Domestic violence in later life: an overview for health care providers

Domestic violence is a significant problem that adversely affects the health and safety of millions of women throughout their life-span. Most cases of what is considered elder abuse occurs at home rather than in institutions, and the evidence suggests that only 1 in 5 cases are recognized. Frequently the perpetrator is a spouse, adult child, or other family member. Given the demographics of aging women and their longer life expectancies, clinicians are increasingly likely to see patients whose injuries or poor health status are caused or affected by abusive relationships. Improving the ability of physicians to identify domestic violence is an important skill needed for establishing comprehensive intervention and prevention efforts. In addition to conducting universal screening of all female patients, using clinical and behavioral indicators is a critical component of the intervention.     

Serious gaming: A tool to educate health care providers about domestic violence

ABSTRACT

Due to many adverse health effects, victims of domestic violence are frequently seen in the health care system. Yet, health care providers may lack the training to assist them. Online curricula can be an effective instructional tool. Our competency-based, serious video game, Responding to Domestic Violence in Clinical Settings, was designed to address health care providers' knowledge gaps through 17 modules, each a half hour in length. Nearly 9,000 participants completed at least one module; nursing students completed the most modules, approximately five hours of instruction. This serious video game-based curriculum is useful in helping health providers and students learn about Domestic Violence.     

Intimate partner violence. A survey conducted in the primary care setting

OBJECTIVES: To determine the prevalence of intimate partner violence (IPV) in a sample of women attending primary care centers for any reason and to analyze the characteristics of this violence. METHODS: A cross sectional study was performed in 23 primary care centers in three regions of Spain (Andalusia, Madrid and Valencia). The sample included 1,402 randomly selected adult women aged between 18 and 65 years attending these centers. Among the variables collected through a self-administered questionnaire were the existence of physical, emotional or sexual abuse, and its timing, duration, and frequency. RESULTS: Overall, 32% had experienced some type of IPV. By type, 7% had experienced both physical and emotional IPV, 14% had experienced emotional IPV, 3% had experienced emotional and sexual IPV, and 6% had suffered all 3 types of IPV. Among the latter, 52% had experienced abuse for more than 5 years. Women who experienced abuse in a previous relationship had a greater probability of being abused by a new intimate partner (OR = 3.30; 95% CI, 2.10-5.18). CONCLUSIONS: These results show the scale of IPV in Spain. Health professionals play an important role in IPV, as they are in a privileged position to tackle this serious public health problem.     

Abortion practice in Mexico: a survey of health care providers

BackgroundLittle is known about abortion practice in Mexico postlegalization of abortion in Mexico City in 2007.Study DesignIn 2009, we anonymously surveyed 418 Mexican health care providers at the Colegio Mexicano de Especialistas en Ginecologia y Obstetricia meeting using audio computer-assisted self-interview technology.ResultsThe majority of respondents were obstetrician gynecologists (376, 90%), Catholic (341, 82%), 35–60 years old (332, 79%) and male (222, 53%) and worked with trainees (307, 74%). Prior to 2007, 11% (46) and 17% (71) provided medical and surgical abortions; now, 15% (62) and 21% (86) provide these services, respectively. Practitioners from Mexico City were more likely to provide services than those from other areas. Most medical abortion providers (50, 81%) used ineffective protocols. Surgical abortion providers mainly used either manual vacuum aspiration (39, 45%) or sharp curettage (27, 32%). Most abortion providers were trained in residency and wanted more training in medical (54, 87%) and surgical (59, 69%) abortion. Among nonproviders, 49% (175) and 27% (89) expressed interest in learning to perform medical and surgical abortion, respectively.ConclusionGiven the interest in learning to provide safe abortion services and the prevalent use of ineffective medical abortion regimens and sharp curettage, abortion training in Mexico should be strengthened.     

A strategy to increase the palliative care capacity of rural primary health care providers

OBJECTIVE: To pilot and evaluate an intervention aimed at increasing the palliative care capacity of primary health care providers in rural and remote communities. DESIGN: Pre- and post-workshop, and three months follow-up questionnaires. SETTING: Four locations in Far North Queensland. SUBJECTS: One hundred and forty-nine primary health care providers ranging from personal care workers to general practitioners (GPs). INTERVENTIONS: Fourteen workshops were conducted. These were tailored to local palliative case loads facilitated by a specialist palliative care team from the Mt Olivet Hospice Service. Workshop content consisted of introductory didactic teaching based on participant-nominated topics, small group case management discussions and a session devoted to psychosocial and counselling inputs. MAIN OUTCOME MEASURES: Cost, GP reach, evaluation of educational and clinical objectives. RESULTS: Average cost per participant--excluding wages--was 271 dollars. Thirty-two per cent of local GPs attended the workshops and 93.2% of participants reported that the workshops had satisfied their educational learning objectives. Evaluation of GP clinical performance revealed significant improvements in confidence regarding palliative care knowledge and skill levels as well as the management of common palliative symptoms. Evaluation of other primary health care providers' clinical performance showed significant improvements in skills, management and rated knowledge. CONCLUSIONS: This intervention is relatively inexpensive, has reasonable reach and is effective as measured by educational and clinical outcomes.     

Use of rapid point-of-care tests by primary health care providers in India: findings from a community-based survey

In a cross-sectional survey conducted in 45 districts of India, we assessed 1) use of any rapid point-of-care (POC) tests by primary health care providers, and 2) their willingness to use POC tests for tuberculosis (TB) in future. A total of 767 primary health care providers, including private and public sector practitioners, health workers and chemists, were interviewed. A quarter of the primary health care providers reported using POC tests, with pregnancy tests being the most common. Nearly half of the respondents expressed willingness to use POC tests for TB, provided the test was available free or at low cost (<US$ 2.00).     

Discontinuity in care: Practice closures among primary care providers and patient health care utilization

We evaluate the consequences for patients of being matched to a new primary care provider due to practice closures. Using an event study and population-level data of patients and providers in Denmark, we find that the transition between providers is smooth; among re-matched patients, there is little change in primary care utilization at the extensive margin. Second, we document a 17% increase in fee-for-service per visit and a large increase in the probability that the patient initiates drug therapy targeting chronic and underdiagnosed diseases (hypertension, hyperlipidemia, and diabetes). Additionally, the re-matched patients are more likely to be admitted to inpatient care for these diseases. The increase in therapeutic initiation is not primarily because the new providers are relatively predisposed to prescribing these drugs. Instead, it appears that when patients match to new providers, there is a consequential reassessment of patients’ medical needs which leads to the initiation of new treatment.     

Ethical issues in primary health care: A survey of practitioners' perceptions

While most health care is provided at the primary care level, little research has been done to document the ethical issues of such care. A stratified random sample of 702 physicians, nurses, physical therapist, and physician assistants within one southeastern state was surveyed to determine the frequency of ethical issues in primary care. The most frequently occurring issue concerned moral decisions about the amount of time to spend with each patient. A comparison of physician and nonphysician professional groups revealed significant differences in frequencies of the issues. Age had a slight impact on the responses, while gender, religion, and region of practice had none. The study showed that the most frequently occurring issues are pragmatic, not dramatic, and center on patient self-determination, adequacy of care and professional responsibility, and distribution of resources.Helen M. Robillard, R.N.-C., M.S.N., is a doctoral student in Organizational Psychology at the University of Michigan, Ann Arbor. Dallas M. High, Ph.D., is Professor in the Department of Philosophy and Associate of the Sanders-Brown Center on Aging, University of Kentucky, Lexington. Juliann G. Sebastian, R.N., M.S.N., is Associate Professor, College of Nursing, University of Kentucky, Lexington. Janet I. Pisaneschi, Ph.D., is Associate Professor and Assistant Dean, College of Allied Health Professions, University of Kentucky, Lexington. Lea J. Perritt, Ph.D., is Assistant Professor, Allied Health Education and Research, College of Allied Health Professions, University of Kentucky, Lexington. D. Mark Mahler, M.D., is Assistant Clinical Professor, Indiana University School of Medicine, Indianapolis. Requests for reprints should be addressed to: Dallas M. High, Ph.D., Professor, Department of Philosophy, University of Kentucky, Lexington, KY, 40506.     

A survey of binge eating and obesity treatment practices among primary care providers

OBJECTIVES: Obesity is an increasingly prevalent condition and many obese individuals binge eat. It is unclear how much knowledge physicians possess regarding binge eating, but the limited existing data suggest that primary care physicians frequently do not identify obesity as a clinical problem. The objective of this study was to examine physician knowledge and treatment recommendations regarding binge eating and obesity. METHOD: A survey on binge eating and obesity assessment and treatment was mailed to 700 licensed physicians. The survey was returned by 272 (38.9%) respondents. RESULTS: Greater than 40% of physicians never assessed binge eating. Body mass index (BMI) was calculated "often or always" by 36.2% of physicians and "rarely or never" by 39.7%. The pattern of obesity treatment methods offered by providers was quite different from the pattern of treatment requested by their patients. Physicians who made higher estimates of binge eating prevalence were more likely to make treatment referrals. DISCUSSION: In this study, physicians frequently did not assess binge eating. Only a minority of physicians utilize BMI in the assessment and management of obesity. Also, physicians report that the obesity treatments they recommend differ from the treatments patients request of them.     

我国基层卫生机构服务功能分析

基层卫生机构功能决定着基本卫生服务的供给。本文利用国家第四次卫生服务总调查以及专题调查资料,对城乡基层卫生机构服务开展情况进行了分析。根据经济社会发展水平、基层卫生机构服务能力和城乡居民需要解决的主要健康问题,本研究将基本卫生服务项目按照优先程度分为三个等级。约三分之一的城乡基层卫生机构尚不能提供最应优先开展的基本卫生服务;农村基层卫生机构服务能力与城市基层卫生机构相比更为薄弱,特别是村级卫生机构基本卫生服务能力需要加强;乡镇卫生院和社区卫生服务中心开展最优先项目的比例均不足70%;村卫生室和社区服务站开展最优先项目比例分别为62%和77%。影响基层卫生机构功能的主要因素为人员数量不足、人员能力不够、缺乏运转资金等。需要以基层卫生机构功能建设为核心,创新我国基本医疗卫生保健体系。     

A tele-otology course for primary care providers

The shortage of otolaryngologists and the high incidence of ear disease in remote areas are major problems in Australia. We have developed a multimedia course for primary care providers that incorporates material about ear anatomy and physiology, ear disease, video-otoscopy and telemedicine software. The computer-based course was followed by a practical one-day course. A multiple-choice test was given to participants before and at the end of the course and a form was used to record feedback. The course was conducted with 30 aboriginal health workers. The participants were able to obtain images of reasonable to good quality after a short period of training. There was an average improvement of about 25% in the test scores, and the feedback regarding the course was extremely positive. The CD-ROM and the Website provide a valuable resource to assist primary care providers in their care of patients with ear disorders.     

Responsibility of health providers in domestic violence reporting

Domestic violence reporting by health providers contributes to the epidemiological assessment of the magnitude of the problem, which allows the development of specific programs and actions. The aim of the study was to assess the level of responsibility of these providers towards reporting violence, especially domestic violence, and potential related legal and ethical implications. The Brazilian legislation and ethics code of Medicine, Dentistry, Nursing and Psychology were studied. Legal sanctions are found in the Criminal Law of Misdemeanor Offenses, the Child and Adolescent Statute, the Elderly Statute and in the law establishing mandatory reporting of violence against women. There are also penalties in all ethics codes reviewed. It is concluded that health providers have the legal duty of reporting known domestic violence cases and they can even be charged with omission.     

A performance evaluation system for primary care providers in a community health services program

A performance evaluation system (PES) serves to motivate employees to provide desired behaviors that achieve organizational objectives. In 1989, Denver Health and Hospital (DHH), a publicly funded, integrated delivery system with a large primary care program, instituted a new PES. This report summarizes performance evaluation results for DHH's community health center program. The evaluation focused on the performance of primary care physicians, midlevel practitioners (i.e., physicians assistants, nurse practitioners, and dentists), over a 4-year study period (1990 to 1993). Category-specific performance ratings were based on a 5-point ordinal scale: unacceptable, expectations not met, meets expectations, exceeds expectations, and outstanding. Performance ratings were analyzed as variables that were dependent on several practice characteristics. Results demonstrated a relationship between performance ratings and specific practice characteristics. Based on the results, limitations of the new PES and implications for designing more effective evaluation systems are discussed.     

A discourse analysis on how service providers in non-medical primary health and social care services understand their roles in mental health care

Enhancing collaboration between specialist mental health services, primary health care and social care services has been a key priority in mental health policy reform in many countries for about 20 years and remains so. Yet progress in terms of widespread implementation of demonstrably effective models of collaborative care has been slow. The views that different providers hold regarding the parameters of their roles, and the values that guide their approach to service delivery, are likely to exert profound effects on engagement with collaborative initiatives. Little research has explored these issues.     

Use of nonphysician health care providers for skin cancer screening in the primary care setting

BACKGROUND: Nonphysician health care providers are in an optimal position to provide cancer prevention and screening services. METHODS: We conducted a survey of primary care physicians to determine physician use and amenability to use of nonphysician health care providers to perform skin cancer screening in comparison with other cancer screening examinations. RESULTS: A total of 1,363 eligible physicians completed the survey. Of these, 631 physicians (46%) reported a nurse practitioner or physician assistant performing at least one type of cancer screening examination on their patients. Twenty-nine and 22% of all physicians reported nurse practitioners or physician assistants performing skin cancer screening, respectively. Family physicians were more likely to use nurse practitioners and physician assistants to perform these cancer screening examinations than internists (chi(2) test, P = 0.001 for each examination). Skin examinations were performed less frequently by nurse practitioners and physician assistants than all other cancer screening examinations. A total of 73-79% of family physicians and 60-70% of internists were amenable to having a nonphysician health care provider perform one or more of these examinations. CONCLUSIONS: Primary care physicians are currently utilizing nonphysician health care providers to perform cancer screening examinations and the majority of those surveyed are amenable to the use of these providers for such examinations. This suggests that one possible strategy for increasing skin cancer screening is through an expanded role of nonphysician health care providers.     

Gender-based barriers to primary health care provision in Pakistan: the experience of female providers

In common with several countries in South Asia, the Pakistan government health system has introduced cadres of community-based female health and family planning workers as a response to gender-based constraints on women's access to services. However, the recruitment, training and retention of such female workers has been difficult. This finding points to the obvious but neglected fact that female health workers must operate within the same gender systems that necessitate their appointment in the first place. The present study used qualitative methods to increase our understanding of the experience of female staff working at the community level and in particular the gender-based constraints that they face. Important problems identified include: abusive hierarchical management structures; disrespect from male colleagues; lack of sensitivity to women's gender-based cultural constraints; conflict between domestic and work responsibilities; and poor infrastructural support. The findings highlight the interconnectedness of women's public and private lives and the interplay of class and gender hierarchies in the patterning of women's employment experiences. The study's conclusions suggest ways in which the organizational functioning of the government health services might be modified to better facilitate the work of female staff.