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Introduction: Knee osteoarthritis (OA) negatively impacts the health outcomes and equity, social and employment participation, and socio‐economic wellbeing of those affected. Little community‐based support is offered to people with knee OA in Aotearoa New Zealand. Identifying Māori and non‐Māori with knee OA in community pharmacy and providing co‐ordinated, evidence‐ and community‐based care may be a scalable, sustainable, equitable, effective and cost‐effective approach to improve health and wellbeing. Aim: Assess whether the Knee Care for Arthritis through Pharmacy Service (KneeCAPS) intervention improves knee‐related physical function and pain (co‐primary outcomes). Secondary aims assess impacts on health‐related quality of life, employment participation, medication use, secondary health care utilisation, and relative effectiveness for Māori. Methods and analysis: A pragmatic randomised controlled trial will compare the KneeCAPS intervention to the Pharmaceutical Society of New Zealand Arthritis Fact Sheet and usual care (active control) at 12 months for Māori and non‐Māori who have knee OA. Participants will be recruited in community pharmacies. Knee‐related physical function will be measured using the function subscale of the Short Form of the Western Ontario and McMaster Universities Osteoarthritis Index. Knee‐related pain will be measured using an 11‐point numeric pain rating scale. Primary outcome analyses will be conducted on an intention‐to‐treat basis using linear mixed models. Parallel within‐trial health economic analysis and process evaluation will also be conducted. Ethics and trial dissemination: Ethical approval was obtained from the Central Health and Ethics Committee (2022‐EXP‐11725). The trial is registered with ANZCTR (ACTRN12622000469718). Findings will be submitted for publication and shared with participants. [ABSTRACT FROM AUTHOR]

As psychosocial factors have been recognised as significant predictors of the recovery trajectory from chronic back pain, the 34-item Back Pain Attitudes Questionnaire (Back-PAQ) was developed based on themes obtained from patient interviews, but previous psychometric analyses with a general population sample revealed uncertainty around the factor structure of the instrument. To provide more detailed information about the psychometric properties of the Back-PAQ when used with participants from the general population and also to test the internal validity of the tool for use with General Practitioners (GPs). After applying partial-credit Rasch analysis with a sample of participants from the general population (n = 600), a replication analysis was conducted with a sample of GPs (n = 184). This approach permitted examination of sample-specific personal factors for differential item functioning. Subtests were used to differentiate between local dependency due to underlying dimensionality from local dependency due to method effects. A unidimensional fit to the Rasch model was achieved after 14 misfitting items had been deleted. The final 20-item solution also fit with a sample of 184 GPs. In both cases, the Back-PAQ-20 demonstrated good reliability (PSI ≥ 0.80), with no evidence of differential item functioning by personal factors. The ordinal-to-interval conversion algorithms presented here further enhance the precision of the scale and permit analysis of Back-PAQ-20 scores using parametric statistics. The present study provided evidence for valid and reliable assessment of the back pain recovery beliefs of both users as well as providers of health services. Psychosocial factors have been recognised as significant predictors of the recovery trajectory from chronic back pain. The 34-item Back Pain Attitudes Questionnaire (Back-PAQ) was developed based on themes obtained from patient interviews, but previous psychometric analyses with a general population sample revealed uncertainty around the factor structure of the instrument. The 20-item version of the Back Pain Attitudes Questionnaire (Back-PAQ) is shown here to have strong psychometric properties for administration with users and providers of health services. [ABSTRACT FROM AUTHOR]

Background: Effective and cost-effective primary care treatments for low back pain (LBP) are required to reduce the burden of the world's most disabling condition. This study aimed to compare the clinical effectiveness and cost-effectiveness of the Fear Reduction Exercised Early (FREE) approach to LBP (intervention) with usual general practitioner (GP) care (control).Methods and Findings: This pragmatic, cluster-randomised controlled trial with process evaluation and parallel economic evaluation was conducted in the Hutt Valley, New Zealand. Eight general practices were randomly assigned (stratified by practice size) with a 1:1 ratio to intervention (4 practices; 34 GPs) or control group (4 practices; 29 GPs). Adults presenting to these GPs with LBP as their primary complaint were recruited. GPs in the intervention practices were trained in the FREE approach, and patients presenting to these practices received care based on the FREE approach. The FREE approach restructures LBP consultations to prioritise early identification and management of barriers to recovery. GPs in control practices did not receive specific training for this study, and patients presenting to these practices received usual care. Between 23 September 2016 and 31 July 2017, 140 eligible patients presented to intervention practices (126 enrolled) and 110 eligible patients presented to control practices (100 enrolled). Patient mean age was 46.1 years (SD 14.4), and 46% were female. The duration of LBP was less than 6 weeks in 88% of patients. Primary outcome was change from baseline in patient participant Roland Morris Disability Questionnaire (RMDQ) score at 6 months. Secondary patient outcomes included pain, satisfaction, and psychosocial indices. GP outcomes included attitudes, knowledge, confidence, and GP LBP management behaviour. There was active and passive surveillance of potential harms. Patients and outcome assessors were blind to group assignment. Analysis followed intention-to-treat principles. A total of 122 (97%) patients from 32 GPs in the intervention group and 99 (99%) patients from 25 GPs in the control group were included in the primary outcome analysis. At 6 months, the groups did not significantly differ on the primary outcome (adjusted mean RMDQ score difference 0.57, 95% CI -0.64 to 1.78; p = 0.354) or secondary patient outcomes. The RMDQ difference met the predefined criterion to indicate noninferiority. One control group participant experienced an activity-related gluteal tear, with no other adverse events recorded. Intervention group GPs had improvements in attitudes, knowledge, and confidence compared with control group GPs. Intervention group GP LBP management behaviour became more guideline concordant than the control group. In cost-effectiveness, the intervention dominated control with lower costs and higher Quality-Adjusted Life Year (QALY) gains. Limitations of this study were that although adequately powered for primary outcome assessment, the study was not powered for evaluating some employment, healthcare use, and economic outcomes. It was also not possible for research nurses (responsible for patient recruitment) to be masked on group allocation for practices.Conclusions: Findings from this study suggest that the FREE approach improves GP concordance with LBP guideline recommendations but does not improve patient recovery outcomes compared with usual care. The FREE approach may reduce unnecessary healthcare use and produce economic benefits. Work participation or health resource use should be considered for primary outcome assessment in future trials of undifferentiated LBP.Trial Registration: ACTRN12616000888460. [ABSTRACT FROM AUTHOR]

Background: Low back pain (LBP) is a major health issue associated with considerable health loss and societal costs. General practitioners (GPs) play an important role in the management of LBP; however, GP care has not been shown to be the most cost-effective approach unless exercise and behavioural counselling are added to usual care. The Fear Reduction Exercised Early (FREE) approach to LBP has been developed to assist GPs to manage LBP by empowering exploration and management of psychosocial barriers to recovery and provision of evidence-based care and information. The aim of the Low Back Pain in General Practice (LBPinGP) trial is to explore whether patients with LBP who receive care from GPs trained in the FREE approach have better outcomes than those who receive usual care.Methods/design: This is a cluster randomised controlled superiority trial comparing the FREE approach with usual care for LBP management with investigator-blinded assessment of outcomes. GPs will be recruited and then cluster randomised (in practice groups) to the intervention or control arm. Intervention arm GPs will receive training in the FREE approach, and control arm GPs will continue to practice as usual. Patients presenting to their GP with a primary complaint of LBP will be allocated on the basis of allocation of the GP they consult. We aim to recruit 60 GPs and 275 patients (assuming patients are recruited from 75% of GPs and an average of 5 patients per GP complete the study, accounting for 20% patient participant dropout). Patient participants and the trial statistician will be blind to group allocation throughout the study. Analyses will be undertaken on an intention-to-treat basis. The primary outcome will be back-related functional impairment 6 months post-initial LBP consultation (interim data at 2 weeks, 6 weeks and 3 months), measured with the Roland-Morris Disability Questionnaire. Secondary patient outcomes include pain, satisfaction, quality of life, days off from work and costs of care. Secondary GP outcomes include beliefs about pain and impairment, GP confidence, and actual and reported clinical behaviour. Health economic and process evaluations will be conducted.Discussion: In the LBPinGP trial, we will investigate providing an intervention during the first interaction a person with back pain has with their GP. Because the FREE approach is used within a normal GP consultation, if effective, it may be a cost-effective means of improving LBP care.Trial Registration: Australian New Zealand Clinical Trials Registry, ACTRN12616000888460 . Registered on 6 July 2016. [ABSTRACT FROM AUTHOR]

Introduction: The purpose of this research was to explore whether New Zealand occupational therapists’ recommendations for chronic low back pain are predicted by their fear avoidance beliefs. Method: In an online survey, 63 therapists rated the strength of recommendation on a four-point Likert scale (for each of: home help, equipment provision, and environmental modification) for a case study of low back pain, and completed two questionnaires about fear avoidance beliefs. The strength of recommendation (definitely not, not likely, likely, definitely yes) was analysed as an ordinal scale response variable, with important predictors each of the Fear Avoidance Beliefs Tool and the Health Care Providers Pain and Impairment Relationship Scale. Potential confounding variables were: age, years in practice or pain practice, and receipt of extra pain education. The main response variable was the probability of recommending home help. Analysis was by proportional odds regression. Findings: 54/63 (85.7%) of the surveys had complete data. The adjusted odds ratio, per point higher on the fear avoidance belief scales, for therapists who were more likely to recommend home help was 1.19 (95% CI 1.06 to 1.35), p = 0.005 for the Fear Avoidance Belief Tool and 1.16 (95% CI 1.04 to 1.29), p = 0.006 for Health Care Providers Pain and Impairment Relationship Scale. This is consistent with those with greater fear avoidance beliefs being more likely to recommend home help. Conclusion: Occupational therapists’ fear avoidance beliefs are associated with treatment recommendations that lessen activity or movement demands. These beliefs are potentially unhelpful and may reinforce avoidance behaviour in patients with chronic low back pain. [ABSTRACT FROM AUTHOR]

PURPOSE The purpose of this study was to explore the formation and impact of attitudes and beliefs among people experiencing acute and chronic low back pain. METHODS Semistructured qualitative interviews were conducted with 12 participants with acute low back pain (less than 6 weeks' duration) and 11 participants with chronic low back pain (more than 3 months' duration) from 1 geographical region within New Zealand. Data were analyzed using an Interpretive Description framework. RESULTS Participants' underlying beliefs about low back pain were influenced by a range of sources. Participants experiencing acute low back pain faced considerable uncertainty and consequently sought more information and understanding. Although participants searched the Internet and looked to family and friends, health care professionals had the strongest influence upon their attitudes and beliefs. Clinicians influenced their patients' understanding of the source and meaning of symptoms, as well as their prognostic expectations. Such information and advice could continue to influence the beliefs of patients for many years. Many messages from clinicians were interpreted as meaning the back needed to be protected. These messages could result in increased vigilance, worry, guilt when adherence was inadequate, or frustration when protection strategies failed. Clinicians could also provide reassurance, which increased confidence, and advice, which positively influenced the approach to movement and activity. CONCLUSIONS Health care professionals have a considerable and enduring influence upon the attitudes and beliefs of people with low back pain. It is important that this opportunity is used to positively influence attitudes and beliefs. [ABSTRACT FROM AUTHOR]

Background: The prevalence of asthma for Indigenous New Zealand Māori is amongst the highest in the world. Recent evidence shows ethnic differences in asthma symptom prevalence in New Zealand have widened, with asthma symptoms and hospitalisation rates consistently higher for Māori across all age-groups, especially children and adolescents. This paper: outlines our qualitative, longitudinal research exploring the practical issues Māori children and their families face trying to achieve optimum asthma outcomes; details the research methods used within this study; and discusses the process evaluation findings of the features that made this approach successful in engaging and retaining participants in the study. Methods: Thirty-two Māori families were recruited using a Kaupapa Māori (Māori way) Research approach. Each participated in a series of four in-depth interviews that were carried out at seasonal intervals over the course of one year. Families also took part in an interviewer-administered questionnaire and participated in a Photovoice exercise. All interviews were digitally recorded, transcribed verbatim and independently coded by two researchers. The research team then conducted the analysis and theme development. The questionnaires were analysed separately, with explanations for findings explored within the qualitative data. Results: The methodology produced a 100 percent retention rate of the participating families over the course of the follow-up. This was attributed to the research collaboration, the respectful research relationships established with families, and the families' judgement that the methods used enabled them to tell their stories. The acceptability of the methodology will add to the validity and trustworthiness of the findings. Conclusion: Given the extent and persistence of ethnic disparities in childhood asthma management, it is imperative that an indigenous approach be taken to understanding the core issues facing Māori families. By conducting community-partnership research underpinned by an indigenous methodology, and employing a range of appropriate methods, we have successfully recruited and retained a cohort of Māori families with experiences of childhood asthma. We aim to make their voices heard in order to develop a series of culturally relevant interventions aimed at remediating these disparities. [ABSTRACT FROM AUTHOR]

Objective: To determine the feasibility, the cluster design effect and the variance and minimal clinical importance difference in the primary outcome in a pilot study of a structured approach to goal-setting.Design: A cluster randomized controlled trial.Setting: Inpatient rehabilitation facilities.Subjects: People who were admitted to inpatient rehabilitation following stroke who had sufficient cognition to engage in structured goal-setting and complete the primary outcome measure.Interventions: Structured goal elicitation using the Canadian Occupational Performance Measure.Main measures: Quality of life at 12 weeks using the Schedule for Individualised Quality of Life (SEIQOL-DW), Functional Independence Measure, Short Form 36 and Patient Perception of Rehabilitation (measuring satisfaction with rehabilitation). Assessors were blinded to the intervention.Results: Four rehabilitation services and 41 patients were randomized. We found high values of the intraclass correlation for the outcome measures (ranging from 0.03 to 0.40) and high variance of the SEIQOL-DW (SD 19.6) in relation to the minimally importance difference of 2.1, leading to impractically large sample size requirements for a cluster randomized design.Conclusions: A cluster randomized design is not a practical means of avoiding contamination effects in studies of inpatient rehabilitation goal-setting. Other techniques for coping with contamination effects are necessary. [ABSTRACT FROM AUTHOR]

Introduction Many New Zealand rural workers have repeated low back pain (LBP) episodes yet continue to work. We wanted to find out why, given that other manual workers with LBP often end up on long term sick leave or permanently disabled. Methods Our primarily qualitative approach used mixed methods to investigate rural workers with non-specific LBP. Participants ( n = 33) were surveyed for demographic data, the Brief Illness Perception Questionnaire and the General Self Efficacy Scale followed by one-to-one semi-structured interviews. Analysis ranged from descriptive content to detailed qualitative Interpretative Phenomenological Analysis. Results Participants had high self efficacy scores, positive perceptions about LBP but strong beliefs that LBP is lifelong. Four distinct themes emerged. ' Thinking with my head before my back' and ' Knowing the risks' described participants' innovation regarding job modifications. ' Just carry on' and ' Love of the land' related to stoical resilience and commitment to something more than employment. Conclusions This rural workforce adopts a 'can do' attitude to work, managing LBP within the context of having job control and flexible work practices. Implications: Rehabilitation interventions promoting job control and targeting positive attitudes towards getting on with work, whilst accepting LBP as part of everyday life, may have merit for other workers with LBP. [ABSTRACT FROM AUTHOR]

Introduction: Persistent non-cancer pain affects one in five adults and is more common in Māori-the Indigenous population of New Zealand (NZ), adults over 65 years, and people living in areas of high deprivation. Despite the evidence supporting multidisciplinary pain management programmes (PMPs), access to PMPs is poor due to long waiting lists. Although online-delivered PMPs enhance access, none have been codesigned with patients or compared with group-based, in-person PMPs. This non-inferiority trial aims to evaluate the clinical and cost-effectiveness of a cocreated, culturally appropriate, online-delivered PMP (iSelf-help) compared with in-person PMP in reducing pain-related disability., Methods and Analysis: Mixed-methods, using a modified participatory action research (PAR) framework, involving three phases. Phase I involved cocreation and cultural appropriateness of iSelf-help by PAR team members. Phase II: The proposed iSelf-help trial is a pragmatic, multicentred, assessor-blinded, two-arm, parallel group, non-inferiority randomised controlled trial. Adults (n=180, age ≥18 years) with persistent non-cancer pain eligible for a PMP will be recruited and block randomised (with equal probabilities) to intervention (iSelf-help) and control groups (in-person PMP). The iSelf-help participants will participate in two 60-minute video-conferencing sessions weekly for 12 weeks with access to cocreated resources via smartphone application and a password-protected website. The control participants will receive group-based, in-person delivered PMP. Primary outcome is pain-related disability assessed via modified Roland Morris Disability Questionnaire at 6 months post intervention. Secondary outcomes include anxiety, depression, stress, pain severity, quality of life, acceptance, self-efficacy, catastrophising and fear avoidance. Data will be collected at baseline, after the 12-week intervention, and at 3 and 6 months post intervention. We will conduct economic analyses and mixed-method process evaluations (Phase IIA)., Ethics and Dissemination: The Health and Disability Ethics Committee approved the study protocol (HDEC18/CEN/162). Phase III involves dissemination of findings guided by the PAR team as outcomes become apparent., Trial Registration Number: ACTRN 12619000771156., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Low back pain (LBP) is a significant health problem and common reason to visit the GP. Evidence suggests GPs experience difficulty applying evidence-based guidelines., Objective: Explore GPs' underlying beliefs about acute LBP and how these influence their clinical management of patients., Methods: Eleven GPs from one geographical region within New Zealand were recruited by purposive sampling. Audio recordings of semi-structured qualitative interviews were transcribed verbatim. Data were analysed with an Interpretive Description framework., Results: Four key themes emerged related to the causes of acute LBP, GP confidence, communicating diagnostic uncertainty and encouraging movement and activity. Acute LBP was seen as a direct representation of tissue injury, consequently the assessment and management of patients' attitudes and beliefs was not a priority. Participants' confidence was decreased due to a perceived inability to diagnose or influence the tissue injury. Despite this, diagnoses were provided to patients to provide reassurance and meet expectations. Guideline recommendations regarding activity conflicted with a perceived need to protect damaged tissue, resulting in reported provision of mixed messages about the need to be both active and careful., Conclusions: GPs' initial focus upon tissue injury during acute care, and providing a diagnostic label, may influence patients' subsequent alignment with a biomedical perspective and contribute to consultation conflict and patients' perception of blame when discussion of psychosocial influences is introduced. Demonstrating the relevance of the biopsychosocial model to acute LBP may improve GPs' alignment with guidelines, improve their confidence to manage these patients and ultimately improve outcomes., (© The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Rehabilitation of patients with low back pain forms an important component of musculoskeletal physical therapist practice, yet treatment outcomes often are poorly measured., Objective: The study examined the methods used to evaluate treatment outcomes and factors influencing the use of outcome measures by New Zealand physical therapists., Design: This cross-sectional study used qualitative and quantitative methods for data collection., Methods: Two focus groups were conducted: one in a private practice (n=6) and one in a public hospital (n=6). A survey questionnaire was mailed to all private practices listed in a telecommunication database and to outpatient physical therapy departments at public hospitals (n=579)., Results: The mail survey achieved a 65% response rate and showed that physical therapists use improvements in person-specific functional activities as their main outcome measure. Only 40% of the respondents reported using back-related outcome measures. The statistically significant factors determining their use were having a master's degree and an increased level of knowledge of outcome measurement, but these factors explained only 22% of the variance in the logistic regression model. Lack of time, frequently mentioned as a reason for not using standardized outcome measures, did not reach statistical significance., Limitations: The data collected relate to the physical therapists' reported or perceived behavior, which may be different from reality., Conclusion: Physical therapists do not routinely use outcome measures in their clinical practice. A master's degree and increased knowledge were statistically significant factors supporting increased use of outcome measures. Further research is needed on how to convey to practitioners that the information they provide can be useful and can improve patient outcomes.

Background: Long term adherence to primary care physical activity intervention is poor. This study explored attitudes and subjective experiences of those who received such an intervention., Methods: Nested qualitative study within mixed methods approach, involving 15 sedentary adults from urban and rural general practices in New Zealand. Semistructured telephone interviews were conducted, transcribed, and analysed using an inductive approach to identify themes., Results: Four themes emerged including: tailoring of advice given; barriers to physical activity such as weather, physical environment, time, health and psychological limitations; internal motivators such as immediate or long term psychological, health or spiritual benefits, commitment, and guilt; and the role of significant others such as health and exercise professionals in initiating advice and continuing support, social interaction and commitment or contracts made to others., Discussion: This study highlights the need for a personalised approach, continued structured external support and the need to focus on barriers and facilitators.

Although evidence reveals that self-efficacy is associated with disability in people with pain, there is less known about this relationship in primary care settings and no published information in general population samples. This study aimed to assess the relationship between pain, self-efficacy, health-related quality of life, psychological distress and disability in a general population sample. A randomly selected sample from electoral registers of the lower North Island of New Zealand was mailed a survey questionnaire. Presence of musculoskeletal pain was defined as "pain present for at least seven consecutive days during the last month". Respondents were divided into three groups on the basis of pain: no pain, pain present for less than 12 months and pain present for 12 months or longer. Health Self-efficacy, General Self-efficacy, General Health Questionnaire, modified Health Assessment Questionnaire and EuroQol-5D were also included in the survey instrument. There were 289/471 (61%) returned questionnaires from eligible subjects (of an original sample of 540). General linear modelling found evidence of an association between pain status and self-efficacy with disability, explaining 16.4-18.8% of variability in mHAQ scores. In addition, we found evidence of an interaction between pain status and general self-efficacy, suggesting a stronger relationship between general self-efficacy and disability for pain present for 12 months or more. This interaction was not observed for health self-efficacy. General self-efficacy was more strongly related to psychological distress and this association was not influenced by pain status. Health-related quality of life was associated with health self-efficacy but not general self-efficacy.