Primary Health Care and General Practicehttp://hdl.handle.net/10523/2492024-03-16T20:24:18Z2024-03-16T20:24:18ZEvaluation of the Primary Mental Health Initiatives: Summary report 2008Dowell, AnthonyGarrett, SueCollings, SunnyMcBain, LynnMcKinlay, EileenStanley, Jameshttp://hdl.handle.net/10523/165862024-03-08T14:18:42Z2024-02-20T19:32:16ZEvaluation of the Primary Mental Health Initiatives: Summary report 2008
2009-07
Dowell, Anthony; Garrett, Sue; Collings, Sunny; McBain, Lynn; McKinlay, Eileen; Stanley, James
Overview:
• Clinically significant mental health problems are common in New Zealand. Many people, particularly those with mild to moderate conditions, are first seen in primary health care and general practice settings.
• The Primary Mental Health Initiatives (PMHIs) represent a significant investment in primary care service delivery and infrastructure. The initiatives were delivered within a timeframe requiring a rapid evolution of service development, and were sustained over a two-year period.
• A range of service delivery models was developed, offering choice to both service users and practitioners. All services were offered at no charge to services users. Every model contained some elements specific to local need.
• The PMHIs were perceived as being efficient and responsive to consumer need, and were judged a success by both practitioners and service users.
• It is unlikely that any single model could be universally applied as none contained all successful elements of an optimal model.
• No service delivery model offered an inherently superior value for money, or an inherently more cost-effective service compared to others.
• The PMHIs provided services to address the needs of service users with a wide range of symptoms and problems. The ability to address undifferentiated and sub-threshold symptom complexes, as well as well-defined conditions such as depression and anxiety, was welcomed by service users.
• Up to 80% of service users benefited from the variety of interventions offered.
• Although common, mental health disorders such as anxiety and depression are complex and it is not surprising that 20% of service users did not improve. Spontaneous remission (getting better without any treatment) is also relatively common. Several studies suggest that it would be reasonable to expect anywhere between 30 and 50% of patients to improve under ‘care as usual’ conditions and fewer under ‘no treatment’ conditions. The 80% improvement rate therefore represents a significant and beneficial treatment effect, which was generally sustained at six months in those for whom data were available.
• Service users expressed satisfaction with the care given by the initiatives.
• Mental health needs arising from mild to moderate common mental health conditions, including those involving social complexity, can be addressed by primary care. Did PMHIs reach different population groups?
• Targeting of services to high-needs populations was a challenge for many PMHIs. Well- defined criteria for determining clinical eligibility for care are important.
• Services for Māori included both kaupapa Māori and mainstream service options, and having both options available was perceived as optimal by Māori. Evaluation of the Primary Mental Health Initiatives: Summary Report ix
• The initiatives provided access to Māori in excess to their proportion in the enrolled population. However, given the higher prevalence of some common mental health conditions among Māori, it is likely there was still some under-utilisation of services by Māori.
• There was under-utilisation by Pacific peoples and significant under-utilisation by Asian people in the PMHIs.
• The mental health needs of children and young people overall were not sufficiently met by the PMHIs, and over half did not offer services to this group.
• Few PMHIs offered services to service users over 65 years of age. Workforce
• The success of the PMHIs was based in part on the investment made in dedicated staff positions such as mental health co-ordinators and mental health nurses. These staff require appropriate administrative support, and need a framework for professional development and supervision.
• The PMHIs are an example of effective interdisciplinary teamwork. In the majority of initiatives, care was provided by more than one discipline. The involvement of practice nurses was not always facilitated.
• There is currently no optimally structured training or education programme for primary mental health care that includes all disciplines.
Infrastructure and methodologies:
• The majority of initiatives made relatively little use of advanced information technology (IT) platforms for administrative and clinical management, or for structured clinical decision support.
• The use of clinical outcome measures was encouraged, both to support the evaluation and as a clinical tool. Further use of assessment and diagnostic tools would mean a significant change in primary mental health care practice.
• A wide range of psychological counselling and therapy approaches was used. There is a need to understand which elements of these interventions contribute to successful management.
Further work:
• Further work is required to define an optimal balance between psychological and pharmacological therapies within primary mental health care.
• Further work is also required to define appropriate and acceptable funding systems to resolve issues of health needs, equity and ability to pay.
• Future development in primary mental health should clarify the appropriate contribution, in terms of funding and co-ordination, from the Ministry of Health and District Health Boards, and should attempt to achieve a degree of equity and consistency in overall service provision.
2024-02-20T19:32:16ZManaging medicines-related continuity of care: the general practice prescriber perspective in New ZealandWells, Cathryn Juliehttp://hdl.handle.net/10523/162392023-10-19T21:36:05Z2023-10-19T21:35:37ZManaging medicines-related continuity of care: the general practice prescriber perspective in New Zealand
2023
Wells, Cathryn Julie
Introduction: Continuity of care is considered a fundamental and essential aspect of good quality primary care. Prescribers in general practice play a pivotal role in managing continuity of care and optimising medicines-related patient health outcomes. Legislative changes have resulted in nurses and pharmacists prescribing medicines alongside general practitioners (GP). There is a paucity of research internationally and in New Zealand (NZ), investigating how different prescribing disciplines view the management of continuity of care, from a medicine’s perspective. Gaining the views of clinicians directly involved in the prescribing process is important to guide future primary health service provision and provide better, sustainable, and more equitable medicines-related health outcomes, for New Zealanders.
Aim and objectives: To explore and describe how general practice prescribers in NZ perceive their role in managing medicines-related continuity of care. Key objectives include understanding current approaches, challenges experienced and strategies or areas for improvements, particularly when more than one prescriber is involved in a single patient’s care.
Methods: A qualitative approach was employed, using semi-structured in-depth interviews. Sixteen participants were recruited from eight North Island general practices (seven general practitioners, four pharmacist prescribers, four nurse practitioners and one registered nurse prescriber). Interviews were transcribed verbatim. NVivo software has been used to aid thematic analysis of interview transcripts, using an inductive approach to analysis of data.
Results: Data analysis identified three key themes (each with sub-themes). These include: (1) a patient-focused approach; (2) interdisciplinary teamwork and (3) optimising the medicine regimen.
Conclusion: Prescribers in this study believe that relational, informational, and management dimensions of continuity of care are interconnected and equally important to achieving safe and beneficial outcomes from medicines. Patient-prescriber relationships in general practice, and interdisciplinary relationships within and across health settings, were considered vital aspects of managing medicines-related continuity of care. Participants expressed concerns relating to increasing multimorbidity and clinical decision-making, time restraints and the non-integration of clinical records between health settings. There was a sense that medicines-related continuity of care is no longer solely the responsibility of general practice prescribers.
2023-10-19T21:35:37ZDo your research? Investigating online vaccine information: a critical discourse analysisElkin, Lucy Emmahttp://hdl.handle.net/10523/156612024-03-08T14:18:31Z2023-07-20T22:11:07ZDo your research? Investigating online vaccine information: a critical discourse analysis
2023
Elkin, Lucy Emma
Childhood vaccines are credited with markedly reducing deaths from infectious diseases. For most children, vaccines are extremely safe and effective. Despite this, childhood vaccination-rates are steadily decreasing worldwide, and in the last decade, there have been several outbreaks of vaccine-preventable infectious diseases such as measles, with fatal consequences. Declining vaccination rates are thought to be caused partly by an abundance of conflicting vaccine information online.
This research examined online vaccine information and had two aims. First, to investigate what a parent looking online for vaccine information would likely find and second, to critically analyse how language-use in online vaccine information might influence vaccine decision-making.
Websites and social media platforms were searched for childhood vaccine information between September 2017 and January 2018 using methods designed to minimise bias from internet platform algorithms. A plethora of vaccine information displaying a variety of vaccine stances, including a significant minority of vaccine-negative information, was readily accessible online.
Three websites were selected for detailed analysis of texts and images using a critical discourse analysis framework to unpack three key functions of the language used: to say things, be things, and do things. These concepts were integrated to investigate each organisation's ideologies in relation to scheduled childhood vaccinations. Two vaccine-positive websites (Centers for Disease Control and Prevention from the United States and the Immunisation Advisory Centre from New Zealand) and one vaccine-negative website (Physicians for Informed Consent from the United States) were analysed.
The vaccine-positive websites asserted and implied vaccine-promoting stances in their information. Physicians for Informed Consent asserted a vaccine-neutral stance but their implicit stance was critical of childhood vaccination. Each organisation used manipulative discourse, however, because Physicians for Informed Consent disguised their vaccine-critical stance, their information delivery was considered more manipulative and potentially coercive.
Centers for Disease Control and Prevention and the Immunisation Advisory Centre discursively distanced themselves from the parent-reader. In contrast, Physicians for Informed Consent discursively narrowed the power gap between themselves and parents. They bolstered their referent power base and fostered empowerment and solidarity with parents.
A key conclusion from this research is that contrasting and conflicting discourses about vaccines are not simply a result of conflicting knowledges, but reveal conflicting ideologies. Therefore providing more "knowledge" to parents is unlikely to overcome vaccine hesitancy, where that is the goal.
Several recommendations that may serve to depolarise vaccine information and reduce vaccine hesitancy are made. For example, vaccine-promoting organisations and healthcare providers should consider discourse strategies that empower parents and build solidarity, creating a shared goal to improve children's health through vaccination. Care should be taken that this information is not deceptive or coercive. Vaccine-promoting organisations could increase the transparency of their information by disclosing rare vaccine harms without euphemism and parents could be supported to resist manipulation in vaccine information through learning critical appraisal skills.
Although this research looked primarily at vaccine information, the findings and reccomendations could be expanded beyond vaccines to other contested health topics where minority groups advocate against established and effective health measures, for example water fluoridation.
Parents will inevitably continue to look for vaccine information online: this information and the way it is presented is likely to influence their vaccine decisions. The findings of this research call for a re-evaluation of how vaccine-promoting information is provided to parents.
2023-07-20T22:11:07ZIt's about who they are and what they can do: Māori perspectives on frailty in later lifeGee, S.Bullmore, I.Cheung, G.Bergler, U.Jamieson, H.http://hdl.handle.net/10523/156502023-09-13T21:05:30Z2023-07-20T01:53:00ZIt's about who they are and what they can do: Māori perspectives on frailty in later life
2021
Gee, S.; Bullmore, I.; Cheung, G.; Bergler, U.; Jamieson, H.
Aim: This study aimed to explore Māori (the indigenous people of Aotearoa New Zealand) understandings of frailty.
Method: Focus groups were held with older Māori in supported living, health professionals working with older Māori and a rural community. A qualitative thematic analysis was conducted.
Results: Two interlinked, overarching themes emerged: (1) Frailty is a multidimensional experience, not simply a physical one. (2) The experience of frailty is a balance between deficits and strengths. The Waikare o te Waka o Meihana model provided a useful framework for structuring the thematic results.
Conclusions: Culturally appropriate and comprehensive support and care for older Māori with frailty will be facilitated by a rounded strength-based approach and listening skills.
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2023-07-20T01:53:00ZPiki Evaluation Final Report (Summary)Dowell, AnthonyStubbe, MariaGordon, SarahMathieson, FionaHilder, JoGarrett, SueTester, RachelFedchuk, DashaGardiner, TraceyDunlop, Abigailhttp://hdl.handle.net/10523/129182022-07-31T22:21:54Z2022-06-06T21:03:30ZPiki Evaluation Final Report (Summary)
2021-05
Dowell, Anthony; Stubbe, Maria; Gordon, Sarah; Mathieson, Fiona; Hilder, Jo; Garrett, Sue; Tester, Rachel; Fedchuk, Dasha; Gardiner, Tracey; Dunlop, Abigail
Piki is an innovative free primary mental health service for youth that has been piloted successfully across the Greater Wellington region of New Zealand. The overall aims for the pilot service were: • to improve access to mental health and wellbeing support for all young people aged 18-25 years with mild to moderate mental and/or substance misuse-related distress; • to increase equity via a strategic focus on priority (‘under-served’) groups; and • to trial an integrated psychological therapies model for youth. The embedded evaluation team used mixed methods within a modified action research framework to encourage ongoing review and adaptation. This was informed by principles of co-design combined with tools from complexity and implementation science. This approach is underpinned by a philosophy of ‘appreciative inquiry’ which seeks to identify opportunities, strengths, and the positive and aspirational features of innovation, whilst commenting constructively on emerging challenges and problems. Key recommendations were to:
• Continue the Piki service locally.
• Roll out similar free or low-cost initiatives more widely.
• Retain successful innovations (e.g., peer support, self-referral, integration).
• Strengthen focus on equity and targeting to priority groups.
• Commit to genuine co-design and engagement with tangata whenua, local communities.
• Offer a range of evidence-based talk therapy and digital options.
• Consider widening the age range (especially 16–18-year-olds).
• Systematically address workforce capacity and training issues.
• Routinely embed formative evaluation/CQI into new initiatives.
2022-06-06T21:03:30ZEvaluation of the Piki Pilot Project (January 2020 - December 2021) – Final ReportDowell, AnthonyStubbe, MariaGordon, SarahMathieson, FionaHilder, JoGarrett, SueTester, RachelFedchuk, DashaGardiner, TraceyDunlop, Abigailhttp://hdl.handle.net/10523/129172022-07-31T21:17:14Z2022-06-06T21:02:27ZEvaluation of the Piki Pilot Project (January 2020 - December 2021) – Final Report
2021-05
Dowell, Anthony; Stubbe, Maria; Gordon, Sarah; Mathieson, Fiona; Hilder, Jo; Garrett, Sue; Tester, Rachel; Fedchuk, Dasha; Gardiner, Tracey; Dunlop, Abigail
Piki is an innovative free primary mental health service for youth that has been piloted successfully across the Greater Wellington region. The Piki youth mental health pilot initiative was instigated to address the needs (and particularly unmet needs) of the 18-25-year-old population who experience mild to moderate mental health and substance use-related distress. The embedded evaluation team used mixed methods within a modified action research framework to encourage ongoing review and adaptation. This approach was informed by principles of co-design combined with tools from complexity and implementation science, underpinned by a philosophy of ‘appreciative inquiry’ which seeks to identify opportunities, strengths, and the positive and aspirational features of innovation, whilst commenting constructively on emerging challenges and problems.
Key recommendations were to:
• Continue the Piki service locally.
• Roll out similar free or low-cost initiatives more widely.
• Retain successful innovations (e.g., peer support, self-referral, integration).
• Strengthen focus on equity and targeting to priority groups.
• Commit to genuine co-design and engagement with tangata whenua, local communities.
• Offer a range of evidence-based talk therapy and digital options.
• Consider widening the age range (especially 16–18-year-olds).
• Systematically address workforce capacity and training issues.
• Routinely embed formative evaluation/CQI into new initiatives
2022-06-06T21:02:27ZExploring Health Professionals' Perceptions of a New Advanced Physiotherapy Scope of Practice in New Zealand; Understanding Barriers and Enablers to Implementation in Primary HealthcareStotter, Gillian Margarethttp://hdl.handle.net/10523/128162022-04-07T14:02:07Z2022-04-06T21:57:22ZExploring Health Professionals' Perceptions of a New Advanced Physiotherapy Scope of Practice in New Zealand; Understanding Barriers and Enablers to Implementation in Primary Healthcare
2022
Stotter, Gillian Margaret
Abstract
Background: Globally, advanced physiotherapy practice, titles, definition, scope, level
of practice, and competencies vary. In New Zealand, the physiotherapy profession is
regulated by the Physiotherapy Board, which sets the standards and prescribes scopes
of practice. Development of a proposed new Advanced Practice Physiotherapist (APP)
scope started in 2016 and was approved in March 2021 with agreement to protect the
title ‘Advanced Practice Physiotherapist’.
Aims and Objectives: This study aimed to provide knowledge of physiotherapists’ and
other health professionals’ understandings and views of advanced physiotherapy
practice within the context of musculoskeletal management in NZ primary healthcare.
The objectives were to: develop a definition of APP; explore physiotherapists’ and
other health professionals’ perceptions and attitudes regarding the introduction of the
new APP scope of practice; and explore physiotherapists’ and other health
professionals’ views of the potential barriers and enablers to the implementation of the
APP scope.
Methods: A qualitative study was conducted using the methodology of Interpretive
Description. Fifteen participants from a variety of professional and stakeholder groups,
including physiotherapists (n=6), general practitioners (n=4), medical specialists (n=3)
and Accident Compensation Corporation case managers (n=2) were interviewed face to
face. Interviews were audio-recorded, transcribed verbatim and analysed.
Results: Five themes, each with subthemes, were identified in the interview data.
Theme one: ‘Perceptions of current musculoskeletal management in primary
healthcare’, had three subthemes, ‘Variability in diagnostic accuracy and inappropriate
use of investigations’, ‘Lack of clear clinical pathways and access to secondary care’,
and ‘Fragmentation, poor communication and lack of collaboration’. Theme two:
‘Current challenges to physiotherapy practice in primary care’, had three subthemes,
‘Lack of career pathway’, ‘Professional culture is a problem’ and ‘Lack of support and
mentoring’. Theme three: ‘How APPs might facilitate change and what their role would
be’, had two subthemes, ‘Improved patient journeys’ and ‘Peer support and mentoring’.
Theme four: ‘Characteristics of an APP’, had two subthemes, ‘Qualifications,
competencies and skills required to be an APP’ and ‘How APPs will be assessed and
recognised’. Theme five: ‘Implementation of the APP role into practice’, had two
subthemes, ‘Opportunities and risks for acceptance of the APP role’ and ‘Barriers to
acceptance of the APP role’.
Conclusion: The APP scope of practice will enable health professionals, funders, the
public and physiotherapists to recognise physiotherapists with specific levels of
expertise and skills. Implementation of the APP scope of practice would provide a
recognised career pathway for physiotherapists. A clear definition of the APP role will
improve understanding of the new scope. Standardised criteria and robust processes for
assessment of clinical skills and competencies are critical to ensure external credibility
and acceptance of the APP scope. To improve recognition and acceptance of the role,
APPs must demonstrate their value to healthcare delivery by improving patient
pathways and outcomes. Valuable insights emerged regarding the culture of private
practice, with a lack of collegiality and collaboration between physiotherapists and
variability in acceptance of supervision and peer support. Recommendations are made to the
Physiotherapy Board, Physiotherapy New Zealand, stakeholders, funders and policy makers
and the universities to support change.
2022-04-06T21:57:22Z"We need to discuss surgery": A multimodal conversation analytic study of intersubjectivity during surgeons' information provision to patientsRoss, Isobel Annehttp://hdl.handle.net/10523/119962022-09-01T03:57:36Z2021-06-08T20:36:00Z"We need to discuss surgery": A multimodal conversation analytic study of intersubjectivity during surgeons' information provision to patients
2021
Ross, Isobel Anne
Providing patients with information, such that they are able to understand the consequences of treatment decisions, is an ethical and legal requirement in New Zealand and many other jurisdictions. While research from the disciplines of bioethics, law, and medicine has shown that patients’ recall and understanding of what they have been told is often limited, such research has focused on the “what” rather than the “how” of informing. While some health communication and health literacy research has addressed the how of informing, such research has relied on observation and coding strategies. By contrast, this thesis project addresses the how of informing via situated interactional analysis.
Information provision creates many challenges for both patients and surgeons. One of the greatest challenges is epistemic asymmetry, which is exacerbated by low health literacy and numeracy. To provide context for my findings in the analytic chapters, I describe the conflicting institutional, social, and psychological demands that surgeons face when providing information to patients. In addition to epistemic asymmetry, these include adherence to legal precepts, upholding bioethical principles, establishing and maintaining social relations, dealing with uncertainty, countering the “curse of expertise”, and forming a mutually acceptable plan for next steps within the circumscribed time frame of a surgical consultation.
In this thesis, I use multimodal conversation analysis to investigate participants’ management of intersubjectivity during surgeons’ extended tellings. Drawing on prior conversation analytic research on intersubjectivity and repair, the structure of storytellings, epistemics, and turn taking, I show that surgeons’ information provision takes the form of extended tellings during which patients say little. Although the content of these tellings varies widely, the content categories, namely Problem, Process, Alternatives, and Risks, which are familiar to me as a former clinician, are similar across most of these tellings. Furthermore, the ordering of these content categories appears designed to scaffold patient understanding.
On the one hand, while structural aspects of extended tellings generally inhibit floor-taking turns by patients, my research reveals that some surgeons use recycling of previous talk to create “unit ends”. Some patients orient to these unit ends by providing full turns-at-talk that initiate repair or display their stance. Furthermore, their full turns (can) provide demonstrations of their understanding. In the event that they reveal misunderstandings, such demonstrations allow surgeons to tailor their repairs.
Notwithstanding the sequential implicativeness of repeats as unit ends, patients’ floor-taking turns are rare in the mid-telling environment. However, patients can claim they are following surgeons’ talk via head nods and minimal vocal responses in the vicinity of TCU completions. In keeping with prior research, my findings show that, providing there is mutual gaze, surgeons in my data usually treat the absence of such on-time acknowledgements as interactional trouble. This orientation is evidenced by progressivity disruptions in the form of post-positioned expansions, reformulations, understanding checks, increments, response pursuits, or reassurances.
While demonstrations of understanding are rare during these extended tellings, patients can upgrade their claims of epistemic access via complex multimodal gestalts, either to claim new understanding or to claim epistemic antecedence. In this regard, analysis shows that the timing of patients’ modal moves (such as nods), in relation both to other modal moves (such as gaze continuation or withdrawal) and to surgeons’ TCU completions, is key to the epistemic affordances created.
Prior research has shown that gaze is central to intersubjectivity management because of its roles in mutual monitoring and in interactional engagement/disengagement. In keeping with this research, my findings emphasise the role of gaze in creating the accountability of patients’ acknowledgements at surgeons’ TCU completions. Furthermore, in keeping with prior research, surgeons in my data use gaze both for response pursuit and recipient selection. Finally, my analysis shows that the epistemic affordances of patients’ complex multimodal gestalts depend on gaze withdrawal or continuation.
In addition to the above theoretical contributions, my multimodal transcription method makes a methodological contribution by facilitating reader access to the simultaneous unfolding of modal moves and gaze direction. Moreover, this thesis has the potential to contribute to training of surgeons and other experts involved in information provision to laypersons.
The essence of my thesis argument, which is based on a combination of empirical multimodal conversation analytic research and the ethnographic insights of a former clinician, is that the central issue with informing for informed decision making is the ever-present tension between interactional intersubjectivity and progressivity. However, despite surgeons doing nearly all the talking during extended tellings for information provision, these tellings are co-operatively constructed by the interactional participants.
2021-06-08T20:36:00Z