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This thesis presents a series of studies about general medical practitioners’ patient management decisions in depression and the role of the clinical guideline within these.  The goal of the research was to identify the factors that influence their prescribing and to investigate how guideline use could be increased so as to promote clinical effectiveness.  A lens model study found that GPs tend to over prescribe compared with the guidelines and place much more emphasis on patients’ reports of thoughts of suicide and sleep disturbance than the guideline. Although GPs’ judgement data were well described by regression models, a simple fast and frugal model of decision-making explained the judgement data equally well.  A cluster analysis was carried out on the resulting GPs’ decision policies and 3 clusters emerged which could be differentiated by the size of practice they worked in.  GPs in the larger practices had decision policies, which were more like those of guideline recommendations.  GPs were found to have good self-insight in to their decision-making when a policy recognition task was used.  A further analysis found that GPs in one area in England prescribed at a greater rate than those in the Grampian region of Scotland and decision policies showed that patient treatment preference had less influence on the English GPs’ decisions. The results from these quantitative studies were explored further by using in-depth interviews with GPs.  A number of factors which help to explain why the GPs are sometimes prevented from following guideline recommendations and fulfilling patient treatment wishes and why changing behaviour in order for it to be more compliant with guideline recommendations it so difficult.

In light of the increasing prevalence of obesity in the UK, health professionals working within general practice are urged to initiate discussion about weight with overweight and obese patients. Despite such appeals, evidence suggests that only a minority of health professionals routinely talk to patients about weight loss. To understand more about the barriers to raising the topic of weight in general practice, three empirical studies guided by qualitative research design were carried out. The first two studies draw on psychological theory to identify barriers to raising the topic of weight. Semi-structured interviews were conducted with 17 GPs and 17 primary care nurses. The third study conducted with 20 GPs is underpinned by discourse analysis and uses trigger film interviews to capture and critically analyse the discursive production of, and macro-discourses shaping, barriers. In study 1 and 2, three main themes summarise barriers identified from GP and primary care nurse perspectives: limited understanding about obesity care, concern about negative consequences and limited time to raise a sensitive topic. In study 3, four discursive frameworks were identified as underpinning constructions about the barriers to broaching discussion about obesity: medical-reductionist, medical-holistic, moral and ethical. Findings extend understanding about the ways in which obesity is constructed as both a medical and non-medical issue. The findings have implications for health professional education, policy and research including the need to expose and challenge dominant understandings of obesity as a behavioural problem, to address barriers operating at the socio-cultural as well as the individual-level, and to enhance understanding about the socially embedded and pernicious effects of obesity stigma in the consultation and beyond.

Yes / Objectives: General practitioners (GPs) are crucial to improving timely diagnosis, but little is reported about how they perceive dementia, and whether their perceptions display any elements of stigma. The aim of this study was to explore how GPs’ perceptions of dementia map onto current conceptualizations of stigma and whether GPs feel that stigma affects timely diagnosis. Methods: Twenty-three GPs from England were interviewed by telephone. Data were analyzed by means of content analysis. This involved open coding followed by the application of a coding framework derived from the literature to explore how and to what extent their perceptions relate to stigma as well as the unique nature of their perceptions. Results: Three themes emerged from the analysis: (1) ‘making sense of dementia’, (2) ‘relating perceptions of dementia to oneself’ and (3) ‘considering the consequences of dementia’. GPs’ perceptions of dementia mapped onto current conceptualizations of stigma. Perceptions about dementia that were linked to their own existential anxiety and to a perceived similarity between people with dementia and themselves were particularly salient. GPs perceived dementia as a stigma which was gradually being overcome but that stigma still hindered timely diagnosis. They provided examples of structural discrimination within the health service, including lack of time for patients and shortcomings in training that were to the detriment of people with dementia. Conclusion: Measures to involve GPs in tackling stigma should include training and opportunities to explore how they perceive dementia, as well as support to address structural discrimination. / The study was funded by Alzheimer Europe (Luxembourg) in the form of tuition fees for Dianne Gove for her PhD study.

Yes / A qualitative exploration of the stigma of dementia reported that GPs described lack of reciprocity as one way in which people with dementia are perceived within society. This was closely linked to their perception of dementia as a stigma. In this paper, we explore whether GPs perceive people with dementia as lacking reciprocity and, so, if this is linked with societal opinions about dementia as a stigma. The implications of both perceptions of people with dementia failing to reciprocate and of stigma for timely diagnosis are explored. GPs’ perceptions of societal views of people with dementia included a perception of a lack of reciprocity. Specifically, an absence of reciprocity was linked with; failing to respond to human contact, the absence of an appropriate return on social investment and failing to contribute to, or being a burden to, society. GPs reported a link between societal perceptions of lack of reciprocity and stereotypes about advanced dementia, difficulties communicating with people with dementia and lack of opportunities for people with dementia to reciprocate. GPs occupy a key position, they can challenge stereotypes and, with support and targeted training about communicating with people living with dementia, can emphasise the ways in which people with dementia can communicate, thereby enhancing their potential to reciprocate. Such changes have implications for improved care and quality of life through the continued maintenance of social inclusion and perceptions of personhood. / none

ABSTRACT INTRODUCTION: Cancer is one of the most common diseases in the developed world and both genetic and environmental factors play a role in the development of cancer. About 5-10% of all cancers are due to predisposing genes. Some of the more common inherited cancer syndromes are hereditary breast and ovarian cancer (HBOC) and two colorectal cancer syndromes, familial adenomatous polyposis (FAP) and hereditary nonpolyposis colorectal cancer (HNPCC). Recognition of cancer susceptibility can allow “at risk” individuals and families to participate in cancer risk assessment, genetic testing, and various cancer prevention strategies. As the public is becoming more aware of inherited cancers, it is expected that there will be an increasing demand for genetic services and testing. For this reason more GP involvement is required to assess patients and families at risk and refer them appropriately. Since the Clinical and Counselling Section, Division of Human Genetics, National Health Laboratory Service and University of the Witwatersrand, Johannesburg is establishing a cancer genetics service it woud be of great value to assess the GPs’ practice, knowledge and attitudes with regards to cancer genetics and this was therefore the aim of this study. METHODOLOGY: A quantitative, exploratory research design was chosen and GPs in the Johannesburg area were selected as subjects. After the completion of a pilot study a research package was mailed to 196 GPs. This package was sent out twice and both times the GPs were asked to respond within 3-4 weeks. The final sample consisted of 61 GPs and the data were analysed using descriptive statistics. RESULTS: Of the 61 participants more male GPs (42, 69%) than female GPs (19, 31%) responded and there were about an equal number of GPs practicing alone (29, 48) and in a multiple practice (32, 52%). Twenty two (33%) of the GPs had never had personal experience of cancer. Practices: The GPs made use of several cancer screening procedures but obtained limited information on cancer history from their patients particularly from second degree relatives and about age of onset. Very few subjects (15, 25%) reported that they assess patients’ risk for inherited cancer susceptibility and only 22 (36%) reported that they refer patients to other facilities for risk assessment and genetic testing. Knowledge: Only 32 (52%) of the GPs were aware of genetic testing facilities and 54 (86%) reported never having received advertising material to promote genetic testing for cancer susceptibility services. They also are not aware of genetic counselling facilities but do feel patients should have genetic counselling by a genetic counselor, clinical geneticist or oncologist before genetic testing. Even though genetic testing for inherited cancer susceptibility is only available at some academic institutions, mostly on a research basis, the GPs seem to be unaware of the availability of genetic testing in South Africa for colorectal cancer genes (8, 13% and 9, 15%) but 28 (46%) knew about breast cancer genes. They were not aware of the autosomal dominant inheritance of hereditary breast cancer and the percentage of individuals with breast cancer who carry the BRCA1/2 gene nor did they know the penetrance of HNPCC genes. Attitudes: The subjects’ attitudes to genetic testing for inherited cancer susceptibility were positive although they reported that they were unaware of several general factors regarding cancer genetic testing. The GPs had limited knowledge about inherited cancers and do not take an active part in cancer genetic management. However, 53 (87%) of the GPs reported interest in learning about these services and expected to play a role in cancer genetics in the future. CONCLUSION: The findings of this study suggest that there is a need to educate GPs about the basic cancer genetic concepts so that they can identify patients at risk for an inherited cancer syndrome. They need to be informed about the genetic tests currently available for the inherited cancer syndromes, and about genetic counselling and testing facilities.

M.Tech.

Faculty of Health Sciences School of Family Medicine 0335022 asmartc@yahoo.co.uk / The epidemic of Sexually Transmitted Infections (STIs), including HIV infection, is one of the major challenges facing South Africa at the present time. Controlling the epidemic of conventional STIs will decrease the suffering and complications caused by these diseases as well as the spread of HIV/AIDS. In order to manage patients in an efficient and cost-effective way, the WHO has advocated syndromic management. This approach is characterised by the management of persons with STIs by providing treatment for a group of diseases, which may cause one or more signs or symptoms, rather than by treating a specific disease. The incidence of STIs is very high in South Africa and many patients with STIs are consulting private general practitioners but very little information is available on syndromic management in general practice. To this view, sexually transmitted diseases tally sheets were given to twenty self selected private general practitioners and were requested to complete sheets for all STI and non- STI patients for a period of eight weeks. Also a demographics questionnaire with regard to the doctors and their practices was given to the doctors for completion. The data was captured and analysed using the Microsoft Access and the EpiInfo 6 statistical package 5 The results indicated that although private general practitioners manage a fair number of STI patients, not all are familiar with syndromic management. While recognising that the respondents were self-selected, 19 (95%) of the 20 participating doctors were very keen to attend courses on syndromic management. It is recommended that more information be made available to general practitioners on syndromic management.

No / To identify factors available to general practitioners (GPs) that are predictive of mortality within a general practice-based population of heart failure patients, and to report the sensitivity and specificity of prognostic information from GPs. Methods: Five hundred and forty-two heart failure patients aged >60 years were recruited from 16 UK GP surgeries. Patients completed quality-of-life and services use questionnaires every 3 months for 24 months or until death. Factors with independent significant association with survival were identified using Cox proportional hazards regression analysis. Results: Women had a 58% lower risk of death. Patients self-reporting New York Heart Association Classification III or IV had an 81% higher risk of death. Patients aged 85+ years had over a five-fold risk of death as compared with those aged <65 years. Patients with a co-morbidity of cancer had a 78% higher risk of death. Of the 14 patients who died in a 12-month period, the GPs identified 11 (sensitivity 79%). They identified 133 of the 217 who did not die (specificity 61%). Discussion: Predictors readily available to GPs, such as patient characteristics, are easy to adapt to use in general practice, where most heart failure patients are diagnosed and treated. Identifying factors likely to influence death is useful in primary care, as this can initiate discussion about end-of-life care. / Department of Health.