Classificatory multiplicity: intimate partner violence diagnosis in emergency department consultations

Aims and Objectives The aim of this research was to explore the naming, or classification, of physical assaults by a partner as ‘intimate partner violence’ during emergency department consultations. Background Research continues to evidence instances when intimate partner physical violence is ‘missed’ or unacknowledged during emergency department consultations. Methods Theoretically this research was approached through complexity theory and the sociology of diagnosis. Research design was an applied, descriptive and explanatory, multiple-method approach that combined: qualitative semi-structured interviews with service users (n=8) and emergency department practitioners (n=9), and qualitative and quantitative document analysis of emergency department health records (n=28). Results This study found that multiple classifications of intimate partner violence were mobilised during emergency department consultations and that these different versions of intimate partner violence held different diagnostic categories, processes, and consequences. Conclusion The construction of different versions of intimate partner violence in emergency department consultations could explain variance in people’s experiences and outcomes of consultations. The research found that the classificatory threshold for ‘intimate partner violence’ was too high. Strengthening systems of diagnosis (identification and intervention) so that all incidents of partner violence are named as ‘intimate partner violence’ will reduce the incidence of missed cases and afford earlier specialist intervention to reduce violence and limit its harms. Relevance to Clinical Practice This research found that identification of and response to intimate partner violence, even in contexts of severe physical violence, was contingent. By lowering the classificatory threshold so that all incidents of partner violence are named as ‘intimate partner violence’, practitioners could make a significant contribution to reducing missed intimate partner violence during consultations and improving health outcomes for this population. This research has relevance for practitioners in any setting where service-user report of intimate partner violence is possible.   SUMMARY BOX What does this paper contribute to wider global community? • Identification of and response to intimate partner violence, even in contexts of severe physical violence was found to be contingent. • Classification of intimate partner violence was connected to: legal duty to respond statutory frameworks of risk of harms; socio-cultural discourses about what counts as intimate partner violence; and health care practitioners’ perceptions of usual modes of disclosure. • Connecting all reports of partner perpetrated violence to intimate partner violence identification and intervention will reduce missed cases in health consultations and mobilise earlier intervention to reduce violence and limit its harms. • The sociology of diagnosis is a valuable conceptual tool for examining variance in identification and response for a wide range of determinants of health of concern for nurses and allied professions

Validating Health Impact Assessment: Prediction is difficult (especially about the future)

Health Impact Assessment (HIA) has been recommended as a means of estimating how policies, programmes and projects may impact on public health, and on health inequalities. This paper considers the difference between predicting health impacts, and measuring those impacts. It draws upon a case study of the building of a new hypermarket in a deprived area of Glasgow, which offered an opportunity to reflect on the issue of the predictive validity of HIA, and to consider the difference between potential and actual impacts. We found that the actual impacts of the new hypermarket on diet differed from that which would have been predicted based on previous studies. Furthermore they challenge current received wisdom about the impact of food retail outlets in poorer areas. These results are relevant to the validity of HIA as a process and emphasise the importance of further research on the predictive validity of HIA, which should help improve its value to decision-makers

Primary care challenges in diagnosing and referring patients with suspected rheumatoid arthritis: a national cross-sectional GP survey

Objective: National guidelines advocate referring patients with persistent synovitis to rheumatology within 3 working days of presentation to primary care. This occurs infrequently. We aimed to identify modifiable barriers to early referral of suspected RA patients among English general practitioners (GPs). Methods: We carried out a national cross-sectional survey of 1388 English GPs (RA Questionnaire for GPs [RA-QUEST] study). Questions addressed GPs’ confidence in diagnosing RA, clinical factors influencing RA diagnosis/referral, timeliness of referrals and secondary care access. Data were captured using 10-point visual analog scales, five-point Likert scales, yes/no questions or free text, and were analysed descriptively. Results: Small joint swelling and pain were most influential in diagnosing RA (91 and 84% rated the importance of these as 4 or 5 on a five-point Likert scale, respectively); investigations including RF (61% rating 4 or 5) and anti-CCP antibody (72% rating 4 or 5) were less influential. Patient history had the greatest impact on the decision to refer (92% rating this 4 or 5 on a 5-point Likert scale), with acute phase markers (74% rating 4 or 5) and serology (76% rating 4 or 5) less impactful. Despite the importance placed on history and examination, only 26% referred suspected RA immediately without investigations; 95% of GPs organizing further tests opted to test for RF. Conclusion: For suspected RA patients to be referred within 3 days of presentation to primary care there needs to be a paradigm shift in GPs’ approaches to making referral decisions, with a focus on clinical history and examination findings, and not the use of investigations such as RF

‘You can’t stand on a corner and talk about it …’: Medicinal cannabis use, impression management and the analytical status of interviews

In this article, I examine how four medicinal cannabis users used impression management during in-depth, qualitative interviews to attend to self-presentational concerns. I examine the rhetorical strategies and narratives articulated by the participants while also attending to the role that I played in co-construction as the interviewer. Later I discuss how, although the participants’ accounts are occasioned by the interviews, they can still provide significant insights into the social worlds of the participants beyond the interviews. While discussions about whether to treat interviews as topic, resource or both are not new, I argue that we can treat interviews as both topic and resource because impression management is a product of the individual’s habitus and it and the accounts it produces are part of their social world

Exploring the relationship between genetic and environmental influences on initiation and progression of substance use

AIMS: To examine the genetic and environmental contributions to the initiation of use and progression to more serious use of alcohol, cigarettes and marijuana during adolescence, and to examine the relationship between initiation and progression of substance use. DESIGN: The study used a twin-based design and a new theoretical model, the causal-common-contingent (CCC) model. This allows modelling of the relationship between initiation of use and progression to heavier use as a two-stage model and the examination of genetic and environmental influences on both stages, while taking into account their relationship. PARTICIPANTS: The participants consisted of 1214 twin pairs (69% response rate) aged 11-19 years sampled from the UK population-based Cardiff Study of All Wales and North-west of England Twins (CaStANET). MEASUREMENTS: Data on adolescent initiation and progression to more serious use of alcohol, cigarettes and marijuana were obtained using self-report questionnaires. FINDINGS: Initiation of alcohol and progression to heavier alcohol use had separate but related underlying aetiologies. For cigarette and marijuana use the relation between initiation and progression to heavier use was stronger, suggesting greater overlap in aetiologies. For all three substances, environmental influences that make twins more similar (common environment) tended to be greater for initiation, while genetic influences were stronger for heavier use. CONCLUSIONS: These findings have implications for policy decisions aimed at an adolescent and early adult age group. Specifically, these findings suggest that it may be more efficacious to focus alcohol interventions on risk factors for the development of heavier use rather than initiation of use. In contrast, interventions aimed at reducing the initiation of cigarettes and marijuana use may be more appropriate

Development of the Thalassaemia Adult Life Index (ThALI)

Abstract: Background: Beta Thalassaemia Major (βTM) is a chronic genetic illness whereby the challenges faced by patients exposes them to increased risk of psychosocial issues. Despite this, a disease-specific tool to measure the impact of this illness on adult patients has yet to be developed. Methods: In collaboration with βTM adult patients, this study aimed to develop a comprehensive, disease-specific, easy to use psychometrically sound tool to measure the impact of chelation and transfusion dependent βTM in a cross-cultural patient group in England.The Thalassaemia Life Index (ThALI) was developed in two stages – item generation and pre-testing and item reduction – in collaboration with service users. Recruited adult patients shaped the design of the instrument including its statements and subscales. Standard item reduction techniques were used to develop the instrument. Results: The final version of the ThALI encompasses 35 statements and five sub-scales - general physical health, coping, body image, appearance and confidence, social relationships and autonomy. This endorses the multidimensionality of quality of life (QoL). The factor structure of the ThALI is highly stable and its internal consistency is high (alpha = 0.87 for the overall scale; 0.83–0.94 for its subscales). The ThALI has sound scaling assumptions, acceptability and score variability. Content validity was confirmed by experts and service user interviewees. The loadings for the items retained were adequate and the item discriminant validity sound. Conclusions: The ThALI covers the impact of βTM in adult patients. Preliminary testing shows its multidimensionality to be reliable and valid. The national authentication of the tool with patients treated in Centres of Excellence will aim to provide further evidence regarding the ThALI’s psychometric properties. Once authenticated, the ThALI may be utilised in research and in clinical settings to assess the effects of new therapies and/or interventions from the patients’ perspective to inform practice and/or to identify areas of concern

Personal continuity and access in UK general practice: a qualitative study of general practitioners' and patients' perceptions of when and how they matter

BACKGROUND: Personal continuity is a core value for family practice, but policy and performance targets emphasise other aspects of care, particularly waiting times for consultation. This study examined patient and general practitioner (GP) perceptions of the value of personal continuity and rapid access, and the relationship between them. METHODS: Qualitative analysis of semi-structured interviews with a purposive sample of 16 GPs and 32 patients in the Lothian region of Scotland, to identify whether, how, why and in which circumstances personal continuity and rapid access were valued. RESULTS: From the patients' perspective, what mattered was 'access to appropriate care' depending on the problem to be dealt with. For a few patients, rapid access was the only priority. For most, rapid access was balanced against greater involvement in the consultation when seeing 'their' trusted doctor, which was particularly valued for chronic, complex and emotional problems. GPs focused on the value of personal continuity in the consultation for improving the diagnosis and management of the same kinds of problem. GPs did not perceive enabling access to be a core part of their work. There was little evidence that GPs routinely discussed with patients when or how personal continuity and access should be balanced. CONCLUSION: 'Access to appropriate care' from the patients' perspective is not fully addressed by GPs' focus on personal continuity, nor by performance targets focused only on speed of access. GPs need to make enabling access as much a part of their core values as personal continuity, and access targets need to be based on less simplistic measures that account for the appropriateness of care as well as speed of access

Will opposites attract? Similarities and differences in students' perceptions of the stereotype profiles of other health and social care professional groups

The extent to which health and social care (HSC) students hold stereotypical views of other HSC professional groups is of great potential importance to team working in health care. This paper explores students' perceptions of different HSC professional groups at the beginning of their university programmes. Findings are presented from an analysis of baseline data collected as part of the New Generation Project longitudinal cohort study which is assessing the impact of interprofessional education over time on a range of variables including stereotyping. Questionnaires were administered to a cohort of over 1200 students from 10 different HSC professional groups entering their first year of university. Stereotypes were measured using a tool adapted from Barnes et al. (2000) designed to elicit stereotype ratings on a range of nine characteristics. The findings confirm that students arrive at university with an established and consistent set of stereotypes about other health and social care professional groups. Stereotypical profiles were compiled for each professional group indicating the distinctive characteristics of the groups as well as the similarities and differences between groups. Midwives, social workers and nurses were rated most highly on interpersonal skills and on being a team player whilst doctors were rated most highly on academic ability. Doctors, midwives and social workers were perceived as having the strongest leadership role, whilst doctors were also rated most highly on decision making. All professions were rated highly on confidence and professional competence and, with the exception of social workers, on practical skills. A comparison of profiles for each professional group reveals that, for example, pharmacists and doctors were perceived as having very similar characteristics as were social workers, midwives and nurses. However, the profiles of nurses and doctors were perceived to be very different. The implications of these similarities and differences are discussed in terms of their potential impact on interprofessional interactions, role boundaries and team working

Early estimation of pandemic influenza Antiviral and Vaccine Effectiveness (EAVE):use of a unique community and laboratory national data-linked cohort study

After the introduction of any new pandemic influenza, population-level surveillance and rapid assessment of the effectiveness of a new vaccination will be required to ensure that it is targeted to those at increased risk of serious illness or death from influenza.  We aimed to build a pandemic influenza reporting platform that will determine, once a new pandemic is under way: the uptake and effectiveness of any new pandemic vaccine or any protective effect conferred by antiviral drugs once available; the clinical attack rate of pandemic influenza; and the existence of protection provided by previous exposure to, and vaccination from, A/H1N1 pandemic or seasonal influenza/identification of susceptible groups.  An observational cohort and test-negative study design will be used (post pandemic).  A national linkage of patient-level general practice data from 41 Practice Team Information general practices, hospitalisation and death certification, virological swab and serology-linked data.  We will study a nationally representative sample of the Scottish population comprising 300,000 patients. Confirmation of influenza using reverse transcription polymerase chain reaction and, in a subset of the population, serology.  Future available pandemic influenza vaccination and antivirals will be evaluated.  To build a reporting platform tailored towards the evaluation of pandemic influenza vaccination. This system will rapidly measure vaccine effectiveness (VE), adjusting for confounders, estimated by determining laboratory-confirmed influenza; influenza-related morbidity and mortality, including general practice influenza-like illnesses (ILIs); and hospitalisation and death from influenza and pneumonia. Once a validated haemagglutination inhibition assay has been developed (and prior to the introduction of any vaccination), cross-reactivity with previous exposure to A/H1N1 or A/H1N1 vaccination, other pandemic influenza or other seasonal influenza vaccination or exposure will be measured.  A new sentinel system, capable of rapidly determining the estimated incidence of pandemic influenza, and pandemic influenza vaccine and antiviral uptake and effectiveness in preventing influenza and influenza-related clinical outcomes, has been created. We have all of the required regulatory approvals to allow rapid activation of the sentinel systems in the event of a pandemic. Of the 41 practices expressing an interest in participating, 40 have completed all of the necessary paperwork to take part in the reporting platform. The data extraction tool has been installed in these practices. Data extraction and deterministic linkage systems have been tested. Four biochemistry laboratories have been recruited, and systems for serology collection and linkage of samples to general practice data have been put in place. Future work: The reporting platform has been set up and is ready to be activated in the event of any pandemic of influenza. Building on this infrastructure, there is now the opportunity to extend the network of general practices to allow important subgroup analyses of VE (e.g. for patients with comorbidities, at risk of serious ILI) and to link to other data sources, in particular to test for maternal outcomes in pregnant patients

Missed opportunities to keep children safe? National survey of injury prevention activities of children’s centres

Objective: To ascertain the activities undertaken by children’s centres to prevent unintentional injuries in the under-fives and, in particular, the prevention of falls, poisoning and scalds. Design: A questionnaire was posted to managers of 851 children’s centres, using stratified cluster sampling. The questionnaire included questions on injury prevention activities undertaken by the centre, knowledge and attitudes to injury prevention, partnership working, and barriers and facilitators to injury prevention. Setting: England. Results: A response rate of 61% was achieved. Most respondents (98%) agreed that children’s centres can be effective in preventing accidents. Over half of the respondents (59%) did not know whether there was an injury prevention group in their area, and 22% did not know whether there was a home safety equipment scheme. Only 12% knew the major cause of injury deaths in children under five. A variety of activities were being undertaken including one to one advice and issuing leaflets. However, for some important topics such as baby walkers and disposal of unwanted medicines, no advice was being provided in some areas. Lack of funding (52%) and lack of capacity (39%) were the most common reasons cited as barriers to injury prevention activities. Conclusion: Injury prevention is an important activity undertaken by children’s centres. Given their position in the heart of the community, their potential as an agency to prevent injuries has been highlighted and recommended. Further support and resource will be needed if they are to fully develop their potential in preventing unintentional injuries in the home