Anthony Dowell

“He aroha whakatō , he aroha puta mai” – if kindness is sown , then kindness you shall receive . Kindness in healthcare is often treated as an individual quality. Less attention has been paid to the organisational and relational conditions that sustain kindness in the daily reality of healthcare work. This study explores those conditions in a specific and instructive context: a large kaupapa Māori primary care organisation in Rotorua, Aotearoa New Zealand. Working in partnership with Korowai Aroha Health Centre, we conducted a co‐designed modified expert panel with fifteen staff members representing clinical, administrative, community and leadership roles. The activity was informed by participatory action research principles and structured within a socio‐ecological framework to explore the conditions for kindness at individual, team and organisational levels. Participants described kindness in relational terms, as something built through many small daily choices and interactions rather than through isolated acts. Kaupapa Māori values, including manaakitanga, whanaungatanga and the protection of mana, were consistently reflected in participant accounts, not as abstract principles but as practical descriptions of how people worked together each day. Conditions identified across all three levels included self‐reflection and reciprocity, seeing colleagues and patients as whānau, open and honest communication and protected time for connection. At the organisational level, participants identified the role of governance, business models, cultural investment and resourcing in either enabling or undermining these relational practices. Sufficient funding, careful hiring and workload design were not peripheral but understood as central to whether kindness could be sustained at all. While grounded in one specific kaupapa Māori context, this study offers something not yet present in the kindness literature: an account of how Indigenous values and organisational infrastructure interact to shape the conditions for kind practice—and what that means for how kindness in healthcare is understood and supported more broadly.

Introduction: International studies suggest that advancing diagnostic technologies have the potential to reduce uncertainty and improve management of acute respiratory infections. Aim: This study aimed to observe the impact that laboratory-based polymerase chain reaction testing for respiratory viruses, alongside a COVID-19 rapid antigen test, had on patient management during a pandemic. Observations may enhance knowledge about the utility of respiratory virus testing in primary care. Method: The electronic medical records of patients tested at one urban general practice in New Zealand were examined 90 days before and after respiratory virus testing to record and analyse data on test results, patient characteristics, antibiotic prescribing, presentations, and follow-up communications. Results: Among 298 presentations reviewed, 53% tested positive via polymerase chain reaction test. Antibiotics were prescribed for 37% of all presentations. Patients who tested positive for a respiratory virus were more likely to receive an antibiotic prescription than those who tested negative, both before and after test results. Notes showed texts and emails being used effectively to convey test results although some lacked evidence of test result communication. No impact on presentation patterns was identified. Discussion: Test results were used for effective follow-up with some patients, but there were also gaps in communication of results and variation in prescribing patterns following receipt of test results. Test-based limitations as well as broader environmental, clinical, and psychological factors are hypothesised as influencing test use. Advancing point-of-care technologies which offer faster result availability may address some, but not all of these issues.

Objectives: To identify and compare respiratory illness presentation rates and service utilisation to primary care in Aotearoa, New Zealand (NZ) before, through and after the COVID-19 pandemic. Design: A natural language processing (NLP) software interference algorithm was used to interrogate quantitative and qualitative cross-sectional and retrospective cohort data from clinical consultation notes. Setting: Primary care presentations across Aotearoa, NZ, encompassing both urban and rural areas. Participants: Electronic records were obtained from general practice interactions from 2018 to end of 2023. Participants consisted of 37 consenting practices from eight districts. Results: A total of 10 421 399 unique medical interactions were processed by the NLP software, of which 15.1% (1 573 631) were related to a respiratory issue. This ranged from 14.2% and 13.7% in 2018 and 2019 to a peak of 25.2% in 2022. Expected patterns of seasonal variation were observed prepandemic with small variance in mean rates. Due to the COVID-19 pandemic, border closures and then SARS-CoV-2 arrival, there was significant disruption to previous seasonal patterns across all respiratory illness presentations in primary care. Patterns vary markedly across different respiratory groups. While the degree of variance has reduced, there continues to be marked disruption of pre-COVID patterns. Conclusions: Primary care respiratory presentations in NZ continue to experience persistent variation from the pre-COVID typical seasonal presentation patterns. There is significant change in presentations, likely due to changing disease prevalence, but also to changing patient and provider behaviour. These results have implications for primary care workload management and public health policy.

Background: Ethnic and socioeconomic inequities in respiratory illness outcomes are well established. Monitoring primary care presentation rates is important for assessing health system equitable responsiveness, particularly during health crises. Aim: To examine changes in primary care respiratory illness presentation rates in Aotearoa New Zealand (NZ) by ethnicity and socioeconomic status before, during and after the COVID-19 pandemic. Design and setting: Retrospective cohort study using natural language processing (NLP) of electronic health records from 37 general practices across eight districts in NZ. Method: Clinical interactions from 2018 to 2023 (n=10 421 399; 4 66 349 patients) were classified into respiratory categories using a validated NLP algorithm. Age-adjusted monthly presentation rates were analysed by ethnicity and deprivation across pre-pandemic, pandemic and post-pandemic periods. Results: Overall, 15.1% (1 573 631/10 421 399) of interactions were respiratory-related, increasing from 13.7% to 14.2% in 2018–2019 to a peak of 25.2% in 2022, before declining to 15.3% in 2023. Pacific peoples had higher presentation rates than European patients both pre-pandemic (+2.2, p=0.03) and during the pandemic (+3.5, p<0.01), and the presentation rates for Pacific peoples more than doubled during the pandemic peak. Post-pandemic, rates declined across all groups with larger reductions for Pacific peoples. Higher presentation rates were consistently observed among those in the most deprived quintile. Acute respiratory presentations varied more over time, while chronic conditions remained relatively stable. Conclusions: Primary care presentation rates increased during the pandemic, particularly among high-needs populations, suggesting responsiveness to need. Post-pandemic declines in acute presentations, especially among Pacific peoples, may indicate emerging access barriers and widening inequities. NLP applied to routinely collected electronic health record data provides a retrospective approach to analysing primary care presentations and may support future development of surveillance approaches for monitoring equity trends.

Background The introduction and roll-out of the COVID-19 vaccine was one of the most important and complex initiatives undertaken by health sectors worldwide. In New Zealand, the Education, Training and Clinical Support to the health sector of the immunisation programme was undertaken by the Immunisation Advisory Centre (IMAC). This paper describes how an embedded evaluation was planned from the outset, acting as a rigorous "critical friend" to the programme: appreciating and recording successes, identifying challenges and opportunities early, and working with stakeholders to generate innovative solutions (Hindsight to Foresight). Method The evaluation research team used an established methodology and evidence base, combining complexity and implementation science with appreciative inquiry (CIS-A), previously applied in immunisation strategy and mental health settings. This approach was taken to acknowledge the complexity of the COVID-19 immunisation context. Both numerical and narrative data were collected to provide information to the programme for endorsement of what was going well and the early identification of challenges. Methods included analysis of IMAC routinely collected workforce data, help line call data, surveys, focus groups and interviews with vaccinators, vaccinees and key stakeholders. There was also direct observation of vaccination sites and settings. Results The embedded evaluation process was sustained throughout the COVID-19 immunisation response. Regular assessment and feedback enabled recognition and support of positive features of activity information about challenges with the opportunity for early course correction. There were specific areas where external evaluation was especially helpful, the focus on important and concise “Toolkit messages for the day” approach and the focus on equity being two examples. One of the challenges in using an iterative embedded methodology is that what might have been traditional "end of project" evaluation findings have already been raised and, in many cases, acted upon. Changes have therefore already been made and there may be a perception that an evaluation is adding little to project development. Conclusions The evaluation was able to assess the overall success and contribution of the programme to the immunisation rollout. We recommend that using a multi-perspective embedded evaluation approach can be of value in implementing complex health sector initiatives.

Background: Rapid, cost-effective diagnosis of acute respiratory infections is now possible using multi-viral rapid-antigen point-of-care tests (MVRA-POCTs) with high sensitivity and specificity. These offer a realistic alternative to polymerase chain reaction tests in primary care. However, evidence of acceptability and clinical utility in this setting is limited. Aim: To pilot feasibility of integrating MVRA-POCTs into routine primary care, and investigate patient and clinician attitudes and behaviours. Design & setting: A prospective mixed-methods pilot study in seven New Zealand (NZ) primary care clinics during winter 2023. Method: Patients with acute respiratory symptoms received an MVRA-POCT (instead of COVID-19-only). Outcomes and acceptability were assessed via audits of electronic medical records, clinician and patient surveys, and interviews and focus groups with patients and clinic staff. Results: Swab results were recorded from a demographically diverse cohort of 1754 patients; 14% tested positive for any virus ( n = 246/1754). All clinicians and most patients surveyed positively evaluated the test. All clinicians incorporated the MVRA-POCT into practice and found it useful. In total, 63% of prescribers ( n = 26/41) reported results influenced antibiotic prescribing; 12% ( n = 5/41) supported decisions about secondary care referrals for 12% ( n = 5/41). All patient responders who tested positive ( n = 39) and most testing negative ( n = 172/180, 96%) would like the MVRA-POCT in future. Patients testing positive self-reported as more likely to follow non-pharmaceutical interventions to reduce transmission compared with those testing negative. Conclusion: MVRA-POCTs were well-accepted and readily incorporated into practice. Routine integration into primary care could potentially improve management of common respiratory illnesses and promote patient behaviour change to reduce transmission.

Introduction Influenza is a major global health concern, responsible for up to 650 000 respiratory-related deaths annually. Although influenza is often perceived as mild in healthy adults, it can cause severe outcomes in high-risk groups, such as older adults, young children, pregnant women and those with underlying medical conditions. Various clinical, sociodemographic and environmental factors influence the progression to severe outcomes, whereas resilience factors, such as vaccination, may reduce risks. Despite growing research, the evidence base regarding risk and resilience is spread across many different aspects of the literature. This umbrella review will synthesise evidence from existing systematic reviews and meta-analyses to identify key risk and resilience factors associated with the progression of influenza to severe outcomes in the general population. Methods and analysis This umbrella review follows the Joanna Briggs Institute (JBI) and Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. We will include systematic reviews and meta-analyses reporting host-related risk or resilience factors for severe influenza outcomes. Four databases (EMBASE, Scopus, Medline and CINAHL) will be searched for English-language publications. Study quality will be assessed using AMSTAR 2, and the body of evidence will be evaluated using Grading of Recommendations Assessment, Development and Evaluation. Due to heterogeneity, findings will be analysed narratively. Risk and resilience factors will be grouped into demographic, clinical, behavioural, social and psychological domains. Ethics and disseminations No ethical approval is required. The completed review will be shared through peer-reviewed journals and conference presentations. PROSPERO registration number CRD420250644475.

Māori are over-represented in Aotearoa New Zealand morbidity and mortality statistics. Other populations with high health needs include Pacific peoples and those living with material deprivation. General practice has evolved into seven models of primary care: Traditional, Corporate, Health Care Home, Māori, Pacific, Trusts / Non-governmental organisations (Trust/NGOs) and District Health Board / Primary Care Organisations (DHB/PHO). We describe nurse work in relation to these models of care, populations with high health need and patient health outcomes. We conducted a cross-sectional study (at 30 September 2018) of data from national datasets and practices at patient level. Six primary outcome measures were selected because they could be improved by primary care: polypharmacy (≥ 65 years), glucose control testing in adults with diabetes, immunisations (at 6 months), ambulatory sensitive hospitalisations (0–14, 45–64 years) and emergency department attendances. Analysis adjusted for patient and practice characteristics. Nurse clinical time, and combined nurse, nurse practitioner and general practitioner clinical time, were substantially higher in Trust/NGO, Māori, and Pacific practices than in other models. Increased patient clinical complexity was associated with more clinical input and higher scores on all outcome measures. The highest rates of preventative care by nurses (cervical screening, cardiovascular risk assessment, depression screening, glucose control testing) were in Māori, Trust/NGO and Pacific practices. There was an eightfold difference, across models of care, in percentage of depression screening undertaken by nurses and a fivefold difference in cervical screening and glucose control testing. The highest rates of nurse consultations afterhours and with unenrolled patients, improving access, were in PHO/DHB, Pacific, Trust/NGO and Māori practices. Work not attributed to nurses in the practice records meant nurse work was underestimated to an unknown degree. Transferring work to nurses in Traditional, Health Care Home, and Corporate practices, would release general practitioner clinical time for other work. Worse patient health outcomes were associated with higher patient need and higher clinical input. It is plausible that there is insufficient clinical input to meet the degree of patient need. More practitioner clinical time is required, especially in practices with high volumes of complex patients.

Introduction: Improvements in diagnostic test accuracy across multiple pathogens have resulted in multi-viral point-of-care testing (POCT) via a rapid antigen test (RAT). Aim: This study aimed to describe general practice practitioners’ reactions to a pilot respiratory virus surveillance programme during the SARS-CoV-2 pandemic, which enabled surveillance for influenza and other respiratory viruses alongside POCT for SARS-CoV-2. Methods: Participating general practices collected viral swabs between May and December 2022. Nasopharyngeal swabs were taken for both an immediate COVID-19 RAT and a polymerase chain reaction (PCR) for testing SARS-CoV-2, influenza, respiratory syncytial virus (RSV) and other respiratory viruses. A questionnaire explored practitioners’ experiences and perceptions, addressing project setup, swabbing process and perceived overall value. Results: Of 4135 swabbed patients, 54% were positive for one of the tested viruses. Involved nurses and doctors reported high adaptability to the swabbing process. Clinicians valued obtaining rapid diagnostic information for patient management and patient communication. While no significant barriers were identified, practitioners acknowledged additional time requirements and potential challenges with swabbing young children. Discussion: The study demonstrated the feasibility and clinical utility of using POCT swabbing for immediate RAT and subsequent PCR testing for respiratory viruses in general practices when managing a viral pandemic. The data assisted in identifying community transmission of respiratory viruses, provided information for patient management and reinforced positive health messages about viral illnesses. The study suggests potential benefits for both individual patient care and population-based surveillance. The study also identified the potential value of multi-viral POCT testing via a RAT.