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Remove as many barriers as possible to access and navigate the system (especially time and expense). Find out what barriers exist for your whānau Māori and Pacific peoples with gout and remove the barriers through other actions:
From the Whanganui GOUT STOP programme evaluation report: Reducing barriers
- Kaiāwhina support made available to all patients, with a focus on Māori and Pacific people.
- Communication, information and education for communities, including through employers, faith-based and other communities.
- Two free primary care consults for patients who meet the eligibility criteria (Māori, Pacific, and/or CSC card holder) to initiate their Gout Stop journey and a 3-month review.
- Funded blister packaging for medications as part of the 12-week Gout Stop programme.
- Expanded role of community pharmacy to include gout education consults and point of care serum uric acid testing.
- Education, training and programme support for general practices, community pharmacy, and other healthcare providers that encounter gout patients who may not be well managed, eg, Whanganui Accident and Emergency.
- Localisation of gout in Community Health Pathways to enable access to consistent clinical advice about key education points, the clinical pathway for management, and the availability of the Gout Stop programme.
- Provision of data and feedback to general practices for individual patients via dashboard and PowerBI report, and population-level feedback with an equity focus, to track their success on process and outcome measures.
Continuity of allopurinol supply is critical during titration. Continuity ensures that there is no interruption during the titration process so there’s no need to start the process again. As whānau Māori and Pacific peoples with gout have more severe gout, they are likely to need a higher dose of allopurinol or other uric acid-lowering medicines and will take longer to be titrated to the correct dose. Any disruption to the titration process increases the likelihood that whānau Māori and Pacific peoples with gout will get disheartened about the time it’s taking to reach their treatment goal and decide not to persevere.
Once the correct dose has been reached, the next focus of your team is to ensure whānau Māori and Pacific peoples with gout always have access to allopurinol. This is why we recommend that it’s best practice for non-clinical members of your team to maintain contact with whānau Māori and Pacific peoples with gout for 12 months after achieving their treatment goal. Contact every 3 months to make sure a new script has been written, and then doing a further check that allopurinol has been dispensed and picked up supports the daily taking of allopurinol, and that this will continue past the 12-month follow-up period. This regular contact also provides an opportunity to address any other health concerns.
This case management approach is particularly important for those whānau Māori and Pacific peoples with gout who are taking a daily medicine for the first time, eg, young men.
Your team may not be aware of the barriers that whānau Māori and Pacific peoples with gout experience in terms of access to clinical support at your practice. For many young whānau Māori and Pacific peoples with gout, their place of work and hours of work are one of the main barriers to accessing primary care.
As part of proactively contacting all whānau Māori and Pacific peoples with gout, details about their ability to access the clinic should be collected and added to each person’s notes to inform decisions about how clinical support for equitable outcomes in gout, and meeting other health needs, could be provided to meet this group’s needs.
The table below contains examples of notes taken at a marae primary health clinic recording the various work situations that prevented whānau Māori and Pacific peoples with gout from accessing the clinic (4)
Examples of notes recording access issues within the clinical record
| Working on cranes at the wharf | Struggles to get in |
|---|---|
| Works on road construction | Usually gone 13 hours per day |
| Works in a dry-cleaning factory | 13-hour days; Struggles to get in |
| Labourer | Works long hours and shifts; has 8 kids and 11 moko live with him and his wife; always stretched |
| Plastic laminator | Both night shifts and day shifts |
| Labourer | On-road construction now struggles to get employment; was in jail in 20s for drunk driving; job security an issue |
| Works days in fish processing and on the trains at night | Diabetic – HbA1c 98 mmol/mol |
| Plasterer | Out on construction sites |
| Linesman | Works out of town |
| Roofer, just changed to cleaner because of multiple OA (osteoarthritis) issues | Can’t finish work until after 5pm |
| Truck driver | Can be out of town for weeks |
| Caretaker cleaner | Struggles to get in |
| Machine operator | Can’t get in |
| Gout at 30 years | Now gets 2/52; roofer; can’t be off work |
| Works until 7pm each day | Hard to get in; mother rings in for scripts |
| Labourer | Gets gout flares 3x yearly, difficult to get in |
| Labourer | Works in the city; starts at 5am |
| Truck driver | Hard to get in |
As a result of understanding these challenges the practice put the following initiatives in place to assist with clinical support:
One of the strongest beliefs in the community about gout is that it’s caused by eating too much meat and seafood and drinking too much beer and fizzy drinks. This leads to people blaming themselves for their painful gout attack without understanding the physiological causes.
Self-blame causes whānau Māori and Pacific peoples with gout to not see the benefits of treatment to live a pain-free life.
When whānau Māori and Pacific peoples with gout come into your practice with a gout attack, they are experiencing severe pain and are blaming themselves for their situation. In addition, the pain takes up most of their cognitive space so this is not a good time to engage with a lot of new information.
What you say to them at this time is crucial in terms of the person’s world view and sparking the idea that living a pain-free life is possible.
The stigma whānau Māori and Pacific peoples with gout experience in their community is also experienced and reinforced in health care settings (1). That’s why it’s important that all members of your team understand the relevant key messages and are empathetic when whānau Māori and Pacific peoples seek an appointment or present to your practice with an acute gout attack. You cannot understand how painful an acute gout attack is unless you have experienced one (6).
If you have a health improvement practitioner (HIP) in your team, then refer to them any whānau Māori and Pacific peoples with gout who are struggling with making changes, such as deciding to take a new medicine like allopurinol which needs to be taken every day.
Other changes people could be struggling with could include:
Members of your team are likely to develop rapport and a trusting relationship with whānau Māori and Pacific peoples with gout during this project. This means that your team will become the initial point of contact for your practice in terms of other wellbeing issues, not just gout. Bearing in mind how gout is linked to other co-morbidities, your team will be able to coach and support whānau Māori and Pacific peoples with gout to manage other long-term conditions once they are no longer having gout attacks.
Your team, especially non-clinical team members will be able to connect whānau Māori and Pacific peoples to other services in the community, and encourage ongoing self-management and proactive preventative health activities such as screening.
(1) Humphrey C, Hulme R, Dalbeth N, Gow P, Arroll B, Lindsay K. A qualitative study to explore health professionals’ experience of treating gout: understanding perceived barriers to effective gout management (2016) JPHC 2016;8(2):149-156.
(4) Karu LT, Harwood M, Arroll B, Bryant L, Kenealy T. The inequity of access to health: a case study of patients with gout in one general practice NZ Med J. 2021;134(1543):51-58. PMID: 34695076
(5) Karu LT, Harwood M, Bryant L, Kenealy T, Arroll B. Compounding inequity: a qualitative study of gout management in an urban marae clinic in Auckland JPHC 2021;13:27-35.
(6) Lindsay, K, Gow P, Vanderpyl J, Logo, P, Dalbeth, N. The experience and impact of living with gout – a study of men with chronic gout using a qualitative grounded theory approach J Clin Rheum. 2011;17(1):1-6.