Using a randomised controlled trial to test the effectiveness of social norms feedback to reduce antibiotic prescribing without increasing inequities.

AIMS: Antibiotic overprescription is a key driver of antimicrobial resistance, and rates of community dispensing of antibiotics in New Zealand are high compared to other developed countries. We aimed to test whether a social-norm-based intervention successful elsewhere would have an effect on GPs with high prescribing rates of antibiotics. We also aimed to assess the effects on prescribing for Maori and Pacific patients. METHODS: A randomised controlled trial (n=1,214) tested the effects of a letter mailed to high-prescribing GPs that presented their prescribing data in comparison to their peers. RESULTS: In September-December 2019, after the letters were mailed, the antibiotic prescribing rate in the control arm was 178.8 patients prescribed antibiotics per 1,000 patients prescribed any medicine, and in the intervention arm it was 162.3, a relative difference of 9.2% (p<0.001). GPs in the intervention arm were responsible for an average of 173.5 prescriptions, versus an average of 186.8 prescriptions for GPs in the control arm, a relative difference of 13.3 or 7.1% (p<0.01). Exploratory analyses showed the intervention reduced prescribing to Maori and Pacific patients among historically high prescribing GPs but had no statistically significant impact on low prescribers. CONCLUSIONS: A targeted intervention using social norms reduced prescribing of antibiotics by high-prescribing GPs. Such an approach may be promising to address inequities in access to and use of antibiotics by Maori and Pacific peoples, historically underserved by prescribers, but further investigation is needed.

YouthCHAT as a Primary Care E-Screening Tool for Mental Health Issues Among Te Tai Tokerau Youth: Protocol for a Co-Design Study.

BACKGROUND: In New Zealand (NZ), 1 in 4 adolescents is affected by mental health issues (eg, depression and anxiety) and engages in risk behaviors (eg, harmful drinking and substance abuse), with rates among Maori youth being significantly higher. The majority of NZ secondary school students visit their local primary health care providers (PHPs) at least annually, yet most do not seek help for mental health and risk behavior (MHB) concerns. While youth think it acceptable to discuss sensitive issues during a consultation with their PHPs, unless problems are severe, such conversations are not initiated by PHPs. Early intervention for MHB concerns can prevent long-term health and well-being issues. However, this relies on the early identification of developing problems and youth being offered and accepting help. YouthCHAT is an electronic, multi-item screening tool developed in 2016 to assess MHB concerns among youth. YouthCHAT is completed before a consultation with the PHP, who can access a summary report straight away. A help question allows young people to identify issues that need addressing. A resource pack uses stepped care pathways to guide providers to use appropriate brief interventions. OBJECTIVE: This study aimed to explore the utility, feasibility, and acceptability of YouthCHAT when tailored for use with youth in primary care settings with large Maori populations. Objectives of the study are to evaluate the implementation of YouthCHAT in nurse-led youth clinics, school-based clinics, and general practice in Te Tai Tokerau (Northland, NZ); to develop a framework for the scaling up of YouthCHAT across further settings; to assess health provider and youth acceptability of the tool; to improve screening rates for mental health and help-seeking behavior; to enable early identification of emerging problems; and to improve brief intervention delivery. METHODS: Using a bicultural mixed-methods co-design approach, 3 phases over a 3-year period will provide an iterative evaluation of the utility, feasibility, and acceptability of YouthCHAT, aiming to create a framework for wider-scale rollout and implementation. RESULTS: Recruitment for the first phase began in September 2018. YouthCHAT was implemented at the first site in October 2018 and is expected to be at a further two sites in late January to early February 2019. The study is due for completion at the end of 2021. CONCLUSIONS: YouthCHAT has potential as a user-friendly, time efficient, and culturally safe screening tool for early detection of MHB issues in NZ youth. The resource pack assists the clinician to provide appropriate interventions for emerging and developed youth mental health and lifestyle issues. Involving input from community providers, users, and stakeholders will ensure that modifiable elements of YouthCHAT are tailored to meet the health needs specific to each context and will have a positive influence on future mental, physical, and social outcomes for NZ youth. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/12108.

Facilitating equitable prevention and management of gout for Maori in Northland, New Zealand, through a collaborative primary care approach.

INTRODUCTION The Gout Stop Programme was developed for primary care in Northland, New Zealand, to address inequitable health outcomes for Maori and Pacific people with gout. AIM The aim of the programme was to make it easier for clinicians to prescribe urate-lowering treatment, facilitate patient adherence through education and support, and reduce barriers to gout prevention and long-term management. METHODS From 2015 to 2017, patients with acute gout who met inclusion criteria were prescribed treatment according to a 'Gout Stop Pack' option, based on renal function and diabetes status. Patients were monitored by community pharmacists. Gout educators and a Gout Kaiawhina (community support worker) provided education and support to patients and whanau (families). Patient completion of the programme and outcomes, according to target serum urate level, were recorded. Patient experience was documented using a questionnaire and rating scale. RESULTS In total, 160 clinicians prescribed therapy at 887 patient presentations; 71% were Maori and Pacific patients. The completion rate was 55% in this group and 84% for the non-Maori and non-Pacific group. In the Maori and Pacific group, 40% reached the target serum urate level (≤0.36 mmol L-1) in 91 days, and 26% required further titration. In the non-Maori/non-Pacific group, these rates were 51% and 19% respectively. Following programme completion, 68% of Maori and Pacific patients and 65% of non-Maori and non-Pacific patients continued to take allopurinol. The 21 patients interviewed rated the programme as excellent or very good. DISCUSSION Culturally appropriate education and support for patients and the primary care team was essential. Collaboration between prescribers, community pharmacists and support workers reduced barriers to initiating prevention and long-term urate-lowering treatment and urate testing in this high-needs gout population.

Student access to primary health care and preventive health screening at a school-based health centre in South Auckland, New Zealand.

AIMS: To determine where students usually access primary health care and compare the quality of preventive health services that students who use the school-based health centre (SBHC) receive to those who go elsewhere for health care. METHODS: A convenience sample of 20 classes were selected and surveyed in 2003. Three hundred and forty-three students completed the Young Adult Health Care Survey using a web-based questionnaire. RESULTS: While most students (79%) access health care from their family doctor, a significant number (40%) of students attended the SBHC in the last 12 months. Overall, health screening and preventive counselling from health care providers was low. Students who used the SBHC were more likely to received private and confidential health care and preventive screening than students who go elsewhere for health care. CONCLUSION: School-based health care provides additional access to health care that does not appear to replace traditional family practice based health care. While the SBHC appears to deliver better quality preventive health services for adolescents compared to traditional primary health care, improvements are needed across all primary health care settings.