Journal Articles
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Item General practitioner and nurse experiences of type 2 diabetes management and prescribing in primary care: a qualitative review following the introduction of funded SGLT2i/GLP1RA medications in Aotearoa New Zealand.(Cambridge University Press, 2024-09-16) Norman K; Mustafa ST; Cassim S; Mullins H; Clark P; Keenan R; Te Karu L; Murphy R; Paul R; Kenealy T; Chepulis LAIM: To explore the views of general practitioners (GPs) and nurses on type 2 diabetes (T2D) management, including the use of recently funded T2D medications in New Zealand (NZ) and their perceived barriers to providing optimal care. BACKGROUND: T2D is a significant health concern in NZ, particularly among Māori and Pacific adults. Characterised by prolonged hyperglycaemia, T2D is generally a progressive condition requiring long-term care. METHODS: Semi-structured interviews were conducted between July and December 2022 with 21 primary care clinicians (10 GPs and 11 nurses/nurse prescribers) from nine different general practice clinics across the Auckland and Waikato regions of NZ. Framework analysis was conducted to identify common themes in clinicians' perceptions and experiences with T2D management. FINDINGS: Three themes were identified: health-system factors, new medications, and solution-based approaches. Lack of clinician time, healthcare funding, staff shortages, and burn-out were identified as barriers to T2D management under health-system factors. The two newly funded medications, empagliflozin and dulaglutide, were deemed to be a positive change for T2D care in that they improved patient satisfaction and clinical outcomes, but several clinicians were hesitant to prescribe these medications. Participants suggested that additional education and specialist diabetes support would be helpful to inform optimal medication prescribing and that better use of a multi-disciplinary team (clinical and support staff) could support T2D care by reducing workload, addressing cultural gaps in healthcare delivery, and reducing burnout. An improved primary care work environment, including appropriate professional development to support prescribing of new medications and the value of collaboration with a non-regulated workforce, may be required to facilitate optimal T2D management in primary care. Future research should focus on interventions to increase support for both clinical teams and patients while adopting a culturally appropriate approach to increase patient satisfaction and improve health outcomes.Item Acceptance and commitment therapy for mild traumatic brain injury (ACTion-mTBI): a quasiexperimental feasibility study(BMJ Publishing Group Ltd, 2025-02-16) Faulkner J; Prouty D; Devlin L; Appleton D; Roche M; Below K; Moffat J; Snell D; Williams MN; Barker-Collo S; Theadom AOBJECTIVES: This study aimed to determine the feasibility of recruiting, implementing and delivering an acceptance and commitment therapy (ACT) intervention for mild traumatic brain injury (mTBI) (ACTion-mTBI) within a multidisciplinary outpatient mTBI rehabilitation services. The study also aimed to conduct a preliminary investigation of group differences between ACTion-mTBI and an equivalent cognitive behavioural therapy (CBT) intervention on various outcome measures and psychological treatment targets. DESIGN: A two-arm quasiexperimental feasibility study. SETTING: Five mTBI rehabilitation clinics throughout New Zealand. INTERVENTION: Psychologists working in mTBI rehabilitation clinics throughout New Zealand were trained to deliver ACTion-mTBI or CBT. Eligible participants were assigned to either of these interventions based on the psychologist available at the clinic they were referred to. ACTion-mTBI is a five sessions intervention that incorporates all six components of the ACT model. The CBT intervention is an equivalent intervention and incorporating all four components of the CBT model. Both interventions are adapted for an mTBI context. PRIMARY OUTCOME MEASURES: The primary outcomes were related to the feasibility of ACTion-mTBI. This included recruitment, retention and treatment adherence of participants, study procedure and fidelity of treatment delivery. SECONDARY OUTCOME MEASURES: To explore group differences between ACTion-mTBI and CBT on functional disability, postconcussion symptoms, mental health, valued living and psychological flexibility. RESULTS: The intervention proved feasible to implement with community-based mTBI rehabilitation services. Attrition rates were comparable between the two psychological interventions and fidelity to the treatments was high. At post-treatment, when covarying pretreatment scores, ACTion-mTBI had a significantly greater improvement in functional disability than CBT (moderate effect). ACTion-mTBI also had a significantly greater reduction in postconcussion symptoms, anxiety and stress. Promisingly, significant improvements in psychological flexibility was also found post-treatment. There were no group differences on depressive symptoms and valued living. CONCLUSION: We conclude that a full clinical trial of ACTion-mTBI for individuals with mTBI is feasible and warranted. TRIAL REGISTRATION NUMBER: ACTRN1262100059482.Item Healthcare performance of leprosy management in peripheral health facilities of Dhanusa and Mahottari, Nepal.(BioMed Central Ltd, 2025-12) Mahato RK; Ghimire U; Bajracharya B; K C B; Bam D; Ghimire D; Pyakurel UR; Hayman DTS; Pandey BD; Das CL; Paudel KPBACKGROUND: The global elimination of leprosy transmission by 2030 is a World Health Organization (WHO) target. Nepal's leprosy elimination program depends on early case diagnosis and the performance of health workers and facilities. The knowledge and skills of paramedical staff (Leprosy Focal Person, LFP) and case documentation and management by health facilities are therefore key to the performance of health care services. METHODS: The performance of health workers and facilities was evaluated through a combined cross-sectional and retrospective study approach of 31 health facilities and their LFPs in Dhanusa and Mahottari Districts in Madhesh Province, Nepal. An average of 6 patients (paucibacillary, PB, or multibacillary, MB) per health facility registered within the 2018/2019 fiscal year were also enrolled in the study. LFP knowledge (e.g., of the three cardinal signs) and skills (e.g., nerve palpation) and facility processes (e.g., record keeping) were scored (e.g., 0, 1) and then rescaled to a proportion, where 1 is perfect. Internal benchmarking was used to guide performance management. RESULTS: Overall LFP knowledge and skill scores of health workers ranged from 0.16 to 0.63 (median 0.53, 95% confidence interval (CI), 0.46-0.6). Case documentation scores ranged from 0.15 to 0.87 (median 0.37, 95% CI 0.36-0.38), case management scores from 0.38 to 0.79 (median 0.54, 95% CI 0.53-0.55) and overall healthcare scores from 0.36-0.62 (median 0.48, 95% CI 0.47-0.49). Leprosy-related training was significantly related to the knowledge and skills of the health workers. All identified cases (n = 187) adhered to the complete treatment and release after treatment (RFT) scheme, out of which 84.5% were satisfied with the service they were provided. Leprosy disability and ear hand and feet (EHF) scores were not significantly reduced in treated patients during the study period, but counseling by LFPs significantly improved cases' positive beliefs and practices regarding self-care. CONCLUSION: Overall leprosy care median performance was low (53%) and can be improved by evidenced-based training, onsite coaching, monitoring, and supervision to facilitate leprosy transmission elimination. The results highlight many of the challenges facing leprosy elimination programs.Item Nicotine exacerbates exertional heat strain in trained men: A randomized, placebo-controlled, double-blind study.(American Physiological Society, 2024-08-16) Moyen NE; Barnes MJ; Perry BG; Fujii N; Amano T; Kondo N; Mundel TTo determine whether using nicotine exacerbates exertional heat strain through an increased metabolic heat production (Hprod) or decreased skin blood flow (SkBF), 10 nicotine-naïve trained males [37 ± 12 yr; peak oxygen consumption (V̇o2peak): 66 ± 10 mL·min−1·kg−1] completed four trials at 20°C and 30°C following overnight transdermal nicotine (7 mg·24 h−1) and placebo use in a crossover, double-blind design. They cycled for 60 min (55% V̇o2peak) followed by a time trial (∼75% V̇o2peak) during which measures of gastrointestinal (Tgi) and mean weighted skin (̅Tsk) temperatures, SkBF, Hprod, and mean arterial pressure (MAP) were made. The difference in ΔTgi between nicotine and placebo trials was greater during 30°C (0.4 ± 0.5°C) than 20°C (0.1 ± 0.7°C), with ̅Tsk higher during nicotine than placebo trials (0.5 ± 0.5°C, P = 0.02). SkBF became progressively lower during nicotine than placebo trials (P = 0.01) and progressively higher during 30°C than 20°C trials (P < 0.01); MAP increased from baseline (P < 0.01) and remained elevated in all trials. The difference in Hprod between 30°C and 20°C trials was lower during nicotine than placebo (P = 0.01) and became progressively higher during 30°C than 20°C trials with exercise duration (P = 0.03). Mean power output during the time trial was lower during 30°C than 20°C trials (24 ± 25 W, P = 0.02), and although no effect of nicotine was observed (P > 0.59), two participants (20%) were unable to complete their 30°C nicotine trials as one reached the ethical limit for Tgi (40.0°C), whereas the other withdrew due to “nausea and chills” (Tgi = 39.7°C). These results demonstrate that nicotine use increases thermal strain and risk of exertional heat exhaustion by reducing SkBF. NEW & NOTEWORTHY In naïve participants, acute nicotine use exerts a hyperthermic effect that increases the risk of heat exhaustion during exertional heat strain, which is driven by a blunted skin blood flow response. This has implications for 1) populations that face exertional heat strain and demonstrate high nicotine use (e.g., athletes and military, 25%–50%) and 2) study design whereby screening and exclusion for nicotine use or standardization of prior use (e.g., overnight abstinence) is encouraged.Item Public Health.(2024-12) Röhr S; Gibson R; Alpass FBACKGROUND: High purpose in life - the extent of engagement in activities that are personally valued and give a sense of direction and meaning to life - has been associated with higher cognitive functioning and may protect against dementia. Less is known about gender differences in cognitive functioning regarding purpose in life. Understanding gender-specific links can inform tailored interventions aimed at promoting cognitive health. METHOD: A subsample (n = 875, aged 50-85 years) of the NZHWR study completed face-to-face cognitive assessments and postal surveys in 2012. Cognitive functioning was assessed with Addenbrooke's Cognitive Examination-Revised (ACE-R), adapted for culturally acceptable use in New Zealand. Purpose in life was measured with the Life Engagement Test. Linear regression analysis assessed associations of gender, purpose in life and their interaction with cognitive functioning, controlling for socioeconomic factors (age, age², education, ethnicity [Māori, Indigenous people of New Zealand, and Non-Māori, mostly of European descent], marital status, employment, individual-level economic hardship, area-based socioeconomic deprivation), lifestyle and health factors (smoking, alcohol consumption, physical activity, SF-12 physical and mental health, social engagement, social loneliness). RESULT: The analytical sample (n = 643) was M = 65.3 (SD = 7.4) years old; 53.3% women, 21.2% Māori. The ACE-R score was M = 92.9 (SD = 5.3). N = 55 (8.5%) scored ≥1.5SD below the mean, indicating cognitive impairment. Women had higher cognitive functioning (M = 93.7, SD = 4.6 vs. M = 92.0, SD = 5.8; Z = -3.88, p<.001) and purpose in life (M = 26.2, SD = 3.8 vs. M = 25.8, SD = 3.4; Z = -2.19, p = .029) than men. In the adjusted regression analysis (R² = 27.6%), higher purpose in life (B = 0.29, 95%CI = 0.12;0.46; p = .001) and female gender (B = 9.97, 95%CI = 4.71;15.24, p<.001) were associated with higher cognitive functioning. The association of purpose in life with cognitive functioning was less pronounced for women than men (B = -0.31, 95%CI = -0.51;-0.11; p = .003) (Fig. 1). Significant covariates included age², education, deprivation, and social loneliness. CONCLUSION: In this sample of older New Zealanders, a gender difference in cognitive functioning varied by level of purpose in life. Women had higher cognitive functioning than men, particularly at lower purpose in life, with the difference decreasing as purpose in life increases. Interventions to enhance purpose in life might particularly benefit men. Notably, cognitive functioning may also impact purpose in life, emphasising the need for longitudinal studies.Item Study Protocol for a Randomized Controlled Trial Investigating the Effects of the Daily Consumption of Ruminant Milk on Digestive Comfort and Nutrition in Older Women: The YUMMI Study.(MDPI (Basel, Switzerland), 2024-12-06) Ong SP; Miller JC; McNabb WC; Gearry RB; Ware LM; Mullaney JA; Fraser K; Hort J; Bayer SB; Frampton CMA; Roy NC; Miranda JMBACKGROUND: Age-related changes can lead to dietary insufficiency in older adults. The inclusion of high-quality, nutrient-dense foods such as ruminant milks can significantly improve health outcomes. However, many older adults worldwide do not meet daily milk intake recommendations because of digestive discomfort and health concerns. Ovine and caprine milks are increasingly popular for their perceived digestive and nutritional benefits. While preclinical studies suggest differences in milk digestion, human studies investigating acute postprandial responses remain inconclusive, and the impacts of sustained milk consumption remain uncertain. OBJECTIVES: Hence, we present a randomized controlled trial investigating how the sustained consumption of bovine, caprine, or ovine milk influences digestion, nutrition, and metabolism in older women. METHODS: A total of 165 healthy older women were randomized to receive bovine, caprine, or ovine milk, or no milk, twice daily for 12 weeks. The primary outcome is the impact of milk consumption on digestive comfort assessed via the Gastrointestinal Syndrome Rating Scale (GSRS). Secondary outcomes include changes in nutrient intake, plasma amino acid and lipid appearance, bowel habits, the gut microbiota, cardiometabolic health, physical function, physical activity, sleep, mood, sensory perception, and emotional response. CONCLUSIONS: The findings could inform dietary recommendations for older women and facilitate the development of targeted functional food products.Item Area-based socioeconomic deprivation is associated with cognitive decline in midlife to early late-life New Zealanders without cognitive impairment(Wiley Periodicals LLC on behalf of Alzheimer's Association, 2025-01-09) Röhr S; Gibson R; Alpass FBackground Research identified individual-level socioeconomic factors as key determinants of cognitive health. This study investigated the effect of area-based socioeconomic deprivation on cognitive outcomes in midlife to early late-life New Zealanders without cognitive impairment. Understanding geographical dimensions of socioeconomic determinants of cognitive health is important from an equity perspective. Method Data stemmed from a subsample of the New Zealand Health, Work and Retirement Study, a cohort study on ageing. In 2010, 1,001 participants aged 49-84 years completed face-to-face interviews and were reassessed two years later. Cognitive functioning was measured using Addenbrooke’s Cognitive Examination–Revised, adapted for culturally acceptable use in New Zealand. Area-based socioeconomic deprivation was assessed using the New Zealand Deprivation Index (NZDep2006). Linear mixed-effects models analysed the association between area-based socioeconomic deprivation and cognitive outcomes, controlling for individual-level socioeconomic (age, age², gender, education, ethnicity [Māori, Indigenous people of New Zealand, and Non-Māori, mostly of European descent], marital status, employment, net personal income), lifestyle and health variables (Lifestyle for Brain Health/LIBRA index, social loneliness). Result The analysis included 783 participants (54.7% female, mean age 62.7 years, 25.0% Māori). Individuals with cognitive impairment at baseline (n = 69) and older than 75 years were excluded (n = 79). Further attrition was due to missing data. At baseline, 39.7% resided in low deprivation areas, 39.0% in moderate, and 21.3% in high deprivation areas. The unadjusted model indicated a significant association between higher area-based socioeconomic deprivation and lower cognitive functioning (B = -0.16, 95%CI: -0.22,-0.10; p < .001) and cognitive decline (B = -0.12, 95%CI: -0.21;-0.03; p = .015). The adjusted model yielded similar results for cognitive functioning (B = -0.08, 95%CI: -0.15;-0.01; p = .050) and cognitive decline (B = -0.12, 95%CI: -0.20;-0.04, p = .013) (Fig. 1). Influential covariates included gender, education, and lifestyle (LIBRA). Conclusion This study demonstrated a relationship between higher area-based socioeconomic deprivation and lower cognitive functioning, along with cognitive decline, in cognitively unimpaired New Zealanders aged 48 to 75 years. These findings emphasize the importance of considering neighbourhood characteristics and broader socioeconomic factors in strategies aimed at mitigating cognitive health disparities and reducing the impact of dementia in disadvantaged communities.Item Characterisation of the Plasma and Faecal Metabolomes in Participants with Functional Gastrointestinal Disorders.(MDPI (Basel, Switzerland), 2024-12-16) Fraser K; James SC; Young W; Gearry RB; Heenan PE; Keenan JI; Talley NJ; McNabb WC; Roy NC; Fukui HThere is evidence of perturbed microbial and host processes in the gastrointestinal tract of individuals with functional gastrointestinal disorders (FGID) compared to healthy controls. The faecal metabolome provides insight into the metabolic processes localised to the intestinal tract, while the plasma metabolome highlights the overall perturbances of host and/or microbial responses. This study profiled the faecal (n = 221) and plasma (n = 206) metabolomes of individuals with functional constipation (FC), constipation-predominant irritable bowel syndrome (IBS-C), functional diarrhoea (FD), diarrhoea-predominant IBS (IBS-D) and healthy controls (identified using the Rome Criteria IV) using multimodal LC-MS technologies. Discriminant analysis separated patients with the 'all constipation' group (FC and IBS-C) from the healthy control group and 'all diarrhoea' group (FD and IBS-D) from the healthy control group in both sample types. In plasma, almost all multimodal metabolite analyses separated the 'all constipation' or 'all diarrhoea' group from the healthy controls, and the IBS-C or IBS-D group from the healthy control group. Plasma phospholipids and metabolites linked to several amino acid and nucleoside pathways differed (p < 0.05) between healthy controls and IBS-C. In contrast, metabolites involved in bile acid and amino acid metabolism were the key differentiating classes in the plasma of subjects with IBS-D from healthy controls. Faecal lipids, particularly ceramides, diglycerides, and triglycerides, varied (p < 0.05) between healthy controls and the 'all constipation' group and between healthy controls and 'all diarrhoea' group. The faecal and plasma metabolomes showed perturbations between constipation, diarrhoea and healthy control groups that may reflect processes and mechanisms linked to FGIDs.Item Depression and anxiety at 1- and 12-months post ischemic stroke: methods for examining individual change over time.(CSIRO Publishing on behalf of the Australasian Society for the Study of Brain Impairment, 2024-12-05) Barker-Collo S; Krishnamurthi R; Nair B; Ranta A; Douwes J; Feigin V; Honan CBackground Depression is commonly studied post stroke, while anxiety is less studied. This study presents prevalence of depression and anxiety at 1- and 12-months post ischemic stroke alongside three methods for examining within-subjects change over time. Methods Participants were ischemic stroke patients of the Auckland Regional Community Stroke Study (ARCOS-V) with Hospital Anxiety and Depression Scale data at 1- (n = 343) and 12-months (n = 307). Change over time was examined using within-subjects repeated measures ANOVA, calculation of the Reliable Change Index, and a Sankey diagram of those meeting cut-off scores (>7) for caseness over time. Results Using repeated measures ANOVA, depression scores didn’t change significantly over time, while anxiety symptoms decreased significantly. When reliable change was calculated, 4.2% of individuals had reliable decreases in anxiety symptoms, while 5.7% had reliable decreases in depression symptoms. Those who had a reliable decrease in one tended to have a reliable decrease in the other. In the Sankey, the proportion of those meeting the cut-off score for anxiety did not change over time (12.8 and 12.7% at 1- and 12-months), while those meeting the cut-off for depression increased slightly (3.7–4.5%) and those meeting cut-offs for both decreased from 10.4 to 8.1%. Conclusion The three methods produced very different findings. Use of cut-off scores is common but has limitations. Calculation of clinically reliable change is recommended. Further work is needed to ensure depression and anxiety are monitored over time post-stroke, and both should be the subject of intervention efforts in both acute and late stages post-stroke.Item Economic burden of patients with leading cancers in China: a cost-of-illness study.(BioMed Central Ltd, 2024-09-27) Wu Z; Yu Y; Xie F; Chen Q; Cao Z; Chen S; Liu GGBACKGROUND: China accounts for 24% of newly diagnosed cancer cases and 30% of cancer-related deaths worldwide. Comprehensive analyses of the economic burden on patients across different cancer treatment phases, based on empirical data, are lacking. This study aims to estimate the financial burden borne by patients and analyze the cost compositions of the leading cancers with the highest number of new cases in China. METHODS: This cross-sectional cost-of-illness study analyzed patients diagnosed with lung, breast, colorectal, esophageal, liver, or gastric cancer, identified through electronic health records (EHRs) from 84 hospitals across 17 provinces in China. Patients completed any one of the initial treatment phase, follow-up phase, and relapse/metastasis phase were recruited by trained attending physicians through a stratified sampling procedure to ensure enough cases for each cancer progression stage and cancer treatment phase. Direct and indirect costs by treatment phase were collected from the EHRs and self-reported surveys. We estimated per case cost for each type of cancer, and employed subgroup analyses and multiple linear regression models to explore cost drivers. RESULTS: We recruited a total of 13,745 cancer patients across three treatment phases. The relapse/metastasis phase incurred the highest per case costs, varying from $8,890 to $14,572, while the follow-up phase was the least costly, ranging from $1,840 to $4,431. Being in the relapse/metastasis phase and having an advanced clinical stage of cancer at diagnosis were associated with significantly higher cost, while patients with low socioeconomic status borne lower costs. CONCLUSIONS: There were substantial financial burden on patients with six leading cancers in China. Health policymakers should emphasize comprehensive healthcare coverage for marginalized populations such as the uninsured, less educated, and those living in underdeveloped regions.