General Practice and Primary Care - Theses
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ItemSupporting primary care practitioners to promote dementia risk reduction in Australian general practice: development and pilot evaluation of a practice change intervention and targeted implementation approach( 2023-10)Background. People in Australia have limited awareness of the potential for dementia risk reduction. General practice is an appropriate setting for promoting dementia risk reduction, yet it is not routinely discussed. The objectives of the Preventing Cognitive Impairment in Practice Project were to (1) develop an intervention for promoting dementia risk reduction in Australian general practice, (2) assess barriers to implementing the intervention, (3) develop an implementation approach in which strategies to mitigate assessed barriers were selected, operationalised, and introduced progressively, and (4) pilot the intervention and implementation approach in Australian general practices. Methods. The project was guided by a range of frameworks (eg, the Knowledge-to-Action Framework, the Consolidated Framework for Implementation Research). The project comprised six separate studies, including two scoping reviews, qualitative interviews with Australian primary care practitioners, retrospective analysis of discussion board posts from non-medically trained enrollees in a free online educational course about dementia risk reduction, development of an intervention and targeted implementation approach based on evidence and stakeholder consultation, and a pilot evaluation of implementation outcomes in five general practices in Melbourne, Australia. Results. The intervention comprised a patient survey to be completed in the waiting room and patient information cards to be used during consultations, both of which were designed to prompt specific practitioner actions. The implementation approach combined educational materials, outreach visits, local consensus discussions about whether dementia risk reduction was important and whether the proposed practice changes were appropriate, champions to drive implementation within general practices, and capturing and sharing knowledge across general practices. On piloting, implementation outcomes were mixed. Both the intervention and implementation approach were broadly acceptable and feasible, but penetration (‘reach’) was low. Discussion. The Preventing Cognitive Impairment in Practice Project led to an acceptable and feasible practice change intervention and targeted implementation approach that can support the promotion of dementia risk reduction in Australian general practices. Interpretation of the evaluation data identified opportunities for refinements to the intervention and implementation approach. Female participants and self-selected participants interested in DRR were overrepresented throughout the project. Future research could examine hypotheses about implementation outcomes arising from the pilot study, consider additional implementation outcomes, and adapt the intervention and targeted implementation approach for other contexts and populations.
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ItemAn exploration of monitoring people with depression in the general practice setting( 2015)This study is about how general practitioners monitor the effectiveness of the care they provide for people experiencing depression. It seeks to better understand how the monitoring of people with depression should occur in the general practice setting, from the perspective of general practitioners, patients and carers. It does this with the intention of contributing to the debate about how to improve the quality of general practice care for people experiencing depression. The study comprises three main parts, beginning with a literature review in two sections. The first chapter discusses key concepts including depression, primary care’s role in depression care and what defines effective depression care. The second chapter is a scoping review of the primary care depression literature outlining what is known about monitoring practice in this context. The second part of the thesis presents the findings of a survey of 576 people with depressive symptoms who attend general practice, regarding how they recognise recovery from depression. The third part of the thesis reports on findings from eight in-depth case studies, which explore the views and experiences of GPs, patients and carers involved in the giving and receiving of depression care in the general practice setting. The findings of the case studies confirm that monitoring practice is a highly complex, iterative process. Broadly speaking, there are three key phases of monitoring that must be addressed as care proceeds, beginning with engagement in care (including ‘watchful waiting’), moving through a phase of ‘paying attention’ (to the individual patient’s experience) and the ultimate phase of ‘getting better’, where monitoring practice may help or hinder the attainment of recovery from depression. The case study data also show that from the very earliest phases of monitoring (commonly beginning before a diagnostic label has actually been applied), work must be done to achieve a shared understanding of the problem, to set priorities for care amidst competing demands, and to revisit issues regarding who and what can help in dealing with the problem. The thesis concludes by presenting four propositions for depression monitoring practice, which are intended to provide a framework to assist GPs in pragmatically addressing both technical and relational aspects of depression care.