Building research capacity in General Practice : Incorporating research as a component of GP vocational training

Aims & rationale/Objectives : Australian research shows that most GP registrar supervisors lack confidence to support registrar research projects and themselves have little or no research experience. Assisting registrars to develop critical thinking skills and an understanding of research methods sufficient to enable active use of these tools in general practice is one of the curriculum statements in the RACGP Training Program Curriculum. A University Department of Rural Health (UDRH) and a General Practice Education and Training (GPET) organisation formed a partnership to: Engage basic term registrars in group research and concurrent research skills training program; Improve research skills, confidence, and knowledge; and Contribute research findings relevant to general practice.

Methods : Registrars' initial research knowledge and confidence was measured by a questionnaire. In addition to a final focus group, feedback via evaluation forms was sought from the 11 registrars and two GPET supervisors at the conclusion of each research training session.

Principal findings : Approaches

Implications : Research skills development training and involvement in research can be successfully integrated into a GP vocational training program.

Dyslipidaemia in rural Australia : the evidence treatment gaps

Aims & rationale/Objectives : Hypercholesterolaemia accounts for 11.6% of total deaths and 6.2% of the disability burden for the Australian population.1 This paper reports population lipid profiles for three rural Australian populations, and assesses evidence-treatment gaps against the most recent (2005-2007) Australian guidelines.

Methods : Three population surveys were undertaken in the Greater Green Triangle. 3,320 adults aged 25-74 yrs were randomly selected using age/gender stratified electoral roll samples and of these 1563 subjects participated in the survey. Anthropometric, clinical and self-administered questionnaire data relating to chronic disease risk were collected in accordance with the WHO MONICA protocol.2 A detailed investigation of dyslipidaemia was included.

Principal findings : All required data was available for 1255 participants. Age-standardised mean total cholesterol (TC), triglycerides, LDL cholesterol and HDL cholesterol concentrations were 5.36 mmol/l, 1.42 mmol/l, 3.23 mmol/l and 1.48 mmol/l, respectively. Amongst those taking lipid-lowering medication, just 11% categorised as secondary prevention/diabetes, and 39% as primary prevention, achieved all lipid targets. In the 20% of untreated participants at high risk of a primary cardiovascular event, 26% were aware of their hypercholesterolaemia and just 2% achieved all lipid targets (2.8% achieved TC?5.5 mmol, 8.5% achieved LDL<3.5 mmol/l). 11.2% of the overall population used lipid-lowering medication (95% was statin monotherapy).

Implications : Most adults do not achieve their target lipid profile. This paper identifies the subpopulations and lipid components which need to be targeted for future interventions. It also identifies substantial evidence-treatment gaps which should be addressed to help improve lipid profiles at a population level.

Guideline for the non-surgical management of hip and knee osteoarthritis

Introduction: Chronic disease is a major public health burden on Australian society. An increasing proportion of the population has risk factors for, or at least one, chronic disease, leading to increasing public health costs. Health service policy and delivery must not only address acute conditions, it must also effectively respond to the wide range of health and public service requirements of people with chronic illness.^1,2 Strong primary health care policy is an important foundation for a successful national health delivery system and long term management of public health, and is linked to practical outcomes including lower mortality, decreased hospitalisation and improved health outcomes.¹ National strategic health policy has recently given increased recognition to the importance of chronic disease management, with the Australian Federal Government endorsement of a number of initiatives for the prevention (or delay in onset), early detection and evidence based management of chronic disease, including osteoarthritis.^1,3
Chronic musculoskeletal conditions, including arthritis, account for over 4% of the national disease burden in terms of disability adjusted life years. Over 6 million Australians (almost one-third of the population) are estimated to have a chronic musculoskeletal disease; chronic musculoskeletal disease represents the main cause of long term pain and physical disability. In Australia, osteoarthritis is self reported by more than 1.4 million people (7.3% of the population4) and is the tenth most commonly managed problem in general practice.5 This number is set to rise as the elderly population grows. Osteoarthritis exerts a significant burden on the individual and the community through reduction in quality of life, diminished employment capacity and an increase in health care costs. For further details, refer to the Evidence to support the National Action Plan for Osteoarthritis, Rheumatoid Arthritis and Osteoporosis: Opportunities to improve health-related quality of life and reduce the burden of disease and disability (2004).⁶
As such, federal government health policy has identified arthritis as a National Health Priority Area and adopted a number of initiatives aimed at decreasing the burden of chronic disease and disability; raising awareness of preventive disease factors; providing access to evidence based knowledge; and improving the overall management of arthritis within the community.4 In 2002, all Australian health ministers designated arthritis and musculoskeletal conditions as Australia’s seventh National Health Priority Area. In response, a National Action Plan was developed in 2004 by the National Arthritis and Musculoskeletal Conditions Advisory Group (NAMSCAG).6 The aim of this document was to provide a blueprint for national initiatives to improve the health related quality of life of people living with osteoarthritis, rheumatoid arthritis and osteoporosis; reduce the cost and prevalence of these conditions; and reduce the impact on individuals, their carers and their communities within Australia. The National Action Plan was developed to complement both the National Chronic Disease Strategy – which is broader – and the National Service Improvement Framework for Osteoarthritis, Rheumatoid Arthritis and Osteoporosis, in addition to other national and state/ territory structures.

Rural Health Week Tasmania 2007

Aims & Rationale/Objectives
To raise the awareness of health issues in rural Tasmania, the work of rural health professionals and community volunteers

Methods
A partnership initiative between the University Department of Rural Health and the Department of Health and Human Services attracted $64,000 sponsorship from government and private sector. It established 28 regional groups which organised local activities and awards for a community volunteeer and a health professional. Regional groups were surveyed about their planning process for rural health week, the activities held, their outcomes and future intentions.

Principal Findings
Regional groups were partnerships of local organisations. Activities had a preventative focus. They included cooking, bike rides, dances, manual handling, health checks, community art, suicide prevention.Events attracted up to 300 participants. There were 48 nominations for the 2 awards, which were perceived to have raised the profile of health professionals and volunteers. Activities that attracted most participation were fun runs and health expos. Most used their understanding of community needs when deciding on activities. Only a small number relied on formal health needs analyses. Groups varied in their assessment of how well the activities they organised actually met needs. Half the group members had not worked together previously. All but 3 intend to work with others in the future. Most group members learnt more about health programs and other professionals in their community.

Implications
Raised profile of health services and role of health professionals and volunteers in rural Tasmania.
Increased range of ongoing health promoting activities. Better planned and coordinated activities.

Supporting self-management of chronic health conditions : Common approaches

Objective : The aims of this paper are to provide a description of the principles of chronic condition self-management, common approaches to support currently used in Australian health services, and benefits and challenges associated with using these approaches.
Methods : We examined literature in this field in Australia and drew also from our own practice experience of implementing these approaches and providing education and training to primary health care professionals and organizations in the field.
Results : Using common examples of programs, advantages and disadvantages of peer-led groups (Stanford Courses), care planning (The Flinders Program), a brief primary care approach (the 5As), motivational interviewing and health coaching are explored.
Conclusions : There are a number of common approaches used to enhance self-management. No one approach is superior to other approaches; in fact, they are often complimentary.
Practice implications : The nature and context for patients’ contact with services, and patients’ specific needs and preferences are what must be considered when deciding on the most appropriate support mode to effectively engage patients and promote self-management. Choice of approach will also be determined by organizational factors and service structures. Whatever self-management support approaches used, of importance is how health services work together to provide support.

Cardiovascular health behaviours and health needs among people with psychiatric disabilities

Recent research in Australia has found that people with a mental illness experience higher mortality rates from preventable illnesses, such as cardiovascular disease, respiratory disease and diabetes compared to the general population. Lifestyle and other behavioural factors contribute significantly to these illnesses. Lifestyle behaviours that affect these illnesses include lack of physical activity, consumption of a poor diet and cigarette smoking. Research on the influence of these factors has been mainly directed towards the mainstream population in Australia. Consequently, there remains limited understanding of health behaviours among individuals with psychiatric disabilities, their health needs, or factors influencing their participation in protective health behaviours. This thesis presents findings from two studies. Study 1 evaluated the utility of the main components of Roger’s (1983) Protection Motivation Theory (PMT) to explain health behaviours among people with a mental illness. A clinical population of individuals with schizophrenia (N=83), Major Depressive Disorder (MDD) (N=70) and individuals without a mental illness (N=147) participated in the study. Respondents provided information on intentions and self-reported behaviour of engaging in physical activity, following a low-fat diet, and stopping smoking. Study 2 investigated the health care service needs of people with psychiatric disabilities (N=20). Results indicated that the prevalence of overweight, cigarette smoking and a sedentary lifestyle were significantly greater among people with a mental illness compared to that reported for individuals without a mental illness. Major predictors of the lack of intentions to adopt health behaviours among individuals with schizophrenia and MDD were high levels of fear of cardiovascular disease, lack of knowledge of correct dietary principles, lower self-efficacy, a limited social support network and a high level of psychiatric symptoms. In addition, findings demonstrated that psychiatric patients are disproportionately higher users of medical services, but they are under-users of preventive medical care services. These differences are primarily due to a lack of focus on preventive health, feelings of disempowerment and lower satisfaction of patient-doctor relationships. Implications of these results are discussed in terms of designing education and preventive programs for individuals with schizophrenia and MDD.

Living with cancer : an ethnographic study of Thai cancer patients

This thesis is an ethnographic investigation aimed at describing the lived experiences of Thai cancer patients residing in Cancer Hostel, a shelter provided for the needy whilst undergoing radiation treatment at Siam Hospital. All names, including the hospital, the shelter, and all respondents have been altered to preserve anonymity. The practice of withholding the true diagnosis from Thai patients meant that very little was known about their own feelings on cancer and its treatment. That, coupled with entrenched medical practice beliefs, presented an unusual challenge, for which an ethnographic research method was advocated as being most appropriate in helping toward a better understanding of the problem and resolving the existing dilemma. To understand the real experiences of Thai cancer patients, it was extremely important that the researcher get as near as possible to becoming one of them. Therefore, by physically 'being with’, establishing rapport, and gaining patients trust, the researcher was assured of acceptance as an insider, and was thus allowed to share the experiences of their life encounters. Research findings graphically illustrated the flaws in the practice of protecting patients from their diagnosis, who almost universally, wanted to know more about their diagnosis in order to seek help from the medical care system. Towards this, patients created meaning by linking folk beliefs, culturally inherited knowledge and a common sense, albeit naive approach in trying to make sense of their illness and treatment. Although patients saw cancer illness and its treatment, especially radiotherapy, as life threatening, it was the fear of radiation treatment, not cancer illness which turned patients away from medical treatment. As well, uncertainty, fear and frustration through the lack of information and involvement in their treatment saw patients employ strategies of both reciprocal and fatalistic acceptance; stoic resistance; and thinking positively in their efforts at coping with those life threatening situations.

Why invest in early psychosis services?

The author reflects on the importance of early psychosis intervention services. She says health decision-makers are planning to include the results of health economic analyses within resource allocation decisions. She refers to a study which showed that early intervention services may save about 14,000 British pounds per patient to the mental health sector. She notes that economic evaluations of early intervention for other mental health problems are also found to be cost-effective.

Chronic disease self-management programs : perspectives on enablers and barriers to GP and patient engagement

Aims & rationale/Objectives : Chronic disease self-management programs (CDSMP) are increasingly being integrated into the health system to improve the care of people with chronic conditions. Despite activity at both policy and program levels, GPs as the 'gatekeepers' to the health system have generally not been well informed or engaged in this process. This study, in collaboration with 3 Victorian Divisions of General Practice, sought both GP and patient perspectives on enablers and barriers to engagement in self-management programs.
Methods : Interviews were conducted with GPs (n=20) and consumers (n=45) purposefully recruited from metropolitan and rural Victoria, representing key demographics of interest including low socioeconomic areas.
Principal findings : Lack of education/information and uncertainty about the effectiveness of self-management programs were key barriers for both GP and patient engagement. Programs that were sustainable and utilised existing community resources were viewed as enablers to increase uptake. GP and patient preferences for disease specific or generic CDSMP differed.
Discussion : Outcomes from the recent Council of Australian Governments' meeting suggest that self-management will be a centerpiece in forthcoming chronic disease initiatives. International evidence has highlighted the need for GP and patient engagement as critical in ensuring the recruitment of a critical mass of individuals to participate in CDSMP to ensure the sustainability of such initiatives. Insight from this study indicates that GPs and patients are not well informed about self-management, have different preferences to current policy trends and identifies several other barriers which need to be addressed if CDSMP are to be successful.
Implications : Identification of barriers and enablers of GP and patient engagement in self-management is essential in shaping current policy initiatives and delivery of future programs. This is supported by international evidence which indicates strongly that GP engagement in particular is crucial to the success of these programs.
Presentation type : Paper

"Not just for me" : researching rural needs through dialogue

Rural decline is a multi-faceted issue, one aspect of which is the difficulty experienced in attracting a range of professionals to rural areas. Counteracting rural decline and supporting the sustainability of local communities can be assisted by ensuring the presence of a diverse range of skills and professions in local towns and regions. While it is accepted that rural areas can never have the same level of servicing as cities, basic services such as primary health care are a fundamental need in any community.

Taking neuroleptic medications as embodied experience : a hermeneutic phenomenological study

This hermeneutic phenomenological study focuses on the question: What is it like to take neuroleptic medications for schizophrenia, and what is the meaning of this experience?