All Publications

  • Web-based Therapy Plus Support by a Coach in Depressed Patients Referred to Secondary Mental Health Care: Randomized Controlled Trial

    Hatcher, S; Whittaker, R; Patton, M; Sylvester, W; Ralph, N; Kercher, K; Sharon, C; (2018)

    JMIR Mental Health 2018; 5(1):e5. DOI: 10.2196/mental.8510. PMID: 29362207.

    View abstract

    BACKGROUND: The evidence for the effectiveness of Web-based therapies comes mainly from nonclinical populations, with a few studies in primary care. There is little evidence from patients referred to secondary mental health care with depression. Adherence to Web-based therapies is often poor. One way to increase this is to create a new health service role of a coach to guide people through the therapy.

    OBJECTIVE: This study aimed to test in people referred to secondary care with depression if a Web-based therapy (The Journal) supported by a coach plus usual care would be more effective in reducing depression compared with usual care plus an information leaflet about Web-based resources after 12 weeks.

    METHODS: We conducted a randomized controlled trial with two parallel arms and a process evaluation that included structured qualitative interviews analyzed using thematic analysis. The coach had a background in occupational therapy. Participants were recruited face-to-face at community mental health centers.

    RESULTS: We recruited 63 people into the trial (intervention 35, control 28). There were no statistically significant differences in the change from baseline in Patient Health Questionnaire-9 (PHQ-9) scores at 12 weeks comparing The Journal with usual care (mean change in PHQ-9 score 9.4 in the intervention group and 7.1 in the control group, t41=1.05, P=.30; mean difference=2.3, 95% CI −2.1 to 6.7). People who were offered The Journal attended on average about one less outpatient appointment compared with usual care, although this difference was not statistically significant (intervention mean number of visits 2.8 (SD 5.5) compared with 4.1 (SD 6.7) in the control group, t45=−0.80, P=.43; mean difference=1.3, 95% CI −4.5 to 2.0). The process evaluation found that the mean number of lessons completed in the intervention group was 2.5 (SD=1.9; range=0-6) and the number of contacts with the coach was a mean of 8.1 (SD=4.4; range=0-17). The qualitative interviews highlighted the problem of engaging clinicians in research and their resistance to recruitment: technical difficulties with The Journal, which prevented people logging in easily; difficulty accessing The Journal as it was not available on mobile devices; participants finding some lessons difficult; and participants saying they were too busy to complete the sessions.

    CONCLUSIONS: The study demonstrated that it is feasible to use a coach in this setting, that people found it helpful, and that it did not conflict with other care that participants were receiving. Future trials need to engage clinicians at an early stage to articulate where Web-based therapies fit into existing clinical pathways; Web-based therapies should be available on mobile devices, and logging in should be easy. The role of the coach should be explored in larger trials.

  • Stakeholder Views Do Matter: A Conceptual Framework for Medication Safety Measurement

    Ng, J; Scahill, S; Harrison, J; (2017)

    Journal of Pharmaceutical Health Services Research Sep 2017; DOI; 10.1111/jphs.12203

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    Many patients are harmed by medications intended to help them. Significant efforts have been directed toward the improvement of medication safety. Policymakers, clinicians, researchers and consumers are interested in knowing the progress of medication safety but it is unclear whether it is safer than before.

    Part of the challenge has been the achievement of a common understanding of what medication safety means to multi-stakeholders, and then developing a measurement framework. Existing approaches to measurement have been narrow and piecemeal, failing to encompass diverse stakeholder beliefs and preferences.

    A multi-stakeholder derived conceptual framework for medication safety measurement was required. The interview method was used to elicit and explore stakeholder views in-depth. Stakeholders were selected by purposive sampling on the basis of their job role or expertise in the area of medication safety in the New Zealand public hospital setting. Snowball sampling was also used and data collection was continued until data saturation which occurred after interviewing 30 people.

    Transcripts were thematically analysed and interpreted with the aid of NVivo and mind maps using a general inductive approach. The developed multi-stakeholder derived conceptual framework for medication safety measurement consists of seven key dimensions meaningful to multi-stakeholders in the New Zealand public hospital setting. These are:
    1) Outcome goals of medication safety;
    2) Financial costs and effectiveness;
    3) Medications available for and their use;
    4) Safety culture;
    5) Technical components of the medication use system;
    6) Factors affecting medication use by patients; and
    7) Staff competency.

    The contribution to knowledge has been the development of a multi-stakeholder derived conceptual framework for medication safety measurement. As a consequence of this research, the measurement of medication safety should change from one which has been narrow and fragmented, to one which is multi-dimensional and holistic.

    The developed framework incorporates diverse multi-stakeholder views and preferences increasing its relevance in the local context and is important for engagement and buy-in. It draws together all meaningful dimensions and facets providing a necessary and robust single theoretical frame to measure medication safety. Understanding stakeholders’ priorities and beliefs for medication safety can also be used to facilitate improvement programmes.

  • An Organisational Study into the Impact of Mobile Devices on Clinician and Patient Experience in Auckland, New Zealand

    Bohot, Kelly L.; Hammond, Rebecca C.; and Stanbrook, Teresa A (2017)

    Patient Experience Journal 2017; 4(1):9

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    Mobile technology has potential to improve workflow, patient safety and quality of care, and has been identified as an important enabler of community services. However, little is known about the impact of mobile device use on clinician and patient experiences. Eleven community allied health clinicians were provided with live access to electronic health records, their email and electronic calendar, peer reviewed education and therapy mobile applications via a mobile device.

    Three data measures were collected over 19-weeks. First, quantitative time and motion data was gathered at baseline and follow-up to enable longitudinal analysis of clinician workflow. Second, a questionnaire consisting of rateable statements, multi-choice and open questions was completed at baseline and follow-up to enable analysis of clinician experience. Third, a short questionnaire was completed with a convenience sample of 101 patients who experienced mobile device use in their home. Clinicians and patients reported positive experiences associated with access to electronic health information at the point of care and the use of pictures, diagrams and videos to support clinical interactions. There was a significant reduction in time spent on patient related administration (p<0.0001) and a significant increase in direct patient contact time (p<0.0001) following 15 weeks of mobile device use.

    This study indicates that mobile device use has potential to improve clinician and patient experiences of community allied health through improvements in workflow and efficiency, improved clinician-patient interactions and improvements in health information flow.

  • Development of a Culturally Tailored Text Message Maternal Health Programme (TextMATCH)

    Dobson, R; Whittaker, R; Bartley, H; Connor, A; Chen, R; Ross, M; McCool, J (2017)

    JMIR mHealth & uHealth Apr 2017; 5(4):e49. DOI:10.2196/mhealth.7205

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    BACKGROUND: Mobile phones are increasingly being used to deliver health information and health services globally. Mobile health (mHealth) interventions may be well-suited for minority groups with greater barriers to accessing traditional health services. However, little has been written about the process of culturally adapting interventions for multiple ethnic and cultural minorities within a population.

    OBJECTIVE: This study describes the process of developing a culturally tailored text message-based maternal health program (TextMATCH: Text for MATernal and Child Health) for Māori, Pacific, Asian, and South Asian families living in New Zealand. We report on engagement and acceptability of the TextMATCH program.

    METHODS: Program data was examined to describe engagement with the program 18 months after implementation. Telephone interviews were conducted with a sample of participants who consented to provide feedback on acceptability and relevance of the program.

    RESULTS: A total of 1404 participants enrolled in TextMATCH over 18 months, with 18.52% (260) actively opting out at some point (after 0 to 17 months of messages). It was found that 356 (70.9%) of the 502 eligible participants actively switched from the initial pregnancy program to the baby program after delivery. Phone interviews were conducted with 29 participants including 6 who had withdrawn (duration of program from 3 to 16 months). Only 2 participants reported that the program was not useful, with the remainder rating the usefulness of messages positively (average 4.24 out of 5). All participants stated that the messages were relevant, culturally appropriate, and easy to understand. Most were happy with the specific advice and the language options provided.

    CONCLUSIONS: We have demonstrated the importance of an intensive approach to the development of a culturally adapted and tailored mHealth program for multiple different cultural minority groups within our population.

  • Getting the Foundations Right for the Measurement of Medication Safety: the Need for a Meaningful Conceptual Frame

    Ng, J; Scahill, S; Harrison, J (2017)

    NZ Medical  Journal 2017; 130(1452):54-62

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    A number of initiatives aimed at improving medication safety in and across New Zealand public hospitals have been introduced over recent years. Clinicians, policymakers and patients now want to know whether patients are safer today from medicine use than they have been in the past.


    The challenge has been determining exactly what should be measured. In this viewpoint, we critically examine the suitability of adverse drug events (ADE) as a primary metric for assessing the progress of medication safety improvement. We provide an overview of contemporary dialogue on medication safety measurement and highlight the emergent challenges.


    Finally, we reflect on how New Zealand has approached medication safety measurement so far and argue the need for a multi-stakeholder informed conceptual framework with a view to further enhancing meaningful assessment of medication safety.

  • Effectiveness of the YourCall™ Text Message Intervention to Reduce Harmful Drinking in Patients Discharged from Trauma Wards: Protocol for a Randomised Controlled Trial

    Ameratunga, S; Kool, B; Sharpe, S; Reid, P; Lee, A; Civil, I; Smith, G; Thornton, V; Walekr, M; Whittaker, R (2017)

    BMC Public Health 2017; 17:48. DOI:10.1186/s12889-016-3967-z

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    BACKGROUND: Behavioural brief interventions (BI) can support people to reduce harmful drinking but multiple barriers impede the delivery and equitable access to these. To address this challenge, we developed YourCall™, a novel short message service (SMS) text message intervention incorporating BI principles. This protocol describes a trial evaluating the effectiveness of YourCall™ (compared to usual care) in reducing hazardous drinking and alcohol related harm among injured adults who received in-patient care.

    METHODS/DESIGN: Participants recruited to this single-blind randomised controlled trial comprised patients aged 16-69 years in three trauma-admitting hospitals in Auckland, New Zealand. Those who screened positive for moderately hazardous drinking were randomly assigned by computer to usual care (control group) or the intervention. The latter comprised 16 informational and motivational text messages delivered using an automated system over the four weeks following discharge. The primary outcome is the difference in mean AUDIT-C score between the intervention and control groups at 3 months, with the maintenance of the effect examined at 6 and 12 months follow-up. Secondary outcomes comprised the health and social impacts of heavy drinking ascertained through a web-survey at 12 months, and further injuries identified through probabilistic linkage to national databases on accident insurance, hospital discharges, and mortality. Research staff evaluating outcomes were blinded to allocation. Intention-to-treat analyses will include assessment of interactions based on ethnicity (Māori compared with non-Māori).

    DISCUSSION: If found to be effective, this mobile health strategy has the potential to overcome current barriers to implementing equitably accessible interventions that can reduce harmful drinking.

  • Text Message-Based Diabetes Self-Management Support (SMS4BG): A Randomized Controlled Trial Protocol

    Dobson, R; Whittaker, R; Jiang, Y; Maddison, R; Shepherd, M; Carter, K; Cutfield, R; McNamara, C; Khanolkar, M; Murphy, R (2016)

    Trials Journal 2016; 17:179. DOI:10.1186/s13063-016-1305-5

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    BACKGROUND: Addressing the increasing prevalence, and associated disease burden, of diabetes is a priority of health services internationally. Interventions to support patients to effectively self-manage their condition have the potential to reduce the risk of costly and debilitating complications. The utilisation of mobile phones to deliver self-management support allows for patient-centred care at the frequency and intensity that patients desire from outside the clinic environment. Self-Management Support for Blood Glucose (SMS4BG) is a novel text message-based intervention for supporting people with diabetes to improve self-management behaviours and achieve better glycaemic control and is tailored to individual patient preferences, demographics, clinical characteristics, and culture. This study aims to assess whether SMS4BG can improve glycaemic control in adults with poorly controlled diabetes. This paper outlines the rationale and methods of the trial.

    METHODS/DESIGN: A two-arm, parallel, randomised controlled trial will be conducted across New Zealand health districts. One thousand participants will be randomised at a 1:1 ratio to receive SMS4BG, a theoretically based and individually tailored automated text message-based diabetes self-management support programme (intervention) in addition to usual care, or usual care alone (control). The primary outcome is change in glycaemic control (HbA1c) at 9 months. Secondary outcomes include glycaemic control at 3 and 6 months, self-efficacy, self-care behaviours, diabetes distress, health-related quality of life, perceived social support, and illness perceptions. Cost information and healthcare utilisation will also be collected as well as intervention satisfaction and interaction.

    DISCUSSION: This study will provide information on the effectiveness of a text message-based self-management support tool for people with diabetes. If found to be effective it has the potential to provide individualised support to people with diabetes across New Zealand (and internationally), thus extending care outside the clinic environment.

  • Assessing a Hospital Medication System for Patient Safety: Findings and Lessons Learnt from Trialling an Australian Modified Tool at Waitemata District Health Board

    Ng, JAndrew, P; Crawley, M; Pevreal, W; Peach, J (2016)

    NZ Medical Journal 2016; 129(1430)

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    AIM: To undertake a review of Waitemata District Health Board’s (WDHB) hospital medication system for patient safety assessment and improvement purposes.

    METHODS: A multidisciplinary group rated current WDHB hospital medication systems against the Medication Safety Self-Assessment for Australian Hospitals (MSSA®-AH) criterion of 247 aspirational practices using a five point scale ("no" to "fully implemented"). Items with a lesser extent of implementation represented practice gaps. The MSSA®-AH database and weighted adjustment scoring system generated an overall hospital score.

    RESULTS: Of the maximum possible score that could be obtained had all MSSA®-AH practices been implemented, WDHB scored 63% and this was comparable to other demographically similar hospitals in Australia. Lowest scoring practices needing improvement related to staffing. Conflict resolution was a previously unidentified practice gap. Previously identified gaps, such as those relating to electronic medication systems suggested ongoing implementation was required.

    CONCLUSION: This was the first documented use of the MSSA®-AH's in a New Zealand hospital setting and helped WDHB identify areas in need of further improvement. The unique generation of a percentage score helped simplify understanding for non-technical stakeholders. Future repeated assessments would help WDHB track progress. Implicit benefits, such as stakeholder engagement, were observed. The MSSA®-AH may be useful in other hospital settings.

  • Text Message and Internet Support for Coronary Heart Disease Self-Management: Results from the Text4Heart Randomised Controlled Trial

    Pfaeffli-Dale, L; Whittaker, R; Jiang, Y; Stewart, R; Rolleston, A; Maddison, R (2015)

    JMIR Oct 2015; 17(10)e237. DOI:10.2196/jmir.4944

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    BACKGROUND: Mobile technology has the potential to deliver behavior change interventions (mHealth) to reduce coronary heart disease (CHD) at modest cost. Previous studies have focused on single behaviors; however, cardiac rehabilitation (CR), a component of CHD self-management, needs to address multiple risk factors.

    OBJECTIVE: The aim was to investigate the effectiveness of a mHealth-delivered comprehensive CR program (Text4Heart) to improve adherence to recommended lifestyle behaviors (smoking cessation, physical activity, healthy diet, and nonharmful alcohol use) in addition to usual care (traditional CR).

    METHODS: A 2-arm, parallel, randomized controlled trial was conducted in New Zealand adults diagnosed with CHD. Participants were recruited in-hospital and were encouraged to attend center-based CR (usual care control). In addition, the intervention group received a personalized 24-week mHealth program, framed in social cognitive theory, sent by fully automated daily short message service (SMS) text messages and a supporting website. The primary outcome was adherence to healthy lifestyle behaviors measured using a self-reported composite health behavior score (≥3) at 3 and 6 months. Secondary outcomes included clinical outcomes, medication adherence score, self-efficacy, illness perceptions, and anxiety and/or depression at 6 months. Baseline and 6-month follow-up assessments (unblinded) were conducted in person.

    RESULTS: Eligible patients (N=123) recruited from 2 large metropolitan hospitals were randomized to the intervention (n=61) or the control (n=62) group. Participants were predominantly male (100/123, 81.3%), New Zealand European (73/123, 59.3%), with a mean age of 59.5 (SD 11.1) years. A significant treatment effect in favor of the intervention was observed for the primary outcome at 3 months (AOR 2.55, 95% CI 1.12-5.84; P=.03), but not at 6 months (AOR 1.93, 95% CI 0.83-4.53; P=.13). The intervention group reported significantly greater medication adherence score (mean difference: 0.58, 95% CI 0.19-0.97; P=.004). The majority of intervention participants reported reading all their text messages (52/61, 85%). The number of visits to the website per person ranged from zero to 100 (median 3) over the 6-month intervention period.

    CONCLUSIONS: A mHealth CR intervention plus usual care showed a positive effect on adherence to multiple lifestyle behavior changes at 3 months in New Zealand adults with CHD compared to usual care alone. The effect was not sustained to the end of the 6-month intervention. A larger study is needed to determine the size of the effect in the longer term and whether the change in behavior reduces adverse cardiovascular events.

  • A Mobile Phone Intervention Increases Physical Activity in People with Cardiovascular Disease: Results from the HEART Randomised Controlled Trial

    Maddison, R; Pfaeffli, L; Whittaker, R; Stewart, R; Kerr, A; Jiang, Y; Kira, G; Leung, W; Dalleck, L; Carter, K; Rawstorn, J; (2014)

    European Journal of Preventive Cardiology Jun 2015; 22(6):701-9. DOI:10.1177/2047487314535076. Epub May 2014

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    AIM: To determine the effectiveness and cost-effectiveness of a mobile phone intervention to improve exercise capacity and physical activity behaviour in people with ischaemic heart disease (IHD).

    METHODS/RESULTS: In this single-blind, parallel, two-arm, randomized controlled trial adults (n = 171) with IHD were randomized to receive a mobile phone delivered intervention (HEART; n = 85) plus usual care, or usual care alone (n = 86). Adult participants aged 18 years or more, with a diagnosis of IHD, were clinically stable as outpatients, able to perform exercise, able to understand and write English, and had access to the Internet. The HEART (Heart Exercise And Remote Technologies) intervention involved a personalized, automated package of text messages and a secure website with video messages aimed at increasing exercise behaviour, delivered over 24 weeks. All participants were able to access usual community-based cardiac rehabilitation, which involves encouragement of physical activity and an offer to join a local cardiac support club.

    All outcomes were assessed at baseline and 24 weeks and included peak oxygen uptake (PVO2; primary outcome), self-reported physical activity, health-related quality of life, self-efficacy and motivation (secondary outcomes). Results showed no differences in PVO2 between the two groups (difference −0.21 ml kg−1 min−1, 95% CI: −1.1, 0.7; p  = 0.65) at 24 weeks. However significant treatment effects were observed for selected secondary outcomes, including leisure time physical activity (difference 110.2 min/week, 95% CI: −0.8, 221.3; p = 0.05) and walking (difference 151.4 min/week, 95% CI: 27.6, 275.2; p = 0.02). There were also significant improvements in self-efficacy to be active (difference 6.2%, 95% CI: 0.2, 12.2; p = 0.04) and the general health domain of the SF36 (difference 2.1, 95% CI: 0.1, 4.1; p = 0.03) at 24 weeks. The HEART programme was considered likely to be cost-effective for leisure time activity and walking.

    CONCLUSIONS: A mobile phone intervention was not effective at increasing exercise capacity over and above usual care. The intervention was effective and probably cost-effective for increasing physical activity and may have the potential to augment existing cardiac rehabilitation services.

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