Intimate partner violence and substance abuse among minority women receiving care from an inner-city emergency department.

A woman's drug and alcohol use has been found to increase her risk of experiencing intimate partner violence (IPV). OBJECTIVE: The study describes the rates of lifetime and current IPV among women awaiting care in an emergency department and explores the association between IPV and having a drug abuse problem, and IPV and having an alcohol abuse problem, after controlling for demographic factors and history of childhood victimization. METHODS: Face-to-face interviews were conducted with 143 low-level triaged women recruited from an inner-city emergency department. RESULTS: Nearly one-half reported ever experiencing IPV, and over 18% reported IPV during the year before the interview. A higher proportion of abused women reported a history of regular crack, cocaine, or heroin use and visiting shooting galleries or crack houses. Participants who were physically abused by their partner during the past year (15%, n = 21) were more likely than nonabused women (85%, n = 122) to report higher scores on the Alcohol Use Disorders Identification Test (AUDIT) (4.9 vs. 2.4), a measure of alcohol-related problems, and the Drug Abuse Severity Test (DAST) (3.0 vs. 1.3), a measure of drug-related problems. Sexually abused women (6%, n = 9) were more likely than their counterparts (94%, n = 134) to have significantly higher AUDIT scores (6.4 vs. 2.5). The findings have implications for how the intersecting public health problems of IPV and substance abuse should be taken into consideration in research and patient care protocols in emergency departments.     

Posttraumatic stress disorder in primary care

BACKGROUND: Primary care providers are aware of the importance of identifying depression and anxiety in their patients. The diagnosis of posttraumatic stress disorder (PTSD), however, is less of a priority. METHODS: Primary care physicians and nurse practitioners in an outpatient facility of a large health maintenance organization administered a psychiatric screening questionnaire to patients whom they suspected had depression or anxiety. Patients with positive results were referred for immediate consultation with a clinical psychologist. RESULTS: One hundred fourteen (38.6%) of the 296 patients referred for consultation met Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) diagnostic criteria for PTSD. The most frequent traumas associated with PTSD were adult domestic violence and childhood abuse. Patients with a diagnosis of PTSD were frequent users of medical services in the 12 months before diagnosis. The majority of patients sought treatment in primary care settings, not mental health settings. CONCLUSIONS: Patients with PTSD often visit outpatient primary care settings. Medical providers may identify symptoms of depression or anxiety but may not recognize PTSD because of the high degree of overlap between these conditions, and the lack of familiarity with PTSD diagnostic criteria. We provide screening questions that may help physicians detect PTSD in their practices.     

The underrecognition of HIV infection in women in an inner-city emergency room.

OBJECTIVES. This study analyzed the recognition of human immunodeficiency virus (HIV) infection and associated factors in women and men attending an emergency room in the Bronx, New York, NY. METHODS. From April 16, 1989, to May 5, 1989, the emergency room records of 2102 consecutive patients 13 years of age or older were reviewed and, for 856 patients undergoing venipuncture, linked anonymously to results of HIV antibody tested in excess blood. RESULTS. HIV seroprevalence was 7.8% in women and 14.6% in men. Among seropositive women, 5.0% had acquired immunodeficiency syndrome (AIDS), compared with 26.0% of men. Excluding patients with AIDS, HIV infection was recognized in 13.2% of women and 27.0% of men. HIV infection was recognized only in women aged 25 through 44 years. In men, recognition occurred in all age groups. Clinical presentation did not distinguish the seropositive from seronegative women. Risk assessments were recorded less frequently for women (11.2%) than men (15.9%). For 92.5% of persons with any behavioral risk assessment, injecting drug use was the only behavior assessed. CONCLUSIONS. HIV infection is underrecognized in women, in part, because of a lower prevalence of AIDS. Universal HIV risk assessment, which includes heterosexual behaviors, may help increase recognition of HIV in women and opportunities for early intervention.     

Improving operational efficiency in an inner-city emergency department.

Saving lives in a high-volume, high-acuity inner-city trauma centre demands operational excellence. We conducted our research in an emergency department where treatment of Acute Coronary Syndrome is a critical operation. Our study results in a better understanding of patient flow, analysis of the waiting lines and an optimization model for labour cost minimization.     

An analysis of telephone calls to an inner-city accident and emergency department.

The general public in the UK often telephone accident and emergency (A&E) departments for medical advice. Such calls are usually dealt with by nursing staff in an informal manner (often with no written record of the call being made). The specific questions addressed in this study are who was calling for advice, when did they call, what were their presenting complaints, and what was the outcome of the call? In addition, the study provided an opportunity to test the implementation of a new system of record-keeping for telephone consultation. A telephone consultation record (TCR) was developed and used to record details of each call made to the A&E department for medical/health advice. An analysis of 597 consecutive documented calls is presented in this paper. The majority of calls were dealt with by 'E' grade nursing staff (42.7%); only four calls (0.7%) were recorded by medical staff. Two hundred and six (43.5%) calls related to patients aged up to 15 years. In 57% of the cases the call was made by a third party. In all, 149 different presenting complaints were recorded on the TCRs. The three most common presenting complaints were dental problems (7.4%), fever (4.3%), and concerns about drug reactions (23%). Seventy-three per cent of callers were advised that a visit to the A&E department was not immediately necessary. The study identifies several important issues for development of a more formal and effective system of telephone advice. The majority of calls made to the A&E department appeared to be of a primary care nature but the extent to which nurses are trained to assess and advise on these problems needs to be questioned. A reluctance to document the calls to A&E was identified, one reason being a concern about accountability. Training and support are clearly required.     

Gender differences in HIV risk behaviors in an adult emergency department in New York City

Background The human immunodeficiency virus (HIV) epidemic in the US increasingly involved urban heterosexual adults, particularly women, belonging to ethnic minority groups. An understanding of gender-based differences in HIV risk behaviors within these groups would be of value in the ongoing struggle to limit HIV transmission in metropolitan centers. Methods This was a prospective study of demographic and historical characteristics and HIV risk behaviors. The study utilized a structured interview format, which was administered to all patients treated by participating emergency department physicians. Results On univariate analysis of data obtained from 1,460 patients who had neither a known HIV infection nor a chief complaint or final emergency department diagnosis associated with HIV risk behaviors, men were more likely to be older, homeless, to have ever injected drugs, used crack, engaged in same-gender sex, paid for sex, been incarcerated, or had syphilis or gonorrhea. Women were more likely to report prior chlamydia infection or to report that their sole sex partners had other partners within the past year. On multivariate analysis, variables independently associated with male gender included homelessness, injection drug use, crack use, any prior sexually transmitted disease (in subjects 35 years of age or older), and sex with prostitutes. In a separate analysis of patients admitting to drug use, the male predominance of other risk behaviors was not observed; the only significant differences between genders were a higher rate of prostitution among women and a higher rate of sexual contact with a prostitute among men. Conclusions In patients visiting an inner-city emergency department in the Bronx, HIV risk behaviors are generally more common in men, but rates of risk behaviors among male and female drug users are comparable. This work was supported in part by a collaborative agreement with the Centers for Disease Control and Prevention (U64/CCU200714). Drs. Shuter, Alpert, and DeShaw were supported in part by a training grant (5-T32-AI070183) from the National Institute of Allergy and Infectious Diseases. This study was presented in part at the 32nd Annual Meeting of the Infectious Diseases Society of America, October 1994, Orlando, Florida.     

Reduced risk of low weight births among indigent women receiving care from nurse-midwives

STUDY OBJECTIVE: To examine the effect of a comprehensive prenatal and delivery programme administered by nurse-midwives on the risk of low weight births among indigent women. STUDY DESIGN: Historical prospective study. Birth outcomes among the cohort were compared with all county births during the same period, adjusting for maternal age and race. Results are expressed as relative risks with 95% confidence intervals. SETTING: An enhanced Medicaid funded pre-natal programme administered by nurse-midwives from 1992 to 1994 in Westchester County, New York. PARTICIPANTS: Indigent mothers (n = 1443), between the ages of 15 and 44, who were residents of Westchester County and indicated having Medicaid or no health care coverage. RESULTS: There were 1474 live births among cohort mothers. Mean (SD) gestational age was 39.4 (1.9) weeks. Less than 6% of births occurred before 37 weeks gestation. The mean birth weight of cohort infants was 3365.6 (518.6) g. Only 4.1% of the cohort births were less than 2500 g. Compared with all county births, the cohort showed a 41% reduction in the risk of low weight births (RRlbw = 0.59, 95% CI: 0.46 to 0.73, p < .001) and a 56% reduction when compared with county Medicaid births only (RR = 0.44, 95% CI: 0.34 to 0.57, p < .005) adjusting for maternal age and race. Larger reductions were found for very low weight births. CONCLUSIONS: Mothers need not be considered at high risk for adverse pregnancy outcomes based on their socioeconomic status alone. Moreover, a comprehensive prenatal programme administered by nurse-midwives may promote a reduction in adverse pregnancy outcomes among indigent mothers.     

Unintended pregnancy risk in an emergency department population

OBJECTIVE: To assess unintended pregnancy risk and associated factors among female urban Baltimore emergency department (ED) attendees. METHODS: A cross-sectional anonymous questionnaire study was completed by 790 women, sufficient to detect a 5% difference of unintended pregnancy risk in the national population and a 10% intersite difference with 80% power. The results were analyzed with chi-square tests, univariate and multivariate logistic regression analyses. RESULTS: Female ED attendees are at greater risk for unintended pregnancy (33.5%), particularly those of lower income (p=.006) and without a primary care provider (p=.003). Unintended pregnancy risk did not vary between sites by any variable except young age despite the fact that sites varied significantly by race, insurance and income measures. CONCLUSION: Women using the ED are at increased risk for unintended pregnancy and are less likely to have access to a regular medical care source; thus, the ED represents a possible contraceptive provision site.     

Contraceptive needs and practices among women attending an inner-city STD clinic.

To assess the potential need, interest, and benefits of provision of contraceptive services in sexually transmitted disease (STD) clinics, we surveyed 516 women attending an inner-city STD clinic regarding contraceptive and sexual practices, STD prevalence, knowledge of contraceptive-related STD prophylaxis, and interest in contraceptive services within the STD clinic setting. The study population was at high risk for unintended pregnancy and STDs; at time of interview 46 per cent of women were not contracepting and 59 per cent were treated for STD or STD exposure. Two-thirds of women had at least one prior pregnancy and 50 per cent had at least one living child. Only 26 per cent of women knew that some contraceptive methods may reduce the risk of STD acquisition; however, 62 per cent expressed interest in contraceptive methods which would reduce their risk of STD acquisition. This study suggests that provision of contraceptive services in STD clinic settings may address dual needs in a group at high risk for both unintended pregnancy and STD.     

Psychiatric symptoms, health services, and HIV risk factors among homeless women

The authors determined whether psychiatric symptoms and lack of health and/or social services contacts were associated with HIV risk behaviors among a probability sample of homeless women. Women were interviewed regarding socioeconomic indicators, psychiatric symptoms, health and/or social services contacts, and past-year HIV risk behaviors. Overall, 8 percent of the women injected drugs, 64 percent engaged in unprotected sex, and 22 percent traded sex. Multiple logistic regression results revealed that substance abuse was positively associated with injection drug use and trading sex. Homeless women with case managers were less likely to inject drugs. Although barriers to obtaining drug treatment were associated with trading sex, women attending self-help meetings for substance abuse were also more likely to trade sex. Homeless women who are substance abusers are vulnerable to HIV risk behaviors. Risk reduction interventions for homeless women should be implemented through substance abuse and intensive case management programs.     

Posttraumatic stress disorder after occupational HIV exposure: two cases and a literature review.

Two healthcare workers developed disabling chronic posttraumatic stress disorder after needlestick exposures to blood from a patient infected with human immunodeficiency virus (HIV), even though both continue to test negative for HIV antibody more than 22 months after their exposures. We describe these 2 cases and review the relevant literature. Prospective studies of psychological morbidity after occupational needlestick injuries are required to determine the role of long-term psychological follow-up, counseling, and support.     

Declining HIV prevalence among women attending antenatal care in Pune, India

A declining prevalence of HIV among young women has been reported by the public sector implementing prevention of mother-to-child transmission (PMTCT) programmes, sentinel surveillance sites and research institutions in India. However, there are no reports evaluating such trends from the private healthcare sector. This study is a retrospective analysis of data collected by PRAYAS as a part of the PMTCT programme at Sane Guruji Hospital (SGH), a secondary care hospital in Pune, India. Women attending the antenatal clinic at SGH were screened for HIV following a group counselling session, with an option to opt out. Between January 2003 and March 2008, the overall HIV prevalence was 111/17 578 (0.6%, 95% CI 0.5-0.7%). The HIV prevalence among antenatal women was 1.1% in 2003 and 0.2% in 2008 (i.e. 82% decline in HIV prevalence over the 5-year period) and the odds ratio (OR) of HIV prevalence declined by 0.24 per year from 2003 to March 2008 (OR = 0.76, 95% CI 0.69-0.87; P < 0.001). The risk of having HIV infection was significantly higher in women aged ≥24 years and those who were uneducated. To our knowledge, this is the first report from any private sector health system in India documenting a declining HIV prevalence among antenatal women. Characterising the risk profile of this small percentage of at-risk women will help in planning prevention strategies.     

Heterosexual women of color and HIV risk: sexual risk factors for HIV among Latina and African American women

This paper examines sexual risk for HIV among 2,318 Latina (60%) and African American (40%) women with a steady male partner who were attending an urban outpatient clinic. We compared ethnic groups on demographic characteristics (including being born in the U.S.) and sexual HIV risk factors (number of partners, history of sexually transmitted infection, condom use, and reported knowledge and perception of partner risk) while controlling for other demographic characteristics. African American women were about 1.5 times more likely than Latinas to report five or more sexual partners in their lifetime, to report two or more partners in the past year, and to perceive their partners as being risky. African American women were about 2.5 times more likely than Latinas to have had a history of sexually transmitted infections (STIs). They were also nearly twice as likely as Latinas to report having used condoms with their main partner in the past 90 days. Intervention strategies for HIV prevention must address ethnic/racial differences in sexual risk factors for HIV among Latina and African American women.     

A study of battered women presenting in an emergency department.

Medical records of female trauma patients were retrospectively reviewed prior to introducing a protocol for enhancing identification of battered women; 5.6 per cent of 359 female trauma patients were identified as having injuries caused by battering; 30 per cent of 412 patients following use of the protocol were so identified. Standardized protocols for identifying battered women among female trauma patients should be instituted in emergency departments.     

Domestic violence experienced by women attending an accident and emergency department

Abstract: The aim of the study was to establish the extent and severity of domestic violence experienced by women attending the accident and emergency department of a large teaching hospital in Newcastle. The data were collected over a five-week period in 1992. All women between 17 and 80 years, attending the emergency or ambulatory areas between 8 a.m. and midnight, were asked to complete a confidential structured interview. A total of 401 women participated in the study, representing 82 per cent of eligible women approached. Each participant was asked if she had ever been physically hurt by someone close to her. Questions were asked to determine the relationship to the perpetrator, the type and cause of injury, treatment necessary and help sought Seven (1.7 per cent, 95 per cent confidence interval (CI) 0.46 to 3.02) of the women surveyed were attending the hospital as a direct result of an incident of domestic violence, and 100 women (25 per cent, CI 21 to 29) had experienced domestic violence at some time. Bruising, fractures and cuts were the most common forms of injury, with the most common locations being the head, face and chest. Weapons, such as guns and knives, were used in 20 per cent of the incidents. A considerable number of the women (68 per cent) did not seek help at the time of their injuries. As a substantial proportion of women have experienced domestic violence in their lives, accident and emergency workers should receive training in recognising and assisting victims of domestic violence.