General Practice and Primary Care - Theses
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ItemYoung people's assessment of general practice care : a practice based study in primary care(University of Melbourne, 2008)
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ItemWitnessing loss during Lockdown: Nurses and Midwives experience caring for women who suffered miscarriage during the Covid-19 lockdown in Melbourne Australia( 2023-08)This qualitative study explored psychosocial care for women who experienced miscarriage in a public hospital during the Covid-19 pandemic in Melbourne, Australia, and the effects of this on the nurses and midwives who cared for them. Findings showed a movement further away from family-focused care increasing the risk of women feeling isolated, alone and psychologically traumatised. This study also showed the increased distress nurses and midwives felt caring for women experiencing miscarriage during the pandemic on both their own wellbeing and for their patients.
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ItemReproductive genetic carrier screening for cystic fibrosis, fragile X syndrome and spinal muscular atrophy in general practice( 2022)The Royal Australian and New Zealand College of Obstetricians and Gynaecologists and The Royal Australian College of General Practice recommend that information on reproductive genetic carrier screening (RGCS) for at least the most common inherited genetic conditions in our population, that is thalassaemia, cystic fibrosis (CF), spinal muscular atrophy (SMA), and fragile X syndrome (FXS), should be offered to all women planning pregnancy or in early pregnancy regardless of family history or ethnicity. While it is recognized that general practice is an appropriate place to undertake RGCS, little is known about when and how general practitioners are offering RGCS in Australia and what their attitude to screening is. This study, using qualitative and quantitative methods, has investigated when, where, how and why general practitioners (GPs) have participated in a 3-condition RGCS testing for FXS, CF, and SMA, and has measured carrier frequencies for these conditions in the community. GP participation was generally low, with much greater participation among obstetricians. Marked inequity of access to RGCS was identified, with very low rates of screening among socioeconomically disadvantaged women and women from rural and regional areas. GPs offering screening had a positive attitude to the role of general practice in RGCS. They were confident in their counselling skills and reported that the offer of screening was acceptable to their patients. Offering screening as part of preconception care was seen as preferable to antenatal screening. Barriers to offering screening in general practice were low levels of GP education in carrier screening, out of pocket cost of screening, regional or rural locations, and low frequency of preconception care consultations. Addressing the causes of inequity of access to screening in general practice, particularly the out-of-pocket cost of screening, and poor provision of preconception care, will allow more women and couples the opportunity to make informed choices about participation in screening.
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ItemGPimED: General Practice: improving management of Eating Disorders: Can a one hour online educational intervention improve the detection and management of patients with Eating Disorders by General Practice Trainees?( 2020)GPimED: Can a one- hour on-line learning module improve early diagnosis and management of Eating Disorders by General Practice Trainees? PROBLEM STATEMENT Eating disorders are a serious and potentially life-threatening group of illnesses within the community. The literature shows that diagnosis and management of these illnesses are inadequately covered during medical school and subsequent General Practice training. This can result in a delay in diagnosis and appropriate referral thus significantly contributing to patient morbidity and mortality plus increased financial burden on the community. The literature demonstrates that patients with ED present repeatedly to General Practice (GP) with a myriad of signs and symptoms There is often delay in diagnosis due to varied reasons. The literature also finds that this delay coupled with lack of appropriate management can greatly exacerbate the morbidity and potential mortality. For example, within this group of disorders, Anorexia Nervosa (AN) has the highest mortality rate of any psychiatric illness with suicide rates 32 times higher than the general population and a mortality rate of 10%. General Practitioners (GPs) are often time poor and lack the knowledge to adequately manage patients with ED Online education for GPs is becoming more popular as it is cost effective, convenient and allows rural and remote GPs access to educational material they might not otherwise be able to access if it is available only via face to face delivery AIM The aim of this study is to determine whether a one-hour online learning module developed to upskill General Practitioners in the recognition and management of Eating Disorders improves the performance of GP trainees. SIGNFICANCE This study will shed light on the effectiveness of online education in upskilling GP trainees and if the ED module is successful, it may lead to improved treatment of patients with evolving or established eating disorders in the General Practice setting. It will potentially reduce the rates of delayed diagnosis resulting in improved outcomes. The literature indicates that patients with an ED present up to 5 times more frequently to primary care than demographically matched peers. General Practice is thus ideally placed to recognize these patients, to make a timely diagnosis and initiate appropriate investigation, management and referrals. The literature also indicates when diagnosis and appropriate intervention occurs within the first three years of the disorder developing, there is a greater than 40% chance of complete recovery. On November 1st 2019, the Federal Government initiated $110 million in extra funding for increased support for patients with a serious ED. This support can only be accessed if the patient as an Eating Disorder Plan completed is be done by the GP who has performed appropriate screening and provided the requisite history, examination and investigations. METHODS The trial design was a randomized, parallel-group study. Participants were recruited from the Victorian General Practice Training Consortia MCCC and EVGPT. The comparator was a general Youth Mental health module. Baseline surveys including demographic details plus a clinical case designed to assess baseline competence in recognising a probable eating disorder case and management thereafter. Following randomisation to either the ED module arm (intervention) or control arm, follow up surveys were completed after 6 weeks, quantitative evaluation was conducted using clinical scenarios presented as case studies in the format of Key Feature Problems (KFPs) which are a component of the FRACGP examination. RESULTS Despite our best efforts, there were only small number of recruits- 15 respondents with 8 completing all components of the study. Despite the small sample, there was measurable improvement in many parameters assessed cross both arms of the trial. In particular, an increase in the identification of ED as a differential diagnosis and improved referrals to health professionals considered integral to the evidence based best practice multidisciplinary team approach to ED management.
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ItemThe role of physiotherapists in providing nutrition care to improve dietary behaviours( 2020)Background: Non-communicable chronic diseases are the foremost cause of death, illness, and disability in Australia. Poor dietary behaviours contribute significantly to the burden of chronic disease and health care costs. Promoting healthy eating is a crucial step to prevent and manage lifestyle-related chronic diseases. Although extensive evidence-based dietary guidelines are available in Australia, poor dietary habits are common. Nutrition care is nutrition or dietary related advice given by health professionals to improve dietary behaviour of patients. Previous studies among healthcare professionals highlighted a 'lack of time' as a barrier to deliver nutrition care in primary care. Physiotherapists are well positioned for such health promotion in comparison to other primary care practitioners as they often have prolonged and repeated consultations with patients. However, to date, there have been no studies in Australia to explore whether physiotherapists could provide nutrition care to their patients. Aim: This study aims to investigate practices, knowledge, and barriers to providing nutrition care of Australian physiotherapists. Method: Mixed methods were used. A qualitative study was conducted with physiotherapists practicing in Victoria, exploring their practices, knowledge, barriers, and personal behaviours in relation to nutrition. Interviews were audio-recorded, transcribed verbatim, and thematically analysed. For further exploration, results were used to inform the development of a national survey of physiotherapists working in the primary care setting. Survey results were analysed using STATA software and reported using descriptive statistics. Results: 20 physiotherapists were interviewed, and 344 practicing physiotherapists participated in the online survey. Three main themes supported by nine sub-themes emerged from the interview data. Participants were strongly motivated to provide nutrition care given the relevance of nutrition to their patients' conditions. However, they suggested the complexity of nutrition care and a lack of training and knowledge often stopped them from promoting healthy eating in their clinical settings. All interview participants engaged in some level of nutrition care in their physiotherapy settings. The results of the national quantitative study suggest physiotherapists in Australia are engaging in nutrition care commonly by providing a referral to a dietitian (71% of survey participants) and verbal advice (65% of survey participants) to encourage patients to eat healthily. Thirty-eight percent of participants reported encouraging healthy eating with patients regularly. The preferred content for 'basic healthy eating advice' includes drinking water (89%), minimizing intakes of processed (89%) and sugary food (89%) and alcohol (75%), and increasing consumption of fruits and vegetables (68-73%). Eighty percent of survey participants were confident with their knowledge of the Australian Guide to Healthy Eating (AGHE), but only 58% were confident to use AGHE to assist them in evaluating patients' dietary intake. Based on a validated questionnaire, participants' self-perceived competence scores (mean score 63%; very confident) in providing nutrition care, showed they were confident with their nutrition knowledge, skills, communication and counselling practices with favourable attitudes towards providing nutrition care for their patients. Barriers identified by the participants to providing nutrition care included lack of clarity in the scope of practice (60%), lack of nutrition-training (52%), lack of time (48%), patient perception (43%) and lack of resources or materials (41%). They have also identified professional development training in nutrition (78%), encouragement or policy statement from the Australian Physiotherapy Association (APA) (76%), and printed or online materials as resources (70%) as facilitators to providing nutrition care to patients. The majority of participants (83-86%) recognized the impact of diet on NCDs and health, besides being aware of evidence-based information. Ninety-three percent of survey participants agreed that physiotherapists serve as role models for their patients, and 85% agreed that they should assist in improving patients' dietary behaviour. More than half (57%) of the participants were eating according to the Australian Dietary Guidelines (ADG). Conclusion: The findings of this study indicated that almost all participating physiotherapists were currently providing nutrition care, with the majority referring patients to a dietitian and encouraging patients to eat healthily. Nearly forty percent of participants reported encouraging healthy eating with patients regularly. Participants preferred offering basic healthy eating advice focussing on drinking water, minimizing the intake of less healthy food, and less commonly on increasing the consumption of healthy foods. The majority of participants were confident with their knowledge of AGHE, but fewer of them were confident to use the guidelines to assess patients' food consumption. The study also indicated that more than half of the participants were eating healthily in alignment with national dietary guidelines. The study showed that the participants were confident with their nutrition-related knowledge, skills, communication, and expressed favourable attitudes towards providing nutrition care in physiotherapy settings. However, they have highlighted that training and approval of a broader scope of practice as facilitators to further development of this role. Their practice and motivation in providing nutrition care suggest that they are parallel with the international health promotion advocacy towards eradicating NCDs.
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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.