General Practice and Primary Care - Theses
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ItemThe provision of psychosocial support in early pregnancy assessment services in Australia( 2019)Background Miscarriage is a common event estimated to affect up to one in four confirmed pregnancies and can result in significant psychological morbidity. Appropriate psychosocial support at the time of a miscarriage can lead to better psychological outcomes in the months or years following a loss. Early Pregnancy Assessment Services (EPASs) are typically dedicated outpatient clinics in public hospitals designed to manage patients with pain and/or bleeding in early pregnancy and are considered the “gold standard” for miscarriage care. Despite some best-practice recommendations outlining the psychosocial support EPASs should offer, very little is known about what they provide. Aim The aim of this study was to explore the provision of psychosocial support in Early Pregnancy Assessment Services in Australia. Method A mixed method approach utilising audit, field notes and semi-structured interviews was conducted to acquire information on clinic structure and operation, and the provision of psychosocial support. Thirty-one key-informants were recruited from 13 EPASs and two miscarriage support organisations across Australia. Interviews were audio-recorded, transcribed, and thematically analysed. Results Findings demonstrated considerable variability in how EPASs functioned in Australia, and therefore the provision of psychosocial support. Results were presented in three categories: psychosocial support currently provided, psychosocial support considered ideal by participants, and barriers to changing psychosocial support. Considerable variation in the structure and function of services were observed, such as staffing arrangements, physical location of service, and availability of ultrasonography. However, most participants described the emotional support provided by EPAS staff similarly, noting the importance of acknowledging and validating patients’ feelings, guilt mitigation, and providing individualised care. Referrals for additional psychological support were rarely reported, however many participants discussed the importance of utilising General Practitioners for follow-up and ongoing support. Common barriers to providing ideal psychosocial support was reported and primarily centred around limitations on time and resources, resulting in the physical care of patients taking priority over psychological care. Despite these restrictions, all EPAS staff demonstrated a clear and strong commitment to providing best possible patient care within their own clinical setting and acknowledged the need for improved psychosocial support. Conclusions This study provides the first exploration of Australian EPASs’ provision of psychosocial support. It has demonstrated that health care professionals working in EPASs are dedicated to providing the best possible care to their patients within their clinical setting. Time and funding restrictions were considered major barriers to providing improved psychosocial support. More research into where psychosocial support is best offered is needed to improve patient experience and lower psychological morbidity following miscarriage.
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ItemThe role of the practice manager in general practice- based research( 2017)Research in the general practice setting is essential to ensure the clinical care provided is effective and evidence-based. To facilitate general practice-based research, studies must be designed in ways that accommodate practice routine. Furthermore, intervention studies need to be managed at the practice level to ensure uptake and implementation. The practice manager is central to the administration and oversight of general practice organisation and routine. However, there is a paucity of research evidence about this role, and no current literature on practice managers’ contributions to research intervention trial facilitation and implementation in the general practice setting. This study investigated the practice manager’s role in facilitating the implementation of an intervention as part of a clinical trial in Australian general practice. This research was a sub-study of the Australian Chlamydia Control Effectiveness Pilot (ACCEPt). ACCEPt was a randomised controlled trial that measured whether a multifaceted intervention designed to increase annual chlamydia testing reduced the transmission and associated complications of chlamydia among 16 – 29 year-old general practice attendees. Using a qualitative thematic methodology, 23 semi-structured interviews were conducted with practice managers during the ACCEPt intervention phase. “The practice managers' role in facilitating and implementing the ACCEPt intervention was explored, along with the barriers and enablers to the conduct of general practice-based research.” The findings of this study suggest practice managers are key to establishing, facilitating and managing research interventions at the general practice level. The participating practice managers described their central positions within the structure of the organisation as pivotal to directly liaising with GPs on research matters, delegating tasks and maintaining the profile of research in general practices. Managers had the capacity to embed non-clinical tasks into their current workloads, which they saw as crucial to sustaining trials and limiting the impact of research on practice routine. New perspectives from practice managers suggest the main enabler to research uptake and sustainability in the practice is the practice manager’s involvement. They reported daily routine and the rigid scheduling of GPs’ appointment times as the main barrier. This is the first Australian study of the role of the practice manager in facilitating intervention studies in general practice. While this study fills a gap in the literature about practice managers and their contribution to general practice-based research uptake, it also highlights the need for further examination of this role, specifically a broader systematic investigation of practice managers’ contribution to managing intervention studies at the practice level. Furthermore, exploration of the training needs of practice managers is required to identify education that would maximise their potential to contribute to research.
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ItemOral health knowledge and behaviours amongst adults with diabetes and their healthcare professionals( 2017)Background: Diabetes and periodontal diseases are common chronic diseases in the community. Diabetes, particularly if sub-optimally managed, is associated with an increased prevalence and severity of periodontal diseases, and severe periodontal disease adversely effects glycemic control. Studies have demonstrated that treating periodontal diseases may help improve a person’s glycemic control. Thus, understanding the association between diabetes and oral health has important implications for people with diabetes and the healthcare professionals that assist with their management. Despite the bidirectional relationship between diabetes and oral health, overseas studies have reported low levels of oral health knowledge and sub-optimal self-care behaviours in people with diabetes and few studies have explored this in Australia. Preventing and managing the chronic complications that arise from diabetes requires a multidisciplinary approach. However, research indicates that there are gaps in the knowledge of medical and oral health professionals with regards to the link between oral health and diabetes. Little is known about how oral health is incorporated into the clinical practice of healthcare providers assisting people with the management of their diabetes in Australia and the extent of collaboration between medical and oral health professionals. Aim: To investigate oral health knowledge and behaviours of adults with diabetes. Additionally, to explore the oral health knowledge of healthcare professionals that provide self-management support, health education and treatment interventions to adults with diabetes. Methods: A mixed methods study comprised of: (1) Online survey of adults with type 1 and type 2 diabetes. The survey results were analysed using STATA software and the findings summarised using descriptive statistics. (2) Qualitative study in which semi-structured interviews were conducted with 10 healthcare professionals: three dentists, two general practitioners (GPs), two dental hygienists and three diabetes educators. Interviews were audio recorded, transcribed verbatim and analysed thematically. Results: 154 people with diabetes completed the survey. A significant proportion (20%) of people with diabetes were unsure if diabetes could worsen their oral health. Many did not report oral self-care behaviours consistent with recommendations for people with diabetes, for instance 41% did not brush twice a day, 49% did not floss daily and 33% did not visit a dentist annually. Three main themes emerged from the interview study. (1) Healthcare professionals reported uncertainty about the relationship between diabetes and oral health, and were unclear about the bidirectional nature of this association. (2) Healthcare professionals do not routinely discuss the link between oral health and diabetes with people with diabetes. (3) Medical and oral healthcare professionals do not actively communicate and collaborate in the management of people with diabetes. Conclusions: Adults with diabetes are in a high-risk group for oral diseases and yet a significant proportion report being uncertain about the relationship between diabetes and oral health and practice less than ideal oral self-care behaviours. Medical and oral healthcare professionals are a primary source of information for people with diabetes. Therefore they require a clear understanding of the bidirectional links between oral diseases and diabetes so that they may provide patient education, support oral self-care and diabetes self-care and preform timely treatment interventions. Using the Chronic Care Model (CCM) as an organising framework, interventions can be instituted at a patient, healthcare professional and healthcare system level in order to improve diabetes care and health outcomes for people with diabetes.
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ItemPatients' experience of using primary care in the context of Indonesian universal health coverage implementation: an interpretative phenomenological analysis( 2015)Background: Jaminan Kesehatan Nasional (JKN) as Indonesian universal health coverage was designed to provide people with easy access to equitable and high-quality health care through introducing primary care as the first contact medical care and as the gatekeeper to secondary care. However, during its first year of implementation, the new member recruitment was slow, less than 50% of Indonesians joined the insurance scheme and referral rates from primary to secondary care remained high. The Indonesian Ministry of Health reported that more than 10% referrals from primary care were unnecessary. There has been little research undertaken on the patient experience of accessing health care in Indonesia, nor their views of the implementation of JKN which may influence them to opt in or out from the JKN insurance. Aims: This research aimed to explore the patients’ views and experience of using primary care service in the context of JKN implementation Methods: This study used in-depth interviews with a topic guide. Patients were selected from Yogyakarta’s primary care with a maximum variation sampling approach. The data collection was conducted from October – December 2014. The data were transcribed, translated and analyzed using interpretative phenomenological analysis. Result: Twenty-three patients were interviewed from eight primary care clinics in Yogyakarta. Three superordinate themes were identified as access, trust, and separation anxiety. Patients described primary care as a convenient way to access medical services, but they reported that the facilities were varied, and unequal access to services existed. Many patients regarded the primary care doctors as second class doctors who were poorly equipped to manage a serious illness. Many participants also thought the primary care doctor’s primary task as providing them with a referral to secondary care. Participants expressed considerable anxiety about the possibility that the JKN scheme would prevent them from receiving specialist care, which they viewed as more desirable than primary care. Discussion: The uptake of JKN has been limited. This study identified a mixed response to the early implementation of a gatekeeper role for primary care. Whilst participants valued the easy access to medical care in a nearby location they expressed a lack of trust in the primary care medical practitioners and a sense of anxiety about what they perceived as ‘giving up’ easy access to specialist care. If these public views are not modified it is unlikely that the full potential of the JKN scheme in primary care will be realized.
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ItemThe readers’ view of using bibliotherapy to cope with depression( 2015)Depression is a common disorder, affecting one in four Australians. Many individuals experiencing depressive symptoms do not seek professional help partially due to limitations with current treatments. There is emerging interest in Bibliotherapy, which is the use of books to treat depression. The benefits of Bibliotherapy include being cost-effective and being less stigmatising. There are two main approaches to Bibliotherapy, Self-help and Creative Bibliotherapy. Self-help Bibliotherapy includes books based on cognitive behavioural therapy and have been shown to reduce symptoms of depression. Creative Bibliotherapy includes fiction, autobiographies and poetry but its effectiveness for depression is yet to be established. Although surveys have identified psychologist recommend Self-help Bibliotherapy to people experiencing depression, it is unclear which type of Bibliotherapy people experiencing depression actually use.
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ItemSexting and young people: a qualitative study( 2012)This study is one of the first Australian studies to describe the phenomenon of sexting from the perspective of young people. ‘Sexting’, which involves the production and distribution of sexually explicit images via information and communication technologies (ICTs) has led to young people being excluded from friendship groups, moving schools, suffering anxiety and depression, and in extreme cases being charged with the production and distribution of child pornography. There is an absence of published studies undertaken in this area, particularly from an Australian perspective and from the point of view of young people themselves. My study addresses this gap by exploring the meaning of sexting in young people’s lives. It focuses in particular on the nature of sexting, the reasons why young people are involved in the behaviour and potential solutions for addressing harmful consequences. A qualitative methodology involving two phases was used. The first phase involved a focus group and individual interviews with twelve key informant professionals to develop a context that would inform the second phase, which involved individual semi-structured interviews with 33 young people aged 15-20 years (female [n=18]; male [n=15]). Young people were sourced via youth health, recreational and educational settings using purposive snowball sampling. Results were thematically analysed using a grounded theory approach. Key informant findings helped frame interviews with young people, and affirmed that young people’s voices needed to be heard. Many of the views of key informants were also reflected in the views of young people. Findings exposed a number of themes, including in particular, the gendered nature of the behavior. Of particular concern is that young women feel pressured by young men, who feel pressured by each other to be involved in the behaviour; young people observed that our sexualised media culture places pressure on young women and men to conform to gendered stereotypes that influence the behavior of sexting. Conversations with young people highlighted complexities of the phenomenon not revealed previously, including that definitions used in prevalence studies need to represent changes in young people’s use of ICTs. Young people’s views on solutions highlight that education about the implications of sexting is not the only answer, especially given young people’s views on the origins of sexting and what is known about young people and risk taking from a developmental perspective. Both young women and men were concerned about the potential harmful outcomes for those involved in the behavior, with recognition that young people should be involved in the design of solutions. Findings present important implications for future prevention approaches.
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ItemChoices women make: prevalence of and the factors associated with contraception use in women of reproductive age attending Family Planning Victoria( 2012)BACKGROUND: Despite good access to contraception, Australia has one of the highest rates of unintended pregnancy in the developed world. Proper use of contraception is important in reducing unintended pregnancy. The factors associated with a Victorian woman’s likelihood to use contraception are unknown. AIMS: To identify and predict women at risk for unintended pregnancy by defining factors associated with ineffective or non-use of contraception in sexually active women of reproductive age attending Family Planning Victoria. Theoretical component: 1. To summarize and categorize current understanding of the factors that may influence a woman’s use of contraception. Practical component: 1. To determine the current pattern of the use of contraception of sexually active women (16–50 years old) attending Family Planning Victoria including the a) percentage who are using contraception and the type of contraception currently used. b) percentage of women using contraception consistently. 2. To examine the associations between demographics, psychosocial factors and contraception use in sexually active women who are not planning a pregnancy, attending Family Planning Victoria. METHOD: This was a cross-sectional study of sexually active women of reproductive age attending Family Planning Victoria, utilizing a questionnaire of contraceptive behaviours and important factors that influence contraception use (identified from a systematic literature review). The variables of interest were analysed for associations with contraceptive use and non use and then as independent predictors of non-contraceptive use. RESULTS: Through a comprehensive literature review of 132 articles, a framework consisting of 8 domains was developed to summarize the factors that may affect a woman’s choice to use contraception. 1006 surveys were analyzed with 95.6% of women using some form of contraception in the last 3 months. The three most commonly reported contraceptives in the last 3 months were male condoms (66.9%), oral contraceptive pill (48.6%) and withdrawal (31.5%). 36.8% of sexually active women were at risk for unintended pregnancy: 60.5% due to inconsistent contraception use, 31.4% due to sole use of an “ineffective” contraception and 8.1% due to non use of contraception. The most common reasons for inconsistent use of contraception were ‘no access’ (38.7%), ‘forgetting’ (35.1%) and ‘too inconvenient’ (14.6%). On multivariate analysis, women at risk for unintended pregnancy compared with women not at risk had demographics of <25 years old (OR 1.83, 95% CI 1.23-2.73); no university/postgraduate degree (OR 1.69, 95% CI 1.18-2.44); >1 partner in the last 3 months (OR 3.23, 95% CI 2.28-4.58). They had attitudes of dissatisfaction with current contraception (OR 2.50, 95% 1.79-3.45); felt “vulnerable” to pregnancy (OR 2.14, 95% CI 1.55-2.95); not confident in contraceptive knowledge (OR 2.63, 95% CI 1.47-4.76); unable to stop to use contraception when aroused (OR 2.08, 95% CI 1.47-2.94) and comfortable in speaking to a doctor about contraception (OR 2.26, 95% CI 1.11-4.07). CONCLUSION: A theoretical framework of 8 domains has been developed to categorize the factors that may affect a woman’s choice to use contraception. Despite more than 95% of women reporting contraception use in the last 3 months, nearly 40% of women are at risk for unintended pregnancy, mainly due to inconsistent or ineffective use of contraception rather than non-use. 8 factors were also found that were associated with women who were at greater odds of being inconsistent or ineffective users of contraception.
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ItemThe sexual health of injecting drug users on opiate pharmacotherapy( 2011)Sexual health is acknowledged as a fundamental human right and contributes significantly to a person’s wellbeing. Injecting drug users (IDU) are a heterogeneous group of sexually active people who have the same right to good sexual health as any other group in society. Opiate pharmacotherapy, that is, treatment with methadone or buprenorphine, is commonly prescribed to IDU as part of harm minimization and rehabilitation from drug use. Patients taking pharmacotherapy attend their prescribing doctor, who is often a general practitioner (GP), much more regularly than most people in the community see their GP. Despite this, those on pharmacotherapy often complain of poor health and are concerned about diseases such as hepatitis C. It is widely acknowledged that pharmacotherapy has a detrimental effect on sexual function but the subjective impact of pharmacotherapy on sexual health has not previously been well documented from the point of view of the patient and their doctor. In this project a comprehensive literature review and qualitative research study was performed to describe the sexual health of IDU who are currently taking pharmacotherapy from the perspective of the patient and their pharmacotherapy doctor, and to determine whether IDU believe that their sexual health needs are being fulfilled through the current health care system available to them. In the research component, in-depth interviews were conducted with ten pharmacotherapy prescribers and ten IDU who were currently on a pharmacotherapy program. The doctors were recruited through Victoria’s Northern Division of General Practice’s Drug and Alcohol Forum and through snowballing. Patients were recruited through their pharmacotherapy provider and also by snowballing. A thematic approach was used to analyze results. Nine major themes were identified from the data analysis: The Therapeutic Relationship; Priorities; Resistance/Inertia; Stigma; Sexual Health; Sexual Dysfunctions; Domestic Violence and Sexual Abuse; Fertility and Contraception; and Sex Work. The findings are that, contrary to this researcher’s expectations, doctors have an appreciation that pharmacotherapy affects their patients’ sexual health. However, for a variety of reasons, sexual health issues were generally not raised in consultations. Barriers to broaching these issues are present from the perspective of both the doctor and patient. Doctors and patients attribute this to other health and social priorities which overrode their sexual health concerns. While IDUs rated the importance of their sexual health highly, they often did not raise these issues with their treating doctor, in part because they had other health priorities, principally managing their addiction, and partly because sexual health was not raised in consultations by their doctors. Pharmacotherapy prescribers, on the other hand, saw the sexual health issues of their patients as important but not their greatest responsibility. There is great scope for improving the sexual health care for this marginalized group. Doctors can raise the possibility of sexual dysfunction with patients who are starting pharmacotherapy. The co-location of addiction services with general practice where health services such as Pap screening and testing for sexually transmitted infections (STIs) are available would improve care. The onus is on doctors working in this field to raise these issues for discussion as it is clear that patients will rarely voice their concerns. Sexual dysfunction in those on pharmacotherapy is an evolving field and requires further research. There is very little literature about the effects of opiate pharmacotherapy on female sexual function. This is an overlooked area which requires further investigation. There needs to be a re-examination of male sexual dysfunction comparing methadone with the now commonly prescribed buprenorphine-naloxone combination. Finally, to ensure the likelihood of patients achieving the optimum level of sexual health, researchers need to determine why some pharmacotherapy providers do not see it as their role to manage their patients’ general and sexual health problems.
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ItemClimate change: what do doctors think? What can doctors do?: An international survey of general practitioners( 2011)Background: Climate change is expected to become one of the biggest public health issues of this century with the health of billions of people potentially affected. It will be the poorer counties and populations that will be most impacted and least able to adapt. A number of responses to climate change have been proposed including efforts to mitigate climate change, and to adapt to the inevitable and growing impacts. Psychological, social and systemic barriers and enablers for action on climate change have been identified. Doctors may have important roles as communities adapt and respond to climate change. A focus on health may enhance public and political will for climate change mitigation. Health promotion, surveillance, and treatment of climate change related health consequences will also be important. The beliefs and attitudes of doctors regarding the scientific basis, predicted impacts and the proposed responses to climate change are largely unexamined. Objectives: To describe GPs’ understanding of the science and public health impacts, their attitudes, feelings and beliefs as well as potential roles in response to climate change. Barriers and enablers will also be explored. Method: In May to June 2010 an international, cross-sectional online survey of GP members of the World Organisation of Family Doctors (WONCA) was conducted. Results: What do GPs think about climate change? GPs in this cohort overwhelmingly agreed with the science of climate change, the health impacts and a role for GPs. There was least agreement that climate change is driven by human activity. Spatial discounting of perceived impacts was evident. The majority of GPs believed that they don’t have the skills to respond. Although 27.6% of GPs self-identified as sceptical of the science, over a quarter of these “sceptics” strongly agreed that climate change is occurring and has a substantial public health impact. Thus agreement/disagreement with the science may be a more useful terminology than the language of scepticism. What can GPs do about climate change? The majority of GPs in the sample believed that WONCA has a role (83%). In addition key climate change related roles that were supported for GPs included CME (79%), teaching (77%), advocacy (75%), and making significant changes in their clinic or office (60%). Compared to GPs from poorer continents, GPs from richer continents were more likely to believe in a role including making changes in their clinic or office. A minority of GPs rated their current response to climate change as done well, and most agreed that assistance would allow them to initiate or improve their responses. In particular, GPs indicated that they are usually not responsible for procurement of medical supplies (a large contributor to the clinics’ carbon footprints). Conclusion: Even though over a quarter of GPs self-identified as sceptics, overall GPs supported the science, impacts and roles that they may play in responding to climate change. There is a need for efforts to increase knowledge of climate change science, including local impacts, and also to build self-efficacy. This has implications for workforce planning, education and engagement of the profession.
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ItemPilot study of an approach to successfully undertake a methodologically rigorous trial of acupuncture( 2011)BACKGROUND: Randomised controlled trials (RCTs) are considered the “gold standard” when evaluating the effectiveness of therapeutic interventions, because of their ability to minimise bias. Bias refers to any process that leads to a conclusion that is systematically different from the truth, and four key features of RCTs that serve to minimise bias have been identified. These are discussed using the case of acupuncture, a popular and safe complementary therapy, for treating hot flushes or vasomotor symptoms (VMS), which are common and bothersome during menopause. The methodological shortcomings of existing RCTs on this topic are discussed. AIM: To determine the feasibility of a rigorous randomised-controlled study evaluating the efficacy of needle acupuncture compared to non-penetrating sham control for treatment of VMS, in Melbourne, Australia. METHOD: A randomised sham-controlled pilot study was conducted. Various recruitment strategies, including online strategies, were implemented to recruit 27 acupuncture-naïve women having more than seven hot flushes a day and who were diagnosed with Kidney Yin deficiency, a Traditional Chinese Medicine diagnosis. Women were randomised into intervention or control groups and received ten treatments over eight weeks. The intervention group received needling at four acupuncture points while the control group received needling with a non-penetrating (blunt) needle (“the Park Sham Device”) at four non-acupuncture points. The main outcome measures were recruitment, enrolment and dropout rates; adequacy of blinding; adverse events; and qualitative assessment of trial procedures by participants. Changes in hot flushes were measured by a seven-day hot flush diary administered at baseline, four weeks, six weeks, end of treatment and three month follow-up. Quality of life (QOL) using the Menopause-Specific Quality of Life Questionnaire (MENQOL) was administered at the same times. Between-group differences for hot flush and QOL measures were analysed using non-parametric measures of equality (Wilcoxon ranksum test). RESULTS: Out of 98 enquiries, 38 women were eligible. The enrolment fraction was 71% and dropout rate 26%. Online strategies were the most effective. None of the women in the control group guessed that they were receiving sham acupuncture. Adverse events were generally mild. 23 women began treatment and 20 completed all treatments and follow-up. 14 women were interviewed and all gave positive feedback on trial procedures. Hot flush score was higher in the intervention group at baseline. There were no statistically significant differences between treatment and control groups in terms of hot flush or QOL measures except for hot flush score at end-of-treatment, with the control group having a lower score. DISCUSSION: A RCT appears to be feasible, based on the success of recruitment, a relatively low dropout rate, the adequacy of the control method, and the acceptability of the trial procedures. Although this pilot study was not powered to detect a treatment effect, lessons learned from this pilot will directly inform the design of a RCT which will evaluate the efficacy of acupuncture for VMS and add significantly to the current body of evidence.