General Practice - Theses
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The gender-sensitive care project: Exploring sexual violence in psychiatric inpatient units
Sexual violence is a major global public health issue. There are strong associations between sexual violence victimisation and mental illness, with one in three women presenting at mental health services have experienced domestic violence, including sexual violence. Women often report feeling disempowered and re-victimised while in psychiatric inpatient units, especially in mixed-gender wards. The biomedical model has been the dominant model of care in psychiatric inpatient units. Recent years have seen a global movement towards gender-sensitive and trauma-informed models of care for those with mental illness. To date, there is limited extant research focused on understanding health professionals' experiences and practices of these care models. This research aimed to understand how trauma-informed care or gender-sensitive care is experienced and enacted by health professionals’ for women victim-survivors of sexual violence across acute psychiatric inpatient units. To address this aim, the research was divided into two phases and four research questions. The first phase answered research questions one and two through a scoping review of the literature. The first research question explored health professionals' experiences of providing trauma-informed care in acute psychiatric inpatient settings. The second research question explored health professionals' awareness of the gendered impacts of trauma and how this impacts the care provided. The second phase included a qualitative case study, including stakeholder interviews, observations, and document analysis. The second phase answered research questions three and four. The third research question explored health professionals' perceptions of providing care for women who are victim-survivors of sexual violence in psychiatric inpatient units. The fourth research question explored health professionals' experiences in providing care for women who are victim-survivors of sexual violence in psychiatric inpatient units. The researcher also conducted a policy review of current mental health and violence against women policy and procedures to understand the context of health professionals' experiences and practices. The findings of these studies are presented in three peer-reviewed published articles. The findings suggest that trauma-informed and gender-sensitive care are inconsistently understood and enacted in practice. A more comprehensive care model, which is gender-trauma and-violence informed, is suggested to address the identified barriers in acute psychiatric inpatient units. This research contributes to improving care provision for women who are victim-survivors of sexual violence during their admissions to psychiatric inpatient units.
GPimED: 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?
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.
"It happens to clinicians too”: The prevalence, impact and implications of domestic and family violence against health professional women
Domestic and family violence (DFV) is a major health and social issue in Australia and across the globe. It affects people of all ages and walks of life, predominantly women and children. DFV is associated with a range of harms and impacts, and more frequent utilisation of health services is one. Consequently, health professionals find themselves at the frontline of responding to the health sequelae of violence and trauma in the family. However, healthcare is a gendered profession, where the majority of employees are women. How commonly DFV affects Australian women working in healthcare, and what, if any, association there is between a health professional’s personal experience of DFV and their clinical care of patients accessing healthcare for DFV, is not known. An additional gap in the evidence-base is understanding the needs and perspectives of both survivor health professionals and key stakeholders about the role of the healthcare workplace in supporting survivor staff, not just patients. To address these research gaps, the aim of this PhD study was to investigate the prevalence, clinical care impacts and workplace implications of DFV against an Australian population of women nurses, doctors and allied health professionals. This study utilised a combined methodological approach to collect both quantitative and qualitative data. The first phase of the project was a descriptive, cross-sectional survey of health professionals at a large Australian tertiary maternity hospital, in which 471 health professional women participated (45.0% response rate). Phase two followed, and individual and group interviews were conducted with 18 hospital managers and other key stakeholders. The original contributions of this thesis to new knowledge was the finding that DFV was common in the lives of the health professional women in this study: intimate partner violence (IPV) had affected one in ten (11.5%, 43) women during the last 12-months, and one third (33.6%, 146) of women since the age of sixteen. Sexual violence by an intimate partner was reported by 12.1% (51) of health professional women. Overall, just under half (45.2%, 212) of the participating health professional women had experienced IPV or violence from another family member (including childhood witnessing of DFV) across the life course. The second original finding of this study was that a health professional’s experience of DFV appeared to facilitate clinical care of survivor patients. Specifically, exposure to DFV was positively associated with preparedness to care for survivor patients through greater uptake of professional DFV training, more sensitive attitudes about survivors and more frequent access of information with which to resource survivor patients. The final original knowledge contribution was how hospital workplaces can best support their survivor staff, drawing on the perspectives and experiences of both survivor health professional women (n=93) and hospital managers (n=18). Survivors wanted their workplace to understand that DFV had affected them and to support both their individual needs and recovery as well as their professional capacity to respond to survivor patients. Managers recognised the imperative of a hospital workplace to ensure the availability of multifaceted support for survivor staff, and suggested mechanisms for this. Safety emerged as a key barrier to a more supportive workplace for survivor staff; participants were clear that occupational violence could render a workplace physically unsafe, and fear or uncertainty about how a disclosure of DFV would be responded to affected feelings of emotional safety. The findings of this thesis are presented across three publications. The results indicate that the cumulative trauma burden in Australian health professional women’s lives is high. That burden is added to by the risk of vicarious trauma that all health professionals face in a role where listening to patient histories of trauma and violence is routine. However, the survivors in this study did not present as enduringly vulnerable; on the contrary, they self-reported an informed and sensitive readiness to respond to patients with whom they have DFV in common. This research indicates the efficacy of a trauma and violence-informed framework to underscore and strengthen a recovery-orientated hospital response towards both survivor staff and patients.
Multimorbidity in People with Type 2 Diabetes: Exploration of Associations with Mortality and Glycaemia
Background Type 2 diabetes is a leading health priority of the 21st century. Type 2 diabetes management is complex for both practitioners and patients, made more so because diabetes rarely occurs on its own. Indeed, multimorbidity (the co-occurrence of two or more chronic conditions in an individual) is the norm in diabetes. Multimorbidity, brings about many challenges including difficulties in managing the competing demands of multiple conditions. This can result in reduced adherence to complicated therapeutic regimens. This in turn could lead to suboptimal glycaemia which has been shown to be associated with poorer health outcomes such as the development of downstream complications and increased mortality. Currently, there is no universally accepted measure of multimorbidity. The literature has suggested that the type as well as number of conditions are both important when considering multimorbidity. It has been suggested that multiple conditions in those with type 2 diabetes should be categorised as concordant (diabetes-related) or discordant (unrelated). While the associations between multimorbidity, glycaemia (HbA1c) and all-cause mortality in people with type 2 diabetes has been studied to some extent, significant gaps remain in the existing literature. In particular, the effects of different patterns of multimorbidity including concordant and discordant conditions have not been studied extensively. Similarly, little is known about the relationships between multimorbidity and emerging novel glycaemic measures, such as glycaemic variability and time-in-range. These new ways of understanding glycaemia may be important independent risk factors for developing complications in people with type 2 diabetes. Aim To explore associations between multimorbidity, all-cause mortality and glycaemic outcomes, including HbA1c and novel measures of glycaemic variability and time-in-range in people with type 2 diabetes. Methods My PhD includes a systematic review and three quantitative studies of more than 150,000 people with type 2 diabetes utilising UK, Taiwan and Australian datasets. This provides a clearer picture of the implications of multimorbidity for people with type 2 diabetes in different populations from different countries, health settings, healthcare systems and of different ethnicities. Results The findings of my studies identified that multimorbidity was highly prevalent among people with type 2 diabetes. More than 80% of the 150,000 people included in my studies were found to have at least one other chronic condition in addition to type 2 diabetes. I found the associations between multimorbidity, mortality and glycaemia were mostly consistent across my studies. Increasing multimorbidity was significantly associated with increased all-cause mortality. This was the case for total count of multimorbidity, as well as counts of concordant and discordant conditions. Increasing concordant counts had the greatest effect on mortality. However, when examining the effects of individual conditions and combinations of two conditions on mortality in the UK and Taiwan cohorts, the results differed between Caucasian and ethnic Chinese populations. I also found that across my studies, all measures of multimorbidity were not associated with higher HbA1c, glycaemic variability and time-in-range. Conclusion This PhD has contributed a novel and deeper understanding of the significance of multimorbidity in people with type 2 diabetes. It has provided an insight into the effects of different patterns of multimorbidity, including concordant and discordant conditions, on important health outcomes in different cohorts of people with type 2 diabetes. My findings highlight the need for clinical guidelines to support a holistic approach to the complex care needs of those with type 2 diabetes and multimorbidity, accounting for the various conditions they be may be living with. While managing glycaemia in people with diabetes is important, it should not overshadow efforts to address multimorbidity, both concordant and discordant. It is important to consider the overall multimorbidity disease burden as a way of recalibrating and personalising our clinical focus in supporting people with diabetes. By taking a holistic approach and caring for the whole person, this could potentially reduce their annual mortality risk by reducing the overall burden of multimorbidity.
The ethical principles which guide the allocation of healthcare resources to rural children
This thesis describes research into the way Australian government officials decide to allocate healthcare resources for children who live in rural and remote areas of the country. It is known that infant mortality and health outcomes are worse for these children than for urban children. Moreover, there is evidence that rural families are more likely to experience difficulties gaining access to healthcare for their children than urban families. Documents and guidelines published by federal and state health departments suggest that the allocation of healthcare resources should be guided by the principles of equity and of obtaining the greatest possible improvement of the health of the whole population for the money spent. Prima facie, these principles are mutually incompatible. Aim: This investigation was designed to answer the following questions: 1. What healthcare resources are currently available for children in rural and remote areas in Australia? 2. How do the parents of children living in rural and remote areas of NSW experience the provision of healthcare resources for their children and the consequences for their child and family of that pattern of resource provision? 3. How are healthcare resources allocated to children living in rural and remote areas and what factors are taken into consideration in making this allocation? 4. What ethical framework underpins the allocation of healthcare resources for children now? 5. What ethical framework could guide healthcare resource allocation for children in a way that best fits the needs of rural children, of their families and of government health officials? Methodology: To gain a picture of the healthcare resources available to rural children in NSW, the decision-making process which led to the current distribution of those resources and the experience of rural families in gaining access to those resources, I employed complementary qualitative and quantitative approaches. In early 2018, information on the geographic location of healthcare resources relevant to the needs of children in the Western New South Wales (NSW) Local Health District was obtained from the National Health Services Directory and compared with the location of child populations of various sizes in geographical units known as State Suburbs. To compare family experiences in gaining healthcare for their children, raw data were obtained from the NSW Health Child Population Health Survey, and the experiences of rural families in their interactions with several kinds of healthcare resource were compared with those of urban families. Elected and non-elected officials of the Australian Government Department of Health and Ageing and the NSW Ministry of Health were interviewed, and themes identified from the transcripts. From this analysis, descriptions of the aims and process of healthcare resource allocation decision-making emerged, including description of the constraints on decision-making and the role of ethical considerations. The analysis also revealed the views of decision-makers on the nature of the ethical principles which guide resource allocations. Findings: Comparison of geographical locations of healthcare resources with those of child populations revealed that healthcare resources needed by rural children were lacking in many localities containing substantial child populations. This evidence partly explains the findings that rural families were more likely than urban families to experience difficulty in accessing healthcare for their children, especially due to lack of resources, long delays in waiting time for scarce resources or transport difficulties in accessing them. Interviewed officials indicated that elected officials (health ministers) and members of the National and NSW Cabinets held the ultimate power to make allocation decisions, and that those decisions had budgetary and political constraints. Ethical principles appeared to play only a minor role in allocation of healthcare resources, and while equity was the principle most often mentioned, there was no agreement on whether equity of resource allocation, equity of access to resources or equity of health was the aim. Discussion and Implications: The investigation canvassed a range of metaethical principles which could inform resource allocation decision-making. It concluded that equity (and especially vertical equity) in access to healthcare resources for equal need was the principle most likely to be acceptable in Australian society and to Australian resource allocation decision-makers. At the same time, it appeared to be the most likely to improve the health and wellbeing of rural children, both absolutely and in relation to that of urban children. Despite the investigation’s identification of the value of equity of healthcare access, there is a discrepancy between the published intentions of the Australian Government Department of Health and NSW Health to allocate healthcare resources according to this principle, and the minor role which ethical principles, including equity, play in actual decision-making. Further, there is lack of certainty among officials about the goal of achieving equity (that is, whether equity in resource allocation, equity in healthcare access or equity in health should be the aim). The investigation suggests two principal reasons why the avowed aim of allocating resources to achieve equity was not, in fact, achieving equity of health or of healthcare access. One was the apparent uncertainty among officials about the aspect of health or healthcare in which equity was to be achieved. The other reason was deficiency in motivation to act on an acknowledged moral reason (to act to achieve equity). The data suggest that adoption of the motivating principles of communitarianism or compassion would be more likely to supply the motivation to act to achieve equity than the assumption that the interests of the individual should underlie all ethical principles.
Urinary tract infections in young children: optimising diagnosis with effective and cost-effective urine sample collection
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.
The role of physiotherapists in providing nutrition care to improve dietary behaviours
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.
The provision of psychosocial support in early pregnancy assessment services in Australia
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.
Does the removal of financial incentives from Australian general practices affect immunisation rates?
Background Financial incentives are commonly used to drive improvements in health care delivery. There is a large body of evidence around the impact of the delivery of financial incentives on health outcomes, quality and prevention. Results from a systematic review of published reviews found that randomised controlled trials and time series studies undertaken between 1980 and 2000 have contributed most of the evidence. Most of the studies looked at associations between the introduction of incentives and improvements in quality. However, poor study design and unaddressed methodological errors have significantly limited the drawing of sound conclusions from the evidence to date. There is a paucity of published research on the removal of financial payments to general practitioners (GPs) and its effect on preventive care. Aim This thesis aims to: (i) determine if the removal of general practitioner financial incentive payments for immunisation are associated with a reduction in paediatric immunisation coverage; (ii) determine if there is evidence of associations between levels of socio-economic disadvantage and paediatric immunisation coverage after removal of financial incentive payments to general practitioners, and; (iii) determine if there is evidence of an association between levels of relative remoteness and paediatric immunisation coverage after removal of financial incentive payments to general practitioners. Method Childhood immunisation has been linked to the delivery of two financial incentives provided to Australian general practitioners for the reporting of paediatric immunisation coverage to the Australian Childhood Immunisation Register (ACIR). The General Practice Immunisation Service Incentive Payments (SIP) and Outcomes Bonus Payments (OBP) were removed incrementally in 2008 and 2013. A systematic review of reviews was undertaken on current evidence of the effect of incentives on immunisation. Paediatric immunisation coverage data for all Australian children under the age of seven was used to examine the impact of the removal of these incentives on immunisation rates. Interrupted segmented regression times-series analysis (ITSA) was performed on postcode-level immunisation coverage data across 64 quarters between 2000 and 2016. Sub-group analysis was performed on the data stratified for socio-economic disadvantage and rurality. The data were transformed using an autoregressive integrated moving average (ARIMA) model to address autocorrelation. Results The results revealed an immediate and statistically significant drop in immunisation coverage following removal of the second of two incentive payments to GPs, the OBP. This drop persisted even after the data was modelled to control for heteroscedasticity and the inflationary effects of the ‘No Jab No Pay’ policy. The effect was still evident after the series had been transformed with weighting coefficients to address the issue of small cells. The analysis also showed an additional 19,441 children would have been reported as being fully immunised between January 2000 and 1 January 2016 had the SIP and OBP incentives not been removed. A reduction in immunisation coverage was evident across all socio-economic quintiles after the national series had been stratified across areas of disadvantage. This effect was found to be larger in areas of greater disadvantage. The same outcome was observed across all geographic regions of Australia, where major city, regional and remote areas showed a statistically significant reduction in immunisation following removal of the OBP. The postcode areas which showed the greatest decrease in immunisation were those outer regional to very remote regions of Australia. There was no statistically significant change in coverage after removal of the SIP. Conclusion This thesis establishes evidence of a strong relationship between the removal of incentives to GPs and the provision of preventive services. Not only does this analysis provide estimates which are statistically significant, it also provides multiple analyses which test the validity of the outcomes. To the author’s knowledge, the innovative methods which have been used in this thesis to measure the effects of the removal of financial incentives to GPs, has not been previously applied to the research around incentive effectiveness in either Australia or overseas. This places this research in a unique position to both contribute evidence and influence future policy.
Australian young women's perceptions of dating and dating violence
Dating violence, or intimate partner violence, in young people’s relationships is a serious, prevalent and important public health concern. It is estimated that approximately one in four Australian young women have experienced dating violence. Despite the well-known burdens of dating violence on Australian young women’s health and well-being, little is known about how Australian young women perceive dating violence in their romantic relationships. This qualitative study explored Australian young women’s perceptions of dating, other romantic relationships, and dating violence. Social constructionist and feminist theoretical perspectives informed the study design. Young women aged 17 to 25 years, were recruited from a range of social and occupational backgrounds if they screened positive for dating violence. Individual narrative interviews were conducted with 35 young women, from across urban and rural Australia, who had predominantly had romantic relationships with young men. Interviews were conducted face-to-face or via telephone. The interviews were analysed using a thematic approach while ensuring that the young women’s stories remained at the forefront of the analysis. This was followed by the application of social script theory with a feminist lens, as an explanatory framework, to better understand the young women’s perceptions of romantic relationships and dating violence. The young women shared stories of their experiences of romantic relationships which were predominantly with young men. Findings revealed that the young women had experienced a range of casual and committed romantic interactions. The young women discussed their experiences and perceptions of these relationships and their roles within them. The young women’s perceptions of romantic relationships, particularly committed ones, were overwhelmingly gendered and scripted. These scripts were reminiscent of romantic fairy tale narratives, such as Beauty and the Beast, which the young women strived to live by. This perception influenced how they made sense of and recognised dating violence within these relationships and therefore how they responded. The young women struggled to leave their abusive relationships and exit was usually only possible if a crisis occurred or if the young man left the young woman. An exit model was formed which highlights these pathways and also the defining gendered roles of the young woman and young man. The young women’s perceptions of dating and dating violence were in conflict with their perceptions of gender equality and feminist identities. While the young women in this study perceived themselves to be liberated individuals in the current wave of feminism, in contrast, their dating and relationship scripts were informed by oppressive and patriarchal master narratives, such as romantic fairy tales. This study contributes to a better understanding of dating and dating violence in the Australian context from the perspective of a typical Australian young woman living in the year 2015. The findings from this study are useful and important to inform policy and practice for the primary and secondary prevention of dating violence. Existing patriarchal social scripts should be challenged with feminist counterstories that empower young women and contribute to practical implications for promotion of gender equality.
Partner notification for syphilis in Chile: exploring health care providers’ perspectives to enhance public health service delivery
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.
The design and implementation of a health and lifestyle screening app to improve the care of young people in general practice
Adolescence and young adulthood are periods of major transition in physical, cognitive, social, and emotional development along the journey from childhood to adulthood. However, despite experiencing a high prevalence and co-occurrence of mental health disorders and lifestyle issues, young people do not usually seek professional help for these concerns. Yet, young people do regularly attend general practice, usually to address physiological concerns, making General Practitioners (GPs) ideally situated to opportunistically discuss a range of health and lifestyle issues and to provide health promotion and early intervention as needed. Technology-based screening provides an acceptable and systematic format for identifying health issues before the consultation. However, this screening technology is not being utilised by GPs. The aim of my research was to investigate the design, implementation, and effectiveness of a preventive screening technology intervention for supporting conversations about young people’s health and lifestyle risks in general practice. To address this aim I conducted three studies using a mixed methods multiphase design. The first study was a systematic review of the literature, which provided an understanding of the need and rationale for developing a health and lifestyle technology-based screening tool in primary care. The second study was a series of co-design workshops with 16 young people, 8 GPs, and 8 parents of young people, and interviews conducted with 11 practice support staff, to identify and explore user and stakeholder design and implementation requirements of a technologybased screening tool. The final study was an effectiveness-implementation study in one general practice clinic in Melbourne, Australia. For the effectiveness component of the final study, I compared the exit surveys of 30 young people in a one-month pre-intervention, treatment-as-usual phase with 85 young people using a health and lifestyle screening app in a two-month intervention phase, when the app was integrated into young people’s routine care. I also conducted semi-structured interviews with 14 young people from the intervention group. The implementation component of the final study was an in-depth implementation case study, with methodology informed by action research. Semi-structured interviews and focus groups were conducted with four GPs and seven support staff at the end of the implementation period. In addition, I analysed the number of times staff were supported by researchers, the location where young people completed the app, whether they felt they had sufficient privacy and received a text messaging (short message service, SMS) link at the time of making their appointment. I present the findings of my studies in this thesis in four published peer reviewed articles. The results indicated that integrating a health and lifestyle screening app into face-to-face regular care of young people improved patient-centred care, and created scope to identify and address unmet health needs. However, the implementation of the app in the dynamic and time-poor general practice setting presented a range of technical and administrative challenges. My research shows that an effective way to engage young people in their health and wellbeing may be to resource preventive screening implementation into routine general practice care. My research also provides evidence that to drive and support sustainable technology innovation and implementation in general practice settings more resources, external to existing practice staff, are needed.