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VOLUME 3 • NUMBER 2 • JUNE 2011 

OF PRIMARY HEALTH CARE 

‘No one has ever 

witnessed shaking 

to cause the collapse 

of a well baby.’ 

See Back to Back page 159 

Original Scientific Paper 

Not all patients with cardiovascular 

disease receive drugs for secondary 

prevention 

See page 93 


Tool to diagnose common 

sleep disorders 

See page 107 


Te reo as indicator of quality 

health care 

See page 123 

Back to Back 

Is shaking a baby likely to cause 

brain damage and death 

See page 159 

Vaikoloa 

Pacific health and wellbeing 

See page 167 

Ethics 

Professional misconduct: 

illegal or immoral 

See page 170

contents 

VOLUME 3 • NUMBER 2 • JUNE 2011 

OF PRIMARY HEALTH CARE 

issn 1172-6164 (Print) 

ISSN 1172-6156 (Online) 

90 Editorials 

From the Editor 

90 Morality, science and the law 

Felicity Goodyear-Smith 

Guest Editorial 

92 The young at risk of CVD are the least likely to receive 

preventive cardiovascular medications in New Zealand 

FD Richard Hobbs 

93 Original Scientific Papers 

Quantitative Research 

93 Under-utilisation of preventive medication in patients with 

cardiovascular disease is greatest in younger age groups 

(PREDICT-CVD 15) 

Suneela Mehta, Sue Wells, Tania Riddell, Andrew Kerr, Romana 

Pylypchuk, Roger Marshall, Shanthi Ameratunga, Wing Cheuk 

Chan, Simon Thornley, Sue Crengle, Jeff Harrison, Paul Drury, 

C Raina Elley, Fionna Bell, Rod Jackson 

102 Language barriers in the community pharmacy: a survey of 

northern and western Auckland 

Emily Chang, Bobby Tsang, Simon Thornley 

107 Development, validation (diagnostic accuracy) and audit of 

the Auckland Sleep Questionnaire: a new tool for diagnosing 

causes of sleep disorders in primary care 

Bruce Arroll, Antonio Fernando III, Karen Falloon, Guy Warman, 


114 Factors influencing cigarette access behaviour among 

14–15-year-olds in New Zealand: a cross-sectional study 

Rupert Nelson, Janine Paynter, Bruce Arroll 

Qualitative Research 

123 The value of te reo in primary care 

Suzanne Pitama, Annabel Ahuriri-Driscoll, Tania Huria, Cameron 

Lacey, Paul Robertson 

128 Patients’ and health professionals’ perceptions of teamwork 

in primary care 

Susan Pullon, Eileen McKinlay, Maria Stubbe, Lindsay Todd, 

Christopher Badenhorst 

136 Making sense of chronic illness—a therapeutic approach 

Sue Jacobi, Rod MacLeod 

Mixed Method Research 

142 Educational needs of practice nurses in mental health 

Anne Prince, Katherine Nelson 

150 Improving Performance 

150 (Preventing) two birds with one stone: improving vitamin D 

levels in the elderly 

Susie Lawless, Phil White, Prue Murdoch, Sharon Leitch 

153 Repeat prescribing—reducing errors 

Steven Lillis, Hayley Lord 

159 Back to Back 

159 The triad of retinal haemorrhage, subdural haemorrhage and 

encephalopathy in an infant unassociated with evidence of 

physical injury is not the result of shaking, but is most likely 

to have been caused by a natural disease 

Yes Waney Squier; No Lucy Rorke-Adams 

165 Continuing Professional Development 

164 String of PEARLS about depression 

164 Cochrane Corner: The Epley (canalith repositioning) 

manoeuvre is effective for benign paroxysmal positional 

vertigo 

Bruce Arroll 

165 Potion or Poison Lemon balm 

Phil Rasmussen 

167 Vaikoloa: Pacific peoples: our health and wellbeing 

Api Talemaitoga 

169 Nuggets of Knowledge: NSAIDs and risk mitigation—if you 

really must use them in the elderly 

Linda Bryant 

170 Ethics 

170 Medical ethics: four principles, two decisions, two roles and 

no reasons 

John Kennelly 

174 Letters to the Editor 

175 Book Review 

175 Abortion Then and Now: New Zealand Abortion Stories 

from 1940 to 1980—Dame Margaret Sparrow 

Reviewer: Hilary Weeks 

176 About the Journal of Primary Health Care 

VOLUME 3 • NUMBER 2 • JUNE 2011 J OURNAL OF PRIMARY HEALTH CARE 89

EDITORIALs 

from the editor 

Morality, science and the law 

Felicity Goodyear- 

Smith MBChB, MGP, 

FRNZCGP, Editor 

Correspondence to: 


Professor and Goodfellow 

Postgraduate Chair, 

Department of General 

Practice and Primary 

Health Care, The 

University of Auckland, 

PB 92019 Auckland, 

New Zealand 

f.goodyear-smith@ 

auckland.ac.nz 

This issue of the Journal of Primary Health 

Care addresses a couple of important areas 

of medical and legal controversy. Actions 

may be immoral, harmful or illegal and these attributes 

may or may not be synonymous. Caution 

is required when moral feelings override scientific 

evidence or legal reasoning. 

Shaking a baby has long been considered to be 

a cause of the ‘triad’ of retinal and subdural 

haemorrhage and encephalopathy. ‘Shaken baby 

syndrome’ has led to the conviction of many 

parents and other caregivers since the 1940s. 

Over the past few years there has been increased 

questioning as to whether, in the absence of any 

other signs of injury, this triad actually is caused 

by trauma or is the result of a number of possible 

natural causes which result in cerebral hypoxia, 

increased intracranial pressure, and raised pressure 

in the brain’s blood vessels. Is conventional 

wisdom right, that shaking a baby, in the absence 

of any impact trauma, can cause severe brain 

damage and death, or are the classical ‘triad’ 

findings likely to be due to natural or accidental 

causes, including attempted resuscitation of a 

collapsed infant This is a debate that needs to 

be had. We are fortunate to have two renowned 

international paediatric neuropathologists go back 

to back on this topic. Dr Lucy Rorke-Adams from 

the United States argues that the triad is likely to 

be caused by shaking and that those who suggest 

otherwise, in order to defend people who have 

hurt babies, do considerable harm to the victims. 1 

Dr Waney Squier from the United Kingdom 

disputes that shaking a baby is likely to cause the 

triad and draws attention to the potential damage 

done by wrongfully removing children from 

their parents or imprisoning the innocent. 2 

On a different topic, John Kennelly explores the 

difficulties of using the four moral principles 

of beneficence, nonmaleficence, autonomy and 

justice to regulate doctors’ conduct within the 

context of a legal tribunal. These four principles 

are not always mutually inclusive. For example 

estimating the potential benefits/risks ratio of 

an intervention is not always a straightforward 

exercise. An action focused on the greater good 

may reduce an individual’s autonomy. 3 Using two 

actual cases heard by the New Zealand Health 

Practitioners’ Disciplinary Tribunal, Dr Kennelly 

demonstrates the serious limitations presented 

when these ethical principles are used rather than 

reasoned legal arguments in considering possible 

professional misconduct. 4 

A diverse range of research is reported in this 

issue. Mehta and colleagues report an important 

finding that about a third of New Zealand 

primary care patients with known cardiovascular 

disease are not receiving blood pressure and lipidlowering 

drugs, and that younger people (aged 

under 55 years) are less likely to be prescribed 

this treatment than older patients. 5 This paper 

is the subject of a guest editorial by Richard 

Hobbs, a British professor of general practice 

with a distinguished professional involvement 

in cardiology. Professor Hobbs reasons patients 

are probably not being prescribed these drugs 

because their general practitioners fail to understand 

that, to address global risk, these medications 

should be given regardless of the patient’s 

baseline blood pressure and lipid levels. He 

highlights that the young are especially disadvantaged 

because they have the most to gain by 

reducing their lifetime risk. 6 

Arroll et al. report on the development and validation 

of a tool for diagnosing sleep disorders. 7 

Named the Auckland Sleep Questionnaire, this 

is the first such questionnaire for use in primary 

care, and a copy can be found in the web version 

of this paper. 

This issue includes a study addressing barriers 

around community pharmacists providing servic- 

90 VOLUME 3 • NUMBER 2 • JUNE 2011 J OURNAL OF PRIMARY HEALTH CARE

EDITORIALs 

from the editor 

es for non-English speaking clients, 8 and another 

study by Pitama and colleagues which found that 

Maori patients may judge the quality of primary 

care they receive by their providers’ willingness 

to use and correctly pronounce Maori words and 

names. 9 Nelson et al. explore influences on young 

people that can promote cigarette smoking, both 

social factors such as family and friends who 

smoke, and the density of tobacco retail outlets in 

their district. 10 

Research is increasingly focusing on the patient’s 

perspective. One study considers the impact on 

patients of the diagnosis of a chronic progressive 

disease, and explores how health professionals 

may assist their patients make sense of their illness 

within the context of their lives. 11 Another 

study that looks at the perception of teamwork in 

primary care from the patient’s and the provider’s 

point of view found that, while the health 

professionals saw patients as part of the team, 

patients tended not to see themselves in this role 

nor embraced the concept of self-management. 12 

While practice nurses have increasing roles as 

team participants, a study by Prince and Nelson 

shows that generally they feel under-trained in 

intervening in patients who have a mental health 

component to their condition. Nurses expressed a 

range of educational needs including up-skilling 

in counselling, knowledge of mental health 

conditions, ability to advise on medication and 

delivering elements of cognitive behavioural or 

family therapy. 13 

The improving performance section presents 

some quality improvement initiatives. An Otago 

innovation reports on increasing vitamin D uptake 

in the frail elderly in the Winter months by 

linking the offer of supplementation with their 

invitation for influenza vaccination in the Autumn, 

14 and an audit process has produced a short 

list of safety checking mechanisms to reduce possible 

errors that arise in repeat prescribing. 15 

Finally, it is my pleasure to introduce a new 

column for the Journal of Primary Health Care, 

Vaikoloa (Pacific primary health care treasures). 

Introduced by Dr Api Talemaitoga who 

is the Clinical Director of Pacific Health in the 

Ministry of Health and also a practising general 

practitioner, Vaikoloa promotes knowledge, 

wisdom and empathy for people from the 22 

diverse Pacific Island nations, towards improving 

their health and wellbeing. 16 The Journal aims 

to address primary health care issues within the 

Pacific rim, hence this column is a fitting addition 

to our publication. 

References 

1. Rorke-Adams L. The triad of retinal haemorrhage, subdural 

haemorrhage and encephalopathy in an infant unassociated 

with evidence of physical injury is not the result of shaking but 

is most likely to have been caused by a natural disease. The 

‘No’ case. J Prim Health Care. 2011;3(2):159–64. 

2. Squier W. The triad of retinal haemorrhage, subdural haemorrhage 

and encephalopathy in an infant unassociated with 

evidence of physical injury is not the result of shaking but is 

most likely to have been caused by a natural disease. The ‘Yes’ 

case. J Prim Health Care. 2011;3(2):159–64. 

3. Goodyear-Smith F, Lobb B, Davies G, Nachson I, Seelau SM. 

International variation in ethics committee requirements: comparisons 

across five Westernised nations. BMC Med Ethics. 

2002 Apr 19;3(2):E2. 

4. Kennelly J. Medical ethics: four principles, two decisions, two 

roles and no reasons. J Prim Health Care. 2011;3(2):170–4. 

5. Mehta S, Wells S, Riddell T, et al. Under-utilisation of preventive 

medication in patients with cardiovascular disease is 

greatest in younger age groups (PREDICT-CVD 15). J Prim 

Health Care. 2011;3(2):93–101. 

6. Hobbs F. The young at risk of CVD are the least likely to receive 

preventive cardiovascular medications in New Zealand. 

J Prim Health Care. 2011;3(2):92. 

7. Arroll B, Fernando A, Falloon K, Warman G, Goodyear-Smith 

F. Development, validation (diagnostic accuracy) and audit of 

the Auckland Sleep Questionnaire: a new tool for diagnosing 

causes of sleep disorders in primary care. J Prim Health Care. 

2011;3(2):107–13 

8. Chang E, Tsang B, Thornley S. Language barriers in the community 

pharmacy: a survey of northern and western Auckland. 

J Prim Health Care. 2011;3(2):102–6. 

9. Pitama S, Ahuriri-Driscoll A, Huria T, Lacey C, Robertson 

P. The value of te reo in primary care. J Prim Health Care. 

2011;3(2):123–7 

10. Nelson R, Paynter J, Arroll B. Factors influencing cigarette 

access behaviour among 14-15-year-olds in New Zealand: a 

cross-sectional study. J Prim Health Care. 2011;3(2):114–22. 

11. Jacobi S, MacLeod R. Making sense of chronic illness—a 

therapeutic approach. J Prim Health Care. 2011;3(2):136–41. 

12. Pullon S, McKinlay E, Stubbe M, Todd L, Badenhorst C. 

Patients’ and health professionals’ perceptions of teamwork in 

primary care. J Prim Health Care. 2011;3(2):128–35. 

13. Prince A, Nelson K. Educational needs of practice nurses in 

mental health. J Prim Health Care. 2011;3(2):142–149. 

14. Lawless S, White P, Murdoch P, Leitch S. (Preventing) two 

birds with one stone: improving Vitamin D levels in the elderly. 

J Prim Health Care. 2011;3(2):150–2. 

15. Lillis S, Lord H. Repeat prescribing—reducing errors. J Prim 

Health Care. 2011;3(2):153–8. 

16. Talemaitoga A. Vaikoloa: Pacific peoples—our health and 

wellbeing. J Prim Health Care. 2011;3(2):167–8. 


EDITORIALs 

guest editorial 

The young at risk of CVD are the least likely to 

receive preventive cardiovascular medications 

in New Zealand 

FD Richard Hobbs 

Professor of Primary Care, 

Primary Care Clinical 

Sciences, University of 

Birmingham, Birmingham, 

United Kingdom 


F D Richard Hobbs 

Professor of Primary Care, 

Primary Care Clinical 

Sciences, University of 

Birmingham, Birmingham 

B15 2TT, United Kingdom 

f.d.r.hobbs@bham.ac.uk 

The paper by Mehta in this issue of the 

Journal of Primary Health Care describes 

the overall provision rates of the main 

cardiovascular (CV) preventive therapies, namely 

blood pressure–lowering (BPL) and lipid-lowering 

(LL) medications in New Zealand between 2006 

and 2009. The methods selected were rigorous 

and valid and, despite inevitable study limitations, 

probably represent best practice, as the authors 

state. We don’t know the relative influence 

of patient factors (such as refusal of medication, 

and non-concordance or persistence) or physician 

under-management in explaining these 

data. However, there are a number of potentially 

important messages for practising clinicians. 

Firstly, these GPs appeared to target individual 

risk factors rather than global risk in their interventions—only 

67% of patients receiving both LL 

and BPL medication, with 87% receiving only one 

intervention type. This is unsurprising because, 

though the concept of global risk in terms of 

patient assessment is now mostly well understood 

(i.e. use a risk algorithm to define who to treat), 

the idea that you should then treat automatically 

with BPL and LL medications regardless of the 

baseline BP and lipid levels is not. (Probably the 

only CV medication that is used holistically in 

this way—a risk factor modifier given as a fixed 

target dose regardless of risk factor level—is 

metformin in Type 2 diabetes.) The message for 

overall CV risk has not been widely promulgated, 

nor how you would practically implement it, i.e. 

which drugs, at what fixed dose, and in what 

order, even though we know each of these factors 

predicts subsequent patient concordance. 1,2 The 

significant number of people who stop their CV 

prevention medications suffer worse clinical outcomes 

3 and cause higher health care costs. 4 

Practising GPs, it appears, are therefore continuing 

to base CV interventions on the ‘traditional’ 

way of treating to specific risk factor targets. 

The general backdrop of health care payer pressure 

on prescribers to limit medication choice 

and reduce overall prescribing costs is likely to 

further influence conservative approaches to 

disease prevention. 

Against this backdrop, the authors further 

identify that, encouragingly for New Zealand, 

this under-utilisation appears to be no worse for 

the more deprived population, and is only worse 

for LL amongst Maori and women. The main 

disadvantaged group, however, were the young: 

compared to those with established CV disease 

at baseline aged 65–75, those aged 35–44 were 

up to 40% less likely to get BPL medication, LL 

medication, or both and those 45–54 up to 15% 

less likely (especially for LL). Given that these 

populations are also under-served by CV risk 

scores that measure short-term (five or 10 year) 

absolute risk rather than lifetime risk to determine 

access to prevention, these data showing 

that even those young patients with established 

CV disease are under-treated are particularly sad. 

These young high-risk patients have the most to 

gain individually and as family members. These 

important data highlight a major challenge to 

health care providers: to shift the emphasis for 

treatment from individual risk factors to global 

risk intervention and, particularly, to overcome 

this inverse age bias. 

References 

1. Dezii C M. A retrospective study of persistence with single-pill 

combination therapy vs. concurrent two-pill therapy in patients 

with hypertension. Manag Care. 2000;9(9 Suppl):2–6. 

2. Schwartz JS, McLaughlin T, Griffis D, Arnold A, Pettitt D. 

Adherence to chronic therapy among patients treated for 

hypertension, dyslipidemia, or both. J Am Coll Cardiol.2003; 

41(6):Suppl 2, 526. 

3. Ho P, Rumsfeld J, Masoudi F, McClure,D, Plomondon M, 

Steiner J Magid D. The impact of medication non-adherence 

on hospitalization and mortality among patients with diabetes. 

J Am Coll Cardiol.2006;47(4):Suppl 1, A264. 

4. Goldman DP, Joyce GF, Karaca-Mandic P. Varying pharmacy 

benefits with clinical status: the case of cholesterol-lowering 

therapy. Am J Manag Care. 2006;12(1):21–8. 


ORIGINAL SCIENTIFIC PAPErS 

quantitative research 

Under-utilisation of preventive medication in 

patients with cardiovascular disease is greatest 

in younger age groups (PREDICT-CVD 15) 

Suneela Mehta MBChB, MPH; 1 Sue Wells MBChB, MPH, PhD; 1 Tania Riddell BSc, MBChB, MPH; 1 Andrew 

Kerr MA, MBChB; 2 Romana Pylypchuk MSc, MPH; 1 Roger Marshall BSc, MSc, PhD; 1 Shanthi Ameratunga 

MBChB, MPH, PhD; 1 Wing Cheuk Chan MBChB, MPH; 3 Simon Thornley MBChB, MPH; 1 Sue Crengle 

MBChB, MPH, PhD; 4 Jeff Harrison BSc (Hons), PhD; 5 Paul Drury MA MB BChir; 6 C Raina Elley MBChB, PhD; 7 

Fionna Bell MBChB, MPH; 8 Rod Jackson MBChB, PhD 1 

ABSTRACT 

Introduction: Blood pressure–lowering (BPL) and lipid-lowering (LL) medications together reduce 

estimated absolute five-year cardiovascular disease (CVD) risk by >40%. International studies indicate 

that the proportion of people with CVD receiving pharmacotherapy increases with advancing age. 

Aim: To compare BPL and LL medications, by sociodemographic characteristics, for patients with known 

CVD in primary care settings. 

Methods: The study population included patients aged 35–74 with known CVD assessed in primary 

care from July 2006 to October 2009 using a web-based computerised decision support system (PRE- 

DICT) for risk assessment and management. Clinical data linked anonymously to national sociodemographic 

and pharmaceutical dispensing databases. Differences in dispensing BPL and LL medications in six 

months before first PREDICT assessment was analysed according to age, sex, ethnicity and deprivation. 

Results: Of 7622 people with CVD, 1625

ORIGINAL SCIENTIFIC PAPERS 


receive pharmacotherapy, even after controlling 

for other factors such as CVD risk. Bennett et 

al. examined variation in prescribing practices 

for patients with ischaemic heart disease in 

Ireland using data sourced from a national database 

recording pharmacy claims. 3 In that study, 

aspirin and statin therapy increased with age 

until 65 years, after which the odds of pharmacotherapy 

declined markedly. Prescription rates 

for ACE inhibitors, on the other hand, continued 

to increase until 75 years of age. There is 

no consensus among published studies as to the 

influence of sex, 3,7,8,12–14 ethnicity, 4,7,12,13,15–20 or 

social class. 8,10,12,14,21–23 Only five of these studies 

investigated whether systematic differences 

in the use of medications for secondary CVD 

prevention exist in New Zealand, 7,15,16,18,23 and 

none examined all of these sociodemographic 

characteristics together within a large study 

population. 

Differences in both the incidence and mortality 

of CVD according to age, sex, ethnic group and 

socioeconomic status are well recognised in New 

Zealand. 23–25 Sociodemographic disparities in 

pharmacotherapy for CVD are likely to contribute 

to these differences in outcomes. Therefore, 

we examined patterns of BPL and LL therapy for 

CVD by age, sex, ethnicity and deprivation for 

people in a large secondary prevention cohort 

who had been assessed in primary care. 

(about 34 000) for whom CVD risk management 

templates were also completed. 

Patients were included in these analyses if they 

had a history of CVD recorded by the primary 

care provider at the time of their initial PREDICT 

assessment, were 35–74 years of age, and were risk 

assessed for the first time between 1 July 2006 and 

16 October 2009. A history of CVD was defined 

as prior angina or myocardial infarction (MI), 

stroke, transient ischaemic attack (TIA), peripheral 

vascular disease (PVD), percutaneous coronary 

intervention, or coronary artery bypass graft. 

Linkage to National Health Index database 

to augment sociodemographic data 

National Health Index (NHI) numbers uniquely 

identify people within the New Zealand health 

system. The NHI database is administered by the 

New Zealand Ministry of Health and records a patient’s 

date of birth, sex, ethnicity, and New Zealand 

Deprivation 2001 index score (NZDep01). 

NZDep01 is a census-based index of deprivation 

for small areas that uses population census data 

relating to eight dimensions of deprivation. 27 

Anonymous linkage via encrypted NHI numbers 

allowed sociodemographic data from PREDICT 

(date of birth, ethnicity and sex) to be verified 

and augmented with data regarding ethnicity and 

NZDep01 from this national database. 

Methods 

Study population 

PREDICT is a web-based clinical decision support 

programme that was developed to provide 

cardiovascular risk assessment and risk management 

advice for health professionals and 

patients. 26 Since 2002, it has been used mainly 

opportunistically in 15 Primary Health Organisations 

(PHOs) across Auckland and Northland 

in New Zealand. When a risk assessment is performed 

with PREDICT, cardiovascular risk factor 

data for each patient are stored anonymously, 

generating a large and evolving patient cohort. 

From August 2002 to October 2009, data from 

about 124 000 patients were gathered. A medication 

history from the primary care provider was 

entered in PREDICT for a subset of participants 

Linkage to medication dispensing data 

Cardiovascular medications dispensed to each patient 

in the cohort were identified by anonymously 

linking the PREDICT database to the Pharmaceutical 

Information Database (PHARMS), using 

encrypted NHI numbers. PHARMS is jointly 

administered by the New Zealand Ministry of 

Health and the Pharmaceutical Management 

Agency of New Zealand (PHARMAC), and collects 

data on government-subsidised medications 

dispensed by community pharmacies nationwide. 

28 In 2006, 92% of PHARMS dispensing 

data were reliably identifiable by NHI numbers, 

and this increased to 96% in 2009. PHARMS 

data collected prior to 2006 were considered inadequate 

for inclusion in these analyses as less than 

87% of this data could be reliably linked. (S Ross, 

personal communication, 2009) 




Drugs of interest 

All classes of BPL and LL medications were 

considered (listed in Appendix 1 published in 

the web version of this paper). Aspirin was not 

investigated because it is available in the community 

without prescription and is less likely to be 

recorded in the PHARMS database. 

Analysis 

The main outcome of interest was dispensing 

of BPL and LL medications at least once in the 

six months prior to first PREDICT assessment. 

A six-month period for data collection was used 

because, although cardiovascular medications 

are usually prescribed three-monthly, people 

sometimes fill their prescription outside this time 

period. Three categories of therapy were used: 

BPL medications alone, LL medications alone and 

both classes of medications together. Dispensing 

was analysed by age, sex, ethnic group and deprivation. 

Age was stratified in 10-year intervals. 

Ethnic groups were defined according to the New 

Zealand Ministry of Health’s Ethnicity Data 

Protocols for the Health and Disability Sector. 29 

Ethnic groups of interest were: European (Level 2 

codes 10–12), Maori (Level 2 code 21), Pacific 

(Level 2 codes 30–37), Indian (Level 2 code 43), 

Chinese (Level 2 code 42), Other Asian (Level 2 

codes 40, 41 and 44), and Other (Level 2 codes 

51–99). Each patient within the PREDICT cohort 

can potentially have six ethnic groups recorded, 

as both the PREDICT template and the NHI 

database allow for three ethnicities to be entered. 

Agreement between ethnicity data recorded in 

the PREDICT and NHI databases has been found 

to be good (kappa coefficient of 0.82). 30 If multiple 

ethnicities were recorded for a patient, then 

the ethnic group was prioritised. Patients defined 

as having ‘Chinese’, ‘Other Asian’, or ‘Other’ 

ethnicities were subsequently excluded due to 

very small numbers. Quintiles of deprivation, 

according to NZDep01, were used to approximate 

socioeconomic status. 

To assess the representativeness of the included 

study population, demographic data from anonymised 

PREDICT participants were compared 

with corresponding data from people across 

Auckland and Northland with an NHI number 

WHAT GAP THIS FILLS 

What we already know: Blood pressure–lowering and lipid-lowering 

medications together have been shown to reduce estimated absolute cardiovascular 

risk over a five-year period by over 40%. Various international 

studies suggest that, in general, the proportion of people with CVD who 

receive pharmacotherapy increases with advancing age, although there is no 

consensus among published studies as to the influence of sex, ethnicity or 

social class. 

What this study adds: Blood pressure–lowering and lipid-lowering medications 

continue to be under-utilised in patients with known cardiovascular 

disease in New Zealand: only two-thirds of patients are on both. Younger 

patients were considerably less likely to be on recommended medications, 

although clinically significant differences in dispensing by sex, deprivation or 

ethnicity were not found. 

during the period 1 July 2006 to 30 June 2007, 

who had a history of CVD. For this Auckland/ 

Northland dataset, a history of CVD was defined 

by dispensing of nitrates or perhexiline on at 

least two occasions between 1 July 2001 and 

30 June 2007, or having a CVD-related hospital 

admission in the public or private sector between 

1 January 1988 and 31 December 2007. 

Data was analysed using STATA 10.0 statistical 

software. A binomial regression model calculated 

crude and adjusted relative risks (RR), with 95% 

confidence intervals (CI), of being dispensed BPL 

medications, LL medications or both for each 

sociodemographic characteristic examined. 

Within the study population, a history of 

prescribed CVD medications was available for 

2736 people. We calculated the proportion of 

prescriptions given to patients for BPL and LL 

medications which were subsequently dispensed. 

This allowed us to determine whether dispensing 

differences among these people were related 

to the decision to prescribe medications or to the 

likelihood of patients filling prescriptions. 

Ethical approval 

The cohort study and research process was approved 

by the Northern Region Ethics Committee 

Y in 2003 (AKY /03/12/314), with subsequent 

approval by the National Multi Region 

Ethics Committee in 2007 (MEC/07/19/EXP). 




Table 1. Characteristics of 7622 people with a known history of CVD at first PREDICT assessment compared to characteristics of people with CVD from 

across Auckland/Northland 

Baseline characteristic 

Age (years) 

Sex 

Ethnicity 

Deprivation quintile 

Dispensed CVD medications 

Number (%) assessed by 

PREDICT with CVD* 

Number (%) across Auckland/ 

Northland with CVD † 

35–44 306 (4%) 1411 (7%) 

45–54 1319(17%) 3689 (18%) 

55–64 2703 (36%) 6908 (33%) 

65–74 3294 (43%) 8714 (42%) 

Male 4760 (63%) 12 110 (58%) 

Female 2862 (38%) 8612 (42%) 

Maori 1556 (20%) 3588 (17%) 

Pacific Island 1151 (15%) 2300 (11%) 

Indian 329 (4%) 903 (4%) 

European and Other 4586 (60%) 13 931 (67%) 

European 4249 (55%) Not available 

Chinese 143 (2%) Not available 

Other Asian 95 (1%) Not available 

Other 99 (1%) Not available 

Quintile 1: NZDep 1–2 744 (10%) 2573 (12%) 


Quintile 3: NZDep 5–6 1287(17%) 3511 (17%) 



Missing data 14 (0.2%) 1282 (6%) 

Blood pressure–lowering medications alone 5868 (81%) Not available 

Lipid-lowering medications alone 5348 (73%) Not available 

Both classes of medication 4860 (67%) Not available 

Either class of medication 6356 (87%) Not available 

Total number with CVD 7622 20 722 

* Patients included in this study population were aged 35–74 years, with a first PREDICT assessment occurring between 1 July 2006 and 16 October 2009. 

† 

This comparison dataset comprised people from across Auckland and Northland, with an NHI number during the period 1 July 2006 to 30 June 2007 inclusive, who had 

a history of CVD. A history of CVD was defined by dispensing of medications commonly used to treat angina on at least two occasions between 1 July 2001 and 30 June 

2007, or having a CVD-related hospital admission in the public or private sector between 1 January 1988 and 31 December 2007. 

Results 

The sociodemographic characteristics of the 7622 

people who met inclusion criteria are detailed 

in Table 1. The age distribution closely approximates 

the corresponding age distribution for 

Auckland and Northland. Among those assessed 

with PREDICT, men and people of Maori and 

Pacific ethnicities were slightly over-represented, 

with Indians similarly represented. The analysis 

was conducted on the 7285 individuals who 

remained after exclusion of ‘Chinese’ (n=143), 

‘Other Asian’ (n=95) and ‘Other’ (n=99) 

ethnic groups. Higher percentages of people 

from deprived quintiles were noted among the 

PREDICT sample, compared to the deprivation 

distribution across Auckland and Northland. 

Among people with a history of CVD recorded 

in PREDICT, 62% (n=4691) had suffered a coronary 

event, 28% (n=2103) had been diagnosed 

with either a stroke or TIA, and 13% (n=963) 

were affected by PVD. 

BPL medications were dispensed to 81% (n=5868), 

LL medications to 73% (n=5348), both BPL 




Table 2. Likelihood, according to age, of being dispensed CVD medications in the six months prior to first PREDICT 

assessment among people with a known history of CVD (reference group is 65–74-year-old age group) 

Medication category 

Blood pressure–lowering 

medications alone 

Lipid-lowering 


Both classes of 

medication 

Age group (years) 

Numbers (%) dispensed 

for each age group 

Sex, ethnicity and 

deprivation adjusted 

relative risks (95% CI)* 

35–44 161 (56%) 0.63 (0.57–0.71) 

45–54 904 (72%) 0.84 (0.81–0.87) 

55–64 2106 (81%) 0.94 (0.92–0.96) 

65–74 2697 (86%) 1 

35–44 155 (56%) 0.70 (0.63–0.78) 

45–54 855 (68%) 0.90 (0.86–0.94) 

55–64 1954 (75%) 0.99 (0.96–1.02) 

65–74 2384 (76%) 1 

35–44 122 (42%) 0.58 (0.51–0.67) 

45–54 767 (61%) 0.86 (0.82–0.91) 

55–64 1759 (68%) 0.95 (0.92–0.99) 

65–74 2212 (70%) 1 

* Please note that the crude relative risks have not been presented as they were not appreciably different to the adjusted relative risks. 

and LL medications to 67% (n=4860), and 87% 

(n=6356) received either class of medication. 

Among people using BPL medications, 63% 

(n=3698) were dispensed ACE inhibitors, 63% 

(n=3695) received beta blockers, 36% (n=2122) 

received calcium channel blockers and 25% 

(n=1447) received thiazides. Statins were dispensed 

to 97% (n=5202) of people receiving LL 

medications. 

Tables 2, 3, 4 and 5 present the numbers and 

proportions of people dispensed each category 

of medication, and adjusted RRs with 95% CI, 

according to age, sex, ethnicity and deprivation. 

Crude RRs are not presented, as they were not 

appreciably different to the adjusted RRs. 

People aged 35–44 years were less likely to be 

dispensed BPL medications by 37% (RR 0.63, 95% 

CI 0.57–0.71), LL medications by 30% (RR 0.70, 

95% CI 0.63–0.78) or both by 42% (RR 0.58, 95% CI 

0.51–0.67) compared to people aged 65–74 years. 

For each medication category, the likelihood of 

dispensing increased with advancing age (Table 2). 

Small differences in dispensing by sex were 

noted. After adjustment for age, ethnicity and 

deprivation, women were equally likely to be dis- 

Table 3. Likelihood, according to sex, of being dispensed CVD medications in the six months prior to first PREDICT 

assessment among people with a known history of CVD (reference group is males) 




Lipid-lowering medications 

alone 

Both classes of medication 

Sex 


for each sex 

Age, ethnicity and deprivation 

adjusted relative risks (95% CI)* 

Female 2213 (81%) 0.99 (0.97–1.01) 

Male 3655 (81%) 1 

Female 1888 (69%) 0.91 (0.88–0.93) 

Male 3460 (76%) 

Female 1726 (63%) 0.91 (0.88–0.94) 

Male 3134 (69%) 1 

1 





Table 4. Likelihood, according to ethnicity, of being dispensed CVD medications in the six months prior to first PREDICT 

assessment among people with a known history of CVD (reference group is European) 







medication 

Ethnicity 


for each ethnicity 

Sex and age-adjusted 


Maori 1246 (80%) 1.03 (1.00–1.06) 

Pacific 939 (82%) 1.05 (1.02–1.08) 

Indian 279 (85%) 1.07 (1.02–1.12) 

European 3404 (80%) 1 

Maori 1069 (69%) 0.96 (0.93–0.99) 

Pacific 864 (75%) 1.04 (0.99–1.08) 

Indian 265 (81%) 1.10 (1.04–1.16) 

European 3150 (74%) 1 

Maori 992 (64%) 1.01 (0.96–1.05) 

Pacific 800 (70%) 1.08 (1.04–1.13) 

Indian 245 (75%) 1.14 (1.07–1.22) 

European 2823 (66%) 1 


In addition, as ethnicity and deprivation are correlated variables, an adjustment for deprivation was not included in Table 4. Adjustment 

for deprivation, however, did not affect the sex and age-adjusted relative risks. 

pensed BPL therapy compared to men (RR 0.99, 

95% CI 0.97–1.01). However, women were 9% 

less likely than men to be dispensed LL medications 

alone (RR 0.91, 95% CI 0.88–0.93) or dual 

therapy (RR 0.91, 95% CI 0.88–0.94) (Table 3). 

The likelihood of being dispensed each category 

of medication was similar across the four ethnic 

groups, even after adjustment for sex and age (Table 

4). RRs were not adjusted for deprivation, as 

ethnicity and deprivation are correlated variables. 

No clinically relevant differences in dispensing 

according to deprivation quintiles were noted 

across the three medication categories (Table 5). 

People with a recorded history of prescribed 

CVD medications (n=2736) had similar characteristics 

to the total study population. Prescriptions 

for BPL medications were subsequently 

dispensed by a pharmacist to 95% of patients, 

while prescriptions for LL medications were 

dispensed to 94% and prescriptions for both BPL 

and LL medications to 93% of this subsample. 

These proportions remained relatively consistent 

when considered according to sociodemographic 

characteristics and documented type of CVD, 

with the exception of dispensing of recorded 

prescriptions of BPL medications (84%, n=50) and 

dual therapy (84%, n=42) to people aged 35–44 

years. (See Appendix 2 published in the web version 

of this paper.) 

Discussion 

In a large primary care cohort with CVD, BPL 

medications were dispensed to 81%, LL medications 

to 73%, both BPL and LL medications to 

67%, and 87% received either class of medication. 

Younger people were the most under-treated, but 

minimal differences in dispensing of medicines 

according to sex, ethnicity and deprivation 

status were found. Among those patients with a 

prescription history available, more than 93% of 

prescriptions for BPL and LL medications were 

subsequently dispensed. 

Our findings demonstrate considerable under-use 

of recommended medications for people with 

CVD, despite current evidence-based guidelines 

for the use of triple pharmacotherapy in such patients. 

Other New Zealand studies have similarly 

noted a substantial treatment gap. A nationwide 

audit of acute coronary patients hospitalised in 

2007 found suboptimal prescribing of aspirin 

(82%), beta blockers (65%), ACE inhibitors (51%), 




and statins (70%) for the 1003 patients examined. 

31 Among another sample of 232 people with 

CVD from three New Zealand general practices, 

aspirin was prescribed to 74%, statins to 65% and 

BPL medications to 79% of participants. 15 Our 

findings may represent a ‘best case scenario’ as 

the study population was identified by primary 

care teams who were taking an active approach to 

CVD management by using the PREDICT decision 

support system. We were unable to investigate 

the use of aspirin. Records of dispensing 

were available for 67% of our study population, 

which probably reflects patients purchasing this 

medication over the counter to avoid prescriptionrelated 

costs. 

The lower level of dispensing in younger people 

with CVD is significant given their greater potential 

and productive years of life lost compared 

with older age groups. This is particularly salient 

for Maori, Pacific and Indian people, whose populations 

have a younger age structure than the 

total New Zealand population. 32–34 Various factors 

could account for this age discrepancy. Firstly, 

general practitioners (GPs) might still be managing 

CVD using a risk factor–based approach rather 

than according to absolute cardiovascular risk. 

Therefore, they may be unwilling to commence 

pharmacotherapy for those younger patients with 

CVD who do not have elevated blood pressure 

or lipids. Younger people may also be less likely 

than older patients to decide in favour of taking 

secondary prevention medications. 35,36 The 

reasons for this are likely to be multifactorial, 

and include financial pressures such as dependent 

children, and an arguably greater likelihood of 

poor lifestyle and health choices among younger 

people with CVD. Medication costs may also 

have been a deterrent for people aged less than 45 

years until July 2007, when prescription charges 

incurred by PHO enrolees from this age group 

reduced markedly. 

Various studies have noted reduced dispensing to 

older people, related to drug–drug interactions, 

drug–comorbid disease interactions, physiological 

intolerance and patient wishes against 

treatment. 3,7–11 We did not observe this finding, 

possibly due to the exclusion of people aged 75 

years or older. 

Table 5. Likelihood, according to deprivation, of being dispensed CVD medications in the six months prior to first 

PREDICT assessment among people with a known history of CVD (reference group is deprivation quintile 1) 







medication 

Deprivation 

quintile 

Numbers (%) dispensed for 

each deprivation quintile 

Sex and age adjusted 


1 525 (77%) 1 

2 739 (81%) 1.05 (1.00–1.10) 

3 984 (81%) 1.04 (0.99–1.09) 

4 1432 (81%) 1.05 (0.99–1.09) 

5 2180 (81%) 1.06 (1.02–1.11) 

1 501 (74%) 1 

2 677 (74%) 1.01 (0.95–1.07) 

3 925 (76%) 1.02 (0.97–1.08) 

4 1282 (72%) 0.98 (0.93–1.04) 

5 1955 (73%) (0.96–1.05) 

1 443 (65%) 1 

2 614 (67%) 1.03 (0.96–1.11) 

3 823 (68%) 1.03 (0.96–1.10) 

4 1171 (66%) 1.02 (0.96–1.08) 

5 1802 (67%) 1.05 (0.99–1.12) 


In addition, as ethnicity and deprivation are correlated variables, an adjustment for ethnicity was not included in Table 4. Adjustment 

for ethnicity, however, did not affect the sex and age adjusted relative risks. 




The differences in dispensing according to sex 

were relatively small, in keeping with published 

studies internationally. 3,7,8,12–14 Women are more 

likely to report statin-related myopathy 37,38 or 

present with non-specific aches and pains 39,40 that 

may be interpreted as intolerance, which may 

account for the slight under-dispensing of LL 

medications and dual therapy to women within 

our cohort. 

We did not find systematic differences in cardiovascular 

medication dispensing based on ethnicity. 

However, primary care professionals should 

maintain a level of vigilance regarding pharmacotherapy 

for high-risk ethnic groups, given their 

younger age distributions, and their disproportionate 

burden of recurrent events. 41 

Relatively equal patterns of dispensing by deprivation 

were also noted, although the NZDep01 

Index employed in our study is a relatively crude 

measure of socioeconomic status. Reduced patient 

co-payments for subsidised prescription medications 

are likely to have eased some of the cost 

barriers for those most deprived. 

Our sample originated from one of the largest 

cohorts of patients prospectively assessed for risk 

of CVD worldwide. The demographic and drug 

dispensing data for the sample were generated 

through routine clinical practice, rather than in 

a simulated research environment, which aids 

the generalisability of the findings to the wider 

primary care setting. Data regarding dispensed 

medications were abstracted from a relatively 

comprehensive nationwide database of medications 

dispensed by community pharmacists. This 

minimised the potential for misclassification 

error based on patient self-report or incomplete 

health provider records of pharmacotherapy. 

Our analyses have several limitations. We did 

not have access to records of patient intolerance to 

medications, which may account for some of the 

treatment gap observed. Prescriptions for CVD 

medications written by hospital or specialist health 

professionals are unlikely to be recorded in the 

PHARMS database; the higher patient co-payment 

associated with such scripts markedly reduces the 

incentive for pharmacists to claim for a subsidy. A 

small number of patients within our study population 

may have experienced their first CVD event 

shortly before their initial PREDICT assessment, 

introducing misclassification error in the event 

that these patients had only redeemed hospital or 

specialist-issued prescriptions prior to risk assessment. 

Similarly, it is possible that a few patients 

may have been first registered as having CVD (e.g. 

new angina) at the time of entry into PREDICT. 

However, the main limitation of these analyses 

is the possibility of selection bias. This study 

population comprised about one-third of the 

estimated total number of people with CVD in 

the study area (see Table 1) and may represent a 

better treated patient group. To enter the study 

population, the participants had to visit a GP and 

a PREDICT assessment is unlikely to have been 

completed on non-regular patients. However, 

the sociodemographic profile of the PREDICT 

sample with CVD is similar to the corresponding 

characteristics of people from across Auckland 

and Northland with CVD at June 2007. Given 

the potential for selection bias, the main focus 

of these analyses was to compare dispensing patterns 

within the study population. The validity 

of these comparisons depends on the assumption 

that similar selection biases are likely to apply 

to the different subgroups within the study. We 

plan to conduct a follow-up analysis examining 

whether CVD risk assessment subsequently 

influenced pharmacotherapy, as well as link 

dispensing of CVD medications to CVD hospital 

discharges for the total New Zealand population. 

A comparison of risk factor profiles and type of 

CVD diagnosis by pharmacotherapy status would 

also be worthwhile. 

In conclusion, under-utilisation of recommended 

medications among people with CVD remains a 

problem in New Zealand, particularly in younger 

patients. Patient likelihood of filling prescriptions 

does not appear to be a major contributor to sociodemographic 

differences in pharmacotherapy for 

CVD, as most prescriptions for CVD medications 

were dispensed. 

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ACKNOWLEDGEMENTS 

The authors would like to 

thank members of both the 

PREDICT Maori Advisory 

Group and the PREDICT 

Pacific Advisory Group. 

The authors would also like 

to thank affiliated general 

practitioners and practice 

nurses and patients 

belonging to ProCare 

Network North, ProCare 

Network Auckland, 

ProCare Network 

Manukau, Auckland PHO 

Ltd, Tamaki Healthcare, 

HealthWest, East Health 

Services, TaPasefika, Te 

Kupenga o Hoturoa, Total 

Healthcare Otara, Te Tai 

Tokerau, Manaia, Kaipara 

Care, Tihewa Mauriora 

and Whangaroa PHOs. 

PREDICT was developed 

by a collaboration of 

clinical epidemiologists 

at The University of 

Auckland, IT specialists 

at Enigma Publishing Ltd 

(a private provider of 

online health knowledge 

systems), primary health 

care organisations, 

non-governmental 

organisations (New 

Zealand Guidelines Group, 

National Heart Foundation, 

Diabetes New Zealand, 

Diabetes Auckland), 

several district health 

boards and the Ministry of 

Health. PREDICT software 

platform is owned by 

Enigma Publishing Ltd 

(PREDICT is a trademark 

of Enigma Publishing Ltd). 

FUNDING 

The PREDICT research 

project is supported 

by grants 03/183 and 

08/121 from the Health 

Research Council. 

COMPETING INTERESTS 

None declared. 




Language barriers in the community pharmacy: 

a survey of northern and western Auckland 

Emily Chang MBChB, DipPaed; 1 Bobby Tsang MBChB, FRACP; 2 Simon Thornley MBChB, MPH 3 

1 

Starship Children’s Health, 

Auckland City Hospital, 

Auckland, New Zealand 

2 

Waitemata District Health 

Board, Auckland 

3 

Section of Epidemiology and 

Biostatistics, The University of 

Auckland, Auckland 

ABSTRACT 

Introduction: Community pharmacists play an important role in increasing patient understanding of 

medication use. Lack of resources to facilitate communication with non-English speaking (NES) patients 

may be a communication barrier. 

Aim: To identify obstacles and coping strategies of community pharmacists when counselling NES patients 

in Auckland’s North Shore and West Auckland. 

Methods: A cross-sectional survey of 46 community pharmacies in West Auckland and the northern 

Auckland region was carried out in February 2009. 

Results: Community pharmacists frequently counsel NES patients (65% reported at least once a week). 

Use of bilingual staff was the most commonly employed strategy (78% of respondents) to communicate with 

these customers. Pharmacies that reported serving NES clients at least daily all had bilingual staff, compared 

with 70% of pharmacies with less frequent NES contact (p=0.017). No pharmacists reported using professional 

interpreting services. In our sample, telephone interpreting was the most preferred (63% of respondents) 

method of communicating with such patients, assuming that further services were made available. 

Discussion: Community pharmacists frequently serve NES patients, with limited access to interpreting 

services or translated resources. Although pharmacists have, in some way, adapted to the needs 

of their patients, our survey suggests that accessible professional interpreting services would further 

improve pharmacist/NES client interaction. 

KEYWORDS: Communication barriers; community pharmacy services; medication errors 

J PRIM HEALTH CARE 

2011;3(2):102–106. 


Emily Chang 

Paediatric Palliative Care 

Fellow, Starship Children’s 

Health, Auckland City 

Hospital, PB 92024, 

Auckland 1124, 


echang@adhb.govt.nz 

Introduction 

Interest in language and cultural barriers in 

the medical context has increased recently in 

academic health care journals. Recent articles 

highlight the importance of providing satisfactory 

standards of care to non-English speakers 

in the pharmacy setting. Most have been 

carried out in North America, in which the 

Spanish speaking, Latino population is most 

frequently studied, although analysis of interactions 

with Asian peoples are becoming more 

commonly reported. 1–5 

Poor communication carries potential adverse 

clinical consequences. Flores et al. 1 describe 

several cases in which inaccuracies made by 

untrained, ad hoc interpreters may lead to 

drug dosing and administration errors. One 

case study described how an infant received 

10 times the recommended dose of a barbiturate, 

due to the mother’s limited understanding 

of English. 2 

The community pharmacist plays an important 

role in increasing patient understanding of medication 

use, especially at the point of dispensing. 

Language barriers potentially inhibit effective 

patient–pharmacist communication. 

We speculated that pharmacists often encounter 

non-English speaking (NES) patients. One of the 

barriers may be a lack of resources to facilitate 

communication with such patients. We also 




thought that ad hoc translators such as family 

members or bystanders may frequently be called 

upon to overcome language barriers. 

The aims of our study were to identify common 

obstacles faced by community pharmacists 

when counselling NES patients, and to identify 

resources available to help overcome communication 

barriers. We also asked pharmacists which 

of a variety of different interpreting options they 

would prefer, if made available, and why they 

made such a choice. 

Methods 

Study design and sample 

We conducted a cross-sectional, paper-based 

survey of all community pharmacies within 

the Waitemata District Health Board (WDHB) 

catchment area in February 2009. This is an 

administratively-defined geographic area from 

Rodney District in the upper North Island of 

New Zealand down to Auckland’s North Shore 

and West Auckland. Both urban and rural 

areas are included in this sample, with most 

pharmacies located in metropolitan Auckland. 

In 2006, the census estimated population was 

481 611. 6 

Ethnic groups residing in this area include 

European (57%), Asian (14%), Maori (9%) and 

Pacific people (6%). Asian peoples include Chinese, 

Korean, and Indian, amongst others. This 

population mostly resides in urban areas. The 

North Shore and West Auckland are home to 

55.4% and 40.9% of Asian peoples respectively. 

Only 3.8% reside in the Rodney District, which 

is largely made up of rural areas. 7 Migrants make 

up a significant part of the Asian population. For 

example, only 17.1% of Chinese people, 20.1% of 

Indian people and 6.7% of Korean people in this 

region were born in New Zealand. 7 In contrast, 

59.1% of Pacific peoples and 96.7% of the Maori 

population were born in this country. Korean 

peoples had the lowest level of English competency 

in the surveyed area, with 29.6% having 

no English language skills. Chinese people 

followed with 17.9% speaking no English. The 

Indian population had higher levels of English 


What we already know: New Zealand has a significant migrant population 

with English as a second language. Communication barriers increase the 

risk of treatment and medication errors. 

What this study adds: Communication barriers are a significant problem 

for retail pharmacists. Although many have adapted to this problem, 

pharmacists have indicated that improved access to professional interpreting 

services is needed. 

language skills with only 5.3% unable to speak 

any English. 7 

Mailing addresses for pharmacies were extracted 

from a database held by WDHB. The survey was 

sent out by mail with a follow-up letter, and, in 

the case of non-response, a follow-up was sent 

two weeks later. 

Data 

Pharmacists were asked to report how frequently 

they encountered NES patients and their likely 

ethnicity. Other information sought included 

knowledge and use of communication resources 

(translated information sheets, pictograms, 

ability to print medication labels in the client’s 

native language, access to telephone interpreting 

services, Internet resources, or bilingual staff). 

Further, we enquired about potential obstacles 

to effective communication and how they were 

managed. Finally, pharmacists were able to suggest 

services they would prefer, if available. We 

asked pharmacists to rank these modalities and 

express reasons underlying their choice. The 

questions were presented in a multiple choice 

format with the ability to choose as many of the 

items as the pharmacist felt relevant. Free text 

responses were also possible (See the Appendix in 

the web version of this paper). 

Statistical analysis 

Responses were aggregated into numeric summaries 

and descriptive statistics reported. Chi-square 

or Fisher exact tests were used to test whether 

reported differences between pharmacies were 

likely to result from systematic or random 




Table 1. Ethnic groups and frequency of NES client encounters 

Ethnic groups served Number of respondents (%) 

Chinese 45 (98) 

Korean 28 (61) 

Indian 16 (34) 

Pacific 14 (30) 

Asian not otherwise specified 13 (23) 

How often respondent encounters NES clients 

Table 2. Characteristics of pharmacies divided by presence or absence of bilingual staff 

Bilingual staff n (%) 

Frequency that NES clients served Yes No 

P-value 

At least daily 16 (44) 0 (0) 0.02 

At least weekly 10 (28) 4 (40) 

At least monthly 4 (11) 2 (20) 

Less than monthly 6 (17) 3 (30) 

Missing data 0 (0) 3 (30) 

Ethnic groups served 

variation, with p



day. Similarly, changes in dosing or frequency 

were difficult to explain. Almost half of pharmacists 

(41%) surveyed reported evidence of probable 

poor adherence to drug regimens, such as failure 

to collect repeat dispensings. 

Preferred interpreting services 

Of the four proposed interpreting services, a 

telephone service was most frequently preferred 

(63% of respondents); with face-to-face interpreting 

the second most frequently preferred choice 

(28%). Pharmacists favoured telephone interpreting 

because they felt it would be easy to use, 

rapid and cheap. Face-to-face interpreting was 

rated ideal for accurate communication. However, 

respondents felt interpreters would be difficult to 

access at short notice and cost would limit their 

use. Reasons for not favouring either webcam or 

teleconferencing services, stated by pharmacists, 

were the cost of setting up specialised equipment 

and software, along with technical barriers. 

Discussion 

Our findings showed that community pharmacists 

in the region surveyed commonly encounter 

NES patients but infrequently use professional 

interpreting services. Lack of funding and/ 

or knowledge about available services may be 

responsible. 

Although services are available, our study indicates 

they are not used. For example, no respondent 

indicated use of Language Line, a user pays 

telephone interpreting service operated by the 

Office of Ethnic Affairs in Wellington. 

Several respondents commented on the urgent 

need for a funded interpreting service. An example 

of this was given by a North Shore pharmacist, 

who wrote: “(We) would be extremely 

grateful for funded interpretation money or 

personnel, we have an extremely high number of 

Asian patients needing better services.” 

Over the time our research was carried out, 

WATIS (Waitemata Auckland Translation & 

Interpreting Service, managed by WDHB’s 

Asian Health Support Services), was funded 

to roll out telephone interpreting services to 

Table 3. Common problems encountered when 

counselling NES patients 

Problem n (%) 

Personal details 17 (39) 

Medication use 39 (89) 

Adherence 18 (41) 

Traditional medicine 7 (16) 

Funding 4 (9) 

primary health care settings with community 

pharmacies in the second phase. Alternatives 

will include face-to-face interpreting, teleconferencing 

and webcam services. 

Our major finding was that pharmacists appear 

to address linguistic barriers by employing 

bilingual staff. Pharmacies that frequently saw 

NES patients were more likely to report the 

presence of staff with such skills. However, 

the direction of the observed association is 

uncertain, because, conversely, the presence 

of bilingual staff members may attract NES 

patients to the pharmacy. 

If pharmacy staff and patients speak the same 

language, more effective communication is likely 

to follow. However, not all multicultural interactions 

would be covered in the region surveyed. 

For example, our survey did not ask which 

languages were spoken by bilingual staff. The 

association we found between Chinese, Korean or 

other Asian patients and employment of bilingual 

staff suggests that such staff mostly speak 

Asian languages. 

Further evidence for this assumption comes from 

an analysis of the ethnic group of pharmacists. 

The Pharmacy Council states that registered 

pharmacists in New Zealand are most likely to 

be New Zealand European or Pakeha (58.3%), 

followed by Other European (10.3%). Of the 

non-European groups, Chinese pharmacists were 

most common (9.6%), followed by Indian (6.3%), 

then “Asian—not otherwise specified” (4.6%). 8 

In the 2006 census, 8.5% of the New Zealand 

population identified as Asian. 6 No distinction 

was made between different Asian peoples 




ACKNOWLEDGMENTS 

Many thanks to Ms Sue 

Lim and the team at Asian 

Health Support Services 

at Waitemata District 

Health Board for their 

assistance and guidance 

throughout this project. 

FUNDING 

Funding for stationery 

and postage was given by 

the Asian Health Support 

Services at Waitemata 

District Health Board. 

None of the authors 

received funding for 

their contribution to 

the manuscript. 



such as Chinese or Indian. If Chinese, Indian 

and “Asian—not otherwise specified” were all 

counted as Asian, that would make up a total 

20.5% of registered pharmacists. Thus, Asian 

peoples appear over-represented amongst pharmacists, 

suggesting that bilingual staff are likely 

to speak Asian languages. Further research into 

how bilingual staff function in this setting may 

shed light on the quality of pharmacist–patient 

communication. 

Our study was limited by responder bias. Of 

note, no pharmacies from the Hibiscus coast 

responded. This area has a low proportion of 

non-European peoples compared with the rest 

of the Auckland region. Less than 5% of Asian 

peoples in northern and western Auckland live 

in the Rodney District, which includes the 

Hibiscus coast. 6 Responses may also be affected 

by recall error. 

Previous studies of pharmacist communication 

have been conducted in the United States 

and Canada. One study surveyed community 

pharmacists in Milwaukee County, Wisconsin. 

3 Compared to respondents surveyed in 

the Waitemata region, Milwaukee pharmacists 

reported better knowledge of, and access to, 

translated material such as information sheets, 

medication labels printed in the patient’s native 

language and professional telephone interpreting 

services. 

However, 78% of responding pharmacies in 

our survey employed bilingual staff and 72% 

used ad hoc interpreters; whereas in Milwaukee 

County, over 60% of pharmacies were either 

“completely unable”, or “only sometimes able” 

to communicate with patients in a language 

other than English. 

Difficulty counselling a patient about proper use 

of medications was frequently reported in our 

study and evidence of non-adherence featured 

prominently (41%). Such a finding is consistent 

with North American research where non-adherence 

was the most commonly identified problem 

when NES clients were encountered. 4, 5 

This study suggests community pharmacies 

have made some adaptation to cater for the NES 

population. However, pharmacists have indicated 

that marketing of, and access to, professional 

interpreting services is required. Accurate 

communication between pharmacist and patient 

about correct use of medicines and potential 

adverse effects are likely to enhance treatment 

outcomes and prevent serious adverse events such 

as overdose. A telephone interpreting service is 

the preferred choice amongst those who returned 

our survey. 

In response to our findings, WDHB WATIS 

has commenced a staged roll-out of interpreting 

services to all community pharmacies located 

in the Waitemata district. This means that all 

community pharmacies should have had access to 

funded professional interpreting services by the 

end of April 2010. 

Conclusion 

New Zealand has a growing population of NES 

residents who access health services. Community 

pharmacists frequently serve this population, 

with limited use of interpreting services 

or translated resources. Although these findings 

indicate that respondent pharmacists have at least 

partially adapted to the needs of their patients, 

if professional interpreting services were made 

accessible, improved communication, and drug 

safety are likely to result. 

References 

1. Flores G, Laws MB, Mayo SJ, Zuckerman B, Abreu M, Medina 

L, Hardt EJ. Errors in medical interpretation and their potential 

clinical consequences in pediatric encounters. Pediatrics. 

2003 Jan;111(1):6–14. 

2. Koren G, Barzilay Z, Greenwald M. Tenfold errors in administration 

of drug doses: a neglected iatrogenic disease in 

pediatrics. Pediatrics. 1986 Jun;77(6):848–9. 

3. Bradshaw M, Tomany-Korman S, Flores G. Language barriers 

to prescriptions for patients with limited English proficiency: a 

survey of pharmacies. Pediatrics. 2007 Aug;120(2):e225–35. 

4. Phokeo V, Hyman I. Provision of pharmaceutical care to 

patients with limited English proficiency. Am J Health Syst 

Pharm. 2007 Feb 15;64(4):423–9. 

5. Westberg S, Sorensen T. Pharmacy-related health disparities 

experienced by non-English speaking patients: impact of 

pharmaceutical care. J Am Pharm Assoc. 2005, 45(1):48–54. 

6. Census of Population and Dwellings. Statistics New Zealand; 

2006. 

7. Zhou L. Health needs assessment for Asian people in Waitemata. 

Auckland: Waitemata District Health Board;2009 Feb. 

8. Pharmacy Council workforce demographics. Pharmacy Council 

of New Zealand; June 2010. 




Development, validation (diagnostic accuracy) 

and audit of the Auckland Sleep Questionnaire: 

a new tool for diagnosing causes of sleep disorders in 

primary care 

Bruce Arroll MBChB, PhD; 1 Antonio Fernando III MD, Am Bd Cert Psych; 2 Karen Falloon MBChB, 

FRNZCGP; 1 Guy Warman PhD; 3 Felicity Goodyear-Smith MBChB, MGP, FRNZCGP 1 

ABSTRACT 

Introduction: Sleep disorders are common in the community and in primary care populations. 

Epidemiological surveys generally report insomnia rather than specific diagnoses. 

Aim: Our aim was to develop a questionnaire that could diagnose common sleep disorders in primary 

care in order to be able to make a diagnosis of primary insomnia by excluding other causes. Having created 

such a questionnaire, we then validated it (assessed the diagnostic accuracy). 

Methods: The questionnaire was developed from the International Classification of Sleep Disorders 

using the criteria to create operational criteria. This was used in a primary care survey. A sub-sample of 36 

primary care patients (aged over 15 years) was chosen to give a spectrum of disorders. A second sample 

of 85 patients was taken from a sleep disorder private practice to act as an extra test of validity. 

1 


Practice and Primary Health 

Care, The University of 

Auckland, Auckland, 


2 

Department of Psychological 

Medicine, The University of 

Auckland 

3 

Department of Anaesthesia, 

The University of Auckland, 

Auckland 

Results: The response rate was 73% (36/49) for the primary care validation. The sensitivity and specificity 

of primary insomnia was 0.78 and 0.77, mood disorders 0.67 and 0.97, obstructive sleep apnoea 

0.8 and 0.94, delayed sleep phase disorder was 0.8 and 0.97 and for health problems affecting sleep 0.92 

and 0.76. There were a wider range of findings in the private practice audit. 

Discussion: The validity of the Auckland Sleep Questionnaire is promising. The second version of the 

questionnaire will use this study to improve its functionality. 

Keywords: Sleep disorders; validation studies; primary health care 

Introduction 

Our research group has been interested in assessing 

the effectiveness of treatments for primary 

insomnia in primary care. In order to offer 

treatment for this condition, it was necessary 

to make a diagnosis. It became apparent that, 

in order to diagnose primary insomnia, other 

common causes of sleep disorders needed to be 

ruled out. The aim of this project was to develop 

a screening questionnaire and a gold standard 

questionnaire against which to test it, and to use 

the questionnaire to diagnose a variety of conditions 

that can cause sleep disorders in primary 

care. The validation of the screening questionnaire 

will be published elsewhere. The study 

consists of a two-page sleep screening tool and a 

seven-page gold standard known as the Auckland 

Sleep Questionnaire (ASQ). Other gold 

standard questionnaires such as the Pittsburgh 

Sleep questionnaire were not suitable because 

they measure the severity of a sleep disorder 

rather than give specific diagnoses. 1 Ohayon 

has produced a computerised version of a sleep 

questionnaire and we have used his algorithm 

as the basis for making a diagnosis. 2 His studies 

so far have been in community populations, but 

the publications enabled us to decide what sleep 


2011;3(2):107–113. 


Bruce Arroll, 

Professor, Department 

of General Practice 

and Primary Health 

Care, The University of 

Auckland, PB 92019 

Auckland 1142, 


b.arroll@auckland.ac.nz 




disorder conditions should and should not be 

included in a primary care sample. The first aim 

of this study was to develop a tool (reference 

standard, i.e. ASQ) to make diagnoses of conditions 

that could cause sleep disorders in general 

medical settings in order to find those with primary 

insomnia through a process of exclusion. 

It was also planned that the ASQ could be used 

for epidemiological purposes. The second aim 

was to determine the sensitivity and specificity 

(diagnostic accuracy) of the tool for the common 

sleep disorders. 

Methods 

This project was conducted in three parts. The 

first part was the development of the ASQ as a 

reference standard. The second part was a validation 

study conducted according to the STARD 

statement for diagnostic tests. 3 The third part 

Table 1. Definition of sleep and other disorders used in the study 

Condition 

Criteria 

Sleep symptoms 

Medical problem 

Mood disorders 

Breathing disorder 

Substance problem 

Other sleep disorder 

(parasomnia and 

restless leg) 

Reported sleep problem 

Significant duration 

Depression 

Anxiety 

Nightmares 

Night panic 

Obstructive sleep apnoea 

Problem getting to sleep, staying asleep OR 

Waking early (on at least 3 nights per week) interfering with activities on the following day 

Symptoms present for >1 month 

Significant health problems affecting ability to sleep well occurring ≥3/week 

PHQ score ≥10 

GAD score ≥8 

Alcohol CAGE score ≥ 2 

Drugs affecting sleep 

Sleepwalking 

Sleeptalking 

Bruxism 

Restless leg 

Delayed sleep phase disorder 

Primary insomnia 

PHQ = Patient Health Questionnaire 

GAD = Generalised Anxiety Disorder Questionnaire 

DSPD = Delayed sleep phase disorder 

Recurrent severe nightmares that wake occurring ≥3/week 

Wake up at night having an anxiety or panic attack occurring ≥3/week 

Having ≥4 of: (i and ii must be present) 

i. Excessive daytime sleepiness 

ii. Pauses in between breaths during sleep 

iii. Morning headache 

iv. Dry mouth 

v. Loud snoring 

Reported drugs affecting sleep or quality of sleep 

Reported sleepwalking, started before a teenager, difficulty arousing during episode and no 

subjective awareness 

Occurring ≥3/week causing disturbance to bed partner and no subjective awareness of 

episode 

Reported teeth grinding AND one of abnormal wear of teeth, sounds associated with 

grinding or jaw muscle discomfort occurring ≥3/week 

Unpleasant sensations (aches, pains or creeping) in legs affecting sleep, relieved by 

movement or rubbing occurring ≥3/week 

Three of the following: 

• Considers self to be an evening person, 

• Choosing to go to bed late, OR 

• Choosing to wake up late, AND 

• Has no medical problem, mood disorder, substance problem, breathing disorder or 

other sleeping disorder 

Reported sleep problem for a significant duration (as defined above) AND has no medical 

problem, mood disorder, substance problem, breathing disorder, other sleep disorder or DSPD 




was an audit of the questionnaire as used by a 

psychiatrist trained in sleep disorders (PTS). 

Part 1. The development of the ASQ 

The ASQ was developed using the criteria from 

the International Classification of Sleep Disorders 

(2001) for conditions that were expected in 

primary care or else were considered potentially 

important in primary care. 4 In a community 

sample in Korea, Ohayon found that the common 

sleep problems were depression, anxiety disorders, 

primary insomnia, disorders of sleeping, 

substance-induced sleep disorder, sleep disorder 

due to a medical condition and circadian rhythm 

sleep disorders. 2 A similar study conducted in 

Italy added hypersomnia to the above list of 

diagnoses from Korea. 5 Our research team met 

to discuss how the criteria could be converted 

to a questionnaire format. In addition to these 

conditions, the research team added questions on 

parasomnias, nightmares, night panic, postmenopausal 

flushes and teeth grinding. For these latter 

conditions they needed to occur on at least three 

nights per week to be considered to be contributing 

to a sleep disorder. Caffeine use was not 

specifically asked about as it was thought this 

would come out in the open-ended questions in 

the questionnaire. Some arbitrary decisions were 

made to enable the diagnostic criteria to be put 

in to a written format (Table 1). For example, obstructive 

sleep apnoea (OSA) ultimately requires 

an overnight sleep study (polysomnography) as 

this is the gold standard for this condition. We 

considered a total of four or five criteria, i.e. (i) 

having both excessive daytime sleepiness (“Do 

you experience excessive sleepiness during the 

day, e.g. falling asleep in waiting rooms, lectures 

or when a passenger in a car”) and (ii) pauses in 

between breaths (“Do you experience frequent 

episodes of breathing pauses (or gasping for air) 

during sleep” or “Has someone told you that you 

stop breathing while you are asleep”) and two 

of three of the following: (iii) morning headaches 

(iv) dry mouth and (v) loud snoring. Thus a score 

of four or five out of five would indicate probable 

OSA as a cause of the sleep disorder. Mood disorders 

included patients with either a score on the 

Patient Health Questionnaire (depression inventory) 

≥10, a score ≥8 on the GAD (general anxiety 

disorder inventory which measures post-traumatic 


What we already know: There are two questionnaires that can determine 

the prevalence of different sleep disorders in clinical and community 

settings. 

What this study adds: This is the first questionnaire that enables the 

diagnosis of multiple sleep disorders in primary care and which has been 

validated in a primary care population. 

Table 2. Demographics for validation study; total participants N=36 

Demographic 

Age 

Number of 

participants 

16–35 years 15 

36–55 years 13 

56–75 years 7 

76–85 years 1 

Gender 

Female 28 

Male 8 

Ethnicity 

European 27 

Maori 1 

Samoan 1 

Other 7 

No sleep disorder according to gold standard interview 9 

Primary insomnia 7 

Sleep disorder diagnoses not mutually exclusive 

as diagnosed by the gold standard interview 


Mood disorder* 6 

Sleep apnoea 4 

Delayed sleep phase disorder 5 

* Includes depression and anxiety and night panic and nightmares but excludes bipolar disorder 

stress disorder, generalised anxiety disorder, panic 

disorder and social anxiety) or if they reported 

nightmares or night panic. 6,7 

Part 2. The validation study 

This was conducted in conjunction with the use 

of the ASQ in a consecutive sample of primary 

care patients (aged over 15 years). 8 As the sample 




was consecutive, the majority of patients were not 

attending for sleep issues and unpublished results 

found that many did not want help with their 

sleep problem even if they were concerned. A 

sub-sample of patients willing to be interviewed 

by a PTS was selected by one of the investigators 

(BA). This was chosen as the gold (reference) 

standard as we wished to validate the ASQ as a 

tool to enable primary care physicians to have a 

working diagnosis on which to act. They were 

purposively selected to ensure a range of patients 

with sleep problems as well as a reasonable proportion 

of those with no sleep problem. A random 

selection of patients would have potentially limited 

the number of conditions covered by the selection, 

especially as our resources only allowed for a 

small sample size. The aim was to get a prevalence 

of approximately 50% for sleep disorders in order 

to get similar confidence intervals around the 

sensitivity/specificity point estimates. A purely 

random sample would have made for a wide 

confidence interval around the sensitivity and a 

narrow one around the specificity. The information 

from the ASQ was not given to the PTS so 

that he was blind to the information according to 

best practice for diagnostic tests. 3 He was given 

contact details and conducted the interview by 

telephone and wrote down his diagnoses which 

were then compared with the diagnoses from the 

ASQ. The PTS interview took place between one 

and four weeks from the completion of the ASQ. 

The sensitivity and specificity and confidence 

intervals were calculated using the Centre for 

Evidence-Based Medicine at the University of 

Toronto website (www.cebm.utoronto.ca/). 9 

Part 3. The audit study 

The study psychiatrist (AF), a PTS, used the 

questionnaire in his private practice. The patients 

completed the form before the face-to-face interview 

with him. He did not see the ASQ prior 

to making his diagnosis. The ASQ had the data 

entry conducted by a research assistant blind to 

the diagnosis of the patients. AF wrote down 

his diagnoses without consulting the ASQ. The 

ASQ was then matched with the PTS diagnosis. 

While this sample is not a primary care sample 

it provided another clinical situation in which to 

audit/validate the ASQ. Ethics approval for this 

study was given by the Northern Regional Ethics 

Committee NTX/07/05/038. 

Results 

Part 1: The questionnaire was piloted on 10 patients 

and changes were made to make it more readable. 

Part 2: Forty-nine people were approached for 

the in-depth interview for the validation study. 

Eleven declined to be involved, four did not 

have sufficiently complete ASQ forms and nine 

were not included for a variety of administrative 

reasons—hence the number of participants interviewed 

was 36. For the demographics of these 

participants see Table 2. 

Table 3 shows the ASQ versus the PTS gold 

standard for common causes of insomnia, and 

Table 4 presents the sensitivities, specificities, 

and positive and negative likelihood ratios of the 

ASQ screening tool against the gold standard. 

It can be seen that the test is highly specific for 

sleep disorders associated with mood, OSA and 

delayed sleep phase disorder (DSPD) along with 

high positive likelihood ratios. 

Part 3. Audit of private practice 

One hundred consecutive files were selected. 

Eleven did not have a complete ASQ, two patients 

came for non-sleep issues and one file could not be 

found—hence there are 85 patients in this analysis. 

Demographics of this sample are shown in Table 5. 

Table 3. 2x2 tables for common causes of insomnia on asq versus pts gold standard interview 

True positive False negative False positive True negative 

Primary insomnia 19 5 2 10 

Mood 4 2 1 29 

Obstructive sleep apnoea 4 1 2 29 

Delayed sleep phase disorder 4 1 1 30 

Health problem 3 8 0 25 




Table 4. Measures of validity for common causes of insomnia on asq versus pts gold standard interview 

Primary insomnia 

Mood 

Obstructive 

sleep apnoea 

Delayed sleep 

phase disorder 

Health problem* 

Sensitivity 

95% CI 

0.78 

(0.58–0.9) 

0.67 

(0.3–0.9) 

0.8 

(0.35–0.96 ) 

0.8 

(0.38–0.96) 

0.92 

(0.39–0.99) 

Specificity 

95% CI 

0.77 

(0.5–0.92) 

0.97 

(0.83–0.99) 

0.94 

(0.79–0.98) 

0.97 

(0.84–0.99) 

0.76 

(0.59–0.87) 

Likelihood ratio +ve 

95% CI 

3.39 

(1.2–9.4) 

20 

(2.7–149) 

12.4 

(3.0–50.8) 

24.8 

(3.4–179.1) 

3.81 

(1.9–7.5) 

Likelihood ratio –ve 

95% CI 

0.28 

(0.12–0.5) 

0.35 

(0.11–1.07) 

0.2 

(0.04–1.2) 

0.21 

(0.036–1.2) 

0.12 

(0.002–4.4) 

* Health problem 0.25 put in false negative cell to allow calculator to work 

Table 5. Demographics in the private practice audit sample; total participants N=85 

Demographic 

Age 

Gender 

Participants 

Range 17 to 77 

Median 42 

Female 40 

Male 45 

Ethnicity 

European 74 

Maori 2 

Niuean 3 

Asian 3 

Other 3 

No sleep disorder according to gold standard interview 0 


Sleep disorder diagnoses not mutually exclusive as diagnosed by the gold standard interview 

Bipolar affective disorder 1 

Mood disorder* 42 

Sleep apnoea 6 

Bruxism 1 

Delayed sleep phase 14 

Sleep walking 3 

Physical health reasons 4 

Social causes 2 

Alcohol cause 1 

Idiopathic hypersomnia 5 

Restless legs 0 

Parasomnia 5 

Night eating syndrome 1 

Menopause 2 

Fibromyalgia 2 

Drug causes 2 

Seizures 1 

* Includes depression and anxiety and night panic and nightmares but excludes bipolar disorder 




Table 6. 2x2 tables for common causes of insomnia on asq versus pts private practice interview; n= 85 

True positive False negative False positive True negative 

Primary insomnia 10 17 9 49 

Primary insomnia only* 8 11 11 55 

Mood 27 4 30 24 

Obstructive sleep apnoea † 3 3 6 73 

Delayed sleep phase disorder 6 3 13 63 

Alcohol sleep 0 2 2 81 

Parasomnia 2 5 3 75 

* This is against the gold standard when primary insomnia was the only diagnosis 

† 

Obstructive sleep apnoea on Auckland Sleep Questionnaire at 4 or 5 

Table 6 shows the ASQ versus the PTS gold 

standard for common causes of insomnia in private 

practice, and Table 7 presents the sensitivities, 

specificities, and positive and negative likelihood 

ratios of the ASQ screening tool against the 

gold standard in this context. 

Discussion 

The ASQ performs well on the five common 

causes of sleep disorder in primary care. The likelihood 

ratio positive for primary insomnia would 

increase the post-test probability by more then 

20% while for mood, OSA and DSPD the likelihood 

would increase by more than 50%. 11 For the 

negative likelihood ratio the reduction in post-test 

probability for primary insomnia is about 25% and 

for mood 20%, OSA 45% and for DSPD less than 

10%. Health issues are the other common cause of 

sleep disorders in primary care and it is probably 

better to assess by clinician questioning although 

it had a good negative likelihood ratio. The ASQ 

performed better overall in the validation sample 

than in the private practice. As it was designed 

for primary care, this is not a major concern. 

A strength of this study is that it was conducted 

in the population in which it has and will be 

used, and that it was conducted using the STARD 

statement criteria for a diagnostic validation 

study. 3 Specifically, the ASQ was asked before the 

blinded gold standard interview. A weakness was 

Table 7. Measures of validity for common causes of insomnia on asq versus pts private practice interview 

Primary insomnia (all)* 

Primary insomnia (only) † 

Mood 

Sensitivity 

(95% CI) 

0.37 

(0.22–0.56) 

0.42 

(0.23–0.64) 

0.87 

(0.71–0.95) 

Obstructive 

sleep apnoea ‡ 0.5 

(0.19–0.81) 

Delayed sleep 

phase disorder 

Alcohol sleep § 

Parasomnia 

0.67 

(0.35–0.88) 

0.11 

(0.01–0.71) 

0.29 

(0.08–0.64) 

Specificity 

(95% CI) 

0.85 

(0.73–0.92) 

0.83 (0.73–0.9) 

0.44 

(0.32–0.58) 

0.92 

(0.84–0.97) 

0.83 

(0.73–0.9) 

0.98 

(0.92–0.99) 

0.96 

(0.89–0.99) 

Likelihood ratio 

+ve 

2.4 

(1.09–5.19) 

2.5 

(1.19–5.4) 

1.57 

(1.19–2.1) 

6.6 

(2.2–20.0) 

3.9 

(1.98–7.7) 

4.6 

(0.09–237) 

7.4 

(1.5–37.3) 

Likelihood ratio 

-ve 

0.75 

(0.55–1.02) 

0.7 

(0.47–1.04) 

0.29 

(0.11–0.76) 

0.54 

(0.24–1.21) 

0.4 

(0.16–1.02) 

0.91 

(0.57–1.45) 

0.74 

(0.46–1.19) 

* This is against the gold standard when primary insomnia could be one of many diagnoses 

† 

This is against the gold standard when primary insomnia was the only diagnosis 

‡ 

Obstructive sleep apnoea on Auckland Sleep Questionnaire at 4 or 5 

§ 

0.25 put in true positive cell to facilitate a calculation without a cell containing zero 




that some of the interviews were done up to one 

month after the ASQ was completed and some 

of the diagnoses may have changed. The other 

weakness was the small sample size. However, 

the resources of the project were limited and we 

plan to make changes to the ASQ and conduct a 

validation study on a larger population. Some of 

the questions did not delineate the severity of the 

question. For example, the question: “At night, do 

you get unpleasant sensations in your legs (aches, 

pains, creeping sensations) which affect your 

sleep” was answered by more than 20% of the 

population, but we did not have a question to ask 

them about how many times it had affected their 

sleep in the past month. We also used the CAGE 

questionnaire for alcohol intake; this is considered 

in some quarters to have a high threshold 

for alcohol problems and in future we plan to 

use the Audit tool. 10 Finally, the ASQ does not 

diagnose idiopathic hypersomnia. We used an 

expert clinical interview as a gold standard for 

OSA. It could be argued that we should have used 

polysomnography or actigraphy. This would be 

a valid conclusion for epidemiological use of the 

ASQ, but for clinical evaluation we are attempting 

to get a clinical diagnosis to enable a primary 

care clinician to make a decision about what step 

to take next. Thus, we are not attempting, in the 

clinical setting, to achieve a secure diagnosis, but 

rather to increase the pre-test probability of OSA. 

We are aware of two other studies that have had 

some validation. The Sleep-EVAL tool developed 

by Ohayon has been assessed by measures of 

agreement using kappa scores. Studies performed 

in the general population and in clinical settings 

show that Sleep-EVAL is a valid instrument in the 

assessment of sleep disorders. In the general population, 

a kappa of 0.85 was obtained in the recognition 

of any sleep problem, and a kappa of 0.70 

was found for insomnia disorders when diagnoses 

obtained by two lay interviewers using Sleep- 

EVAL were compared against those obtained by 

two clinical psychologists. In clinical settings, a 

kappa of 0.93 12 and 0.92 13 were obtained on OSA 

syndrome and kappa of 0.78 12 and 0.71 13 were 

obtained on insomnia diagnoses between Sleep- 

EVAL’s diagnoses and sleep specialists’ diagnoses 

using polysomnography. The other questionnaire 

is the GSAQ (Global Sleep Assessment Questionnaire) 

which studied patients from primary care 

and sleep clinics and validated against a sleep specialist. 

14 It reported sensitivities and specificities 

of 0.79 and 0.57 for primary insomnia, 0.83 and 

0.51 for insomnia with a mental disorder, 0.93 and 

0.58 for OSA. Our results are generally as good 

and usually better. The ASQ seems to validate 

well in a small primary care sample. The way one 

of us (BA) uses the ASQ in practice is to book a 

longer appointment time for those who say they 

have a sleep problem and ask the patient to complete 

the form before the consultation. Our plans 

are to improve the questionnaire so it can be used 

as a gold standard for other sleep work as well as 

an epidemiological tool for population studies. 

Copies of the original ASQ version 1, 2008 are included 

in the web version of this paper. Please note 

that version 2 is currently being developed. 

References 

1. Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. 

Pittsburgh sleep quality index: a new instrument for psychiatric 

practice and research. Psychiatr Res. 1989;28:193–213. 

2. Ohayon MM. Prevalence of DSM-IV diagnostic criteria of 

insomnia: distinguishing insomnia related to mental disorders 

from sleep disorders. J Psychiatr Res. 1997;31(3):333–46. 

3. Bossuyt PM, Reitsma JB, Bruns DE, Gatsonis CA, Glasziou 

PP, Irwig LM, et al. Towards complete and accurate reporting 

of studies of diagnostic accuracy: the STARD initiative. BMJ. 

2003;326:41–4. 

4. American Academy of Sleep Medicine. International classification 

of sleep disorders, revised: diagnostic and coding manual. 

Chicago, Illinois: American Academy of Sleep Medicine; 2001. 

5. Ohayon MM, Smirne S. Prevalence and consequences of 

insomnia disorders in the general population of Italy. Sleep 

Med. 2002;3(2):115–20. 

6. Nease DE, Malouin JM. Depression screening:a practical 

strategy. J Fam Pract. 2003;52:118–26. 

7. Kroenke K, Spitzer RL, Williams JB, Monahan PO, Lowe B. 

Anxiety disorders in primary care: prevalence, impairment, 

comorbidity and detection. Ann Int Med. 2007;146:317–25. 

8. Why don’t patients sleep We need the correct diagnosis; a 

prevalence study of sleep disorders in primary care. The Royal 

New Zealand College of General Practitioners annual conference; 

2010; Christchurch. 

9. Centre for Evidence-Based Medicine University of Toronto; 

http://www.cebm.utoronto.ca 

10. Wennberg P, Escobar F, Espi F, Canteras M, Lairson DR, 

Harlow K, et al. The alcohol use disorders identification test 

(AUDIT): A psychometric evaluation. Reports from the Department 

of Psychology, U. Stockholm. No. 1996;811(2):1–14. 

11. Mcgee S. Simplifying likelihood ratios. J Gen Intern Med. 

2002;17:647–50. 

12. Ohayon MM, Guilleminault C, Zulley J, Palombini L, Raab H. 

Validation of the Sleep-EVAL system against clinical assessments 

of sleep disorders and polysomnographic data. Sleep. 

1999;22(7):925–30. 

13. Hosn R, Shapiro CM, Ohayon MM. Diagnostic concordance 

between sleep specialists and the sleep-EVAL system 

in routine clinical evaluations (abstract). J Sleep Res. 2000;9 

(suppl):86. 

14. Roth T, Zammit G, Kushida C, Doghramji K, Mathias SD, Wong 

JM, et al. A new questionnaire to detect sleep disorders. Sleep 

Med. 2002;3:99–108. 

FUNDING 

We wish to thank The 

University of Auckland 

Research Committee 

for funding this study. 






Factors influencing cigarette access 

behaviour among 14–15-year-olds in 

New Zealand: a cross-sectional study 

Rupert Nelson; 1 Janine Paynter PhD; 1 Bruce Arroll MB ChB, PhD, FRNZCGP 2 

1 

Action on Smoking and 

Health New Zealand, 


2 



Care, School of Population 

Health, The University of 


ABSTRACT 

Introduction: Young people access tobacco from both retail and social sources such as family or 

friends. Both social influences and density of tobacco retail outlets may be associated with frequency of 

youth smoking. 

Aim: To update New Zealand data on demographic factors and social influences associated with retail 

access and social sources. 

Methods: The sample consisted of 14–15-year-old New Zealand youth who self-reported as current 

smokers. Outcome measures were participants’ reporting of three different methods of cigarette access. 

Descriptive data was presented and multiple logistic regressions were used to examine associations 

between demographic and social influence factors and cigarette sources. 

Results: Current smoking habits was found to be the strongest predictor of cigarette source, with daily 

smokers much more likely to report retail purchase than less than monthly smokers (adjusted OR 11.23, 

95% CI 10.10–12.47). The second strongest predictor was parental smoking habits—students with both 

parents smoking being much more likely to obtain from family than students with neither parent (adjusted 

OR 2.10, 95% CI 1.95–2.26). Socioeconomic status and living in highly populated areas were also factors 

significantly associated with particular sources of tobacco. 

Discussion: Though this study is cross-sectional, many potential confounders were controlled for, and 

results are consistent with the notion that financial means and urban proximity to tobacco retailers are enabling 

some students to use retailers as a cigarette source. Increased taxation and persuading adult family 

members to quit and to be more possessive about their cigarettes will help protect youth from smoking. 

KEYWORDS: Smoking; youth; adolescent; supply; availability; nicotine; social; retail 


2011;3(2):114–122. 


Janine Paynter 

Research and Policy 

Analyst, Action on 

Smoking and Health New 

Zealand, PO Box 99126, 

Newmarket, Auckland, 


jpaynter@ash.org.nz 

Introduction 

In 2008, 39.5% of New Zealand’s Year 10 students 

had smoked at least once in their lives and 

12% were smoking at least monthly. 1 Youth smoking 

rates are falling, 1 but remain a problem in 

New Zealand (NZ) and elsewhere: it is estimated 

that in the United States, 75–90% of smokers begin 

smoking before 18 years old. 2 Despite policies 

implemented to restrict youth access to cigarettes, 

such as a minimum purchase age of 18 years, 

controlled purchase operations to check retailer 

compliance and banning cigarettes from schools, 

the average age of youth smoking initiation in 

NZ is 14.6 years. 3 

Interventions targeting youth access to cigarettes 

are considered inefficient because retailer 

compliance is expensive to enforce and cigarettes 

are often sold on by youth. However, perceived 

accessibility is a strong predictor of both smoking 

initiation and progression to heavier smoking. 4,5 

Furthermore, youth who smoke daily are more 

likely, and able, to buy cigarettes. 6,7 Finally, cigarettes 

in ‘social’ circulation originate from adults, 

such as retailers or parents: obtaining cigarettes 

from friends is not a form of supply that can sustain 

itself. Thus, it is important to address supply 

and increasing tax has had a measurable effect in 

reducing access to tobacco in other countries. 8,9 




The 2002 New Zealand Youth Lifestyle Survey 

reported that 35.3% of smokers aged 14–16 usually 

purchased their cigarettes from shops, 6 while others 

obtained tobacco from social sources. Scragg et 

al. 10 found that relative risk of obtaining cigarettes 

from family members doubled if one parent 

smoked and almost tripled when both parents 

smoke. Friends and parents were significant social 

sources in New Zealand and globally. 4,6,7,11,12 

This study updates previous studies conducted 

by Darling et al. 6 and Scragg et al. 10 and investigates 

more recent trends in sources of cigarettes 

for youth in New Zealand. Variables considered 

in the study were investigated in other studies 

of youth sources of tobacco such as Leatherdale. 7 

The variables include age and gender, plus parental, 

sibling and friend smoking habits on supply 

of tobacco. Level of urbanisation was also considered 

because recent studies have found associations 

between the youth smoking and density of 

tobacco retail outlets. 13 Finally, the frequency of 

a student’s current smoking was considered, as 

Darling et al. 6 measured an association between it 

and youths’ source of tobacco. 6 

Methods 

This study examines a subset of data from the 

National Year 10 ASH Snapshot Survey collected 

from 2002 to 2005, 1 which also provided 

data for Scragg et al.’s study. 10 This is an annual 

census style survey and all New Zealand schools 

with Year 10 students were invited to administer 

a questionnaire to all Year 10 students. 14 The 

questionnaire was an anonymous, pen-and-paper 

questionnaire completed during class time and 

supervised by teachers. The Ministry of Health 

Auckland Ethics Committee gave permission to 

survey without formal referral to the Committee. 

Eligibility 

Students were included in this study based on 

whether or not they were current smokers. This 

was determined by students’ answers to the 

following question: “How often do you smoke 

now” Students had the options of “I have never 

smoked/I am not a smoker now.”; “At least once 

a day.”; “At least once a week.”; “At least once a 

month.”; and “Less often than once a month”. 


What we already know: Perceived accessibility to tobacco is a predictor 

of youth smoking. Youth obtain tobacco from both retail and social sources. 

There have been some changes in laws relating to retail sale of tobacco in 

New Zealand in recent years. 

What this study adds: This study adds a detailed examination of factors 

associated with obtaining tobacco from either retail or social sources and 

demonstrated a significant association between socioeconomic status, population 

density and purchase of tobacco. 

Those who answered: “I have never smoked/I am 

not a smoker.” were not included in this study. 

Eligibility was also restricted to students of 14 or 

15 years of age (students outside this age bracket 

are likely to be atypical for their school level). 

Access to tobacco variables 

Students’ tobacco access behaviours were determined 

by the following question: “Where do you 

get your cigarettes” and students were asked to 

tick as many places as applied out of: “I buy them 

myself.”; “From a family member.”; and “From a 

friend or someone else.” 

Covariates 

The survey asked age, gender, and self-assigned 

ethnicity. Students could choose more than one 

ethnic group and a priority system was used to 

group the students for analysis. Maori, Pasifika, 

Asian, New Zealand European then other ethnicities 

is the order of prioritisation. This order 

of prioritisation is also used in the New Zealand 

Tobacco Use Survey. 15 

School decile was used as a proxy measure for 

socioeconomic status (SES). Decile 1 schools 

are those in the 10% of New Zealand schools 

with the highest proportion of students from 

low socioeconomic status backgrounds, whereas 

decile 10 schools are those in the 10% of New 

Zealand schools with the lowest proportion of 

these students. 

Urban category was determined by dividing 

participants into three categories based on their 




District Health Board (New Zealand is divided 

into 21 DHBs) and the DHB each participant belonged 

to was determined by the student’s school 

address. Participants in category 1 (least urban) 

were from those DHBs with less than 50% of 

their population living in one of New Zealand’s 

16 main urban areas. Participants in category 2 

were from DHBs with between 50% and 85% of 

their population living in these areas. Participants 

in category 3 were from DHBs with more than 

85% living in these areas. Demographic characteristics 

of the DHBs were courtesy of the New 

Zealand Ministry of Health as well as Statistics 

New Zealand. 16,17 

To obtain data about smoking by friends and family, 

students were asked: “Which of the following 

people smoke” They could choose as many 

options as applied out of “Mother”, “Father”, 

“older brother or sister” or “best friend”. The 

question: “Do people smoke inside your house” 

was also asked, with participants given the options 

of “Yes” or “No”. 

Statistical analysis 

All descriptive data and crude odds ratios were 

obtained using Stata version 10 (StataCorp, 

USA). Adjusted odds ratios were estimated by 

using three two-level multiple logistic regression 

models (Stata 10) for each of the three different 

sources of tobacco (retail, family or friends) and 

the covariates age, gender, ethnicity, year, school 

socioeconomic status, parental smoking, sibling 

smoking, peer smoking, smoking in the home, 

current smoking frequency and urban category. 

These variables formed the first level and the second 

level was a school identity variable included 

to account for clustering of the data by school. 

All variables were categorical variables, with the 

exception of year, which was treated as a continuous 

variable. Students with missing data for any 

one of these variables were excluded from logistic 

regression analysis. 

Results 

The annual school response rate was 67% in 

2002 (n=312), 66% in 2003 (n=312), 65% in 2004 

(n=319) and 58% in 2005 (n=278). 

Demographic characteristics and smoking behaviours 

are shown in Table 1. As only smokers were 

eligible to be participants in this study, certain 

demographic groups such as females were more 

strongly represented than groups with proportionally 

fewer smokers (e.g. males). Additionally, 

for each demographic, Table 1 shows the number 

and unadjusted proportion of participants reporting 

retail purchase, obtaining from family and 

obtaining for friends or others. The results of 

multiple logistic regression analysis are shown in 

Table 2 and 3. 

Year 

Odds of a teenager reporting they had purchased 

tobacco from a shop were significantly lower in 

2005 compared to 2002. When adjusted for confounders, 

the odds ratio for retail purchase still 

showed a small but significant decline. Adjusted 

odds ratios for obtaining from family showed a 

small increase over time. Odds ratios for obtaining 

from friends or others did not change 

significantly. 

Age 

Both crude and adjusted odds ratios showed 

15-year-olds are more likely to make retail purchase 

than 14-year-olds. Conversely, 15-year-olds 

are less likely to report obtaining cigarettes from 

friends or others less than 14-year-olds. 

Gender 

Females were significantly less likely to purchase 

cigarettes but more likely to report obtaining 

cigarettes from social sources. 

Ethnicity 

Maori smokers were more likely to obtain cigarettes 

via retail purchase and from family than 

NZ Europeans, but less likely to obtain them 

from friends or others. Asians had the highest 

crude and adjusted odds ratios for retail purchase 

(adjusted OR 1.52, 95% CI 1.43–1.76), and the 

lowest crude and adjusted odds ratios for obtaining 

from friends and others (adjusted OR 0.54, 

95% CI 0.47–0.63). 




Table 1. Descriptive statistics of sample 1 

Variable Number Retail purchase (%) From family (%) From friends or others (%) 

n 36441 22.3 26.0 74.2 

Year 

2002 9927 24.0 23.3 75.1 

2003 10257 22.9 26.8 73.4 

2004 8155 20.3 26.7 73.5 

2005 8102 21.6 27.7 74.7 

Age 

14 years 17356 19.9 25.7 76.0 

15 years 19085 24.5 26.3 72.5 

Gender 

Male 14603 23.4 22.3 70.1 

Female 21700 21.5 28.5 77.0 

Ethnicity 

NZ European 21437 19.5 21.1 78.8 

Maori 10133 26.3 37.3 67.0 

Pasifika 2744 23.6 26.5 72.6 

Asian 1355 31.3 19.8 62.8 

Other 413 21.6 19.9 70.2 

School decile 

1 1356 25.2 36.4 66.7 

2 3034 22.9 35.3 68.8 

3 3131 23.1 32.3 69.8 

4 3773 22.6 30.4 71.0 

5 4530 22.4 27.4 74.8 

6 4590 21.6 26.8 76.2 

7 4628 21.4 23.6 75.2 

8 3948 21.0 21.0 76.8 

9 2791 21.5 20.3 77.6 

10 4460 23.2 16.6 77.9 

Urban category 

1 8768 18.4 29.0 74.5 

2 15358 22.3 26.8 73.4 

3 12315 25.2 22.9 74.9 

Current smoking 

Daily 13940 40.4 40.4 59.1 

Weekly 5324 22.1 21.5 79.4 

Monthly 5481 11.4 17.0 85.4 

Less than monthly 11696 5.90 15.1 84.5 

Parental smoking 

Neither smoke 15662 19.4 14.3 81.2 

One smokes 11248 22.1 31.1 72.2 

Both smoke 9012 27.5 40.3 64.6 

Smoking in home 

No 20562 20.0 18.3 78.9 

Yes 15137 25.4 36.6 68.0 

Sibling smoking 

No 20618 19.1 18.4 79.2 

Yes 15304 26.5 36.5 67.6 

Friend smoking 

No 13758 14.7 21.5 74.7 

Yes 22164 26.9 29.0 73.9 




Table 2. Association between demographic variables and cigarette source 

Variable 

Crude OR 

(95% CI) 

Retail purchase Obtaining cigarettes from family Obtaining cigarettes from friends or others 

p 

value 

Adjusted OR 

(95% CI) 

p 

value 

Crude OR 

(95% CI) 

p 

value 

Adjusted OR 

(95% CI) 

p 

value 

Crude OR 

(95% CI) 

p 

value 

Adjusted OR 

(95% CI) 

p 

value 

Year 0.88 (0.87–0.90)



Table 3. Association between social influence variables and cigarette source 

Retail purchase Obtaining cigarettes from family Obtaining cigarettes from friends or others 

Variable 

Crude OR 

(95% CI) 

p 

value 

Adjusted OR 

(95% CI) 

p 

value 

Crude OR 

(95% CI) 

p 

value 

Adjusted OR 

(95% CI) 

p 

value 

Crude OR 

(95% CI) 

p 

value 

Adjusted OR 

(95% CI) 

p 

value 

Current smoking 

Less than monthly 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference) 1.00 (reference) 

Monthly 1.88 (1.74–2.04)



Socioeconomic status 

Students who attended schools in a higher decile 

were more likely to purchase tobacco. (Adjusted 

OR 1.91, 95% CI 1.46–2.49, p



A limitation was the response rate of Year 10 

students. Over the four-year period, 129 315 out 

of a total of 247 336 Year 10 students completed 

the questionnaire (52.3%), creating some self-selection 

bias. 15 However, much (although not all) of 

this non-response was due to a student’s school’s 

non-participation, rather than from individuals 

choosing to opt out. Other limitations were the 

measures of socioeconomic status and degree of urbanisation. 

School decile is unlikely to be a precise 

measure of socioeconomic status, but collapsing 

the deciles into three categories will compensate 

for this imprecision. All participants of the same 

DHB were classed in the same urban category, despite 

considerable variability within some DHBs. 

However, the looseness of these measures is likely 

to mean that the true effects of these two variables 

are likely to be under-estimated. 

An additional limitation was the use of crosssectional 

data, which meant that direction of 

causality cannot be determined. For example, 

the relationship between intensity of current 

smoking and retail purchase may be due to 

the fact that regular smokers rely on a regular 

source (as suggested by DiFranza) 18 However, 

more alarmingly, it may be that regular smokers 

become regular smokers due to the existence of 

a reliable source. 

Another limitation was the use of odds ratios 

instead of risk ratios—a requirement due to the 

use of logistic regression. Odds ratios overestimate 

risk ratios in cross-sectional studies, 

particularly when there is a high prevalence of 

the outcome variable. 

Comparison with literature 

and implications 

Many findings of this study concur with those 

found by Leatherdale. 7 For example, male 

students and older students are more likely to 

buy their own cigarettes. This study’s strongest 

finding, that regular smokers are more likely to 

seek retail purchase, reaffirms what was found 

in another New Zealand study by Darling et al. 6 

Despite increases in controlled purchase operations 

in some areas, retail supply is still a significant 

problem in New Zealand. 

Research has been carried out on the effect of 

cigarette taxes on youth smoking rates. Two studies 

8,9 made quantitative estimates of the effect of 

raising cigarette prices on youth smoking rates, 

with one reporting that “the real price of cigarettes 

has a negative and significant impact on the 

number of youth and young adults who smoke 

and average level of smoking among those who 

smoke”. This evidence is supported by results 

from this study which suggest that barriers for 

retail purchase exist for low SES students. Increasing 

tax beyond inflation will extend barriers 

to students of higher SES. Moreover, NZ-based 

research is required to examine the effect of taxation 

on youth smoking rates and cigarette access. 

Two observational studies 13,19 have found increased 

smoking prevalence was associated with 

higher population density and this study found 

significantly increased odds of retail purchase 

of cigarettes with higher urbanisation. Reasons 

for this may be that a lack of physical proximity 

to tobacco retailers acts as a barrier to retail 

purchase or less anonymity of the students. One 

study 4 has established perceived accessibility as a 

strong predictor of youth smoking rates. Urban 

youth, who have more tobacco retailers within 

close proximity, are at higher risk of seeing cigarettes 

as easily accessible commodities. 

Primary care practitioners have the potential to 

reduce family and social access to cigarettes in 

the first instance by encouraging cessation and 

also by highlighting the importance of social 

sources in maintaining or allowing experimentation 

by younger family members. 

Conclusion 

This study illustrates the presence of a wide 

number of circumstantial and demographic factors 

which affect the cigarette access behaviours 

of youth smokers. The smoking habits of those 

around them act as an influence on the sources 

that they seek, suggesting an opportunistic method 

of access. Financial means and the physical 

proximity to tobacco retailers in cities are both 

variables which are strongly associated with retail 

purchase acting as a viable source of cigarettes for 

some youth. 





This questionnaire was a 

large undertaking and was 

made possible by large 

amounts of voluntary work 

over the course of several 

years. In particular, we are 

extremely grateful to New 

Zealand school principals, 

teachers and students for 

their efforts. Questionnaire 

development from 2003 to 

2005 relied on the input of 

the research coordinating 

group, comprising; 

Associate Professor Robert 

Scragg, Dr Judith McCool, 

Dr Tony Reeder, Sharon 

Ponniah, Anaru Waa and 

Kate Garland. Thanks also 

to Ben Youdan, the director 

of ASH, who agreed 

to provide resources 

while this research 

was conducted, and to 

Professor Bruce Arroll for 

his efforts in supervising 

this project. Finally, thanks 

must go to Professor Chris 

Wild of The University of 

Auckland for the statistical 

consultation he provided. 

FUNDING 

The questionnaire was 

funded by the New 

Zealand Ministry of Health 

(MoH) and was managed 

cooperatively by Action on 

Smoking and Health and 

the Health Sponsorship 

Council. The MoH had 

no part in the decision to 

conduct this specific study, 

nor was it involved in this 

study in any way other than 

through funding of the 

questionnaire. The Faculty 

of Medical and Health 

Sciences of The University 

of Auckland provided a 

grant towards the carrying 

out of this research. We are 

highly appreciative of The 

University of Auckland’s 

financial support. 

References 

1. Paynter J. National Year 10 ASH Snapshot Survey, 1999–2008: 

trends in tobacco use by students aged 14–15 years. Auckland: 

ASH New Zealand; 2009. 

2. Elders MJ, Perry CL, Eriksen MP, Giovino GA. The report of 

the Surgeon General: preventing tobacco use among young 

people. Am J Public Health. 1994;84(4):543–7. 

3. Ministry of Health. Tobacco trends 2006: monitoring tobacco 

use in New Zealand. Wellington: Ministry of Health; 2006. 

4. Doubeni CA, Li W, Fouayzi H, Difranza JR. Perceived accessibility 

as a predictor of youth smoking. Ann Fam Med. 

2008;6(4):323–30. 

5. Robinson LA, Klesges RC, Zbikowski SM, Glaser R. Predictors 

of risk for different stages of adolescent smoking in a biracial 

sample. J Consult Clin Psychol. 1997;65(4):653–62. 

6. Darling H, Reeder A, McGee R, Williams S. Access to 

tobacco products by New Zealand youth. N Z Med J. 

2005;118(1213):U1408. 

7. Leatherdale ST. Predictors of different cigarette access 

behaviours among occasional and regular smoking youth. 

Can J Public Health. Revue Canadienne De Santé Publique 

2005;96(5):348–352. 

8. Tauras JA, Peck RM, Chaloupka FJ. The role of retail prices 

and promotions in determining cigarette brand market shares. 

Review of Industrial Organization 2006;28(3):253. 

9. Carpenter C, Cook PJ. Cigarette taxes and youth smoking: 

new evidence from national, state, and local Youth Risk Behavior 

Surveys. J Health Econ. 2008;27(2):287–99. 

10. Scragg R, Laugesen M, Robinson E. Parental smoking and 

related behaviours influence adolescent tobacco smoking: 

results from the 2001 New Zealand national survey of 4th form 

students. N Z Med J. 2003;116(1187):U707. 

11. Wong G, Glover M, Nosa V, Freeman B, Paynter J, Scragg 

R. Young people, money, and access to tobacco. N Z Med J. 

2007;120(1267):U2864. 

12. Widome R, Forster JL, Hannan PJ, Perry CL. Longitudinal patterns 

of youth access to cigarettes and smoking progression: 

Minnesota Adolescent Community Cohort (MACC) study 

(2000–2003). Prev Med. 2007;45(6):442–6. 

13. Novak SP, Reardon SF, Raudenbush SW, Buka SL. Retail tobacco 

outlet density and youth cigarette smoking: a propensitymodeling 

approach. Am J Public Health. 2006;96(4):670. 

14. Ministry of Education. Education Counts. 2008. 

15. Ministry of Health. New Zealand Tobacco Use Survey 2006. 

Wellington, New Zealand: Ministry of Health; 2007. 

16. Ministry of Health. Frequently asked questions about District 

Health Boards. Wellington, New Zealand: Ministry of Health; 

2008. 

17. Statistics New Zealand. Subnational population estimates tables. 

Wellington, New Zealand: Statistics New Zealand; 2009. 

18. DiFranza JR. Has youth access to tobacco changed over the 

past decade Changing Adolescent Smoking Prevalence, 

Smoking and Tobacco Control Monograph No 14. Bethesda, 

USA: US Department of Health and Human Services; 

2001:183–192. 

19. McCarthy WJ, Mistry R, Lu Y, Patel M, Zheng H, Dietsch B. 

Density of tobacco retailers near schools: effects on tobacco 

use among students. Am J Public Health. 2009;99(11):2006– 

13. 





quaLitative research 

The value of te reo in primary care 

Suzanne Pitama MA Hons, Dip Ed Psych; 1 Annabel Ahuriri-Driscoll MPH Distinction; 2 Tania Huria BA, BN 

RcpN, MPH Credit; 1 Cameron Lacey MBChB, FRANZCP; 1 Paul Robertson PhD, MAHons, DipClinPsych 1 

ABSTRACT 

Introduction: The influence of indigeneity is widely recognised as a health determinant; however 

the impact of the utilisation of the indigenous language on health care has not been closely examined. 

Aim: To explore the Maori language (te reo) as a determinant of health from a Maori patient’s perspective. 

1 

Maori Indigenous Health 

Institute, University of Otago, 

Christchurch, New Zealand 

2 

The Institute of 

Environmental Science 

and Research (ESR) Ltd, 

Christchurch 

Methods: Maori patients were recruited through Maori health networks and the snowballing technique. 

Thirty participants participated in one of three focus group interviews. A semistructured interview 

explored the utilisation of health services, comfortability with service delivery and perceptions of general 

practice surgeries’ cultural competency. Thematic analysis was utilised to interpret the data. 

Results: Te reo was recognised as an important cultural competency, noted by participants as contributing 

to the development of appropriate doctor–patient relationships and their feelings of being valued 

within a practice. Patient-led use of te reo was identified as most appropriate, an indicator of quality of care. 

Discussion: The training of primary care staff in te reo should be encouraged. Developed as a competency, 

this will see primary care settings better able to respond to Maori patients and in turn support 

Maori health gains. 

Keywords: Maori health; Maori language; family practice; quality health indicators 

Introduction 

The influence of one’s ethnic culture, and more 

specifically indigenous culture, as a health 

determinant is well recognised. 1–5 However, the 

impact of utilisation of the indigenous language 

on health care has not been closely examined. 6 

The current article examines patients’ perceptions 

of the value of use of the Maori language (te reo*) 

in primary health care settings. 

* Te reo refers to ‘Maori language’ for the purposes of this paper. 

Health disparities between indigenous and nonindigenous 

peoples have been well documented 

in New Zealand (NZ) and a number of other 

countries. 7–10 A range of factors have been identified 

as contributing to these disparities, with 

increasing evidence that variables relating to clinician 

and institutional practice have a significant 

impact. 11–14 Such findings have prompted the development 

of strategies specifically for clinicians 

and health care providers to strengthen their 

capacity to support indigenous health outcomes. 

In the NZ health environment this has involved 

the promotion of cultural competency and safety, 

particularly in the health education sector. 15 

This provides a context in which to consider 

Maori health issues and explore/develop appropriate 

competencies and skills. 16 To date, inclusion 

of the Treaty of Waitangi, cultural protocols, 

communication strategies, epidemiological data 

and Maori health models, as well as facility in te 

reo have been identified as pivotal in increasing 


2011;3(2):123–127. 


Suzanne Pitama 

MIHI, University of Otago, 

PO Box 4345, Christchurch, 


Suzanne.pitama@ 

otago.ac.nz 




the clinician’s ability to work effectively with 

Maori patients and whanau. 15,17–19 The application 

of elements of te reo is the focus of the current 

article; specifically, data drawn from Maori 

patients’ perspectives on determinants of quality 

in primary health care. 

Methods 

The wider study from which the current data 

was drawn was conducted in 2001 and involved 

the evaluation of a Ministry of Health funding 

model used in contracting an Independent 

Practitioners Association (IPA). 20 This study 

involved a multi-methods evaluation approach 

to determine the efficacy of this funding model 

and its potential to be transferred to other IPAs. 

For the purpose of this paper, an aspect of 

the project, which involved Maori community 

perceptions of this IPA’s health service delivery, 

is reported on. 

Maori patients were identified and invited to 

participate through the local Maori provider 

referrals were followed up by the research team 

and, utilising the general information form, were 

invited to participate in one of two further focus 

group interviews. All those invited to take part 

in the research agreed. 

All participants were asked their ethnicity upon 

recruitment, using the Census 2001 question. 

Participants ranged in age from 25 to 70 years of 

age, with 19 of the participants being female. Participants 

ranged in work experience. At the time 

of the interview, 10 worked within the health 

environment, five were involved within the education 

sector, five were retired, eight worked in other 

fields of employment and two were not employed 

at the time of the interviews. Participants attended 

the same GP surgery each time (except in emergencies 

where they would access either the 24-hour 

after-hours clinic or the emergency department). 

The exact number of surgeries represented by the 

participant group was not specifically captured. 

However, the experiences shared within the transcripts 

highlight that these practices ranged across 

deprivation areas within Christchurch and were all 

Participants recounted many experiences of having their name 

mispronounced, and noted how this had led them to feel belittled 

or unwelcome in the clinic, discouraging them from attending again. 

network. To be included participants needed 

to self-identify as Maori, be registered with a 

general practitioner (GP) from the IPA, and to 

have visited their GP at least four times in the 

previous 12 months. The latter criteria allowed 

participants to comment on the basis of multiple 

visits, as opposed to a single experience. Exclusion 

criteria included those who were under 16 

years of age, and those deemed as cognitively 

unable to give personal informed consent. 

Ten participants agreed to participate through 

the initial provider network recruitment strategy. 

Twenty more participants were subsequently recruited 

through a snowballing technique. 21 This 

involved the initial 10 participants identifying 

other friends/family/colleagues they knew who 

might be interested in participating. These initial 

urban-based. Participants received a petrol voucher 

as koha for their time and sharing of knowledge. 

For the purpose of this study, 30 participants 

were seen as adequate to provide the breadth and 

depth of experiences necessary to saturate any 

themes arising from the data. 22 

A semi-structured interview schedule was used 

to explore utilisation of health services, comfortability 

with service delivery and perceived 

cultural competency of their general practice 

surgery. Interview times were 1.5 and two hours 

respectively. All focus groups were audio taped 

and transcribed verbatim. 

Data analysis took an inductive thematic approach 

in order to represent the patient voice 




without imposing coding schemes. The interview 

transcripts were analysed by two researchers 

and broad themes identified. These themes were 

collated and condensed according to similarity. 

The final categorisation of themes resulted after 

four sorting procedures; consensus was reached 

throughout the process by the researchers agreeing 

on the category generation. 

The Canterbury Ethics Committee reviewed 

and approved the complete research evaluation 

(CTY/01/03/031). 

Findings 

Although the interview schedule did not ask 

specifically about te reo, this emerged as a significant 

theme in all focus groups. The results are 

presented below in relation to the three primary 

themes derived from the data. 

1. Name pronunciation 

“I would really like to have my name pronounced 

correctly.” 

During discussion of barriers to care, participants 

were asked what constitutes ‘good health care’. The 

focus groups’ initial responses related to the medical 

receptionist pronouncing their name correctly. 

Participants recounted many experiences of having 

their name mispronounced, and noted how this 

had led them to feel belittled or unwelcome in the 

clinic, discouraging them from attending again. 

“I hate that every clinic I’ve ever been into it’s 

always Ms X [mispronounced Maori name by medical 

receptionist] and now I don’t bother saying my 

name or any of my children’s names [correctly]. 

Things won’t change.” 

“You are in the waiting room and you hear the 

receptionist/nurse go TTTTTTTTT….and you sigh, 

get up and go in, you know it’s you.” 

“You look at people that go to my doctors… a hell of 

a lot of Pakeha, every single thing is Pakeha. Right 

down to the abuse, verbal abuse of your name.” 


What we already know: Increasing evidence has identified that variables 

relating to clinical and institutional practice have an impact on indigenous 

health outcomes. 

What this study adds: The use of Maori language, patient-directed, is 

a variable that impacts Maori patients’ perceptions of quality care within a 

primary care setting. 

Participants agreed that everyone in the practice 

(the medical receptionist, nurse and GP) pronouncing 

their name correctly was a measure of 

‘gold standard’ health care. They saw this, as not 

only a sign of respect, but also indicative of the 

GP’s intention to engage with them, as Maori. 

“I get on a first name basis now in our medical clinic, 

it’s not very often you get called by your name 

correctly.” [Participant had a Maori first name.] 

2. Relationship development skill 

A second theme to emerge was that the use of te 

reo had assisted in the development of positive 

relationships between participants and their 

general practice surgeries. Although all patients 

spoke fluent English, there were times when 

they preferred to use te reo. The main reason for 

this was that they felt they were better able to 

articulate how they felt about their health condition 

and/or presenting complaint characteristics. 

Often this was conveyed by the use of one word 

(e.g. hoha) or a phrase (he mate au). It was also 

seen as an opportunity to share more with the 

general practice about themselves and their connection 

to the Maori world and Maori beliefs and 

values—including te reo. 

There was an expectation by participants that 

their general practice surgeries would either 

know/understand these words or seek clarification. 

When general practice staff ignored or 

reacted to te reo negatively (e.g. body language 

or verbal commentary), participants took this as 

a sign that Maori perspectives were not valued, 

or seen as valid. Furthermore, participants also 

perceived this as a strong message that general 

practice did not want to develop a relationship 

with them. Such negative experiences had led 

some participants to disengage with the health 

system for a period of time. 




“They ask you how you feel and you say hoha, and 

they say what ...waste of time… they just don’t get 

you… so you say nothing.” 

Participants reported feeling high levels of satisfaction 

and having enhanced connection with 

primary health care providers who did engage in 

te reo, either by repeating Maori words used, or 

seeking further clarification of the word/phrase 

meaning. Participants perceived a general practice 

prepared to attempt te reo as more ‘trustworthy’. 

“My GP was a good doctor… I would go in there and 

I could say xyz [words in te reo] and there was a 

relationship.” 

It is interesting to note that for participants the 

relationship was seen as pivotal to the quality of 

health care; several noted that if their GP moved 

surgeries they would follow, in order to maintain 

the relationship. Some participant accounts saw 

whanau travelling for more than 40 minutes to 

maintain continuity with that GP. 

3. Quality of care indicator 

Participants identified that Maori visual media 

(such as posters, signs and brochures) alone were 

not sufficient as a sole mechanism for engaging 

with Maori patients. Such efforts were seen as 

tokenistic, as indicated by the following brief 

conversation: 

Interviewer: “How would you define tokenism” 

P1: “Seeing a Maori bear sitting in the corner…” 

P2: “…or Manu doll” 

P3: “…or just a ‘haere mai’ sticker or something on 

the door like that…” 

The use of te reo was seen as an important nontokenistic 

indicator of cultural competency. Overall, 

participants felt strongly that future health 

care for Maori should encompass the use of te reo 

as a quality indicator. 

“I mean the ideal that being like a culturallysensitive 

experience is right out there, it’s sort 

of like the year 2020. I’m hearing kia ora when I 

walk through the door… I’d like it to be but it’s 

sort of dreaming. That’s where I’d like to take my 

children… somewhere like that.” 

All participants agreed that use of te reo should 

be patient-led. However, they clearly identified 

that if patients do use te reo within the general 

practice setting, it needed to be valued and 

responded to in a positive way. 

Discussion 

This study highlights the value of te reo usage 

within primary care, as perceived by participants. 

This can be as simple as making an effort to correctly 

pronounce patients’ names and to utilise 

te reo spoken by the patient. Te reo was clearly 

identified as assisting in relationship-building 

between clinician and patient and as an indicator 

of quality health care. 

Over the past decade there has been a trend 

towards the use of te reo in health promotion, 

reflecting both increasing numbers of te reo 

speakers within NZ and recognised benefit of 

providing targeted health care messages/interventions. 

23,24 The use of te reo is seen as a core 

cultural competency central to enhancing communication 

and engagement. More specifically, te 

reo can be a vehicle to better understand cultural 

protocols (tikanga) and Maori health perspectives. 

However, in order to be sensitive and responsive 

to individual Maori patients, clinicians should 

mirror patients’ use of te reo, rather than assume 

fluency or acceptability. 

International attempts to develop a range of 

cultural competencies have tended to focus on 

clinician knowledge of health disparities and 

eliciting patients’ health beliefs. 25–27 The value of 

clinicians’ adoption of indigenous language as a 

key cultural competency and clinical skill has not 

previously been explored. 

There are a number of limitations within this 

study. Firstly, the participant group was drawn 

from a single community and it is unknown 

whether similar beliefs are held throughout 

Aotearoa. Secondly, the inclusion of health care 

workers within the focus groups may also limit 

the generalisability of conclusions drawn in this 




study to Maori patients in general. Additionally, 

the absence of adolescent participants within this 

study means that we were not able to explore the 

value of te reo to younger Maori in this context, 

a group amongst whom there is increasing usage 

and fluency. Finally, whilst the use of te reo was 

valued by these participants, it remains to be 

shown whether use of te reo in primary care will 

ultimately affect Maori health outcomes. 

However, despite these limitations it is clear 

from the study findings that use of te reo can 

significantly enhance the experience of Maori 

patients in general practice and primary care. 

From the perspective of strengthening service 

responsiveness and therefore quality, staff 

within primary health care providers ought to be 

encouraged to improve their pronunciation and 

use of te reo. This is a powerful symbol of provider 

interest and willingness to engage meaningfully, 

can assist in understanding a patient’s 

health beliefs and, ultimately, foster a stronger 

therapeutic alliance. 

References 

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of disparity: ethnic mortality trends in New Zealand 

1980–1999. Wellington: Ministry of Health and University of 

Otago; 2003. 

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Palafox N, Jackson-Pulver L. Indigenous health in Australia, 

New Zealand, and the Pacific. The Lancet. 2006; 

2006/6/2/;367(9524):1775–85. 

3. Bramley D, Herbert P, Jackson R, Chassin M. Indigenous 

disparities in disease-specific mortality, a cross-country 

comparison: New Zealand, Australia, Canada, and the United 

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4. Stephens C, Porter J, Nettleton C, Willis R. Disappearing, displaced, 

and undervalued: a call to action for Indigenous health 

worldwide. Lancet. 2006;367(9527):2019–28. 

5. White H, Walsh W, Brown A, et al. Rheumatic heart disease 

in indigenous populations. Heart Lung Circ. 2010/6//;19(5– 

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6. King M, Smith A, Gracey M. Indigenous health part 2: 

the underlying causes of the health gap. Lancet. 

2009;374(9683):76–85. 

7. Ministry of Health. He Korowai Oranga: Maori Health Strategy. 

Wellington: Ministry of Health; 2002. 

8. Ministry of Health and University of Otago. Decades of disparity 

3: ethnic and socioeconomic inequities in mortality, New 

Zealand, 1981–1999. Wellington: Ministry of Health; 2006. 

9. Robson B, Harris R, editors. Hauora: Maori Standards of 

Health IV. A study of the years 2000–2005. Wellington: Te 

Ropu Rangahau Hauora a Eru Pomare; 2007. 

10. Reid P, Robson B. State of Maori Health. In: Mulholland M, 

editor. State of the Maori nation: twenty-first century issues in 

Aotearoa New Zealand. Reed Publishing; 2006. p17–32. 

11. Bramley D, Riddell T, Crengle S, et al. A call to action on Maori 

cardiovascular health. N Z Med J. 2004;115:176–9. 

12. Crengle S, Lay-Yee R, Davis P, Pearson J. A comparison of 

Maori and non-Maori patient visits to doctors, 2005. Report 

No. 6. 

13. Harris R, Tobias M, Jeffreys M, Waldegrave K, Karlsen S, 

Nazroo J. Effects of self-reported racial discrimination and 

deprivation on Maori health and inequalities in New Zealand: 

cross-sectional study. Lancet. 2006;367:2005–09. 

14. Westbrooke I, Baxter J, Hohan J. Are Maori underserved for 

cardiac interventions N Z Med J. 2001;114(1143):484–7. 

15. Jansen P. Culturally competent health care. N Z Fam Phys. 

2002; 29(5):306–311. 

16. Tipene-Leach D. Cultural sensitivity and the GP: a Maori GP’s 

perspective. Patient Management. 1994:1–4. 

17. Cram F, Smith L, Johnstone W. Mapping the themes of Maori 

talk about health. N Z Med J. 2003;116:1170. 

18. Durie M. Providing health services to indigenous peoples. 

BMJ. 2003;327:408–409. 

19. Pitama S, Robertson P, Cram F, Gillies M, Huria T, Dallas-Katoa 

W. Meihana model: a clinical assessment framework. NZ J 

Psych. 2007;36(No. 3):118–25. 

20. Kirk R, Barnett P, Clayden C, et al. Evaluation of Pegasus 

Health Global Budget Contract: New Zealand Health Technology 

Assessment. 2002. 

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South Melbourne, Victoria, Australia: Oxford University 

Press; 1999. 

22. Green J, Thorogood N. Qualitative methods for Health Research. 

London: SAGE Publications; 2004. 

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Injury Prevention Project. Ethnicity Health. 2004;9(1):5–15. 

24. Henwood W. Maori knowledge: a key ingredient in nutrition 

and physical exercise health promotion programmes for 

Maori. Soc Policy J NZ. 2007;32:155. 

25. Betancourt JR. Cultural competence—marginal or mainstream 

movement N Engl J Med. 2004 Sep 2;351(10):953–5. 

26. Kumas-Tan Z, Beagan B, Loppie C, Macleod A, Frank B. Measures 

of cultural competence: examining hidden assumptions. 

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29–36. 


The authors would like to 

thank the participants and 

the IPA for participating 

in this research. We 

also acknowledge Maria 

Hepi (nee Jellie) for 

her contribution as an 

interviewer on this project, 

and Dr Catherine Savage 

for her assistance in the 

review of this paper. 

FUNDING 

This study was funded by 

the Ministry of Health. 






Patients’ and health professionals’ 

perceptions of teamwork in primary care 

Susan Pullon MPHC, FRNZCGP (Dist), MBChB; Eileen McKinlay MA (Appl); Maria Stubbe DipTESL 

DipTCHG PhD; Lindsay Todd BSc; Christopher Badenhorst BSc 

Department Primary Health 

Care and General Practice, 

University of Otago, 

Wellington, New Zealand 

ABSTRACT 

Introduction: Effective teamwork in primary care settings is integral to the ongoing health of those 

with chronic conditions. This study compares patient and health professional perceptions about teams, 

team membership, and team members’ roles. This study aimed to test both the feasibility of undertaking 

a collaborative method of enquiry as a means of investigating patient perceptions about teamwork in 

the context of their current health care, and also to compare and contrast these views with those of their 

usual health professionals in New Zealand suburban general practice settings. 

Methods: Using a qualitative methodology, 10 in-depth interviews with eight informants at two practices 

were conducted and data analysed using inductive thematic analysis. 

Findings: The methodology successfully elicited confidential interviews with both patients and the 

health professionals providing their care. Perceptions of the perceived value of team care and qualities 

facilitating good teamwork were largely concordant. Patient and health professionals differed in their 

knowledge and understanding about team roles and current chronic care programmes, and had differing 

perceptions about health care team leadership. 

Conclusion: This study supports the consensus that team-based care is essential for those with 

chronic conditions, but suggests important differences between patient and health professional views as 

to who should be in a health care team and what their respective roles might be in primary care settings. 

These differences are worthy of further exploration, as a lack of common understanding has the potential 

to consistently undermine otherwise well-intentioned efforts to achieve best possible health for patients 

with chronic conditions. 

KEYWORDS: Primary health care; chronic disease; physicians; nurses; patients; patient care team 


2011;3(2):128–135. 


Susan Pullon 

Senior Lecturer, 

Department Primary 

Health Care and 

General Practice, 

University of Otago 

PO Box 7343, Wellington 

South, New Zealand 

sue.pullon@otago.ac.nz 

Introduction 

Effective collaborative practice is a key principle 

of health service delivery in primary care; 1 interdisciplinary 

teamwork is an essential component 

of best practice chronic conditions care. 2,3 Over 

60% of all clinical work in New Zealand (NZ) 

primary care involves patients with ongoing 

chronic conditions. 4 Both general practitioners 

(GPs) and practice nurses (PNs) are usual on-site 

primary care providers within general practices. 

Understanding the nature of teamwork is increasingly 

important. 

Positive effects of good teamwork are well documented, 

but much less is known about the nature 

of chronic care teams in primary care settings. 

While much has been made of patient-centred 

approaches to care 5 in the last 20 years, an extensive 

literature review found few studies about 

patients’ views of team care, and no empirical 

research where both patients and health professional 

views were directly compared. However, 

patients are known to report different elements 

than clinicians in relation to patient satisfaction, 6 

suggesting that there may also be divergent views 

about teamwork. 




Collaborative teamwork occurs along a continuum, 

with not all care requiring high 

level alliance. 7 Multidisciplinary teamworking 

(where health professionals work alongside 

one another each undertaking aspects of care, 

but with little interaction) is at the minimal 

end of the continuum, and for many types of 

episodic care, entirely appropriate. Interdisciplinary 

teamworking implies mutually respectful 

engagement between health professionals 

in planning and implementing care together. 8 

Transdisciplinary teamwork lies at the maximal 

end of the continuum, occurring when all 

members have excellent knowledge and appreciation 

of everyone’s roles within a common 

reference framework. Such complex shared care 

runs smoothly because team members have the 

ability to act quickly in accordance with shared 

interprofessional objectives using shared skill 

sets. 9 In primary care, the busy, diverse nature 

of clinical practice means collaboration varies 

along this continuum; for patients with complex 

conditions, interdisciplinary and transdisciplinary 

teamworking are essential to achieving best 

possible patient outcomes. 

To be effective, teamwork must also be visible 

to, and valued by, patients. 10 There is increasing 

evidence of the health benefits of effective 

teamwork, but there has been little research investigating 

patients’ perceptions of the value and 

make-up of health care teams, or of their own 

place within such teams. Limited evidence available 

suggests that many people with long-term 

chronic conditions value a ‘partnership’ between 

patient, health care professionals and carers. 11 

Patient knowledge about health professional roles 

is uncertain. In recent NZ studies, 12,13 patients 

reported only a vague understanding of the PN’s 

role, and “frequently spoke interchangeably about 

nurses, receptionists and technicians”. 12 

Perceptions about the nature and value of teamwork 

vary among health professionals. There is 

often poor understanding of roles and tasks of 

other professionals, 8 which makes the value of 

teamwork at best implicit, often invisible to the 

inexperienced. 

Consistent government policies, regulatory 

frameworks and funding models that foster 


What we already know: People with complex health conditions benefit 

from a team approach to their health care with, and from, a range of health 

professionals. Teamwork in health care is often assumed, but much less often 

realised. 

What this study adds: There appear to be some important differences 

between patient and health professionals’ perceptions about teamwork in 

health care, particularly in relation to CarePlus. Whereas health professionals 

perceived themselves to be working in health care teams with defined roles 

and explicit outcomes, patients appeared largely unaware of the nature of 

health professional teams or their own role in their care. 

collaboration are essential. 7,14,15 During the past 

decade there has been emphasis in the NZ 

health system on primary health care, including 

expectation of effective interprofessional 

teamwork and integration across primary and 

secondary care. 16 

The CarePlus programme was introduced by the 

Ministry of Health in 2004 to fund systematic 

management of patients with two or more 

chronic conditions (approximately 5% of the 

general practice population). CarePlus encourages 

goal setting by patients and well-informed 

self-management. 17 

Our previous work suggests that, despite nurses 

and doctors sometimes being perceived as having 

poor interprofessional relationships, there are notable 

examples of excellent collaborative relationships 

in primary care settings. 18,19 However, this 

is not universal practice; principles of chronic 

care management are often poorly understood. 20 

Despite ‘teamwork intention’, little is known 

about nurses’, doctors’ and patients’ perceptions 

of collaboration and teamwork in NZ primary 

care workplaces. 

This study aimed to test the feasibility of 

undertaking a collaborative method of enquiry 

as a means of investigating patient perceptions 

about teamwork in the context of their 

current health care, and also to compare and 

contrast these views with those of their usual 

health professionals in NZ suburban general 

practice settings. 




Method 

A qualitative methodology based on principles of 

naturalistic enquiry 21 was chosen as appropriate to 

explore patient and health professional perceptions 

about teamwork in ongoing patient care. 

Because no previous comparative studies of this 

nature have been conducted, either in NZ or in a 

comparable health system, it was necessary to test 

the feasibility of a collaborative data collection 

and analysis process. Data were collected from 

patients and their usual health care professionals 

using very similar flexible interview schedules. 

Practice–researcher collaboration was required 

to set up interviews in a manner acceptable to 

patients and health professionals. Two researcher– 

interviewers conjointly collected data and undertook 

analysis. 

Two medium-sized general practices in Wellington 

NZ, recognised as using a ‘team-based’ 

approach in their management style, were purposively 

selected. One was a suburban-rural practice 

with many younger patients (18–30 years), the 

other an urban practice with more middle-aged 

and older patients (over 40 years). Both were 

situated in densely populated areas with a diverse 

cultural and ethnic mix. Ten interviews were 

conducted in 2009 with four health professionals 

and four patients; two patients undertook a 

second interview. A semi-structured schedule 

was developed to guide the interviews with key 

topic areas relating to participants’ understanding 

of teamwork within health care, barriers and 

facilitators to such teamwork, who is or should 

be included in a patient care team, team member 

roles, appropriate leadership of a patient care 

team, and additionally for patients—perceptions 

about their own health care team(s), roles, leadership 

their own place in the team, and knowledge 

about the CarePlus scheme. 

Ethics approval 

This study was approved as two inter-related 

substudies by the Central Regional Ethics 

Committee, NZ (CEN/08/42/EXP and 

CEN/08/43/EXP). 

Recruitment, data collection 

A health professional at each participating practice 

(one PN, one GP) nominated 10–12 patients 

within the CarePlus programme who fitted inclusion 

criteria. Patients were eligible for selection 

if they had two or more chronic conditions that 

necessitated regular, frequent interaction with 

more than one health professional at the practice. 

It was accepted that patients selected in this 

way would more likely be satisfied with their 

care. Although the health professionals provided 

the initial list of possible patients, they had no 

knowledge of which patients were subsequently 

approached and/or interviewed. Patients were 

tele phoned by receptionists and asked if they 

would be agreeable to being interviewed. This 

process continued until a balanced sample was 

achieved of male/female and older/younger 

patients living with a range of chronic conditions 

(see Table 1). 

Two patients from each practice were interviewed 

face-to-face at a location of their choice. 

Two interviewers worked conjointly; LT as 

interviewer, CB as observer/technical supporter. 

Two of the four patients also participated in a 

follow-up phone interview two weeks later, to 

extrapolate on previous topics or voice new ideas. 

Health professionals (one PN and one GP from 

each practice), were interviewed (after completion 

of the face-to-face patient interviews) to obtain 

their different perspectives on the same work 

environment. At first contact, health profession- 

Table 1. Patient characteristics 

Practice Participant Gender Age in years Ethnicity* Chronic condition 

1 

P1 Male 48 NZ European Type 2 diabetes 

P2 Female 27 NZ European Depression, neurofibromatosis 

2 

P3 Male 88 NZ European Asbestosis, COPD 

P4 Female 33 NZ European Tuberculosis 

* Ethnicity identified using NZ census question pertaining to ethnic identification. 




als were provided with a brief explanation of 

the study objectives and process of maintaining 

confidentiality. 

All those invited (patients and health professionals) 

readily agreed to be interviewed. Workplace 

interviews took place at different times for each 

participant, with care taken to ensure each interview 

was confidential and uninterrupted (CB 

interviewer, LT technical support). 

All respondents completed a short form to collect 

data on age and ethnic group, signed a consent 

form, and agreed to audio recording of the 

interview using digital voice recording. Interviews 

lasted 30–60 minutes (patients) and 20–30 

minutes (health professionals). Interviews were 

transcribed in de-identified format by a professional 

transcriber. 

Data analysis 

Each set of transcripts was analysed initially 

by the principal interviewer. Transcripts were 

read vertically; responses to main lines of 

questioning were summarised and tabulated. 

Commonalities, discrepancies and outliers 

within and between transcripts were identified 

via subsequent horizontal analysis. Following 

this initial phase, inductive thematic analysis 22 

was undertaken, with transcripts critically read 

and re-read to identify themes which did not 

arise explicitly from direct lines of questioning. 

Each stage of analysis was rechecked by the 

whole research team. Finally, themes identified 

underwent third-tier interpretive analysis by all 

researchers to derive a set of conclusions and 

recommendations. 

Findings 

This study has tested the feasibility of undertaking 

a collaborative method of qualitative 

enquiry as a means of investigating patient 

perceptions about teamwork in the context 

of their current health care. Given that this 

research question has not been examined before, 

the study demonstrated that, with attention to 

anonymity, it is possible to undertake successful 

individual patient and health professional 

interviews in the same general practice setting. 

Furthermore, the data acquired and subsequently 

analysed through a collaborative and conjoint 

process has provided comparable information 

about patient and health professional perceptions 

regarding teams, team membership, and team 

members’ respective roles. 

Confidentiality for patients and health professionals 

was successfully maintained, despite 

multiple relationships between each patient and 

their key health providers. Patients and health 

professionals spoke freely about positive and 

negative aspects of team care. First interviews 

with all participants provided data suitable for 

analysis, but two second interviews with patients 

yielded little new material. 

Five key themes were identified: 

• Perceived value of team care 

• Qualities facilitating good teamwork 

• Roles 

• Leadership, and 

• Chronic care, CarePlus and self-management. 

Patient and health professional perceptions were 

well aligned for the first two themes. However, 

patients and health professionals had different 

understandings about roles of each team member, 

team leadership, and knowledge or otherwise of 

the CarePlus programme. 

Perceived value of team care 

For patients, the principal value of team care lay 

in tangible benefits such as the greater amount 

of time and attention a nurse could provide, and 

avoiding vulnerabilities that might arise where 

only one professional is knowledgeable about the 

complex medical history typical of most patients 

with chronic conditions: 

“I’m in a win-win situation. There’s no way I’d get 

the care and attention from…[the GP] who’s very 

busy that…[the nurse] can give me… I’m the benefit, 

a recipient of teamwork.” (P1) 

Health professionals took a broader view, with 

teamwork perceived to benefit team members and 

improve the overall quality of care delivery by 

drawing on the skills and knowledge of multiple 

health professionals: 




“A team is many different people, and with many 

different qualifications and backgrounds, and contributions 

to make… it gives you… a pool of skills 

for any one problem… no individual can provide a 

complete service…” (GP2) 

Qualities facilitating good teamwork 

Good communication was identified by patients 

and health professionals as a key quality facilitating 

teamwork. The patient participants especially 

valued regular contact, as well as information 

sharing and coordination between members of 

the primary care team: 

“…they’ve always got the practice nurse and the doctor 

working together for my benefit. The nurse has 

got how it is, because they put it on computer… so I 

often see the nurse, but I don’t see the doctor.” (P3) 

Health professionals similarly highlighted good 

communication as a vital ingredient of successful 

teamwork, but focused more on the value of 

regular meetings, good co-worker relationships, 

and a willingness to listen and debate issues: 

“The old GPs are the ones that struggle with the 

team… but these doctors here… well, they’re young, 

which helps, but they’re also willing to listen to 

what we have to say and they’re willing to work 

together with nurses.” (PN2) 

A second key quality identified was trust. Patients 

put store on being able to trust that their 

health professionals would work as a team and 

seek help when needed: 

“[Most patients] would want their doctor to be reliable, 

and to be somebody that they trust… should 

anything serious come up, they will go through the 

right channels, and work as part of a team.” (P4) 

Health professionals spoke of the need for developing 

mutual respect and interprofessional trust, 

which included sharing workloads amongst team 

members and recognising different skill sets and 

limitations: 

“We need to have mutual respect for each other… 

We need to have an understanding of each other’s 

roles and… what people are capable of.” (PN2) 

Conversely, there was some concern among 

patient participants that being cared for by a team 

might result in a loss of patient–doctor trust: 

“They’d be… because you can have quite a personal relationship 

with your doctor. So to be kind of palmed 

off to someone else feels like being palmed off.” (P1) 

Roles 

All the health professionals identified clearly 

defined roles as a prerequisite for effective teamwork. 

All described a doctor’s role in primary 

care as most often dealing with acute situations 

(including acute care for those with chronic 

conditions). All felt that current management 

of chronically ill patients, as with the CarePlus 

initiative, now fell mainly within the role of a 

nurse: 

“Most patients would see the doctor at least once a 

year… But a lot of the time in between it’s a nurse 

consultation.” (PN2) 

In contrast, patient participants appeared vague 

about the roles of each health care professional in 

their team. Patients lacked awareness about nursing 

capabilities. Nurses were not seen as holding 

responsibility for autonomous clinical decisionmaking: 

“Well, obviously the doctor is [the leader]. I mean, 

the nurse is just a sort of a reporter, isn’t she, for 

the doctor.” (P3) 

Patients considered the role of the GP was to 

have a certain overall knowledge and expertise, 

prescribe new medications, carry out examinations 

and to refer patients to specialists. As this 

participant explained: 

“…you have to rely on the doctor for all the [clinical] 

expertise.” (P1) 

The role of the patient was variously perceived. 

The two doctors viewed the patient as a recipient 

of a service being offered by a professional team, 

whereas both nurses perceived the patient to be a 

member of the team. All four patients wanted to 

be part of their own health care team, with three 

considering this was currently the case. 



The existing literature suggests that teamwork in 

NZ primary health care is underdeveloped. 23 The 

health professionals interviewed for this study 

perceive that they are working in well-functionquaLitative 

research 

Leadership 

Patients and health professionals held different 

views regarding who should take on the role of 

leader of the health care team for a particular 

patient. All the health professionals expressed 

the view that leadership was shared and skill-set 

dependent: 

“…We are all clinically accountable for the decisions 

we make, if they are seen by a nurse then the nurse is 

accountable for the decisions they make… decisionmaking, 

we are all responsible for our own.” (GP2) 

However, three out of four patient participants 

considered that their doctor (GP or hospital specialist) 

was the leader of their health care team. 

In one case, the patient concluded that either the 

doctor or he himself should take the leading role, 

as defined by who took ultimate responsibility 

for decision-making: 

“Leader… I think ultimately the responsibility comes 

back to myself. I’m sort of tossing up between 

whether it should be… it would either be [the doctor] 

or myself…” (P1) 

None of the patients considered the nurse as their 

health care team leader, even though three saw 

their nurse most often, and explained how the 

nurse coordinated care, communicated concerns 

to the GP and made necessary changes to medications 

or management: 

“I’ve had quite a lot to do with my nurse of late; I 

see or hear a lot more from her than I would my 

GP.” (P1) 

Chronic care, CarePlus and 

self-management 

The health professionals agreed that effective 

management of chronic conditions required a 

strong team-based approach, and readily identified 

CarePlus as the programme now in place to 

foster a proactive, team-based approach. Respondents 

suggested that this team-based approach 

promoted individualised care of patients with 

chronic conditions: 

“Each member of the team has got different skills to 

offer, and they complement each other… you’ve got 

to use your team skills to provide the best service 

for those patients’ needs… if you all work together, 

you can often find things that are useful to that 

individual patient…” (GP2) 

However, patients seemed unclear about the 

intent of the CarePlus programme, what it 

provided and who was involved in delivering the 

programme. Concepts of patient self-management 

were almost absent from the talk of patients. 

There was lack of recognition that this is one of 

the primary goals of CarePlus. Patients largely 

saw CarePlus as a reminder service or a (subsidised) 

tool for staff to check up on them: 

“…it can help prompt you with things that you may 

have previously thought about… it’s offered me a 

lot of peace of mind, knowing that it’s every three 

months, and yes, that it’s scheduled in…” (P4) 

“I think it means that I get a bit of a [payment] 

concession…” (P1) 

However, patient participants recognised that, in 

general, the type of care necessary for those with 

chronic conditions needed to be different from 

those who were otherwise well, with teamwork 

being an essential component: 

“I think it [teamwork] is necessary. Especially for 

people who have long-term conditions that need 

to be monitored on a regular basis… if there was 

somebody that just had day-to-day health issues, 

they probably wouldn’t see the need for a team to 

be overseeing their health care.” (P4) 

Discussion 

The introduction of an overtly team-based Care- 

Plus model in NZ primary care has crystallised 

the need for better understanding of effective 

teamwork by both patients and health professionals. 

Significant changes in primary care delivery, 

and resulting changed roles of both nurses and 

GPs in caring for patients with chronic conditions, 

seem invisible and unexplained to patients. 




ing teams. The reality probably lies somewhere 

in between. While the health professionals interviewed 

placed considerable value on good teamwork, 

and liked and respected their colleagues, 

their descriptions of practice did not often equate 

to working in a fully-fledged transdisciplinary 

team; 9 rather, they described working collaboratively 

to varying degrees. 

As in an Australian study, 11 patients in this 

study wanted to be part of their own health care 

team, and actively involved in decision-making. 

Common goals for health care teams, developed 

with patients, not only foster teamwork but 

also improve efficiency and maximise limited 

resources. 7,24 Even experienced health professionals 

would benefit from teamwork training to 

effectively achieve these goals. For some patients, 

especially within the CarePlus programme, major 

was little elaboration on how this knowledge was 

best applied to their care. 

In contrast, health professionals recognised the 

importance of understanding each other’s team 

roles and responsibilities, particularly in relation 

to successfully utilising the funding allocated to 

general practices for NZ’s CarePlus programme. 

They described how their practices were now 

organised to utilise the skills of both nurses and 

doctors, resulting in many CarePlus patients being 

principally managed by experienced practice 

nurses with GP back-up. 

The patient sample was obviously biased towards 

patients with whom health professionals 

already had a functional professional relationship. 

However, this bias is most likely to have 

produced concordance between patient views 

While the health professionals interviewed placed considerable 

value on good teamwork, and liked and respected their colleagues, 

their descriptions of practice did not often equate to working in a 

fully-fledged transdisciplinary team. 

gains may be possible from adopting a more 

intentional team approach where the patient is 

clearly identified as a team member, if not the 

team leader, and where self-management is an 

explicit goal. 

Although the patient participants were clear 

about their desire for participation, they were 

much less clear about what their own role might 

entail, or what the respective roles of each of 

‘their team’ of health professionals was or could 

be. Despite the pivotal role of nurses in CarePlus 

programme delivery, patients found it difficult to 

detail the role of ‘their’ nurse, appearing to lack 

understanding of nursing capability and skills, 

results similar to other recent NZ studies. 12,13 

Patient descriptions of the GP’s and/or the hospital 

specialist’s role was a little clearer, described 

as ‘an expert with special knowledge’, but there 

and health professional views. That this was not 

the case suggests greater discrepancies between 

patient and health professionals’ views are likely 

if this research were to be extended to other 

practice settings. 

It is also possible that patient and health professional 

perceptions would be different among 

Maori and at Maori provider practices. Other ethnic 

groups, and rural communities, may approach 

chronic condition management and collaborative 

practice differently. 

Because this was a preliminary study with 

a small number of participants, findings 

must be regarded as tentative and in need 

of corroboration with a larger number of 

participants in a wider variety of practices. 

The feasibility of directly collecting data from 

both patients and their health professionals 




has been tested and found to be a successful 

method of investigating the nature of teamwork 

in a primary care setting. 

Conclusion 

There appear to be important differences between 

patients’ and health professionals’ understandings 

about current collaborative health care 

practice in primary care settings. These warrant 

further investigation if the goals of modern 

chronic conditions care, with its emphasis on 

teamwork and effective self-management 25,26 are 

to be realised. The challenge now is to corroborate 

these preliminary findings and find ways 

to appropriately incorporate health professionals 

and patients into functional, enduring health 

care teams. 

References 

1. World Health Organization. Alma Ata Declaration. In: International 

Conference on Primary Health Care; 1978; Alma Ata, 

USSR; 1978. 

2. Wagner E. Meeting the needs of chronically ill people. BMJ. 

2001;323:945–6. 

3. World Health Organization. Innovative care for chronic 

conditions: building blocks for action. Geneva: World Health 

Organization; 2002. 

4. National Health Committee. Meeting the needs of people with 

chronic conditions. Wellington: Ministry of Health; 2007. 

5. Stewart M, Brown J, Weston W, McWhinney I, McWilliam C, 

Freeman T. Patient-centred medicine transforming the clinical 

method. Thousand Oaks, California: Sage Publications; 1995. 

6. Sitzia J, Wood N. Patient satisfaction: a review of issues and 

concepts. Soc Sci Med. 1997;45:1829–43. 

7. Oandasan I, Baker G, Barker K, et al. Teamwork in healthcare: 

promoting effective teamwork in health care in Canada. 

Ottawa: Canadian Health Services Research Foundation; 

2 June 2006. 

8. Hall P, Weaver L. Interdisciplinary education and teamwork: a 

long and winding road. Med Educ. 2001;35:867–75. 

9. Vyt A. Interprofessional and transdisciplinary teamwork. 

Diabetes Metab Res Rev. 2008;24:S106–S9. 

10. Rothman A, Wagner E. Chronic illness management: what is 

the role of primary care Ann Intern Med. 2001;138:257–62. 

11. Infante F, Proudfoot J, et al. How people with chronic illnesses 

view their care in general practice: a qualitative study. Med J 

Aust. 2004;181:70–3. 

12. Carryer J, Snell H, Perry V, Hunt B, Blake J. Long-term conditions 

care in general practice settings: patient perspectives. 

N Z Fam Phys. 2008;35:319–23. 

13. Kenealy T, Docherty B, Sheridan N, Gao R. Seeing patients 

first: creating an opportunity for practice nurse care. J Prim 

Health Care. 2010;2:136–41. 

14. Pullon S, McKinlay E, Dew K. Primary health care in New 

Zealand: the impact of organisational factors on teamwork. Br J 

Gen Pract. 2009;59 191–7. 

15. Sibbald B, Shen J, McBride A. Changing the skill-mix of the 

health care workforce. J Health Serv Res Policy. 2004;9 Suppl 

1:28–38. 

16. King A. The Primary Health Care Strategy. Wellington: Ministry 

of Health; 2001. 

17. Primary Health Care—Care Plus Funding. 2009. [Cited 2009 

April 17]. Available from: http://wwwmohgovtnz/mohnsf/ 

indexmh/phcs-funding-careplus.) 

18. Blue I, Fitzgerald M. Interprofessional relations: case studies of 

working relationships between registered nurses and general 

practitioners in rural Australia. J Clin Nurs. 2002;11:314–21. 

19. Pullon S. Competence, respect and trust: key features of 

successful interprofessional relationships. J Interprof Care. 

20 08;22:133–47. 

20. McKinlay E, McBain L. Evaluation of the Palliative Care Partnership: 

a New Zealand solution to the provision of integrated 

palliative care. N Z Med J. 2007 120:1263. 

21. Lincoln Y, Guba E. Naturalistic enquiry. Newbury Park: Sage 

Publications; 1985. 

22. Seale C. The quality of qualitative research. London: Sage 

Publications; 2000. 

23. Waitemata DHB. Interdisciplinary teamwork in primary health 

care. In: Paper presented at the CPHAC Meeting; 2008. 

24. Wagner E, Glasgow E, Davis C, et al. Quality improvement in 

chronic illness care: a collaborative approach. J Qual Improv. 

2001;27:63–80. 

25. Grumbach K, Bodenheimer K. Can health care teams improve 

primary care practice JAMA. 2004;291:1246–51. 

26. Wagner E, Austin B, Davis C, Hindmarsh M, Schaefer J, 

Bonomi A. Improving chronic illness care: translating evidence 

into action. Health Aff (Millwood). 2001;20:64–78. 


The authors wish to 

thank all the staff of the 

Department of Primary 

Health Care and General 

Practice, in particular Anne 

Robertson and Lesley Gray 

for their help coordinating 

the summer students, 

and Joy Wearne from the 

Wellington Medical School 

Library for their time and 

assistance. Thanks are 

also due to the patient 

participants and the health 

professional respondents. 

The study would not 

have been possible 

without their insights 

and thoughtfulness. 

FUNDING 

This study was funded by 

The Royal New Zealand 

College of General 

Practitioners and the 

Wellington Medical 

Research Foundation, and 

hosted by the University 

of Otago Wellington. 






Making sense of chronic illness 

—a therapeutic approach 

Sue Jacobi MHSc(Hons), BA,BD,Hons.Dip.Theol, MNZAC; 1 Rod MacLeod MBChB, MMedEd, FRCGP, 

FAChPM, PhD 2 

1 

Meadowbank Village, 


2 



Care, School of Population 

Health, The University of 


ABSTRACT 

Introduction: A diagnosis of any chronic progressive illness can be a traumatic experience. People 

wonder how they will be able to cope and health care professionals wonder how they can help those so 

affected. The aim of the study was to discover how people find meaning when they are diagnosed with 

chronic illness. The research question asked is: How do people make sense of living with chronic progressive 

illness 

Method: This is a qualitative study using a phenomenological approach to apply what is learned to developing 

therapeutic strategies in order to help those so diagnosed to find the meaning they need in order 

to live with resilience. Semi-structured interviews with seven people were held in order to determine how 

they cope with living with chronic progressive illness. The results were then used to develop some suggestions 

for health professionals as they seek to assist people with chronic progressive illness. 

Findings: All participants displayed much resilience and determination which was found to emerge 

from three main themes: memory, hope and meaning. Memory was seen to be the link between all the 

themes. These are described and, arising out of the results of this study, some suggestions are made in 

order to assist in management. 

Conclusion: It is possible for health care professionals to assist patients to make sense of chronic illness 

by helping them to view their illness as part of life, and therefore a challenge to be faced rather than 

seeing life as dominated by illness. 

KEYWORDS: Chronic disease; resilience, psychological; narration; psychology, existential 


2011;3(2):136–141. 


Rev. Sue Jacobi 

PO Box 87196, 

Meadowbank 1742, 


sjacobi@xtra.co.nz 

Introduction 

The origins of this article are to be found in 

a thesis submitted in 2009 for the degree of 

Master of Health Sciences. 1 The research question 

originates in the experience of the corresponding 

author who has multiple sclerosis. 

When cure is not possible, the relief of suffering 

is the cardinal role of medicine. 2 Caring for 

people with chronic illness involves more than 

relieving physical symptoms. Making sense 

of life is important to everyone, not simply to 

people with chronic progressive illness. However, 

when people become ill, and especially if their 

life ambitions are conflicted because of that, then 

making sense of the situation becomes urgent. 

Roos and Neimeyer 3 make the point that chronic 

loss can hamper the reconstruction of meaning. 

If we are to help patients with chronic illness 

find meaning, then we need to ensure that their 

grief is assessed and that they are helped to deal 

with it. 

Telling one’s story is at the heart of a narrative 

approach and the story is used to imagine different 

endings and reflect how the story might 

change. Not only is narrative a useful therapeutic 

tool, but it can be invaluable in terms of research. 

4 By analysing the stories of patients and 




making use of the collected stories of illness, 

researchers can learn about the ways in which 

suffering affects the self. It teaches professionals 

about suffering from people who are the experts 

(i.e. those who are suffering). Suffering is more 

than of the body and more than a psychological 

response. It involves more than coping. Therefore, 

narrative medicine has the potential to keep practitioners 

more focused on what much of medicine 

is about—caring for patients. 5 

In a study focusing on people with multiple sclerosis, 

Eeltink and Duffy 6 suggest that the experience 

of illness as well as the experience of caring for, 

and living with, an ill family member represents a 

set of unique cultural experiences. Identity is too 

often blurred by the merging of the experience 

of being a person with the experience of being a 

person who is ill—this is a life-limiting situation. 

Health professionals can help patients see their 

life events in terms which are different—by helping 

them look at new ways of being in the world. 

Finding a ‘good outcome’ in rehabilitation is no 

easy task. ‘Quality of life’, which is easily and 


What we already know: A diagnosis of chronic progressive illness can 

cause patients distress as they struggle with not only physical symptoms but 

also with existential questions. Such questions can undermine the patient’s 

ability to cope with the diagnosis. 

What this study adds: Various types of therapeutic approaches, including 

the use of narrative-type interventions, can aid the patient in their struggle 

for meaning. This study includes suggestions which may provide a way 

for patients to make sense of what is happening. 

‘Taking charge’ does not necessarily mean disposing 

of caregivers. It means that emotionally the 

patient remains as the author of his or her own 

story. Suffering from chronic, progressive illness 

does not mean simply opting out of life with all 

its ambitions, although it may mean reframing 

ambitions and making some significant emotional 

as well as physical changes. Thorne et al. 

investigate this concept by focusing on a group 

of people suffering from Type 2 diabetes, HIV/ 

AIDS and multiple sclerosis. 8 The question they 

asked was, “How do persons with chronic illness 

Identity is too often blurred by the merging of the experience of 

being a person with the experience of being a person who is ill— 

this is a life-limiting situation. Health professionals can help 

patients see their life events in terms which are different—by 

helping them look at new ways of being in the world. 

naturally assumed to be the outcome of rehabilitation, 

is difficult to determine and generally 

poorly defined. Personality plays an important 

part in the ways in which people respond to their 

disability. McPherson et al. introduce the concept 

of ‘taking charge’—which stresses the importance 

of those who are suffering ‘taking charge’ of 

aspects of their lives which in the past have been 

taken charge of by other people. 7 In the words of 

the authors: 

“The term embraces the overall philosophy of living 

with arthritis rather than relating just to disease 

control.” 

describe self-care decision-making” All participants 

reflected the outcome of an unconscious decision 

to gain control of the management of their 

disease and their subsequent efforts to do that. 

They understood that their illness was going to 

be part of their lives for the foreseeable future 

and that being in control meant that they could 

live as normally as possible, therefore knowledge 

about their disease was important. 

Carter et al. bring the concept of ‘taking charge’ 

to the fore in a study of people living with a 

terminal illness 9 . These authors demonstrate that 

preparation for dying is of far less importance 




than living life to the full, within the constraints 

of their illness. 

Suffering is more than physical and a whole 

range of issues needs to be addressed if holistic 

care is to be offered to people with chronic illness. 

10 A variety of influences in a patient’s life 

may affect their perception and experience of 

pain. Speck reminds us of the growing evidence 

for the importance of spirituality and the importance 

of addressing and responding to this. 11 

This view is supported by many patients, some of 

whom view relationships especially with family 

and friends as forming the basis of spirituality. 12 

Speck suggests that spirituality is often described 

as a search for meaning and, in fact, many people 

link spirituality and meaning. He calls this 

“existential meaning”. The aim of this study is 

to look at the components which contribute to 

finding meaning in the midst of chronic progressive 

illness. 

Method 

Table 1 Characteristics of participants 

This is a qualitative study and a phenomenological 

approach was used. Seven people (six with 

chronic progressive disease and one with severe 

irritable bowel syndrome and food intolerances) 

aged between 36 and 78 were interviewed in 

order to discover if they made sense of their 

illness and, if they did, then what strategies 

they used. Three of the participants were 

retired, one worked as a volunteer and three 

were professionals in full-time employment. 

All were European. 

Participant Age Gender Diagnosis 

Duration 

of illness 

A 65 Female Huntington’s 11 years 

B 69 Female Rheumatoid arthritis 15 years 

C 78 Female 

RA, diabetes 1, osteoarthritis, 

coeliac disease 

40 years 

D 36 Female Crohn’s 13 years 

E 67 Female 

Atrial fibrillation, diabetes 1, 

lymphoma 

25 years 

F 53 Male Renal failure, cancer, stroke 31 years 

X 46 Female 

Irritable bowel syndrome 

and food intolerances 

30 years 

Approval for the research and the ways of approaching 

potential participants was given by the 

Northern X Regional Ethics Committee of the 

Ministry of Health. (NTX/08/105). Participants 

were recruited in two ways: initially, letters were 

sent to 25 general practitioners and others were 

recruited by word of mouth. Willing participants 

were sent information sheets and consent forms, 

contacted and arrangements made for interviews. 

Each interview lasted under an hour and was audio 

taped and transcribed. The interviews were semistructured 

in order to provide similar questions for 

each interviewee. Questions were asked about the 

history of the illness, the significance of diagnosis, 

changes to life because of it, the role of spirituality 

(if any), support, disruption to life and the construction 

of meaning. Field notes were also kept. 

Transcripts were re-read several times, paying 

attention to what was said by the participant, as 

well as to become familiar with the participant’s 

situation. When all the interviews were completed, 

the transcripts were analysed and themes identified. 

Transcripts were compared with each other 

and that was followed by a comparison between 

this research and that of other researchers. 

Findings 

It became apparent that all participants demonstrated 

a large degree of determination and resilience. 

This led to questioning from whence that 

theme derived. It became clear that the emerging 

themes could be categorised under the headings 

of memory, hope and meaning. 

Participants were asked to speak about their illness 

and the effect it had on their lives. Memory 

was found to play an important role. As they 

reviewed their lives and the ways in which illness 

had impacted them, it became clear that they were 

all proud of their achievements and proud too of 

the ways in which they had coped with challenges. 

A participant with Huntington’s disease said: 

“You know I had a lovely job with teaching… I was a 

very successful teacher.” 

She also looked back with pride on the fact that 

in the past she was able to cook beautiful meals 

for people. 




Another, who has chronic renal failure, speaks of 

his experience following a stroke which left him 

severely incapacitated and having to learn to walk 

again. He had been physically very fit and describes 

how his wife “stole” him out of hospital 

one day and took him to the river basin where he 

used to run: 

“It [used to take me] 17 minutes to run around… and 

I wandered around that track… and it took me two 

and a half hours to get around… it was a long trip 

so um… yes it was a good benchmark—two-and-ahalf 

hours. I’d get back to 17 minutes one day.” 

While receiving a diagnosis can end a period of 

uncertainty, it can also bring pain and distress; but 

it also appears that having a diagnosis can allow 

people to ‘move on’ to living with the symptoms. 

Most of the participants had lived for some time 

with the symptoms before receiving a diagnosis. 

One participant felt devastated by her diagnosis 

after she had had a blood test to find out whether 

she had Huntington’s disease, but arising out of 

the shattering experience of receiving the diagnosis 

came her conclusion: 

“I decided I could live or just become a couch potato.” 

It became apparent that reflecting on past successes 

and reviewing how they coped with challenges, 

disappointments and difficulties became a 

significant part of enabling the participants to see 

their illness as part of their life narrative rather 

than seeing life in terms of the illness. 

All participants demonstrated a considerable 

amount of hope, despite their diagnosis, and, for 

some, serious incapacity. While this hope was 

fed by the memories they have of the past, both 

in terms of pride in achievement and also in conquering 

problems, there was also an appreciation 

of the fact that they had support in a variety of 

ways, including family and friends. Some spoke 

of their faith. One says: 

“I couldn’t live without my faith. And I couldn’t 

manage without it… I thank God every day for the 

gift because it is a gift.” 

Another says: 

Table 2. Themes 

Memory Hope Meaning Outcome 

Pride in achievements 

Diagnosis 

Illness as a journey 

Acceptance 

Grief 

Frustrations, changes 

and challenges 

Wider support—family, 

friends, Church 

Spirituality—role of Church 

and /or personal faith 

“Well… I ’as a chat with him every night… But I can’t 

hear him saying anything but I’m sure he does.” 

All participants were asked how they made sense 

of their condition. One spoke of genetics—her 

mother, two sisters and some of her children have 

the same disease: 

“This is something awful—this has teeth which are 

vicious.” 

Others spoke of their faith and pointed out that 

because of their experience with illness they 

were able to contribute more to the community. 

Another initially stated that she thought meaning 

was not an appropriate category: 

“Well… to me it seems everybody gets something… 

we all are going to suffer… and to die… well maybe 

not to suffer but we’re going to die. Why do we 

need to find a meaning This is God’s will for us… 

this is our cross… that’s my meaning.” 

However, later in the interview she shared a 

somewhat different opinion: 

“I strictly believe this… it’s very flaky but I believe 

that I gave the disease to myself… Because… nobody 

in my family’s got it… there’s no history of it… just 

me and why I did it is that for three weeks I put 

my body under enormous stress, trying to be Mrs 

Perfect… doing about 15 jobs when I could really 

seriously only manage three… I was doing exam 

supervision… um… I was looking after a lady… I had 

to do her shopping… I was working… I had an hour 

or so just between finishing work and getting to 

the university… I pushed, pushed, pushed myself… 

Making 

sense 

Resilience and 

determination 




After three weeks—blow me down… I had a stiff 

knee… a very painful wrist… the nodules which are 

another key symptom… I was finished… so I truly 

believe that and no medical people would accept 

that but that’s what I believe and yes I grieved over 

that but I didn’t have to do all that I was just trying 

to be too blooming perfect! And now I can’t change 

it… it’s non-returnable… you see what I mean The 

symptoms are distressing… but I knew I’d brought it 

on myself… I had no one to blame… so there you go.” 

Someone else simply said: “Maybe people like 

us inspire people who have nothing wrong with 

them.” 

All displayed high levels of resilience and determination. 

Despite all that seemed to be going 

wrong in their lives, they seem to have risen 

above it and become stronger. 

to find meaning in the midst of chronic illness. 

Memory forms the heart of such narrative. 

Chochinov, 13 in writing about people who are 

dying, encourages the treatment of patients in 

ways which help them feel valued as human 

beings. People who are dying are invited to 

share their memories with a biographer who 

will write up parts of their life story and then 

edit it so that it may be bequeathed to loved 

ones. Being able to relate their story to someone 

else enables patients to find a sense of hope 

in that they can hand on to the next generation 

something of value which they themselves 

have learned and would like to pass on. The 

important point, in terms of this research, is 

the fact that it appears to be the telling of the 

story and handing it on which gives the patient 

a sense of hope. 

Memory plays a central role in our sense of being. Nouwen writes 

that emotions—such as pain and joy and sorrow and feelings of 

grief and satisfaction—are not simply dependent on events in life, 

but on the ways in which they are remembered. Memories provide 

a lens through which to see life. 

Discussion 

Making sense of what is happening, asking why 

and seeking answers to that question seems to 

be part of the human condition. The participants 

in this study make sense of what is happening 

to them in terms of their situation as well as in 

their wider belief structure. It is of significance 

that the majority see their illness as an opportunity 

to reach out and continue to contribute 

to the wider community. All were able to make 

sense of their illness and find meaning in life. A 

wider study may well include people for whom 

the process of meaning-making is impossible. 

Six out of the seven participants spoke about the 

importance of spirituality. 

This study has shown the importance of paying 

attention to the entire life narrative in order 

Memory plays a central role in our sense of being. 

Nouwen writes that emotions—such as pain and 

joy and sorrow and feelings of grief and satisfaction—are 

not simply dependent on events in life, 

but on the ways in which they are remembered. 14 

Memories provide a lens through which to see life. 

The past can become an important teacher. In this 

study, all the participants shared painful memories 

and times of frustration, but dealing with those 

times gave them the strength to face and to deal 

with what was happening in the present in terms 

of their illness. Nouwen reflects on the French 

expression ‘reculer pour mieux sauter’, meaning ‘to 

step back in order to jump farther’. Certainly, the 

participants in this study demonstrated in many 

ways that they were able to do that. 

While this study deals only with a small group 

of participants, this finding could influence the 




ways in which health professionals and others 

assist people diagnosed with chronic progressive 

illness to cope with both their diagnosis and with 

leading a fulfilled lifestyle. Chronic progressive 

illness is, by its nature, about change and helping 

people to cope with those changes is part of a 

holistic approach to health care. Change sometimes 

comes dramatically but, more frequently, it 

is a much slower process. Living with such illness 

may involve constantly readjusting to changes in 

life which are brought about by the illness. 

Arising out of this research, some suggestions are 

offered which may assist the health professional 

help people who are struggling with chronic 

progressive illness. There are no ‘quick-fixes’ or 

‘magical cures’ when it comes to chronic progressive 

illness, and this approach certainly does not 

offer them. However, it does suggest that respectful 

listening to the patient’s story may reveal 

some strengths (often hitherto unrecognised) that 

may become triggers for new ways of looking at 

the situation. 

The participants in this study were able to use 

the experience of being successful in the past 

in order to assist them to deal with issues in the 

present. In working with a patient who feels 

‘stuck’ in the diagnosis, it is necessary to begin 

with the presenting issue and take that seriously 

before proceeding to help the person find 

strength from past achievements which may in 

fact be times of coping with failure. Open-ended 

questions need to be asked concerning the present 

issue before focusing on successful coping strategies 

from the past. 

It may involve careful analysis of the past and 

an ability to ‘reframe’ some events which, to the 

patient, have appeared to be negative. Such an 

approach needs to be seen in terms of assisting 

people to develop life skills rather than assisting 

them to face past trauma. Crises may occur more 

than once in a person’s life as he or she seeks to 

deal with new situations and symptoms which 

may arise. When a person receives a diagnosis of 

chronic progressive illness it may feel as though 

life is falling apart. Likewise, when illness 

deteriorates to the point where changes have to 

be made, it can feel like a threatening blow and a 

disruption of security. Many people feel ‘stuck’ 

and alone and may find it impossible to believe 

that they have a future—or any future which 

will bring happiness and fulfilment. Looking at 

past successes and affirming them may enable the 

patient to apply what he or she has learned in the 

past to the present situation. 

When people are encouraged to tell their stories, 

it becomes possible to help them identify 

strengths and coping strategies which they may 

not realise they had. 

References 

1. Jacobi SI. Master’s thesis submitted for the degree of Master of 

Health Sciences. Auckland: The University of Auckland; 2009. 

2. Doyle D et al., editors. Oxford textbook of palliative medicine. 

3rd ed. Oxford: Oxford University Press; 2005. 

3. Roos S, Neimeyer RA. Reauthoring the self: chronic sorrow 

and posttraumatic stress following the onset of CID. In: Coping 

with chronic illness and disability: theoretical, empirical 

and clinical aspects. Martz E and Livneh H, editors. Springer; 

2007. p89–106. 

4. Charon R. Narrative and Medicine. New Eng J Med. 2004;350: 

862–864. 

5. www.narrativemedicine.org 

6. Eeeltink C, Duffy M. Restorying the illness experience in 

multiple sclerosis. Fam J. 2004;12(3):282–286. 

7. McPherson KM, et al. Living with arthritis—what is important 

Disabil Rehabil. 2001;23(16):706–721. 

8. Thorne S, et al. The structure of everyday self-care 

decision making in chronic illness. Qual Health Res. 

2003;13(10):1337–1352. 

9. Carter H, et al. Living with a terminal illness: patients’ priorities. 

J Adv Nurs. 2004;45(6):611–620. 

10. Saunders C. The management of terminal illness. London: 

Arnold; 1967. 

11. Speck PW. Spiritual concerns in management of advanced 

disease. Sykes N, Edmonds P and Wiles J, editors. London: 

Arnold; 2004. p.471–81. 

12. Edwards A, et al. The understanding of spirituality and the 

potential role of spiritual care in end-of-life and palliative 

care: a meta-study of qualitative research. Palliat Med. 2010 

Dec;24(8):753–770. 

13. Chochinov MH. Dignity conserving care—a new model 

for palliative care: helping the patient feel valued. JAMA. 

2002;287(17):2253–2260. 

14. Nouwen HJM. The living reminder. San Francisco: 

Harper San Francisco; 1976. 


We are grateful to the 

participants who were 

prepared to be interviewed 

about their experiences 

of living with chronic 

progressive illness. 

COmpeting INTERESTs 




MIXED METHOD research 

Educational needs of practice nurses 

in mental health 

Anne Prince MA (Applied) RN; 1 Katherine Nelson PhD, RN 2 

1 

Tairawhiti District Health 

Board, Gisborne, 


2 

Graduate School of 

Nursing, Midwifery and 

Health, Victoria University of 

Wellington, New Zealand 

ABSTRACT 

Introduction: Large numbers of patients see practice nurses (PNs) daily for their health care. Many 

of these patients will have a mental health need. International research suggests that practice nurses are 

undertaking mental health assessment and interventions without the requisite skills and knowledge. 

Aim: To describe the needs of PNs in mental health education and to explore any involvement with 

patients with mental health concerns. 

Methods: Postal survey of PNs in Hawkes Bay and Tairawhiti regions. Analysis was by descriptive, correlation 

and inferential statistics and content analysis for open questions. 

Results: Fifty-two respondents completed the survey (response rate 36%) and the results demonstrate 

that these PNs are caring for patients with an extensive range of mental health concerns daily. Most 

common are people with depression and anxiety. The nurses perform a variety of mental health interventions 

such as counselling and advice on medication and have minimal confidence in their skill level. Their 

expressed learning needs included education on many mental health conditions including suicidal ideation, 

all types of depression and bipolar disorder, and of therapies such as cognitive behavioural therapy 

and family therapy. 

Discussion: PNs require education and support specifically designed to meet their identified needs in 

mental health to help improve care to patients. This will require collaboration between secondary mental 

health services, primary mental health nurses and tertiary institutions. With targeted education these 

nurses should become more confident and competent in their dealings with people who present to their 

practice with a mental health concern. 

KEYWORDS: Education; mental health; practice nurse; survey; primary health care 


2011;3(2):142–149. 


Anne Prince 

Tairawhiti District Health 

Board, Private Bag, 

Gisborne, New Zealand 

anne.prince@tdh.org.nz 

Introduction 

Internationally, a review of primary mental 

health policy has occurred which has led a shift 

in responsibility of care for patients with mild to 

moderate mental health concerns to the primary 

health sector. 1–5 In New Zealand (NZ), it is recognised 

that 80% of patients will visit their general 

practice at least once a year and 35% of the 

patients will have a mental illness. 6 However, in 

up to 50% of these patients, the existence of their 

mental illness goes undiagnosed and treated. 

Practice nurses (PNs) are the largest group of 

primary health care nurses who work in general 

practice and an increasing number of patients 

visiting surgeries may only see a PN for care and 

treatment. 7 Given the number of patients who 

may experience a mental illness at some time in 

their lives, it is important that PNs can recognise 

and address patients’ mental health concerns. 

Without knowing the basic mental health knowledge, 

skill level and educational needs of the PN 

it is difficult to know how prepared PNs are to 

implement the policy changes. 

In recent years there has been a plethora of 

research which has looked at the provision of 

mental health services in the community and 




education of GPs; 6,8–10 yet there has been limited 

research that has examined the skill level of PNs 

caring for patients with a mental health concern. 

It is clear from international research that PNs 

encounter patients with mental health needs. 11–12 

However, there is debate over the role PNs 

should take in the delivery of primary mental 

health care in relation to assessment, gatekeeping, 

management of care and liaison with GP and 

community psychiatric teams, therefore research 

in this topic is timely. 13–14 

Exact figures on the types of mental illness in 

primary health vary internationally and with 

age. In childhood anxiety disorders (16%), oppositional/conduct 

disorder (15%), substance 

abuse (12%) and depression (10%) dominate. 15 At 

adolescence one of the most significant mental 

health problems is drug and alcohol abuse. 16–17 In 

adults depression (20–40%) and anxiety (11–20%) 

are problematic. 6,18–20 Lastly, one-fifth of people 

aged 65 and older experience mental illness, with 

the most common conditions being dementia and 

depression. 21–22 Some people have comorbidity 

of simultaneous mental health problems or with 

physical problems. 9,18,23–25 

Therefore, it is important that patients from 

across the lifespan can be appropriately assessed 

and helped or referred to other health professionals 

in primary health. To date it is not known 

what part the PN plays in this process, which age 

groups of patients and mental health concerns 

they regularly deal with, what interventions 

the nurses perform or how prepared they are to 

deliver these interventions. 

The aim of this research was to describe the 

involvement practice nurses have with patients 

with mental health issue and to identify the 

needs of PNs in mental health education. 

Methods 

In August 2008, a survey was carried out of 

PNs in the Tairawhiti District Health Board and 

Hawkes Bay regions. This method was chosen as 

it fits well with descriptive exploratory research, 

is relatively low cost and has the potential to 

obtain information from a large sample. Ethical 

approval for the study was granted by the 


What we already know: Practice nurses (PNs) provide patient care 

across a broad spectrum and have a role in primary mental health care. In 

New Zealand, primary health care has an expanded role in mental health care 

assessment and treatment. Practice nurses who are skilled and knowledgeable 

in primary mental health will be essential for improving mental health 

outcomes. 

What this study adds: This study provides information about the extent 

of primary mental health activities undertaken by practice nurses and how 

confident the PNs are in providing mental health care. It identifies areas 

which deserve particular attention for education for practice nurses to 

enhance the service they provide and to ensure that patients and nurses are 

safe in their practice. 

Victoria University of Wellington Human Ethics 

Committee. 

Study population 

The target population included PNs in the 

Tairawhiti and Hawkes Bay region between 

Te Araroa to Taradale. In the absence of a master 

list of PNs in the region a list of general practices 

employing practice nurses across the region was 

collated and each practice phoned to establish the 

number of nurses working there and to identify 

the senior nurse as a contact person for mailing 

the surveys. A named contact nurse was used to 

help increase the response rate. 26 

The survey and its administration 

Each practice was sent the number of packages 

that the senior nurse indicated were required. 

Packages consisted of a participant letter explaining 

the research, the survey tool, a participant 

sheet for a prize draw and a pre-addressed, 

stamped envelope. Surveys were numbered by 

practice. Practice nurses were given two weeks 

to return their survey. One postal reminder was 

sent to all practices where fewer than 50% of 

returns were received. 

The survey consisted of 33 questions of which 

15 were closed, 11 open, five rating scales and 

two Likert scales. Before its distribution, the 

survey was reviewed for content validity by 

community mental health nurses, mental health 




management teams, community and mental 

health nurse educators, PNs and public health 

nurses. It was also pre-tested on a convenience 

sample of four PNs to ensure clarity and ease 

of administration. The survey included three 

sections: practice nurse qualifications, education 

in mental health and educational needs related 

to mental health (11 items); self-rated confidence 

and competence in primary mental health nursing 

generally and of particular mental health 

disorders, screening and referral processes (14 

items); and demographic and general practice 

characteristics (7 items). 

Table 1. Frequency of practice nurse encounters with patients with a mental health need 

by age 

Age Groups 

Child 



Table 3. Frequency and confidence of mental health interventions undertaken by practice nurses 

Intervention 

No. performing 

intervention 

n (%) 

No 

confidence 

n (%) 

Little 

confidence 

n (%) 

Confident 

n (%) 

Reasonably 

confident 

n (%) 

Totally 

confident 

n (%) 

Not 

known 

n (%) 

Depot injections 35 (67) 3 (6) 1 (2) 12 (23) 11 (21) 20 (39) 5 (10) 3.94 (1.17) 

Counselling 31 (61) 12 (23) 27 (52) 8 (15) 4 (8) 0 (0) 1 (2) 2.04 (0.81) 

Medication advice 28 (54) 1 (17) 14 (27) 15 (29) 11 (21) 0 (0) 3 (6) 2.54 (1.04) 

Problem solving 25 (48) 11 (21) 20 (39) 12 (23) 5 (10) 0 (0) 4 (8) 2.19 (0.90) 

Anxiety management 23 (44) 11 (21) 22 (42) 11 (21) 4 (7) 1 (2) 3 (6) 2.19 (0.94) 

Grief management 17 (33) 9 (17) 19 (37) 14 (27) 5 (10) 0 (0) 4 (8) 2.34 (0.96) 

Education 11 (21) 18 (35) 21 (40) 4 (8) 1 (2) 0 (0) 8 (15) 1.73 (0.73) 

Treatment advice 6 (11) 16 (31) 22 (42) 5 (10) 2 (4) 0 (0) 7 (13) 1.84 (0.80) 

Mean 

±SD 

older adult. Conditions seen on a daily to weekly 

basis were anxiety and depression. Children with 

mental health issues were seen least. 

Nurses undertook a comprehensive number of 

interventions, with 82% of respondents indicating 

they performed more than two types 

of intervention (Table 2). Their self-assessed 

confidence in performing these interventions 

indicates they had little confidence and this did 

not vary by level of education or practice setting. 

The only exception to this was giving treatment 

advice to patients where there was a statistically 

significant finding. Those with degrees were 

more confident in giving treatment advice than 

non-degree respondents (p=0.05). Screening tools 

were used by 37% of nurses, but only one nurse 

was totally confident in their use. Confidence 

in caring generally for mental health patients 

was average (mean 2.8 ± SD 0.90, range 1–4). 

However, one-fifth (21%) reported they had no 

confidence and no respondents stated they were 

totally confident. 

Practice nurses liaised with a wide range of 

mental health services on behalf of their patients 

(Table 4) and 78% of nurses knew how to access 

specialist services, but only 24% knew of a process 

to follow when accessing services. Many nurses 

made comments about the process and there 

appears to be no standardisation of this process. 

Written responses centred on what the nurse 

considered was the right thing to do: 

“Sometimes our work is intuitive—gut feeling tells 

you something is not right.” 

Table 4. Liaison between practice nurses and mental health services 

Team referred to 

Crisis 38 

Community mental health 20 

Child and adolescent services 10 

Inpatient/hospital services 6 

Counsellor/psychologist 4 

Psychiatrist 3 

Maori mental health service 3 

Link nurse/mental health liaison service 2 

Other service 9 

Nil/no service 2 

One nurse added: 

“I think people know me well and come in to discuss 

with me what they can’t discuss with family and 

friends and sometimes initially with the GP.” 

Another stated: 

“If I feel it’s serious I will discuss with the patients 

that I may need to speak with their GP.” 

And a third commented on communication between 

services stating: 

“Interdisciplinary services communication can let 

people with mental health issues down.” 

Only 82% of nurses would inform the GP if 

concerned about a patient. One nurse stated she 

would listen to the patient and described how she 

No. 




would collaborate with the doctor before making 

an appointment. In contrast, another nurse would 

just leave “a note for the GP”. 

Education needs 

The mental health topics nurses prioritised as 

wanting education sessions on and the subjects 

nurses were least knowledgeable about are listed 

in Table 5. The most common issue with the 

highest priority for education was suicidal issues, 

with 28 (54%) of respondents listing this and 14 

(50%) of these respondents listed this as their 

highest priority. Schizophrenia with 21% was the 

number one condition most PNs felt they had the 

least knowledge about with a third of respondents 

expressing this. Suicide and bipolar disorder 

were also indicated frequently. The responses 

indicate the PNs have limited knowledge of 

comorbid conditions around mental health, with 

44% mentioning coexisting physical diseases with 

mental illness, where coexisting mental health 

issues were asked for. 

Barriers to providing education were similar to the 

MoH survey of 2003 14 and included finance, staffing 

and time. Comments here included having to 

attend study outside work hours, no locum to cover 

when on leave and difficulty in accessing study 

from rural locations. Access to education was also 

of concern, with 55% of respondents reporting 

Table 5. Practice nurses’ educational preferences and self-expressed knowledge gaps in 

mental health conditions 

Condition 

Education 

preference 

n (%) 

Knowledge gap 

n (%) 

All conditions 13 (25) 8 (16) 

Schizophrenia 11 (21) 17 (33) 

Suicide/suicidal ideation 28 (54) 14 (28) 

Postnatal depression 18 (35) – 

Depression 17 (33) – 

Cognitive behavioural therapy 15 (29) – 

Bipolar disorder 15 (29) 12 (23) 

Family issues/therapy 13 (25) – 

Personality disorders – 9 (17) 

Adolescent/child issues 7 (13) – 

Addiction 5 (10) – 

Eating disorders – 4 (8) 

they had no access to any education. Finance was 

only mentioned by one nurse who stated: 

“Who pays for it Have attended outside of work 

hours. Outside the DHB you are outside the loop of 

continuing education information.” 

This nurse further commented that she thought 

with the new PHO structure this should be addressed. 

Practice nurses indicated that they would 

prefer a targeted short course (58%) in mental 

health, preferably delivered by the community 

mental health team (71%). 

Discussion 

It is clear from the results of this study that PNs 

are encountering patients across the age span 

with a mental illness almost every day. It is apparent 

from Table 4 that depression was the most 

common illness seen, with two-thirds of nurses 

seeing this condition at least weekly. Given the 

importance and prevalence of depression in the 

community, 33–34 the recognition of depression as 

a learning need within the nursing literature 35–36 

and the significant proportion of nurses in this 

study who reported insufficient knowledge, this 

finding should not be ignored. Practice nurses 

often see patients on their own; it is therefore 

important that all PNs are confident in recognising 

this condition and that they are regularly 

updated on changes in the management of depression. 

Given that the PNs report seeing patients 

with varying mental health conditions frequently 

and that it is known that one in four patients will 

have a mental illness and at least half of these 

patients will have their illness undiagnosed and 

untreated, 6 it is important that PNs have education 

in how to screen and assess for a range of 

mental health conditions. 

The World Health Organization 37 states that 

screening for mental health should be part of a 

nurse’s role and the MoH published report by 

Kent et al. 30 states that health care screening is a 

common task for practice nurses. Early intervention 

for patients with a subacute mental illness 

greatly improves outcomes for patients and often 

relies on adequate screening and assessment. 38 It is 

important that PNs can recognise and respond to 

the presence of such illness at an early stage of ill- 




ness. This requires assessment skills, access to the 

relevant screening and diagnostic tools and competence 

and confidence in their use. 22 The findings 

of a low use (37%) of tools and low confidence 

in their use by PNs, highlights an urgent educational 

need. The New Zealand Guidelines Group’s 

recently-released assessment frameworks 39 which 

are easy to use and designed for use by primary 

health nurses should aid in addressing this issue. 

Knowledge about comorbidity in primary health 

is also important as 50% of patients with a 

mental illness will have some comorbidity, but 

in 35% of these patients their coexisting disease 

is undiagnosed. 18 In this study, the majority of 

PNs acknowledged working with patients with 

comorbid mental illness, but written answers 

were confusing both for coexisting mental illness 

and physical illness. 

Management of mental health issues 

Although the PNs performed a wide variety of 

interventions (Table 3), the majority had limited 

confidence in their skills and knowledge. The 

finding that the most common intervention performed 

was the administration of depot injections 

is similar to Gray et al.’s 40 British study where 

61% of PNs administered long-term antipsychotic 

medication in the form of depot. The PNs were 

generally confident in giving this treatment. 

Their use of interventions such as counselling, 

medication advice, problem-solving and anxiety 

management are similar to the findings of two 

UK-based studies. 11–12 The areas where confidence 

at performing interventions was lowest is where 

extra educational input is required. These are important 

areas as these interventions are commonly 

performed. Confidence in caring for patients with 

a mental health issue in general scored low, mean 

confidence in performing specific interventions 

for patients with a mental illness also scored low, 

and this was not influenced by whether nurses 

had completed postgraduate education. International 

research states PNs can be influential in 

improving care for patients with a mental health 

issue when taught interventions. 41–42 These influences 

are in assessment, general mental health 

education and giving treatment advice and medication 

adherence. These are interventions some 

nurses in this current research use, therefore an 

increase in nurses’ confidence through targeted 

education could contribute to improved patient 

outcomes. This education needs to be at both 

in-service and postgraduate levels. Specific postgraduate 

education in mental health is not only 

needed to increase the skills and consequently 

improve confidence and competence for these 

nurses, but also to assist with the development of 

this work. 

Referrals are an area where PNs, GPs, mental 

health nurse educators, psychiatric liaison nurses 

and community mental health staff at a local 

level need processes and guidelines for use by 

PNs and the primary health care team generally. 

Such guidelines will assist PNs with their 

decision-making process and potentially influence 

early intervention and patient outcomes. Standardisation 

such as this could ensure speedier 

access to mental health services when the patient 

is in need. 

Education 

Barriers to receiving education for this group of 

nurses have not changed from previous studies. 

14,43 Where training additional to primary 

qualifications has been given to PNs, it has 

improved outcomes. Katon et al. 41 reported on 

a study where PNs were trained in brief interventions 

including clinical assessment, patient 

education, monitoring adherence to treatments, 

follow-up and referrals for patients suffering 

from depression, and found no difference in 

outcomes for patients allocated to nurse intervention 

or GP intervention groups. Therefore, with 

the right education and skills, PNs can become 

proficient at helping these patients. The specific 

mental health issues individual PNs would 

like additional education on are varied. With 

the nurses in this study reporting their lack of 

experience in mental health, and identifying that 

undergraduate education was of little help in 

gaining confidence in mental health skills, this 

education has to start with assessment through to 

management and be built upon. 

Prioritising these needs should be a combination 

of the patients most often seen, the PNs perceived 

learning needs and areas where confidence 

in performing interventions was low. Condi- 




tions such as anxiety, grief, alcohol and drug 

issues which nurses see often, and schizophrenia, 

bipolar disorders, and suicide which nurses 

highlighted as important are likely priority areas. 

As nurses’ confidence in mental health is generally 

very low, undergraduate training experience 

limited and postgraduate primary mental health 

for PNs is not yet available, then this training 

should start at the basics of mental health and 

be built on to cover the types and conditions the 

nurses care for. 

Limitations 

The low return occurred despite using a number 

of strategies to increase the number of returns. 

This response rate, although typical for this type 

of research and this group of nurses, does mean 

that the results are not generalisable to all PNs 

in New Zealand. However, the respondents were 

similar with the MoH surveys on age and gender, 

but differed ethnically from the MoH 2005 survey, 

with this study having 13% Maori compared 

to the 5% in the MoH survey. The final survey 

tool inadvertently left out schizophrenia as a condition 

that the PNs could see people with—while 

this was picked up in the description of ‘other’ by 

many respondents, this was not done routinely, 

so the extent of engagement by PNs with this 

group is not clear. 

Conclusion 

This study demonstrates that PNs are involved 

daily with patients with broad-ranging mental 

health concerns and provide a wide range of 

mental health interventions, but with limited 

confidence in their skill level. The respondents 

liaised with a wide range of services, but with 

no standardised referrals process in place, nurses 

used professional judgement when referring 

patients. The PNs listed their perceived learning 

needs which centred on general mental health 

conditions. Other learning needs included education 

on comorbid disease and mental health and 

screening. Given the expanded role of the nurse in 

primary health care, it is important that education 

in primary mental health for nurses is prioritised. 

Enhancing nurses’ skills and knowledge should 

help improve mental health outcomes. 

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depression. J Ment Health Policy Econ. 2000;3(4):175–86. 

34. Goodyear-Smith F, Arroll B, Coupe N, Buetow S. Ethnic differences 

in mental health and lifestyle issues from multi-item 

general practice screening. N Z Med J. 2005;118. 

35. Renwick R. Improving outcomes for people experiencing 

depression: the road ahead for New Zealand primary mental 

healthcare nursing. Research Report. Wellington: Victoria 

University of Wellington; 2007. 

36. Russell G, Potter L. Mental health issues in primary care. J Clin 

Nurs. 2002;11:118-25. 

37. World Health Organization. WHOQOL-BREF: Introduction, 

administration, scoring, and generic version of assessment. 

Geneva: World Health Organization; 1996. p18. 

38. McMenamin JP. Targeted health checks by nurses in 

general practice: are they feasible N Z Fam Physician. 

2005;32:382–8. 

39. New Zealand Guidelines Group. Identification of common 

disorders and management of depression in primary care. 


40. Gray A, Parr A, Plummer S, et al. A national survey of practice 

nurses involvement in mental health interventions. J Adv Nurs. 

1999;30:901–6. 

41. Katon W, Von Korff M, Lin E, Simon G. Rethinking practitioner 

roles in chronic illness: the specialist, primary care 

physician and the practice nurse. Gen Hosp Psychiatry. 

2001;2:138–44. 

42. Sokhela NE. The integration of comprehensive psychiatric/ 

mental health care into the primary health system: Diagnosis 

and treatment. J Adv Nurs. 1999;30:229–337. 

43. Baird A. What being a practice nurse really means: Part 4. 

Clinical skills and future learning. Prac Nurs. 2003;26:15–9. 

Competing Interests 



improving performance 

(Preventing) two birds with one stone: 

improving vitamin d levels in the elderly 

Susie Lawless MBChB, Dip Obst, FRNZCGP; Phil White MBChB, MRCGP, FRNZCGP; Prue Murdoch MBChB, 

Dip Obst, FRNZCGP; Sharon Leitch MBChB, DCH, MRNZCGP 

Amity Health Centre, 

Dunedin, New Zealand 

ABSTRACT 

Background and context: A majority of adults have sub-optimal vitamin D levels in the winter 

in southern New Zealand. This is associated with an increased risk of falls and fragility fractures in the 

elderly, with long-term adverse outcomes likely. Vitamin D supplementation decreases the risks of both 

falls and fractures. 

Assessment of problem: An intervention was undertaken by a small urban general practice to increase 

the number of elderly patients receiving vitamin D supplementation by linking vitamin D prescription 

to the annual flu vaccination campaign. 

Results: Uptake of the supplementation was high and costs to the practice low. Thirty-eight patients 

were identified for whom long-term supplementation with vitamin D was indicated. 

Strategies for improvement: The study could have been strengthened by incorporating a more 

formal method of evaluating uptake. 

Lessons: Encouraging patients to take supplements as a population-based strategy is a realistic intervention, 

and linking it to the flu vaccination campaign is both seasonally appropriate and efficient. 

KEYWORDS: Vitamin D deficiency; elderly; vitamin D supplementation; cholecalciferol; prevention; 

fragility fractures; intervention 


Susie Lawless 

Amity Health Centre, 

343 Highgate, Roslyn, 

Dunedin 9010, 


susie@amityhc.co.nz 

Background 

Increasingly it seems that vitamin D is going 

to be the aspirin of the 21st century—good 

for every thing that ails you. The evidence for 

vitamin D supplementation reducing fragility 

fractures and falls in the elderly is clear. 1,2 

Epidemiological evidence shows those with the 

highest quintile of vitamin D levels have the 

lowest incidence of several cancers and heart 

disease, although there is no evidence to date 

that supplementation influences this. 3 While 

it is known that a high proportion of adults 

who live in southern New Zealand have low 

vitamin D levels, particularly in the winter, 

there is still debate about optimal serum levels 

of vitamin D. 4 Although vitamin D levels of 

at least 50 nmol/L are widely recommended, 

definitions of vitamin D deficiency are variable. 

There is some evidence that the optimal 

level to maintain bone health may be as high 

as 75–80 nmol/L. 5,6 One study in adults in 

Canterbury (n=201) found 35% of subjects were 

vitamin D deficient (


months to all our patients over 65 years old. 10 

Since we run an active recall system for all these 

patients for flu vaccination in autumn, it seemed 

opportune to combine these two strategies. 

Method 

Before beginning this intervention, the endocrinology 

department at Dunedin Hospital was 

consulted, to discuss concerns about safety, 

contraindications and potential drug interactions. 

It was established that providing six tablets all 

at once with instructions to take one tablet per 

month was a safe and effective dose. 11 

The query builder on the MedTech system 

was used to identify patients of 65 years and 

above, and a letter was printed for each outlining 

the benefits of vitamin D supplementation 

(available as an Appendix in the web version 

of this paper.) These letters were then given 

to the patient’s general practitioner (GP), who 

checked the clinical record to see if they were 

already taking vitamin D supplementation or 

had any contra indications to its use. Patients 

were excluded if they were taking calcitriol, 

using calcipitriol, or if they had previously 

had elevated PTH, phosphate or calcium. This 

was a relatively labour-intensive part of the 

process for the GPs. It was recognised that 

there was a potential interaction with thiazide 

diuretics, but this was not felt to be a 

contraindication to the use of cholecalciferol. 

The four local pharmacies were notified of the 

initiative, to ensure they held sufficient stocks 

of cholecalciferol. 

The GP then generated a prescription for six 

tablets of cholecalciferol 1.25 mg for appropriate 

patients, with the instructions “one per month, 

or as directed”. The prescription was then stapled 

to the letter which specified the dose that should 

be taken and the pile passed back to be held at 

reception in alphabetical order. 


What we already know: Vitamin D levels in older adults are sub-optimal 

in southern New Zealand in the winter. Vitamin D supplementation reduces 

falls and fragility fractures, but only a minority of elderly patients receive 

supplementation. 

What this study adds: A simple, cost-effective intervention at an individual 

practice level to increase uptake of vitamin D supplementation in the elderly. 

Ethical approval 

One of the authors was a member of the Lower 

South Region Health and Disability Ethics 

Committee. After consultation with the Ethical 

Guidelines for Observational Studies it was felt 

that Ethics Committee Review was unnecessary 

as the activity would be classed as an audit or 

related activity which did not involve a departure 

from normal care nor reach any other threshold 

of risk of harm. 12 

Outcome 

There were 550 patients in the eligible age group 

enrolled with the practice. Excluding those who 

were already taking some form of vitamin D supplementation 

or who had some contraindication 

Figure 1. Patients for vitamin D supplementation 

367 letters given 

with flu vaccine 

550 patients over 65 

400 vitamin D letters and scripts 

33 letters posted 

150 patients 

excluded 

As each patient came in for their flu vaccine, they 

were given their letter and prescription to read 

while they were waiting to see the practice nurse 

or GP. Any immediate questions or concerns 

about taking vitamin D supplements could then 

be discussed with their clinician. 

90% of patients asked 

report taking vitamin D 

38 patients started on 

long-term vitamin D 




Thanks to the nursing 

and reception staff at 

Amity Health Centre. 



Table 1. Estimated cost of intervention 

Estimated costs 

GP 9 hours @ $110 per hr $990.00 

Reception 2.5 hours @ $20 per hr $50.00 

Stationery $300.00 

Total cost $1340.00 

to its use, there were 400 patients to whom letters 

and prescriptions were generated. Three hundred 

and sixty-seven patients were given these 

letters at the time of flu vaccine. The remaining 

33 either declined flu vaccine or were missed 

when they attended, and their letters were posted 

out to them (see Figure 1). 

Around 30% of patients were asked at their next 

visit whether they had the prescription filled and 

were taking the tablets. The majority were taking 

them, and all of those were taking them correctly 

once per month. The most likely group to decline to 

take the supplement were the youngest, most active 

patients, who felt their outdoor lifestyles provided 

them with sufficient vitamin D. The feedback from 

the patients was universally positive. The study 

could have been strengthened by incorporating a 

more formal method of evaluating uptake. 

An unexpected outcome was that 38 patients were 

identified for whom long-term supplementation 

with vitamin D was indicated, and these patients 

were started on vitamin D with the intention 

of continued use. Indications for long-term use 

included risk factors for osteoporosis (low body 

weight, smoking, family history of osteoporosis, 

inactivity, low sun exposure, long-term corticosteroid 

use) increased risk of falling, established 

osteoporosis or a history of fragility fracture. 

Lessons and messages 

Potential benefits from vitamin D supplementation 

are becoming well established, and the risk 

of harm is extremely low. Encouraging patients to 

take supplements as a population-based strategy 

is a realistic intervention, and linking it to the flu 

vaccination campaign is both seasonally appropriate 

and efficient. There were costs to the practice 

in terms of time spent by both clinical and support 

staff, and stationery expenses (see Table 1), and 

these were not able to be recouped from either the 

patients or other sources of revenue. Checking the 

clinical record of each patient took a significant 

amount of time for the GPs, although the patient 

population is very stable and the patients were 

generally well known to their doctor. An attempt 

to streamline this process by using the MedTech 

query builder to identify patients with contraindications 

or previous vitamin D prescription was 

made, but did not identify all such patients. 

This intervention was not designed to detect 

decreased fracture risk or other benefits of 

vitamin D for patients, since these are well 

established. It is described here as an exemplar for 

other practices of how to structure an intervention 

to increase uptake of vitamin D supplementation 

in an at-risk population. 

References 

1. Gass M, Dawson-Hughes B. Preventing osteoporosisrelated 

fractures: an overview. Am J Med. 2006 Apr;119 

(4 Suppl 1):S3-S11. 

2. Papadimitropoulos E, Wells G, Shea B, et al. Meta-analyses 

of therapies for postmenopausal osteoporosis. VIII: Metaanalysis 

of the efficacy of vitamin D treatment in preventing 

osteoporosis in postmenopausal women. Endocr Rev. 2002 

Aug;23(4):560–9. 

3. Scragg R. Vitamin D, sun exposure and cancer: a review prepared 

for the Cancer Society of New Zealand. Cancer Society. 

Wellington: 24 Sept 2007. Available from: www.cancernz.org. 

nz/about-us/position-statements/ 

4. Scragg R, Bartley J. Vitamin D—how do we define deficiency 

and what can we do about it in New Zealand NZ Med J. 

2007;120(1262):U2735. 

5. Dawson-Hughes B. Serum 25-hydroxyvitamin D and 

functional outcomes in the elderly. Am J Clin Nutr. 2008 

Aug;88(2):537S–540S. 

6. Cancer Society. Position Statement. The risks and benefits of 

sun exposure in New Zealand. Wellington; July 2007. Available 

from: www.cancernz.org.nz/about-us/position-statements/ 

7. Livesey J, Elder P, Ellis MJ, McKenzie R, Lilley B, Florkowski 

CM. Seasonal variation in vitamin D levels in the Canterbury, 

New Zealand population in relation to available UV radiation. 

NZ Med J. 2007;120(1262):1–13. 

8. Callister P. Skin colour: does it matter in New Zealand Policy 

Quarterly. 2008:4(1):18–24. 

9. Campbell J, Kerse N, Reid I, Scragg R, Madison L. Vitamin D 

prescribing criteria. ACC publication. November 2008. Available 

from: www.acc.co.nz/vitamin-d 

10. Trivedi DP, Doll R, Khaw KT. Effect of four monthly oral vitamin 

D (cholecalciferol) supplementation on fractures and mortality 

in men and women living in the community: randomised 

double blind controlled trial. BMJ. 2003;326(7387):469–475. 

11. Hackman K, Gagnon, C, Briscoe, R, Lam, S, Mahesan A, 

Ebeling, P. Efficacy and safety of oral continuous low-dose 

versus short-term high-dose vitamin D: a prospective 

randomised trial conducted in a clinical setting. Med J Aust. 

2010;192(12):686–689. 

12. Ethical Guidelines for Observational Research. Ministry of 

Health; Dec 2006. Available from: www.neac.health.govt.nz/ 

moh.nsf.pagescm/520/$file/ethicalguidelines.pdf 



Repeat prescribing—reducing errors 

Steven Lillis MBChB FRNZCGP MGP, RNZCGP; 1 Hayley Lord B Soc Sci, MHSM 2 

ABSTRACT 

Background and context: Prescribing errors account for a significant proportion of overall error 

in general practice. Repeat prescribing occurs commonly in New Zealand and is a likely cause of error in 

practice. 

Assessment of problem: This paper reports on two related aspects of repeat prescribing; an audit 

of adherence to a repeat prescribing protocol and self-reported repeat prescribing incidents in a network 

of 97 general practices. 

1 

Senior Lecturer in General 

Practice, Waikato Clinical 

School, Bryant Education 

Centre, Hamilton, 


2 

Pinnacle Group Ltd Quality 

Manager, Midlands Health 

Network, Hamilton 

Results: The audit of adherence to the repeat prescribing protocol revealed that some issues persist. In 

particular, prescribing medication outside an approved list and exceeding specified time limits or maximal 

scripts before clinical review were problematic. Repeat prescribing encompassed a range of departures of 

process from minor (such as prescription not available on time) to major (wrong medication). Corrective 

measures highlighted the importance of both the pharmacist and the patient in error detection. 

Strategies for improvement: Repeat prescribing needs to be recognised as a process potentially 

fraught with error. Effective practice systems, patient involvement and enhanced pharmacy communication 

are important contributing factors in reducing error. 

Lessons: There is need for robust data regarding error rates in prescribing and the impact of changing 

prescribing protocols on error rates. 

Keywords: Medication errors; electronic prescribing 

Introduction 

Safe medical care requires carefully considered 

systems. Donald Berwick’s work on reducing 

error in medicine reminds us that the error rate 

is dependent on the number of steps in a system 

and becomes magnified by each successive step. 1 

Repeat prescribing in general practice (prescribing 

when the medication has previously been 

commenced, there is no reason to suspect change 

in the underlying condition and no face-to-face 

consultation occurs) can represent an efficient, 

cost-effective and convenient method of managing 

some aspects of chronic disease that are clinically 

stable and other medical processes such as 

ensuring a supply of oral contraceptives. 

The practice is widespread, with 99% of New 

Zealand general practitioners indicating they have 

issued such prescriptions. 2 The number of repeat 

prescriptions issued as a ratio to other prescriptions 

ranges from 19% 3 to 75% of all items. 4 

However, overseas research raises concern over 

the safety of this practice. 5 What little research 

that has been undertaken on repeat prescribing 

indicates that poor management systems are commonly 

found. 6 An electronic medical record would 

seem likely to decrease error rates in prescribing. 7 

The Pinnacle Network represents a network of 97 

practices with a high rural practice ratio. Network 

members complete an annual quality plan, 

now in its fourteenth year, which has included 

the development of incident management systems 

at a practice level. Practices receive training and 

support to implement their incident management 

system and are able to submit anonymysed 

reports to a centralised database to facilitate 

learning at a network as well as a practice level. 


Steven Lillis 

Chair, Education Advisory 

Group, The Royal New 

Zealand College of 

General Practitioners, 

PO Box 10440, Wellington, 


slillis@wave.co.nz 



All practices in the network have in place a repeat 

prescribing protocol implemented approximately 

five years ago. Practices’ repeat prescribing protocols 

were developed from a standardised network 

template based on nine key areas (see Table 1). 

The template was developed by clinicians based 

on best practice, and peer reviewed. The principles 

underpinning the design were informed 

by the previous research on barriers to effective 

incident management where time constraints, 

methods of remembering to use incident management 

systems and apprehension over external 

bodies becoming aware of such incidents were 

the major concerns voiced by all members of the 

general practice team. 8,9 Practice protocols detail 

each of the nine key areas but are unique to the 

individual practice, for instance all protocols detail 

the person authorised to take the prescription 

request but in Practice A this may be a general 

practitioner and in Practice B a practice nurse. 

This paper reports on two aspects of repeat 

prescribing across the 97 practices in the network: 

1. The identification of adherence to the practice 

repeat prescribing protocol, and 

2. The analysis of significant events associated 

with the repeat prescribing process. 

Method 

Formal ethical application was not obtained 

because the data reported here were used for the 

purpose of quality assurance by employees of the 

health care provider. 

Practice audit of adherence to 

repeat prescribing protocol 

A total of 97 practices were involved in the audit 

process, representing 322 general practitioners. 

Each general practitioner audited the first 15 

repeat prescriptions issued during a given week 

for compliance against their repeat prescribing 

protocol. The week of the audit was chosen three 

weeks retrospectively so that the audit would 

represent true performance rather than maximal 

competence. Repeat prescriptions were identified 

by interrogating the practice database for invoices 

tagged as repeat prescriptions. Incidents that occurred 

with the 15 cases were notified. Data were 

available for 3359 repeat prescriptions. 

Repeat prescribing incidents 

Practices submitted a register of all incidents 

related to repeat prescribing during a designated 

week. A total of 312 incidents from the 97 practices 

in the network related to repeat prescribing 

were reported for audit. All incidents are 

required to be submitted in a format stripped of 

identifying data such as names and locations. An 

underlying principle of the Incident Management 

System was to build and develop methods of 

continuous quality improvement at the practice 

level. Subsequently, the incidents outlined below 

were self-reported by practices with inevitable 

variation in how they reported the data. This in 

turn causes difficulties in aggregating the data. 

Indeed, some reported incidents were simply 

descriptions of good process, some demonstrated 

no breach of protocol and some are lacking in 

sufficient detail to accurately categorise. For these 

reasons, accurate analysis of rates of error is not 

possible. Consequently, the 312 reported comments 

should be considered more in the realm of 

descriptive research with the role of identifying 

factors that give rise to error in repeat prescribing, 

rather than accurately assessing the contribution 

of each factor to the overall error rate. 

Individual reports were discussed by the authors 

for commonality of error types, a basic taxonomy 

developed and all reports classified within the 

taxonomy. Examples of comments made by 

respondents that describe an incident are given to 

add depth of understanding to the data. 

Results 

1. Adherence to repeat prescribing 

protocol (practice audit) 

Several aspects of the repeat prescribing policy 

were universally well followed. These included 

correct authorisation of the person receiving the 

request, correct recording of the request, appropriate 

presentation of request to the prescriber, 

recording the request in the practice notes and 

availability of the notes to the prescriber, as 

shown in Table 1. The audit did raise concerns 

over prescribing of medications that were not 

in the practice agreed list. Also, there was poor 

concordance between number of issued prescriptions 

and previously agreed maximum number of 



scripts before seeing the patient and with the time 

frames allowable by the protocol. Of issued prescriptions, 

12% were queried or had some anomaly 

that required remedial action by the practice. Of 

these 12% with an anomaly or query, only 72% 

were managed according to practice policy regarding 

management of adverse incidents. 

2. Repeat prescribing incidents 

The overt manifestation of error and corrective 

mechanisms that detected error will be reported 

separately. 

Error indicator 

1. Prescription not ready on time 

A prescription not being ready on time accounted 

for the majority (74 of 312) of incidents: “Patient 

came to pick up Rx: couldn’t be found—reprinted”. 

The comments about these incidents indicate 

the main causes are the prescription being lost by 

the practice, never being generated or not being 

signed by the doctor on time. 

2. Fax oversight 

There were 20 incidents involving faxed prescriptions. 

Of these, four were faxing the prescription 

to the wrong pharmacy. Missing details regarding 

fax instructions stalled the process in several 

other incidents: “Patient went to the pharmacy 

to pick up prescription which was not there— 

had not been faxed through due to the name of 

the pharmacy not being written on top of the 

prescription”. Other fax-related incidents were 

impossible to classify or understand where the 

process faulted, such as “Urgent ‘refax’ of script 

not received at pharmacy”. This incident could 

have been either practice- or pharmacy-related. 

3. Overdue for clinical review 

Overdue clinical review accounted for 23 

incidents. One leading cause was practice staff 

overlooking the maximal time period after 

which repeat prescriptions should not be issued. 

“Time between last visit >12/12. Protocol is 

every 6/12 to be seen. Alert placed on patient’s 

file for review next repeat.” Difficulties finding 

semi-urgent appointment slots for patients who 

What gap this fills 

What we already know: Prescribing is a common and well-documented 

source of medical error. A significant majority of general practitioners issue 

repeat prescriptions, yet there is little described data regarding error occurring 

from these. 

What this study adds: This research revealed a number of systemic problems 

that cause error in repeat prescriptions as well as demonstrating that it is 

possible to introduce a network-wide protocol designed to reduce error rates. 

Table 1. Adherence to protocol for repeat prescribing; N=3359 

1 Is the person who received the request authorised to do so in 

the repeat prescribing policy 

2 Was the request recorded as per the repeat prescribing policy 

(For instance, in a dedicated book.) 

3 Was the request/script presented to the prescriber according 

to the repeat prescribing policy (For instance, together in 

folder once per day.) 

4 Is the drug prescribed listed in Appendix 1 of the repeat 

prescribing policy (i.e. drugs that are deemed unsuitable for 

repeat prescribing) 

5 Did the prescriber know the patient or have access to the 

patient’s notes 

6 Are the maximum time period and/or number of repeat scripts 

between clinical reviews for this condition documented in the 

patient’s notes 

7 Were the details of the repeat script recorded in the patient’s 

notes according to policy 

8 Was there an anomaly or query (For instance was the script 

requested within the time period documented in the patient’s 

notes) 

9 If there was an anomaly or query, was it managed according 

to practice policy (For instance, documented in the patient’s 

notes and/or managed according to the harm reduction policy.) 

unwittingly run out of medications add to the 

pressure of adhering to reasonable time frames 

for clinical review before continuing to issue 

repeat prescriptions. 

4. Missing medication 

The vast majority of practices in the network 

utilise electronic medical records in the repeat 

prescribing process. Eight incidents involved 

regular medications not being designated as regular 

in the electronic record and therefore causing 

confusion for practice staff receiving requests for 

repeat prescriptions. 

Yes 

n (%) 

3297 (98.1) 

3146 (93.6) 

3280 (97.6) 

282 (8.4 

3353 (99.8) 

1794 (53.4) 

3218 (95.8) 

417 (12.4) 

2428 (72.2) 



5. Wrong patient 

Failing to change the computerised file to the 

correct patient before prescribing would seem to 

be facilitated by the nature of electronic clinical 

records: “Prescription made out for wrong patient 

(wrong name, right medications)”. 

6. Wrong dose/formulation/amount 

Some of these incidents were minor in nature 

or part of an informal check process, such as 

“Pharmacist rang. Dr changed patients Betaloc 

dose was 23.75 and up to 47.5 mg. Pharmacist 

query about 47.5 mg and Dr confirmed 47.5 mg 

is the correct dose as he prescribed.” However, 

some of these incidents were potentially hazardous 

to patient safety: “Script for Prednisone 5 mg 

was given as 1 mg tabs. Patient noted change 

and informed us” and “Patient requested repeat 

script for insulin—when picked up insulin dose 

incorrect—script rectified and confirmed with 

patient.” A common source for wrong dose/formulation 

errors were changes in medications being 

made by specialists but this information not 

translating into prescribing processes in primary 

care. Reasons quoted for lack of translation range 

from absence of discharge summary or outpatient 

letter to failure to update the patient record held 

in general practice. There were nine incidents 

where the incorrect quantity of medication had 

been prescribed: “Computer generated script for 

45 Accupril tabs in place of 90. Fields checked 

and adjustment made”. Although such errors 

are most unlikely to lead to patient harm, they 

nevertheless cause inconvenience and cost to both 

patient and practice. 

Error detection 

1. Pharmacist detecting error 

There were 20 incidents in which the pharmacist 

was the person who alerted the medical centre 

of a potential medication error and the prescription 

was altered as a result. These incidents 

ranged from the minor to potentially major in 

nature. “Prescription handed to incorrect patient. 

Pharmacy notified reception.” Other common 

errors picked up by pharmacists were incomplete 

medication lists “Losec missed off prescription by 

nurse generated script. Returned from pharmacist”, 

wrong dose prescribed; “Pt telephoned to 

request repeat Rx wrong dosage was prescribed. 

Chemist rang re. same and Dr rectified the problem” 

and sometimes issues of convenience or cost 

that do not necessarily represent error “Call from 

pharmacy, OC scripted no longer subsidized and 

patient requested change. New script generated.” 

2. Patient detecting error 

Patients also provide a check of prescription 

accuracy: “Script request taken by receptionist. 

Wrong medication selected from list. Patient 

recognised error on collection so a new script 

was generated by nurse and signed by GP” and 

“Patient reported a required medication had been 

left off repeat prescriptions”. 

Discussion 

A position paper on reducing prescribing error 

states, “Medication errors are probably the most 

prevalent form of medical error, and prescribing 

errors are the most important source of medication 

errors” 10 and discusses the crucial role of 

changing organisational culture so that prescribing 

is perceived as a complex process requiring 

effective teamwork if error rates are to be 

minimised. The “Swiss Cheese” model of error 

in medicine, as described by Reason, is highly 

appropriate to understanding error in repeat prescribing. 

11 The safety checking mechanisms can 

be understood as: 

1. The practice-computerised system to ensure 

correct medication, correct dose, correct 

formulation and correct quantity and correct 

patient 

2. The staff member who gives the prescription 

across the counter or faxes the prescription 

directly to the pharmacy 

3. The patient who checks the prescription 

against what they wanted 

4. The pharmacist to check what has been 

ordered against pharmacy held records, and 

5. The patient after receiving the medications. 

Successful detection of error is dependent on 

these systems operating well. Good processes 

within the practice and between practice and 

pharmacy are required to ensure that all checking 

mechanisms are in place and are functional. 



The errors described above illustrate parts of this 

process that have not worked well. 

Electronic medical records have revolutionised 

many of the steps regarding repeat prescribing. 

Unfortunately, automation may also cause a 

degree of complacency, where what is identified 

as “regular medications” may be simply 

accepted without question. This problem was 

identifiable in many of the incidents reported. 

Clearly, changes in medication in secondary 

care coupled with poor communication from 

secondary to primary care may well subvert the 

accuracy of the practice-held electronic record 

of regular medications. 

It is apparent from this research that the 

pharmacy remains a crucial part of the safety 

mechanism for repeat prescribing. However, 

relationships between general practices and 

malise an effective error detection mechanism. 

Inappropriate patient requests also raise questions 

as to how well a practice has informed its 

practice population about repeat prescriptions 

and the limitations of the process due to factors 

directly related to patient safety. Of interest to 

Berwick’s concept of error rate being proportional 

to the number of steps in a system is the 

error rate caused by faxed prescriptions. Faxing 

requires two additional steps over prescriptions 

handed to patients; identification of the right 

fax number and the action of faxing. Both these 

steps caused error in this data set. 

It is most encouraging to see the widespread 

adherence of practices in the Pinnacle Network 

to the majority of the repeat prescribing protocol. 

For those aspects that were not so rigorously 

followed, further work needs to be undertaken 

regarding the appropriateness of including them 

Electronic medical records have revolutionised many of the steps 

regarding repeat prescribing. Unfortunately, automation may also 

cause a degree of complacency, where what is identified as 

“regular medications” may be simply accepted without question. 

pharmacies are, for the most part, quite informal 

and are effective more by good will than 

design. It is suggested that more formalised relationships 

that describe respective responsibilities 

and provide clear lines of communication 

and feedback may be effective not only in ‘last 

stance’ error detection, but also in identifying 

deficient processes. Such a relationship could include 

weekly meetings between the pharmacist 

and practice, maintaining a log book of errors 

to be discussed or shared access to relevant 

patient information. A commonly overlooked 

step in error detection is the check conducted 

by the patient. Several of the instances reported 

for this research identified patient detection 

of error as the corrective mechanism. Yet it 

is not part of usual process in many practices 

to request the patient review the prescription 

once generated. Incorporating this step into the 

practice protocol and at the pharmacy may forin 

the protocol by understanding why practices 

do not use them. 

It is tempting to regard a delay in having the prescription 

ready as somewhat separate from patient 

safety and more in the realm of convenience. 

However, these incidents could also be viewed as 

indicators of faults in a system and therefore the 

question is raised about differing rates of serious 

repeat prescribing errors in practices where delay 

in providing the prescription is rare against practices 

where delay is common. 

The obvious weakness in this study is the selfreported 

nature of both errors in repeat prescribing 

and adherence to the repeat prescribing 

protocol that can lead to lack of consistency in 

data collection. There may have been incidents 

that the practice or practitioner chose not to 

report and these may have shed further light on 



errors that occur. Consequently, the data does 

not give meaningful insight regarding the rate of 

incidents per repeat prescription and cannot be 

considered. 

Conclusions 

Repeat prescribing is part of the ‘heuristic’ of 

general practice; it is an accepted activity that 

has been traditionally undertaken for many years 

without acknowledging that a changing environment 

has significantly shifted expectations 

regarding safety. Some important conclusions 

from this research are: 

1. It is possible to institute a protocol for repeat 

prescribing across a network. 

2. There is good observance of many aspects of 

the protocol overall. 

3. It is clearly of benefit to evaluate the results 

of instituting such a process, even accepting 

the limitations of evaluating practice driven 

continuous quality improvement initiatives. 

4. Aggregating data can add value to 

understanding where flaws exist in systems 

for safe repeat prescribing. 

References 

1. Berwick D. Improvement, trust, and the healthcare workforce. 

Qual Saf Health Care. 2003;12:i2-i6 doi:10.1136/qhc.12. 

suppl_1.i2 

2. Pullon S, McBain L, Allison S. Repeat prescribing practice in 

New Zealand. N Z Fam Physician. 2002;29:19–23. 

3. Saastamoinen L, Enlund H, Klaukka T. Repeat prescribing 

in primary care: a prescription study. Pharm World Sci. 

2008;30(5):605–9. 

4. Harris CM, Dajda R. The scale of repeat prescribing. Br J Gen 

Pract. 1996;46(412):649–53. 

5. De Smet PA, Dautzenberg M. Repeat prescribing: scale, problems 

and quality management in ambulatory care patients. 

Drugs. 2004;64(16):1779–800. 

6. McGavock H, Wilson-Davies K, Connolly P. Repeat prescribing 

management. Br J Gen Pract. 1999;49(447):836. 

7. Varkey P, Aponte P, Swanton C, Fischer D, Johnson SF, Brennan 

MD. The effect of computerized physician-order entry 

on outpatient prescription errors. Manag Care Interface. 

2007;20(3):53–7. 

8 Lord H, Lillis S. Implementing significant event management 

in general practice; potential barriers and solutions. N Z Fam 

Physician. 2005;32:247–250. 

9. Lillis S, Lord H, Ward D. Implementing Incident Management—reservations 

of practice staff. N Z Fam Physician. 

2008;35:253–256. 

10. Barber N, Rawlins M, Dean Franklin B. Reducing prescribing 

error: competence, control, and culture. Qual Saf Health Care. 

2003;12 Suppl 1:i29-32. 

11. Reason J. Human error: models and management. Br Med J. 

2000;320(7237):768–70. 


We wish to acknowledge 

the time and attention 

required to provide 

the data by the general 

practitioners and the 

practices in the Midlands 

Health Network. 

FUNDING 

Material support was 

provided by Pinnacle. 


Steven Lillis is employed 

as medical advisor for 

the Medical Council 

of New Zealand, is 

Chair of the Education 

Advisory Committee 

for the RNZCGP and is a 

Pinnacle board member. 

Hayley Lord is the quality 

manager for Midlands 

Health Network. 

There is a need to recognise and formalise the 

crucial role of the pharmacist in detecting and 

correcting prescribing error. Similarly, the patient 

for whom the prescription is written may also 

be incorporated and formalised into such processes 

as they represent a potent method of error 

detection. It is also suggested that protected time 

for repeat prescribing would reduce error rates. 

Timely communication from secondary to primary 

care would also be likely to reduce error rate. 

Clearly informing the patients of a practice about 

boundaries that need to be set around repeat 

prescribing would reduce requests for medications 

inappropriate for repeat prescribing. 

For an activity that generates substantial error 

rates even when process and protocol is in place, 

continuing questions have to be raised around 

safety. Further research should be aimed at assessing 

the reduction in error rates that can be achieved 

by attention to the system’s flaws found in this research, 

as well as methods of successfully integrating 

improved systems into general practices. 


BACK TO BACK 

The triad of retinal haemorrhage, subdural haemorrhage 


evidence of physical injury is not the result of shaking, but 

is most likely to have been caused by a natural disease 

YES 

In January of this year, the British Crown Prosecution 

Service dealt another blow to the ‘shaken 

baby’ hypothesis in their latest guidance 1 when 

they abandoned the term ‘shaken baby syndrome’ 

in favour of ‘non-accidental head injury’. Although 

shaking remains the mechanistic lynchpin 

of their theory, the name change belatedly acknowledges 

that the shaking hypothesis has been 

seriously undermined by research of the past two 

decades. It is 23 years since Duhaime wrote: “It 

is our opinion based on the clinical data and the 

studies outlined, that the ‘shaken baby syndrome’ 

is a misnomer, implying a mechanism of injury 

which does not account mechanically for the 

radiographic or pathological findings”. 2 

Background 

At the heart of this problem is the diagnostic 

dilemma of young infants, usually less than six 

months of age, who present with the triad of 

retinal haemorrhage (RH), thin-film subdural 

haemorrhage (SDH) and encephalopathy. 

Forty years ago, Guthkelch and others seized 

upon recently published biomechanical studies 

in adults to seek a traumatic explanation for this 

triad. 3 Since fractures, abrasions, bruises and 

other objective evidence of trauma were often 

lacking, they hypothesised that these infants 

must have been shaken and that the characteristic 

bilateral thin-film subdural bleeds were the result 

of bridging vein rupture from rotational forces 

induced by shaking. 

Problems with the hypothesis 

The first problem with the shaking hypothesis 

is empirical: in nearly 40 years, no one has ever 

witnessed shaking to cause the collapse of a 

well baby. The only three witnessed cases in the 

world literature were babies who had already 

collapsed. 4,5 

The second problem is biomechanical. Once 

Duhaime demonstrated that even minor impacts 

generated forces considered sufficient to cause 

the triad while shaking did not, the term ‘shaken 

impact syndrome’ was born. However, there is no 

evidence that shaking must precede or accompany 

impact to cause brain injury; impact of itself 

is enough. Since then, multiple biomechanical 

studies have validated Duhaime’s conclusion and 

endorsed the commonsense view that violent 

Waney Squier 

Consultant Paediatric 

Neuropathologist, 

Department of 

Neuropathology, 

Level 1, West Wing, 

John Radcliffe Hospital, 

Oxford, OX3 9DU, UK 

Waney.Squier@clneuro. 

ox.ac.uk 

The triad of retinal 

haemorrhage, subdural 

haemorrhage and encephalopathy 

in an infant 

unassociated with evidence 

of physical injury is not the 

result of shaking but is most 

likely to have been caused by 

a natural disease—the ‘yes’ 

case. J Prim Health Care. 

2011;3(2):159–161. 

While 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 with 

his or her own set of conditions, capabilities, beliefs, expectations and social 

circumstances. There are areas of uncertainty, ethics and aspects of care for which 

there is no one right answer. General practice is an art as well as a science. Quality 

of care also lies with the nature of the clinical relationship, with communication and 

with truly informed decision-making. The Back to Back section stimulates 

debate, with two professionals presenting their opposing views regarding a clinical, 

ethical or political issue. 

Waney Squier 

Lucy B Rorke-Adams 

BACK TO BACK this issue: 


BACK TO BACK 

shaking would cause neck injury, which is rarely 

identified. 2,3 Biomechanical models are criticised 

as not fairly representing the biological structure 

of the human infant, but the same models, based 

on animal, mathematical and tissue experiments 

and injury reconstruction are used to design car 

seats, head restraints, airbags etc. We all depend 

on them in our daily lives. They are also consistent 

with experience. In one real-life example, 

a baby who suffered serious neck injury in a 

70 mph crash had no SDH or RH, 6 confirming 

the vulnerability of the infant neck 7 and raising 

the question: if 70 mph whiplash does not produce 

the triad, how can the ‘single firm shake’ do 

so, as so frequently cited in Court 

A final problem is anatomical. While models and 

hypotheses may be criticised, there is no arguing 

with the anatomy. Anatomically, the hypothesis 

that shaking can cause thin-film subdural bleeding 

by bridging vein rupture is untenable. As 

these vessels are few in number and carry large 

volumes of blood, rupture would lead to large 

localised bleeds and would occur in the subarachnoid 

space. 2 The thin diffuse bleeds in triad 

babies are more likely to originate in the dura, 

reflecting the extensive vascularity characteristic 

of the infant dura. 10,11 If sufficient, this intradural 

bleeding leaks onto the dural surface, creating 

a ‘subdural’ bleed. Since subdural and retinal 

bleeds are seen in about half of asymptomatic 

neonates, and bleeding into the dura is almost 

universal at neonatal autopsy whatever the cause 

of death, the hypothesis that these bleeds are 

caused by shaking and are immediately symptomatic 

cannot be supported. 

The sole remaining basis for the shaking hypothesis 

rests on confessions, 8 which must be viewed 

with caution given the number of confessions 

which have been shown to be unreliable following 

DNA exonerations. The confession data on 

shaking has not been subject to critical review, 

but a recent study 9 found little correlation 

between confessed accounts of shaking and objective 

brain scan observations. 

Alternative explanations 

Triad infants appear to be manifesting a response 

to disruption of intracranial homeostasis predicated 

on the immaturity of the infant intracranial 

structures. Even the staunchest supporters of 

shaking agree that there is a multitude of causes 

of the triad, including trauma, birth defects, 

metabolic or genetic conditions, cardiorespiratory 

arrest, seizures, ruptured aneurysms, infection, 

stroke and sinovenous thrombosis. 

Triad babies, whose deaths are presumed to be 

nonaccidental, have many features in common 

with cot death babies, whose deaths are presumed 

to be natural. There are distinguishing features; 

cot death babies are found dead and have no pathological 

findings, but we still don’t know why 

they die. But the most obvious, and the most frequently 

overlooked, distinctive feature of many 

triad babies is an extended period of hypoxia 

prior to resuscitation and ventilation, frequently 

with a ‘downtime’ of over 30 minutes. This 

period of hypoxia damages vascular endothelium; 

subsequent reperfusion and the pressure surges of 

resuscitation and ventilation can be expected to 

produce the triad. The association of these factors 

with RH has already been demonstrated. 12 

In every case one must ask: what caused this baby 

to collapse If there are fractures, bruises and 

abrasions, we may assume the triad was due to impact 

injury, inflicted or accidental. If there is neck 

injury, whiplash (and shaking) may be implied. 

We can all agree that it is never safe to shake a 

baby, since severe shaking could damage the vital 

centres of the brain stem and spinal cord, with 

disastrous consequences. But without objective 

evidence of trauma, the triad remains nonspecific. 

In a case of my personal experience, a mother 

found her baby comatose in hospital during an 

admission for suspected infection. A brain scan 

showed SDH and a swollen brain, with RH found 

at autopsy along with a small ruptured vein of Galen 

varix, hidden in the dural folds. How different 

this story would have been if the mother had 

discovered the collapsed baby at home! Once the 

triad was identified, the mother, as the sole carer, 

would almost automatically have been accused 

of shaking her baby. This is a salutary lesson; the 

triad may occur on an open hospital ward, just as 

natural diseases may present at home. 

Failure to recognise abuse risks leaving a 

perpetrator at large and other children unpro- 


BACK TO BACK 

tected. Failure to look beyond the simplistic and 

increasingly untenable shaking hypothesis risks 

incalculable damage by wrongfully removing 

children from loving parents or incarcerating innocent 

people. Further, by focusing on shaking or 

inflicted trauma to the exclusion of accidental and 

natural causes, we are almost certainly missing 

opportunities to save babies through prevention, 

early diagnosis and treatment. 

References 

1. Crown Prosecution Service. Non-accidental Head Injury 

(NAHI, formerly referred to as Shaken Baby Syndrome [SBS])- 

Prosecution Approach. http://www.cps.gov.uk/legal/l_to_o/ 

non_accidental_head_injury_cases/. 2011. 

2. Duhaime AC, Gennarelli TA, Sutton LN, Schut L. ‘Shaken 

Baby Syndrome’: a misnomer J Pediatr Neurosciences. 

1988;4(2):77–86. 

3. Ommaya AK, Goldsmith W, Thibault L. Biomechanics and 

neuropathology of adult and paediatric head injury. Br J Neurosurg. 

2002 Jun;16(3):220–42. 

4. Leestma JE. Case analysis of brain-injured admittedly shaken 

infants: 54 cases, 1969–2001. Am J Forensic Med Pathol. 2005 

Sep;26(3):199–212. 

5. Shannon P, Smith CR, Deck J, Ang LC, Ho M, Becker L. Axonal 

injury and the neuropathology of shaken baby syndrome. Acta 

Neuropathol (Berl). 1998 Jun;95(6):625–31. 

6. Winter SC, Quaghebeur G, Richards PG. Unusual cervical 

spine injury in a 1 year old. Injury. 2003;34(4):316–9. 

7. Barnes PD, Krasnokutsky MV, Monson KL, Ophoven J. 

Traumatic spinal cord injury: accidental versus nonaccidental 

injury. Semin Pediatr Neurol. 200815(4):178–84. 

8. Christian CW, Block R. Abusive head trauma in infants and 

children. Pediatrics. 2009;123(5):1409–11. 

9. Adamsbaum C, Grabar S, Mejean N, Rey-Salmon C. Abusive 

head trauma: judicial admissions highlight violent and repetitive 

shaking. Pediatrics. 2010;126(3):546–55. 

10. Browder J, Kaplan HA, Krieger AJ. Venous lakes in the 

suboccipital dura mater and falx cerebelli of infants: surgical 

significance. Surg Neurol. 1975;4(1):53–5. 

11. Mack J, Squier W, Eastman JT. Anatomy and development of 

the meninges: implications for subdural collections and CSF 

circulation. Pediatr Radiol. 2009;39(3):200–10. 

12. Matshes E. Retinal and optic nerve sheath haemorrhages are 

not pathognomonic of abusive head injury. Presentation G1 

(Pathobiology). American Academy of Forensic Sciences. 

Seattle, 2010:p272. 

The triad of retinal haemorrhage, subdural haemorrhage 


evidence of physical injury is not the result of shaking, but 

is most likely to have been caused by a natural disease 

NO 

It has been the practice of physicians to organise 

historical, physical and laboratory findings which 

occur with some frequency into syndromes or 

specific disease entities, and contributions by 

pathologists often provide a morphological base 

for the disorder. Thus, in the century and a half 

interval since Rudolf Virchow’s studies earned 

him the sobriquet of ‘Father of Pathology’, innumerable 

diseases have been recognised, although 

unfamiliar constellations continue to challenge 

the diagnostic acumen of physicians, requiring 

ongoing clinical and pathological investigations to 

establish their place in the spectrum of disease. 

Among this group are those that appear to be 

associated with child abuse. Although there is 

ample historical documentation of child abuse 

throughout the ages, a scientific approach to 

define the nature and extent of such abuse is a 

relatively recent phenomenon. 1 Whereas abuse 

may take many forms, the majority do not cause 

death, e.g. psychological or sexual abuse, but 

infliction of injury to the central nervous system 

(CNS) is among the most lethal; about two-thirds 

of child abuse victims who die do so because of 

CNS trauma. 2 

Clinical and pathological studies have documented 

three features associated with CNS trauma 

that occur so frequently they are commonly 

referred to as ‘the triad’, specifically, subdural 

haemorrhage (SDH), retinal haemorrhage (RH), 

and encephalopathy. 

This triad is found in infants who may/may 

not exhibit other injuries, such as bruising and/ 

Lucy B Rorke-Adams 

MD, Senior 

Neuropathologist, The 

Children’s Hospital of 

Philadelphia; Consultant 

Forensic Neuropathologist, 

Office of the Medical 

Examiner, City of 

Philadelphia and Clinical 

Professor of Pathology, 

Neurology and Pediatrics, 

University of Pennsylvania 

School of Medicine, USA 

rorke@email.chop.edu 


BACK TO BACK 

The triad of retinal 

haemorrhage, subdural 

haemorrhage and encephalopathy 

in an infant 

unassociated with evidence 

of physical injury is not the 

result of shaking but is most 

likely to have been caused by 

a natural disease—the ‘no’ 

case. J Prim Health Care. 

2011;3(2):161–163. 

or fractures. Pathogenesis of the triad has been 

ascribed to severe acceleration–deceleration forces 

consequent to shaking, plus or minus impact. 

An enormous body of evidence based upon 

peer-reviewed studies has established the high 

frequency of association between the triad and 

shaken impact syndrome, with the caveat that 

this triad may not be pathognomonic for inflicted 

trauma. 3 Specifically, one or more components 

may signal a naturally occurring disease, including 

among others, a variety of haematological/ 

coagulopathic disorders, rare metabolic diseases, 

vascular malformations, etc. 

Routine diagnostic evaluation of infants who 

present with one or more features of the triad 

therefore includes a search for one of the known 

diagnostic possibilities in the context of history 

and ancillary investigations. 4,5 

Those who challenge the triad as a sentinel of possible 

nonaccidental trauma have advanced alternative 

disease states to explain its occurrence. Their 

list includes hypoxia-ischemia, birth injury, excessive 

coughing/vomiting, infections, vaccinations 

and venous thromboses. 4 It is of note that these 

alternative suggestions purporting to account for 

the features of the triad have been extant for a 

relatively short time, first appearing in 2003. 6 

This was a publication by Geddes et al, who theorised 

that pathogenesis of SDH and retinal haemorrhage 

was hypoxia-ischemia and not trauma. 

The study upon which this extraordinary claim 

was based was severely flawed, including, for example, 

no clinical or pathological examination of 

the eyes; two years later it was retracted by Geddes, 

but by that time, the evil genie had escaped 

Pandora’s box, repercussions of which have been 

far-ranging. A considerable literature has since 

accumulated with contributions both from Geddes’s 

supporters (even after her retraction) and a 

host of challengers. 7 Of primary importance is 

the fact that, to date, no reliable evidence base 

supporting a pathogenetic relationship between 

hypoxia-ischemia and subdural bleeding or retinal 

haemorrhages has been forthcoming. 

Also lacking is evidence-based literature supporting 

the assertion that late consequences of ‘birth 

injury’ may be mistaken for nonaccidental head 

trauma. Experienced paediatric pathologists have 

documented falcine and small SDH in perinates 

dying of problems unrelated to the CNS, e.g. 

congenital anomalies, infections etc., and recent 

radiological studies have confirmed these observations. 

8 The majority of the haemorrhages have 

resolved by one month of age, and if the infant 

comes to postmortem after a month or more, a 

delicate avascular membrane is sometimes found. 

The assertion that it is highly vascularised and 

may bleed spontaneously or consequent to minor 

trauma has no documented factual base. 

It is also well established that retinal haemorrhages 

occur peripartum and these, too, disappear 

by four weeks of age. 9 

The claim that venous thromboses cause the 

triad is blatantly false. Although intracerebral 

haemorrhages are common, no standard texts of 

radiology or pathology document association of 

thromboses with SDH, although it is conceivable 

that small posterior pole retinal haemorrhages 

may result from increased intracranial pressure. 9 

Although subdural effusions and retinal haemorrhages 

are sometimes found in infants with 

bacterial meningitis, SDHs are exceptionally rare, 

even if the agent is haemolytic ‘strep’. The retinal 

haemorrhages are basically caused by increased 

intracranial pressure and distinguishable by an 

experienced ophthalmologist from those consequent 

to trauma. 9 

Assertions that vaccinations or excessive coughing/vomiting 

cause subdural and retinal haemorrhages 

are clearly ludicrous. There is, in fact, 

strong evidence to the contrary concerning 

coughing/vomiting. 10–12 Surridge et al. 10 studied 

72 patients who required intensive care because 

of pertussis, 97% of whom were less than 12 

months of age, and reported CNS complications 

to include seizures and encephalopathy; three 

patients died. They found neither SDH nor RH 

clinically or pathologically. 

A companion study by Cherry 11 of children with 

severe croup with/without pneumonia (including 

some with diphtheria) made no mention of 

SDH/RH as a complication in severely affected 


BACK TO BACK 

patients. Similarly, Fitzpatrick et al., who studied 

a group of children with cyclical vomiting syndrome, 

found none with complicating SDH/RH. 12 

The scientific base for shaken impact syndrome 

has accumulated over a period of at least 150 

years, although sporadic writings of physicians, 

anatomists and writers commenting about effects 

of CNS trauma, in particular concussion, appeared 

long before that time. 

The concept that SDH was a consequence of 

shaking was advanced in 1930, and innumerable 

observations of traumatised infants by Caffey, 

Kempe, Gutkelch and countless others, laid 

the foundation for the objective base of shaken 

impact syndrome upon which contemporary 

investigators continue to build. 

Contributions by paediatricians, neuroradiologists, 

neurosurgeons, clinical and forensic 

pathologists, physiologists, ophthalmologists, 

biomechanical engineers, social workers, and law 

enforcement agents have formed the evidence 

base that currently supports the diagnosis of 

shaken impact syndrome. 

Although components of the syndrome include 

the triad, the diagnosis is actually based upon 

a complex constellation of clinical-pathologicalinvestigative 

findings. These include: 

1. investigative data 

2. clinical history, examination and therapeutic 

requirements 

3. laboratory studies to rule out natural disease, 

and 

4. radiological, ophthalmological and pathological 

findings, all of which are evaluated against a 

knowledge base of clinical disease and features 

of accidental versus nonaccidental trauma. 

The triad is an important component within this 

complex constellation, but does not stand alone. 

Specialists involved in the tragic field of child 

abuse remain ever mindful of the wisdom of 

John Dewey who said: “Intelligence is not something 

possessed once and for all. It is in constant 

process of forming, and its retention requires 

constant alertness in observing consequences, 

an open-minded will to learn and courage in readjustment.” 

Those who offer untested hypotheses 

to defend individuals who have harmed 

infants do considerable disservice to science and 

to the victims. 

References 

1. Block H. Abandonment, infanticide and filicide. Am J Dis 

Child. 1988;142:1058–1060. 

2. Rorke LB. Neuropathology. In: Ludwig S, Komberg AE, editors. 

Child abuse. 2nd ed. New York: Churchill Livingston; 

1992. 

3. Munns RA, Brown JK, eds. Shaking and other non-accidental 

head injuries in children. Cambridge: Mac Keith/Cambridge 

University Press; 2005. 

4. Reece RM. Differential diagnosis of inflicted childhood 

neurotrauma. In: Reece RM, Nicholson CE, editors. Inflicted 

childhood neurotrauma. United States: Amer Acad Pediatrics; 

2003. 

5. Chiesa A, Duhaime A-C. Abusive head trauma. Pediatr Clin N 

Am. 2009;56:317–331. 

6. Geddes JF, Tasker RC, Hackshaw AK, et al. Dural haemorrhage 

in non-traumatic infant deaths: does it explain bleeding 

in ‘shaken baby syndrome’ Neuropathol Appl Neurobiol. 

2003;29:14–22. 

7. Jaspan T. Current controversies in the interpretation of non-accidental 

head injury. Pediatr Radiol. 2008;38 Suppl 3:S378–87. 

8. Rooks VJ, Eaton JP, Ruess L, Petermann GW, Keck-Wherley 

J, Pedersen RC. Prevalence and evolution of intracranial 

hemorrhage in asymptomatic term infants. Am J Neuroradiol. 

2008;29(6):1082–9. 

9. Levin AV. Retinal hemorrhages: Advances in understanding. 

Pediatr Clin N Am. 2009;56:333–344. 

10. Surridge J, Segedin ER, Grant CC. Pertussis requiring intensive 

care. Arch Dis Child. 2007;92:970–975. 

11. Cherry JA. Croup. NEJM. 2008;358:384–391. 

12. Fitzpatrick E, Bourke B, Drumm B, et al. Outcome for 

children with cyclical vomiting syndrome. Arch Dis Child. 

2007;92:1001–1004. 


continuing professional development 

pearls 

cochrane corner 

String of PEARLS 

Practical Evidence About Real Life Situations 

Depression 

PEARLS are succinct summaries of Cochrane Systematic Reviews 

for primary care practitioners—developed by Prof. Brian McAvoy 

for the Cochrane Primary Care Field (www.cochraneprimarycare. 

org), New Zealand Branch of the Australasian Cochrane Centre at the 

Department of General Practice and Primary Health Care, University 

of Auckland (www.auckland.ac.nz/uoa), funded by the New Zealand 

Guidelines Group (www.nzgg.org.nz) and published in NZ Doctor 

(www.nzdoctor.co.nz.). 

Tricyclic antidepressants and selective serotonin 

reuptake inhibitors are effective for depression in 

primary care 

Exercise may improve depression 

Relaxation techniques have some benefit in depression 

St John’s wort is effective for depression 

Sertraline (escitalopram) is effective for acute major 

depression 

Antidepressants are effective for depression in 

physically ill people 

Disclaimer: PEARLS are for educational use only and are not meant 

to guide clinical activity, nor are they a clinical guideline. 

The Epley (canalith repositioning) 

manoeuvre is effective for benign 

paroxysmal positional vertigo 

Bruce Arroll MBChB, PhD, FRNZCGP; Professor of General Practice 

and Primary Health Care, The University of Auckland, PB 92019, 

Auckland, New Zealand; Email: b.arroll@auckland.ac.nz 

The problem: Your patient has vertigo, especially when 

their head is in a particular position, e.g. when sitting up from 

a lying position. You diagnose benign paroxysmal positional 

vertigo and wish to know how effective the Epley manoeuvre 

is. You were shown it at medical school, but were very sceptical 

about its effectiveness. 

Clinical bottom line: The Cochrane review suggests that 

it is effective compared with sham moving with a numbers 

needed to treat of 2 to 3.3. There are videos on the web which 

demonstrate one of the many ways in which it is conducted. 

(http://www.youtube.com/watchv=ZqokxZRbJfw). 

What is the pathology: The cause of benign positional 

vertigo is believed to be canalithiasis, principally affecting 

the posterior semicircular canal. In canalithiasis, free-floating 

debris in the semicircular canal is hypothesised to act like 

a plunger, causing continuing movement of the endolymph 

even after head movement has ceased. This causes movement 

of the cupula, bending of the hairs of the hair cells, and 

provokes vertigo. 1 

Epley manoeuvre is effective for benign paroxysmal positional vertigo 

Epley 

manoeuvre 

Success Evidence Harms 

Effective in short-term 

subjective benefit NNT 2 

to 3.3 (range of NNT). 

There is no long-term 

data on benefit 

Cochrane 

review 1 

No reported 

harms 

References 

1. Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign 

paroxysmal positional vertigo. Cochrane. Database of Systematic Reviews 2004, 

Issue 2. Art. No.: CD003162. DOI: 10.1002/14651858.CD003162.pub2. 

All people residing in New Zealand have access to the Cochrane Library 

via the Ministry website www.moh.govt.nz/cochranelibrary 



POTION OR POISON 

Lemon balm 

Melissa officinalis; also known as lemon balm, bee balm, 

garden balm, Melissa, melissengeist 

Preparations: Leaf preparations are used, and 

were traditionally taken mainly as a tea. Alcoholbased 

liquid extracts or tinctures are now commonly 

dispensed by herbal practitioners, often 

in combination with other herbs. Tablet, capsule 

and tea preparations combining lemon balm with 

other anxiolytic herbs such as valerian and passionflower, 

and combinations with chamomile, 

peppermint and other herbs aimed at improving 

digestive function, are available through pharmacies, 

health food outlets or herbal practitioners. 

Creams and ointments containing concentrated 

extracts are also sold. 

Active constituents: Known constituents 

include simple phenolic acid compounds, particularly 

rosmarinic acid, caffeic acid, chlorogenic 

acid, and metrilic acid; flavonoids such as luteolin, 

apigenin and derivatives; monoterpene glycosides; 

sesquiterpenes, including β-caryophyllene 

and germacrene; triterpenes such as oleanolic and 

ursolic acids; volatile oil, and tannins. Different 

constituents contribute to the various pharmacological 

activities. 

Main uses: Lemon balm is a herb with a lemon 

scent native to southern Europe, now naturalised 

and widely cultivated around the world. It’s 

documented use as a medicine dates back more 

than 2000 years, traditionally being used as a 

mild sedative and calming agent, and for a range 

of nervous system complaints. 1 Usage throughout 

Europe was widespread by the middle ages, and 

in the London Dispensary of 1696 it was said 

to “renew youth, strengthen the brain, relieve 

languishing nature and prevent baldness”. 

Summary Message 

Evidence to date supports mild relaxant and cognitive enhancing actions by 

lemon balm in healthy persons, and results from one small trial suggest similar 

effects in Alzheimer’s patients. However, further studies involving much larger 

numbers of patients are needed. Evidence is less convincing for its efficacy in 

digestive conditions or herpes simplex. As with all herbal medicines, different 

lemon balm products vary in their pharmaceutical quality, and the implications 

of this for dosage, efficacy and safety should be considered. 

Lemon balm is also regarded as a gentle antispasmodic 

and digestive aid, and concentrated 

extracts are applied topically for the treatment of 

oral and genital herpes simplex. 

Most published research on lemon balm over the 

past 10 years relates to its potential activities as 

an antianxiety agent and cognitive enhancer. 2 

Evidence for efficacy: Reduced anxiety 

and improved mood during laboratory models of 

psychological stress have been reported in studies 

on healthy humans, following single doses of 

lemon balm in placebo-controlled crossover studies. 

2 Similar effects have also been reported for a 

combination of lemon balm and valerian. Chronic 

administration reduces anxiety-like reactivity and 

brain corticosterone concentrations in a mouse 

model of anxiety (effects that may be partly attributable 

to increasing GABA levels). 

Improvement in memory performance has also 

been reported after lemon balm ingestion in 

these laboratory-induced stress studies. 3 Findings 

Phil Rasmussen 

MPharm, MPS, Dip Herb 

Med, MNIMH (UK), 

FNZAMH, MNHAA 

Herbal medicines are a popular health care choice, but few have been tested to contemporary standards. 

POTION OR POISON summarises the evidence for the potential benefits and possible harms of wellknown 

herbal medicines. 



POTION OR POISON 

from an Iranian placebo controlled clinical trial 

involving 42 elderly patients with mild to moderate 

Alzheimer’s disease, suggested improvement 

in cognitive function following four months’ 

treatment with an extract equivalent to 3 g lemon 

balm daily. 2 Reduced agitation was also seen 

in the lemon balm–treated group, as it was in 

another trial involving lemon balm essential oil 

aromatherapy in patients with severe dementia. 

Various studies have reported significant antioxidant 

activities, including improvement in 

oxidative stress and reduced DNA damage in 

radiology staff. In vitro studies using a rat model 

of dopaminergic neurons have suggested possible 

neuroprotection against diseases such as Parkinson’s 

and Alzheimer’s, as a result of antioxidant 

properties. 

While creams containing a highly concentrated 

extract of lemon balm have been studied for the 

treatment of active viral herpes, variable results 

have been achieved in trials to date. 

doses, suggests the need for caution when taking 

it alongside either thyroxine, propylthiouracil, 

carbimazole or methimazole, although no case 

reports concerning such interactions have been 

published. 

The possibility of as yet unknown interactions 

between lemon balm and other drug therapies 

also exists. 

Key references 

Full reference list available from the author on request: 

philrasm@ihug.co.nz 

1. Ulbricht C. Lemon balm (Melissa officinalis L): an evidencebased 

systematic review by the Natural Standard Research 

Collaboration J Herbal Pharmacotherapy. 2005;5(4):71–114. 

2. Akhondzadeh S. Noroozian M, Mohammadi M, Ohadinia S, 

Jamshiti A.H., Khani M. Melissa officinalis extract in the treatment 

of patients with mild to moderate Alzheimer’s disease: 

a double blind, randomised, placebo controlled trial. J Neurol 

Neurosurg Psychiatry. Jun 2003;74(7):863–866. 

3. Kennedy DO, Little W, Scholey AB. Attenuation of 

laboratory-induced stress in humans after acute administration 

of Melissa officinalis (lemon balm). Psychosomatic Med. 

2004;66:607–613. 

Adverse effects: Findings from clinical trials 

indicate that lemon balm is generally well tolerated, 

with the frequency of adverse effects being 

similar to that of placebo. Those reported include 

headache, reduced alertness, palpitations and 

gastrointestinal complaints. Appraising the significance 

of each of these is difficult, as different 

dosage forms, including some containing other 

herbal medicines, have been studied. Patient and 

participant numbers in clinical trials have also 

been relatively low. 

Hypersensitivity reactions have been reported, 

particularly with topical preparations. 

Lemon balm has been placed on the GRAS (Generally 

Regarded As Safe) list of the FDA. 

Lemon balm is theoretically contraindicated in 

those with hypothyroidism, due to its possible 

thyrotoxic properties with high doses. 

Drug interactions: No significant adverse 

interactions have been reported, although a 

theoretical potentiation of the effects of sedative 

and CNS depressant medications exists. The 

possible antithyroid action of lemon balm in large 



VAIKOLOA 

Pacific peoples: 

our health and wellbeing 

Api Talemaitoga, Clinical Director Pacific Health, Pacific Programme Implementation, Ministry of Health 

Ni sa bula vinaka. This is an important 

occasion for me to open another communication 

channel for all who care 

about Pacific peoples’ health and wellbeing, to 

share their koloa and celebrate the joy of giving 

and receiving. In New Zealand (NZ), Pacific 

peoples are unique in that we are a vibrant and 

diverse population group from 22 different Pacific 

Island nations, each with its own distinct 

language and culture. We often come together 

in our various communities to celebrate our 

rich heritage, our faith, and our achievements. 

We also constitute a rapidly increasing population, 

representing the largest Pacific population 

group in the world. 

largest Pacific groups in Counties Manukau District 

Health Board found an emerging pattern— 

Samoans and Tongans shared similarities across 

several indicators, as did Cook Island Maori and 

Niueans. For example, Samoans and Tongans 

were more likely to live in crowded households 

and have higher rates of child hospitalisations 

for respiratory-related illnesses than Cook Island 

Maori and Niueans. 4 

As emphasised in ‘Ala Mo’ui—Pathways to Pacific 

Health and Wellbeing 2010–2014, 5 all these 

aspects of diversity (place of birth, multiple 

ethnicities, and cultural variation between Pacific 

groups) mean that services for Pacific peoples 

VAIKOLOA 

Pacific Primary 

Health Care 

Treasures 

Vai (water) 

is a symbol of 

‘life-source’ and 

koloa (treasures) 

to share 

In New Zealand, Pacific peoples are unique in that we are a vibrant 

and diverse population group from 22 different Pacific Island 

nations, each with its own distinct language and culture. 

The Pacific population is undergoing significant 

demographic changes. The proportion of Pacific 

peoples born in NZ has increased, with the 

larger NZ-born groups being Niueans, Cook 

Island Maori, and Tokelauans. The number of 

Pacific children born with dual or multiple 

ethnic ancestries has also increased significantly, 

and the Pacific population is youthful compared 

with the total NZ population. 1 Furthermore, 

there is evidence that health outcomes, such as 

cardiovascular disease (CVD) mortality, vary 

between Pacific groups, with the highest CVD 

mortality rate among Cook Island Maori (approximately 

1.66 times the Samoan rate). 2,3 Similarly, 

a recent needs assessment that compared 

a number of health indicators between the four 

need to be particularly adaptable and innovative 

to respond to Pacific peoples’ varied needs 

and preferences. In this connection, I reiterate 

the principles in ‘Ala Mo’ui when working with 

Pacific peoples: 

• health and disability services need to 

work across other sectors like education, 

housing and social development 

• families and culture are important 

and play a significant role in Pacific 

peoples health and wellbeing 

• key dimensions of quality like access, 

equity, cultural competence and patientcentredness, 

are implicit in the delivery 

of health and disability services. 


Api Talemaitoga 

Api_Talemaitoga@ 

moh.govt.nz 



VAIKOLOA 

The challenges we face across the entire social 

and economic spectrum continue to grow. Pacific 

peoples are disproportionately represented in the 

lower socioeconomic strata, and this is significant 

because of our experiences with poor health 

outcomes. Health inequalities exist in sociallydisadvantaged 

groups due to poorer health, a 

greater exposure to health hazards across the 

whole life course, and limited access to highquality 

health services than other more privileged 

population groups. Nowhere is this more 

obvious than amongst Pacific children, who have 

a higher prevalence of obesity compared with the 

total population, and the prevalence nearly doubles 

between the age groups of two to four years 

and five to nine years. All of us who work in 

the health sector should be aware of the serious 

challenges we face as we navigate and chart our 

course for the next three to five years, in light of: 

…services for Pacific peoples need to be 

particularly adaptable and innovative to respond 

to Pacific peoples’ varied needs and preferences. 

rest of the world. May you also grow in knowledge, 

wisdom, and empathy for Pacific peoples, 

their health and wellbeing, as you receive of our 

koloa—Vaikoloa. Vinaka vakalevu. 

References 

1. Callister P, Didham R. Emerging demographic and socioeconomic 

features of the Pacific population in New Zealand. In: 

Bisley A, editor. Pacific interactions: Pasifika in New Zealand, 

New Zealand in Pasifika. Wellington: Institute of Social Studies; 

2008. 

2. Blakely T, Tobias M, et al. Tracking disparity: trends in ethnic 

and socioeconomic inequalities in mortality, 1981–2004. Wellington: 


3. Blakely T, Richardson K, et al. Does mortality vary between 

Pacific groups in New Zealand Estimating Samoan, Cook 

Island Maori, Tongan, and Niuean mortality rates using hierarchical 

Bayesian modelling. N Z Med J. 2009;122(1307):18–29. 

4. McCool J, Woodward A, Percival T. Health of Pacific Islanders: 

achievements and challenges. Asia Pac J Public Health. 

2011;23(1):7–9. 

5. Minister of Health and Minister of Pacific Island Affairs. ‘Ala 

M’oui: Pathways to Pacific health and wellbeing 2010–2014. 


6. Ministry of Health. Improving quality of care for Pacific Peoples. 


7. Ministry of Health. A focus on the health of Maori and Pacific 

children: Key findings of the 2006/07 New Zealand Health 

Survey. Wellington: Ministry of Health; 2009. 

8. Ministry of Health. Pacific Health. Message from the Clinical 

Director Pacific Health. January 2011. 

• the economic difficulties many of our communities 

and providers find themselves in 

• the emerging health issues coupled with the 

changing demographics of our communities 

• the challenges of implementing Whanau 

Ora alongside our Pacific models of care. 6–8 

I believe these challenges will strengthen our 

resolve to work together, pool our resources, 

and share our koloa for the improved health and 

wellbeing of our people. I am committed to working 

with all health providers to reinforce their 

service delivery models of health care so they 

remain responsive to the health needs of Pacific 

peoples for the future. I am also committed to the 

Ministry of Health’s ‘Ala Mo’ui as it represents a 

significant milestone for enabling Pacific peoples 

to improve their educational opportunities as well 

as their living and working conditions, over the 

next five years. May Vaikoloa refocus our commitment 

to each other and enrich our families 

and relationships as we share and exchange koloa 

in NZ and beyond to the Pacific Islands and the 



NUGGETS OF KNOWLEDGE 

NSAIDs and risk mitigation 

—if you really must use them in the elderly 

Linda Bryant MClinPharm, PGDipHospPharmAdmin, PhD, FNZHPA, FNZCP, FPSNZ, MCAPA 

If you have balanced the risks and benefits of 

using a NSAID in an older person, then the following 

points are some risk mitigation strategies. 

• Prescribe low dosages e.g. naproxen 

250 mg up to bd, or diclofenac 25 mg bd 

–– For general inflammation/pain ‘half doses’ 

are usually adequate. High doses are 

mainly required for rheumatoid arthritis 

–– You do not need to prescribe the slow release 

forms, which generally mean higher dosages. 

• Renal adverse effects 

–– Renal adverse effects are dose-related 

–– Check baseline renal function and repeat in 

one to two weeks, then one to three monthly 

depending on the baseline renal function 

–– Try to avoid the ‘triple whammy’—a 

diuretic and ACE inhibitor or an angiotensin 

II antagonist, plus an NSAID 

–– Warn the person not to become dehydrated. 

Keep fluid intake up to 

at least 1500 mL per day. 

• Gastrointestinal adverse effects 

–– Gastrointestinal effects are dose-related 

–– The risk is about 1%/patient/year (a 

relative risk of four to seven, i.e four to 

seven times the risk of a GI bleed) 

–– For high-risk people prescribe 

a proton pump inhibitor 

–– High risk people are people with at 

least two of the following criteria: 

• Over 65 years old 

• Previous peptic ulcer disease 

• On a second NSAID (including aspirin) 

• On warfarin or other antithrombotic 

medicine. This includes SSRIs and tramadol 

(antiplatelet effects). The effect of these 

medicines may be very small when used 

alone, but is cumulative with NSAIDs 

• On prednisone 

–– There is poor correlation between dyspepsia 

and the risk of a gastrointestinal bleed 

(i.e. GI bleeds are usually asymptomatic in 

that pain does not often precede the bleed) 

–– Warn patients to be observant for black stools 

and report this to their GP immediately. 

• Cardiovascular adverse effects 

–– Increased risk of a cardiovascular event 

• Naproxen at 1000 mg daily is considered 

the NSAID with the 

least cardiovascular risk 

• High doses of diclofenac (150 mg daily) 

is associated with an increased cardiovascular 

risk 

–– Heart failure 

• The relative risk for de novo heart failure is 

approximately 1.6 (i.e. 1.6 times greater risk) 

• The relative risk for an exacerbation 

of heart failure is approximately 26 

(i.e. 26 times the risk) 

–– Blood pressure 

• On average an NSAID may increase 

blood pressure 5 mmHg—a clinically 

significant increase 

• Monitor patients monthly for three months. 

• Other 

–– NSAIDs have a number of other adverse 

effects that are a risk for all people. These 

include common adverse effects such as: 

• Headache, rash, dizziness, vertigo, gastric 

upset, raised transaminases 

• Beware of exacerbations of asthma 

in older people with nasal polyps. 

Author’s conclusions: There are times 

when a NSAID is unavoidable in an older person. 

When one is necessary start with a low dose, 

avoid long-acting (high dose) preparations, and 

monitor gastrointestinal, cardiovascular and 

renal adverse effects. Record risk mitigation strategies 

in the person’s medical records. 

Nuggets of Knowledge provides succinct summaries of pharmaceutical evidence about 

treatment of common conditions presenting in primary care and possible adverse drug reactions. 

key points 

• Improved quality of 

life is the ultimate 

goal of medicines 

therapy. 

• For some elderly 

people regular 

paracetamol is 

inadequate, an 

opiate is not suitable/ 

not tolerated and a 

NSAID is necessary 

to provide good pain 

relief, increase 

mobility, maintain 

independence, 

improve mood and 

generally improve 

quality of life. 

• If a NSAID is 

necessary for an 

older person then 

management of the 

potential adverse 

effects is essential. 

CORRESPONDENCE TO: 

Linda Bryant 

Clinical Manager, Clinical 

Advisory Pharmacist, 

East Health Trust PHO 

PO Box 38248, Howick 


l.bryant@auckland.ac.nz 

VOLUME 3 • NUMBER 1 • MARCH 2011 J OURNAL OF PRIMARY HEALTH CARE 169

ETHICS 

Medical ethics: four principles, two decisions, 

two roles and no reasons 

John Kennelly MBChB, LLB, LLM(Hons), FRNZCGP, FACLM 

ABSTRACT 

The ‘four principle’ view of medical ethics 

has a strong international pedigree. 

Despite wide acceptance, there is 

controversy about the meaning and use 

of the principles in clinical practice as a 

checklist for moral behaviour. Recent 

attempts by medical regulatory authorities 

to use the four principles to judge 

medical practitioner behaviour have not 

met with success in clarifying how these 

principles can be incorporated into a 

legal framework. This may reflect the 

philosophical debate about the relationship 

between law and morals. In this 

paper, legal decisions from two cases in 

which general practitioners have been 

charged with professional shortcomings 

are discussed. Difficulties with the 

application of the four principles (autonomy, 

beneficence, nonmaleficence 

and justice) to judge medical practitioner 

behaviour are highlighted. The 

four principles are relevant to medical 

practitioner behaviour, but if applied as 

justifications for disciplinary decisions 

without explanation, perverse results 

may ensue. Solutions are suggested 

to minimise ambiguities in the application 

of the four principles: adjudicators 

should acknowledge the difference 

between professional and common 

morality and the statutory requirement 

to give decisions with reasons. 

Introduction 

Ethically acceptable conduct by New 

Zealand health care practitioners is 

determined by statute in the Health 

Practitioners Competence Assurance Act 

(HPCAA) 2003 Section 118(i). For medical 

practitioners the HPCAA authorises 

the Medical Council to set the “standards 

of clinical competence, cultural 

competence, and ethical conduct to be 

observed by health practitioners of the 

profession”. 

The NZ Medical Council (NZMC) 

endorses the four ethical or moral principles 

which are also the moral mantra of 

medical practice emerging from the UK 

and USA. 

Standard treatises on medical ethics cite 

four moral principles: autonomy, beneficence, 

nonmaleficence, and justice. Autonomy 

recognises the rights of patients 

to make decisions for themselves. Beneficence 

requires a doctor to achieve the 

best possible outcome for an individual 

patient, while recognising resource constraints. 

Nonmaleficence implies a duty 

to do no harm. (This principle involves 

consideration of risks versus benefits 

from particular procedures.) Justice 

incorporates notions of equity and of the 

fair distribution of resources. 1 

The Health (formerly Medical) Practitioners 

Disciplinary Tribunal is established 

under the HPCAA to investigate 

and, if necessary, discipline a health 

practitioner. The grounds for discipline 

include “malpractice or negligence” or 

bringing “discredit to the profession”. 

The Statute does not include reference 

to any moral codes, but it is not uncommon 

for judges to consider moral 

criteria before coming to a decision. The 

relationship between moral principles 

and law is the subject of debate among 

legal philosophers. Consistent with the 

dominant legal positivist view, here it 

will be assumed that there is no necessary 

connection between law and morals 

and “…it is in no sense a necessary truth 

that laws reproduce or satisfy certain 

demands of morality, though in fact they 

have often done so.” 2 The separation of 

law and morals is a consistent theme and 

is supported by courts in New Zealand 

and Australia. 3,4 One instance of the incorporation 

of morals into law occurred 

with the changes to the Crimes Act 1961 

with the 2007 Section 59(2) amendment 

making it illegal to use parental force for 

purposes of “correction” or punishment. 

A moral principle of nonmaleficence towards 

children became law and now does 

not require consideration of the moral 

force behind the principle. 

CORRESPONDENCE TO: 

John Kennelly 

Senior Lecturer, Department of 

General Practice and Primary Health 

Care, The University of Auckland, 

PB 92019, Auckland, New Zealand 

j.kennelly@auckland.ac.nz 

The ethics column explores issues around practising ethically in primary health care 

and aims to encourage thoughtfulness about ethical dilemmas that we may face. 

THIS ISSUE: Dr John Kennelly addresses the difficulty of applying the four moral 

principles (autonomy, beneficence, nonmaleficence, justice) in the legal context of two 

cases of general practitioners charged with professional misconduct. 


ethics 

The following two cases will demonstrate 

that the use of moral principles to 

regulate medical practitioner conduct is 

not simple. A tribunal wishing to refer 

to moral principles should give reasoned 

decisions and be prepared that their 

findings about moral behaviour do not 

survive a legal decision. 

Two cases 

The two cases concern two general 

practitioners (GPs): one (Dr S) who failed 

to complete an Accident Compensation 

Corporation (ACC) form for a patient 

with a suspected work-related disease 

and the other (Dr G), who was charged 

with having a sexual relationship with a 

former patient. 

Dr S 

Dr S, a GP with an interest in occupational 

medicine and employed 

by a freezing works, was consulted 

by Mr A, a freezing worker who was 

suffering from symptoms suggestive 

of Leptospirosis. Dr S chose to delay 

the completion of an ACC claim for a 

work-related disease, but eventually the 

laboratory tests confirmed the presence 

of Leptospirosis. Eventually, in Dr S’s 

opinion, Mr A recovered and he was 

sent back to work despite his protestations 

that he was not well. Mr A’s own 

GP diagnosed Chronic Fatigue Syndrome 

(CFS) which Dr S believed was 

not caused by Leptospirosis and hence 

not an ACC claim. Mr A complained 

and this was referred to the Medical 

Practitioners Disciplinary Tribunal 

(MPDT). The MPDT decided that the 

issue was not about Dr S’s clinical skills 

but his skills in relation to “communication, 

and ethical issues surrounding 

conflicting interests…” 5 The MPDT also 

charged Dr S with breaching the four 

principles, “relating to nonmaleficence, 

beneficence and justice”. Counsel for 

the disciplinary body submitted that 

the allegations relating to the ethical 

guidelines were self-explanatory and 

“non-maleficence by failing to accept 

the hospital diagnosis” and “principle of 

justice by failing to accept the hospital 

diagnosis” and not providing “ACC 

certification during this period resulting 

in major stress and financial hardship 

for Mr A”. 6 

Dr S appealed the decision to the 

District Court and charges that Dr S 

breached the fundamental principles of 

nonmaleficence, beneficence and justice, 

were dismissed. 7 The Court did uphold 

the charge that Dr S “did not accept that 

the patient’s chronic malaise and fatigue 

were due to the after effects of Leptospirosis 

and therefore did not provide 

ACC certification during this period 

resulting in major stress and financial 

hardship for the patient.” In agreeing 

with this decision the District Court 

may have been influenced by the Tribunal’s 

findings that Dr S’s “primary focus 

was on protecting his [Dr S] employer 

and that he was clearly not focusing on 

Mr A’s needs”. The Court decision was 

not reported so the reasoning of the 

Court is not available. 

There are three unanswered questions 

about certification, financial hardship 

and the blurring of professional roles: 

1. Was Dr S acting illegally to refuse 

to complete the ACC certificate and 

insist that Mr A returned to work 

A medical advisor to the Medical 

Council stated—reflecting the Council’s 

guidelines and commenting on a case 

where a doctor refused to claim ACC 

funding for a patient—that the doctor 

“acted entirely correctly (though 

bravely): the diagnosis is a professional 

judgment for the doctor, and he would 

have been wrong to sign a document he 

believed to be false and misleading.” 8 

Dr S believed what he was doing was 

correct and had expert evidence to support 

that view. 

2. Should Dr S be responsible 

for “major stress and financial 

hardship for the patient” 

It is unlikely that a court would consider 

that Mr A would have suffered ‘harm’ 

from having to receive social welfare assistance 

compared with ACC payments, 

despite the monetary difference. In a 

2008 High Court decision, the benefits 

of ACC versus non-ACC compensation 

were considered and the Court stated 

that it was “illogical to claim that the 

Ministry of Health has failed [the patient] 

by not giving her the benefits that 

another government agency would, if 

her circumstances were different”. 9 

If it was decided that Mr A did suffer 

economic loss, then there are strong legal 

arguments against Dr S having to bear 

economic responsibility for the advice he 

gave Mr A or ACC, whether or not that 

advice was negligent. 10 

3. Did Dr S blur his roles and favour 

his employer over the patient 

when considering his actions 

during his treatment of Mr A 

The Tribunal was of the view that 

Dr S’s “primary focus was on protecting 

his employer and that he was clearly not 

focusing on Mr A’s needs” and that Dr S 

“was blurring his various roles and did 

not appear to be addressing his mind to 

which role he was undertaking and for 

whom at any given time”.³ 

The MPDT had previously recognised 

the importance of legal obligations to 

insurance companies when it recognised 

the obligation arising out of a contract 

between the patient and the insurance 

company and the “trust between insurance 

companies and members of the 

medical profession”. 11 

In the case of Dr S, the Tribunal 

preferred the expert evidence from 

Dr Walls that Dr S had a primary 

responsibility to Mr A at the expense 


ETHICS 

of his responsibility to ACC. “Dr Walls 

took issue with Professor Gorman’s 

opinion that with regard to matters of 

certification Dr S was operating as a 

commissioned agent of a third party and 

that this therefore altered in some way 

Dr S’s responsibilities to Mr A.” Dr S 

had two roles, the role of the treating 

physician and the role to a third party, 

the insurer (ACC). Those roles need not 

be conflicting and Professor Gorman 

was correct, the obligations to the third 

party did alter Dr S’s obligations but 

did not eliminate them, they were no 

longer just to the patient. It would appear 

that Dr S fulfilled his obligations 

in those two roles: he followed his belief 

that CFS in this case was not caused 

by Leptospirosis and Mr A’s chances of 

rehabilitation were improved by his being 

back at work. The latter is a strongly 

evidence-based medical recommendation 

and officially endorsed in the UK, 

Australia and New Zealand. 12 

It is possible that Dr S did not fulfil 

the roles of treating doctor and occupational 

advisor to a high standard, and 

he also felt that he could have improved 

the way he dealt with Mr A. Dr S was 

charged because of his poor communication 

and a conflict of interest, but that 

is a different scenario to Dr S making a 

professional decision not to sign an ACC 

certificate and the remote possibility 

that this decision contributed to Mr A’s 

financial hardship. The Tribunal decided 

after considering the four principles 

that the allegations they made based on 

those principles were “self-explanatory”. 

With a finding of a serious charge such 

as professional misconduct against Dr S, 

a reasoned decision should be considered 

obligatory. 

Dr G 

Dr G met Mrs B at an immigration 

medical examination and at a later date 

performed a cervical smear and urine 

test. He also later employed her as a 

practice nurse. Mrs B maintained that 

she had a sexual relationship with Dr G 

while there was a doctor/patient relationship, 

but Dr G denied that this ever took 

place. The Health and Disability Commissioner 

(HDC) 13 and the HPDT preferred 

Mrs B’s recollection of events. 14 

The HDC duly charged Dr G with 

breaching Right 2 (freedom from sexual 

exploitation) and Right 4(2) (services 

provided that complied with professional 

and ethical standards). 

Dr G chose to defend the charges in 

the High Court against the HPDT who 

contended that Dr G’s “conduct amounts 

to both misconduct and to the bringing 

of discredit to the medical profession”. 12 

It was alleged that Dr G had initially 

entered into an employer/employee 

relationship and then developed a sexual 

relationship that lasted three years. Durnot 

given...” and a similar failing was 

identified from the minority decision: 

“Like the majority, the minority did not 

express the standards and objectives he 

applied to arrive at his view. This makes 

it hard to assess the minority’s view.” 15 

Furthermore, the “majority’s failure to 

express a proper basis for its finding 

on the duration of the doctor/patient 

relationship is an error that makes their 

decision on this issue unreliable and 

wrong.” 15 The Judge then gave both parties 

time to make further submissions 

that “should deal with whether or not 

Dr G’s conduct…constitutes professional 

misconduct…” 15 

At a later hearing, after further submissions, 

the Director of Public Prosecutions 

(DPP) “set out broad principles 

underlying the practice of medicine 

that can be used to undertake an ethical 

The four principles in medical ethics compete with 

other approaches to moral theory, such as virtue 

ethics as one example, but the principles were 

never intended to exclude other moral discourse 

and are complementary to other approaches. 

ing that time Dr G had given medical 

treatment including a cervical smear and 

requested a midstream urine. The HPDT 

concluded that there was a doctor/patient 

relationship during the time Dr G 

was having a sexual relationship. One 

HPDT member disagreed with these 

findings thus raising the possibility of 

another view. 

The High Court preliminary decision 

was strongly worded that “…the majority 

has identified the evidence it relied on 

to find the doctor/patient relationship… 

but the rationale for that reliance is 

analysis of a problem in medicine...” 16 

and listed the four principles of autonomy, 

nonmaleficence, beneficence and 

justice. The DPP stated that these were 

“the underlying fundamental principles 

which…should be the basis from which 

Dr G’s actions are considered.” 16 In relation 

to the four principles the DPP asked 

the questions: “which situations are possibly 

harmful to patients, at what point 

in the situation is the patient’s status 

as a person with the power to decide 

and act in his or her own best interests 

threatened” but was silent on questions 

related to justice and beneficence. 16 


ethics 

The DPP submitted that there was 

“potential for harm” when Dr G 

performed a cervical smear and urine 

analysis on Mrs B because “there was 

still a role for Dr G in respect of subsequent 

treatment” and a “potential for 

impaired judgment regarding diagnosis 

or treatment due to a lack of independence 

and objectivity remained”. 16 The 

Judge disagreed with the DPP’s conclusions 

“regarding the broad principles 

underlying the practice of medicine”. 

He did “not consider that there has 

been any maleficence…because I do not 

see how what has occurred can be said 

to have been harmful to Mrs B. Nothing 

that happened has interfered with 

her autonomy. Nor has there been any 

interference with justice or professional 

integrity”. 16 

The Judge seemed sympathetic to counsel 

for Dr G who was “critical of the 

prosecution not producing evidence from 

a medical ethicist or some similarly qualified 

expert on appropriate professional 

conduct. Apart from the guidelines from 

the Medical Council on doctors not 

entering into sexual relationships with 

their patients, there was no evidence 

before the Tribunal” because “it means 

that there is little to use as a measure 

against Dr G’s conduct”. 16 

In the absence of any professional 

guidance, the Judge measured Dr G’s 

behaviour against common morality: 

“Whilst there are those in the community 

who would consider a married 

man engaging in sexual relations with 

a married woman who was not his wife 

was shabby, if not immoral conduct, it is 

clear to me that the professional standards 

and ethical standards to be applied 

do not go so far as to regard extra marital 

affairs per se by doctors as amounting to 

professional misconduct.” 16 

Both the DPP and the Judge were silent 

on how the four principles might be 

applied in a legal setting. However, the 

Judge correctly identified that immoral 

conduct (measured by common morality) 

is different to the morality demanded 

by a professional role. It is surprising 

that the Tribunal missed this point. 

They appear clumsy in their handling 

of the four principles in a legal setting. 

If they had done as Section 103(1) of 

the HPCAA demanded, that “an order 

of the Tribunal must (b) contain a 

statement of the reasons for the order” 

then unnecessary litigation would have 

been avoided. The Judge challenged 

the Tribunal to provide reasons for the 

application of the four principles and 

recognised the importance of the moral 

demands of professional roles. 

In both cases (Dr S and Dr G) the four 

principles did not provide the legally 

enforceable path to judge professional 

behaviour. The Tribunal failed to make 

the transition from a moral wish-list to 

producing principles that the Courts 

could use so as to judge practitioner 

behaviour and incorporate the principles 

into law. They failed to do so because 

they did not undertake the intellectual 

exercise of providing reasons for their 

decision and because they failed to 

recognise the importance of role morality. 

The Tribunal also showed naivety 

in their handling of the meaning of the 

four principles which were glossed over 

summarily. For example, justice is a complex 

topic and if it is to be applied with 

any meaning, deserves some discussion. 

Justice is concerned with distribution 

of health care resources, not whether or 

not a patient should have one type of 

certification compared with another. If 

the Tribunal persists in using the four 

principles, some reference to standard 

texts for guidance on the application of 

the principles is recommended. 

Objections to the 

four principles 

The four principles in medical ethics 

compete with other approaches to 

moral theory, such as virtue ethics as 

one example, but the principles were 

never intended to exclude other moral 

discourse and are complementary to 

other approaches. 17,18 As a checklist for a 

student or ‘newbie’, the principles may 

ensure that all relevant moral considerations 

have been covered, although the 

teaching of the four principles in medical 

schools has been accused of being 

“pointless and at worst dangerous”. 19 

The two cases discussed give credence to 

Harris’s concern that: “The principles allow 

massive scope in interpretation and 

are, frankly, not wonderful as a means 

of detecting errors and inconsistencies 

in argument.” And that: “The four 

principles impose a sort of straitjacket 

on thinking about ethical issues and 

encourage a one-dimensional approach 

and the belief that this approach is all 

that ethical thinking requires.” 20 Harris’s 

concerns are reflected in the Tribunal decision. 

If all that is required to be said is 

that this action is prohibited because it is 

maleficent or unjust then the argument 

risks being fatuous. Simple answers 

about maleficence or harm may mask 

other deeper questions about degree 

of harm, harm to individual or others, 

pre-existing conditions causing harm or 

a calculation of risk of harm versus benefit. 

Considerations need also to be run 

in tandem, discussing justice, beneficence 

and autonomy. Consideration of 

one or two principles before pronouncing 

that the behaviour is bad, harmful 

for the patient, not good for the patient, 

or does not respect their autonomy, may 

justify a disciplinary action but it does 

not deliver an explanation and risks an 

easy guilty verdict without consideration 

of opposing moral views. 

Discussion 

One judgement from the Courts (regarding 

Dr G) was available for analysis and 

demonstrated the heavy reliance of the 

HPDT on the four principles in mount- 


ETHICS 

ing a case against Dr G’s behaviour. The 

Judge expressed frustration with the 

lack of reasoning for the Tribunal’s decision 

against Dr G. The second case also 

relied upon the four principles and the 

majority of the Tribunal’s decision was 

overruled in the District Court. In both 

cases it was decided by the Tribunal that 

the doctors had caused harm to the patient. 

It is not questioned that from the 

patient’s perspective they were harmed 

in some way and that this could justify 

the decision that the doctor’s behaviour 

is maleficent. One Judge suggested that 

the behaviour may be “shabby if not immoral 

conduct” but that is not enough to 

impose disciplinary proceedings against 

a doctor. Had the Tribunal in both cases 

given reasoned decisions with explanations 

as to why they were imposing 

moral standards rather than purely justifying 

the imposition of a disciplinary 

measure, their conclusions might have 

been safer. The moral behaviour of the 

doctors in these two cases emphasises 

the often difficult consideration of rolerelated 

obligations, e.g. to the patient 

versus third party or employer/employee. 

When two professional roles are operating, 

it is important to give clear reasons 

in the argument that imposes disciplinary 

action. The four principles may 

have a place in disciplinary procedures 

but no reasons are good for no-one. 

References 

1. Medical Council of New Zealand. Coles Medical 

Practice in New Zealand. 10th ed. [cited 2011 

March 10]. Available from: http://www.mcnz. 

org.nz/portals/0/publications/coles/coles_medical_2011%20-%20george.pdf. 

2. Hart HLA. The concept of law. Oxford: Oxford 

University Press;1997. 

3. Lowns v Woods [1996] Aust Torts Reports 81–376. 

4. Brownie Wills v Shrimpton [1998] 2 NZLR 320. 

5. Dr S v MPDT 309/03/115C. 

6. CAC v Dr S 306/03/115C. 

7. Doctor T v CAC DC Wellington CIV-2005-085- 

355, 6 October 2008. 

8. St George IM. Issues with medical certificates. NZ 

Fam Physician. 2004;31(3):184. 

9. Tevethick v The Ministry of Health HC Wellington 

CIV-2007-485-2449, 1 April 2008. 

10. Coote B. Assumption of responsibility and pure economic 

loss in New Zealand. NZ Law Review; 2005;1. 

11. MPDT v Dr Singh 50/98/28C. 

12. RACP, Australasian Faculty of Occupational and 

Environmental Medicine. Realising the Health 

Benefits of Work. Position Statement: Sydney; 

April 2010. 

13. Case 07HDC11761. 

14. DP v Dr N HPDT 202/Med08/100D. 

15. Dr G v DP Auckland CIV-2009-404-000951, 13 

October 2009. 

16. Dr G v DP Auckland CIV-2009-404-000951, 5 

March 2010. 

17. Beauchamp T. Kennedy Institute Ethics J. 

1995;5(3):181-198. 

18. Campbell AV. The virtues (and vices) of the four 

principles. J Med Ethics. 2003;29:292–296. 

19. Cowley C. The dangers of medical ethics. J Med 

Ethics. 2005;31:739–742. 

20. Harris J. In praise of unprincipled ethics. J Med 

Ethics. 2003;29:303–306. 

LETTERS TO THE EDITOR 

The frail elderly and their bitter pills 

read with interest in your December issue the Back to Back 

I on treating the elderly with statins. In the same journal I 

was also stimulated by Bruce Arroll’s book review of A Bitter 

Pill: How the Medical System is Failing the Elderly by John 

Sloan and have purchased a copy. Bruce says this should be 

compulsory reading for all GPs and I can only agree. Dr Sloan 

is a Canadian family physician who specialises in care of the 

frail elderly and his observations resonate with all of us who 

see in our daily practice the dangers, risks and futility of much 

preventive treatment in this group. The book points out that 

there is NO scientific basis for the vast majority of prevention 

that is advocated for the frail elderly, and gives a persuasive 

and logical argument for offering withdrawal of much of it. 

Can I suggest that Bruce shares this book with his colleagues 

who seem so eager to recommend yet more medications for 

the elderly. Although Sue Wells’s advice on prevention seems 

reasonable in theory, the net effect is often frail elderly patients 

on 20–30 medications, sometimes losing weight because after 

taking their pills there is literally no room in their stomach for 

food! The standard fare for frail elderly unlucky enough to be 

hospitalised for any reason is to leave on two to three osteoporosis 

medications, statins, oral hypoglycaemics, aspirin, several 

antihypertensives and of course omeprazole. I am sure a good 

case can be made for each of these drugs in a younger person— 

the cumulative result in the elderly is usually a disaster. 

Paul Corwin 

Letters may respond to published papers, briefly report original research or case reports, or raise matters of interest relevant to 

primary 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. 


BOOK REVIEW 

Abortion Then and Now: New Zealand 

Abortion Stories from 1940 to 1980 

Dame Margaret Sparrow 

Reviewed by Hilary Weeks, general practitioner and certifying consultant, Medical Director Auckland Medical 

Aid Centre (AMAC), 1991–2004. 

This unusual and, at times, somewhat 

disturbing book will be of interest to both 

the public and to anyone providing abortion 

services, including the general practitioner or 

referring doctor. 

The author, Dame Margaret Sparrow, is well 

known for her long career in general and reproductive 

health, and has been recognised for 

her services to medicine and the community. 

Her theme is that unsafe self-induced, and illegal 

abortions must never be allowed to return 

to New Zealand (NZ), and that safe humane 

services of a high standard must always be provided. 

She feels there is still a stigma attached to 

abortion and a need to dispel some of the secrecy 

that surrounds it. Her intention is to bring a 

“healthier perspective to a very common female 

experience”. 

The first half of the book contains 70 personal 

stories of women seeking abortion in the early 

decades. There is an introductory essay written 

for each decade, with accounts of the illegal 

abortionists, their Court trials and also Coroner’s 

inquests into the many tragic deaths from septic 

abortion, often self-induced. 

I find it noteworthy that in the 1940s there were 

on average about 25 deaths per year from septic 

abortion. This death rate was reduced in the 

1960s by the advent of antibiotics, but in the 30 

or more years since the opening of the Auckland 

Medical Aid Centre (AMAC) in 1973, no deaths 

have been reported from abortion in NZ. 

The second half of the book contains accounts 

from the doctors, Police and the many advocates 

and activists who worked to bring about change. 

It details the history of the setting up of AMAC, 

the resulting court cases, Parliamentary debate, 

and eventual legislation of the present CS&A Act 

of 1978. 

As a doctor emigrating to NZ from England in 

1972, and arriving to a country where it was 

extremely difficult to obtain a medically safe 

abortion for one’s patient, I immediately found 

myself involved. Therefore, for me, this book is 

both extremely interesting and also easy to read. 

It is well researched, well written and organised, 

as one would expect of an author of this calibre. 

I would suggest that not only referring doctors, 

but also any doctors who still feel that they 

are unable to support their unhappily pregnant 

patient in their request for abortion, would find 

this groundbreaking book of value to read. 

Publisher: Victoria University Press, Wellington 

Date of publication: 2010 

No. of pages: 304 

ISBN: 9780864736321 


about the journal of primary health care 

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JPHC acts as a knowledge refinery to provide 

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contains pithy digests of the latest evidence 

including a String of PEARLS (Practical Evidence 

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and Gems, 100 word outlines of NZ primary 

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Evidence can help inform best practice. However 

sometimes there is no evidence available 

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needs to be placed in context. General 

practice is an art as well as a science. Quality of 

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While published in New Zealand by the Royal 

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much of this research has generic 

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Editor 

Dr Felicity Goodyear-Smith: Professor and 

Goodfellow Postgraduate Chair, Department 

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Care, University of Auckland, Auckland, New 

Zealand; editor@rnzcgp.org.nz 

Deputy Editors 

Dr Derelie Mangin: Associate Professor, 

Department of Public Health and General 

Practice, University of Otago, Christchurch, NZ 

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Please send all submissions to the Editor: editor@rnzcgp.org.nz 

eral Practice, Wellington School of Medicine, 

University of Otago, NZ 

Editorial Board 

Dr Bruce Arroll: Professor and Head of the 

Department of General Practice & Primary 

Health Care, University of Auckland, NZ 

Dr Jenny Carryer: Professor of Nursing, 

School of Health and Social Services, Massey 

University, Palmerston North, NZ 

Dr Peter Crampton: Dean and Head of 

Campus, Wellington School of Medicine and 

Health Sciences, University of Otago, NZ 

Ms Eileen McKinlay: Senior Lecturer in 

Primary Health Care, Department of Primary 

Health Care and General Practice, University 

of Otago Wellington, NZ 

Dr Barry Parsonson: Psychologist for NZ 

Ministry of Education and International Consultant, 

UNICEF (Georgia) Training Project 

for Institutional Staff working with disabled 

children 

Dr Shane Reti: Assistant Professor, International 

Program Director Clinical Informatics 

and CEO of Clinical Informatics Industrial 

Research, Harvard Medical School, USA 

Dr Kurt Stange: Professor of Family 

Medicine, Case Western Reserve University, 

Cleveland, OH, USA and Editor, Annals of 

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Dr Colin Tukuitonga: Associate Professor 

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Wellington, NZ 

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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 2011. All Rights Reserved.

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