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VOLUME 5 • NUMBER 1 • MARCH 2013 

OF PRIMARY HEALTH CARE 

‘On the basis of their 

personhood, patients 

and clinicians are 

moral equals.’ 

See page 76 

Original Scientific Paper 

Bedtime restriction for treating 

primary insomnia 

See page 5 


Students in need least likely to access 

health care 

See page 11 


Social networking for adjunctive 

health care delivery 

See page 36 


Interprofessional education may 

improve collaborative practice 

See page 52 


Nutrition care by GPs 

See page 59 

Ethics 

Media reporting of suicides 

See page 82

CONTENTS 

VOLUME 5 • NUMBER 1 • MARCH 2013 

OF PRIMARY HEALTH CARE 

ISSN 1172-6164 (Print) 

ISSN 1172-6156 (Online) 

2 Editorials 

From the Editor 

2 Patient and provider participation in health care provision 

Felicity Goodyear-Smith 

Guest Editorial 

4 Primary care intervention for primary insomnia 

Wendy Troxel, Daniel Buysse 

5 Original Scientific Papers 

Quantitative Research 

5 A double-blind randomised controlled study of a brief 

intervention of bedtime restriction for adult patients with 

primary insomnia 

Antonio Fernando III, Bruce Arroll, Karen Falloon 

11 Forgone health care among secondary school students in 

New Zealand 

Simon Denny, Bridget Farrant, John Cosgriff, Mo Harte, Toby 

Cameron, Rachel Johnson, Viv McNair, Jennifer Utter, Sue Crengle, 

Theresa Fleming, Shanthi Ameratunga, Janie Sheridan, Elizabeth 

Robinson 

19 Characteristics of nurses providing diabetes community and 

outpatient care in Auckland 

Barbara Daly, Bruce Arroll, Nicolette Sheridan, Timothy Kenealy, 

Robert Scragg 

Qualitative Research 

28 Could the polypill improve adherence The patient 

perspective 

Linda Bryant, Nataly Martini, Jacky Chan, Lisa Chang, Ahmed 

Marmoush, Belinda Robinson, Karen Yu, Many Wong 

36 Exploring the opinions and perspectives of general 

practitioners towards the use of social networking sites for 

concussion management 

Osman Ahmed, S John Sullivan, Anthony Schneiders, Sam Moon, 

Paul McCrory 

43 Management of skin infections in Pacific children prior to 

hospitalisation 

Elaine Ete-Rasch, Katherine Nelson 

Mixed Method Research 

52 Interprofessional education for physiotherapy, medical and 

dietetics students: a pilot programme 

Sue Pullon, Eileen McKinlay, Louise Beckingsale, Meredith Perry, 

Ben Darlow, Ben Gray, Peter Gallagher, Kath Hoare, Sonya Morgan 

Systematic Review 

59 General practitioners can offer effective nutrition care to 

patients with lifestyle-related chronic disease 

Short Report 

Lauren Ball, Cristina Johnson, Ben Desbrow, Michael Leveritt 

70 Assessing readiness to work in primary health care: the 

content validity of a self-check tool for physiotherapists and 

other health professionals 

Jenny Stewart, Kate Haswell 

74 Back to Back 

74 Medical professionalism requires that the best interest of the 

patient must always come first 

Yes: Nicolette Sheridan; No: Stephen Buetow 

78 Continuing Professional Development 

78 String of PEARLS about smoking cessation 

78 Cochrane Corner: Acupuncture for migraine is at least as 

effective as prophylactic drug treatment 

Megan Arroll 

79 Nuggets of Knowledge: Cephalosporins for people with 

penicillin allergy 

Linda Bryant 

81 Potion or Poison Probiotics 

Shane Scahill 

82 Ethics 

82 Reporting suicide: safety isn’t everything 

Colin Gavaghan, Mike King 

86 Book Review 

86 Buck Up: The real bloke’s guide to getting healthy and living 

longer—Buck Shelford and Grant Schofield 

Reviewed by Peter Sandiford 

87 Gems of New Zealand Primary Health Care Research 

88 About the Journal of Primary Health Care 

VOLUME 5 • NUMBER 1 • MARCH 2013 J OURNAL OF PRIMARY HEALTH CARE 1

EDITORIALS 

FROM THE EDITOR 

Patient and provider participation in 

health care provision 

Felicity Goodyear- 

Smith MBChB, MD, 

FRNZCGP, Editor 

J PRIM HEALTH CARE 

2013;5(1):2–3. 

CORRESPONDENCE TO: 

Felicity Goodyear-Smith 

Professor and Goodfellow 

Postgraduate Chair, 

Department of General 

Practice and Primary 

Health Care, The 

University of Auckland, 

PB 92019 Auckland, 


f.goodyear-smith@ 

auckland.ac.nz 

Patient welfare is central to primary health 

care and, in this issue’s Back to Back, Associate 

Professor Nicolette Sheridan argues 

persuasively that professionalism demands that 

the interests of patients are placed above those 

of their physicians. 1 Associate Professor Stephen 

Buetow eloquently presents the counter position 

that, as moral equals, both patients and physicians 

have rights and responsibilities towards 

fulfilling their respective interests of receiving 

and giving care. 2 Because clinician and patient 

interests are integrally connected, subordination 

of clinician interests can harm both. Equal 

consideration of their interests does not equate to 

patients and clinicians being treated the same. 

As equal partners in health care management, 

understanding patients’ perspectives is a vital 

component when new interventions are being 

considered. With work progressing on development 

of a cardiovascular ‘polypill’, Bryant el al. 

explore patients’ views on the acceptability of 

such an initiative. 3 

Engaging patients in self-management is a rapidly 

increasing component of primary health care. 

Our lead article reports a randomised controlled 

trial suggesting that the simple intervention of 

bed restriction can be an effective treatment for 

primary insomnia. 4 This technique requires the 

clinician and patient to work together to calculate 

the bed restriction required, and then the 

patient to carry it out. In our guest editorial, 

international sleep experts Wendy Troxel and 

Daniel Buysse emphasise the value of such nonpharmaceutical 

and patient-centred alternatives 

in helping insomnia sufferers. 5 Assisting patients 

to make behavioural changes towards healthier 

eating is a key component of managing lifestylerelated 

chronic disease. A systematic review by 

Ball and colleagues finds that general practitioners 

(GPs) can provide effective nutritional care. 6 

Pleasingly, often this can be achieved relatively 

rapidly, sometimes within a single consultation, 

and therefore may not be a huge demand on a 

GP’s workload. 

Increasingly patients are looking to the internet 

for health care solutions, including seeking 

‘interactive support’ (discussing symptoms and 

seeking advice) through social network sites such 

as Facebook. One such example is sports-related 

concussion, where individuals, for whatever 

reason, may not consult a doctor about their 

condition. An interesting pilot study explores 

GPs’ perspectives on whether such sites can be a 

safe and effective means of assisting patients in 

their concussion management. 7 With hundreds of 

health-related groups now using Facebook, this 

study highlights the importance of health care 

providers being aware of the values and risks of 

this adjunctive medium for health care delivery. 

According to Tudor Hart’s inverse care law, 

the availability of good health care tends to 

vary inversely with the need of the population 

served. 8 This principle is clearly demonstrated in 

a national study of secondary school students by 

Denny et al., who found that those adolescents 

most in need of care for both mental and physical 

health problems are the least likely to be accessing 

it. 9 

Up-skilling and education of our primary care 

workforce is an ongoing challenge. In a study of 

primary care nurses providing community care 

for people with diabetes, Daly and colleagues 

found an ageing workforce in which many lacked 

post-registration education and 20% had no access 

to the internet. 10 In another study of 11 Pacific 

children admitted to hospital with skin infections, 

prior consultation with their GP was found 

not to have prevented their admission, although 

of course the number of consultations which 

2 VOLUME 5 • NUMBER 1 • MARCH 2013 J OURNAL OF PRIMARY HEALTH CARE

EDITORIALS 

FROM THE EDITOR 

averted subsequent hospitalisation is unknown. 11 

Increasingly physiotherapists are members of our 

inter disciplinary team. Stewart and Haswell report 

their work developing and validating a selfcheck 

tool for physiotherapists and other allied 

health professionals to assess their readiness to 

work in primary health care. 12 Interprofessional 

practice is becoming established as a keystone of 

primary health care, and this is being reflected in 

pre-registration teaching. Pullon et al. evaluate a 

pilot programme which delivered an interprofessional 

case-based component to medical, physiotherapy 

and dietetic undergraduate students’ 

education, providing a collaborative approach to 

chronic condition management. 13 

Finally, Gavaghan and King, a lawyer and a 

bioethicist respectively, offer a thoughtful 

discussion on the role of the media in reporting 

suicide. 14 Traditionally there has been a media 

ban on reporting such events. While concerns 

may be raised that reporting details may lead to 

the encouragement of further incidents and that 

suicide is normalised or even glorified, Gavaghan 

and King argue that other considerations may 

support media coverage. For example, particular 

cases may highlight serious social or legal issues, 

or help inform policy debates. Families might 

want privacy, or they might want their case to be 

known to prevent this happening to others. Just 

as in health care, such decisions require the careful 

and informed balancing of various risks and 

benefits on a case-by-case basis. 

1. Sheridan N. Medical professionalism requires that the best 

interest of the patient must always come first: the ‘yes’ case. J 

Prim Health Care. 2013;5(1):74–75. 

2. Buetow S. Medical professionalism requires that the best 

interest of the patient must always come first: the ‘no’ case. J 

Prim Health Care. 2013;5(1):76–77. 

3. Bryant L, Martini N, Chan J, Chang L, Marmoush A, Robinson 

B, et al. Could the polypill improve adherence The patient 

perspective. J Prim Health Care. 2013;5(1):28–35. 

4. Fernando III A, Arroll B, Falloon K. A double-blind randomised 

controlled study of a brief intervention of bedtime restriction 

for adult patients with primary insomnia. J Prim Health Care. 

2013;5(1):5–10. 

5. Troxel W, Buysse D. Primary care intervention for primary 

insomnia. J Prim Health Care. 2013;5(1):4. 

6. Ball L, Johnson C, Desbrow B, Leveritt M. General practitioners 

are capable of providing effective nutrition care to patients 

with lifestyle-related chronic disease. J Prim Health Care. 

2013;5(1):59–69. 

7. Ahmed O, Sullivan S, Schneiders A, Moon S, McCrory P. 

Exploring the opinions and perspectives of general practitioners 

towards the use of social networking sites for concussion 

management. J Prim Health Care. 2013;5(1):36–42. 

8. Tudor Hart J. The inverse care law. The Lancet. 

1971:297(7696):405–412. 

9. Denny S, Farrant B, Cosgriff J, Cameron T, Johnson R, McNair 

V, et al. Forgone health care among secondary school students 

in New Zealand. J Prim Health Care. 2013;5(1):11–18. 

10. Daly B, Arroll B, Sheridan N, Kenealy K, Scragg. R. Characteristics 

of nurses providing community and out-patient 

care to diabetes patients in Auckland. J Prim Health Care. 

2013;5(1):19–27. 

11. Ete-Rasch E, Nelson K. Management of skin infections of 

Pacific children prior to hospitalisations. J Prim Health Care. 

2013;5(1):43–51. 

12. Stewart J, Haswell K. Assessing readiness to work in primary 

health care: the content validity of a self-check tool for physiotherapists 

and other health professionals. J Prim Health Care. 

2013;5(1):70–73. 

13. Pullon S, McKinlay E, Beckingsale L, Perry M, Darlow B, Gray 

B, et al. Interprofessional education for physiotherapy, medical 

and dietetics students; a pilot programme. J Prim Health Care. 

2013;5(1):52–58. 

14. Gavaghan C, King M. Reporting suicide: Safety isn’t everything. 

J Prim Health Care. 2013;5(1):82–85. 

References 


EDITORIALS 

GUEST EDITORIAL 

Primary care intervention for primary 

insomnia 

Wendy Troxel PhD; 1 Daniel Buysse MD 2 

1 

Behavioral and Social 

Scientist, RAND Corporation, 

Pittsburgh, USA 

2 

Department of Psychiatry, 

University of Pittsburgh, 

Pittsburgh 


2013;5(1):4. 


Wendy Troxel 

RAND Corporation, 4570 

Fifth Avenue, Suite 600, 

Pittsburgh, PA 15213, USA 

wtroxel@rand.org 

Insomnia is a highly prevalent and debilitating 

sleep disorder, with prevalence estimates ranging 

from 10 to 15% in the general population 1 

and up to 20–30% in primary care medical settings. 

2 Despite its high prevalence and associated 

morbidity across a host of mental and physical 

health conditions, insomnia remains underdiagnosed 

and untreated for the vast majority of 

insomnia sufferers. 3 

Psychological treatments for insomnia, including 

multi-component cognitive-behavioural therapy 

for insomnia (CBT-I), have been proven efficacious 

in numerous randomised clinical trials 4,5 

and are recommended as the front-line treatment 

for insomnia by the American Academy 

of Sleep Medicine. 6 However, demonstrations of 

‘real-world’ clinical effectiveness of CBT-I lag 

significantly behind efficacy trials, in part due to 

the critical shortage of specialty-trained clinical 

psychologists, 7 as well as the duration and intensity 

of initial treatment (typically delivered over 

6–8 sessions). Consistent with recent calls within 

the sleep community and within the broader 

primary care community (who disproportionately 

provide the front-line care for patients presenting 

with insomnia), the article by Fernando 

and colleagues presents preliminary data from a 

study of primary insomnia patients treated with 

a brief, single-session intervention utilising sleep 

restriction as compared to a sleep hygiene control 

condition. Results are promising in that patients 

with insomnia who received the sleep restriction 

therapy were significantly more likely to 

describe their sleep as ‘better’ or ‘much better’ as 

compared to those receiving sleep hygiene alone. 

Although a single-item subjective measure of 

sleep improvement following treatment, particularly 

without control for baseline symptom severity, 

is somewhat limited, an advantage of this 

approach is that the outcome is patient centred 

and is salient to both patients and their primary 

care providers. 

These findings add to a growing body of literature, 

including work from our laboratory. 8,9 These 

studies have utilised streamlined behavioural 

sleep treatment approaches which capitalise on the 

components of CBT-I shown to have the largest 

effects on treatment outcomes (i.e. sleep restriction 

and stimulus control), in order to fill the gap 

between efficacy and effectiveness of behavioural 

sleep treatments in real-world clinical settings. In 

addition, ‘stepped care’ approaches, including different 

components of standard CBT-I tailored to 

the needs of the patient, as well as internet-based 

approaches may also facilitate the dissemination of 

efficacious behavioural sleep treatments. 

The vast majority of insomnia sufferers are rarely, 

if ever, seen by a specialty-trained provider in 

CBT-I. Given this, efforts to educate primary care 

providers and other professionals in the diagnosis 

and treatment of insomnia are critical to meeting 

the unmet needs of the numerous patients with 

insomnia who currently remain undiagnosed and 

untreated, and to provide patients with alternatives 

to pharmacologic management of their insomnia. 

References 

1. Ohayon MM, Guilleminault C. Epidemiology of sleep disorders. 

In: Chokroverty S, editor. Sleep disorders medicine: basic 

science, technical considerations and clinical aspects. 2nd ed. 

Boston: Butterworth-Heinemann; 1999. p. 301–16. 

2. Shochat T, Umphress J, Israel AG, Ancoli-Israel S. Insomnia in 

primary care patients. Sleep. 1999;22 Suppl 2:S359–S365. 

3. Roth T. New developments for treating sleep disorders. J Clin 

Psychiatry. 2001;62(suppl):3–4. 

4. Edinger JD, Carney CE. Overcoming insomnia: a cognitivebehavioral 

therapy approach therapist guide (treatments that 

work). 1st ed. Oxford University Press, Inc.; 2008. 

5. Morin CM. Cognitive-behavioral approaches to the treatment 

of insomnia. J Clin Psychiatry. 2004;65 Suppl 16:33–40. 

6. Morgenthaler T, Kramer M, Alessi C, Friedman L, Boehlecke 

B, Brown T, et al. Practice parameters for the psychological 

and behavioral treatment of insomnia: an update. An American 

Academy of Sleep Medicine report. Sleep. 2006;29:1415–9. 

7. Morin CM. Chronic insomnia: recent advances and innovations 

in treatment developments and dissemination. Can Psychol. 

2010;51:31–9. 

8. Buysse DJ, Germain A, Moul DE, Franzen PL, Brar LK, Fletcher 

ME, et al. Efficacy of brief behavioral treatment for chronic 

insomnia in older adults. Arch Intern Med. 2011;171:887–95. 

9. Troxel WM, Germain A, Buysse DJ. Clinical management of 

insomnia with brief behavioral treatment (BBTI). Behav Sleep 

Med. 2012;10:266–79. 


ORIGINAL SCIENTIFIC PAPERS 

QUANTITATIVE RESEARCH 

A double-blind randomised controlled study 

of a brief intervention of bedtime restriction 

for adult patients with primary insomnia 

Antonio Fernando III MD, ABPN(USA); 1 Bruce Arroll MBChB, PhD, FRNZCGP; 2 Karen Falloon MBChB, 

FRNZCGP 2 

ABSTRACT 

INTRODUCTION: Bedtime restriction is effective for volunteer patients with primary insomnia. 

AIM: To determine the effectiveness of bedtime restriction in adult volunteers with primary insomnia. 

METHODS: Patients were recruited in response to articles in local newspapers. The study hypothesis 

was not given in the articles. Patients were assessed as to whether or not they had primary insomnia. 

They completed a two-week sleep diary after which they met the investigators and were randomised to 

either bedtime restriction and basic sleep hygiene or the control group with basic sleep hygiene only. 

A total of 224 potential participants applied to be in the study. Of the 52 who had primary insomnia, 45 

were randomly allocated to either control or intervention group and only two did not complete the study. 

Randomisation was concealed and participants were blinded regarding the treatment. The primary outcome 

was also measured in a blinded fashion. 

1 

Psychological Medicine, 

Faculty of Medical and Health 

Sciences, The University of 

Auckland, Auckland, 


2 

General Practice and Primary 

Health Care, Faculty of 

Medical and Health Sciences, 

The University of Auckland 

RESULTS: The outcome evaluated was patient description of ‘better’ or ‘much better’ quality of sleep 

versus the ‘same’, ‘worse’ or ‘much worse’ quality of sleep at six weeks. Overall, 73% (16/22) of those in 

the intervention group were either having better or much better quality of sleep after treatment, while 

in the control group this was 35% (8/23). The number needed to treat was 3 [95% CI 2–11] for bedtime 

restriction and sleep hygiene versus sleep hygiene alone. 

DISCUSSION: This is the first study using bedtime restriction designed to be feasible in primary care by 

using a brief intervention and a patient-oriented outcome. 

KEYWORDS: Insomnia; primary health care; randomized controlled trial 

Introduction 

Primary insomnia accounts for 12% of insomnia 

in primary care. 1 It is defined as self-reported 

difficulty in sleep initiation or maintenance for 

at least one month and does not have a specific 

cause, such as anxiety, depression, a medical 

condition or other sleep disorder. 2 In addition to 

poor functioning the following day, the risk for 

developing depression and anxiety from untreated 

insomnia has been reported. 3,4 

Cognitive-behavioural therapy for insomnia 

(CBT-I) has been shown to be an effective treatment 

for primary insomnia in randomised trials 5 

and aims at addressing the cognitive and behavioural 

aspects of insomnia using a combination of 

various interventions. These include behavioural 

strategies (e.g. bedtime restriction, stimulus 

control therapy, relaxation-based interventions), 

education (e.g. sleep hygiene), and cognitive strategies 

(cognitive therapy). 5 Although effective, 

CBT-I is not designed as a treatment that can be 

administered by primary care clinicians (typically 

it is administered as a 6–8 session model) 5 and 

thus it remains underutilised in primary care. 

One of the authors (AF) had noted in his private 

practice that patients with primary insomnia had 


2013;5(1):5–10. 


Antonio Fernando 

Faculty of Medical and 

Health Sciences, The 


PB 92019, Auckland, 


a.fernando@auckland.ac.nz 




improved quality of sleep after one or two sessions 

with bedtime restriction, without the other 

components of CBT-I. 

Bedtime restriction requires the clinician to work 

out how many hours a patient spends in bed at 

night and how many hours they perceive they 

actually sleep (average sleep time). Average sleep 

time can be calculated from the patient’s history 

and/or a sleep diary. The patient is then asked to 

limit their time in bed to their calculated average 

sleep time (with a minimum time in bed of 

five hours). Anecdotally, the common response 

found was that patients reported a more satisfying 

sleep experience. When planning this study, 

the authors found three studies of bedtime 

restriction in elderly patients. 6–8 However, each 

study required four or more visits and use of 

objective measures of sleep, such as polysomnography 

(overnight sleep studies) or actigraphy 

(movement watches). 

As neither these means of assessment nor the 

repeated visits are feasible in primary care, the 

question of the efficacy of this treatment for the 

primary care population of interest remained 

unanswered. The authors considered a subjective 

effectiveness measure in primary care would be 

more appropriate, as insomnia is defined using 

subjective reports. If bedtime restriction was 

an effective treatment for primary insomnia, 

it would have the potential to be used alone in 

primary care as a treatment for patients with 

primary insomnia, without resorting to the need 

for input from a CBT therapist. Therefore, it was 

decided to test a brief version of bedtime restriction 

that, if effective in a population of volunteers, 

could be evaluated further in a primary 

care population. 

Methods 

Patients were eligible for this study if they 

had primary insomnia. Primary insomnia was 

defined as having trouble with sleep initiation or 

maintenance on at least three nights per week for 

more than one month and with no other causes 

of insomnia identified. 2 Inclusion criteria were: 

aged 16 years or older, Hospital Anxiety and 

Depression Scale (HADS) score for depression of 

≤8, 9 ability to read and understand the participant 

information sheet written in English, and 

competent to sign the consent form. 

Recruitment was undertaken through articles 

about the first author in local newspapers, with 

interested individuals contacting him directly 

asking to be in the study. There was no mention 

of bedtime restriction in the articles. Initially, 

patients were interviewed by telephone by 

the authors (AF and BA) to determine if they 

had primary insomnia. As this became very 

time-consuming, patients were later recruited 

by mailing out the ASQV1 (Auckland Sleep 

Questionnaire Version 1), a seven-page paper 

questionnaire asking about the common causes 

of insomnia. 10 This made the process of selecting 

those with primary insomnia a much easier 

task because it was possible to make a provisional 

diagnosis of primary insomnia from the 

questionnaire. 

Those who had a provisional diagnosis of primary 

insomnia attended a face-to-face interview with 

either AF or BA or both for confirmation of the 

diagnosis. During this attendance, a participant 

information sheet was provided and the consent 

form was signed. The information sheet stated 

each participant would be receiving instruction 

about one of two non-drug treatments for insomnia 

and that the alternate treatment would not be 

revealed until the end of the six-week study. The 

treatments were bedtime restriction plus basic 

sleep hygiene or basic sleep hygiene alone. 

Participants were sent a sleep diary to be completed 

in the two weeks prior to their interview 

and they were asked to stop any hypnotic medication 

for a month before the study and to stay off 

medication for the six weeks of the study. Using 

the sleep diary, it was determined how long each 

participant reported spending in bed and how 

long they felt they actually were asleep during 

time in bed. 

Randomisation was done by one of the investigators 

(BA) using an Microsoft Office Excel 

spreadsheet before any patients were recruited. 

Allocation to one of the two groups was sealed 

in numbered opaque envelopes which were 

opened in order, usually in the presence of two 

investigators (BA and AF), once the patient had 




given consent for participation in the study. 

This ensured that randomisation was concealed. 

The patients were randomised to two 

parallel groups. 

Written instructions regarding sleep hygiene 

were given to both groups. Based on their sleep 

diary information, the bedtime restriction group 

received personalised instructions on bedtime 

and wake time to be adhered to over the following 

six weeks. Some negotiation was permitted 

regarding bedtime allocation in the bedtime 

restriction group if initiated by the participant. 

Care was taken not to disclose which group each 

participant was in (i.e. intervention or control 

group). There was a visit at two weeks to check 

that the patients had understood the instructions 

given at the first visit. At six weeks, a staff member 

of The University of Auckland Department 

of Psychological Medicine phoned the patients 

and asked how well they had been sleeping in 

the past month in comparison to prior to the 

study: ‘much worse’, ‘worse’, ‘same’, ‘better’ or 

‘much better’. The staff member was instructed 

not to ask about the patient’s intervention and so 

remained blind to the intervention. This was a 

second level of blinding. 

The study was conducted according to the 

CONSORT statement 11 and data collection was 

from March 2006 until January 2008. The only 

aspect of the CONSORT statement that the 

study did not fulfil was that it was not registered 

with a trials register, as it commenced 

in 2006 and the Australian and New Zealand 

Clinical Trials Registry was not started until 

2007. The sample size calculation expected a 

40% effect size with 90% of the intervention 

group getting better with bedtime restriction 

and 50% with sleep hygiene, p-value 0.05 and 

beta 0.2, two-sided, which required 24 participants 

in each group. The 40% effect size was 

based on a conservative estimate of the private 

practice patients of author AF. Analysis was 

done using Chi-square and intention-to-treat 

analysis. 12 Ethics approval was obtained from 

the Northern Ethics Committee on 19 December 

2005, reference number NTX/05/09/117. 

Analysis of the data was done using the website 

at the Centre for Evidence-Based Medicine at 

the University of Toronto. 

WHAT GAP THIS FILLS 

What we already know. Bedtime restriction has been shown to be effective 

for elderly patients with primary insomnia, usually in studies using 

actigraphy and polysomnography. 

What this study adds: Bedtime restriction is effective for adults with 

primary insomnia, using resources available to primary care practitioners. 

This study also used an outcome measure that is relevant to primary care clinicians 

and their patients, rather than equipment such as polysomnography 

or actigraphy, which is not routinely available to primary care practitioners. 

Figure 1. Flow diagram of study participants through randomised controlled trial of 

bedtime restriction for primary insomnia 

Allocated to bedtime restriction 

and basic sleep hygiene 

22 

Lost to follow-up 

1 

Analysed 21 

16 sleeping better or much better 

Replies to newpaper articles. 

Assessed for eligibility 

224 

Primary insomnia 

52 

Randomised into trial 

45 

Allocated to basic sleep hygiene 

23 

Lost to follow-up 

1 

Analysed 22 

8 sleeping better or much better 

Excluded other 

causes of insomnia 

172 

Dropped out before 

randomisation 

7 




Table 1. Baseline characteristics of participants 

Intervention group (n=22) 

Control group (n=23) 

Age (median) 58 years (range 35–70 years) 53 years (range 29–84 years) 

Gender 

Women 15 13 

Men 7 10 

Sleep quality (median)* 3 3 

Ethnicity 

20 NZ European 

1 Indian 

22 NZ European 

1 Indian 

1 Tongan 

HADS † depression score (median) 2 (range 0 to 8) 3 (range 0 to 8) 

HADS anxiety score (median) 5 (range 2 to 11) 4 (range 0 to 14) 

* Sleep quality rated as 1 ‘very good’, 2 ‘fairly good’, 3 ‘fairly bad’, 4 ‘very bad’ 

† 

HADS: Hospital Anxiety and Depression Scale 

Results 

A total of 224 people replied to the newspaper 

articles, of whom 52 had primary insomnia. Of 

these, seven dropped out before randomisation 

(see Figure 1). Table 1 shows the demographics 

of the participants. Table 2 shows the results 

of the two interventions. Two people were lost 

to follow-up after randomisation, one from the 

intervention group and one from the control 

group. For the intention-to-treat analysis, those 

who were lost to follow-up were allocated their 

baseline status, i.e. ‘same/worse/much worse’. 

Those who scored either ‘better’ or ‘much better’ 

were considered to have improved sleep. In the 

intervention group, 16 participants were either 

‘better’ or ‘much better’ compared with eight 

participants in the control group. 

The absolute risk of benefit was 38% [95% CI 8.8– 

59%] with the intervention group having 73% getting 

better (experiencing improved sleep) and 35% 

in the control group getting better. The number 

needed to treat (NNT) to get one person to experience 

improved sleep at six weeks was 3 [95% 

CI 2–11] for the intervention with sleep hygiene 

versus sleep hygiene alone. Using a Chi-square 

analysis, 12 the p-value was = 0.0107. Taking into 

account the two who were lost to follow-up, the 

per protocol analysis was statistically significant 

(p=0.0085) and the NNT stayed the same. The 

study was stopped at 45 participants as we had 

no further candidates from our initial advertising 

and were very close to our sample size calculation 

of 48. The only harm reported was a patient in 

the intervention group scraping her car on a fence 

on two occasions when backing out of a driveway. 

Discussion 

This study shows that time-in-bed restriction 

leads to improvement in sleep, with a numbers 

needed to treat of 3. The control group showed 

improvement, with 35% of participants sleeping 

‘better’ or ‘much better’, but the intervention 

group had 73% sleeping ‘better’ or ‘much better’. 

This suggests that for a third of patients with 

primary insomnia, basic sleep hygiene may be 

effective while another third will benefit further 

with the addition of bedtime restriction. 

Table 2. Outcome of blinded telephone call to participants* 

‘Better’ or ‘much better’ ‘Same’, ‘worse’, or ‘much worse’ Total 

Intervention group 16 6 22 

Control group 8 15 23 

* Assumes those lost to follow-up were sleeping ‘worse’ 




We chose a patient-oriented outcome that was 

relevant to patients, rather than sleep diary 

outcomes or more technical measures, such as 

polysomnography or actigraphy. However, there 

are some limitations with the simple outcome 

measure used. It may over-estimate the efficacy 

of each of the treatments. For example, someone 

responding that their sleep was ‘better’ may still 

experience poor quality sleep or be unhappy with 

their sleeping (thus still being regarded as experiencing 

insomnia). Although describing their 

sleep as better, they may not experience good 

sleep or feel that the treatment was particularly 

effective for them. Another limitation is the 

short timeframe for the study, with a follow-up 

period of only six weeks; however, this reflects 

the intention of the study as a pilot precursor 

to a larger study. The study population was also 

likely to be both those with more severe insomnia 

and those who were particularly motivated to 

improve their sleep, as it involved responding to 

an article calling for those with poor sleep to contact 

the investigator. The numbers in the study 

are relatively small, but the recruiting was very 

time intensive. The study was conducted with 

no external funding and was stopped when the 

initial supply of participants ran out. The study 

was powered for the small sample size as clinical 

experience suggested that the intervention was 

quite powerful. 

A strength of this study was that it was a 

randomised controlled trial conducted according 

to the CONSORT statement. It was also a 

double-blind study, with the patients being blind 

to their allocation and the outcome assessor being 

blind to the intervention group. The short 

intervention (two sessions) without the use of 

actigraphy or polysomnography was deliberate to 

assess an intervention that would be appealing to 

primary care physicians. 

Sleep restriction was first proposed as an effective 

treatment for insomnia by Spielman and 

colleagues in the 1980s. 8 Since then, recommendations 

developed and published by the 

American Academy of Sleep Medicine in 2006 5 

have described sleep restriction as an empirically 

supported treatment. Two randomised controlled 

trials of sleep restriction were included in their 

systematic review. 6,7 Both these studies were in 

community-dwelling older adults. In the study 

by Friedman et al., 6 39 subjects were randomised 

to either sleep restriction plus sleep hygiene, 

sleep restriction with napping plus sleep hygiene, 

or sleep hygiene alone (as an active control). 

Actigraphy and sleep diary data were used as 

outcome measures and polysomnography was 

conducted in a subgroup. All subjects met with 

a therapist for six sessions. Both sleep restriction 

conditions produced an increase in sleep efficiency, 

with reduced time spent in bed compared 

to the control group, but no difference in effect 

was found between the sleep restriction therapy 

groups and the control group on actigraphy or 

polysomnography measures. In contrast with the 

current study, the above study did not include 

clinical report of patient perception of improvement. 

It is not clear whether an improvement 

in sleep efficiency would be correlated with 

any clinically significant (patient perception of 

improved sleep) improvement in sleep and no 

subjective outcomes apart from sleepiness were 

investigated. 

In the study by Lichstein et al., 7 89 older adults 

with primary insomnia were randomised to either 

sleep restriction (called ‘sleep compression’ in 

the paper), relaxation therapy or a placebo group. 

All subjects underwent two consecutive polysomnography 

tests prior to treatment for diagnosis 

and met with a therapist weekly for six sessions. 

Both treatment groups were more effective than 

placebo for reducing wake time after sleep onset 

(WASO), with sleep restriction producing the 

best outcome at one-year follow-up. All groups 

showed improvements on measures of fatigue and 

insomnia impact. 

A recent trial, again in elderly patients, used 

brief behavioural treatment for insomnia which 

included a reduction of time in bed, getting up 

at the same time each day (regardless of sleep 

duration) and not going to bed unless sleepy. 13 

Polysomnography and actigraphy were used to 

assess diagnosis and sleep and the results showed 

a benefit at four weeks, with an NNT of 2.4. 

The intervention included a follow-up visit at 

two weeks and two telephone calls at weeks one 

and three. 




There is little research on the use of bedtime 

restriction alone as an intervention in the general 

adult population and existing studies mostly do 

not report clinically meaningful outcomes (which 

the authors believe should include subjective perception 

of sleep improvement). The trial designs, 

in requiring multiple therapist sessions, also limit 

generalisability and translation into most primary 

care settings. 

There is little research on the use of bedtime 

restriction alone as an intervention in the general 

adult population and existing studies mostly do 

not report clinically meaningful outcomes 

In the authors’ primary care practice (BA and 

KF), patients are asked to turn up early to 

sleep consultations and complete the ASQV1 10 

which takes about 20 minutes. It is then a fairly 

straightforward process to decide the cause 

of their insomnia. The majority of cases are 

patients with depression or anxiety or physical 

health issues. 1 For those with primary insomnia, 

sleep restriction (referred to as bedtime restriction 

by the authors to avoid negative associations 

patients may ascribe to ‘restricting their sleep’) 

is discussed, with a preliminary sleep schedule 

set based on patient estimates of average time 

spent in bed and average sleep duration. A handout 

on how to follow the bedtime restriction is 

also given to reduce time spent in the consultation 

process. 

References 

1. Arroll B, Fernando A, Falloon K, Goodyear-Smith F, Samaranayake 

C, Warman G. The prevalence of causes of insomnia in 

primary care. Br J Gen Pract. 2012;62:e99–e103. 

2. American Psychiatric Association. Diagnostic and Statistical 

Manual of Mental Disorders, Fourth Edition—Text Revision 

(DSM-IV-TR). Washington, DC: American Psychiatric Publishing 

Inc.; 2000. 

3. Ford DE, Kamerow DB. Epidemiologic study of sleep disturbances 

and psychiatric disorders. An opportunity for prevention 

JAMA. 1989;262(11):1479–84. 

4. Perlis ML, Smith LJ, Lyness JM, Matteson SR, Pigeon WR, 

Jungquist CR, et al. Insomnia as a risk factor for onset of depression 

in the elderly. Behav Sleep Med. 2006;4(2):104–13. 

5. Morgenthaler T, Kramer M, Alessi C, Friedman L, Boehlecke 

B, Brown T, et al. Practice parameters for the psychological 

and behavioral treatment of insomnia: an update. An 

American Academy of Sleep Medicine report. Sleep. 

2006;29(11):1415–9. 

6. Friedman L, Benson K, Noda A, Zarcone V, Wicks DA, 

O’Connell K, et al. An actigraphic comparison of sleep restriction 

and sleep hygiene treatments for insomnia in older adults. 

J Geriatr Psychiatry Neurol. 2000;13(1):17–27. 

7. Lichstein KL, Riedel BW, Wilson NM, Lester KW, Aguillard 

RN. Relaxation and sleep compression for late-life 

insomnia: a placebo-controlled trial. J Consult Clin Psychol. 

2001;69(2):227–39. 

8. Spielman AJ, Saskin P, Thorpy MJ. Treatment of chronic insomnia 

by restriction of time in bed. Sleep. 1987;10(1):45–56. 

9. Bjelland I, Dahl AA, Haug TT, Neckelmann D. The validity 

of the Hospital Anxiety and Depression Scale. An updated 

literature review. J Psychosom Res. 2002;52(2):69–77. 

10. 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):107–3 

11. Moher D, Schulz KF, Altman DG. The CONSORT statement: 

revised recommendations for improving the quality 

of reports of parallel-group randomised trials. Lancet. 

2001;357(9263):1191–4. 

12. Dean AG, Sullivan KM, Soe MM. OpenEpi: Open Source 

Epidemiologic Statistics for Public Health, Version 2.3.1 www. 

openepi.com [accessed 21 December 2012] 

13. Buysse DJ, Germain A, Moul DE, Franzen PL, Brar LK, Fletcher 

M, et al. Efficacy of brief behavioural treatment for chronic 

insomnia in older adults. Arch Intern Med. 2011;171:887–95. 

COMPETING INTERESTS 

None declared. 

Conclusion 

This study gives strong support to the brief intervention 

of bedtime restriction being effective 

for improving sleep in adult volunteers with 

primary insomnia. The intervention, using two 

visits, is feasible in primary care. The bedtime 

restriction method is relatively simple and could 

easily be managed in primary care, thereby 

saving the time and cost of CBT-I for the 

majority of patients. We are currently conducting 

a larger trial of this brief intervention in a 

primary care population. 




Forgone health care among secondary 

school students in New Zealand 

Simon Denny MPH, FRACP; 1,2 Bridget Farrant MPH, FRACP; 1,2 John Cosgriff FRACGP; 2 Mo Harte RN, 

MN, NP; 2 Toby Cameron RN; 2 Rachel Johnson FRACP; 2 Viv McNair RN; 2 Jennifer Utter MPH, PhD; 3 Sue 

Crengle PhD, FRNZCGP, FNZCPHM; 4 Theresa Fleming MHSci, DSW; 1 Shanthi Ameratunga MBChB, PhD; 3 

Janie Sheridan PhD, RegPharmNZ; 5 Elizabeth Robinson MSc 3 

ABSTRACT 

INTRODUCTION: Perceived lack of confidential health care is an important barrier for young people 

accessing health care services in New Zealand (NZ). 

AIM: To determine the prevalence of forgone health care among a nationally representative sample of 

NZ secondary school students and to describe the health concerns and specific health issues for which 

young people had difficulty accessing health care. 

METHODS: Random sample of 9107 NZ secondary school students participated in a 2007 health survey 

using internet tablets. Questions about access to health care included whether there had been a time 

when they had not accessed health care when needed, reasons for difficulty in accessing health care, 

current health concerns and health risk behaviours. 

RESULTS: One in six students (17%) had not seen a doctor or nurse when needed in the last 12 months. 

Female Maori and Pacific students and those living in neighbourhoods with high levels of deprivation 

were more likely to report forgone health care. Students with chronic health problems, those engaging 

in health risk behaviours or experiencing symptoms of depression were more likely to report being unable 

to access health care when needed. Students reporting privacy concerns were more likely to report 

difficulty accessing health care for sensitive health issues, such as sexual health, emotional problems, 

pregnancy-related issues, stopping cigarette smoking, or alcohol or drug use. 

1 

Department of Community 

Paediatrics, School of 

Population Health, The 


Auckland, New Zealand 

2 

Centre for Youth Health, 

Counties Manukau District 

Health Board, Auckland 

3 

Section of Epidemiology 

and Biostatistics, School 

of Population Health, The 

University of Auckland 

4 

Te Kupenga Hauora Maori, 

School of Population Health, 

The University of Auckland 

5 

School of Pharmacy, Faculty 

of Medical and Health 

Sciences, The University of 

Auckland 

DISCUSSION: NZ secondary school students who forgo health care are at increased risk of physical and 

mental health problems and in need of accessible and confidential health services. 

KEYWORDS: Access to health care; adolescent health services; general practice; preventive health 

services 

Introduction 

Adolescents who forgo health care are a vulnerable 

group at risk of physical and mental health 

problems. 1 There are a number of factors that 

influence health care access and utilisation among 

adolescents, including individual characteristics 

such as age, gender and socioeconomic factors, 

availability and adolescent perceptions of their 

health care provider, and level of need or illness. 1,2 

For adolescents, perceived provider characteristics 

such as confidentiality are especially important, as 

well as adolescents’ perceptions of their provider’s 

honesty, respectfulness and equity. 3 Adolescents 

who forgo health care due to confidentiality concerns 

are more likely to experience psychological 

distress, high rates of risk behaviours, and parent– 

teen communication issues. 4 

Young people in New Zealand have a poor record 

of youth health, with high rates of suicide, 

motor vehicle accidents and teenage pregnancy 


2013;5(1):11–18. 


Simon Denny 

Department of Community 

Paediatrics, School of 

Population Health, 

The University of 

Auckland, PB 92019, 


s.denny@auckland.ac.nz 




compared to other high income countries. 5 Given 

New Zealand’s poor youth health record, there 

is a need to better understand the issues around 

primary care access and forgone health care 

among adolescents in New Zealand. To date, few 

studies have investigated what specific health 

issues adolescents have had difficulty accessing 

health care for, especially due to confidentiality 

concerns. The aims of this study are to describe 

the prevalence and reasons for forgone health care 

among a nationally representative sample of secondary 

school students and to describe the health 

concerns and health issues for which these young 

people had difficulty accessing health care. 

Methods 

A nationally representative sample of all secondary 

schools was drawn from the New Zealand 

Ministry of Education database in June 2006. 

Schools with fewer than 50 students in years 9 to 

13 were excluded, leaving 389 schools eligible to 

participate. From these schools, 115 were randomly 

selected and 96 agreed to participate, representing 

an 84% response rate. The majority of participating 

schools were publically funded (70%), co-educational 

(71%), and had rolls of less than 700 students 

(60%), reflecting the general characteristics of secondary 

schools in New Zealand. Ethical approval 

was obtained from the University of Auckland 

Human Subject Ethics Committee. Written 

consent was obtained from the principal of each 

participating school; students and parents were 

given written information about the survey and 

each student gave their own consent to participate. 

Participants 

The survey was carried out from March to October 

in 2007. In each participating school, 18% 

of year 9 to 13 students were randomly selected 

from the school roll and invited to take part. In 

total 9107 students out of the 12 355 students 

invited took part in the study, representing a 

73% response rate. Apart from a slightly higher 

percentage of male students, the participating 

students were similar demographically to the 

national population of secondary school students. 

The survey was carried out using internet 

tablets—small hand-held computers with highresolution 

touch screens. 6 

No keyboard data entry was required; questions 

and answers could also be heard through headphones 

and responses were made by touching the 

screen with a stylus. Students could elect to miss 

any question or section of the survey at any point. 

Data collection 

To assess forgone health care, students were 

asked ‘In the last 12 months, has there been 

any time when you wanted or needed to see a 

doctor or nurse (or other health care worker) 

about your health, but weren’t able to’ with 

response options ‘yes’ or ‘no’. Age, gender, and 

ethnicity were determined by self-report. Ethnicity 

was assessed using the standard ethnicity 

question developed for the New Zealand census 

where participants can select all of the ethnic 

groups that they identify with. Approximately 

40% of students identified with more than one 

ethnic group. To facilitate statistical analyses, 

discrete ethnic populations were created using 

a prioritisation method where students were 

assigned to one ethnic group in the following 

order: Maori, Pacific, Asian, NZ European, and 

other ethnicities. Table 1 describes the indicators 

of health concerns and health risk behaviours 

used in this study. 

During the survey, students were asked to 

provide their home address in order to ascertain 

the small-area geographical unit or meshblock 

in which they lived. That unit was recorded 

and later matched to the 2006 New Zealand 

Deprivation Index (NZDep2006). The home 

address was not saved to protect the participating 

student’s anonymity. NZDep2006 is an 

area-based socioeconomic deprivation index that 

assesses eight dimensions of deprivation (beneficiary, 

home ownership, single-parent families, 

unemployment, lack of educational qualifications, 

overcrowding, no access to a telephone, no 

access to a car) using 2006 New Zealand census 

data. 7 Each participating student’s NZDep2006 

index was determined by linking their residential 

meshblock number to the NZDep2006 index. The 

index deciles were categorised into five groups, 

from low deprivation (1 and 2) to high deprivation 

(9 and 10) neighbourhoods. The meshblock was 

also used to classify students’ residential location 

into main urban (cities, major urban areas or large 




regional centres with a minimum population of 

10 000 people), minor urban (urbanised settlements 

with a population between 1000 and 9999 

people) and rural (rural centres and locations with 

populations less than 1000 people). 

Data analysis 

Descriptive statistics are presented as percentages 

with their 95% confidence intervals accounting 

for the unequal probability of selection and 

the clustered survey design using the survey 

procedures in SAS (SAS Institute, Cary, North 

Carolina). Multivariate logistic regression analysis 

was used to compare differences between groups, 

controlling for age, sex, ethnicity and socioeconomic 

deprivation and urban or rural location. As 

the main outcomes were common (>10%), adjusted 

relative risk (aRR) of forgone health care by 

health problems and health risk behaviours were 

estimated using a Poisson model. 8 Differences 

are interpreted conservatively given the size of 

the sample and the number of comparisons being 

made between demographic groups. 


What we already know: Young people in New Zealand have a poor 

record of youth health. Perceived lack of confidential health care has been 

identified in the literature as one of the barriers to young people accessing 

health care services. 

What this study adds: New Zealand secondary school students have 

high rates of forgone health care. Confidentiality concerns are an important 

barrier young people face accessing health care, especially for those with 

emotional and sexual health concerns. 

Results 

One in six students (17%) had not seen a doctor 

or nurse when needed in the last 12 months 

(Table 2). Forgone health care was more common 

among female students compared to male students 

(p



Table 2. Demographic characteristics of secondary school students participating in study of forgone health care 

Total 

Students who report not accessing health care when 

needed in last 12 months 

n (%) n % p-value* 

Total 9107 (100) 1485 16.8 

Gender



Table 3. Reasons students reported for not accessing health care when needed, by gender 

By gender 

Total 

Male Female 

n % % % p-value* 

Didn’t know how to 312 21.8 22.0 21.6 0.71 

Couldn’t get an appointment 331 23.1 21.8 24.2 0.41 

Didn’t want to make a fuss 789 55.0 51.1 58.3 0.009 

Couldn’t be bothered 560 39.1 45.2 34.0



Table 4. Percentage of students reporting forgone health care in the last 12 months by health problem and health risk 

behaviours 

Chronic health 

problem or disability 

Current cigarette use 

Binge drinking 

Sexually active 

High depressive 

symptoms 

Weight status 

Forgone health care in past 12 months 

Total n (%) % aRR* 95% CI 

no 6379 (79.8) 13.9 1.0 

yes 1628 (20.2) 24.5 1.8 1.6–2.0 † 

no 6892 (83.1) 14.2 1.0 

yes 1409 (16.9) 28.2 1.8 1.6–2.0 † 

no 5418 (65.6) 13.9 1.0 

yes 2829 (34.4) 21.5 1.5 1.4–1.7 † 

no 5133 (63.6) 12.7 1.0 

yes 2931 (36.4) 23.5 1.8 1.6–2.0 † 

no 7661 (89.4) 14.1 1.0 

yes 910 (10.6) 37.2 2.5 2.2–2.8 † 

Normal weight 5563 (63.2) 15.7 1.0 

Underweight 229 (2.6) 12.9 0.8 0.5–1.1 

Overweight 3010 (34.1) 18.9 1.1 1.0–1.2 

* Adjusted relative risk controlling for sex, age, ethnicity, and socioeconomic deprivation 

† p



were aware that their health care provider could 

provide this. 12 

Among the students in the current study who reported 

problems accessing health care, those with 

concerns about privacy were more likely to report 

problems accessing health care for sensitive health 

care issues, such as pregnancy worries, drug and 

alcohol issues, and emotional health concerns. 

In New Zealand, over 80% of secondary school 

students access health services in a given year, 

predominantly from their usual primary care provider. 

13 It is of interest then that forgone health 

care was higher among students who had accessed 

health care in the last year compared to those who 

had not. While this could reflect ongoing health 

concerns among young people accessing health 

care, it also could mean that primary health care 

services are not meeting the needs of this age 

group. Data from the same population as the 

current study have shown that among students 

who had accessed health care, only 27% reported 

receiving private and confidential care. 13 In New 

Zealand primary care settings, young people have 

the lowest utilisation rates, are least likely to see 

the same primary care doctor consistently, and 

receive the least time with their primary care doctor 

compared with any other age group. 14 Furthermore, 

among adolescents who do utilise primary 

care services, few receive the recommended 

preventive health counselling, health promotion 

or screening for health risk behaviour or emotional 

health concerns. 15 This is despite research 

from the US showing that adolescents trust their 

health care professionals, view them as credible 

sources of health information, and want to talk to 

their doctors about sensitive health issues. 16,17 It 

is of concern that both students with health concerns 

and students from populations experiencing 

disparities in health outcomes were most at risk 

of forgone health care, as these issues are arguably 

amenable to good quality primary care. 18 

One of the more common reasons students reported 

not accessing health care when needed was 

cost. Previously published data from this population 

of secondary school students has shown 

that students accessed health care in the previous 

year from the following sites: general practitioners 

(GPs) or family doctors (93%), school health 

clinics (23%), after-hours or 24-hour accident 

and medical centres (16%), hospital emergency 

departments (18%), family planning or sexual 

health clinics (5%) and youth centres (2%). 13 

There are significant cost barriers for adolescents 

accessing health care from GPs and after-hours 

medical centres. GPs or family doctors receive 

government subsidies but are able to charge their 

patients on a fee-for-service basis. After-hours 

care is also based on a fee-for-service model with 

government subsidies, but is often more expensive 

than health care accessed during regular 

hours. In contrast, youth centres, sexual health 

clinics and school-based health clinics are free, 

but their availability is limited. 

Several potential limitations warrant consideration 

in interpreting the findings of this study. 

The data are cross-sectional in nature and this 

limits the ability to make inferences regarding 

causality. The response rate was 73% which 

limits the generalisation of the findings to the 

entire secondary school population. There was 

also limited information on details around the 

privacy and confidentiality concerns reported. 

Privacy concerns among adolescents include not 

only the disclosure of personal information but 

psychological, social, and physical aspects of 

privacy as well. 19 Another limitation is that the 

sample was limited to students at school and 

may not apply to out-of-school youth. It is well 

recognised that students who are absent or excluded 

from mainstream schools engage in more 

health risk behaviours and have poorer emotional 

wellbeing than students who are at school, 

and are also likely to experience additional 

barriers accessing health care. 20 In New Zealand, 

students who experience psychosocial difficulties 

are also more likely to leave school early, as 

education in New Zealand is compulsory only 

up until the age of 15 years. This may explain 

the drop in forgone health care reported among 

17-year-olds and older students. 

Despite these potential limitations, our findings 

suggest several areas for improving health care 

access for adolescents in primary care settings 

in New Zealand. Firstly, health care providers 

need to review their practice and environment 

with respect to confidentiality and privacy from 

a youth perspective. Position statements from 

national and international medical organisations 




ACKNOWLEDGEMENTS 

We thank all the students, 

staff and schools who 

participated in and 

supported this project. We 

also wish to acknowledge 

and thank the project 

team members for all 

their work, especially 

those who travelled to 

different parts of the 

country gathering data. 

FUNDING 

The Youth ’07 project 

was funded by the 

Health Research Council 

of New Zealand (grant 

05/216), the Department 

of Labour, Families 

Commission, Accident 

Compensation Corporation 

of New Zealand, Sport and 

Recreation New Zealand, 

the Alcohol Advisory 

Council of New Zealand 

and the Ministries of Youth 

Development, Justice, 

Health and Te Puni Kokiri. 

Vodafone New Zealand 

provided support for 

electronic communication. 



have recommended specific measures to address 

the health needs of the youth population. 21–24 

However, recent regional initiatives in primary 

care make no mention of the adolescent age group 

in their strategic plans, let alone identify ways to 

improve access for young people. This is despite 

a wealth of resources available to primary care 

services interested in improving their practice. 25 

Secondly, there is a need for better training in 

adolescent health among primary care providers. 

Many primary care providers are uncomfortable 

providing health care to adolescents and feel 

inadequately trained in youth health issues. 26,27 

Specialised training in adolescent health significantly 

increases the likelihood of adolescents 

receiving confidential care. 28 To improve health 

care access for young people in New Zealand will 

require a comprehensive approach, with primary 

care providers being trained and responsive to the 

needs of the adolescent population. 

References 

1. Ford CA, Bearman PS, Moody J. Foregone health care among 

adolescents. JAMA. 1999;282:2227–2234. 

2. Andersen RM. Revisiting the Behavioral Model and access 

to medical care: does it matter J Health Soc Behav. 

1995;36:1–10. 

3. Ginsburg KR, Slap GB, Cnaan A, Forke CM, Balsley CM, Rouselle 

DM. Adolescents’ perceptions of factors affecting their 

decisions to seek health care. JAMA. 1995;273:1913–1918. 

4. Lehrer JA, Pantell R, Tebb K, Shafer M-A. Forgone health 

care among US adolescents: associations between risk 

characteristics and confidentiality concern. J Adolesc Health. 

2007;40:218–226. 

5. Ministry of Health. New Zealand Youth Health Status Report. 

Wellington: Ministry of Health; 2002. 

6. Denny SJ, Milfont TL, Utter J, et al. Hand-held internet tablets 

for school-based data collection. BMC Res Notes. 2008;1:52. 

7. Salmond C, Crampton P, Atkinson J. NZDep2006 Index of 

Deprivation. Wellington: University of Otago; 2007. 

8. Spiegelman D, Hertzmark E. Easy SAS calculations for 

risk or prevalence ratios and differences. Am J Epidemiol. 

2005;162:199–200. 

9. Denny SJ, Robinson EM, Utter J, Fleming TM, Grant S, 

Milfont TL, et al. Do schools influence student risk-taking 

behaviors and emotional health symptoms J Adolesc Health. 

2011;48:259–267. 

10. Tylee A, Haller DM, Graham T, Churchill R, Sanci LA. Youthfriendly 

primary-care services: how are we doing and what 

more needs to be done Lancet. 2007;369:1565–1573. 

11. Bernard D, Quine S, Kang M, Alperstein G, Usherwood T, 

Bennett D, et al. Access to primary health care for Australian 

adolescents: how congruent are the perspectives of health 

service providers and young people, and does it matter Aust 

N Z J Public Health. 2004;28:487–492. 

12. Thrall JS, McCloskey L, Ettner SL, Rothman E, Tighe JE, Emans 

SJ. Confidentiality and adolescents’ use of providers for health 

information and for pelvic examinations. Arch Pediatr Adolesc 

Med. 2000;154:885–892. 

13. Denny S, Farrant B, Cosgriff J, Hart M, Cameron T, Johnson 

R, et al. Access to private and confidential health care among 

secondary school students in New Zealand. J Adolesc Health. 

2012;51:285–91. 

14. Ministry of Health. A portrait of health. Key results of the 

2006/07 New Zealand Health Survey. Wellington: Ministry of 

Health; 2008. 

15. Denny S, Balhorn A, Lawrence A, Cosgriff J. Student access 

to primary health care and preventive health screening at a 

school-based health centre in South Auckland, New Zealand. 

N Z Med J. 2005;118:U1561. 

16. Park MJ, Macdonald TM, Ozer EM, Burg SJ, Millstein SG, 

Brindis CD. Investing in clinical preventive health services for 

adolescents. University of California—San Francisco: Policy 

Information and Analysis Center for Middle Childhood and 

Adolescence, and National Adolescent Health Information 

Center. 2001. 

17. Brown JD, Wissow LS. Discussion of sensitive health topics 

with youth during primary care visits: relationship to youth 

perceptions of care. J Adolesc Health. 2009;44:48–54. 

18. Brindis C, Park MJ, Ozer EM, Irwin CE, Jr. Adolescents’ access 

to health services and clinical preventive health care: Crossing 

the great divide. Pediatr Ann. 2002;31:575–581. 

19. Britto MT, Tivorsak TL, Slap GB. Adolescents’ needs for health 

care privacy. Pediatrics. 2010;126:e1469–1476. 

20. Bovet P, Viswanathan B, Faeh D, Warren W. Comparison 

of smoking, drinking, and marijuana use between students 

present or absent on the day of a school-based survey. J Sch 

Health. 2006;76:133–137. 

21. Elster AB, Kuznets NJ. AMA guidelines for adolescent 

preventive services (GAPS). Recommendations and rationale. 

Baltimore: Williams & Wilkins; 1994. 

22. Committee on Adolescence. Achieving quality health services 

for adolescents. Policy Statement of the American Academy of 

Pediatrics. Pediatrics. 2008;121:1263–1270. 

23. Society for Adolescent Medicine. Access to health care 

for adolescents and young adults. J Adolesc Health. 

2004;35:342–344. 

24. RACP Joint Adolescent Health Committee. Confidential 

Health Care for Adolescents and Young People (12–24 years). 

Sydney: The Royal Australasian College of Physicians; 2010. 

25. Chown P, Kang M, Sanci LA, Newnham V, Bennett D. Adolescent 

health: enhancing the skills of general practitioners in 

caring for young people from culturally diverse backgrounds. 

GP Resource Kit. 2nd ed. Sydney: NSW Centre for the 

Advancement of Adolescent Health and Transcultural Mental 

Health Centre; 2008. 

26. Blum R. Physicians’ assessment of deficiencies and desire for 

training in adolescent care. J Med Educ. 1987;62:401–407. 

27. Veit FC, Sanci LA, Coffey CM, Young DY, Bowes G. Barriers 

to effective primary health care for adolescents. Med J Aust. 

1996;165:131–133. 

28. Sanci LA, Coffey CM, Veit FC, Carr-Gregg M, Patton GC, 

Day N, et al. Evaluation of the effectiveness of an educational 

intervention for general practitioners in adolescent health 

care: randomised controlled trial. BMJ. 2000;320:224–230. 

29. Reynolds WM. Reynolds Adolescent Depression Scale: Short 

Form Professional Manual. Lutz, Florida, USA: PAR Inc.; 2008. 

30. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a 

standard definition for child overweight and obesity worldwide: 

International survey. BMJ. 2000;320:1240–1243. 




Characteristics of nurses providing diabetes 

community and outpatient care in Auckland 

Barbara Daly PhD, MHSc, BSc, RN; 1 Bruce Arroll PhD, MBChB, FNZCPHM, FRNZCGP; 2 Nicolette Sheridan 

PhD, MPH, RN; 1 Timothy Kenealy PhD, MBChB, FRNZCGP; 2 Robert Scragg PhD, MBBS, FRNZCPHM 2 

ABSTRACT 

INTRODUCTION: There is a worldwide trend for diabetes care to be undertaken in primary care. 

Nurses are expected to take a leading role in diabetes management, but their roles in primary care are 

unclear in New Zealand, as are the systems of care they work in as well as their training. 

AIM: To describe and compare demographic details, education and diabetes experience, practice setting 

and facilities available for the three main groups of primary health care nurses working in the largest 

urban area in New Zealand. 

1 

School of Nursing, Faculty of 

Medicine and Health Science, 

The University of Auckland, 


2 

School of Population 

Health, Faculty of Medicine 

and Health Science, The 


METHOD: Of the total number of practice nurses, district nurses and specialist nurses working in 

Auckland (n=1091), 31% were randomly selected to undertake a self-administered questionnaire and 

telephone interview in 2006–2008. 

RESULTS: Overall response was 86% (n=284 self-administered questionnaires, n=287 telephone 

interviews). Almost half (43%) of primary care nurses were aged over 50 years. A greater proportion of 

specialist nurses (89%) and practice nurses (84%) had post-registration diabetes education compared 

with district nurses (65%, p=0.005), from a range of educational settings including workshops, workplaces, 

conferences and tertiary institutions. More district nurses (35%) and practice nurses (32%) had 

worked in their current workplace for >10 years compared with specialist nurses (14%, p=0.004). Over 

20% of practice nurses and district nurses lacked access to the internet, and the latter group had the least 

administrative facilities and felt least valued. 

DISCUSSION: These findings highlight an ageing primary health care nursing workforce, lack of a national 

primary health care post-registration qualification and a lack of internet access. 

KEYWORDS: Community health nursing; diabetes mellitus; internet; nurses; primary health care 

Introduction 

New Zealand (NZ) is in the middle of a growing 

epidemic of diabetes. 1 Since the 1990s, results 

from major international intervention studies 

have shown that improved clinical management 

of blood glucose levels (BGLs) in patients with 

diabetes reduces microvascular complications, 2 

and that improvements in major cardiovascular 

(CV) risk factors reduces all diabetes-related 

complications. 3–7 Despite the increasing role and 

need for health professionals in the detection and 

management of diabetes, there already exists a 

shortage of specialists to manage the condition in 

NZ. 8 Thus, it is unlikely that the demands from 

increasing numbers of patients diagnosed with 

Type 2 diabetes, and from expanded roles into 

screening, can be met without a re-examination 

and re-defining of existing work practices of 

health professionals, including primary health 

care (PHC) nurses. 

In 2010, there were 42 334 registered nurses 

working in NZ and, of those, 23% were working 

in a community or rural setting. 9 The four main 

groups of nurses providing PHC are practice nurs- 


2013;5(1):19–27. 


Barbara Daly 

School of Nursing, 

Faculty of Medical and 

Health Sciences, The 




b.daly@auckland.ac.nz 




es (PNs), district nurses (DNs), diabetes specialist 

nurses (DSNs), and chronic care management 

(CCM) nurses—formerly referred to as disease 

state management nurses. CCM nurses receive 

funding for further education and to develop 

competencies in chronic condition management, 

and during the survey were employed by general 

practices, Primary Health Organisations (PHOs) 

and independent providers. PNs are primarily 

employed in general practice and have the greatest 

opportunity to develop new roles in the PHO 

environment, as they comprise the largest group 

of nurses working in the community—45% in the 

2010 national survey. 9 All DNs in Auckland are 

employed by the three Auckland District Health 

Boards (DHBs) and their role is aligned with secondary 

health care services to provide home care 

for patients. DSNs predominantly work within 

secondary health care services, although as in the 

United Kingdom, a proportion now work in PHC 

settings or across both sectors. 10 

The Ministry of Health encouraged the development 

of PHOs, following the PHC Strategy 

in 2001, 11 which offered new opportunities for 

nurses working in community settings, including 

professional development and leadership, to enable 

nurses to work more independently. 12 

The aim of this paper is to describe and compare 

the demographic characteristics, current practice 

settings and diabetes training and experience 

of the main groups of PHC nurses to gain an 

understanding of their experience and skill set in 

providing community-based services for patients 

with diabetes in Auckland. 

Methods 

The current study is a cross-sectional survey 

of PHC nurses providing community management 

for patients with diabetes in the Auckland 

region, conducted between September 2006 and 

February 2008. Approval was obtained from 

the Northern X Regional Ethics Committee 

(NTX/05/10/128). 

A total of 1091 nurses providing PHC services 

were identified in 2006/7 and stratified by nurse 

group with the aim of randomly sampling approximately 

25% from each group. In total, 813 

PNs were identified as working in Auckland 

from an updated register of PNs and general 

practitioners (GPs) held by the Department of 

General Practice and Primary Health Care, The 

University of Auckland. Further, 180 DNs were 

identified from lists obtained by the three Auckland 

DHBs in 2007, and 73 DSNs and 25 CCM 

nurses were identified by contacting all 19 PHOs 

in the Auckland region and the three independent 

Maori providers. Of the total 1091 nurses, 

383 were randomly selected and, of those, 335 

(31%) nurses were still working in PHC (based 

on telephoning their workplace) and were invited 

to participate in the survey. Of the total number 

invited, 287 (86%) agreed to participate, including 

210 (85%) PNs, 49 (83%) DNs, 19 (95%) DSNs and 

9 (100%) CCM nurses. 

A self-administered four-page questionnaire 

consisting of closed questions with ‘other’ 

response options, where appropriate, and a replypaid 

envelope were mailed to all 335 randomly 

selected nurses. This was followed by a telephone 

call a week later to solicit participation and arrange 

a time for a telephone interview for those 

who agreed to participate. A total of 284 nurses 

returned and completed the self-administered 

questionnaire. This contained questions about 

their nursing training, subsequent diabetes education 

and experience, facilities and processes for 

managing patients with diabetes in their current 

workplace, and their involvement in managing 

diabetes. All 287 nurses who agreed to participate 

completed the telephone interview, including two 

PNs and one DN who did not complete the selfadministered 

questionnaire. The telephone interview, 

made up of closed questions or multi-choice 

options, was designed to elicit further information 

on work facilities and how valued and supported 

nurses felt in the management of patients with 

diabetes. Responses were recorded in writing. 

For statistical analyses, nurses were categorised 

into three groups: PNs, DNs, and specialist 

nurses (SNs), who included both the DSNs (n=19) 

and CCM (n=9) nurses. The latter two groups 

were combined because of small numbers. Standard 

univariate methods were used for analysing 

categorical outcome data, using PROC FREQ 

in SAS version 9.2 (SAS Institute, Cary, North 

Carolina, 2008). 




Results 

Table 1 shows the biographical details of the 284 

PHC nurses who completed the self-administered 

questionnaire. Almost all were female, 80% 

were aged over 40 years and significantly more 

DNs had graduated more recently than SNs and 

PNs. Three-quarters of nurses self-identified as 

NZ Europeans, and only 4% as Maori; the latter 

were more likely to be CCM nurses (Table 1). 

Most nurses had completed their undergraduate 

nursing education in NZ and half of the nurses 

had, or were working towards, post-registration 

qualifications, including significantly more SNs 

(Table 1). 

Table 2 outlines previous community nursing 

experience and current work settings of the 

nurses. Over half had worked within the community 

for over 10 years and significantly more 

PNs and DNs had also been in their current work 

positions for >10 years compared with SNs. However, 

more SNs worked full-time compared with 

DNs and PNs who tended to work three to four 

days per week (Table 2). The proportion of PHC 

nurses working in each DHB was similar, being 

Waitemata (35%), Auckland (34%) and Counties 

Manukau (30%), as was the distribution for each 

nurse group (p=0.12). 

Table 3 shows details of prior diabetes education 

and work experience. Although a large proportion 

of participants had undertaken specific diabetes 

education, this was predominantly workshop- and 

workplace-based. Furthermore, significantly more 

DNs and PNs had received ≤10 hours diabetes 

education compared with SNs and almost 20% of 

nurses surveyed listed over 30 diabetes courses or 

education providers where they had received this 

education. 

Table 4 reports the practice size and workplace 

setting of nurses. Almost half of the PNs worked 

at mid-sized practices, while most SNs worked 

in larger practices or services. In contrast, only a 

small proportion of PNs and SNs worked in small 

(one GP) practices. 

Over half of SNs and about 40% of PNs had their 

own office or room to carry out administrative 

work (Table 4). In contrast, the majority of DNs 


What we already know: There is a shortage of specialists involved in diabetes 

care. Primary health care nurses are increasingly taking a greater role in 

the management of patients with diabetes. 

What this study adds: This is the first cross-sectional study reporting 

on the demographic characteristics, diabetes education and experience of a 

representative sample of primary health care nurses from the wider Auckland 

region. Practice and district nurses need to be supported to further their diabetes 

education and to gain access to internet and email services. Further effort 

is required to ensure district nurses feel valued and supported in this role 

and are adequately connected to other primary health care professionals. 

carried out administrative work in a shared room, 

in patients’ homes and/or in their car, and typically 

carried out administrative work in one large 

office with a limited number of computers. Most 

SNs had access to broadband internet compared 

with only 78% of PNs and DNs (Table 4) and 

nine nurses used dial-up internet. A high proportion 

of all three nurse groups had access to a telephone, 

computer and printer (93–100%), although 

far less had access to emails—internal (72%) and 

external (45%). A significantly larger proportion 

of PNs (54%) had external email access compared 

with only 18% of DNs and SNs (p



Table 1. Biographical details of primary health care nurses (n=284), by nursing group—sex, age, ethnicity and country of graduation. 

Variable and level 

Total 

N=284 

n (%) 

Practice nurses 

n=208 (%) 

Type of nurse 

District nurses 

n=48 (%) 

Specialist nurses 

n=28 (%) 

p-value* 

Sex (n=284) 0.43 

Female 278 (98) 99 96 96 

Male 6 (2) 1 4 4 

Age, years (n=280) 0.27 

25–40 57 (20) 20 25 14 

41–50 104 (37) 34 46 43 

51 and older 119 (43) 46 29 43 

Ethnicity (n=284) 0.001 

NZ European 209 (74) 76 75 54 

Asian 20 (7) 8 2 7 

Pacific 14 (5) 6 0 7 

United Kingdom 14 (5) 3 8 11 

Maori 11 (4) 1 6 18 

† 

Other 16 (6) 5 8 3 

Year of graduation (n=279) 0.04 

1959–1975 91 (33) 36 17 30 

1976–1985 94 (34) 34 32 33 

1986–2006 94 (34) 29 51 37 

Country of graduation (n=284) 0.13 

New Zealand 224 (79) 78 77 86 

United Kingdom 22 (8) 5 17 11 

Pacific nation 12 (4) 5 2 0 

Australia 10 (4) 4 2 0 

Asia / Malaysia / Middle East 10 (4) 5 0 0 

North America / South Africa 6 (2) 2 2 4 

‡ 

Academic qualification/s 140 (49) 45 46 86 0.0003 

Certificate 66 (23) 22 19 39 0.81 

Diploma 48 (17) 14 17 43 0.17 

Degree 43 (15) 15 10 25 0.63 

Master’s degree 15 (5) 3 6 21 0.03 

Other qualifications 0.72 

Hospital course 7 (3) 3 2 0 

Midwifery 7 (3) 2 2 4 

Nutrition/non-health 3 (1) 1 0 0 

* p-value showing significance of variation in percentages in subgroups, from the Chi-square value 

† 2% each from Australia and North America and 1% from Europe 

‡ Post-registration qualifications 




Table 2. Primary health care nurses (N=284) by nursing group—community experience and current demographic work details. 


Total 

N (%) 


n=208 (%) 



n=48 (%) 


n=28 (%) 

p-value* 

Years of community experience 0.048 

10 152 (54) 57 42 46 

Years in current PHC role 0.002 

10 124 (44) 48 35 25 

Current work setting



Table 3. Proportion of primary health care nurses (N=284) with specific diabetes education and experience. 


Diabetes education and experience 

Total 

N (%) 


n=208 (%) 



n=48 (%) 


n=28 (%) 

p-value* 

Specific diabetes education 230 (81) 84 65 89 0.005 

Workshop (n=212) 145 (51) 55 27 64 0.0008 

Workplace (n=212) 110 (39) 34 44 64 0.007 

Conferences (n=212) 52 (18) 17 8 46 0.0001 

Tertiary (n=212) 31 (11) 8 6 39



Table 5. The proportion of primary health care nurses, by group, reporting specific health professionals involved in diabetes care at each practice or 

service (N=283). 


Total 

N (%) 


n=208 (%) 



n=48 (%) 


n=27 (%) 

p-value* 

Specialist in diabetes: 141 (50) 38 79 85



the 19% and 22.5% reported for PNs in Great 

Britain 17 and Scotland 13 respectively. In contrast, 

a quarter of the SNs sampled held post-registration 

degrees, which was comparable with the 

28% reported for DSNs in Great Britain. 17 Further, 

6% of DNs and 3% of PNs (similar to the 

3.5% reported for PNs in the Scottish survey) 13 

and 21% of SNs held a master’s degree—almost 

twice the proportion of CCM nurses compared 

with DSNs, which was more than the 6% 

reported as undertaking post-registration study 

in the UK 17 and the 8–9% of diabetes educators 

holding doctorates in the US. 20,21 

Most SNs (89%) sampled had received specific 

diabetes education, which was a similar proportion 

to that reported for DSNs in the UK 14,22 

and experienced staff nurses in an older survey 

from South Africa. 18 A large proportion of PNs 

(84%) sampled reported having specific diabetes 

education, similar to that reported by PNs in 

Scotland 13 and those surveyed from 123 general 

practices in Nottingham, UK, 23 and almost twice 

the proportion reported from the 1999 (47%) and 

far higher than that reported in the 1990 (14%) 

NZ surveys, 16 illustrating the increasing trend in 

post-registration diabetes education for PNs. Despite 

this, no national post-registration diabetes 

programme or qualification exists in NZ, making 

comparisons difficult on the quality and core 

content covered. 

Most PNs and SNs had gained their diabetes 

experience in PHC, similar to the proportion 

reported for PNs in Scotland 13 and SNs had spent 

longer in PHC than diabetes educators in the 

US. 20 About half of the PNs worked in mid-sized 

practices—similar to that reported in NZ from 

the 1999 survey and more than in 1990 16 —and 

in practices in the Waikato region, 24 and with 

more nurses than the majority of PNs in Scotland 

where the majority worked with one to two 

other nurses (74%). 13 SNs tended to work in large 

practices or services with fewer working in multidisciplinary 

teams compared with DSNs in the 

Netherlands (78%) 15 and the UK. 10 

The majority of PNs and SNs had access to a 

private room when consulting patients, and 

computer access. However, fewer had access to 

external email and, most concerning, over 20% of 

PNs and DNs had no internet access, especially 

as 99% of general practices in NZ, prior to this 

survey, had internet services. 25 It is imperative in 

a modern practice that PNs and SNs have similar 

access as GPs in NZ who source information 

using internet sites more often than referring to 

textbooks 26 —an increase from earlier NZ 27, 28 and 

international reports. 29,30 

DNs had the fewest administrative facilities 

and least access to electronic patient data and 

received the least specialist nursing support. In 

addition, they felt the least valued in managing 

patients with diabetes, although this was comparable 

with DNs sampled in the UK who also 

felt undervalued. 31 The high proportion of SNs 

who ‘always or often’ felt valued was similar to 

that reported for DSNs in the Netherlands who 

felt more positive in their roles compared with 

hospital and nursing home–based nurses, 15 and 

both higher than PHC nurses in an older South 

African survey who suggested communication 

between health professionals should be improved 

to enhance patient care. 18 

This is the first comprehensive cross-sectional 

survey of PHC nurses in the largest urban area in 

NZ. Selection bias was unlikely to have occurred 

because of the very high response rate; however, 

differences in the PHC nursing workforce may 

differ in other urban areas. Limitations of the 

survey include potential bias on self-reported 

information and changes in practice facilities, 

including internet access, which may have improved 

since data collection. 

In conclusion, PHC nurses represent a stable 

workforce. Funding for ongoing PHC and 

diabetes education for PNs and DNs should be 

extended along with a clearly defined national 

post-registration education that includes a core 

knowledge 19 of diabetes and common chronic 

health conditions, and career pathway that 

encourages ethnically diverse graduate nurses 

into PHC. DNs feeling less valued and their 

separation from PHC providers requires further 

investigation. The lack of access to the internet 

and patient management systems for PNs and 

DNs impedes communication between providers 

and patients and limits access to research and best 

practice guidelines. 




References 

1. Ministry of Health. The Primary Health Care Strategy. Wellington, 

New Zealand: Ministry of Health; 2001. 

2. Hemmingsen B, Lund SS, Gluud C, Vaag A, Almdal T, Hemmingsen 

C, et al. Intensive glycaemic control for patients with 

type 2 diabetes: systematic review with meta-analysis and 

trial sequential analysis of randomised clinical trials. BMJ. 

2011;343:d6898. 

3. Baigent C, Keech A, Kearney PM, Blackwell L, Buck G, 

Pollicino C, et al. Efficacy and safety of cholesterol-lowering 

treatment: prospective meta-analysis of data from 90,056 

participants in 14 randomised trials of statins. Lancet. 

2005;366(9493):1267–78. 

4. UK Prospective Diabetes Study Group. Tight blood pressure 

control and risk of macrovascular and microvascular complications 

in type 2 diabetes (UKPDS 38): UK prospective diabetes 

study (UKPDS) group. BMJ. 1998;317(7160):703–13. 

5. Conen D, Bamberg F. Noninvasive 24-h ambulatory blood 

pressure and cardiovascular disease: a systematic review and 

meta-analysis. J Hypertens. 2008;26(7):1290–9. 

6. Campbell C, Moffatt RJ, Stamford BA. Smoking and smoking 

cessation—the relationship between cardiovascular disease 

and lipoprotein metabolism: a review. Atherosclerosis. 

2008;201(2):225–35. 

7. Sowers JR. Treatment of hypertension in patients with diabetes. 

Arch Int Med. 2004;164(17):1850–7. 

8. PricewaterhouseCoopers. Type 2 diabetes: managing for better 

health outcomes. Wellington, New Zealand: Diabetes New 

Zealand Inc.; 2001. 

9. Nursing Council of New Zealand. The New Zealand nursing 

workforce: workforce statistics 2010. Wellington, New Zealand: 

Nursing Council of New Zealand; 2010. 

10. Winocour PH, Ford M, Ainsworth A. Association of British 

Clinical Diabetologists (ABCD): survey of specialist diabetes 

care services in the UK, 2000. 2. Workforce issues, roles and 

responsibilities of diabetes specialist nurses. Diabet Med. 

2002;19(Suppl 4):27–31. 

11. Quin P. New Zealand health system reforms: research paper 

09/03. Wellington, New Zealand: New Zealand Parliamentary 

Library; 2009. 

12. Ministry of Health. Investing in health: Whakatohutia te 

oranga tangata: a framework for activating primary health care 

nursing in New Zealand. Wellington, New Zealand: Ministry of 

Health; 2003. 

13. O’Donnell CA, Jabareen H, Watt GC. Practice nurses’ workload, 

career intentions and the impact of professional isolation: 

A cross-sectional survey. BMC Nurs. 2010;9:2. 

14. Llahana SV, Poulton BC, Coates VE. The paediatric diabetes 

specialist nurse and diabetes education in childhood. J Adv 

Nurs. 2001;33(3):296–306. 

15. van den Berg TI, Vrijhoef HJ, Tummers G, Landeweerd JA, van 

Merode GG. The work setting of diabetes nursing specialists 

in the Netherlands: a questionnaire survey. Int J Nurs Stud. 

2008;45(10):1422–32. 

16. Kenealy T, Arroll B, Kenealy H, Docherty B, Scott D, Scragg 

R, et al. Diabetes care: practice nurse roles, attitudes and 

concerns. J Adv Nurs. 2004;48(1):68–75. 

17. Peters J, Hutchinson A, MacKinnon M, McIntosh A, Cooke J, 

Jones R. What role do nurses play in Type 2 diabetes care in the 

community: a Delphi study. J Adv Nurs. 2001;34(2):179–88. 

18. Goodman GR, Zwarenstein MF, Robinson, II, Levitt NS. Staff 

knowledge, attitudes and practices in public sector primary 

care of diabetes in Cape Town. S Afr Med J. 1997;87(3):305–9. 

19. Finlayson M, Sheridan N, Cumming J. Evaluation of the implementation 

and intermediate outcomes of the primary health 

care strategy second report: nursing developments in primary 

health care 2001–2007. Wellington, New Zealand: Health 

Services Research Centre Victoria University; 2009. 

20. Kaufman MW, All AC, Davis H. The scope of practice of 

diabetes educators in the state of Georgia. Diabetes Educator 

1999;25(1):56–64. 

21. Cypress M, Wylie-Rosett J, Engel SS, Stager TB. The scope of 

practice of diabetes educators in a metropolitan area. Diabetes 

Educ. 1992;18(2):111–4. 

22. Thompson KA, Coates VE, McConnell CJ, Moles K. Documenting 

diabetes care: the diabetes nurse specialists’ perspective. 

J Clin Nurs. 2002;11(6):763–72. 

23. Stewart J, Kendrick D. Setting and negotiating targets in 

people with type 2 diabetes in primary care: a cross sectional 

survey. Diabet Med. 2005;22(6):683–7. 

24. Lightfoot R, Davis P, Finn E, Lay-Yee R, Gribben B, McAvoy 

B. Practice nurses in the Waikato, 1991–1992, I: occupational 

profile. N Z Med J. 1999;112(1081):26–8. 

25. Didham R, Martin I, Wood R, Harrison K. Information technology 

systems in general practice medicine in New Zealand. N Z 

Med J. 2004;117(1198):U977. 

26. Gravatt ZB, Arroll B. What resources do Auckland general 

practitioners use for answering immediate clinical questions 

and for lifelong learning J Prim Health Care. 2010;2(2):100–4. 

27. Cullen RJ. In search of evidence: family practitioners’ use 

of the internet for clinical information. J Med Libr Assoc. 

2002;90(4):370–9. 

28. Kerse N, Arroll B, Lloyd T, Young J, Ward J. Evidence databases, 

the internet, and general practitioners: the New Zealand 

story. N Z Med J. 2001;114(1127):89–91. 

29. Coumou HC, Meijman FJ. How do primary care physicians 

seek answers to clinical questions A literature review. J Med 

Libr Assoc. 2006;94(1):55–60. 

30. Bidwell SR. Finding the evidence: resources and skills for 

locating information on clinical effectiveness. Singapore Med 

J. 2004;45(12):567–72, quiz 73. 

31. Cook R. BJCN/QNI survey informs the QNI’s 2020 vision report 

on district nursing. Br J Community Nurs. 2009;14(1):27–9. 


We sincerely thank all the 

primary health care nurses 

throughout Auckland who 

participated in this study. 

FUNDING 

This research was 

supported by funding 

from Novo Nordisk, the 

Charitable Trust of the 

Auckland Faculty of The 

Royal New Zealand College 

of General Practitioners, 

and the New Zealand 

Ministry of Health. 





QUALITATIVE RESEARCH 

Could the polypill improve adherence 

The patient perspective 

Linda Bryant MClinPharm, PhD; 1 Nataly Martini PhD; 2 Jacky Chan BPharm; 2 Lisa Chang BPharm; 2 Ahmed 

Marmoush; 2 Belinda Robinson; 2 Karen Yu; 2 Many Wong 2 

1 


Practice and Primary Health 

Care, Faculty of Medical 

and Health Sciences, The 



2 

School of Pharmacy, 


Sciences, The University 

of Auckland 

ABSTRACT 

INTRODUCTION: Multiple medications are recommended for the management of ischaemic heart 

disease. Unfortunately, increasing the number of medicines reduces adherence to medicines therapy. 

The concept of a polypill with a fixed dose combination of the common cardiovascular medicines (aspirin, 

statin, two blood pressure–lowering medicines) has been promoted. Patient perceptions about this concept 

have not been explored. 

METHODS: People taking at least three cardiovascular medicines were interviewed using a semi-structured 

interview about their views on a polypill that could reduce the number of tablets they would need 

to take. 

FINDINGS: The participants considered that the polypill would be very convenient, especially when 

travelling and would reduce the pill burden. If the polypill was subsidised by the government, they would 

have reduced dispensing fee costs. There were concerns around the inflexibility of dosing of individual 

components of the polypill, and some concerns about safety and efficacy. Medical practitioners were 

identified as having an important role in influencing participants about the acceptability of the polypill. 

CONCLUSION: Generally the concept of the polypill was acceptable to participants, primarily because 

of the convenience and reduced number of tablets required daily. There were concerns about whether 

the polypill would be as effective and safe as the individual medicines. 

KEYWORDS: Cardiovascular diseases; medication adherence; prevention 


2013;5(1):28–35. 


Linda Bryant 


Practice and Primary 

Health Care, Faculty 

of Medical and Health 


of Auckland, PB 92019, 


linda@cpsl.biz 

Introduction 

Cardiovascular disease (CVD) is the leading cause 

of hospitalisation and premature death in New 

Zealand (NZ), resulting in significant years of life 

lost to disability. 1 Ischaemic heart disease (IHD) is 

the most common cause of CVD. Since the peak 

of the IHD epidemic in the late 1960s, rates of 

IHD have fallen, but this trend is not applicable 

to the Maori population where the burden is projected 

to increase over the next decade. 1,2 

Strong evidence supports the use of a statin, an 

antiplatelet agent and blood pressure–lowering 

medicines to reduce IHD morbidity and mortality. 

3 The absolute risk of having a cardiovascular 

event can be halved by taking this ‘triple therapy’. 

4 Efficacy of medicines therapy is hampered by 

poor medication adherence, unaffordable costs of 

treatment and inadequate prescribing of medication. 

5 Many people find it difficult to take their 

medications 6 and the number of medicines may 

seem overwhelming. Multiple medications and 

complexity of treatment regimens are major determinants 

of poor medication adherence 7–10 which 

threatens health outcomes. 11 O’Brien et al. 12 found 

that when patients were prescribed a single medication, 

it was taken 85% of the time. When five or 

more medications were prescribed, this reduced to 

65%, highlighting that an increase in the number 

of prescribed medications reduces the likelihood 

of adherence. Reducing the pill burden by 

reducing the number of medicines taken has been 

shown to improve medication adherence. 13–16 




Strategies for simplifying complex medication 

regimens to reduce the patient’s pill burden 10 include 

decreasing the frequency of dosing intervals 

and using fixed-dose combination medications. 17 

Historically, fixed-dose combinations were not 

widely accepted due to dosing inflexibility, 18 but 

there are an increasing number of fixed-dose blood 

pressure–lowering medicine combinations available, 

such as a thiazide plus an ACE inhibitor. 

Fixed-dose combination medications are a combination 

of two active ingredients combined into a 

single tablet to reduce the complexity of the drug 

treatment. 10 Fixed-dose combination medications, 

as opposed to multiple individual drug component 

regimens, have been shown to improve 

adherence by 19% after 12 months in people with 

high blood pressure. 10 Using once-daily dosing 

as opposed to multiple-dosing strategies may 

improve patient adherence by up to 42%. 10,19 

A controversial 2002 paper suggested that over 

80% of cardiovascular disease could be prevented 

if patients over 55 years old took a polypill that 

contained cardiovascular preventative medications. 

20 It was argued this would increase convenience 

and reduce pill burden. This would be 

expected to lead to improved adherence, although 

it is uncertain whether this would be more for 

unintentional non-adherence (forgetting to take, 

running out of medicines, misunderstanding of 

which tablets to take) or intentional non-adherence 

(overwhelmed by the number of tablets and 

so selectively being non-adherent). It could be an 

integral part of the solution to the pharmacological 

management of IHD. 4 

Currently, two different polypill formulations 

combining four different medications are being 

trialled in NZ: simvastatin 20 mg or 40 mg, 

aspirin 75 mg, lisinopril 10 mg and either hydrochloro 

thiazide 12.5 mg or atenolol 50mg. 4 

The aim of this research was to explore patient 

perceptions of the polypill, focusing on people 

already taking multiple cardiovascular medicines. 

Methods 

Pharmacies within the Auckland region were 

selected randomly using a computer-generated 


What we already know: Adherence to medication regimens is less than 

satisfactory and this impinges on optimal medication-related health outcomes. 

People with cardiovascular disease have multiple medicines, and 

multiple medicines are recognised as reducing medication adherence. The 

concept of a polypill, with one capsule containing four cardiovascular medicines, 

has been promoted as a method to improve compliance. 

What this study adds: People on cardiovascular medicines think that a 

polypill would be convenient and likely to improve adherence, with possible 

cost reductions. They are concerned about the lack of flexibility of the combination 

formulation, and issues around safety and efficacy. 

system. The pharmacy manager was invited 

to assist with the study. A researcher attended 

each pharmacy for one day, with the pharmacist 

identifying potential participants and inviting 

them to participate in the interview. If the participant 

agreed to be interviewed, the pharmacist 

referred him/her to the researcher, who obtained 

informed consent. 

Inclusion criteria were that the person was on 

three or more cardiovascular medicines and 

could communicate in English. Participants were 

recruited until thematic saturation was reached. 

A semi-structured interview was conducted in 

a private consultation room at the pharmacy 

(See appendix in the web version of this paper). 

Interviews were audiotaped and transcribed 

into the qualitative data software NVivo (QSR 

International Pty Ltd, Doncaster, Australia). 

Student researchers collectively explored trends 

and identified common themes. 

Ethics approval was granted by the University of 

Auckland Human Participants Ethics Committee 

on 10 June 2010 (Reference 2010/178). 

Results 

Forty-nine semi-structured interviews were 

undertaken from seven pharmacies (see Table 1 

for details of participant demographics). Slightly 

more female participants (53%) were interviewed, 

with the majority of participants aged 61–80 

years. Most participants were taking between 

four and nine medicines daily. Approximately 




Table 1. Participant demographics 

Characteristics n (%) 

Gender 

Male 23 (47) 

Female 26 (53) 

Age group (years) 

41–50 4 (8) 

51–60 8 (16) 

61–70 16 (33) 

71–80 16 (33) 

>80 5 (10) 

Ethnicity 

New Zealand European 30 (61) 

Maori 3 (6) 

Asian 6 (12) 

Other 10 (21) 

Table 2. Participant medication-related factors 

Medication-related issues n (%) 

Blister packing use 

Yes 17 (35) 

No 32 (65) 

Number of medications 

9 4 (8) 

Duration of taking cardiovascular medications 

0–5 years 18 (37) 

6–10 years 17 (35) 

>10 years 14 (28) 

Participant views on which medications were most important 

All medications are equally important 25 (51) 

Cardiac medications 19 (39) 

Diabetic medications 5 (10) 

Perceived importance of medication adherence 

Very important 33 (67) 

Important 12 (25) 

Neutral 3 (6) 

Not important 0 (0) 

I don’t know 1 (2) 

Knowledge of what their medications were for 

Yes 20 (41) 

No 4 (8) 

Some knowledge 25 (51) 

90% were taking more than four medications 

each day. The majority did not use any form of 

adherence packaging, such as pharmacy-prepared 

blister packs or self-prepared pill boxes (Table 2). 

About half the participants believed that all their 

medications were equally important. Others regarded 

either their cardiac or diabetic medications 

to be the most important. Most had some knowledge 

of their medications such as why they were 

taking them and how they worked, although four 

were unaware of the reasons for taking them. 

Nevertheless, they claimed to adhere to their 

doctor’s instructions. 

Reasons for non-adherence 

Forgetting to take medications on an occasional 

basis was reported to be an issue by 32 of the 49 

participants. 

I forget to take my medicines quite often, especially 

the lunchtime ones. I get far too busy and forget. (B11) 

Being out of routine was the other most common 

reason for missed medication doses. Many 

expressed the importance of having a routine to 

assist in adhering to complicated dosing schedules. 

It was common that participants missed 

their doses as a result of missing meals. Changes 

in sleeping patterns or shift work also had an effect 

on adherence. When participants were away 

from home, the likelihood of missing doses was 

increased. 

The other day we had to go out… we planned to 

come home at 12 o’clock, but we actually came 

home at four in the afternoon, so I missed my 

tablets. If I knew I was going to go out for so long, 

I would take my tablets with me. This only really 

happens once every four months or so. The other 

time I had to take my daughter to the hospital, so 

I had a period where I didn’t have my tablets. If I 

was to go out for dinner, I would take my tablets 

with me. (J6) 

Five participants made a conscious choice to deliberately 

miss doses, considering them unnecessary. 

Other reasons given for not taking medicines 

included lack of organisation, such as not picking 

up repeat prescriptions on time and forgetting 




which medications had not been taken due to 

complex regimens. Participants also mentioned 

that they would avoid taking their medications if 

they knew alcohol was to be consumed, so as to 

prevent any potential interactions. 

Seven participants stated they had never missed 

a dose and that taking medications regularly had 

become part of their routine. The fear of the consequences 

that may occur if doses were missed 

was one of the main reasons for this. 

I have never missed a dose. I’m too scared to in case 

my heart stops. This is what I’ve been told. You get 

so used to taking them. It was initially a big deal. It 

isn’t anymore. (A3) 

Perceptions of the polypill concept 

The polypill concept was conveyed to participants 

as a tablet that combined all their cardiac 

medications. Benefits and concerns were raised by 

participants, and the main themes identified were 

convenience, efficacy, inflexibility, safety, pill 

burden, and cost (Table 3). 

Convenience 

Convenience was the most popular benefit to 

emerge from the interviews; 35 participants 

believed that taking their medication would be 

made easier with the polypill, particularly those 

with complex regimens. Participants envisaged 

that the polypill would save them time and, 

when travelling, save them space. 

Simplified regimens 

Multiple medications with doses at varying times 

throughout the day were described as ‘difficult’ 

and ‘inconvenient’. Therefore, the idea of a single 

tablet taken once a day was appealing to ease 

the burden associated with complex medication 

regimens. 

The thing is people today have got attention spans 

like a lightning flash, so anything that saves people 

taking that many medicines has got to be a good 

thing. It would make it a lot easier; you won’t need 

to take so many pills. One would be much easier 

than four or five. (J8) 

Travelling 

Participants who travelled frequently or those 

who were not at home often found taking multiple 

medications a burden. This appeared to hinder 

adherence. Travelling for prolonged periods created 

further problems. 

[The polypill] would be ideal for someone like myself, 

who travels regularly and takes regular medication. 

I end up taking, literally, plastic bags filled 

with boxes and boxes away with me. Imagine when 

I go away for three months on business and have 

five lots of medicines that I must take on a daily 

basis. That’s 450 tablets to take. It’s a wonder I don’t 

get arrested for drug pushing. It would certainly be 

much simpler if all I had to take was 90 tablets. (A2) 

Time saving 

Of the 17 participants who had their medications 

incorporated into a blister pack or other type of 

container, seven had been organising their medications 

themselves. A common concern was the 

amount of time spent coordinating blister packs 

and pill containers to ensure they were accurate. 

If there was a polypill that fit your doses, then definitely. 

It would save me the trouble of making my 

monthly package in my pill box. Also, occasionally 

one pill will pop out of the pill box and I have great 

trouble finding it. Taking one pill will save me the 

hassle of all of this. (L4) 

Table 3. Themes identified about use of a polypill cardiovascular medication 

Benefits 

Convenience 

Simple regimen 

Ease of use when travelling 

Time-saving 

Concerns 

Efficacy 

Inflexibility 

Published evidence 

That polypill is 

equivalent to current 

medications 

Practitioner 

recommended 

Reputable manufacturer 

Set formulation 

Dose titration 

Safety Reduced confusion Safety Adverse effects 

Compatibility 

Inability to adjust 

dosages 

Pill burden Reduced number of tablets Pill burden Size of tablet 




Efficacy 

The efficacy of the polypill was one of the most 

important issues raised by the participants. There 

were many questions surrounding its efficacy 

compared to their current individual medications. 

These participants wanted assurance that combining 

the four individual medications in the polypill 

was appropriate. Participants mentioned that 

if a study had been conducted with significant 

results displaying the efficacy of the polypill, 

they would feel more comfortable and be more 

likely to accept it. 

Dose differences between their current medications 

and the polypill were a concern raised by 

four participants. 

Will it be effective I think it’s too generic for my 

condition. As my cholesterol is sky high, I need a 

maximum dosage for my simvastatin, whereas my 

other three tablets are on the lowest possible dosage. 

Taking more tablets on top of my statin dose will 

just defeat the purpose of taking the polypill. (L4) 

Participants valued their medical practitioner’s 

recommendations and trusted their advice. If 

their medical practitioner recommended the 

polypill, participants were more willing to accept 

the concept. 

Participants commented on the importance of 

the polypill being developed by a reputable 

manufacturer. In order to be considered, the 

manufacturer must be renowned within the 

pharmaceutical industry for producing medication 

of a high standard. Several participants were 

aware of the strict guidelines associated with 

manufacturing medication and believed wellknown 

pharmaceutical companies were more 

likely to adhere to these. 

Inflexibility of the polypill 

Eleven participants were concerned about having 

their medications included in a single-dose 

form due to the inability to alter doses or remove 

medication from the combination if required. 

The timing of doses was mentioned frequently, 

particularly for simvastatin, which participants 

had been advised to take at night. Four participants 

reported that there had been trial and 

error involved to find a suitable dose for certain 

medications. From this, it appeared that a ‘onesize-fits-all’ 

approach may not be viable. 

Safety 

Safety of the polypill was a major concern for 39 

participants. This included side effects, compatibility, 

stability of the combined medication, and 

dose adjustments. Many were worried about the 

consequences of missing a dose of polypill, as 

they would not be protected by any of the four 

medications. Similarly, some participants raised 

concerns about overdosing if they took additional 

tablets by mistake. Either of these situations was 

perceived as relatively dangerous. 

Conversely, some participants said that there 

were some times when they were confused about 

whether or not they had taken their medications 

and, without an established routine, they could 

forget or miss tablets accidentally. Condensing 

medications into one tablet would not only reduce 

the problems of taking multiple medications, but 

also would remove the need to develop strategies 

to ensure that they were all taken as directed. 

It would be so much easier. Sometimes in the past, 

I got confused about whether or not I have taken 

one specific tablet. I would be too worried to double 

up and experience bad side effects so I would just 

not take it. With one pill only, I would know that 

I would have covered all the medications by just 

swallowing the one pill. (M10) 

Eight participants were worried that they would 

experience additional adverse effects if their current 

medications were combined into a single pill. 

For those who had experienced adverse effects 

from their medication in the past, the concern 

was much greater. Some participants queried the 

formulation of the polypill, and whether it was 

possible to combine all their medication into a 

single tablet. Four participants were unsure of 

the chemical stability when combining all medications 

into a single formulation. 

Pill burden 

Thirteen participants thought the number of tablets 

they took each day was a burden. The complexity 

of their medication regimens also brought 




with it a psychological burden. Two participants 

reported issues of embarrassment and the perception 

of increased illness according to the number of 

medications they took. Although they still adhered 

to their prescribers’ instructions, their sense of 

wellbeing and integrity were adversely affected. 

[The polypill] would be great! It cuts down on my 

medication, so it’s good. Well, sitting in a restaurant 

taking out every pill, I feel I’m a showcase for 

other people. (J3) 

The polypill would address these problems, 

although eight participants were apprehensive 

about the possible size of the polypill, questioning 

whether the formulation was likely to ‘block 

the throat’. However, the majority of participants 

had no trouble swallowing, and often took all 

their tablets in one single gulp. 

[The polypill] is only one tablet. One of the 

problems is I can’t swallow the tablet if it is a little 

bigger. I need to swallow a big glass of water just 

to swallow it. Instead of taking 10 tablets a day, I 

could take 4 or 5 tablets a day. (J6) 

Discussion 

Of the six themes identified, convenience was 

the most important benefit participants associated 

with the polypill. Inflexibility and efficacy were 

the concerns participants would like to see addressed 

before considering the concept appealing. 

Cost and safety were seen as providing benefits 

but also raising some concerns. 

Perceived benefits of the polypill 

The polypill concept was perceived to assist 

participants in taking their medications regularly, 

improving adherence and optimising health 

outcomes. Participants placed an emphasis on the 

benefits associated with the increased convenience, 

making the polypill an appealing alternative 

to their current regimens. Many participants 

expressed concerns about multiple dosing of 

their medications disrupting their daily routine, 

especially frequent travellers who reported 

greater difficulties adhering to their medication. 

The polypill would cause minimal interference 

in daily activities and improve convenience. 

Cost 

Cost influenced the willingness of participants to 

accept the polypill. Two participants mentioned 

that if the polypill was subsidised, it would reduce 

the cost burden associated with their medication, 

as they would only be required to pay a 

single dispensing fee instead of four. Participants 

would be reluctant to consider the polypill if it 

was not subsidised by the government. Although 

they were appreciative of the concept behind the 

polypill, the cost burden related to financing it 

was far greater than the convenience of using it. 

Thirty-three participants on multiple drug 

therapies strongly favoured the polypill concept 

for other medical conditions. Many perceived 

the number of tablets they took each day to be 

a burden which made the idea of a polypill very 

appealing. 

Yes, for my diabetes tablets definitely. I take metformin 

and gliclazide. That is 10 tablets a day just 

for my diabetes. It would be much easier to take 

just one dose rather than multiple doses. (L1) 

Participants valued their medical 

practitioner’s recommendations and trusted 

their advice. If their medical practitioner 

recommended the polypill, participants 

were more willing to accept the concept. 

Independent blister packing of their medications 

was seen as time-consuming and tedious, and so 

the polypill was seen as a time-saving approach. 

Other studies have reported that fixed-dose combinations 

offer advantages of convenience. 7,18 The 

literature correlates well with the findings in this 

research and it appears to be generally accepted 

that the use of a combination pill will improve 

the convenience of taking regular medication, 

leading to greater adherence to regimens and 

improved health outcomes. 

Since the majority of participants were taking 

four or more tablets on a daily basis, a reduction 




in pill burden was appealing. Decreasing the total 

number of daily doses can aid drug adherence. 13–16 

A meta-analysis demonstrated that fixed-dose 

combination regimens reduced the risk of nonadherence 

by 24 to 26% compared to free-drug 

combination regimens. 8 

The cost burden when taking regular medications 

was seen as a further barrier to adherence. The 

majority of participants were paying at least four 

dispensing fees each time they collected their 

prescriptions, and based on the presumption that 

the polypill would be subsidised, participants perceived 

it would reduce the cost of their medication. 

Concerns about the polypill 

The size of the polypill was a concern to participants. 

Tablet-related factors, such as the size and 

shape, negatively influenced patient preference 

and acceptance, which may lead to non-adherence. 

One study found that participants preferred 

smaller, soft-gel capsules as opposed to tablets 

because they were easier to swallow, despite a 

twice-daily dosing. 21 Such findings demonstrate 

an important limitation that has been associated 

with fixed-dose combination medication. This 

may be an issue if the polypill tablet size is not 

considered when being manufactured. 

Research has demonstrated that, from a patient 

perspective, there is a need for an effective, highly 

tolerable and convenient medication regimen that 

would not interfere with their daily lives. 

The majority of participants were concerned with 

possible adverse effects of the polypill and restrictions 

associated with dose titration, particularly 

with blood pressure–lowering medications. It is 

unlikely that combining medications into one 

formulation would increase adverse effects, but 

using lower doses of different medications would 

reduce the incidence. 22 Some participants felt it 

would be safer to continue with their current 

regimen as it provided them with the option of 

adjusting doses to maintain therapeutic benefits. 

Participants emphasised the importance of 

adhering to their medications to manage their 

condition effectively. This meant that they 

were reluctant to accept the concept behind the 

polypill unless it was equally, if not more, effective 

than the individual medications. They were 

aware that valid trials and studies were required 

to demonstrate efficacy for their current medications, 

and therefore required similar evidence 

that the polypill was comparable. Research has 

demonstrated that, from a patient perspective, 

there is a need for an effective, highly tolerable 

and convenient medication regimen that would 

not interfere with their daily lives. 23 

Compatibility and stability issues with combination 

preparations were raised by participants. 

Medical practitioners played an important role 

in influencing participants’ decisions around 

medication. Participants strongly believed in the 

importance of medications being developed by a 

reputable manufacturer. Therefore, provided that 

participants were convinced that the polypill was 

proven to be effective, they would find the concept 

more appealing. A study reported that many 

participants did not find combination therapy 

appealing and would not be keen to change, as 

a fixed combination may not adequately mirror 

their personalised medication regimen. However, 

they also mentioned that they would consider 

switching if their medical practitioner recommended 

it. 24 

Limitations of the study 

This study involved a small, non-randomised 

sample of people attending a community 

pharmacy who were willing to engage with 

the pharmacy student researchers, and so were 

perhaps inclined to answer in a socially desirable 

way. Despite the questions being hypothetical, 

there did appear to be consideration to the 

potential negative aspects of the polypill concept. 

Unfortunately, being a sampling of convenience, 

only three Maori participants and no Pacific 

people were included in the sample. Considering 

the CVD risk is significantly higher in these 

populations, perceptions of these patients would 

be much valued as they are likely to be potential 

users of a polypill. There is a need for further 

research involving Maori and Pacific people, and 




also of the concepts concerning how the number 

of tablets taken by a person may influence illness 

or health behaviours. 

Conclusion 

The majority of participants found the concept 

of the polypill appealing. The benefits of convenience, 

reduced pill burden, improved safety 

associated with reduced confusion about dosing, 

and reduced cost, were all key factors that made 

the polypill favourable. Conversely, participants 

had concerns with the inflexibility and 

efficacy of the polypill. Many enquired about 

dose changes and various formulations of the 

polypill that would be required for those who 

needed dose titration. Other concerns were the 

manufacturer reliability, subsidy issues and tablet 

size. Willingness of participants to switch 

to a combination therapy may be hampered if a 

polypill formulation that mirrored their current 

regimen was unavailable. 

Participants discussed having greater confidence 

in the polypill following medical practitioner 

recommendation. Initiation of the polypill 

immediately on diagnosis of IHD may reduce 

some concerns about dosing. There is a need to 

explore whether the proposed improved adherence 

using a polypill will produce improved 

outcomes that are greater than the individualisation 

of dosages for some medicines, that 

is, whether compliance with one polypill may 

improve adherence and outcomes compared to 

requiring four or five tablets that have dosing 

‘fine tuned’. A further area of research is 

whether the prescribing of all classes of medicine 

recommended for IHD would be improved 

through having one medicine to prescribe 

rather than three or four medicines. 

References 

1. Chan WC, Wright C, Riddell T, Wells S, Kerr A, Gala G, 

et al. Ethnic and socioeconomic disparities in the prevalence 

of cardiovascular disease in New Zealand. NZ Med J. 

2008;121(1285):11–20. 

2. Tobias M, Sexton K, Mann S, Sharpe N. How low can it go 

Projecting ischaemic heart disease mortality in New Zealand to 

2015. NZ Med J. 2006;119:1232. 

3. New Zealand Guidelines Group. New Zealand cardiovascular 

guidelines handbook: a summary resource for primary care 

practitioners. 2nd ed. Wellington: New Zealand Guidelines 

Group; 2009. 

4. Elley C. A polypill is the solution to the pharmacological 

management of cardiovascular risk: yes. J Prim Health Care. 

2009;1(3):232–4. 

5. Sanz G, Fuster V. Fixed-dose combination therapy and 

secondary cardiovascular prevention: rationale, selection of 

drugs and target population. Nature Clin Pract Cardiovasc 

Med. 2008;6(2):101–10. 

6. Elliot R, Ross-Degnan D, Adams A, Safran D, Soumerai S. 

Strategies for coping in a complex world: adherence behaviour 

among adults with chronic illness. J Gen Intern Med. 

2007;22(6):805–10. 

7. Basile J. Critical appraisal of amlodipine and olmesartan medoxomil 

fixed-dose combination in achieving blood pressure 

goals. Integr Blood Press Control. 2010;9:91–104. 

8. Bangalore S, Kamalakkannan G, Parkar S, Messerli F. Fixeddose 

combinations improve medication compliance: a metaanalysis. 

Am J Med. 2007;120(8):713–9. 

9. Vermeire E, Hearnshaw H, Van Royen P, Denekens J. Patient 

adherence to treatment: three decades of research. A comprehensive 

review. J Clin Pharm Ther. 2001;26(5):331–42. 

10. Bangalore S, Shahane A, Parkar S, Messerli F. Compliance and 

fixed-dose combination therapy. Curr Hypertens Reports. 

2007;9(3):184–9. 

11. Volpe M, Chin D, Paneni F. The challenge of polypharmacy 

in cardiovascular medicine. Fundam Clin Pharmacol. 

2010;24(1):9–17. 

12. O’Brien M, Petrie K, Raeburn J. Adherence to medication 

regimens: updating a complex medical issue. Med Care Rev. 

1992;49(4):435. 

13. Kripalani S, Yao X, Haynes R. Interventions to enhance medication 

adherence in chronic medical conditions. Arch Intern 

Med. 2007;167:540–50. 

14. Schedlbauer A, Davies P, Fahey T. Interventions to improve 

adherence to lipid lowering medication. Cochrane Database of 

Systematic Reviews 2010;Issue 3. Art. No.: CD004371. DOI: 

10.1002/14651858.CD004371.pub3. 

15. Schroeder K, Fahey T, Ebrahim S. How can we improve adherence 

to blood pressure lowering medication in ambulatory 

care. Arch Intern Med. 2004;164:722–32. 

16. Conn V, Hafdahl A, Cooper P, Ruppar T, Mehr D, Russell 

C. Interventions to improve medication adherence among 

older adults: meta-analysis of adherence outcomes among 

randomised controlled trials. Gerontologist. 2009;49:447–62. 

17. Claxton A, Cramer J, Pierce C. A systematic review of the 

associations between dose regimens and medication compliance. 

Clin Ther. 2001;23(8):1296–310. 

18. Schmieder R. The role of fixed-dose combination therapy with 

drugs that target the renin-angiotensin system in the hypertension 

paradigm. Clin Exp Hypertens. 2010;32(1):35–42. 

19. Eisen S, Miller D, Woodward R, Spitznagel E, Przybeck T. The 

effect of prescribed daily dose frequency on patient medication 

compliance. Arch Intern Med. 1990;150(9):1881. 

20. Wald N, Law M. A strategy to reduce cardiovascular disease 

by more than 80 percent. BMJ. 2003;326(7404):1419. 

21. Bhosle M, Benner J, DeKoven M, Shelton J. Difficult to swallow: 

patient preference for alternative valproate pharmaceutical 

formulations. Pat Pref Adherence. 2009;3:161–71. 

22. Law M, Wald N, Morris J, Jordan R. Value of low dose combination 

treatment with blood pressure lowering drugs: analysis 

of 354 randomised trails. BMJ. 2003;326(7404):1427. 

23. Mengden T, Uen S, Bramlage P. Management of hypertension 

with fixed-dose combinations of candesartan cilexetil and 

hydrochlorothiazide: patient perspectives and clinical utility. 

Vasc Health Risk Manag. 2009;5:1043–58. 

24. Williams B, Shaw A, Durrant R, Crinson I, Pagliari C, De 

Lusignan S. Patient perspectives on multiple medications 

versus combined pills: a qualitative study. QJM. 

2005;98(12):885–893. 


We wish to thank the 

community pharmacists 

who identified patients 

and allowed students 

to interview them in the 

pharmacy; and also to 

thank the patients who 

took time to discuss the 

polypill concept with the 

student interviewers. 

FUNDING 

This study was undertaken 

as a fourth-year student 

project through the School 

of Pharmacy, University 

of Auckland, and funding 

was met through standard 

student project funds. 






Exploring the opinions and perspectives 

of general practitioners towards the use 

of social networking sites for concussion 

management 

Osman Ahmed PG Dip (Sports Physiotherapy); 1 S John Sullivan PhD; 1 Anthony Schneiders PhD; 1 

Sam Moon MBChB; 2 Paul McCrory PhD 3 

1 

Centre for Physiotherapy 

Research, School of 

Physiotherapy, University 

of Otago, Dunedin, New 

Zealand 

2 

Student Health Services, 

University of Otago, Dunedin 

3 

Florey Neuroscience 

Institutes and the Centre 

for Health, Exercise and 

Sports Medicine, University 

of Melbourne, Melbourne, 

Australia; Australian Centre 

for Research in Sports Injury 

and its Prevention, Monash 

University, Melbourne 

ABSTRACT 

INTRODUCTION: Social networking sites (SNSs) are increasingly being used for health-related purposes. 

Many patients now use sites such as Facebook to discuss symptoms, seek support, and search for 

advice on health conditions, including concussion. Innovative methods of delivering health information 

using these technologies are starting to emerge and it is important to seek the input of key stakeholder 

groups (including general practitioners) to establish their feasibility and to highlight areas of concern. 

AIM: This study aimed to seek the opinions of general practitioners towards the use of SNSs in concussion 

management. 

METHODS: Semi-structured interviews were captured with a digital voice recorder and analysed using 

interpretative description methodology. Participants were general practitioners whose caseload included 

persons with a concussion between the ages of 16 and 30 years, and who had treated a patient with a 

concussion in the past 12 months. 

FINDINGS: The clinical experience of the participants ranged from 3 to 35 years and 50% of the participants 

had a Facebook account themselves. While all participants were positive towards the use of SNSs 

for this purpose, concerns were raised regarding the issues of privacy and moderation. 

CONCLUSION: SNSs, particularly Facebook, have the potential (if correctly utilised) to be a viable adjunct 

to traditional concussion management programmes. In order for SNSs to be successfully used in this 

manner, the quality of information shared needs to be accurate and patients using them need to ensure 

that they get adequate cognitive rest. 

KEYWORDS: Brain concussion; general practitioners; health education; internet; social networking. 


2013;5(1):36–42. 


Osman Ahmed 


Research, University 

of Otago, PO Box 56, 

Dunedin 9054, 


osman.ahmed@otago.ac.nz 

Introduction 

Best practice concussion management centres on 

achieving physical and cognitive rest until symptoms 

resolve, and seeking medical clearance from 

a medical doctor prior to making a return to full 

sporting activity. 1 Although doctors are an integral 

part of the professional sports environment, 

this is not necessarily the case at a community 

level where many individuals playing sport do 

not have immediate access to, or choose not to 

consult, a doctor about their concussion. 2–3 This 

may lead to individuals ignoring or self-managing 

their condition in isolation, without appropriate 

medical advice. A possible consequence of this 

is that individuals may elect to seek advice from 

others (such as friends, peers, or family members) 

or search the internet for concussion information 

and advice, the quality of which has been shown 

to be inconsistent. 4 




Recently, there has been a rapid rise in the use 

of the internet in the domain of health services. 

A report in 2011 by the Pew Research Center 

states that 80% of internet users have looked 

online for health information, and 25% of internet 

users have watched a health-related video 

online. 5 Many patients now also use the internet 

to research their symptoms prior to seeing 

a doctor. 6 Increasingly, social networking sites 

(SNSs) are being used as a portal for patients 

to discuss their symptoms, seek support, and 

search for health care advice. 7 SNSs (including 

Facebook, Twitter and YouTube) are websites 

which connect individuals and allow interactive 

communication in lieu of static information, 8 

and the SNS Facebook has hundreds of healthrelated 

groups serving this purpose. Many of 

these groups are condition-specific, such as 

Facebook support groups for breast cancer, 9 

diabetes, 10 and attention deficit hyperactivity 

disorder (ADHD). 11 

A seminal investigation into the use of concussion-related 

Facebook groups showed that users 

were interacting with each other and sharing stories 

relating to their concussion. This process was 

described as ‘interactive support’ (‘iSupport’) 12 

and can be considered a digital media equivalent 

of traditional peer support groups. This interaction 

was not moderated, however, meaning there 

was no vetting or quality control by medical or 

health care professionals and thus the quality of 

the information exchange was not necessarily reflecting 

best practice. Other SNSs are also being 

used to share concussion information. Twitter has 

been shown to disseminate large amounts of concussion 

information to a global audience, 13 while 

a preliminary evaluation of concussion-related 

video clips on YouTube indicated the power of 

this medium to convey concussion information to 

a wide audience. 14 


What we already know: Social networking sites are widely used by many 

for communicating with their peers. Increasingly, sites such as Facebook are 

being used for health-related purposes. Concussion is often not reported to 

a medical practitioner, leading individuals to seek information and support 

from other sources (including from Facebook). 

What this study adds: General practitioners in this study showed consistently 

positive attitudes to the use of Facebook as an adjunct to traditional 

concussion management, and felt it was an appropriate medium to assist 

individuals recovering from a concussion. Concerns were raised relating to 

individuals using Facebook and not getting adequate cognitive rest after 

concussion, and about the quality of concussion information being shared 

on Facebook. 

The growth in the use of SNSs is having an influence 

on the traditional doctor–patient relationship, 

which has been affected in recent years by 

patients retrieving information online. In a recent 

Dutch study, the majority of doctors reported 

having experience of patients presenting online 

information to them during a consultation. 15 Doctors 

have shown mixed attitudes towards patients 

using such sources. Positive attitudes towards patients 

using online information have been shown 

by primary care physicians, 16 and some physicians 

have also stated that patients using online health 

information does not detract from the doctor–patient 

dynamic. 17 However, certain doctors have 

reported feelings of discomfort when patients 

present online information to them at consultations, 

16 and feel that internet-informed patients 

are a challenge to their medical expertise. 18 

As innovative interventions are developed, 19 it is 

important to canvas the attitudes of key stakeholder 

groups to establish the feasibility of new 

ideas and to highlight areas of concern. At present 

there has been no investigation of the views 

of general practitioners (GPs) relating to the use 

of SNSs in the field of concussion. The aim of 

this study was to explore the opinions of GPs 

towards SNSs, in particular Facebook, being used 

for concussion management. This is a preliminary 

step in the subsequent development of a Facebook 

concussion management intervention. 

Methods 

The study used semi-structured interviews to 

survey the opinions of GPs regarding the use of 

SNSs for concussion management, and analysed 

the findings using interpretative description 

methodology. 20 Ethical approval for the study 

was granted by the University of Otago Human 

Ethics Committee. GPs whose caseload included 

persons with a concussion between the ages of 16 

and 30 years and who had treated a patient with 




Table 1. Participant background information 

Participant ID 

Clinical experience 

(years) 

Number of concussion events 

seen in past 12 months 

Member of a social 

network 

PO1 16 10 to 15 No 

PO2 25 2 Facebook 

PO3 35 6 No 




PO7 25 10 No 

PO8 20 6 No 

concussion in the past 12 months were eligible 

for inclusion in the study. 

GPs were recruited into the study via a purposive 

recruiting strategy. Doctors known to the research 

team identified potential participants (GPs) 

who met the inclusion criteria. These potential 

participants were contacted by phone by the 

principal investigator (PI) to gauge their interest 

in participating in the study. Once the inclusion 

criteria had been verified, interested participants 

were invited to participate and sent a study information 

sheet to be read prior to their attendance 

at the interview. 

Interviews were conducted in Dunedin, New 

Zealand, in April and May 2011 at each GP’s 

practice, with informed consent given prior to 

commencing the interview. Before the interview 

began, participants completed a brief questionnaire 

providing background information about 

their clinical experience, number of concussion 

events treated, and their use of SNSs. Twelve 

pre-prepared questions were clustered into four 

domains to generate a framework for the semistructured 

interviews: 

1. Information: the content of concussion 

information given to patients. 

2. Delivery: the mode of delivery of concussion 

information given to patients. 

3. Concerns and recommendations: potential 

issues in using SNSs for concussion 

management. 

4. General discussion: inviting participants to 

raise any other points not already covered. 

The questions were constructed to cover a range 

of issues within each area of the interview. 

Prompts were prepared for each question in advance 

in order to elicit further information where 

necessary. All interviews were recorded using a 

digital voice recorder, transcribed verbatim by 

the PI, and the series of interviews was continued 

until there was saturation of information, 21 

that is, until no new themes emerged from the 

interviews. 

The principal stage of data analysis was the 

multiple reading of the transcripts by the PI (OA) 

and then a preliminary analysis to provisionally 

attribute themes to the text in each transcript. 

This process involved identifying commonalities 

between each transcript, and then grouping 

similar concepts together in order to identify 

common themes under which quotes/dialogue 

could be classified. Following this stage, annotated 

transcript copies were reviewed by two 

other members of the research team (SS and 

AS), along with unmarked copies of the original 

transcripts to confirm theme allocation. The final 

stage of analysis was the verification of themes 

by an independent GP (SM) not involved in the 

interview component of the study, to ensure that 

the themes identified were representative of those 

that could be expected from this stakeholder 

group. Anonymous supporting quotes were extracted 

from the data to reinforce key themes. 

Findings 

A total of eight GPs with between 3 and 35 years 

of clinical experience were interviewed (Table 1). 




Collectively they had seen a total of 76 concussion 

events in the previous 12 months, and all of 

the GPs regularly saw sporting injuries as part of 

their caseload. Half (n=4) of the GPs interviewed 

had personal Facebook accounts, with all of the 

GPs having a working knowledge of Facebook. 

Seven key themes emerged from the data: 

1. Management of concussion 

2. SNSs 

3. Use of technology for health 

4. Use of Facebook for concussion 

5. Moderation 

6. Privacy, and 

7. Risks and dangers. 

These themes are presented in Table 2, along 

with examples of supporting quotes (verbatim). 

All of the GPs stated that Facebook was an 

appropriate medium to facilitate health care 

management, and that they would support the 

use of Facebook as an adjunct to traditional faceto-face 

concussion management consultations. 

The support for this approach was not unconditional, 

however, and a number of points were 

raised. The privacy of those using Facebook was 

highlighted as an important issue, as reflected 

by the quote: 

I would have concerns about how we would manage… 

privacy and clinical governance issues. (P08) 

In addition, the role of moderation was mentioned 

by several GPs in this study, with one 

stating: 

…as long as… it’s moderated, I think that’s the 

important thing. (P07) 

It was suggested that this moderation needs to 

be frequent, accurate, and from a source that the 

users can trust, and this was demonstrated by the 

following quotes: 

Information needs to be checked so that it’s at a 

good standard before it gets put on Facebook. (P01) 

People can share their ignorance and spread wrong 

information, but this… could be addressed by having 

someone who corrects these responses. (P02) 

Discussion 

The views of the GPs interviewed towards 

concussion management were in keeping with 

the best practice recommendations from the 

international consensus statement on concussion 

in sport. 1 Key issues, such as the importance of 

cognitive rest and seeking re-review if symptoms 

deteriorated, were highlighted by the GPs. Consistently 

positive views towards the use of Facebook 

in concussion management were displayed, 

and all of the GPs stated that they felt Facebook 

was an appropriate medium to use to facilitate 

concussion management. 

GPs and other health care practitioners need 

to consider how their practice might be 

affected and influenced by social media, and 

how best to manage this evolution of care. 

The popularity and widespread use of Facebook 

was stated by the GPs as being a positive 

aspect of using it for concussion management, 

and it was suggested that younger individuals 

would be particularly likely to engage with this 

platform. The interactive component of Facebook 

was highlighted as being especially useful, and 

several of the GPs said that they believed the use 

of social media for health information dissemination 

will grow significantly in the near future; a 

point previously made by others. 22 GPs and other 

health care practitioners need to consider how 

their practice might be affected and influenced by 

social media, and how best to manage this evolution 

of care. 

One of the concerns highlighted in the interviews 

was that patients would not be resting 

cognitively if they were on Facebook for extended 

periods of time. Best practice concussion management 

supports cognitive rest in the early stages 

following a concussion, 1 and thus an intervention 

operated through an SNS could potentially 

impede recovery. However, in the real world 




Table 2. Use of social networking sites in concussion management: emergent themes with examples of quotes from interviews 

Theme 

1. Management of concussion 

2. Social networking sites 

3. Use of technology for 

health (eHealth) 

4. Use of Facebook for 

concussion 

5. Moderation 

6. Privacy 

7. Risks and dangers 

Example of supporting quotes 

‘It’s important to… explain to patients what concussion is, to be respectful of it and when to seek review’ (P01) 

‘Rest is important… often young people don’t want to stop sport’ (P04) 

‘It’s good to have something to give to patients… as their memory may not be good’ (P06) 

‘The concussion information sheets we give to patients are… not necessarily the best format for delivery’ (P03) 

‘Facebook is definitely appropriate to help manage concussion… whereas Twitter wouldn’t get enough 

information across’ (P01) 

‘Facebook is trying to evolve and become more universal… and would seem appropriate for health’ (P01) 

‘Facebook is just another way of using the internet to get information so I wouldn’t have any problems with it’ (P05) 

‘Young people would probably engage with each other on Facebook about their concussions… and they may 

engage with health care professionals too’ (P05) 

‘Patients tend to use the internet and Google for everything’ (P04) 

‘We’ve found text messaging a great help with younger people for appointments’ (P08) 

‘Social networks can play a role in health… I imagine it is going to get massive’ (P07) 

‘I would say 50% of patients have [searched for health information online], particularly if they’ve got something 

that they’ve not immediately got a handle on what it is’ (P08) 

‘I think the interactive side [of using Facebook for concussion management] would be likely to be very helpful’ (P03) 

‘Facebook could be used to reiterate some very core messages [about concussion]’ (P05) 

‘… sometimes issues are better assessed face-to-face with patients. So I just don’t think Facebook is a 

replacement for face-to-face contact with clinicians. Particularly when there’s comorbidities there’ (P08) 

‘Facebook is another way of using the internet to get information [about concussion]’ (P05) 

‘… sometimes [individuals] are a bit… undirected. They’re not quite sure on how to interpret what they are 

looking at [on the internet]’ (P03) 

‘It’s possible that somebody might be falsely reassured [by other Facebook members] when they are actually sort 

of getting worse’ (P07) 

‘… in a moderated group… I dare say it could work quite well’ (P07) 

‘… if the group is not well moderated, then they could get poor information’ (P06) 

‘… people may inadvertently reveal more than they intend to about their medical condition, which they might be 

happy about at the moment but in the future might come back to bite them’ (P06) 

‘… confidentiality is the thing, it seems to be a wide open web…when you talk to people on that, huge numbers of 

people can tap into it. That would be my only concern’ (P03) 

‘People get into strife on the net as it is with putting information on there, and that could potentially be a problem 

for people with jobs I would think down the track’ (P02) 

‘… you need to be careful with privacy settings, and that information that they may think they are keeping private, 

once it is out there on Facebook it is out there forever’ (P05) 

‘… you can’t delete it off when you’ve said something silly… with head injuries insight is not always good, the 

anger expressed isn’t good, and so, because it’s there written, for other people to see’ (P04) 

‘… concentration time is no good if you’ve got a really bad one [concussion]’ (P04) 

‘… you don’t want them [young persons] sitting on the computer for eight hours a day when they are supposed 

to be resting, but they will go look at their Facebook account anyway. Most of them have them open all day or 

several times a day’ (P05) 

‘… people sharing their ignorance and disseminating kind of wrong information and yeah, you’ve got kind of no 

control over that’ (P02) 




it is unrealistic to expect patients to have total 

cognitive rest, 23,24 and provided individuals were 

guided to use an online intervention sensibly, the 

benefits of receiving accurate medical information 

and advice could outweigh any potential risks. 

Another concern raised was that individuals with 

a concussion may be emotionally labile, and may 

type something online which they may later 

regret. 

While the openness of Facebook may attract 

users to engage on the site for social and recreational 

reasons, managing this openness and 

attempting to maintain patient confidentiality 

when discussing sensitive information is an 

important challenge to overcome. GPs and individuals 

with concussion would be more likely to 

commit to this mode of health care if all parties 

could be satisfied with regards to the privacy of 

information that they disclose. In addition, appropriate 

and high quality moderation (the vetting of 

information through this service by a health care 

professional) is essential to assist users to contextualise 

information and to provide appropriate 

responses to inaccurate postings. 25 

The field of social media and health (termed 

‘Medicine 2.0’ 26 ) is in its infancy, but the literature 

base is starting to permeate with possibilities 

for its application. 27,28 Facebook has a relatively 

untapped potential in the field of health, and 

sports medicine organisations are beginning to 

utilise social media as a means by which they 

can communicate best practice information in a 

user-friendly manner to their consumers and the 

general public. 29 The high incidence of sports 

concussion in the younger population, allied with 

the familiarity of ‘Generation Y’ with evolving 

media technologies, suggests that SNSs could be 

an ideal medium through which to facilitate the 

management of a sports concussion at a community-based 

level. 

This is the first exploration of the opinions of 

health care providers towards the use of social 

media in topics relating to the field of sports 

medicine. Although the sample of eight participants 

might be considered small, the recruitment 

was terminated as no new information/opinions 

were emerging (i.e. saturation of information was 

reached). The data should be considered as an accurate 

representation of the opinions of the local 

medical community, and other groups in different 

cities or countries may have different views. 

As in any qualitative study, there is the potential 

for bias in the coding and interpretation of the 

information provided. This study employed a 

multi-stage analysis of the transcripts from the 

interview, using a panel of researchers which 

minimised any potential bias. Further investigation 

into the opinions that GPs and other health 

professionals have towards the application of 

social media to the management of health conditions 

in the domain of sports medicine should be 

conducted, in order to gauge the wider role that 

SNSs such as Facebook could play in the management 

of these conditions. 

References 

1. McCrory P, Meeuwisse W, Johnston K, Dvorak J, Aubry M, 

Molloy M, et al. Consensus statement on concussion in sport: 

the 3rd international conference on concussion in sport held in 

Zurich, November 2008. Br J Sports Med. 2009;43:i76–i84. 

2. McCrea M, Hammeke T, Olsen G, Leo P, Guskiewicz K. Unreported 

concussion in high school football players: implications 

for prevention. Clin J Sport Med. 2004;14(1):13–17. 

3. Williamson IJS, Goodman D. Converging evidence for the 

under-reporting of concussions in youth ice hockey. Br J 

Sports Med. 2006;40(2):128–132. 

4. Ahmed OH, Sullivan SJ, Schneiders AG, McCrory PR. Concussion 

information online: evaluation of information quality, 

content and readability of concussion-related websites. Br J 

Sports Med. 2012; 46(9):675–683. 

5. Pew Internet & American Life Project. The social life of health 

information, 2011: Washington DC, Pew Research Center. 

May 2011. 

6. Gualtieri LN. The doctor as the second opinion and the 

internet as the first. CHI 2009: Proceedings of the 27th international 

conference extended abstracts on human factors in 

computing systems. Boston, USA. April 4–9, 2009. 

7. Farmer AD, Bruckner Holt CEM, Cook MJ, Hearing SD. Social 

networking sites: a novel portal for communication. Postgrad 

Med J. 2009;85(1007):455–9. 

8. Eytan T, Benabio J, Golla V, Parikh R, Stein S. Social media and 

the health system. Perm J. 2011;15:71–4. 

9. Bender JL, Jimenez-Marroquin MC, Jadad AR. Seeking support 

on Facebook: a content analysis of breast cancer groups. 

J Med Internet Res. 2011;13(1), e16. 

10. Greene JA, Choudhry NK, Kilabuk E, Shrank WH. Online 

social networking by patients with diabetes: a qualitative 

evaluation of communication with Facebook. J Gen Intern 

Med. 2011; 26(3), 287–92. 

11. Gajaria A, Yeung E, Goodale T, Charach A. Beliefs about 

attention-deficit/hyperactivity disorder and response to 

stereotypes: youth postings in Facebook groups. J Adolescent 

Health. 2011;49(1):15–20. 

12. Ahmed OH, Sullivan SJ, Schneiders AG, McCrory, P. iSupport: 

do social networking sites have a role to play in concussion 

awareness Disabil Rehabil. 2010;32(22):1877–83. 

13. Sullivan SJ, Schneiders AG, Cheang CW, Kitto E, Lee H, 

Redhead J, et al. What’s happening A content analysis of 




concussion-related traffic on Twitter. Br J Sports Med. 2012; 

46(4):258–63. 

14. Williams D, Sullivan SJ, Schneiders AG, Ahmed OH, Lee H, 

Balasundaram AP, et al. Big hits on the small screen: an evaluation 

of concussion-related videos on YouTube. (Personal 

communication). 

15. van Uden-Kraan CF, Drossaert CH, Taal E, Smit WM, 

Seydel ER, van de Laar MA. Experiences and attitudes 

of Dutch rheumatologists and oncologists with regard to 

their patients’ health-related internet use. Clin Rheumatol. 

2010;29(11):1229–36. 

16. Giveon S, Yaphe J, Hekselman I, Mahamid S, Hermoni D. 

The e-patient: a survey of Israeli primary care physicians’ 

responses to patients’ use of online information during the 

consultation. Isr Med Assoc J. 2009;11(9):537–41. 

17. Kim J, Kim S. Physicians’ perception of the effects of internet 

health information on the doctor–patient relationship. Inform 

Health Soc Care. 2009;34(3):136–48. 

18. Broom A. Virtually healthy: the impact of internet use on 

disease experience and the doctor–patient relationship. Qual 

Health Res. 2005;15(3):325–45. 

19. Hoppe KM. Rehabilitation confronts technology: knowing 

how to manage innovations and expectations. PM R. 

2011;3(8):683–85. 

20. Thorne S, Kirkham SR, O’Flynn-Magee K. The analytic 

challenge in interpretive description. Int J Qual Meth. 

2004;3(1):1–11. 

21. Morse JM. The significance of saturation. Qual Health Res. 

1995;5:147–149. 

22. Chou WS, Hunt YM, Beckjord EB, Moser RP, Hesse BW. Social 

media use in the United States: implications for health communication. 

J Med Internet Res. 2009;11(4):e48. 

23. McLeod TCV, Gioia GA. Cognitive rest: the often neglected 

aspect of concussion management. Athl Ther Today. 

2010;15(2):1–3. 

24. Sullivan SJ, Alla S, Lee H, Schneiders AG, Ahmed OH, McCrory, 

PR. The understanding of the concept of ‘rest’ in the management 

of a sports concussion by physical therapy students: 

a descriptive study. Phys Ther Sport. 2012;13(4):209–213. 

25. Lindsay S, Smith S, Bellaby P, Baker R. The health impact 

of an online heart disease support group: a comparison of 

moderated versus unmoderated support. Health Educ Res. 

2009;24(4):646–54. 

26. Eysenbach G. Medicine 2.0: social networking, collaboration, 

participation, apomediation, and openness. J Med Internet 

Res. 2008;10(3):e22. 

27. Chu LF, Young C, Zamora A, Kurup V, Macario A. Anesthesia 

2.0: Internet-based information resources and web 2.0 applications 

in anesthesia education. Curr Opin Anaesthesiol. 

2010;23(2):218–27. 

28. Scanfeld D, Scanfeld V, Larson EL. Dissemination of health 

information through social networks: Twitter and antibiotics. 

Am J Infect Control. 2010;38(3):182–8. 

29. Khan KM. The only constant is change: UKSEM, ISEM, Twitter, 

Podcasts and YouTube reflect the dynamic nature of sport 

and exercise medicine. Br J Sports Med. 2010;44(13):911. 






Management of skin infections in Pacific 

children prior to hospitalisation 

Elaine Ete-Rasch RGON, MA (Appl); 1 Katherine Nelson RGON, PhD 2 

ABSTRACT 

INTRODUCTION: Hospital admissions for childhood skin infections in New Zealand (NZ) are on the 

increase. Pacific children make up a high number of those who are admitted. This study describes the 

parents of Pacific children’s understanding and management of skin sores in the home prior to the sores 

becoming infected and requiring hospital admission. 

1 

Regional Public Health, Hutt 

Valley District Health Board, 

Lower Hutt, New Zealand 

2 

Graduate School of 

Nursing, Midwifery and 

Health, Victoria University, 

Wellington, New Zealand 

METHODS: A descriptive qualitative approach combined with the Pacific research frameworks of 

Fa’afaletui and the Metaphor of Kakala were used to elicit parents’ understanding and management of 

children’s skin sores in the home. The semi-structured interviews were conducted in English or Samoan, 

and all transcribed into English. 

FINDINGS: Mothers of 11 Pacific children admitted with skin infections between 2006 and 2008 were 

interviewed. The children’s infections started with insect bites in some cases. Parents actively sought 

treatment to ensure children’s optimal health was maintained. Initial management included a ‘watch and 

see’ approach for some, until deterioration was noted. 

CONCLUSION: This is the first known study in New Zealand that has captured children’s experiences 

when sustaining a skin infection/s and the activities that took place while seeking treatment in the community. 

Although most of the children received medical attention in primary health care (PHC), this 

did not prevent the need for hospital admission. The acuteness and seriousness of children’s health on 

admission shows that preventive efforts need to increase and the early management of infections in PHC 

settings needs to be better understood. 

KEYWORDS: Children; Pacific health, primary health care; skin infections 

Introduction 

Skin sores are often viewed as a benign skin problem 

that require basic hygiene care or heal naturally 

without medical interventions. This general 

assumption may be true in many cases. However, 

statistics on New Zealand (NZ) children reveal 

skin infections are a serious health problem. 1 

Children spend days in hospitals for secondary 

interventions, including extensive surgery. 2–4 

Skin infection is a broad term given to various 

infections of the skin caused by the presence and 

colonisation of microorganisms. Staphylococcus 

aureus and Streptococcus pyogenes are the predominant 

causative organisms. 5–6 Cellulitis, impetigo, 

furuncles and carbuncles (simply known as 

abscesses or boils) are the most common infections 

that result in children’s hospitalisation. 6 It 

is a worldwide problem; however, NZ children 

are significantly affected compared to other 

developed countries, such as Australia and the 

United States of America. 1–2 Over a decade ago, 

cellulitis was ranked the third commonest reason 

for children’s hospitalisation in the Auckland 

region. 7 The review of skin infections for Wellington 

shows the admission rate for children 

aged 0–14 years increased significantly between 

the years 2002/03–2008/09, with Pacific and 


2013;5(1):43–51. 


Elaine Ete-Rasch 

Public Health Nurse, 

Regional Public Health, 

Hutt Valley DHB, PB 31907 

Lower Hutt 5040, 


ete_rasch@xtra.co.nz 




Maori children making up a high proportion of 

those admitted. 1,8 

Despite the lack of published literature, the available 

information has consistently reported the 

disproportionate representation of Pacific children 

with serious skin infections. 1,2,7,8 They were the 

leading cause of acute hospital admissions in children 

for the years 2002–2006. 9 Statistics on skin 

health contributes to the recognised poor health 

status of Pacific children. 10–12 Pacific children 

were more likely than other children to acquire 

staphylococcal bacteraemia. 4,13 Four children, of 

whom three were Pacific were reported to have 

died of this cause in the NZ study reported 

by Hill and colleagues. 4 Deaths have also been 

reported in a further study, but ethnicities were 

not specified. 13 

While the high number of hospital admissions 

with skin infections in children is a concern, 

the information available on why this is so is 

scattered and not well understood. Preventative 

measures primarily focus on hygiene and household 

crowding as the key factors known to play a 

major role in the spread of infectious diseases. 14–15 

Parents’ roles in managing the children’s sores at 

home are also crucial, but are poorly understood 

and have not been researched. 

This research was designed to explore the knowledge 

and understanding of parents of Pacific children 

in relation to managing skin sores in their 

child in the home prior to the wound becoming 

infected and requiring hospital admission. Recognition 

of the early signs and symptoms of infection 

and access to health care in the community 

were also explored. 

Methods 

A descriptive qualitative approach 16–17 combined 

with the emerging Pacific research frameworks 

of Fa’afaletui 18 and the Metaphor of Kakala 19 

were used. This study takes into account the 

importance of the ‘three different perspectives’ or 

views used in the Fa’afaletui framework to ensure 

‘critical knowledge and understanding’ of the 

research topic is obtained by carefully considering 

the perspectives of three key parties involved. 

These perspectives are of the participants’ (mothers 

of admitted children) accounts, the researcher’s 

view on how the study is conducted and the 

supervisor’s and mentor’s guidance throughout 

the study. 

The Metaphor of Kakala by Konai Helu Thaman 19 

was used to inform the research. The three key elements 

associated in the making of the Kakala are 

toli (gather), tui (weave), and luva (presenting). In 

this study, toli refers to the collection of the data 

through the interviews. Tui refers to the careful 

selection and analysis of the data into themes; and 

this article is one aspect of the luva process, that 

is, presenting and sharing results. Comparative 

analysis was also incorporated to highlight the 

basic differences and similarities amongst the participants’ 

accounts in managing the children’s skin 

sores. The criteria used to ensure rigorous findings 

were the six elements of research ‘goodness’ recommended 

by Arminio and Hultgren. 20 A key to 

this process was using an audit trail and honouring 

the participants’ voices. The study was approved 

by the Central Region Ethics Committee. 

Parents were recruited through the eligibility of 

their children. Inclusion criteria were: a child of 

Pacific ethnicity; aged between 1 and 14 years; 

admitted for either cellulitis, infected boils, or 

infected sores. Children who were admitted 

with infected eczema were excluded. Recruitment 

involved using flyers in children’s wards, 

Aoga Amata (Samoan preschools), and primary 

health care (PHC) services and paediatric nurses 

identifying and asking parents if they would be 

interested in the research. Parents were provided 

a written information sheet to make an informed 

choice whether to participate. 

The mothers of the 11 children who were admitted 

and discharged up to 18 months earlier agreed 

to be interviewed. A face-to-face semi-structured 

interview, with a mix of closed and open questions, 

was used to elicit parents’ knowledge and 

experiences. The interview was divided into nine 

sections. These included the participant’s relationship 

to the hospitalised child; the sequence of 

events leading to hospital admission; why the 

child was admitted and the home remedies initially 

utilised; the family contacts with PHC services 

about the skin issue prior to admission; the first 

aid facilities the participants had in their homes; 




the participants’ understanding of skin injury 

and infection hygiene practices; family practices 

regarding hand washing; participants’ training 

in first aid; and demographic information. Ten 

audiotaped interviews, ranging from 45 to 90 

minutes in length, took place in the participants’ 

homes, and one at a workplace. Seven interviews 

were fully conducted in English, three in Samoan, 

and one in English with some Tongan. The 

principal investigator spoke English and Samoan. 

All interviews were transcribed into English. 

Findings 

Eleven Pacific children aged between three 

months and 15 years old who were admitted 

with skin infections between January 2006 and 

January 2008 took part in this study through 

their mothers sharing their experiences. All 11 

mothers lived in NZ; six were born and raised 

in NZ and five were born in the Pacific Islands. 

Seven spoke English as their first language while 

four had English as their second language. Three 

mothers were employed full-time, six worked 

part-time and two mothers were not in paid 

employment. Table 1 summarises participants’ 

demographic information. Fathers played active 

roles in caring for the children’s sores despite the 

absence of their voice in the study. 

Overall, parents were not concerned about the 

general wellbeing of the children before admission. 

One child had Type 1 diabetes. Six children 

were reported to have other family members with 

skin infections. Some relatives lived in the same 

household, while others lived elsewhere but had 

regular contact with the children. All children 

were registered with a general practitioner (GP). 

The accounts summarising the pre-hospitalisation 

events are outlined in Figure 1. Nine children 

were seen by GPs for skin problems prior to 

admission. Of these nine, four saw the GP once 

and five saw the GP two or more times. Three 

children were referred to the Accident and Emergency 

(A&E) by the GP and six were referred by 

the parents as the child’s condition deteriorated. 

The two children who did not visit their GP 

were admitted when they presented to the A&E 

department. Home interventions and admitting 

diagnosis are summarised in Table 2. Mothers’ 


What we already know: New Zealand has a high number of hospital 

admissions for skin infections in children. Pacific children make up a high 

number of these admissions. 

What this study adds: Parents were committed to ensuring children 

accessed medical care in primary health services but this did not prevent 

them from being hospitalised. The acuteness and seriousness of children’s 

health on admission shows preventive efforts need to increase and the early 

management of infections in primary health care settings needs to be better 

understood. 

Table 1. Demographic information for mothers and children involved in the study. 

descriptions of the events leading to hospital 

admission are presented in themes that emerged 

from the data analysis. 

Parents in action 

Mother 

Parents took actions in an effort to maintain the 

wellbeing of their children, despite their uncertainty 

on how the changes on the child’s skin 

occurred. Parents’ actions in managing the sores 

were guided by their understanding and beliefs on 

what they thought would work best. 

Recognising and monitoring 

the signs and symptoms 

Parents were first alerted to the children’s illnesses 

by the unusual changes or appearances of 

the skin, which they simply referred to as a rash, 

red spot or pimple. The phrase ‘I thought it was 

Child 

Age Ethnicity Place of birth Age group Sex 

1 25 Cook Island/Maori New Zealand Infant Male 

2 41 Tongan Tonga Teenager Male 

3 30 European New Zealand Preschool Female 

4 39 Samoan Samoa Teenage Female 

5 29 Tokelauan New Zealand Infant Male 

6 34 Samoan Samoa Infant Female 

7 28 Samoan New Zealand Toddler Male 

8 39 Samoan Samoa Toddler Female 

9 31 Cook Island New Zealand Toddler Male 

10 31 European New Zealand Preschool Female 

11 40 Samoan Samoa Infant Male 




Figure 1. Events prior to admission for each child. 

Child #1—Admitted with orbital cellulitis. 

The mother thought it was a ‘pimple’ until a Kohanga Reo teacher pointed out to the mother her child had chickenpox. The rash started with one ‘spot’ 

on his back which later spread to the rest of his body. The spot on the right eye got infected which initiated the admission. 

Child #2—Admitted with infected insect bites. 

The child sustained the insect bites while on holiday in the islands. The child received treatments while in the islands and was doing well. The child 

was subsequently admitted three weeks after returning to New Zealand. 

Child #3—Admitted with cellulitis of the calf. 

The mother thought this had started from an insect bite. The mother thinks her daughter is allergic to insects, as the child had had previous hospital 

admissions for similar skin problems. Other admissions were from different causes. 

Child #4—Admitted with an infected toe. 

The wound was healing and responding well to the home remedies until a friend accidently stood on the injured toe, which then became inflamed and 

infected. The child had recently been diagnosed with Type 1 diabetes—had had previous hospital admissions. During the course of the infected toe, 

the child’s diabetes ‘got out of control’ which led to an urgent visit to Accident and Emergency (A&E). 

Child #5—Admitted with ‘small spots or blisters’ in the nappy area; Staphylococcus aureus was found to be present. 

Grandmother who cares for the baby during the day was concerned about the nappy rash. The mother didn’t take much notice until a nappy change in 

the evening and found that the rash was spreading and turning into ‘big blisters’. The child was urgently taken to the A&E and was admitted. 

Child #6—Admitted with cellulitis of the periorbital area. 

The mother said she first noticed a little pus in the child’s eye and did not take much notice until the eye swelled up. Medical help was sought when 

the mother saw immediate danger to the child’s health. The mother could not explain how it got to this stage. 

Child #7—Admitted with cellulitis of the lower extremity; Streptococcus pyogenes was present. 

The child attended preschool and the mother thought the child got flea bites from playing in the sandpit. The mother sought medical treatment for the 

skin sores. One bite was noticeably becoming worse overnight which resulted in admission. 

Child #8—Admitted with an abscess in the left groin; Staphylococcus aureus was present. 

The mother first noticed a red spot in the groin area. The mother applied thumb pressure hoping it would stop the boil from growing but the child 

ended up in the hospital having minor surgery. The child was seen by a medical doctor and a traditional healer in the community. 

Child #9—Admitted with bullous impetigo. 

This started with what looked like flea bites. The sores got worse over a couple of days and affected the child’s whole body. The child had a history of 

‘bad reactions’ to insect bites in the past. This time it ‘got out of control’ and led to admission to the hospital. 

Child #10—Admitted with a boil in the perineal area. 

The child alerted her mother to a ‘pimple’ in her groin. The mother knew it was a boil and immediately sought help from a friend at a chemist. A 

dressing was applied to draw out the pus but was unsuccessful. The boil grew bigger overnight and the child ended up in hospital for minor surgery. 

Child #11—Admitted with orbital cellulitis. 

The child’s eye became red and swollen from an unknown cause. The mother applied drops of breast milk but the swelling got worse over the 

weekend. The child was seen by the GP and was urgently referred to hospital. 

just a pimple’ was often referred to by the mothers 

to describe their initial response to the skin 

changes. As Mother #5 puts it: 

It started with two pimples … it’s like small pimples, 

so I thought they were just heat rash. 

While some mothers were unable to provide precise 

information on what caused the ‘rash’ or the 

‘spot’ on the child’s skin, four mothers referred 

to insect bites as the cause. 

[He] came up with what looked like flea bites… in 

the morning he showed us he’d been bitten all up 

his left arm and they were quite red, they looked 

like angry rashes… One in particular at the back of 

his right leg started to bubble, he [also] had bites on 

his left foot. (Mother #9) 




One mother mentioned the probable link between 

her child’s sores and other family members 

while the rest did not. The other relatives with 

the infected sores were not sick enough to be 

admitted. 

I thought she got it from my dad because my dad 

got an eye infection just before she did. He was admitted 

to the hospital because it was getting worse. 

(Mother #6) 

Parents’ initial responses to the 

signs and symptoms 

Parents’ initial responses to the children’s signs and 

symptoms took a variety of forms, such as cleaning 

and tidying up bedding, soaking the wound in 

salty water, or home baths using anti septic solutions. 

The three mothers who kept first aid kits in 

the house did not mention the use of this resource 

when treating the children. Some sought both 

conventional and traditional medicine. 

I try to treat it at home… well sometimes I gave her 

that, kind of Pinetarsol in the bath, I put her in the 

bath or bathed by my mother-in-law… they give her 

the Samoan oil and Savlon. (Mother #3) 

When one method did not work, others were tried. 

I gave him the leaf called Bora Bora… but then it 

did not settle. When it did not settle that day we 

took him to the chemist. (Mother #2) 

Mothers’ actions were also targeted at preventing 

other children from becoming infected. 

Table 2. Admitting diagnosis and care children received before admission 

Child 

1 

Admitting 

diagnosis* 

Cellulitis: orbital 

(chickenpox) 

GP visits and 

hospital referral 

Referred on 2nd visit 

Who referred 

to hospital 

Health centre 

2 Insects bites Seen and sent home Parents 

3 Cellulitis: calf Seen and sent home Parents 

4 

5 

6 

7 

8 

Cellulitis: toe 

(Diabetes Type 1) 

Infected nappy 

region 

S. aureus 

Cellulitis: 

periorbital 

Cellulitis:leg 

S. pyogenes 

Groin abscess 

S. aureus 

Seen and sent home 

Parents 

Home interventions 

Bath with Pinetarsol; 

calamine lotion applied 

Herbal leaves, sea bath and 

cream (while in the Islands) 

Bath with solutions (unsure 

of name) 

Wound cleaned with salty 

water (homemade solution) 

and covered 

First aid kit 

No Parents Vaseline No 

No 

Parents 

Applied mild pressure with 

thumb to the affected eye 

Seen and sent home Parents Ointment and bath No 


Parents 

9 Bullous impetigo Referred on 1st visit Health centre 

10 

Boil: perineal 

area 


Parents 

11 Cellulitis: orbital Referred on 1st visit Health Centre 

* Diagnosis for each child was included with the information given to the researcher. 

Ointment and Pamol; 

traditional herbs 

Bath cleaning; mother 

attempted to clean and 

burst blister 

Dressing material from 

chemist 

Drop of breast milk; eye 

cleansed with warm flannel; 

mild pressure applied on 

affected eye 

No 

No 

No 

No 

No 

Yes 

Yes 

Yes 

No 




We stripped the bed, cleaned all his linen, around 

the bedroom and the clothes that he’d been wearing. 

We also did the same for his baby brother 

because… they share the room together. (Mother #9) 

The search for healing and cure 

The search for healing and cure was sought 

between medical doctors and traditional healers 

simultaneously for some children. Help was 

sought when the changes on some children’s skin 

were first recognised, while others took the ‘wait 

and see’ approach and sought help later when the 

signs and symptoms appeared to be worsening. 

NZ-born parents used conventional medicine 

only, while Pacific Island–born parents utilised 

both traditional and conventional medicine. 

Mother #8 (Pacific Island–born) went between 

the traditional practitioner and the GP, as the 

medicine prescribed did not work and she feared 

her child would be operated on if she took her to 

the hospital. 

The redness was more noticeable on the second day. 

It [boil] was getting bigger as if it was spreading. I 

took her to the family doctor but only Pamol and a 

cream were given to help take the pain away. I have 

applied them for two days but no change, so I took 

her to the fofo Samoa… to see if there was something 

to draw the pus out, in case we take her in [to 

the hospital] and that will make her very sick, [and 

doctors] incise the boil and make her very sick... 

The Samoan fofo [gave her] ... Samoan medicine. 

It was a leaf of a plant... we just covered the boil 

overnight with it, that helped draw the pus out, but 

[child] didn’t take herbs orally. (Mother #8) 

Children’s health deteriorated rapidly 

Parents were caught by surprise with the sudden 

acute changes in the children’s conditions. The 

uncharacteristic behaviour and the worsening 

changes such as fever, pain, persistent crying and 

the increasing size of the ‘pimple’ or the ‘spot’ 

alerted and heightened parents’ concern that the 

child was experiencing something more serious 

than just a pimple or rash. 

Oh he was really [sick], really, he’s got a fever. And 

his body was all red and he [was] really hot, he can’t 

even lie down, he wasn’t comfortable so we [had to] 

rush him to the hospital. (Mother #2) 

It happened very fast. It was a big bubble on his 

leg, it was all red, he was crying, he had a fever so 

we took him straight to A&E and they admitted 

him, they said that oral antibiotics is not going to 

work so he has to get a drip. He started vomiting as 

well… we could tell he was dehydrating, [he was] 

really unwell. (Mother #7) 

After home interventions were to no avail, parents 

decided to seek medical help. However, some 

parents encountered problems arranging appointments. 

One family was told there was no appointment 

available due to a shortage of doctors. The 

father persisted and took his son to the health 

centre. The child was urgently referred to the 

hospital after a quick assessment by the doctor. 

Health information for parents 

Access to information on skin infections was the 

least discussed topic of the interviews. When 

mothers were asked about the topic, ‘No’ was the 

direct response. Despite the number of contacts 

with health professionals in the PHC settings, 

mothers had very little recollection of health 

information on skin infection being offered to 

them. Similarly, most mothers had the same 

recall of their experiences in the hospital setting. 

Only two recalled education being provided on 

hygiene and handwashing. Of these, one mother 

said she did not understand the information presented 

to her as English was her second language. 

Mothers generally spoke of health professionals 

being more interested in finding out what happened 

than in providing them with the information 

they needed at the time. 

Besides hygiene care, Mother #4 recalled previous 

conversations with health professionals who emphasised 

the importance of seeking medical help 

early for her daughter with diabetes. 

About two days [after sustaining the injury] when 

she felt the pain, she said it’s better to go to the 

hospital, because the nurses/doctors [referring to 

the GP service] told us any problem with the skin, 

even if it’s just a minor scratch, we should bring 

her to the hospital. 




All mothers wanted more information about skin 

infections. Some of their suggestions were that 

parents should be given information on what skin 

infections are, the causes, and how to treat them 

before they get infected. Mother #4 questioned 

the effectiveness of giving mothers pamphlets 

without one-to-one practical directions. 

I don’t know anything about skin infections. But 

I thought about it at the time while I was treating 

him. I thought, this is how I treated him in [the 

island] it will make it a bit better but in the future 

time I’d rather learn more about skin infection. 

(Mother #4) 

Mothers found the ordeal unpleasant and frightening. 

In retrospect, two shared how they now 

looked for infections more often and were more 

conscious of regularly checking their children’s 

skin. One remarkable finding in this study was 

the absence of preventive information on skin 

health in the Well Child Tamariki Ora booklet. 

This absence is an indication of skin health 

being a low priority compared to other health 

issues in children. 

Discussion 

This is the first known study that has captured 

mothers’ accounts of managing children’s skin 

sores in the home. Parents were forthcoming with 

information that revealed their active participation 

during the course of the children’s illness. 

Mothers’ accounts revealed their commitment 

and efforts to ensure children’s optimal health 

were maintained. Their willingness and determination 

to protect their children from harm 

are notable findings. However, despite their best 

effort, children ended up in the hospital with 

systemic infections requiring aggressive medical 

and surgical interventions. 

The active roles displayed by parents in this 

study are consistent with the findings from 

previous studies. 21–22 The majority of parents were 

highly motivated and remained committed by 

intervening and pursuing treatments once the 

child’s symptoms were recognised. Despite their 

innocuous initial perceptions and uncertainty 

about how the skin changes had occurred, parents 

took actions which they thought were appropriate. 

Monitoring children’s conditions led to 

urgent visits to the hospital. 

Parents’ interpretation and understanding of children’s 

symptoms varied. It has previously been 

acknowledged that symptoms of children’s illnesses 

are often ‘context-bound [and] subjective’ 

in nature. 23 The meanings of serious and minor 

symptoms are open to interpretation and many 

symptoms are only regarded ‘as serious in retrospect 

either by lay people or professionals’. 23 Some 

parents took the ‘wait and see’ approach which is 

consistent with results from previous studies. 24 

However, such actions are considered a ‘laid back’ 

approach by some health professionals. Pacific 

parents’ ‘relaxed attitude towards things’ on the 

basis that things will improve on their own has 

been referred to as ‘unhealthy optimism’. 25 The 

One remarkable finding in this study was the 

absence of preventive information on skin health in 

the Well Child Tamariki Ora booklet. This absence 

is an indication of skin health being a low priority 

compared to other health issues in children. 

majority of parents in this study did not display 

a ‘relaxed attitude’. Help was sought when the 

symptoms first appeared for some, while others 

waited and took action when children’s situations 

deteriorated. Even if children saw a GP, most 

children’s symptoms were not considered serious 

and children were usually initially sent home. A 

recent examination of GP records indicates that 

the majority of children with skin infections are 

successfully managed by PHC. 26 

Most of the children were acutely admitted for 

the purposes of administering intravenous antibiotics 

and/or performing minor surgery. These 

are extremely costly ways of dealing with the 

health issue 2 and can be traumatic for children 

and families. Access to PHC is an opportunity to 

prevent unnecessary hospitalisation. 27 The notion 

that high cellulitis admissions for Pacific children 

is an indication that access to PHC is particularly 

poor for this population group 28 was not con- 




firmed in this study. All children were registered 

with a GP and most received medical attention 

more than once before admission. Children in 

previous studies had similar experiences. 21–22 

An apparent lack of PHC nursing contact with 

parents and children is evident in this study. For 

example, there was no mention of contacts with 

Plunket nurses for children under five years old, 

or mention of contacts with public health nurses 

for school-age children. The absence of nursing 

contacts with children was not explored in depth; 

therefore, this finding needs to be treated with 

caution. However, a question arises from this 

finding as to whether children’s health outcomes 

would be different and hospitalisation avoided if 

PHC nurses were to intervene. 

A variety of education materials on skin 

infections is available in the English language. 

The fact that mothers did not mention these 

resources raises questions about the accessibility, 

utilisation and effectiveness of these materials. 

A variety of education materials on skin infections 

is available in the English language. The 

fact that mothers did not mention these resources 

raises questions about the accessibility, utilisation 

and effectiveness of these materials. The need to 

discuss the information with parents face-to-face 

in a language they understand was highlighted 

in an international study 29 and was confirmed in 

this study. Messages on the spread of infections 

in the household need to be reinforced whenever 

any person—adult or child—has an infection, as 

at least one child in the study had an older relative 

who had a skin infection. Mothers relied on 

their cultural and traditional knowledge to guide 

them through the ordeal. The use of traditional 

medicine is a practice that is popular with Pacific 

people and it is likely that they will continue 

to use them for healing and cure 30 when they 

consider this necessary. Acknowledging existing 

knowledge and cultural beliefs is important, as 

this contributes to the success in the process of 

educating parents 31 and positive health outcomes 

for children. Given that skin infection is a growing 

health problem, we recommend that skin 

health information is included in the Well Child 

Tamariki Ora booklet. This resource is of great 

value to all New Zealand parents and should be 

in different languages. 

Socioeconomic status and hygiene are wellknown 

determining factors for skin health. 

However, this study draws attention to the 

need to explore other factors at the PHC level 

that are likely causes of failure to smooth 

recovery from a simple skin sore. These 

include the effectiveness of treatments in the 

early phase and the appropriateness of health 

resources and education. An exploration may 

involve establishing evidence-based guidelines 

for what are the effective treatments children 

should receive on their first visits to PHC with 

skin infections. A protocol for the management 

of children’s skin sores in the community is in 

progress in Greater Wellington coordinated by 

Regional Public Health. 

PHC nurses should be more vigilant in their assessment 

and follow-up of children who present 

with minor sores. A well-coordinated referral 

system between public health nurses, and PHC 

nurses, including practice nurses, should be in 

place to ensure parents and children are provided 

with the best support they need to ensure 

a child’s uncomplicated recovery. Medication 

adherence was not discussed in detail with the 

mothers in this study due to the likely inaccuracy 

of details regarding this. 

The findings raise issues for further research 

for the prevention and management of skin 

sores in Pacific children. An expanded, comprehensive 

study to verify results in this study 

is recommended. The high use of PHC by the 

small number of study participants prior to 

hospitalisation raises questions about the PHC 

system and its capability to provide effective 

care for Pacific children. Research from multiple 

stakeholder perspectives is needed into the 

events and actions taken by health professionals 

in response to children’s presentations with 

skin sores. Such research should also examine 

the possible causes of why some children with 




skin sores recover with PHC in the community, 

while others subsequently require admission to 

hospital. 

The issue of poor health for Pacific children in 

New Zealand has been documented for some 

time and addressing this is a priority. Hospitalisations 

for infections, including skin infections, are 

increasing. 1 Parents in the study were determined 

and committed, which are very positive and 

encouraging findings. Valuing parents’ roles in 

the early management of children’s illnesses and 

providing them with the necessary support can 

make a difference in children’s health. 

Study limitations 

Mothers and children in this study do not fully 

reflect the broad ethnic diversity of the population 

of Pacific children and their families in New 

Zealand. Some children had also been in hospital 

18 months prior to the interview, which may 

have limited their recall of events. 

References 

1. O’Sullivan CE, Baker MG, Zhang J. Increasing hospitalizations 

for serious skin infections in New Zealand children, 

1990–2007. Epidemiol Infect. 2011;139(11):1794–804. 

2. Hunt D. Assessing and reducing the burden of serious skin infections 

in children and young people in the greater Wellington 

Region. Wellington: Capital and Coast District Health Board, 

Hutt Valley District Health Board, Regional Public Health, 2004. 

3. Finger F, Rossaak M, Umstaetter R, Reulbach U, Pitto R. Skin 

infections of the limbs of Polynesian children. NZ Med J. 

2004;117(1192):U847. 

4. Hill PC, Wong CG, Voss LM, Taylor SL, Pottumarthy S, Drinkovic 

D, et al. Prospective study of 125 cases of Staphylococcus 

aureus bacteremia in children in New Zealand. Pediatr Infect 

Dis J. 2001;20(9):868–73. 

5. Bhumbra NA, McCullough SG. Skin and subcutaneous infections. 

Prim Care. 2003;30(1):1–24. 

6. Sladden MJ, Johnston GA. Common skin infections in children. 

BMJ. 2004;329(7457):95–9. 

7. Leversha A, Aho G. Paediatric cellulitis. New Eth J. 

2001(Jul):47–52. 

8. Thompson I. Serious skin infection hospitalisations in children. 

Wellington region 2010 update. Wellington: Regional Public 

Health; 2010. 

9. Craig E, Taufa S, Jackson C, Han DY. The health of Pacific 

children and young people in New Zealand. Wellington: New 

Zealand Child and Youth Epidemiology Service, Ministry of 

Health; 2008. 

10. Ministry of Health. Making a Pacific difference in health policy. 

Wellington, 1998. 

11. Ministry of Health. Pacific child health: A paper for the Pacific 

health and disability action plan review. Wellington; 2008. 

12. Ministry of Health and Ministry of Pacific Island Affairs. Tupu 

Ola Moui: Pacific Health Chartbook 2004. Wellington: Ministry 

of Health; 2004. 

13. Miles F, Voss L, Segedin E, Anderson BJ. Review of Staphylococcus 

aureus infections requiring admission to a paediatric 

intensive care unit. Arch Dis Child. 2005;90(12):1274–8. 

14. McNicholas A, Lennon D, Crampton P, Howden-Chapman P. 

Overcrowding and infectious diseases—when will we learn 

the lessons of our past NZ Med J. 2000;113(1121):453–4. 

15. Bailie RS, Stevens MR, McDonald E, Halpin S, Brewster D, 

Robinson G, et al. Skin infection, housing and social circumstances 

in children living in remote Indigenous communities: 

testing conceptual and methodological approaches. BMC Publ 

Health. 2005;5:128. 

16. Taylor B, Kermode S, Roberts K, editors. Research in nursing 

and health care: evidence for practice. 3rd ed. Australia: 

Nelson Australia Pty Ltd; 2007. 

17. Schneider Z, Whitehead D, Elliot D, LoBiondo-Wood G, 

Haber J, editors. Nursing and midwifery research. Methods 

and appraisal for evidence-based practice. 3rd ed. Sydney: 

Elsevier-Mosby; 2007. 

18. Tamasese K, Peteru C, Waldegrave C, Bush A. Ole Taeao 

Afua, the new morning: a qualitative investigation into Samoan 

perspectives on mental health and culturally appropriate 

services. Aust NZ J Psychiatry. 2005;39(4):300–9. 

19. Helu-Thaman K. Looking towards the source: A consideration 

of cultural context in teacher education. ACCESS: Critical 

Perspectives Edu Policy. 1992;11(2):44–50. 

20. Arminio JL, Hultgren FH. Breaking out from the shadow: the 

question of criteria in qualitative research. J Coll Stud Dev. 

2002;43(4):446–60. 

21. Young N. The pre-hospital experiences of Samoan families 

who have had a child admitted to hospital with pneumonia: a 

qualitative investigation. Pac Health Dialog. 2001;8(1):20–8. 

22. Bolitho S, Huntington A. Experiences of Maori families accessing 

health care for their unwell children: a pilot study. Nurs 

Prax N Z. 2006;22(1):23–32. 

23. Cunningham-Burley S, Maclean U. Recognising and responding 

to children’s symptoms: mother’s dilemma. Matern Child 

Health. 1987;12:248–56. 

24. Spencer N. Parents’ recognition of the ill child. In: MacFarlane 

J, editor. Progress in child health. 1st ed. London: Churchill 

Livingstone/Longman; 1984. 

25. Buetow S, Adair V, Coster G, Hight M, Gribben B, Mitchell E. 

Reasons for poor understanding of when and how to access 

GP care for childhood asthma in Auckland, New Zealand. Fam 

Pract. 2002;19(4):319–25. 

26. O’Sullivan C, Baker MG. Skin infections in children in a New 

Zealand primary care setting: exploring beneath the tip of the 

iceberg. NZ Med J. 2012;125(1351):70–9. 

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

of Health; 2001. 

28. Donaldson M. Avoidable hospitalisations: Update to health 

needs assessments 2000/2001 and 2001/2002. Wellington: 

Capital and Coast District Health Board; 2003. 

29. Keatinge D. Parents’ preferred child health information 

sources: implications for nursing practice. Aust J Adv Nurs. 

2006;23(3):13–8. 

30. Finau SA, Tipene-Leach D, Finau E. Traditional healing and 

Pacificans: a manual for community workers. Auckland: Tongan 

Health Society Inc.; 2004. 

31. Yoos HL, Kitzmann H, Henderson C, McMullen A, Sidora- 

Arcoleo K, Halterman JS, et al. The impact of the parental 

illness representation on disease management in childhood 

asthma. Nurs Res. 2007;56(3):167–74. 


A special thank you to Dr 

Margaret Southwick for 

her valuable comments 

and support of this work. 

FUNDING 

We would like to 

acknowledge financial 

support from the Health 

Research Council of New 

Zealand (Pacific Health 

Masters Award) and the 

Ministry of Health through 

the Primary Health Care 

Nursing Scholarship. 





MIXED METHOD RESEARCH 

Interprofessional education for physiotherapy, 

medical and dietetics students: a pilot programme 

Sue Pullon MPHC, FRNZCGP, MBChB; 1 Eileen McKinlay MA (App), RN; 1 Louise Beckingsale PGDipDiet; 2 

Meredith Perry PhD, MManipTh, BPhty; 3 Ben Darlow MSportsPhysio, BPhty;3 Ben Gray FRNZCGP, MBChB; 1 

Peter Gallagher PhD, RN; 4 Kath Hoare MA, RN; 4 Sonya Morgan MHSc 1 

1 

Department of Primary 

Health Care and General 

Practice, University of Otago, 

Wellington, New Zealand 

2 

Dietetic Programme, 

University of Otago, 

Wellington 

3 


Research, University of 

Otago, Wellington 

4 

Medical Education Unit, 


Wellington 

ABSTRACT 

INTRODUCTION: Interprofessional education (IPE) has been shown to enhance interprofessional 

practice among health professionals. Until recently there has been limited opportunity to undertake such 

initiatives within existing pre-registration degree courses in New Zealand. 

AIM: This study aimed to test the feasibility of delivering an interprofessional component within existing 

health professional courses for medicine, physiotherapy and dietetics at the University of Otago, Wellington, 

New Zealand. 

METHODS: An interprofessional case-based course component (on chronic condition management) 

was developed by academic clinical teachers from schools of medicine, physiotherapy and dietetics at 

the same location. Evaluation was undertaken using a previously validated pre- and post-survey tool, to 

ascertain changes in attitude among students towards interprofessional practice, IPE and the effectiveness 

of health care teams. Focus groups were conducted with students and teachers. 

RESULTS: Survey results indicated pre-existing positive attitudes to interprofessional practice and education 

among students. There was a statistically significant increase in positive attitude towards such practice 

and education, and increased confidence in the effectiveness of heath care teams. Focus group findings were 

consistent with the survey results for students, and highlighted challenges experienced by the teachers. 

DISCUSSION: Students and teachers alike enjoyed the interprofessional interaction and benefited from 

a collaborative approach to chronic condition management. The timing and nature of learning activities 

and assessment methods created logistical challenges. Such course components have potential to improve 

collaborative practice and the quality and safety of health care among graduates. Interprofessional 

course components need to be equitable across disciplines and embedded in the unidisciplinary courses. 

KEYWORDS: Dietetics; education; interprofessional relations; medicine; New Zealand; physiotherapy; 

primary health care 


2013;5(1):52–58. 

CORRESPONDENCE TO 

Sue Pullon 

Associate Professor, 

Department of 

Primary Health Care 

and General Practice, 

University of Otago 

PO Box 7343, Wellington 

South, New Zealand 

sue.pullon@otago.ac.nz 

Introduction 

Interprofessional practice optimises the use of 

multiple skill sets to provide best possible care 

for patients to improve health outcomes and patient 

satisfaction. Such practice is a cornerstone of 

primary health care—and has been shown to benefit 

patients in a variety of clinical settings, and 

improve job satisfaction for health professionals. 1 

Quality of care and patient safety are improved; 

staff are more readily retained and recruited. 2,3 

Effective care for patients with chronic conditions 

is most often achieved when health professionals 

with complementary skill sets work closely 

together to meet their multiple needs. 4 The more 

complex the patient, the greater the range of 

skills required and the more important collaborative 

care becomes. 5 Collaborative interprofessional 

practice in primary care settings often means 

providers have to work across multiple sites, 

including the patient’s home. 

One important way of fostering and enhancing 

interprofessional practice is through interprofessional 

education (IPE). IPE occurs when health 

professionals from more than one discipline 

learn with, from and about each other, actively 




negotiating to participate in patient care together, 

and extending students well beyond occasional 

interaction with a teacher of a different discipline. 

6 Although often challenging to introduce, 

7,8 IPE undertaken with good facilitation in 

turn enhances interprofessional practice. 9 

Internationally, IPE has been successfully 

introduced into a number of health professional 

courses. 10 While the number of new programmes 

designed from the outset to incorporate an 

interprofessional ethos remains small, established 

unidisciplinary programmes have been able to 

introduce interprofessional components in both 

classroom and clinical settings. For IPE to be successful, 

staff need to be able to engage in and role 

model collaborative practice; they need to be ‘IPE 

ready’. In clinical settings, clinical providers need 

to be engaged in interprofessional practice and 

open to further enhancement. 11 Key interprofessional 

competencies include effective, respectful 

communication, successful conflict negotiation 

and resolution, shared decision-making, and 

active collaboration with patients and families. 

Tools have been developed to not only measure 

these competencies but to also demonstrate improvement 

over time. 12,13 

IPE has been shown to develop and improve interprofessional 

competencies over the duration of a 

course, 14 although as yet little data exists to demonstrate 

continued interprofessional practice as a 

direct result of specific IPE course components. 

In New Zealand, there are a number of established 

IPE programmes at postgraduate level, but 

little at undergraduate level. The Wellsford IPE 

programme (based at a comprehensive primary 

care facility north of Auckland) has been a 

notable exception, 15 overcoming considerable curricula 

alignment and timetabling issues to deliver 

an effective programme to small numbers of 

students. At the University of Otago, Wellington 

(UOW), increasing numbers of medical, dietetic 

and physiotherapy students are co-located on the 

same campus. Could an IPE course component 

based in primary care, involving students from 

three disciplines, be successfully developed and 

delivered at UOW This pilot study aimed to test 

the feasibility and acceptability of delivering an 

interprofessional component in chronic condition 


What we already know: Collaboration amongst health professionals to 

provide best possible care for patients is a central tenet of primary health 

care. Interprofessional education (IPE) is one important way to train health 

professional students to work together more effectively. 

What this study adds: IPE can be successfully delivered as a component 

within established courses of pre-registration study in a New Zealand setting, 

notwithstanding structural and organisational institutional barriers. Teaching 

staff need to be committed to working together as interprofessional role 

models. 

management across and within three existing but 

separate pre-registration programmes in medicine, 

dietetics and physiotherapy, with students learning 

with, from and about each other. 

Methods 

Academic clinical teachers responsible for curricula 

design and delivery in the three programmes 

agreed to work together to modify an existing 

interactive chronic conditions course component 

for use as an IPE curriculum component in 2011. 

The course was designed around a patient-centred 

approach and informed by Wagner’s model 

for chronic condition management. 16 Intended 

learning outcomes for interprofessional interaction 

were developed and agreed across the three 

disciplines. These included key elements of interprofessional 

practice: respectful, open communication, 

patient-centred collaboration, mutually 

satisfactory negotiation and re-negotiation, and 

shared decision-making. 

Due to small numbers, all seven fourth-year (of a 

five-year course) dietetic students were requested 

to take part in the course. Physiotherapy and medical 

students (fourth and final year, and fourth 

year of a six-year course respectively) were invited 

to participate, to make up an interdisciplinary 

group of 21 students—seven from each discipline. 

Year selection of students was made for both 

convenience and educational equivalence reasons. 

Students were given information about the pilot 

programme, the consent process and the associated 

evaluation process prior to participation. 

The programme commenced with a ‘meet, greet 

and eat’ early evening session for all 21 students 




and the academic clinical teachers, who were 

from diverse disciplinary backgrounds. The 

course outline and requirements were introduced 

alongside teambuilding activities where no one 

group or discipline would have an advantage. The 

interprofessional practice pilot then ran concurrently 

with other usual course requirements. 

Together, some two weeks later, students participated 

in a three-hour interactive session jointly 

facilitated by four teachers from the three established 

degree courses (with disciplinary backgrounds 

in medicine, nursing, physiotherapy and 

dietetics) to learn about collaborative approaches 

in chronic condition management. Subsequent 

contributions to an e-learning platform (IPE 

CCM—Interprofessional Education Chronic Care 

Management) provided continued communication 

and the opportunity to learn from each other 

about chronic condition management. 

In interdisciplinary groups of three, students 

then had two to three weeks to arrange and 

undertake a home visit together, to a previously 

identified person currently receiving health care 

for a number of comorbidities. Suitable people 

attending a local primary care provider were 

approached and their consent sought for students 

to make contact and arrange to visit them. 

Students were expected to talk with the person 

they visited to gain an understanding of multiple 

facets of their illness and its impact, including 

caregivers’ perceptions if appropriate. Following 

the visit, the students worked together to prepare 

group presentations for peers and the teaching 

team. They outlined the person’s conditions 

and perspectives and used their own and each 

other’s respective disciplinary knowledge to share 

decision-making, construct an appropriate joint 

management plan and make recommendations 

about future care. 

Assessment of this interprofessional curriculum 

component was undertaken in conjunction with 

the students’ usual course requirements. Students 

were assessed on the content and process of their 

joint presentation, as well as their ability or 

otherwise to participate and contribute to their 

group. Tutor, self- and peer-assessment tools were 

used. Summative assessment (either graded or 

pass/fail) was a requirement for the dietetic and 

medical students, but participation in the project 

was not able to count towards the physiotherapy 

students’ grades in this pilot. The course (as opposed 

to the students’ individual performance) 

was evaluated using both an established survey 

tool and independently conducted focus groups. 

Survey tool 

Students completed a pre- and post-survey using 

an established tool, 17 adapted with permission 

(personal communication, Professor V Curran 

Memorial University NL, Canada, 2011). This 

tool collects demographic and disciplinary data, 

and includes three validated surveys 18–20 ascertaining 

aspects of interprofessional practice and 

learning. Scale 1 measures Attitudes Towards 

Interprofessional Health Care Teams; Scale 2, 

Attitudes Towards Interprofessional Education; 

and Scale 3, Perception of Effective Interprofessional 

Teams. Scales 1 and 2 measure readiness 

to participate in IPE, whereas Scale 3 asks about 

perceived effectiveness, including students’ own 

ability to work within an interprofessional team. 

For each scale, data were collected on a 5-point 

Likert-type scale across a number of sub-items. 

For Scales 1 and 2, scores range from 1 to 5, where 

1=strongly disagree; 5=strongly agree. Reverse 

scoring is required on some items. For Scale 3, 

scores range from 1 to 5; this time 1=poor; 

5=excellent, with no reverse scored items. 

A global score for each student was calculated 

as the mean over all sub-items on a given scale. 

Mean pre-scores and changes in scores were then 

calculated over the whole group. One-sample 

t-tests were used for each scale to test whether 

mean change scores were significantly different 

from zero (i.e. to determine if opinions regarding 

IPE shifted during the programme). 

Focus groups 

Three separate discipline-specific student focus 

groups were convened and facilitated by two 

independent educationalists (from nursing backgrounds) 

immediately after the completion of the 

CCM course. Questions were initially suggested 

by the teachers; the facilitators adapted these and 

remained open to other comments and sugges- 




tions during each of the focus groups. Students 

were asked about their perceptions of learning 

in an IPE class, the process undertaken and the 

clinical content (about chronic condition management) 

of the interprofessional course. 

The same facilitators also held a focus group 

some eight weeks later with the academic clinical 

teachers involved with the teaching and facilitation; 

questions were similar to those asked of students, 

but appropriately adapted. Audio-recording 

was undertaken for all four groups and brief, 

handwritten notes were made during the sessions. 

At a later date, the two facilitators listened 

together to the recordings and made separate 

notes for comparison. Subsequent discussion 

enabled agreement about recurring key points 

identified in each discussion group. Some comparisons 

were able to be made between student 

and staff perceptions about the programme. Data 

were summarised and presented anonymously to 

the teaching team. 

The study received ethical approval via the University 

of Otago’s category B process. 

Results 

Student participation 

The dietetic and physiotherapy students were 

enthusiastic from the outset about participating 

in the project; medical students were initially 

more reticent, needing reassurance about possible 

additional workload. All 21 students successfully 

completed the course. All 21 students separately 

consented to take part in the evaluation process; 

it was made clear that participation in the 

evaluation was optional and did not affect course 

assessment. 

Course set-up, content, delivery and 

assessment—teacher perceptions 

The teaching team focus group results identified a 

number of significant challenges in course set-up. 

Working within the constraints of already established 

and centrally imposed timetables was challenging 

and the pilot was only able to be scheduled 

once, relatively late in the academic year. 

Much time was spent finding mutually acceptable 

dates for the three teaching sessions and associated 

activities. In contrast, the teachers spoke of 

many similarities in the concepts and approaches 

appropriate to chronic care management. 

In the set-up phase, identification and selection 

of course objectives acceptable to the three 

disciplines was not difficult and was achieved by 

comparing and mapping the three different sets 

of curricula. The team discussed viewpoints on 

chronic care approaches, observed the teaching 

of the prototype curriculum to medical students, 

considered different pedagogical methods 

and agreed on how each teaching team member 

would be involved. Although time consuming, 

it was felt that the process for sorting all the 

practicalities enhanced already good prior professional 

relationships, resulting in a collective and 

trusting team approach by the time the teaching 

programme began. 

During programme delivery, teachers found that 

the informal sessions and processes were as important 

to the programme as the formal requirements. 

They described the challenges faced by 

the students in organising their joint home visits 

as informally assisting the IPE process, with the 

visit and the associated tasks central to the more 

formal learning. 

Although the ‘internal’ assessment of the joint 

presentations had been agreed, the differing 

contributions to the three degree courses of study 

presented problems. All the teachers described 

this as unsatisfactory, and readily identified the 

need to better integrate any such IPE component 

within current courses, especially in relation to 

assessment. 

Course content, delivery and 

assessment—student perceptions 

Students also identified the informal sessions and 

processes as being as important to the programme 

as the formal requirements. The ‘meet, greet and 

eat’ session was popular, as was the working together 

to achieve a common goal (the presentation). 

Students said they learned of the contribution 

made by each profession not so much in the actual 

classroom teaching, but by ‘…what we learned by 

hanging out with other members of the group’. 




Students found the home visit challenging to 

arrange, but more importantly, identified that 

simultaneous visiting was not the way they had 

seen patient visits working in practice. Some 

expressed frustration that they were not able to 

ask what they perceived as all the necessary assessment 

questions. In the focus group they suggested 

visiting sequentially (as this was the way 

they had seen an MDT (multidisciplinary team) 

in the hospital operating). 

While students agreed that chronic condition 

management was a suitable content area for IPE, 

some identified team care of the acutely unwell 

patient as also lending itself to interprofessional 

learning. Some students felt poorly prepared for 

IPE prior to participating in the programme, so 

had little idea of what to expect. Students disliked 

the idea of a formal assessment, but agreed 

that if it is in the course then it must be compulsory 

in the same manner for all students. 

Changes in students’ understanding 

of interprofessional practice, 

education and health care teams 

Pre-course survey data from all 21 students 

indicated generally positive attitudes to interprofessional 

health care teams (Scale 1), IPE (Scale 2) 

Figure 1. Pre-course survey results of understanding of interprofessional practice and 

learning 

and perceived effectiveness of interprofessional 

teams (Scale 3). Responses on Scale 3 had more 

variability than for the other two scales, suggesting 

more mixed views on the effectiveness of 

interprofessional teams (See Figure 1—pre-course 

survey scores). 

Significant pre- to post-course improvements in 

scores were found on all three scales. For Scale 1, 

the mean improvement was 0.2 points (95% CI 

0.02–0.386; t(20)=2.34, p=0.03); for Scale 2, mean 

improvement was 0.26 points (95% CI 0.08–0.45; 

t(20)=3.06, p=0.006); for Scale 3, mean improvement 

was 0.64 points (95% CI 0.36–0.92; 

t(20)=4.73, p



cohort participated in the programme, medical 

and physiotherapy students were self-selected, 

so were likely to be those more interested in 

interprofessional approaches than non-participating 

colleagues. The successful weaving of the 

IPE programme into existing curricula without 

creating significant additional student work and 

the commitment of individual teachers in each 

discipline to use IPE principles to work effectively 

and visibly together proved to be particular 

strengths of the pilot study. 

Nevertheless, although the interdisciplinary 

teaching team found the designing and delivery 

of the programme enjoyable, it was time consuming 

and required a considerable willingness for 

previously accepted teaching methods and overall 

approaches to health care to be challenged. All 

teachers found they actively moved to adopt an 

interprofessional approach to the student group as 

a whole, valuing the range of contributions and 

perspectives. Furthermore, as described elsewhere, 

21 they found it necessary to make their 

own working processes particularly explicit. 

These pre-registration students already had a 

well-developed sense of their own professional 

identity; the attitudes of the teaching team to 

each other had to ensure participative safety 22 in 

honouring professional identity through consistent 

interprofessional respect. 23 Much about the 

process had to be considered and intentional, including 

such things as how and who in the teaching 

team should answer particular questions or 

introduce specific teaching points—a process not 

dissimilar to the building of a clinical team. 24,25 

Although not specifically measured in this feasibility 

study, it seemed important to students that 

their ‘disciplinary’ teacher be visible and be seen 

to be a credible teacher by the student group— 

something that readily happened when at least 

one IPE teacher from each discipline was involved 

in each teaching session. The effect of prior role 

modelling was evident; students expected to 

replicate the MDT processes (serial visiting by 

multiple health providers at different times) they 

had observed from hospital wards, rather than 

consider what might be achieved by simultaneous 

person/patient visits at the same time, as they 

undertook in this programme. 

Figure 2. Mean score changes in results of understanding of interprofessional practice and 

learning between pre- and post-course surveys 

Student recruitment and student assessment both 

presented difficulties in the pilot because processes 

varied across the disciplinary groups. For such 

a pilot, these variations were unavoidable, but 

need to be addressed in any sustained roll-out of 

such a programme. Standard participation in IPE 

course components has been advocated in other 

settings; 26 recruitment issues for this programme 

at UOW could be solved by making structural 

changes in unidisciplinary programmes so that 

all students in a rotational group could participate. 

Similarly, further alignment of assessment 

requirements is needed across the different degree 

courses. Student representation in early curriculum 

development 7 is one way concerns regarding 

unfamiliarity with IPE processes and values 

could be alleviated. 

Using the survey instrument, 17 student attitudes 

towards interprofessional health care teams and 

IPE appeared to be reasonably positive before the 

programme commenced, indicating a readiness for 

IPE. 20 For students already involved in experiential 

clinical learning in workplaces where some 

interprofessional practice already occurs, this is 

not unexpected, and further positive change may 

be difficult to demonstrate over the course of a 

short programme component such as this one. 





The authors wish to thank 

all the students who so 

willingly participated 

and without whom the 

pilot programme would 

not have been possible. 

Grateful acknowledgement 

is extended to the Office 

of Interprofessional 

Education, Memorial 

University, NL Canada, 

for permission to adapt 

and use the survey tool. 

Biostatistician Dr James 

Stanley kindly provided 

statistical advice and 

manuscript suggestions. 

Thanks are also due to 

Dr Lynn McBain and 

other staff of the 

Department of Primary 

Health Care and General 

Practice, the School of 

Physiotherapy and the 

Dietetic Programme at the 

University of Otago, who 

provided support to the 

academic clinical teachers. 



Though perceptions about the effectiveness of 

interprofessional health care teams were somewhat 

mixed prior to the commencement of the 

programme, an overall significant improvement 

in post-programme scores was demonstrated. 

Numbers were too small to make any sensible 

interdisciplinary comparisons. The survey instrument 

findings appear largely consistent with the 

findings from the focus groups, although further 

research involving greater student numbers 

would be needed to confirm the validity of the 

tool and consider possible disciplinary differences. 

The study did not seek to investigate changes 

in student understanding of chronic care nor 

investigate the relative value of each component 

of the IPE programme; both these aspects need 

further investigation. 

This IPE pilot study has shown that interprofessional 

components can be successfully introduced 

across existing pre-registration health professional 

degree courses in a New Zealand context. The 

success or otherwise of this course component 

appeared here to be particularly dependent on the 

ability of the interdisciplinary teaching team to 

work explicitly together, actively demonstrating 

interprofessional principles that are able to be applied 

to clinical workplaces. Students already positively 

disposed towards interprofessional practice 

and education benefited from modest changes in 

their degree course structure to accommodate an 

enjoyable interprofessional course component in 

the area of chronic condition management that 

involved little additional student workload. 

References 

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

primary care practice JAMA. 2004;291:1246–1251. 

2. Strasser D, Falconer J, Stevens A, Uomoto J, Herrin J, 

Bowen S, et al. Team training and stroke rehabilitation 

outcomes: a cluster randomized trial. Arch Phys Med Rehabil. 

2008;89(1):10–15. 

3. Borrill C, Carletta J, Carter A, Dawson J, Garrod S, Rees A, 

et al. The effectiveness of health care teams in the National 

Health Service. Glasgow: Aston Centre for Health Service 

Organization Research, 2000. 

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

2001;323:945–946. 

5. Oandasan I, Baker G, Barker K, Bosco C, D’Amour D, Jones L, 

et al. Teamwork in healthcare: promoting effective teamwork 

in health care in Canada. Ottawa: Canadian Health Services 

Research Foundation, 2006:33. 

6. Freeth D, Hammick M, Koppel I, Reeves S, Barr H. A critical review 

of evaluations of interprofessional learning. LTSN Centre 

for Health Sciences and Practice; 2002. 

7. Charles G, Bainbridge L, Gilbert J. The University of British 

Columbia model of interprofessional education. J Interprof 

Care. 2010;24(1):9–18. 

8. Centre for Education and Research on Aging and Health 

(CERAH) Northern Ontario School of Medicine. Evaluation of 

the Experiencing Rural Interprofessional Collaboration (ERIC) 

Project: implications for teaching and learning. Thunderbay 

ON: Northern Ontario School of Medicine, Lakehead University; 

2011. 

9. Zwarenstein M, Reeves S, Barr H, Hammick M, Koppel I, 

Atkins J. Interprofessional education: effects on professional 

practice and health care outcomes. Cochrane Database Sys 

Rev 2002 (Issue 2). 

10. Barr H, Koppel I, Reeves S, Hammick M, Freeth D. Effective 

interprofessional education: argument, assumption and 

evidence. Oxford: Blackwell; 2005. 

11. Oandasan I, Reeves S. Key elements of interprofessional 

education. Part 2: factors, processes and outcomes. J Interprof 

Care. 2005;19 Suppl 1:39–48. 

12. CIHC Canadian Interprofessional Health Collaborative. A 

national interprofessional competency framework. Vancouver: 

College of Health Disciplines University of British Columbia; 

2010. 

13. Curran V, Casimiro L, Banfield V, Hall P, Lackie K, Simmons B, 

et al. Research for interprofessional competency-based evaluation 

(RICE). J Interprof Care. 2009; 23(3):297–300. 

14. Cullen L, Fraser D, Symonds I. Strategies for interprofessional 

education: the Interprofessional Team Objective Structured 

Clinical Examination for midwifery and medical students. 

Nurse Educ Today. 2003;23:427–433. 

15. Boyd M-A, Horne W. Teamworking in primary health care. 

Teamworking and interprofessional education. Auckland: 

Three Harbours Trust; 2008. 

16. Wagner E, Glasgow E, Davis C, Bonomi A, Provost L, Mc- 

Culloch D, et al. Quality improvement in chronic illness care: a 

collaborative approach. J Qual Improv. 2001; 27(2):63–80. 

17. Centre for Collaborative Health Professional Education. Collaborating 

for education and practice: an interprofessional 

education strategy for Newfoundland and Labrador. Student 

survey. St John’s NL: Memorial University NL; 2005. 

18. Heinemann G, Schmitt M, Farrell M. Attitudes towards health 

care teams. In: Heinemann G, Zeiss A, editors. Team performance 

in health care: assessment and development. New 

York: Kluwer Academic/Plenum Publishers; 2002:155–159. 

19. Hepburn K, Tsukuda R, Fasser C. Team skills scale. In: Heinemann 

G, Zeiss A, editors. Team performance in health care: 

assessment and development. New York: Kluwer Academic/ 

Plenum Publishers; 2002:159–163. 

20. Parsell G, Bligh J. The development of a questionnaire to assess 

the readiness of health care students for interprofessional 

learning (RIPLS). Med Educ. 1999;33(2):95–100. 

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

long and winding road. Med Educ. 2001;35:867–875. 

22. Poulton B, West M. The determinants of effectiveness in 

primary health care teams. J Interprof Care. 1999;13(1):7–18. 

23. Davies C. Workers, professions and identities. In: Henderson 

J, Atkinson D, editors. Managing care in context. London: 

Routledge; 2002. 

24. Mickan S, Rodger S. Effective health care teams: a model of six 

characteristics developed from shared perceptions. J Interprof 

Care 2005;19(4):358–370. 

25. Quinlan E. The ‘actualities’ of knowledge work: an institutional 

ethnography of multi-disciplinary primary health care teams. 

Soc Health Illn. 2009;31(5):625–641. 

26. Cook D. Models of interprofessional learning in Canada. J 

Interprof Care. 2005;19 (S1):107–115. 



SYSTEMATIC REVIEW 

General practitioners can offer effective 

nutrition care to patients with lifestylerelated 

chronic disease 

Lauren Ball BAppSc, MNutrDiet; Cristina Johnson BBiomedSc, MBBS (Hons); Ben Desbrow BSc, GradDip 

Nutrition and Diet, GradDipSc, MHSc Human Nutrition, PhD; Michael Leveritt BSc (Hons), MNutrDiet, PhD 

ABSTRACT 

INTRODUCTION: Nutrition is a key priority for the management of lifestyle-related chronic disease, and 

the demand on general practitioners (GPs) to provide nutrition care is increasing. 

School of Public Health 

and Griffith Health 

Institute, Griffith University, 

Queensland, Australia 

AIM: The aim of this systematic review was to investigate the effectiveness of nutrition care provided 

by GPs in improving the nutrition-related behaviour and subsequent health outcomes of individuals with 

lifestyle-related chronic disease. 

METHODS: A systematic literature review was conducted using the Cochrane Library, MEDLINE and ISI 

Web of Knowledge databases. Randomised controlled trials that investigated a nutrition care intervention 

feasible within general practice consultations, and that utilised outcome measures relevant to nutritionrelated 

behaviour or indicators of health, were included in the review. 

RESULTS: Of the 131 articles screened for inclusion, nine studies, totalling 9564 participants, were 

included in the review. Five interventions observed improvements in the nutrition behaviour of participants, 

such as a reduction of energy consumption, reduction of meat consumption, increase in fruit 

and vegetable intake, increase in fish intake and increase in fibre intake. Seven interventions observed 

improvements in risk factors, including in weight, serum lipid levels and blood pressure. Some inconsistencies 

in findings were observed in the reviewed studies. 

DISCUSSION: This systematic review demonstrates that GPs have the potential to provide nutrition care 

that improves the nutrition behaviour and risk factors in individuals with lifestyle-related chronic disease. 

However, the consistency and clinical significance of the intervention outcomes are unclear. Further investigation 

regarding the development of nutrition care protocols and the attributes of nutrition care that 

result in improved outcomes are required. 

KEYWORDS: Chronic disease; general practice; general practitioners; nutritional management 

Introduction 

Lifestyle-related chronic diseases, such as 

overweight and obesity, Type 2 diabetes and 

cardiovascular disease, account for over 60% of 

deaths worldwide. 1 As a result, the prevention 

and management of these conditions are a key 

focus of primary health care systems. 2 General 

practitioners (GPs) are extensively involved in the 

health care of individuals with lifestyle-related 

chronic disease, 3 and over one-third of consultations 

involve this care. 4 

The importance of optimal nutrition for the 

prevention and management of lifestylerelated 

chronic disease is well documented. 5,6 

Additionally, nearly two-thirds of the risk 

factors for overweight and obesity, Type 2 

diabetes and cardiovascular disease relate to 


2013;5(1):59–69. 


Lauren Ball 

School of Public Health 

and Griffith Health 

Institute, Griffith 

University, Queensland 

4222, Australia 

L.Ball@griffith.edu.au 




poor nutrition behaviour. 7 Improvements in 

the nutrition behaviour of individuals, such as 

reducing saturated fat and sodium intake, have 

been shown to reduce risk factors associated 

with lifestyle-related chronic disease, such as 

hyperlipidaemia and hypertension. 6 In order 

to assist individuals to improve their nutrition 

behaviour, GPs may provide nutrition care within 

a consultation. 8,9 Nutrition care is a core principle 

of best practice guidelines for the management 

of chronic disease, and includes practices such 

as the assessment of a patient’s nutrition intake, 

the provision of nutrition-related advice, and the 

evaluation of nutrition behaviour on patients’ 

health outcomes. 10,11 As a result of increasing 

presentation rates of lifestyle-related chronic 

disease in general practice, 4 the demand on GPs 

to provide nutrition care is growing. 

GPs hold diverse perceptions regarding the 

level of complexity involved in providing 

nutrition care, 8 as well as their role in providing 

nutrition care. 12,13 However, patients perceive 

nutrition care to be an important part of the care 

provided by GPs for lifestyle-related chronic 

disease management. 14 Furthermore, many 

patients prefer to receive nutrition care from 

GPs, despite having access to nutrition-specific 

health care professionals such as dietitians. 14 

‘Effective’ health care is perceived by GPs to 

incorporate appropriate investigation, diagnosis 

and management of conditions in order to 

assist patients to improve their health status. 15 

Therefore, it is important that the nutrition 

care provided by GPs is effective at improving 

the nutrition behaviour and subsequent risk 

factors in patients with lifestyle-related chronic 

disease. Some health professionals hold anecdotal 

perceptions that GPs are ineffective at improving 

the nutrition behaviour and associated risk factors 

in patients. 12 Therefore, the following paper is 

a systematic review of published literature that 

investigates the effectiveness of nutrition care 

provided by GPs in improving the nutrition 

behaviour and subsequent risk factors in 

individuals with lifestyle-related chronic disease. 

Methods 

All applicable items from the PRISMA guidelines 

for reporting of systematic reviews were included. 16 

Search strategy 

A literature search was conducted using the 

Cochrane Library, MEDLINE and ISI Web of 

Knowledge databases. The following search terms 

and Medical Subject Headings (MeSH) were used 

to identify all relevant peer-reviewed publications: 

• For nutrition care: Nutrition Care 

OR Nutrition Advice OR Nutrition 

Therapy (MeSH) OR Diet (MeSH) OR 

Diet Therapy (MeSH) OR Food Habits 

(MeSH) OR Health Education (MeSH). 

• For lifestyle-related chronic disease: 

Chronic Disease OR Overweight OR 

Obesity OR Weight Loss OR Hypertension 

(MeSH) OR Type 2 Diabetes Mellitus 

(MeSH) OR Hypercholesterolemia OR 

Hyperlipidemia OR Cardiovascular Disease. 

• For general practitioner: General Practitioners 

(MeSH) OR Family Physicians (MeSH) OR Primary 

Care Physicians (MeSH) OR Family Doctor 

OR Family Practice OR General Practice. 

All randomised controlled trials (RCTs) published 

in English with at least one search term 

from each category were included for consideration. 

No limitation was applied regarding the year 

of publication. Cross-matching reference lists and 

forward citation searching was conducted in order 

to identify additional studies for consideration. 

Study selection 

Studies that investigated the effectiveness of 

nutrition care provided by GPs by measuring 

patients’ nutrition behaviour and/or changes to 

risk factors for lifestyle-related chronic disease 

were included in the review. The inclusion 

criteria were studies of adult populations (>18 

years of age). Specific eligibility criteria were also 

developed in relation to the intervention: 

1. The nutrition care must have been provided 

by a GP or international equivalent, such as 

a family physician or primary care physician. 

Studies investigating the effectiveness of other 

primary care health professionals, such as 

practice nurses, nutritionists and/or dietitians 

were not included. 

2. The effectiveness of the intervention must 

have been investigated using a control group, 




such as a ‘no care’ group, or a ‘usual care’ 

group. Studies comparing the effectiveness 

of nutrition care between different health 

professionals were not included. 

3. The nutrition care must have occurred in 

general practice consultations. Interventions 

investigating other aspects of the general 

practice setting, such as self-help resources or 

computer technologies in the absence of GPfacilitated 

nutrition care, were not included. 

4. The intervention must have included identical 

baseline and follow-up measurements of 

either nutrition-related behaviour or biological 

indicators of health. Interventions that did 

not assess changes to these measurements over 

time were not included. 


What we already know: The demand on general practitioners (GPs) to 

provide nutrition care to patients with lifestyle-related chronic disease is 

increasing. However, it is unclear whether GPs are effective at improving the 

nutrition behaviour and associated risk factors in these patients. 

What this study adds: This systematic review demonstrates that GPs 

have the potential to provide nutrition care that improves the nutrition 

behaviour and risk factors in individuals with lifestyle-related chronic disease. 

However, the consistency and clinical significance of the intervention 

outcomes are unclear. Further support is needed for GPs to provide nutrition 

care to patients. 

Figure 1. Study eligibility flow chart 

The article selection process is illustrated in 

Figure 1. 

Data extraction 

117 records identified through 

database searching 

14 additional records identified 

through citation searching 

Articles for inclusion were selected independently 

by two researchers (LB and CJ) using the same 

search strategy. Relevant articles were identified 

independently, and differences in selections 

were discussed prior to reaching final consensus. 

A third party was not required in the process 

of study selection. For each study the sample 

description, intervention protocol, outcome 

variables and results were extracted by careful 

review of each manuscript into a spreadsheet for 

comparison, and they are summarised in Table 1. 

131 records screened by 

title and abstract 

72 records 

excluded after 

screening by title 

and abstract* 

Outcomes assessed 

Relevant study outcomes to the review were 

those that reflected patients’ nutrition behaviour, 

and those reflecting patients’ modifiable risk 

factors for lifestyle-related chronic disease. Many 

studies that were reviewed also included outcome 

measures that reflected other lifestyle behaviours, 

such as smoking and physical activity. These 

studies were only included in the review if they 

also measured patients’ nutrition behaviour or 

risk factors for lifestyle-related chronic disease. 

Nutrition behaviour outcomes included overall 

dietary intake, energy consumption, and macronutrient 

intake. Risk factors included body 

weight, Body Mass Index (BMI), waist circumference, 

blood pressure, and serum lipid levels. 

59 studies retrieved and 

screened by full text 

9 studies included 

in review 

* Exclusion criteria: 

• Did not address the main objective of the study (n=72) 

• Provision of nutrition care was by non-GP (n=28) 

• Was not an RCT (n=11) 

• Study population not adults (n=9) 

50 studies excluded 

after screening by 

full text* 




Table 1. Studies selected for inclusion in review. 

Study details Sample Intervention protocol Outcome measures Follow-up period Summary of findings 

1. Christian, 

et al., 19 USA 

(2008) 

2. Martin et 

al., 20 USA 

(2008) 

3. Sacerdote 

et al., 21 

Italy (2006) 

4. van der 

Veen et al., 22 

Netherlands 

(2002) 

Overweight (BMI 

>25 kg/m 2 ), men 

and women with 

Type 2 diabetes. 

Overweight (BMI 

>25 kg/m 2 ), lowincome 

women 

Men and women 

seeking health 

care from their 

GP. 

Men and 

women with 

lifestyle-related 

chronic disease 

(hyperlipidaemia, 

hypertension or 

Type 2 diabetes) 

A: Intervention group, 

n=155. Patients identified 

goals for nutrition and 

physical activity using 

a tailored computer 

programme. Progress 

towards goals was reviewed 

every 3 months by PCP. 

B: Control group, n=155. 

Patients were provided with 

a pack of health education 

materials, including nutrition 

information. Patients were 

reviewed every 3 months 

by PCP but no prompts for 

nutrition advice provided. 

A: Intervention group, n=68. 

Patients received 6 x 15 

min physician-counselled 

consultations on the topic 

of weight loss. Each visit 

was one month apart, and 

patients received oral and 

written information. 


Patients received no directed 

advice for weight loss and 

were seen as needed for 

regular medical care. 


n=1592. Patients received 

1 x 15 min GP-administered 

nutrition care session based 

on Italian Guidelines for 

Correct Nutrition 1998. 


Patients received 1 x 15 min 

GP-administered ‘sham’ 

nutrition care session without 

use of brochure or provision 

of personalised advice. 


n=71. GPs assessed each 

patient’s SOC re: improving 

nutrition behaviour and then 

provided SOC-matched 

counselling. GPs provided 

from 1 to 3 consultations, 

each 2 weeks apart. Note: 

depending on the SOC, this 

sometimes included referral 

to a dietitian. 


Patients received ‘usual care’ 

from their GP. 

Nutrition behaviour 

measures: 

Energy intake.* 

Risk factor measures: 

Weight, BMI, waist 

circumference, HbA1c, 

serum lipids, blood 

pressure. 


measures: 

Usual dietary intake. † 


Weight. 


measures: 


‘Healthy Diet score’. ‡ 


Weight, blood pressure. 


measures: 



Height, weight, waist 

and hip circumference, 

serum lipid levels. 

12 months 32% of participants in the 

intervention group lost 

6 or more pounds at the 

completion of follow-up, 

compared with 18.9% 

of controls (odds ratio, 

2.2; p=0.006). No other 

differences in outcome 

measures were observed 

between groups. 

18 months Participants in the 

intervention group lost more 

weight than participants 

in the control group (-1.52 

kg vs +0.61; p=0.01) at 9 

months post intervention, 

but not at 12 months or 

18 months. No other 

differences in outcome 




intervention group reduced 

their BMI (-0.41 kg/m 2 ; 

p=0.02), reduced their 

intake of meat and increased 

their intake of fruit and 

vegetables, fish products 

and olive oil (p



Table 1 cont. 


5. Ockene et 

al., 23 USA 

(1999) 

Men and 

women with 

hyperlipidaemia 

(upper 25th 

percentile of 

population) 

A: Physician training group, 

n=333. GPs participated 

in nutrition counselling 

training and then provided 

patients with one nutrition 

counselling consultation. 

B: Physician training + 

office-support group, n=315. 

GPs participated in nutrition 

counselling training and 

also utilised office-based 

support (mainly information 

pamphlets and patient 

blood test results) to assist 

in providing patients with 

one nutrition counselling 

consultation. 


measures: 



Height, weight, blood 

pressure, serum lipid 

levels. 

12 months Participants in the physician 

training + office-support 

group reduced their 

saturated fat intake (-10.3%; 

p=0.01) and lost weight 

(-2.3 kg; p



Table 1 cont. 


8. Alli et al., 26 

Italy (1992) 

9. Logsdon et 

al., 18 USA 

(1989) 

Men and women 

with hypertension 

taking 

antihypertensive 

medication. 

Men and women 

seeking health 

care from their 

GP. 

A: Intervention group, n=40. 

GPs provided ‘simple’ dietary 

advice to patients 6 times 

over a 12-month period, 

using a leaflet on low sodium 

nutrition. 





n=1409. GPs provided one 

15-minute consultation 

promoting healthy 

behaviours, including 

nutrition, in line with 

preventive guidelines. 




* Energy Intake was assessed using a validated food frequency questionnaire. 


measures: 

Nil. 


Weight, height, blood 

pressure. 


measures: 

Usual dietary intake, † 

alcohol intake. 


Weight. 

† No measurement description of ‘usual dietary intake’ was provided in these studies. 

‡ ‘Healthy Diet Score’ was calculated by the authors based on the 1998 Italian Guidelines for Correct Nutrition. 

§ Total and relative intakes of fat and fibre were assessed using a validated food frequency questionnaire. 

|| Dietary fat intake was assessed using an adapted food questionnaire. 

12 months No differences in outcome 



Many participants openly 

stated that they were noncompliant 

with the dietary 

advice provided by the GP. 


intervention group were 

more likely to lose weight 

(>5 lb, p



2008, 19 and four date from after 2000. 19–22 Five of 

the studies were conducted in the USA, 18–20,23,24 

three were conducted in Europe, 21,22,26 and one 

was conducted in Australia. 25 The number of 

participants included in each study ranged from 

77 26 to 3179. 21 The interventions incorporated 

between one and six consultations with a GP, 

where the GP provided basic nutrition care to 

the participant. Three of the studies included 

nutrition-related training for the GPs prior to the 

intervention, 18,23,25 and two of the studies utilised 

the national dietary guidelines as supporting 

material for the nutrition care. 21,24 

Each study’s sample description, intervention 

protocol, outcome variables and results are 

presented in Table 1. Eight studies incorporated at 

least one nutrition behaviour outcome, typically 

in the form of usual dietary intake. 18–25 All 

nine studies incorporated at least one risk factor 

outcome, such as weight, waist circumference, 

serum lipid levels or blood pressure. 18,19,21–26 Eight 

interventions utilised a follow-up period of 12 

months, 18,19,21–26 and one intervention utilised a 

follow-up period of 18 months. 20 

Five interventions observed improvements in 

the nutrition behaviour of participants, such as 

a reduction of energy consumption of 0.7 MJ/ 

day, 22 a reduction in excessive alcohol consumption 

of 36%, 18 a reduction of meat consumption 

to three serves or less per week, 21 and a reduction 

of fat intake of 5–10%. 22–24 The interventions 

also observed an increase in fruit and vegetable 

intake by two serves per week, 21 an increase in 

fish intake to at least one serve per week, 21 and 

an increase in fibre intake of 0.55 g/1000 kcals. 24 

The five interventions that were conducted 

most recently observed significant reductions 

in participants’ body weight of 0.4–2.3 kg, or 

0.2–0.81 kg/m 2 . 19–23 Reductions in serum cholesterol 

levels of 0.46–0.83 mmol/L, and reductions 

in diastolic blood pressure of 4.0 mm Hg were 

also observed. 25 

The quality attributes of each study are displayed 

in Table 2. Two of the studies received a ‘positive’ 

quality assessment rating, 19,24 and seven received a 

‘neutral’ quality assessment rating. 18,20–23,25,26 Both 

of the studies that received a ‘positive’ quality assessment 

rating incorporated nutrition behaviour 

measures and risk factor measures. 19,24 However, 

only one of these studies observed an improvement 

in the nutrition behaviour of participants 

(specifically, reduced fat and increased fibre 

intake), 24 and one observed an improvement in 

participants’ body weight. 19 Due to the nature of 

the interventions, some of the quality assessment 

criteria were not feasible to meet, such as the use 

of blinding by the GPs. Furthermore, a neutral 

rating was allocated to many of the assessment 

criteria due to lack of information in the articles, 

rather than poor intervention design. Common 

information missing from articles included the 

method for allocating participants to groups, the 

reasons for participant withdrawal, and if ‘intention-to-treat’ 

statistical analysis was implemented. 

Discussion 

Summary of main findings 

This systematic review investigated the effectiveness 

of nutrition care provided by GPs in 

improving the nutrition behaviour and subsequent 

risk factors in individuals with lifestylerelated 

chronic disease. The interventions suggest 

that GPs may be effective at providing nutrition 

care to individuals with lifestyle-related chronic 

disease. Interestingly, the studies that observed 

improvements in participants’ nutrition behaviour 

were not necessarily the same studies that observed 

improvements in participants’ risk factors. 

For example, Beresford et al. 24 observed improvements 

in participants’ energy, fat and fibre intake, 

but not any improvements in risk factors such as 

weight or serum lipid levels. Conversely, Martin 

et al. 20 observed improvements in participants’ 

body weight, but not any measures of nutrition 

behaviour. It is possible that the different 

findings were due to differences in the outcomes 

measured. For example, five of the studies measured 

‘usual dietary intake’ but did not specify 

which nutrients were analysed to assess the effectiveness 

of the intervention. 18,20–23 Furthermore, 

three of the interventions only measured one 

component of dietary intake (e.g. energy intake), 

and therefore reduced the likelihood of observing 

improvements in nutrition behaviour. 19,24,25 

Of the three interventions that provided 

nutrition-related training to GPs, one observed 




Table 2. Quality assessment attributes for each study assessed using the Quality Criteria Checklist (QCC). 17 

Criteria scores 

Study 

1. Clear research 

question 

2. Participant selection 

free from bias 

3. Comparable study 

groups 

4. Participant 

withdrawals described 

5. Use of blinding 

6. Description of 

intervention protocol 

7. Outcomes clearly 

defined 

8. Appropriate statistical 

analysis 

9. Conclusions supported 

by results 

10. Unlikely funding bias 

Overall quality 

rating* 

1. Christian 

et al. 19 + + + + Ø + + + + + + 

2. Martin 

et al. 20 + + Ø + Ø Ø + + + + Ø 

3. Sacerdote 

et al. 21 + Ø + + Ø Ø + + + + Ø 

4. van der 

Veen 

+ Ø + + Ø + + Ø Ø + Ø 

et al. 22 

5. Ockene 

et al. 23 + + Ø - Ø + + Ø + + Ø 

6. Beresford 

et al. 24 + + + + + + + Ø + + + 

7. Salkeld 

et al. 25 + + Ø Ø Ø - Ø Ø + + Ø 

8. Alli 

et al. 26 + Ø Ø + Ø Ø + Ø + + Ø 

9. Logsdon 

et al. 18 + + + - Ø - Ø + + + Ø 

* + Positive overall score: This overall score is given if criteria 2, 3, 6, 7 of the QCC and one additional criterion have received a positive score. 

Ø 

Neutral overall score: This score is given if more criteria are met than for a negative overall score but an overall positive score is not reached. 

- Negative overall score: This score is given if 6 or more QCC criteria are not met. 

significant improvements in participants’ dietary 

fat intake and body weight, 23 another observed 

improvements in participants’ serum lipid levels 

and blood pressure 25 and one observed improvements 

in participants’ alcohol behaviour and body 

weight. 18 Interestingly, two of the studies incorporated 

four identical outcome measures into the 

interventions (dietary fat intake, body weight, 

blood pressure and serum lipid levels), but 

observed contradictory outcomes. Therefore, the 

impact of nutrition-related training on the effectiveness 

of the nutrition care provided may differ 

under various circumstances. The inconsistencies 

observed in the reviewed studies indicate that the 

positive impact of nutrition-related training for 

GPs requires further investigation. 

No association was apparent between the magnitude 

of outcomes and the number of consultations 

that were incorporated into the interventions. 

For example, of the six interventions that 

observed significant reductions in participants’ 

body weight, three interventions incorporated 

one consultation each, 18,21,23 two interventions incorporated 

between three and four consultations 

each, 19,22 and one intervention incorporated six 

consultations. 20 Therefore, it would appear that 

the number of consultations is not a determining 

factor for the effectiveness of nutrition care 

provided by GPs. This suggests that effective 

nutrition care can be provided in relatively few 

consultations, and may not have a significant 

influence on GPs’ workload. 




Comparison with existing literature 

Typically, weight loss interventions that involve 

lifestyle modification observe significant 

improvements in outcomes measured six months 

after the intervention and then trend back 

towards baseline 12 months after the intervention. 

33 As a result, the overall effectiveness of the 

reviewed studies may be underestimated because 

the final follow-up measures in each study were 

taken at least 12 months after the intervention 

commenced. Previous literature indicates that 

short-term improvements in risk factors persist to 

improvements in long-term disease risk reduction 

and are therefore important. 34,35 Interestingly, two 

studies in the current review observed similar 

trends, with participants losing a significant 

amount of weight at six months 22 and nine 

months 20 after the intervention, but regressing 

back towards baseline body weight at 12 months 

and 18 months after the intervention. 

Despite observing significant improvements in 

patients’ nutrition behaviour and risk factors, the 

current review does not compare the magnitude 

of effect of GP-facilitated nutrition care with 

other health professionals or services that provide 

nutrition care to individuals with lifestyle-related 

chronic disease. Of note, a 12-month intervention 

utilising a commercial weight loss programme 

(Weight Watchers) observed an average weight 

loss of 5.06 kg for completing participants, which 

is higher than the observed weight loss reported in 

the reviewed studies (0.4–2.3 kg). 19–23,36 However, 

the commercial programme involved a relatively 

high participant burden, with weekly meetings 

and ‘weigh-ins’, and also observed a lower completion 

rate (61%) than the reviewed studies (64–93%). 

This finding indicates that high-intensity interventions 

may result in improved health outcomes, 

but the overall impact may be reduced due to high 

attrition rates. 37 The provision of nutrition care 

by GPs is important because the general practice 

setting provides exposure to individuals who prefer 

to receive nutrition care from GPs rather than 

other health professionals or services. 14 

Implications for practice 

The interventions that were reviewed demonstrate 

the potential for GPs to provide effective 

nutrition care to patients. However, the studies 

that were reviewed may not reflect the current 

nutrition care practices of GPs. Each of the interventions 

included a ‘usual care’ group that acted 

as a control, and suggests that the usual practices 

of GPs do not include nutrition care. It is important 

that GPs provide nutrition care to patients 

when appropriate in order to promote healthy 

nutrition behaviour and improve associated risk 

factors. Furthermore, each of the intervention 

studies in the review utilised a protocol for the 

provision of nutrition care. This suggests that 

in order to replicate the outcomes of the studies, 

GPs may require a nutrition care protocol for 

daily practice, and the development of appropriate 

protocols consequently requires investigation. 

Strengths and limitations 

Many of the outcome measures that improved 

following the nutrition care interventions are key 

indicators of chronic disease management, such 

as weight and dietary intake. 38 However, none 

of the studies explored the clinical significance 

of the outcomes. Clinical significance of health 

outcomes, such as body weight, are usually 

estimated as losses greater than 5% of initial body 

weight. 39 For each study that measured body 

weight, the results were reported in absolute 

terms rather than as a percentage of initial body 

weight. Therefore, the clinical significance of the 

health outcomes is difficult to determine, and 

requires further investigation. 

The quality of the reviewed interventions 

requires consideration, with two studies receiving 

positive quality scores, and seven receiving 

neutral quality scores. Due to the nature of the 

interventions, some of the quality assessment 

criteria were not feasible to meet, such as the use 

of blinding by the GPs. Furthermore, a neutral 

rating was allocated to many of the assessment 

criteria due to lack of information in the articles, 

rather than poor intervention design. Common 

information missing from articles included the 

method for allocating participants to groups, 

the reasons for participant withdrawal, and 

if ‘intention-to-treat’ statistical analysis was 

implemented. In addition, the nutrition behaviour 

of participants was usually monitored using 

self-reported data, and it is therefore important to 




carefully consider the reliability of this data due 

to the potential variability in reporting. 40 

An important limitation to the current review is 

that the eligibility criteria for included studies 

is restrictive, and does not account for alternative 

interventions conducted by non-GP health 

professionals or supplementary services available 

in the primary health care setting. Typically, 

primary health care systems allow individuals 

to select the type of treatment to be received, as 

well as the type of health care provider. 41 The 

reviewed interventions do not account for individual 

preferences regarding their health care, 42,43 

and other nutrition care services that are not 

provided by GPs. Consequently, the factors that 

promote the use of GPs as a source of nutrition 

care within the primary health care system warrant 

exploration. 

Finally, this review focuses on the influence of 

nutrition care on individuals’ nutrition behaviour. 

However, westernised societies have previously 

been described as ‘obesogenic’, whereby nutrition 

behaviour is influenced by the built and food 

environments. 44 As a result, the ability of GPs 

to provide nutrition care that assists in reducing 

lifestyle-related chronic disease at a population 

level requires further investigation. 

Conclusion 

It appears that GPs have the potential to provide 

nutrition care that improves nutrition behaviour 

and risk factors in individuals with lifestyle-related 

chronic disease. However, the consistency and 

clinical significance of the intervention outcomes 

are unclear. Further investigation regarding the 

development of nutrition care protocols, as well 

as the attributes of nutrition care that result in 

improved outcomes, is indicated. 

References 

1. World Health Organization. Tough choices: investing in health 

for development. Geneva; 2006. 

2. Commonwealth of Australia. Primary Health Care Reform in 

Australia: Report to Support Australia’s First National Primary 

Health Care Strategy. Canberra, Australia; 2009. 

3. Royal Australian College of General Practitioners. What is 

general practice Definition of general practice and general 

practitioners. 2005. [Cited 2010 March 29]. Available from: 

http://www.racgp.org.au/whatisgeneralpractice. 

4. Britt H, Miller G, Knox S. General practice activity in Australia 

2010–11. General Practice Series. Canberra: Australian Institute 

of Health and Welfare; 2011. 

5. World Health Organization. Diet, nutrition, and the prevention 

of chronic diseases. Geneva WHO Technical Report 

Series; 2003. 

6. World Health Organization. Obesity and overweight: 

WHO global strategy on diet, physical activity and health. 

Geneva; 2003. 

7. Nicholas L, Roberts D, Pond D. The role of the general practitioner 

and the dietitian in patient nutrition management. Asia 

Pac J Clin Nutr. 2003;12(1):3–8. 

8. Ball L, Hughes R, Leveritt M. Nutrition in general practice: role 

and workforce preparation expectations of medical educators. 

Aust J Prim Health. 2010;16(4):304–10. 

9. Crowley J, Ball L, Wall C, Leverett M. Nutrition beyond drugs 

and devices: a review of the approaches to enhance the capacity 

of nutrition care provision by general practitioners. Aust J 

Prim Health. 2012;18(2):90–5. 

10. Australian Government. Clinical Practice Guidelines for the 

management of overweight and obesity: a guide for general 

practitioners. Canberra, Australia: Department of Health and 

Ageing; 2003. 

11. Dietitians Association of Australia. Evidence based practice 

guidelines for the nutritional management of type 2 diabetes 

mellitus for adults. Sydney, Australia; 2006. 

12. Ball L, Hughes R, Leveritt. A study of health professionals’ 

views of the effectiveness of nutrition care in general practice. 

Nutr Diet. 2012. doi: 10.1111/j.1747-0080.2012.01627.x 

13. Pomeroy S, Worsley A. Nutrition care for adult cardiac 

patients: Australian general practitioners’ perceptions of their 

roles. Fam Pract. 2008;25:123–9. 

14. Ball L, Hughes R, Desbrow B, Leveritt M. Patients’ perceptions 

of nutrition care received from general practitioners: focus on 

type 2 diabetes. Fam Pract. 2012;29(6):719–725. 

15. Tomlin Z, Humphrey C, Rogers S. General practitioners’ perceptions 

of effective health care. BMJ. 1999;318(7197):1532–5. 

16. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting 

items for systematic reviews and meta-analyses: the 

PRISMA Statement. Public Library of Science and Medicine. 

2009;6(7). 

17. American Dietetic Association. Quality Criteria Checklist. 

Chicago, USA; 2011. 

18. Logsdon DN, Lazaro CM, Meier RV. The feasibility of behavioral 

risk reduction in primary medical care. Am J Prev Med. 

1989;5(5):249–56. 

19. Christian J, Bessesen D, Byers T, Christian K, Goldstein M, 

Bock B. Clinic-based support to help overweight patients with 

type 2 diabetes increase physical activity and lose weight. 

Arch Intern Med. 2008;168(2):141–6. 

20. Martin P, Dutton G, Rhode P, Horswell R, Ryan D, Brantley P. 

Weight loss maintenance following a primary care intervention 

for low-income minority women. Obesity. 2008;16(11):2462–7. 

21. Sacerdote C, Fiorini L, Rosato R, Audenino M, Valpreda M, Vineis 

P. Randomized controlled trial: effect of nutritional counselling 

in general practice. Int J Epidemiol. 2006;35(2):409–15. 

22. van der Veen J, Bakx C, van den Hoogen H, Verheijden M, van 

den Bosch W, van Weel C, et al. Stage-matched nutrition guidance 

for patients at elevated risk for cardiovascular disease: a 

randomized intervention study in family practice. J Fam Pract. 

2002;51(9):751–8. 

23. Ockene I, Hebert J, Ockene J, Saperia G, Stanek E, Nicolosi 

R, et al. Effect of physician-delivered nutrition counseling 

training and an office-support program on saturated fat intake, 

weight, and serum lipid measurements in a hyperlipidemic 

population—Worcester Area Trial for Counseling in Hyperlipidemia 

(WATCH). Arch Intern Med. 1999;159(7):725–31. 




24. Beresford S, Curry S, Kristal A, Lazovich D, Feng Z, Wagner 

E. A dietary intervention in primary care practice: the eating 

patterns study. Am J Public Health. 1997;87(4):610–6. 

25. Salkeld G, Phongsavan P, Oldenburg B, Johannesson M, 

Convery P, Graham-Clarke P, et al. The cost-effectiveness of 

a cardiovascular risk reduction program in general practice. 

Health Policy. 1997;41(2):105–19. 

26. Alli C, Avanzini F, Bettelli G, Bonati M, Colombo F, Corso R, et 

al. Feasibility of a long-term low-sodium diet in mild hypertension. 

J Hum Hypertens. 1992;6(4):281–6. 

27. Steptoe A, Kerry S, Rink E, Hilton S. The impact of behavioral 

counseling on stage of change in fat intake, physical activity, 

and cigarette smoking in adults at increased risk of coronary 

heart disease. Am J Public Health. 2001;91(2):265–9. 

28. Glasgow R, LaChance P, Toobert D, Brown J, Hampson S, 

Riddle M. Long-term effects and costs of brief behavioural 

dietary intervention for patients with diabetes delivered from 

the medical office. Patient Educ Couns. 1997;32(3):175–84. 

29. Keyserling T, Ammerman A, Davis C, Mok M, Garrett J, Simpson 

R. A randomized controlled trial of a physician-directed 

treatment program for low-income patients with high blood 

cholesterol: the Southeast Cholesterol Project. Arch Fam 

Med. 1997;6(2):135–45. 

30. Glasgow R, Toobert D, Hampson S. Effects of a brief officebased 

intervention to facilitate diabetes dietary self-management. 

Diabetes Care. 1996;19(8):835–42. 

31. Ashley J, St Jeor S, Schrage J, Perumean-Chaney S, Gilbertson 

M, McCall N, et al. Weight control in the physician’s office. 

Arch Intern Med. 2001;161(13):1599–604. 

32. Willaing I, Ladelund S, Jorgensen T, Simonsen T, Nielsen L. 

Nutritional counselling in primary health care: a randomized 

comparison of an intervention by general practitioner or dietician. 

Eur J Cardiovasc Prev Rehabil. 2004;11(6):513–20. 

33. Franz M, VanWormer J, Crain A, Boucher J, Histon T, Caplan 

W, et al. Weight-loss outcomes: a systematic review and metaanalysis 

of weight-loss clinical trials with a minimum 1-year 

follow-up. J Am Diet Assoc. 2007;107(10):1755–67. 

34. Tuomilehto J, Lindstrom J, Eriksson J, Valle T, Hamalainen H, 

Ilanne-Parikka P, et al. Prevention of type 2 diabetes mellitus 

by changes in lifestyle among subjects with impaired glucose 

tolerance. New Eng J Med. 2001;344(18):1343–50. 

35. Knowler W, Barrett-Connor E, Fowler S, Hamman R, Lachin 

J, Walker E, et al.; Diabetes Prevention Program Research 

Group. Reduction in the incidence of type 2 diabetes 

with lifestyle intervention or metformin. New Eng J Med. 

2002;346(6):393–403. 

36. Jebb S, Ahern A, Olson A, Aston L, Holzapfel C, Stoll J, et al. 

Primary care referral to a commercial provider for weight loss 

treatment versus standard care: a randomised controlled trial. 

Lancet. 2011;378(9801):1485–92. 

37. Tsai AG, Wadden TA. Systematic review: an evaluation of 

major commercial weight loss programs in the United States. 

Ann Intern Med. 2005;142(1):56–66. 

38. Australian Institute of Health and Welfare. Prevalence of risk 

factors for chronic diseases. Canberra, Australia; 2009. 

39. Jacobson N, Roberts L, Berns S, McGlinchey J. Methods for 

defining and determining the clinical significance of treatment 

effects: description, application, and alternatives. J Consult 

Clin Psych. 1999;67(3):300–7. 

40. Trabulsi J, Schoeller D. Evaluation of dietary assessment 

instruments against doubly labeled water, a biomarker of 

habitual energy intake. Am J Physiol Endocrinol Metab. 

2001;281(5):E891–E9. 

41. Al-Bashir M, Armstrong D. Preferences of healthy and ill 

patients for style of general practitioner care: implications for 

workload and financial incentives under the new contract. Br J 

Gen Pract. 1991;41(342):6–8. 

42. Charlton K, Brewitt P, Bourne L. Sources and credibility of nutrition 

information among black urban South African women, 

with a focus on messages related to obesity. Public Health 

Nutr. 2004;7(6):801–11. 

43. Eggleston J, Gallagher J, Gallagher M, Hares T,Murray E, 

Naroz N, et al. Who should give lifestyle advice in general 

practice and what factors influence attendance at health 

promotion clinics—survey of patients’ views. Br J Gen Pract. 

1995;45(401):669–71. 

44. Stanton RA. Nutrition problems in an obesogenic environment. 

Med J Aust. 2006; 16;184(2):76–9. 





SHORT REPORT 

Assessing readiness to work in primary health 

care: the content validity of a self-check tool for 

physiotherapists and other health professionals 

Jenny Stewart MPH NSW, DipPhty; 1 Kate Haswell BSc, MHSc (Hons), Dip Phty, PgDipHSc(Manip) 2 

1 

Rehabilitation and 

Occupation Studies, 

AUT University, Auckland, 


2 

Office of the Dean, Faculty 

of Health and Environmental 

Sciences, AUT University, 

Auckland 

ABSTRACT 

INTRODUCTION: The New Zealand Primary Health Care Strategy has emphasised the importance of 

well-coordinated service teams in managing complex chronic conditions. There is international evidence 

that physiotherapists can contribute effectively to the prevention and management of these conditions. 

However, there are few examples of physiotherapists in New Zealand (NZ) engaging in primary health 

care (PHC). It has been recognised that professional development is necessary to optimise physiotherapists’ 

participation in PHC. 

AIM: The aim of this study was to both design a self-check tool that physiotherapists could use as an 

initial step in preparing to work in PHC and to assess the content validity of the tool. 

METHODS: A literature review informed the development of the self-check tool. The tool was reviewed 

by members of the Physiotherapy New Zealand PHC working party to establish content validity. 

RESULTS: The tool was found to have excellent content validity with an overall score of 0.937, exceeding 

the acceptable index of 0.8. Item validity was excellent or acceptable for all except two items, which were 

subsequently modified in the final tool. 

DISCUSSION: This investigation provides initial support for the tool’s potential use by physiotherapists 

as a means of determining their readiness to work in PHC. It could have application beyond individual 

professional development to the wider context of team and organisational development. Additionally, 

with minor modifications the tool could have broader application to other professional groups. 

KEYWORDS: Continuing education; New Zealand; physiotherapy; primary health care; validity and 

reliability 


2013;5(1):70–73. 


Jenny Stewart 

School of Rehabilitation 

and Occupation 

Studies, Department 

of Physiotherapy, 

Akoranga Campus, AUT 

University, PB 92006, 


jenny.stewart@aut.ac.nz 

Introduction 

The New Zealand Primary Health Care Strategy 1 

has emphasised the importance of multidisciplinary 

service teams in improving efficiencies in 

health care delivery at a time when there are significant 

increases in health need alongside a static 

budget. The management of long-term conditions 

is one area of rapidly rising costs and increasing 

inequities, where well-coordinated service teams 

can contribute to improved care. 2 Care Plus is 

an example of an initiative in the primary care 

sector targeting improved service coordination 

for people with complex and chronic conditions. 2 

This initiative has strengthened the role of 

nurses and community health workers, alongside 

general practitioners, in community-based teams. 

Psychologists, podiatrists, dietitians and social 

workers have also been recognised as having 

complementary roles in these teams. 2 Although 

the Primary Health Care Strategy document 1 

includes physiotherapy in the health care team, 

there are very few examples of physiotherapists 

in New Zealand (NZ) engaging in primary health 

care (PHC). 

There is international evidence of physiotherapists’ 

contribution to the prevention and management 

of long-term conditions. For instance, the 

value of physiotherapy has been demonstrated 

in falls prevention, 3 the management of chronic 

respiratory conditions, 4 and rehabilitation of 



SHORT REPORT 

joint disorders and neurological conditions. 5,6,7 

Physiotherapists’ exercise prescription expertise 

has been shown to contribute to improvement 

in postnatal wellbeing, 8 management of diabetes 

and associated risk factors, 9,10,11 enhancement of 

recovery in mental health, 9,10 and following breast 

cancer surgery. 12 

In NZ, 56% of physiotherapists work in primary 

care where their work mainly involves the 

treatment of musculoskeletal disorders. 13 Until 

recently, physiotherapy education has had a 

similar emphasis. However, in the last decade the 

profession has become increasingly aware of its responsibility 

to contribute to PHC. 14,15 Professional 

development opportunities are being introduced 

so that current practitioners are more adequately 

prepared for this work 16 and university programmes 

have recently made significant curricular 

changes to prepare future physiotherapists. 17 

The purpose of this research was to develop a 

tool that physiotherapists could use as an initial 

step in preparing to work in PHC. The aim of 

this study was to design a self-check tool for 

physiotherapists to assess their readiness for 

working in PHC and to establish the content 

validity of the tool. 

Methods 

The design of the self-check tool was underpinned 

by the principles outlined in the NZ 

Primary Health Care Strategy, which is based on 

the Alma-Ata Declaration. 1,18,19 A literature review 

informed the development of the questions. 

Literature included a discussion paper to support 

implementation of the PHC Strategy 20 and 

a critical analysis of its implementation, 19 guides 

to developing health promotion programmes in 

PHC settings, 21,22 a paper on integrated care in a 

DHB, 23 guidelines for health promotion planning 

and action in PHOs, 24 a national survey of health 

equity in the NZ health care system 2 and a paper 

on factors influencing wellbeing among Maori 

and non-Maori in NZ. 25 The draft tool developed 

from this literature comprised questions relating 

to knowledge and networks associated with 

working in PHC. 1,2,18–25 There were also questions 

relating to importance and confidence that aimed 

to assess readiness to work in PHC. 26 


What we already know: International evidence supports a role for physiotherapists 

in primary health care teams in the management of complex chronic 

conditions. There are currently few examples of physiotherapists engaging in 

primary health care in New Zealand and professional development is considered 

to be a necessary prerequisite to optimise their engagement in this work. 

What this study adds: A self-check tool has been developed for NZ 

physio therapists to assess their readiness to work in primary health care. Content 

validity of the tool was found to be excellent. The tool could have potential 

for broader use in teams, organisations and by other health professionals. 

Six reviewers assessed the content validity of the 

self-check tool to ensure that all content areas of 

importance were sufficiently represented and that 

all items were relevant to the purpose of the tool. 

Reviewers were elected members of the Physiotherapy 

New Zealand PHC Working Party. All 

had at least 10 years’ experience and were recognised 

for their expertise in primary care. 

The reviewers were requested to evaluate each of 

the 32 items on the participant’s score sheet as ‘1 

= not relevant, 2 = somewhat relevant, 3 = quite 

relevant or 4 = highly relevant’. Item content 

validity (I-CVI) was computed as the number of 

reviewers giving a rating of either three or four, 

divided by the total number of reviewers. 27 For 

each item a content validity score of 0.8 or above 

was an acceptable value. 27 Overall content validity 

(CVI) for the tool was calculated as the mean 

percentage of items with a score of three or four, 

divided by the total number of reviewers. An 

acceptable CVI is defined as 0.8 or above, while 

an average of 0.90 or above indicates excellent 

content validity. 27 Reviewers were also invited to 

provide feedback under two headings; ‘any items 

missing’, ‘any comments’. 

Results 

All reviewers completed the content validity 

score sheet. Content validity scores for individual 

items (I-CVI) of the self-check tool are listed 

in Table 1. Two items had unacceptable content 

validity (item 13, I-CVI 0.50; and item 14, I-CVI 

0.66). The self-check tool CVI as determined 

by the six reviewers was 0.937. No reviewers 

reported any items missing and there were no 

recommendations for major changes. 



SHORT REPORT 

Discussion 

The self-check tool developed and investigated in 

this study was found to have excellent content 

validity with an average CVI of 0.937, exceeding 

the acceptable index of 0.8. 27 Item validity was 

excellent or acceptable for all draft items except 

13 and 14 (see Appendix A in web version of 

this paper). Poor scoring was attributed to the 

fact that these items regarding physiotherapy 

networks overlapped and the recommendation 

was that they be amalgamated. Minor wording 

changes were also recommended to draft items 

18 and 32. All recommendations have been ad- 

dressed in the final tool (see Appendix B in web 

version of this paper). 

The content validity results need to be viewed 

cautiously in the light of the small number of 

reviewers in the expert panel. For example, another 

study evaluating content validity employed 

a larger panel of nine experts. 28 However, the 

findings do provide initial support for the tool’s 

potential use by physiotherapists as a means of 

determining their readiness to work in PHC. 

The justification for including questions in the 

tool related to importance and confidence was 

Table 1. Self-check tool item content validity scores* by reviewers. 

Sections Items Reviewer A Reviewer B Reviewer C Reviewer D Reviewer E Reviewer F I-CVI 

1 Item 1 3 4 4 4 4 4 1.0 

Item 2 4 4 4 4 4 4 1.0 

Item 3 4 3 4 4 4 4 1.0 

2 

Item 4 4 4 4 4 3 4 1.0 

Item 5 4 4 4 4 4 4 1.0 

Item 6 3 4 4 4 3 4 1.0 

Item 7 3 4 4 4 4 4 1.0 

Item 8 4 3 3 4 3 4 1.0 

Item 9 3 4 4 4 3 4 1.0 

3 

Item 10 3 3 3 4 4 3 1.0 

Item 11 3 3 3 4 3 4 1.0 

Item 12 3 3 4 4 2 4 0.83 

Item 13 2 2 4 4 2 4 0.50 

Item 14 2 3 4 4 2 3 0.66 

Item 15 3 4 4 4 4 4 1.0 

4 

Item 16 4 4 4 4 4 4 1.0 

Item 17 4 4 4 4 4 4 1.0 

Item 18 4 4 4 4 4 4 1.0 

Item 19 4 3 3 4 4 4 1.0 

5 Item 20 4 4 4 4 4 4 1.0 

Item 21 3 4 4 4 4 4 1.0 

Item 22 3 4 4 4 3 4 1.0 

Item 23 3 3 4 4 3 4 1.0 

6 

Item 24 3 4 4 4 4 4 1.0 

Item 25 3 4 3 3 4 4 1.0 

Item 26 4 4 4 4 3 4 1.0 

Item 27 4 4 4 4 3 4 1.0 

Item 28 3 3 4 3 4 3 1.0 

7 Item 29 3 4 3 4 3 4 1.0 

8 Item 30 3 4 3 4 4 4 1.0 

9 Item 31 3 4 † 

NR 4 3 4 0.83 

10 Item 32 3 4 † 

NR 4 4 4 0.83 

* Scoring: 1 = Not relevant; 2 = Somewhat relevant; 3 = Quite relevant; 4 = Highly relevant 

† 

NR = No response 



SHORT REPORT 

the established use of this approach for assessing 

readiness in the stages of change model of 

behaviour change. 26 This model has been used extensively 

to assess readiness to change long-term 

health behaviours, such as quitting smoking. 29 Its 

relevance to assessing health professionals’ readiness 

to change long-term professional behaviours 

merits further investigation. The questions related 

to knowledge and networks were informed 

by the same model that posits awareness-raising 

is part of making behaviour change. 26 

The self-check tool appears to be well aligned 

with the Physiotherapy New Zealand PHC draft 

document 17 which sets out a competency pathway 

for physiotherapists to engage in PHC. While it 

has application to individual professional development 

of physiotherapists, it may also be useful 

in the wider context of team and organisational 

development. For example, it could form the basis 

for discussion between line managers and staff 

concerning gaps and opportunities for contributing 

to PHC and strategies for changing practice. 

Additionally, with minor modifications it has the 

potential to be used by other health professional 

groups. 

As this is the first investigation of this self-check 

tool, further research into its validity is required 

to support its use by the physiotherapy profession 

and other health professions. 

References 

1. Ministry of Health. The Primary Health Care Strategy. Wellington: 

Ministry of Health; 2001. 

2. Sheridan NF, Kenealy TW, Connolly MJ, Mahony F, Barber PA, 

Boyd MA, et al. Health equity in the New Zealand health care 

system: a national survey. Int J Equity Health. 2011;10(45):1–14. 

3. Michael YL, Whitlock EP, Lin JS, Fu R, O’Connor EA, Gold R. 

Primary care-relevant interventions to prevent falling in older 

adults: a systematic evidence review for the U.S. preventive 

services task force. Ann Intern Med. 2010;153:815–25. 

4. The Australian Lung Foundation & the Thoracic Society of 

Australia & New Zealand. The COPD-X Plan: Australian and 

New Zealand guidelines for the management of chronic 

obstructive pulmonary disease: Australia; 2006. 

5. Hay EM, Foster NE, Thomas E, Peat G, Phelan M, Yates 

HE, et al. Effectiveness of community physiotherapy and 

enhanced pharmacy review for knee pain in people aged over 

55 presenting to primary care: pragmatic randomised trial. 

BMJ.2006;333(7576):995. 

6. Ferrarello F, Baccini M, Rinaldi LA, Cavallini MC, Mossello E, 

Masetti G, et al. Efficacy of physiotherapy interventions late 

after stroke: a meta-analysis. J Neurol Neurosurg Psychiatry. 

2011;82:136–43. 

7. Mulligan H, Fjellman-Wiklund A, Hale L, Thomas D, Hager- 

Ross C. Promoting physical activity for people with neurological 

disability: perspectives and experiences of physiotherapists. 

Physiother Theory Pract. 2011;27(6):399–410. 

8. Norman E, Sherburn M, Osborne RH, Galea MP. An exercise 

and education program improves well-being of new mothers: 

a randomized controlled trial. Phys Ther. 2010;90(3):348–55. 

9. Dean E. Physical therapy in the 21st century (Part I): Toward 

practice informed by epidemiology and the crisis of lifestyle 

conditions. Physiother Theory Pract. 2009;25(5–6):330–53. 

10. Dean E. Physical therapy in the 21st century (Part II): 

evidence-based practice within the context of evidenceinformed 

practice. Physiother Theory Pract. 2009;25(5– 

6):354–68. 

11. Schlessman AM, Martin K, Ritzline PD, Petrosino CL. The 

role of physical therapists in pediatric health promotion and 

obesity prevention: comparison of attitudes. Pediatric Phys 

Ther. 2011;23(1):79–86. 

12. Collins L, Nash R, Round T, Newman B. Perceptions of upperbody 

problems during recovery from breast cancer treatment. 

Support Care Cancer. 2004;12:106–113. 

13. Ministry of Health. Physiotherapists: Health Workforce Annual 

Survey. Wellington: Ministry of Health; 2011. 

14. Stewart JJ, Haswell K. Primary health care in Aotearoa, New 

Zealand: challenges and opportunities for physiotherapists. 

NZJP. 2007;35(2):48–53. 

15. New Zealand Society of Physiotherapists. Engaging in primary 

health care: New Zealand Society of Physiotherapists Primary 

Health Care Working Party Report. Wellington; 2008. 

16. Physiotherapy New Zealand Primary Healthcare Working 

Group. Draft Physiotherapy Primary Healthcare Working 

Group Report: developing a competency pathway to primary 

healthcare. Wellington; 2011. 

17. Auckland University of Technology. The Auckland University 

of Technology Calendar 2012. Auckland; 2012. 

18. World Health Organization and UNICEF. Primary Health Care: 

Report of the International Conference on Primary Health 

Care. Alma-Ata USSR. Geneva;1978. 

19. Ministry of Health. Critical analysis of the implementation of 

the Primary Health Care Strategy implementation and framing 

of issues for the next phase. Wellington: Ministry of Health; 

2009. 

20. Winnard D, Crampton P, Cumming J, Sheridan N, Neuwelt P, 

Arroll B, et al. ‘Population Health’—meaning in Aotearoa New 

Zealand A discussion paper to support implementation of the 

Primary Health Care Strategy. Wellington; 2008. 

21. Winnard, D. Health promotion in PHOs: towards a mutual 

understanding of this new resource in the primary care team. 

N Z Fam Phys. 2007;34(1):45–5. 

22. Ministry of Health. A guide to developing health promotion 

programmes in primary health care settings. Wellington: 

Ministry of Health; 2003. 

23. Rea R, Kenealy T, Wellingham J, Moffitt A, Sinclair G, 

McAuley S, et al. Chronic Care Management evolves towards 

Integrated Care in Counties Manukau, New Zealand. N Z Med 

J. 2007;120(1252):1–11. 

24. Auckland Regional Public Health Service. Guidelines for health 

promotion planning and action in PHOs: Auckland; 2008. 

25. Dulin PL, Stephens C, Alpass F, Hill RD, Stevenson B. The 

impact of socio-contextual, physical and lifestyle variables 

on measures of physical and psychological wellbeing among 

Maori and non-Maori: the New Zealand Health, Work and 

Retirement Study. Ageing Soc. 2011;31:1406–1424. 

26. Prochaska J, DiClemente C. Stages and processes of selfchange 

of smoking: towards an integrated model of change. J 

Consult Clin Psychol. 1983;52:390–5. 

27. Polit DF, Beck CT, editors. Nursing research: generating and 

assessing evidence for nursing practice. 8th edition. Philadelphia: 

Lippincott Williams & Wilkins; 2008. 

28. Leach MJ, Gillham D. Evaluation of the evidence-based 

practice attitude and utilization survey for complementary 

and alternative medicine practitioners. J Eval Clin Pract. 

2008;14:792–8. 

29. Cahill K, Lancaster T, Green N. Stage-based interventions 

for smoking cessation. Cochrane Database Syst Rev. 

2010;11:CD004492. 




BACK TO BACK 

Medical professionalism requires that the 

best interest of the patient must always 

come first 

Nicolette Sheridan 

PhD, RN 

Associate Dean Equity, 



of Auckland and Associate 

Professor, School of Nursing, 

The University of Auckland, 



n.sheridan@auckland.ac.nz 

Sheridan N. Medical professionalism 

requires that the 

best interest of the patient 

must always come first—the 

‘yes’ case. J Prim Health Care. 

2013;5(1):74–75. 

YES 

Patient welfare has been central to every declaration 

of medical professionalism and medical ethics 

from the oath of Hippocrates to the recent Physicians’ 

Charter. 1,2 The latter is a combined statement 

from the European Federation of Internal Medicine, 

American College of Physicians, American 

Society of Internal Medicine, and American Board 

of Internal Medicine. It reaffirms the fundamental 

principles that physicians’ professionalism lies in 

‘placing the interests of patients above those of 

the physician, setting and maintaining standards 

of competence and integrity, and providing 

expert advice to society on matters of health’. 1,2 

The continual need to re-state the ‘universal 

truth’ of patient centrality can only be because 

current practice is seen to fall short of ideal, and 

principles need re-interpretation to be relevant in 

an increasingly complex and changing world. 

That practice often falls short of ideal is clear and 

uncontested. In part this is due to the shortcomings 

of doctors-as-human. In part it is due to the 

health care environment that includes radical 

increases in technology, changing market forces, 

problems in health care delivery systems, bioterrorism, 

and globalisation. 1,2 In recent decades, 

managerial ideology has infiltrated health care 

and driven economic efficiency over effectiveness 

and quality. The tools and methods of business 

science and managers were applied in attempts to 

solve complex problems within the health sector. 

Medical professionalism became subsumed by 

these values, which has negatively affected morale. 

3 Marmor contends that ‘modern medicine’s 

most prominent topics—cost, quality, access, and 

organisation—are marked by linguistic muddle 

and conceptual confusion’. 4 

If medicine is to be governed by a philosophy 

rather than a balance sheet 3 and doctors are to 

reassert the values of patient primacy, a focus 

on the re-organisation and re-valuing of medical 

work is vital. The numerous specialties and subspecialties 

within medicine no longer meet the 

health needs of the growing number of patients 

with chronic and overlapping conditions. 5 Plochg, 

Klazingal and Starfield, 5 among others, have argued 

that by instilling in the medical profession 

the belief that population health needs should be 

the leading principle for the professionalisation 

processes within medicine, professional models 

of care could be transformed in ways that better 

serve patient populations with complex and/or 

chronic illnesses. There is an increasing awareness 

of the need for medical professionalism to be 

reoriented towards ageing populations, multimorbidity, 

accelerating costs and the anticipated 

health workforce crisis. 

BACK TO BACK this issue: 

Nicolette Sheridan 

Stephen Buetow 

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. 


BACK TO BACK 

Whilst the direct physician–patient relationship 

is important, the Physicians’ Charter promotes 

equity in the provision of health care resources 

and is intended to be applicable to different 

cultures and political systems. In a New Zealand 

context, this mandates specific attention to equity 

for Maori and Pacific populations. Alongside 

the principle of primacy of patient welfare (a 

dedication to serving the interest of the patient), 

and of no less importance, are the principles of 

patient autonomy (physician respect for patient 

autonomy, honesty with patients, and actions that 

empower patients to make informed decisions 

about their treatment) and social justice (the 

medical profession must promote justice in the 

health system, including the fair distribution of 

resources, and physicians should work to eliminate 

discrimination in health care). The Charter 

promotes competence, confidentiality, honesty, 

appropriate relationships with patients, improving 

quality and access to health care, fair distribution 

of resources, integrity of scientific knowledge, 

trust, and professional responsibilities. 1,2 It is 

through a longstanding commitment to promote 

public good that the medical profession has been 

given the right of self-regulation and accepts 

the responsibility that comes with professional 

status. Individual physicians are being asked to 

reaffirm the fidelity of medicine’s social contract 

through a commitment not only to the welfare of 

their patients, but also to the welfare of society 

through actions that improve the health system. 

The medical profession has a central role to play 

in the way medicine and health care is organised. 

The coordination of care and teamwork that ‘puts 

the patient first’ are features of a well-performing 

primary health care system that reports better 

health and equity outcomes. 6 Although competition 

between professions, such as nursing and 

pharmacy, and between medical specialties has 

been inherent to the professionalisation process, 

there are interdependent relationships that must 

be built and maintained if good care is to be 

delivered over time and in different settings. 

Furthermore, the health system is recognised 

as a determinant of health, ‘influenced by and 

influencing, the effect of other determinants of 

health’. 7 Physicians have a fiduciary duty to their 

patients because the asymmetry of knowledge 

and clinical information favours the physician. 

Patients often feel vulnerable, and those with 

chronic conditions can experience the compounding 

jeopardy associated with poverty, ethnic 

minority status, and older age. 8 Physicians in 

primary health care require knowledge, skills 

and competence if they are to assist patients to 

navigate the health system. Patients repeatedly 

state the qualities they value most in their doctor 

include listening to their most important concerns, 

respecting their beliefs, and assisting them 

to engage in their own care. 9 Redefining medical 

professionalism to better respond to the changing 

health needs of individuals and populations promotes 

good doctoring and is the only legitimate 

route to securing the long-term place of medicine 

within the future health system. 

My perspective is that of an academic nurse with 

considerable experience in undertaking research 

with patients and families about their experiences 

of living with chronic illnesses and their expectations 

of health professionals, including doctors. 

In addition, I have institutional responsibilities 

for monitoring and promoting equity, which is a 

strongly held personal principle. 

References 

1. Medical Professionalism Project. Medical professionalism 

in the new millenium: a physicians’ charter. Lancet. 

2002;359:520–22. 

2. ABIM Foundation. American Board of Internal Medicine; ACP- 

ASIM Foundation. American College of Physicians–American 

Society of Internal Medicine; European Federation of Internal 

Medicine. Medical professionalism in the new millennium: a 

physician charter. Ann Intern Med 2002;136:243–6. 

3. Horton R. The doctor’s role in advocacy. Lancet. 

2002;359:458. 

4. Marmor TR. Fads in medical care policy and politics: the rhetoric 

and reality of managerialism. In: Marmor TR, editor. Fads, 

fallacies and foolishness in medical care management and 

policy. Singapore: World Scientific Publishing; 2007. p. 1–26. 

5. Plochg T, Klazinga NS, Starfield B. Transforming medical 

professionalism to fit changing health needs. BMC Med. 

2009;7:64. DOI: 10.1186/1741-7015-7-64. 

6. World Health Organization (WHO). The World Health Report 

2008. Primary health care: now more than ever. Geneva: 

WHO; 2008. p. 119. 

7. Commission on Social Determinants of Health (CSDH). Closing 

the gap in a generation: health equity through action on 

the social determinants of health. Final Report of the CSDH. 

Geneva: WHO; 2008. p. 247. 

8. Sheridan NF, Kenealy TW, Kidd JD, Schmidt-Busby JI, Hand 

JE, McKillop AM, et al. Patients’ engagement in primary care: 

powerlessness and compounding jeopardy. A qualitative 

study. Health Expect. 2012;Epub 2012 Oct 4. DOI: 10.1111/ 

hex.12006. 

9. Sheridan N, Kenealy, T, Salmon E, Rea H, Raphael, D, Schmidt- 

Busby J. Helplessness, self blame and faith may impact on self 

management in COPD: a qualitative study. Prim Care Respir J. 

2011;20(3):307–14. 


BACK TO BACK 

Medical professionalism requires that the 

best interest of the patient must always 

come first 

Stephen Buetow PhD 

Associate Professor, 


Practice and Primary Health 

Care, The University of 



s.buetow@auckland.ac.nz 

Buetow S. Medical 

professionalism requires that 

the best interest of the patient 

must always come first—the 

‘no’ case. J Prim Health Care. 

2013;5(1):76–77. 

NO 

As one of six key elements of high-quality care, 1 

patient-centred care puts patients first. So too, 

for example, does the 2002 Physician Charter, 

endorsed by over 130 medical organisations 

worldwide. 2 The Charter’s first principle, the 

‘primacy of patient welfare’, has been the basis 

of medicine’s contract with society since at least 

the time of Hippocrates. This principle also finds 

explicit support in New Zealand primary care, for 

example through the Patients First partnership. 

How could anyone seriously doubt that patients’ 

interests are paramount in health care 

One reason for such doubt is that people do not 

always say what they mean. Even when speaking 

in support of patient-centred care, clinicians 

may tend to exclude patients as active partners 

by using clinician-centric terms such as ‘medical 

error’, ‘provider continuity’ and ‘pay-forperformance’. 

3–5 Moreover, the individualistic 

focus of patient-centred care contradicts clinicians’ 

engagement with both the epidemiological 

pedigree of evidence-based medicine (and 

its inference of individual effects from average 

group effects) and policy initiatives such as New 

Zealand’s Primary Health Care Strategy. This 

Strategy has increased the tension that clinicians 

can face between personal and population 

health care delivery. Seduced into adopting the 

potentially adversarial role of a ‘double agent’, 6,7 

primary care clinicians have been expected 

to advocate for patients while implementing 

government health policy that confers much 

larger benefits to the community than to most 

individual patients. 8 

The alternative to putting patients first is not 

clinician self-interest or a communitarian ethic. 

What is needed instead is an inclusive and 

interactionist approach informed by a minimal 

principle of equality. This ethical principle requires 

‘equal consideration of equal interests’ as 

advocated by philosophers such as David Hume 

and, more recently, Peter Singer. For the sake 

of clarity, I will explain this principle for the 

dyadic case of the clinician–patient relationship. 

On the basis of their personhood, patients and 

clinicians are moral equals. Their equal interests 

include being treated, and treating others, 

with dignity. Each of these parties has a moral 

right—and, within the limits of what individual 

circumstances can allow, a moral responsibility—to 

help satisfy these equal interests through 

giving and receiving care. One justification for 

this right is moral sentiment theory, which 

explains the entitlement to equality in terms of 

‘the faculty of empathy and the fact of interdependence’. 

9 Equal consideration of equal interests 

is also important because it can enhance the 

consequences of medical care. 

The greater the lack of consideration of equal 

interests, the greater the capacity for an imbalance 

and misuse of power by clinicians—and 

indeed by patients, whose modern relationship 

with the clinician has increasingly developed 

through role convergence into an ‘adult–adult’ 

relationship. Such a relationship between 

the clinician and patient is characterised by 

mutuality of different but equally important 

sources of participatory power. 10 However, in 

any clinician–patient relationship, subordination 

of clinician interests can harm clinicians and 

patients because the interests of both parties 

are integrally connected. For example, when 

clinicians feel tired, devalued and neglect their 


BACK TO BACK 

own health, patients may share the fallout. As 

Foucault 11 proposed, care of the self is required 

for ‘the proper practice of freedom in order to 

know oneself … form oneself’—and so be able 

to care about others. Of course, sometimes the 

interests of the patient will trump those of the 

clinician, and vice versa. Stress may lead clinicians, 

for example, to ask patients to wait, or 

return for another visit. It can be seen, therefore, 

that equal consideration of interests does 

not necessarily require treating the patient and 

clinician the same. 

Glyn Elwyn and I drew upon the principle of 

equality to frame our advocacy for a new, more 

egalitarian model of the patient–clinician relationship. 

12 Characterised by reciprocated caring, 

this model is described by the metaphor of a 

‘window mirror’, 12 wherein ideally the clinician 

and patient may see—and care for—both themselves 

and another person at the same time; and 

alternate the focus. The window mirror makes 

concurrently visible at least four directions of 

sight: clinician to patient, patient to self, clinician 

to self, and patient to clinician. These pathways 

intersect with each other, precluding the equal 

interests of either the patient or the clinician 

from coming first. 

References 

1. National Research Council. Crossing the quality chasm: a new 

health system for the 21st century. Washington, DC: The 

National Academies Press; 2001. 

2. ABIM Foundation. American Board of Internal Medicine; ACP- 

ASIM Foundation. American College of Physicians–American 

Society of Internal Medicine; European Federation of Internal 

Medicine. Medical professionalism in the new millennium: a 

physician charter. Ann Intern Med 2002;136:243–6. 

3. Buetow S. Towards a new understanding of provider continuity. 

Ann Fam Med. 2004;2:509–11. 

4. Buetow S, Elwyn G. Patient safety and patient error. Lancet 

2007;369:158–61. 

5. Buetow S, Elwyn G. Patient performance standards: the next 

bold policy initiative in health care J Health Serv Res Policy. 

2007;12:48–53. 

6. Buetow S, Docherty B. The seduction of general practice and 

illegitimate birth of an expanded role in population health 

care. J Eval Clin Pract. 2005; 11:397–404. 

7. Angell M. The doctor as double agent. Kennedy Inst Ethics J. 

1993;3:279–86. 

8. Rose G. The strategy of preventive medicine. Oxford: Oxford 

University Press; 1992. 

9. Krause S. Moral sentiment and the politics of human rights. 

Art Theory 2010. [Cited 2012 Nov 29]. Available at: www. 

artoftheory.com/moral-sentiment-and-the-politics-of-humanrights-sharon-krause/ 

10. Goodyear-Smith F, Buetow S. Power issues in the doctorpatient 

relationship. Health Care Anal. 2001;9:449–62. 

11. Foucault M. Essential works of Foucault 1954–84. London: 

Penguin Books; 1997. 

12. Buetow S, Elwyn G. The window mirror: a new model of the 

patient-physician relationship. Open Med 2008;2:E20–5. 

13. Miles A, Mezzich J. Advancing the global communication of 

scholarship and research for personalized healthcare: the International 

Journal of Person Centered Medicine. Int J Person 

Cent Med. 2011;1:1–5. 

Recent support for the principle of equality 

comes from mounting evidence that a modern 

version of person-centred medicine has started 

to supercede patient-centred care. Defined as 

‘a medicine of the person, for the person, by 

the person and with the person’, 13 this model 

focuses centrally on people, including patients 

and clinicians, as moral agents. Through the 

construct of people-centred public health, it 

also responds—beyond clinical practice—to the 

interests of individuals in the context of their 

communities; and carries the imprimatur of over 

30 international groups, including the World 

Health Organization, World Organization of 

Family Doctors and International Alliance of 

Patients’ Organizations. 

Putting patients first helps neither clinicians nor 

their patients. Both of these parties, among others, 

are entitled to, and can benefit from, respect 

for a principle of equality that considers equal, 

interconnected interests in health care. 


CONTINUING PROFESSIONAL DEVELOPMENT 

PEARLS 

COCHRANE CORNER 

String of PEARLS 

Practical Evidence About Real Life Situations 

Smoking cessation 

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 Ministry of Health, and 

published in NZ Doctor (www.nzdoctor.co.nz.). 

Reduction and abrupt cessation equally effective for 

smokers wanting to quit 

Motivational interviewing may assist smokers to quit 

Mobile phone–based interventions effective in short 

term for smoking cessation 

Nicotine receptor partial agonists effective for smoking 

cessation 

Acupuncture for migraine 

is at least as effective as 

prophylactic drug treatment 

Megan Arroll PhD, FHEA, CPsychol, CSci, AFBPsS; Visiting Research 

Fellow, Chronic Illness Research Team, University of East London, 

Stratford Campus, Water Lane, London, E15 4LZ, United Kingdom; 

m.a.arroll@sa.uel.ac.uk 

THE PROBLEM: Migraine is a common problem in the general 

population, often leading to a patient retreating to a darkened 

room until the symptoms pass. Some patients suffer from attacks 

so frequently that they require prophylactic intervention; 

however, pharmacological treatments may be accompanied by 

adverse and sometimes distressing side effects, which patients 

and doctors alike would prefer to avoid. Acupuncture is a 

widely used complementary therapy that causes neurophysiological 

changes in the patient, without the side effects of 

medication that may lead to poor compliance. 

CLINICAL BOTTOM LINE: This review shows acupuncture is 

more effective than no treatment and at least as effective as, or 

possibly more effective than, prophylactic drug treatment, and 

has fewer adverse effects. 

Insufficient evidence for effectiveness of acupuncture 

for smoking cessation 

Insufficient evidence for hypnotherapy in smoking 

cessation 

Limited evidence for exercise in smoking cessation 

DISCLAIMER: PEARLS are for educational use only and are not meant 

to guide clinical activity, nor are they a clinical guideline. 

Treatments for migraine: acupuncture vs prophylactic drug treatment 

Acupuncture 

vs prophylactic 

drug treatment 

Success Evidence Harms 

Effective: 

Up to 8–12 weeks 

NNT for acupuncture vs 

no treatment = 4.5 

(range 1 to 7) 

NNT for acupuncture vs 

medication = 8 

(range 7 to 9) 

Cochrane 

review 1 

No major 

harms 

NNT = numbers needed to treat. An NNT of 4.5 means that for every 4–5 people 

given the treatment, 1 person will find the treatment effective. 

Reference 

1. Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture 

for migraine prophylaxis. Cochrane Database of Systematic Reviews 2009, Issue 

1. Art. No.: CD001218. DOI: 10.1002/14651858.CD001218.pub2. 

All people residing in New Zealand have access to the Cochrane Library 

via the Ministry website www.health.govt.nz/cochrane-library 



NUGGETS OF KNOWLEDGE 

Cephalosporins for people with penicillin allergy 

Linda Bryant MClinPharm, PGDipHospPharmAdmin, PhD, FNZHPA, FNZCP, FPSNZ, MCAPA 

Cross-allergy between penicillins 

and cephalosporins 

Interpretation of the literature regarding any 

cross-allergy between penicillins and cephalosporins 

is fraught with difficulty. The main 

issues in the literature concern the definition of 

the type of allergy, that drug allergies are heterogeneous 

and multifactorial, and that there has 

been little or no account taken of the generation 

of cephalosporin. 

Definition of the type of allergy 

• Only 80–90% of those with a history of penicillin 

allergy have a true allergy (see Table 1). 

Others have experienced a delayed hypersensitivity 

or ‘adverse drug reaction’ rather than 

a Type 1, IgE-mediated allergic response. 1–6 

• It can be difficult to distinguish between IgEand 

non-IgE-mediated hypersensitivity, especially 

the delayed T-cell-mediated reactions. 4,5 

• Few people have a ‘penicillin allergy’ 

confirmed by skin test. 

• For older people the allergy or hypersensitivity 

may have been due to an impurity 

in the earlier penicillin products. 

• Early cephalosporins contained trace amounts 

of penicillin, leading to an over-estimate 

of the cross-hypersensitivity reactions. 

Drug allergies are heterogeneous 

and multifactorial 

• For penicillins, an IgE-mediated allergy is 

most likely to be due to the side chain, 3,4 

but there may be other determinants, 

such as the β-lactam ring or an unknown 

hapten. This influences the cross-hypersensitivity 

rates and predictability. 

• People who have a hypersensitivity to penicillin 

are three times more likely to be hypersensitive 

to any medicine. 6 For example, one 

study found that the people with penicillin 

hypersensitivity (no IgE/skin testing done) 

were as likely to have a hypersensitivity reaction 

to a sulphonamide as to a cephalosporin. 2 

The generation of cephalosporin is 

not usually taken into account 

• The greatest cross-hypersensitivity appears to 

be with first generation cephalosporins, less 

with second generation cephalosporins and 

there appears to be negligible cross-hypersensitivity 

with third and fourth generation cephalosporins—but 

a person may have a hypersensitivity 

to any cephalosporin independent 

of any hypersensitivity to penicillin. 4,6 

• In general practice, oral antibiotics are predominantly 

used and the oral cephalosporins currently 

available are first- and second-generation 

cephalosporins. Ceftriaxone, the once-daily 

injection, is a third-generation cephalosporin. 

Hospitals are more likely to use third- and 

fourth-generation intravenous cephalosporins. 

Revised rate of cross-hypersensitivity 

The most reliable way to estimate the crosshypersensitivity 

rate is to consider studies where 

IgE testing was undertaken to confirm a true 

penicillin allergy, and checked for a cross-reaction 

against a range of cephalosporins. Skin testing 

for allergy is not perfect, but is currently the best 

method available for determining IgE-mediated 

reactions. Using this methodology, cross-hypersensitivity 

rates range from 4 to 11%, but are dependent 

on the generation of cephalosporin. 2,6,9,10 

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 

Cross-hypersensitivity 

ranges from 4 to 11% 

but is dependent on 

the generation of 

cephalosporin, with 

first-generation cephalosporins 

having the 

highest risk. 


2013;5(1):79–80. 


Linda Bryant 

Clinical Manager, Clinical 

Advisory Pharmacist, 

East Health Trust PHO 

PO Box 38248, Howick 


l.bryant@auckland.ac.nz 



NUGGETS OF KNOWLEDGE 

Table 1. Drug hypersensitivity is classified as four types 12–14 

Type 1 

Type II 

Type III 

Type IV 

Type I is IgE mediated and is ‘allergic’. It is an immediate 

reaction with anaphylaxis, angioedema, urticaria and 

bronchospasm. The drug or drug metabolite reacts with 

IgE bound to the surface of the mast cells and leads to 

the activation, degranulation and release of mast cell-like 

vasoactive mediators like histamine and tryptase. Non-IgEmediated 

are generally but not always delayed, occurring 

after 72 hours. The reactions are haemolytic anaemia, 

interstitial nephritis, thrombocytopenia, serum sickness, 

drug fever, morbilliform eruptions, erythema multiforme, 

maculopapular exanthema, delayed urticaria, Stevens 

Johnson syndrome and toxic epidermal necrolysis. 

Type II reactions involve IgG antibodies. 

Type III reactions involve IgG or IgM antibodies. 

Type IV reactions are T-cell dependent. 

Risk mitigation strategies 

• Is it clinically equivalent to use an alternative 

antibiotic 

• If the description of the hypersensitivity 

suggests an immediate and/or severe reaction, 

do a skin penicillin sensitivity test to confirm 

whether the hypersensitivity is IgE mediated. 

• If the ‘allergy’ is to penicillin, then caution is 

required with cephaloridine, cephalothin, 

cephamandol 6 and cefoxitin (similar side 

chains). Cefuroxime, cefpodoxime, and 

cefdinir carry less risk. 1,10 

• If the ‘allergy’ is to amoxicillin, then caution is 

required with cephalexin, cephradine, cefaclor, 

cefatrizine, cefadroxil and cefprozil. 1,10 

• Be aware that some people are allergic to 

cephalosporins and not penicillin. 

• A negative skin test may not have identified a 

minor determinant. 

• Before the risk for an immediate reaction can 

be ruled out, and regardless of skin test results, 

patients should receive a graded challenge of 

the drug in question in settings with readily 

available emergency medical support. 11 

References 

1. Pichichero M. A review of evidence supporting the American 

Academy of Pediatrics recommendation for prescribing cephalosporin 

antibiotics for penicillin-allergic patients. Pediatrics. 

2005;115:1048–57. 

2. Lam A, Randhawa I, Klaustermeyer W. Cephalosporin induced 

toxic epidermal necrolysis and subsequent penicillin drug 

exanthem. Allergol Int. 2008;57:281–4. 

3. Antunez C, Martin E, Cornejo-Garcia J Blanca-Lopez N, 

R-Pena R, Mayorga C, et al. Immediate hypersensitivity reactions 

to penicillins and other beta-lactams. Curr Pharm Des. 

2006;12:3327–33. 

4. Morena E, Macias E, Davila I, Laffond E, Ruiz A, Lorente F. 

Hypersensitivity reactions to cephalosporins. Expert Opin 

Drug Saf. 2008;7:295–304. 

5. Guglielmi L, Guglielmi P, Demoly P. Drug hypersensitivity: epidemiology 

and risk factors. Curr Pharm Des. 2006;12:3309–12. 

6. Romano A, Gueant-Rodriguez R, Viola M, Pettinato R, Gueant 

J. Cross-reactivity and tolerability of cephalosporins in patients 

with immediate hypersensitivity to penicillins. Ann Intern 

Med. 2004;141:16–22. 

7. Apter A, Kinman J, Bilker W, Herlim M, Margolis DJ, Lautenbach 

E, et al. Is there cross-reactivity between penicillins and 

cephalosporins Am J Med. 2006;119:354.e11–9. 

8. Torres M, Blanca M. The complex clinical picture of betalactam 

hypersensitivity: penicillins, cephalosporins, monobactams, 

carbapenems, and clavams. Med Clin North Am. 

2010;94:805–20. 

9. Park M, Li J. Diagnosis and management of penicillin allergy. 

Mayo Clin Proc. 2005;80:405–10. 

10. Cormier A, Rieder M, Matsui D. What is the risk of using a 

cephalosporin in a patient with a penicillin allergy Paediatr 

Child Health. 2007;12:387–8. 

11. Postemnick M. How effective is penicillin skin testing 

Medscape. November 2nd 2010 [cited 2012 Dec 7]. Available 

from: http://www.medscape.com/viewarticle/731204src=m 

p&spon=30&uac=1752BZ 

12. Riedl M, Casillas A. Adverse drug reactions: types and treatment 

options. Am Fam Phys. 2003;68:1781–91. 

13. Pichler W, Adam J, Daubner B, Gentinetta T, Keller M, Yerly D. 

Drug hypersensitivity reactions: pathomechamism and clinical 

symptoms. Med Clin N Am. 2010;94:945–64. 

14. Solensky R, Khan D, editors. Drug allergy: an updated practice 

parameter. Ann Allergy Asthma Immunol. 2012;105:e1-78. 



POTION OR POISON 

Probiotics 

Some community pharmacies are recommending 

purchase of probiotics with antibiotic prescriptions: 

Where does the evidence lie 

SOME AVAILABLE BRANDS: These include 

Natren, Blackmores, Inner Health, Nature’s Way, 

NFS, Oragenics, Thompson’s. 

ACTIVE CONSTITUENTS: These vary depending 

on the product, but the most common probiotics 

include Lactobacilli spp., Bifidobacterium spp., 

Streptococcus spp. and Saccharomyces boulardii. 

MANUFACTURER CLAIMS: Probiotics are 

deemed to be ‘good bacteria’ claimed to help 

relieve a variety of health problems, including 

chronic diseases, autoimmune diseases, acid 

reflux, coronary heart disease, irritable bowel 

syndrome, food poisoning and lactose intolerance. 

There are claims probiotics have an involvement 

with autism and yeast infections and that they 

may restore the ‘natural balance’ of bacteria in the 

intestinal tract depleted through antibiotic use. 

EVIDENCE FOR EFFICACY: There are 26 

Cochrane Library Reviews covering a range of 

indications, including one on antibiotic-associated 

diarrhoea (AAD) in children, which suggests that 

Lactobacillus rhamnosus and Saccharomyces boulardii 

at a high dosage of 5–40 billion CFU/day 

may prevent the onset of AAD, but this needs to 

be confirmed by a large, well-designed blinded 

randomised trial. No conclusions about effectiveness 

and safety of other probiotic agents for paediatric 

AAD can be drawn. More refined studies 

are needed to evaluate strain-specific probiotics 

and report both effectiveness (e.g. incidence and 

duration of diarrhoea) and safety of probiotics. 

There is insufficient evidence to recommend probiotic 

therapy in adults as an adjunct to antibiotic 

therapy for Clostridium difficile colitis. There is 

no evidence to support the use of probiotics alone 

in adults for the treatment of C. difficile colitis. 

Summary Message 

Two types of probiotic (Lactobacillus rhamnosus and Saccharomyces boulardii) 

at high doses may prevent the onset of antibiotic-associated diarrhoea 

in children. Probiotics are generally well tolerated. Clinical benefit needs to 

be confirmed in larger studies across a greater range of probiotics. There is 

insufficient evidence to recommend probiotic therapy in adults as an adjunct 

to antibiotic therapy, specifically for Clostridium difficile-induced colitis. 

ADVERSE EFFECTS: Probiotics are reported to 

be generally well tolerated in children. Minor 

side effects occur infrequently. Rash, nausea, 

gas, flatulence, vomiting, increased phlegm, chest 

pain, constipation, taste disturbance, and low appetite 

have been reported. 

CONTRAINDICATIONS: These include hypersensitivity 

to lactose or milk (Lactobacillus) and 

yeast allergies (S. boulardii). 

PRECAUTIONS: Probiotics should be used with 

caution in the critically ill or severely immunecompromised, 

those with short bowel syndrome, 

and those using central venous catheters. 

DRUG INTERACTIONS: More drug interaction 

studies and surveillance is required. It is recommended 

to separate administration of probiotics 

from antibiotics by at least two hours. Probiotics 

should not be taken with systemic antifungals, 

immunosuppressants or chemotherapeutics. 

Key references 

Johnston BC, Goldenberg JZ, Vandvik PO, Sun X, Guyatt GH. Probiotics 

for the prevention of paediatric antibiotic-associated 

diarrhoea. Cochrane Library www.cochranelibrary.com 9th 

November 2011 DOI: 10.1002/14651858.CD004827.pub3 

Pillai A, Nelson RL. Probiotics for treatment of clostridium 

difficile-associated colitis in adults. Cochrane Library www. 

cochranelibrary.com 16th July 2008, DOI: 10.1002/14651858. 

CD004611.pub2 

Williams NT. Probiotics. American Journal of Health-System Pharmacy. 

2012; 67(6):449–458. 

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. 

Shane L Scahill 

BPharm, MMgt, 

PhD, RegPharmNZ 


2013;5(1):81. 


Shane L Scahill 

Honorary Senior Lecturer, 

School of Pharmacy, 

The University of 



s.scahill@auckland.ac.nz 


ETHICS 

Reporting suicide: safety isn’t everything 

Colin Gavaghan LLB (Hons), PhD; 1 Mike King BAppSc (Hons), PgDipArts, PhD 2 

1 

Faculty of Law, University 

of Otago, Dunedin, New 

Zealand 

2 

Bioethics Centre, University 

of Otago, Dunedin 


2013;5(1):82–85. 


Colin Gavaghan 

Faculty of Law, 


PO Box 56, Dunedin 

9054, New Zealand 

colin.gavaghan@ 

otago.ac.nz 

Between July 2011 and July 2012, 547 New 

Zealanders took their own lives. 1 Although 

considerably higher than Canada, Australia 

or the United Kingdom, this figure is not especially 

high by international standards, and New 

Zealand sits near the average for overall suicide 

rate among OECD countries and has done for 

some time. 2 However, New Zealand youth suicide 

rates are among the worst in OECD countries. 

We have recorded the third highest rate for males 

aged 15–24 years, and the highest rate for young 

females of the same age, in recent data. 3 It is 

therefore with good reason that the Government, 

the Law Commission, the Chief Coroner and others 

continue to develop and investigate initiatives 

and proposals aimed at reducing our suicide rate, 

particularly among this younger cohort. 

Given that this age group is widely considered to 

be particularly vulnerable to peer pressure and 

‘copycat’ behaviour, it is perhaps no surprise that 

significant attention is being paid to the possible 

correlation between depictions of, and incidence 

of, suicide. The debate around media reporting 

on suicide is not a new one, but it has been given 

increased prominence by some recent events and 

statements by influential figures. Much of this has 

focused on whether media depictions of suicide are 

likely to increase or decrease numbers of suicides, 

why this may be, and how it might be avoided. 

While these are obviously important questions, 

they are not the only considerations that should 

inform policy in this area. Privacy rights of the 

deceased and their family are weighty concerns 

militating against public dissemination of information 

pertaining to a suicide or suicide attempt, 

unless such rights are waived. However, it may be 

that the details of particular suicides, or suicide 

attempts, can also play an important role in informing 

public discussion of current and emerging 

social problems, policy debates, and proposed 

law reforms. The background to, and circumstances 

of, some suicide deaths can raise a legitimate 

case for media scrutiny in the public interest. 

While factors favouring public reporting of the 

details of suicides have to be weighed against any 

risk of encouraging further incidents of it, focusing 

only on the latter would be a mistake. 

What the law says 

New Zealand law presently imposes fairly strict 

limits on reporting suicide. Section 71(1) of the 

Coroners Act 2006 provides that ‘No person 

may, without a coroner’s authority, make public 

any particular relating to the manner in which a 

death occurred if— 

(a) the death occurred in New Zealand after the 

commencement of this section; and 

(b) there is reasonable cause to believe the death 

was self-inflicted; and 

(c) no inquiry into the death has been completed.’ 

Some doubt surrounds what, for these purposes, 

would constitute a ‘particular relating to the 

manner in which a death occurred.’ Is it reporting 

on the precise manner of the suicide that is 

banned Or would reporting the mere fact, or 

suspicion, of a suicide amount to a breach of the 

law The current Chief Coroner, Neil MacLean, 

has made it clear that in his opinion, ‘the media 

would breach the Act if the death is reported 

as an apparent, suspected or presumed suicide.’ 4 

Unless and until the issue comes before a court, 

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: This issue focuses on media reporting of suicide and aspects other than safety that warrant 

consideration. 


ETHICS 

though, the point remains moot. (For a thoughtful 

discussion of this point, see Steven Price’s 

article ‘Killing the Messenger’. 5 ) 

Even after a coroner’s inquiry has concluded that 

a death was suicide, statutory restrictions remain 

in place. Under section 71(2) of the Coroners Act 

2006, ‘no person may, without a coroner’s authority 

or permission … make public a particular of 

the death other than— 

(a) the name, address, and occupation of the 

person concerned; and 

(b) the fact that the coroner has found the death 

to be self-inflicted.’ 

Section 71(3) of the 2006 Act states that the only 

grounds on which a coroner may authorise the 

making public of any other particulars of the 

death are ‘that the making public of particulars of 

that kind is unlikely to be detrimental to public 

safety.’ In making this determination, the coroner 

must have regard to a number of factors, including 

the characteristics of the person who is, or is 

suspected to be, the dead person concerned. It is 

interesting to note that these safety concerns are 

the only grounds which the coroner may use to 

justify authorising making public the details of 

a suicide. Consequently the other considerations 

we have claimed should feature in such a decision 

appear, prima facie at least, to be excluded as 

justifiable grounds at the level of statute. 

The existence and precise parameters of these 

restrictions have been the subject of ongoing 

controversy. In May 2011, the Chief Coroner 

made a public call for ‘more discussion, more accurate 

information’ about suicide. 6 A few months 

later, Prime Minister John Key advocated a more 

liberal approach to suicide reporting. 7 

Some experts, though, have taken issue with 

such calls. In a recent editorial of the New 

Zealand Medical Journal, Annette Beautrais and 

David Fergusson stated that: 

While it is sometimes argued that media publicity 

is beneficial in that it brings an important social 

and health issue to public attention, there is, in 

fact, no evidence that this form of education or dissemination 

does good. 8 

They point to a range of studies that demonstrate 

a causal link between (at least certain kinds of) 

suicide reporting and an increase in the incidence 

of suicide. Indeed, it is precisely such concerns 

that lie behind the reporting restrictions; the fear 

is that frequent and detailed accounts of suicide 

in the media will, at least, normalise suicide as a 

solution to life’s problems, and at worst, potentially 

glamorise it. To quote Chuck Palahniuk: 

‘The only difference between a suicide and a martyrdom 

really is the amount of press coverage.’ 9 

The empirical question of whether, how, and to 

what extent, media depictions of suicide contribute 

to its incidence is, of course, an important 

one. It may be a mistake, however, to regard this 

as the only factor that should weigh upon the 

law’s approach to the subject. There are a number 

of other issues of considerable public importance 

that may be informed or highlighted by reference 

to accounts of suicide. 

Cyber-bullying and online harms 

In August of this year, the New Zealand Law 

Commission published its proposals regarding ‘cyber-bullying’ 

and harmful digital conduct. 10 These 

included introducing a new criminal offence, and 

a Tribunal which would be empowered to order 

‘take-downs’ of harmful online material. In support 

of these proposals, the Commission sought to 

emphasise that ‘harmful digital communications’ 

can cause more than trifling and transient harms. 

By way of emphasising this point, the Commission 

drew attention to several instances of suicide 

or self-harm by (predominantly teenaged or 

younger) victims of such conduct. 

Since the Report’s publication, two widely 

publicised incidents have drawn attention to the 

purported link between harmful online conduct 

and suicidal behaviour: the suicide of Canadian 

teenager Amanda Todd, and the hospitalisation of 

television personality Charlotte Dawson following 

an apparent suicide attempt. 

While the Law Commission’s report set out the 

principled case for reform, it is arguable that 

this alone is often insufficient to effect political 

change. Rather, the emotional impetus is often 

provided when we have the tragic stories of iden- 


ETHICS 

tifiable people to illustrate the problem with the 

status quo. It is sometimes said by cliché-loving 

law lecturers, that hard cases make for bad law; 

but it may also sometimes be true that tragic, 

high-profile cases are the catalysts for necessary 

law. At the very least, such incidents may give us 

pause before dismissing online harms as merely 

digital ‘sticks and stones’, requiring ‘thicker 

skins’ rather than tougher laws. 

Yet, as things stand, had Amanda Todd taken 

her life in New Zealand, it would be a criminal 

offence to mention it in this article, without the 

explicit permission of a coroner—even in the 

context of writing specifically about the Law 

Commission’s proposed reforms. With respect to 

this, it is curious that suicides occurring in other 

countries can be reported without statutory restriction. 

If minimising harm to the public is the 

justification for restriction of suicide reporting 

in New Zealand, this ought to apply regardless 

of the location of the suicidal act in question (at 

least, in the absence of evidence that the emulation 

effect is notably stronger among compatriots). 

Assisting suicide 

In July of this year, Labour MP Maryan Street introduced 

her End of Life Choice Bill. This would 

allow all mentally competent New Zealand adults 

to be provided with medical assistance to end 

their life if they suffer from a terminal disease or 

an irreversible and unbearable medical condition. 

Although the members’ bill has yet to be drawn 

from the ballot, it has already generated considerable 

debate on the issue of assisted suicide. 

Assisted suicide and euthanasia remain contentious 

issues internationally. In jurisdictions 

where they are permitted, like the Netherlands, 

Switzerland and Oregon, attention has often 

focused on people who have availed themselves 

of these laws, sometimes in fairly controversial 

circumstances. The assisted suicide of Edward 

Brongersma, an 86-year-old Dutchman who was 

not terminally ill but had grown ‘tired of life’, 

was seized upon by opponents of liberalisation, 

who saw this as evidence of the ‘slippery slope’ 

towards assistance on demand. In fact, Brongersma’s 

assisted suicide was held by a Haarlem court 

not to satisfy the requirements of the Dutch law. 

However, the case still sheds some valuable light 

on the challenges that can face drafters of any 

such law, and on the possibility that particular 

doctors would misapply it. 

In those jurisdictions where such assistance is 

not permitted, scrutiny has sometimes turned to 

people driven to desperate lengths to end their 

own lives. In New Zealand, the recent suicide of 

Gretha Appleby 11 and the prosecutions of Sean 

Davison and Evans Mott for assisting close relatives 

to take their own lives have been argued by 

assisted dying advocates to illustrate the ‘backstreet’ 

alternatives to providing legal assistance. 

While deaths in the Netherlands are not covered 

by the Coroners Act, those New Zealand deaths 

most assuredly are, so it is interesting that we 

are able to know so much about them. This suggests 

either that the coroners gave permission for 

these details to be published, or that prosecutors 

elected not to bring charges under the 2006 

Act. Either way, it suggests that, contrary to the 

apparent restrictiveness of the Act, a sensible degree 

of discretion is being exercised, whereby the 

risk of emulation is being balanced against the 

contribution such information makes to important 

policy debates. 

Unanswered questions 

There are also those whose suicides may be, to 

some extent, attributable to questionable official 

action—or indeed, inaction. The suicide of medical 

marijuana campaigner Stephen McIntyre has 

led to a campaign by blogger Malcolm Bradbury, 

who has alleged that ‘bullying tactics’ by police 

may have played a significant part in McIntyre’s 

death. 12 UK-based journalist Patrick Butler has 

collected several accounts of suicides that, he argues, 

were related to cuts to benefits and welfare 

services. 13 Medical ethicist Carl Elliott, Mary 

Weiss and others have used details surrounding 

the suicide of Weiss’s son Dan Markingson 

during an anti-psychotic drug trial, to expose and 

attempt to rectify flaws in the conduct and regulation 

of this, and potentially other drug trials. 14 

We are in no position to offer any perspective 

on the truth or otherwise of any of these. But 

the prospect of the law preventing the pursuit of 

justice when suicide is involved is, we suggest, a 

legitimate concern. 


ETHICS 

Conclusion 

Though restrictions on suicide reporting were 

also found in predecessors to the present Coroners 

Act, it was the 2006 Act that introduced the 

rule that ‘the only grounds on which a coroner 

may authorise the making public of any other 

particulars of the death … are that the making 

public of particulars of that kind is unlikely to be 

detrimental to public safety.’ Public safety is of 

course a highly important consideration. However, 

it is not the only valid consideration which 

should bear on such decisions. 

When a suicide seems likely to cast light on a 

serious social or legal problem, or to inform an 

important policy debate, a coroner should be able 

to take that into consideration when deciding 

whether to allow reporting. Indeed, the fact that 

we are able to know something of the background 

to the suicide of, for example, Gretha Appleby, 

suggests that coroners are taking such considerations 

into account (assuming, of course, that permission 

was given, rather than the reports being 

in prima facie violation of the Act). 

The privacy interests, both of the deceased and 

of the surviving family, should also be given 

significant weight. In one of the few occasions 

when a coroner’s decision on such a matter was 

challenged in court, the judge—having carefully 

weighed the competing interests—decided that 

such privacy interests should, on that occasion, 

be given more weight than the public interest in 

open justice. 15 Despite the fact that Section 71 of 

the 2006 Act makes no reference to such privacy 

interests, effort should be put into ascertaining 

the nature and strength of these interests in each 

case, and they should be given due consideration 

by coroners. It would be unwise for coroners to 

assume too much about the wishes of relatives for 

privacy. Chief Coroner Neil MacLean has reported 

some anecdotal evidence of change in this regard: 

What I’m picking up increasingly now is, families 

are asking for [some details of a suicide to be made 

public]. In the past they’ve been saying—please, 

this is a personal private tragedy. Please don’t 

publish anything. Could you even restrict publication 

of the name. That’s starting to change. They 

will often say: we don’t want this to ever happen to 

other parents in a comparable situation. 6 

In short, there is no single consideration that 

should determine all such decisions. Rather, a 

sophisticated and informed balancing of multiple 

interests and values would be the appropriate 

response from coroners. Reducing the suicide rate 

among vulnerable populations is a worthy and 

important concern; but it would be disproportionate 

if heightening of risk to the public, however 

marginal, automatically outweighed all other 

considerations when deciding what restrictions 

to place on reporting suicides. Competing recent 

arguments have tended to focus on the likely 

effects on suicide rates of more open or more 

restrictive reporting. Those arguments deserve 

serious attention and scrutiny. While they make 

important contributions to the issue of suicide 

reporting, they should not be the final word on it. 

References 

1. Ministry of Justice. Chief Coroner releases annual suicide statistics. 

Wellington; September 2012. 

2. OECD. Health at a glance. 2011: OECD indicators. OECD Publishing; 

2011. 

3. Mental Health Commission. National indicators 2011: measuring 

mental health and addiction in New Zealand. Wellington; 2011. 

4. Ministry of Health. Reporting suicide: a resource for the media. 

Developed by the media Roundtable and adopted by the Media 

Freedom Committee and the Newspaper Publishers’ Association. 

Wellington; 2011 December 2011. 

5. Price S. Killing the messenger [Internet]. 2010 Aug 29 [cited 

2012 Nov 30]. Available from: http://www.medialawjournal. 

co.nz/p=387 

6. Banks C. The chief coroner and suicide reporting [Internet]. 

Auckland, New Zealand: Suicide Prevention Information New 

Zealand. 2011 May 27 [cited 2012 Nov 2012]. Available from: 

http://www.spinz.org.nz/page/157-may-2011+improvingsuicide-reporting-the-chief-coroners-view 

7. Chapman K. Key favours loosening suicide reporting rules [Internet]. 

Auckland, Wellington, New Zealand: Fairfax NZ News. 

2011 Aug 29 [cited 2012 Nov 30]. Available from: http://www. 

stuff.co.nz/national/health/5523624/Key-favours-looseningsuicide-reporting-rules 

8. Beautrais AL, Fergusson DM. Media reporting of suicide in New 

Zealand: ‘More matter with less art’ (Hamlet, Shakespeare). N Z 

Med J. 2012;125(1362):5–10. 

9. Palahniuk C. Survivor. New York: W. W. Norton & Company; 

1999. 

10. New Zealand Law Commission. Harmful digital communications: 

the adequacy of the current sanctions and remedies. Wellington, 

New Zealand; 2012 Aug 2012. 

11. Editorial. Woman’s death adds fuel to debate [Internet]. Nelson, 

New Zealand: The Nelson Mail. 2012 Sept 18 [cited 2012 Nov 

30]. Available from: http://www.stuff.co.nz/nelson-mail/ 

news/7695643/Womans-death-adds-fuel-to-debate 

12. Bradbury M. Tumeke exclusive: Did NZ Police tactics kill 

my friend Stephen McIntyre Part 1 [Internet]. 2012 Nov 11 

[cited 2012 Nov 30]. Available from: http://tumeke.blogspot. 

co.nz/2012/11/tumeke-exclusive-did-nz-police-tactics.html 

13. Butler P. Do cuts kill [Internet]. 2011 Nov 16 [cited 2012 Nov 

30]. London, England: The Guardian. Available from: http:// 

www.guardian.co.uk/society/patrick-butler-cuts-blog/2011/ 

nov/16/do-public-spending-cuts-kill 

14. Elliott C. White coat, black hat. Massachusetts: Beacon Press; 

2010:11–16. 

15. Fardell v Attorney General [2007] NZAR 122 (HC). 


BOOK REVIEW 

Buck Up: The real bloke’s guide to getting 

healthy and living longer 

Buck Shelford and Grant Schofield 

Reviewed by Peter Sandiford MBChB, PhD, MMedSci, MSc, FRSM, FFPH, FNZCPHM 

Public Health Physician, 

Planning and Funding, 

Waitemata DHB, Auckland, 



2013;5(1):86. 


Peter Sandiford 

peter.sandiford@ 

waitematadhb.govt.nz 

I 

agreed to review this book with some trepidation, 

as I am not sure the book was intended 

for someone like me who doubts his ‘real bloke’ 

credentials. Nevertheless, my interest in men’s 

health, and perhaps more pertinently my interest 

in my own health as a 52-year-old male easily 

overcame these qualms and I was rewarded as a 

result. 

Buck Up is written by All Black legend Buck 

Shelford together with AUT public health 

professor Grant Schofield. The former provides a 

‘down-to-earth’ personal account of his battle 

with lymphoma and his efforts to keep in 

top physical and mental health, despite going 

through a period of significant weight gain. 

Grant Schofield annotates Buck’s exposition with 

the relevant medical facts and figures, along 

with some of the empirical evidence from which 

these are derived. The book provides a wealth of 

practical advice on how to get and stay fit, how to 

attain and maintain a healthy weight, and how to 

keep mental resilience in the face of modern life’s 

challenges. The final section entitled ‘Medical 

Stuff’ is a useful compendium of information on 

some of the key risks and health problems that 

men may have to confront, including the allimportant 

prostate cancer. 

Although I would consider myself reasonably 

well informed on much of the topic matter in 

this book, I think I learned a lot from reading 

it (especially on matters to do with rugby and 

fitness that I am perhaps not so well versed in). 

I was also pleased to find myself agreeing with 

many of the more philosophical viewpoints 

expressed by Buck and Grant, such as the need 

to allow more free-ranging risk taking (within 

reason) by children, and the importance of family 

mealtimes. I even found myself doing a bit more 

exercise. 

Inevitably there were a few things that I would 

like the authors to have done differently. I felt 

that a book on men’s health shouldn’t go without 

a section offering help on how to quit smoking, 

and I would like to have seen randomised trials 

featuring more prominently in the cited evidence 

for the benefits of exercise. An exhortation to 

greater workplace and recreational safety would 

also have been welcome. To avoid extending the 

length of the book, perhaps the section on sports 

nutrition, which is probably only relevant to a 

minority of readers, could have been omitted. 

These are minor quibbles though and I will 

heartily recommend the book to my male friends 

and my wife too—because, in a way, the title 

of the book seems to narrow down its potential 

readership a bit too much. You don’t have to be 

a real bloke to enjoy its chatty style and benefit 

from its advice. In fact, encouraging one’s partner 

to read at least the sections on diet and eating 

is surely going to greatly increase the chance of 

making and sustaining the sort of changes that 

the book recommends. 

Publisher: Penguin Group (NZ) 

Date of publication: 2012 

No. of pages: 272 

ISBN: 9780143568308 


RESEARCH GEMS 

GEMS OF NEW ZEALAND 

Primary Health Care Research 

Brain stimulation to treat tinnnitis 

Many people describe tinnitus as a ringing, 

buzzing, humming, or whistling 

sound in the absence of its external 

source. In the past five years, attention 

has been drawn towards the use of noninvasive 

brain stimulation for tinnitus 

management. This study examined doseresponse 

effects of transcranial direct 

current stimulation (tDCS) for tinnitus 

relief by stimulation of the left temporoparietal 

area of the brain. In total, 56% 

of participants experienced transient 

suppression of tinnitus and 44% of participants 

experienced long-term improvement 

of symptoms. This suggests that 

tDCS can be a potential intervention 

tool for tinnitus, although more research 

is needed in this area. 

Shekhawat GS, Stinear CM, Searchfield 

GD. Transcranial direct current stimulation 

intensity and duration effects on tinnitus 

suppression. Neurorehabil Neural Repair. 

2013;27(2):164–172. Corresponding 

author: Dr Grant Searchfield; email: 

g.searchfield@auckland.ac.nz 

Providing equity in HPV vaccination 

Vaccination rates across ethnicities in 

New Zealand are not equal. Immunisation 

uptake by Pacific and Maori 

generally has been lower compared with 

NZ European in childhood vaccination 

programmes. A study found this 

trend reversed in 8665 female students 

in the Auckland District Health Board 

area, where Maori and Pacific students 

achieved high levels of vaccination in the 

HPV school-based immunisation programme. 

Girls in higher socioeconomic 

groups were more likely to be vaccinated 

by general practice, indicating that a mix 

of delivery options (school-based and primary 

care) is needed to optimise coverage 

of the New Zealand population. 

Poole T, Goodyear-Smith F, Petousis- 

Harris H, Desmond N, Exeter D, Pointon 

L, Jayasinha R, Human Papillomavirus 

vaccination in Auckland: reducing 

ethnic and socioeconomic inequities. 

Vaccine. 2012. 11 DOI:10.1016/j. 

vaccine.2012.10.099. Corresponding 

author: Felicity Goodyear-Smith; email: 

f.goodyear-smith@auckland.ac.nz 

New Zealand pharmacists’ 

alignment with a future vision 

In 2004, the Pharmaceutical Society 

of New Zealand launched a Ten Year 

Vision (TYV). Significant buy-in from 

pharmacists is required in order to 

implement the TYV. The aim of this 

study was to determine alignment between 

New Zealand pharmacists’ views 

and the TYV. A postal survey was 

undertaken based on attitude statements 

informed through six focus groups. 

Pharmacists’ responses indicated a high 

level of alignment with the TYV. Pharmacists 

appear receptive to practice and 

funding changes in order to facilitate 

greater contribution to patient care. 

Respondents demonstrated a clear desire 

to be involved in medicines-related 

health policy and feel underrepresented 

at this level. 

Harrison J, Scahill SL, Sheridan J. Pharmacy 

in the future: New Zealand pharmacists’ 

alignment with the ‘Ten Year Vision for 

Pharmacists’. Res Soc Admin Pharm 2012, 

8(1):17-35. Corresponding author: Jeff 

Harrison; email: j.harrison@auckland.ac.nz 

Ethnic differences in pre-eclampsia 

Pre-eclampsia affects 3–5% of pregnancies 

and is associated with maternal morbidity 

and mortality. Our multi-ethnic Auckland 

population (n=26 254) study identified 

clinical risk factors independently 

associated with pre-eclampsia, including 

overweight and obesity, nulliparity, 

Type 1 diabetes, chronic hypertension 

and pre-existing medical conditions. 

Chinese women had an approximate 50% 

reduction and Maori a 50% increase in 

risk after adjustment for confounding 

factors. Reduced risk in Chinese women 

has been reported by others and may 

be related to lifestyle or genetic factors. 

The finding of an increased risk amongst 

Maori women is novel and unexpected. 

The mechanism is currently unexplained 

but may be related to metabolic factors. 

Anderson NH, Sadler LC, Stewart AW, Fyfe 

EM, McCowan LME. Ethnicity, Body Mass 

Index and risk of preeclampsia in a multiethnic 

New Zealand Population. Aust N Z J 

Obstet Gynaecol. 2012 DOI:10.1111/j.1479- 

828x.2012. Corresponding author: Ngaire 

Anderson; email: n.anderson@auckland.ac.nz 

GEMS are short précis of original papers published by NZ researchers. FOR A COPY of a full paper please 

email the corresponding author. Researchers, TO HAVE YOUR WORK INCLUDED please send a 100 word 

summary of your paper and the full reference details to: editor@rnzcgp.org.nz 


ABOUT THE JOURNAL OF PRIMARY HEALTH CARE 

The Journal of Primary Health Care 

(JPHC) began publishing in 2009, 

superseding the previous RNZCGP 

journal the New Zealand Family Physician. 

It is a interdisciplinary publication aimed at 

moving research into primary health care 

practice and practice into research. This 

includes the fields of family practice, primary 

health care nursing and community pharmacy 

as well as areas such as health care delivery, 

health promotion, epidemiology, public health 

and medical sociology of interest to a primary 

health care provider audience. It is positioned 

as relevant to countries within the Pacific rim. 

JPHC publishes peer-reviewed quantitative 

and qualitative original research, systematic 

reviews, papers on improving performance 

and short reports that are relevant to its 

primary health care practitioners. For the aim, 

scope, instructions to authors and templates 

for publications see www.rnzcgp.org.nz/ 

journal-of-primary-health-care/. 

JPHC includes pithy digests of the latest 

evidence including a String of PEARLS 

(Practical Evidence About Real Life 

Situations), Potion or Poison (evidence for 

the potential benefits and possible harms of 

well-known herbal medicines), Cochrane 

Corner (a summary of a Cochrane review), 

Nuggets of Knowledge (succinct synopses 

of pharmaceutical evidence for primary care) 

and Pounamu and Vaikoloa, (Maori and Pacific 

primary health care treasures respectively). 

JPHC publishes viewpoints, commentaries 

and reflections that explore areas of 

uncertainty on aspects of care for which 

there is no one right answer. Debate is 

stimulated in Back to Back, where two 

professionals present their opposing views 

on a topic. There is a regular Ethics column. 

Letters to the Editor are welcomed. 

INDEXING 

The Journal is indexed in MEDLINE, Excerpta 

Medica (EMBASE), Cumulative Index 

to Nursing and Allied Health Literature 

(CINAHL), Scopus and Index New Zealand 

(INNZ). It is also included in the Directory 

of Open Access Journals (DOAJ), http:// 

www.doaj.org). Complete text of the Journal 

is available online at www.rnzcgp.org.nz/ 

journal-of-primary-health-care/ and through 

various aggregators including PubMed 

Central and EBSCO. 

EDITOR 

Prof. Felicity Goodyear-Smith: Professor and 

Goodfellow Postgraduate Chair, Department 

of General Practice and Primary Health Care, 

University of Auckland, Auckland, New 

Zealand; editor@rnzcgp.org.nz 

EDITORIAL BOARD 

The Editorial Board comprises renowned 

and active primary care clinicians, clinical 

and scientific academics and health policy 

experts with both New Zealand and 

international representation. 

Prof. Bruce Arroll: Professor, Department 

of General Practice & Primary Health Care, 

University of Auckland, NZ 

Prof. Jenny Carryer: Professor of Nursing, 

School of Health and Social Services, Massey 

University, Palmerston North, NZ 

Prof. Peter Crampton: Pro-Vice-Chancellor, 

Division of Health Sciences, School of 

Medicine and Health Sciences, University of 

Otago, Dunedin, NZ 

Dr Ofa Dewes: Research fellow, Department 

of Pacfic Health, School of Population Health, 

University of Auckland. 

Prof. Tony Dowell: Professor, Department 

of Primary Health Care and General Practice, 

Wellington School of Medicine, 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 

Prof. Pauline Norris: Profesor and Chair 

in Social Pharmacy, University of Otago, 

Dunedin, NZ 

Dr Barry Parsonson: Psychologist for NZ 

Ministry of Education, Napier, NZ 

Dr Shane Reti (QSM): International Program 

Director Clinical Informatics and CEO of 

Clinical Informatics Industrial Research, 

Harvard Medical School, USA 

Prof. Kurt Stange: Professor of Family 

Medicine, Case Western Reserve University, 

Cleveland, OH, USA and Editor, Annals of 

Family Medicine 

SUBMISSIONS 

Full instructions for authors can be found at http://www.rnzcgp.org.nz/information-for-authors 

Please send all submissions to the Editor: editor@rnzcgp.org.nz 

For queries about submitted articles please contact the Managing Editor: managingeditor@rnzcgp.org.nz 

JPHC ADMINISTRATION 

For subscription and advertising queries, or to sign up for email alerts, please contact the Publications Coordinator: 

RNZCGP, PO Box 10440, Wellington 6143, New Zealand; jphcnz@rnzcgp.org.nz 

JPHC is printed on uncoated, acid-free paper which meets the archival requirements of ANSI/NISO Z39.48-1992 (Permanence of Paper) and is 

Forest Stewardship Council (FSC)–certified which meets the highest environmentally responsible standards. 

The Journal of Primary Health Care is the official journal of the RNZCGP. However, views expressed are not necessarily those of the 

College, the Editor, or the Editorial Board. ©The Royal New Zealand College of General Practitioners 2013. All Rights Reserved.

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