Relationship between decile score of secondary school, the

VOLUME 2 • NUMBER 3 • SEPTEMBER 2010OF PRIMARY HEALTH CARE‘The reluctance ofsome Maori patientsto talk about personalfeelings may provideclues about mentalwell-being anddepression’See Original Scientific Paper page 208Guest EditorialAre New Zealand primary health careservices ready to deal with a majordisaster?See page 180Original Scientific PaperMany parents prefer their daughtersreceive the HPV vaccine in primarycare rather than school settingsSee page 190Original Scientific PaperRecognising and treating depression inMaori patientsSee page 208Original Scientific PaperUnderstanding why Samoan patientsmay not take their medicationSee page 217Back to BackIs physician-assisted suicide everacceptable?See page 249EthicsIs it ever acceptable to tell an unnamedpatient’s story to others?See page 256

EDITORIALsfrom the editorJPHC achieves MEDLINE statusFelicity Goodyear-Smith MBChB, MGP,FRNZCGP, EditorCorrespondence to:Felicity Goodyear-SmithProfessor and GoodfellowPostgraduate Chair,Department of GeneralPractice and PrimaryHealth Care, TheUniversity of Auckland,PB 92019 Auckland,New Zealandf.goodyear-smith@auckland.ac.nzWe are delighted to announce thatthe Journal of Primary Health Care(JPHC) has been selected by the UnitedStates National Library of Medicine (NLM)for inclusion in Index Medicus and MEDLINE.The primary consideration in selecting journalsfor indexing is the scientific merit of a journal’scontent. The validity, importance, originality,and contribution to the coverage of the field ofthe overall contents are key factors considered bythe NLM’s selection panel in recommending ajournal for indexing.If a journal is published three or more times ayear, four issues are needed to apply for indexing.The application to NLM was made in January2010 based on the first four issues (2009, volume1, issues 1 to 4). MEDLINE indexing of the JPHChas therefore been achieved in the shortest possibletime. Throughout its 35 years of publication(1974 to 2008), the New Zealand Family Physicianwas unsuccessful in its bids to be indexed inMEDLINE. 1 One of the drivers for launching theJPHC was to create a flagship publication for theRNZCGP that would be internationally recognisedas a quality journal and obtain MEDLINEstatus.While the editor plays a substantial role, producinga journal is a team effort. This milestoneis a formal recognition of the contributionsmade by the many people who help create thejournal—the authors who submit their work,peer reviewers who critique it, members of theeditorial board who provide advice and guidance,the College staff who work to produce a firstrateprint and online journal and the readerswho provide thoughtful feedback. Many thanksto all who have played a part towards us reachingthis goal.MEDLINE is a bibliographic database containingover 18 million references to journal articles inlife sciences and biomedicine from about 5000 selectedjournals. Articles published in MEDLINEindexedjournals can be found using PubMed.Research published in non-MEDLINE journalshas little chance of being accessed and quoted byothers, hence it is of great value for journals tobe indexed in MEDLINE. Indexing will enablereaders to search and retrieve all JPHC articlesincluding our back issues.In 2009, Professor Chris van Weel, past Presidentof Wonca, was instrumental in the NLM introducinga new Subject Heading ‘Primary HealthCare’ (including Family Medicine) in IndexMedicus and reallocating the journals that focuson primary health care, family medicine andgeneral practice to this subject. 2 This means thatthe JPHC will be categorised alongside leadinggeneral practice journals such as Annals of FamilyMedicine, Family Practice and the British Journalof General Practice.Some of our readers still wish for a publicationby GPs for GPs, as attested in our Lettersto the Editor, while others applaud the interdisciplinaryapproach adopted by the JPHC. Thisissue certainly continues with our cross-specialtyapproach. Authors include GPs and other medicalpractitioners, nurses, psychologists, pharmacists,epidemiologists and other assorted researchersand academics and cover a broad spectrum ofprimary health care issues.Mitchell and colleagues explore whether secondaryschool decile rating and size of their townof origin has any impact on medical students’subsequent career choices such as rural generalpractice. 3 There are two studies from the team at178 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

EDITORIALsguest editorialWhile it is unlikely that there will be a war here,recent international seismic events have raisedour awareness that, in NZ, we too are highlylikely to experience natural disasters by virtue ofour geographic location on major, active tectonicplate intersections, volcanic zones and the oceanicand climatic impacts which bring tsunami, majorfloods and landslips. Climatic conditions mayalso generate circumstances for transport-relateddisasters, including road transport and aircraftcrashes as well as maritime disasters. Althoughthere are Civil Defence plans for immediateemergency disaster intervention, few, if any,resources appear to have been made available fortrauma treatment over the longer term.Any major disaster is accompanied by traumafor those upon whom it impacts either directlyor indirectly, making them susceptible to posttraumaticreactions of varying levels of severity.Estimates suggest PTSD will affect up to 30% ofiour and academic performance of children andadolescents. 1,7 The Georgian experience has beenthat PTSD also has economic and social impactson adults, with observed increases in alcoholand drug abuse, depression and family violence.These impacts affected adults’ ability to care forchildren and also those normally expected towork with them, such as teachers and communityhealth providers. 8There is an extensive body of evidence supportingtrauma-focussed CBT as the most effectiveintervention for post-traumatic symptoms. 4,5,9,10There is also evidence that such CBT is alsothe intervention of choice when working withtraumatised children, 11 including those as youngas two years old. 12Given that only a small proportion of NZ’smental health professionals is trained to providetrauma-focussed CBT interventions, it is likelyHealth professionals resident in a disaster area may be able toprovide an initial response, but it has to be recognised that, in anymajor disaster, locals are themselves frequently traumatised andthus less well able to deliver an effective servicedisaster victims. 1 Because of delayed reactions andfactors associated with disruption of normal life,displacement from home, exposure to death orinjury of family members, loss of employment orother family stressors, PTSD symptoms may continueto emerge over periods as long as six monthsto two years post-disaster. 1,2 Research indicatesthat those most susceptible to development ofPTSD are children, women and the elderly, whichis not to suggest that males are immune as themilitary data on male PTSD indicate. 4,5Post-disaster studies of children exposed to theeffects of earthquakes, floods, tornados and the9/11 terror attack show that they are particularlysusceptible to PTSD. 2,3,6,7 These effects aredurable, especially if untreated, being evidentfor at least three years afterwards. The impactsof PTSD are found to affect both school behavthateven fewer primary health care professionalswill have had such training. As a result,provision of an effective response to moderateto severe trauma effects will be unlikely unlesssome consideration is given to training a cadreof professionals who would then be availableto respond to the traumatic aftermath of anymajor disaster. Health professionals resident ina disaster area may be able to provide an initialresponse, but it has to be recognised that, in anymajor disaster, locals are themselves frequentlytraumatised and thus less well able to deliver aneffective service.We identified a number of lessons for primaryhealth providers from the Russian–Georgianconflict and from the research literature thatcould be considered relevant to the NZ context inpreparing for a natural disaster.VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 181

EDITORIALsguest editorialFirst, an initial emergency response, while helpful,is insufficient to provide significant benefitsfor persons suffering from moderate to severepost-traumatic effects, particularly as PTSD can,by definition, only be diagnosed at least fourweeks after exposure to the traumatic experience. 13Second, children and the elderly are the mostvulnerable to the development of post-traumaticsymptoms, females are more susceptible thanmales, and post-traumatic symptoms have amajor impact upon children’s academic performance,particularly concentration, memory, andclassroom demeanour and upon adults’ ability tofunction normally.Third, there were cultural and gender differencesin symptom expression. In the cultural context,increases in somatic complaints (e.g. headaches,stomach pains) were noted, along with complaintsof ‘illness’. Cultural beliefs around mental illnessmade somatic symptoms a more acceptable modeof expressing stress and trauma than reporting‘mental’ symptoms such as anxiety, phobias,panic reactions or re-experiencing. In terms ofgender, boys tended to display post-traumaticproblems through increases in their aggressiveplay, disobedience and displays of anger, aggressionor anxiety (externalising), while girls tendedto become withdrawn, depressed or anxious andless able to focus on school work (internalising).Women often expressed concerns about the menand children rather than their own symptoms,and tried to avoid discussing the situation thatcaused the trauma. Men were more likely to denyany traumatic symptoms and to avoid treatment,while at the same time demonstrating increasesin drinking, smoking, anger and sleeplessness.Substance abuse and domestic violence increasedamongst displaced and unemployed males, affectingboth women and children in their familieswho already were living in very stressful circumstances.Males displaying trauma symptomsoften denied trauma or avoided engaging withtreatment services. The emergency service andmilitary personnel exposed to the conflict werenot immune from trauma effects, but frequentlyfailed to seek assistance or be offered it.Fourth, we found that, with our novice professionals,key CBT trauma intervention skillscould be taught to a level of mastery relativelyeasily and in a short time (six weeks), whichmade effective intervention available for thosewho accepted treatment. Our trainee therapistsfound that CBT produced rapid beneficial effectswith adults and children, even in cases of severePTSD symptoms and often after relatively briefexposure to treatment, so that symptoms such asavoidance, re-experiencing, insomnia and panicattacks became manageable, allowing normalfunctioning to be achieved.Our conclusion was that it would make sense totrain a cadre of primary health care personnelto deliver CBT for trauma so that NZ was wellprepared for the effects of any major disaster onits own shores and better able to offer assistanceto nearby Pacific countries experiencing naturaldisasters.References1. Kruczek T, Salsman J. Prevention and treatment of posttraumaticstress disorder in the school setting. Psychol Sch.2006;43(4):461–470.2. Bal A. Post-traumatic stress disorder in Turkish child and adolescentsurvivors three years after the Marmara earthquake.Child Adolesc Ment Health. 2008;13(3):134–139.3. Bokszcanin A. PTSD symptoms in children and adolescents28 months after a flood: age and gender differences. J TraumaStress. 2007;20(3):347–351.4. Briere J, Scott C. Principles of trauma therapy: symptoms,evaluation and treatment. New York: Sage Publications; 2006.5. Taylor S. Clinician’s guide to PTSD: a cognitive-behavioralapproach. New York: Guilford Press; 2006.6. Evans LG, Oehler-Stinnett J. Structure and prevalence of PTSDsymtomology in children who have experienced a severetornado. Psychol Sch. 2006;43(3):283–295.7. Sahin NH, Batigun AD, Yilmaz B. Psychological symptoms ofTurkish children and adolescents after the 1999 earthquake:exposure, gender, location and time duration. J Trauma Stress.2007;20(3):335–345.8. World Health Organization. Unpublished report by the GeorgianWHO Mental Health Cluster Survey of IDP communitiesin conflict zones and collection centres in Georgia; 2009.9. Foa EB, Keane TM, Friedman MJ, editors. Effective treatmentsfor PTSD. New York: Guilford Press; 2000.10. Zayfert C, Becker CB. Cognitive-behavioral therapy forPTSD: a case formulation approach. New York: GuilfordPress; 2007.11. Cohen J A, Mannarino AP, Deblinger E. Treating trauma andtraumatic grief in children and adolescents. New York: GuilfordPress; 2006.12. Scheeringa MS, Salloum A, Arnberger RA, Weems CF,Amaya-Jackson L, Cohen JA. Feasibility and effectiveness ofcognitive-behavioral therapy for post traumatic stress disorderin preschool children: Two case reports. J Trauma Stress.2007;20(4):631–636.13. American Psychiatric Association Diagnostic and StatisticalManual. 4th Ed. (Text Revision) (DSM-IV-TR). WashingtonDC; 2000.182 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPErSquantitative researchRelationship between decile score ofsecondary school, the size of town of originand career intentions of New Zealandmedical studentsClinton J Mitchell MBChB, Med;¹ Boaz Shulruf PhD,² Phillippa J Poole BSc, MBChB¹ABSTRACTintroduction: New Zealand is facing a general practice workforce crisis, especially in rural communities.Medical school entrants from low decile schools or rural locations may be more likely to chooserural general practice as their career path.1Medical Education Division,The University of Auckland,Auckland, New Zealand2Centre for Medical andHealth Sciences Education,The University of AucklandAim: To determine whether a relationship exists between secondary school decile rating, the size of thetown of origin of medical students and their subsequent medical career intentions.Methods: University of Auckland medical students from 2006 to 2008 completed an entry questionnaireon a range of variables thought important in workforce determination. Analyses were performed ondata from the 346 students who had attended a high school in New Zealand.Results: There was a close relationship between size of town of origin and decile of secondary school.Most students expressed interests in a wide range of careers, with students from outside major citiesmaking slightly fewer choices on average.DISCUSSION: There is no strong signal from these data that career speciality choices will be determinedby decile of secondary school or size of town of origin. An increase in the proportion of rural students inmedical programmes may increase the number of students from lower decile schools, without addinganother affirmative action pathway.KEYWORDS: Education, medical; social class; career choiceBackgroundSome of the most important decisions in theshaping of the future medical workforce relate tothe selection of medical students. There is a socialobligation on universities to facilitate the developmentof a wide range of medical practitioners tomeet the health needs of the population.It is likely that medical graduates from diversebackgrounds would address priority areas ofneed and result in the range of doctors needed. 1–3Diversification also allows equity of access forminority groups. For around 40 years, Maoriand Pacific medical student admission schemeshave been in place to redress the lack of minorityrepresentation within the medical workforce.Around 16% of the current Auckland studentbody identifies as Maori or Pacific (Medical ProgrammeDirectorate, The University of Auckland,personal communication). Since 2004, TheUniversity of Auckland has offered places to 20students of rural origin. Evidence suggests thesestudents will be more likely to return to practisein rural settings. 4,5 In recent years in the UnitedKingdom, a number of efforts have been made togive students from lower socioeconomic backgroundsthe opportunity to become doctors. 6 Fewstudies have reported on the career pathways andchoices of individuals from low socioeconomiccommunities.J PRIMARY HEALTH CARE2010;2(3):183–189.CORRESPONDENCE TO:Phillippa PooleAssociate Professor,Medical EducationDivision, School ofMedicine, Faculty ofMedical and HealthSciences, The Universityof Auckland, PB 92019Auckland 1142,New Zealandp.poole@auckland.ac.nzVOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 183

ORIGINAL SCIENTIFIC PAPERSquantitative researchcould classify practising doctors. Although anopen field was also included, in all instancesresponses could be attributed to one of the 18options.The careers in which students indicated an interestin working were analysed by high schooldecile and by size of town of origin. Odds ratios(OR) and 95% confidence intervals (CI) were calculated;instances where the OR value +/- 95% CIdid not cross 1.00 were deemed significant. Othertechniques included logistic regression and crosstabulation.Statistical analyses were preparedusing SPSS for Windows Version 16.0.ResultsData were available from 397 medical studentsin the entry cohorts 2006 to 2008, which wasan 82% return rate. Of this cohort, 51 sets ofdata were excluded where the secondary schoolattended by the student was overseas or the NewZealand Correspondence School.There was a marked preponderance of studentsfrom decile 9 and 10 schools (see Figure 1). Itshould be noted that the number of year 13 studentsin each decile nationwide is not uniform;in fact decile 9 and 10 students make up 30%of year 13 students in New Zealand (Centre forMedical and Health Sciences Education, personalcommunication).The average decile of the schools for studentsfrom a major city was 8.1 compared with 6.4 and6.3 for provincial centre and small town respectively.By far, the largest number of city-origin studentscame from Auckland; Hamilton, Wellington andChristchurch were also represented. Over thethree-year period of the study, students camefrom 120 schools throughout New Zealand.Students made a mean of 9.75 expressions ofinterest from the possible 18 career choices. Ingeneral, students from lower decile schools and/or smaller towns made fewer choices (Tables 2and 3), although this exceeded the significancelevel of 0.05 only for town size when analysis ofvariance was used.WHAT GAP THIS FILLSWhat we already know: Students from impoverished backgrounds arerare in medical student classes. The current retention crisis in New Zealand isuntenable, especially in rural communities.What this study adds: Seventy-two percent of students indicated aninterest in general practice on entry to medical school. An increase in thenumber of medical students from lower socioeconomic and rural areas mayhave the benefit of an added number of students choosing to practise incertain specialties, including general practice.When the data of students from small towns andprovincial centres were combined, students frommajor cities made more choices (10.20 (SD 5.4)versus 8.15 (SD 5.9); p

ORIGINAL SCIENTIFIC PAPErSquantitative researchNonetheless, some differences were seen in thepatterns of choice among students from differentbackgrounds.The major differences emerged in an analysiscomparing students who came from high decileschools in major cities and those in the remaininggroups. Students from high decile schools weremore likely to signal an interest in most specialties(Figure 5) and they were twice as likely asother students to signal an interest in medicineand surgery and respective subspecialties.DiscussionThere was a strong relationship between thedecile of a secondary school and the size of townFigure 2. Location of origin of University of Auckland medical students by regions ofNew Zealand and size of town.of origin. The average decile of the schools of‘major city’ students was two decile points higherthan their provincial/small town counterparts.These variables were associated with a relativelyminor effect on intended medical career choices.The majority of students came from the greaterAuckland region and the upper North Island.There was a very wide range of secondary schoolof origin—this is in contrast to a common viewthat most students in the Auckland programmecome from a limited number of city schools inAuckland. We were encouraged to find over 11%came from areas with a population of 10 000 orless. To put these findings in context, a studyfrom the University of Otago found that 84.5%came from main urban areas, while only 2.9%came from rural areas. 11 This observation may bean indication that the rural entry programmesintroduced in 2004 are having the desired effecton diversification.With the limitation that the decile of a highschool can at most be an approximation of thesocio economic status of an individual student,it was encouraging that 45% of students in thestudy reported they did not attend decile 9 or10 schools. Traditionally, medical students havecome largely from upper socio economic groups. 12Even though students aiming for medical schoolare, by and large, capable students, it is stilllikely that the academic and personal preparationneeded during final years of high school andthe admissions process unduly favour studentsfrom higher decile schools. Both universities nowselect students after at least one year at universityfor a number of reasons, one of which is thatthis may allow capable students who seek entryto medicine to compete on relatively level terms,regardless of socio economic status and location ofhigh school.Thompson and Subich have recently discernedthat social status was predictive of ‘career decisionself-efficacy’, 13 and extended upon previousfindings that the range and implementation ofchoices was also affected by social status. 13,14At the opposite end of the spectrum, studentsperceiving themselves as having greater economicresources compared with their peers reportedmore certainty in, and comfort with, career186 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPERSquantitative researchFigure 3. Odds ratio for students from low (left) or middle (right) decile schools choosing a particular specialty compared with those from high decile schools.Figure 4. Odds ratio for students from small towns (left) or provincial centres (right) choosing a particular specialty compared with those from major cities.VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 187

ORIGINAL SCIENTIFIC PAPErSquantitative researchFigure 5. Odds ratio (OR) for students from high decile schools in major cities choosing aparticular specialty compared with those from all other areas and deciles.choices. 13 A different effect was seen with thiscohort of students. We found that NZ domesticstudents entering medical school in Aucklandare enthusiastic about the range open to them; onaverage, students rate an interest in nearly 10 ofthe 18 options available to them. Students fromlower decile schools, provincial centres and smalltowns made fewer choices. The implication ofthis finding is not yet clear and there are severalpossible explanations. There may be a lack ofawareness in these groups of the potential careerswithin medicines, or deliberate strategies used bystudents from larger towns/higher deciles to keepmany options open. An alternative hypothesis isthat students from lower deciles or smaller townsmay be more definite about what they do and donot want to do in medicine.Studies have shown that only a minority ofstudents (45%) correctly identified their lateractual choice of specialty prior to their first dayof lectures. 15 There were few strong and consistentpatterns in the intended careers of medicalstudents’ intention at entry due to the fact thatthere were relatively small numbers of studentsin the survey and a wide range of choices available.However, we found that students from highdecile schools in major cities were over twice aslikely to signal an interest in medicine and/orsurgery and their subspecialties. In five of the18 specialties, including the clinical specialtiesof geriatrics, general practice and obstetrics andgynaecology, there was no significant differencein preferences between any of the student groupsin this study.A positive finding was that 250 of the 346students (72%) indicated an interest in generalpractice, a priority specialty area in NZ. Areasin NZ with high chronic disease burdens areover-represented by low decile schools and underservedby GPs. In Counties-Manukau, 65.5%of schools are decile 4 or below; 16 there are 280general practitioners for every 100 000 population,compared with 425 for the same populationin Auckland DHB. 17 Vaglum found that studentsinterested in a career in family medicine at entryto medical school were motivated by status/security,more so than for any other career. They postulatedthat students coming from a lower ‘socialorigin’ may be more aware of a change in statusand/or security that accompanies being a doctor. 18This present study, however, does not supportthis notion—students from all groups signalledan interest in general practice similarly.Time will allow the testing of the secondaryhypotheses generated from this study that studentsfrom smaller centres/lower decile schoolsare more accurate in their predictions of careerchoices, and that students from high decile cityschools are twice as likely to become NZ’s futurephysicians and surgeons.The students entering the programme now willnot be specialists until at least 2020. A strategyof seeking to ‘grow our own’ health professionalsseems appropriate. Zayas opines that professionalspractising in their home communities aremore cognisant of, and sensitive to, local needs. 19For us to achieve this will require overcomingthe perception that students from lower socioeconomicgroups identify medical school as ‘culturallyalien and “posh”; few consider they haveany chance of ever gaining a place’. 20 Selection188 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPERSquantitative researchprocesses and pathways must continue to enhancethe prospects of a medical career for studentsfrom outer metropolitan areas and beyond, andfrom lower decile schools.The announcement of an imminent increase inmedical student numbers provides both medicalschools with the impetus to review and possiblyamend admission policies. Given that half ofNZ’s population live in the upper North Island,recruiting strategies for The University of Aucklandmight target outer metropolitan, regionaland rural schools in this region. Because of thestrong relationship between the school decileand rurality identified in this study, an increasein the proportion of students from outside majorcities in the rural origin pathway would have thecorollary of more students coming from lowerdecile schools. It might not be necessary to haveanother specific pathway. Over time, we hope tohelp shed light on this debate.14. Blustein DL, Chaves AP, Diemer MA, Gallagher LA, et al.Voices of the forgotten half: the role of social class in theschool-to-work transition. J Couns Psychol. 2002;49:311–323.15. Zedlow PB, Preston RC, Daugherty SR. The decision toenter a medical specialty: timing and stability. Med Educ.1992;26:327–32.16. Big Cities. School decile ratings. [document on the Internet].Quality of Life ’08; 2008 [cited 19 December, 2008]. Availablefrom: http://www.bigcities.govt.nz/pdf2001/decile.pdf.17. Medical Council of New Zealand. The New Zealand medicalworkforce in 2007. Wellington: Medical Council of NewZealand; 2007.18. Valgum P, Wiers-Jenssen J, Ekeberg O. Motivation for medicalschool: the relationship to gender and specialty preferences ina nationwide sample. Med Educ. 1999;33:236–42.19. Zayas LE, McGuigan D. Experiences promoting healthcarecareer interest among high-school students from underservedcommunities. J Natl Med Assoc. 2006;98(9):1523–1531.20. Mathers J, Parry J. Why are there so few working-class applicantsto medical schools? Learning from the success stories.Med Educ. 2009;43:21–228.References1. Angel CV, Johnson A. Broadening access to undergraduatemedical education. BMJ. 2000;321:1136–8.2. Lakhan SE. Diversification of U.S. medical schools via affirmativeaction implementation. BMC Med Educ. 2003;3:6.3. Komaromy M, Grumbach K, Drake M. The role of Black andHispanic physicians in providing health care for underservedpopulations. New Engl J Med. 1997;4:1305–1310.4. Easterbrook M, Godwin M, Wilson R, Hodgetts G et al. Ruralbackground and clinical rotations during medical training:effect on practice location. CMAJ. 1999;160:1159–63.5. Hsueh W, Wilkinson T, Bills J. What evidence-based undergraduateinterventions promote rural health? N Z Med J.2004;117(1204):U1117.6. Garlick PB, Brown G. Widening participation in medicine.BMJ. 2008;336:1111–1113.7. Medical Training Board. Collation of discussion papers released30 September 2008. Wellington: Government PublishingService; 2008.8. Ministry of Education. How the decile is calculated [documenton the Internet]. Wellington: MOH; 2008 [cited 19 December,2008]. Available from: http://www.minedu.govt.nz/educationSectors/Schools/SchoolOperations/Resourcing/OperationalFunding/Deciles/HowTheDecileIsCalculated.aspx.9. Roulston D. Educational policy change, newspapers andpublic opinion in New Zealand, 1988–1999. Victoria Universityof Wellington: Wellington; 2005.10. Shulruf B, Hattie J, Tumen S. Individual and school factorsaffecting students’ participation and success in higher education.J Higher Educ. 2008;56(5):613–632.11. Heath C, Stoddart C, Renwick J. Urban and rural origins ofOtago Medical students. N Z Med J. 2002;115(1165).12. Heath C, Stoddart C, Green H. Parental backgrounds of Otagomedical students. N Z Med J. 2002;115(1165):U233.13. Thompson MN, Subich LM. The relation of social statusto the career decision-making process. J Vocat Behav.2006;96:289–301.COMPETING INTERESTSNone declared.VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 189

ORIGINAL SCIENTIFIC PAPERSquantitative researchbegan at the start of the 2009 school year offeringvaccination to girls in Year 8 and above(12 years up). Administration of the Gardasil ®vaccine is recommended at an early age asyounger girls mount a greater antibody responseand therefore may be afforded better protectionagainst the virus, 3 and vaccination prior to sexualdebut ensures girls have not already been exposedto the virus. 4In NZ, Maori and Pacific women have the highestincidence of cervical cancer and a poorerprognosis once diagnosed. 5,6 Disparities have alsobeen reported in access to both screening (breastand cervical) and immunisation for Maori andPacific women. 5–7 The National HPV immunisationimplementation plan therefore recognisesMaori and Pacific as priority groups for vaccination,with additional funding provided to DHBsto address these priority groups. 8 To achieve highuptake, and to minimise the risk of increasing inequalitiesfor both Maori and Pacific, we need anunderstanding of those factors that may increase,or conversely hinder, widespread coverage.Studies have been conducted overseas to exploreparental attitudes towards the new HPV/cervicalcancer vaccine. 9–19 NZ research has exploredparental views towards other childhood vaccines,and barriers to vaccination. 20–23 Place of vaccinationis an important factor when consideringaccess and uptake; the success of the MeNZB TMprogramme that was predominately school-based(for five- to 17-year-olds) played a role in thedecision to deliver Gardasil ® via schools, despitedifferences in the nature of the disease targetedby these vaccines. 8 Non-return of signed consentforms prohibits receipt of the vaccine. Analysisof data from one DHB region on receipt of the11-year-old vaccine (diptheria/tetanus/whoopingcough) showed that Maori were significantly lesslikely to return consent forms than non-Maori. 23By contrast, consent form return rates were highfor Maori in the MeNZB TM programme. 8The cervical cancer vaccine differs from otherson the immunisation schedule in a numberof important ways. For example, it targets aninfection that is sexually transmitted and ismost effective when administered prior to sexualonset, it reduces likelihood of developing aWHAT GAP THIS FILLSWhat we already know: The HPV/cervical cancer vaccine has the potentialto reduce current disparities in cervical cancer incidence for Maori andPacific if high uptake is achieved. The vaccine will be delivered via a schoolbasedprogramme in most areas of New Zealand to girls in Year 8 and above.What this study adds: Parents indicated a preference for their daughters’receipt of the HPV/cervical cancer vaccine in primary care, and many wouldseek the views of their GP before making a decision about vaccination fortheir daughter(s). The rationale for vaccination at a young age needs to be explainedclearly and information provided in a way that is accessible to parentsfrom all backgrounds.time-distant disease, and is currently only availablefor girls. Given the unique nature of thisvaccine, we aimed to explore factors that mightimpact on uptake, including: parents’ preferenceson where their daughter(s) receive the vaccineand at what age; age-appropriate informationfor girls; information needed to assist parentswith decision-making; parental contact regardingconsent and information-sharing between schooland primary care.MethodsThe study was approved by the Central RegionEthics Committee on 17 June 2008(CEN/08/04/014). Surveys were distributed toschools in October and November in term 4 ofthe 2008 school year. Return of a completedsurvey signified a parent’s consent to participate;surveys were received up until the end of January2009. Questions were developed based on findingsfrom key informant interviews conductedwith parents, similar work conducted overseasand local attitudinal research on immunisation.20–22 Surveys were piloted with 15 participants,and modified following feedback on clarityand ambiguity in question formatting.Recruitment and distribution of surveysEligibility criteria for schools included: locatedin Wellington, more than 100 pupils (with theexception of one Kura Kaupapa Maori languageimmersion school that had fewer than 100pupils), and attended by girls in Year 8 and above(intermediate and secondary schools). SchoolsVOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 191

ORIGINAL SCIENTIFIC PAPErSquantitative researchwere stratified by decile rating into low (deciles1–3), medium (deciles 4–7) and high (deciles 8–10).Schools with lower ratings had higher proportionsof Maori and Pacific students so were oversampledto achieve good representation of priority groups.The decile rating of a school is an indicator ofsocioeconomic status of the population withinthe school-defined area, where children attendinga decile 1 school are likely to be from a lowersocioeconomic background than those attending adecile 10 school. 24 All eligible schools in the Wellingtonarea with decile ratings between 1 and 5were invited to participate. Schools with decileratings of 6 and above were randomly chosen (usingthe Excel RAND function).A letter of invitation was sent to the principal at22 of 41 eligible schools (10 low, six medium andsix high decile). Arrangements for administeringthe survey were made and a $50 book vouchergiven as a token of appreciation. Parents wereeligible for participation if they had a daughterattending one of the participating schools.Surveys (with a brochure about cervical cancerand the HPV vaccine) 25 were distributed in one oftwo ways, as nominated by the school: girls tookthe survey home to their parents (10 schools),or the school posted the survey to parents (fourschools). For three high-decile schools with largerolls, we asked schools to distribute surveys toparents of only half their students. Surveys werereturned directly to the researchers by freepostenvelope (eight schools), or students returned surveysto the school with small incentives offeredby the school (for example, entry into a draw towin vouchers) in an attempt to increase responserates. Reminder notices about completion andreturn of surveys were sent out by all schoolsin their newsletters and/or in daily notices. Theresearch team did not send reminders to nonrespondersas contact details for parents were notobtained due to privacy reasons.Data collection and analysisQuestionnaires collected demographic data andasked parents about their vaccination preferenceswith regards to age, venue and information needs,as well as the likelihood of seeking vaccinationfor their daughter(s). Ethnicity was collectedusing the 2001 NZ census question and wasrecoded to the following four groups: Maori, Pacific,New Zealand European (NZEu) and Other.Assignment was based on prioritised ethnicity. 26‘Strongly agree’ and ‘agree’ responses were pooledfor analysis, as were ‘strongly disagree’ and ‘disagree’responses. Comments made to open-endedquestions were analysed for content and coded toallow for a frequency count (reason for preferenceon place of vaccination, format and content offurther information if desired). Kruskal-Wallistests followed by Wilcoxon pairwise comparisonswere performed in situations where data couldnot be assumed to follow a normal distribution.For these pairwise comparisons, Bonferroni correctionswere applied to control for Type I errorresulting from multiple comparisons (significancelevel set at 0.05/n comparisons). Chi-square testswere performed to test for significant differencesbetween categorical variables, and 95% confidenceintervals calculated where appropriate. Statisticalanalyses were performed using SAS (v9.2).ResultsFifteen of the 22 schools agreed to participate and,of those, 14 took part (six co-ed, two girls only,five intermediate and one full Kura Kaupapa Maorischool) giving a population of 3123 girls in theage range. Five schools declined (all low decile) dueto ‘lack of time’, two were undecided (one highandone low-decile school) after several weeks sowere not further pursued. The overall responserate from parents was 24.6% (769/3123). Co-educationsecondary schools had the lowest responserate (19.6%, 370/1889); followed by intermediateschools (30.5%, 215/704), the highest response ratewas parents of girls at girls-only secondary schools(35%,182/520). Participating schools were spreadacross deciles, with a response rate of 18.7% fromfour low-decile schools (157/838), 24.4% from sixmedium-decile schools (380/1560) and 32% fromfour high-decile schools (232/725).Table 1 presents the characteristics of participatingparents who returned completed surveys(n=769), with p-values denoting significantoverall differences between ethnic groups ondemographic variables using chi-square tests forsignificance. Pairwise comparisons showed thatMaori and Pacific parents were significantly more192 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPERSquantitative researchlikely to be younger (p

ORIGINAL SCIENTIFIC PAPErSquantitative researchTable 2. Likelihood of seeking vaccination for daughter and preferred venue and age at receipt of vaccinationWant daughter to receiveHPV vaccineTotal Maori Pacific NZEu ‘Other’(n=769) (n=126) (n=57) (n=477) (n=109)n % n % n % n % n %(95% CI) (95% CI) (95% CI) (95% CI) (95% CI)514 66.8 84 66.7 36 63.2 323 67.7 71 65.1(63.4 – 70.2) (57.7 – 74.8) (49.3 - 75.6) (63.3 – 71.9) (55.4 – 74.0)Preferred venueClinic* 302 39.3 55 43.7 31 54.4 179 37.5 37 33.9(35.8 – 42.8) (34.8 – 52.8) (40.7 – 67.6) (33.2 – 42.0) (25.1 – 43.6)School 197 25.6 28 22.2 6 10.5 135 28.3 28 25.7(22.6 – 28.9) (15.3 – 30.5) (4.0 – 21.5) (24.3 – 32.6) (17.8 – 34.9)Clinic or school 89 11.6 17 13.5 5 8.8 56 11.7 11 10.1(9.4 – 14.0) (8.1 – 20.7) (2.9 – 19.3) (9.0 – 15.0) (5.1 – 17.3)Her choice 156 20.3 21 16.7 10 17.5 98 20.5 27 24.8(17.5 – 23.3) (10.6 – 24.3) (8.7 – 29.9) (17.0 – 24.5) (17.0 – 34.0)No preference /16 2.1 2 1.6 3 5.3 8 1.7 3 2.8Not having it(1.2 – 3.4) (0.2 – 5.6) (1.1 – 14.6) (0.7 – 3.3) (0.6 – 7.8)Preferred ageNever 22 2.9 1 0.8 4 7 12 2.5 5 4.6(1.8 – 4.3) (0.0 – 4.3) (1.9 – 17.0) (1.3 – 4.4) (1.5 – 10.4)Not sure 131 17 21 16.7 15 26.3 74 15.5 21 19.3(14.4 – 19.9) (10.6 – 24.3) (15.5 – 39.7) (12.4 – 19.1) (12.3 – 27.9)Median age 13 13 14 13 15(Interquartile range) (12 – 15) (12 – 14) (13 – 15) (12 – 15) (12.3 – 16)Age 10 years 25 3.3 12 9.5 2 3.5 11 2.3 0 0Age 11 years 24 3.1 7 5.6 1 1.8 11 2.3 5 4.6Age 12 years 167 21.7 31 24.6 5 8.8 115 24.1 16 14.7Age 13 years 121 15.7 18 14.3 5 8.8 89 18.7 9 8.3Age 14 years 88 11.4 15 11.9 7 12.3 59 12.4 7 6.4Age 15 years 76 9.9 9 7.1 9 15.8 42 8.8 16 14.7Age 16 or older 102 13.3 12 9.5 7 12.3 54 11.3 29 26.6* Includes GP or nurse clinic, Maori and Pacific health clinicsNon-return of consent formsand information-sharingThe majority of parents (87%) were happy to bephoned if they had not returned a consent form(672/769). Few parents (8%) answered ‘no’ tobeing phoned (63/769) and only 3% were unsure.Maori (13%) and Pacific (14%) parents had aslightly higher proportion of ‘no’ responses thanNZEu (5.7%) parents (p

ORIGINAL SCIENTIFIC PAPERSquantitative researchyounger girls (causes and risks of cervical cancer,how HPV is passed on, abstinence, possible sideeffects of the vaccine, genital warts and STIs).Table 4 presents data relating to parents’ desirefor more information (other than the Ministry ofHealth brochure provided) to assist with decisionmakingabout the vaccine. Three-quarters ofthese parents (77%) responded to an open-endedquestion about the type of information theywould want (184/236). Responses included: informationon side effects and risks (39/184); efficacyand long-term effects of vaccination (38/184);evidence-based research and scientific information(37/184); and safety (31/184). A few parentsalso noted they would want ‘unbiased’ information,details about vaccine contents, updated informationabout the programme, and informationon whether a booster is needed at five years.DiscussionParents indicated a greater preference for deliveryof the Gardasil ® vaccine in clinic rather thanschool settings. Reasons for clinic-based vaccinationwere, most frequently, that it would allowfor continuity of care (from the family GP),enable parental involvement and the opportunityfor parents to provide comfort and support totheir daughter. Given that the HPV vaccinationprogramme will be run predominantly throughschools, enabling girls to have whanau/familysupport on vaccination day at school might bebeneficial. Parents also need to be encouraged toseek vaccination for their daughter(s) through primarycare if that is their preference. Conveniencewas cited as a key reason for preferring schoolbaseddelivery. In a previous study, parents expresseda preference for delivery of childhood immunisations(meningococcal disease and measles)in general practice, with the exception of Pacificparents who preferred school-based delivery 20 —afinding that differs from the current study.Just over a quarter of parents (28%) thought ages10–12 appropriate for receipt of the vaccine. Parentsof Pacific and ‘Other’ ethnicities were morelikely to indicate a preference for older age at re-Table 3. Information deemed appropriate for girls when discussing the HPV vaccineWhat should be discussed withgirls aged 12–15, and girls aged 16and older?*Topic (n responding to question)‘Yes’ responses presented by age groupBoth age groups 16 years and older only 12 to 15 years only Neither age groupn % n % n % n %(95% CI) (95% CI) (95% CI) (95% CI)Cervical cancer—causes and risks 615 95.3 28 4.3 1 0.2 1 0.2(645) (93.4 – 96.8) (2.9 – 6.2) (0.0 – 0.9) (0.0 – 0.9)HPV: What it is and how it’s passedon (during sexual contact) 587 92.2 47 7.4 2 0.3 1 0.2(637) (89.8 – 94.1) (5.5 – 9.7) (0.0 – 1.1) (0.0 – 0.9)Cervical screening and pap smears 545 86.6 78 12.4 1 0.2 5 0.8(629) (83.7 – 89.2) (9.9 – 15.2) (0.0 – 0.9) (0.3 – 1.8)Practising safe sex 545 86.6 78 12.4 1 0.2 5 0.8(629) (83.7 – 89.2) (9.9 – 15.2) (0.0 – 0.9) (0.3 – 1.8)Not having sex 490 78 26 4.1 42 6.7 69 11(628) (74.6 – 81.2) (2.7 – 6.0) (4.9 – 8.9) (8.6 – 13.7)Possible side effects of the vaccine 603 94.2 27 4.2 2 0.3 8 1.3(640) (92.1 – 95.9) (2.8 – 6.1) (0.0 – 1.1) (0.5 – 2.4)Genital warts and STIs 559 86.7 53 8.2 2 0.3 16 2.5(630) (86.0 – 91.1) (6.4 – 10.9) (0.0 – 1.1) (1.5 – 4.1)* Respondents were asked to answer for both age groups. A number of parents responded only for the age group in which their daughter fell, so their responses are notrecorded here to avoid skewing of the data.VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 195

ORIGINAL SCIENTIFIC PAPErSquantitative researchTable 4. Desire for more information to assist decision about vaccinationInformation needsWant more informationbefore deciding on HPVvaccinationTotal Maori Pacific NZEu Other(n=769) (n=126) (n=57) (n=477) (n=109)n % n % n % n % n %(95% CI) (95% CI) (95% CI) (95% CI) (95% CI)Yes 236 30.7 34 27 25 43.9 141 29.6 36 33(27.4 – 34.1) (19.5 – 35.6) (30.7 – 57.6) (25.5 – 33.9) (24.3 – 42.7)No 405 52.7 64 50.8 22 38.6 263 55.1 56 51.4(49.1 – 56.2) (41.7 – 59.8) (26.0 – 52.4) (50.5 – 59.7) (41.6 – 61.1)Don’t know 94 12.2 21 16.7 7 12.3 52 10.9 14 12.8Would seek other’s viewsabout the vaccine(10 – 14.7) (10.6 – 24.3) (5.1 – 23.7) (8.2 – 14.0) (7.2 – 20.6)Yes 582 75.7 96 76.2 47 82.5 358 75.1 81 74.3(72.5 – 78.7) (67.8 – 83.3) (70.1 – 91.3) (70.9 – 78.9) (65.1 – 82.2)No 137 17.8 19 15.1 4 7 96 20.1 18 16.5(15.2 – 20.7) (9.3 – 22.5) (1.9 – 17.0) (16.6 – 24.0) (10.1 – 24.8)Don’t know 41 5.3 7 5.6 3 5.3 22 4.6 9 8.3If Yes, would seek views of:(3.9 – 7.2) (2.3 – 11.1) (1.1 – 14.6) (2.9 – 6.9) (3.8 – 15.1)P-value*Extended family/whanau 231 39.7 48 50 18 38.3 143 39.9 22 27.2

ORIGINAL SCIENTIFIC PAPERSquantitative researchceipt of the vaccine. This might reflect characteristicsof parents in these groups; they were morelikely to be immigrants (over 50% have English asa second language), and have a religious affiliationso might have different views on the appropriateage for vaccination. A recent NZ study reportedthat practice nurses would be more likely torecommend the vaccine to girls aged 16–26 (thanto younger girls), and that GPs would most likelyrecommend the vaccine to girls aged 13–15 yearsold, followed closely by 9–12-year-olds. 27 In thecurrent programme, the vaccine will be offeredto girls in Year 8 (girls aged 12), therefore carefulexplanation will be needed for parents (andhealth providers) to understand the importantreasons for vaccination at this age.The majority of parents deemed informationrelating to HPV vaccination (presented in Table 3)suitable for girls of all vaccine-eligible ages.Cervical screening and pap smears, practisingsafe sex, genital warts and STIs were thoughtto be appropriate for discussion only with girlsaged 16 and older by 8–12% of parents. A third ofparents wanted more information about Gardasil ®before making a decision about vaccination, andmany indicated that they would seek the viewsof others—most commonly those of the familydoctor (GP). A telephone survey of 1052parents conducted in 2009 also showed the GP/nurse/medical centre was the preferred place toget information on the vaccine. 28 As with othervaccines, health professionals’ endorsement andsupport of the HPV vaccine will be important toensure the success of this programme. Henniger’ssurvey showed that GPs and practice nurses indicateda high level of willingness to recommendthe vaccine to their patients. 27With parental or patient permission, receipt ofthe HPV vaccine will be recorded on the NationalImmunisation Register (NIR), and authorisedhealth professionals will be able to access thisinformation. Parents in this study were happy forinformation-sharing to occur between the NIRand primary care, stating that it was importantthat their daughter’s GP receive this informationfor their records. However, it appears that GPs/health providers are not routinely notified whentheir patients receive Gardasil ® at school, but canrequest information on their patients’ vaccinationstatus. This lack of information-sharing willpotentially limit opportunities for vaccination.Parents were also happy to be phoned if theyhad not returned a consent form to enable theirdaughter’s receipt of the vaccine. Resources tofollow-up on consent forms will be particularlyimportant in schools or areas known to have lowreturn rates of (any) school-related paperworkfrom parents. The mass communicationcampaign, integrated information systems(schools and primary care) and the resources tosupport recall and follow-up have been cited askey to the success of the MeNZB TM programme.Our findings support the view of Grant etal. who advocated for an integrated systemto enable all opportunities for immunisationwith Gardasil ® to be utilised, 29 with vaccineadministration and information-sharing betweenprimary care and education providers.This is the first NZ study to describe parents’preferences on where and when their daughters’receive the Gardasil ® vaccine. The inclusion ofgroups most at-risk for cervical cancer (Maori,Pacific and lower socioeconomic groups) is astrength of this research. By targeting schoolsknown to have a higher proportion of Maori andPacific students, we aimed to oversample parentsin these ethnic groups, but response rates weregenerally lower from those schools. The distributionof our predominantly female participantsacross ethnic groups (62% European, 16.4% Maoriand 7.4% Pacific) closely reflects that of femalesaged 30–55 in the Wellington region where 70%are European, 11.7% Maori and 4.7% Pacific. Respondentsmay be more representative of parentswho have stronger views towards this vaccine.Pacific parents most often responded in waysthat differed from the three other groups, butfindings should be interpreted with caution dueto the smaller sample size (n=57). The responserate (25%) and recruitment of parents from onlyone region limits the generalisability of the findingsbeyond the study participants. However, theresponse rate is likely to be slightly higher thanthat reported, as we were generous in the numberof surveys distributed to schools, having beengiven estimates of student numbers at participatingschools. A survey of parent attitudes to HPVVOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 197

ORIGINAL SCIENTIFIC PAPErSquantitative researchACKNOWLEDGEMENTSWe gratefully acknowledgeparticipation by 769parents and theirdaughters as well asprincipals and theirschools for facilitatingdistribution and returnof surveys. Thanks alsoto a small advisory groupfor early advice on thestudy, and to Dr JamesStanley (Biostatistician,Department of PublicHealth) for statisticaladvice and assistancewith analyses.FUNDINGThis study was fundedby a grant from theHealth Research CouncilPartnership programme(REF 08/602).COMPETING INTERESTSNone declared.vaccination achieved a similar response rate (22%)in the United Kingdom, 30 and the Christchurchsurvey of GPs and practices nurses reached a 39%response rate. 27ConclusionsWe suggest that a programme jointly deliveredin primary care and school settings, that is appropriatelyresourced for follow-up and information-sharingwould increase vaccine coverage.The rationale for vaccination at age 12 needsto be made clear to parents and evidence-basedinformation needs to be delivered appropriately toparents and girls. As with other vaccines, healthprofessionals’ endorsement of and support forthis new programme will be important to ensureits success.References1. Muñoz N, Bosch FX, Castellsagué X, Díaz M, Sanjose Sd,Hammouda D, et al. Against which human papillomavirustypes shall we vaccinate and screen? The international perspective.Int J Cancer. 2004;111(2):278–85.2. Wiley DJ, Douglas J, Beutner K, Cox T, Fife K, Moscicki AB, etal. External genital warts: diagnosis, treatment, and prevention.Clin Infect Dis. 2002;35:S210–S24.3. Block SL, Nolan T, Sattler C, Barr E, Giacoletti KE, MarchantCD, et al. Comparison of the immunogenicity and reactogenicityof a prophylactic quadrivalent human papillomavirus(types 6, 11, 16, and 18) L1 virus-like particle vaccine in maleand female adolescents and young adult women. Pediatrics.2006;118(5):2135–45.4. Villa LL, Costa RL, Petta CA, Andrade RP, Paavonen J, IversenOE, et al. High sustained efficacy of a prophylactic quadrivalenthuman papillomavirus types 6/11/16/18 L1 virus-likeparticle vaccine through five years of follow-up. Br J Cancer.2006;95(11):1459–66.5. Robson B, Purdie G, Cormack D. Unequal Impact: Maori andNon-Maori Cancer Statistics 1996–2001. Wellington: Ministryof Health Report; 2006. [Accessed Dec 2009]:Available from:http://www.moh.govt.nz/moh.nsf/pagesmh/4761/$File/unequal-impact-maori-nonmaori-cancer-statistics-96-01.pdf.6. Centre for Public Health Research. Annual monitoring report2004, National Cervical Screening Programme. Wellington:Massey University; 2007.7. Ministry of Health. Immunisation handbook 2006. Wellington,New Zealand: Ministry of Health; 2006.8. Ministry of Health HPV Project Team. The HPV (HumanPapillomavirus) Immunisation Programme: National ImplementationStrategic Overview. Population Health Directorate,Wellington: Ministry of Health; 2008. [Accessed Aug2009]:Available from: http://www.moh.govt.nz/moh.nsf/pagesmh/7893/$File/hpv-national-implementation-strategicoverview.pdf.9. Waller J, Marlow LAV, Wardle J. Mothers’ attitudes towardspreventing cervical cancer through human papillomavirusvaccination: a qualitative study. Cancer Epidemiol BiomarkersPrev. 2006;15(7):1257–61.10. Olshen E, Woods ER, Austin SB, Luskin M, Bauchner H. Parentalacceptance of the human papillomavirus vaccine. J AdolescHealth. 2005;37(3):248.11. Brabin L, Roberts SA, Kitchener HC. A semi-qualitativestudy of attitudes to vaccinating adolescents against humanpapillomavirus without parental consent. BMC Public Health.2007;7:20.12. Vallely LA, Roberts SA, Kitchener HC, Brabin L. Informingadolescents about human papillomavirus vaccination: whatwill parents allow? Vaccine. 2008;26(18):2203–10.13. Dempsey AF, Zimet GD, Davis RL, Koutsky L. Factors that areassociated with parental acceptance of human papillomavirusvaccines: a randomized intervention study of written informationabout HPV. Pediatrics. 2006;117(5):1486–93.14. Chan SSC, Cheung TH, Lo WK, Chung TKH. Women’s attitudeson human papillomavirus vaccination to their daughters.J Adoles Health. 2007;41(2):204.15. Marshall H, Ryan P, Roberton D, Baghurst P. A cross-sectionalsurvey to assess community attitudes to introduction ofhuman papillomavirus vaccine. Aust NZ J Public Health.2007;31(3):235–42.16. Constantine NA, Jerman P. Acceptance of human papillomavirusvaccination among Californian parents of daughters:a representative statewide analysis. J Adolesc Health.2007;40(2):108–15.17. Hausdorf K, Newman B, Whiteman D, Aitken J, Frazer I. HPVvaccination: what do Queensland parents think? Aust NZ JPublic Health. 2007;31(3):288–9.18. Marlow LAV, Waller J, Wardle J. Parental attitudes to prepubertalHPV vaccination. Vaccine. 2007;25(11):1945.19. Ogilvie GS, Remple VP, Marra F, McNeil SA, Naus M, PielakK, et al. Intention of parents to have male children vaccinatedwith the human papillomavirus vaccine. Sex Trans Infect.2008;84(4):318–23.20. Petousis-Harris H, Turner N, Soe B. Parent views on schoolbased immunisation. NZ Fam Phys. 2004;31(4):222–28.21. Petousis-Harris H, Turner N, Kerse N. New Zealand mothers’knowledge of and attitudes towards immunisation. NZ FamPhys. 2002;29(4):240–46.22. Petousis-Harris H, Goodyear-Smith F, Godinet S, Turner N.Barriers to childhood immunisation among New Zealand mothers.NZ Fam Phys. 2002;29(6):396–401.23. Loring BJ, Curtis ET. Routine vaccination coverage of 11 yearolds, by ethnicity, through school-based vaccination in SouthAuckland. N Z Med J. 2009;122(1291):14–21.24. Ministry of Education. Frequently asked questions aboutdeciles. Wellington: Ministry of Education; 2007. [AccessedJun 2009]: Available from: http://www.minedu.govt.nz/index.cfm?layout=document&documentid=7696&data=l25. Ministry of Health. Cervical cancer vaccine brochure—information for girls, young women and their familes. Ministryof Health website: HPV Immunisation programme 2008.[Accessed Aug 2008]:Available from: http://www.moh.govt.nz/moh.nsf/indexmh/immunisation-diseasesandvaccineshpv-programme#resources.26. Ministry of Health. Ethnicity data protocols for the health anddisability sector. Wellington: Ministry of Health; 2004. [AccessedFeb 2010]:Available from: http://www.nzhis.govt.nz/moh.nsf/pagesns/228/$File/ethnicity-data-protocols.pdf.27. Henninger J. Human papillomavirus and papillomavirusvaccines: knowledge, attitudes and intentions of general practitionersand practice nurses in Christchurch. J Primary HealthCare. 2009;1(4):278–85.28. Wyllie A, Brown R. HPV vaccine communications first trackingmonitor. Research report for GSL network on behalf of theMinistry of Health. 2009; October (Phoenix Research, Unpublished).29. Grant CC, Turner N, Jones R. Eliminating ethnic disparities inhealth through immunisation: New Zealand’s chance to earnglobal respect. N Z Med J. 2009;122(1291):10–13.30. Brabin L, Roberts SA, Farzaneh F, Kitchener HC. Future acceptanceof adolescent human papillomavirus vaccination: Asurvey of parental attitudes. 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ORIGINAL SCIENTIFIC PAPERSquantitative researchIncreasing the uptake of opportunisticchlamydia screening: a pilot study in generalpracticeBeverley A Lawton ONZM, MBChB, FRNZCGP, DObst; 1 Sally B Rose PhD; 1 C Raina Elley MBChB, PhD; 2Collette Bromhead PhD; 3 E Jane MacDonald MBChB, FAChSHM, DTM&H; 4 Michael G Baker MBChB,FAFPHM, FRACMA, DComH, DObst 5ABSTRACTIntroduction: Genitourinary Chlamydia trachomatis infection is common and associated with considerablepersonal and public health cost. Effective detection strategies are needed.Aim: To assess feasibility of an opportunistic incentivised chlamydia screening programme in generalpractice over six months.MethodS: This study was designed as a pilot for a randomised controlled trial in primary care. Threegeneral practices were randomly allocated to intervention (two practices) and control groups. Theintervention involved practice education, self-sample collection and practice incentives (funding andfeedback) for a three-month ‘active’ intervention period. Feedback and education was discontinued duringthe second three-month period. Practice-specific nurse- or doctor-led strategies were developed foridentifying, testing, treating and recalling male and female patients aged 16–24 years. The main outcomemeasure was the difference between the practices’ chlamydia screening rates over the six months followingintroduction of the intervention, controlling for baseline rates from the previous year.Results: Chlamydia testing rates during the year prior to the intervention ranged from 2.9% to 7.0%of practice attendances by 16–24-year-olds. The intervention practices had higher rates of screeningcompared with the control practice (p

ORIGINAL SCIENTIFIC PAPErSquantitative researchof pelvic inflammatory disease (PID), 5,6 demonstratingthe individual benefit of diagnosing andtreating chlamydia. However, a chlamydia controlstrategy that aims to test and treat the widerpopulation is necessary to reduce the overallprevalence in the community. The US PreventiveServices Task Force recommends screening of allsexually-active women 24 years and younger. 2The challenge for any chlamydia control programmeis not only to increase testing in theprimary care environment, but also to engagewith primary care.The general practice setting is an obvious choicefor opportunistic testing as a high proportion ofunder-25-year-olds attend in any one year (80%of females in Australia, 7 and 84% of females and70% of males in New Zealand). 8 In 2007 the annualrate of chlamydia infection in New Zealandis estimated to be 714 per 100 000 which is overtwice that of Australia (244.9/100 000). The highestrates occur in 15–19-year-olds with rates of2887 and 6382 per 100 000 respectively for theWaikato and Bay of Plenty regions. 9 Despite thesehigh rates of infection, good primary care systemsand the availability of testing and treatment, thereis currently no organised programme to reducechlamydia in Australia or in New Zealand. 10,11The question still remains about how to achievesustained control of the transmission of chlamydia.The aim of this study was to pilot an opportunisticchlamydia screening programme targetingmales and females aged 16–24 years. The programmeincorporates practice-specific screeningstrategies, incentives, and self-sample collectionwith feedback of testing rates over three months.MethodsThis study was approved by the Central RegionalEthics Committee in July 2006 (Ref.CEN/06/06/053), and carried out during 2007in Wellington. Three primary care practiceswere invited to participate by letter of invitationfollowed by a phone call and face-to-facemeeting. Written informed consent was obtainedfor participation. Eligibility criteria for practicesincluded: located in Wellington and attended byat least 300, 16–24-year-old patients in the previousyear. The three practices were selected basedon location—Practice A was located in an outercity suburb, Practice B in the central city, andPractice C in an inner city suburb. All three ofthe invited practices were willing to participate,and were randomly allocated to the intervention(two practices) or control group (one practice), asdetermined by the flip of a coin.InterventionPrior to the start of data collection, the researchteam worked with practices in the interventiongroup over a six-week period to identify ways tobest achieve the goal of testing all 16–24-yearoldpatients attending for any reason. Thismethod was based on the ‘systems approach’used by Shafer to increase screening rates, andinvolved engaging the practice in the implementationof the programme, assembling a teamto champion the project, identifying the gapbetween best practice and current practice, andregular monitoring and feedback of progressover the trial period. 12 Sexual histories were nottaken prior to offering screening. Practices wereencouraged to develop a system for identifyingappointments for patients in the age-group atthe beginning of the day. Verbal scripts weredeveloped for use by practice staff in offeringchlamydia screening tests. Females were offeredself-taken swab or urine tests, while males wereoffered urine tests. A brief instruction sheetwas provided for females as a guide to obtaininga vaginal swab. The active interventionphase ran for three months once opportunisticscreening began at intervention practices. Duringthis phase, practices were provided withregular feedback at face-to-face meetings withthe programme team about their screening rates.During the second three months of the study(post-active intervention phase), the practices receivedno feedback, and no contact or meetingswith the programme team.The financial incentive provided to interventionpractices included a payment equivalent to twotenthsof a nurse’s time over six months (paidin two instalments over six months) to ensurethe programme was adequately resourced. Allgeneral practices in the study region can claimfor an already existent payment for a consultation(NZ$11 for a short consultation and NZ$40 for200 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPERSquantitative researcha long consultation) relating to sexual health inthe under–25-year-olds. The control practice wasable to claim for this, but only the interventionpractices were reminded to claim.Intervention practices were asked to contactpatients about their results in the usual way(either by telephone or in writing) and to offerAzithromycin 1g stat as first-line treatment forpositive tests. Partner treatment was also recommended.A recall system was put in place to offera repeat test at three months for patients whotested positive for chlamydia and at one year forpatients who tested negative. All chlamydia testingtook place at an ISO15189 accredited medicallaboratory using the Cobas TaqMan v2.0 PCRtest. This test has high sensitivity and specificityfor the detection of chlamydia from clinician orself-obtained specimens. 13 Laboratory results forpatients tested during the study period were fedback to requesting practices in the normal way(electronically).Outcome measuresData collection ran for six months from thestart of the intervention. The primary outcomeWHAT GAP THIS FILLSWhat we already know: Chlamydia trachomatis is the most commonlydiagnosedbacterial sexually-transmitted infection in New Zealand andworldwide, and is responsible for considerable personal and public healthcost. There is a lack of evidence for effective chlamydia control programmes.What this study adds: Opportunistic screening in primary care can besignificantly increased by the use of incentives, practice education and feedbackof screening rates.was change in rate of chlamydia testing in theintervention practices compared with the controlpractice over six months (including active andpost-active phases of the intervention). Monthlytest rates were calculated by taking laboratorytesting data as the numerator, and practice consultationsby 16–24-year-old patients during theassessment period as the denominator. Data ongender, age and ethnicity were also provided byWIPA (now Compass Health) who routinely collectpractice consultation data for their members.All data were de-identified so that no identifyingpatient details were provided to the researchteam. As consultation and testing rates werecollected electronically and automatically, thereFigure 1. Percentage of 16–24-year-olds screened for chlamydia in intervention compared with control practices before,during and after the interventionVOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 201

ORIGINAL SCIENTIFIC PAPErSquantitative researchTable 1. Number and characteristics of 16–24-year-old patients attending study practices during the study periodCharacteristic Intervention ControlPractice ANurse-ledPractice BDoctor-ledPractice C(usual care)n % n % n %All patients 756 712 936Females 508 67.2 500 70.2 613 65.5Males 248 32.8 212 29.8 323 34.5Age-band16–19 years 363 48.0 107 15.0 344 36.820–24 years 393 52.0 605 85.0 592 63.2Ethnic groupNew Zealand European 362 47.9 514 72.2 688 73.5Maori 266 35.2 20 2.8 53 5.7Pacific 60 7.9 7 1.0 4 0.4Asian 25 3.3 35 4.9 58 6.2Other/not known 43 5.7 136 19.1 133 14.2was no risk of assessor bias. Data relating to testresults were obtained from the laboratory.AnalysisTo assess the differences in changes in chlamydiascreening rates over time between the interventionand control practices (proportion tested), aregression model was used including baselinerates as a covariate. Analyses were also controlledfor gender proportions in each practice andscreening rates from the previous year. Percentagesscreened each month at each practice werearc-sine transformed to better satisfy the assumptionsof normality. Two hypotheses were testedusing contrasts. One a priori analysis assessedwhether there was an effect of the interventionin general compared with no intervention, anda post hoc analysis assessed whether there wasa significant difference in effect between thenurse-led and the doctor-led model interventionpractices. A p-value of

ORIGINAL SCIENTIFIC PAPERSquantitative researchTable 2. Description of intervention programme componentsComponentsFundingNurse-led interventionPractice ADoctor-led interventionPractice BControl (usual care)Practice C$11 payment* $11 payment* $11 payment*$400 study participation feeplus equivalent 2/10ths practicenurse time paid for six months$400 study participation feeplus equivalent 2/10ths practicenurse time paid for six months$400 study participationfeeProvided by theprogramme teamDocumentation22-page study manual customisedfor practice, covering all relevantaspects of chlamydia testing andtreatment22-page study manual customisedfor practice, covering all relevantaspects of chlamydia testing andtreatmentBest practice chlamydiamanagement guidelines(four pages) posted topracticeFeedbackFeedback on testing rates providedto practice team during the activeintervention phase (four face-to-facemeetings in weeks 2, 4, 6 and 10)Feedback on testing rates providedto practice team during activeintervention phase (two face-to-facemeetings in weeks 5 and 7; emailedfeedback in weeks 9 and 11)Method used toidentify eligiblepatientsSystematic identification of eligiblepatients by nurse at start of day,sometimes utilised Medtech † alertsOpportunistic identification ofeligible patients by doctor duringday‘Usual practice’Information forpatients abouttestingPosters placed in waiting room andclinical roomsGP and nurses used brief ‘script’ tooffer testsOne page pamphlet of informationabout chlamydia offeredGP used brief ‘script’ to offer testsOne page pamphlet of informationabout chlamydia offeredPractice-specificsystems developedin consultation withprogramme teamSample collectionFemales: urine; self-collected swab(instruction sheet offered), clinicianswab with cervical smearsMales: urineFemales: urine; clinician swab withcervical smearsMales: urineNotificationof results andtreatmentPatients asked to phone for results;positives phoned by nurseInvited partners to attend fortreatmentSent letter to patients regardless ofwhether result positive or negativeInvited partners to attend fortreatmentRecall of patientstestedAim to send letter to recall patientsPositive chlamydia—recall enteredinto Medtech for three monthsNegative chlamydia—recall enteredinto Medtech for 12 monthsAim to send letter to recall patientsPositive chlamydia—recall enteredinto Medtech for three monthsNegative chlamydia—recall enteredinto Medtech for 12 months* Available to all practices in the study region, payment can be claimed from the District Health Board for a short sexual health consult†Medtech is a computerised patient management system used in many general practices in New Zealand.proach (p=0.04). Screening rates declined at bothintervention practices after the three months ofthe active intervention, with rates returning tobaseline by the end of the six-month period (Figure1). Screening rates tended to be similar formales and females at practice A, but were lowerfor males at practice B during the three monthsof active intervention (Table 4).In the 12 months prior to the intervention, theoverall rate of chlamydia infection detectedat the three study practices (intervention andcontrol) was 10.5% (23/219). Practice A had thehighest proportion of chlamydia-positive casesdetected at baseline with 20.3% (13/64), PracticeB detected chlamydia in 14.8% (4/27) of patientstested, and the control practice detected chlamy-VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 203

ORIGINAL SCIENTIFIC PAPErSquantitative researchTable 3. Number (percent) of attendances of 16–24-year-olds where screening for chlamydia occurred in interventioncompared with control practicesTimePre-interventionNurse-ledintervention (A)Doctor-ledintervention (B)A vs BControlpractice (C)n/N* % n/N % n/N %Previous 12-months 66/1304 5.1 27/924 2.9 137/1952 7.0Active interventionMonth 1 52/148 35.1 18/120 15.0 11/209 5.3Month 2 39/123 31.7 12/92 13.0 10/171 5.8Month 3 31/130 23.8 6/143 4.2 8/156 5.1Post active interventionMonth 4 20/125 16.0 6/112 5.4 5/127 3.9Month 5 13/103 12.6 4/115 3.5 9/133 6.8Month 6 7/127 5.5 2/127 1.6 6/140 4.3Interventionvs ControlP-value † 0.04

ORIGINAL SCIENTIFIC PAPERSquantitative researchDiscussionThis pilot study found that the three-monthintervention programme comprising practiceeducation, practice-specific screening strategies,self-sample collection, incentives and face-to-facefeedback on screening rates significantly increasedthe proportion of 16–24-year-old patientsscreened for chlamydia over six months.The rates of testing in the intervention practicesover three months (Practice A, 30.4%; Practice B,10.1%) compare favourably with those of theUnited Kingdom (UK) screening programmewhich had an average uptake of 9.5% by December2008. There was a return to pre-interventionscreening rates by the end of the six-monthdata-monitoring period. Interaction with the programmeteam and feedback of testing rates ceasedat the end of three months, which coincided withthe gradual fall-off in rates back to baseline testingrates at six months. Comments from partici-50% uptake of chlamydia testing by the eligiblefemale population was achieved. 15 General practitionersreceived a fee-for-service for chlamydiatesting in the pilot and 60% of positives weredetected through this setting. 16 Incentives werealso a component of an Australian randomisedcontrolled trial designed to increase chlamydiatesting in women presenting for Pap smears. Thisstudy found that women had a twofold greaterchance of being tested in the intervention arm(6.9% vs 4.5% in the control). 17 The initial aim ofthe UK National Chlamydia Screening Programme(NCSP) was to achieve the modest targetof offering testing to 15% of all 15–24-year-olds. 18The NCSP began roll-out in 2003 with theexpectation of full national participation by allprimary care trusts by the end of 2007; howevertargets have not yet been met. 19The challenge for any chlamydia control programmeis not only to increase testing in theA strength of the present study was that testing was offered to allmales and females in the eligible age group regardless of sexualactivity. Doctors in this study supported this approach suggesting itwas less threatening, and ‘normalised’ testingpating practice staff at the end of the six monthsindicated that they stopped offering tests becausethe study had stopped. This suggests that, as wellas incentives, being part of a broader programmemay assist in maintaining higher levels of screeningin general practice.Past research has also demonstrated that usinga ‘practice champion’ may be effective. 14 Thepresent study showed that the screening strategyled by a practice nurse champion was significantlymore effective than the doctor-led strategy,although this may have been due to othercharacteristics of the practices involved. Financialincentives, combined with practice educationand feedback of testing rates, have contributedto the increased testing rates seen in this study.Incentives were also used in a UK screeningpilot study in Wirral and Portsmouth in whichprimary care environment, but also to engagewith primary care. It has been suggested that thelack of engagement with general practitioners inthe NCSP might be explained by the absence ofany incentives. 20–23 The relative failure of pastor existing screening programmes to reduce theprevalence of chlamydia may also be related inpart to the failure to screen males, as well as factorssuch as failure to treat partners. 24Although males appear to have lower ratesof chlamydia infection compared to females,it seems logical to screen and treat males toreduce the prevalence of chlamydia morbidityin females. 24,25 A strength of the present studywas that testing was offered to all males andfemales in the eligible age group regardless ofsexual activity. Doctors in this study supportedthis approach suggesting it was less threatening,VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 205

ORIGINAL SCIENTIFIC PAPErSquantitative researchand ‘normalised’ testing. This is consistent withqualitative research that concluded that womendid not want a sexual history taken and preferredtests to be offered based on age rather than sexualhistory. 26,27 Rates of screening in this study weresimilar for males and females, suggesting thatthis approach was accepted by both genders andwas particularly effective in reaching males (43%tested in month 1 at Practice A). The UK screeningprogramme had achieved 4.5% coverage ofmales as of 2008. 19The use of self-sample collection in the practicemay also have increased acceptance rates,particularly for females who prefer self-collectionto traditional (more invasive) clinician-obtainedmethods. 19Detection of chlamydia cases in the presentstudy was significantly lower for interventionpractices during the three-month active interventionperiod (8.9%) compared with baseline(18.7%, p

ORIGINAL SCIENTIFIC PAPERSquantitative researchInstitute of Environmental Science and Research Limited; 2008April 2008 Contract No.: Document Number|.10. Hocking JS, Walker J, Regan D, Chen MY, Fairley CK. Chlamydiascreening—Australia should strive to achieve what othershave not. Med J Aust. 2008 21;188(2):106–8.11. Coughlan E, Bagshaw S. Chlamydia—the problem that justwon’t go away. N Z Med J. 2005 August; 118(1220). http://www.nzma.org.nz/journal/118-1220/605/.12. Shafer MA, Tebb KP, Pantell RH, Wibbelsman CJ, NeuhausJM, Tipton AC, et al. Effect of a clinical practice improvementintervention on chlamydial screening among adolescent girls.JAMA. 2002;288(22):2846–52.13. Skidmore S, Kaye M, Bayliss D, Devendra S. Validation of CO-BAS Taqman CT for the detection of Chlamydia trachomatis invulvo-vaginal swabs. Sex Transm Infect. 2008;84(4):277–8;discussion 8–9.14. McNulty CAM, Freeman E, Oliver I, Ford-Young W,Randall S. Strategies used to increase chlamydia screeningin general practice: a qualitative study. Public Health.2008;122(9):845-56.15. Pimenta JM, Catchpole M, Rogers PA, Perkins E, JacksonN, Carlisle C, et al. Opportunistic screening for genitalchlamydial infection. I: Acceptability of urine testing in primaryand secondary healthcare settings. Sex Transm Infect.2003;79(1):16–21.16. Pimenta JM, Catchpole M, Rogers PA, Hopwood J, Randall S,Mallinson H, et al. Opportunistic screening for genital chlamydialinfection. II: Prevalence among healthcare attenders,outcome, and evaluation of positive cases. Sex Transm Infect.20 03;79(1):22–7.17. Bowden FJ, Currie MJ, Toyne H, McGuiness C, Lim LL, ButlerJR, et al. Screening for Chlamydia trachomatis at the time ofroutine Pap smear in general practice: a cluster randomisedcontrolled trial. Med J Aust. 2008;188(2):76–80.18. Department of Health. National Chlamydia Screening Programme(NCSP) in England accessed 24th May 2010. http://www.chlamydiascreening.nhs.uk/ps/index.html 200419. National Chlamydia Screening Programme. National overviewApril–December 2008; 2008 [updated 2008; cited]. Availablefrom: http://www.chlamydiascreening.nhs.uk/ps/data/data_tables.html20. White C. Most trusts will not meet chlamydia screening target.Br Med J. 2007;335(7628):1010.21. Kalwij SA. Time for action on chlamydia. Br Med J.2007;334(7598):813–4.22. Ma R, Clark A. Chlamydia screening in general practice:views of professionals on the key elements of a successfulprogramme. J Fam Plann Reprod Health Care. 2005;31:302–6.23. Ma R. With appropriate incentives, general practice canimprove the coverage of the National Chlamydia ScreeningProgramme. Br J Gen Pract. 2006 November;56(532):892–3.24. Greer AL, Fisman DN. Punching above their weight: males,reinfection, and the limited success of chlamydia screeningprograms. Sex Transm Dis. 2009;36(1):9–10.25. Dunne EF, Gift TL, Stamm WE. What about the men? SexTransm Dis. 2008;35(11 Suppl):S1–2.26. Pavlin N, Parker R, Fairley C, Gunn J, Hocking J. Take the sexout of STI screening! Views of young women on implementingchlamydia screening in general practice. BMC Infect Dis.2008;8(1):62.27. Hobbs MM, van der Pol B, Totten P, Gaydos CA, Wald A,Warren T, et al. From the NIH: proceedings of a workshop onthe importance of self-obtained vaginal specimens for detectionof sexually transmitted infections. Sex Transm Dis. 2008Jan;35(1):8–13.28. Low N. Screening programmes for chlamydial infection: whenwill we ever learn? Br Med J. 2007;334(7596):725–8.FUNDINGFunding was receivedfrom the Universityof Otago ResearchGrants Committee, theMinistry of Health andthe Capital and CoastDistrict Health Board.COMPETING INTERESTSThe funding agencies hadno influence on the resultsof this study. All authorshave declared no directconflicts of interest. BLhas received grants andlecture honoraria, and SRgrants from a variety ofindustry sources includingRoche Diagnostics whomanufacture chlamydiatesting reagents.VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 207

ORIGINAL SCIENTIFIC PAPErSqualitative researchGeneral practitioners’ views aboutdiagnosing and treating depression inMaori and non-Maori patientsDavid R Thomas BA, MA, PhD, FNZPsS; 1 Brooke Arlidge BA, MPH; 2 Bruce Arroll MBChB, PhD, FRNZCGP; 3Hinemoa Elder MBChB, RANZCP 41Emeritus Professor, Socialand Community Health,School of Population Health,The University of Auckland,Auckland, New Zealand2Maori Health Researcher3Department of GeneralPractice and Primary HealthCare, Faculty of Medicaland Health Science, TheUniversity of Auckland,Auckland4Consultant Child andAdolescent Psychiatrist atHauora Waikato, Hamilton,New ZealandABSTRACTIntroduction: The study investigated general practitioners’ (GPs’) views about recognising andtreating depression among patients to establish possible reasons for reported lower levels of diagnosisand treatment of depression among Maori compared to non-Maori patients.MethodS: Semi-structured interviews with 23 GPs in the Auckland region, including both Maori andnon-Maori GPs, elicited GPs’ views about risk factors for depression, recognising depression and circumstancesin which GPs would prescribe medication or recommend other treatments for depression.Findings: A framework was developed which incorporated the strategies GPs reported using to diagnoseand treat depression. This consisted of three categories: (a) how depression is identified, (b) factorsinfluencing treatment decisions, and (c) treatment outcomes. Reasons reported by GPs as most likely tolead to ethnic differences in diagnosing depression were greater stigma relating to admitting depressionamong Maori patients, Maori patients being less likely to talk about being depressed, and the need for patientsto have effective communication with their GP. Effective communication, where Maori patients feltfree to talk about personal feelings, was more likely when there was an established relationship betweenthe GP and patient.Conclusion: The findings are consistent with previous reports that depression is less likely to bediagnosed by GPs among Maori patients, compared to non-Maori patients. GPs who are able to establisheffective communication with patients, gain their trust and take account of the reluctance of some Maoripatients to talk about personal feelings, are more likely to diagnose and treat depression effectively.KEYWORDS: Depression; diagnosis; treatment; primary care; Maori; ethnicity; New ZealandJ PRIMARY HEALTH CARE2010;2(3):208–216.Correspondence to:David Thomas,Emeritus ProfessorSocial and CommunityHealth, The Universityof Auckland, PB 92019,Auckland, New Zealand.dr.thomas@auckland.ac.nzIntroductionA study of depression in one general practice inAuckland noted that Maori patients were prescribedantidepressants at a much lower rate thannon-Maori patients. 1 A similar finding was reportedfrom the 2002 National Primary MedicalCare Survey (NatMedCa) on general practice inNew Zealand (NZ), which noted that antidepressantswere less commonly prescribed for Maoripatients. 2 In NatMedCa, antidepressant prescriptionsaccounted for 1.6% of all Maori prescriptionitems compared to 3.3% of prescription itemsamong non-Maori patients. The prescribing ratewas 2.1/100 visits by Maori patients compared to4.2/100 for non-Maori patients. In total, antidepressantsaccounted for 12.9% of the nervoussystem drug prescriptions for Maori compared to22.0% of non-Maori.Research on the prevalence of mental healthdisorders in NZ has indicated that Maori peopletend to have similar or somewhat higher prevalenceof depression than non-Maori. 3,4 Given theapparent undertreatment of depression in Maori,208 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPERSqualitative researchwhat factors might be influential? A 2005 nationalsurvey noted that Maori respondents weresomewhat less likely to encourage someone withdepression to seek professional help than non-Maori (48% vs 58%). 5 In relation to people who doseek primary health care, are general practitioners(GPs) less likely to diagnose depression in Maori?Are they less likely to prescribe antidepressantmedication to Maori even when diagnosed, orboth? The study reported here addressed thequestion of why Maori patients seem to beprescribed antidepressants by primary health careproviders at a lower rate than non-Maori.To identify other demographic factors that mightbe related to the differences in prescribing antidepressantmedication to patients, we approachedthe authors of the NatMedCa study in June 2006to further analyse their data. 2 In the NatMedCastudy data, the diagnosis rate for depression as apercentage of all visits and all ages was 0.7% forMaori men and 2.8% for non-Maori men, and 3.1%for Maori women and 4.5% for non-Maori women.The differences between Maori and non-Maori inboth diagnosis and prescribing were most evidentamong males 25–44 years of age. A key issue iswhether these ethnic differences in diagnosingdepression and prescribing anti depressants are dueto doctor or patient effects, or both.A qualitative study of mental health consultationsin general practice in New Zealand reportedfour key features that had an impact on consultationswith GPs. 6 These included:• practice pressures (lack of time, a primaryfocus on physical conditions);• sociocultural factors (stigma attached topatients disclosing mental health problems,patient qualities of stoicism and self-reliance);• the medicolegal framework (e.g. patientaccess to medical notes, resistanceto mental health labels thatmight disadvantage patients); and• the consultation process (dealingwith physical problems first).GPs employed a number of strategies duringconsultations and do recognise mental healthproblems in patients. However practice pressuresand the other features noted above result inWHAT GAP THIS FILLSWhat we already know: Maori are prescribed antidepressant medicationin primary health care less frequently than non-Maori patients, even thoughprevalence surveys show high rates of depression among Maori. A likely reasonfor the difference is that general practitioners are less likely to diagnoseMaori patients as having depression.What this study adds: GPs reported that Maori patients tended to showgreater stigma relating to admitting depression and were less likely to talkabout being depressed compared to non-Maori patients. Effective communicationthat allows Maori patients to talk about personal feelings related todepression is more likely when there is an established relationship betweenthe GP and patient.consultations not being given the label ‘mentalhealth’. 6 Previous studies have reported a generaltrend for depression to be underdiagnosed,or difficult to diagnose in primary health careservices 7–9 and that stigma associated with mentalhealth problems and depression is a majorfactor in lack of disclosure of relevant informationby patients. 10,11The aim of the current study was to explore processesrelated to diagnosis and treatment of depressionamong Maori and non-Maori patients. Thefocus was on the views and experiences of GPsin relation to patients who may have depression.The specific research objectives were to:1. Explore the views of GPs about causes,diagnosis and treatment of depression amongpatients.2. Develop a framework to describe the processesand procedures GPs typically use to diagnoseand treat depression.3. Document GPs’ views about possibledifferences between Maori and non-Maoripatients in the diagnosis and treatment ofdepression.The study reported here was part of a largerqualitative study examining the treatment ofdepression by GPs. Given that the New ZealandHealth Strategy includes a section on reducingthe rate of suicide in New Zealanders 12 a betterunderstanding of depression should help in thisendeavour.VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 209

ORIGINAL SCIENTIFIC PAPErSqualitative researchMethodsThe research design was a qualitative interviewstudy using face-to-face interviews with GPsworking in the Auckland region in NZ.Interview sampleTable 1. Questions used in interviews with GPs• How would you recognise depression in a patient?A total of 23 interviews were completed. BothMaori and non-Maori GPs were included toensure that Maori perspectives were representedin relation to diagnosis and treatment of Maoripatients and that the findings were based ona diverse sample. The study began by recruitingMaori practitioners identified through thenetworks of the research team. For each MaoriGP who agreed to participate, a non-Maori GPmatched by gender, approximate age and areaof practice was recruited for interviewing. Thefinal sample consisted of 11 Maori GPs (sevenmale, four female) and 12 non-Maori GPs (sevenmale, five female). All were from practices in thegreater Auckland area. Most worked in smallgroup or private practices. Seven worked for iwibased(Maori service provider) health clinics. Theinterviews were carried out by the second author(BA), a Maori public health researcher (a nonclinician).Ethics approval was obtained from theNorthern X Ethics Committee.• What kinds of people do you think might be more likely to get depression?• In your experience, what are the main causes of depression?• Are there differences between your Maori and non-Maori patients?• When would you prescribe medication to treat depressed patients?• When would you prescribe other therapies to depressed patients?• How effective do you think medication is to treat depression?• How effective do you think other therapies are to treat depression?• What do you think would be ‘best practice’ treatment for depression?• Are there differences in the way you would prescribe either medication or anothertherapy to your Maori and non-Maori patients?• What, if any, do you think some of the barriers might be to adherence of treatmentfor patients?• Do you think there are any differences in patient adherence?Interview questionsThe interview schedule included semi-structuredand open-ended questions (Table 1). Interviewswere conducted in a flexible manner that allowedGPs to share their experiences in relation to thetopics covered by the questions.ProceduresFace-to-face interviews were conducted with 22GPs at their health practices. One was interviewedby phone. Most of the interviews tookapproximately half an hour and all were audiorecordedand transcribed verbatim, with thetranscripts used for qualitative analysis.Data analysisThe analysis used an inductive approach 13 suitablefor the research objectives and the interview datacollected. An initial analysis was conducted bythe interviewer to identify specific themes andcategories. Subsequently text from the interviewtranscripts was imported into the qualitativeanalysis software NVivo (v7) and analysed bya second team member (DRT). This confirmedthe initial categories and constructed an overallframework that incorporated the specific categoriesand provided an overview of GPs’ strategiesfor identifying and treating depression. The finalset of categories was reviewed by the researchteam. A key focus of the analysis was on GPs’experiences in relation to potential differencesin identifying and treating depression betweenMaori and non-Maori patients, not to systematicallycompare Maori and non-Maori GPs.FindingsFindings from the reports of GPs were organisedinto two sections: (a) the framework incorporatingthe processes and procedures GPs reported usingto diagnose and treat depression and challengesthey faced, and (b) differences between Maoriand non-Maori patients.Diagnosing and treating depressionThree primary categories were constructedfrom the inductive analyses of the interviews.These were:210 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPERSqualitative researchTable 2. Categories constructed from GP interviewsPrimary categories Specific categories DescriptionsIdentifyingdepressionTreatmentdecisionsTreatmentoutcomesCommunication effectivenessRecognising depressionCauses and risks for depressionTreatment options and strategiesPatient expectations re treatmentFactors influencing treatment decisionsBarriers to effective treatmentPatient compliance with treatmentEffectiveness of treatmentsPatient responses to treatmentGood communication and a sense of trustbetween the GP and patient are important foridentifying depressionSigns or indicators used by GPs to recognisedepressionGP views about causes of depression and riskfactors for depressionGP options relating to pharmaceutical (medication)and non-pharmaceutical treatmentsPatients’ views about medication and othertreatmentsPatient factors affecting GP decisions abouttreatment, including age, treatment preferencesand availability of treatmentsBarriers relating to medication and counsellingtreatments, and stereotyping of mental illnessPatient characteristics related to compliance andreasons for non-complianceGP views about the effectiveness of treatments fordepressionGP reports about how patients responded totreatments• identifying depression—how GPs reportedidentifying depression;• treatment decisions—factors which influencedGPs’ treatment decisions; and• treatment outcomes—the outcomesof treatment for depression.Table 2 shows these categories, the associatedsubcategories and their descriptions. These providea framework for understanding the strategiesGPs use to identify and treat depression, and acontext for the differences some GPs reportedbetween Maori and non-Maori patients.enough to be able to recognise any significantchanges in their behaviour that might indicaterisk factors for depression. Some GPs emphasisedthat an adequate level of trust by their patientswas needed before patients would be comfortableenough to disclose personal issues.Unless your patient feels that they have confidencein you then they’re not going to tell youanything. They’re often divulging very personal,private information and they’re just not goingto tell you unless they have confidence in you.[Maori GP11, female]Identifying depressionThree specific categories relating to identifyingdepression were evident in GPs’ accounts.1. Communication effectivenessHaving good communication and a sense of trustbetween the GP and patient were important indetecting signs of depression. Effective communicationrequires GPs knowing their patients well2. Recognising depressionMost GPs reported that patients with depressioncould present in several ways, with differentsymptoms. The most common ways of identifyingdepression were disclosure of depressiondirectly by the patient, the patient reportingsymptoms that were commonly associated withdepression and, less commonly, the use of screeningquestions or a checklist to assess depression.Some GPs noted that women appeared moreVOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 211

ORIGINAL SCIENTIFIC PAPErSqualitative researchlikely to say they were depressed. When patientsdid not directly disclose depression, GPs reportedother indications such as lack of motivation, notsleeping well or major negative events occurringin the patients’ lives and changes in behaviourpatterns. Patients might use phrases like feelinglow, down, wanting to give up, complaining oftiredness, or not being able to sleep.Quite often it’s their behaviour rather than necessarilywhat they say. For instance I find if theystart being difficult and a little bit aggressive anddemanding, or just different from how they havebeen. And then there’s the obvious ways when theyactually tell you, which is easy. I guess I’m probablyalways looking for underlying reasons for whythey’re presenting, rather than just the symptomsthat they come with. [Non-Maori GP3, female]3. Causes and risks for depressionThe most frequently mentioned cause of depressionfor their patients was related to life eventsand the patient’s social environment. GPs referredto reactive depression developing as a result of amajor traumatic life event. Some examples givenwere breakdown of a relationship, loss of a lovedone, or becoming chronically ill.Many GPs related depression to specific riskfactors. A personal or family history of depressionwas seen as a risk factor, as was havingexperienced abuse, including physical, sexual,and verbal abuse, as well as drug and alcoholabuse. Isolation was also seen as a majorcontributing risk factor for depression. Isolationincluded being separated from families, fromsocial groups, from work, geographical isolation,or emotional isolation.Treatment decisions1. Treatment options and strategiesThe GPs reported two main types of treatmentoptions, pharmaceutical (medication) and nonpharmaceuticaltreatments such as counselling.Within each treatment type, treatment decisionswere related to patient age, severity of depression,past history, duration of symptoms as well aspatient preference.All GPs spoke about offering medication totreat patients with depression, most commonlyfor patients who had moderate to severe levelsof depression. They reported choosing medicationthey felt would work best for the level ofseverity or that would suit the patient. The mainnon-pharmaceutical treatment GPs mentionedwas counselling or psychotherapy. This includedpsychological and psychiatric therapies such ascognitive behavioural therapy, as well as basiccounselling and group counselling.Some GPs mentioned they preferred to offertheir patients counselling therapies first beforethey would prescribe antidepressant medication,particularly for mild depression. For the moreseverely depressed cases they were more likely toconsider medication.I don’t like using medication for depression unlessI’m at a point of saying these other things haven’tdone enough to help a person. They’re still reallydown to despite our own efforts. So I don’t go tomedication first. [Maori GP1, male]Many GPs noted that a combination of bothmedication and a counselling therapy was theirrecommended ‘best-practice’ treatment for moderateto severely depressed patients. Some nonpharmaceuticaltreatments that were mentionedby the GPs included recommending a ‘GreenPrescription’ for physical exercise to help liftthe mood of patients. As well as these treatments,alternative therapies were mentioned bya few GPs. These included rongoa Maori (Maoritraditional medicine), homeopathic remediesand acupuncture.2. Patient expectations regarding treatmentSeveral GPs talked about patients’ views about,and expectations of, treatment for depression.These often related to patients’ attitudesregarding antidepressant medication, which werereported to be diverse. Some mentioned patientswho did not want to be given antidepressantmedication, because they were seen as beingaddictive or having negative side effects. Incontrast, some patients had no problems withtaking antidepressants—they just wanted a‘quick fix’.212 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPERSqualitative research3. Factors influencing treatment decisionsGPs referred to multiple influences on theirchoice of treatments for depression. Treatmentchoices could be influenced by the patient’sage, personal preferences and the availability ofspecific treatments. Discussion with the patientsabout depression as an illness and the possibletreatment options was a priority for many GPs.I really talk to the person and it’s a discussion withthem and where they’re at, you know… a lot ofother people are like yeah I’m not into pills and youknow, you’ve just sort of got to leave it there as anoption. [Maori GP9, female]During discussion with their patients, GPs wouldtalk through the treatment options that they feltwere most appropriate for their patient. Theywere more likely to go ahead with a suggestedtreatment once the patient had agreed.I treat them with medication when I feel thatthey’re using all their energy to just control theirsymptoms and so they’ve got no extra energy tomake changes in their lives. I give the similarityof, it’s like a Panadol for a headache. That you takethe Panadol to get rid of the headache, but you’vestill got to work out why you’re getting the headaches.And I often say that as an idea to patients.[Non-Maori GP3, female]GPs’ decisions regarding treatment options fortheir patients were usually made after assessingthe severity and duration of the depression. If theGP thought the patient’s level of depression wasmoderate or severe, they might be more likely totry antidepressants, or antidepressants in conjunctionwith counselling therapy.Well I think if someone, if someone is suicidalyou want to have them on treatment and if they’resuicidal, see a specialist, or a psychiatrist. I mean ifsomeone has had a chronic ongoing depression for,you know some months and they’re just not gettingout of it, it’s worthwhile trying an antidepressant.Yeah it’s people generally with more serious symptoms,or with ongoing symptoms, consider tryingan antidepressant. [Non-Maori GP11, male]Access to counselling services was considered byGPs when considering this option. Some accessdifficulties mentioned were cost, lack of goodquality therapists, or no therapists being availablein some regions.4. Barriers to effective treatmentBarriers to effective treatment mentioned by GPsincluded patient concerns about taking medicationfor depression, views about counsellingtreatments, and negative stereotyping aroundmental illness. Many GPs felt that the stigmasurrounding antidepressant medication was asignificant barrier to patient acceptance and compliancewith treatment for depression.Other barriers to treatment mentioned includedbeliefs about negative side effects from thedrugs, having to take the medication regularlyand the lengthy duration of the treatment. Accessto counselling treatments was very difficultfor many patients due to cost, lengthy waitinglists to therapists, and therapists not being availablelocally.Treatment outcomesThree themes were evident in GPs’ views aboutthe factors affecting treatment outcomes.1. Patient compliance with treatmentPatient compliance or non-compliance with treatmentwas usually raised in relation to patients nottaking their prescribed medication. Some felt lackof compliance in taking antidepressant medicationwas related to the long course of treatment,or to side effects that some patients reported aftertaking medication.2. Effectiveness of treatmentsThere was a range of views among GPs aboutthe effectiveness of treatments for depression.Some used observed improvements in theirpatients as a basis for assessing treatment effectivenessand some referred to research evidencethey had read. Most GPs felt that antidepressantmedication was in many cases an effective treatmentfor depression, especially in conjunctionwith other treatments. While noting benefitsfrom using medication with their patients, someVOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 213

ORIGINAL SCIENTIFIC PAPErSqualitative researchGPs also emphasised the limitations and otherfactors that needed to be considered. Medicationcould be ineffective or inappropriate forsome people. Some medication suited youngerpatients but were not suitable for elderly people.The uncertain nature of outcomes from takingmedication was pointed out.3. Patient responses to treatmentThe GPs interviewed commented that there wasa wide range of patient responses to treatments.One response noted was patients stopping theirmedication. While patients had various reasonsfor ceasing their drug treatments, it was commonnot to notify or discuss the issue withtheir GP.… you see them six months later and you ask, howis your depression? And they say, they’re a lot better.And you say, did you take the medication? Andthey say, yeah I took it for a week or I took it for amonth, or I didn’t take it. So yeah there certainlyare some people who don’t take it even though theyaccept it. [Non-Maori GP6, male]Differences between Maoriand non-Maori patientsDuring the interviews GPs were asked aboutdifferences among Maori and non-Maori patientsrelating to diagnosing and treating depression.The most common theme evident in the analysisrelated to ethnic differences was the difficultyin identifying or diagnosing depression in Maoridue to differences in communication styles.1. Identifying depressionSeveral GPs referred to the difficulties theyhad with diagnosing depression in some Maoripatients. Three specific features evident in theinterviews were:i. A greater sense of stigma relating tomental illness generally and depressionamong Maori patients;ii. Maori patients being less likely to talkabout being depressed;i. Effective communication and anestablished relationship in which thepatient trusted the GP being especiallyimportant for Maori patients before theyare likely to talk about personal feelingssuch as depression.The stigma attached to depression wasmentioned by several GPs. This was consistentwith the themes that Maori patientswere less likely to talk about depression andneeded to develop a greater sense of trustwith GPs before they were willing to talkabout personal feelings.My impression is that the Maori patients areperhaps less likely to be forthcoming… like certaingroups, you know they’re always thinking aboutpsychological things. So your average middle-agedEuropean woman is going to come in and tell you Ithink I’m depressed, because… they’d been readingit in a magazine. Your average Maori patient is notgoing to come in and say that as a general rule.Some do, some of the younger ones [but not] someof the older women, and hardly ever any of themen. [Maori GP4, female]Some GPs noted that it is more difficult todiagnose depression among Maori, particularlyMaori men. They are less likely to say they aredepressed and more reluctant to accept a diagnosisof depression. Maori men tend to become lesscommunicative when depressed.Quite a few of them [Maori males] might come inwith sort of funny other symptoms, physical symptomsand gradually they might disclose that they’redepressed as well. But often it can be quite hard toget that group of people to admit to depression inany sort of consultation type really. [Non-MaoriGP7, male]Several GPs reported that some Maori patientshave a different communication style from non-Maori. They take longer to get to know their GPand trust them, particularly among older Maori.GPs may need to use culturally-specific communicationstyles with Maori patients and allowmore time for trust to develop.I think that sort of trust is more likely to be anestablished GP. They don’t want to bring it up withan A&E GP. That’s a problem with Maori people.214 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPERSqualitative researchThey’re worried about the trust… You can imaginewhat depression does to an uncommunicative Maorimale. It just makes them less communicative. Andsometimes you need Maori doctors to be able tolink into that uncommunicative person. Like we’reused to it and don’t get frightened by it and canhandle it. [Maori GP3, female]A few GPs noted that Maori patients can presentdifferently from non-Maori. This meant depressionmay be diagnosed late.One of the things that you’re always meant to beaware of, that they [Maori patients] may presentquite differently. And because of that, I guess ifwe’re not aware of it, we may not pick it up at thesame point in time. We may be a bit late in diagnosingit. And so there could be a consequence tothat… They may have progressed to a more seriousstage. [Maori GP5, male]2. Factors influencing treatmentMost of the GPs (14 out of 23) stated explicitlythat their antidepressant treatment wasnot related to the patient’s ethnicity and thattreatment was tailored to the specific needs ofpatients.…if I felt medication was indicated on the case Iwould offer it to anyone, who was even, regardlessof their ethnicity, I wouldn’t differentiate on thatbasis. [Non-Maori GP1, male]Whichever treatment option was recommended,consultation with the patient and thepatient’s agreement were required. The likelycost of treatment and whether the GP thoughtthe patient could afford a specific treatmentwere issues that were taken into considerationwhen recommending counselling or similartherapies. The availability of suitable counsellorsand counsellors of the same ethnic backgroundas the patient were important factorsfor some GPs when considering counselling fortheir patients.The other thing is cognitive behavioural therapy…Is it readily available? Not as much as I’d hoped. Imean counsellors are certainly around, you know,you can get hold of counsellors. They’ve beenthrough some difficulties like if you’re trying tofind a Maori one, they’re quite few and far between.So there are difficulties trying to tailor your patient’sneeds to what’s available. [Maori GP12, male]A number of the GPs viewed Maori as generallyhaving better whanau support systems. Somerecognised whanau support as being an integralpart along the pathway of care to better healthfor patients.I think my Maori patients are more likely to havesupport structures in place that we can tap into,that I can say to them, hey how about talking to soand so. [Maori GP1, male]Some GPs reported that Maori patients tend tobe less accepting of the idea of taking medication.Reasons for reluctance in taking medicationincluded being suspicious of pharmacologicalproducts, cost and cultural reasons.I think probably the Maori perhaps are a little bit[less] keen on taking anti-depressants than the Europeans…part of it may be cost, part of it just, youknow, perhaps a little bit fearful of perhaps a lot ofmedicine, or antidepressants. You know it may bepartly cultural, where some of the elders might say,you know, you don’t have to take those, or what areyou taking those for, that sort of thing. [Non-MaoriGP11, male]DiscussionThe present study investigated reasons whyMaori patients might appear to be less likely tobe diagnosed with depression and less likely tobe prescribed antidepressant medication. Themost likely contributing factor to the disparitywas the process of diagnosing depression.If depression was diagnosed, GPs reported thatMaori patients were offered or recommended asimilar range of treatment options to non-Maoripatients. Processes most likely to lead to ethnicdifferences in diagnosing depression were agreater stigma relating to admitting depressionamong Maori patients, Maori patients being lesslikely to talk about being depressed, and theneed to have effective communication with theirGP. Effective communication that allowed Maoripatients to talk about personal feelings, such asVOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 215

ORIGINAL SCIENTIFIC PAPErSqualitative researchthose related to depression, was more likely whenthere was an established relationship between theGP and patient.The findings of the present study were intendedto contribute to an understanding of the reasonswhy Maori patients are less likely to be prescribedantidepressants even though prevalencestudies show Maori to have similar rates of depressionto non-Maori. The findings are consistentwith previous reports that depression amongMaori patients is less likely to be diagnosed byGPs than among non-Maori. The implications ofthese findings point to the need for GPs to takespecial care in establishing effective communicationwith Maori patients, the need to gain thetrust of Maori patients and note the reluctanceof some Maori patients to talk about personalfeelings which may provide clues about mentalwell-being and depression.A previous study has suggested that Maori healthcare providers are better able to establish effectivecommunication with Maori who have experiencedcancer. 14 The pattern of findings we havereported is consistent with the view that bothpatient characteristics and health care providercharacteristics are influential in whether Maoripatients get effective treatment when they aredepressed. 15 Compared to non-Maori, some Maoripatients may be reluctant seek professional helpfor depression and to disclose information thatprovides GPs with clues about depression. Healthcare providers who are able to establish effectivecommunication with Maori patients are morelikely to diagnose depression among Maori andthen be able to treat it.References1. Arroll B, Goodyear-Smith F, Lloyd T. Depression inpatients in an Auckland general practice. N Z Med J.2002;115(1152):176–9.2. Crengle S, Lay Yee R, Davis P, Pearon JA. A comparison ofMaori and non-Maori patient visits to doctors: the NationalPrimary Medical Care Survey (NatMedCa) 2001/2002. Wellington:Ministry of Health, Report 6; 2005.3. Arroll B, Goodyear-Smith F, Kerse N, Hwang M, Crengle S,Gunn S, et al. The prevalence of depression among Maoripatients in Auckland general practice. J Prim Health Care.2009;1(1):26–9.4. Oakley Browne MA, Wells JE, Scott KM, editors. Te RauHinengaro: The New Zealand Mental Health Survey. Wellington:Ministry of Health; 2006.5. Wyllie A, Goodman K, Akroyd S, Star L. Public health depressioninitiative benchmark survey. Wellington; Ministry ofHealth; October 2005.6. Dew K, Dowell A, McLeod D, Collings S, Bushnell J. ‘Thisglorious twilight zone of uncertainty’: mental health consultationsin general practice in New Zealand. Soc Sc Med.2005;61:1189–200.7. Henke R, Chou A, Chanin J, Zides A, Scholle S. Physicianattitude toward depression care interventions: implications forimplementation of quality improvement initiatives. ImplementationSci. 2008;3(1):40.8. Pollock K. Maintaining face in the presentation of depression:constraining the therapeutic potential of the consultation.Health. 2007;11(2):163–80.9. Thomas-MacLean R, Stoppard J, Miedema BB, Tatemichi S.Diagnosing depression: there is no blood test. Can Fam Physician.2005;51(August):1102–3.10. Barney, L, Griffiths, K, Jorm, A, Christensen, H. Stigma aboutdepression and its impact on help-seeking intentions. Aust NZJ Psychiatry. 2006;40(1):51–4.11. Brown, C, Conner, K, Copeland, V, Grote, N, Beach, S,Battista, D, et al. Depression stigma, race, and treatment seekingbehavior and attitudes. J Community Psychol. 2010;38(3):350–68.12. Ministry of Health. New Zealand Health Strategy. Wellington;2000.13. Thomas DR. A general inductive approach for analyzing qualitativeevaluation data. Am J Eval. 2006;27(2):237–46.14. Walker T, Signal L, Russell M, Smiler K, Tuhiwai-Ruru R, OtakiCommunity Health Centre, et al. The road we travel: Maoriexperience of cancer. N Z Med J. 2008;121(1279):27–35.15. Tapsell R, Mellsop, G. The contributions of culture and ethnicityto New Zealand mental health research findings. Int J SocPsychiatry. 2007;53(4):317–24.ACKNOWLEDGEMENTSWe wish to thankthe GPs who agreedto be interviewedfor this project.FUNDINGThe project was fundedby a grant from theHealth Research Councilof New Zealand.COMPETING INTERESTSNone declared.A limitation of the present study is the relativelysmall number of GPs interviewed and thereliance on GPs’ accounts only. However, thefindings do provide a lead for further researchon possible reasons for the underdiagnosis ofdepression among Maori patients. A strength ofthe study was the inclusion of both Maori andnon-Maori GPs. While the GPs interviewedworked in a range of different practices, we didnot have sufficient numbers to make comparisonsbetween those working for Maori healthcare providers and GPs working in other healthcare settings.216 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPERSqualitative researchPerspectives on adherence to blood pressure–lowering medications among Samoan patients:qualitative interviewsKuinileti Chang Wai MBChB, MMedSci(Hons); C Raina Elley MBChB, PhD; Vili Nosa BA, MA (Hons), PhD;John Kennelly MBChB; Thusitha Mabotuwana BE (Hons); Jim Warren PhDABSTRACTSchool of Population HealthThe University of Auckland,Auckland, New ZealandAim: To explore influences on adherence to taking long-term medications among Samoan patients in anAuckland general practice.Methods: Twenty Samoan participants from an Auckland general practice were identified and interviewedabout their views on adherence or non-adherence to taking blood pressure–lowering medications.One-to-one semi-structured interviews using open-ended questions were undertaken in Samoanand English, recorded, transcribed and translated into English. Transcriptions were examined by tworesearchers to identify themes.Findings: Patients with ‘high’ and ‘lower’ rates of adherence to taking usual medication were identifiedusing medication possession ratio cut-offs from medical records of timely prescribing. Ten participantswith ‘high’ and 10 with ‘lower’ rates of adherence were interviewed, including 11 women and nine men.Themes identified for those with lower adherence included ‘lack of transport’, ‘family commitments’,‘forgetfulness’, ‘church activities’, ‘feeling well’ and ‘priorities’. Themes identified for those with highrates of adherence included ‘prioritising health’, ‘previous event’, ‘time management’, ‘supportive familymembers’ and ‘relationship with GP (language and trust)’. A theme common to both was ‘coping with thestress of multiple comorbidities’.Conclusion: Reasons for adherence and non-adherence to taking blood pressure–lowering medicationsamong the Samoan patients interviewed were multifactorial and encompass personal, social,cultural and environmental factors. Interdisciplinary teams to support treatment decisions (including Pacifichealth professionals or community health workers), systematic identification of those with low ratesof adherence, phone or text follow-up, use of church or family networks, provision of transport whereneeded and better tools and resources may help address this problem.Keywords: Medication adherence; New Zealand; Pacific Islands; ethnic groups; qualitative research;antihypertensive agentsJ PRIMARY HEALTH CARE2010;2(3):217–224.IntroductionRaised blood pressure is an important risk factorfor cardiovascular and renal disease. 1–7 There isstrong evidence that lowering blood pressure reducescardiovascular and renal events. 8,9 However,only about 30% of patients who take blood pressure–loweringmedication achieve adequate bloodpressure control. 10 According to the World HealthOrganization (WHO), at least 50% of patients donot take their blood pressure–lowering medicationsas prescribed. 11 Low adherence threatens theeffectiveness of these medications. Unfortunatelyfew interventions have been shown to improveadherence. 3,12,13 The WHO estimates that morehealth benefit could be achieved by successfulinterventions to improve adherence than fromnew medications. 11Correspondence to:C Raina ElleyDepartment of GeneralPractice and PrimaryHealth Care, School ofPopulation Health, TheUniversity of Auckland,PB 92019, Auckland,New Zealandc.elley@auckland.ac.nzVOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 217

ORIGINAL SCIENTIFIC PAPErSqualitative researchTable 1. Participant characteristicsParticipant Age SexIt is known that Pacific Island people in NewZealand have high rates of coronary heart disease,hypertension, diabetes and renal disease,including dialysis, compared with Europeans. 14–19Furthermore, low rates of adherence have beendocumented in Pacific people. A recent audit ofa largely Pacific clinic found that 38% of patientswith ‘hypertension’ routinely failed to collecttheir prescriptions in a timely fashion. 20 Some ofthe factors that have been suggested to influenceadherence among Pacific people include socioeconomicfactors, cultural values and beliefs,attitudes towards taking medications, views surroundingtraditional healing practices comparedwith Western methods, and the side effects ofthe medications in use. 21–24Years inNew ZealandYears diagnosed with‘hypertension’P1 60 Male 10 5P2 70 Female 11 20P3 70 Male 17 4P4 69 Female 44 10P5 46 Female 13 1P6 64 Female 21 12P7 45 Male 19 7P8 47 Male 3 9P9 81 Male 51 9P10 68 Male 36 10P11 61 Female 42 13P12 44 Female 21 5P13 63 Female 6 6P14 59 Female 33 4P15 59 Male 38 4P16 66 Male 45 5P17 41 Female 41 3P18 65 Female 7 22P19 63 Male 36 28P20 55 Female 9 7There are few studies that have investigated thereasons and no studies among Samoan people inNew Zealand primary care. Understanding thereasons and addressing these directly may informinterventions to improve adherence and in turnimprove health outcomes for Pacific people inNew Zealand. The aim of this study was to exploreinfluences on adherence to taking long-termmedications among Samoan patients in an Aucklandgeneral practice. The study was a qualitativedescriptive study using one-to-one interviews.MethodsStudy populationThe study population included Samoan patientswithin one predominantly Pacific general practicein Auckland. An independent researcher randomlyselected 10 Samoan patients with ‘high rates ofadherence’ and 10 Samoan patients with ‘lowerrates of adherence’ to taking blood pressure–lowering medications from 280 patients withhypertension, identified only by code numberin a recent audit of the practice. 20 ‘High rates ofadherence’ was defined as a medication possessionratio (MPR) of at least 80%. 20,25 In other words,more than 80% of days from the previous 12months were covered by a prescription accordingto practice records. ‘Lower rates of adherence’ wasdefined as an MPR of less than 80%.The codes of the 20 selected patients were givento the principal author, a clinician at the practice,who then matched codes with names and contactedthe patients by phone to invite participation inthe study. If they were interested, patients weresent a participant information sheet in Samoan orEnglish. Informed consent was obtained prior tocommencement of the interview. Invited patientswere assured that their decision to participate ornot would not affect their care.InterviewsA semi-structured interview schedule was used.All interviews were one-to-one and recorded byaudiotape. The interviews were conducted inSamoan or English, according to the choice ofthe participant, by the principal author who isfluent in both languages. The interview questionswere informed by a literature search and previousstudies addressing this specific area. 26 Allinterviews were conducted during 2008 at theusual general practice of the participant, althoughparticipants were given the choice of home orpractice venue. Interviews were approximately45 minutes in duration. Demographic informa-218 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPERSqualitative researchtion was also collected, as was information aboutusual medications and known medical conditions.AnalysisThe taped interviews were transcribed and transcriptionssent to the patients for final commentbefore completing analysis of the interviews.The principal author listened to the audiotapes,transcribed, interpreted and translated the interviewsfrom Samoan into English. The transcriptswere analysed separately by two researchers toidentify themes.Ethical approvalExpedited ethical approval for the study wasgranted by the Northern X Regional Ethics Committeein February 2008, Ministry of Health(NTX/08/17/EXP).FindingsAll 20 participants completed the interviews.Nineteen were undertaken in Samoan. One participantwas New Zealand–born and chose to havethe interview conducted in English. Participantcharacteristics are included in Table 1. Elevenwere female and ranged in ages from 41 to 81years (mean 60 years). The time spent in New Zealandranged from three to 51 years (mean 25 years)and the duration of ‘diagnosed hypertension’varied from one to 28 years (mean nine years).Participants had between one and eight long-termconditions, such as obesity, hypertension, diabetes,gout, hyperlipidaemia, chronic obstructiveairways disease, bronchiectasis, cerebrovascularaccidents (strokes), myocardial infarction (heartattacks), aortic stenosis, hepatitis B carrier, Parkinson’sdisease, peptic ulcer and osteoarthritis.Themes from those with ‘lowerrates of adherence’Lack of transportA number of participants commented on the lackof transport as a problem for them not attendingtheir clinic appointments, thereby being unableto collect their prescriptions for their medicationWHAT GAP THIS FILLSWhat we already know: Adherence to taking long-term medications islow internationally, including among Pacific people. Pacific people have highrates of cardiovascular and renal morbidity and mortality. Little is knownabout the reasons for ‘high’ or ‘lower’ rates of medication adherence amongPacific patients. Rates of medication adherence can be estimated using medicationpossession ratio (MPR), or the percentage of days over the previous 12months that were covered by a prescription according to practice records.What this study adds: Factors contributing to lower rates of adherenceto taking antihypertensive medication by Samoan patients include lack oftransport, family and church commitments and priorities, forgetfulness,time management issues and feeling ‘well’. Factors conducive to adherenceinclude family support, prioritising health, a previous cardiovascular event,and a good relationship with the health professional. Common language andcultural understanding between patient and health professional also assists inadherence to taking medication.supply. For example, participant 13 (female, aged63) commented:Everyone at home works, so there is no one to bringme to the clinic when my appointment is due. Ihave to wait for someone to be free and that couldbe weeks, meanwhile, my tablets are finished. Idon’t want to be a pain to the workers, so I wait forone of them to be free.Participant 20 (female, aged 55) commented:I take the bus because there is no car at home, but ifit is a rainy day, then I stay home, because the busstop is a little far from home.Family commitmentsFamily commitments were also highlighted asanother factor for not taking high blood pressuremedication. This included being busy with lookingafter children for the women, and for the menit included their commitment to their work as partof being the main breadwinner, thereby showingtheir commitment to their family. For example,participant 6 (female, aged 64) commented:I often look after the grandchildren, so I am verybusy looking after them, that I forget my tablets,until late in the night. By then, it is too late totake them.VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 219

ORIGINAL SCIENTIFIC PAPErSqualitative researchParticipant 7 (male, aged 45) commented:I have a busy job and I work long hours often leavinghome very early in the morning and not returningtill very late at night, so I do forget my tablets alot of the time.ForgetfulnessSome of the participants mentioned that they oftenforget to take their medications. For example,participant 17 (female, aged 41) commented:My day is usually very busy with taking childrento school, then there’s the shopping and houseworkand then back at the school again in the afternoonto collect children and once we are home, there’sthe evening food to prepare, so I forget my tablets.On some days, like the weekends, even if I am notbusy, I just forget about the tablets, which I knowis bad, but I can’t help it, I am just forgetful.Church activitiesMany of the participants also spoke of theirresponsibilities within the church as anotherfactor that contributed. For example, participant 1(male, aged 60) commented:There is always family responsibilities and churchactivities, like I am a deacon at church, so theresponsibilities there are a lot with all the meetingsyou have to go to, so it is easy to forget the tablets.Feeling wellSome of the participants stated that they didnot take their medications when they felt well.For example, participant 7 (male, aged 45) commented:When I feel well, I do not take my medication. Ionly take my tablets when I feel unwell like myhead is hurting. Sometimes I do not take my tabletsfor about three or more weeks.PrioritiesSome did not see taking their medications as apriority. For example, participant 10 (male, aged68) commented:I never liked taking tablets in my forties because Iwas too busy partying and drinking, but then afterI had my stroke and now that I am getting older, Ineed to take my tablets, so I am better at taking thetablets now.Themes from those with ‘highrates of adherence’Prioritising healthMost knew that their medications were importantso they prioritised taking their tablets over otheractivities. This group of participants also knewexactly what kind of medication they were taking,and if they did not remember the names ofthe tablets, they knew the reasons why they weretaking the tablets such as a description of thetablets as below:Participant 14 (female, aged 59) commented:If I don’t take my medication then I don’t lovemyself at all, so yes, it’s important to me to take mymedication as instructed. For example, I take mybetaloc in the morning then my cartia after food.At lunchtime, I take my next tablet. However, if Inotice that my medication bag is still on the fridgethen I know I have not taken my tablet.Previous eventSome of the patients had experienced events suchas stroke or heart attack and they did not wantanother event. So, they made sure that they tooktheir medications.Participant 10 (male, aged 68) commented:I used to be very bad at taking my tablets in my youngerdays, but now, after my stroke, I make sure I takemy tablets everyday so I do not get another stroke.Participant 8 (male, aged 47) commented:The day I had my stroke was a very bad day, so Idecided I needed to make some changes and listento my doctor and take the tablets. I still have someproblems with walking and my mind being slowafter the stroke, but it also reminds me that I needto continue taking my tablets.220 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPERSqualitative researchTime managementMany planned in advance to collect their medications.For example, participant 4 (female, aged 69)commented:I make sure I count how many of my tablets areleft and when there is only two weeks left of mytablets, then I make my appointment to come andsee you to get more tablets.Participant 2 (female, aged 70) commented:I try my best to keep an eye on my tablets, andwhen I see there is only a few left, I tell my childrenthat I need to come and see the doctor to geta check-up and get more tablets. My children aregood like that; they will bring me in to the doctorsbefore my tablets run out.Supportive family membersMany commented on a supportive family. Familymembers would often remind them to take theirmedication. Participant 3 (male, aged 70) commented:I am lucky that I have my wife. She knows everythingand she reminds me when I need to take mytablets.Participant 18 (female, aged 65) commented:My husband is very good at reminding me aboutmy medications. Otherwise I forget. Sometimeswhen he reminds me, I get annoyed but then Iknow that it is important to take my medications,otherwise I would not be here.Relationship with the GP—languageThe majority of the participants commentedon the importance of language, whereby theyfelt comfortable communicating with a Samoandoctor.As participant 3 (male, aged 70) said:We went all the way to… to see Dr… because he wasSamoan and we wanted to talk to him in our ownlanguage so we can understand each other…and itwas good to be able to talk in Samoan. This helpedus understand the blood pressure problem and theneed for medication plus diet changes and exercise.Participant 20 (female, aged 55) commented:It was the Samoan doctor, Dr… who explained hypertensionto me and so I really understood what he said.Participant 6 (female, aged 64) commented:I like coming here to see you since I can talk to youin Samoan and I know that you understand and Ican also understand what you say. Sometimes whenI come in and you are not here, I get shy since I donot have good English and so I prefer to wait until Ican get an appointment to see you.Relationship with the GP—trustAll participants had comorbid conditions andmultiple medications. The majority of the participantsthought that they were coping well withthe multi-medication regimes, although a few didmention that their families expressed concernabout the number of tablets they were taking.Participant 6 (female, aged 64) commented:My children come home and look at my tablets.Then they worry and ask why I am taking so manytablets and maybe I should stop some of them. Ijust tell them that I have to listen to my doctor andtake my medication, no matter how many there are.Participant 16 (male, aged 66) commented:Even though I take a lot of tablets, I don’t mindsince I want to be well, and the doctors know whatthey are doing, so I do my part and take my tablets.Coping with the stress ofmultiple comorbiditiesMany participants admitted that the multiplemedical conditions and medications were stressful.Some coped by having a positive attitude.Participant 16 (male, aged 66) commented:Even though my life is busy with being a builderand having to advise my children…, add to thisthe problem of pain in my back from arthritis plusVOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 221

ORIGINAL SCIENTIFIC PAPErSqualitative researchblood pressure problem, there are some days whenI have just had enough of all the stress. But, then, Ithink of those who are less fortunate than me, thenI try and focus on the good things and cope thatway, so I do not feel sad.Participant 18 (female, aged 65) commented:If it was just the blood pressure problem, I wouldbe okay. But add to this the Parkinson’s plus thediabetes and all these tablets I have to take, thenI sometimes feel sad. But, I am usually a positiveperson and I have a good sense of humour, so I donot feel sad for very long at all.Those who did not cope so well with the comorbiditiesplus the pressures of lack of finance andlack of support made the following remarks:Participant 17 (female, aged 41) commented:There are times when I feel all the pressure from financesand having no support, add to that all thesemedical problems then I feel down.When asked about suicide ideation, the sameparticipant said:When I look at my children, I know I cannot doanything like that, so they help me get out of thebad place.Participant 20 (female, aged 55) denied that theyhad diabetes but accepted they had hypertension:The diagnosis of diabetes made me angry sincethere is no one in my family who has diabetes andso therefore I will not accept the diagnosis and I amnot going to take the tablets.DiscussionMain findingsThis is the first study to investigate reasonsfor high or lower rates of adherence to takinglong-term medications among Samoan people inNew Zealand primary health care. This studyhas highlighted that those with lower rates ofadherence had a number of issues such as lack oftransport, family commitments, forgetfulness,church activities, feeling well and other prioritiesthat contributed to the non-adherence to takingblood pressure medications. On the other hand,themes from those with high rates of adherenceincluded: prioritising health; a previous cardiovascularevent; time management; supportivefamily members and the relationship with theirGP, both in terms of a common language andtrust. The majority of participants also had anumber of comorbid conditions and multiplemedication regimes, which they found stressful.There was a range of coping mechanisms fromhaving a positive attitude to denial of the condition,and hence conscious non-adherence.Compared with the literatureThese findings reflect the Samoan model ofhealth as described by the Fonofale model,whereby health belief is viewed in the context ofculture, language, and family, and encompassestime and the environment that surrounds aperson. 23 For example, the importance of cultureand language came through, where patients werewilling to travel long distances to see a doctor oftheir own ethnicity because they could understandthe explanations about their medical condition,therefore encouraging adherence.A study by Barnes et al. in 2004 comparedillness beliefs and adherence in diabetes mellitusbetween Tongan and European patients.This study found that there was a perceptionthat some of the medications were unnecessary,and higher levels of emotional distress relatedto their diabetes, among the Tongan participants,which were associated with lower ratesof adherence to diet and medication taking. Thestudy highlighted the need for an assessmentof patients’ personal and cultural beliefs abouttheir illness and, most importantly, that thereis a need to understand the patients’ perceptionsabout illness and medication, and this mayprovide avenues for improving adherence to selfcareregimens. 27 The current study found similarbeliefs among some of the Samoan participantswith lower rates of adherence. However, whilesome did not think taking medications wasimportant, more commonly the beliefs were thatthe tablets were useful but that the ‘busyness’ oflife took priority.222 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPERSqualitative researchThere are several factors that have been identifiedin previous studies that contribute to adherence.These include: ‘the specific condition beingtreated, the health care system and team deliveringthe intervention, the social and economicconditions of the patient and setting, characteristicsof the therapy itself and the contributionof the individual patient’. 1,11,28 In Burnier’s (2006)review, some of the potential reasons for lowerrates of adherence to taking blood pressure medicationscan be divided into physician and patientfactors or medication factors. 1 Physician andpatient factors included cost of medication andrelated care; unclear instructions to the patient;the primary caregivers not increasing the dosesof medications or changing the medications; poorpatient education and lack of inclusion of the patientin their overall plan. Medication-related factorsincluded the side effects of the medicationsand, in addition to this, a complicated dosingregimen. In the current study, the issues involvingfamily, church and transport, relate both tosocioeconomic factors and cultural priorities.However, there were few comments about themedications themselves, potential or actual sideeffects or complicated medication regimes. Withthe problem of comorbidities, despite evidencefrom the literature that simplifying regimenswould help adherence, 29 none of the participantsin the current study commented on this as a factorfor them.Medication adherence is only one part of‘self-management’ where the individual mustmanage symptoms, treatment, physical andpsychosocial consequences, and the lifestylechanges associated with having a long-termcondition. 30 Two literature reviews of selfmanagementinterventions found that diseasespecificinterventions improved knowledge,performance of self-management behaviourssuch as medication adherence, self-efficacy andaspects of health status compared with standardcare. 30,31 Such interventions included individualorgroup-based education or counselling led byhealth professionals, peers or other lay people,addressing barriers to change or adherence, andsymptom management techniques. 30,31 Consequently,it was recommended that health careproviders focus on improving patients’ selfmanagementabilities, promote flexibility and apatient-centred approach in negotiated managementplans, and improve information provisionfor patients by making it relevant, accessible,while understandable yet evidence-based usingflexible modes of delivery. 30,32 Structuralchanges to improve access to services were alsorecommended.Strengths and limitationsThe fact that the researcher was also the doctorof several of the patients may have influencedparticipation or responses to the questions. Thismay limit validity of the findings. Use of anindependent interviewer may have avoided anyrisk of participants feeling obliged to participateor limiting responses to questions. On the otherhand, the interviewer’s fluency in Samoan andMedication adherence is only one part of ‘selfmanagement’where the individual must managesymptoms, treatment, physical and psychosocialconsequences, and the lifestyle changesassociated with having a long-term conditionknowledge of and familiarity with the participantsmay have been more conducive to trustand disclosure of concerns than if interviewedby someone they did not know. The study alsoassumed that patient and clinician initiallyagreed on the use of blood pressure–loweringmedication, but the validity of this assumptionwas not explored.Almost all participants were born in Samoa;hence the themes may be different for Samoansborn in New Zealand. Furthermore,only Samoan patients were interviewed. Issuesaround adherence to taking medications maybe different within other Pacific groups. Thestudy was conducted in one Auckland practice,which again may be different from the experiencesof Samoan people from other practices orother regions of New Zealand, or indeed in thePacific Islands.VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 223

ORIGINAL SCIENTIFIC PAPErSqualitative researchACKNOWLEDGEMENTSThanks to the patientsand practice staff of theparticipating practice.FUNDINGThanks to the PacificTeam at the HealthResearch Council for thefinancial award in 2008.COMPETING INTERESTSNone declared.RecommendationsInterdisciplinary teams to support treatmentdecisions (including Pacific health professionalsor community health workers with a commonculture and language), systematic identificationof those with low rates of adherence, phone ortext follow-up, use of church or family networks,provision of transport where needed to improveaccess to care, or use of community pharmacies,as well as better tools and resources, may helpaddress the problem of low rates of adherence totaking medications.References1. Burnier M. Medication adherence and persistence as thecornerstone of effective antihypertensive therapy. Am JHypertens. 2006;19:1190–1196.2. Fahey T, Schroeder K, Ebrahim S, Glynn L. Interventions usedto improve control of blood pressure in patients with hypertension.Cochrane Database Syst Rev 2007.3. Schroeder K, Fahey T, Ebrahim S. Interventions for improvingadherence to treatment in patients with high blood pressurein ambulatory settings. Cochrane Database Syst Rev 2004:CD004804.4. Andersson K, Melander A, Svensson C, Lind O, Nilsson JL.Repeat prescriptions: refill adherence in relation to patient andprescriber characteristics, reimbursement level and type ofmedication. Eur J Public Health. 2005;15:621–626.5. Takiya LN, Peterson AM, Finley RS. Meta-analysis of interventionsfor medication adherence to antihypertensives. AnnPharmacother. 2004;38:1617–1624.6. MacMahon S, Peto R, Cutler J, Collins R, Sorlie P, Neaton J,et al. Blood pressure, stroke, and coronary heart disease.Part 1, Prolonged differences in blood pressure: prospectiveobservational studies corrected for the regression dilutionbias. Lancet. 1990;335:765–774.7. Stewart JH, McCredie MRE, Williams SM, Canadian OrganReplacement Register, Fenton SS, Trpeski L, et al. The enigmaof hypertensive ESRD: observations on incidence and trendsin 18 European, Canadian, and Asian-Pacific populations, 1998to 2002. Am J Kidney Dis. 2006;48:183–191.8. de Galan B, Perkovic V, Ninomiya T, et al. Lowering bloodpressure reduces renal events in type 2 diabetes. J Am SocNephrol. 2009;20:883–892.9. Law M, Morris J, Wald N. Use of blood pressure loweringdrugs in the prevention of cardiovascular disease: meta-analysisof 147 randomised trials in the context of expectations fromprospective epidemiological studies. BMJ. 2009;338:1665.10. Wetzels GEC, Nelemans P, Schouten JS, Prins MH. Factsand fiction of poor compliance as a cause of inadequateblood pressure control: a systematic review. J Hypertens.2004;22:1849–1855.11. World Health Organization. Adherence to long-term therapies:evidence for action 2003: Available from: http://www.emro.who.int/ncd/Publications/adherence_report.pdf:September 17 2007.12. Fahey T, Schroeder K, Ebrahim S. Interventions used to improvecontrol of blood pressure in patients with hypertension.Cochrane Database Syst Rev 2006: CD005182.13. Haynes RB, Yao X, Degani A, Kripalani S, Garg A, McDonaldHP. Interventions for enhancing medication adherence.Cochrane Database Syst Rev 2007.14. Bell AC, Swinburn BA, Simmons D, Wang W, Amosa H,Gatland B. Heart disease and diabetes risk factors in PacificIslands communities and associations with measures of bodyfat. N Z Med J. 2001;114:208–213.15. Schaaf D, Scragg R, Metcalf P. Cardiovascular risk factors levelsof Pacific people in a New Zealand multicultural workforce.N Z Med J. 2000;113:3–5.16. Scragg R, Baker J, Metcalf P, Dryson E. Prevalence of diabetesmellitus and impaired glucose tolerance in a New Zealandmultiracial workforce. N Z Med J. 1991;104:395–397.17. Bell C, Swinburn B, Stewart A, Jackson R, Tukuitonga C,Tipene-Leach D. Ethnic differences and recent trends incoronary heart disease incidence in New Zealand. N Z Med J.1996;109:66–68.18. Scragg R, Baker J, Metcalf P, Dryson E. Hypertension and itstreatment in a New Zealand multicultural workforce. N Z MedJ. 1993;106:147–150.19. Bathgate M. The health of Pacific Islands people in New Zealand.Public Health Commission Wellington; 1994.20. Mabotuwana T, Warren J, Gaikwad R, Kennelly J, Kenealy T.Analysis of medication possession ratio for improved bloodpressure control—towards a semantic web technology enabledworkbench. Health Care and Informatics Review Online2008;12:19–24.21. Ioasa-Martin I. Tulaga I Talitonuga Fa’aSamoa e Aafia ai letogafiti Ole Gasegase Ole Mafaufau.The role of traditionalSamoan beliefs in non-adherence amongst Samoan consumerswith psychotic disorders [Masters Thesis]. VictoriaUniversity; 2006.22. Macpherson C, Macpherson L. Samoan medical belief andpractice. Auckland: Auckland University Press; 1990.23. Pulotu-Endemann F, Spoonley P. Being Samoan: Samoanethnicity in New Zealand. Palmerston North: Massey University;1992.24. Ministry of Health. The Pacific Health and Disability ActionPlan. Wellington: Ministry of Health; 2002.25. Mabotuwana T, Warren J, Kennelly J. A computationalframework to identify patients with poor adherence toblood pressure lowering medication. Int J Med Inform.2009;78:745–756.26. Morecroft C, Cantrill J, Tully MP. Patients’ evaluation of theappropriateness of their hypertension management—a qualitativestudy. Res Soc Admin Pharm. 2006;2:186–211.27. Barnes L, Moss-Morris R, Kaufusi M. Illness beliefs and adherencein diabetes mellitus: a comparison between Tongan andEuropean patients. N Z Med J. 2004;117:U743.28. Miller DB. Secondary prevention for ischemic heart disease.Relative numbers needed to treat with different therapies.Arch Intern Med. 1997;157:2045–2052.29. van Dulmen S, Sluijs E, van Dijk L, de Ridder D, Heerdink R,Bensing J. Patient adherence to medical treatment: a review ofreviews. BMC Health Serv Res. 2007;7:55.30. Barlow J, Wright C, Sheasby J, Turner A, Hainsworth J. Selfmanagementapproaches for people with chronic conditions: areview. Patient Educ Couns. 2002;48:177–187.31. Newman S, Steed L, Mulligan K. Self-management interventionsfor chronic illness. Lancet. 2004;364:1523–1537.32. Kennedy A, Rogers A, Bower P. Support for self care forpatients with chronic disease. BMJ. 2007;335:968–970.224 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPERSqualitative researchGeneral practitioner perceptions ofclinical medication reviews undertaken bycommunity pharmacistsLinda Bryant PhD; Gregor Coster PhD; Ross McCormick PhDABSTRACTIntroduction: Delivery of current health care services focuses on interdisciplinary teams andgreater involvement of health care providers such as nurses and pharmacists. This requires a change inrole perception and acceptance, usually with some resistance to changes. There are few studies investigatingthe perceptions of general practitioners (GPs) towards community pharmacists increasing theirparticipation in roles such as clinical medication reviews. There is an expectation that these roles may beperceived as crossing a clinical boundary between the work of the GP and that of a pharmacist.Department of GeneralPractice and Primary HealthCare, The University ofAuckland, Auckland,New ZealandMethodS: Thirty-eight GPs who participated in the General Practitioner–Pharmacists Collaboration(GPPC) study in New Zealand were interviewed at the study conclusion. The GPPC study investigatedoutcomes of a community pharmacist undertaking a clinical medication review in collaboration with aGP, and potential barriers. The GPs were exposed to one of 20 study pharmacists. The semi-structuredinterviews were recorded and transcribed verbatim then analysed using a general inductive thematicapproach.Findings: The GP balanced two themes, patient outcomes and resource utilisation, which determinedthe over-arching theme, value. This concept was a continuum, depending on the balance. Factors influencingthe theme of patient outcomes included the clinical versus theoretical nature of the pharmacistrecommendations. Factors influencing resource utilisation for general practice were primarily time andfunding.conclusion: GPs attributed different values to community pharmacists undertaking clinical medicationreviews, but this value usually balanced the quality and usefulness of the pharmacist’s recommendationswith the efficiency of the system in terms of workload and funding.KEYWORDS: Family physicians; community pharmacy services; drug utilization review; primary healthcare;health plan implementation; qualitative research; interprofessional relationsIntroductionDrug-related morbidity and mortality is a costlyproblem which cannot be resolved by one healthcare profession in isolation. The numerous stepsinvolved in the generation and resolution of adrug therapy problem requires coordination andcollaboration between professions, usually withinan interdisciplinary team. This role expansion forhealth professionals such as pharmacists and nurseshas not necessarily been a comfortable changefor all the health care workers ‘at the coalface’.Norris 1 reviewed the sociological developmentof community pharmacy in New Zealand (NZ)from 1930 to 1990, particularly focussing on thenegotiation and renegotiation of occupationalcontrol, and the relationship between generalpractitioners (GPs) and pharmacists. Provisionof health care was a division of labour usuallydecided by the medical practitioner. Nurseswere considered subordinate to medical practitionersand occupations such as optometryhad limited practice opportunities or required aJ PRIMARY HEALTH CARE2010;2(3):225–233.Correspondence to:Linda BryantDepartment of GeneralPractice and PrimaryHealth Care, TheUniversity of Auckland,PB 92019 Auckland,New Zealandlinda@cpsl.bizVOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 225

ORIGINAL SCIENTIFIC PAPErSqualitative researchreferral system. Pharmacists were subordinate tomedical practitioners in terms of being requiredto dispense prescriptions written by the medicalpractitioner, but generally had commercialindependence and autonomy, unlike practicenurses who are seen as a core part of the healthcare team. The pharmacist’s place in the medicalmodel was ill-defined and marginal. Becausethey were associated with shopkeeping, therewas a perception that pharmacists were taintedas health professionals. 1 This is a view shared bythe British researchers Harding and Taylor. 2A small number of qualitative studies exploringgeneral practitioners’ views of community pharmacistshave helped identify barriers to collaborationwith community pharmacists. Early studiesindicated that GPs were unaware of pharmacists’professional training and responsibilities, viewingthem as players in the commercial or retail environment.3,4 In other studies, medical practitionofthe GPs saw the practice pharmacist as thepreferred model because it removed the complicationsassociated with the shopkeeper image.Edmunds and Calnan 8 considered the medicalprofession’s status may be under threat inthe United Kingdom, particularly from otherhealth-related occupations such as communitypharmacy attempting to re-professionalise.Their study explored community pharmacists’and GPs’ perceptions of an extended role forcommunity pharmacy using repeat dispensing,extended adherence support and pharmaceuticalcare focussing on ischaemic heart diseaseprovided from within a general practice, asexamples of extended services. The interviewees,26 GPs and 37 pharmacists, were selectedfrom extended services schemes and so likelyto be proactive. While the GPs had high regardfor pharmacists’ skills and were supportive ofthe repeat dispensing schemes and pharmacistsWhile the GPs had high regard for pharmacists’ skills and weresupportive of the repeat dispensing schemes and pharmacistshelping patients’ manage their medicines, they discriminatedbetween those activities that were acceptable… and those thatencroached on their territoryers, usually in a hospital setting, who workedwith or more closely to pharmacists had morepositive perceptions for their expanding roles. 2,5,6This view apparently has not changed. A 2003British study 7 found that the image of a communitypharmacist as a shopkeeper was a superordinatetheme that pervaded other themes thatemerged—access, hierarchy and awareness. Theshopkeeper image was considered to generate conflictbetween health care and business, with someperverse incentives identified that might serveto increase the use of drugs. Lack of privacy inthe shop was also noted. Issues of territory wereraised with a view of community pharmacistsas subordinate to doctors and considered to beon the periphery of the health care team. Manyhelping patients’ manage their medicines, theydiscriminated between those activities that wereacceptable (delegated activities that reduced thegeneral practitioner’s workload but didn’t removecontrol) and those that encroached on their territory.They were ambivalent about other patientcentredroles, being less keen on communitypharmacists screening for medical conditions andother clinical activities such as intervening inprescribing decisions, monitoring blood pressureor sharing medical records. The pharmacists werenot considered as equals. 8Ambler 9 noted the new initiatives occurring inthe United Kingdom that impact on pharmacist–general practitioner relationships. Two questionswere discussed. The answer to, ‘Can a226 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPERSqualitative researchpharmacist currently undertake the main taskof a general practitioner?’ was, ‘Obviously not,as diagnosis beyond minor, self-limiting conditionsis not part of the pharmacists’ knowledgeor skills base’. However, to the question ‘Cana community pharmacist work with a generalpractitioner to provide quality health care?’ itwas considered that the answer is ‘yes’, with thequalifier that the pharmacist is working withinthe general practice.In Australia, an independent report was commissionedby the Department of Health andAgeing into the Home Medicines ReviewProgramme (HMR), a programme similar to thatinvolved in the GPPC study with communitypharmacists undertaking patient medicationreviews. 10 Most of the 27 GPs interviewed wereambivalent about the HMRs, considering themineffective in producing substantial improvementsin a patient’s health. The recommendationsincluded allowing direct referrals from thegeneral practitioner to accredited pharmacists,without the need to go through a communitypharmacy, and allowing the accredited pharmaciststo claim fees directly, again without goingthrough the community pharmacy.When changing roles, the perceptions of theindividuals involved are important because ofthe barriers or facilitators generated. As pharmacistsmove towards more involvement in clinicalservices, the perceptions of GPs regarding thepharmacists’ shopkeeper image, the pharmacists’ability to perform clinical services and the pharmacists’role in the health care team, influencestheir acceptance of new pharmacist roles and theextent of collaboration that can occur.The General Practitioner–Pharmacist Collaboration(GPPC) study was a multi-centred randomised,controlled study conducted between2002 and 2004 comparing people older than 65years and on five or more medicines who receiveda clinical medication review with similar patientswho did not receive a consultation. The GPs wereinvited into the study by a participating pharmacistand then identified and invited eligiblepatients consecutively until 12 patients wereenrolled. The community pharmacists had accessto patient medical records, met with the patientWHAT GAP THIS FILLSWhat we already know: Health care providers, including pharmacists,are under pressure to increase their input into direct patient care in what maybe traditionally considered general practitioner roles. There is little informationabout how appropriate general practitioners perceive the input of communitypharmacists into clinical medication reviews for patients.What this study adds: General practitioners who had been exposed tocommunity pharmacists undertaking clinical medication reviews for generalpractice patients, evaluated this service in terms of value. The value of the serviceswas arrived at by balancing the potential for improved patient outcomesagainst the resources required for the service, particularly time and funding.to review their medicines either in the pharmacyor at home, and then discussed potential medicationalterations with the general practitioner ina meeting that took approximately 10 minutesper patient. There were two to four patientsdiscussed per meeting. The general practitionerswere reimbursed NZ$50 from research funds foreach patient they enrolled and the pharmacistsNZ$160 per patient through a government contractto provide medication reviews. The aim ofthe GPPC study was to determine the impact ofcommunity pharmacy–based clinical medicationreviews on medicines-related health outcomes,and to investigate the potential barriers to theimplementation of this service.The aim of this qualitative study is to explore theperceptions of GPs after working in this environmentto determine the barriers, if any, thatlimit community pharmacists and GPs workingtogether clinically. The perceptions of pharmacistsare discussed in a companion paper.MethodsAt the end of the GPPC study, face-to-face semistructuredinterviews of GPs and pharmacistswere undertaken by the pharmacist researcher.Ethical approval for the study was obtained fromthe regional ethics committees (ref: 99/207). AllGPs who participated in the GPPC study wereinvited to participate in an interview. The interviewswere up to 30 minutes and were audiotapedwith permission from the interviewee. Theprimary areas discussed with the GPs were:VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 227

ORIGINAL SCIENTIFIC PAPErSqualitative researchTable 1. Characteristics of the general practitioners interviewed.AgeGenderNationalityLocationGeneral practitioners% (no.)50 years old 22% (10)Range: 33–59 yearsMale 80% (30)Female 20% (8)New Zealand 71% (27)Other29% (11)South African x6, UK x4, USA x1Town 24% (9)Peripheral city 47% (18)City 29% (11)Solo practice 21% (8)• Particularly useful aspects of themedication review service.• Their existing or envisaged problemswith the service.• Practicalities such as communicationissues, implementation issuesand location of the service.• The future they envisaged for clinical medicationreviews by community pharmacists.The interviews were transcribed and analysedusing QSR NVivo v2.0. An analysis wasundertaken initially within six months of theinterviews using a thematic approach, and thenre-analysed by the same researcher 18 monthslater to aid with consistency of interpretation.An inductive reasoning process was used, generatingideas or hypotheses.FindingsThirty-eight of the 56 GPs who started thestudy were interviewed. Reasons for not beinginterviewed were, primarily, being on holidayat the time of the interview period or not beingable to make an appointment on the day theresearcher was visiting. Of those interviewed,two had been invited by a pharmacist whowithdrew during the GPPC study. Overall theGPs interviewed had been exposed to one of 20study pharmacists, from the total of 27 studypharmacists. The characteristics of the GPs aredescribed in Table 1.OverviewThe overarching theme from the interviews wasthe concept of ‘value’, a balance of the theme ofpatient benefits against the theme of resourcessuch as general practitioner time and governmentfunding of the pharmacist required for theservice. There was a continuum of how muchvalue the GPs placed on the service, but theyconsistently weighed up the perceived benefitsFigure 1. Summary of the thematic analysis from the general practitioner interviewsVALUEPatient healthoutcomesResourceutilisation• Clinical advice / recommendations– Usefulness / appropriateness– Reassurance• Patient view• Time• Funding• Practicalities– Communication– LocationRelationships / role perception228 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPERSqualitative researchand resources. Influencing this balance wereviews on relationships and territoriality. Thisprovides a complex model that balances twoseparate themes with a range of perceptions togive a diverse stance on the overarching themeof ‘value’. An underlying third theme related torelationships and territoriality (Figure 1). Thisled to a continuum between positive and negativeresponses.The positive responders acknowledged the usefulnessof an outside perspective on the patient’sviews and use of medicine, and included commentsabout creating an opportunity to stop orchange medicines. As the continuum changed tomore negative views, the value of the service wasreduced because some medication problems wereconsidered unsolvable or recommendations hadalready been tried, and so little changed despitethe effort put in.I thought it was really invaluable because often,although we try, you know, sometimes you are justso busy you just don’t have a chance to review one’smedication and one of the problems that we have witholder people is they tend to come in with complaintsabout certain drugs and you end up treating them witha drug, and another drug, and you end up chasing yourtail; and that is where it has been really good. [GP1]I suspect for the amount of time and effort and possibilityeven money that was put into it, I am notconvinced that we made a big difference. [GP3]Of the specific aspects that the GPs found useful,information on pharmacokinetic issues such asinteractions and dosing in renal impairment wereappreciated and considered important. The GPsconsidered that, with a heavy workload, this wasan area on which they often found it difficult tomaintain up-to-date information. Similarly, identificationof actual or potential adverse effectsand issues raised about compliance were useful.Patient health outcomesUsefulness of pharmacists’ recommendationsTo help determine the value of the service, GPsconsidered the usefulness and appropriatenessof the pharmacist recommendations. The GPsgenerally found the recommendations usefulalthough at times theoretical. The overall valueof the recommendations appeared to depend onhow frustrating the GPs found the provision oftextbook-type advice. Conversely, reassurancethat the prescribed medicines were appropriatewas important to some GPs.Lots of good advice came out. Lots of changes happenedand I think almost 100% of them would havedefinite benefits from it, not just in terms of drugsor whatever but actually their well-being improvednoticeably, which was great. [GP4]Medicine is a mixture of science and art whereasthe medication review was purely science andsometimes the science doesn’t go with the person…The clinical implications versus the textbook is notalways the same and I think for a reviewer to go insimply from a scientific point of view it is not reallygoing to work as I think we have to deal with boththe science and the person themselves. [GP6]Resource utilisationTime and fundingBalanced against the theme of potential patienthealth outcomes was the theme of resourceutilisation, with time and funding being theprimary domains. There was a strong view thatGPs should be funded for their time as they arestill primarily a fee-for-service business, and notfully capitated. There was also consideration ofthe expense of monitoring recommendations—laboratory time and nurses’ time.Approximately 10 minutes needed to be set asideto talk about each patient, although this was notnecessarily considered a negative if the time wasfunded. It was acknowledged that having someone(the pharmacist) able to spend time doingresearch or spend time with the patient to pick upon potential problems was usually useful.So, I mean, we don’t have the time and the facilitiesto sit and research. She had about X numberof patients where she can really work. I don’t havethe time to do that, so I thought, excellent. In fact,I told her we should really do some more over aperiod of time. [GP7]VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 229

ORIGINAL SCIENTIFIC PAPErSqualitative researchNo, in many ways, I mean, time is the biggest issue.In many ways it would be lovely if we could sitdown and discuss every third or fourth patient, youknow, and it would be learning for both but thereis just not that time or money for that. [GP1]Practical aspects of the serviceThere were some prompts provided for discussionon the practicalities of these medication reviews,including the preferred communication method,any preference for location of the service and issueswith the implementation of recommendations.The preferred communication method forfeedback was face-to-face, with a small numberbelieving face-to-face was useful initially, butonce a relationship was established, a letter wouldbe adequate. Towards the end of the interview itwas asked whether there would be any benefit inhaving the pharmacist work in the practice on asessional basis or whether it was better to have itWhen asked about difficulties in implementingsome of the recommendations a few admitted thatit was hard to remember who had been reviewed,and to not let the medicines review be supersededby other problems. Extra consultation time neededto be allocated to cover the medication review.Interprofessional relationshipsRelationships was an underlying theme thatpotentially influenced the balance between thethemes of patient health outcomes and resourceutilisation. It incorporated views on the pharmacist’srole through concepts of trust and respect.Having a professional relationship with the pharmacistwas very important to the GPs. Becausethe pharmacists enrolled the GPs into the study,and so in most situations some prior workingrelationship existed, this view was open to bias.Emerging through the theme of relationshipsthere appeared to be some traces of territoriality.Through many of the comments regarding the clinicalrecommendations and implementation, there was an underlyingemphasis on the role of the general practitioner in controlling clinicaldecision-making, and that this was not the territory of the pharmacistprovided from a community pharmacy. A smallmajority of the GPs thought that having thepharmacist in the practice was reasonable becausethey would be independent of the local pharmacistsand more part of the general practice team.I would prefer it to be a practice service, I think,yes… I think the independent side is quite important.I feel that quite strongly actually… I thinkwe have a different relationship with the localpharmacist. [GP8]I think it probably would be good to have thepharmacist in the practice because if you did have aquery you could go to them and say why or what…plus from the point of view of the two way communicationbetween the doctor and the pharmacistit would be better. [GP9]When the issue of territoriality was specificallyraised, the GPs generally commented that thiswas not an issue for them and they did not findthe medication reviews threatening or encroachingon their territory, but they could imaginethat it may be a problem for a number of theircolleagues. However, through many of the commentsregarding the clinical recommendationsand implementation, there was an underlyingemphasis on the role of the general practitioner incontrolling clinical decision-making, and that thiswas not the territory of the pharmacist.I think initially I was a wee bit sceptical. I supposewe all try to protect our patches a wee bit. Thereis certainly a feeling amongst the medical, some ofmy medical colleagues, that it is sort of an invasionof their right if you like. I don’t necessarily see it230 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPERSqualitative researchthat way. I think anything that will benefit us inwhat we do, looking at how we care for people, andalso for the people themselves, is fine. I mean itis up to us whether we actually read that and say,yes, I will do this or do that, or whether we say,alright, that’s fine thank you and tend to ignore it.It is up to us I guess. [GP10]Well the, I think, the issue of, sort of, boundaries.Where was the line between pharmaceutical adviceand clinical decision-making? And I think that, Ithink, there were one or two points where you justfelt sort of, maybe, hackles rising slightly, ‘well that’sour department’ sort of thing and I think that is probablyan issue; and that is an attitudinal thing I think,and it is very easy to fall into the sort of, ‘well, I knowmy individual patients so I don’t know what you aretalking about’, but that is not really the point. [GP8]Perceptions of a potential futurefor clinical medication reviewsIn response to direct questioning, GPs wereambivalent about whether there was a future forcommunity pharmacists undertaking clinicalmedication reviews. A reflection of this ambivalencewas that over three-quarters of them hadnot made a referral for a review since study initiation,although this was a service available outsideof the study. Reasons for not referring includedthat it was not something that was in the frontof their mind when they were seeing patients,or they were too rushed to refer even if they didthink about it. There were comments that thereneeded to be a system to make the process moreof a standard practice and that currently thesystem was not practical.Just over half the GPs appeared positive thatthere was some future for the medication reviews.Hesitancy was focussed primarily on thefunding and time issues, and the view that therewould be only a limited number of patients whowould be suitable. There were comments that thereviews had to be done well if they were going towork, and the pharmacist had to have credibility.A wide range of views were presented rangingfrom positive to more negative statements.I know how useful it was in the hospital, fantasticallyuseful in the hospital service, and it shouldbe useful in the community too, especially for theolder people and to make sure that they have goteverything straight because they get so muddled.(Yes, I like the idea.) [GP11]From a clinical point of view I think it is excellentbut you are going to get back to a point of view offunding and what you are about to do, regardless ofhow excellent you think it is, will depend totallyon funding. (Sees value but funding issues.) [GP12]I suppose I am slightly guarded about that. I amsure there is a role. I am sure there is an extendedrole for pharmacists, put it that way, but we are stillfiguring out what that is and I guess some of us area bit nervous too about, I mean, there are pharmacistswho are very commercially orientated and theyare already sort of pick around aspects of generalpractice which some of us tend to think might notbe really be their business. (No, not keen.) [GP13]DiscussionThe GPs interviewed evaluated the benefits topatient health outcomes against the resourcesrequired for the service to produce a concept of‘value’. The threshold for GPs to perceive the usefulnessof the recommendations varied, with somefinding that reassurance that they were prescribingappropriately was useful, others finding theinformation and advice useful, even if not necessarilyacted upon, and others being frustrated bythe theoretical nature of some recommendations.GPs considered the time and money needed wasa large factor but despite the pressure of findingtime to spend with the pharmacist, most GPspreferred to have a face-to-face discussion with thepharmacist. Time and funding may be particularlyrelevant in NZ because of our fee-for-service systemand only partial capitation. Provided fundingbarriers can be met, it may be more efficient tohave a clinical pharmacist providing sessions fromthe practice and so be part of the practice team,with easier communication. In the USA and UKpostgraduate-qualified clinical pharmacists havebeen shown to have positive outcomes when workingin primary care clinics or general practices. 11–15GPs tended to distance themselves from viewson territoriality, commenting on how theirVOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 231

ORIGINAL SCIENTIFIC PAPErSqualitative researchcolleagues may perceive the service. While notseeing themselves as territorial, there was anunderlying impression from the comments thatcontrol of clinical decision-making was the roleand territory of the general practitioner. As longas the pharmacist did not encroach on this role,there were no feelings of territoriality. Thistends to be similar to the work by Edmundsand Calnan. 8 The GPs had high regard for pharmacists’skills that focussed on them helpingpatients ‘manage their medicines’, but were lessaccepting of a more clinical role such as interveningin prescribing decisions, monitoring orsharing patient records. Reebye et al. 16 identifieda suggestion that pharmacists undertaking rolessuch as dependent prescribing should be workingin primary care clinics, under the control ofdoctors. Hughes and McCann 7 found that GPsreferred to community pharmacists as ‘shopkeepers’,but a pharmacist located in generalpractices could be considered more part of thehealth care team (and under the control of thegeneral practitioner). This greater acceptance of apharmacist in the general practice was similar tothe current study.Hospitals have a strong focus on interdisciplinaryteams and continue to develop this conceptwith increasing professional respect and trustbetween hospital doctors and pharmacists, allowingbetter teamwork, collaboration and decisionsharing. Within the hospital environment thereis more opportunity for medical practitioners tohave contact with clinical pharmacists and to beexposed to a new service. This exposure to aneffective service helps break down the stereotypicalperceptions as discussed by Adamick et al. 17and will enhance the opportunities for furtherimplementation. A new service that is not donewell impedes any further implementation.A limitation of this study was that the GPs generallyhad a prior relationship with the communitypharmacist before the GPPC study, were willingto participate in the study, and therefore werepossibly favourably predisposed to the concept.The GPs were aware that the researcher was apharmacist studying through the Departmentof General Practice and Primary Health Careat Auckland University, with a background inpharmacist facilitation, working with GPs in aPrimary Health Organisation. It did not appearthat the GPs were providing socially acceptableresponses because the researcher was a pharmacist,and some of the less favourable commentswould support this, although the intervieweesmay have responded differently to a general practitionerinterviewer.The lack of a second investigator checking thetranscripts for themes was a limitation.On reflection, it would have been useful toexplore whether the GPs would have useddiscretionary funding to employ a pharmacistto undertake this work. This concept wouldrequire more research on the cost-effectivenessof clinical pharmacist medication reviews. Theliterature is conflicting with some randomisedcontrolled trials suggesting a lack of impact ofcommunity pharmacists undertaking clinicalmedication reviews, 18–23 but other studies indicatingthat clinical pharmacists in clinics or generalpractices have a positive impact on patient healthoutcomes. 11,14,24,25 Clinical pharmacists in practicesor clinics occur in the United Kingdom and theUSA, but are only starting in NZ and need furtherresearch into the barriers and effectiveness.ConclusionGPs tended to balance the themes of patientoutcomes against the resources required to determinethe value of clinical medication reviewsby pharmacists. Pertinent factors involved thequality and usefulness of the recommendations,the efficiency of the system in terms of timeand funding required, and some issues of roleperception or territoriality. Taken in conjunctionwith other literature, it may be more suitable touse clinical pharmacists working within generalpractice to improve the efficiency of the clinicalmedication reviews and reduce drug-related morbidityand mortality. This system would createcloser association and communication with thepractice team. It may also be preferable for theclinical pharmacist to have collaborative prescribingprivileges to implement recommendationsthat are agreed by the general practitioner toimprove efficiency, provided some of the generalpractice funding and territorial barriers are met.232 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPERSqualitative researchReferences1. Norris P. The negotiation and re-negotiation of occupationalcontrol. A study of retail pharmacy in New Zealand. 1930–1990.A PhD (Sociology) thesis submitted to the Victoria University ofWellington. Wellington: Victoria University; 1993.2. Harding G, Taylor KM. Professional relationships betweengeneral practitioners and pharmacists in health centres. Br JGen Pract. 1990;40(340):464–6.3. Smith WE, Ray MD, Shannon DM. Physicians‘ expectations ofpharmacists. Am J Health-Syst Pharm. 2002;59(1):50–7.4. Bleiker P, Lewis A. Extending the role of community pharmacists:The views of GPs. Int J Pharm Pract. 1998;6(3):140–144.5. Sulick JA, Pathak DS. The perceived influence of clinicalpharmacy services on physician prescribing behavior: amatched-pair comparison of pharmacists and physicians.Pharmacotherapy. 1996;16(6):1133–41.6. Ritchey FJ, Raney MR. Effect of exposure on physicians‘attitudes toward clinical pharmacists. Am J Hosp Pharm.1981;38(10):1459–63.7. Hughes C, McCann S. Perceived interprofessional barriersbetween community pharmacists and general practitioners: aqualitative assessment. Br J Gen Pract. 2003;53:600–06.8. Edmunds J, Calnan MW. The reprofessionalisation of communitypharmacy? An exploration of attitudes to extendedroles for community pharmacists amongst pharmacists andgeneral practitioners in the United Kingdom. Soc Sci Med.2001;53(7):943–55.9. Ambler S. General practitioners and community pharmacists:times they are a-changing. Br J Gen Pract. 2003;53:594–95.10. Campbell Research & Consulting. Home Medicines ReviewProgram qualitative research project. Final report. http://www.health.gov.au/internet/main/publishing.nsf/Content/B2992EBF12BE7E1ECA2573D8007F91F3/$File/HMR%20Final%20Report.pdf. Canberra, ACT, Australia: Prepared forthe Department of Health and Ageing; Dec 2008.11. Ellis SL, Carter BL, Malone DC, Billups SJ, Okano GJ, ValuckRJ, et al. Clinical and economic impact of ambulatory care clinicalpharmacists in management of dyslipidemia in older adults:the IMPROVE study. Impact of Managed Pharmaceutical Careon Resource Utilization and Outcomes in Veterans AffairsMedical Centers. Pharmacotherapy. 2000;20(12):1508–16.12. Malone DC, Carter BL, Billups SJ, Valuck RJ, Barnette DJ,Sintek CD, et al. An economic analysis of a randomized, controlled,multicenter study of clinical pharmacist interventionsfor high-risk veterans: the IMPROVE study. Impact of ManagedPharmaceutical Care Resource Utilization and Outcomesin Veterans Affairs Medical Centers. Pharmacotherapy.2000;20(10):1149–58.13. Rothman RL, Malone R, Bryant B, Shintani AK, Crigler B,Dewalt DA, et al. A randomized trial of a primary care-baseddisease management program to improve cardiovascular riskfactors and glycated hemoglobin levels in patients with diabetes.Am J Med. 2005;118(3):276–84.14. Shojania KG, Ranji SR, McDonald KM, Grimshaw JM, SundaramV, Rushakoff RJ, et al. Effects of quality improvementstrategies for type 2 diabetes on glycemic control: a metaregressionanalysis. JAMA. 2006;296:427–40.15. Zermansky AG, Petty DR, Raynor DK, Freemantle N, Vail A,Lowe CJ. Randomised controlled trial of clinical medicationreview by a pharmacist of elderly patients receiving repeat prescriptionsin general practice. BMJ. 2001;323(7325):1340–3.16. Reebye RN, Avery AJ, Bissell P, Van Weel C. The issue of territorialitybetween pharmacists and physicians in primary care.Int J Pharm Pract. 2002;10(2):69–75.17. Adamcik BA, Ransford HE, Oppenheimer PR, Brown JF, EaganPA, Weissman FG. New clinical roles for pharmacists: a studyof role expansion. Soc Sci Med. 1986;23(11):1187–1200.18. Holland R, Battersby J, Harvey I, Lenaghan E, Smith J, Hay L.Systematic review of multidisciplinary interventions in heartfailure. Heart. 2005;91(7):899–906.19. Holland R, Brooksby I, Lenaghan E, Ashton K, Hay L, Smith R,et al. Effectiveness of visits from community pharmacists forpatients with heart failure: HeartMed randomised controlledtrial. BMJ. 2007. DOI:10.1136/bmj.39164.568183. AE (published23 April 2007).20. Holland R, Lenaghan E, Harvey I, Smith RB, Shepstone L,Lipp A, et al. Does home based medication review keep olderpeople out of hospital? The HOMER randomised controlledtrial. BMJ. 2005;330:293–97.21. Carter BL, Chrischilles E, Scales CJ, Hayase N, Bell N. Extentof services provided by pharmacists in the Iowa MedicaidPharmaceutical Case Management Program. J Am Pharm Assoc.2003;43:24–33.22. Community Pharmacy Medicines Management ProgrammeEvaluation Team. The MEDMAN study: a randomised controlledtrial of community pharmacist-led medication managementfor patients with coronary heart disease. Fam Pract.2007;24(2):189–200.23. RESPECT Trial Team. Effectiveness of shared pharmaceuticalcare for older patients: RESPECT trial findings. Br J Gen Pract.2010;60(570):10–19.24. Zermansky AG, Petty DR, Raynor DK, Freemantle N,Vail A, Lowe CJ. Randomised controlled trial of clinicalmedication review by a pharmacist of elderly patientsreceiving repeat prescriptions in general practice. BMJ.2001;323(7325):1340–3.25. Merenich J, Olson KL, Delate T, Rasmussen J, Helling DK,Ward D. Mortality reduction benefits in a comprehensive cardiaccare program for patients with occlusive coronary arterydisease. Pharmacotherapy. 2007;27(10):1370–78.ACKNOWLEDGEMENTSWe wish to thank thegeneral practitioners whoparticipated in the GPPCstudy, and showed anappreciated willingnessto participate in this newpharmacist service.FUNDINGFunding for the GPPCstudy, including theinterviews, was providedthrough the governmentagency, the TransitionalHealth Authority(reimbursement ofgeneral practitioners)and the PharmaceuticalSociety Education andResearch Fund (printingand postage costs). Thesefunding bodies had noinfluence on the studydesign or any publication.The general practitionerswere funded $NZ150 forthe for the interviews.COMPETING INTERESTSNone declared.VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 233

ORIGINAL SCIENTIFIC PAPErSqualitative researchCommunity pharmacist perceptions ofclinical medication reviewsLinda Bryant PhD; Gregor Coster PhD; Ross McCormick PhDDepartment of GeneralPractice and Primary HealthCare, Faculty of Medicineand Health Science, TheUniversity of Auckland,Auckland, New ZealandAbstractIntroduction: Changes in delivery of health care services has led to pressure for community pharmaciststo extend their traditional role and become more involved with patient-focussed services such asmedication reviews, in collaboration with general practitioners (GPs). This has not been generally implementedinto routine practice, and many barriers have been suggested that inhibit community pharmacistsextending their role. These have often focussed on physical or functional barriers. This study explorespossible attitudinal factors that prevent increased participation of community pharmacists in medicationreviews undertaken in collaboration with GPs.MethodS: Twenty community pharmacist participants who participated in the General Practitioner–Pharmacist Collaboration (GPPC) study were interviewed. The GPPC study investigated the outcomes ofcommunity pharmacists undertaking a clinical medication review in collaboration with GPs, and the potentialbarriers. Semi-structured interviews were analysed using a general inductive thematic approach.Findings: Emerging themes were that community pharmacists perceived that they were not mandatedto undertake this role, it was not a legitimate role, particularly from the business perceptive, and pharmacistswere concerned that they lacked the skills and confidence to provide this level of input.Conclusion: While there is concern that community pharmacists’ skills are underutilised, thereare probable attitudinal barriers inhibiting pharmacists from increasing their role in clinical medicationreviews. Perceived legitimacy of the service was a dominant theme, which appeared to be related to issuesin the business model. Further investigation should consider the use of a clinical pharmacist workingwithin a general practice independent of a community pharmacy.KEYWORDS: Community pharmacy services; drug utilization review; primary healthcare; health planimplementationJ PRIMARY HEALTH CARE2010;2(3):234–242.Correspondence to:Linda BryantDepartment of GeneralPractice and PrimaryHealth Care, TheUniversity of Auckland,PB 92019 Auckland,New Zealandlinda@cpsl.bizIntroductionInternationally there has been a drive for communitypharmacists to extend their practice froma product focus towards more patient-focussedservices, including involvement in medicationreviews. The term ‘medication review’ encompassesa wide range of review types—from a reviewof the person’s use of the medicine (adherencesupport, specific counselling or education) toclinical medication reviews involving collaborationwith the prescriber. These reviews have notbeen implemented from community pharmacy asuniversally as could be expected, and are not anintegral part of community pharmacy serviceseven though pharmacists appear enthusiastic. Anumber of published studies have indicated a lackof participation and high withdrawal rate, despitegood intentions by the community pharmacists. 1–5This is in contrast to clinical medication reviewsthat are undertaken by clinical pharmacists** In the literature, clinical pharmacists are generally those pharmacists who focus primarily on medication use by and for patients for the majorityof their work, rather than supply and distribution (dispensing) roles. Previously the term was associated with hospital pharmacists workingwith medical teams and seeing patients on the wards. It now includes pharmacists in primary care who work closely with general practitioners,usually in general practice / physicians’ offices or primary care clinics. These pharmacists usually have postgraduate qualifications.234 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPERSqualitative researchwithin a general practice in the UK 6 or in primarycare clinics / physicians’ offices in the USA. 7–10The literature describes barriers to implementationof medicine management services, includingadherence support or medicine use reviews. Thebarriers include:11–18• Time/funding;13,14,19,20,21• Poor use of staff;• Lack of facilities, includingspace and privacy; 11,12,14,19• Lack of interprofessional relationshipsand collaboration with general practitioners,17,18,20,22,23 although those pharmacistsin a non-community pharmacy setting(clinics, family physician offices) were lesslikely to agree that this was a barrier; 18• Postgraduate training and skillsenhancement; 17,20,21• The type of role or type of communitypharmacy (e.g. managers versusstaff pharmacists; chain store versus independentcommunity pharmacy); 17,20• Concerns about the quality of the reviews,especially in chain store pharmacies; 1720• The attitudes of community pharmacists;• Access to documentation, althoughthis was not considered a barrier fornon–community pharmacy pharmacistsbased within physician offices. 18Explorative work into why change is slow andhow change could be managed raises diverse concepts.In a USA study, 24 four consistent factorsemerged from four pharmacies that had successfullyimplemented innovative medication reviewprogrammes. These were:• Philosophy of practice—defining valuesthat guide professional behaviours and settingpriorities when confronting challengingclinical decisions or ethical dilemmas• Patient care process—assuming responsibilityfor all the patient’s drug therapy needs; developinga long-term therapeutic relationshipwith the patient; collaborating with physiciansand other care providers to enhance care• Management system—including creatingthe physical environment of care areasWHAT GAP THIS FILLSWhat we already know: Community pharmacists are being encouragedto increase their participation in patient-focussed services such as medicationreviews. Implementation of these services into routine practice have beenvery limited because of perceived physical or functional barriers.What this study adds: This study explored attitudes of community pharmacistswho participated in a study of clinical medication reviews in collaborationwith general practitioners. Barriers to this service were a perceived lack ofmandate, a lack of perceived legitimacy of the service, and a perception thatthere was a lack of adequacy to provide the service.and care rooms that are separate and distinctfrom the dispensing environment• Clinical knowledge—access to upto-dateand reliable clinical information;a desire to learn and keep up withcourses and continuing education.Along a similar theme, Latif 25 argued that theparadigm shift from a product-focussed professionof dispensing to a more patient-focussedone with ‘shared’ responsibility for optimaldrug therapy outcomes required the developmentof an ethical covenant between thepharmacist and patient. This was considered important,particularly in some organisational settings,e.g. chain drug stores, because there wasan increased opportunity for ethical problems toarise where there could be an inherent conflictbetween professional values and organisationaldemands. For example, where the primaryreimbursement is from dispensing prescriptionsand selling retail products, a conflict may arisewhen more time is required for patient-focussedactivities such as counselling.Edmunds and Calnan 26 investigated issues evolvingfrom health-related occupations attemptingto re-professionalise, including communitypharmacy, a group that the authors believed wasdeveloping strategies to enhance its professionalstatus as a bid for survival, rather than tryingto usurp the general practitioner’s role per se.They recognised pharmacists were holding backchanges to community pharmacy. They reasonedthat this is because many community pharmacistsstill attribute ultimate authority to the generalpractitioner, and that there are internal divisionsVOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 235

ORIGINAL SCIENTIFIC PAPErSqualitative researchbetween retail pharmacists and employee pharmacists,with profit-orientated versus health servicesconflicts. The pervasive view of pharmacy isdescribed as marginal, incomplete, limited, with‘quasi’ status due to reduced craftsman skillsrequired to compound medicines, and with occupationalor professional limitations due to lackof control over clinical autonomy with respect toinvolvement with prescription medicines usage,and consequently lack of economic autonomybeyond the retail role.Edmunds and Calnan considered that pharmacywould remain viable only if full use of thepharmacists’ skills and qualifications were utilised,yet identified a basic dilemma of a conflictbetween community pharmacists as traders orhealth professionals. Despite wishing to pursuemore patient-focussed roles, many pharmacistsdid not want to encroach on the general practitioner’sterritory, generally seeing their roleas reducing the general practitioner’s workload(delegatory roles) and helping with adherenceproblems and patients’ management of medicinesrather than more clinical roles. They describedconflicting views about the management oflong-term medical conditions by pharmacists.Basically, as perceived by the pharmacists, thereremained an entrenched division between generalpractitioners as prescribers and pharmacistsas dispensers. 26The GPPC study was a multi-centred randomised,controlled study conducted between2002 and 2004 comparing people older than65 years and on five or more medicines who receiveda clinical medication review, with similarpatients who did not receive a medication review.The trial used community pharmacists workingcollaboratively with general practitioners. Theintervention required the pharmacist to meetwith the patient, with access to patient medicalrecords, and then meet with the general practitionerto discuss potential medication alterations.The pharmacists were funded NZ$160 permedication review. General practitioners werereimbursed for enrolling the patient at NZ$50per patient.The aim of the GPPC study was to determine theimpact of community pharmacy–based clinicalmedication reviews on medicines-related healthoutcomes, and to investigate the potential barriersto the implementation of this service. A poorcompletion rate in the study, with only 39% ofpharmacists who agreed to participate providingusable data, indicated significant barriers to implementationof such a service. This paper exploresthe perceptions of New Zealand community pharmacistsafter working in this environment andto determine the barriers that limit communitypharmacists and general practitioners workingtogether clinically. The perceptions of generalpractitioners are discussed in the previous paper. 27MethodsAt the end of the GPPC study face-to-facesemi-structured interviews of pharmacists wereundertaken by the researcher to determine whatthey perceived as inhibitors to wider implementationof clinical medication reviews. Theinterviews were up to 30 minutes and wereaudiotaped with permission from the interviewee.The primary areas discussed with thepharmacists were:• Aspects of the medication reviewservice that went well.• Barriers to the provision of themedication review service.• Practicalities such as communicationprocesses, general practitioner acceptance,patient response, implementationproblems and location of the service.• The future they envisaged for clinicalmedication reviews.The interviews continued until no furtherinformation or concepts were forthcoming andwere transcribed and analysed using QSR NVivoversion 2.0. An analysis was undertaken by theresearcher (LB) initially within six months ofthe interviews. The transcriptions were thenre-analysed by the researcher using a general inductivethematic approach 18 months later to aidwith consistency of interpretation. It was on thesecond analysis that the themes, beyond the basicresponses to the questions, emerged.Ethical approval for the study was obtained fromthe regional ethics committees (ref: 99/207).236 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPERSqualitative researchFindingsTwenty of the 26 pharmacists who started theGPPC study were interviewed. Of these 20, twopharmacists had withdrawn during the study,two provided no clinical data and one providedclinical data only for the intervention arm. † Thesix pharmacists who were not interviewed wereunavailable for an interview at the time theresearcher visited. The characteristics of the pharmacistsare noted in Table 1.OverviewThe themes that emerged from the interviewswere whether the provision of clinical medicationreviews was mandated, had legitimacy, waseffective, and the adequacy of the pharmacistto provide the service. Views on governmentendorsement and the perceptions of others suchas general practitioners and patients reflectedconcerns about a mandate. The concept of legitimacywas raised through comments relatingto time requirements and funding, suggestingthat medication reviews were not somethingthat had priority over traditional pharmacybusiness matters. Comments on lack of confidencein clinical and personal skills, plus aneed for peer support, indicated a perception oflack of adequacy.The themes of mandate, legitimacy, effectivenessand adequacy are interrelated, with providersrequiring adequacy in order to achieve effectiveness,which then gives legitimacy to the service,which should eventually become a role mandatedby the profession and by others external to theprofession. For the pharmacists the businessperspective was important to the theme of legitimacy,which became the major theme.The good aspects of medication reviewsIn response to the broad question about the goodaspects of the reviews, the pharmacists foundparticular satisfaction in building a better rapportwith customers, and making a difference or helpingpeople.Table 1. Characteristics of the pharmacists interviewed.Age (in 2002)GenderI think it builds a really good relationship withcustomers. [P1]I have really enjoyed them because I have met differentpeople and got to know them on a level that Iwouldn’t just in the shop. [P2]LegitimacyThere were some general comments about communitypharmacy as a business and the challengeof incorporating an extra service into the normaldispensing or supply and distribution priorities,particularly in times of staff shortages throughholidays, sickness, etc. The medication reviewservice was not seen as a priority or a part of thebusiness, but more a ‘nice-to-do’. The majorityof pharmacists commented that the medicationreviews were generally not done in routinework time, but in the pharmacist’s own time.The funding was paid to the pharmacy, not thepharmacist. This meant that it was not incorporatedinto the normal routine of the business andPharmacists(n=20)% (no.)50 years old 15% (3)Range: 27–57 yearsMale 30% (6)Female 70% (14)Ethnicity European 100% (20)LocationRolePostgraduate studyTown 15% (3)Peripheral city 60% (12)City 25% (5)Proprietor 35% (7)Employee 45% (9)Independent contractor 25% (4)Completed Masters or PG Diploma 30% (6)Completing Masters or PG 35% (7)No postgraduate study 35% (7)† In the GPPC study only 26 of the 44 pharmacists who agreed to participate started the study (59%); of these, 21 completed the study(48%) and only 17 completed the study and provided useable data (39%).VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 237

ORIGINAL SCIENTIFIC PAPErSqualitative researchother tasks, such as dispensing and retail, wereconsidered a higher priority.The time spent on each of the patient medicationreviews was estimated by the pharmacists as fourto six hours generally, with a few estimating ashigh as eight hours, and one about one-and-a-halfto two hours.Because you start off in the supply mode you gettrapped into that because that’s what, that’s kind ofthe grind that you get into and it is really hard tobreak out and do something different, particularlywhen you are working for someone. [P3]I can’t do it. It needs a degree of dedicated time. Ipersonally find it too hard to do an interview, comeback to work, be a pharmacist dispensing then gohome and write up the case studies, or try and findsome time out, because I don’t get space in the office…My head is in one place, and it has got to be inanother because I have got a growing pharmacy. [P4]It is down time in the pharmacies. [P5]My impression from other community pharmaciststrying to do it is that the pressures of communitypharmacy impinge too much to allow them to doCPC ®‡ [P6]Sometimes the shop detracts from the work ofpharmacy. [P2]I mean that’s the other thing to reduce a person’smedicines, they are actually taking away their business.I talked to a pharmacist in [NZ region] who ismy age who said, ‘why would you do CPC ® becauseyou are basically reducing my income’. [P7]MandateThe perception of whether there is a mandate fora new service is an important aspect of acceptanceof a service. The pharmacists perceived thatthere was little mandate from general practitioners,although at times this seemed ambivalentand dependent on exposure. Despite governmentfunding for the service at the time of the study,the pharmacists did not think the government hadgiven them a clear mandate to undertake this role.The biggest problem is I am actually, like, hitting abrick wall. It is whether you get doctors to buy into it. Whatever it takes to get them to buy in, oncethey are bought in I think they are okay. [P4]There seems to be quite a demarcation line betweenmedical things and pharmacy things and I thinkthe Guild, the Doctors’ Guild, see us as just countingtablets and selling makeup. [P8]There needs to be clear guidance from the Ministryabout the implications and the realisation of whatCPC ® can give the country. [P4]AdequacyThe pharmacists need to feel they have adequateclinical knowledge and skills to provide theclinical medication review service, or have themotivation to obtain the necessary skills. Duringthe interviews there were a number of commentsmade regarding clinical skills, personalconfidence and the desire for peer support, withan indication that a number of the pharmacistsfelt they were working in isolation. The issueof funding is also relevant to the concept of adequacyto provide clinical medication reviews. Todo these efficiently for the funding provided, thepharmacists require adequate skills and knowledgeto complete the review within the expected(funded) time frame.I probably need to up-skill to be able to be moreconfident and say, ‘okay this is the research that Iam talking about’, not just my gut feeling. [P9]I don’t have the confidence. [P10]I think it needs to be done properly, but havingsaid that, that is one of the reasons why there aren’tenough people to actually do it now. [P6]That is one thing I do struggle with, I would prefer tobe able to discuss every care plan basically. It worriesme not having any backup, any double checking. [P11]‡ CPC ® is Comprehensive Pharmaceutical Care, a structured model used for the clinical medication reviews.238 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

Twelve months after the GPPC study ended, 44pharmacists who initially accepted the invitationto participate in the study were asked how manymedication reviews they had done in the previousyear. Thirty-eight pharmacists (86%) responded.Of the 25 pharmacists who had not undertakenany medication reviews in the previous12 months, six no longer worked in communitypharmacy (two had moved to hospital, two to aPrimary Health Organisation (PHO) and two toa professional organisation), three had sold theirpharmacy, and three were focussed on familycommitments. Of the 13 pharmacists who hadcompleted medication reviews in the previous 12months, six were rest home–based completingthree to 30 reviews over 12 months, and four haddone minimal numbers for ambulatory patients(two to eight). Three pharmacists who had under-ORIGINAL SCIENTIFIC PAPERSqualitative researchEffectivenessTo undertake a service there must be a perceptionthat it is effective—for the patient, the generalpractitioner and the pharmacist. The pharmacist’sfocus on effectiveness also included an efficiencyand business perspective. This came through incomments relating to communication, feedback,implementation of recommendations, and potentiallocation of the service.Feedback on the acceptability of recommendationswas generally considered to be lacking, andso left the pharmacists not knowing whethertheir work had been useful. There were also someproblems with implementation, despite apparentacceptance of the recommendation in some cases.This seemed to be related to communication,with the preferred communication method betweenthe pharmacist and the general practitionerbeing face-to-face. It was recognised that this wasmore time consuming, but a written summaryplus a discussion appeared to be more productiveand assisted the pharmacist in understanding thegeneral practitioner perspective.You do the first few and you don’t get any feedback.They are not good at giving feedback and how goodthey found it. Actually that is probably the biggestdowner… if they don’t refer other patients toyou for a while you think, oh, did I do somethingwrong? Did they think it was a waste of time? [P12]Opinion on the best location of the service was divided.Home visits had recognised advantages butbecame a significant time factor in the total service,and problems with being in the pharmacy…I personally find it too hard to do an interview,come back to work, be a pharmacist dispensing thengo home and write up the case studies or try andfind some time out because I don’t get space in theoffice. [P4]If you are an independent person you can do it inthe pharmacies, so long as you get yourself organisedand, like, have a morning a week to book inpatients and… I think it would be difficult to do itif you worked full-time in that pharmacy, and thenonce a week you were trying to do this because,when you go to write them up, if you are trying todo it in work time and if you are trying to do it onthe premises, it is very difficult to say to a memberof the public why you are doing something in thedispensary one day and the next day you are ignoringthem. [P13]Feasibility of clinical medicationreviews in the futureAlthough the themes of mandate, legitimacy,effectiveness and adequacy emerged, a final questionon whether the pharmacists believe there is afuture for clinical medication reviews provided asummary of their overall view. All the pharmacistsconsidered that these reviews should be partof the future for pharmacy, though two pharmacistsfelt that it was not something that theywould pursue because of their perceived skilllevel and the stage they were at in their career.No pharmacist could see themselves providingthe service full-time, but usually for one to twodays a week. The reasons for this varied: fittingit around children; having interests in otherparts of the business; finding difficulty fittingit into the business staff-wise for more than oneday a week and finding the intensity difficult.This may also indicate a perceived lower priorityof the service, and that it is merely an ‘add-on’service. A number of pharmacists commentedthat the standard of the reviews needed to bemaintained and the service needed to be doneproperly if there was to be a future for clinicalmedication reviews.VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 239

ORIGINAL SCIENTIFIC PAPErSqualitative researchtaken a substantial number of medication reviewsfor ambulatory patients had done so after movinginto a PHO environment and no longer workedin community pharmacy. (Figure 1) This demonstratesthe lack of incorporation of the clinicalmedication reviews service into routine communitypharmacy services after the study, despitefunding being available at the time.DiscussionDespite the funding provided by the governmentfor clinical medication reviews, the communitypharmacists did not perceive that they have amandate to provide the service, that it was alegitimate service or that they had adequate skillsand experience to provide the service, despite anapparent desire to undertake these services. If theFigure 1. Ongoing involvement in clinical medication reviews of the pharmacists who agreed to participate in the GPPC studySurvey sent to all pharmacists whoinitially agreed to participate in theGPPC studyN=44No responseN=6Responded to surveyN=38Had done no medication reviews inthe previous 12 monthsN=25Had done at least one medical reviewin the last 12 monthsN=13No longerworking in thecommunitypharmacyN=6Sold thepharmacyN=3Focussingon familycommitmentsN=3No reason givenN=13Working in PHOenvironment(substantialnumbers)N=3Reviews forambulatorypatients (minimalnumbers)N=4Reviews done inrest home (range3 to 30 reviews)N=6240 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ORIGINAL SCIENTIFIC PAPERSqualitative researchreviews were perceived as a legitimate service,then they should receive reasonable priority interms of time.While other researchers identified a number ofphysical or system barriers, this study supportsthe findings that pharmacist attitudes contributeadditional barriers, 20 particularly the concept ofwhether this is a legitimate service from a communitypharmacy.The work of Edmunds and Calnan 26 suggest somereasons for this, including that, despite a viewthat their skills were underutilised and theirdesire for an extended role in patient health care,community pharmacists find it difficult to managethe conflict between being a trader and beinga health professional. They believe that pharmacistssee themselves as dispensers of the generalpractitioner’s prescriptions and wish to avoidconflict with general practitioners over clinicaldecisions. They feel unworthy to challenge thestatus quo, despite a perception that they areknowledgeable about drug therapy.In contrast, clinical pharmacists working withingeneral practice or primary care clinics appear tobe more integrated into the health care team andexperience fewer barriers to providing clinicalmedication reviews and other medicine managementservices independent of dispensing andsupply. 6–10 A further area of research shouldinvolve the perceptions and acceptance of clinicalpharmacists working within PHOs and generalpractices, independent of a community pharmacy,as well as the influence this has on patientmedication–related health outcomes.The limitations of this study are that the pharmacistsgenerally already had a relationship withthe general practitioners in the study, thereforereducing one barrier identified in previousresearch. 17,18,20,22,23 The nature of these medicationreviews were clinical rather than just focussingon adherence support, which is the current fundedservice in New Zealand and likely to generateless hesitancy about adequacy. These findings alsorelate to pharmacists who were motivated, havingundertaken extra training to provide the clinicalmedication reviews. It would be of academicinterest to assess the views of less motivatedpharmacists. Presumably they would be evenless accepting of their role in clinical medicationreviews. Conversely exploring the perceptions ofclinical pharmacists working in PHOs may findthat these pharmacists perceive a legitimate rolein clinical medication reviews and believe theyhave adequate knowledge and skills.ConclusionWhile the skills of community pharmacistsappear to be underutilised, there are barriers toincreasing the role of community pharmacists inmedicines management services. One of the mainproblems that needs to be addressed is the perceptionof community pharmacists and their attitudetowards the new services, particularly the needto see these services as a priority and a legitimateservice. It may be preferable to provide clinicalmedication reviews from within a PHO or generalpractice by a clinical pharmacist, independentof a community pharmacy.References1. Chrischilles E, Carter BL, Lund B, Rubenstein LZ, Chen-hardeeS, Voelker M, et al. Evaluation of the Iowa Medicaid PharmaceuticalCase Management Program. J Am Pharm Assoc.2004;44:337–49.2. Becker C, Bjornson DC, Kuhle J. Pharmacist care plansand documentation of follow-up before the Iowa PharmaceuticalCase Management Program. J Am Pharm Assoc.2004;44:350–7.3. Weinberger M, Murray MD, Marrero DG, Brewer N, LykensM, Harris LE, et al. Effectiveness of pharmacist care for patientswith reactive airways disease: a randomized controlledtrial. JAMA. 2002;288(13):1594–602.4. The Community Pharmacy Medicines Management ProjectEvaluation Team. The MEDMAN study: a randomised controlledtrial of community pharmacy-led medicines managementfor patients with coronary heart disease. Family Practice.2007;24:189–200.5. 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ORIGINAL SCIENTIFIC PAPErSqualitative researchACKNOWLEDGEMENTSWe wish to thank thededicated pharmacistswho participated in theGPPC study, and showeda true pioneering spirit anda keen desire to improvepatient medicine-relatedhealth outcomes.FUNDINGFunding for the GPPCstudy was originallyprovided through theTransitional HealthAuthority (reimbursementof general practitioners)and the PharmaceuticalSociety Education andResearch Fund (printingand postage costs). Thesefunding bodies had noinfluence on the studydesign or any publication.COMPETING INTERESTSNone declared.9. Rothman RL, Malone R, Bryant B, Shintani AK, Crigler B,Dewalt DA, et al. A randomized trial of a primary care-baseddisease management program to improve cardiovascular riskfactors and glycated hemoglobin levels in patients with diabetes.Am J Med. 2005;118(3):276–84.10. Shojania KG, Ranji SR, McDonald KM, Grimshaw JM, SundaramV, Rushakoff RJ, et al. Effects of quality improvementstrategies for type 2 diabetes on glycemic control: a metaregressionanalysis. JAMA. 2006;296:427–40.11. Amsler MR, Murray MD, Tierney WM, Brewer N, Harris LE,Marrero DG, et al. Pharmaceutical care in chain pharmacies:beliefs and attitudes of pharmacists and patients. J Am PharmAssoc. 2001;41(6):850–5.12. Dunlop JA, Shaw J. Community pharmacists’ perspectives onpharmaceutical care implementation in New Zealand. PharmWorld Sci. 2002;24:224–30.13. Rutter PR, Hunt AJ, Jones IF. Exploring the gap: Communitypharmacists’ perceptions of their current role compared withtheir aspirations. Int J Pharm Pract. 2000;8(3):204–208.14. Krska J, Veitch GBA. Perceived factors influencing thedevelopment of primary care-based pharmaceutical care inScotland. Int J Pharm Pract. 2001;9(4):243–252.15. van Mil F, de Boer W, Tromp T. European barriers toimplementation of pharmaceutical care. Int J Pharm Pract.2001;9:163–8.16. Lee E, Braund R, Tordoff J. Examining the first year of MedicinesUse Review services provided by pharmacists in NewZealand: 2008. NZMJ. 2009;122(1293):26–35.17. Bradley F, Wagner A, Elvey R, Noyce P, Ashcroft DM. Determinantsof the uptake of medicines use reviews (MURs) bycommunity pharmacies in England: A multi-method study.Health Policy. 2008;88:258–68.18. Lounsbery J, Green CF, Bennett MS, Pedersen CA. Evaluationof pharmacists’ barriers to the implementation of medicationtherapy management services. J Am Pharm Assn.2009;49(1):51–8.19. Brown CM, Barner JC, Shepherd MD. Issues and barriersrelated to the provision of pharmaceutical care in communityhealth centers and migrant health centers. J Am Pharm Assoc.2003;43(1):75–7.20. Muijrers PE, Knottnerus JA, Sijbrandij J, Janknegt R, Grol RP.Pharmacists in primary care. Determinants of the care-providingfunction of Dutch community pharmacists in primary care.Pharm World Sci. 2004;26(5):256–62.21. Rossing C, Hansen E, Krass I, Traulsen J. Pharmaceutical Carein Denmark: perceived importance of medicine-related problemsand participation in postgraduate training. Pharm WorldSci. 2003(25):73–78.22. Rossing CH, E. Traulsen, J. Krass, I. Actual and perceivedprovision of pharmaceutical care in Danish communitypharmacies: the pharmacists’ opinion. Pharm World Sci.2005;27:175–81.23. Wilcock M, Harding G. General practitioner’s perceptionsof medicines use reviews by pharmacists. Pharm J2007;279:501–03.24. Willink DP, Isetts BJ. Becoming ‘indispensable’: developinginnovative community pharmacy practices. J Am Pharm Assoc.2005;45(3):376–86.25. Latif DA. The relationship between pharmacists’ tenure inthe community setting and moral reasoning. J Bus Ethics.2001;31(2):131–41.26. Edmunds J, Calnan MW. The reprofessionalisation of communitypharmacy? An exploration of attitudes to extendedroles for community pharmacists amongst pharmacists andGeneral Practitioners in the United Kingdom. Soc Sci Med.2001;53(7):943–55.27. Bryant L, Coster G, McCormick R. General practitionerperceptions of clinical medication reviews undertaken by communitypharmacists. J Primary Health Care. 2010;2(3):225–33.242 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

improving performanceReducing health disparities for low decilechildren and families: a nurse-led responseCatrina Riley RN, BN, MN (Child & Family); 1 Ruth Crawford RN, BA, PGCert. (Tertiary Teaching), M.Phil (Nursing) 2ABSTRACTBackground and context: Reducing health disparities for children living in deprived areas hasbeen difficult to achieve. This paper describes the implementation of a nurse-led, child-specific clinicwithin a general practice setting to improve health outcomes for high needs Maori/Pacific Island andNZDep96 quintile groups 4 and 5 children and their whanau/families.1The Doctors, Napier,Napier, New Zealand2Eastern Institute ofTechnology, Hawkes Bay,New ZealandAssessment of problem: The medical centre that implemented the clinic had a high number ofenrolled children with chronic and recurrent morbidities. Children frequently did not attend clinic appointments,and there was high use of after-hours services.Results: An outcome audit after 18 months demonstrated a significant (>30%) reduction in eczemaseverity, daily irritability, and daily occurrence of pain. Post-intervention fewer children were hospitalisedand there was a 50% reduction in antibiotic use.Strategies for improvement: The aim of the nurse-led clinic was to improve health gains, facilitatemorbidity control of chronic conditions, and to offer prevention strategies to promote wellness forthe target population. The reduction of morbidity severity by 10% was measured with specific morbidityscoring systems for eczema, constipation and nocturnal enuresis. Other outcome indicators measuredvomiting/reflux, wheezing/coughing, constipation/soiling, irritability, sleep disturbances, hospital admissions,and antibiotic use.Lessons: Nurse-led clinics facilitated by nurses with advanced skills can reduce health disparities forthe target population. The amount of time the nurse is able to spend with the child and whanau/family,and the provision of opportunistic assessments as required, has effected positive change in thosechildren most in need.KEYWORDS: Child health; low decile families; Maori/Pacific families: chronic conditions; nurse-led clinicBackgroundReducing health disparities for Maori and Pacificchildren and for children living in areas of highdeprivation is a goal underpinning health provisionin New Zealand. These children have rates ofcommon chronic health conditions two to six timeshigher than those not living in socioeconomicdeprivation. 1 This paper outlines an outcomeevaluation of a child health nurse-led clinic whichaimed to improve health gains, facilitate morbiditycontrol of chronic conditions, and offer preventionstrategies to promote wellness in this population.Nurse-led clinics have become more commonplacein the provision of primary health care sincethe implementation of the Primary Health CareStrategy in 2001. 2 Government supported thedevelopment of innovative models of primaryhealth care nursing practice which would helpdeliver the objectives of the Primary HealthCare Strategy. 3 A more recent driver of nurse-ledclinics has been funding from Primary HealthOrganisations (PHOs) to meet the specific healthneeds of the population. 4 Services which arenurse-led are not merely replacing the doctorCorrespondence to:Ruth CrawfordSchool of Nursing, EITHawkes Bay, PB 1201Napier, New Zealandrcrawford@eit.ac.nzVOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 243

improving performancewith the nurse: nurses take the lead to add anenhanced quality of care. 5 Nurse-led clinics havebeen implemented successfully internationally 6–8and nationally. 9,10 Child health conditions suchas atopic eczema, asthma, functional constipation,urinary tract infections and iron deficiencyanaemia have been successfully managed withinthe nurse-led clinic model. 5,7–9,11–15 Benefits ofnurse-led clinics include increased patientsatisfaction, longer consultations, and improvedpatient education. 5Hawkes Bay, a region on the east coast of NewZealand, has higher than the national averagenumbers of children and young people living inthe most deprived (NZDep01 decile 10) areasaccording to the 2006 census. Thirty-five percentof children in Hawkes Bay live in deprivationareas 9 and 10 compared to 24% nationally. 16One of the authors (CR) works as a practice nurseat a general medical facility in Hawkes Bay. Thisfacility serves a culturally diverse urban area,with an enrolled child population (0–18 years)of 4968. The demographics of the enrolled childpopulation are shown in Table 1.PurposeThe purpose of this paper is to present an outcomeevaluation of a nurse-led clinic. An audit-basedapproach was used to evaluate the impact theclinic has had on children with chronic childhoodconditions with particular emphasis on highneeds Maori/Pacific Island children and NZDep96quintile groups 4 and 5 whanau/families.An application for ethical approval for thisoutcome evaluation was made to the Central RegionalHealth and Disability Ethics Committee.The Committee advised that this study does notrequire ethical approval, as it falls under exemptions11.8 and 11.9 of the Ethical Guidelines forObservational Studies: Observational Research,Audits and Related Activities (NEAC, December2006) and therefore requires no further review.Assessment of problemSignificant numbers of the enrolled child populationin the practice experienced chronic and recurrentmorbidities. Nineteen percent of patientshad outstanding debts to the practice. Sixty-eightchildren (0–18 years) did not attend their bookedappointments over a two-month period. Over aone-year period, there were 70 011 child presentationswithout a scheduled appointment (walkins),or after-hours, and 62% of these childrenresided in NZDep96 quintile groups 4 and 5. 17In one year, 1644 children less than 18 yearswere identified as having a chronic condition.Repeat exacerbations were problematic¸ withthe number of presentations ranging from twoto eight per child. Sixty-five percent of thesechildren lived in NZDep96 quintile groups 4and 5. 17Strategies for qualityimprovement/changeThe aim of the intervention was to improvehealth gains, facilitate morbidity control ofchronic conditions, and offer prevention strategiesto promote wellness to the target group ofchildren. Chronic conditions included atopic eczema,asthma, food allergies/intolerances suspectedor actual, functional constipation, gastroesopha-Table 1. Demographics of enrolled children (n=4968) 0–18years. 17CharacteristicEthnicity n (%)NZ European 2807 (57%)Maori 1645 (33%)Pacific Island 167 (3%)Asian 68 (1%)Indian 23 (0.5%)African 18 (0.4%)Middle Eastern 10 (0.2%)Other 230 (5%)NZDep96Quintile 1 278 (5.6%)Quintile 2 400 (8%)Quintile 3 854 (17%)Quintile 4 854 (17%)Quintile 5 2582 (52%)244 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

improving performancegeal reflux disease, nocturnal enuresis, and obesity.The clinic excluded children with complexcardiac, respiratory, renal, endocrinological, andneurological chronic morbidities. The service wasfunded by the Hawkes Bay Primary Health Organisation(HBPHO). All children under 18 yearswho were identified as having a chronic conditionwere sent a letter explaining the purpose of theclinic, and were offered the opportunity to makean appointment.Each consultation was 45 minutes, which gavetime to discuss, educate, and offer preventionstrategies. Within each consultation, wider socialissues affecting the child and their whanau/family were assessed, such as financial assistance,smoking cessation, transport issues, familyviolence screening, and housing concerns.Opportunistic assessments were often performedout of designated child health clinic hours, andafter hours (4pm to 7pm). Language barriers weremanaged with an interpreter service. The clinicrecognised and embraced the ‘Te Whare TapaWha’ concept as described by Durie. 18 Te WhareTapa Wha refers to the four walls of the whare(house), with each wall representing a dimensionof health; taha wairua (spiritual), taha tinana(physical), taha hinengaro (mental/intellect),and taha whanau (extended family). 18 Followingreview of international best practice literatureregarding the impact of child-specific, nurseledclinics relating to eczema, constipation, andurinary tract infection, outcome indicators wereadopted. 5,11–14,20–22The nurse-led clinic had specific objectives withregard to assessment of particular childhoodchronic conditions. The reduction of morbidityseverity by 10% was measured with morbidityscoring systems, such as the Six Area, Six SignAtopic Dermatitis (SASSAD) severity score forchildren with eczema; the Bristol Stool Scalefor children with constipation; and number ofwet nights per week for children with nocturnalenuresis. Other child health outcome indicatorsmeasured vomiting/reflux, wheezing/coughing,constipation/soiling, irritability, sleep disturbances,hospital admissions, and antibiotic use. Anoutcome audit utilising the Medtech32 PatientManagement System Query Builder functionWHAT GAP THIS FILLSWhat we already know: Children from Maori and Pacific families, andlow decile groups have two to six times the rates of common chronic healthconditions than other children. Improving the health status of these childrenhas been difficult to achieve. High incidences of families not attending clinicappointments, and reduced access to health care because of increasing waitingtimes for outpatient clinics have led to widening health disparities.What this study adds: A nurse-led, child-specific clinic for low-decilechildren with mild–moderate chronic conditions has been successfully implementedin New Zealand. Significant reductions in eczema severity, irritabilityand pain, alongside a decrease in hospital admissions and antibiotic use havebeen achieved by advanced nurses working with children and their whanau/families.extracted data for analysis. Baseline data was collectedat the time of the first visit from whanau/families, using direct questioning and observation.Post-intervention data was collected onemonth following the first clinic visit.The purpose of the intervention was to reducethe frequency of the indicator(s) from daily toevery second or third day, weekly, or none over aperiod of one month post-intervention.The children and their whanau/families werethe major stakeholders in the intervention. Theywere offered the choice of completing (or not)a consultation satisfaction survey (Appendix 1,available in the web version of this paper) postedto them with a prepaid return addressed envelopewithin three months of their last visit tothe child health clinic. Another major group ofstakeholders were the general practitioners (GPs)who worked within the practice. All GPs wereoffered the opportunity to complete a survey ofthe clinic (Appendix 2, available in the web versionof this paper).Results of assessment/measurementTwo hundred and sixty-five consultations werecarried out over an 18-month period. Seventyfivepercent were from NZDep96 quintiles 4 and5. 19 Table 2 shows demographic data of childrenreviewed at the clinic. Results are reported undereach of the specific chronic conditions.VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 245

improving performanceEczemaFifty-four children with eczema were included inthe outcome audit. Children were excluded fromthe audit if follow-up did not occur one monthafter the first visit. The average SASSAD baselinescore was 29, and the average post-interventionSASSAD score was 13. This demonstrates anaverage reduction of 16 in the SASSAD scores,and equates to a 32% reduction in eczema severity(Figure 1). 19A possible correlation may be noted between theincrease in daily emollient utilisation, the reductionin daily topical corticosteroid use (TCS),the reduction in daily itching, and the reductionin eczema severity (Figure 1). Daily emollientuse increased by 51%, daily TCS reduced by15%, daily itching reduced by 32%, and eczemaseverity decreased by 32%. Similar findings werenoted in the United Kingdom in research whichassessed the efficacy of education and demonstrationof topical therapies for children with eczemain a nurse-led clinic environment. 12 Their resultsalso demonstrated a significant increase in dailyemollient utilisation and a significant reductionin eczema severity with no increase in the use oftopical corticosteroids.ConstipationTen children who experienced constipationwere included in the audit; seven were excludedbecause they did not attend their follow-up visitFigure 1.Comparison of baseline and post-intervention eczema outcome indicatorsTable 2. Demographics of children (n=265) 0–18 yearsreviewed in the child health clinicCharacteristic n (%)EthnicityNZ European 123 (46%)Maori 99 (37%)Pacific Island 24 (9%)Indian 8 (3%)Asian 3 (1%)Other 8 (3%)Age in years

improving performancemonth, and post intervention 28% had received acourse of antibiotics within the month interval.Figure 2. Constipation outcomesOther findings showed a 36% reduction in dailymood irritability; a 28% increase in childrensleeping throughout the night with 13% reductionin nightly sleep disturbances; a 22% reductionin the daily occurrence of pain; a 13% reductionof vomiting/reflux on a daily basis; a 12%reduction in daily occurrence of constipation/soiling;and an 11% reduction in children experiencingdaily, or every second/third day, wheezing/coughing symptoms. 19GP survey resultsTwelve GPs who worked within the practicegave feedback via a confidential survey (Appendix2, available in the web version of this paper).All agreed the nurse-led clinic was a usefulresource which had positively impacted upontheir workload.Figure 3. Nocturnal enuresis outcomesFamily satisfaction resultsTwenty whanau/families of the 68 children whohad attended the nurse-led clinic gave feedbackvia a confidential consultation satisfaction survey(Appendix 2 in the web version). Findings showedall whanau/families strongly agreed or agreedthat they were satisfied with the care received inthe clinic; most whanau/families felt they wereinvolved with goal setting; 85% felt the advice andeducation contributed to their child’s improvedTable 3. Comparison of baseline and post-intervention child health indicators (n=68)Indicator None Weekly Every 2 nd to 3 rd day DailyB PI B PI B PI B PISleep disturbance 22 (32%) 41 (60%) 12 (18%) 11 (16%) 13 (19%) 4 (6%) 21 (31%) 12 (18%)Pain 22 (32%) 46 (67%) 18 (26%) 15 (22%) 12 (18%) 6 (9%) 16 (24%) 1 (2%)Vomiting/reflux 53 (78%) 65 (96%) 5 (7%) 3 (4%) 1 (2%) 0 (0%) 9 (13%) 0 (0%)Wheeze/cough 47 (69%) 67 (98%) 14 (20%) 1 (2%) 6 (9%) 0 (0%) 1 (2%) 0 (0%)Irritability 22 (32%) 49 (72%) 5 (7%) 11 (16%) 12 (18%) 3 (4%) 29 (43%) 5 (7%)Constipation/soiling 53 (78%) 59 (87%) 3 (4%) 5 (7%) 3 (4%) 3 (4%) 10 (14%) 1 (2%)Antibiotic use 40 (59%) 49 (72%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 28 (41%) 19 (28%)Hospital admissions 64 (94%) 67 (98%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 4 (6%) 1 (2%)B = BaselinePI = Post interventionVOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 247

improving performanceACKNOWLEDGEMENTSThe authors would liketo acknowledge theHawkes Bay PrimaryHealth Organisation andthe medical centre fortheir ongoing supportof the nurse-led clinic.COMPETING INTERESTSNone declared.health, and felt more confident and motivated; andfinally, all whanau/families reported increasedunderstanding of their child’s diagnosis, medication,and treatment plan, and were satisfied withthe amount of time the nurse spent with them.Lessons and messagesPrimary health care is population- and patientfocussed.The introduction of the child healthnurse-led clinic provided a new resource for themedical practice. There were no primary healthchild-specific nursing services available to supportchildren with common chronic conditions inthe region. The clinic was developed to meet theneeds of a specific population within the medicalpractice. Over an 18-month period, 265 nurseledconsultations were undertaken. Seventy-fivepercent of children in the group were fromNZDep96 quintiles 4 and 5, and 46% were ofMaori or Pacific Island descent.The clinic’s success could be attributed to earlyreview of children with mild to moderate formsof chronic conditions, and hence preventing theseconditions from becoming more severe. A furtherachievement of the clinic was facilitating a shiftin service provision to primary health care in linewith government targets outlined in the PrimaryHealth Care Strategy.Intervening when morbidities are mild to moderate,and then working closely with whanau/families with education and support, has enabledmore efficient condition control.Benefits for the practice have enabled nurses toundertake independent nurse-led clinics, thususing their knowledge and skills in ways notpreviously achieved. 23 The introduction of thechild health nurse-led clinic did not require majorpractice change as all processes were acceptable andpracticable for nurses, GPs, and whanau/families.PHO, GP and practice nurse support has beenessential to the success of the child healthnurse-led clinic. It is anticipated that, with thisongoing support, the service will continue in theforeseeable future, addressing the health needs ofchildren and young people in Hawkes Bay, and thusreducing the burden of ongoing chronic illness.References1. The Paediatric Society Monitoring the Health of New ZealandChildren and Young People: Indicator Handbook. 2007. RetrievedJanuary 10, 2008 from http://www.paediatrics.org.nz2. Ministry of Health. The Primary Health Care Strategy. Wellington;2001.3. Nelson K, Wright T, Connor M, Buckley S, Cumming J. Lessonsfrom eleven primary health care nursing innovations inNew Zealand. Int Nurs Rev. 2009;56(3)291–298.4. Hawkes Bay Primary Health Organisation. Nurse-led healthylifestyle clinics. Practice Nurse. 2008;7(3):20–21.5. Moore E, Williams A, Manias E, Varigos G. Nurse-led clinicsreduce severity of childhood atopic eczema: a review of theliterature. B J Dermatol.2006;155:1242–1248.6. Hanson-Turton T, Miller ME. Nurses and nurse-managedhealth centers fill healthcare gaps. The Pennsylvania Nurse.2006; June, 18.7. Rance KS, Trent CA. Profile of a primary care practice asthmaprogram: improved patient outcomes in a high-risk population.J Pediatr HealthCare. 2005;19(1):25–32.8. Wooler E. The role of the nurse in paediatric asthma management.Paediatric Respiratory Review. 2001;2:76–81.9. Bolitho S, Huntington A. Experiences of Maori families accessinghealth care for their unwell children: a pilot study. NursPrax NZ. 2006;22(1)23–32.10. Clendon J, White G. The feasibility of a nurse practitioner-ledprimary health care clinic in a school setting: a communityneeds analysis. J Adv Nurs. 2001;34(2)171–178.11. Burnett C, Juszczak E,Sullivan P. Nurse management of intractablefunctional constipation: A randomised controlled trial.Arch Dis Child. 2004;89(2)717–722.12. Cork M, Britton J, Butler L, Young S, Murphy R, Keohane S.Epidemiology and health services research: comparison ofparent knowledge, therapy utilisation and severity of atopiceczema before and after explanation and demonstration oftopical therapies by a specialist dermatology nurse. B J Dermatol.2003;149(8):582–589.13. Coulthard M, Vernon S, Lambert H, Matthews J. A nurse-lededucation and direct access service for the management ofurinary tract infections in children: prospective controlled trial.BMJ. 2003;327(6):1346.14. Muir J, Burnett C. Setting up a nurse-led clinic for intractablechildhood constipation. Br J Community Nurs.1999;4(8):395–399.15. Bartle C. Developing a service for children with iron deficiencyanaemia. Nurs Stand. 2007;21(19):44–49.16. Hawkes Bay Primary Health Organisation. Strategic Plan2008–2011. Hastings; 2008.17. The Doctors Systems. Query builder. Retrieved March 12,2008 from The Doctors Systems.18. Durie M. Whaiora: Maori health development. 2nd ed.Oxford: Oxford University Press; 1999.19. The Doctors Systems. Query builder. Retrieved Feb 2010 fromThe Doctors Systems.20. Loening-Baucke,V. Constipation in early childhood: patientcharacteristics, treatment, and long-term follow up. BMJ.1993;34(1136):1400–1404.21. Fletcher M. Commentary: Nurse management of chronicconstipation. Paediatr Nurs. 2004;6(7):12.22. Wild S. (2006). Eczema clinics: Developing eczema experts.Retrieved January 20, 2008 from http://web.ebscohost.com.ezproxy.massey.ac.nz/ehost/detail.23. Henty C, Dickinson A. Practice nurses’ experience of the CarePlus programme: A qualitative descriptive study. NZ Fam Phys.2007;34(5):335–338.248 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

BACK TO BACKSometimes a case can be made forphysician-assisted suicideYESArguably this side of the moot is the easier;provide only one instance and the case is made,whilst arguing ‘no’ means anticipating all possiblecases. Moreover, the ethical principle ofpatient autonomy implies the need to providegood reasons for refusing. Indeed, given a defaultposition of autonomy, it is not actually necessaryto make a case, merely to refute any potentialobjections to physician-assisted suicide (PAS).Weak objectionsObjecting that the Hippocratic Oath forbidsPAS has little force, given the routine ignoringof other aspects of the oath (one could object toabortion on these grounds) and the ludicrousnessof imagining that ethical problems of the twentyfirstcentury should be solved by guidelines fromthe ancient Greeks. Similarly the objection that ‘adoctor’s job is to save life, not to end it’ is neithernecessarily true (fields like cosmetic surgery arerarely lifesaving) nor immutable.Other objections might appear more compelling.It is certain that PAS would affect thedoctor–patient relationship, but it is questionablewhether this would be a change for the worse.In countries where PAS and euthanasia areavailable, there is no evidence of this, althoughthose whose enthusiasm outweighs their rigoursometimes produce apocryphal and unsubstantiatedscare stories of frightened people worryingthat their doctor will kill them. Elsewhere theextension of autonomy appears to produce betterpatient well-being and relationships with professionals,1 and there seems little reason to believethat this would be any different for PAS.Perhaps the most persistent is the so-called‘slippery slope’ argument. 2 According to mostversions of this, a procedure such as PAS, whilstacceptable in itself, would later lead to someunacceptable future scenario such as the mass executionof the old and infirm. As a purely logicalargument it need not be taken seriously—indeedlogicians usually refer to the ‘slippery slopefallacy’, 3 only ceasing to be fallacious when theintervening steps are inevitable. Such steps couldof course occur—for example, we may find thatdeaths through PAS are more peaceful, and thusmore opt for it, or maybe those who would havecommitted suicide alone may welcome assistance.If these can be demonstrated, then the argumentcan have real status, although one might questionwhether the examples given are undesirable.Unfortunately the data cited are typically correlationaland highly selected. 4 Rarely are counter-Glynn Owens PhDProfessor, Departmentof Psychology, Faculty ofScience, The Universityof Auckland, PB 92019,Auckland, New Zealandg.owens@auckland.ac.nzWhile evidence can help inform best practice, it needs to be placed in context.There may be no evidence available or applicable for a specific patient withhis or her own set of conditions, capabilities, beliefs, expectations and socialcircumstances. There are areas of uncertainty, ethics and aspects of care for whichthere is no one right answer. General practice is an art as well as a science. Qualityof care also lies with the nature of the clinical relationship, with communication andwith truly informed decision-making. The Back to Back section stimulatesdebate, with two professionals presenting their opposing views regarding a clinical,ethical or political issue.Rod MacLeodGlynn OwenBACK TO BACK this issue:VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 249

BACK TO BACKexamples given—as with the United KingdomAbortion Act of 1967, which was introducedamong fears that the 28-week limit might ‘slip’ tofull-term but in fact went in the other directionand later was reduced to 24 weeks.PAS and palliative care are not, as some claim,mutually exclusive. Like many working in end-oflifecare, I have heard, and accepted, claims thatwe are able to deal adequately with pain in around95–98% of cases, and have no argument with this.But even these figures imply that around one in50 of our patients may suffer unacceptably andit is important to remember that pain may not bethe only or even the main reason for wanting toend one’s life. 5 The suggestion that PAS is unnecessarywhere palliative care is available contrastswith our own New Zealand data showing illegaleuthanasia to be as likely when there is access topalliative care services as not. PAS and palliativecare can peacefully coexist, and indeed liberalisationin Holland has been paralleled by a markedincrease in provision of palliative care. 6Potentially strong objectionsOne of the more compelling arguments concernsnot the patients but the practitioners. Typicallyfears are raised that providing PAS may lead toending life being seen as an easier or cheaper optionthan good palliative care, but Kay Mitchell’sinterviews with Dutch doctors performing euthanasiasuggest quite the opposite—doctors findingit extremely difficult and going to great lengthsto find alternatives. 7Also persuasive is the argument of ‘mistakes’;we might mistakenly allow PAS when someonecould be treated and allowed to enjoy theirlast days before dying naturally. Proponents,however, conveniently forget mistakes in theother direction—where someone is compelled tosuffer because the present systems cannot workproperly. Consider the following account of amyeloma patient in the USA who, saying that shedid not ‘have the energy to go another round’ decidedto refuse food and drink from the Sundayevening ‘…only to find that the process wasn’t atall quick… by midnight Thursday she was alreadybeginning to choke on the liquid in her lungs…during the height of her struggles in the earlymorning hours of [Friday] she sweated, producedtears and manifested physical contortions whilemoaning… her body writhed despite a displacedhip fracture and lack of bone definition in thelong bone of one arm…’ (account from patient’shusband). Of course it could have been handledbetter—but mistakes happen under all policies,and, if comparing policies, we need to look at themistakes on both sides.Finally there is the argument that ‘many ask forhelp in dying, but typically only once’. Of coursemany patients may ask only once because the ‘no’is so resounding as to discourage repetition. But,in any event, no-one is suggesting legislationto permit PAS without evidence of an ‘enduringrequest’, as seen in such legislation in othercountries. For those who change their mind,this requirement provides safety and protection,whilst allowing those who do have an enduringwish to control their own lives.The picture that emerges, then, is one of ourperpetuating the old ‘doctor knows best’ myth,depriving patients of control over their own liveswithout any sound justification. Perhaps the mosttelling argument comes from my colleague ProfessorRod McLeod. After one of his very impressivelectures, a student said he’d been very impressedby Rod’s asking (and my apologies if he’s misquoted)‘Who are we to decide that someone else’s lifeisn’t worth living?’. Of course we have no right todo so, any more than we have the right to insistfor them that it is when they know otherwise.References1. Deadman JM, Leinster SJ, Owens RG, Dewey ME, Slade PD.Taking responsibility for cancer treatment. Soc Sci Med.2001;53,669–677.2. Van Delden JJ. Slippery slopes in flat countries—a response. JMed Ethics. 1999;25:22–24.3. Enoch D. Once you start using slippery slope arguments you’reon a very slippery slope. Oxford J Leg Stud. 2001;4:629–647.4. Jochemsen H, Keown J. Voluntary euthanasia under control?Further empirical evidence from the Netherlands. J Med Ethics.1999;25:16–215. Marquet RL, Bartelds A, Visser GJ, Spreeuwenberg P, Peters L.Twenty five years of requests for euthanasia and physician assistedsuicide in Dutch general practice: trend analysis.Br MedJ. 2003;327:201–202.6. Kuin A, Courtens AM, Deliens L, Vernooij-Dassen MJFJ, vanZuylen L, van der Linden B, van der Wal G. Palliative care consultationin the Netherlands; a nationwide evaluation study. JPain Symptom Manage. 2001;27:53–60.7. Mitchell K. Medical decisions at the end of life that hastendeath. PhD thesis. University of Auckland; 2002.250 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

BACK TO BACKSometimes a case can be made forphysician-assisted suicideNOWorking for most of my professional lifetimewith people who are dying, it has been commonfor me to hear requests from individuals fortheir lives to be ended—mostly, I think, becauseof their sense of frustration, sadness, hopelessnessor fear. Some express their explicit opinionthat they may be a burden on their family or onsociety and that is why they are asking for theirlife to be ended.It is hard to imagine—even though I spend muchof my clinical life with people who are desperatelyill—what it must be like to reach a stage wherethey ask for death. Whatever it is that triggerssuch a request they are rarely repeated overtime—once adequate palliative care is instituted,the request to die loses its urgency and the focusis once again on living. What I believe is thatmost, if not all, of these requests are from peopletelling me they ‘don’t want to live like this’,which is, of course, very different to wantingto die. The notion of real or potential sufferingthat cannot be relieved is a potent driverin some of these requests. Some years ago theEuropean Association for Palliative Care EthicsTask Force 1 produced a carefully constructed andwell thought out document that crystallised thethinking of many who are involved in end-of-lifecare. In that document they suggested, amongother things, that: ‘Individual requests for euthanasiaand physician-assisted suicide are complexin origin and include personal, psychological, social,cultural, economic and demographic factors.Such requests require respect, careful attention,together with open and sensitive communicationin the clinical setting.’They go on to suggest that ‘requests for euthanasiaand physician-assisted suicide are often alteredby the provision of comprehensive palliative care.Individuals requesting euthanasia or physicianassistedsuicide should therefore have access topalliative care expertise’. This is to say that weneed to explore, to our utmost abilities, what itis that is driving this request for the ending ofa life and, in doing so, find ways to alleviate ormitigate suffering to such a degree that the desirefor death is diminished.The Task Force argues that ‘if euthanasia is legalisedin any society, then the potential exists for:i. pressure on vulnerable persons;ii. the underdevelopment or devaluation ofpalliative care;iii. conflict between legal requirements andthe personal and professional valuesof physicians and other health careprofessionals;iv. widening of the clinical criteria to includeother groups in society;v. an increase in the incidence of non-voluntary and involuntary medicalisedkilling;vi. killing to become accepted within society.’All of these are real concerns that are met on aregular basis when caring for the most vulnerableand sick in our society and it is not unreasonable tosuppose that any intention to ‘permit’ assisted dyingwould put varying degrees of pressure on thosewho ask for the end of their life to be precipitated.Many who are receiving palliative care have afear of their life being prolonged unnecessarilyor for it to end in ‘unbearable’ distress. Clearlyno-one would want this, least of all for someonethey love, so it is incumbent upon us to ensurethat all who need it receive the best possiblephysical, psychological, spiritual and social care.In this way, assisted dying is not an option thatneeds be considered.Rod MacLeod MBChB,FRCGP, FAChPM, PhDHonorary Clinical Professorand Associate Professor,Department of GeneralPractice and Primary HealthCare, School of PopulationHealth, The University ofAuckland, and Directorof Palliative Care, NorthShore Hospice, Takapuna,Auckland, New Zealandrd.macleod@auckland.ac.nzVOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 251

BACK TO BACKEstablishing palliative care within mainstreamhealth care systems of all countries is essentialand this must be supported by appropriatefinance, education and research. In New Zealand,successive governments have demonstrated awillingness to support the provision of palliativecare through hospice programmes, but we stillfall behind many countries in the way in whichwe teach our health professionals to deal withthis most challenging of health-related issues.Doctors have repeatedly reported being unpreparedto deal with end of life care on a practicallevel, let alone a legal or moral one. Repeatedly,the majority of doctors have voiced their viewsthat physician-assisted suicide is wrong. 2 Anothercompelling discussion is to be found in the writingof McLachlan 3 who asserts that one can ‘considerparticular actions to be contrary to appropricouldbe argued that, in palliative care, one ofthe main things we have to offer is that personalbond, but I would like to think that peoplewho are sick or dying should all be attended bythose who cared as well as attempted to cure,and neither of those aspects involves the endingof a life. When people consult their doctor it isbecause they feel unwell, uncertain or they aresuffering. It is hard enough to provide humanemedical care for these people who seek helpwithout the added burden of an expectation thatsomewhere in that relationship between doctorand patient there may be a tacit understandingthat this person, in whom they have entrustedtheir life, their fears, their concerns, may be requiredultimately to end their life. There is nevera case to be made for physician-assisted suicide inany humane society.One of the many tensions in the doctor–patient relationship is thedifferent perspective from which each party views the medicalencounter. Patients need caring as much as they need curing and itis often caring that can be missingate professional conduct even in the absence oflegal and ethical objections to them.’The major reason that physician-assisted suicideis so at odds with the rest of medical practiceis because of the unique bond that developsbetween doctor and patient. We need to ensurethat we strive to fully understand what it is thatthe patient is experiencing. Shimon Glick 4 writesthat one of the many tensions in the doctor–patient relationship is the different perspectivefrom which each party views the medicalencounter. Patients need caring as much as theyneed curing and it is often caring that can bemissing. 5 Francis Peabody, in the Journal of theAmerican Medical Association in 1927 wrote:‘The reward is to be found in that personalbond which forms the greatest satisfaction inthe practice of medicine.’ 6 Any situation wherephysician-assisted suicide is contemplated willirreparably damage that relationship or bond. ItReferences1. Materstvedt LJ, Clark D, Ellershaw J, Førde R, Boeck GravgaardA-M, Müller-Busch HC, Porta i Sales J, Rapin C-H.Euthanasia and physician-assisted suicide: a view from anEAPC Ethics Task Force. Palliat Med. 2003;17:97–101.2. Seale C. Legalisation of euthanasia or physician-assistedsuicide: survey of doctors’ attitudes. Palliat Med.2009;23:205–212.3. McLachlan HV. Assisted suicide and the killing of people?Maybe. Physician-assisted suicide and the killing of patients?No: the rejection of Shaw’s new perspective on euthanasia.J Med Ethics. 2010;36:306–309.4. Glick S. The empathic physician. In. Spiro H et al. (editors).Empathy and the practice of medicine. New Haven and London:Yale University; 1993.5. Janssen A, MacLeod RD What can people approaching deathteach us about how to care? Patient Education and Counseling.2010. In press.6. Peabody F. The care of the patient. JAMA (1927) 1984.(88:877–82) 252:813–18.252 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

continuing professional developmentcochrane cornerTopical nasal decongestants: use up to 10 days maynot cause rhinitis medicamentosaBruce Arroll MBChB, PhD, FRNZCGPThe problem: The common cold affects almostevery human being at least once per year. Nasalcongestion is one of the most common symptomsof this condition and relief is sought from oralor topical decongestants. I was taught not to usetopical decongestants for more than three daysdue to concerns about rebound rhinitis known asRhinitis Medicamentosa, but have had patientswho have used topical decongestants for yearswith no such problem. Most of the literatureabout rhinitis medicamentosa comes from ENTclinics where patients have been using topicaldecongestants for many years. This CochraneCorner includes the Cochrane review 1 on nasaldecongestants for the common cold (now removedfrom the library, but available from Bruce Arrollvia email) and a randomised controlled trial byEccles (2008). 2More recently is the concern regarding illicit useof oral pseudoephedrine as a source of methamphetamine.Of medical concern may be the riskof increasing blood pressure and one oral decongestantphenylpropanolamine is no longer used.One case control study compared the use of coldpreparations containing phenylpropanolamine in702 people with a history of haemorrhagic strokeversus 1376 control people with no history ofstroke. 3 The study found a non-significant trendtowards increased haemorrhagic stroke with phenylpropanolamine(RR 1.50, 95% CI 0.85 to 2.65).Clinical bottom line. The Cochrane reviewrecommended that topical nasal decongestantsseem to have an effect at least after the firstdose. The paper by Eccles found a similar benefitwhich persisted up to 10 days with three timesdaily use. The Cochrane review recommendednot using topical decongestants long-term andalso cautioned about using it in children asrhinitis medicamentosa has been reported after asingle dose in children. The Eccles paper foundno such problem in adults with three times dailyuse for 10 days.The University of Auckland,Auckland, New ZealandTopical nasal decongestants for the common coldTopical decongestants fornasal obstruction due tothe common coldSuccess Evidence HarmsNNT of about 10 forimprovement in symptomsCochrane review 1RCT 2Possible risk of reboundcongestion with long-term useand in childrenNNT = numbers needed to treatReferences1. Taverner D, Latte GJ. Nasal decongestants for the common cold. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No:CD001953. DOI: 10.1002/14651858.CD001953.pub3.9 (now withdrawn but copy available from b.arroll@auckland.ac.nz)2. Eccles R, Eriksson M, Garreffa S, Chen SC. The nasal decongestant effect of xylometazoline in the common cold. Am J Rhinol.2008;22:491–496.3. Keman WN et al. Phenylpropanolamine and the risk of hemorrhagic stroke. N Engl J Med. 2000;343:1826–32.All people residing in New Zealand have access to the Cochrane Library via the Ministry websitewww.moh.govt.nz/cochranelibraryCorrespondence to:Bruce ArrollProfessor of GeneralPractice and PrimaryHealth Care, TheUniversity of Auckland,PB 92019, Auckland,New Zealandb.arroll@auckland.ac.nzVOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 253

continuing professional developmentcharms & harmsNoniMorinda citrifolia L.Also known as great morinda, Indian mulberry, nunaakai, dogdumpling, mengkudu, beach mulberry, vomit fruit and cheese fruitFelicity Goodyear-Smith MBChB, MGP,FRNZCGP; Professor,Department of GeneralPractice and PrimaryHealth Care, School ofPopulation Health, TheUniversity of Auckland,Auckland, New ZealandPreparations: The fruit is sometimes eaten asa food, especially in the Pacific Islands, althoughit has a strong smell and bitter taste. The seedsare edible if roasted. The root, leaves, bark, flowers,fruit and seed oil are all used medicinally.Roots, stem, bark, leaves and fruit may be appliedexternally as a poultice or consumed as an infusionor juice. Flowers and leaves may be taken astablets or teas and the fruit is often juiced.Active constituents: Approximately 200compounds have been isolated from noni, includinga number of anthraquinones and anthraquinoneglycosides, fatty acids and their derivatives,iridoids and iridoid glycosides, lignans, neolignans,flavonol glycosides, phenylpropanoids,saccharides, triterpenoids and fatty acids. 1 Thefruit provides a good source of vitamin C andpotassium. In vitro research is being conductedinto some of the anthraquinones and lignans butno ingredient has yet to be proven as a usefulbiologically active compound. Wide-rangingbenefits have been attributed to an alkaloid calledxeronine, which is reported to exist in noni as itsprecursor, proxeronine. However the presence ofxeronine and proxeronine has not been confirmedin any peer-reviewed scientific publication norhave the structures of xeronine and proxeroninebeen provided. 1Main uses: Noni has been used as a medicinethroughout South East Asia, Polynesia and theSummary MessageEvidence for the efficacy of noni for the widerange of medicinal purposes for which it may beused is not available. Health professionals shouldbe aware of the possibility of (undisclosed) useof noni and its use should be avoided, or at leastused only with caution, in patients on warfarin.Suspected adverse drug reactions should bereported to CARM. As with all herbal medicines,different noni products vary in their pharmaceuticalquality, and the implications of this forefficacy and safety should be considered.Caribbean for centuries. Externally it is appliedto cuts, sores and stings from poisonous fish.The green fruit, leaves and root traditionallyhave been used to treat menstrual cramps, bowelirregularities and urinary tract infections. Morerecently noni preparations have been promoted astreatment for cancer. Noni is purported to havea diverse range of effects including analgesic,anti-inflammatory, antimicrobial, anti-tubercular,antihypertensive and anticancer. 1 Its promotion asa panacea has led to a dramatic rise in its use inNorth America, Europe and Australasia and it isnow widely available in pharmacies, health foodstores, pharmacies and via the Internet.Herbal medicines are a popular health care choice, but few have been tested to contemporary standards.CHARMS & HARMS summarises the evidence for the potential benefits and possible harms of wellknownherbal medicines.254 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

continuing professional developmentpearlsEvidence for efficacy: A number of invitro and animal studies involving noni extractshave been conducted, but there has beenvery little research conducted under clinicaltrial conditions, and hence no Cochranesystematic review of trials of noni has beenundertaken.Adverse effects: Daily consumption ofnoni juice has led to hyperkalaemia in somepatients on potassium-restricted diets. Therehave also been reported cases of clinicallysignificant elevation in liver enzymes, includingtransaminases and lactate dehydrogenase,from daily noni juice, with return to normalonce the noni was discontinued. However,recent in vitro tests suggest that a normaldose of noni fruit juice is unlikely to induceadverse liver effects. 2Drug interactions: There is some evidencethat noni may interact with warfarin 3and that it may have an angiotensin I convertingenzyme (ACE) inhibiting effect. 1Key references1. Pawlus AD, Kinghorn DA. Review of the ethnobotany,chemistry, biological activity and safety of the botanicaldietary supplement Morinda citrifolia (noni). J PharmPharmacol. 2007 Dec;59(12):1587–609.2. West BJ, Su CX, Jensen CJ. Hepatotoxicity and subchronictoxicity tests of Morinda citrifolia (noni) fruit. J Toxicol Sci.2009 Oct;34(5):581–5.3. Carr ME, Klotz J, Bergeron M. Coumadin resistanceand the vitamin supplement ‘Noni’. Am J Hematol. 2004Sep;77(1):103.String of PEARLSPractical Evidence About Real Life SituationsPEARLS are succinct summaries of Cochrane Systematic Reviewsfor primary care practitioners—developed by Prof. Brian McAvoyfor the Cochrane Primary Care Field (www.cochraneprimarycare.org), New Zealand Branch of the Australasian Cochrane Centre at theDepartment of General Practice and Primary Health Care, Universityof Auckland (www.auckland.ac.nz/uoa), funded by the New ZealandGuidelines Group (www.nzgg.org.nz) and published in NZ Doctor(www.nzdoctor.co.nz.).Watch and wait is usually as effective as antibiotics inchildren over six months of age with acute otitis mediaAntihistamines and/or decongestants are notrecommended for children with otitis media witheffusionGrommets are effective for recurrent acute otitis mediaAutoinflation for otitis media with effusion is helpful inthe short-termTopical treatments are better than systemic antibioticsfor chronically discharging earsIntranasal corticosteroids may improve nasalobstruction symptoms in children with adenoidalhypertrophyTonsillectomy or adeno-tonsillectomy are effective forchronic and recurrent acute tonsillitisDisclaimer: PEARLS are for educational use only and are not meantto guide clinical activity, nor are they a clinical guideline.VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 255

ETHICSWork storiesVanya Kovach PhDIn 2006, the New Zealand Policelaunched its now long-runningrecruitment campaign based on theslogan ‘Better Work Stories’, and manymight have wondered what duties ofconfidentiality should constrain officerswhen talking about what happens tothem at work.* But we must acknowledgethat talking to our partners and friendsabout significant events has undeniablevalue, because storytelling is a centralpart of human life, connecting us toothers and revealing us to ourselves.However, when these events occur inprofessional life, this very natural aspectof life is curtailed by obligations ofconfidentiality. The aim in what followsis to raise some questions about workstories and to explore one argument forallowing them, under certain circumstances,and with certain limitations.The telling of work stories in the professionsis not much studied or the ethicsof it often addressed. † However, one1982 study in the USA reported thatwhile 17% of patients had the expectationthat their case would be discussedwith the medical staff members’ spouseor partner, 70% of medical staff admittedthat this was a common practice.Only 9% of patients thought it likelythat medical staff would use their caseas an interesting story to tell to nonmedicalfriends at a party, and yet 45%of medical staff reported that they didthis. Interestingly, only 2% of patientsexpected that they might be identifiedby name to non-medical personnel, andonly 8% of medical staff acknowledgedthat they had done this. 1 No studieshave been done in New Zealand, so asyet we have no information about theexpectations of patients here.What telling of stories is allowable bylaw? The Health Information PrivacyCode (2008) Rule 10, 1(e) allows that patientinformation may be used ‘in a formin which the individual concerned is notidentified’, and this is clarified as use‘within the agency’ or by students writingcase histories of patients who haveconsented to be seen by that student.Note, though, that these restrictions onthe use of anonymised information arein the non-binding commentary sectionof the Code. It seems the law does notclearly determine, at least in this Code,whether anonymised information canbe used for other purposes, though theimplication is that any use should beconnected with health care. Just whatthis might encompass is a matter forethical debate.The professional obligation to keepinformation about patients confidentialis grounded on a number of differentvalues or principles: respect for patients’autonomous control over themselves;promises made by professionals totheir clients; benefits that can only begained when a client is assured thatthe information they provide is keptsecret, and the relationship of trustbetween clients and professionals. ‡ Thegeneral requirements of the obligationof confidentiality in health care, as setout in numerous codes of ethics, arethat information given by patients to* At the time, the police had no formal code of ethics, but the vulnerability of the people they come in contact with should suffice to ground an obligation of confidentiality.Many of the work stories recorded on the police website are general and innocuous, but one worrying one is posted, entitled ‘Pregnant’.† A number of empirical studies have been published about patient expectations of confidentiality, but the ethical issue of works stories in particular has not been muchexamined. One exception is: James S. Gossip, stories and friendship: confidentiality in midwifery practice. Nursing Ethics. 1995;2(4):295–302. The issue is mentioned,but not discussed, in the canonical text Beauchamp TL and Childress JF. Principles of biomedical ethics. 6th edition. New York: Oxford University Press; 2008, p 305.‡ An excellent (and classic) paper on the justification and limits of confidentiality is: Bok S. The limits of confidentiality. Hastings Center Report. 1983;13(1):24–31.Correspondence to:Vanya KovachDepartment of Philosophy, Facultyof Arts, The University of Auckland,PB 92019 Auckland, New Zealandv.kovach@auckland.ac.nzThe ethics column explores issues around practising ethically in primary health careand aims to encourage thoughtfulness about ethical dilemmas that we may face.THIS ISSUE: Vanya Kovach, ethicist with the Philosophy Department at The Universityof Auckland, explores the morality and legality of health professionals’ sharedanonymous stories about their patients.256 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ethicshealth professionals is to be used onlyfor the purposes for which it was given,and that this information, and any factsabout the patient’s condition, be sharedonly with those who have an institutionally-recognisedrole in the care ofthe patient, unless the patient gives permissionfor others to have access. Legitimateexceptions to these requirementsare made when serious and imminentharm to the patient or third partiesthreatens or when the court orders,and when the use of statistics based onpatient information is allowed for auditand service provision planning. All ofthis is familiar, and accepted. Concernshave been raised about the debasementof confidentiality, given the number ofstaff who might have electronic accessto a patient’s information, 2 and no-onebelieves that bedside curtains in wardsare soundproof, but the expectation ofpatients persists that only a few willknow the intimate details of theirmedical conditions, and their familialand social circumstances.However, we know that work storiesabound, and that there are a variety ofmotives for telling them. Stories aretold to provide entertainment, for socialself-promotion, to establish commonality,to unwind and unload at the end ofthe day, to warn of health dangers orto stimulate reflection and gain counseland comfort. Other factors may havesignificance in evaluating the recountingof a story which involves informationabout patients, and these includewho is speaking, who is listening, thelevel of detail which is disclosed, thecontext in which the information wasgathered and recounted, and the expectationsof the people whose informationis being disclosed. Some of these factorswill be explored in the followingthree scenarios.1A doctor is regaling her friends withstories at a dinner party, and describesan unnamed patient in a way thatmakes them seem ridiculous.There are a number of reasons why thismight be unacceptable. Even if it is arguedthat this is not a breach of confidentiality,because the information is anonymised,this behaviour is in conflict with otherprofessional obligations: to treat one’spatients with dignity, and to respectthem. Although the doctor may not beable to show disrespect to a particularperson if their name is not mentioned,she can herself fail to respect them—andalso encourage disrespect to others whoshare characteristics with the person inthe story. There is no direct harm to thepatient, but there may be harm to thedoctor’s character and to the reputationof her profession in the minds of thehearers. Perhaps it could be said that notrust between patient and doctor is lost, asthe patient is unaware that they have beenused in this way. But the obligation is to betrustworthy, not trusted. Trustworthinessis a disposition which can be understood asconsisting of a collection of conditionals:…If I was asked to lie…If someone offeredme money… (and, most relevantly here)if my patients did hear me talking aboutthem… But what of telling an unnamedpatient’s story without disrespect?2A nurse is concerned about theunhealthy habits and risky behaviourof her young relatives. Motivated by herlove for them, and, she thinks, a properprofessional desire to educate and inform,she tells them some stories about unnamedpast patients who have suffered seriouslyfrom the effects of those behaviours.In this case there is no disrespect topatients and no attack on their dignity.This is not a case of using patient informationfor the purposes for which it wasgiven, and yet the motive for telling thestories is consistent with the wider aimsof health care. We accept the use of anonymisedpatient information for medicaleducation, so is its use for education ofthe wider public any different? First,patients usually do have an expectationthat their cases will be used for teaching;§ second, such teaching takes place ina formal context where only medical professionalsattend, and third, the hearerstake themselves to be under obligationsof confidentiality and respect. (Note thatif medical students discuss cases in bars,the latter two conditions are not met.)One further difference is that the useof detailed cases is necessary for medicaleducation, but not for passing on healthadvice, though there seems little doubtthat stories do lodge in the minds of hearersmore firmly than do generalisationsand statistics. If we do think that the necessityfor telling the story is importantin its justification, then this might showthat even respectful recounting of cases,as interesting stories, is unacceptable.A pharmacist has encountered a3 troubling situation, which raises anumber of ethical and clinical issues andhe is unsure about how to respond. He hasdiscussed it with a colleague, but reachedno conclusion. He spends the eveningtalking about the case with his partner, ||(mentioning no names or identifyingcharacteristics), framing and reframingthe facts, constructing and evaluating differentsolutions, struggling to find a goodway to proceed. He is tense and unhappy,and feels responsible for things outsideof his control. His partner listens, asksquestions, suggests alternative points ofview, and tries to get him to see that he isdoing all that he can. Is this apparentlycommon occurrence acceptable in the lightof obligations of confidentiality?§ If patient expectations are relevant to the justification of what we do, then research into what they are is essential, as is public acknowledgement of what medical professionalsactually do with stories.|| What follows might apply to close friends, or relatives, as well as partners.VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 257

ETHICSIn this case, again, no lack of respect orattack on dignity is involved. But, again,the information has been disclosed tosomeone who has no formal role in thecare of the patient, and who is thereforenot under any formal obligations tokeep the information confidential. Is itsafe to disclose, in these circumstances?This might depend on a number of factors.Although no names are mentioned,will the partner know who the patientis? In small communities, it mightbe hard to avoid this. Is the partnersomeone who takes seriously the trustreposed in him or her, when thesestories are shared? Or are they likelyto pass the stories on, for entertainment,self-promotion or even spite? Twopositions are possible here; first, that allsuch discussions are to be prohibited,because safety from identification orfrom misuse cannot be fully assured orenforced, or second, that such discussionsare acceptable to the extent thatit can be reasonably predicted that theinformation is safe, given the degree ofdetail disclosed, the social context ofthe people involved and the character ofthe partner.the relevant knowledge and experienceneeded for assisting decision-making,though they may be able to contributeastute questions and useful perspectives.Decision-making might be aided bydiscussion with a partner, but it cannotbe claimed that they have a necessaryrole in the process. The other purposefor telling the story is more personal.The pharmacist may need to vent emotions,explore psychological issues, orseek comfort. He may need to talk overhis responses to challenges, sad outcomesand mistakes in order integratethem into his life and the way he thinksabout himself, both personally andprofessionally. This second purpose isconsistent with the goals of health care,in that it provides significant support fortrue of a partner, though in most caseswe can assume that the partner hasat least that capacity for close attentionand sympathetic concern that atherapist offers. One important limitto what is told is suggested by identifyingthis purpose of telling workstories—what is talked about must be‘about me’, and that the detail disclosedshould be only enough to provide thenecessary context for understandingthe personal difficulties and distressexperienced.Perhaps what this shows is that allhealth care workers should have regularprofessional counselling, and thismay be so. However, there is a deeperpurpose to sharing work stories withWhereas social workers and counsellors have formalsupervisory relationships within which they can reflecton how they have been affected personally by incidentsin their practice, most health professionals do notIn the situation described, there are twopurposes for telling the story. One isto seek assistance in making a decisionabout how to act. Should this take placeoutside the health care team? Reasonsfor maintaining that it shouldn’t includenot just confidentiality but efficacy, asnon-medical partners are likely to lackAcknowledgementsMy thanks to Allen Fraser,Christine Johannis, RobynBennitt, Peter Hoar, StephenKovacevich and students inthe Diploma in ProfessionalEthics at the University ofAuckland for helping clarifymy thoughts on this issue.a professional to perform his or her role.But is this sufficient to satisfy the intentof the Health Information PrivacyCode, and the ethical basis of promisesof confidentiality?How necessary is it for the pharmacistto seek this support from his partner?Whereas social workers and counsellorshave formal supervisory relationshipswithin which they can reflect on howthey have been affected personally byincidents in their practice, most healthprofessionals do not. Colleagues mayperform this supervisory and counsellingrole, though they might havelimited time, and lack the skills or theintimacy of relationship required forsuch ‘counselling’ to be effective andsafe. Of course, this could be equallypartners, and that is to meet the needto be known intimately, and to shareour lives fully with our life companions.Professional life requires that weabjure many quite natural things—including always applying our ownmorality to the work that we do. It isnot too much to ask that in joining aprofession we give up the freedom touse our work stories to gossip, preenand entertain, but is it too much toask that we give up sharing our wholeselves with our partners?References1. Weiss B. Confidentiality expectations of patients,physicians and medical students. JAMA. 1982;247(19):2695–97.2. Siegler M. Confidentiality in medicine—a decrepit concept. New Eng J Med.1982;307(24):1518–21.258 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

ook reviewsHerbs and Natural Supplements: An Evidence-based Guide3rd editionEdited by L. Braun and M. CohenReviewed by Felicity Goodyear-SmithThe University of AucklandThis reference book is written for anAustralian and New Zealand audienceof health practitioners fromvarious disciplines to provide a comprehensiveguide to the evidence base ofcommonly-used herbs and supplements.The first section covers discussion oncomplementary medicine in general,and herbal medicine, clinical nutrition,aromatherapy and food as medicine inparticular. This is followed by severalchapters on their use in clinical practice.However, the bulk of the book is analphabetical compendium of evidencebasedreviews of 130 popular herbs andnatural supplements available over thecounter in Australia and New Zealand.The final section is appendices of summarisedtables.The book is well set out and indexed. Themonographs follow a standard formatwith headings such as chemical components,main actions, clinical use, adversereactions, interactions, contraindicationsand precautions, pregnancy use and answersto frequently asked questions. Theyoften include a box of ‘practice points’.The reviews are generally well referenced.However, on careful examination ofsome of the reviews, there is a tendencyto overemphasise the effectiveness ofthe remedies and downplay the potentialharms. For example, the monograph onsaw palmetto claims there is substantialscientific evidence that it is an effectivetreatment for benign prostatic hypertrophy,whereas a 2009 Cochrane reviewfound it no more effective than placebo.Similarly, the book concludes that clinicaltrials support the use of black cohoshfor menopausal symptoms, whereas theevidence for effectiveness is inconclusive,and there is a small but serious riskof liver reactions to this compound.While this book is a systematic andcomprehensive approach to documentingthe evidence for herbs and natural supplements,the interpretation tends to beslanted in favour of their use. I wouldadvise caution in following all theirrecommendations.Publisher: Churchill LivingstoneDate of publication: 2010No. of pages: 1221Evidence-based Practice across the Health ProfessionsBy Tammy Hoffmann, Sally Bennett and Chris Del MarReviewed by Gill Robb, Epidemiology andBiostatistics, School of Population Health,The University of AucklandAs the authors suggest in the preface:why another book about evidence-basedpractice? The valueof this book about evidence-based practiceis that it does indeed target a wide rangeof health professionals. For each studydesign (including qualitative research),worked examples are provided that relateto each of the major professional groups,including occupational therapy, physiotherapy,speech pathology, podiatry,medicine, nursing, nutrition, radiationand complementary and alternative therapies.Using a wide range of examples givesan opportunity to illustrate many of thekey concepts and challenges in appraisingevidence. This provides a rich source ofinformation for all health professionals.The book is clearly written and usessimple, non-technical language, makingit easy to read. The content is well structuredand organised, making good use ofheadings, tables and figures to navigatethe reader through the text and understandthe material. There are 16 chapters,which follow logically through the fivesteps of evidence-based practice (EBP).Each chapter starts with an outline ofthe key learning objectives and concludeswith summary points and references.The first chapter introduces the conceptof evidence-based practice, its rationale,origins and scope. The second chapterdescribes how to translate informationneeds into answerable questions, andwhich study design is most suited toVOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 259

BOOK REVIEWSanswer each type of question. Readersare introduced to some of the importantconcepts for EBP, such as chance, biasand confounding, statistical and clinicalsignificance. Chapter three is an excellentresource for people who find searchingfor the evidence a challenging exercise.After describing the basics of searching,readers are guided through the searchprocess, starting with the top layer of theEvidence Pyramid described by Haynes(the higher up the pyramid, the morereliable the information) and workingdown. For each ‘layer’, a comprehensivelist of sources of evidence is supplied. Forlocating individual studies (bottom layer)the common databases are explained andmore detailed instruction is given onhow to undertake an effective search,including how to used the ‘Clinical Queries’function in PubMed and Medline.Worked examples are provided for searchesfocussed around clinical questions.Chapters 4–11 deal with the core materialof the book. Two chapters are devotedto each type of evidence (intervention,diagnosis, prognosis and client’s experiencesand concerns). Using a clinicalscenario for each, the initial chapter worksthrough the five steps of EBP, explainingkey concepts. Of particular value are theexplanations of the meaning of the results,which often present a barrier whenappraising evidence. The second chapterprovides worked examples for each ofthe major professional groups.Systematic reviews and meta-analyses aredealt with in Chapter 12, and guidelinesin Chapter 13. Chapter 14 focuses on howto communicate evidence to patients andincludes an eloquent discussion on thecomplex issue of shared decision-making.Several simple ways of communicatingstatistical information to patients arepresented, and a tool ‘Discern’ is providedto help practitioners evaluate any writteninformation patients may have locatedon the Internet. The chapter on clinicalreasoning provides an interesting insightinto the complexities of professionalpractice—a topic not often covered inmany EBP texts. The inherent difficultiesof integrating the many sources of ‘evidence’,while at the same time fulfillingrole expectations and delivering a service,are acknowledged. The final chapter coversthe last and probably the most challengingstep in the EBP process—closingthe evidence–practice gap. A number ofmethods are described, along with thebarriers and enablers. The importance ofusing a theoretical framework to addressfactors that influence getting evidenceinto practice is emphasised.In summary, this book is an excellentresource for all health practitioners. Theway it has been structured and writtenwill encourage readers to ‘dip into’ thebook frequently as they embark on theirjourney of lifelong learning.Publisher: Churchill Livingstone, AustraliaDate of publication: 2010No. of pages: 349A History of the ‘Unfortunate Experiment’at National Women’s Hospital—by Linda Bryderand The Cartwright Papers: Essays on the CervicalCancer Inquiry of 1987–88—edited by Joanna ManningReviewed by Jane Gunn, Professor, Chairof Primary Care Research and Head of theDepartment of General Practice, Universityof Melbourne, AustraliaMore than 20 years have passedsince Sandra Coney and PhillidaBunkle published an articlein Auckland’s Metro magazine titled‘An unfortunate experiment at NationalWomen’s’. The article claimed that DrHerbert Green, an associate professorand gynaecologist, had withheld treatmentfrom women at risk of developingcervical cancer. The response to thearticle was alarming and unprecedented,resulting in the now famous ‘CartwrightInquiry into Cervical Cancer’ whichhad important and lasting ramificationson health care provision, especially forwomen—ramifications that spread farbeyond the shores of New Zealand.Now, two decades later, the controversyhas been reignited by the publication oftwo books presenting opposing views. InA History of the ‘Unfortunate Experiment’at National Women’s Hospital, themedical historian Linda Bryder, fromThe University of Auckland, arguesthat Dr Herbert Green was in manyways ahead of his time—‘a thinkinggynaecologist’—a reflexive practitionerwho questioned the level of interventionand radical treatments delivered towomen with precancerous and carcinomain situ lesions. She makes a convincingargument that Green was a scapegoatwho was outwitted by a passionate andactive feminist movement. If one wasto read only Bryder’s book one wouldbe convinced that Green was dealt a260 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

BOOK REVIEWSWith regards to the Back to Back in the last issue of theJPHC on population-based screening for ADHD, 1 Iwish to support Ross Lawrenson’s objections to Tony Hanne’sproposal for population-based screening for attention deficithyperactivity disorder (ADHD) from a non-medical perspective.The problem with viewing behaviours of concern from amedical viewpoint is that the process of diagnosis, assignmentof cause and the mode of intervention are all regarded primarilyfrom a physiological or organismic position. The contexsevereinjustice. Yet, here enters JoannaManning, an associate professor of law,also from The University of Auckland,who responded to Bryder’s book with anedited series on The Cartwright Papers.Manning and colleagues appear to haveproduced their book with the mainpurpose of discrediting Bryder’s account.It is not made clear whether Bryder andManning (both from The University ofAuckland) know each other, or have hadpast disputes. I would have found thisdeclaration a useful piece of information.For anyone interested in how one storycan be portrayed in two completely opposingways, then I recommend readingthese two books as a pair. Every medicaland nursing student would benefit fromreading and discussing these bookstogether—there are just so many lessonsto be learned. I would start with Bryder.Here you will get to know Dr HerbertGreen and see his actions in the bestpossible light. Moving on to the essaysedited by Manning, you will find yourselfquestioning Bryder’s view. In theend you will have to decide for yourself.Personally, I could never condone theway in which Dr Green changed previousdiagnostic categories—this is justbad and unethical research. Yet, on theother hand, I agree with Bryder that inmany ways he was ahead of his time andthe way he thought about cervical dysplasiawas potentially groundbreaking.The outcome could have been so differentif only he could have had betterresearch training and maintained a moreobjective view. His lack of communicationwith colleagues and patients is, inmy mind, his great undoing. Bryder’sdefense of Green’s behaviour as beingtypical of the time, makes for worthyreflection. Yet in both books, Green,the somewhat intimidating gynaecologist,is a familiar character to anyonetrained prior to the late eighties. Thereis certainly a feeling that this storycould have been found in any number ofinstitutions. The medical profession andwider health care system has changeddramatically since the days when DrGreen was a presiding power at the NationalWomen’s. Whether you rememberthe Cartwright Inquiry, whether youwere taught or treated by Dr HerbertGreen (or someone remarkably similar),these two books make excellent reading.Most of all, they make you think. Theinclusion of a chapter by Clare Matheson(the patient at the centre of initial controversy)in the Manning book makes forpowerful reading. The view that such adebacle could happen again somewherein our health care system is put forwardas a chilling warning—another reason toget these books and read them!A History of the ‘Unfortunate Experiment’at National Women’s HospitalPublisher: Auckland University PressDate of publication: 2009No. of pages: 264The Cartwright Papers: Essays on theCervical Cancer Inquiry of 1987–88Publisher: Bridget Williams BooksDate of publication: 2010No. of pages: 223LETTERS TO THE EDITORWe should not screen for ADHDtual and ecological contributors which may generate, maintainand elaborate such behaviours thus remain ignored or, at best,poorly analysed and consequently go unresolved. Further,screening instruments are notoriously coarse-grained, oftenof poor validity, and are likely to provide, at best, numbers offalse positives and negatives. Asking parents and teachers tomake appropriate judgments in a questionnaire upon whicha diagnosis is then based exposes the process to bias becauseboth may simply be seeking a solution which does not involveeither party to examine or modify their behaviour managementmethods, even though these may be major contributorsto the behaviours of which they complain.Letters may respond to published papers, briefly report original research or case reports, or raise matters of interest relevant toprimary health care. The best letters are succinct and stimulating. Letters of no more than 400 words may be emailed to:editor@rnzcgp.org.nz. All letters are subject to editing and may be shortened.VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 261

LETTERS TO THE EDITORA one-off screen and a consulting room assessment cannotprovide an adequate basis for diagnosis or intervention. Working,as I do, with families and in schools with children whoare deemed problematic by parents and teachers emphasises therole of adults in mismanaging children’s behaviour. Teachersfrequently identify children as ‘hyperactive’ when theycannot manage them or find them disruptive. Closer analysiscan reveal that the teacher provides high rates of attentionfor disruption and little encouragement for desired behaviourwhen it occurs. Sometimes the child lacks the entry skills intothe academic programme or comes to school troubled and/orhungry from a dysfunctional family and so engages in alternativeactivities which attract adult attention. Failure to identifyand deal with these ecological factors or simply masking themwith methylphenidate begins to verge on the irresponsible inmy opinion. I have systematically observed the classroom behaviourof children diagnosed as ADHD by paediatricians andpsychiatrists. Some have remained non-medicated by parentalrequest and my data have shown them to be functioning aswell as, if not better than, peers in terms of on-task behaviour,compliance and disruption. Such data raise questions of thevalidity of diagnosis by those currently assigned the role and,consequently, questions about the utility of population-basedscreening and treatment of ADHD by GPs.Barry S Parsonson MA(Hons), PGDipClinPsychPhD FNZPsS MICP, Registered PsychologistReferences1. Hanne T, Lawrenson R. Back to Back: New Zealand general practice shouldadopt population-based screening for attention deficit hyperactivity disorder. JPrimary Health Care. 2009;2(2):155–8.Too many articles by nursesThank you for the last edition of Journal of Primary HealthCare (better to be named ‘Journal of RNZCGP’). I enjoyreading the articles in every issue. The last edition was hugelychanged in format. There were so many articles by nurses Iwondered whether I was reading a nursing journal?Why don’t you encourage and stimulate young doctors todo research and write some learning and educational articleswhich will be useful for GPs? If you advertise in the NZ Doctormagazine and primary health journals inviting the doctorsand registrars to write, definitely all will get the message.Also you could give them awards or certificates for doing suchresearch activities and writings.Hope you welcome our comments in a positive way.Dr Mrs M RamanathanA well designed journal for the primary care sectorAs Editor of the Journal of Primary Health Care, we applaudyou for re-launching the traditional GP journal(New Zealand Family Physician) as a primary care, rather thansolely GP-orientated publication. Likewise, we believe that bysupporting the Journal of Primary Health Care, the Royal NewZealand College of General Practitioners (RNZCGP) demonstratesa commitment to the wider view of the primary carelandscape. There is an expectation by health policy-makersthat the primary care sector delivers high quality health carethrough the development of effective multidisciplinary teams.Patients also assume this happens but, sadly, it is not alwaysthe case. Your journal supports a step in the right direction.In terms of ‘usability’ as a resource, this new look journalhas a lot to offer the primary care sector. There is clinical materialwhich will assist general practitioners, practice nurses,community pharmacists and PHO-based clinical advisorypharmacists to stay current. The Back to Back section engagesspecialists into the primary care arena and allows informeddebate to be facilitated in peer group sessions. For academicsand applied health services researchers, the Journal of PrimaryHealth Care provides a platform for publishing robust researchwhich is locally relevant and interesting. There is a Gems sectionwhich refers us back to the good work that New Zealandprimary care researchers are publishing abroad. Finally, for themore political amongst us there is a commentary/essay/viewpointssection.In addition to the vigorous, multidisciplinary nature of thejournal, we really like the multiple categories under which wecan publish. There is no need for themed issues as the regularcategories within the journal cater for a myriad of topics. Asresearchers we don’t need to wait any longer than we should tohave our papers reviewed and accepted, but can feel reassuredthat speed of publication is not at the expense of thoughtfuland robust review from experts in the field, as well as practicebasedacademics.Based on our experience of reading, reviewing and publishingin local and international journals over the past few yearswe think that the Journal of Primary Health Care fulfils animportant role in bringing together primary care researchersfrom a range of disciplines to publish and comment on theissues that are relevant to primary care practitioners and policymakers alike. We would like to thank you and the RNZCGPfor the energy and insight in bringing us the Journal of PrimaryHealth Care.Shane Scahill (Doctoral candidate, School of Pharmacy andClinical Advisory Pharmacist), Dr Jeff Harrison (School ofPharmacy), Dr Peter Carswell (School of Population Health—Division Health Systems), Prof. John Shaw (School of Pharmacy)262 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE

RESEARCH GEMSGems of New ZealandPrimary Health Care ResearchWhich anticonvulsant drug is effectivefor which types of neuropathic pain?Anticonvulsant drugs are used fortreating neuropathic pain. This paperreviewed all the evidence for the efficacyof different anticonvulsants for specificconditions. It includes a table whichsummarises which drugs have been assessedfor which conditions and whetherthe evidence supports their use or not.Gaps in the evidence are striking.Goodyear-Smith F, Halliwell J. Anticonvulsantsfor neuropathic pain: gaps in the evidence.Clin J Pain. 2009;25(6):528–536. DOI:10.1097/AJP.0b013e318197d4cc.Corresponding author: F. Goodyear-Smith.Email: f.goodyear-smith@auckland.ac.nzUse of antidepressants fordepression in primary carePrevious reviews have looked at the useof antidepressant treatment in secondarycare settings, but there has been doubtabout the effectiveness of antidepressantsin primary care. This Cochranereview included 14 studies conducted inadults (not the elderly) in primary caresettings, in which tricyclic antidepressants(TCAs) or selective serotonin reupdateinhibitors (SSRIs) were comparedagainst placebo controls in the treatmentof depression. The results showed thatboth types of antidepressants were effectivefor depression. There appearedto be more adverse effects with TCAsthan with SSRIs, although the rates ofwithdrawal from the study medicationdue to adverse effects were very similarbetween the two classes of drugs.Arroll B, Elley CR, Fishman T, Goodyear-Smith FA, Kenealy T, Blashki G, Kerse N,MacGillivray S. Antidepressants versusplacebo for depression in primary care(review), The Cochrane Library, pp 61,Issue 3, 2009. ID 692702053115360884.Corresponding author: B. Arroll.Email: b.arroll@auckland.ac.nzStopping smoking early in pregnancymay prevent pre-term birthsA cohort study of 2500 women foundthat current smokers had higher rates ofspontaneous pre-term birth and smallfor gestational age infants than stoppedsmokers. Women who stopped smokingbefore 15 weeks’ gestation had the samerates of spontaneous preterm birth andsmall-for-dates babies as non-smokers,indicating that these severe adverseeffects of smoking may be reversible ifsmoking is stopped early in pregnancy.McCowan L, Dekker G, Chan E, StewartA,Chappell L, Misty Hunter M, Moss-Morris R, North R On behalf of the SCOPEconsortium. Spontaneous preterm birthand small for gestational age infantsin women who stop smoking early inpregnancy: prospective cohort study. BMJ.2009;338:b1081. doi:10.1136/bmj.b1081.Corresponding author: L. McCowan.Email: l.mccowan@auckland.ac.nzAcclimatisation by aeroplaneIt is generally accepted that the performanceof athletes participating in aerobicendurance events is adversely affectedby altitude, whereas athletes involvedin speed and anaerobic events are eitherunaffected or perform even better ataltitude than at sea level. Athletes travellingoverseas in long-haul flights areeffectively spending up to 13 hours atelevated altitude, because aircraft cabinsare pressurised to maximum effectivealtitudes of 2440 metres. This studyshowed that oxygen saturation declinedsignificantly in athletes during longhaulcommercial flights, in response toreduced cabin pressure. Athletes oftenneed to compete at altitudes similar tothe effective altitudes experienced inairliner cabins. The exact timing andimpact of these changes on performanceis still unclear but has implicationsfor altitude acclimatisation planning byathletes.Geertsema C, Williams AB, Dzendrowskyj P,Hanna C. Effect of commercial airline travelon oxygen saturation in athletes. Br J SportsMed. 2008;42(11):577–81.Corresponding author: C. Geertsema.Email: celeste.g@ihug.co.nzGEMS are short précis of original papers published by NZ researchers. For a copy of a full paper pleaseemail the corresponding author. Researchers, to have your work included please send a 100word summary of your paper and the full reference details to: editor@rnzcgp.org.nzVOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE 263

about the journal of primary health careThe Journal of Primary Health Care(JPHC) is a peer-reviewed journalwhich has replaced the New ZealandFamily Physician. It is a interdisciplinarypublication aimed at moving research intoprimary health care practice and practice intoresearch. This includes the fields of familypractice, primary health care nursing andcommunity pharmacy as well as areas suchas health care delivery, health promotion,epidemiology, public health and medicalsociology of interest to a primary health careprovider audience.The journal publishes peer-reviewed quantitativeand qualitative original research,systematic reviews, papers on improving performanceand short reports that are relevantto its primary health care practitioners. Forthe aim, scope, instructions to authors andtemplates for publications see www.rnzcgp.org.nz/journal-of-primary-health-care/.JPHC acts as a knowledge refinery to providebusy practitioners with up-to-date knowledgeabout the latest evidence and best practice.Continuing professional developmentincludes pithy summaries of the latest evidencesuch as Cochrane Corner, a String ofPEARLS (Practical Evidence About Real LifeSituations) and Charms & Harms (evidence ofeffectiveness and safety of complementaryand alternative medicines). JPHC includesPoumanu (treasures of Maori wisdom) andGems of NZ Primary Health Care Researchpublished at home and internationally.Evidence can help inform best practice. Howeversometimes there is no evidence availableor applicable for a specific patient with hisor her own set of conditions, capabilities,beliefs, expectations and social circumstances.Evidence needs to be placed in context.General practice is an art as well as a science.Quality of care lies also with the nature of theclinical relationship, with communication andwith truly informed decision-making. JPHCpublishes viewpoints, commentaries and reflectionsthat explore areas of uncertainty onaspects of care for which there is no one rightanswer. Debate is stimulated by the Back toBack section where two professionals presenttheir opposing views on a topic. There is aregular Ethics column. Letters to the Editorare welcomed.While published in New Zealand by the RoyalNew Zealand College of General Practitioners,much of this research has genericimplications. Our Editorial Board comprisesrenowned and active primary care clinicians,clinical and scientific academics and healthpolicy experts with both New Zealand andinternational representation.EditorDr Felicity Goodyear-Smith: Professor andGoodfellow Postgraduate Chair, Departmentof General Practice and Primary HealthCare, University of Auckland, Auckland, NewZealand; editor@rnzcgp.org.nzDeputy EditorsDr Derelie Mangin: Associate Professor,Department of Public Health and GeneralPractice, University of Otago, Christchurch, NZDr Tony Dowell: Professor and Head of theDepartment of Primary Health Care and GeneralPractice, Wellington School of Medicine,University of Otago, NZEditorial BoardDr Bruce Arroll: Professor and Head of theDepartment of General Practice & PrimaryHealth Care, University of Auckland, NZDr Jo Barnes: Associate Professor ofPharmacy, School of Pharmacy, University ofAuckland, NZDr Jenny Carryer: Professor of Nursing,School of Health and Social Services, MasseyUniversity, Palmerston North, NZDr Peter Crampton: Dean and Head ofCampus, Wellington School of Medicine andHealth Sciences, University of Otago, NZMs Eileen McKinlay: Senior Lecturer inPrimary Health Care, Department of PrimaryHealth Care and General Practice, Universityof Otago Wellington, NZDr Barry Parsonson: Psychologist for NZ Ministryof Education and International Consultant,UNICEF (Georgia) Training Project for InstitutionalStaff working with disabled childrenDr Shane Reti: Assistant Professor, InternationalProgram Director Clinical Informaticsand CEO of Clinical Informatics IndustrialResearch, Harvard Medical School, USADr Kurt Stange: Professor of FamilyMedicine, Case Western Reserve University,Cleveland, OH, USA and Editor, Annals ofFamily MedicineDr Colin Tukuitonga: Associate Professorand CEO of the Ministry of Pacific Island Affairs,Wellington, NZSubmissionsPlease send all submissions to:The Editor: editor@rnzcgp.org.nz, or to:The Editorial Assistant—Cherylyn Borlase: editorialassistant@rnzcgp.org.nzaccompanied by a covering letter as outlined at:http://www.rnzcgp.org.nz/journal-of-primary-health-care/#coverSubscription and advertising queriesCherylyn Borlase, Publications CoordinatorRNZCGP, PO Box 10440, Wellington 6143, New Zealand; jphcnz@rnzcgp.org.nzJPHC is printed on uncoated, acid-free paper which meets the archival requirements of ANSI/NISO Z39.48-1992 (Permanence of Paper) and is Forest Stewardship Council (FSC)–certifiedwhich meets the highest environmentally responsible standards.The Journal of Primary Health Care is the official journal of the RNZCGP. However, views expressed are not necessarily those of the College,the Editor, or the Editorial Board. ©The Royal New Zealand College of General Practitioners 2010. All Rights Reserved.264 VOLUME 2 • NUMBER 3 • SEPTEMBER 2010 J OURNAL OF PRIMARY HEALTH CARE