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Our aim was to describe characteristics of GPs working in practices that achieve higher immunization coverage and more timely delivery. We conducted computer-assisted telephone interviews with randomly selected GPs from randomly selected practices. Most GPs believed immunization to be important and were confident about their knowledge of immunization although assessment revealed their knowledge to be incomplete. A minority considered six weeks is too young to immunize. Greater GP knowledge and confidence in their knowledge was associated with higher practice immunization coverage, whereas immunization delivery was more timely at practices where GPs perceived parental access difficulties a barrier.

Aim: To scope future needs of the NZ Pacific primary care workforce., Method: Semi-structured interviews with key informants including Pacific primary care workers in both Pacific and mainstream primary health care organisations and managers at funding, policy and strategy levels. Qualitative thematic analysis using general inductive approach., Results: Thirteen stakeholders interviewed (four males, nine females) in 2006. Included both NZ- and Island-born people of Samoan, Tongan, Niuean, Fijian and NZ European ethnicities; age 20-65 years. Occupations included general practitioner, practice nurse, community worker, Ministry of Health official and manager representing mainstream and Pacific-specific organisations. Key themes were significant differences in attributes, needs and values between 'traditional' and contemporary Pacific people; issues regarding recruitment and retention of Pacific people into the primary health care workforce; importance of cultural appropriateness for Pacific populations utilising mainstream and Pacific-specific primary care services and both advantages and disadvantages of 'Pacific for Pacific' services., Conclusion: Interviews demonstrated heterogeneity of Pacific population regarding ethnicity, age, duration of NZ residence and degree of immersion in their culture and language. Higher rates of mental disorder amongst NZ-born Pacific signpost urgent need to address the impact of Western values on NZ-born Pacific youth. Pacific population growth means increasing demands on health services with Pacific worker shortages across all primary health care occupations. However it is not possible for all Pacific people to be treated by Pacific organisations and/or by Pacific health workers and services should be culturally competent regardless of ethnicity of providers.

Background: Women seeking termination of pregnancy in Auckland, New Zealand can chose between medical and surgical options up to eight weeks gestation., Aims: To assess demographic differences or changes over time between proportions of women choosing medical or surgical abortions at a single centre and determine whether changing the mifepristone-misoprostol interval from two to one day impacted on outcomes., Methods: Retrospective audit of two consecutive years (December 2005-November 2006 and December 2006-November 2007) of first-trimester surgical and medical terminations where the mifepristone-misoprostol interval was reduced from two to one day between years. Analysis using descriptive statistics and assessment of probability of observed differences between groups., Results: A total of 1495 terminations were performed in 2005-2006 and 1588 in 2006-2007. No significant difference (P = 0.4) of eligible women choosing medical (21% and 23%) or surgical abortion between years. Ethnicity, age and residency status did not influence choice. Medical termination of pregnancy was more likely in women who were without previous children (P = 0.009), pregnancies (P = 0.02) or terminations (P = 0.04). Medical termination was similarly effective within six hours with either two- or one-day intervals., Conclusions: Both medical and surgical first-trimester abortions are safe and effective. It is optimal to be able to offer women choice. Reducing the medical interval to one day does not increase adverse outcomes.

Aim: To provide a succinct summary of the diagnosis of soft tissue injuries to the shoulder for primary health care practitioners based on the New Zealand guideline., Methods: A multidisciplinary team developed the guideline by critically appraising and grading retrieved literature using the Graphic Appraisal Tool for Epidemiology (GATE). Recommendations were derived from resulting evidence tables., Results: Diagnostic ultrasound is a valid tool for the diagnosis of a full thickness rotator cuff tear. If a significant tear is suspected, referral for diagnostic ultrasound is recommended. There is a paucity of evidence for the diagnosis of soft tissue shoulder injuries and most recommendations are based on the consensus of the guideline team., Conclusion: Assessment relies on thorough history-taking and physician examination with appropriate referral where there is evidence of serious damage or the diagnosis remains unclear.

Aim: To provide a succinct summary of the management of soft tissue injuries to the shoulder for primary health care practitioners based on the New Zealand guideline., Methods: A multidisciplinary team developed the guideline by critically appraising and grading retrieved literature using the Graphic Appraisal Tool for Epidemiology (GATE); and the Scottish Intercollegiate Guideline Network. Recommendations were derived from resulting evidence tables., Results: For the management of soft tissue shoulder disorders there is little evidence to support or refute the efficacy of common interventions for shoulder disorders in general and rotator cuff disorders in particular. For rotator cuff tendinosis and partial tears, use NSAIDs and subacromial corticosteroid injections with caution and provide a trial of supervised exercise. For frozen shoulders, intra-articular corticosteroid injection should be considered and refer for supervised exercise after acute pain has settled. For shoulder instability, good evidence supports the referral of physically active young adults for orthopaedic intervention following a first traumatic shoulder dislocation., Conclusion: While there is a dearth of good evidence, this guideline does provide a framework for the management of common soft tissue injuries of the shoulder.

Introduction: There has been concern over high rates of mental illness in Maori. Previous studies in general practice have had small sample sizes., Aim: To determine the prevalence of major depression among Maori patients in Auckland general practice using the CIDI and the PHQ as measurement tools., Methods: This prevalence study is part of a larger randomised trial. The patients were recruited from 77 general practitioners from around Auckland who could provide a private room for interviewing. The patients were invited to participate in the waiting room and all consecutive patients were approached. For this study all patients received a computerised CIDI examination and one third received a PHQ assessment prior to getting the CIDI. The interviewer was blind to the questionnaire results when the patient did the CIDI., Results: There were 7994 patients approached from whom there were data on 7432. The prevalence of Maori in the study was 9.7%. The overall 12-month prevalence of major depression based on the CIDI was 10.1% 95% CI (8.8 to 11.4). For Maori the prevalence was 11.5% 95% CI (8.8 to 14.2) and for non-Maori 10.1% 95% CI (8.6 to 11.3). For Maori men and Maori women the prevalence was 8.5% and 13.4% and for non-Maori men and non-Maori women it was 8.3% and 11.1%. The prevalence of depression over at least the previous two weeks on the PHQ > or = 9 for all participants was 12.9% 95% CI (11.2 to 14.5)., Discussion: The prevalence of depression among Maori is high, but not as high as earlier studies. This may be due to the bigger sample size of this study.

The health of the male population is a substantial contributor to the health of the nation. In general, men have a poorer health status and lower utilisation of health services than women. They have a lower life expectancy and are more likely to die from avoidable deaths than women. Men's health is increasingly being recognised as a specialty area of health promotion and of clinical practice. Male-specific approaches may assist in maximising the positive outcome of interventions aimed at educating men about their health issues, attracting men into seeking clinical services, and establishing and maintaining a gender-orientation in health services that encourages men to engage. With appropriate training and resources, primary health care is ideally placed to provide accessible, male-friendly services with lead to reduction in gender inequalities in health.

Purpose: To explore the quality of data recording by practices and identify issues to be considered and addressed before such data can be used as a continuous measure of immunisation delivery., Methods: One hundred and twenty-four randomly selected general practices visited to measure immunisation coverage using the various practice management systems (PMS) in use. To capture all target children it was necessary to build two queries: one generated a list of all children aged between 6 weeks and 2 years who had been to the practice, regardless of enrollment status; the other asked dates and nature of all immunisations given. Each different PMS required a unique query to extract the necessary information., Results: Variability encountered included different types and versions of PMS and operating systems; variable degree of staff technical competence with their PMS; proportion of enrolled children ranging from nearly 0 to 100%; lack of consistency of the nature and location of data entry and coding; and unreliability of dates relating to some vaccination events., Recommendations: To improve recording of immunisation coverage we recommend a standard early age of registration and enrollment; standard definitions of the denominator and of immunisation delay; greater uniformity of PMS; improved staff training; intrinsic data quality checks; integration of PMS with changes in the immunisation schedule; incentives and interval electronic checks to improve data quality.

Aim: To explore barriers to, and incentives for, clients on methadone-maintenance treatment (MMT) in Auckland, New Zealand to transfer from secondary care to general practitioner (GP) care., Design: Surveys (with free text response sections) of MMT secondary care staff, stabilised clinic clients, authorised GPs and GP patients., Results: High response rates from secondary care staff (77%) and GPs (74%). Barriers to stable clients' transfer included financial cost and attitudes of secondary care staff and clients. Incentives for patient transfer included confidentiality, a holistic approach to their care, continuity of care, increased patient control, convenience and avoidance of contact with other opioid-dependent people. Distrust in the quality of care provided by authorised GPs was a major barrier for some secondary care staff and their clients, despite prerequisite training for authorisation. In contrast, patients rated primary better than secondary care with none stating a likelihood to return to the secondary service within 6 months., Conclusions: Progression from secondary to primary care should be incorporated in MMT planning from the outset, with secondary services staff reassured about the quality of primary care. An integrated transition period and exploration of funding options to assist transfer from largely publicly funded secondary to largely privately funded primary care are also recommended.

Objective: To obtain a 2005 snapshot of New Zealand (NZ) rural primary health care workforce, specifically GPs, general practice nurses and community pharmacists., Design: Postal questionnaires, November 2005., Setting: NZ-wide rural general practices and community pharmacies., Participants: Rural general practice managers, GPs, nurses, community pharmacy managers and pharmacists., Main Outcome Measures: Self-reported data: demographics, country of training, years in practice, business ownership, hours worked including on-call, intention to leave rural practice., Results: General practices: response rate 95% (206/217); 70% GP-owned, practice size ranged from one GP/one nurse to 12 GPs/nine nurses. PHARMACIES: Response rate 90% (147/163). Majority had one (33%) or two (32%) pharmacists; <10% had more than three pharmacists. GPs: response rate 64% (358/559), 71% male, 73% aged >40, 61% full-time, 79% provide on-call, 57% overseas-trained, 78% male and 57% female GPs aged >40; more full-time male GPs (76%) than female (37%) . Nurses: response rate 65% (445/685), 97% female, 72% aged >40, 31% full-time, 28% provide on-call, 84% NZ-trained, 45% consulted independently in 'nurse-clinics' within practice setting. Pharmacists: response rate 96% (248/258), 52% male, 66% aged >40, 71% full-time, 33% provide on-call, 92% NZ-trained, 55% sole/partner pharmacy owners. Many intend to leave NZ rural practice within 5 years: GPs (34%), nurses (25%) and pharmacists (47%)., Conclusion: This is the first NZ-wide rural workforce survey to include a range of rural primary health care providers (GPs, nurses and pharmacists). Ageing rural primary health care workforce and intentions to leave herald worsening workforce shortages.

Background: Best practice for health care practitioners is considered patient-centred approaches which empower patients. Immunization of young children requires maintaining this approach while retaining professional management., Objective: The objectives were to assess situations within the immunization event with discordance between health provider and caregiver and evaluate strategies used to empowering parents while obtaining the desired clinical outcome., Methods: This was a qualitative study nested within a larger study of immunization rates in 124 randomly selected primary care practices. Interactions between immunizing practice nurses, caregivers and children were videotaped and transcribed and underwent conversation analysis. Six purposively sampled primary care practices in Auckland, New Zealand, served as the setting. The participants were eight practice nurses immunizing 10 children and their parents. Normative pattern of interactions and 'deviant cases' involving discordance between nurse and parent., Results: A total of 168 minutes of video-recorded conversation from 10 immunization sessions provided strong 'typical' pattern and equally striking 'deviant cases'. Parents mostly treated nurses as 'experts' and accepted asymmetry of knowledge over medical matters. Nurses demonstrated skilful strategies in delineating their area of medical expertise from areas in which patients are expert-their knowledge of themselves and their children., Conclusion: While patient centredness and empowering patients are contemporary goals of primary health care delivery, these attributes are not precisely defined. Patients may wish to be informed, but many trust their health professionals to direct their decision making. Although health professionals may impart as much knowledge as they can, asymmetry of knowledge remains. However, patients hold expertise beyond their clinical situation in the social and economic world in which they live.

New Zealand (NZ) has low immunization coverage for a Western country. Media coverage, including views and content expressed on editorial pages, can affect immunization uptake both positively and negatively. The objectives of this research were to analyze the content of written media in 2001 and 2003 throughout NZ in terms of vaccination and vaccine preventable diseases from a supporting, neutral, or opposing perspective; how vaccination and vaccine-preventable diseases are presented to their target audiences; and changes over time with possible influences on these changes. Print media clippings were analyzed from 400 national publications in 2001 and 2003 for references to immunization and vaccine-preventable diseases. Articles were coded as supportive, neutral, or opposing immunization. During two 12-month periods, 2,113 articles, including letters to the editor and opinion columns were analyzed: 1,228 from 2001; and 885 from 2003. Thirty-three percent (704) were classified as "supportive," 17% (362) as "opposing," and 51% (1,081) as "neutral." Articles and perspectives in the media opposed to immunization were significantly more plentiful in 2001 than in 2003 (328/1,228; 27% vs. 34/885; 4% of all immunization media; chi(2) = 189.46; p = <0.0001; df = 1). References to specific vaccines and disease were examined. During this study period there were high-profile infectious disease and vaccine issues that may have shaped the differences observed in the media clippings. This study indicates an overall positive trend toward reduction in alarmist anti-immunization messages in media. Strategies implemented by the Immunization Advisory Centre to counter misinformation may have contributed to reduction in anti-immunization messages.

International consensus guidelines state that Neisseria gonorrhoeae infection in pre-pubertal children is always, or nearly always, sexually transmitted. A systematic literature review does not concur with this. N gonorrhoea was believed to solely sexually transmitted when first identified in the 1880s. However it became recognised that when the infection was introduced into children's institutions, it rapidly spread among pre-pubertal girls. The medical literature records over 40 epidemics involving about 2000 children in Europe and the United States. Communal baths, towels or fabric, rectal thermometers and caregivers hands were identified as means of transmission. Although sensitive to heat and drying, gonorrhoea may remain viable in pus on cloth for several days. Several unusual accidental transmissions are reported, often due to contamination from laboratory samples. Indirect transmission occurs in epidemics of conjunctivitis in third world rural populations. Spread of infection can occur via contaminated hands of infected caregivers. While all paediatric cases of gonorrhoea must be taken seriously, including contact tracking and testing, forensic medical examiners should keep an open mind about possible means of transmission. Doctors and lawyers need to be cognisant of the large body of literature demonstrating both sexual and non-sexual means of transmission of gonorrhoea in children.

Aims: To identify the frequency of non-English languages used in general practice consultations and to explore the effects on practice for general practitioners (GPs)., Methods: Randomly selected Auckland GPs were telephone-interviewed using standardised questions. Interview data were entered electronically in real time and audiotaped. Data were reviewed upon collection and analysed using constant comparison thematic content analysis. Quantitative data were analysed using SPSS (v12) software., Results: Eighty GPs were interviewed. Forty-two spoke one or more languages apart from English. Thirty-one different languages were spoken, 83% of which were used in patient consultation. Most GPs (73/80) experienced language difficulties in practice. Three broad issues arose: English language proficiency per se, accented English, and physical problems affecting speech. Four themes reflected the influence of language difficulties on the encounter: information sharing, process effects, cultural issues, and use of interpreters., Conclusions: Non-English language consultations occur commonly within current Auckland general practice with associated issues of misunderstanding and interpretation difficulties. GPs are often called upon to use their own language skills, especially Asian and Pacific Island tongues. Non-English speaking encounters frequently require additional time. Patients with some English language proficiency may cause more anxiety than those with none. Non-professional interpreters may colour or alter patients' meaning and accurate translation is required rather than 'interpretation'.

We tested the hypothesis that beliefs in the purported attributes of recovered memories of child sexual abuse (CSA) are associated with knowledge of the "recovered/false memory debate", and that such beliefs will be related to assessments of the credibility of statements made by participants in a vignette about CSA. Participants from five countries (the United States, Canada, New Zealand, the United Kingdom and Israel) responded to a questionnaire regarding beliefs about recovered memory as well as self-reported exposure to and knowledge of the debate. In addition, they assessed the credibility of statements made by a daughter (reporting recovery of memories of sexual abuse by her father), her father (denying the allegation and accusing the daughter's therapist of implanting in her false "memories" of abuse), and two experts (each supporting one of the two protagonists). We found that prior knowledge of the debate across countries was linked to beliefs in specific attributes of recovered memories and to a subset of the credibility assessments of statements made by the protagonists and their experts. For individuals, however, credibility assessments were unrelated to knowledge of the debate, but they were related to beliefs about memory recovery. Finally, credibility of the protagonists' statements was differentially associated with those made by the daughter's and the father's experts. The results suggest that whereas familiarity with the debate does not affect the credibility of the statements made by the complainant and the accused, expert testimony does, as has been found in prior research. The psycholegal implications of this conclusion are discussed.

Aims: To summarise evidence and key recommendations for general practitioner diagnosis and management of acute soft-tissue knee injuries, based on the New Zealand guideline., Methods: A multidisciplinary team developed the guideline by critically appraising and grading retrieved literature using the Graphic Appraisal Tools for Epidemiology, Clinical decision rules and the Scottish Intercollegiate Guideline Network. Recommendations were derived from resulting evidence tables., Results: For both diagnosis and management there is a paucity of good evidence to support diagnosis and treatment of internal derangements of the knee, hence some aspects of the guideline are guideline team consensus. Good evidence supports the use of the Ottawa Knee rules to guide decisions about the use of X-ray, and the Lachman test in diagnosing anterior cruciate ligament (ACL) tears. Evidence supports inclusion of proprioceptive training in rehabilitation programmes following ACL reconstruction and in people with ACL-deficient knees. There is good evidence that ultrasound is of little benefit, and there is no evidence that physiotherapy be routinely advocated following meniscectomy., Conclusion: This guideline provides an evidence-based framework for diagnosis and management of internal derangements of the knee following acute injury. Moreover, its development highlights significant gaps in the evidence base and identifies priorities for new research.

Aim: To assess change in general practitioner (GP) management of upper respiratory tract infections (URTIs) during a nationwide project to reduce antibiotic consumption in a half-decade (1998 to 2002-3)., Method: Telephone survey of 100 randomly selected Auckland GPs in 1998 and 2002-3. Sixty-five GPs were in both samples., Results: A 69% response rate was recorded for an additional 35 GPs recruited in 2002-3. Of the 65 GPs interviewed at both periods, the number agreeing that most patients who consult for URTIs expect antibiotics decreased from 82% to 57%. Seventy-seven percent of GPs reported they were less likely to prescribe antibiotics, with over a quarter believing this change resulted from both GP and patient education. Common situations where GPs increased their antibiotic prescribing were patient request/expectation; smokers; older; or having sinusitis, purulent sputum, purulent nasal discharge, or imminent overseas travel. Thirty-nine percent of GPs reported an increasing use of delayed prescriptions over the half-decade. Reported use of amoxicillin clavulanate reduced from 21% to 4% (p<0.001)., Conclusion: The GPs' response that they are less likely to prescribe antibiotics is consistent with the reduction in national antibiotic use. This may be related to the national campaign. The reduction may be a combination of combined GP and patient change.

Aims: To assess changes in public knowledge, attitudes, and reported behaviour of antibiotic use in the management of the common cold and to compare with results of a 1998 study. The context is a nationwide project to reduce the consumption of antibiotics., Method: Cross-section survey: telephone interviews of random sample of consenting Auckland telephone subscribers aged over 15 years comparing 1998 and 2003 responses., Results: A 55% response rate of eligible participants was recorded. No change was noted between 1998 and 2003 in public awareness that antibiotics are not helpful in treating viral infections (38%). However there was a significant reduction in those attending doctor for the common cold (24% to 15%). In 2003, patients were less likely to receive antibiotic prescription and more likely to receive a delayed prescription., Conclusions: The majority of general public still do not understand that the common cold does not need antibiotic treatment. The advertising campaign may have reduced doctor prescribing hence the reduction in antibiotic use from 1998 to 2003.

This study aimed to conduct quantitative and qualitative analyses of anonymous data from an immunisation hotline call centre over equal periods in 1999 and 2003. Transcripts for all telephone calls in two periods were analysed using thematic and descriptive statistical analyses and significance testing of comparisons made between data from the two periods. Caller numbers increased from 1010 in 1999 to 3413 in 2003. There was a significant increase in service utilisation by both the public (mostly parents) and health professionals, especially by general practice nurses. The nature of the enquiries shifted according to schedule changes and media stories. Findings are discussed in the context of prominent issues at that time, and suggestions are made for improving communication to meet the needs of both the public and health professionals.

Objective: To determine timeliness and completeness of MMR immunization uptake and general immunization status of egg-allergic children referred to hospital for MMR vaccine who were referred back to their primary care providers with explanatory information that community-based vaccination is safe in these children., Method: Referred children's immunization status obtained from referring practices. Where the practice had no record parents were contacted. Parents whose children had not received MMR were asked reasons for their choice. Timeliness of immunizations was examined for both MMR and the primary schedule. Practices referring more than one child to immunization clinic were analysed to determine whether previous letters from the immunization clinic influenced their referring practice., Results: 82 children were eligible from 67 practices. MMR status was obtained for 78 (95% response rate). Of these 78, 73 (94%) received MMR vaccination with no reported adverse events: 8 (11%) on time, 54 (69%) late and 11 (14%) timeliness unknown. Five (6%) children had not received MMR vaccination. Three practices were unwilling to carry out MMR immunization of egg-allergic children, even after recommendation from the immunization clinic. Of the five parents whose children had not received MMR, two had actively decided against vaccination., Discussion: 94% children received their MMR in primary care with no reported adverse effects. The current strategy utilised by the immunization clinic appears to result in MMR immunization of egg-allergic children. While the referral process may result in delayed immunizations, continued education of health professionals may improve timeliness and immunization rates.

New Zealand (NZ) has low immunisation coverage for infants and children compared to many other westernised countries. Barriers to improving uptake are multifactorial, with health professional knowledge and attitudes identified as important modifiable factors. In NZ practice nurses give most childhood vaccinations in the primary health care setting. This study explored aspects of 150 family practice nurse views, knowledge and experience about immunisation. Qualitative and quantitative text data were obtained through randomised computer assisted telephone surveys and converged using a triangulated multi-method approach. Response rate was 89.3% nurses identified parents' fear as the greatest barrier to achieving better immunisation uptake and disagreed that health professional knowledge was a barrier. However, findings showed lack of knowledge among many participants, despite many feeling confident about their knowledge base. Factors associated with lower practice coverage of infants under 2 years were poorer knowledge of contraindications to vaccination and lack of completion of vaccinator training, especially an update course. A high level of confidence, more years in practice, dedicated time to follow-ups were not associated with better coverage rates. Practice nurses may be unaware that their knowledge in some areas needs improving. A trained practice nurse appears to play a significant role in overcoming fears and maintaining high coverage rates in their practice. We conclude that strategies that focus on primary health care provider support and education are more likely to gain high coverage than those that are purely directed at overcoming access barriers.

Aim: To determine ethnic differences in response, acceptance and desire to address problems identified by the multi-item screening tool (MIST)., Methods: Patients were assessed using the MIST in urban Auckland. Fifty consecutive adult patients from 20 randomly selected practices completed the MIST and evaluation sheet before their consultation. All patients and general practitioners (GPs) completed feedback forms. Analysis adjusted for the clustered nature of the data., Results: Participants were 1000 patients and 20 urban GPs. The participation rate was 87% of GPs and 97.75% of patients. Compared with New Zealand Europeans, Pacific Island people were significantly more likely to be concerned about abuse and anger control. Maori were significantly more likely to want help with cutting down their alcohol use. The screening tool was accepted by all patients (<1% objection rate) regardless of ethnicity., Discussion: This is the first study to examine possible ethnic differences between primary care patients' response to screening on lifestyle behaviours and mental health issues.

Aims: To determine the rate of chlamydia and other sexually transmitted infections (STIs), and to describe treatment and factors associated with chlamydia in patients presenting for a termination of pregnancy (TOP)., Methods: A retrospective audit of patients attending one of two TOP clinics from 1 February 2003. (Clinic A, n=500; Clinic B, n=501). Age, ethnicity, marital status, previous pregnancies, contraception, STIs, and treatment were recorded., Results: Ten percent of patients tested positive for an STI. Chlamydia was most commonly detected, in 7.7% of all patients. Higher rates of chlamydia were observed at clinic B (10.2% vs 5.2%, p=0.005) and in under 25 year olds (11.2% vs 3.6%, p<0.001). Rates of chlamydia in Pacific women were 18.6%, in Maori 12.9%, in Asian 7.3% and 4.4% in New Zealand European women. All patients testing positive for chlamydia were treated prior to TOP but only 41% of partners were treated. Other infections detected included 18 cases of human papillomavirus (HPV), three cases of trichomoniasis, one case of gonorrhoea, and one case of syphilis., Conclusions: There is a high rate of chlamydia in women presenting for TOP, particularly in under 25 year olds, Pacific, and Maori women. There is an immediate need for policymakers to respond to this increasing burden of chlamydia by instigating targeted education, guidelines, and mandatory chlamydia screening and contact tracing for pregnant women.

Background: There are no systematic reviews of corticosteroids for shoulder pain that calculate the numbers needed to treat., Aim: We wished to determine the effectiveness in terms of improvement of symptoms of intra-articular and subacromial injections of corticosteroid for rotator cuff tendonitis and frozen shoulder., Design of Study: Systematic review and meta-analysis of randomised controlled trials., Method: Data sources included the Cochrane Controlled Trials Register, Medline, EMBASE, hand searches and author contacts. The review methods required any randomised controlled trial in which the effectiveness of subacromial or intra-articular steroid injections versus placebo and versus non-steroidal anti-inflammatory medication, could be ascertained. The outcome was improvement of symptoms. The data abstraction was done independently, as was the validity assessment. The data was pooled using Review Manager 4.1., Results: Seven studies were reviewed for corticosteroids versus placebo and three for corticosteroids versus nonsteroidal anti-inflammatory drugs (NSAIDs). The relative risk for improvement for subacromial corticosteroid injection for rotator cuff tendonitis was 3.08 (95% confidence interval [CI] = 1.94 to 4.87). The number needed to treat based on the pooled relative risk was 3.3 (95% CI = 1.8 to 7.7) patients to obtain one improvement. The relative risk for high dose (50 mg of prednisone or more) was 5.9 (95% CI = 2.8 to 12.6). The relative risk for improvement with steroids compared with NSAIDs was 1.43 (95% CI = 0.95 to 2.16). The number needed to treat for corticosteroids versus NSAIDs was 2.5 (95% CI = 1 to 9) for one significant study. The relative risks for intra-articular steroid injection for rotator cuff tendonitis were not statistically significant., Conclusion: Subacromial injections of corticosteroids are effective for improvement for rotator cuff tendonitis up to a 9-month period. They are also probably more effective than NSAID medication. Higher doses may be better than lower doses for subacromial corticosteroid injection for rotator cuff tendonitis.

Background: Skeletal muscle cramps affect over a third of the ambulatory elderly population. Quinine is the established treatment, but there are safety concerns, and evidence for efficacy is conflicting. A recent meta-analysis established a small advantage for quinine, but identified the need for additional studies. N-of-1 trials compare two treatments, in a randomised, double-blind, multiple crossover study on a patient-by-patient basis. They have been used to compare treatments in osteoarthritis and may be suitable for determining the individual efficacy of quinine., Aim: To establish efficacy and safety of quinine sulphate use for the treatment of leg-muscle cramp., Design of Study: Double-blind, randomised series of n-of-1 controlled trials of quinine versus placebo for muscle cramps., Setting: New Zealand general practices., Method: The participants were 13 general practice patients (six males; seven females; median age = 75 years) already prescribed quinine. Following a 2-week washout, each patient received three 4-week treatment blocks of quinine sulphate and matched placebo capsules with an individual, randomised crossover design. The main outcome measures were: patient diaries of cramp occurrence, duration and severity; capsule counts; and blood quinine levels in the final treatment block., Results: Ten patients completed the trial. Three patients were identified for whom quinine was clearly beneficial (P <0.05), six showed non-significant benefit and one showed no benefit. All patients elected to continue quinine post-study., Conclusion: Series of n -of-1 studies differentiated patients whom quinine had statistically significant effects; those with trend towards effectiveness; those for whom quinine was probably not effective. Ideally n-of-1 trial should be performed when a patient is commenced on quinine. More cycles in n-of-1 studies of quinine may address issues of statistical power.

Aims: To develop a short screening tool for lifestyle and mental-health risk factors that adults can self-administer, and to determine acceptability and feasibility of use of this tool in primary care settings., Methods: The multi-item tool was designed to screen patients in rural and urban New Zealand general practices for smoking, alcohol and drug misuse, problem gambling, depression, anxiety, abuse, anger, sedentary lifestyle, and weight issues. Patients were offered help for identified risk factors. Fifty consecutive adult patients per practice (n=2,543) were recruited to participate from 20 randomly-selected urban general practitioners; 20 general practice nurses and 11 rural general practitioners., Results: Patients came from diverse ethnic, geographical, and socioeconomic backgrounds. The sample prevalence of positive responses identified ranged from 2.8% (gambling) to 42.7% (depression). The number of patients requesting immediate assistance with these responses (0.5 to 13.5%) did not overwhelm clinicians. The tool was well accepted by patients, with few objections to specific questions (0.1-0.8%). Most practitioners stated they will use the screening tool once available., Conclusions: Screening for lifestyle and mental health risk factors is becoming increasingly important in primary health care. This screening tool was acceptable to patients and was not considered overly burdensome by practitioners.

New Zealand (NZ) has inadequate vaccine coverage and associated disease outbreaks. International research illustrates the importance of provider behaviour in improving vaccine uptake. To understand the immunisation knowledge, views, concerns and educational needs of NZ family physicians, qualitative and quantitative national data was gathered from randomised telephone surveys. Response rate was 60% with respondents' characteristics closely matched to key demographics of NZ family physicians. The most significant barrier to improving immunisation rates identified was parental concern over vaccine safety and associated misconceptions. The second major barrier identified was lack of funding to health providers. A clear need for improvement in family physician knowledge of contraindications to vaccines was highlighted. Family physicians expressed a need for better resources to more effectively address parental fears and misconceptions. Strategies to address these issues include an increased focus on family physician educational needs, extra resources to assist with more effective communication to parents and a review of the present funding of providers for immunisation services.

Background: We undertook a literature review to produce evidence-based recommendations for nonsurgical family physician management of carpal tunnel syndrome (CTS)., Methods: Study design was systematic review of randomized controlled trials (RCTs) on CTS treatment. Data sources were English publications from all relevant databases, hand searches, and guidelines. Outcomes measured were nonsurgical management options for CTS., Results: We assessed 2 systematic reviews, 16 RCTs, and 1 before-and-after study using historical controls. A considerable percentage of CTS resolves spontaneously. There is strong evidence that local corticosteroid injections, and to a lesser extent oral corticosteroids, give short-term relief for CTS sufferers. There is limited evidence to indicate that splinting, laser-acupuncture, yoga, and therapeutic ultrasound may be effective in the short to medium term (up to 6 months). The evidence for nerve and tendon gliding exercises is even more tentative. The evidence does not support the use of nonsteroidal anti-inflammatory drugs, diuretics, pyridoxine (vitamin B6), chiropractic treatment, or magnet treatment., Conclusions: For those who are not able to get surgery or for those who do not want surgery, there are some conservative modalities that can be tried. These modalities include ones for which there is good evidence. It would be reasonable to try some of the techniques with less evidence if the better ones are not successful. Reconsideration of surgery must always be kept in mind to avoid permanent nerve damage.

Objectives: To determine the efficacy of intra-articular corticosteroid injections for osteoarthritis of the knee and to identify numbers needed to treat., Data Sources: Cochrane controlled trials register, Medline (1966 to 2003), Embase (1980 to 2003), hand searches, and contact with authors., Inclusion Criteria: Randomised controlled trial in which the efficacy of intra-articular corticosteroid injections for osteoarthritis of the knee could be ascertained., Results: In high quality studies, the pooled relative risk for improvement in symptoms of osteoarthritis of the knee at 16-24 weeks after intra-articular corticosteroid injections was 2.09 (95% confidence interval 1.2 to 3.7) and the number needed to treat was 4.4. The pooled relative risk for improvement up to two weeks after injections was 1.66 (1.37 to 2.0). The numbers needed to treat to get one improvement in the statistically significant studies was 1.3 to 3.5 patients., Conclusion: Evidence supports short term (up to two weeks) improvement in symptoms of osteoarthritis of the knee after intra-articular corticosteroid injection. Significant improvement was also shown in the only methodologically sound studies addressing longer term response (16-24 weeks). A dose equivalent to 50 mg of prednisone may be needed to show benefit at 16-24 weeks.

Context: The effectiveness of moving to compulsory, prescriptive continuing medical education (CME) for New Zealand general practitioners (GPs) is questioned. Motivational interviewing theory suggests that a series of interventions gradually increase awareness of the need to change until change is finally actioned. This study aimed to explore GPs' views on their need for CME, experiences regarding its provision and perceptions on the effect of CME in changing their clinical behaviour., Method: Qualitative study using semi-structured interviews of 24 GPs from Auckland and North Island rural areas assessing their CME experiences and preferences., Findings: All participants acknowledged that CME is a life-long process essential for GPs. Changing behaviour is generally seen as an incremental, evolutionary process with reinforcement of knowledge from different sources. Single events were perceived to effect change rarely. These were often high-impact, either punitive or incentive-based. GPs have a myriad of CME sources including reading, the internet, specialist letters, conversations with colleagues, quality assurance feedback, as well as traditional meetings. Credit-based quota requirements received mixed opinions but mostly were perceived negatively, discouraging needs-based approaches to learning. GPs' greatest barrier to obtaining CME is time., Discussion: GPs perform poorly in assessing their specific learning needs. Their behaviour change is likely to be incremental. Therefore multi-faceted interventions and reinforcement from different sources are likely to be most effective in changing clinical practice. Understanding this is important for CME providers, GP Colleges and funders. Narrow, credit-based approaches to CME may discourage time-strapped GPs obtaining motivation to change from exposure to a wide variety of CME sources.

Aim: To explore the experiences and preferences of general practitioners (GPs) regarding their continuing medical education (CME)., Methods: Qualitative study using semi-structured interviews of twenty four GPs from Auckland and North Island rural areas assessing GPs' experiences and preferences., Results: The need for CME was emphasised. Primary themes identified were: the value of personal interaction; the perception that CME that did not involve personal interaction was adjunctive; an opportunistic rather than needs-based approach to learning; a preference for succinct, evidenced-based, GP-focused content; and lack of time as a major barrier to obtaining optimal CME., Conclusions: Interactive formats are generally preferred, but identification of which elements of interactive formats facilitate learning is not established. Most GPs do not direct their CME according to the adult learning model. The challenge for CME providers is to provide avenues to facilitate needs identification and self-directed learning.

Objective: To explore the experiences and opinions of family physicians and patients regarding the delay of antibiotic prescriptions, to be dispensed if symptoms persist or worsen over time, in treating upper respiratory tract infections., Study Design: Qualitative study using semistructured interviews conducted in family practice in Auckland, New Zealand., Population: Thirteen physicians recruited from a study of family physicians' reported antibiotic prescribing and 13 patients recruited from the intervention arm of a randomized controlled trial on delayed antibiotic prescribing., Outcomes Measured: Patients' and physicians' experiences of delayed antibiotic prescriptions for upper respiratory tract infections., Results: The primary themes identified were value judgments of antibiotics, decreased antibiotic use, patient-centered factors, effects on the physician-patient relationship, patient convenience, adverse effects of delaying prescription, and selectivity for use of antibiotics. Many themes were common to both patients and physicians. Physicians valued empowering patients' decision making about their health care management more highly than did patients. Decreasing antibiotic use was not a key factor for most patients. Both groups acknowledged the value in saving patients time and money. Physicians viewed the strategy as giving patients reassurance and meeting their expectations for antibiotics. Negative implications included perception of physician incompetence and physician loss of management control. Opinions were mixed regarding which patients, under which conditions, were suitable for delayed antibiotic prescriptions., Conclusions: Although delayed antibiotic prescriptions are effective in decreasing antibiotic use for conditions not clinically warranting antibiotics, neither patients nor physicians universally endorsed this strategy. Research to establish formalized recommendations for patient suitability and instructions for use would be of value.

This study assessed characteristics of women presenting for termination of pregnancy subsequent to stopping combined oral contraceptive use in response to publicity-mediated fears regarding venous thromboembolism. Records of 400 women attending for pregnancy termination assessment were reviewed retrospectively. Panic-stopping of oral contraceptives was implicated in 9.5%. Nearly 50% of combined pill users claimed their pregnancy resulted from panic-stopping because of media-promoted fear of health risks, especially 'clots.' Panic-stoppers had significantly lower identified risk factors for venous thromboembolism than pill users who had not panic-stopped. The relative safety of third-generation pills is under debate. The risk-benefit ratio of contraceptive pills is overwhelmingly positive but practitioners must be vigilant in screening for risk factors and contraindications. Panic-stopping results in unwanted pregnancies with concomitant psychological distress and potential physical morbidity. In future situations where research findings may precipitate drug scares, we recommend recall of patients by their health provider, funded by the relevant health authority or pharmaceutical companies, to allow discussion of risks before the media is enabled to have access to the information.

Aim: To measure the rate of detected and undetected depression in patients attending an Auckland general practice., Method: At their consultation conclusion, general practitioners (GPs) asked all consecutive patients over sixteen years attending for consultation to participate in a health and mood questionnaire. A researcher administered the Beck Depression Inventory (BDI) to consenting participants. The GPs previously recorded whether they considered these patients depressed., Results: Response rate among patients was 81% (253/314). The BDI found a 13.8% (35/253) 95% CI (9.6-18.5) depression prevalence among patients. GPs picked up 51% of cases (sensitivity 0.51 and specificity 0.91). Mäori patients were no more likely to be depressed than non-Mäori but they were less likely to be receiving or have received treatment with antidepressants., Conclusion: The rate of depression in this practice was higher than an earlier study suggesting the true rate may be >10%. GPs see more depressed patients than other health professionals, therefore improvement in detection and management of depression in primary care is important. More work is needed on the difference between Mäori and non-Mäori in the use of antidepressants.

Background: Ethics committees typically apply the common principles of autonomy, nonmaleficence, beneficence and justice to research proposals but with variable weighting and interpretation. This paper reports a comparison of ethical requirements in an international cross-cultural study and discusses their implications., Discussion: The study was run concurrently in New Zealand, UK, Israel, Canada and USA and involved testing hypotheses about believability of testimonies regarding alleged child sexual abuse. Ethics committee requirements to conduct this study ranged from nil in Israel to considerable amendments designed to minimise participant harm in New Zealand. Assessment of minimal risk is a complex and unreliable estimation further compounded by insufficient information on probabilities of particular individuals suffering harm. Estimating potential benefits/ risks ratio and protecting participants' autonomy similarly are not straightforward exercises., Summary: Safeguarding moral/humane principles should be balanced with promotion of ethical research which does not impede research posing minimal risk to participants. In ensuring that ethical standards are met and research has scientific merit, ethics committees have obligations to participants (to meet their rights and protect them from harm); to society (to ensure good quality research is conducted); and to researchers (to treat their proposals with just consideration and respect). To facilitate meeting all these obligations, the preferable focus should be promotion of ethical research, rather than the prevention of unethical research, which inevitably results in the impediment of researchers from doing their work. How the ethical principles should be applied and balanced requires further consideration.

Internationally-recognised criteria for screening for a particular disorder require the following: availability of a clear diagnosis; a suitable validated screening test; acceptability of routine screening by patients and health providers; benefits of earlier detection and application of appropriate interventions to prevent the progression of a disorder, and hence reduction in incidence of morbidity and mortality; identification of possible harm from screening (false positives, false negatives, adverse effects of labelling, early diagnosis or unnecessary treatment of persons with true-positive test results with inconsequential disease) and weighing this against potential benefits; identification of possible sub-populations with the possibility of targeted screening of high-risk populations; good quality evidence of interventions effective in preventing or managing the disorder; and a cost-effectiveness assay. The New Zealand Ministry of Health have launched a best-practice guideline recommending all female general practice patients sixteen years and over be routinely screened for physical and sexual abuse by their partners. Inter-partner violence, especially against women by male partners and expartners, is a serious public health problem. However, review of existing research indicates that this guideline meets none of the criteria listed above. Considerable funding is invested in training health providers to implement this screening protocol, but, in the absence of effectiveness studies, cost-effectiveness cannot be assessed. Under current conditions, routine screening of adult women for partner abuse cannot be justified. However, GPs should be encouraged to learn about partner abuse and consider this possibility in patients presenting with physical injuries, psychological disturbance or social dysfunction, especially in high-risk patients. Research should be supported for the development and validation of effective, acceptable screening tools and randomised controlled trials of appropriate interventions. The desire to intervene for the public good should not dictate the implementation of a screening programme that disregards accepted screening criteria.

Genetic modification involves the insertion of genes from other organisms (within or between species) into host cells to select for desirable qualities. Potential benefits of GM foods include increased nutritional value; reduced allergenicity; pest and disease-resistance; and enhanced processing value. Possible detrimental outcomes include producing foods with novel toxins, allergens or reduced nutritional value, and development of antibiotic resistance or herbicide-resistant weeds. Benefits to individuals or populations need to be weighed against adverse health and environmental risks, and may differ between developing and Westernised countries. Whether testing and monitoring should exceed requirements for conventional foods is under debate. While not necessarily scientifically justifiable, consumer concerns have resulted in Australian and New Zealand requirements to label foods containing GM-produced proteins. Dissatisfied consumer advocacy groups are calling for all foods involving GM technology to be labelled, irrelevant of whether the final product contains novel protein. Goals to improve the quantity, quality and safety of foods are laudable; however, the primary aim of the bio-food industry is financial gain. GM foods may be as safe as conventional foods but public distrust runs high. It is important that discussion is informed by science and that claims of both benefits and risks are evidence-based, to ensure that the process is driven neither by the vested interest of the bio-technical multinational companies on the one hand, nor ill-informed public fears on the other.

Background: A patient's psychological adaptation to heart failure can influence its impact on his or her life. However, attempts to understand how patients cope mentally with severe emotional strain have led to inconsistent use of a plethora of concepts, making communication and clinical care difficult., Objectives: The aim of the present study was to develop a framework for conceptualizing how patients with chronic heart failure cope mentally with their illness, and then use the framework to suggest how GPs can facilitate patient self-care., Methods: We systematically reduced and reassembled the narrative texts of personal, semi-structured interviews until their interpretation was complete. The interviews were conducted during late 1999 with 62 heart failure patients under GP care in 30 practices across central Auckland, New Zealand., Results: Our framework describes four coping strategies: avoidance, disavowal, denial and acceptance. Disavowal provides a distinct coping strategy through which patients, who basically understand the threat to their life situations, seek hope through positively reconstructing this threat. Use of this strategy was highly salient regardless of patients' age, the length of time since their recorded diagnosis or the degree of self-reported limitation of recent physical function due to heart failure. Only over age 70 were avoidance and acceptance also highly salient among patients whose heart failure was diagnosed at least 3 years previously and had mildly limited their recent physical function., Conclusion: Many different heart failure patients use disavowal to palliate the emotional strain and find hope. Disavowal is not a problem to deal with but a process GPs can facilitate by implementing a range of suggested strategies through methods such as story telling.

We reviewed the literature on patient management following arthroscopic meniscal surgery. A critical appraisal of the literature produced 8 randomized controlled trials evaluating the use of non-steroidal anti-inflammatory drugs or various forms of physiotherapy and pain control. Different treatments and outcome measures precluded meta-analysis. The limited evidence suggests that this is a relatively pain-free procedure with rapid recovery, and that in most cases simple analgesia in the first 1-2 days following surgery and a well-planned home-based exercise program should be sufficient. It is possible that routine daily non-steroidal anti-inflammatory drugs post-operatively for 3-6 weeks may enhance recovery rates. One study found that physiotherapy was beneficial for regaining muscle strength and on pain assessment but this did not translate into functional improvement. Descriptive studies are required to ascertain the types and duration of treatments being offered to patients after arthroscopic meniscectomy. Further research is needed to perform well-designed studies of current treatments that take into account predisposing factors and their impact on outcome, including use of prerandomization and real-life functional outcome measures.

Power is an inescapable aspect of all social relationships, and inherently is neither good nor evil. Doctors need power to fulfil their professional obligations to multiple constituencies including patients, the community and themselves. Patients need power to formulate their values, articulate and achieve health needs, and fulfil their responsibilities. However, both parties can use or misuse power. The ethical effectiveness of a health system is maximised by empowering doctors and patients to develop 'adult-adult' rather than 'adult-child' relationships that respect and enable autonomy, accountability, fidelity and humanity. Even in adult-adult relationships, conflicts and complexities arise. Lack of concordance between doctors and patients can encourage paternalism but may be best resolved through negotiated care. A further area of conflict involves the 'double agency' of doctors for both patients and the community. Empowerment of all players is not always possible but is most likely where each party considers and acknowledges power issues.

Aim: To assess General Practice (GP) description and management of upper respiratory tract infections (URTI), including conditions under which they prescribe antibiotics., Method: A telephone survey of a randomised sample of Auckland GPs., Results: There was a 61% response rate. 82 of the 100 GPs interviewed agreed that most patients presenting with URTI expected antibiotics. Persistent symptoms and indication of specific infection (tonsillitis, otitis media, sinusitis, pharyngitis, purulent sputum) were common reasons for prescribing. Patients travelling overseas, expecting or requesting antibiotics and prior use of over-the-counter (OTC) medications increased antibiotic prescribing-rates. Most GPs (95%) issued as-needed prescriptions on occasion; 13% did this often. Amoxicillin and amoxicillin/clavulanic acid were most commonly used. Despite wide-ranging antibiotic use for URTI (0 to 90%), only 6% of GPs felt they prescribed more antibiotics than others., Conclusions: The results suggest over-prescription is common-place, but use of as-needed prescriptions to reduce antibiotic use is encouraging. Exploration of patient expectations in the consultation may assist in decreasing prescribing rates.

Aim: Sedentary lifestyle is a significant risk factor for increased morbidity and mortality in many medical conditions. A Hillary Commission initiative, Green Prescription is a written exercise prescription given by general practitioners (GPs) to sedentary patients to encourage physical activity. Our aim was to establish the extent to which GPs in the North Health region in 1997 issued with Green Prescription packages had used them, the circumstances under which they were used, and barriers to their use., Methods: 433 GPs issued with packs were faxed a one-page questionnaire for immediate completion, with follow-up of non-responders., Results: The response rate was 73%, with 65% of respondents having written Green Prescriptions. Their main reasons for use were patient need for more exercise and presence of high-risk medical conditions such as hypertension, cardiovascular disease, obesity and diabetes. Reasons for non-use were: GP already giving advice about physical activity; concern that Green Prescription was patronising and simplistic; compliance issues and time restraints. Some requested a computerised version., Conclusion: Non-responders may be non-users, hence we estimate that 48-65% of targeted GPs used Green Prescription. Barriers identified by GPs have assisted in Green Prescription development, which is now nationwide and assessed by independent researchers tri-annually.

Far more people in relationships are subjected to violent acts than those who receive injuries. The degree of damage sustained may not reflect the perpetrator's intent to deliberately harm a partner. Data documenting aggressive acts determines the population at risk and their prevention and early treatment requirements; whereas data focusing on harm and injury helps determine emergency medical and refuge services. Data from national crime surveys, police records, or clinical populations should not be generalized to the population at large. Even if men perpetrate the majority of serious partner attacks, addressing the issue of female violence will significantly reduce the overall level of domestic violence. Judicial, medical, and social services should take note that while male violence may be more problematic, violence is a relationship issue, not a male issue., (Copyright 1999 John Wiley & Sons, Ltd.)