decreased due to a perceived inability to diagnose or influence the tissue injury. Despite this, diagnoses were provided to patients to provide reassurance and meet expectations. Guideline recommendations regarding activity conflicted with a perceived need to protect damaged tissue, resulting in reported provision of mixed messages about the need to be both active and careful. CONCLUSIONS: GPs' initial focus upon tissue injury during acute care, and providing a diagnostic label, may influence patients' subsequent alignment with a biomedical perspective and contribute to consultation conflict and patients' perception of blame when discussion of psychosocial influences is introduced. Demonstrating the relevance of the biopsychosocial model to acute LBP may improve GPs' alignment with guidelines, improve their confidence to manage these patients and ultimately improve outcomes.

Geographic accessibility to physiotherapy care in Aotearoa New Zealand.

Disparities in care access for health conditions where physiotherapy can play a major role are abetting health inequities. Spatial analyses can contribute to illuminating inequities in health yet the geographic accessibility to physiotherapy care across New Zealand has not been examined. This population-based study evaluated the accessibility of the New Zealand physiotherapy workforce relative to the population at a local scale. The locations of 5,582 physiotherapists were geocoded and integrated with 2018 Census data to generate 'accessibility scores' for each Statistical Area 2 using the newer 3-step floating catchment area method. For examining the spatial distribution and mapping, accessibility scores were categorized into seven levels, centered around 0.5 SD above and below the mean. New Zealand has an above-average physiotherapy-to-population ratio compared with other OECD countries; however, this workforce is maldistributed. This study identified areas (and locations) where geographic accessibility to physiotherapy care is relatively low.

The enduring impact of what clinicians say to people with low back pain.

PURPOSE: The purpose of this study was to explore the formation and impact of attitudes and beliefs among people experiencing acute and chronic low back pain. METHODS: Semistructured qualitative interviews were conducted with 12 participants with acute low back pain (less than 6 weeks' duration) and 11 participants with chronic low back pain (more than 3 months' duration) from 1 geographical region within New Zealand. Data were analyzed using an Interpretive Description framework. RESULTS: Participants' underlying beliefs about low back pain were influenced by a range of sources. Participants experiencing acute low back pain faced considerable uncertainty and consequently sought more information and understanding. Although participants searched the Internet and looked to family and friends, health care professionals had the strongest influence upon their attitudes and beliefs. Clinicians influenced their patients' understanding of the source and meaning of symptoms, as well as their prognostic expectations. Such information and advice could continue to influence the beliefs of patients for many years. Many messages from clinicians were interpreted as meaning the back needed to be protected. These messages could result in increased vigilance, worry, guilt when adherence was inadequate, or frustration when protection strategies failed. Clinicians could also provide reassurance, which increased confidence, and advice, which positively influenced the approach to movement and activity. CONCLUSIONS: Health care professionals have a considerable and enduring influence upon the attitudes and beliefs of people with low back pain. It is important that this opportunity is used to positively influence attitudes and beliefs.

Physiotherapists' attitudes and beliefs about self-management as part of their management for low back pain.

BACKGROUND: Perceptually, there is a discrepancy between research evidence and clinical physiotherapy practice for supporting self-management in people with low back pain (LBP). OBJECTIVE: This study aimed to explore physiotherapists' understanding of LBP; ascertain their knowledge of self-management concepts; and explore their attitudes and beliefs about supporting self-management for LBP within present physiotherapy practice in private and hospital settings. DESIGN: Interpretive Description qualitative methodology, involving in-depth data interpretation to clinical practice, was used. METHODS: Semi-structured interviews with physiotherapists throughout New Zealand were conducted via video conferencing. Data was analysed and themes were defined. RESULTS: Seventeen physiotherapists (24-65 years old), with between one and 40+ years of experience, participated. Four main themes were defined: 1) Evolving understanding of LBP, 2) apportioning responsibility, 3) self-management is important, 4) understanding self-management. CONCLUSION: Novel findings from this research demonstrate examples of attitudes and beliefs that determine when and how self-management for people with LBP is implemented. Due to these attitudes and beliefs, physiotherapists may not consistently provide supported self-management for people with LBP. Participants had good understanding of LBP but lacked a contemporary knowledge of the natural history and tended to apportion responsibility for persistent or recurrent episodes to the person with LBP. Physiotherapists should be encouraged to assimilate more contemporary research evidence into their expectations of recovery for LBP. Further education about the role of physiotherapists in supporting self-management, the core components of self-management, including engagement, and reflection upon individual unconscious bias should be encouraged.

'Thinking about pain in a different way': Patient perspectives of a neuroscience-informed physiotherapy programme for rotator cuff-related shoulder pain.

BACKGROUND: Rotator cuff-related shoulder pain (RCRSP) is a common musculoskeletal problem. The multi-factorial contributors to persistent pain are often overlooked during treatment. Pain neuroscience education (PNE) contributes to a holistic approach for patients with persistent pain but has not yet been researched for patients with RCRSP. OBJECTIVE: To explore the perspectives and experiences of participants with RCRSP who had completed a programme of PNE-informed pragmatic physiotherapy. DESIGN: A qualitative study using semi-structured interviews. METHODS: We included a sub-group of five males and five females, aged 46-75 years, with persistent RCRSP of at least three months. They had undertaken a three-month pragmatic physiotherapy integrated with PNE. Individual semi-structured interviews were recorded, transcribed verbatim, and analysed using the General Inductive Approach. RESULTS: Four themes emanated from the interviews. The first two themes were named 'Patient Beliefs' and overall 'Rapport and Relationship'. Another theme, 'Perspective and Understanding of the Resources', indicated diverse uptake of the resource information. The participants reported developing self-management skills, active coping strategies and a reduction in fear of pain described by the theme: 'Empowerment: My Shoulder into the Future'. CONCLUSIONS: Participants experienced a change in their beliefs, which were enhanced by an individualised delivery and a strong therapeutic relationship through the course of the physiotherapy care. The participants appeared to value when the physiotherapist listened to and understood their beliefs. This required a shift in the patient-therapist relationship from the physiotherapist being the 'expert' to facilitating the patient's ability to take control of their shoulder health.

The effectiveness of play as an intervention using International Classification of Functioning outcome measures for children with disabilities - a systematic review and meta-synthesis.

PURPOSE: Over 240 million children worldwide experience inequities due to disablement/disability. Play is important for children's global development, to enable participation in life, and has been used in therapeutic settings. The purpose of this systematic review is to determine the effectiveness of play used in therapy for children with disabilities, to explore ways that play is used in therapy, and to classify and map outcome measures used in play-based interventions to the International Classification of Functioning. METHODS: A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: The search yielded 22 articles eligible for inclusion. A meta-analysis found significant heterogeneity for play-based intervention outcomes, precluding estimates of effectiveness. Body function and structure outcomes accounted for 61% of reported outcome measures. CONCLUSION: There is a trend towards a small positive effect of play used in therapy for children with disabilities, but certainty of the effect is poor, and replication difficult due to heterogeneous reports of how play is used. Research aims and outcome measures focusing on meaningful aspects of activity and participation in addition to body function and structure domains of the International Classification of Functioning should be considered for play-based interventions for children with disabilities.

Play-based interventions trend towards a positive effect on ICF outcomes, but the certainty of effect is limited.Play is used in diverse ways making it a versatile method to promote engagement or deliver therapy to a wide variety of children with disabilities.Play-based studies measuring outcomes solely related to body function and structure domains of the ICF may not capture the broader holistic benefits of play.When using play in clinical practice, professionals should consider the child's personal and environmental factors and the influence of play on activity and participation.

Disabled People or Their Support Persons' Perceptions of a Community Based Multi-Sensory Environment (MSE): A Mixed-Method Study.

Multi-sensory environments (MSEs) are specialised spaces purposely designed to stimulate the senses, whilst providing a calming and relaxing environment for leisure and enjoyment, predominantly intended for disabled people. Most MSEs are in institutions, hospitals, or educational settings, with a few in community-based settings. We explored disabled users' experiences of a community based MSE in a large metropolitan area in New Zealand, with a view to expanding access to MSE-type environments within the area. We used a convergent mixed method design with a web-based electronic survey (e-survey; n = 105), as well as semi-structured interviews (n = 14) with disabled MSE users (adults and children), who were supported, where necessary, by their support person/s. We collected the MSE users' demographics, frequency of use with respect to age, disability, and ethnicity, and experiences of the room, equipment, and accessibility. The participants and their support persons' perspectives about their experiences of using the MSE were represented by four themes: (i) Self-determination; (ii) Enhancing wellbeing opportunities; (iii) the MSE itself; (iv) Accessibility. While the MSE was considered positively, the MSE experience could be enhanced by addressing access challenges and broadening the scope of equipment to improve the usability and make it a more inclusive environment for all.

Health System Factors Affecting the Experience of Non-Invasive Ventilation Provision of People with Neuromuscular Disorders in New Zealand.

Non-invasive ventilation (NIV) is a critical therapy for many patients with neuromuscular disorders (NMD), supporting those with respiratory failure to achieve adequate respiration and improve their quality of life. The aim of this study was to explore the experiences of access to, consent, uptake, maintenance and safe use of non-invasive ventilation by people with NMD. Semi-structured individual interviews were conducted with 11 people with NMD, each using NIV for more than 12 months. A critical realism ontological paradigm with contextualism epistemology guided the Reflexive Thematic Analysis. An Equity of Health Care Framework underpinned the analysis. Three themes were interpreted: Uptake and informed consent for NIV therapy; Practicalities of NIV; and Patient-clinician relationships. We identified issues at the system, organization and health professional levels. Conclusions: We recommend the development of national service specifications with clear standards and dedicated funding for patients with NMD and call on the New Zealand Ministry of Health to proactively investigate and monitor the variations in service delivery identified. The specific areas of concern for patients with NMD suggest the need for NMD-related NIV research and service provision responsive to the distinct needs of this population.

"Me and 'that' machine": the lived experiences of people with neuromuscular disorders using non-invasive ventilation.

PURPOSE: Neuromuscular disorders (NMD) encompasses a wide range of conditions, with respiratory weakness a common feature. Respiratory care can involve non-invasive ventilation (NIV) resulting in fewer hospital admissions, a lower mortality rate and improved quality of life. The aim of this study was to explore the 'lived experience' of NIV by people with NMD. METHODS: Interpretive Phenomenological Analysis (IPA) with semi-structured, face to face interviews with 11 people with NMD, using bi-level positive airway pressure for NIV for more than 12 months. RESULTS: Three themes were interpreted: (i) Alive, with a life; (ii) Me and 'that' machine; and (iii) Precariousness of this life. NIV enabled hope, independence and the opportunity to explore previously perceived unattainable life experiences. Yet, participants felt dependent on the machine. Furthermore, practical considerations and fear of NIV failure created a sense of precariousness to life and a reframing of personal identity. CONCLUSION: The findings highlight the broad ranging positive and negative effects that may occur for people with NMD when using this important therapy. Ongoing non-judgemental support and empathy are required from health professionals as the use of NIV challenged concepts such as 'living life well' for people with NMD. IMPLICATIONS FOR REHABILITATIONNeuromuscular disorders may result in respiratory weakness requiring non-invasive ventilation (NIV).When prescribed early, NIV can results in fewer hospital admissions, a lower mortality rate and improved quality of life.The relationship of people with NMD with their NIV machine is complex and impacts on and requires adjustment to their identity.NIV users acknowledged that NIV provided hope but simultaneously recognised the precariousness of NIV on their life.In order to better support people with NMD healthcare professionals need to better understand how the physical, psychological and social implications of NIV affect an individual's life.

Digital Technologies for Women's Pelvic Floor Muscle Training to Manage Urinary Incontinence Across Their Life Course: Scoping Review.

BACKGROUND: Women with urinary incontinence (UI) may consider using digital technologies (DTs) to guide pelvic floor muscle training (PFMT) to help manage their symptoms. DTs that deliver PFMT programs are readily available, yet uncertainty exists regarding whether they are scientifically valid, appropriate, and culturally relevant and meet the needs of women at specific life stages. OBJECTIVE: This scoping review aims to provide a narrative synthesis of DTs used for PFMT to manage UI in women across their life course. METHODS: This scoping review was conducted in accordance with the Joanna Briggs Institute methodological framework. A systematic search of 7 electronic databases was conducted, and primary quantitative and qualitative research and gray literature publications were considered. Studies were eligible if they focused on women with or without UI who had engaged with DTs for PFMT, reported on outcomes related to the use of PFMT DTs for managing UI, or explored users' experiences of DTs for PFMT. The identified studies were screened for eligibility. Data on the evidence base for and features of PFMT DTs using the Consensus on Exercise Reporting Template for PFMT, PFMT DT outcomes (eg, UI symptoms, quality of life, adherence, and satisfaction), life stage and culture, and the experiences of women and health care providers (facilitators and barriers) were extracted and synthesized by ≥2 independent reviewers. RESULTS: In total, 89 papers were included (n=45, 51% primary and n=44, 49% supplementary) involving studies from 14 countries. A total of 28 types of DTs were used in 41 primary studies, including mobile apps with or without a portable vaginal biofeedback or accelerometer-based device, a smartphone messaging system, internet-based programs, and videoconferencing. Approximately half (22/41, 54%) of the studies provided evidence for or testing of the DTs, and a similar proportion of PFMT programs were drawn from or adapted from a known evidence base. Although PFMT parameters and program compliance varied, most studies that reported on UI symptoms showed improved outcomes, and women were generally satisfied with this treatment approach. With respect to life stage, pregnancy and the postpartum period were the most common focus, with more evidence needed for women of various age ranges (eg, adolescent and older women), including their cultural context, which is a factor that is rarely considered. Women's perceptions and experiences are often considered in the development of DTs, with qualitative data highlighting factors that are usually both facilitators and barriers. CONCLUSIONS: DTs are a growing mechanism for delivering PFMT, as evidenced by the recent increase in publications. This review highlighted the heterogeneity in types of DTs, PFMT protocols, the lack of cultural adaptations of most of the DTs reviewed, and a paucity in the consideration of the changing needs of women across their life course.

Measuring Maori Health, Wellbeing, and Disability in Aotearoa Using a Web-Based Survey Methodology.

High-quality evidence on the prevalence and impact of health, wellbeing, and disability among Maori, and other Indigenous peoples, is crucial for mitigating health inequities. Current surveys are predominantly centred within a biomedical paradigm, with the constructs mismatched with Indigenous worldviews. We aimed to develop and deploy an accessible and culturally grounded survey exploring Maori health, wellbeing, and disability using a Kaupapa Maori Research methodology. An extensive codesign process with Maori community partners interrogated all aspects of the design to ensure the process and outcomes met the needs of Maori. A large-scale, nationally representative survey of people of Maori descent was conducted. We used a multi-modal deployment approach that included online and alternate methods of completion. Our analysis included a novel dual-weighting system to ensure generalisability of results to the national Maori population. This achieved a survey of 7230 participants, a sample size comparable with government-administered surveys. The response rate was 11.1%, with 7.3% opting for alternate methods. A high completion rate of 93.4% was observed. This approach demonstrated a high level of engagement, resulting in an unprecedented collection of Maori health, wellbeing, and disability data. This highlights the importance of Indigenous codesign for ensuring accessible and culturally appropriate survey methods.

iSelf-Help: a co-designed, culturally appropriate, online pain management programme in Aotearoa.

INTRODUCTION: Current best practice recommends group-based pain management programmes for long-term improvements in persistent pain-related disability. However, there are barriers for people to access in-person delivered pain management programmes in Aotearoa. AIMS: To develop a co-designed, culturally responsive, online group-based pain management programme (iSelf-help) for people with persistent pain. METHODS: A modified participatory action research (PAR) framework was used to co-design contents and cultural-appropriateness of iSelf-help. The PAR team included: (1) seven end-users living with persistent pain, who had previously attended an in-person delivered group pain management programme, (2) two pain management clinicians, (3) two health researchers, (4) two digital health experts, and (5) a health literacy expert. Five meetings were held with the PAR group and a Nominal Group Technique was used to rank order the preferred features of content delivery. In parallel, to ensure cultural appropriateness of iSelf-help, three focus groups (n = 15) were held with Maori (the Indigenous population of Aotearoa) living with persistent pain in collaboration with a Maori community health trust. All contents were reviewed by a Maori Health literacy expert and core contents were translated into Te Reo (Maori language). All contents were finalised by iterative discussion among the PAR team and consultation with Maori stakeholders. The preliminary version of iSelf-help was pilot tested with the PAR group participants and Maori community members living with persistent pain and their feedback was included. The iterative co-design process occurred over a period of nine months. RESULTS: The finalised version of iSelf-help included a total of 130 resources organised in to 12 content relevant online modules plus a dedicated welcoming page and an online community forum. Each module included: short videos, animations explaining main concepts, patient stories, written content to accompany visual content, podcasts of relaxation techniques, illustrated texts, and evidence-summaries. A dedicated module of videos demonstrating cardiovascular and strengthening exercises of varying intensity was also included. CONCLUSIONS: This is the first co-created, culturally appropriate, on-line group pain management programme for people with persistent pain, developed in Aotearoa. The next step is to evaluate the clinical and cost-effectiveness of iSelf-help compared to in-person delivered pain management programme.

Pain management programmes delivered in a group format are best practice to support people living with persistent non-cancer pain to live well. Some people can find accessing these programmes hard due to lack of referral, transportation costs and lack of trained health professionals. Further, people from Indigenous and non-Western backgrounds are poorly represented in these programmes despite having a high prevalence of persistent pain. One way of improving access is delivering services via technology. We aimed to co-design an online version of an existing hospital-based pain management programme (iSelf-help) and to ensure cultural appropriateness of the iSelf-help for Maori. Maori are the Indigenous population of Aotearoa (an accepted Maori word to describe New Zealand). We used a modified participatory action research (PAR) framework for our co-design process. This framework actively encouraged people with lived experience of pain and community partners to have a voice in the content design. The PAR team included: (1) seven end-users living with persistent pain, who had previously attended hospital-based pain management programme, (2) two pain management clinicians, (3) two health researchers, (4) two digital health experts, and (5) a health literacy expert. Five meetings were held with the PAR team. We used a Nominal Group Technique, whereby PAR team members ranked their preferences on content design and delivery, until concensus was reached. In parallel, three focus groups (n = 15) were held with Maori living with persistent pain in collaboration with a Maori community health trust. All contents were reviewed by a Maori Health literacy expert and core contents were translated into Te Reo (Maori language). The finalised version of iSelf-help included 130 resources, tested for accessibility, organised in to 12 online modules plus a dedicated welcoming page and an online community forum. Each module included: short videos, animations, patient stories, podcasts of relaxation techniques, illustrated texts, and evidence-summaries. This is the first co-created, culturally appropriate, on-line group pain management programme for people with persistent pain, developed in Aotearoa. We are currently evaluating if iSelf-help is acceptable to users, and clinically and cost effective as compared to the hospital-based pain management programme.

The Multidimensional Impacts of Inequities for Tangata Whaikaha Maori (Indigenous Maori with Lived Experience of Disability) in Aotearoa, New Zealand.

People with lived experience of disability have poorer health and socioeconomic outcomes than people without it. However, within this population, certain social groups are more likely to experience poorer outcomes due to the impacts of multiple intersecting forms of oppression including colonisation, coloniality and racism. This paper describes the multidimensional impacts of inequities for Indigenous tangata whaikaha Maori (Maori with lived experience of disability). Semi-structured in-depth interviews were conducted with 28 tangata whaikaha Maori and their whanau (extended family) using a kaupapa Maori Research methodology. An equity framework was used to analyse the data. The results describe: (1) inequitable access to the determinants of health and well-being; (2) inequitable access to and through health and disability care; (3) differential quality of health and disability care received; and (4) Indigenous Maori-driven solutions. These data confirm that tangata whaikaha Maori in the nation-state known as New Zealand experience racism, ableism and disablism, compounded by the intersection between these types of discrimination. Recommendations from the data support the inclusion of tangata whaikaha Maori in decision-making structures, including all policies and practices, along with equal partnership rights when it comes to designing health and disability systems and services.