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INTRODUCTION The Department of General Practice and Primary Health Care at the University of Auckland is considering developing a Master of Primary Health Care (MPHC) programme. Masters level study entails considerable investment of both university and student time and money. AIM To explore the views of potential students and possible employers of future graduates to discover whether there is a market for such a programme and to inform the development of the programme. METHODS Semi-structured interviews were conducted with 30 primary health care stakeholders. Interviews were digitally recorded, transcribed and analysed using a general inductive approach to identify themes. FINDINGS Primary care practitioners might embark on MPHC studies to develop health management and leadership skills, to develop and/or enhance clinical skills, to enhance teaching and research skills, or for reasons of personal interest. Barriers to MPHC study were identified as cost and a lack of funding, time constraints and clinical workload. Study participants favoured inter-professional learning and a flexible delivery format. Pre-existing courses may already satisfy the post-graduate educational needs of primary care practitioners. Masters level study may be superfluous to the needs of the primary care workforce. CONCLUSIONS Any successful MPHC programme would need to provide value for PHC practitioner students and be unique. The postgraduate educational needs of New Zealand primary care practitioners may be already catered for. The international market for a MPHC programme is yet to be explored.

This paper describes development of a prototype data analytics portal for analysis of accumulated screening results from eCHAT (electronic Case-finding and Help Assessment Tool). eCHAT allows individuals to conduct a self-administered lifestyle and mental health screening assessment, with usage to date chiefly in the context of primary care waiting rooms. The intention is for wide roll-out to primary care clinics, including secondary school based clinics, resulting in the accumulation of population-level data. Data from a field trial of eCHAT with sexual health questions tailored to youth were used to support design of a data analytics portal for population-level data. The design process included user personas and scenarios, screen prototyping and a simulator for generating large-scale data sets. The prototype demonstrates the promise of wide-scale self-administered screening data to support a range of users including practice managers, clinical directors and health policy analysts.

Background: Implementation science research, especially when using participatory and co-design approaches, raises unique challenges for research ethics committees. Such challenges may be poorly addressed by approval and governance mechanisms that were developed for more traditional research approaches such as randomised controlled trials., Discussion: Implementation science commonly involves the partnership of researchers and stakeholders, attempting to understand and encourage uptake of completed or piloted research. A co-creation approach involves collaboration between researchers and end users from the onset, in question framing, research design and delivery, and influencing strategy, with implementation and broader dissemination strategies part of its design from gestation. A defining feature of co-creation is its emergent and adaptive nature, making detailed pre-specification of interventions and outcome measures impossible. This methodology sits oddly with ethics committee protocols that require precise pre-definition of interventions, mode of delivery, outcome measurements, and the role of study participants. But the strict (and, some would say, inflexible) requirements of ethics committees were developed for a purpose - to protect participants from harm and help ensure the rigour and transparency of studies. We propose some guiding principles to help square this circle. First, ethics committees should acknowledge and celebrate the diversity of research approaches, both formally (through training) and informally (by promoting debate and discussion); without active support, their members may not understand or value participatory designs. Second, ground rules should be established for co-design applications (e.g. how to judge when 'consultation' or 'engagement' becomes research) and communicated to committee members and stakeholders. Third, the benefits of power-sharing should be recognised and credit given to measures likely to support this important goal, especially in research with vulnerable communities. Co-design is considered best practice, for example, in research involving indigenous peoples in New Zealand, Australia and Canada.

Background: Although mild to moderate mental health problems are common and often debilitating, treatment options in primary care settings in New Zealand are often severely limited for patients with these conditions. Previously, we developed an ultra-brief intervention (UBI) to address mild to moderate psychological concerns, designed to be delivered by primary care clinicians. Recent feasibility testing, including an adaptation for Māori individuals (the indigenous people of New Zealand), showed that the brief intervention was feasible and acceptable to both clinicians and their patients. This protocol describes a large pragmatic randomized controlled trial of our UBI in primary care settings across the greater Wellington region, compared with practice as usual., Methods/design: We are using a two-arm cluster randomized controlled trial, with primary care practices randomized to exclusively deliver either the UBI or practice as usual to all their recruited participants. The structured, guided self-help UBI is delivered in three brief general practitioner (GP) appointments over a five week period. Participants are invited into the study based on partner primary health organization access criteria (youth, people with low income, or people with Māori or Pacific Island heritage). Improvements in mental health from baseline to post-treatment will be compared between the intervention and control groups using a mixed-models application of analysis of covariance. Data analysis will be on an intention-to-treat basis, to increase the real-world relevance of UBI and to meet the study's objective of releasing UBI to primary care clinicians nationwide., Discussion: The UBI is a first-line intervention tool for GPs that models the stepped care approach advocated in New Zealand, against a background of limited access to treatments for often-overlooked patient groups. It is proposed to be accessible to clinicians and patients alike, with the potential to be relevant to primary care clinicians across New Zealand., Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12613000041752.

Introduction: The way information is presented to communicate risk and treatment benefit affects patients' understanding and perception of their risk and can influence their decisions., Aim: To assess the effect of ethnicity on patient preferences for different ways of expressing risk and treatment benefits., Methods: Using tailored questionnaires, we surveyed Ma¯ori , Pacific and Indian peoples of known CVD risk to assess format preferences encouraging them to take medication or assist their understanding of possible treatment benefits. Statistical analysis determined any association of ethnicity with patient preferences., Results: Of the 376 participants, 50% identified as New Zealand (NZ) European; 15% Maori ; 25% Pacific and 10% Indian ethnicity. Patients preferred positive framing of risk (66%). Relative risk was the format reported as most encouraging to take medication and to understand risk, with natural frequencies least preferable, although Pacific people significantly preferred natural frequencies (p<0.0001) compared with other ethnic groups. The majority (55%) preferred pictures to numbers for explaining risk. Ma¯ori , Pacific and Indian participants significantly preferred 100-people chart formats over bar graphs compared with NZ Europeans/Others (p=0.002). Most (68%) preferred doctors to give their opinion on taking medication instead of explaining risks using numbers and/or pictures. Pacific and Indian peoples significantly preferred doctors to make decisions on treatment compared to NZ European/Other and Ma¯ori participants (p<0.0001)., Discussion: Ethnic differences in patient preferences for communication formats and decision-making should be considered when tailoring effective communication in primary care. However, individual preferences cannot be presumed and a combination of methods should routinely be used.

Pain on vaccine injection and subsequent site reactions of pain and swelling may influence confidence in vaccines and their uptake. This study aimed to identify factors associated with reported pain on injection and reactogenicity following administration of a strain specific meningococcal B outer membrane vesicle vaccine. A retrospective analysis of data was conducted from a phase II single center randomized observer-blind study that evaluated the safety, reactogenicity and immunogenicity of this vaccine in 2 cohorts of healthy 8 to 12 y old children. Vaccine administration technique was observed by an unblinded team member and the vaccine administrator instructed on standardized administration. Participants kept a daily diary to record local reactions (erythema, induration and swelling) and pain for 7 d following receipt of the vaccine. Explanatory variables were cohort, vaccine, age, gender, ethnicity, body mass index, atopic history, history of frequent infections, history of drug reactions, pain on injection, vaccinator, school population socioeconomic status, serum bactericidal antibody titer against the vaccine strain NZ98/254, and total IgG. Univariate and multivariable analyses were conducted using ordinal logistic regression for factors relating to pain on injection and reactogenicity. Perceived pain on injection was related to vaccine formulation, vaccine administrator and ethnicity. Reactogenicity outcomes varied with ethnicity and vaccine administrator. Maintaining community and parental confidence in vaccine safety without drawing attention to differences between individuals and groups is likely to become increasingly difficult. Vaccine administration technique alone has the potential to significantly reduce pain experienced on injection and local vaccine reactions.

Background: Social and emotional challenges of migration and integration include managing memories and perceptions of country of birth, leaving loved relatives behind, and the challenges of maintaining traditions, such as cultural food and practices. For many migrants, the strong connection with their birth country is never completely severed, which may become pertinent at particular events and stages in life with inherent emotional impact. This may be particularly the case for end-of-life experience., Objective: We undertook a systematic review of published evidence of research to identify the lived experience of migrants dying in a country different from their country of birth., Design: The search terms [transnationals OR migran* OR immigran*] AND [emotions OR belonging OR acculturation OR national identity] AND [dying OR end-of-life OR contemplation of dying] AND [palliative care OR terminal care] were used on the following electronic databases: MEDLINE, Embase, CINAHL, EBSCO, Geobase, PsychINFO, and Scopus to the end date of January 2014. No date limit was imposed. All research methodologies were included. The search was restricted to human subjects and English language., Results: Seven qualitative studies met the criteria. Thematic analysis of these studies identified three main themes: sense of dual identity, importance of traditions from their country of origin, and dying preferences., Conclusion: Findings have implications for the provision of palliative end-of-life care for dying transnationals, particularly in relation to providing support for migrants who are dying to resolve social and emotional issues.

Introduction: While New Zealand (NZ) immunisation coverage has improved steadily over the years, there is inequity between ethnic groups, with rates lower in Maori and Pacific people and highest in Asian people. This qualitative study aimed to identify attitudes and behaviours of NZ Asian parents of children under the age of five years that might contribute to their seeking immunisation for their children., Methods: In-depth, semi-structured interviews were conducted to explore attitudes, values, experiences, knowledge, behaviour and perceived barriers regarding childhood immunisation. Transcripts were analysed using a general inductive approach., Findings: Key themes identified were a general positive attitude towards immunisation, being well-informed and aware of the value of immunisation, accepting governmental encouragement to use immunisation services, and perceiving minimal barriers to immunisation services access., Conclusion: The findings of this study suggest that high immunisation coverage rates among NZ Asians may be primarily due to parental attitudes, rather than the quality and accessibility of immunisation services in NZ.

Introduction: Evidence is limited regarding the effectiveness of brief interventions delivered through primary care to improve healthy living and increase physical activity. The Healthy As programme delivering brief interventions programmes in primary care to promote physical activity, improved nutrition and weight management was developed, implemented and assessed. This study aimed to identify aspects of the programme that worked well, those that presented problems or barriers, along with suggestions for improvement., Methods: Three provider organisations in Auckland were contracted to deliver the Healthy As intervention in primary care settings. Semi-structured interviews were conducted with those delivering the risk assessments and providing the intervention from each provider organisation. A thematic analysis approach based on grounded theory was used to analyse the emerging key themes., Findings: The emerging themes related to the holistic nature of the programme, its structure, resources used with participants, engagement of the providers with the participants, and whether the programme was effective in changing behaviour., Conclusion: Initial engagement of participants was found to be particularly important for the success of the Healthy As programme. For a patient-centred approach, good communication between the patient and health provider is required to facilitate shared decision-making and self-management prior to implementation of an intervention. Patients need to indicate whether they want help to make changes. Advice on healthy eating and exercise should not be given in isolation. Patients may also need help with mental health or other lifestyle issues before they can actively engage in exercise or weight reduction programmes.

Objective: To assess the feasibility and acceptability of administering the validated Case-finding Health Assessment Tool (CHAT) in Canadian family practice waiting rooms to identify risk factors for depression, anxiety, anger control,smoking, drinking, other drug use, gambling, exposure to abuse, and physical inactivity., Design: Cross-sectional survey., Setting: One urban academic family practice and one inner-city community health centre in British Columbia., Participants: Convenience sample of consecutive adult patients (19 years of age or older) and their attending family physicians., Main Outcome Measures: Rates of completion; positive responses to and wanting help with identified lifestyle and mental health risk factors; rates of objections to any questions; and positive and negative comments about the CHAT by participating physicians and patients., Results: A total of 265 eligible adults presented in the waiting rooms over 5 full days and 3 half-days, 176 (66%) of whom enrolled in the study; 161(91%) completed the CHAT, and 107 (66%) completed acceptability feedback forms. The prevalence of risk factors among patients in the academic and inner-city practice samples was different, with 20% and 63%, respectively,recording positive responses to both depression screening questions,34% and 60% positive for anxiety, 11% and 71% currently smoking, 6%and 22% feeling they needed to cut down on alcohol, 1% and 48% having used recreational drugs in the past year, and 11% and 65% with problems controlling anger. While many requested help with reducing risk factors,such as smoking (20%) and mental health symptoms (25% to 27%), a total of 35% (57 of 161) wanted help with an identified issue that day. Patients and physicians found the CHAT acceptable, with no patients objecting to any question except the alcohol question (2 objected). Most comments were positive., Conclusion: The CHAT allowed efficient identification of 9 risk factors, as well as identification of those wanting help. It could be used to screen all or targeted adult Canadian primary care patients in waiting rooms.

A 10-year-old girl with untreated congenital HIV developed acute sepsis to which she succumbed despite emergency treatment. Her red and dilated anal region with small areas of tissue breakdown due to advanced HIV destructive disease was misinterpreted as anal assault. Suffocation was then hypothesised to be the cause of her profound hypoxia and multi-organ failure. Criminal proceedings against her adoptive uncle ensued over a 5-year period at huge legal and social cost. Following the first acquittal, appellant hearings led to re-trial at which her uncle was acquitted for the second time. A shared idée fixe (anal assault and asphyxiation) resulted in the most likely clinical diagnosis (advanced HIV infection with subsequent overwhelming sepsis) being discarded. This was a case where the principle of parsimony (Occam's Razor) led to exclusion of a diagnosis when in fact multiple diagnoses applied (Hickam's Dictum), with devastating consequences for the family.

Background: Pertussis is a vaccine modified disease in most age groups and hence subtle in its presentation. Current diagnostic approaches require relatively invasive sampling., Aim: To determine the incidence of B. pertussis infection among people aged 5-49 years identified in primary care with acute persistent cough using an oral fluid based diagnostic test., Design and Setting: Active surveillance of acute persistent cough of 2 weeks duration or greater was established in Auckland, New Zealand from May to October 2011. The 15 participating primary care practices provided care for a socioeconomically diverse population., Method: Recent B. pertussis infection was determined by measurement of IgG antibodies to pertussis toxin (PT) in an oral fluid sample. An IgG antibody titre to PT of ≥70 arbitrary units defined recent infection. Participants reported symptoms at presentation and kept a cough diary., Results: A total of 226 participants were enrolled: 70 (31%) were children (5-16 years) and 156 (69%) were adults (17-49 years). Oral fluid samples were obtained from 225 participants. Ten per cent (23/225) had recent B. pertussis infection including a larger proportion of children than adults (17% versus 7%, P = 0.003). Neither cough duration nor any individual symptom discriminated between those with and without recent B. pertussis infection., Conclusion: Pertussis is a frequent cause of acute persistent cough presenting to primary care. Clinical differentiation of pertussis from other causes of acute persistent cough is difficult. An oral fluid based diagnostic test, which is less invasive than other diagnostic approaches, has high acceptability in primary care.

Recent changes to the law in New Zealand have led to a marked increase in experts being called to give evidence in cases of alleged child sexual abuse. Here we outline some of the common misconceptions that are held by expert witnesses in these cases and we review research on patterns of abuse disclosure and retraction, symptoms of abuse, external influences on children's reports, and experts' ability to distinguish true from false reports. We also consider what experts can say about memory that has relevance for these cases. We conclude that many long-held notions of child sexual abuse and children's testimony that make their way into our courtrooms are not supported by empirical research, raising questions about who is-and who is not-qualified to act as an expert witness.

Background: Previous research suggests vaccine injection technique can influence local reactogenicity., Objective: To identify characteristics of vaccination technique and individual vaccinees associated with frequency and severity of pain on injection and local reactogenicity following immunisation with quadrivalent human papillomavirus vaccine., Design: Randomised cross-over trial of three injection techniques. Data were collected on health history, perceived stress and social support using a 10 item perceived stress scale and a single item social support question. Pain on injection was measured using a visual analogue scale and reactogenicity data was collected using participant-held diaries., Setting: Clinic rooms at the University of Auckland., Participants: Females aged 14-45 years and males aged 14-26 years recruited to the study., Main Outcome Measures: Primary outcome measures were perceived pain on injection and the local injection site reactions pain, erythema, swelling and induration., Results: The three injection techniques did not affect injection site reactogenicity. Females tended to experience more reactogenicity. Perceived stress, social support and atopy were not associated with reactogenicity outcomes and exercise showed little effect. No variables, including injection technique, were associated with wide variation in perceived pain in injection. Case by case observational data suggest some variations in anatomical site may be important., Conclusions: Most injection site reactions in this study were mild. The three injection techniques used in this study were equivalent in their reactogenicity and pain profiles and could be recommended for use in this population., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: The New Zealand HPV publicly funded immunisation programme commenced in September 2008. Delivery through a school based programme was anticipated to result in higher coverage rates and reduced inequalities compared to vaccination delivered through other settings. The programme provided for on-going vaccination of girls in year 8 with an initial catch-up programme through general practices for young women born after 1 January 1990 until the end of 2010., Objective: To assess the uptake of the funded HPV vaccine through school based vaccination programmes in secondary schools and general practices in 2009, and the factors associated with coverage by database matching., Methods: Retrospective quantitative analysis of secondary anonymised data School-Based Vaccination Service and National Immunisation Register databases of female students from secondary schools in Auckland District Health Board catchment area. Data included student and school demographic and other variables. Binary logistic regression was used to estimate odds ratios and significance for univariables. Multivariable logistic regression estimated strength of association between individual factors and initiation and completion, adjusted for all other factors., Results: The programme achieved overall coverage of 71.5%, with Pacific girls highest at 88% and Maori at 78%. Girls higher socioeconomic status were more likely be vaccinated in general practice., Conclusion: School-based vaccination service targeted at ethic sub-populations provided equity for the Maori and Pacific student who achieved high levels of vaccination., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Introduction: Children who have missed or delayed immunisations are at greater risk of vaccine-preventable diseases and getting their first scheduled dose on time strongly predicts subsequent complete immunisation. Developing a relationship with an infant's parents and general practice staff soon after birth followed by a systematic approach can reduce the number of delayed first immunisations., Aim: To assess the effectiveness of a general practice-based pre-call intervention to improve immunisation timeliness., Methods: Clustered controlled trial of general practices in a large urban district randomised to either delivery of pre-call intervention to all babies at aged four weeks or usual care., Results: Immunisation timeliness for infants receiving the primary series of immunisations among their nominated Auckland general practices was higher than expected at 98% for the six week event. The intervention was statistically but not clinically significant. Coverage was significantly lower among infants with no nominated practice which reduced overall coverage rate for the district., Discussion: Pre-call letters with telephone follow-up are simple interventions to introduce into the practice management system and can be easily implemented as usual standard of care. Early identification of newborn infants, primary care engagement and effective systems including tracking of infants not enrolled in general practices has the greatest potential to improve immunisation coverage rates even further.

Introduction: Delay in receipt of the first vaccine dose in the primary series is one of the strongest and most consistent predictors of subsequent incomplete immunisation., Aim: To describe the on-time immunisation delivery of New Zealand infant scheduled vaccines by primary care practices and identify characteristics of practices, health professionals and patients associated with delays in receipt of infant immunisations., Methods: Timeliness of immunisation delivery and factors associated with timely immunisation were examined in 124 randomly selected primary care practices in two large regions of New Zealand., Results: A multiple regression model of demographic, practice, nurse, doctor and caregiver association explained 68% of the variance in immunisation timeliness between practices. Timeliness was higher in practices without staff shortages (ß-coefficient -0.0770, p= 0.01), where nurses believed parental apathy (ß-coefficient 0.0819, p=0.008) or physicians believed parental access (ß-coefficient 0.109, p=0.002) was a barrier, and lower in practices with Maori governance (ß-coefficient -0.0868, p=0.05), higher social deprivation (ß-coefficient -0.0643, <0.001) and where caregivers received immunisation-discouraging information (ß-coefficient -0.0643, p=0.04)., Discussion: Interventions supporting practice teams and providers in primary care settings could produce significant improvements in immunisation timeliness.

Introduction: Anxiety is a common mental health disorder in primary care, with a higher prevalence among women compared to men., Aim: This is the first study to validate the Generalised Anxiety Disorder-7 questionnaire (GAD-7) as a case-finding instrument for anxiety in a primary care setting in Malaysia. The objective was to determine the diagnostic accuracy of the Malay version of the GAD-7 in detecting anxiety among women., Methods: This cross-sectional study was conducted in a government-funded primary care clinic in Malaysia. Consecutive women participants attending the clinic during data collection were given self-administered questionnaires including the GAD-7 (Malay version). Participants then were selected using systematic weighted random sampling for Composite International Diagnostic Interviews (CIDI). The GAD-7 was validated against the CIDI reference standard., Results: The response rate was 87.5% for the questionnaire completion (895/1023), and 96.8% for diagnostic interviews (151/156). The prevalence of anxiety was 7.8%. The GAD-7 had a sensitivity of 76% (95% CI 61%-87%), a specificity of 94% (88%-97%), positive LR 13.7 (6.2-30.5) and negative LR 0.25 (0.14-0.45)., Discussion: The Malay version of the GAD-7 was found to be valid and reliable in case-finding for anxiety in this study. Due to its brevity, it is a suitable case-finding instrument for detecting anxiety in primary care settings in Malaysia.

Background: To better prepare practitioners for the complex world of clinical decision-making, teaching evidence-based practice needs to move beyond its focus on skills and knowledge to give students an experience and understanding of applying evidence in practice., Aim: To explore whether incorporating an online values-based tool enhanced learning in a post graduate epidemiology course., Methods: Having completed a critical appraisal of an epidemiological study, students were asked to then respond to a case scenario, using the analytical frameworks of the Values-Exchange, a software tool that highlights ethical domains in decision-making. The student experience of the Values-Exchange was evaluated using focus groups. Sessions were audiotaped and transcribed. In total, 613 responses were analysed by two independent coders to identify emergent themes., Results: Three main themes emerged: (1) the Values-Exchange exposed students to new concepts and ideas relating to healthcare decision-making; (2) the diversity of other student values broadened their perspectives and (3) the experience brought reality to what it means to apply evidence in practice., Conclusion: Adding an online values-based tool to clinical epidemiology teaching was highly valued by students and enabled new understandings of empirical evidence and its application in practice.

Aim: To identify primary care factors associated with immunisation coverage., Methods: A survey during 2005-2006 of a random sample of New Zealand primary care practices, with over-sampling of practices serving indigenous children. An immunisation audit was conducted for children registered at each practice. Practice characteristics and the knowledge and attitudes of doctors, nurses and caregivers were measured. Practice immunisation coverage was defined as the percentage of registered children from 6 weeks to 23 months old at each practice who were fully immunised for age. Associations of practice, doctor, nurse and caregiver factors with practice immunisation coverage were determined using multiple regression analyses., Results: One hundred and twenty-four (61%) of 205 eligible practices were recruited. A median (25th-75th centile) of 71% (57-77%) of registered children at each practice was fully immunised. In multivariate analyses, immunisation coverage was higher at practices with no staff shortages (median practice coverage 76% vs 67%, P = 0.004) and where doctors were confident in their immunisation knowledge (72% vs 67%, P= 0.005). Coverage was lower if the children's parents had received information antenatally, which discouraged immunisation (67% vs 73%, P = 0.008). Coverage decreased as socio-economic deprivation of the registered population increased (P < 0.001) and as the children's age (P = 0.001) and registration age (P = 0.02) increased. CONCLUSIONS Higher immunisation coverage is achieved by practices that establish an early relationship with the family and that are adequately resourced with stable and confident staff. Immunisation promotion should begin antenatally., (© 2011 The Authors. Journal of Paediatrics and Child Health © 2011 Paediatrics and Child Health Division (Royal Australasian College of Physicians).)

Introduction: Sleep disorders are common in the community and in primary care populations. Epidemiological surveys generally report insomnia rather than specific diagnoses., Aim: Our aim was to develop a questionnaire that could diagnose common sleep disorders in primary care in order to be able to make a diagnosis of primary insomnia by excluding other causes. Having created such a questionnaire, we then validated it (assessed the diagnostic accuracy)., Methods: The questionnaire was developed from the International Classification of Sleep Disorders using the criteria to create operational criteria. This was used in a primary care survey. A sub-sample of 36 primary care patients (aged over 15 years) was chosen to give a spectrum of disorders. A second sample of 85 patients was taken from a sleep disorder private practice to act as an extra test of validity., Results: The response rate was 73% (36/49) for the primary care validation. The sensitivity and specificity of primary insomnia was 0.78 and 0.77, mood disorders 0.67 and 0.97, obstructive sleep apnoea 0.8 and 0.94, delayed sleep phase disorder was 0.8 and 0.97 and for health problems affecting sleep 0.92 and 0.76. There were a wider range of findings in the private practice audit., Discussion: The validity of the Auckland Sleep Questionnaire is promising. The second version of the questionnaire will use this study to improve its functionality.

Background: This is the first study investigating anxiety among women attending a primary care clinic in Malaysia., Aim: The objective was to determine the factors associated with anxiety among these women., Design: This cross-sectional study was conducted in a government-funded primary care clinic in Malaysia. Consecutive female patients attending the clinic during the data-collection period were invited to participate in the study., Method: Participants were given self-administered questionnaires, which included the validated Generalised Anxiety Disorder-7 questionnaire (GAD-7) Malay version to detect anxiety., Results: Of the 1023 patients who were invited, 895 agreed to participate (response rate 87.5%). The prevalence of anxiety in this study was 7.8%, based on the GAD-7 (score ≥8). Multiple logistic regression analysis found that certain stressful life events and the emotional aspect of domestic violence were significantly associated with anxiety (P<0.05)., Conclusion: The prevalence of anxiety among women in this study is similar to that found in other countries. Factors found to be associated with anxiety, especially issues on domestic violence, need to be addressed and managed appropriately.

Purpose: We wanted to determine patients' willingness to take preventive cardiovascular disease (CVD) medication in relation to their 5-year CVD risk score and modes of communicating benefits of therapy., Methods: Study participants were 934 consecutive patients drawn from family practitioners' waiting rooms in Auckland, New Zealand, who knew their 5-year CVD risk (ranging from 5% to 30%) and who completed a questionnaire asking them to rate how much various modes of communicating the benefits of therapy would encourage them to take medication daily, where the benefits from medication were proportional to their estimated CVD risk score., Results: Patients' rankings for modes of communicating the benefits of therapy were little influenced by sex, age, ethnicity, numeracy score, 5-year CVD risk, or concern about a heart attack. Patients clearly found relative risk reduction most encouraging, with absolute risk reduction rated second overall and numbers needed to treat the least likely to be persuasive, although preferences covered the full range and were not predictable from demographic or 5-year CVD risk data. Pictures were preferred to numbers by 55.1%, with a people-chart or a bar chart being equally favored. Even so, 61.8% preferred a doctor's opinion to any presentation by numbers or pictures., Conclusions: Patients' willingness to take preventive cardiovascular medication depends more on mode of communicating treatment benefit than on their short-term CVD risk score or their level of concern about a future cardiovascular event. Because individual preferences were not predictable, more than 1 modality is likely to be clinically useful for each patient.

Objective: To determine the diagnostic accuracy of the two questions with help question (TQWHQ) in the Malay language. The two questions are case-finding questions on depression, and a question on whether help is needed was added to increase the specificity of the two questions., Method: This cross sectional validation study was conducted in a government funded primary care clinic in Malaysia. The participants included 146 consecutive women patients receiving no psychotropic drugs and who were Malay speakers. The main outcome measures were sensitivity, specificity, and likelihood ratios of the two questions and help question., Results: The two questions showed a sensitivity of 99% (95% confidence interval 88% to 99.9%) and a specificity of 70% (62% to 78%), respectively. The likelihood ratio for a positive test was 3.3 (2.5 to 4.5) and the likelihood ratio for a negative test was 0.01 (0.00 to 0.57). The addition of the help question to the two questions increased the specificity to 95% (89% to 98%)., Conclusion: The two qeustions on depression detected most cases of depression in this study. The questions have the advantage of brevity. The addition of the help question increased the specificity of the two questions. Based on these findings, the TQWHQ can be strongly recommended for detection of depression in government primary care clnics in Malaysia. Translation did not apear to affect the validity of the TQWHQ.

Background and Context: Currently, in New Zealand general practice, the introduction of new initiatives is such that interventions may be introduced without an evidence base. A critical role is to respond to the challenges of chronic illness with self-management a key component. The 'Flinders Model' of self-management collaborative care planning developed in Australia has not been evaluated in New Zealand. A study was designed to assess the usefulness of this 'Model' when utilised by nurses in New Zealand general practice. This paper describes the issues and lessons learnt from this study designed to contribute to the evidence base for primary care. Assessment of problems Analysis of interviews with the nurses and the research team allowed documentation of difficulties. These included recruitment of practices and of patients, retention of patients and practice support for the introduction of the 'new' intervention., Results of Assessment: A lack of organisational capacity for introduction of the 'new' initiative alongside practice difficulties in understanding their patient population and inadequate disease coding contributed to problems. Undertaking a research study designed to contribute to the evidence base for an initiative not established in general practice resulted in study difficulties., Lessons Learnt: The need for phased approaches to evaluation of complex interventions in primary care is imperative with exploratory qualitative work first undertaken to understand barriers to implementation. Collaborative partnerships between researchers and general practice staff are essential if the evidence base for primary care is to develop and for 'new' interventions to lead to improved health outcomes.

Purpose: Although screening for unipolar depression is controversial, it is potentially an efficient way to find undetected cases and improve diagnostic acumen. Using a reference standard, we aimed to validate the 2- and 9-question Patient Health Questionnaires (PHQ-2 and PHQ-9) in primary care settings. The PHQ-2 comprises the first 2 questions of the PHQ-9., Methods: Consecutive adult patients attending Auckland family practices completed the PHQ-9, after which they completed the Composite International Diagnostic Interview (CIDI) depression reference standard. Sensitivities and specificities for PHQ-2 and PHQ-9 were analyzed., Results: There were 2,642 patients who completed both the PHQ-9 and the CIDI. Sensitivity and specificity of the PHQ-2 for diagnosing major depression were 86% and 78%, respectively, with a score of 2 or higher and 61% and 92% with a score 3 or higher; for the PHQ-9, they were 74% and 91%, respectively, with a score of 10 or higher. For the PHQ-2 a score of 2 or higher detected more cases of depression than a score of 3 or higher. For the PHQ-9 a score of 10 or higher detected more cases of major depression than the PHQ determination of major depression originally described by Spitzer et al in 1999., Conclusions: We report the largest validation study of the PHQ-2 and PHQ-9, compared with a reference standard interview, undertaken in an exclusively primary care population. The PHQ-2 score or 2 or higher had good sensitivity but poor specificity in detecting major depression. Using a PHQ-2 threshold score of 2 or higher rather than 3 or higher resulted in more depressed patients being correctly identified. A PHQ-9 score of 10 or higher appears to detect more depressed patients than the originally described PHQ-9 scoring for major depression.

Background: Immunisation coverage in New Zealand is lower than what is necessary to prevent large epidemics of pertussis. Primary care is where most immunisation delivery occurs. General practices vary in their structure and organisation, both in a general sense and specifically with respect to immunisation delivery., Aim: To identify the structural and organisational characteristics of general practices associated with higher immunisation coverage and more timely immunisation delivery., Design of Study: A random sample of practices during 2005 and 2006., Setting: General practices in the Auckland and Midland regions, with over-sampling of indigenous Maori governance practices., Method: Practice immunisation coverage and timeliness were measured. Primary care practice characteristics relevant to immunisation delivery by the practice were described. Associations of these practice characteristics with higher practice immunisation coverage and more timely immunisation delivery were determined., Results: A total of 124 (61%) of 205 eligible practices were recruited. A median (25th to 75th centile) of 71% (57-77%) of registered children at each practice were fully immunised, and 56% (40-64%) had no immunisation delay. In multivariate analyses, both practice immunisation coverage (P<0.001) and timeliness (P<0.001) decreased with increased social deprivation. After adjustment for socioeconomic deprivation, region, and governance, immunisation coverage and timeliness were better at practices that enrolled children at a younger age (coverage: P = 0.002; timeliness P = 0.007), used one of the four available practice management systems (coverage: P<0.001; timeliness: P = 0.006), and had no staff shortages (coverage: P = 0.027; timeliness: P = 0.021)., Conclusion: Practice immunisation coverage and timeliness vary widely in New Zealand. General organisational and structural aspects of general practices are key determinants of general practice immunisation delivery.