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Biomedical subjects

Deborah McLeod

Publications and source records attributed to Deborah McLeod.

At least 19 recordsLinked to original sources
PubMed2005

The treatment of common mental health problems in general practice.

BACKGROUND: Previous studies report GPs under-treat mental health disorders, particularly depression, and treatments are non-specific and lack an evidence base. They conclude further training and education of GP's is required. OBJECTIVE: To describe the treatment of common mental health disorders in relation to the level and severity of psychological problems as defined by the GP and external assessment. METHODS: Cross sectional survey of General Practice attenders in New Zealand. Fifty consecutive adult patients were recruited from each practice of 70 randomly selected GP's. The psychological status of 773 respondents selected via the General Health Questionnaire (GHQ) was assessed, and details of management provided. Management options were compared with the level of psychological problem identified by the GP. RESULTS: Treatment varied depending on the level of problem identification, and frequency of consultation, from 93% given treatment when an explicit diagnosis was made to 22.3% in patients with subclinical symptoms. The most commonly given treatment with an explicit diagnosis was psychotropic medication [73% (95% CI 63.6-82.9)] while for those patients with subclinical symptoms the most common form of treatment was discussion and counselling [15.7% (7.1-24.2)]. Only 1.7% (0.3-3.0) of patients with subclinical symptoms received psychotropics. CONCLUSION: There is a clear association between the level of psychological problem identified and treatment. In contrast to previous views that treatment often appears to be given regardless of diagnosis, these results provide a picture of general practice management of common mental disorders more in line with evidence-based practice than previously described.

Adult↗
PubMed2005

Do patients want to disclose psychological problems to GPs?

BACKGROUND: GPs are an accessible health care provider for most patients with mental disorders and are gatekeepers to specialist care. The extent to which patients consider their primary care team as relevant to their mental health problems needs to be explored. OBJECTIVES: To explore reasons why patients choose not to disclose psychological problems to GPs, and to discuss the implications for the provision of primary mental health care. METHODS: A cross-sectional survey of consecutive patients attending general practices in New Zealand (part of the MaGPIe study). Patients were screened using the GHQ-12 and a stratified sample participated in a structured in-depth interview to assess their psychological health. Non-disclosure of psychological problems was explored. GPs assessed patients' psychological health using a 5-point scale of severity. RESULTS: Seventy GPs (90%) and 775 patients (70%) participated. Overall, 29.8% of all patients and 36.9% of patients with current symptoms reported non-disclosure of self-perceived psychological problems. Younger patients, those consulting more frequently and those with greater psychiatric disability were more likely to report non-disclosure. The most frequently given reasons were beliefs that a GP is not the 'right' person to talk to (33.8%) or that mental health problems should not be discussed at all (27.6%). CONCLUSIONS: Interventions such as screening and GP education may be ineffective in improving primary mental health care unless accompanied by educational programmes for the general public to increase mental health literacy, de-stigmatise mental illness and increase awareness of general practice as an appropriate and effective source of health care.

Adolescent↗
PubMed2005

Can Quit Practice: a comprehensive smoking cessation programme for the general practice team.

AIMS: To develop, implement, and evaluate a programme of training and support for smoking cessation provision in general practice. METHODS: The Can Quit Practice Programme was developed for delivery in general practices with a particular focus on the skills of the practice nurse (PN) in providing quit support. The Programme utilises the principles of brief intervention by the GP or PN followed by a systematic quit support programme delivered by trained practice nurses (quit advisors). Alternative implementation strategies and the provision of ongoing support and problem solving sessions were integral parts of the Programme. The evaluation used qualitative and quantitative methods to establish quit rates for participants enrolled in the Programme and explore the efficacy of programme delivery. RESULTS: The quit rates achieved by 85 smokers (from 14 general practices) enrolled in the Can Quit Practice Programme evaluation were; 25.9% at 3 months; 22.4% at 6 months; and 20.0% at 9 months. Important components of successful implementation were: an autonomous role for PNs; well-managed practice procedures; adequate consultation time; and adequate funding for health promotion. CONCLUSION: Smoking cessation programmes can be successfully implemented and maintained within general practices as an integrated part of primary healthcare.

Family Practice↗
PubMed2005

"This glorious twilight zone of uncertainty": mental health consultations in general practice in New Zealand.

General practitioners provide treatment for the majority of people diagnosed as having a mental disorder in New Zealand, but much research suggests that they fail to diagnose many common mental disorders. This paper explores the issue of GP recognition of mental health problems through four discussion groups with GPs from the lower half of the North Island of New Zealand. GPs were asked to consider what they thought their role was in relation to mental health, what facilitated discussion of mental health issues in consultations and what could influence patients to disclose mental health problems. The analysis of the data collected drew on thematic and discourse analysis. Four key domains that had an impact on the consultation were identified, which were categorised as practice pressures, socio-cultural factors, the medico-legal framework and the consultation process. GPs employ a number of strategies to respond to the systemic and social issues influencing the consultation. This research suggests that GPs do recognise mental health problems in patients, but that a number of important factors result in the consultations not being labeled as mental health ones. The paper concludes by offering a framework for the mental health consultation that illustrates the systemic issues that GPs consider when making decisions about mental health consultations.

Family Practice↗
PubMed2005

Explicit rationing of elective services: implementing the New Zealand reforms.

In an attempt to make rationing of elective surgery in the publicly funded health system more explicit, New Zealand has developed a booking system for surgery using clinical priority assessment criteria (CPAC). This paper is based on research undertaken to evaluate the use of CPAC. To explore whether the goals of explicit rationing were being met 69 interviews were undertaken with policy advisors, administrators and clinicians in six localities throughout New Zealand. The aims of reforming policy for access to elective surgery included improving equity, providing clarity for patients, and achieving a paradigm shift by relating likely benefit from surgery to the available resources. The research suggests that there have been changes in the way in which patients access elective surgery and that in many ways rationing has become more explicit. However, there is also some resistance to the use of CPAC, in part due to confusion over whether the tools are decision-aids or protocols, what role the tools play in achieving equity and differences between financial thresholds for access to surgery and clinical thresholds for benefit from surgery. For many surgical specialties implicit rationing will continue to play a major part in determining access to surgery unless validated and reliable CPAC tools can be developed.

Elective Surgical Procedures↗
PubMed2005

"What sort of health promotion are you talking about?": a discourse analysis of the talk of general practitioners.

In New Zealand, health promotion is now expected to be an integral part of the work of a general practitioner, and in the recently implemented New Zealand Primary Health Organisation structure, specific funding is available to undertake health promotion activities in primary care. Eighteen general practitioners recruited to take part in two focus groups discussing men's health, talked extensively about health promotion. This talk was analysed through a discourse analysis. This study of the 'talk' of general practitioners suggests that there are problems in transferring the concept, which must be recognised and addressed if health promotion is going to be taken up effectively within general practice. The meaning given to health promotion in the consultation is unclear and general practitioners were unsure about its value in 'health checks' and screening. Lack of time and lack of confidence in the evidence appeared to be barriers to undertaking health promotion within general practice consultations. In the current climate general practitioners are uncertain, to the point of ambivalence, about health promotion in their work. Further work will be required to ensure this ambivalence does not result in covert resistance.

Adult↗
PubMed2004

Genetic testing in New Zealand: the role of the general practitioner.

AIM: The aim of the study commissioned by the National Health Committee (NHC) was to explore the current practice and training needs of general practitioners (GPs) in relation to genetic testing in New Zealand, and to gauge GPs' perceptions of access to genetic services for their patients. METHOD: A postal survey was sent to a national, random sample of 600 GPs. Responses were received from 328 (56%) of the 586 eligible GPs. RESULTS: Most GPs felt they lacked experience and knowledge of genetic testing, had received little formal training, and many were unsure of how to contact genetic services locally. GPs recognised the importance of their role in genetic testing and requested further information. CONCLUSIONS: GPs in New Zealand have an increasingly important role to play in genetic testing. The nature of this role in the new genetics era needs to be carefully considered as will the best way to implement any future educational strategies.

Attitude of Health Personnel↗
PubMed2004

Clinical practice guidelines' development and use in New Zealand: an evolving process.

AIMS: This study explores the use of evidence-based guidelines by New Zealand general practitioners, and describes strategies developed to overcome identified barriers in the New Zealand setting. METHODS: In-depth, semi-structured interviews with a purposeful sample of New Zealand guideline stakeholders including policy makers and general practitioners. Data were analysed using inductive thematic analysis. Feedback of emergent themes to the New Zealand Guidelines Group (NZGG) and further collaboration resulted in strategies to overcome barriers to use, some of which have now been implemented. RESULTS: At the time of the research (2000/2001), general practitioners reported that they did not regularly use guidelines to support decision-making regarding patient care. Reasons given included guidelines formats not being recognisable or user-friendly, lack of general practitioner involvement in prioritisation and development processes, influence of stakeholders, and recommendations not being accessible or relevant. Policy and other interviewed stakeholders reported general acceptance of guidelines, however there were minimal interfaces between the NZGG and these organisations. CONCLUSIONS: Effective implementation of guidelines requires more than guidelines endorsement by policy stakeholders and passive dissemination strategies, but rather an understanding of the issues facing general practitioners and their attitudes to guideline use.

Attitude of Health Personnel↗
PubMed2004

Can support and education for smoking cessation and reduction be provided effectively by midwives within primary maternity care?

OBJECTIVE: To test the hypothesis that appropriate interventions delivered by midwives within usual primary maternity care, can assist women to stop or reduce the amount they smoke and facilitate longer duration of breast feeding. DESIGN, SETTING AND PARTICIPANTS: In a cluster randomised trial of smoking education and breast-feeding interventions in the lower North Island, New Zealand, midwives were stratified by locality and randomly allocated into a control group and three intervention groups. The control group provided usual care. Midwives in the intervention groups delivered either a programme of education and support for smoking cessation or reduction, a programme of education and support for breast feeding or both programmes. Sixty-one midwives recruited a total of 297 women. INTERVENTIONS: Structured programmes provided by midwives. FINDINGS: Women receiving only the smoking cessation or reduction programme were significantly more likely to have reduced, stopped smoking or maintained smoking changes than women in the control group, at 28 weeks and 36 weeks gestation. Women receiving both the smoking cessation and breast-feeding education and support programmes were significantly more likely than women in the control group to have changed their smoking behaviour at 36 weeks gestation. There was no difference in rates of cessation or reduction between the groups in the postnatal period. There was no difference in rates of full breast feeding between the control and intervention groups for women who planned to breast feed. KEY CONCLUSIONS: Education and support by midwives, as part of primary midwifery, can facilitate smoking cessation and reduction during pregnancy.

Breast Feeding↗
PubMed2004

Clinicians' reported use of clinical priority assessment criteria and their attitudes to prioritization for elective surgery: a cross-sectional survey.

OBJECTIVES: To explore the attitudes of clinicians working in New Zealand publicly funded hospitals towards prioritizing patients for elective surgery, and their reported use of clinical priority assessment criteria (CPAC). DESIGN: A cross-sectional study using a postal questionnaire. The questionnaire drew on themes identified from an earlier qualitative study. Questions were closed and information was sought about perceptions of the need to prioritize patients, effective ways of doing so and the use of CPAC. SETTING: New Zealand. PARTICIPANTS: A national sample of cardiologists, cardiac, general and orthopaedic surgeons, and registrars. RESULTS: Three hundred and thirty-two clinicians responded to the survey (74.1%). Respondents generally agreed that a nationally consistent method of prioritizing patients for surgery was required but felt their clinical judgement was the most effective way of prioritizing patients. Current CPAC were considered to be administrative tools and there was marked variation in their reported use. Consistent use of CPAC using the constructs provided was more likely to be reported by cardiac specialists than general or orthopaedic surgeons. Other features of the hospital system in which surgeons worked also had a major impact on access to elective surgery. CONCLUSIONS: Clinicians recognized the need for a nationally consistent method of prioritizing patients. Although most did not consider current CPAC were effective in achieving this, many felt there was some potential in further development of tools. However, further development is problematic in the absence of objective measures of need and ability to benefit.

Attitude of Health Personnel↗
PubMed2004

Equity of access to elective surgery: reflections from NZ clinicians.

OBJECTIVES: To explore factors potentially influencing equitable access to elective surgery in New Zealand by describing clinicians' perceptions of equity and the factors they consider when prioritising patients for elective surgery. METHODS: A qualitative study in selected New Zealand localities. A purposive sample of 49 general practitioners, specialists and registrars were interviewed. Data were analysed thematically. RESULTS: General practitioners described unequal opportunities for patients to access primary and secondary care and, in particular, private sector elective surgery. They felt that socio-economically disadvantaged patients were less able to advocate for themselves and were more vulnerable to being lost to the elective surgical booking system as well as being less able to access private care. Both GPs and secondary care clinicians described situations where they would personally advocate for individual patients to improve their access. Advocacy was related to clinicians' perceptions of the 'value' that patients would receive from the surgery and patients' needs for public sector funding. CONCLUSIONS: The structure of the health system contributes to inequities in access to elective care in New Zealand. Subjective decision making by clinicians has the potential to advantage or disadvantage patients through the weighting clinicians place on socio-demographic factors when making rationing decisions. Review of the potential structural barriers to equitable access, further public debate and guidance for clinicians on the relative importance of socio-demographic factors in deciding access to rationed services are required for allocation of services to be fair.

Attitude of Health Personnel↗
PubMed2004

Use of, and attitudes to, clinical priority assessment criteria in elective surgery in New Zealand.

OBJECTIVES: To describe the ways patients access elective surgery in New Zealand, and to understand the use of, and attitudes to, clinical priority assessment criteria (CPAC) in determining access to publicly funded elective surgery. METHODS: A qualitative study in selected New Zealand localities. A purposive sample of general practitioners, surgeons and administrators in publicly funded hospitals were interviewed. Data were analysed by a process of thematic analysis. RESULTS: Sixty-five interviews were completed. General practitioners had a key role in determining which patients were seen in the public sector and, by utilising strategies to actively advocate for patients, influenced both waiting times for first assessment by surgeons and for surgery. CPAC had been developed as decision support guides with the intention that they would provide transparency and equity in determining access. However, there was variation in the way CPAC were being used both in score construction and in the influence of the score on access to surgery. The management of the hospital system also limited the extent to which CPAC could be used to prioritise patients for surgery. CONCLUSIONS: Variability in the use of CPAC tools meant that at the time of the study they did not provide a transparent and equitable method of determining access to surgery. This highlights the difficulties in developing and implementing CPAC and suggests that further development is difficult in the absence of evidence to identify patients who will benefit the most from surgery.

Attitude of Health Personnel↗
PubMed2003

Screening for prostate cancer: a survey of New Zealand general practitioners.

AIM: To determine the views of general practitioners (GPs) in relation to screening for prostate cancer. METHODS: A questionnaire was sent to a random, national sample of 575 New Zealand general practitioners, stratified to include equal numbers of rural and urban GPs. RESULTS: The response rate to the questionnaire was 66.3%. A 55-year-old man presenting for an annual checkup or requesting advice about screening for prostate cancer would be given a prostate specific antigen (PSA) test by 74% of GPs. If the same man had a family history of prostate or breast cancer, 93% of GPs would carry out a PSA test. Most GPs overestimated the effectiveness of screening tests for prostate cancer and were uncertain about the importance of associated risk factors. Some form of screening for prostate cancer is performed by 97.5% of GPs, and 50% of GPs support a national population-screening programme. 'Watchful waiting' is considered to be a reasonable treatment option for a man with localised prostate cancer and less than 10 years' life expectancy by 40% of GPs compared with 2% for a man with more than 10 years' life expectancy. CONCLUSIONS: Most GPs undertake screening for prostate cancer, even though there is no evidence that screening improves life expectancy and quality of life.

Adult↗
PubMed2003

Factors that influence changes in smoking behaviour during pregnancy.

AIMS: This study explored characteristics of women who continue to smoke beyond the first trimester of pregnancy. METHODS: A cohort of 1283 pregnant women were surveyed at the time they registered with a maternity care provider, using a postal questionnaire. Women who reported they were ex-smokers were asked when they had stopped smoking. Data were analysed using logistic regression to identify socio-demographic variables associated with smoking and with stopping smoking. RESULTS: 829 (69.2%) women responded to the questionnaire. 183 (22.2%) reported smoking when they became pregnant. Forty nine (26.8%) of the women smoking at conception reported giving up in the first trimester. Factors significantly associated with stopping smoking in the first trimester were current employment (OR 2.37, 95% CI 1.16-4.85), first pregnancy (OR 2.18, 95% CI 1.11-4.28), and experiencing nausea during the pregnancy (OR 2.59, 95% CI 1.11-6.04). Women who held a community services card (OR 0.41, 95% CI 0.19-0.86), Maori women (OR 0.38, 95% CI 0.15-0.98) and women whose partners smoked (OR 0.35, 95% CI 0.17-0.70) were significantly less likely to have stopped smoking. CONCLUSION: Socioeconomically deprived women were more likely to continue to smoke beyond the first trimester of pregnancy and this needs to be taken into account in the provision of smoking cessation support.

Cohort Studies↗
PubMed2003

The midwife's role in facilitating smoking behaviour change during pregnancy.

OBJECTIVE: To explore the midwife's role in providing education and support for changes in smoking behaviour during usual primary maternity care. DESIGN: A qualitative study using a thematic approach to analysis of data collected in face-to-face interviews. SETTING AND PARTICIPANTS: Eleven women who had participated in the intervention groups of the MEWS Study, a cluster randomised trial of education and support for women who smoke, and 16 midwives from the intervention and control arms of the trial. The trial was set in the lower North Island of New Zealand in 2000. FINDINGS: Midwives acknowledged that asking women about smoking was part of their role as maternity care providers. However, many found it difficult to know how to ask women about their smoking, how to identify the women who would be receptive to advice and how to support them to make changes to their smoking. Midwives were also concerned about making women feel guiltier than they already did about their smoking, and about the impact of providing smoking cessation on their relationship with women. In contrast, women expected their midwife to ask them about their smoking. When women wanted to quit their midwife was an extremely valuable source of information and support. Midwives were also in a position to help women who did not want to quit to make other changes to their smoking behaviour. Even women who did not want to quit were prepared to be asked about their smoking. Problems arose when the way the midwife asked and the frequency of her enquiries were not appropriate for the stage of the change cycle the woman was in. IMPLICATIONS FOR PRACTICE: Midwives can effectively provide education and support for smoking change during pregnancy if they match the woman's readiness to make changes with the type of advice and support they provide.

Adult↗
PubMed2003

Smoking cessation in New Zealand: education and resources for use by midwives for women who smoke during pregnancy.

This study describes the development and evaluation of education programmes and associated resource materials to support smoking cessation and reduction, and breastfeeding promotion strategies for pregnant women who smoke, during usual primary maternity care by midwives. Education programmes and resource materials were developed by midwives and researchers as part of a cluster randomized trial of Midwifery Education for Women who Smoke (the MEWS study). Development included a cohort study, advice from lactation consultants and smoking cessation counsellors (including Ma-ori professionals), and early consultation with midwives who would be delivering the programmes. Resources developed included videotapes, charts and laminated information cards. Resources were pre-tested with pregnant women and opinion leaders. Consultation with the midwives allocated to each of the intervention groups in the trial raised a number of issues. These were addressed, and solutions incorporated into each of the programmes, to enable effective delivery within usual care. Following delivery of the programmes, women and their midwives were surveyed and a sample interviewed to ascertain attitudes to the programmes and resources. Women and their midwives responded positively to the smoking cessation education programme, the breastfeeding promotion programme and the resources used. Those women who did not stop smoking completely often succeeded in significantly reducing their tobacco consumption. Women identified their midwife as a valuable resource and appreciated her ongoing encouragement. Involvement of health professionals who are to deliver health promotion interventions is essential for successful integration of programmes into usual care. Midwives were able to effectively deliver programmes that were developed and targeted to their needs as health educators. The pregnancy-specific resources developed for women who smoke played an important part in helping midwives deliver their health promotion messages more effectively.

Adult↗
PubMed2003

Mystery shopping in health service evaluation.

BACKGROUND: Over the last 5 years, primary care telephone triage systems have been introduced in the United Kingdom, United States, Australia, and most recently in New Zealand. Evaluation of the clinical safety of such systems poses a challenge for health planners and researchers. AIM: To evaluate the use of simulated patients in the assessment of aspects of clinical safety in a pilot New Zealand primary care telephone triage service. DESIGN OF STUDY: 'Mystery shopping', an evaluation strategy commonly used in market research, was adapted by using simulated patients for telephone triage service evaluation. SETTING: New Zealand. METHODS: Four scripted clinical scenarios were developed by academic general practitioners, validated in student teaching situations, and then used by simulated patients to make 101 telephone calls. The scenarios were designed to necessitate a referral to a medical practitioner for further investigation. The documentation kept by the callers was compared with the call records from the telephone triage company, and both were analysed for capture and handling of the clinical safety features of each scenario. In cases where the endpoint was not a medical assessment, possible reasons for this were explored. RESULTS: Records were retrieved for 85 telephone calls. Considerable triage variability was discovered. There were discrepancies between expected and actual triage outcomes with 51% of analysed calls resulting in a self-care recommendation. A number of reasons were identified both for the triage variability and the unpredicted outcomes. Audiotaping of consultations would have enhanced the credibility of the evaluation but it would have carried ethical constraints. CONCLUSION: Simulated patients can be used to evaluate the limitations of health services and to identify areas that could be addressed to improve patient safety. Evaluation of patient satisfaction with services is not sufficient alone to evaluate safety.

Adult↗