General Practice and Primary Care - Theses
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ItemUnderstanding mental distress in young people from a migrant background in Australia through photo-interviewing( 2017)Young people from a culturally and linguistically diverse (CALD) background in Australia are reluctant to engage with formal support services when they experience mental health problems, and are under-represented amongst the users of such services. These discrepancies in service engagement may be the result of differences in how they identify and explain mental distress experiences in comparison with the prevailing perspectives within the Australian health system. Kleinman described this conceptually as a conflict between “the cultural construction of clinical realities”. I had the following aims for this research project: to discover how young people from a CALD migrant background identified and described their experiences of mental distress, to identify the explanatory models and belief systems they utilised to understand these experiences, and to explore how their responses to these experiences – including any interactions with formal mental health services – were influenced by these understandings. Knowledge of these explanatory models and belief systems can inform the enhancement of existing mental health services, as well as provide fresh opportunities for the development of new services and programs with greater appeal and perceived relevance for this population. Fifteen participants between 18-25 years of age from a CALD migrant background and residing in Melbourne, Australia engaged with ‘photo-interviewing’ to express personal mental distress narratives. They each created up to 20 photographs that represented their mental health and distress experiences, and discussed the meaning of these photographs within the setting of an open qualitative interview. This method encouraged rich descriptions, reflective interpretation, and a storied expression of their lived experiences. The interview transcripts were analysed for themes that were relevant to how they identified, explained, and responded to these mental distress experiences. A variety of colloquial and psychological terms were used interchangeably to identify mental distress, as well as temporally situated accounts that did not utilise signifying terminology. Mental distress was explained as the result of disruptions to self-identity, social identity, and established social connections. ‘Self-identity’ referred to idealised concepts of the self that participants had either lost, aspired to attain, or sought to escape; whilst ‘social identity’ referred to their value and status amongst peers, family, and the broader community. These notions of identity were influenced by archetypal social roles and values embedded within their cultural background, and were subject to challenges from their interactions with Australian society. Separation from trusted social connections due to their migration journey resulted in disruptions to their informal support networks and their established social identities. The participants favoured self-directed actions and receiving informal social support over the engagement of formal support services. These actions were directed towards the restoration of a spoiled identity and a sense of social belonging. These findings suggest that young people from a CALD migrant background would benefit from multidisciplinary support interventions that address concerns related to disrupted identities, promote post-migration social inclusion, and build upon the capacity of informal social supports to facilitate their engagement with formal mental health services.
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ItemTelemedicine for Insulin treated Gestational Diabetes Mellitus (TeleGDM): an exploratory randomised controlled trial of the effects of a web-based GDM support system on health service utilisation, maternal and foetal outcomes, costs and user experiences( 2017)Gestational diabetes mellitus (GDM) is a condition characterised by elevated blood glucose that occurs in pregnancy and affects 11-15% of pregnant women. Tightly maintaining blood glucose levels (BGL) within target in GDM is associated with better maternal and foetal outcomes. In contrast poorly controlled hyperglycaemia is associated with adverse outcomes such as higher rates of caesarean delivery, macrosomia, foetal shoulder dystocia and admission of the new-born to a special care nursery or neonatal intensive care unit. At least 50% of women with GDM need insulin to maintain glycaemic levels within target. In the early stages of insulin commencement, women with GDM often require intensive monitoring, frequent advice and support for insulin titration. This can be difficult to manage in pregnant women who are often faced with other competing demands, including work and caring for a young family, which contribute to the challenges of managing GDM. Further, the need for intensive support, together with inconsistent attendance for appointments, contribute to difficulties with managing GDM through the out-patient setting. Telemedicine has previously been shown to enhance patient self-monitoring and enabling provision of accurate and timely data transmission and sharing between patients and clinicians. Use of telemedicine potentially enabled efficient communication with timely response by clinicians in addressing urgent situations where BGLs are outside the desired target range. As a result, telemedicine may provide an innovative approach to streamline GDM management given the intensity of support and demand for insulin-treated GDM services and burden to GDM patients to attend appointments for ongoing monitoring and support. My PhD study involved a complex intervention and as a result drew from elements of the three theoretical frameworks. First the Medical Research Council (MRC) Framework which guides the development and evaluation of complex interventions which draws attention to the steps to follow, i.e. intervention piloting and then proceeding to the exploratory phase which was the mainstay for my study. The second was the Normalisation Process Theory (NPT) which emphasises translating and embedding complex interventions in practice, noting the TeleGDM study was implemented in real practice. The third framework was the Telehealth Evaluation Framework which provides a guide to the elements to consider in order to standardise the evaluation of telehealth interventions. My PhD project aimed to explore the impact of telemedicine on the management of insulin-treated GDM at Northern Health (NH). The project which is described in detail in this thesis consisted of: i) A background literature review including a systematic literature review and meta-analysis of telemedicine for GDM management; ii) Piloting the protocol at one of the campuses of NH. The pilot was aimed at gaining insights into the flow of the recruitment process and getting feedback on the chosen telemedicine system, before proceeding to an exploratory randomised controlled trial (RCT) stage; iii) An exploratory RCT comparing an adjunct telemedicine intervention to usual care in the management of insulin-treated GDM. The study primarily looked at impact on service utilisation, i.e. outpatient GDM clinic appointments. Other outcomes included a range of maternal and foetal/new-born clinical outcomes, patient and clinician satisfaction and service provider costs; and iv) A mixed methods outcome and process evaluation of the exploratory RCT. Ninety-four patients and five CDE-RNs participated in my study. The findings showed that telemedicine support in the management of GDM produced health service and clinical outcomes similar to usual care. Adjunct telemedicine support had no significant impact on the number of face-to-face outpatient GDM clinic appointments, foetal biometrics, rates of caesarean deliveries, macrosomia, large for gestational age, admission of new-borns to the special care nursery, birth-weight or costs. The intervention had the advantage of significantly reducing the time for patients to achieve optimum glycaemic control, an important outcome in GDM management. Importantly, while not superior to usual care in terms of health service use, telemedicine did not compromise the quality and safety of care in terms of foetal and maternal outcomes. Uptake of the intervention, as reflected by the volume of GDM self-monitoring data entered into the telemedicine system by patients, showed that patients using this approach shared less data with clinicians, when compared to the usual care method of handwritten data. There was greater usage of the telemedicine system to share data in first four weeks of the intervention. Statistically, there was no difference between the intervention and control on health service provider costs. However, limitations of scaling up the intervention notwithstanding, there was potentially for a significant cost saving from a health service perspective. Themes from patient interviews showed that telemedicine as a concept, may be acceptable among patients, facilitated proactive self-management, and enabled personalised feedback. Some patients suggested telemedicine could potentially reduce face-to-face clinic attendances, thus, saving them travel time or allow them to balance work and ongoing GDM care. These views were possibly from a self-selected group of patients who engaged more with using the telemedicine system element of the intervention. Patients who engaged less with using the system were reluctant to participate in interviews. As clinicians involved in performing the clinical aspects of the study, Credentialed Diabetes Education-Registered Nurses (CDE-RNs) had mixed responses regarding telemedicine. For instance, some expressed views that telemedicine may be a supplement usual care, rather than an alternative substitute. They also cited the telemedicine system’s technical design, and lack of integration with existing ehealth systems as the negatives of telemedicine, as these factors resulted in increased work to use the system, adversely impacting on workflow and productivity. In conclusion, while my study was exploratory, telemedicine support for GDM showed no impact on service utilisation and provider costs. Telemedicine produced similar maternal and foetal clinical outcomes as usual care, suggesting no added risk to clinical quality of care, but with the possibility of a shorter time to insulin dose stabilisation. Further research in telemedicine using, user-friendly technological platforms that are fit for purpose, and including robust health economic evaluation in GDM is still needed.
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ItemReducing outcome disparities for rural Victorians with colorectal cancer: understanding pathways to treatment and informing policy.( 2017)In Victoria, rural patients with colorectal cancer have poorer outcomes than urban counterparts. To date, research and policy initiatives have focused on addressing potential variation in cancer treatment. However, pre-treatment delays may also be important. Policy change is required to reduce disparities for rural patients with cancer. Determining potential models of rural cancer care and understanding the policymaking process could enhance the success of future policies to address geographic cancer disparities. The overarching aim of the research program was to develop evidence to inform potential health system policies to reduce outcome disparities for colorectal cancer patients in rural Victoria. There were three research objectives: 1. Compare rural and urban patient pathways and experiences to diagnosis and treatment for those with colorectal and breast cancer in Victoria; 2. Identify potential models of rural cancer care that could inform future policies; and 3. Understand how large-scale health service policies in cancer care develop and are implemented. The research used a multi-phase, mixed methods design in five studies. The first phase examined rural and urban patient pathways to colorectal or breast cancer diagnosis and treatment in two studies. Breast cancer patients were included as a comparison group since outcomes are equivalent for women across Victoria. In the first study, interviews with 43 patients showed that rural and urban patients with either cancer experienced relatively similar pathways, though some had difficulty accessing GPs and longer time to specialist referral. Qualitative results informed hypotheses tested in a quantitative study of time intervals to treatment. Survey data from 922 patients with colorectal (n=433) and breast cancer (n=489), 621 GPs and 370 specialists were supplemented with cancer registry data. In quantile regression analyses, the time from first symptom or screening test to treatment was significantly longer for rural than urban patients with colorectal cancer, but not breast cancer. This was likely driven by longer diagnostic intervals for rural patients with colorectal cancer. In the second phase, patient interview data were re-analysed to explore experiences of choice of cancer treatment provider. Although most patients had limited involvement in choosing a provider, decision-making considerations were more complex for rural than urban patients. Studies in the final phase were a scoping review of rural cancer models of care and an interview study with 13 local and international key informants regarding the policymaking process. Across 47 reviewed articles, telehealth models were most common. Navigator and alternative provider models were identified for the pre-treatment period, but very few studies measured time to cancer care, and none assessed clinical cancer outcomes. Developing and implementing cancer policies at national or state-level was found to involve specific change mechanisms, such as stakeholder collaboration and evidence-use, influenced by the physical, political and temporal context. Based on these results, it is recommended that policies to address rural–urban inequities in colorectal cancer patient outcomes in Victoria focus on the diagnostic interval. Initiatives such as GP endoscopy, waiting time reporting or diagnostic centres should be investigated, acknowledging the potential impact of context in policy-change. The current research provides a baseline to assess the impact of future policies, and a starting-point for further research to understand policy development and implementation in cancer care.
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ItemFrequent users of crisis helplines: Who are they and why do they continue to call?( 2017)Crisis helplines were established in the 1950s to provide an immediate telephone response to anyone in an acute crisis. They now operate around the world, and Lifeline is recognised as one of Australia’s largest national crisis helpline services. A disproportionate number of calls to crisis helplines come from frequent users, who make multiple calls over an extended period of time. It has long been thought that frequent users are isolated individuals who call about non-crisis related issues; however, this assumption has never been investigated. Service providers struggle in knowing how to respond to frequent users while still addressing the needs of other callers. An evidence-based approach is required. AIM: The aim of this thesis was to investigate the socio-demographic characteristics of frequent users of crisis helplines and the factors driving their frequent use. Specifically, it answered the research questions: 1. What is the socio-demographic profile of frequent users of crisis helplines? 2. What are the reasons for frequent users’ continued use of crisis helplines and how do they differ to those of other callers? 3. What are the health service use patterns of frequent users of crisis helplines? METHODS: Three studies were conducted to address the research questions. Study 1, a brief survey of callers to Lifeline, investigated the socio-demographic characteristics of frequent users and differences in their reasons for calling compared with episodic and one-off callers. Quantitative analyses were conducted using ordered logistic regression. Study 2 involved interviews with Lifeline frequent users. Inductive thematic analysis was used to generate common themes to understand why some users may call crisis helplines frequently. Study 3, a longitudinal analysis of data from the diamond study, examined the relationship between frequent use of crisis helplines and health service use patterns over time. Crisis helpline use was measured at 3, 6, 9, and 12 months and analysed using ordered logistic regression. RESULTS: Compared to other callers, frequent users were more socially isolated individuals and lacked people to turn to in moments of despair. They had come to rely on crisis helplines for support; although, this was not the only factor driving them to call. They also reported disabling and chronic mental health issues, physical illnesses, and ongoing crises. The circumstances under which they called varied, but there was evidence to suggest that the current service model was not meeting their long-term needs and may in fact reinforce their calling behaviour. Frequent users also visited the general practitioner, psychiatrist, psychologist, and the emergency department at rates higher than other callers; yet, they were less satisfied with their access to these services. CONCLUSIONS: Frequent users have a genuine need for crisis support, yet, they use crisis helplines in a manner different from their intended use. They account for a substantial number of callers to crisis helplines and service providers may benefit from recognising frequent users as a legitimate group of service users. This might have implications to how counsellors approach these users and may require a change in the operation of crisis helplines.