Pounamu: Achieving health equity in Aotearoa New Zealand: the contribution of medicines optimisation

Management of type 2 diabetes in New Zealand: a scoping review of interventions with measurable clinical outcomes

OBJECTIVE

This review aimed to assess the effectiveness of interventions for type 2 diabetes (T2D) management in New Zealand on clinical outcomes, and explore the factors impacting their feasibility and acceptability.

STUDY DESIGN

Scoping review.

METHODS

Three databases (PubMed, Web of Science and Scopus) were searched between January 2000 and July 2023. Reference lists of included studies were hand searched to identify additional articles.

RESULTS

The search yielded 550 publications, of which 11 were included in the final review. Most interventions (n = 10) focussed on education and seven were delivered by health professionals. Supporting factors for interventions included clinical/peer support (n = 8) and whānau (family) involvement (n = 6). Hindering factors included non-adherence (n = 4) and high drop-out (n = 4). Most studies reported modest improvement in HbA1c and weight at six months, but minimal change in HbA1c, weight, lipids, renal profile, and blood pressure by two years.

CONCLUSION

Future interventions should involve culturally appropriate approaches to improve engagement and acceptability while addressing lifestyle and medication adherence for T2D management. T2D interventions not widely disseminated via academic channels need to be further identified.

Pharmacy practice and First Peoples health equity: a scoping review protocol

OBJECTIVE

The objective of this review is to examine and describe global pharmacy practice strategies and interventions designed to achieve health equity for First Peoples.

INTRODUCTION

Access to medicines and quality use of medicines is critical to achieving health equity for First Peoples. Pharmacists are uniquely placed to lead the charge in transforming current health systems, reducing health disparities, and bolstering the movement toward health equity.

INCLUSION CRITERIA

Global studies describing pharmacy practice strategies and interventions designed to achieve health equity for First Peoples will be considered for inclusion in the review. Studies relating to all areas of pharmacy practice, including community and clinical pharmacy, social, administrative, pharmaceutical sciences, practice, teaching, research, advocacy, or service relevant to the review's objective will also be considered for inclusion. The types of studies to be included are qualitative, quantitative, and mixed methods systematic reviews, scoping reviews, literature reviews, and gray literature.

METHODS

This review will be conducted in accordance with JBI methodology for scoping reviews. Embase, MEDLINE, Scopus, CINAHL, and gray literature sources will be searched from 1998 to the present. Titles, abstracts, and full texts will be screened against the inclusion criteria. Strategies and interventions identified in the included reviews will be mapped to a published framework, outlining actionable strategies for pharmacy practice inclusion in sustainable efforts to achieve health equity. Qualitative content analysis and descriptive statistics will be utilized with data presented in tables, accompanied by a narrative.

REVIEW REGISTRATION

Open Science Framework osf.io/qa64b.

Translating research into a relevant education activity to fulfil pharmacists' continuing professional development requirements

Background

In New Zealand (NZ), provision of culturally safe care by pharmacists is mandated, including an expectation of understanding issues relevant to Māori, the Indigenous people of NZ, yet there are few pharmacy-specific resources to support attainment.

Objectives

To: i) test whether a research-informed education activity (short video summarising research findings plus reflective exercises) meets NZ pharmacists' annual continuing professional development requirements including those relating to culturally safe care ii) identify suggested improvements to the education activity; and iii) identify individual pharmacists' proposed actions in response to reflection prompted by the education activity.

Methods

Previous research was utilised to develop an education activity (short, animated research summary video and reflective questions). Participants (NZ-registered pharmacists or intern pharmacists) were asked to watch the video and respond to questions online related to perceived relevance and usefulness of the video to informing practice and meeting CPD requirements. Simple descriptive analysis (quantitative data) and general inductive thematic analysis (qualitative data) were applied to the research data.

Results

Thirty-three people participated from Nov-Dec 2022. Most participants said the video was relevant/very relevant to practice (91%), that the reflective exercise was very or extremely useful (100%) and that it met their CPD requirements as relevant to cultural safety (100%).

Conclusion

The education activity appeared to be an appropriate and relevant for CPD and was seen to be concise and exposed ideas in a logical and succinct manner with the potential to benefit the populations receiving care from these providers.

"Prescribing for the whole person": A qualitative study exploring prescribing pharmacist views on type 2 diabetes management in New Zealand

BACKGROUND

Pharmacist prescribers have comprehensive pharmacotherapy knowledge that can be useful for management of complex health conditions such as type 2 diabetes, yet the number of pharmacist prescribers working in New Zealand primary care is low.

AIM

To explore the experiences of pharmacist prescribers in supporting type 2 diabetes management in New Zealand primary care.

METHODS

Qualitative research design using semi-structured interviews with six pharmacist prescribers working in NZ primary care. Thematic analysis guided this study and themes were finalised with the wider research team.

RESULTS

Three major themes were identified: team approach, health inequity and the role of a pharmacist prescriber. This study found that pharmacist prescribers may improve health equity by providing advanced pharmacotherapy knowledge within a wider primary care team to support complex patient needs and understanding the wider social determinants of health that impact effective diabetes management. Participants reportedly had more time to spend with patients (than GPs or nurses) and could also contribute to improving health outcomes by directly educating and empowering patients.

CONCLUSION

The views of pharmacist prescribers have seldom been explored and this study suggests that their role may be under-utilised in primary care. In particular, pharmacist prescribers can provide specialist prescribing (and often mobile) care, and may contribute to improving health outcomes and reducing inequity when used as part of a multi-disciplinary team.

Feasibility and acceptability of a paeārahi (Indigenous Whānau Ora navigator) intervention for unintentional injury prevention for older Māori: non-randomised, non-comparator trial study protocol

Background

Māori (the Indigenous population of Aotearoa New Zealand) experience increased burden of unintentional injury and reduced access to publicly funded injury prevention and rehabilitation services, compared with non-Māori. Māori-led models of care have been shown to improve outcomes for Māori. Paeārahi navigate across sectors (including health, education, housing and employment) to advocate for the best possible outcomes for individuals and families. This study aims to (1) test the acceptability and feasibility and (2) undertake exploratory efficacy analysis of a paeārahi injury intervention for Māori older adults.

Methods

A prospective non-randomised, non-comparator study with preintervention and postintervention measurements of predefined outcomes. Eligible participants who consented to participate (Māori, 55+ years, community-dwelling and enrolled in one of three study general practices) will undergo a multivisit paeārahi intervention. The intervention includes home-hazard assessment, basic health screening, teaching of strength and balance exercises, education relating to injury prevention and access to injury-related, referral and connection to other health and social services) and participants can choose to have whānau (family) involved in the intervention.

Outcomes

The primary outcome of interest is participant, whānau and paeārahi acceptability of the intervention. Secondary outcomes include intervention feasibility, cost-effectiveness and exploratory efficacy (including preintervention and postintervention unintentional injury-related hospitalisation, primary care access and public injury-related claims).

Discussion

The findings of this intervention research will be used to inform injury care models for older Māori and process for Māori-led health intervention development more generally.

Trial registration number

ACTRN12621001691831p.

Māori, pharmacists, and medicines adherence – A mixed methods study exploring indigenous experiences of taking medicines ‘as prescribed’ and mechanisms of support

Background

Objectives

Methods

Results

Conclusions

•

Māori experiences of medicines adherence are diverse.

•

Pharmacists can support Māori medicines adherence in a variety of practical ways.

•

Indigenous-led research promotes discourse reflective of Indigenous experience.

Utilising te Tiriti o Waitangi to approach health intervention development and research: pharmacist-facilitated medicines review interventions for Māori older adults

INTRODUCTION te Tiriti o Waitangi guarantees Māori the right to: self-determination, equitable health outcomes, be well informed, health care options, including kaupapa Māori and culturally safe mainstream services, and partnership in the health care journey. Despite integration of these principles into policy, there remains a lack of application in health service development, and health inequities remain. AIM We aimed to use te Tiriti o Waitangi to structure the development of a culturally safe health intervention, using as an exemplar pharmacist-facilitated medicines review for Māori older adults. METHODS Previous research undertaken by our group (a systematic review, and interviews with stakeholders including Māori older adults) was used to inform the aspects to include in the intervention. Kaupapa Māori theory was used to underpin the approach. Intended outcomes, requirements for change, and outcome measures to assess change were mapped to te Tiriti o Waitangi principles as a way to structure the pharmacist-facilitated medicines review intervention and research processes. RESULTS Findings from our previous research identified 12 intended intervention outcomes, including that the intervention be flexible to adapt to diverse needs in a way that is acceptable and culturally safe for Māori and that it supports Māori older adults to control and have confidence in their medicine treatment and wellbeing. DISCUSSION We present an approach to the development of a pharmacist-facilitated medicines review intervention for Māori older adults, structured around the principles of te Tiriti o Waitangi, to support the implementation of a culturally safe, pro-equity intervention.

Inequities in people with gout: a focus on Māori (Indigenous People) of Aotearoa New Zealand

Health equity can be defined as the absence of systematic disparities in health between more and less advantaged social groups. Gout is one of the most common forms of arthritis and disproportionally affects Indigenous peoples, including Māori in Aotearoa New Zealand. Inequities in gout management are well documented and clearly evidenced in Indigenous populations. For example, while gout occurs at a younger age and is more severe in Māori, there is less regular dispensing of urate-lowering therapies. Indigenous peoples are also under-represented in clinical trials. Herein, we will review inequities in gout using Aoteoaroa New Zealand as an example. We will explore reasons for health inequities and challenges that need to be faced to achieve health equity.

Feasibility of a pharmacist-facilitated medicines review intervention for community-dwelling Māori older adults

Background

Objective

Methods

Results

Conclusion

•

A medicines review model developed with and for older Māori was feasible to deliver.

•

Medicines reviews led to medicine and non-medicine related recommendations.

•

Almost 10 recommendations were made per participant with high prescriber acceptance.

Clinical expertise, advocacy and enhanced autonomy – Acceptability of a pharmacist-facilitated medicines review intervention for community-dwelling Māori older adults

Background

Pharmacist-facilitated medicines reviews are effective at identifying medicines-related problems and can improve the appropriate use of medicines in older adults. Current services in Aotearoa New Zealand (NZ) are not developed specifically for Māori (Indigenous people of NZ) and may increase health disparities between Māori and non-Māori. We developed a medicines review intervention for and with Māori older adults, and tested it in a feasibility study.

Objective

To assess patient acceptability of a pharmacist-facilitated medicines review intervention for Māori older adults.

Methods

The intervention consisted of a medicines education session (pharmacist and participant) and an optional medicines optimisation session (pharmacist, participant, and prescriber). Participant acceptability was assessed post-intervention using a structured telephone interview developed specifically for this study. Participants responded to statements using a five-point Likert scale (strongly agree-strongly disagree; numerical analysis/reporting) which focused on the topics of power/control, support mechanisms, intervention content and delivery, and perceived usefulness. Open-ended questions relating to the intervention value and suggestions for improvement were analysed using general inductive analysis.

Results

Seventeen participants took part in the feasibility study from December 2019–March 2020 and all completed the acceptability interview. Participants perceived the intervention content and mode of delivery to be appropriate, and that their power and control over their medicines and health improved and as did their confidence in self-management. Five themes were generated: medicines knowledge from a trusted professional, increased advocacy, ‘by Māori, for Māori’, increased confidence and control, and financial and resource implications.

Conclusion

A pharmacist-facilitated medicines review intervention for Māori older adults developed by Māori, for Māori, was acceptable to patient participants. Participants valued the clinical expertise and advocacy provided by the pharmacist, and the increase in medicines knowledge, control and autonomy. Participants wanted the service to continue on an ongoing basis.

•

Medicines reviews developed by Māori, for Māori were acceptable to participants.

•

Older Māori perceived the intervention improved medicines knowledge and autonomy.

•

Older Māori participants valued the pharmacist's clinical expertise and advocacy.

Developing pharmacist-facilitated medicines review services for community-dwelling Māori older adults in New Zealand - A qualitative study exploring stakeholder views

Māori (Indigenous people of New Zealand [NZ]) experience inequitable health outcomes compared to non-Māori, across the spectrum of clinical care, including those relating to medicines. Internationally, pharmacist-facilitated medicines review services have been shown to benefit older adults. Despite national policies calling for the increased implementation of these services, NZ data relating to them remain limited, and these services may increase disparities between Māori and non-Māori. There are currently no medicines review services developed specifically for Māori older adults. The current study aims to elicit stakeholder views of current and potential pharmacist services to help inform the development of a pharmacist-facilitated medicines review service for community-dwelling Māori older adults. Kaupapa Māori theory was applied within this qualitative research. Purposive sampling was used to recruit participants who were involved in providing, planning, funding developing or culturally supporting health services in Waitematā District Health Board, Auckland, NZ. Data were collected in semi-structured interviews and in a focus group and analysed using reflexive thematic analysis. The study was reported in accordance with the Consolidated Criteria for Reporting Qualitative research. Eleven participants took part in the research in one focus group (n = 4) and seven semi-structured interviews, conducted between November 2018 and March 2019. Three main themes were generated: (a) moving out of the shadows - claiming pharmacists' unique role within a healthcare whānau (family); (b) 'give them the power to be able to ask' - upholding the mana (self-esteem, pride, standing) and autonomy of kaumātua (Māori older adults) and (c) rights versus realities - reimagining pro-equity Māori health services within the constraints of the colonial health system. The right of Māori to experience equitable health outcomes needs to be included in policy and also operationalised in relation to medicines review services through improved utilisation of pharmacist skills and improving Māori older adults' autonomy and control.

The views of New Zealand general practitioners and patients on a proposed risk assessment and communication tool: a qualitative study using Normalisation Process Theory

BACKGROUND

Communicating risks of medication harm and obtaining informed consent is difficult due to structural barriers, language and cultural practices, bias and a lack of resources appropriately tailored for the health literacy of most patients. A decision support tool was proposed to alert prescribers of risk and provide tailored information for patients to facilitate informed decision-making with patients and their whānau (family) around medication use. Patient and prescriber co-design was used to ensure the tool was designed to best meet the needs of end-users and avoid increasing health inequity. This paper describes the first stage of the co-design process.

METHOD

Normalisation Process Theory (NPT) was used to prospectively evaluate the tool. Semi-structured interviews were held with fifteen patients (five Māori, five Pasifika and five NZ European) and nine general practitioners (two Māori and seven European).

RESULTS

Three themes were identified, which related to the three NPT concepts most relevant to developing the tool. Theme 1 (coherence: meaning and sense making by participants) explored participants' understanding of prescribing safety, medication harm and risk, which is based on experience. Patients want as much information as possible about their medications and risk, but doctors find it difficult to communicate that information. Theme 2 related to the NPT concept of cognitive participation (commitment and engagement by participants) explored what participants thought about a prescribing decision support tool. Participants were cautiously optimistic, but worried about potential harm arising from its use. They also identified requirements for the tool and features to avoid. Theme 3 describes the collective action required for successful implementation of the tool; namely, culturally safe and trustworthy doctor-patient relationships.

CONCLUSION

Patients and general practitioners provided different perspectives when prospectively evaluating the proposed risk assessment and communication tool. This co-design research identified important pre-requisites for the tool and features to avoid and novel ideas for the proposed tool. Overall participants supported the development of the proposed risk assessment and communication tool, but identified the important role that doctor-patient relationships would play to ensure successful implementation. The use of Māori and Pacific languages in the proposed tool may enhance engagement and understanding.

Ethnic Variations in the Quality Use of Medicines in Older Adults: Māori and Non-Māori in Aotearoa New Zealand

In Aotearoa New Zealand (NZ), ethnic inequities in health outcomes exist. Non-Māori experience better access to healthcare than Māori, including access to the quality use of medicines. Quality medicines use requires that medicines provide maximal therapeutic benefit with minimal harm. As older adults are more at risk of harm from medicines, and, because inequities are compounded with age, Māori older adults may be at more risk of medicines-related harm than younger and non-Māori populations. This narrative review examined ethnic variation in the quality use of medicines, including medicines utilisation and associated clinical outcomes, between Māori and non-Māori older adult populations in NZ. The review was structured around prevalence of medicine utilisation by medicine class and in particular disease states; high-risk medicines; polypharmacy; prevalence of potentially inappropriate prescribing (PIP); and association between PIP and clinical outcomes. 22 studies were included in the review. There is ethnic variation in the access to medicines in NZ, with Māori older adults often having reduced access to particular medicine types, or in particular disease states, compared with non-Māori older adults. Māori older adults are less likely than non-Māori to be prescribed medicines inappropriately, as defined by standardised tools; however, PIP is more strongly associated with adverse outcomes for Māori than non-Māori. This review identifies that inequities in quality medicines use exist and provides a starting point to develop pro-equity solutions. The aetiology of inequities in the quality use of medicines is multifactorial and our approaches to addressing the inequitable ethnic variation also need to be.

A pharmacist-led medicines review intervention in community-dwelling Māori older adults- a feasibility study protocol

BACKGROUND

Pharmacists have a role to play in supporting the optimal use of medicines to ensure older adults receive therapeutic benefit whilst minimising medicines-related harm. In Aotearoa New Zealand (NZ), Māori (Indigenous people of NZ) experience inequities in the determinants of health, including access to medicines, resulting in increased morbidity, earlier onset of chronic conditions and reduced life expectancy. This study aims to test the feasibility of a pharmacist-led medicines review intervention in community-dwelling Māori older adults.

METHOD

This is a non-randomised, non-controlled feasibility study undertaken within a kaupapa Māori methodological framework which supports the right of Māori to be included throughout the research process and seeks to potentiate transformational, positive change for Māori. The research pharmacist will recruit 30 participants (Māori; 55 years or older; community-dwelling). Participants will undergo a medicines education session with the pharmacist (medicines reconciliation, medicines information, well-being goal setting), with the option to proceed to a medicines optimisation session that includes the participant, pharmacist and primary prescriber (review of potentially inappropriate prescribing (PIP); medicines management plan development). Primary outcomes: participant and prescriber acceptability of intervention. Secondary outcomes include baseline and post-intervention medicines knowledge, PIP and quality of life scores, and number of changes made to the medicines regimen.

ETHICS AND DISSEMINATION

Ethical approval was granted by the Northern B Health and Disability Committee (9/NTB/106). Study results will be disseminated to various stakeholders including Māori communities, health practitioners and providers, and researchers through meetings and conference presentations, lay summaries and peer-reviewed journals. This study is an example of health service design, delivery and evaluation, informed by Indigenous knowledge and methodology, developed explicitly to address inequities in health outcomes for, and with, Māori and will inform the decision to proceed to a randomised controlled trial to test the effect of this intervention.

TRIAL REGISTRATION NUMBER

ACTRN12619001070123.

On allegations of invasive species denialism

Science denialism retards evidenced-based policy and practice and should be challenged. It has been a particular concern for mitigating global environmental issues, such as anthropogenic climate change. But allegations of science denialism must also be well founded and evidential or they risk eroding public trust in science and scientists. Recently, 77 published works by scholars, scientists, and science writers were identified as containing invasive species denialism (ISD; i.e., rejection of well-supported facts about invasive species, particularly the global scientific consensus about their negative impacts). We reevaluated 75 of these works but could find no examples of refutation of scientific facts and only 5 articles with text perhaps consistent with one of the 5 characteristics of science denialism. We found, therefore, that allegations of ISD were misplaced. These accusations of science denialism may have arisen because invasion biology defines its subjects-invasive species-based on multiple subjective and normative judgments. Thus, more than other applied sciences its consensus is one of shared values as much as agreed knowledge. Criticisms of invasion biology have largely targeted those subjective and normative judgments and their global imposition, not the knowledge on which the discipline is based. Regrettably, a few invasion biologists have misinterpreted the critique of their values-based consensus as a denial of their science when it is not. To make invasion biology a more robust and widely accepted science and to avoid unnecessary misunderstandings and conflicts, invasion biologists could be more accepting of perspectives originating from other disciplines and more open to values-based critique from scholars and scientists outside their field. This recommendation applies to all conservation sciences, especially those addressing global challenges, because these sciences must serve and be relevant to communities with an extraordinary diversity of cultures and values.

A systematic review of pharmacist-led medicines review services in New Zealand - is there equity for Māori older adults?

BACKGROUND

Pharmacist involvement in medicines reviews for older adults can improve prescribing and reduce adverse drug reactions. Māori experience poorer health outcomes than non-Māori resulting, in part, from inequitable access to and quality of medicine-related care. Despite international data showing benefit, it is unclear whether pharmacist-led medicines review services can improve outcomes for Māori older adults.

OBJECTIVE

This systematic review aims to describe pharmacist-led medicines review services for community-dwelling adults in New Zealand, assess effectiveness of these interventions and identify their effect on health equity for Māori and older adults.

METHODS

The review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Equity (PRISMA-E 2012). Observational studies were included. The intervention in included studies had to involve a pharmacist, occur in the outpatient setting in New Zealand, and involve review of all medicines for an individual patient. At least one patient-related outcome had to be reported.

RESULTS

The search identified seven observational studies with 542 total participants. Study interventions included adherence-based reviews in community pharmacies and multi-step comprehensive clinical reviews in outpatient haemodialysis units. Medicines reviews identified up to a median of 3 drug-related problems per review. The effect of interventions on medicines adherence and knowledge was not clear. Māori may have been less likely than non-Māori to benefit from improved medicines knowledge as a result of interventions. None of the studies incorporated aspects in study design or delivery to address inequities for Māori.

CONCLUSION

Further investigation is needed to understand whether the development of culturally safe pharmacist-led medicines review services, responsive to community identified needs, can help to achieve equity in health outcomes for Māori older adults.