Health Care Providers In Response Research Articles

Ethical Awareness and Decision-making of Healthcare Providers in Response to Pandemic Influenza - Focused on Middle East Respiratory Symptom Coronavirus -

신종감염병 대응 시 의료인은 윤리적 갈등에 직면하게 된다. 본 연구는 2015년 메르스 확산 시 수도권 소재 5개의 대형병원에서 근무하는 의료인 227명을 대상으로 신종감염병 대응에 대한 윤리인식과 윤리적 의사결정의 수준을 파악하고자 시도되었다. 연구결과, 신종감염병 관련 경험에 있어, 대상자 중 31.3%가 ‘능동적 감시’나 ‘자가격리’ 경험이 있었으며, 직접 메르스 환자를 진료하거나 간호한 경우는 18.9%, 자녀가 등교 또는 등원을 거부 받은 경험은 자녀를 둔 대상자의 31.5%였다. 메르스 확산 시 의료인은 소속기관으로부터 정확한 정보 및 개인보호장비를 제공받는 것에 대해 중요하게 인식하였으며, 소속기관에 따라 윤리적 의사결정 수준에 있어 유의한 차이를 보였다. 결론적으로, 의료인은 신종감염병 대응과 관련하여 윤리적 이슈에 대해서는 민감하나, 감염의 위험성에도 불구 하고 윤리적 의사결정 4원칙에 충실한 것으로 나타났다. 본 연구결과를 바탕으로, 향후 의료인의 윤리적 측면을 구체적으로 측정할 도구 개발과 의료인을 위한 구체적인 신종감염병 대응지침 개발이 이어질 것을 제언한다.This study attempted to identify the level of ethical awareness and decision-making among healthcare providers (HCPs) in response to pandemic influenza. The data from 227 HCPs working at five hospitals in Seoul and suburbs were analyzed. During the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) in 2015, 31.3% of them had experiences in “active surveillance” or “home-isolation”; 18.9% provided direct care for MERS-CoV patients; and 31.1% of whose parents experienced “refusal” from their children’s kindergarten or school. They were aware of their rights to receive accurate information and to be protected by their hospitals, while there was a significant difference in the level of ethical decision-making across hospitals. In conclusion, HCPs were sensitive to ethical issues related to pandemic influenza, and were faithful to four principles of ethical decision-making. As a further study, developing a tool for measuring ethical aspects of HCPs and ethical guidelines in response to pandemic influenza are recommended

What affects pediatric healthcare providers to encourage receipt of routine childhood vaccinations? Results from the Northern District of Israel, 2016

BackgroundPediatric healthcare providers (HCPs) are a major resource which helps parents make decisions about their children's vaccinations. It is important to assess their behavior to encourage the receipt of routine vaccines. Objectives(1) To evaluate the knowledge level of and attitudes towards routine childhood vaccinations among pediatric HCPs; (2) To assess their behavior to encourage the receipt of routine vaccinations and associated predictors; (3) To examine their willingness to receive immunization training and to improve their skills to cope with vaccine-hesitant parents. Study design and settingsThis is a cross-sectional study among pediatric physicians and nurses working at primary clinics (curative service) and mother-child health clinics (preventive service) in Jewish localities in the Northern District of Israel. MethodsA structured, anonymous, self-administered questionnaire was used. ResultsThe study included 271 HCPs (response rate = 72.2%). An insufficient knowledge level about vaccines was demonstrated among participants (mean score: 5.2 ± 0.91 and 4.71 ± 1.21 points out of 6 in the preventive and curative services, respectively; p = 0.000). The overall attitude towards vaccinations was positive (mean score: 45.40 ± 5.98 and 42.95 ± 6.84 points out of 56 in the preventive and curative services, respectively; p = 0.002). The two predictors that were associated with the behavior of HCPs to encourage childhood vaccinations were workplace (preventive vs. curative service) and the number of parents encountered by the HCP who opposed or feared vaccines. No association was found between the behavior and the knowledge level and the attitudes. Of the HCPs, 79.3% were interested in immunization training and 66.1% in participating in workshops to improve their communication skills to cope with vaccine-hesitant parents. ConclusionsThere is a need to increase the commitment of HCPs to encourage parents to vaccinate their children with routine vaccines, to improve their knowledge about vaccines, and to provide them with communication tools to deal with vaccine-hesitant parents.

OBSERVATIONAL VIGNETTE STUDY TO EXAMINE PATIENT, HEALTHCARE PROVIDER, AND CAREGIVER PERCEIVED BURDEN OF ASTHMA-RELATED EXACERBATIONS

Introduction Little is known about how patients, caregivers and healthcare providers (HCPs) perceive the impact of asthma-related exacerbations. This study examined the burden of asthma-related exacerbations on patients’ lives from these different perspectives. Methods Web-based surveys were administered to a US sample of adult asthma patients, caregivers, and HCPs. Participants reviewed six vignettes describing two hypothetical asthma patients (25-year-old, single, unemployed; or 45-year-old, married, employed) experiencing mild, moderate, or severe exacerbations and rated the impact on eight measures: EuroQOL-5 Dimensions (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression), sleep, household costs, and medical costs. The proportions reporting “problems”, “impact”, or “burden” for each measure were calculated for each vignette; and patient responses were compared to caregiver and HCP responses. Results 302 asthma patients, 300 caregivers, and 300 HCPs completed the survey. Table 1 shows characteristics of these groups. No differences were detected in the proportions of perceived problems/impact/burden between patients and caregivers. Compared to HCPs, a greater proportion of patients reported problems with pain/discomfort related to mild and moderate exacerbations. HCPs were more likely to indicate sleep impact, mobility problems, and financial burden across all exacerbation severity levels; self-care problems with moderate and severe exacerbations; and problems with usual activities and anxiety/depression for severe exacerbations, as compared to patients. Conclusions Patients and caregivers share similar views on the impact of asthma exacerbations, yet HCPs may be less aware of patients' concerns about pain and discomfort related to exacerbations. Recognizing distinctions in perceptions may be an important consideration for optimizing patient care.

Health-care providers' perspectives on traditional and complementary alternative medicine of childhood cancer in Kenya.

Traditional and complementary alternative medicine (TCAM) use is rising globally. In many African countries, TCAM has been a way of life as the first and last resort remedy for many ailments, including cancer. Health-care providers (HCP) should address this need properly. This study explores HCP perspectives on TCAM in Kenya. This cross-sectional study used questionnaires. HCP involved in the care of children with cancer at a Kenyan academic hospital were interviewed. In total, 155 HCP (response rate 79%) participated. Only 18% of HCP were positive about TCAM use. However, most HCP (85%) use TCAM themselves. More doctors (90%) than other HCP (56%) think that chemotherapy can cure cancer (P<0.001).Thirty-three percent of HCP believe a combination of TCAM and chemotherapy is the best way to cure cancer, while 56% think that usefulness of TCAM is underestimated in conventional medicine. Self-prayer is regarded as most effective (58%) and safe (76%). Most harmful is witchcraft (80%). Most HCP (71%) think their knowledge about safety and efficacy of TCAM is inadequate. HCP think that their cancer patients use TCAM (97%) and that it is important that parents inform them about this (97%). However, only 5% of HCP always openly discuss TCAM with parents. HCP need to improve their knowledge of TCAM and facilitate open communication about TCAM with families so parents feel safe to discuss their interest in it.

Health-care providers' perspectives on health-insurance access, waiving procedures, and hospital detention practices in Kenya.

Patients at Kenyan public hospitals are detained if their families cannot pay their medical bills. Access to health insurance and waiving procedures to prevent detention may be limited. This study explores the perspectives of health-care providers (HCP) on health-insurance access, waiving procedures, and hospital detention practices. A self-administered structured questionnaire was completed by 104 HCP (response rate 78%) involved in childhood cancer care. The perspectives of respondents were as follows: all children with cancer should have health insurance according to 96% of HCP. After parents apply for health insurance, it takes too long before treatment costs are covered (67% agree). Patients with childhood cancer without health insurance have a higher chance of abandoning treatment (82% agree). Hospitals should waive bills of all children with cancer when parents have payment difficulties (69% agree). Waiving procedures take too long (75%). Parents are scared by waiving procedures and may decide never to return to the hospital again (68%). Poor families delay visiting the hospital because they fear hospital detention and first seek alternative treatment (92%). When poor families finally come to the hospital, the disease is in advanced stage already (94%). Parents sometimes have to abandon their detained child at the hospital if they cannot pay hospital bills (68%). Detention of children at the hospital if parents cannot pay their medical bills is not approved by 84% of HCP. HCP acknowledge that access to health insurance needs improvement and that waiving procedures contribute to treatment abandonment. By far, most HCP disapprove of hospital detention practices. These factors warrant urgent attention and adjustment.

Equalizing access to pandemic influenza vaccines through optimal allocation to public health distribution points.

Vaccines are arguably the most important means of pandemic influenza mitigation. However, as during the 2009 H1N1 pandemic, mass immunization with an effective vaccine may not begin until a pandemic is well underway. In the U.S., state-level public health agencies are responsible for quickly and fairly allocating vaccines as they become available to populations prioritized to receive vaccines. Allocation decisions can be ethically and logistically complex, given several vaccine types in limited and uncertain supply and given competing priority groups with distinct risk profiles and vaccine acceptabilities. We introduce a model for optimizing statewide allocation of multiple vaccine types to multiple priority groups, maximizing equal access. We assume a large fraction of available vaccines are distributed to healthcare providers based on their requests, and then optimize county-level allocation of the remaining doses to achieve equity. We have applied the model to the state of Texas, and incorporated it in a Web-based decision-support tool for the Texas Department of State Health Services (DSHS). Based on vaccine quantities delivered to registered healthcare providers in response to their requests during the 2009 H1N1 pandemic, we find that a relatively small cache of discretionary doses (DSHS reserved 6.8% in 2009) suffices to achieve equity across all counties in Texas.

Talking to healthcare providers about sex in later life: Findings from a qualitative study with older Australian men and women.

Healthcare providers (HCPs) can play an important role in supporting the sexual health of older adults; however, we know little about the experiences of older people in talking to HCPs about sex. This article examines older adults' experiences and perceptions of talking to HCPs about sex. Semi-structured interviews were conducted with 30 men and 23 women aged 60 and older recruited from a national, online survey of older Australians. Data were analysed using a thematic approach. Most participants did not discuss sex with their HCP, and their HCP did not raise it. For those who did discuss sex with a HCP, negative and stigmatising responses were common. Positive responses could facilitate access to sexual health care. Older people benefit when HCPs are proactive and ask about sexual health. Education in how to talk about sex with older people would also be beneficial for HCPs.

Health care provider responses to initial parental reports of autism spectrum disorder symptoms: results from a nationally representative sample

Health care provider (HCP) responses to initial parental report of autism spectrum disorder (ASD) symptoms were examined in relation to latency to diagnosis and child chronological age at diagnosis. Secondary data analyses were conducted for a sample of 1384 parents of children with ASD utilizing data from the National Survey of Children with Special Health Care Needs (NS-CSHCN, 2009-2010 National Survey of Children with Special Health Care Needs, 2009) and the Centers for Disease Control and Prevention Pathways to Diagnosis and Services (CDC PDS, Survey of pathways to diagnosis and services, 2011). Approximately 44% of the sample experienced predominantly delayed HCP responses, 38% experienced predominantly proactive responses, while the remaining 18% experienced a relatively even mix of delayed and proactive responses across HCPs. With regard to outcomes correlated with the type of HCP response, individuals exposed to proactive HCPs were diagnosed with ASD almost a year earlier for child chronological age than individuals exposed to mixed HCPs. This difference increased beyond a year between individuals receiving proactive HCPs versus individuals experiencing delayed HCPs. Finally, after controlling for socioeconomic status, parent-reported severity of ASD symptoms, and age at time of referral, proactive HCP was correlated with decreased time to diagnosis from parental first report of ASD symptoms. Results are discussed with regard to increasing proactive HCP responses to parental first concerns of ASD symptomology versus a mix or delayed responses.

P023: Code Resus - using a quality improvement approach to improve health care provider response during resuscitations

Introduction: In order to achieve the best possible outcomes for patients requiring resuscitation (PRRs) in the emergency department (ED), health care providers (HCPs) must provide an efficient, multi-disciplinary and coordinated response. A quality improvement (QI) project was undertaken to improve HCP response to PRRs at two tertiary care hospital EDs in Toronto. Methods: We conducted a before-and-after mixed-method survey to evaluate the perception of the adequacy of HCP response and clarity of HCP role when responding to PRRs. The results were compared using the Chi-square test. Qualitative responses to the first survey were also used to inform the development of the QI project. Through interviews of key stakeholders and with continuous input from front-line ED HCPs, a multi-disciplinary team modified the ED resuscitation protocol. This included standardized pre-hospital communication form with paramedics, ED-wide overhead announcement of ‘Code Resus’, dedicated HCPs assigned to respond to PRRs, and specific duties assigned to each responder. Change initiatives were reinforced through education and posters in the ED. Six months after implementation, a second survey was conducted to evaluate the sustained effects of the intervention. Results: Baseline measures indicated that 16 of 52 (30.8%) nurses surveyed believed their role was often or always apparent to themselves and others when they attended to a PRR (on a 5-point rating scale). This proportion increased to 35 of 55 (63.6%) nurses in the post-implementation survey (p &lt; 0.001). Regarding adequacy of the number of HCPs responding to PRRs, 17 of 39 (43.6%) physicians and 23 of 53 (43.4%) nurses surveyed thought the appropriate number of HCPs responded to PRRs; the remainder thought that there were too few or too many HCPs. In the post-implementation survey, 34 of 41 (82.9%) physicians (p &lt; 0.001) and 36 of 56 (64.3%) nurses (p = 0.029) surveyed felt that the appropriate number of HCPs attended to PRRs. Conclusion: Using a quality improvement approach, we identified and quantified perceived deficiencies in HCP response to PRRs in the ED. Through feedback-based modifications of the ED resuscitation protocol and by engaging HCP stakeholders, change initiatives were implemented to improve HCP response. As a result, this project achieved significant and sustained improvements in HCPs’ perceived response to PRRs.

Eliciting Personhood Within Clinical Practice: Effects on Patients, Families, and Health Care Providers

ContextFailure to acknowledge personhood is often the cause of patient and family dissatisfaction. We developed the Patient Dignity Question (PDQ) as a simple means of inquiring about personhood: “What do I need to know about you as a person to give you the best care possible?” ObjectivesThis study aimed to evaluate the impact of the PDQ on patients and families, evaluate its influence on health care providers (HCPs), and determine if HCP characteristics mediate receptivity to PDQ-elicited information. MethodsPalliative care patients or their family members were asked to respond to the PDQ. Responses were summarized, read to participants to ensure accuracy, and with permission, placed in their charts. Patient, family, and HCP responses to the PDQ were then elicited. ResultsA total of 126 participants (66 patients and 60 family members) responded to the PDQ; 99% indicated that the summaries were accurate, 97% permitted the summary to be placed in the chart, 93% felt that the information was important for HCPs to know, and 99% would recommend the PDQ for others. A total of 137 HCPs completed 293 evaluations of individual PDQs; 90% indicated that they learned something new from it, 64% that they were emotionally affected by it, 59% that it influenced their sense of empathy, and 44% that it influenced their care. HCP empathy, job satisfaction, having a meaningful life, and social support mediated responsiveness to PDQ-elicited information. ConclusionThe PDQ offers an effective way of eliciting personhood, enhancing patient, family, and HCP experience alike.

Acceptability of Sexual Health Discussion and Testing in the Pediatric Acute Care Setting

The objective of this study was to determine acceptability of sexual health discussion and testing among adolescents, parents, and health care providers (HCPs). We conducted a cross-sectional study of acute care patients (aged 14-19 years), parents, nurses, and physicians/nurse practitioners. Subjects rated sexual health discussion, sexually transmitted disease and pregnancy testing as acceptable/unacceptable and verbally explained their reasoning. Reasons were transcribed verbatim, coded, and analyzed. Agreement with individual adolescent responses was determined. Controlling for visit type, logistic regression was used to evaluate association between location and acceptance with odds ratios (ORs). Visits were categorized as reproductive/nonreproductive. Subjects included 127 adolescents, 90 parents, and 190 HCP responses. Mean adolescent age was 15.5 years; 57% were female; 43% reported previous intercourse; 43% were black, and 39% were white. Most visits (76%) were nonreproductive. Adolescents and parents were highly accepting of discussion and testing and were more accepting than HCPs. Acceptance was more likely for reproductive versus nonreproductive visits (P ≤ 0.05). Emergency department HCPs were more likely to accept discussion (OR, 2.8) and sexually transmitted disease testing (OR, 3.1) than urgent care HCPs. Acceptance themes among adolescents were comfort with system/HCP, confidentiality concerns, and desire for good health; among parents, acceptance themes were identification as a safe place for disclosure and desire for adolescent good health and information; and among HCPs, these were relevance to chief complaint and perception of appropriate care. In contrast to HCPs, adolescents and parents expressed broad support for sexual health discussion and testing, which may inform HCP practice to improve access to care.

Disparity in Perceptions of Disease, Treatment Effectiveness and Treatment Adherence Between Physicians and Patients with Myelodysplastic Syndromes (MDS)

AbstractAbstract 4949 Background and Methods:Previous studies have suggested that many patients (pts) with MDS have incomplete understanding of their disease and its treatment. In addition, contemporary drug therapies (tx) for MDS often require repeated treatment administration cycles to achieve clinical effect, and premature discontinuation or incomplete adherence may result in lack of benefit in pts who might have responded to a longer course of tx. In order to better understand physician and pt perceptions about MDS and decisions about continuing tx, we conducted two online surveys in February 2012: one for pts with MDS and one for healthcare providers (HCP) registered with the Aplastic Anemia & MDS International Foundation. A $50 Amazon gift card was offered to the first 200 respondents in each group; acceptance constituted consent. The protocol was approved by a central Institutional Review Board. Pt and HCP surveys consisted of 57 and 49 questions, respectively, assessing understanding of MDS, perceptions of specific tx, perceived barriers to tx adherence, and overall tx experience. Data were analyzed using proportions, means and medians, and comparisons between groups were calculated using Pearson’s Chi square where appropriate. Results:477 complete pt responses were received from 42 US States, as well as 120 complete HCP responses. Of pt responders, 247 (52%) were men, 63% were ≥60 years old, and the median time from MDS diagnosis was 5 years (range, 0–32 years). Because of low participation among other HCP groups, only physician (MD) responses are analyzed here. Of the 61 physicians (from 23 US states), 35 (57%) practice in an academic setting and 26 (43%) in the community setting; 48% reported they see 5–19 new MDS pts per year. Survey responses from academic and community physicians did not differ significantly.Only 10% of pts reported agreement that MDS is a “cancer”, compared to 59% of physicians (p<. 001). Only 29% of pts report that MDS is a “curable” condition, compared to 52% of physicians (p<. 001). Forty-two percent of patients had received at least one active tx: azacitidine (AZA, 58%), decitabine (DAC, 27%), lenalidomide (LEN, 35%) or hematopoetic stem cell transplant (HSCT, 26%) (total >100% due to multiple answers). Physicians and pt perceptions of specific active tx were significantly different, especially regarding quality of life (QOL), adverse events and impact of tx on pt activities. [Table 1]. Physicians viewed the potential benefits of active tx significantly greater than did pts, however pts perceived the actual tx experience more positively than doctors. [Table 2]Table 1Specific Tx – MD & Pt PerceptionsAZADACLENStatementsMDs n=55Pts n=115P-valueMDs n=23Pts n=54P-valueMDs n=40Pts n=69P-valueCan improve QOL89%63%P=.00185%65%NS80%56%P=.023Makes patients (me) feel better while taking it62%29%P<.00162%46%NS63%35%P=.009Has no side effects7%24%P=.0145%28%P=.0125%24%P=.019Makes regular activities difficult on tx days27%45%P=.03826%41%NS30%25%NSMade regular activities difficult for days following tx25%43%P=.04631%44%NS60%21%P<.001Table 2Tx for MDS – MD & Pt PerceptionsMD StatementsMDs N=61Pts n=200P-valuePt StatementsMy patients' lives are better because I prescribed tx95%79%P=.007My life is better because I received txMy patients are glad they have received tx93%82%P=.049I'm glad I had the txTx cured my patients' MDS44%25%P=.005The tx cured my MDSTx is uneventful16%34%P=.016Tx was uneventfulGetting tx is “easy”21%51%P<.001Getting tx was “easy”Sixty-nine percent of physicians reported recommending stopping tx prior to the completion of a planned tx course, most commonly due to adverse events and the burden of therapy outweighing benefit. [Table 3]Table 3:Barriers to Adherence/Reasons for Discontinuation – MD & Pt PerceptionsStatements (pt)MDs n=42Pts n=116P-valueBurden of tx outweighed benefit to pt (me)69%35%P<.001Burden of tx was too great on the family/caregiver50%23%P=.002Patient fatigue was too great to continue60%33%P=.004Tx made the patient (me) feel too sick to continue79%33%P<.001Tx side effects interfered with the pt's (my) regular activities74%35%P<.001 Conclusion:Physicians and pts with MDS have disparate views of MDS characteristics and the value and limitations of tx for MDS. Improved communication and education may increase understanding of disease and achieve better results, including greater treatment adherence. Disclosures:Huber:Celgene: Research Funding, This study was funded by an unrestricted grant from Celgene to the AA&MDS IF. Other. Dennison:Celgene: Research Funding.

Text Messaging as a Strategy to Address the Limits of Audio-Based Communication During Mass-Gathering Events with High Ambient Noise

The provision of medical care in environments with high levels of ambient noise (HLAN), such as concerts or sporting events, presents unique communication challenges. Audio transmissions can be incomprehensible to the receivers. Text-based communications may be a valuable primary and/or secondary means of communication in this type of setting. To evaluate the usability of text-based communications in parallel with standard two-way radio communications during mass-gathering (MG) events in the context of HLAN. This Canadian study used outcome survey methods to evaluate the performance of communication devices during MG events. Ten standard commercially available handheld smart phones loaded with basic voice and data plans were assigned to health care providers (HCPs) for use as an adjunct to the medical team's typical radio-based communication. Common text messaging and chat platforms were trialed. Both efficacy and provider satisfaction were evaluated. During a 23-month period, the smart phones were deployed at 17 events with HLAN for a total of 40 event days or approximately 460 hours of active use. Survey responses from health care providers (177) and dispatchers (26) were analyzed. The response rate was unknown due to the method of recruitment. Of the 155 HCP responses to the question measuring difficulty of communication in environments with HLAN, 68.4% agreed that they "occasionally" or "frequently" found it difficult to clearly understand voice communications via two-way radio. Similarly, of the 23 dispatcher responses to the same item, 65.2% of the responses indicated that "occasionally" or "frequently" HLAN negatively affected the ability to communicate clearly with team members. Of the 168 HCP responses to the item assessing whether text-based communication improved the ability to understand and respond to calls when compared to radio alone, 86.3% "agreed" or "strongly agreed" that this was the case. The dispatcher responses (n = 21) to the same item also "agreed" or "strongly agreed" that this was the case 95.5% of the time. CONCLUSION The use of smart phone technology for text-based communications is a practical and feasible tool for MG events and should be explored further. Multiple, reliable, discrete forms of communication technology are pivotal to executing effective on-site medical and disaster responses.

Emergency Preparedness for Home Healthcare Providers

Unfortunately, disasters occur. We cannot always know the effects ahead of time, but we do know that lives can be lost, property damaged, and public health and home care agencies may not be able to provide the normal standard of care. Studies have shown that disaster preparedness content is limited in U.S. nursing programs (). Given the magnitude of recent natural disasters, such as the Japanese earthquake and tsunami in 2011, these findings are alarming. The increasing demands on healthcare providers in response to emergencies force home healthcare clinicians to identify their roles and responsibilities in emergency preparedness. This article discusses 1 model of disaster response and the role of the home healthcare provider at each stage. It further guides home healthcare nurses in creating a personal and professional plan, enabling them to understand how to minimize the impact of disasters and address the needs of their patients and those close to them.

Stress, coping, and mental health‐seeking behaviors: Gender differences in OEF/OIF health care providers

Health care providers (HCPs) are often placed in positions of heightened stress when serving in military operations. As military HCPs have a large number of female providers, there is a concern that gender may influence both risk and resiliency within the health care provider subgroup. The purpose of this secondary analysis of the 2005 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel (data collected April through August 2005) is to describe stress, coping, and health-seeking behaviors of Operation Enduring Freedom and Operation Iraqi Freedom deployed military health care providers and the role gender may have for both health care officers and specialists. Female HCP responses indicate the lives of these women are significantly impacted by their family responsibilities. Reluctance of females to seek mental health care is concerning with perhaps more concern over career than personal well-being. Findings included (a) concern about performance, odds ratio (OR) = 1.86, 95% confidence interval (CI) [0.43, 8.12] for enlisted females, OR = 2.83, 95% CI [0.31, 25.66] for female officers; (b) problems with money, OR = 1.6 CI [0.69, 3.7] for enlisted females; (c) having a drink to cope, OR = 3.26, 95% CI [0.22, 48.68] for enlisted females; and (d) damage military career to seek mental health care, OR = 1.78, 95% CI [0.59, 5.39] for female officers. Results indicate needed provider awareness concerning mental health-seeking behavior and sensitivity toward gender differences that contribute to unique manifestations of operational stress outcomes.

Falls in Multiple Sclerosis

To examine incidence, associated factors, and health care provider (HCP) response to falls in persons with multiple sclerosis (MS). Cross-sectional retrospective design. Community setting. Four hundred seventy-four persons with MS. Mailed survey questionnaire examined incidence, risk factors, and HCP response to falls in persons with MS who were dwelling in the community. Univariate and multiple ordinal regression analysis identified variables associated with single and multiple falls. Falls, causes and perceived reasons for falls, and HCP response. A total of 265 participants (58.2%) reported one or more falls in the previous 6 months, and 58.5% of falls were medically injurious. Trips/slips while walking accounted for 48% of falls. Factors associated with falls included use of a cane or walker (odds ratio [OR] 2.62; 95% confidence interval [CI] 1.66-4.14), income <$25,000 (OR 1.85; 95% CI 1.13-3.04), balance problems (OR 1.28; 95% CI 1.11-1.49), and leg weakness (OR 1.26; 95% CI 1.09-1.46). Fifty-one percent of those who fell (135/265) reported speaking to an HCP about their falls; recommended strategies included safety strategies (53.2%), use of gait assistive devices (42.1%), exercise/balance training (22.2%), and home modifications (16.6%). Factors associated with falls in persons with MS are similar to those in other populations with neurologic diseases. Despite the high incidence of falls, fewer than 50% of people with MS receive information about prevention of falls from an HCP.

Irritable bowel syndrome patients' perspectives on their relationships with healthcare providers

Objective. The objective of this qualitative study was to examine patients' perspectives on their relationships with healthcare providers (HCPs) as communicated in their expressive writings about irritable bowel syndrome (IBS). Methods. As part of a large national online study, IBS patients were asked to: (a) write expressively about their IBS illness experience for 30 min/day for four consecutive days and (b) answer the question, “What is the most important thing your HCP can do to maximize his/her relationship with you?” A key word search was used to identify comments that mentioned the words “doctor,” “doc,” “physician,” “MD,” “gastroenterologist,” “nurse,” “nurse practitioner,” or “physician assistant” in the 228 expressive writings completed by the first 57 participants (four writings for each subject). Analyses of the comments about the patient–HCP relationship and responses to the above question were performed by the authors who identified themes and their frequencies over several sessions using a quantitative content analysis method. Results. We report the results of the first 57 subjects who participated in the study. Subjects' mean age was 41.1 (± 12.7) years, gender was 82% female, 98% had seen an MD for IBS, 58% had IBS <10 years, with mild/moderate disease severity (IBS severity scale (IBSSS) 190.6 + 45.55), and IBS-quality of life (QOL; 62.7.3 + 21.58). Of the 57 subjects who wrote expressively about their experiences related to IBS, 40 (70%) wrote about their relationships with their HCPs in at least one of their four writings. Of the 197 relationship comments about HCPs made in a total of 84 writings, 106 (54%) were categorized as “negative,” 22 (11%) as “positive,” and 69 (35%) comments were categorized as “neutral mentions.” The top five themes identified were: “I need more empathy and listening from my HCP about how much IBS affects my life” (27%), “Nothing my HCP does helps my IBS” (25%), “My HCP has been helpful and reassuring” (17%), “My HCP thinks I'm crazy” (8%), and “I don't trust my HCP” (5%). Forty-nine (86%) subjects answered the question regarding maximizing the relationship with their HCP, with 53% reporting that listening, empathy, and providing education were the most important factors for maximizing the relationship. Conclusion. Our results demonstrate that the patient–HCP relationship is central to patients' illness experience. The majority of our study subjects viewed their relationships with HCPs negatively, with major concerns relating to being heard and receiving empathy. The study findings highlight the need for improved patient–HCP communication. Further research utilizing novel modalities, such as expressive writing, in eliciting patient information and perspectives, may provide valuable educational tools.

Challenges in Understanding Functional Decline, Prognosis, and Transitions in Advanced Illness

This article has 2 purposes: to inform the health care provider's response to the common question asked by older adults with advancing illness, “How long do I have?” and to provide caregivers with a framework which can guide provision of care in advancing illness. Both purposes are addressed by exploring 3 major concepts associated with declining functional ability: (1) common functional changes and strategies to identify and manage these changes, (2) the extent to which prognostic tools provide insight for the prediction of rate of decline, and (3) the transitions in the focus of care that are required with advancing disease. Although the article is focused on the residential care setting the concepts examined can be applied more broadly to other practice settings such as palliative care. Declining functional ability is a common feature of the journey toward end of life. Irreversible decline in function is frequently accompanied by the resident and family's need to understand the probable duration of survival and the caregiver's need to adjust priorities for care. To better inform the clinician's response to the question of “How long do I have?” prognostic tools which incorporate measurement and interpretation of declining function can be utilized to improve the ability to predict survival. A 10-step approach to formulating and discussing prognosis is presented to assist clinicians in predicting rate of decline and sharing difficult news. Finally, in recognition of how declining functional ability affects priorities for provision of care, a framework which advocates the shift in focus from function, to safety, and ultimately to comfort, is provided.

System Issues: Challenges to Intimate Partner Violence Screening and Intervention

This ethnographic study examines the experiences of health care providers (HCPs) and advocates implementing intimate partner violence (IPV) screening and interventions in their health care organizations. Numerous policies and protocols have been developed to improve the response of HCPs to survivors of IPV. Typically studies have focused on HCPs with little attention to the role of organizations in providing care. The findings from this study highlight that even with IPV programs in place the organizational environment can contribute to suboptimal outcomes. Identified challenges included time constraints, organizational expectations for increased productivity, and dwindling organizational support and services for IPV. With the continuing debate regarding universal screening, this study illuminates the need for clinicians to have a supportive clinical environment and resources for IPV screening and intervention.

The impact of intimate partner violence on women's reproductive health and pregnancy outcome

SummaryThe aim of this study was to evaluate and elucidate the impact of intimate partner violence (IPV) on women's reproductive health and pregnancy outcomes taking into account data from various countries. The search of the literature was made in MEDLINE database service for the years 2002–2008. Original articles, reviews, surveys, clinical trials and investigations pertinent to the theme were considered for this review. The lifetime physical or sexual IPV or both varied from 15% to 71% in many countries. Adolescent violence, negative emotionality and quality of the relationship with the intimate partner were associated with genesis of IPV, besides demographic, social and structural difference in attitudes. IPV affected woman's physical and mental health, reduced sexual autonomy, increased risk for unintended pregnancy and multiple abortions. Risk for sexual assault decreased by 59% or 70% for women contacting the police or applying for a protection order, respectively. Quality of life of IPV victims was found significantly impaired. Women battered by IPV reported high levels of anxiety and depression that often led to alcohol and drug abuse. Violence on pregnant women significantly increased risk for low birth weight infants, pre-term delivery and neonatal death and also affected breast-feeding postpartum. Women preferred an active role to be played by healthcare providers in response to IPV disclosure. Gynaecologists reported interventions for the patient disclosing IPV and provided treatment for their physical and emotional complaints. Educating and empowering women and upgrading their socioeconomic status may abate the incidence of IPV. Women should also seek protection against IPV.