Patient and clinician perspectives of factors that influence the delivery of alcohol brief interventions in Australian primary care: a qualitative descriptive study.

BACKGROUND: Brief interventions (BIs) delivered in primary care can reduce harmful alcohol consumption. Yet, clinicians do not routinely offer BIs to reduce harmful alcohol use. OBJECTIVE: We explored the perspectives of clinicians and patients about the use of alcohol BIs during consultations in Australian primary care. METHODS: Semi-structured interviews and focus groups (face-to-face and virtual) were undertaken with 34 general practitioners, eight practice nurses and 17 patients. Field notes were made from audio-recordings and themes were identified using a descriptive qualitative approach with the field notes as the point of data analysis. RESULTS: Participants identified barriers within the consultation, practice setting and wider healthcare system plus across the community which reduce the delivery of BIs in primary care including: Australian drinking norms; inconsistent public health messaging around alcohol harm; primary care not recognized as a place to go for help; community stigma towards alcohol use; practice team culture towards preventive health, including systems for recording alcohol histories; limitations of clinical software and current patient resources. CONCLUSION: Multiple layers of the healthcare system influence the use of BIs in primary care. Identified facilitators for embedding BIs in primary care included: (i) raising community and clinician awareness of the health harms of alcohol, (ii) reinforcing a primary care culture that promotes prevention and, (iii) supportive resources to facilitate discussion about alcohol use and strategies to reduce intake. Alcohol BIs in primary care could be further supported by community public health messages about alcohol use.

Alcohol is a major source of harm in the community and primary care (including family doctor and general practice settings) can play a role in reducing harmful alcohol use. When clinicians talk to their patients about alcohol use, research has shown they can reduce how much they drink each week. We spoke with general practitioners, nurses and patients in Australia to work out what is getting in the way of conversations about alcohol in primary care. We found that both clinicians and patients think we need to raise community awareness about the health harms of alcohol, that there are health system barriers, and there could be better resources to use in consultations. Low-income patients are particularly disadvantaged by financial costs associated with alcohol and counselling services when they seek help. To increase conversations about alcohol in primary care, it could be more helpful to target the broader community, the health system and primary care.

'Every medicine is part poison': a qualitative inquiry into the perceptions and experiences of choosing contraceptive methods of migrant Chinese women living in Australia.

BACKGROUND: In Australia, ethnic Chinese people are one of the largest, youngest and fastest growing overseas-born groups. Yet, little is known about their perceptions of contraceptive methods and their experiences with choosing one. Decisions about contraceptive methods are preference sensitive. Understanding the influencing factors of Chinese migrant women's contraceptive method choice and practices will help cater to their decision-making needs in a culturally sensitive and responsive way. METHODS: A qualitative study design underpinned by critical realism approach was used to explore Chinese migrant women's perceptions and experiences of choosing contraceptive methods. Semi-structured interviews were conducted with 22 women who self-identified as being ethnically Chinese and had been living in Australia for no more than 10 years. The interview guide was adapted from the Ottawa Decision Support Framework. Majority of the interviews were conducted in Mandarin Chinese. Transcribed data was analysed using thematic analysis method. RESULTS: Four major themes were identified, including: 'every medicine is part poison: hormonal contraceptives cause harm to the body'; 'intrauterine device, a device used in the past for married women'; 'it takes two (or one) to decide, depending on the relationship dynamics and contraception preferences'; and 'it is not necessary to seek medical advice in choosing contraceptive methods'. CONCLUSIONS: Our findings suggest that Chinese migrant women's perceptions and experiences of choosing contraceptive methods are influenced by complex personal, cultural, societal and inter-relational factors. Chinese migrant women were cautious of using hormonal methods due to fears of side-effects, including reduced or absent menstrual bleeding. Women were also reluctant to consider intrauterine devices as options due to associating them with past experiences of other women and themselves and also fears of potential complications. There was a reluctant attitude towards seeking medical advice regarding contraception due to beliefs that needing to use contraception is not an illness requiring treatment. Such findings are likely to be useful in increasing healthcare professionals' and policy makers' understanding of Chinese migrant women's contraceptive method preferences, beliefs and behaviours. They also help to develop culturally and linguistically sensitive strategies, which goes beyond the provision of contraceptive counselling, in assisting Chinese migrant women's decision-making needs.

The role of older patients' goals in GP decision-making about medicines: a qualitative study.

BACKGROUND: To optimise medication use in older people, it is recommended that clinicians evaluate evidence on potential benefits and harms of medicines in light of the patients' overall health, values and goals. This suggests general practitioners (GPs) should attempt to facilitate patient involvement in decision-making. In practice this is often challenging. In this qualitative study, we explored GPs' perspectives on the importance of discussing patients' goals and preferences, and the role patient preferences play in medicines management and prioritisation. METHODS: Semi-structured interviews were conducted with GPs from Australia (n = 32). Participants were purposively sampled to recruit GPs with variation in experience level and geographic location. Transcribed audio-recordings of interviews were coded using Framework Analysis. RESULTS: The results showed that most GPs recognised some value in understanding older patients' goals and preferences regarding their medicines. Most reported some discussions of goals and preferences with patients, but often this was initiated by the patient. Practical barriers were reported such as limited time during busy consultations to discuss issues beyond acute problems. GPs differed on the following main themes: 1) definition and perception of patients' goals, 2) relationship with the patient, 3) approach to medicines management and prioritisation. We observed that GPs preferred one of three different practice patterns in their approach to patients' goals in medicines decisions: 1) goals and preferences considered lower priority - 'Directive'; 2) goals seen as central - 'Goal-oriented'; 3) goals and preferences considered but not explicitly elicited - 'Tacit'. CONCLUSIONS: This study explores how GPs differ in their approach to eliciting patients' goals and preferences, and how these differences are operationalised in the context of older adults taking multiple medicines. Although there are challenges in providing care that aligns with patients' goals and preferences, this study shows how complex decisions are made between GPs and their older patients in clinical practice. This work may inform future research that investigates how GPs can best incorporate the priorities of older people in decision-making around medicines. Developing practical support strategies may assist clinicians to involve patients in discussions about their medicines.

Online training in evidence-based medicine and research methods for GP registrars: a mixed-methods evaluation of engagement and impact.

BACKGROUND: Evidence-based medicine (EBM) is a core skillset for enhancing the quality and safety of patients' care. Online EBM education could improve clinicians' skills in EBM, particularly when it is conducted during vocational training. There are limited studies on the impact of online EBM training on clinical practice among general practitioner (GP) registrars (trainees in specialist general practice). We aimed to describe and evaluate the acceptability, utility, satisfaction and applicability of the GP registrars experience with the online course. The course was developed by content-matter experts with educational designers to encompass effective teaching methods (e.g. it was interactive and used multiple teaching methods). METHODS: Mixed-method data collection was conducted after individual registrars' completion of the course. The course comprised six modules that aimed to increase knowledge of research methods and application of EBM skills to everyday practice. GP registrars who completed the online course during 2016-2020 were invited to complete an online survey about their experience and satisfaction with the course. Those who completed the course within the six months prior to data collection were invited to participate in semi-structured phone interviews about their experience with the course and the impact of the course on clinical practice. A thematic analysis approach was used to analyse the data from qualitative interviews. RESULTS: The data showed the registrars were generally positive towards the course and the concept of EBM. They stated that the course improved their confidence, knowledge, and skills and consequently impacted their practice. The students perceived the course increased their understanding of EBM with a Cohen's d of 1.6. Registrars identified factors that influenced the impact of the course. Of those, some were GP-related including their perception of EBM, and being comfortable with what they already learnt; some were work-place related such as time, the influence of supervisors, access to resources; and one was related to patient preferences. CONCLUSIONS: This study showed that GP registrars who attended the online course reported that it improved their knowledge, confidence, skill and practice of EBM over the period of three months. The study highlights the supervisor's role on GP registrars' ability in translating the EBM skills learnt in to practice and suggests exploring the effect of EBM training for supervisors.

Healthcare providers' perceptions of the challenges and opportunities to engage Chinese migrant women in contraceptive counselling: a qualitative interview study.

Background In Australia, there are many culturally and linguistically diverse communities and Chinese migrants make up one of the largest. Yet, little is known about healthcare providers' (HCPs) unique experiences in providing contraceptive care for Chinese migrant women. There is minimal research into the HCPs' perceptions of challenges or opportunities in engaging Chinese migrant women in informed and shared decision-making processes during contraceptive counselling. The aim of this study is to explore HCPs' experiences of providing contraceptive care for Chinese migrant women, their perceptions of women's care needs when choosing contraceptive methods, as well as their own needs in supporting women's decision-making. METHODS: Semi-structured interviews were conducted with 20 HCPs in Sydney, Australia who had substantial experience in providing contraceptive services to Chinese women who were recent migrants. Transcribed audio-recorded data were analysed using thematic analysis. RESULTS: Four main themes were identified, including: 'Are you using contraception?': the case for being proactive and opportunistic; 'Getting the message across': barriers to communication; 'Hormones are unnatural?': women favouring non-hormonal methods; and 'Word of mouth': social influence on contraceptive method choice. CONCLUSIONS: In order to facilitate informed choice and shared decision-making with Chinese migrant women during contraceptive counselling, broader health system and community-level strategies are needed. Such strategies could include improving HCPs' cultural competency in assessing and communicating women's contraceptive needs; providing professional interpreting services and translated materials; and improving women's health literacy, including their contraceptive knowledge and health system awareness.

Can research that is not intended or unlikely to be published be considered ethical?

BACKGROUND: For research to be ethically acceptable, the potential benefits must justify any risks involved for participants. Dissemination of research findings through publication is one way of creating benefit, but not all researchers intend to publish their research. Other factors, such as lack of size or representativeness, generalisability or innovativeness, or negative findings mean the research is unlikely to be published in a peer-reviewed medical journal. OBJECTIVE: This paper discusses ethical considerations in research where peer-reviewed publication is not intended or unlikely. DISCUSSION: Proposing research that is not intended or unlikely to be published in a peer-reviewed journal does not preclude it from being considered ethical. Additional benefits of such projects may include professional development of investigators, pilot data collection leading to more definitive studies, or developing collaborations with research users that increase relevance and improve utility of findings.

General practitioner follow-up in older patients after an emergency department admission.

BACKGROUND: Few studies have investigated older patients with regards to general practice follow-up after an emergency department (ED) admission. We measured the proportion of older patients given explicit general practice follow-up instructions who sought care by day seven after an ED admission. METHODS: Patients discharged from Fairfield Hospital ED (south-western Sydney) who were 65 years and older were approached for a structured telephone interview. Data from the interview and patients' ED discharge summaries were analysed descriptively. Exploratory statistical analyses were conducted to identify potential explanatory factors. RESULTS: Fifty patients participated in the study. Most participants (76%) attended general practice follow-up by day seven. Those with more relatives who could be called on for help were more likely to attend the follow-up appointment (P = 0.003). Participants who were not married (54% versus 84%) and non-drivers (53% versus 90%) were less likely to attend for follow-up. DISCUSSION: Close family support and car transport might influence general practice follow-up in older people. Further exploration of contributing factors may be warranted.

Ethical considerations in recruiting primary care patients to research studies.

BACKGROUND: How patients are selected and subsequently invited to take part in research has important implications for gaining informed, voluntary consent. OBJECTIVE: This article identifies and discusses common ethical issues that are faced by researchers when recruiting patients from primary care settings. DISCUSSION: Recruiting primary care patients for research studies should be guided by the core ethical values of merit and integrity, respect, justice and beneficence. Issues of patient privacy and risk of coercion are major concerns when selecting and recruiting primary care patients, but the ethical issues will depend on the type of research and the potential risks to participants. The National Statement on Ethical Conduct in Human Research, and Australian privacy laws and principles, should be reviewed to ensure recruitment meets contemporary ethical standards prior to submitting a study protocol for ethical review.

Alcohol enquiry by GPs - Understanding patients' perspectives: A qualitative study.

BACKGROUND: Patients' beliefs and attitudes toward receiving alcohol enquiry from general practitioners (GPs) are unclear. These need to be understood to implement pragmatic, early detection and brief intervention strategies. METHODS: We purposively sampled 23 participants from respondents of an earlier survey conducted in a general practice clinic in Sydney, Australia. Semi-structured interviews were conducted between June and August 2014, recorded, transcribed and analysed using grounded theory method to develop an explanatory model. RESULTS: There were three factors that influenced patients' acceptability of alcohol enquiry by GPs: • perceived relevance of the alcohol enquiry dialogue to the consultation • approach and language used in the patient-doctor interaction • unease regarding the moral and stigmatising dimension of alcohol consumption. DISCUSSION: Patients are positive towards the role of GPs in health promotion, but nonetheless have reservations towards engaging in alcohol discussions. Setting the context for alcohol dialogue, linking it to patients' agendas, collaborative consultation styles and respecting patients' sensitivity may improve acceptability.

Research ethics and approval process: A guide for new GP researchers.

BACKGROUND: The underlying moral principles and values, and the virtues held as desirable for a researcher, should be reflected upon and embedded in the research. The foundation step is to download the National Health and Medical Research Council's (NHMRC's) National Statement on Ethical Conduct in Human Research and the NHMRC's Guidelines for Ethical Conduct in Aboriginal and Torres Strait Islander Health Research to use as references. OBJECTIVE: This paper draws on the experience of The Royal Australian College of General Practitioners' (RACGP's) National Research and Evaluation Ethics Committee to provide an eight-step approach to the research ethics process. DISCUSSION: The researcher should use the research ethics process as an opportunity to foster and guide the development and conduct of ethical research.

Let's listen to patients' and GPs' perspectives on alcohol-screening research.

Alcohol-screening questionnaires have been found to be effective in the early detection of risky drinking but are rarely used by clinicians in primary care. As research agenda tend not to seek the perspectives of patients and general practitioners (GPs), the best way to address the barriers to implementation is unclear. Contemporary research to explore patient beliefs and attitudes towards alcohol enquiry by GPs is needed.

Consultation contexts and the acceptability of alcohol enquiry from general practitioners - a survey experiment.

BACKGROUND: General practitioners have a crucial role in detecting risky drinking in patients. However, little is known about how the context of the consultation affect patient acceptability of these discussions. METHODS: During one week in May 2014, adult patients seen at a community general practice in Sydney were randomised to receive one of two postal questionnaires. Participants rated the acceptability of alcohol enquiry in 20 vignettes of general practice consultations, either within a SNAP (smoking, nutrition, alcohol, physical activity) framework (intervention) or alone (control). RESULTS: Of the 441 patients who received the questionnaires, 144 returned completed and returned it. The intervention group rated an additional 2.1 (95% CI = 0.38-3.7, P = 0.016) vignettes as acceptable compared to the control group. Alcohol enquiry acceptability varied greatly between individual scenarios. DISCUSSION: Alcohol-use assessment may be more acceptable to patients when it is framed within the SNAP framework, especially in certain presentations (eg diabetes management).

Heavy drinkers' expectations and experiences when discussing alcohol use during a general practice visit in Australia: A qualitative study.

BACKGROUND AND OBJECTIVES: Our understanding of community members' expectations and experiences of discussing alcohol use in general practice settings is limited, particularly for people with heavy alcohol use. METHOD: Qualitative interviews were conducted with people with heavy alcohol use to explore their experiences of discussing alcohol use with their general practitioner (GP). Interviews were audio-recorded and transcribed, and data were analysed using an inductive thematic approach. RESULTS: Three themes were identified: (1) patient perceptions of alcohol discussions in primary care; (2) the importance of the doctor-patient relationship; and (3) consequences of unmet health needs and expectations. Patients expect their GPs to initiate conversations about alcohol use. Positive interactions are characterised by GPs' caring, non-judgemental and collaborative approach, whereas negative interactions focus on a perceived lack of knowledge or ability to manage excessive alcohol use. DISCUSSION: Alcohol harm reduction efforts should include strategies for bolstering the therapeutic relationship between GPs and their patients.

Australian general practitioner perceptions of the detection and screening of at-risk drinking, and the role of the AUDIT-C: a qualitative study.

BACKGROUND: At-risk drinking is common in Australia. Validated screening tools such as the AUDIT-C have been promoted to general practitioners (GPs), but appear rarely used and detection of at-risk drinking in primary care remains low. We sought to describe Australian GP perceptions of the detection and screening of at-risk drinking; to understand their low uptake of alcohol screening questionnaires, and in particular, their attitude to the adoption of the AUDIT-C. METHODS: Semi-structured focus group interviews of four groups of GPs and GP trainees were conducted in metropolitan Sydney between August and October 2011. Audio recordings were transcribed and analysed using grounded theory methodology. RESULTS: We identified four main themes: there was consensus that detecting at-risk drinking is important but difficult to do, social and cultural attitudes to alcohol consumption affect willingness to ask questions about its use, the dynamics of patient-doctor interactions are important, and alcohol screening questionnaires lack practical utility. Analysis suggests that the conceptual barriers to detecting at-risk drinking were: community stigma and stereotypes of "problem drinking", GP perceptions of unreliable patient alcohol use histories, and the perceived threat to the patient-doctor relationship. CONCLUSION: This small exploratory study found that the practice of, and barriers to, detecting at-risk drinking appear to be inextricably linked to the sociocultural beliefs surrounding alcohol use. Screening questionnaires such as the AUDIT-C are not designed to address these issues. In the current context, it is unlikely that approaches that focus on the use of these tools will be effective at improving detection of at-risk drinking by GPs.

Supporting conversations about medicines and deprescribing: GPs' perspectives on a Medicines Conversation Guide.

OBJECTIVES: To explore GP perspectives on a Medicines Conversation Guide to support deprescribing communication. METHODS: Semistructured interviews with GPs from Australia (n = 32). Participants were purposively sampled with varying experiences and locations. Transcribed audio recordings of interviews were coded using framework analysis. KEY FINDINGS: Most GPs stated they would use the Guide in consultation with an older patient to discuss medications. The strengths of the Guide included empowering the patient voice on an important topic. Limitations included time and complex concepts. CONCLUSIONS: Overall, the Medicines Conversation Guide was perceived by GPs to be a useful communication tool to support discussions about deprescribing with patients.

Multifaceted intervention to increase the delivery of alcohol brief interventions in primary care: a mixed-methods process analysis.

BACKGROUND: Brief interventions (BIs) are effective for reducing harmful alcohol consumption, but their use in primary care is less frequent than clinically indicated. The REducing AlCohol- related Harm (REACH) project aimed to increase the delivery of BIs in primary care. AIM: To assess the effectiveness of the REACH programme in increasing alcohol BIs in general practice and explore the implementation factors that improve or reduce uptake by clinicians. DESIGN AND SETTING: This article reports on a sequential, explanatory mixed-methods study of the implementation of the REACH project in six general practice clinics serving low-income communities in Melbourne, Australia. METHOD: Time-series analyses were conducted using routinely collected patient records and semi-structured interviews, guided by the consolidated framework for implementation research. RESULTS: The six intervention sites significantly increased their rate of recorded alcohol status (56.7% to 60.4%), whereas there was no significant change in the non-intervention practices (344 sites, 55.2% to 56.4%). CONCLUSION: REACH resources were seen as useful and acceptable by clinicians and staff. National policies that support the involvement of primary care in alcohol harm reduction helped promote ongoing intervention sustainability.

General practitioners' perspectives regarding early developmental surveillance for autism within the australian primary healthcare setting: a qualitative study.

BACKGROUND: Significant challenges remain in the early identification of child developmental disabilities in the community. Implementing supports and services early in the life course has been shown to promote positive developmental outcomes for children at high likelihood of developmental disabilities, including autism. As part of a cluster randomised controlled trial, this study seeks to examine and compare the perspectives and experiences of Australian general practitioners (GPs) in relation to a digital developmental surveillance program for autism and usual care pathway, in general practice clinics. METHODS: A qualitative research methodology with semi-structured interviews and thematic inductive analysis underpinned by grounded theory was utilised. All GPs from South Western Sydney (NSW) and Melbourne (Victoria) who participated in the main program ("GP Surveillance for Autism") were invited to the interview. GPs who provided consent were interviewed either over online or in-person meeting. Interviews were audio-recorded, transcribed, and coded using NVivo12 software. Inductive interpretive approach was adopted and data were analysed thematically. RESULTS: Twenty-three GPs across the two sites (NSW: n = 11; Victoria: n = 12) agreed to be interviewed; data saturation had reached following this number of participants. Inductive thematic coding and analysis yielded eight major themes and highlighted common enablers such as the role of GPs in early identification and subsequent supports, enhanced communication between clinicians/professionals, relationship-building with patients, and having standardised screening tools. Specific facilitators to the feasibility and acceptability of a digital screening program for the early identification of developmental disabilities, including the early signs of autism, and encouraging research and education for GPs. However, several practical and socioeconomic barriers were identified, in addition to limited knowledge and uptake of child developmental screening tools as well as COVID-19 lockdown impacts. Common and specific recommendations involve supporting GPs in developmental/paediatrics training, streamlined screening process, and funding and resources in the primary healthcare services. CONCLUSIONS: The study highlighted the need for practice and policy changes, including further training of GPs alongside sufficient time to complete developmental checks and appropriate financial remuneration through a Medicare billing item. Further research is needed on implementation and scale up of a national surveillance program for early identification of developmental disabilities, including autism.

Available, intuitive and free! Building e-learning modules using web 2.0 services.

BACKGROUND: E-learning is part of the mainstream in medical education and often provides the most efficient and effective means of engaging learners in a particular topic. However, translating design and content ideas into a useable product can be technically challenging, especially in the absence of information technology (IT) support. There is little published literature on the use of web 2.0 services to build e-learning activities. AIM: To describe the web 2.0 tools and solutions employed to build the GP Synergy evidence-based medicine and critical appraisal online course. METHODS: We used and integrated a number of free web 2.0 services including: Prezi, a web-based presentation platform; YouTube, a video sharing service; Google Docs, a online document platform; Tiny.cc, a URL shortening service; and Wordpress, a blogging platform. RESULTS: The course consisting of five multimedia-rich, tutorial-like modules was built without IT specialist assistance or specialised software. The web 2.0 services used were free. The course can be accessed with a modern web browser. CONCLUSIONS: Modern web 2.0 services remove many of the technical barriers for creating and sharing content on the internet. When used synergistically, these services can be a flexible and low-cost platform for building e-learning activities. They were a pragmatic solution in our context.

The role of quality improvement collaboratives in general practice: a qualitative systematic review.

BACKGROUND: This systematic review used qualitative methodologies to examine the role of quality improvement collaboratives (QICs) in general practice. The aim was to inform implementers and participants about the utility of using or participating in QICs in general practice. METHODS: Included studies were published in English, used a QIC intervention, reported primary research, used qualitative or mixed methods, and were conducted in general practice.A Medline search between January 1995 and February 2020 was developed and extended to include Embase, CINAHL and PsycInfo databases. Articles were sought through chaining of references and grey literature searches.Qualitative outcome data were extracted using a framework analysis. Data were analysed using thematic synthesis. Articles were assessed for quality using a threshold approach based on the criteria described by Dixon-Woods. RESULTS: 15 qualitative and 18 mixed-methods studies of QICs in general practice were included. Data were grouped into four analytical themes which describe the role of a collaborative in general practice: improving the target topic, developing practices and providers, developing the health system and building quality improvement capacity. DISCUSSION: General practice collaboratives are reported to be useful for improving target topics. They can also develop knowledge and motivation in providers, build systems and team work in local practice organisations, and improve support at a system level. Collaboratives can build quality improvement capacity in the primary care system. These roles suggest that QICs are well matched to the improvement needs of general practice.General practice participants in collaboratives reported positive effects from effective peer interaction, high-quality local support, real engagement with data and well-designed training in quality improvement.Strengths of this study were an inclusive search and explicit qualitative methodology. It is possible some studies were missed. Qualitative studies of collaboratives may be affected by selection bias and confirmation bias. PROSPERO REGISTRATION NUMBER: CRD4202017512.