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.