Individual and community responses to depression in a comprehensive primary health care model of service delivery: examination of equity and empowerment aspects

Author: Elsa Barton

Barton, Elsa, 2017 Individual and community responses to depression in a comprehensive primary health care model of service delivery: examination of equity and empowerment aspects, Flinders University, School of Medicine

This electronic version is made publicly available by Flinders University in accordance with its open access policy for student theses. Copyright in this thesis remains with the author. This thesis may incorporate third party material which has been used by the author pursuant to Fair Dealing exceptions. If you are the owner of any included third party copyright material and/or you believe that any material has been made available without permission of the copyright owner please contact copyright@flinders.edu.au with the details.

Abstract

This thesis investigated individual and community responses to depression at four primary health care (PHC) services in South Australia. Comprehensive primary health care (CPHC), an approach to service delivery and health promotion, was the model used at the four PHC services. This study aimed to examine how comprehensive four case study PHC services were in practice and the extent to which they responded to depression in individuals and the community. Of particular interest is the way empowerment and equity featured in these models of practice. For the purposes of this thesis, the definition of CPHC is taken from the WHO Alma Ata Declaration (1978) and includes key elements of equity of access, collaboration across sectors beyond health and individual and community empowerment and participation in services. This research used a critical inquiry approach to examine how comprehensive PHC services were in practice and the extent to which they operated from a social view of health that recognises the impact that social, physical, economic and cultural aspects of the environment have on the health of the community and individuals. Five questions guided this thesis: 1. What are the range of responses to depression offered in a PHC model of service delivery in terms of mental health promotion, prevention of depression, and treatment and rehabilitation for people with depression? 2. What are clients’ experiences and understandings of PHC service delivery and how does this model help prevent/treat/manage/aid in the recovery of depression? 3. What are staff views and reflections about their practice both in terms of responding to depression among individuals and the community and how these services fit into the broader health system? 4. What are the opportunities for and barriers to individual and community empowerment in relation to mental health and the prevention of depression? 5. What system constraints and enablers support or detract from the implementation of CPHC service delivery for responding to depression in individuals and the community? Quantitative and qualitative methods were used to investigate these questions. The quantitative component involved the analysis of 86 client journeys and provided an overall description of how the PHC services were working with clients and other agencies in terms of mental health promotion, prevention of depression, treatment and rehabilitation. This analysis complemented the qualitative study which involved the analysis of 21 client interviews and 28 staff interviews. The interviews explored client experiences of PHC service delivery and how it helped their depression, and staff reflections about their practice in terms of the work they do with individuals and the community. In particular, the role of power and the way services consider equity in view of clients’ social determinants of health was investigated. This study found there were different models of PHC evident among the four case study sites. The PHC services were constrained in the extent to which they could respond to depression among individuals and the community in an approach that aligns with CPHC. A model of service delivery more aligned to CPHC was evident at the start of this study in 2011. The PHC services were able to respond to depression among individuals, for example, clients reported improved management of depression and some individual empowerment. However, a broader perspective on health that responds to depression among the community by considering the social determinants of health through health promotion, advocacy and community development, key principles of a CPHC model, were not evident. The findings identified the role of power in shaping PHC and showed how the implementation of CPHC was constrained by the dominance of neoliberalism and individualism that shaped health reforms and led to disempowerment of clients and staff. This finding confirmed other research that operation of a CPHC model is best supported in a favourable political and social context. This thesis offers insight into how the implementation of CPHC can be strengthened and supported through adequate funding and resources for health promotion and prevention activities, infrastructure to support community participation and social connectedness and training and support for mental health practitioners to undertake advocacy for individuals and to support broader forms of collective action. Depression is one of the most prevalent mental illnesses and having a health system that can respond to individuals and communities in a comprehensive and culturally respectful way is important for mental health and wellbeing. Models of PHC that align with a CPHC response to depression offer an important perspective of health that has potential to improve mental health and wellbeing and reduce health inequities. This thesis offers new knowledge regarding the implementation of CPHC within PHC services and offers insights into factors that detract from the implementation of this model.

Keywords: Comprehensive Primary Health Care, depression, empowerment, health promotion, equity, health service delivery.
Subject: Medicine thesis

Thesis type: Doctor of Philosophy
Completed: 2017
School: School of Medicine
Supervisor: Professor Fran Baum