What is the place of generalism in the 2020 primary care team?

Primary health care is a domain of reform and change. To maintain a cost-effective, equitable and accessible health care system, policy and strategies must address growing health system complexities. These include workforce shortages, technological advances, an ageing population, rising rates of chronic disease, increases in co-morbidity and growing multi-morbidities. A single-disease focussed approach is not sufficient. Should the generalist be developed to address these multiple issues? What is generalism and its place within the 2020 primary health care team?The research reported in this paper is a project of the Australian Primary Health Care Research Institute, which is supported by a grant from the Australian Government Department of Health and Ageing under the Primary Health Care Research, Evaluation and Development Strategy

Embedding effective depression care: using theory for primary care organisational and systems change

Background: depression and related disorders represent a significant part of general practitioners (GPs) daily work. Implementing the evidence about what works for depression care into routine practice presents a challenge for researchers and service designers. The emerging consensus is that the transfer of efficacious interventions into routine practice is strongly linked to how well the interventions are based upon theory and take into account the contextual factors of the setting into which they are to be transferred. We set out to develop a conceptual framework to guide change and the implementation of best practice depression care in the primary care setting.Methods: we used a mixed method, observational approach to gather data about routine depression care in a range of primary care settings via: audit of electronic health records; observation of routine clinical care; and structured, facilitated whole of organisation meetings. Audit data were summarised using simple descriptive statistics. Observational data were collected using field notes. Organisational meetings were audio taped and transcribed. All the data sets were grouped, by organisation, and considered as a whole case. Normalisation Process Theory (NPT) was identified as an analytical theory to guide the conceptual framework development.Results: five privately owned primary care organisations (general practices) and one community health centre took part over the course of 18 months. We successfully developed a conceptual framework for implementing an effective model of depression care based on the four constructs of NPT: coherence, which proposes that depression work requires the conceptualisation of boundaries of who is depressed and who is not depressed and techniques for dealing with diffuseness; cognitive participation, which proposes that depression work requires engagement with a shared set of techniques that deal with depression as a health problem; collective action, which proposes that agreement is reached about how care is organised; and reflexive monitoring, which proposes that depression work requires agreement about how depression work will be monitored at the patient and practice level. We describe how these constructs can be used to guide the design and implementation of effective depression care in a way that can take account of contextual differences.Conclusions: ideas about what is required for an effective model and system of depression care in primary care need to be accompanied by theoretically informed frameworks that consider how these can be implemented. The conceptual framework we have presented can be used to guide organisational and system change to develop common language around each construct between policy makers, service users, professionals, and researchers. This shared understanding across groups is fundamental to the effective implementation of change in primary care for depressio

Diffracting addicting binaries: An analysis of personal accounts of alcohol and other drug ‘addiction’

Associated with social and individual harm, loss of control and destructive behaviour, addiction is widely considered to be a major social problem. Most models of addiction, including the influential disease model, rely on the volition/compulsion binary, conceptualising addiction as a disorder of compulsion. In order to interrogate this prevailing view, this article draws on qualitative data from interviews with people who describe themselves as having an alcohol or other drug ‘addiction’, ‘dependence’ or ‘habit’. Applying the concept of ‘diffraction’ elaborated by science studies scholar Karen Barad, we examine the process of ‘addicting’, or the various ways in which addiction is constituted, in accounts of daily life with regular alcohol and other drug use. Our analysis suggests not only that personal accounts of addiction exceed the absolute opposition of volition/compulsion but also that the polarising assumptions of existing addicting discourses produce many of the negative effects typically attributed to the ‘disease of addiction’

Exploring Doctor–Patient Communication in Immigrant Australians with Type 2 Diabetes: A Qualitative Study

OBJECTIVE: The study explored the perceptions of Australian immigrants about their interactions with doctors regarding the diagnosis, treatment, and management of type 2 diabetes mellitus. RESEARCH DESIGN AND METHODS: In-depth interviews were conducted with 30 men and women from Greek, Indian, Chinese, and Pacific Island backgrounds living in Melbourne, Australia, to elicit their perceptions of the management of diabetes and its impact. Participants were recruited through a convenience sample of general practitioners and community organizations providing support to people living with diabetes. Topics discussed included initial reaction to diagnosis, patient—health care provider communication, and the influence of message framing on the perception of the quality of the doctor–patient relationship. Transcripts were coded and analyzed by both authors. RESULTS: Numerous issues facilitate or inhibit constructive and positive relationships between doctors and patients with type 2 diabetes. Patients reported difficulty in absorbing all the information provided to them at early consultations, and experienced difficulty comprehending the practical aspects of management. Styles of communication and discourses of normalization and catastrophe influenced participants’ responses. CONCLUSION: Doctors face a complex task in encouraging behavioral change and adherence and establishing and maintaining a supportive relationship with patients. The timing and technical complexity of communication about diabetes, its management, and the prevention of complications require further attention

Depression in multicultural Australia: Policies, research and services

BACKGROUND: Depression is one of the leading causes of disability in Australia. The cultural and linguistic diversity of the Australian population poses a significant challenge to health policy development, service provision, professional education, and research. The purpose of this study is to explore the extent to which the fact of cultural and linguistic diversity has influenced the formulation of mental health policy, the conduct of mental health research and the development of mental health services for people with depression from ethnic minority communities. METHODS: The methods used for the different components of the study included surveys and document-based content and thematic analyses. RESULTS: Policy is comprehensive but its translation into programs is inadequate. Across Australia, there were few specific programs on depression in ethnic minority communities and they are confronted with a variety of implementation difficulties. The scope and scale of research on depression in Ethnic minority communities is extremely limited. CONCLUSION: A key problem is that the research that is necessary to provide evidence for policy and service delivery is lacking. If depression in Ethnic minority communities is to be addressed effectively the gaps between policy intentions and policy implementation, and between information needs for policies and practice and the actual research that is being done, have to be narrowed

Intellectuals and migration

The focus of this thesis is on intellectuals trained as academics in Croatia, the Czech Republic, Hungary and Poland who have settled in Australia during the 1980s and 1990s. The study explores the major issues influencing these migrant intellectuals in their decision to migrate to Australia. The study concentrates on two crucial phases of the migration process as articulated by Demuth (2000a), the starting or decision making phase, and the sojournal phase when migrant intellectuals have more (or less) settled in their new country. Focus on these two phases allows exploration of why some intellectuals decide to emigrate, whilst others (in apparently similar circumstances) decide to remain, and why some intellectuals settle permanently in their new country, whilst others after a period of living away, repatriate. The actual research, then, was carried out both in East Central Europe and in Australia. Intellectuals in Croatia, the Czech Republic, Hungary and Poland were interviewed, and academic literature was explored to ascertain the position and status of intellectuals in East Central Europe before and after 1989, the year of major social and political transformation in the region. Interviews in Croatia, the Czech Republic, Hungary and Poland dealt specifically with the views of intellectuals on emigration - whether they had contemplated emigration themselves and their opinions on the motives of others emigrating or returning. Within the Australian context, this research involves examination of Australian immigration policies in relation to university educated immigrants, and analysis of in-depth interviews conducted with academics from Croatia, the Czech Republic, Hungary and Poland who have settled in Australia. East Central European emigration trends and Australian immigration policies are discussed jointly to gain a general sense of the context in which the interviewed academics migrated. The interviews conducted with East Central European academics encompass issues relating to their current circumstances in Australia, their experiences with diverse university cultures, how they interpret their biographies and construct relationships with their countries of origin by means of maintaining links with their former colleagues and academic institutions in East Central Europe. Interviews also explore the possibility of repatriation. This study provides an insight into the current position of intellectuals in East Central Europe and how this position is viewed by East Central European academics settled in Australia. It is proposed in the thesis that the social role of intellectuals in East Central Europe has declined after 1989, and that this has influenced the intellectual identity of both intellectuals who remained in East Central Europe and those who immigrated to Australia

‘I’m managing myself’: how and why people use St John’s wort as a strategy to manage their mental health risk

In this article, we examine the choice to use a complementary and alternative medicine product (St John’s wort) for the management of mental health risk. We draw on data from a study in which we conducted in-depth, semi-structured interviews with 41 adults who self-reported depression, stress or anxiety, in Melbourne, Australia, in 2011. We identified three groups of users – regular St John’s wort users, whose use was continuous; irregular users, whose use was occasional; and non-users, who had stopped or were contemplating use. In each group, St John’s wort use centred around managing risk, taking control and self-management. Participants described a process of weighing up risks and benefits of different treatment options. They viewed St John’s wort as a less risky and/or safer option than antidepressants because they perceived it to be more natural, with fewer side effects. They saw their use of St John’s wort as a means of exercising personal control over mental health risks, for example, to alleviate or self-manage symptoms of depression. Their use of St John’s wort was also linked to perceptions of broader social risks including the stigma and shame of needing to use antidepressants. The findings deepen our understanding of notions of mental health risk by pointing to the importance of localised knowledge of risk in decision-making, and the ways in which perceptions of, and hence responses to, risk differ between groups