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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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.
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ItemSexting and young people: a qualitative study( 2012)This study is one of the first Australian studies to describe the phenomenon of sexting from the perspective of young people. ‘Sexting’, which involves the production and distribution of sexually explicit images via information and communication technologies (ICTs) has led to young people being excluded from friendship groups, moving schools, suffering anxiety and depression, and in extreme cases being charged with the production and distribution of child pornography. There is an absence of published studies undertaken in this area, particularly from an Australian perspective and from the point of view of young people themselves. My study addresses this gap by exploring the meaning of sexting in young people’s lives. It focuses in particular on the nature of sexting, the reasons why young people are involved in the behaviour and potential solutions for addressing harmful consequences. A qualitative methodology involving two phases was used. The first phase involved a focus group and individual interviews with twelve key informant professionals to develop a context that would inform the second phase, which involved individual semi-structured interviews with 33 young people aged 15-20 years (female [n=18]; male [n=15]). Young people were sourced via youth health, recreational and educational settings using purposive snowball sampling. Results were thematically analysed using a grounded theory approach. Key informant findings helped frame interviews with young people, and affirmed that young people’s voices needed to be heard. Many of the views of key informants were also reflected in the views of young people. Findings exposed a number of themes, including in particular, the gendered nature of the behavior. Of particular concern is that young women feel pressured by young men, who feel pressured by each other to be involved in the behaviour; young people observed that our sexualised media culture places pressure on young women and men to conform to gendered stereotypes that influence the behavior of sexting. Conversations with young people highlighted complexities of the phenomenon not revealed previously, including that definitions used in prevalence studies need to represent changes in young people’s use of ICTs. Young people’s views on solutions highlight that education about the implications of sexting is not the only answer, especially given young people’s views on the origins of sexting and what is known about young people and risk taking from a developmental perspective. Both young women and men were concerned about the potential harmful outcomes for those involved in the behavior, with recognition that young people should be involved in the design of solutions. Findings present important implications for future prevention approaches.
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ItemChoices women make: prevalence of and the factors associated with contraception use in women of reproductive age attending Family Planning Victoria( 2012)BACKGROUND: Despite good access to contraception, Australia has one of the highest rates of unintended pregnancy in the developed world. Proper use of contraception is important in reducing unintended pregnancy. The factors associated with a Victorian woman’s likelihood to use contraception are unknown. AIMS: To identify and predict women at risk for unintended pregnancy by defining factors associated with ineffective or non-use of contraception in sexually active women of reproductive age attending Family Planning Victoria. Theoretical component: 1. To summarize and categorize current understanding of the factors that may influence a woman’s use of contraception. Practical component: 1. To determine the current pattern of the use of contraception of sexually active women (16–50 years old) attending Family Planning Victoria including the a) percentage who are using contraception and the type of contraception currently used. b) percentage of women using contraception consistently. 2. To examine the associations between demographics, psychosocial factors and contraception use in sexually active women who are not planning a pregnancy, attending Family Planning Victoria. METHOD: This was a cross-sectional study of sexually active women of reproductive age attending Family Planning Victoria, utilizing a questionnaire of contraceptive behaviours and important factors that influence contraception use (identified from a systematic literature review). The variables of interest were analysed for associations with contraceptive use and non use and then as independent predictors of non-contraceptive use. RESULTS: Through a comprehensive literature review of 132 articles, a framework consisting of 8 domains was developed to summarize the factors that may affect a woman’s choice to use contraception. 1006 surveys were analyzed with 95.6% of women using some form of contraception in the last 3 months. The three most commonly reported contraceptives in the last 3 months were male condoms (66.9%), oral contraceptive pill (48.6%) and withdrawal (31.5%). 36.8% of sexually active women were at risk for unintended pregnancy: 60.5% due to inconsistent contraception use, 31.4% due to sole use of an “ineffective” contraception and 8.1% due to non use of contraception. The most common reasons for inconsistent use of contraception were ‘no access’ (38.7%), ‘forgetting’ (35.1%) and ‘too inconvenient’ (14.6%). On multivariate analysis, women at risk for unintended pregnancy compared with women not at risk had demographics of <25 years old (OR 1.83, 95% CI 1.23-2.73); no university/postgraduate degree (OR 1.69, 95% CI 1.18-2.44); >1 partner in the last 3 months (OR 3.23, 95% CI 2.28-4.58). They had attitudes of dissatisfaction with current contraception (OR 2.50, 95% 1.79-3.45); felt “vulnerable” to pregnancy (OR 2.14, 95% CI 1.55-2.95); not confident in contraceptive knowledge (OR 2.63, 95% CI 1.47-4.76); unable to stop to use contraception when aroused (OR 2.08, 95% CI 1.47-2.94) and comfortable in speaking to a doctor about contraception (OR 2.26, 95% CI 1.11-4.07). CONCLUSION: A theoretical framework of 8 domains has been developed to categorize the factors that may affect a woman’s choice to use contraception. Despite more than 95% of women reporting contraception use in the last 3 months, nearly 40% of women are at risk for unintended pregnancy, mainly due to inconsistent or ineffective use of contraception rather than non-use. 8 factors were also found that were associated with women who were at greater odds of being inconsistent or ineffective users of contraception.