General Practice and Primary Care - Research Publications
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ItemNo Preview AvailableHealth issues in newly arrived African refugees attending general practice clinics in Melbourne(Australasian Medical Publishing Company, 2006)Objective: To identify the most common health issues diagnosed by general practitioners in newly arrived African refugees. Design: Descriptive study based on a purposive sample of six GPs to collate data from medical records of patients from African countries who had attended their clinics for the first time between 1 January and 30 June 2005. Setting: Two community health centres and two private general practices in metropolitan Melbourne. Participants: African refugee patients who arrived in Australia after 1 June 2004 and were seen by the six participating GPs between 1 January and 30 June 2005. Main outcome measures: Demographic characteristics, laboratory test results and final diagnoses. Results: Data were collected from 258 patient files. Most patients were from Sudan (57%) or Liberia (17%). Half were aged under 15 years. The most common health problems identified were inadequate vaccinations, nutritional deficiencies (vitamin D and iron), infectious diseases (gastrointestinal infections, schistosomiasis, and latent tuberculosis) and dental disease. Musculoskeletal, psychological and social problems were common in adults. 37% of patients were tested for latent tuberculosis, and 25% of these tested positive. Conclusions: African refugees require comprehensive health assessments for undiagnosed and untreated health problems. While most of the common diseases identified are non-communicable, if left untreated they will affect the long-term health and productivity of new settlers.
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ItemStepwise screening for diabetes identifies people with high but modifiable coronary heart disease risk. The ADDITION study(SPRINGER, 2008-07)AIMS/HYPOTHESIS: The Anglo-Danish-Dutch study of intensive treatment in people with screen-detected diabetes in primary care (ADDITION) is a pragmatic randomised controlled trial of the effectiveness of intensified multi-factorial treatment on 5 year cardiovascular morbidity and mortality rates in people with screen-detected type 2 diabetes in the Netherlands, UK and Denmark. This paper describes the baseline characteristics of the study population, their estimated risk of coronary heart disease and the extent to which that risk is potentially modifiable. METHODS: Stepwise screening strategies were performed using risk questionnaires and routine general practice data plus random blood glucose, HbA(1c) and fasting blood glucose measurement. Diabetes was diagnosed using the 1999 World Health Organization criteria and estimated 10 year coronary heart disease risk was calculated using the UK Prospective Diabetes Study risk engine. RESULTS: Between April 2001 and December 2006, 3,057 people with screen-detected diabetes were recruited to the study (mean age 59.7 years, 58% men) after a stepwise screening programme involving 76,308 people screened in 334 general practices in three countries. Their median estimated 10 year risk of coronary heart disease was 11% in women (interquartile range 7-16%) and 21% (15-30%) in men. There were differences in the distribution of risk factors by country, linked to differences in approaches to screening and the extent to which risk factors had already been detected and treated. The mean HbA(1c) at recruitment was 7.0% (SD 1.6%). Of the people recruited, 73% had a blood pressure > or =140/90 and of these 58% were not on antihypertensive medication. Cholesterol levels were above 5.0 mmol/l in 70% of participants, 91% of whom were not being treated with lipid-lowering drugs. CONCLUSIONS/INTERPRETATION: People with type 2 diabetes detected by screening and included in the ADDITION study have a raised and potentially modifiable risk of CHD. ClinicalTrials.gov ID no.: NCT 00237549.
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ItemEthnic disparities in diabetes management and pay-for-performance in the UK: The Wandsworth prospective diabetes study(PUBLIC LIBRARY SCIENCE, 2007-06)BACKGROUND: Pay-for-performance rewards health-care providers by paying them more if they succeed in meeting performance targets. A new contract for general practitioners in the United Kingdom represents the most radical shift towards pay-for-performance seen in any health-care system. The contract provides an important opportunity to address disparities in chronic disease management between ethnic and socioeconomic groups. We examined disparities in management of people with diabetes and intermediate clinical outcomes within a multiethnic population in primary care before and after the introduction of the new contract in April 2004. METHODS AND FINDINGS: We conducted a population-based longitudinal survey, using electronic general practice records, in an ethnically diverse part of southwest London. Outcome measures were prescribing levels and achievement of national treatment targets (HbA1c < or = 7.0%; blood pressure [BP] < 140/80 mm Hg; total cholesterol < or = 5 mmol/l or 193 mg/dl). The proportion of patients reaching treatment targets for HbA1c, BP, and total cholesterol increased significantly after the implementation of the new contract. The extents of these increases were broadly uniform across ethnic groups, with the exception of the black Caribbean patient group, which had a significantly lower improvement in HbA1c (adjusted odds ratio [AOR] 0.75, 95% confidence interval [CI] 0.57-0.97) and BP control (AOR 0.65, 95% CI 0.53-0.81) relative to the white British patient group. Variations in prescribing and achievement of treatment targets between ethnic groups present in 2003 were not attenuated in 2005. CONCLUSIONS: Pay-for-performance incentives have not addressed disparities in the management and control of diabetes between ethnic groups. Quality improvement initiatives must place greater emphasis on minority communities to avoid continued disparities in mortality from cardiovascular disease and the other major complications of diabetes.
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ItemStaffing in postnatal units: is it adequate for the provision of quality care? Staff perspectives from a state-wide review of postnatal care in Victoria, Australia.(Springer Science and Business Media LLC, 2006-07-04)BACKGROUND: State-wide surveys of recent mothers conducted over the past decade in Victoria, one state of Australia, have identified that women are consistently less satisfied with the care they received in hospital following birth compared with other aspects of maternity care. Little is known of caregivers' perspectives on the provision ofhospital postnatal care: how care is organised and provided in different hospitals; what constrains the provision of postnatal care (apart from funding) and what initiatives are being undertaken to improve service delivery. A state-widereview of organisational structures and processes in relation to the provision of hospital postnatal care in Victoria was undertaken. This paper focuses on the impact of staffing issues on the provision of quality postnatal care from the perspective of care providers. METHODS: A study of care providers from Victorian public hospitals that provide maternity services was undertaken. Datawere collected in two stages. Stage one: a structured questionnaire was sent to all public hospitals in Victoria that provided postnatal care (n = 73), exploring the structure and organisation of care (e.g. staffing, routine observations, policy framework and discharge planning). Stage two: 14 maternity units were selected and invited to participate in a more in-depth exploration of postnatal care. Thirty-eight key informant interviews were undertaken with midwives (including unit managers, associate unit managers and clinical midwives) and a medical practitioner from eachselected hospital. RESULTS: Staffing was highlighted as a major factor impacting on the provision of quality postnatal care. There were significant issues associated with inadequate staff/patient ratios; staffing mix; patient mix; prioritisation of birth suites over postnatal units; and the use of non-permanent staff. Forty-three percent of hospitals reported having only midwives (i.e. no non-midwives) providing postnatal care. Staffing issues impact on hospitals' ability to provide continuity of care. Recruitment and retention of midwives are significant issues, particularly in rural areas. CONCLUSION: Staffing in postnatal wards is a challenging issue, and varies with hospital locality and model of care. Staff/patient ratios and recruitment of midwives in rural areas are the two areas that appear to have the greatest negative impact on staffing adequacy and provision of quality care. Future research on postnatal care provision should include consideration of any impact on staff and staffing.
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ItemThe early postnatal period: exploring women's views, expectations and experiences of care using focus groups in Victoria, Australia.(Springer Science and Business Media LLC, 2008-07-22)BACKGROUND: There is growing evidence from Australia and overseas that the care provided in hospital in the early postnatal period is less than ideal for both women and care providers. Many health services face increasing pressure on hospital beds and have limited physical space available to care for mothers and their babies. We aimed to gain a more in-depth understanding of women's views, expectations and experiences of early postnatal care. METHODS: We conducted focus groups in rural and metropolitan Victoria, Australia in 2006. Fifty-two people participated in eight focus groups and four interviews. Participants included eight pregnant women, of whom seven were pregnant with their first baby; 42 women who were in the postpartum period (some up to twelve months after the birth of their baby); and two partners. All participants were fluent in English. Focus group guides were developed specifically for the study and explored participants' experiences and/or expectations of early postnatal care in hospital and at home, with an emphasis on length of hospital stay, professional and social support, continuity of care, and rest. Discussions were audio-taped and transcribed verbatim. A thematic network was constructed to describe and connect categories with emerging basic, organizing, and global themes. RESULTS: Global themes that emerged were: anxiety and/or fear; and the transition to motherhood and parenting. The needs of first time mothers were considered to be different to the needs of women who had already experienced motherhood. The women in this study were generally concerned about the safety of their new baby, and lacked confidence in themselves as new mothers regarding their ability to care for their baby. There was a consistent view that the physical presence and availability of professional support helped alleviate these concerns, and this was especially the case for women having a first baby. CONCLUSION: Women have anxieties and fears around early parenting and their changing role, and may consider that the physical availability of professional care providers will help during this time. Care providers should be cognisant of these potential issues. It is crucial that women's concerns and needs be considered when service delivery changes are planned. If anxiety around new parenting is a predominant view then care providers need to recognise this and ensure care is individualised to address each woman's/families particular concerns.
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ItemDepression and termination of pregnancy (induced abortion) in a national cohort of young Australian women: the confounding effect of women's experience of violence(BIOMED CENTRAL LTD, 2008-02-26)BACKGROUND: Termination of pregnancy is a common and safe medical procedure in countries where it is legal. One in four Australian women terminates a pregnancy, most often when young. There is inconclusive evidence about whether pregnancy termination affects women's rates of depression. There is evidence of a strong association between partner violence and depression. Our objective was to examine the associations with depression of women's experience of violence, pregnancy termination, births and socio-demographic characteristics, among a population-based sample of young Australian women. METHODS: The data from the Younger cohort of the Australian Longitudinal Study on Women's Health comprised 14,776 women aged 18-23 in Survey I (1996) of whom 9683 aged 22-27 also responded to Survey 2 (2000). With linked data, we distinguished terminations, violence and depression reported before and after 1996.We used logistic regression to examine the association of depression (CES-D 10) as both a dichotomous and linear measure in 2000 with pregnancy termination, numbers of births and with violence separately and then in mutually adjusted models with sociodemographic variables. RESULTS: 30% of young women were depressed. Eleven percent (n = 1076) reported a termination by 2000. A first termination before 1996 and between 1996 and 2000 were both associated with depression in a univariate model (OR 1.37, 95%CI 1.12 to 1.66; OR 1.52, 95%CI 1.24 to 1.87). However, after adjustment for violence, numbers of births and sociodemographic variables (OR 1.22, 95%CI 0.99 to 1.51) this became only marginally significant, a similar association with having two or more births (1.26, 95%CI. 1.00 to 1.58). In contrast, any form of violence but especially that of partner violence in 1996 or 2000, was significantly associated with depression: in univariate (OR 2.31, 95%CI 1.97 to 2.70 or 2.45, 95% CI 1.99 to 3.04) and multivariate models (AOR 2.06, 95%CI 1.74 to 2.43 or 2.12, 95%CI 1.69 to 2.65). Linear regression showed a four fold greater effect of violence than termination or births. CONCLUSION: Violence, especially partner violence, makes a significantly greater contribution to women's depression compared with pregnancy termination or births. Any strategy to reduce the burden of women's depression should include prevention or reduction of violence against women and strengthening women's sexual and reproductive health to ensure that pregnancies are planned and wanted.
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ItemGeneral practice and pandemic influenza: a framework for planning and comparison of plans in five countries.(Public Library of Science (PLoS), 2008-05-28)BACKGROUND: Although primary health care, and in particular, general practice will be at the frontline in the response to pandemic influenza, there are no frameworks to guide systematic planning for this task or to appraise available plans for their relevance to general practice. We aimed to develop a framework that will facilitate planning for general practice, and used it to appraise pandemic plans from Australia, England, USA, New Zealand and Canada. METHODOLOGY/PRINCIPAL FINDINGS: We adapted the Haddon matrix to develop the framework, populating its cells through a multi-method study that incorporated the peer-reviewed and grey literature, interviews with general practitioners, practice nurses and senior decision-makers, and desktop simulation exercises. We used the framework to analyse 89 publicly-available jurisdictional plans at similar managerial levels in the five countries. The framework identifies four functional domains: clinical care for influenza and other needs, public health responsibilities, the internal environment and the macro-environment of general practice. No plan addressed all four domains. Most plans either ignored or were sketchy about non-influenza clinical needs, and about the contribution of general practice to public health beyond surveillance. Collaborations between general practices were addressed in few plans, and inter-relationships with the broader health system, even less frequently. CONCLUSIONS: This is the first study to provide a framework to guide general practice planning for pandemic influenza. The framework helped identify critical shortcomings in available plans. Engaging general practice effectively in planning is challenging, particularly where governance structures for primary health care are weak. We identify implications for practice and for research.
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ItemPrevalence and determinants of child maltreatment among high school students in Southern China: a large scale school based survey.(Springer Science and Business Media LLC, 2008-09-29)BACKGROUND: Child maltreatment can cause significant physical and psychological problems. The present study aimed to investigate the prevalence and determinants of child maltreatment in Guangzhou, China, where such issues are often considered a taboo subject. METHODS: A school-based survey was conducted in southern China in 2005. 24 high schools were selected using stratified random sampling strategy based on their districts and bandings. The self-administered validated Chinese version of parent-child Conflict Tactics Scale (CTSPC) was used as the main assessment tool to measure the abusive experiences encountered by students in the previous six months. RESULTS: The response rate of this survey was 99.7%. Among the 6592 responding students, the mean age was 14.68. Prevalence of parental psychological aggression, corporal punishment, severe and very serve physical maltreatment in the past 6 months were 78.3%, 23.2%, 15.1% and 2.8% respectively. The prevalence of sexual abuse is 0.6%. The most commonly cited reasons for maltreatment included 'disobedience to parents', 'poor academic performance', and 'quarrelling between parents'. Age, parental education, places of origins and types of housing were found to be associated with physical maltreatments whereas gender and fathers' education level were associated with sexual abuse. CONCLUSION: Though largely unspoken, child maltreatment is a common problem in China. Identification of significant determinants in this study can provide valuable information for teachers and health professionals so as to pay special attention to those at-risk children.
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ItemDevelopment of a quality assessment tool for systematic reviews of observational studies (QATSO) of HIV prevalence in men having sex with men and associated risk behaviours.(Springer Science and Business Media LLC, 2008-11-17)BACKGROUND: Systematic reviews based on the critical appraisal of observational and analytic studies on HIV prevalence and risk factors for HIV transmission among men having sex with men are very useful for health care decisions and planning. Such appraisal is particularly difficult, however, as the quality assessment tools available for use with observational and analytic studies are poorly established. METHODS: We reviewed the existing quality assessment tools for systematic reviews of observational studies and developed a concise quality assessment checklist to help standardise decisions regarding the quality of studies, with careful consideration of issues such as external and internal validity. RESULTS: A pilot version of the checklist was developed based on epidemiological principles, reviews of study designs, and existing checklists for the assessment of observational studies. The Quality Assessment Tool for Systematic Reviews of Observational Studies (QATSO) Score consists of five items: External validity (1 item), reporting (2 items), bias (1 item) and confounding factors (1 item). Expert opinions were sought and it was tested on manuscripts that fulfil the inclusion criteria of a systematic review. Like all assessment scales, QATSO may oversimplify and generalise information yet it is inclusive, simple and practical to use, and allows comparability between papers. CONCLUSION: A specific tool that allows researchers to appraise and guide study quality of observational studies is developed and can be modified for similar studies in the future.
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ItemDevelopments in Australian general practice 2000-2002: what did these contribute to a well functioning and comprehensive Primary Health Care System?(Springer Science and Business Media LLC, 2006-01-15)BACKGROUND: In recent years, national and state/territory governments have undertaken an increasing number of initiatives to strengthen general practice and improve its links with the rest of the primary health care sector. This paper reviews how far these initiatives were contributing to a well functioning and comprehensive primary health care system during the period 2000-2002, using a normative model of primary health care and data from a descriptive study to evaluate progress. RESULTS: There was a significant number of programs, at both state/territory and national level. Most focused on individual care, particularly for chronic disease, rather than population health approaches. There was little evidence of integration across programs: each tended to be based in and focus on a single jurisdiction, and build capacity chiefly within the services funded through that jurisdiction. As a result, the overall effect was patchy, with similar difficulties being noted across all jurisdictions and little gain in overall system capacity for effective primary health care. CONCLUSION: Efforts to develop more effective primary health care need a more balanced approach to reform, with a better balance across the different elements of primary health care and greater integration across programs and jurisdictions. One way ahead is to form a single funding agency, as in the UK and New Zealand, and so remove the need to work across jurisdictions and manage their competing interests. A second, perhaps less politically challenging starting point, is to create an agreed framework for primary health care within which a collective vision for primary health care can be developed, based on population health needs, and the responsibilities of different sectors services can be negotiated. Either of these approaches would be assisted by a more systematic and comprehensive program of research and evaluation for primary health care.
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