Recognising and responding to partner abuse: challenging the key facts.
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Child↗
Biomedical subjects
Felicity Goodyear-Smith
Publications and source records attributed to Felicity Goodyear-Smith.
Recognising and responding to partner abuse: challenging the key facts.
Inter-partner violence is a serious public health problem for a minority of the population. Frequently the problem is hidden and goes undetected. Recognising this violence within the primary healthcare setting and responding appropriately are laudable aims, with significant health gains. However it is important that in raising professional and public awareness of the issue, the case is not over-stated. Too often figures such as a NZ$141 million annual cost of family violence to health are quoted and presented as 'fact' without critical appraisal. Family violence is an emotional topic, and challenge to prevailing viewpoints may be misconstrued as a denial of the problem. These are important issues, and I invite academic debate.
Attitude to Health↗
Family physician perspectives on barriers to childhood immunisation.
New Zealand (NZ) has inadequate vaccine coverage and associated disease outbreaks. International research illustrates the importance of provider behaviour in improving vaccine uptake. To understand the immunisation knowledge, views, concerns and educational needs of NZ family physicians, qualitative and quantitative national data was gathered from randomised telephone surveys. Response rate was 60% with respondents' characteristics closely matched to key demographics of NZ family physicians. The most significant barrier to improving immunisation rates identified was parental concern over vaccine safety and associated misconceptions. The second major barrier identified was lack of funding to health providers. A clear need for improvement in family physician knowledge of contraindications to vaccines was highlighted. Family physicians expressed a need for better resources to more effectively address parental fears and misconceptions. Strategies to address these issues include an increased focus on family physician educational needs, extra resources to assist with more effective communication to parents and a review of the present funding of providers for immunisation services.
Child↗
Corticosteroid injections for osteoarthritis of the knee: meta-analysis.
OBJECTIVES: To determine the efficacy of intra-articular corticosteroid injections for osteoarthritis of the knee and to identify numbers needed to treat. DATA SOURCES: Cochrane controlled trials register, Medline (1966 to 2003), Embase (1980 to 2003), hand searches, and contact with authors. INCLUSION CRITERIA: Randomised controlled trial in which the efficacy of intra-articular corticosteroid injections for osteoarthritis of the knee could be ascertained. RESULTS: In high quality studies, the pooled relative risk for improvement in symptoms of osteoarthritis of the knee at 16-24 weeks after intra-articular corticosteroid injections was 2.09 (95% confidence interval 1.2 to 3.7) and the number needed to treat was 4.4. The pooled relative risk for improvement up to two weeks after injections was 1.66 (1.37 to 2.0). The numbers needed to treat to get one improvement in the statistically significant studies was 1.3 to 3.5 patients. CONCLUSION: Evidence supports short term (up to two weeks) improvement in symptoms of osteoarthritis of the knee after intra-articular corticosteroid injection. Significant improvement was also shown in the only methodologically sound studies addressing longer term response (16-24 weeks). A dose equivalent to 50 mg of prednisone may be needed to show benefit at 16-24 weeks.
Adrenal Cortex Hormones↗
Delayed prescriptions.
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Anti-Bacterial Agents↗
Experiences and preferences of general practitioners regarding continuing medical education: a qualitative study.
AIM: To explore the experiences and preferences of general practitioners (GPs) regarding their continuing medical education (CME). METHODS: Qualitative study using semi-structured interviews of twenty four GPs from Auckland and North Island rural areas assessing GPs' experiences and preferences. RESULTS: The need for CME was emphasised. Primary themes identified were: the value of personal interaction; the perception that CME that did not involve personal interaction was adjunctive; an opportunistic rather than needs-based approach to learning; a preference for succinct, evidenced-based, GP-focused content; and lack of time as a major barrier to obtaining optimal CME. CONCLUSIONS: Interactive formats are generally preferred, but identification of which elements of interactive formats facilitate learning is not established. Most GPs do not direct their CME according to the adult learning model. The challenge for CME providers is to provide avenues to facilitate needs identification and self-directed learning.
Attitude of Health Personnel↗
General practitioners' perceptions of continuing medical education's role in changing behaviour.
CONTEXT: The effectiveness of moving to compulsory, prescriptive continuing medical education (CME) for New Zealand general practitioners (GPs) is questioned. Motivational interviewing theory suggests that a series of interventions gradually increase awareness of the need to change until change is finally actioned. This study aimed to explore GPs' views on their need for CME, experiences regarding its provision and perceptions on the effect of CME in changing their clinical behaviour. METHOD: Qualitative study using semi-structured interviews of 24 GPs from Auckland and North Island rural areas assessing their CME experiences and preferences. FINDINGS: All participants acknowledged that CME is a life-long process essential for GPs. Changing behaviour is generally seen as an incremental, evolutionary process with reinforcement of knowledge from different sources. Single events were perceived to effect change rarely. These were often high-impact, either punitive or incentive-based. GPs have a myriad of CME sources including reading, the internet, specialist letters, conversations with colleagues, quality assurance feedback, as well as traditional meetings. Credit-based quota requirements received mixed opinions but mostly were perceived negatively, discouraging needs-based approaches to learning. GPs' greatest barrier to obtaining CME is time. DISCUSSION: GPs perform poorly in assessing their specific learning needs. Their behaviour change is likely to be incremental. Therefore multi-faceted interventions and reinforcement from different sources are likely to be most effective in changing clinical practice. Understanding this is important for CME providers, GP Colleges and funders. Narrow, credit-based approaches to CME may discourage time-strapped GPs obtaining motivation to change from exposure to a wide variety of CME sources.
Attitude of Health Personnel↗
Screening for domestic violence in general practice: a way forward?
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Domestic Violence↗
Depression in patients in an Auckland general practice.
AIM: To measure the rate of detected and undetected depression in patients attending an Auckland general practice. METHOD: At their consultation conclusion, general practitioners (GPs) asked all consecutive patients over sixteen years attending for consultation to participate in a health and mood questionnaire. A researcher administered the Beck Depression Inventory (BDI) to consenting participants. The GPs previously recorded whether they considered these patients depressed. RESULTS: Response rate among patients was 81% (253/314). The BDI found a 13.8% (35/253) 95% CI (9.6-18.5) depression prevalence among patients. GPs picked up 51% of cases (sensitivity 0.51 and specificity 0.91). Mäori patients were no more likely to be depressed than non-Mäori but they were less likely to be receiving or have received treatment with antidepressants. CONCLUSION: The rate of depression in this practice was higher than an earlier study suggesting the true rate may be >10%. GPs see more depressed patients than other health professionals, therefore improvement in detection and management of depression in primary care is important. More work is needed on the difference between Mäori and non-Mäori in the use of antidepressants.
Adolescent↗
International variation in ethics committee requirements: comparisons across five Westernised nations.
BACKGROUND: Ethics committees typically apply the common principles of autonomy, nonmaleficence, beneficence and justice to research proposals but with variable weighting and interpretation. This paper reports a comparison of ethical requirements in an international cross-cultural study and discusses their implications. DISCUSSION: The study was run concurrently in New Zealand, UK, Israel, Canada and USA and involved testing hypotheses about believability of testimonies regarding alleged child sexual abuse. Ethics committee requirements to conduct this study ranged from nil in Israel to considerable amendments designed to minimise participant harm in New Zealand. Assessment of minimal risk is a complex and unreliable estimation further compounded by insufficient information on probabilities of particular individuals suffering harm. Estimating potential benefits/ risks ratio and protecting participants' autonomy similarly are not straightforward exercises. SUMMARY: Safeguarding moral/humane principles should be balanced with promotion of ethical research which does not impede research posing minimal risk to participants. In ensuring that ethical standards are met and research has scientific merit, ethics committees have obligations to participants (to meet their rights and protect them from harm); to society (to ensure good quality research is conducted); and to researchers (to treat their proposals with just consideration and respect). To facilitate meeting all these obligations, the preferable focus should be promotion of ethical research, rather than the prevention of unethical research, which inevitably results in the impediment of researchers from doing their work. How the ethical principles should be applied and balanced requires further consideration.
Behavioral Research↗
Termination of pregnancy following panic-stopping of oral contraceptives.
This study assessed characteristics of women presenting for termination of pregnancy subsequent to stopping combined oral contraceptive use in response to publicity-mediated fears regarding venous thromboembolism. Records of 400 women attending for pregnancy termination assessment were reviewed retrospectively. Panic-stopping of oral contraceptives was implicated in 9.5%. Nearly 50% of combined pill users claimed their pregnancy resulted from panic-stopping because of media-promoted fear of health risks, especially 'clots.' Panic-stoppers had significantly lower identified risk factors for venous thromboembolism than pill users who had not panic-stopped. The relative safety of third-generation pills is under debate. The risk-benefit ratio of contraceptive pills is overwhelmingly positive but practitioners must be vigilant in screening for risk factors and contraindications. Panic-stopping results in unwanted pregnancies with concomitant psychological distress and potential physical morbidity. In future situations where research findings may precipitate drug scares, we recommend recall of patients by their health provider, funded by the relevant health authority or pharmaceutical companies, to allow discussion of risks before the media is enabled to have access to the information.
Abortion, Induced↗
Delayed antibiotic prescriptions: what are the experiences and attitudes of physicians and patients?
OBJECTIVE: To explore the experiences and opinions of family physicians and patients regarding the delay of antibiotic prescriptions, to be dispensed if symptoms persist or worsen over time, in treating upper respiratory tract infections. STUDY DESIGN: Qualitative study using semistructured interviews conducted in family practice in Auckland, New Zealand. POPULATION: Thirteen physicians recruited from a study of family physicians' reported antibiotic prescribing and 13 patients recruited from the intervention arm of a randomized controlled trial on delayed antibiotic prescribing. OUTCOMES MEASURED: Patients' and physicians' experiences of delayed antibiotic prescriptions for upper respiratory tract infections. RESULTS: The primary themes identified were value judgments of antibiotics, decreased antibiotic use, patient-centered factors, effects on the physician-patient relationship, patient convenience, adverse effects of delaying prescription, and selectivity for use of antibiotics. Many themes were common to both patients and physicians. Physicians valued empowering patients' decision making about their health care management more highly than did patients. Decreasing antibiotic use was not a key factor for most patients. Both groups acknowledged the value in saving patients time and money. Physicians viewed the strategy as giving patients reassurance and meeting their expectations for antibiotics. Negative implications included perception of physician incompetence and physician loss of management control. Opinions were mixed regarding which patients, under which conditions, were suitable for delayed antibiotic prescriptions. CONCLUSIONS: Although delayed antibiotic prescriptions are effective in decreasing antibiotic use for conditions not clinically warranting antibiotics, neither patients nor physicians universally endorsed this strategy. Research to establish formalized recommendations for patient suitability and instructions for use would be of value.
Adult↗
National screening policies in general practice: a case study of routine screening for partner abuse.
Internationally-recognised criteria for screening for a particular disorder require the following: availability of a clear diagnosis; a suitable validated screening test; acceptability of routine screening by patients and health providers; benefits of earlier detection and application of appropriate interventions to prevent the progression of a disorder, and hence reduction in incidence of morbidity and mortality; identification of possible harm from screening (false positives, false negatives, adverse effects of labelling, early diagnosis or unnecessary treatment of persons with true-positive test results with inconsequential disease) and weighing this against potential benefits; identification of possible sub-populations with the possibility of targeted screening of high-risk populations; good quality evidence of interventions effective in preventing or managing the disorder; and a cost-effectiveness assay. The New Zealand Ministry of Health have launched a best-practice guideline recommending all female general practice patients sixteen years and over be routinely screened for physical and sexual abuse by their partners. Inter-partner violence, especially against women by male partners and expartners, is a serious public health problem. However, review of existing research indicates that this guideline meets none of the criteria listed above. Considerable funding is invested in training health providers to implement this screening protocol, but, in the absence of effectiveness studies, cost-effectiveness cannot be assessed. Under current conditions, routine screening of adult women for partner abuse cannot be justified. However, GPs should be encouraged to learn about partner abuse and consider this possibility in patients presenting with physical injuries, psychological disturbance or social dysfunction, especially in high-risk patients. Research should be supported for the development and validation of effective, acceptable screening tools and randomised controlled trials of appropriate interventions. The desire to intervene for the public good should not dictate the implementation of a screening programme that disregards accepted screening criteria.
Adolescent↗
What can family physicians offer patients with carpal tunnel syndrome other than surgery? A systematic review of nonsurgical management.
BACKGROUND: We undertook a literature review to produce evidence-based recommendations for nonsurgical family physician management of carpal tunnel syndrome (CTS). METHODS: Study design was systematic review of randomized controlled trials (RCTs) on CTS treatment. Data sources were English publications from all relevant databases, hand searches, and guidelines. Outcomes measured were nonsurgical management options for CTS. RESULTS: We assessed 2 systematic reviews, 16 RCTs, and 1 before-and-after study using historical controls. A considerable percentage of CTS resolves spontaneously. There is strong evidence that local corticosteroid injections, and to a lesser extent oral corticosteroids, give short-term relief for CTS sufferers. There is limited evidence to indicate that splinting, laser-acupuncture, yoga, and therapeutic ultrasound may be effective in the short to medium term (up to 6 months). The evidence for nerve and tendon gliding exercises is even more tentative. The evidence does not support the use of nonsteroidal anti-inflammatory drugs, diuretics, pyridoxine (vitamin B6), chiropractic treatment, or magnet treatment. CONCLUSIONS: For those who are not able to get surgery or for those who do not want surgery, there are some conservative modalities that can be tried. These modalities include ones for which there is good evidence. It would be reasonable to try some of the techniques with less evidence if the better ones are not successful. Reconsideration of surgery must always be kept in mind to avoid permanent nerve damage.
Adult↗