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Pauline Norris, School of Pharmacy: Creating knowledge for change in medicines policy

This is Case Study Five for the Research Impacts study.

Pauline Norris and Simon Horsburgh image
Professor Pauline Norris and Dr Simon Horsburgh.

Participants interviewed for the case study

Principal investigator

Professor Pauline Norris
Centre for Pacific Health (formerly School of Pharmacy)

Researcher

Simon Horsburgh
Dunedin School of Medicine

Stakeholder

Andi Shirtcliffe
Chief Advisor, Pharmacy, Ministry of Health

Catherine Proffitt
Manager – Strategic Planning and Performance, Pharmaceutical Management Agency (PHARMAC / Te Pātaka Whaioranga)

Sandy Bhawan
Manager – Access Equity, PHARMAC / Te Pātaka Whaioranga

Summary of the impact

Professor Pauline Norris is a social pharmacy researcher who has achieved impact via advancing knowledge around social pharmacy, writing guidelines, and built academic capability in the students she works with. Pauline has achieved impact by answering research questions addressing current social issues, engaging meaningfully with stakeholders, collaborating with research partners, being adaptable, and disseminating findings in accessible ways.

“Working with Pauline was awesome. I think she’s just amazing- she builds an impact and she’s so clearly focused on trying to improve things for people. It makes you feel like your research does have meaning.”

Dr Simon Horsburgh – Department of Preventive and Social Medicine, Dunedin School of Medicine

Underpinning research

Professor Pauline Norris is a social pharmacy researcher who aims to understand how people access and use medicines using social science methods. Social pharmacy is an applied research discipline which investigates the overlap between the social and behavioural sciences and pharmacy practice, including understanding and improving access to, use of, medicines. Pauline has undertaken research into a variety of areas, including prescription charges, socioeconomic and ethnic variation in the use of medicines, personal medicine storage, medicine availability and funding under PHARMAC (the Pharmaceutical Management Agency / Te Pātaka Whaioranga), and people’s knowledge and use of antibiotics.

Prescription charges

Pauline undertook research into prescription charges in 2012 when the government increased the co-payment for prescription medicines to $5 (for up to 20 prescriptions, after which there should be no charge) from $3. Pauline’s research found that for the 10.3 per cent of New Zealanders living in poverty, paying $5 per prescription was prohibitive and meant people went without medication, putting their health at risk1. PHARMAC/Te Pātaka Whaioranga data highlighted by Pauline showed 40 per cent of New Zealanders continued to pay for 90 per cent of their prescription items, even after they reached 20 items, resulting in unnecessary spending of $2.5 million1. Pauline’s research highlights that affordability of medicines is an easily-modifiable barrier to accessing healthcare. Qualitative research published in 2016 showed people were forgoing prescription items, or making sacrifices such as delaying picking up medicines or reducing dosage due to cost, which comes with potential health risks2.

Socioeconomic and ethnic variation in use of medicines

Pauline became interested in socioeconomic variation in the use of medicines once the means became available to study this - in the form of the National Health Index (NHI) numbers used on all prescriptions since 2006. The Equity in Prescription Medicines Use study investigated issues around medicine access, including geographic access and access to different types of drugs, using linked pharmacy data3–7. Part of this study investigated antibiotic use in people of different ethnicities in the Tairāwhiti (Gisborne) area4. It was undertaken in conjunction with Turanga Health (a Māori healthcare organisation) and Ngāti Porou Hauora (a Primary Health Organisation). The study found that antibiotic use was much lower amongst Māori, particularly in rural areas, than non-Māori. This was concerning as Māori have one of the highest documented rates of acute rheumatic fever and rheumatic heart disease in the world.

People’s knowledge and use of antibiotics

Pauline’s research has further explored understanding of antibiotic use in New Zealand, with ethnic variation in use and perceptions addressed amongst immigrant, Māori and Samoan populations. One study involved interviews with Samoans living in New Zealand about their understanding and reported use of antibiotics8. Results showed there was some confusion about antibiotic medicine. Less than 2 per cent of participants identified the correct purpose for antibiotics, and 66 per cent thought they were used to relieve pain. Respondents thought that a wide range of medicines were classed as antibiotics. This has implications for health practitioners, as they should not assume Samoan patients share a Western scientific understanding of antibiotics and illness8.

Personal medicines storage

Pauline’s study on the storage of medicines looked at how people store medicines and why9. Results revealed people often store medicines in places where temperature and humidity are likely to affect medicine quality and that items should not be stored in kitchens and bathrooms, in bags or cars longer than strictly necessary, or in a plane’s cargo hold. The authors recommended health professionals, particularly pharmacists, should emphasise the importance of correct medicine storage, and that poor storage should be considered when medicines are not achieving their desired effect.

PHARMAC / Te Pātaka Whaioranga and medicines availability and funding in New Zealand

Pauline undertook research on perceptions of medicine availability and funding through PHARMAC / Te Pātaka Whaioranga10, who make decisions on which medicines are funded in New Zealand11.

Respondents felt PHARMAC / Te Pātaka Whaioranga constrained medicine costs effectively, was politically neutral, and resistant to lobbying. Pauline also investigated the availability of specific medicines in New Zealand, such as the breast cancer drug Herceptin12. Another study, undertaken with a PhD student, compared medicine availability and subsidisation in New Zealand and Finland13.

Funding

  • Health Research Council (HRC), (including $1 million project grant for the Equity in Prescription Medicines study and the current Prescription Charges study, a randomised controlled trial.
  • Marsden Fund
  • New Zealand Pharmacy Education and Research Fund
  • Pauline has worked with multiple students, mainly of Māori and Pasifika descent, who have obtained Summer Studentship funding from the HRC and the University of Otago

Research snapshot

  • Pauline has produced 30 research articles on the topics included in this case study, which have been cited 321 times by authors in 61 countries14.
  • Pauline’s research has been featured in a broad range of New Zealand news media, including the Dominion Post, the New Zealand Herald, NewsHub, the Otago Daily Times, The Press, Radio New Zealand, stuff.co.nz, the Sunday Star Times, and the Star15–20.

Details of the impact

Advancing knowledge

  • Pauline aims to increase the awareness of the public, pharmacists, and those concerned with medicine use, around social pharmacy issues such as prescription charges and medicines storage. An example of this is the Twenty is Plenty campaign, a two-year initiative started in 2016 by University of Otago Pharmacy students. It was designed to inform the public that they only need to pay for a maximum of twenty prescriptions per year, with any additional prescriptions being fully subsidised. The students put stickers on prescription bags, and created a Facebook page (receiving 461 likes and 454 follows)21, 22, Twitter account and YouTube channel. The students also attended community events, such as the Otago Farmers Market, to promote the campaign.

Policy

  • According to Andi Shirtcliffe (Chief Advisor – Pharmacy at the Ministry of Health), Pauline’s research on prescription charges has broadened the awareness of issues with Ministry of Health Officials, and this, in turn, has had a positive impact on advancing policy discussions. It has also enabled the co-payment policy to be referred for consideration as part of the Health and Disability System Review.
  • Pauline’s research underpinned a 2019 literature review by PHARMAC / Te Pātaka Whaioranga entitled Equitable access to medicines via primary healthcare23 and a discussion paper Achieving medicine access equity in Aotearoa New Zealand: towards a theory of change24.
  • PHARMAC / Te Pātaka Whaioranga have presented the above work to stakeholders including the Ministry of Health, District Health Boards and the Health Quality and Safety Commission, Primary Health Organisations, Pacific Health providers and Māori stakeholders (such as Whānau Ora collectives) at conferences and symposiums. Sandy Bhawan (Manager – Access Equity at PHARMAC / Te Pātaka Whaioranga) has noted that the discussion document on medicine access equity is of potential use to stakeholders as it has been presented in a way that facilitates translation into policy.


“For us, it’s so important to have those voices of communities, and having their stories told through research.”

Sandy Bhawan – Manager – Access Equity, PHARMAC / Te Pātaka Whaioranga

Guidelines

  • Pauline was invited onto the group adapting the National Institute for Clinical Excellence (NICE) guidelines on antibiotic resistance for New Zealand, for the Best Practice Advocacy Centre (BPAC), published in 201725.

Capability building

  • Student supervision has been a key factor in achieving impact. Pauline supported a PhD student, Shirley Keown from Turanga Health, through an HRC grant. This paved the way for an enduring relationship with the Māori healthcare organisation since 2006. Now Shirley is a co-investigator on the latest HRC grant, and Pauline is working with her on another HRC application.
  • Pauline has supervised many Pacific and Māori students through summer research studentships, enabling them to undertake projects that will benefit their own communities.
  • Pauline has also supported practising pharmacists to complete Masters degrees, enabling promotion into more senior positions.

Pathway to impact

Answering the right questions

  • Impact has been achieved by identifying and answering the questions that will be of benefit to end users. This may be different from researching a topic that will get you a publication in a good journal or receive praise from colleagues.

“I think that it would be better if people were brave and tried to answer questions that the world needs an answer to.”

Professor Pauline Norris – Centre for Pacific Health (formerly School of Pharmacy)

Engagement and collaboration

  • Face-to-face engagement has been a priority through all of Pauline’s research. Making direct connections with people enables an understanding of who is committed to pushing projects forward, as well as an understanding of the local context. The annual visits by Pauline and Dr Simon Horsburgh, a co-researcher, to healthcare providers for The Equity in Prescription Medicines Use study is one example of Pauline’s engagement. Visits were facilitated by Dr Jenny Harre-Hindmarsh, Research Officer at Ngāti Porou Hauora.
  • Early engagement with key policy and implementation contacts in government is crucial. This can help test whether an idea will be able to achieve the desired impact. This was a key feature of the work with Ngāti Porou Hauora and Turanga Health, where a local advisory group was set up to ensure research was going to benefit the community.
  • Collaboration and co-creation of projects has been essential for achieving impact. This involved harnessing the combined knowledge of researchers and stakeholders, as well as the existing connections between pharmaceutical scientists and social pharmacists in the School of Pharmacy.

“When you’re sitting here in Dunedin, you don’t really know the details of how things work on the ground, whereas you go up there and you spend a couple of hours chatting to people, and you realise why something has happened that way, or why something is not really accurate, because you’re missing out a whole lot of something else that they do. You really need that local context.”

Professor Pauline Norris – Centre for Pacific Health (formerly School of Pharmacy)

Responsiveness

  • An awareness of, and a responsiveness to, emerging themes has been key to achieving impact. For example, findings of the Prevalence and Extent of Antibiotic Use study identified rheumatic fever as an important area for health policy and practice, and one that was also very relevant to the local community4. The findings were picked up by the media (for example, 26, 27) and were widely publicised to illustrate inequities in antibiotic prescribing between Māori and non-Māori. These findings were used by politician Dame Tariana Turia in a speech to medical students, and in comment to the media saying that doctors are failing their patients28, 29.

Dissemination

  • Pauline has actively disseminated her work beyond academic publications. This has included presenting at organisations such as PHARMAC / Te Pātaka Whaioranga, and writing press releases for a variety of media formats, for example in newspapers29 and on the radio30.
  • Dissemination of research in multiple formats makes the key messages more accessible to the public as well as to government stakeholders and policy makers, encouraging them to take on board evidence-based messages.
  • It is important that communication is directly targeted at government stakeholders as, unless research is published in a seminal journal, it is unlikely to be seen and implemented.
  • Media exposure has increased interactions between the researchers and interested organisations.

What next?

  • The ultimate aim of Pauline’s research is to ensure people in New Zealand (and elsewhere) have access to medicines they need.
  • Pauline is currently recruiting for a new study called Free Meds about prescription charges, aiming to ascertain the extent to which prescription charges are stopping patients from accessing medicines. This was featured on Radio New Zealand in January 202031.

References

  1. Norris P, Horsburgh S, Cumming J, Tordoff J. New Zealand Health Care Editorial–Prescription Charges: Prescription charge increase in New Zealand penalise the poor and sick. Journal of primary health care. 2014;6(1):4-5.
  2. Impact of prescription charges on people living in poverty: a qualitative study. Research in Social and Administrative Pharmacy. 2016;12(6):893-902.
  3. Horsburgh S, Norris P, Becket G, Crampton P, Arroll B, Cumming J, et al. The equity in prescription medicines use study: Using community pharmacy databases to study medicines utilisation. Journal of biomedical informatics. 2010;43(6):982-7.
  4. Norris P, Horsburgh S, Keown S, Arroll B, Lovelock K, Cumming J, et al. Too much and too little? Prevalence and extent of antibiotic use in a New Zealand region. Journal of antimicrobial chemotherapy. 2011;66(8):1921-6.
  5. Norris P, Horsburgh S, Becket G, Keown S, Arroll B, Lovelock K, et al. Equity in statin use in New Zealand. Journal of primary health care. 2014;6(1):17-22.
  6. Norris P, Horsburgh S, Lovelock K, Becket G, Keown S, Arroll B, et al. Medicalisation or under-treatment? Psychotropic medication use by elderly people in New Zealand. Health Sociology Review. 2011;20(2):202-18.
  7. Horsburgh S, Norris P, Becket G, Arroll B, Crampton P, Cumming J, et al. Allopurinol use in a New Zealand population: prevalence and adherence. Rheumatology international. 2014;34(7):963-70.
  8. Norris P, Churchward M, Fa’alau F, Va’ai C. Understanding and use of antibiotics amongst Samoan people in New Zealand. Journal of primary health care. 2009;1(1):30-5.
  9. Hewson C, Shen CC, Strachan C, Norris P. Personal medicines storage in New Zealand. Journal of Primary Health Care. 2013;5(2):146-50.
  10. Ragupathy R, Tordoff J, Norris P, Reith D. Key informants’ perceptions of how PHARMAC operates in New Zealand. International journal of technology assessment in health care. 2012;28(4):367-73.
  11. PHARMAC. Our place in the health system. 2019.
    https://pharmac.govt.nz/about/what-we-do/our-place-in-the-health-system/
  12. Gabe J, Chamberlain K, Norris P, Dew K, Madden H, Hodgetts D. The debate about the funding of Herceptin: a case study of ‘countervailing powers’. Social Science & Medicine. 2012;75(12):2353-61.
  13. Aaltonen K, Ragupathy R, Tordoff J, Reith D, Norris P. The impact of pharmaceutical cost containment policies on the range of medicines available and subsidized in Finland and New Zealand. Value in Health. 2010;13(1):148-56.
  14. Scopus. 30 article search results - citation data Pauline Norris 2020 [cited 2020 January 23].
  15. Gibb J. Prescription charges hindrance to health for some. Otago Daily Times. 2018.
    https://www.odt.co.nz/news/dunedin/prescription-charges-hindrance-health-some
  16. Gibb J. Prescription cost too much for some. Otago Daily Times. 2016.
    https://www.odt.co.nz/news/dunedin/prescription-cost-too-much-some
  17. Torrie B. People paying for free medication. stuff.co.nz. 2012.
    http://www.stuff.co.nz/national/7942400/People-paying-for-free-medication
  18. Gooselink D. Kiwis pay millions extra on prescriptions – study. 2012.
    https://www.newshub.co.nz/politics/kiwis-pay-millions-extra-on-prescriptions--study-2012111317
  19. Sick are reducing doses to save money. 2015.
    https://www.rnz.co.nz/news/national/292074/sick-are-reducing-doses-to-save-money
  20. Harwood B. Spreading word about subsidy. 2017.
    https://www.thestar.co.nz/news/spreading-word-about-subsidy/
  21. John Gibb. Prescription subsidy message. Otago Daily Times. 2016.
    https://www.odt.co.nz/news/campus/university-of-otago/prescription-subsidy-message
  22. 20 is Plenty. 20 is Plenty Facebook page. 2017.
    https://www.facebook.com/20isplenty/
  23. Carswell S, Donovan E, Pimm F. Equitable access to medicines via primary healthcare - a review of the literature. 2018.
    https://www.pharmac.govt.nz/assets/equitable-access-to-medicines-literature-review.pdf
  24. PHARMAC. Achieving medicine access equity in Aoetearoa New Zealand: towards a theory of change. 2019.
    https://www.pharmac.govt.nz/assets/achieving-medicine-access-equity-in-aotearoa-new-zealand-towards-a-theory-of-change.pdf
  25. BPAC NZ Guidelines. Antimicrobial stewardship: Systems and processes for effective antimicrobial medicine use within human health and healthcare in New Zealand. 2017.
    https://bpac.org.nz/guidelines/3/#about
  26. Otago study finds Māori miss out on medicines. Otago Daily Times. 2011.
    https://www.odt.co.nz/news/dunedin/high-levels-rheumatic-fever-worry
  27. Gibb J. High levels of rheumatic fever a worry. Otago Daily Times. 2012.
    https://www.odt.co.nz/news/dunedin/high-levels-rheumatic-fever-worry
  28. Turia T. Speech: Turia - ‘Sowing the seed’. 2012.
    https://www.scoop.co.nz/stories/PA1207/S00401/speech-turia-sowing-the-seed.htm?from-mobile=bottom-link-01
  29. Hill M. Māori overlooked as antibiotics doled out. 2011.
    https://www.pressreader.com/new-zealand/sunday-star-times/20110730/281715496286452
  30. Nine to Noon. Poorest communities skipping meds due to high cost. 2015.
    https://www.rnz.co.nz/national/programmes/ninetonoon/audio/201782715/poorest-communities-skipping-meds-due-to-high-cost
  31. Nine to Noon. Free meds? Counting the cost of prescriptions. 2020.
    https://www.rnz.co.nz/national/programmes/ninetonoon/audio/2018730432/free-meds-counting-the-cost-of-prescriptions