General Practice and Primary Care - Theses
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ItemSupporting primary care practitioners to promote dementia risk reduction in Australian general practice: development and pilot evaluation of a practice change intervention and targeted implementation approach( 2023-10)Background. People in Australia have limited awareness of the potential for dementia risk reduction. General practice is an appropriate setting for promoting dementia risk reduction, yet it is not routinely discussed. The objectives of the Preventing Cognitive Impairment in Practice Project were to (1) develop an intervention for promoting dementia risk reduction in Australian general practice, (2) assess barriers to implementing the intervention, (3) develop an implementation approach in which strategies to mitigate assessed barriers were selected, operationalised, and introduced progressively, and (4) pilot the intervention and implementation approach in Australian general practices. Methods. The project was guided by a range of frameworks (eg, the Knowledge-to-Action Framework, the Consolidated Framework for Implementation Research). The project comprised six separate studies, including two scoping reviews, qualitative interviews with Australian primary care practitioners, retrospective analysis of discussion board posts from non-medically trained enrollees in a free online educational course about dementia risk reduction, development of an intervention and targeted implementation approach based on evidence and stakeholder consultation, and a pilot evaluation of implementation outcomes in five general practices in Melbourne, Australia. Results. The intervention comprised a patient survey to be completed in the waiting room and patient information cards to be used during consultations, both of which were designed to prompt specific practitioner actions. The implementation approach combined educational materials, outreach visits, local consensus discussions about whether dementia risk reduction was important and whether the proposed practice changes were appropriate, champions to drive implementation within general practices, and capturing and sharing knowledge across general practices. On piloting, implementation outcomes were mixed. Both the intervention and implementation approach were broadly acceptable and feasible, but penetration (‘reach’) was low. Discussion. The Preventing Cognitive Impairment in Practice Project led to an acceptable and feasible practice change intervention and targeted implementation approach that can support the promotion of dementia risk reduction in Australian general practices. Interpretation of the evaluation data identified opportunities for refinements to the intervention and implementation approach. Female participants and self-selected participants interested in DRR were overrepresented throughout the project. Future research could examine hypotheses about implementation outcomes arising from the pilot study, consider additional implementation outcomes, and adapt the intervention and targeted implementation approach for other contexts and populations.
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ItemAn exploration of monitoring people with depression in the general practice setting( 2015)This study is about how general practitioners monitor the effectiveness of the care they provide for people experiencing depression. It seeks to better understand how the monitoring of people with depression should occur in the general practice setting, from the perspective of general practitioners, patients and carers. It does this with the intention of contributing to the debate about how to improve the quality of general practice care for people experiencing depression. The study comprises three main parts, beginning with a literature review in two sections. The first chapter discusses key concepts including depression, primary care’s role in depression care and what defines effective depression care. The second chapter is a scoping review of the primary care depression literature outlining what is known about monitoring practice in this context. The second part of the thesis presents the findings of a survey of 576 people with depressive symptoms who attend general practice, regarding how they recognise recovery from depression. The third part of the thesis reports on findings from eight in-depth case studies, which explore the views and experiences of GPs, patients and carers involved in the giving and receiving of depression care in the general practice setting. The findings of the case studies confirm that monitoring practice is a highly complex, iterative process. Broadly speaking, there are three key phases of monitoring that must be addressed as care proceeds, beginning with engagement in care (including ‘watchful waiting’), moving through a phase of ‘paying attention’ (to the individual patient’s experience) and the ultimate phase of ‘getting better’, where monitoring practice may help or hinder the attainment of recovery from depression. The case study data also show that from the very earliest phases of monitoring (commonly beginning before a diagnostic label has actually been applied), work must be done to achieve a shared understanding of the problem, to set priorities for care amidst competing demands, and to revisit issues regarding who and what can help in dealing with the problem. The thesis concludes by presenting four propositions for depression monitoring practice, which are intended to provide a framework to assist GPs in pragmatically addressing both technical and relational aspects of depression care.
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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.