Large men and New Zealand primary care: the views of practitioners and patients regarding obesity and its management

Background New Zealand is ranked third in terms of obesity prevalence globally, with male obesity rates equalling those of females. There have been calls for primary care to take a more proactive approach to the diagnosis and management of obesity, but little is known about weight management practices within New Zealand general practice. Less is known regarding the weight management experiences of large men. This thesis aims to assess the beliefs, attitudes, knowledge and practices of general practitioners and practice nurses regarding obesity and specifically male obesity and explore the impact of these factors on large men. In addition, it seeks to understand the lived experiences of large Kiwi men. Methods This study utilised a mixed methods approach. The quantitative phase employed a random cross-sectional design and involved the development, piloting and administration of an extensive survey. The results were analysed using a combination of descriptive and inferential statistics. The qualitative phase used a thematic analytic approach and purposive sampling to recruit participants. An interview schedule was developed, piloted and used to guide the semi-structured interviews. Text data was analysed using general inductive principles. Results In total 1,344 surveys were returned by health professionals. Of these 735 were from practice nurses, creating a significant database of practice nurse information. Fourteen interviews with large men were completed and analysed thematically. The majority of health professionals considered weight management part of their role and obesity was deemed a chronic disease, underpinned by complexity. Individuals were viewed as responsible for their weight but needing weight loss support. Body mass index was the diagnostic measurement most frequently used and the majority were confident in their ability to provide weight management counselling, but time was a significant barrier. Both health professional groups considered male weight management would be enhanced by improved access to gender specific community-based options. The men felt weight was a sensitive topic but one that needed discussing using appropriate terms. Getting weighed was common but waist circumference measurement less so. Men expressed a desire for tailored weight loss advice and support, compared to the generic advice received. Their feelings on the need for primary care professionals to be role models were mixed. Overall life as a large man was challenging. Although these men experienced discrimination during interactions with general practice, they did not feel it was the main source of stigma in their lives, with discriminatory experiences more common from family, friends and work colleagues. Conclusion Considering the findings from the surveys and interviews together this thesis is able to provide guidance to primary care. The combined findings have clarified the role of contemporary primary care in regard to male weight management as being one of awareness raising, diagnosis and support for onward referral where appropriate. The synthesis of the findings revealed a shared model of obesity causation and responsibility between health professionals and large men, not seen in other studies. Opportunities exist for primary care to enhance its responsiveness to men seeking to lose weight, thereby making it a more suitable environment for large men seeking to lose weight in the future

Developing and Implementing a Framework for System Level Measures: lessons from New Zealand

Background: Measuring performance is now the norm in health systems. System Level Measures (SLMs), implemented at New Zealand’s Counties Manukau Health (CMH) are designed to support quality improvement activities undertaken across the health system using only a small set of measures. While the healthcare and performance measurement literature contains information regarding the facilitators and barriers to quality improvement initiatives, there is an absence of studies into whether these factors are germane to the establishment and implementation of a SLM framework. Methods: A purposive sample of thirteen senior managers and clinicians involved in the construction and implementation of SLMs were invited to participate. Semi-structured telephone interviews were completed and recordings transcribed verbatim. Transcriptions were thematically analysed using a general inductive approach. Findings: In total, ten interviews took place. Six facilitative themes were identified including: dispersed and focused leadership; communication; data; alignment of the measures with organisational strategic data; alignment of the measures with organisational strategic plans and values; stakeholder engagement; and a dedicated project team. Conversely, five themes were identified that hindered the process. These were: reaching consensus; perfection versus pragmatism; duplication and process burden; achieving buy-in and workload. Discussion: The factors that facilitate and hinder establishing and implementing a framework of SLMs are common to other quality improvement approaches. However, this study demonstrated that these factors were also germane to SLMs. These findings are of particular relevance as researchers and policy makers elsewhere increasingly aim to adopt measurement arrangements for health systems that address equity, safety, quality, access and cost. Abbreviations: CMH – Counties Manukau Health; DHB – District Health Board; IHI – Institute for Healthcare Improvement; QI – Quality Improvement; SLM – System Level Measure

Large men and New Zealand primary care: the views of practitioners and patients regarding obesity and its management

Background New Zealand is ranked third in terms of obesity prevalence globally, with male obesity rates equalling those of females. There have been calls for primary care to take a more proactive approach to the diagnosis and management of obesity, but little is known about weight management practices within New Zealand general practice. Less is known regarding the weight management experiences of large men. This thesis aims to assess the beliefs, attitudes, knowledge and practices of general practitioners and practice nurses regarding obesity and specifically male obesity and explore the impact of these factors on large men. In addition, it seeks to understand the lived experiences of large Kiwi men. Methods This study utilised a mixed methods approach. The quantitative phase employed a random cross-sectional design and involved the development, piloting and administration of an extensive survey. The results were analysed using a combination of descriptive and inferential statistics. The qualitative phase used a thematic analytic approach and purposive sampling to recruit participants. An interview schedule was developed, piloted and used to guide the semi-structured interviews. Text data was analysed using general inductive principles. Results In total 1,344 surveys were returned by health professionals. Of these 735 were from practice nurses, creating a significant database of practice nurse information. Fourteen interviews with large men were completed and analysed thematically. The majority of health professionals considered weight management part of their role and obesity was deemed a chronic disease, underpinned by complexity. Individuals were viewed as responsible for their weight but needing weight loss support. Body mass index was the diagnostic measurement most frequently used and the majority were confident in their ability to provide weight management counselling, but time was a significant barrier. Both health professional groups considered male weight management would be enhanced by improved access to gender specific community-based options. The men felt weight was a sensitive topic but one that needed discussing using appropriate terms. Getting weighed was common but waist circumference measurement less so. Men expressed a desire for tailored weight loss advice and support, compared to the generic advice received. Their feelings on the need for primary care professionals to be role models were mixed. Overall life as a large man was challenging. Although these men experienced discrimination during interactions with general practice, they did not feel it was the main source of stigma in their lives, with discriminatory experiences more common from family, friends and work colleagues. Conclusion Considering the findings from the surveys and interviews together this thesis is able to provide guidance to primary care. The combined findings have clarified the role of contemporary primary care in regard to male weight management as being one of awareness raising, diagnosis and support for onward referral where appropriate. The synthesis of the findings revealed a shared model of obesity causation and responsibility between health professionals and large men, not seen in other studies. Opportunities exist for primary care to enhance its responsiveness to men seeking to lose weight, thereby making it a more suitable environment for large men seeking to lose weight in the future

Boletín Oficial de la Provincia de Oviedo: Número 85 - 1914 abril 15

Background In 2003 the New Zealand Guidelines on the screening and management of patients for cardiovascular risk were published, with a revised handbook for primary healthcare staff updated in 2009. Several studies however have identified a significant gap between the guideline recommendations and current practice. This study was initiated to investigate the possible reasons for the evidence-practice gap. Aim and objectives The aim of this research study was to explore how primary health care teams manage those at high risk of cardiovascular disease (CVD) and what changes could be made that would enhance management. The study objectives were: • To explore how those found to be at high risk of a cardiovascular event are managed in primary care; • To determine what facilitates and hinders CVD risk management at practice level in the current primary health care environment in New Zealand; • To establish what strategies and support providers would like to enhance the current management of those at high risk. Methods A qualitative approach was utilised for this study using focus groups for the collection of relevant information and opinions. Following the review of the literature an interview schedule was developed to guide the focus group discourse. The selection of the focus groups was guided by a sampling frame which ensured that they were drawn from a variety of settings. Focus groups were digitally recorded and the recordings transcribed. The Chronic Care Model (CCM) was used as a framework to guide consideration of the literature review findings as well as the process of analysing the text data. The text data was analysed using a general inductive approach which resulted in the emergence of key themes. Findings There was a high level of conformity between the findings from the focus group and the literature review but some additional issues did emerge. The self management domain and the delivery system domain of the CCM dominated both the findings from the literature and the themes from the focus groups. The decision support domain appears to have a moderate impact on optimal management of cardiovascular risk, both in the literature and from the focus group findings. Participants in the focus groups identified more barriers to optimal management of those at high cardiovascular risk related to the health system organisation domain, than emerged from the literature. Surprisingly they identified no barriers or facilitators to the use of community resources to assist them in supporting individuals with lifestyle behaviour changes. Conclusion This study, elicited new perspectives from New Zealand primary healthcare staff, relevant to issues surrounding the management of patients at high cardiovascular risk. The research has elucidated drivers of sub-optimal management and highlighted solutions available to address the issues within the current New Zealand primary health care environment

Multimorbidity, clinical decision making and health care delivery in New Zealand Primary care: a qualitative study

© 2017 The Author(s). Background: Multimorbidity is a major issue for primary care. We aimed to explore primary care professionals’ accounts of managing multimorbidity and its impact on clinical decision making and regional health care delivery. Methods: Qualitative interviews with 12 General Practitioners and 4 Primary Care Nurses in New Zealand’s Otago region. Thematic analysis was conducted using the constant comparative method. Results: Primary care professionals encountered challenges in providing care to patients with multimorbidity with respect to both clinical decision making and health care delivery. Clinical decision making occurred in time-limited consultations where the challenges of complexity and inadequacy of single disease guidelines were managed through the use of “satisficing” (care deemed satisfactory and sufficient for a given patient) and sequential consultations utilising relational continuity of care. The New Zealand primary care co-payment funding model was seen as a barrier to the delivery of care as it discourages sequential consultations, a problem only partially addressed through the use of the additional capitation based funding stream of Care Plus. Fragmentation of care also occurred within general practice and across the primary/secondary care interface. Conclusions: These findings highlight specific New Zealand barriers to the delivery of primary care to patients living with multimorbidity. There is a need to develop, implement and nationally evaluate a revised version of Care Plus that takes account of these barriers

Doctors’ experiences of providing care in rural hospitals in Southern New Zealand : a qualitative study

Objective: To explore rural hospital doctors’ experiences of providing care in New Zealand rural hospitals. Design: The study had a qualitative design, using qualitative content analysis. Setting: The study was conducted in South Island, New Zealand, and included nine different rural hospitals. Respondents: Semistructured interviews were conducted with 16 rural hospital doctors. Results: Three themes were identified: ‘Applying a holistic perspective in the care’, ‘striving to maintain patient safety in sparsely populated areas’ and ‘cooperating in different teams around the patient’. Rural hospital care more than general hospital care was seen as offering a holistic perspective on patient care based on closeness to their home and family, the generalist perspective of care and personal continuity. The presentation of acute life-threatening low-frequency conditions at rural hospitals were associated with feelings of concern due to limited access to ambulance transportation and lack of experience. Overall, however, patient safety in rural hospitals was considered equal or better than in general hospitals. Doctors emphasised the central role of rural hospitals in the healthcare pathways of rural patients, and the advantages and disadvantages with small non-hierarchical multidisciplinary teams caring for patients. Collaboration with hospital specialists was generally perceived as good, although there was a sense that urban colleagues do not understand the additional medical and practical assessments needed in rural compared with the urban context. Conclusions: This study provides an understanding of how rural hospital doctors value the holistic generalist perspective of rural hospital care, and of how they perceive the quality and safety of that care. The long distances to general hospital care for acute cases were considered concerning

Patients’ accounts of living with and managing inflammatory bowel disease in rural Southern New Zealand: a qualitative study

Objective To explore how adults living with inflammatory bowel disease (IBD) in rural New Zealand manage their condition and engage with healthcare providers.Design Qualitative exploratory design with semi-structured interviews analysed thematically.Setting and participants Interviews were conducted with 18 people living with IBD in the Otago region of the South Island.Results Five important constructs were identified: (1) journey to confirming and accepting diagnosis; (2) importance of the relationship with the healthcare team; (3) support from others; (4) learning how to manage IBD and (5) care at a distance—experiences of rurality. Pathways to confirming diagnosis involved two contrasting journeys: a long and slow process where diagnosis remained unclear for a prolonged period, and a more acute process where diagnosis typically came as a shock. Central to the acceptance process was acknowledging the chronicity of the condition, which involved feelings of grief but also the fear of judgement and stigma. Building a strong relationship with the specialist was central to medical management, particularly in the initial stage following diagnosis. Support from others was critical, enabling participants to progress through acceptance of the disease and developing confidence in its everyday management. Participants shared different strategies on how to manage IBD, describing a ‘trial and error’ process of ‘finding what is right’ at different stages of the condition. Managing IBD rurally involved challenges of access to specialist care, with perceptions of delayed referrals and concerns about disparities in specialist access compared with urban counterparts. Rural living also had financial implications—cost of time and cost of mobilising resources for long travels to the urban centre for treatments.Conclusions Findings from this study provide a rich understanding of the complex health journeys of people living with IBD and the challenges of managing the condition rurally