Ministry of Health figures estimate there are 286,693 patients with diabetes in Aotearoa New Zealand, 49,140 of whom reside in South Auckland (Counties Manukau District Health Board [DHB]).[[1]] Counties Manukau DHB patients have predominantly type 2 diabetes and they are predominantly Māori 6,497 (11.9%), Pacific 17,959 (32.5%) and South Asian 7,167 (12.6%), compared with NZ European patients 17,517 (35.6%). Poorer health outcomes have persisted among Māori and Pacific people with type 2 diabetes for more than 20 years.[[2]] In response to this, more effective and equitable management of type 2 diabetes in New Zealand has been urged by health professionals and health academics.[[3,4]]

In September 2020, Pharmac announced the funding of two diabetes drugs, empagliflozin and dulaglutide, for the treatment of all type 2 diabetes.[[5]] These drugs were representative of two new classes of medications, SGLT2 inhibitors and GLP1 receptor agonists that have rapidly become the mainstay of type 2 diabetes management around the world. They are the first diabetes drugs that are shown to modify disease outcomes such as cardiovascular death and progression to end-stage renal failure.[[6–8]] Compared with traditional treatments (metformin, sulphonylurea & insulin), they are easier to administer, more convenient to take, and they have a more acceptable adverse event profile. They cause weight loss rather than weight gain and they do not cause hypoglycaemia.

Pharmac initially proposed that the new medications should be subject to special authority (SA) application based on cardiovascular risk and risk of diabetes complications. SA is an application process in which a prescriber requests government subsidy on a community pharmaceutical for a particular person. Many groups lobbied Pharmac to extend eligibility to all Māori and Pacific patients irrespective of complication status and comorbidities and this was agreed by Pharmac.[[9]] However, we were concerned that Pharmac’s SA system could still be a barrier-to-care for Māori, Pasifika peoples and people living in high deprivation with inequitable access for prescribing clinicians. Whether or not SA is a barrier-to-care also depends on primary care access to the electronic SA approval mechanism.

The Diabetes Foundation Aotearoa is a community charitable trust established in 1994, whose mission is to reduce the impact of diabetes and its complications in the South Auckland community. The Diabetes Foundation Aotearoa decided to fund and undertake a campaign to ensure as many eligible patients as possible applied for these new medicines or asked their doctor about whether the treatment was suitable for them.

Methods

The campaign targeted communities within the Counties Manukau DHB Region using a talanoa, word-of-mouth approach using a succinct combination of facts, data and language that highlights the personal life-enhancing benefits of the medicines. Information on the medicines was spread through the community by influential community leaders and peer-to-peer at its grassroots. Influential community leaders comprised: justices of the peace; kapa haka leaders; chairs/treasurers of cultural and hobby clubs; chairs/secretary of sports clubs; school principals and teachers; health promotion agencies; doctors/nurses; and church ministers.[[10]] The key components of the message included the following four points:

• if you or one of your family members has diabetes, they may be able to receive 2 new medicines;

• these medicines can significantly improve your health and can delay diabetes-related deaths and need for dialysis by 10–15 years;

• the new medicines have fewer side effects and are much easier to take than existing diabetes medicines;

• please ask your doctor if you qualify for these.

This message about the new medicines and how they can be accessed was passed through local organisations, family, friends, influential community leaders and colleagues. This was intended to spread through the community to reach people with type 2 diabetes their families and ask them to contact their doctor and see if they are eligible.

Twenty-five thousand double-sided “personal impact” leaflets were printed (see Figure 1). The design focussed on everyday life enhancements the medicines could have for individuals and asked those with type 2 diabetes to “call your doctor right now to see if you are eligible”. The pamphlets offered translations in Samoan, Tongan, and Māori. Pamphlets were sent out with an explanation kit detailing the Diabetes Foundation Aotearoa efforts and how they can help through spreading the word and the pamphlets. A page on the Diabetes Foundation Aotearoa website was curated which detailed the campaign and presented information about the two new medicines empagliflozin and dulaglutide. It was hoped the webpage would heighten trust and authenticity, alongside giving clarity on the SA process.

Six tertiary health students at AUT University who grew up and lived in Counties Manukau were employed as part of the program. Five students identified as Pacific and one as Asian (Malaysian). They contacted significant and well-known influential community leaders to ask that they pass on the new medicine information to people that they knew. They kept in contact with these influential community leaders to ensure the information was passed on and gave them pamphlets to those who were interested in distributing them in person. The students were very effective. They were keen and proud to disseminate the information to their community. They reported a positive reception from each contact and recorded at least one confirmed subsequent transmission from that contact to another person in their network.

One hundred and two primary care practice clinics in the Counties Manukau Region were identified and notified of the campaign and the new medicines. All Alliance Health Plus Primary Health Organisation clinics received leaflets to spread through their networks and to the Pasifika community via their Pacific Equity team. An email system was developed that allowed patients to easily request an appointment with their general practitioners to determine if they were eligible for the new diabetes medicines. By scanning a QR code printed on the leaflets and graphics on social media using a smartphone, the user was sent to a webpage to select their local health clinic and general practitioner to phone, or to send an appointment request. If they wanted to email, a Google form took their name and phone number and automatically emailed their selected clinic to request an appointment.

Finally, Diabetes Foundation Aotearoa, retained a public relations company (Blackland PR) to assist with the campaign. Blackland PR had previous experience in performing community outreach having successfully promoted two separate vaccine products for pharmaceutical companies. Blackland PR contacted South Auckland community trusts, councillors, and community boards, local churches, sports clubs, and marae for distribution among members and affiliates asking for their help with the awareness project. They also enlisted the help of local radio stations Ake 1179, the official radio station of Ngāti Whātua, and Tama-Ohi Radio, a Tongan community radio station based in Panmure, Manukau.

Results

An estimated 45,000 people received communications about the new medicines by way of this campaign (see Figure 2). A survey was administered by each student employee with at least three influencers (18 in total). The number of people subsequently contacted by the influential community leaders varied greatly. For example, well respected people each reached around five to six people, and church ministers reached over 100 people. From that, we estimate a minimum contact ratio from this approach of at least 1:5 (i.e., for every influential community leader contacted, another five people get the information). We estimate the student outreach passed the information to over 5,000 people of whom 98% were Pasifika. The “natural limit” of influential community leaders is unknown; however, the students felt comfortable that each influencer reached a minimum of 80 contacts.

Public Relations Company Blackland PR reached out to approximately 500 trusts, clubs, community groups, small businesses and individual influencers. They were each sent emails, leaflet packs and phone calls were made to groups. Approximately 15,000 of the leaflets were distributed through these groups of whom 68% were Pasifika based on the ethnic makeup of the area from the 2018 Census. Follow-ups indicated that all leaflets were distributed. The more formalised, sizable, or established an organisation, the more reluctant they were to assist due to COVID-19. They expressed concerns about community engagement with the new medicines due to a focus on the virus or were themselves busy with community matters concerning COVID-19. However, informal community groups did not share the same concerns and were more supportive of this campaign.

View Table 1 and Figure 1–4.

An estimated 5,000 people were reached via health clinics of whom 98% were Pasifika and an estimated 20,000 people on listenership (50% Pasifika) were reached via radio networks. Community radio stations broadcast the voice of one of the students delivering a 40 second recording promoting the new medicines. The advertisement called on people with type 2 diabetes to contact their doctor about the new medicines and asked others to spread the word. The message was recorded and played in English, Tongan and Samoan. Each broadcast spanned the Counties Manukau Region.

Diabetes Foundation Aotearoa board members were also interviewed by Pasifika radio stations specifically about the campaign. In contrast to the community-level media interest, mainstream media assistance proved difficult to engage due to New Zealand entering a COVID-19 lockdown during the crucial contacting period of the campaign.

To determine the effectiveness of the campaign we originally planned to monitor SA applications from Counties Manukau suburbs within days of activity compared with the entire country. However, after lengthy negotiations with Pharmac, we were only able to access month-by-month prescription data for the Counties Manukau DHB Region instead. Data were collected from when empagliflozin was first made available on 1 February 2021 to 31 July 2021 for the Counties Manukau DHB Region compared with all other DHBs (see Table 1). Dulaglutide was not available until 1 September 2021, after the study had completed.

After standardising for ethnicity and population numbers, data showed reduced prescriptions for the new medicines for Counties Manukau DHB Region compared with all other DHBs for the first 2 months. Thereafter, there was a relative 40% increase in prescriptions in Pacific patients in Counties Manukau DHB with relatively static numbers in other ethnic groups (see Figure 3).

Discussion

This was a pilot campaign that tested the effectiveness of dissemination of information targeted to the Pasifika community as close as possible at the grass roots, and tested the effectiveness of messages that were clear and explicit about the health benefits to an individual that new medicines offered. Contacts generally perceived the request made to them was to contact people with diabetes that they knew rather than to pass on the information to everyone they knew. These influential community leaders had to be culturally connected to them. Community knowledge, comfort and interest were the important traits.

The data show Pacific patients, the focus of about 64% of the delivery of campaign messages, were 40% more likely to apply and get a prescription in Counties Manukau than anywhere else in the country (Figure 3). The large impact in Pacific patients was higher than anticipated. The Pasifika community in South Auckland have high levels of social connectedness; more so over lockdown when Pasifika radio stations became more prominent as listeners were trying to keep abreast of the latest COVID-19 updates.[[11]] Word-of-mouth communication is more effective in Pasifika communities as they tend to have more extensive social circles that include large extended family, church, village, sports club and friend networks. The nature of our campaign was informed by “The Fonofale model of health” in that it was holistic, community based, incorporated aspects of culture and family.[[12]] Key delivery methods of our campaign are also strongly aligned to the Pasifika concept of “talanoa”, which acknowledges the importance of oral communication in communicating important messages to community.[[13]]

Previous research by Faletau et al.[[14]] found that Tongan individuals diagnosed with pre-diabetes were poorly cared for by the New Zealand health system. Messages regarding pre-diabetes were not clearly communicated to these individuals meaning that they were not aware that they were diagnosed with pre-diabetes. This caused feelings of disbelief and fear once the diagnoses were clearly explained and understood in the study. Further, there was also no understanding of what pre-diabetes meant and that pre-diabetes was reversible.[[14]] We are reassured that in contrast, our campaign, clearly communicated its key messages about the availability of these new diabetes medicines to our Pasifika communities—indicated by the higher uptake of these medicines following the campaign. However, suggest that future research should measure how Pacific patients with diabetes understand the effects of the newly funded medications, and education around it and the management of diabetes using the new medications.

We are unaware of any other direct-to-consumer style campaigns that have promoted newly funded medicine for treatment of diabetes in New Zealand. However, there have been many mainstream campaigns that have targeted Pasifika and Māori communities for health issues such as the COVID-19 and meningitis B vaccinations, and diabetes prevention, rheumatic heart disease prevention.[[15–18]] These programmes were generally successful however in some instances unintentionally victimised Pasifika communities.[[19]] In considering and designing our campaign we were careful to ensure that it would not harm any communities by indirectly assigning blame in any way.

Empagliflozin and dulaglutide are the first new diabetes medicines funded by Pharmac in more than a decade. This generated a high level of interest in the diabetes community and prompted several organisations to run awareness campaigns at the same time as this pilot program. Pharmac mounted a national social media campaign through Whare PR. Pharmac’s campaign recruited four well-known and respected Māori personalities who either live with type 2 diabetes or have whānau members living with the disease. The campaign consisted of a multi-channel three-month campaign, delivered through Māori television, national newspapers, posters, digital ads, public relations and social media. Bay of Plenty based kaumātua Phil Merritt; rugby league star, Adam Blair; founder of “Kura Kai”, Makaia Carr; and playwright, journalist and film-maker, Aroha Awarau, encouraged whānau to visit their doctor to enquire about the new diabetes medicines. The New Zealand Society for the Study of Diabetes disseminated an information package and PowerPoint presentation to primary care; and the Goodfellow Unit (The University of Auckland) and primary health organisations also ran education sessions for primary care. We controlled for the impact of these national programs on our data by relating new prescriptions in Counties Manukau controlled for ethnic breakdown to national prescription data over the same period see Figure 3).

There were a number of limitations to this project. We were unable to employ a Māori student, which may have contributed to the lower response for Māori. This campaign also occurred at a time where primary care in South Auckland was already overloaded and distracted by the COVID-19 pandemic and Auckland regional lockdowns would have adversely affected patient access to primary care in Counties Manukau compared to the rest of the country. Finally, dulaglutide was not available until 1 September 2021 after the study had completed, so our assessment of impact was restricted to empagliflozin.

Direct-to-consumer advertising is currently allowed only in the USA and New Zealand.[[20]] It is associated with increased prescription of advertised products and there is substantial impact on patient’s request for specific drugs and physician’s confidence in prescribing.[[21]]

Health literacy amongst Māori and Pasifika peoples may be another contributory factor to the slow uptake of new medicines, although it is as much a barrier and the responsibility of the health provider, organisation, and system as the consumer.[[22]] Advertisements are a legitimate form of patient’s information, and the benefits are targeted directly at patients and the public. Our findings suggest that a direct-to-consumer approach increases health awareness, improves doctor-patient communication, and improves concordance leading to an increase in prescriptions of new medicines for Pacific patients. We hope this will translate to improved health outcomes for our community in the long-term.