‘Piki te Ora’, a qualitative exploratory study of a primary care-led, interprofessional team for supporting patients with type 2 diabetes in rural communities

Data collection

Initially, all patients enrolled in the Piki te Ora service between January 2021 and October 2023 were identified using the clinic’s patient management system and contacted by text message to invite them to participate in an interview, followed by a phone call or face-to-face interaction with those who responded. Those who expressed interest were provided with a participant information sheet outlining the purpose of the study, and any concerns or questions were discussed and answered prior to gaining written informed consent from each participant.

Interviews were arranged at a time and place suitable for the participant (in-person, online or by phone). A student researcher was involved in carrying out all interviews (KG), under supervision from more experienced researchers (SM, LC). The wider research team included a Māori advisory group (made up of clinicians and academics, KTB, HM, DF and RK) to ensure any Māori participant data were collected, analysed and presented in a culturally safe way.

Ethical approval was granted by the University of Waikato Human Research Ethics Committee (HREC(Health)2022#19).

Procedure

Interviews were conducted using a semi-structured interview guide consisting of open-ended questions between December 2023 and January 2024. KG, supervised by SM, conducted interviews, obtained consent, and ensured ethical adherence. The interview guide was created by SM, KG and LC with the wider team’s input to explore participants’ experiences with the culturally informed service and identify any barriers or facilitators in accessing health care to manage T2D. The semi-structured questions were designed to gain an in-depth understanding of how participants navigated healthcare services and their perceptions of the services’ impact, while allowing flexibility in their responses. Questions explored the patients’ experiences with managing their T2D, medication use, T2D knowledge and healthcare access both prior to and following their engagement with the Piki te Ora service. Further questions explored their opinions and thoughts about the service, as well as whether they had been referred to/provided with any diabetes-specific resources, including whether these were culturally safe. These questions helped guide the thematic analysis by highlighting recurring themes, such as access barriers and participants’ experiences with the programme. At the beginning of each interview, the objective of the study was verbally re-stated, and participants were reminded that they may end the interview and/or withdraw from the study at any time. Participants voluntarily provided sociodemographic information such as ethnicity, sex and age. Before the interviews began, participants were offered culturally appropriate ways to open the meeting, such as inōi (prayer) or kārakia (Māori incantation). Interviews lasted between 15 and 60 min and were audio-recorded. All participants were given a $NZ50 gift card in recognition of their time and kai (food) was provided if interviewed in person in keeping with kawa (Māori cultural norms).

Analysis

Interview data were transcribed verbatim, and participants could review their transcripts for accuracy. KG and a research assistant, guided by Braun and Clarke’s²¹ thematic analysis under an experienced qualitative researcher’s (SC) supervision, identified key narratives and experiences. For this process, each transcript was read and re-read by the researchers to facilitate familiarity with the data. On each transcript, areas of text were highlighted that were deemed to be significant to the participants narratives and their experiences with the service, which formed the codes of this analysis. These transcripts were shared and reviewed between the research team, with a focus on building consensus (KG and RA). The coded transcripts were then shared with SC, KTB, DF, HM and LC. This wider group then held an analysis session where these transcripts and codes were comparatively re-analysed for any missing codes, narratives were discussed and codes were then grouped into four broad themes. The themes were discussed in depth with the wider multi-disciplinary team to ensure they were robust and clear. This process involved a comparison of themes, discussions and re-analysing of transcripts until the themes were finalised. Collaboration between SM and CC provided contextual insights to ensure the analysis remained focused on the participants’ experiences, without the coding or themes being influenced by the clinic’s practices. The study aimed to capture the views of the participants without attempting to align them with any specific clinic practices. An additional experienced qualitative researcher (HC) was brought onto the team to support the writing process due to limited availability of other team members. To maintain clarity and coherence, a single illustrative quote was selected for each theme to capture both the individual narrative and the broader thematic pattern.

Healthcare accessibility

Many participants identified that healthcare accessibility had improved due to their involvement in the Piki te Ora service. Participants reported having greater access to their primary care team through more frequent and less costly appointments. The removal of appointment fees enabled seeking health care when needed. Participant nine reported, ‘I can more or less get a walk in appointment if I need to.’

For many participants, home visits and telehealth were regularly provided by the interprofessonal primary care team (eg by the dietitian or kaiāwhina rather than the GP), and this was also reported to improve healthcare access, mostly via reduced travel costs and time for patients. This was noted to be particularly useful for those who live in more rural communities where travel to a health clinic was deemed to be a barrier. Similarly, those participants who were usually at work during normal clinic hours reported that they appreciated the flexibility to access appointments outside usual working hours. For example, participant seven identified, ‘Sometimes work is a big barrier for me. But they’re quite open to change. So I just get in as soon as I can after [work].’

A further key element of accessibility was access to an extended primary care team rather than the traditional GP or nurse, as is often the case in many rural primary care clinics. For example, participants highlighted that diet was important to diabetes self-care and valued easy access to dietitians. Many reported struggling to access dietitian support before being enrolled with the service. Those who had previously accessed dietitians mentioned long wait times through secondary care or high private costs. Participant eight, for example, noted ‘I like the programme because they offer free services with nutritionists [sic].’

Healthcare accessibility was also enhanced by Piki te Ora, enabling longer consultations than the routine 15-min visit that would occur at a GP clinic. For example, participant nine explained that the programme’s dietitian, ‘spent an hour and a half with me going through everything.’ Longer appointments allowed time for participants to build trust with clinicians and to learn about aspects of diabetes self-care at their own pace.

Access to health care remained a challenge, with a few participants noting that the clinic in their remote town was understaffed and distances to other clinics were difficult to manage. However, these participants also mentioned that they were unaware that they were enrolled in Piki te Ora, and they had not been offered any in-person (mobile) healthcare visits. Participant eight, for example, when told she could request a telehealth consultation about their diabetes exclaimed, ‘I didn’t even know you could do that.’ Furthermore, some participants mentioned that the suggested changes in diet from the dietitians were challenging to adopt. The cost of recommended foods was a common barrier, and other barriers included difficulties eating different food to other family members and a lack of familiarity with the recommended foods. Some participants also found the written resources provided by both Piki te Ora and other health providers to not be particularly helpful. Only one participant reported having found the written resources to be useful to them. Moreover, a number of participants suggested that they would prefer to have access to informational videos that used language they were familiar with. Notably, participant two did not appear to feel as empowered through their engagement with the service as other participants. This participant expressed confusion about having to continue to take diabetes medication and did not appear to understand that for most people, T2D is a chronic condition that requires ongoing medication. No other participant described similar issues.

Care and support (manaakitanga)

Most participants identified that the Piki te Ora team interacted with them in a manner that they found to be caring and culturally sensitive (embodying the concepts of manaakitanga: reciprocity, respect and hospitality²²), thereby putting them at ease. All participants felt that the team provided a patient-centric service. Participants explained they were easily able to approach the team members, which allowed them to feel confident and encouraged in their interactions. Participant four noted ‘they’re never too busy to talk to you’.

Relatedly, participants identified that the Piki te Ora team were empathetic, with participant three stating, ‘they care more [than clinicians in other services]’. Importantly, Piki te Ora staff worked to identify approaches to best support participants. This was highlighted by participant six, who explained, ‘she used to phone me practically every week … just to find out how I was and talk’. Additionally, for some participants, having the whole team based in their region contributed to the experience of support/manaakitanga. Participant nine, for example, suggested, ‘being a local helps,’ while other participants shared that the connections they had to various clinic staff through the community were an important factor in their experiences of manaakitanga. Overall, participants indicated that by fostering a supportive environment alongside accessibility, participants felt genuinely supported.

For most of our participants, their engagement with Piki te Ora was the first time they had experienced a supportive environment within the healthcare system. Several participants described being ‘talked at’ by clinicians prior to joining Piki te Ora, without ever having their T2D, its treatment or other conditions explained in ways that built their understanding or ability to engage in self-management. Notably, only one participant described feeling this type of support prior to joining Te Korowai Hauora o Hauraki, and this was when their GP visited them at home out of hours to talk them through their initial diagnosis of T2D (again providing support for the importance of a mobile and accessible healthcare team).

Tailored holistic approach

A third theme identified from the interviews was the whole-of-person approach that the programme delivered, including supporting the cultural needs of participants who identified as Māori. Participant nine expressed enjoyment in the inclusive way of looking at their health care, stating, ‘I think it’s about Māori healthview [sic]’ and:

[the Piki te Ora programme was] more helpful, to be honest. I think Western medicine think it’s a bit crap … where you see a different person each time. They haven’t read your notes, and they don’t know who you are. (Participant 9)

The whole-of-person approach also recognised that T2D impacted more than biophysical health. In particular, participants highlighted that many aspects of diabetes care were discussed during their visits/engagements with the team, with participant six describing ‘so in that [one] appointment, it wasn’t just about food. It was like a lot of stuff being talked about.’

Similarly, other participants noted a solution-focused approach in which healthcare professionals were advocates for their patients. Participants gave examples of staff providing referrals to other health and welfare services and assisting with booking appointments to ensure that their needs were being met. Participant five recalled a discussion with the dietitian in which the participant raised the cost of healthy food as a challenge she was experiencing. Participant three recalled the dietitian responded, ‘well, I can help you with that. I’ll go write a letter to WINZ [Work and Income New Zealand] to give you more money [to buy healthy food].’

Empowerment

Feelings of empowerment was a strong theme that ran throughout the interviews, with most participants’ gaining confidence and autonomy in their ability to self-manage their conditions as a result of their involvement in Piki te Ora. Participants stated that they were able to better understand their condition because of education about their medications, which gave them more internal strength for decision making around their T2D. Participant nine explained, ‘the other thing that’s really good with medications is that they [the Piki te Ora team] go through the side effects as well.’

Similarly, participants also found that they were able to advocate to have their condition explained in a way that they understood. Participant four explained that they had been able to approach their GP for clarification (after being enrolled in the Piki te Ora service), telling them, ‘I can’t understand that. Will you please tell me in common plain ordinary English?’ Many participants felt empowered through being supported to learn more about their diets, with participant seven explaining, ‘I changed my diet huge [sic] from when I was first diagnosed.’

Fundamentally, the majority of participants found the approach used by staff to consistently be empowering and non-judgmental, which encompasses the concept of ‘Whakamana’ (to enable and give respect and has similarities to empowerment²³).

Participants reported that they had regular contact from staff, passing on blood test results and reminding them about tasks that needed to be completed. Participant three reported, ‘you know, when my blood tests go, go astray, they just ring me.’ Importantly, these types of communications were understood by participants to be supporting their autonomy, rather than judging their diabetes self-management. This was connected to participants’ broader feeling that Piki te Ora staff were on their side. Participant four, for example, explained, ‘I’ve got a lot of help from the staff there, and with them sort of what I call batting for me.’ Multiple participants expressed these feelings, often clarifying that they had never previously felt supported by their healthcare providers.