Research
Volume 47, Issue 11, November 2018

An online resource supporting refugee healthcare in Australian general practice: An exploratory study

Timothy Wittick    Kate Walker    John Furler    Phyllis Lau   
doi: 10.31128/AJGP-05-18-4567   |    Download article
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Background and objectives
General practitioners (GPs) are known to encounter challenges when working with patients from refugee backgrounds. In this study we explore GPs’ perceptions of a trial version of the Australian Refugee Health Practice Guide website, an online resource designed to support GPs working in refugee health.
Methods
We conducted semi-structured interviews in two phases with 10 GPs from Melbourne, Victoria. Data analysis involved a mixed inductive and deductive framework analysis approach.
Results
The website was viewed as a central repository of refugee health–specific information with useful links. It helped fill knowledge gaps for participants and affirm existing practice. The volume of text on each page was a potential barrier to use in clinical practice.
Discussion
Supporting GPs to become familiar with the website, further adapting it to make key information rapidly accessible and keeping it up to date will be critical to its future uptake.
 

Australia is projected to accept 18,750 refugees through the offshore Humanitarian Program in 2018–19.1 People from refugee backgrounds, including people seeking asylum, are known to be at high risk of complex mental and physical health conditions.1 General practitioners (GPs) play an important part in working with this patient group, to manage their health issues.2 Research indicates that GPs face a number of challenges when working with patients from refugee backgrounds.3–5 Farley et al interviewed GPs who worked with patients from refugee backgrounds in Brisbane.3 The GP participants in their study described uncertainties in their clinical knowledge relating to refugee health, issues relating to language barriers and the use of interpreters, cross-cultural challenges and health systems barriers. Similar results are documented in studies conducted in the UK4 and Denmark.5

Multiple information resources have been developed to address these challenges and support GPs when seeing patients from refugee backgrounds.1,6–9 Two of these resources include the paper-based guide ‘Promoting refugee health: A guide for doctors, nurses and other health care providers caring for people from refugee backgrounds’7 and its accompanying desktop guide ‘Caring for refugee patients in general practice: A desktop guide’.6 They are produced by the Victorian Foundation for Survivors of Torture (Foundation House) and the Forum of Australian Services for Survivors of Torture and Trauma. Foundation House has recently updated these existing resources and translated them into an online format, incorporating information from the recently updated Australasian Society for Infectious Diseases (ASID) and Refugee Health Network of Australia (RHeaNA) ‘Recommendations for comprehensive post-arrival health assessment for people from refugee-like backgrounds’.1 The new resource, the Australian Refugee Health Practice Guide, includes a website (refugeehealthguide.org.au) and desktop guide and became available in early 2018. It includes information about approaches to patient care, conducting a refugee health assessment, common health concerns, approaches to working with refugee population subgroups and referral pathways.

This research project involved gathering feedback from GPs on a trial version of the website prior to the official website launch earlier this year. Our aims in completing this study were to provide feedback to Foundation House that could be used to inform future changes to the site and to add to a relatively new and developing body of literature into the use of online resources in clinical practice. Our primary research objective was to determine the perceived utility of a trial version of the website by GPs working in Melbourne, Victoria. Our secondary objective was to determine GP perceptions of how the trial website could be adapted and optimised to better support them when managing patients from refugee backgrounds.

Method

We used a qualitative approach to answer our research aims. The study is designed to be exploratory in nature, not aiming for generalisability.

Ethics approval

Ethical approval was obtained from the Human Ethics Advisory Group, Department of General Practice, at The University of Melbourne (ID number 1749681).

Sample and recruitment

Purposive and snowball sampling were used to recruit 10 GPs working in Melbourne, Victoria, between July and September 2017. Our aim was to include GPs with a range of experience in working with people from a refugee background. We initially contacted GPs known to members of our research team via email and invited them to participate in the study. These GPs then disseminated information about our study to their colleagues. To be included in the study, participants were required to be currently working clinically in Melbourne, Victoria as a vocationally qualified GP. All participants consented to involvement in the study in keeping with The University of Melbourne’s requirements. We envisaged that conducting between nine and 12 interviews would enable broad views to be elicited. After completing 10 interviews, we were confident that data saturation had been achieved.

Study design and interviews

Each participant completed two semi-structured interviews with researcher TW. These interviews were conducted either over the phone or face to face and audio-recorded. The interview schedule was informed by two theoretical frameworks: the Technology Acceptance Model10 and the research conducted by Cook et al,11 which describes key features of effective medical knowledge resources used by clinicians at the point of care. The first interview (phase one) involved questions relating to participant demographics and their experience using existing refugee health–related information resources. Participants were then introduced to a trial version of the website and given a written case vignette as a way to standardise their responses. The vignette described a common general practice presentation of a patient with a refugee background. It was developed by TW and KW, GPs with experience working with patients from refugee backgrounds, with input from JF and PL. Participants were asked to read the vignette in their own time and to use the trial website to complete a series of clinical tasks relating to the vignette. Subsequently, participants completed a follow-up interview (phase two) with TW to discuss their experience using the trial website.

Data analysis

The content analysis approach was used to analyse the characteristics of each of the 10 participants. We conducted a mixed inductive and deductive analysis of all other data, drawing on a framework approach.12 After becoming familiar with the data, we approached the coding process using the two theoretical frameworks that informed our interview schedule10,11 to guide the deductive component of the analysis. As data were coded, we also looked for codes that sat outside of these theoretical frameworks. Codes were subsequently arranged into themes. The data coding was completed in NVivo11 by TW. Samples of the data were coded independently by JF and PL. A subsequent group discussion led to consensus on the final themes.

Results

Descriptive analysis

The characteristics of the 10 GP participants are described in Table 1. We used the Australian Bureau of Statistics Australian Statistical Geography Standard13 to define the practice location, with a practice defined as being inner metropolitan if located within Statistical Area Level 4 ‘Melbourne – Inner’. Participants self-reported their level of refugee health experience.

There was an even distribution between participants who work in private practice and those based in community health centres. Participant experience working in refugee health was also evenly distributed, from having very little to considerable refugee health experience. Six of the 10 participants were female and half of participants were recent fellows of The Royal Australian College of General Practitioners, with five participants having worked in clinical general practice for five or fewer years.
 

Table 1. Participant characteristics

Participant number

Gender

Practice type

Practice location

Years working in clinical general practice

Refugee health experience

1

F

Private practice

Outer metropolitan

5

A little

2

F

Community health centre

Inner metropolitan

7

A lot

3

F

Private practice

Outer metropolitan

4

Some

4

F

Private practice

Outer metropolitan

>25

Some

5

F

Community health centre

Inner metropolitan

4

Some

6

M

Private practice

Outer metropolitan

4

A little

7

M

Community health centre

Inner metropolitan

10

A lot

8

F

Community health centre

Outer metropolitan

>20

A lot

9

M

Private practice

Outer metropolitan

5

A little

10

M

Private practice and community health centre

Outer metropolitan

>10

Some

 

Phase one interviews

During the initial interview, participants described drawing on a range of existing resources to support their management of patients from refugee backgrounds in their current clinical practice. This included Google searches, the ‘Caring for refugee patients in general practice desktop guide’,6 the Australian immunisation handbook,14 Therapeutic guidelines,15 the Royal Children’s Hospital website,16 recommendations from the ASID and the RHeaNA1 and guidelines from the World Health Organization and the Centre for Disease Control. Participants also indicated that colleagues act as a key source of information and support. The main issue of importance to GP participants in using these resources was the time taken to find an answer to their specific clinical question. One GP explained this by saying:

I won’t even bother to go somewhere where I don’t know if I’m going to find (what I want to know) quickly. (Participant 8)

Phase two interviews

Three themes relating to the website from the second phase of interviews were identified. These were: affirming existing practice and filling knowledge gaps; a central hub, linking GPs with services and resources; and the feasibility of using the website in clinical practice. Each theme related to our aims of exploring perceived utility and identifying areas for improvement of the online resource.

Theme 1: Affirming existing practice and filling knowledge gaps

When participants read information on the website that confirmed their existing knowledge and practice, it reportedly gave them confidence. One GP explained that a section of the website:

… sort of confirmed what I know … it’s always good to realise that there isn’t something new that you should be thinking about. (Participant 8)

Other aspects of the website filled knowledge gaps for GP participants. This included the clinical information on specific diseases and the examples of questions that GPs could use when taking a mental health history. One GP stated:

You don’t want to re-traumatise them … it’s useful to have a guide saying yes, do ask these general questions, like when did you leave your country? Were you forced to leave? What led you to leave? But … it’s rarely necessary to ask in detail about their trauma and torture history. (Participant 1)

The ‘practice tips’ provided on the site were also perceived to be useful, in particular by participants with limited refugee health experience. The following example was given:

One of the things that I learnt was that it’s important to explain how a prescription works here … I didn’t actually think about that … Back home they may not even know what a script is, what to do with that script and the concept of repeats [may be foreign] … I wouldn’t have thought about that beforehand. (Participant 6)

Several participants commented that it may be useful to have information on specific ethnic groups of patients on the website. This was highlighted by one GP when she stated:

I was a little bit disappointed that it didn’t have some information about particular ethnicities … I guess I was thinking, oh maybe this will tell me a bit about the cultural background of people from Burma, or from Afghanistan or Syria, you know, just to give me a little bit of background. (Participant 8)

It was, however, noted that this information could be difficult to deliver in an appropriate manner:

It would be very hard to be politically correct about it and keep it up to date. (Participant 2)

Theme 2: A central hub, linking GPs with services and resources

The website was viewed by participants as a central repository of refugee health specific information. One GP expressed that:

It collated a lot of information that I didn’t really know existed. (Participant 5)

Another GP stated:

I think it was just good to have all the resources in one place. (Participant 9)

The website was additionally perceived to be credible and current:

… all the clinical evidence was very up to date and well referenced … it was easy to see all the references and hyperlinks so you could follow that up further if you wanted to. (Participant 5)

The links to other websites that had relevance to working in refugee health were also seen as useful. One GP used the Translating and Interpreters Service (TIS) link to sign up for a code in order to use this service at his private practice:

I got myself a TIS code as well for my other practice, which is great. (Participant 10)

There were, however, occasional issues with broken links and challenges finding specific translated patient information resources on the links provided.

Participants noted that the information on referral pathways was particularly useful and relevant to their clinical practice:

The section on referrals … that was really good … I will use that. (Participant 3)

One GP went on to explain that:

… even in areas where I am well established, things always change and I think it’s a good resource to fall back on. (Participant 7)

Theme 3: Feasibility of using the website in clinical practice

When considering the feasibility of using the website in clinical practice, participants indicated that they want a resource that is easy to use:

… you just want something really simple and obvious. (Participant 8)

With this in mind, GPs reported the website as having a user-friendly interface:

My first impression of the website was that it was a very easy interface to deal with. (Participant 5)

It is clear and the tabs are easy (to use) and uncluttered. (Participant 9)

Concerns were, however, raised regarding the volume of information presented on each website page. One GP described this issue by stating:

… there’s a lot of information on every page … I look at this page and I think, where can I find the bit I need? You’ve got to skim through quite a lot of stuff for what you need. (Participant 2)

The use of dot points and highlighting were suggestions given for making the key information quicker and easier to find.

There were mixed responses as to whether and how GPs would use the website in their clinical practice. Some participants indicated that they would use it during a consultation, while others cited the volume of information as a barrier to using it in the consultation, indicating that they may look at it afterwards, in their own time:

I think a lot of it will actually end up being more of an educational tool that I will use, but probably after the patient has gone or after hours, and I’ll just recap, check my management … in that refugee context. I mean, it’s well laid out, each of the sections, but because they’re quite wordy I might not have time to read it all (during the consultation). (Participant 5)

User familiarity with the website was another factor identified by participants as an important issue influencing how likely they would be to use the website. One GP explained that:

… people form habits and the first thing that pops into your mind is something that you’ve used lots before … When I’m in the middle of a busy clinic, the first thing that pops into my mind at this point in time might not be the website just because the pathway in my brain is not wired to think about that first … So perhaps if I did (become) more familiar with it I would start using it more. (Participant 8)

Discussion

Findings from our study indicate that the trial website contains information that is useful to GPs with varying levels of experience in refugee health. Our participants indicated that the website content either affirmed existing practice, which reportedly built confidence, or filled gaps in knowledge that could be translated to clinical practice. The information on referral pathways was considered to be particularly useful. While information on the website is reportedly presented with a user-friendly web-interface, formatting changes could make it easier for GPs to use the website at the point of care, where they need to access key information in a timely manner. The most common suggestion from participants was to condense sections of text with the use of dot points and to highlight key words/phrases. Formatting such as this was reported to be helpful when navigating other online resources such as the Royal Children’s Hospital clinical practice guidelines.16

To our knowledge, our study documents the first research conducted on the use of online refugee health–specific information resources in clinical practice. We found one internationally-based study that sought to determine rates of practitioner adherence to national guidelines for refugee health screening in primary care clinics in Boston, US.17

There is, however, considerable literature on the broader use of information resources in clinical practice, including clinical practice guidelines, clinical decision support systems and point of care resources.18–24 These studies indicate that making information resources available to health practitioners can have a positive impact on patient care.

We found very limited literature describing evaluations that are similar in nature to our study. Of closest relevance is the research conducted on the point-of-care resource HealthPathways.25–28 HealthPathways is a web-based program containing locally agreed-upon, evidence-based clinical pathways that aim to support health practitioners with the assessment and management of patients with various clinical conditions.27 It was developed in New Zealand and has been adopted by several Primary Health Networks in Australia. Interestingly, the results of our evaluation reflect much of what has been documented in the HealthPathways literature. As the GPs in our study reported, research on HealthPathways similarly indicates that practitioners want information to be succinct and clear because of the time pressures they experience at the point of care.26 Additional similarities were that GPs primarily use HealthPathways for information on clinical conditions and referral pathways, with some using it for the links to patient education resources;26 when the information on the website confirms their existing knowledge and practice, it gives GPs confidence.27

As participants in our study noted, existing habits and user familiarity with a resource are likely to affect whether GPs will use it. This is in line with both the HealthPathways literature and other studies describing GP use of clinical practice guidelines.27,29,30 Clearly publicising the Australian Refugee Health Practice Guide website and educating GPs so they are familiar with it will therefore be crucial to its future uptake.

Study limitations

There are limitations to consider when interpreting our study results. Firstly, the existing confidence of participants in using information technology may have influenced the feedback they gave on the website. We did not collect data on this variable. Secondly, the lead researcher (TW) had an existing relationship with six of the participants. While TW was not involved in the production of the website and this was emphasised to all participants, these existing relationships may have influenced the feedback participants gave. Thirdly, because of resource limitations, our study included GPs from metropolitan Melbourne only. While the website is intended for GPs working Australia-wide, our study is exploratory in nature and the results are not generalisable. Finally, our study focused on evaluating a trial version of the website. The results of this evaluation do not necessarily represent the views of our participants on the website that is now ‘live’.

Implications for general practice

In addition to providing feedback on the Australian Refugee Health Practice Guide website, this research adds to our understanding of a growing field: online information resource use in Australian general practice. GPs need resources that are easy to use at the point of care, where they encounter time pressures. Online resources such as this website have the potential to be easily accessible and time-efficient to use. In the case of this site, supporting GPs to become familiar with it, ensuring the information and links are up to date and further adapting the site to make the key information rapidly accessible are crucial factors that will influence future use.

Competing interests: None.
Provenance and peer review: Not commissioned, externally peer reviewed.
Funding: This research is supported by the Victorian Foundation for Survivors of Torture and the Royal Australian College of General Practitioners. Funding was received from the Australian Government under the Australian General Practice Training program.
Acknowledgements
We give particular thanks to Samantha Furneaux for her expertise, advice and support of this project.
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