General Practice and Primary Care - Theses
Permanent URI for this collection
Search Results
1 - 7 of 7
-
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.
-
ItemAn investigation of the implementation of Victorian smoking cessation guidelines in public antenatal care services( 2015)Background: Modifying smoking behaviour in pregnancy can contribute to a significant improvement in infant health outcomes. Systematic review evidence supports the effectiveness of antenatal smoking cessation interventions to reduce smoking and improve infant health outcomes, such as preterm births and low birthweight. Victorian antenatal smoking cessation guidelines were developed in the early 2000s, and follow a 5As approach (five steps to ask, assess, advise, assist and ask again about smoking behaviour). The annual auditing of Victorian public maternity hospitals, available in State Government reports, indicates that not all women are being offered smoking cessation support, and that variation exists between hospitals in the proportion of women offered initial and follow-up support. At the time of designing this study, no other evidence was available documenting how antenatal smoking cessation guidelines have been implemented in Victoria, and how implementation might be improved. Aim: The overall aim of this PhD study is to examine the implementation of Victorian smoking cessation guidelines in public antenatal care services. The primary research questions are: 1. To what extent, and how, have antenatal smoking cessation guidelines been implemented in Victorian public maternity hospitals? 2. How can implementation be improved? Methods: The study uses a mixed methods approach, with a sequential explanatory research design with two phases: 1. Secondary analyses of data from a Victorian population-based survey of women who gave birth in 2007. 2. An exploratory qualitative study with healthcare providers and managers at two Victorian public maternity hospitals. Results: The survey results show that smoking cessation guidelines in Victoria are poorly implemented, with only 9.4% of women (36/381) reporting that they had received all of the 5As. Most women smoking in pregnancy reported that they had been asked about smoking (352/377, 93.4%), and told about the harmful effects of smoking (290/350, 82.9%). However, less than half of women were offered advice (169/349, 48.4%) or given written information (159/349, 45.6%). One in five women reported being told about stop smoking programs (76/349, 21.8%), and one-third said that caregivers had discussed smoking with them on more than one occasion (135/349, 38.7%). The qualitative study shows that provision of smoking cessation advice and support is inconsistent and varies according to the model of care a woman is enrolled in, her level of medical risk, the timing of the first pregnancy visit, and social circumstances. The study also identified that the provision of smoking cessation support is influenced by organisational systems that support clinicians in their clinical practice; the relationship that develops between health professionals and individual women; health professionals’ knowledge, experience, beliefs, and understanding of risk; and the level of priority that health professionals place on smoking cessation conversations. The survey results show that women experience mixed feelings about being asked by health professionals about smoking. Approximately three-quarters of women were happy to be asked about smoking; however, one-third of women felt like they were being judged. Women who smoke during pregnancy are more likely to experience multiple stressful life events and social health issues. However, tailoring of smoking cessation support to specific populations or women’s social circumstances is not routine practice. Implications for policy and practice: Organisations and health professionals are struggling to provide smoking cessation advice and support according to the guidelines. Currently, apart from the annual auditing of the maternity performance indicator for the hospital provision of smoking cessation support, there is little innovation or guidance from the Victorian Department of Health to support hospitals to implement the Victorian smoking cessation guidelines. Funding constraints have resulted in Quit Victoria having limited capacity to provide ongoing state-wide training to support maternity healthcare organisations and health professionals to implement smoking cessation guidelines. Additionally, the findings from this study show little return on the investment for previous state-wide training initiatives, suggesting that a new approach needs to be considered for future training initiatives. Conclusion: Evidence from this study illustrates major gaps in the provision of smoking cessation support, and identifies organisational, people, and systems barriers to implementation. There needs to be a ‘whole of systems’ approach to thinking about improvements, with careful consideration given to the interactions between different parts of the system and the contextual environment. Key recommendations arising from the findings address six major areas where action is needed to improve the implementation of the guidelines. This includes the development and application of a ‘whole of systems’ approach, training, smoking cessation resources, data systems, flow of communication between GPs and public maternity hospitals, and tailored approaches to specific populations.
-
ItemProfessional roles and relationships in health models of care: a study of insulin initiation in Australian general practice( 2015)Background: The majority of care for people with type 2 diabetes occurs in general practice in Australia, yet insulin initiation is often delayed in this setting and many people are referred to specialists (endocrinologists and registered nurse credentialed diabetes educators (RN-CDEs)). Stepping Up (SU) is a new model of care supporting insulin initiation in general practice which includes an enhanced role for practice nurses (PNs) with support and mentoring from a SU RN-CDE. Successful implementation of this model of care is likely to be shaped by interprofessional roles and relationships. Relational Coordination (RC) theory provides a conceptual framework to study key factors underpinning effective interprofessional work. Aim: To explore the roles and relationships between health professionals involved in insulin initiation, how these are affected by models of care and whether, within the Stepping Up model of care, they are associated with improved clinical outcomes. Methods: I conducted five related sub-studies utilising RC theory. The first two sub-studies were exploratory and utilised a survey and interviews to explore current levels of RC between endocrinologists, RN-CDE, General Practitioners (GPs) and PNs for the task of insulin initiation, perceived appropriateness of this task in general practice and contextual factors influencing RC. The last three sub-studies were nested within a randomised controlled trial testing the effectiveness of SU. I analysed a baseline cross sectional survey exploring characteristics of participating GPs, PNs and general practices associated with RC for the task of insulin initiation. I explored how GPs and PNs perceived that SU had impacted on professional roles and RC using qualitative methods. Finally, I performed a quantitative analysis to determine whether RC was a partial mediator of the effect of SU on glycaemic outcomes. Results: There was agreement from all four health professional groups that general practice-based initiation of insulin was appropriate. Potential barriers to achieving this in practice included a lack of communication and relationships between health professionals across secondary/specialist and primary care, with weak RC reported between PNs and RN-CDE. Specialists had concerns about the competence and capacity for PNs to have a role in insulin initiation. Factors associated with stronger RC included PN qualifications in diabetes education, PN prior experience with insulin initiation, younger PN age and increasing rurality of general practices. Dedicated space and protected time for PNs to participate in insulin initiation and RN-CDE mentoring were identified as important facilitators for an expanded PN role. While SU was associated with improved glycaemic outcomes, this was not mediated by RC with RN-CDE reported by PNs. Conclusion: SU was explicitly designed to change professional roles to support insulin initiation in general practice. SU was associated with stronger inter-professional relationships, particularly between PNs and the SU RN-CDE, and improved clinical outcomes for patients. Other important factors in normalising the SU model of care into Australian general practice include achieving interprofessional consensus on the role of PNs in insulin initiation, funding structures to support the PN and SU RN-CDE roles and organising general practice to support expanded PN roles.
-
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.
-
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.
-
ItemSafety and resiliency at home: voices of children from a primary care population( 2015)Almost one quarter of Australian children experience family violence perpetrated by their father or step father which has significant health outcomes across the lifespan. However, some children who experience family violence are thought to be resilient. Children lack opportunities to have their voices heard, therefore children’s own understandings of their safety and resilience are often missing. As a site of early intervention, primary care is well placed to respond to these children. The aim of the research was to hear children’s voices about their safety and resilience in the context of family violence, and to determine an appropriate primary care response. Qualitative methodologies underpinned the research which involved semi-structured interviews and focus groups with 23 children and 18 mothers from primary care settings, all of whom had experienced family violence. I developed a child-centred approach utilising ethical and safe methods. A theoretical framework of ethics of care and dialogical ethics informed the research. Hermeneutic phenomenological analysis revealed that children and mothers understood children’s safety in the context of: awareness of family violence; whether the violence was named and by whom; who provided care and protection; and children’s sense of trust in relationships. Resilience was understood differently by children and mothers. Children understood their resilience according to social recognition of their achievements and talents. The children’s meaning was independent of adversity and aligned with the concept of relational self-worth. Mothers however, only understood children’s resilience with reference to the adversity their child had experienced. This was underpinned by the mother’s sense of responsibility for the adversity and the child’s apparent resilience despite this adversity. Understandings of safety and resiliency were further analysed to reveal the key finding that children required agency to negotiate their safety in the context of family violence and post-separation. A ‘model of children’s agency’ was developed to reflect the four factors that facilitated children’s agency: physical and emotional distance from the perpetrator; awareness of disruption or danger in the parental relationship; modelling of safety in relationships by non-violent adults; and the child’s sense of co-constructing family resiliency. To inform an appropriate primary care response, I also sought children’s and mothers’ understandings of primary care. Their insights focused on: questioning the role of primary care to respond to children experiencing family violence; the importance of knowing and modelling within the child-mother-health practitioner relationship; and the expectation that the health practitioner would facilitate communication about family violence. Using these insights, I proposed an approach based on collaboration, relationship and shared language, an ‘informed trialogue’ within the child-mother-health practitioner triad to foster children’s agency in the primary care consultation. The ‘informed trialogue’ guides the health practitioner to encourage and impart the ‘model of children’s agency’ by advocating physical and emotional distance from the perpetrator; building child awareness of family violence; supporting the modelling of safety in trusted relationships and demystifying family resiliency. The ‘model of children’s agency’ and the ‘informed trialogue’ bring children’s voices to the fore to inform primary care and those that work with children experiencing family violence.
-
ItemExploring social constructions of, and the use of power to deal with, patient aggression in general practice( 2015)This thesis investigates the meaning of patient aggression in general practice and the use of power to deal with it, through a multi-case comparison of four general practices sampled on the basis of different business models. Much debate on the topic has focused on encapsulating the concept so that prevalence and associated factors could be determined. Current accounts highlight aggression directed towards general practitioners, but pay less attention to the experiences of other workers. Previous research has overlooked the contested nature of the concept along with contextual and interactional circumstances surrounding patient aggression. This thesis addresses these gaps by exploring how general practice workers from different occupational backgrounds understand patient aggression and how various types of general practice organisations use power to deal with the phenomenon. I adopt a social constructionist approach to argue that the meaning of patient aggression arises from the type of interaction. Qualitative methodologies underpin this multiple case study, which involved semi-structured interviews, observation, and document analysis. To explore the use of power, I draw on an analytical framework based on Steven Lukes’ (2005) critical conceptualisation of power. I discovered two interactional prototypes in general practice: front-line interactions between practice gatekeepers and patients, and rapport-building interactions between health professionals and patients. Gatekeepers tend to normalise patient aggression, whilst health professionals lean towards trivialisation. Normalisation renders the frequent exposure to aggression at the front line an acceptable and normal ‘part of the job’. In contrast, trivialisation enables health professionals to suppress perceptions of heightened vulnerability and avoid victimisation. Both interactional prototypes employ medicalisation and stigmatisation. To understand the use of power to deal with patient aggression, I compare a small partnership practice, a community health service, a large group practice, and a corporate-owned practice. I discuss how these practices manage the meaning of their interactions with patients differently. I interpret this management of meaning as an exercise of power in the third dimension, which is the most sophisticated way to deal with patient aggression. The current understanding of how to deal with patient aggression aligns with the use of power in the first dimension and, therefore, overlooks less manifest types of power. This thesis makes three contributions to the literature on patient aggression. First, it offers insights into different constructions of meaning based on the nature of the interaction. Second, it clarifies how business models shape ways general practices interact with their patients. In departing from a mere behavioural focus, data analysis focuses on processes behind the social construction of ‘patient aggression’ and examines organisational characteristics that determine the use of power to deal with aggression. Third, this thesis contributes to the literature that applies Lukes’ (2005) framework to the examination of organisational phenomena. The findings help in identifying organisational features that influence interactions with patients. Implications for further research include the application of a similar design to a rural-urban comparison, specialist care settings, and a cross-national study. It is also of interest to further explore the impact of the organisational context on other phenomena.