A complex intervention to support 'rest home' care: a pilot study.

AIMS: To describe an intervention supporting Aged Related Residential Care (ARRC) and to report an initial evaluation. METHODS: The intervention consisted of: medication review by a multidisciplinary team; education programmes for nurses; telephone advice 'hotlines' for nursing and medical staff; Advance Care Planning; and implementing existing community programmes for chronic care management and preventing acute hospital admissions. Semi-structured interviews were conducted with members of the multidisciplinary team, rest home nurses and caregivers. Quantitative data were collected on medication changes, hotline use, use of education opportunities and admissions to hospital. RESULTS: Medications were reduced by 21%. Staff noted improvements in the physical and mental state of residents. There was no significant reduction in hospital admissions. Nurses were unable to attend the education offered to them, but it was taken up and valued by caregivers. There was minimal uptake of formal acute and chronic care programmes and Advance Care Planning during the intervention. Hotlines were welcomed and used regularly by the nurses, but not the GP. CONCLUSIONS: The provision of high status specialist support on site was enthusiastically welcomed by ARRC staff. The interventions continue to evolve due to limited uptake or success of some components in the pilot.

The influence of the birthplace and models of care on midwifery practice for the management of women in labour.

This paper will examine how the settings in which midwives practice (the birthplace) and models of care affect midwives' decision making during the management of labour. One-hundred-and-four independent, team and hospital based midwives and 100 low obstetric risk nulliparous women to whom labour care was provided were surveyed. These midwives and women resided in the Auckland metropolitan area of New Zealand. The majority of midwives who participated worked in models of care which provided women with continuity of carer and care, however, this was not found to influence the way the midwives provided labour care. Instead, practice was found to be relatively homogenous regardless of whether the midwives worked in independent, team, or hospital-based practice. The birthplace setting in which the labour care took place did influence midwifery practice. The majority of midwives provided labour care in large obstetric hospitals and identified practices dominated by the medical model of care. Practice was described as being influenced by intervention and the need for technology, however, this did not prevent the majority of women from perceiving they were actively involved in the decision making process and that they worked in partnership with their midwives. Closer examination of the midwives' decision making processes whilst providing the labour care revealed that the midwives' individual decisions were influenced by the needs of the women rather than the hospital protocols. What became evident was that the midwives in this study had adopted a humanistic approach to care whereby technology was used alongside relationship-centred care.

What makes 'place' attractive to overseas-trained doctors in rural New Zealand?

The present paper investigates what keeps doctors 'in place' in New Zealand rural communities and what prompts their departure from practice. The study is based on in-depth interviews conducted with nine overseas-trained medical practitioners within rural areas in New Zealand during 2004. A thematic analysis was undertaken. The resulting narratives reveal the unintended circumstances under which respondents often arrived in their rural communities, as well as some of the 'pull' factors which a more relaxed rural lifestyle offers. Recurring themes relating to the attractiveness of place include community loyalty and the enjoyment of 'fully practicing medicine'. Themes which corroded the attractiveness of place included 'entrapment', lack of choice in secondary schooling, restricted spousal employment opportunities, the lack of cultural and entertainment activities, and difficulties accessing continuing medical education. The authors conclude that addressing the question of what makes 'place' attractive to overseas-trained general practitioners in rural New Zealand requires an understanding of place as context rather than mere location.

Teenage use of GP care for moderate to severe asthma in Auckland, New Zealand.

OBJECTIVES: To describe and understand teenagers' frequency of attendance for General Practitioner (GP) care of moderate to severe asthma in the Auckland region. METHODS: Ten Auckland schools identified 510 children aged 13-14 years with breathing problems, who were invited to complete a screening questionnaire. 271 children participated, of whom 114 had moderate to severe asthma. RESULTS: 39% of the 114 had made 0-1 GP visit for asthma, and 17% made 'greater than and equal to' 5 visits. Low attendees (0-1 visit) were disproportionately New Zealand European. High attendees ('greater than and equal to' 5 visits) tended to be Maori and/or Pacific Islanders. Half of the teenagers attended GP asthma care as often as it wanted, independently of ethnicity; 62% tell their parents when they cannot manage their asthma; and 29% must pay for GP care. Expected attendance was increased for Maori and Pacific students versus others by 77% (p=0002), and by asthma of increased severity (p<0.001). Teenager resistance to accessing GP asthma care reduced expected attendance by 24% (p=0.003). CONCLUSIONS: Maori and Pacific peoples have traditionally faced barriers to accessing GP care, but their their more frequent attendance (than New Zealand Europeans) in this case, challenges whether such barriers persist, at least for acute care of moderate to severe asthma.

Attendance for general practitioner asthma care by children with moderate to severe asthma in Auckland, New Zealand.

Attendance for general practitioner (GP) care of childhood asthma varies widely in New Zealand (NZ). There is little current research to account for the variations, although groups such as Maori and Pacific peoples have traditionally faced barriers to accessing GP care. This paper aims to describe and account for attendance levels for GP asthma care among 6-9 year-olds with moderate to severe asthma in Auckland, NZ. During 2002, randomly selected schools identified all 6-9 year-olds with possible breathing problems. Completion of a questionnaire by each parent/guardian indicated which children had moderate to severe asthma, and what characteristics influenced their access to GP asthma care. A multilevel, negative binomial regression model (NBRM) was fitted to account for the number of reported GP visits for asthma, with adjustment for clustering within schools. Twenty-six schools (89.7 percent) identified 931 children with possible breathing problems. Useable questionnaires were returned to schools by 455 children (48.9 percent). Results indicated 209 children with moderate to severe asthma, almost one in every three reportedly making 5 or more GP visits for asthma in the previous year. Maori, Pacific and Asian children were disproportionately represented among these 'high attendees'. Low attendees (0-2 visits) were mainly NZ Europeans. The NBRM (n=155) showed that expected visits were increased by perceived need, ill-health, asthma severity and, in particular, Maori and Pacific child ethnicity. It may be that Maori and Pacific children no longer face significant barriers to accessing GP asthma care. However, more likely is that barriers apply only to accessing routine, preventative care, leading to poor asthma control, exacerbations requiring acute care, and paradoxically an increase in GP visits. That barriers may increase total numbers of visits challenges the assumption, for all health systems, that access can be defined in terms of barriers that must be overcome to obtain health care.

Partnership in midwifery care in New Zealand.

OBJECTIVE: to examine whether equal power is essential to the perceptions of partnership in midwifery practice and to propose an alternative model of how power might best be shared. DESIGN: a cross-sectional design was employed using the predominant methods of interview, questionnaires and thinking aloud tape recordings as triangulation of data. SETTING: two large metropolitan hospitals in Auckland, New Zealand and home birth settings. SAMPLE: Forty one independent and hospital-based midwives and 37 nulliparous women at low obstetric risk for whom labour care was provided. FINDINGS: the majority of the midwives and the women in the two studies presented believed they had achieved a midwifery partnership with little emphasis placed on the need for equality in decision making. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the model proposed provides a framework that identifies how power can be shared without the need for equality. The integration of this model into practice may assist midwives and women to recognise and utilise differences in their experience and knowledge to achieve their aims of achieving a partnership and a successful birth.

GP care for moderate to severe asthma in children: what do infrequently attending mothers disagree with and why?

OBJECTIVES: Our aim was to identify and account for areas of disagreement with GP care for moderate to severe child asthma among mothers who infrequently use this care. Identifying and understanding these areas of disagreement has the potential to improve child access to GP care. METHODS: This qualitative study in Auckland, New Zealand, used a general inductive approach to analyse 23 semi-structured, personal interviews during March-October 2001 with samples of 11 mothers of children with moderate to severe asthma, and 12 medical providers (10 in general practice and two in hospital emergency departments). Disagreement was defined by mothers' non-acceptance or disapproval of aspects of GP care they reported getting for child asthma. RESULTS: Mothers and providers described four areas in which some mothers disagree with aspects of GP care for child asthma. Contributing to infrequent attendance, the areas are the validity of the diagnosis, the level of service provision, the effectiveness of care and the level of respect from practice staff. These areas revealed three groups of mothers. GP factors contributing to disagreements among mothers were reported to be inconsistent care; information deficits on asthma and individual children; a lack of commitment to identifying the cause(s) and self-management of asthma in children; and an unmet need for asthma management plans that incorporate families' knowledge, goals and preferences. CONCLUSIONS: Disagreement, among mothers, with areas of GP care for child asthma contributes to non-attendance for this care. This paper identifies opportunities for GPs to keep disagreements to a minimum and facilitate access.

Exploring paternal influences on the dieting behaviors of adolescent girls.

In this article we investigate fathers' influence on the dieting behavior of their adolescent daughters. Fifty father-daughter dyads (N = 100) participated. The girls completed a questionnaire concerning their beliefs and behaviors with respect to dieting, their body satisfaction, and their perception of the advantages of being thinner. Fathers were surveyed in order to ascertain their perceptions of the advantages of slimness for adolescent girls and their beliefs regarding the importance of physical appearance and weight control in females of all ages. Associations were found between fathers attitudes to physical attractiveness in females, their perceptions of the impact of being slimmer for adolescent girls, and their daughters dieting behavior. Fathers who believed strongly in the importance of attractiveness and careful control of food intake by females were significantly more likely to have daughters who induced vomiting to lose weight. Fathers play an influential role in determining the dieting behavior of their adolescent daughters.

Reasons for poor understanding of when and how to access GP care for childhood asthma in Auckland, New Zealand.

BACKGROUND: Attempts to explain why some patients lack the understanding needed to access GP care for childhood asthma are uncommon and have tended to be based on reported statistical associations. OBJECTIVES: The aims of this study were to describe and account for poor patient understanding of when and how to access GP care for childhood asthma in Auckland, New Zealand. METHODS: A general inductive approach was used to analyse 29 semi-structured, personal interviews, during March-May 2001, with Auckland key informants selected through maximum variation sampling. Informant checking and the literature supported the text analysis by two independent researchers. RESULTS: Key informants reported wide variations in the extent to which guardians and asthmatic children understand when and how to access GP services. Two sets of barriers to patient understanding were identified. The first limits the willingness of people to seek understanding and the second limits their ability to understand, even if they want to understand. CONCLUSIONS: Use of qualitative methodology was able to reveal barriers to patient understanding. Strategies operating at the GP and system levels were identified to help overcome these barriers.