General Practice and Primary Care - Theses
Permanent URI for this collection
Search Results
1 - 3 of 3
-
ItemPartner notification for syphilis in Chile: exploring health care providers’ perspectives to enhance public health service delivery( 2019)Partner Notification (PN) has long been considered an essential strategy for sexually transmissible infection (STI) control, but both policies and methods of implementation vary between countries. Although the provision of clinical services in sexual health has improved in Chile, syphilis among the general population is one of the most commonly reported STIs. This research explores the role of PN in syphilis control in public health services in Chile. A qualitative case study was designed, and two regional Health Services, each representing a single case, were recruited. Different data collection methods were used to obtain information from different sources. A qualitative document analysis was carried out using the latest national regulations and technical documents available on the Ministry of Health website at the beginning of the study (2015) and in April 2018 for information related to PN (12 documents were reviewed). Also, a review of the current syphilis management regulations was performed to contextualise the defined local approach at the two regional Health Services, which was explored through a syphilis management clinic review in each of the 14 primary health care centres and 6 sexual health clinics which participated. Semi-structured face-to-face interviews were conducted in participating health services with 48 health care providers (HCPs), mostly midwives with more than 10 years of professional experience, as well as with 10 key informants from different backgrounds between May and September 2016. The data collected from the clinic reviews were organised using Microsoft Excel, and from the semi-interviews were transcribed verbatim. Data from both sources were managed using QSR International's NVivo 11 PRO Software. Data were thematically analysed using an inductive approach, with both within-case and cross-case thematic analysis of data from the cases. Selected quotes were translated from Spanish to English. Codes and themes were reviewed and discussed with supervisors. Findings revealed that syphilis management has a well-organised approach in public health services, but little knowledge or understanding of the infection among patients leads to a lack of recognition of the importance of informing sexual partners about their risk of having syphilis. While guidelines and recommendations highlighted syphilis prevention, PN was not suggested as an essential strategy. The management of partner(s) or sexual contact(s) was acknowledged as critical for syphilis control in the guidelines and by participants, but no document provides comprehensive information about how to deliver PN. Patient referral was the most common approach for PN delivery; however, interviewees commented that index cases do not provide information about their partners easily and the delivery of PN is further impacted by gender and the socio-cultural context of Chile. Eventually, the use of electronic communication technologies could be an alternative for enhancing current approaches. PN was perceived by HCPs as an exhausting, difficult and challenging process due to poor public understanding of syphilis, absence of practical recommendations for delivery and health system limitations. These findings are important for local and national Chilean authorities. They need to understand how PN has been implemented in these services and the experiences of HCPs in their daily routine. By following international recommendations and by including knowledge gained from this research, current practices and guidelines in Chile could be strengthened to ensure that STI control is enhanced at the population level.
-
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.
-
ItemFostering health: an Australian health policy and systems study of health assessment for children and young people in out-of-home care( 2014)This thesis reports on the first multi-centre health policy and systems study of the complex problem of health assessment for children and young people in Out-of-Home Care (OOHC) in Australia. The study has been conducted within a context of poor uptake of routine health assessment recommended by medical colleges. Analysis of the research literature around OOHC in Australia revealed that the implementation of routine health assessment had not been investigated in any systematic way. A national symposium held as part of this study confirmed the knowledge gap and identified a community of interest who supported research in this area. RESEARCH AIM: The study aimed to identify systemic and policy factors which enabled or inhibited the work of health professionals in health assessment for children in OOHC. METHODOLOGY: Guided by soft systems methodology I developed a series of conceptual models in which I imagined the elements of systems for each key step of care and then used these models as tools for comparison with experiences in the social or real world. Each of the models was built on a discrete theoretical purpose related to health assessment. The five purposes were to: I. Collect and maintain child health histories; II. Provide initial or preliminary health assessments at entry to OOHC; III. Provide comprehensive health assessments; IV. Develop individual child health management plans; V. Monitor the provision of assessment and treatment services and child health outcomes. In order to explore experiences in the social world, I undertook an embedded case-study to collect data from 9 organisations (incorporating 12 geographical sites) across two states of Australia with large OOHC populations. Case study data comprised my analysis of policy and procedural documents from state jurisdictions and local sites, observations from site visits and analysis of recordings from 47 semi-structured interviews with health professionals and policy advisors spanning 10 disciplines. RESULTS: The outcomes demonstrated that a lack of agreement about central concepts, such as how health is defined hampered consistency of assessment processes. Similarly I uncovered disparate ideas about the purpose of health assessment in OOHC, underpinned to some extent, by variable appreciation of child abuse and neglect as health determinants. At a systemic level, I found a synergy between conceptual models of systems of care associated with health assessment and the steps which health professionals both value and strive to implement in everyday practice. The results provide a compelling illustration of systemic complexity and interconnectedness. Across all steps of care the study results show that much hinges on the efficacy and effectiveness of the first step of collecting and sharing child health histories. In this step health professionals find themselves in a dependent relationship with staff from the child protection sector whose roles include gate-keeper, referrer, family liaison officer, child case manager and corporate parent. This dependence exemplifies a recurring theme in the everyday experiences of health professionals: the contrast between usual processes of patient care and the greater complexity of health assessment steps in OOHC. I argue for rethinking health policies which have been premised on minimalist approaches involving either usual, universal health care or “tweaking” usual health care processes. Minimalist interventions, such as giving children in OOHC priority in the queue for assessment cannot by themselves bring about the extent of systemic changes desired by health professionals. Of critical need are permanent and accessible health records for children who have experienced maltreatment. This thesis demonstrated that the health policy and system approach has broad utility in improving our understanding of what has been problematic about health assessment in OOHC in Australia and what changes are desirable in assessment approaches. A key strength of the study was that multi-centre and multi-disciplinary recruitment across two legislative jurisdictions enabled me to capture health professionals’ views and experiences from multiple contexts. This added richness to the data and rigour to the generalizability of the study results. IMPLICATIONS: As a result of this study I formed a view that professional purposes, judgement and volition among health professionals are individual matters, more influenced by peers, training and clinical experience than by public policy. Not only do doctors have a unique role to play in clinical governance in OOHC but their knowledge and skills, their professional roles and identity and their beliefs about the consequences of their work are important influences in bringing about quality improvement in health care. Messages from research and the recommendations of medical colleges in Australia, U.S. and U.K. were clear that health professionals believed individualized, systematic health assessment was warranted in OOHC, notwithstanding the cost. Furthermore, doctors in this study demonstrated sufficient power and professional autonomy to stop, start, block, enhance or lead initiatives to improve health assessment in OOHC. Analysis of the steps of care associated with health assessment in OOHC revealed a deeply complex web of inter-connected activities which rest on sophisticated clinical decision making by doctors. The results of this thesis indicate that health professionals are aided in their work when governments and child protection agencies appreciate this complexity and sophistication. The results of this study suggest areas where change is desirable in order to break the impasse of poor implementation of health assessment. A more congruent common understanding of the concept of health in OOHC is essential i.e. what is being assessed. Alongside this a more careful alignment of theoretical and practical purposes in health assessment is needed. I argue that in the context of Australia’s moral and civic obligations under the 1989 United Nations Convention on the Rights of the Child, purposes of health assessment must be more coherently aligned around reparative health care, and responsive to the impacts of child maltreatment on life-course health outcomes. More widespread appreciation of maltreatment as a health determinant is required in order for policy advisors and health practitioners to better align health assessment policies and practices.