General Practice and Primary Care - Theses
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ItemUrinary tract infections in young children: optimising diagnosis with effective and cost-effective urine sample collection( 2020)BACKGROUND Urinary tract infections (UTIs) are very common in young children, but hard to diagnose, and easily missed. Diagnosis is important: if untreated UTI can cause sepsis and permanent kidney scarring. Many young children with unexplained fever must have a urine sample tested to check for potential UTI. The problem is that collecting urine samples from young pre-continent children is extremely difficult. Existing collection methods all have limitations. Standard care in Australia of waiting for a clean catch is time-consuming and often unsuccessful. Urine bags have unacceptably high contamination. Catheter and needle procedures are painful and distressing, and require expertise and equipment to perform. Suboptimal practice compromises patient care and wastes healthcare resources. AIMS & METHODS The doctoral research had the overall objective to improve non-invasive urine sample collection for young pre-continent children. Specific aims were to discover: 1. A quick, simple and effective non-invasive collection method 2. Cost-effectiveness of current and new collection methods 3. Which collection methods are practical in the primary care setting 4. Knowledge translation of findings into practice These aims were examined with the following research methodologies: 1. Two clinical trials of a novel voiding stimulation method 2. Economic evaluation of existing and new collection methods 3. Qualitative study in Australian general practice 4. Local guideline update and development of consumer resources RESULTS The novel Quick-Wee voiding stimulation method was conceptualised, using cold wet gauze to gently rub the suprapubic region. This triggers cutaneous bladder reflexes for faster and more successful urine sample collection. A pilot study (n=40) demonstrated the method was feasible. A randomised trial (n=354) demonstrated significantly higher success in collecting a urine sample within 5 minutes, and significantly higher parental and clinician satisfaction, compared to standard clean catch practice. An economic evaluation comprehensively modelled the costs and cost-effectiveness to collect a definitive sample for all common urine sample collection methods. Overall, catheterisation was the favoured collection method, Quick-Wee the favoured non-invasive method, and urine bags were the most expensive method. This is the first cost-effectiveness analysis of its kind, filling a significant evidence gap, and identifying potential cost savings. A qualitative study explored the barriers and enablers to collecting urine samples from young children in Australian general practice. Non-invasive methods were strongly favoured and invasive methods were rarely used. Key barriers included time and space constraints in clinics. Key enablers included parental motivation, education handouts and voiding stimulation methods. These important insights can inform policy, education and future research. Knowledge translation activities were undertaken including updating statewide guidelines and creating consumer resources. The Quick-Wee method is now recommended in guidelines across a range of settings internationally. CONCLUSION This body of work developed the new Quick-Wee voiding stimulation method and has shown it is more effective, more cost-effective, and more acceptable than standard care. It is gentle for children and simple for clinicians. This research has addressed key evidence gaps, contributing new knowledge to optimise investigation of UTI in young children. Findings have changed practice and been implemented in policies and guidelines internationally.
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ItemSafety and resiliency at home: voices of children from a primary care population( 2015)Almost one quarter of Australian children experience family violence perpetrated by their father or step father which has significant health outcomes across the lifespan. However, some children who experience family violence are thought to be resilient. Children lack opportunities to have their voices heard, therefore children’s own understandings of their safety and resilience are often missing. As a site of early intervention, primary care is well placed to respond to these children. The aim of the research was to hear children’s voices about their safety and resilience in the context of family violence, and to determine an appropriate primary care response. Qualitative methodologies underpinned the research which involved semi-structured interviews and focus groups with 23 children and 18 mothers from primary care settings, all of whom had experienced family violence. I developed a child-centred approach utilising ethical and safe methods. A theoretical framework of ethics of care and dialogical ethics informed the research. Hermeneutic phenomenological analysis revealed that children and mothers understood children’s safety in the context of: awareness of family violence; whether the violence was named and by whom; who provided care and protection; and children’s sense of trust in relationships. Resilience was understood differently by children and mothers. Children understood their resilience according to social recognition of their achievements and talents. The children’s meaning was independent of adversity and aligned with the concept of relational self-worth. Mothers however, only understood children’s resilience with reference to the adversity their child had experienced. This was underpinned by the mother’s sense of responsibility for the adversity and the child’s apparent resilience despite this adversity. Understandings of safety and resiliency were further analysed to reveal the key finding that children required agency to negotiate their safety in the context of family violence and post-separation. A ‘model of children’s agency’ was developed to reflect the four factors that facilitated children’s agency: physical and emotional distance from the perpetrator; awareness of disruption or danger in the parental relationship; modelling of safety in relationships by non-violent adults; and the child’s sense of co-constructing family resiliency. To inform an appropriate primary care response, I also sought children’s and mothers’ understandings of primary care. Their insights focused on: questioning the role of primary care to respond to children experiencing family violence; the importance of knowing and modelling within the child-mother-health practitioner relationship; and the expectation that the health practitioner would facilitate communication about family violence. Using these insights, I proposed an approach based on collaboration, relationship and shared language, an ‘informed trialogue’ within the child-mother-health practitioner triad to foster children’s agency in the primary care consultation. The ‘informed trialogue’ guides the health practitioner to encourage and impart the ‘model of children’s agency’ by advocating physical and emotional distance from the perpetrator; building child awareness of family violence; supporting the modelling of safety in trusted relationships and demystifying family resiliency. The ‘model of children’s agency’ and the ‘informed trialogue’ bring children’s voices to the fore to inform primary care and those that work with children experiencing family violence.