There are widespread concerns about the increasing use of multiple medicines. The aims of this thesis were to identify older patients' and general practitioners' (GPs) attitudes to and experiences of multiple medicine use, as well as to describe patterns of multiple medicine use in different age groups in association with patient-related factors. An additional aim was to contribute to scientific methodological development by providing an empirical example of the application of the Lehoux, Poland, & Daudelin template for the analysis of interaction in focus groups. Data were collected via qualitative focus group discussions and from a cross-sectional community-based population survey conducted during 2001-2005. The patients revealed co-existing accounts of both immediate gratitude that medicines exist and problems with using multiple medicines such as worrying whether multiple medicine use is 'good' for the body. The patient-doctor relationship coloured their attitudes towards their treatment and care. The GPs at times felt insecure, though surrounded by treatment guidelines. Lack of communication with hospital specialists was perceived to reduce treatment quality, while influence of patient pressure was thought to contribute to the development of multiple medicine use. An interaction analysis helped in appreciating and clarifying the contexts in which results from the content analysis were created. Further discussion is needed on how to best report these results. Different cut-offs are useful in defining multiple medicine use in different age groups. Vast majorities of users of multiple medicines were found to have unique medicine combinations. Multiple medicine use was found to be associated with morbidity and poor self-rated health across all age groups.

Britain's Asians are a young population and their socio-economic status is low, with racial disadvantage in housing, employment, education and health. Research on their health has usually not been conducted in its socio-economic and demographic context and there is little on their use of primary care. Three studies were conducted to investigate their relationship with primary care in Bradford. A study of general practice attenders of white/British, Pakistani and Indian origin confirmed the demographic and socio-economic differences between the groups. The former had higher rates of alcohol and cigarette consumption. For Pakistanis and Indians, fluency and literacy in English was poor. Ethnic and linguistic match between doctor and patient was more important in patients' choice of doctor than the doctor's sex. Differential employment status of Asian and white/British accounted for some of the differences in health. A study of general practice attendance showed similar rates of surgery consultations between Asians and Non-Asians; the latter made greater use of domiciliary services. Both these studies were conducted in an inner Bradford health centre with an Asian male, a white male and a white female doctor. Bradford GPs were found to perceive that Asian patients made greater use of surgery and domiciliary consultations; attended more often for trivial complaints; and had lower compliance rates than Non-Asians. These perceptions were not supported by objective data. Better qualified GPs had a smaller, and Asian doctors had a greater proportion of Asian patients on their lists. Research, and action on Asians' health, needs to take account of their poorer socio-economic status.

Hintergrund: Die wachsende Anzahl älterer multimorbider Patienten und der damit zunehmende Versorgungsbedarf am Lebensende erfordern eine gut funktionierende Basisversorgung mit dem Hausarzt als zentralem Ansprechpartner. Hausärzte versorgen ihre Patienten zumeist über mehrere Jahre und bis ans Lebensende. Darüber gibt es jedoch bisher keine ausreichenden Kenntnisse. Ziel der Studie: Die Versorgungssituation und Charakteristika hausärztlich versorg-ter Patienten in der letzten Lebensphase aus hausärztlicher Sicht, durch eine retro-spektive Erhebung abzubilden. Methode: Im Raum Hannover und Göttingen wurden 30 Hausärzte (Teilnehmerrate: 19%) mittels eines selbst entwickelten standardisierten Erhebungsbogen zu ihren in den letzten 12 Monaten eines natürlichen Todes verstorbenen Patienten (n = 451) befragt. Erfasst wurden vor allem Daten zur Soziodemographie und Betreuungssituation, zu den Erkrankungen, den Symptomen und der Symptomkontrolle. Neben einer rein deskriptiven Darstellung der Ergebnisse erfolgte ein Vergleich mit Daten aus der Hospiz- und Palliativerfassung (HOPE) 2010. Ergebnisse: Im Mittel hatte jeder teilnehmende Hausarzt 15 Patienten (SD: 7,3; Me-dian: 14,5; Range: 4-36), für die er Angaben im Erhebungsbogen machte. Das durchschnittliche Sterbealter betrug 78,5 Jahren (SD: 12,9; Median: 81; Range: 19-102), 55% der Patienten waren Frauen, der Großteil der Patienten (60%) lebte zu-letzt in der eigenen Wohnung beziehungsweise im eigenen Haus. Obwohl die meisten Patienten sich ein Versterben in häuslicher Umgebung wünschen, verstarben 41% der Patienten im Krankenhaus und nur 22% zu Hause beziehungsweise in einer Alten- oder Pflegeeinrichtung. Das Krankheitsspektrum war vielfältig und zeigte eine Dominanz der chronischen Erkrankungen (beispielsweise des Herz-Kreislauf-Systems und der Psyche). Im Vergleich mit den HOPE-Daten zeigten sich im Spektrum der Erkrankungen und in der Häufigkeit der Symptome deutliche Unterschiede. Die meisten Verstorbenen wurden im Rahmen der allgemeinen hausärztlichen Basisversorgung in der letzten Lebensphase betreut. Die Häufigkeit der Arzt-Patienten-Kontakte nahm zum Lebensende zu. Bei 48% der Patienten war der Hausarzt auch in den letzten 48 Stunden vor dem Tod noch in die Versorgung involviert. Eine palliativmedizinisch spezialisierte ärztliche Betreuung erhielten in der HAVEL-Studie nur 10% der Patienten. Neben der ärztlichen Betreuung spielten Angehörige (bei 49% der Patienten), Pflegedienste (bei 29%) und Pflegeheimpersonal (bei 33%) eine bedeutende Rolle in der ambulanten Versorgung in den letzten Lebensmonaten. Schlussfolgerung: Hausärzte sind unabhängig vom Sterbeort maßgeblich in die Betreuung ihrer Patienten bis ans Lebensende involviert. Die Unterschiede in den Patientencharakteristika sowie in den Versorgungsformen zwischen hausärztlicher und spezialisierter Versorgung am Lebensende sollten in der ärztlichen Aus- und Weiterbildung stärker berücksichtigt werden. Um der aktuellen Versorgungssituation auch in der Forschung gerecht zu werden und über die Qualität der ambulanten Versorgung am Lebensende Aussagen treffen zu können, sind weitere Untersuchungen erforderlich.

Doctor of Public Health / For many years the major cause of infant mortality in NSW has been the result of Sudden Infant Death Syndrome (SIDS). Statistics show the area defined as 'Western Sydney' is no exception, and in 2002, a report prepared by the Epidemiology, Indicators, Evaluation and Research Unit (EIRE) in Western Sydney presented data indicating SIDS rates in the area were higher than the state average. In particular, two Local Government Areas (LGAs) had clusters of SIDS deaths. Previous Australian research identified a higher risk of SIDS and other causes of infant mortality in Aboriginal and Torres Strait Islander populations. The areas of Western Sydney where SIDS rates were higher than expected were home to Aboriginal, Torres Strait Islander and Pacific Island residents. The number of SIDS deaths in Aboriginal infants did not explain the higher than expected rate of SIDS in the areas under investigation. Studies undertaken in New Zealand and the Pacific Islands have identified higher than expected risk of SIDS in Maori and Pacific Island communities in those countries, although this has never been studied in Pacific Island residents living in Australia. The reasons for these communities exhibiting a higher than normal SIDS rate is not completely understood, but can be partially explained by behavioural practices which are known to impact adversely on the risk of SIDS. This study sought to investigate the level of knowledge concerning the prevention of sudden and unexpected death in infants (SUDI) in three key groups of infant caregivers: general practitioners, nurses and parents living or working in the area geographically defined by Sydney West Area Health Service (WSAHS). In addition, the study sought to identify any variation in knowledge of SIDS reduction strategies in the three groups under study, and to investigate factors influencing knowledge and practice in these participants. The study findings were then used as a basis on which to develop strategies and recommendations to enhance the delivery of safe sleeping messages through the health care system. Using a combination of qualitative and quantitative methods, this cross-sectional study highlights a number of issues around infant care practices and the major influences on new parents living in a multicultural community. Results of the study showed there is a large variation in knowledge around safe sleeping practices (including SIDS reduction strategies) in all the groups studied. Although educational campaigns are conducted regularly, many general practitioners and parents are confused about the key SIDS reduction messages and still place infants in sleeping positions considered unsafe. While nurses and midwives were aware of the SIDS reduction strategies, they still occasionally used infant sleeping positions considered unsafe. General practitioners born overseas in a country where English is not the first language were less likely to be familiar with safe sleeping messages, including SIDS reduction strategies. Families from a Culturally and Linguistically Diverse (CALD) background were less likely to have seen SIDS information in their own language than families who spoke English, and as a result were more likely to use traditional methods of infant care, including co-sleeping with siblings and parents and side or tummy sleeping. CALD parents were more likely to rely on herbal remedies and friends and family for assistance, than English speaking parents who accessed health professionals as the first point of call when infants were unwell. The study identified a relatively recent practice, which until reported in this study, has not been documented in the literature. The practice of draping infant prams with blankets originated from the Cancer Council of Australia guidelines which recommend covering a pram with a light muslin wrap to protect infants’ skin from the sun. It appears parents have misinterpreted this message and are covering infant prams with blankets to encourage sleep, even when sun exposure is not an issue. Research suggests that poor air quality around the head of an infant may affect an infant’s arousal response. While no research has been conducted on the air quality around an infants head when covered by a heavy blanket in a pram, it is possible based on research into air quality around infants, that that this practice may increase the risk of sudden and unexpected death in an infant. In conclusion, this study found that multiple changes to the SIDS reduction messages since the initial ‘Reduce the Risks’ Campaign have led to confusion about ways of preventing SIDS in GPs, nurses and parents in Western Sydney. The study makes seven recommendations aimed at improving knowledge of safe sleeping practices in these groups, and optimizing health outcomes for infants using a collaborative approach to service delivery and future initiatives.

Introduction: Satisfaction of primary care is important factor that improve persons trust to primary care and encourage visiting their GP more often. Therefore it is one of key point to provide society with lasting and continuous medical care. Good access to GPs is even more important to full time employed persons because of limited time resources. However, there is a lack of studies about factors that influence Latvian full time employed adult population satisfaction with GPs.Objective: The aim of the study was to analyse socio economics factors, usage of the health care resources, GP availability and communication influence to full time employed adult satisfaction with GP in Latvia.Method: Quantitative survey study design was used based on data from Health Behaviour among Latvian Adult Population 2016 survey (FINBALT). Data from 1864 persons were used for data analysis with SPSS Statistic 25,0.Result: Opening (contact) hours, way of contacting GP practice, seeing GP in the appointed time, GP characteristics, patient’s self-assessed health condition and visiting GP in last year were factors that affected full time employed person’s satisfaction with GP in Latvia.Conclusion: Targeted measures in stately, praxis and individual level could be introduced to improve full time employed person’s satisfaction with GP.

Orientador: Alessandro Ferrari Jacinto / Resumo: Introdução: O número de idosos com idade de 60 anos ou mais está aumentando no mundo. Esse fenômeno é acompanhado do aumento de doenças crônicas como hipertensão, diabetes, osteoporose, osteoartrose. As doenças neurodegenerativas, representadas pelas demências apresentam alta prevalência na maioria dos países do mundo. Entretanto, há evidências de que as demências não são detectadas pelo médico generalista. Objetivo: Avaliar conhecimentos e atitudes em demências por parte dos médicos generalistas da atenção básica à saúde. Método: Estudo quasi-experimental. Aplicação de dois instrumentos, auto respondidos em dois momentos, antes e após intervenção com seis aulas sobre demência. Participantes: 34 médicos generalistas da rede de atenção básica à saúde, da cidade de Botucatu-SP. Resultados: A média de idade dos médicos generalistas foi de 33,9 10,2 anos. 18(53%) do sexo masculino e 16(47%) sexo feminino. 29 (85.3%) médicos receberam aula sobre demência durante a graduação. A média de acertos no questionário sobre conhecimentos em demência foi de 8,35 antes e 9,97 após a intervenção (pontuação total 14 pontos). Houve significância estatística no subitem diagnóstico de demência p<0,001. Os médicos mostraram atitudes positivas em relação a oferecer o diagnóstico de demência. Conclusão: Estudo pioneiro no Brasil que avaliou, diretamente, conhecimentos e atitudes em demência por parte dos médicos da atenção básica à saúde de um município. Houve deficiência no conhecimento do médico ... (Resumo completo, clicar acesso eletrônico abaixo) / Abstract: Introduction: The number of people with 60 years old and over is increasing in the world and the chronic diseases such as hypertension, diabetes, osteoporosis, osteoarthrosis. The neurodegenerative diseases as dementia show high prevalence in the major countries. However, there is evidence that dementias are not detected by general practitioners. Objective: To evaluate knowledge and attitudes about dementia with general practitioners in primary health care. Method: Quasi-experimental study with a self-administered questionnaire about dementia in two different moments before and after intervention through six lessons about dementia. Participants: 34 generals’ practitioners of the primary health care of the city of Botucatu in Sao Paulo state. Results: The average age of general practitioners was 33.9 ±10.2 years. 18(53%%) were male. Most physicians, 29 (85.3%) received a lesson about dementia during graduation. The average of answers in the dementia knowledge questionnaire was 8.35 before and 9.97 after the intervention. There was statistical significance in the dementia diagnostic sub-item (p <0.001). Physicians showed positive attitudes towards offering the diagnosis of dementia. Conclusion: This is a pioneering study in Brazil that evaluated directly knowledge and attitudes in dementia with general practitioners. There was a lack of knowledge of general practitioner regarding prevention and especially, management of people with dementia. Therefore, continuing medical educat... (Complete abstract click electronic access below) / Doutor

<p>Allmänläkare i primärvården är den första vårdgivare som människor i behov av psykisk hjälp möter. Det saknas forskning om behandling av psykiskt sjuka inom primärvården i enskilda länder. I syfte att hitta nya frågeställningar och få djupare förståelse av hur primärvården fungerar med avseende på psykiskt sjuka intervjuades elva allmänläkare i en kroatisk stad. Insamlade data från intervjuerna strukturerades och bearbetades genom en induktiv tematisk analys. Resultaten visar att allmänläkare upplever en hög arbetsbelastning. Deras tid för samtal med psykiskt sjuka är väldigt begränsad. Behandling med psykofarmaka blir ofta det enda vårdalternativet. Psykosociala problem och psykotrauma förekom ofta som konsekvens av krig. Sjukpensionering av krigsveteraner med PTSD-diagnos blev en omdiskuterad fråga. Undersökningen visar att det kan bli ansträngande för allmänläkare att behandla psykisk ohälsa. De behandlar dessutom majoriteten av psykiskt sjuka men deras vård kompletteras inte med några psykosociala tjänster. Behovet av psykiskt stöd blir inte bemött hos många patienter.</p>

Allmänläkare i primärvården är den första vårdgivare som människor i behov av psykisk hjälp möter. Det saknas forskning om behandling av psykiskt sjuka inom primärvården i enskilda länder. I syfte att hitta nya frågeställningar och få djupare förståelse av hur primärvården fungerar med avseende på psykiskt sjuka intervjuades elva allmänläkare i en kroatisk stad. Insamlade data från intervjuerna strukturerades och bearbetades genom en induktiv tematisk analys. Resultaten visar att allmänläkare upplever en hög arbetsbelastning. Deras tid för samtal med psykiskt sjuka är väldigt begränsad. Behandling med psykofarmaka blir ofta det enda vårdalternativet. Psykosociala problem och psykotrauma förekom ofta som konsekvens av krig. Sjukpensionering av krigsveteraner med PTSD-diagnos blev en omdiskuterad fråga. Undersökningen visar att det kan bli ansträngande för allmänläkare att behandla psykisk ohälsa. De behandlar dessutom majoriteten av psykiskt sjuka men deras vård kompletteras inte med några psykosociala tjänster. Behovet av psykiskt stöd blir inte bemött hos många patienter.

Au Québec, face à la prévalence élevée des problèmes de santé mentale et à la pénurie de médecins psychiatres, le médecin omnipraticien (MO) occupe une place primordiale dans la prise en charge et le suivi des soins de santé mentale. Dans le contexte de réforme du système de santé mentale axée sur un renforcement de la collaboration entre les MO, les psychiatres et les équipes de santé mentale, notre étude vise à mieux comprendre la pratique clinique et la pratique collaborative développée par les MO, leur appréciation des outils de travail et de la qualité des services de santé mentale, dans le but d’améliorer la complémentarité des soins au niveau primaire. Cette étude transversale impliquait 1415 MO de neuf territoires de centre de santé et de services sociaux (CSSS) du Québec. L’échantillon final était constitué de 398 MO représentatifs de lieux de pratique diversifiés et le taux de réponse était de 41%. Nos résultats mettent en évidence que la pratique clinique et la pratique collaborative des MO diffère selon le degré de gravité des problèmes de santé mentale des patients rencontrés, c’est à dire, trouble transitoire/modéré de santé mentale (TTM.SM) ou trouble grave de santé mentale (TG.SM), et que les MO sont favorables au fait de travailler en collaboration avec les autres professionnels de la santé mentale. Ainsi, il apparaît important de renforcer l’accessibilité des MO aux professionnels de la santé mentale, particulièrement les psychiatres, et de les informer de l’existence des autres acteurs en santé mentale sur leur territoire, pour renforcer la collaboration et la qualité des soins primaires de santé mentale. / In Quebec, considering the high prevalence rate of mental health disorder and the scarcity of psychiatrists, general practitioners (GPs) hold an importante role in the management and the follow-up of mental health care. In the context of the ongoing mental health system reform aimed at reinforcing collaboration between GPs, psychiatrists and mental health teams, our objectives are to have a better understanding of clinical practice and collaborative practice, developed by GP and their assessment of working tools and quality of mental health services, in order to improve the complementary of primary mental health care. The study was carried out using a cross-sectional design, involving 1415 GPs from nine Quebec territories. The final sample included 398 GPs, representing diverse practice places, and the response rate was 41%. The study highlighted that GPs have different clinical and collaboration practices according to the seriousness of mental disorder patients seen, i.e. transient and moderate mental disorder (TMMD) or serious and permanent mental disorder (SPMD); and GPs strongly support care coordination efforts with all mental health professionals. Therefore, it appears important to reinforce GP accessibility to other mental health professionals, particularly psychiatrists, and to inform them on the presence of all actors in mental health in their territory, in order to develop collaboration and quality of primary mental healthcare.

This research project addresses the following: how topical talk operates in the organisation and management of MSE interactions; and how topical talk operates in the co-ordination of specific service requests and service provisions. It draws on a corpus of audio-recorded and transcribed interactions between general practitioners and persons seeking general medical services in suburban clinics in Brisbane, Australia. The corpus comprised a total of 67 medical service events (henceforth MSEs), audio-taped with the full informed consent of the participants. Many contemporary medical sociological accounts of the operation of topical talk in MSEs, typified by the work of Mishler (1981, 1984) and Waitzkin (1991), remain anchored to the 'professional dominance' thesis (Freidson 1970a; 1970b), arguing for the fundamental conflict between two perspectives - lay and professional. Topical talk has been formulated as one expression of this conflict in 'doctor-centred' communicative 'styles' (Byrne and Long 1976; Silverman 1987). Within such accounts, familiar interactional patterns in MSEs, including the content and structure of topics, have been theorised as instruments of power and control whereby the dominance of specialised medical knowledge and expertise are established and maintained. Mishler's (1984) characterisation of the conflict between a biomedically oriented 'voice of medicine' used by professional physicians (henceforth GPs) and a 'voice of the lifeworld' used by persons seeking medical services (henceforth Ps) is an expression of the 'professional dominance' thesis. The voices are characterised as attesting to a fundamental, theoretically problematic, asymmetry of power relations between GPs and Ps, thereby reinforcing the ideological status of professionals in general and the medical profession in particular. Further, recommendations regarding correctives to 'professional dominance' centre on advice GPs to attend to the primacy of Ps' talk on their experiences of illnesses rather than apparently 'ignoring' or transforming these topics into biomedical accounts of disease. This research project critiques this formulation of topical talk and the traditional theoretical and empirical bases on which it has drawn. This critique arises from the application of ethnomethodological approaches to the study of MSEs. Such approaches, as outlined in Chapters 2 and 3, are characterised by a number of conceptual and analytic premises: First, particular social structural features of social activities and the institutional contexts within which activities occur should not be assumed to be the primary criteria for judging the import and adequacy of situated action. Second, the parties to situated social events mutually constitute those events in the real world. Third, issues of agency are collaborative situated accomplishments such that the management of everyday social activities is accomplished by the people involved who show one another the rationalities of their actions as they assemble the familiar scenic features of those same institutional events (Garfinkel 1967; Sacks 1992a, 1992b). These assumptions have been applied in ethnomethodological analyses of social action, including the analysis of professional service encounters that have critiqued the 'professional dominance' thesis (Eglin and Wideman 1986; Sharrock 1979). The novelty of this study is the analysis of the operation of topic organisation as a phenomenon of order. This study also draws on recommendations within Ethnomethodology (Hester & Eglin 1997b; Watson 1997) that sequential and categorial organisations are mutually informative in the analysis of the rationality of situated social action. One of the particular contributions of this thesis is that it not only jointly applies both conversation analysis and membership categorisation analysis but also extends this recommendation to the inclusion of topic analysis as was originally provided for by Sacks (1992a , 1992b) and Garfinkel and Sacks (1970). Within this study a model of analysis has been constructed that has enabled the analytical consideration of four dimensions of social organisation: local sequential, extended sequential, topical and categorial organisations. The theoretical and empirical concepts of ethnomethodogical analysis have thus been developed and extended within this project. The central findings of this study are that in institutional service events, the 'service topic' is both significant and consequential, and that persons constitute themselves as bona fide incumbents of the categories GP or P by attending to their actions as topically organised. The local adequacy of any particular interactional move (such as questioning-answering, greetings, the design of a topic proposal, etc) is shown to be referenced to the service topic. This study found no evidence of potential or actual "struggles" between the 'voice of the life-world and the voice of medicine'. Rather, this study finds routine recognition on the part of both Ps and GPs of the centrality of the service topic and, thereby, the service task, and no evidence of orientation to distinctive biographical contributions staged in competition with biomedically relevant service topics. It is found that Ps' biographical references were made in the context of an assembled service topic such that particular service tasks, however conventional, were constituted as both relevant and reasonable as medical goods and service for the specific service recipient and provider. At the most general level, it is concluded that the service topic operates as a phenomenon of order in MSEs where order, as defined by Garfinkel and Weider (1992: 202), refers to all of the rationalities evident in the generic features of institutional events and settings, that is, the situated logic and intelligibility as well as the procedures whereby they are constituted as recognisable social events. The thesis concludes with a discussion of the implications of the findings for the theorisation, policy-making, medical education, and practices of GPs and Ps within MSEs. Overall, the significance of this work for researchers into medical interactions is that the relevance of the service topic and its pervasive organisational consequences need to be considered analytically. A major outcome of this thesis is the establishment of a new order of interest within the study of institutional interactions. The project demonstrates the pervasive consequences of service topics and thus provides a step forward in the study of institutional service interactions and ways of theorising their rationality, a step that extends beyond social structural pre-theorisations of power and domination and also beyond interactional accounts of the primary relevance of turn taking structures.