Child maltreatment: pathway to chronic and long-term conditions?

The manifesto Start Well, Live Better by the UK Faculty of Public Health (Start Well, Live Better-A Manifesto for the Public's Health. London: UK Faculty of Public Health, 2014) sets out 12 compelling priorities for the protection of people's health. The focus of this document is preventative, calling for a comprehensive strategy to target a wide-ranging set of challenges to public health; however, it fails to mention child maltreatment and its negative impact on long-term health outcomes. In this article, we explore the long-term negative consequences of child maltreatment and how these can be conceptually aligned with four different characteristics of long-term health conditions. We suggest that situating child maltreatment within a long-term conditions framework could have significant advantages and implications for practice, policy and research, by strengthening a commitment across disciplines to apply evidence-based principles linked with policy and evaluation and recognizing the chronic effects of maltreatment to concentrate public, professional and government awareness of the extent and impact of the issue. We argue that a public health approach is the most effective way of focusing preventative efforts on the long-term sequelae of child maltreatment and to foster cooperation in promoting children's rights to grow and develop in a safe and caring environment free from violence and abuse.

Priorities and strategies for improving disabled women's access to maternity services when they are affected by domestic abuse: a multi-method study using concept maps.

BACKGROUND: Domestic abuse is a significant public health issue. It occurs more frequently among disabled women than those without a disability and evidence suggests that a great deal of domestic abuse begins or worsens during pregnancy. All women and their infants are entitled to equal access to high quality maternity care. However, research has shown that disabled women who experience domestic abuse face numerous barriers to accessing care. The aim of the study was to identify the priority areas for improving access to maternity services for this group of women; develop strategies for improved access and utilisation; and explore the feasibility of implementing the identified strategies. METHODS: This multi-method study was the third and final part of a larger study conducted in the UK between 2012 and 2014. The study used a modified concept mapping approach and was theoretically underpinned by Andersen's model of healthcare use. Seven focus group interviews were conducted with a range of maternity care professionals (n = 45), incorporating quantitative and qualitative components. Participants ranked perceived barriers to women's access and utilisation of maternity services in order of priority using a 5-point Likert scale. Quantitative data exploration used descriptive and non-parametric analyses. In the qualitative component of each focus group, participants discussed the barriers and identified potential improvement strategies (and feasibility of implementing these). Qualitative data were analysed inductively using a framework analysis approach. RESULTS: The three most highly ranked barriers to women's access and utilisation of maternity services identified in the quantitative component were: 1) staff being unaware and not asking about domestic abuse and disability; 2) the impact of domestic abuse on women; 3) women's fear of disclosure. The top two priority strategies were: providing information about domestic abuse to all women and promoting non-judgemental staff attitude. These were also considered very feasible. The qualitative analysis identified a range of psychosocial and environmental barriers experienced by this group of women in accessing maternity care. Congruent with the quantitative results, the main themes were lack of awareness and fear of disclosure. Key strategies were identified as demystifying disclosure and creating physical spaces to facilitate disclosure. CONCLUSIONS: The study supports findings of previous research regarding the barriers that women face in accessing and utilising maternity services, particularly regarding the issue of disclosure. But the study provides new evidence on the perceived importance and feasibility of strategies to address such barriers. This is an important step in ensuring practice-based acceptability and ease with which improvement strategies might be implemented in maternity care settings.

Disabled women's experiences of accessing and utilising maternity services when they are affected by domestic abuse: a critical incident technique study.

BACKGROUND: Women and their babies are entitled to equal access to high quality maternity care. However, when women fit into two or more categories of vulnerability they can face multiple, compound barriers to accessing and utilising services. Disabled women are up to three times more likely to experience domestic abuse than non-disabled women. Domestic abuse may compromise health service access and utilisation and disabled people in general have suboptimal access to healthcare services. Despite this, little is known about the compounding effects of disability and domestic abuse on women's access to maternity care. METHODS: The aim of the study was to identify how women approach maternity care services, their expectations of services and whether they are able to get the type of care that they need and want. We conducted a qualitative, Critical Incident Technique study in Scotland. Theoretically we drew on Andersen's model of healthcare use. The model was congruent with our interest in women's intended/actual use of maternity services and the facilitators and barriers impacting their access to care. Data were generated during 2013 using one-to-one interviews. RESULTS: Five women took part and collectively reported 45 critical incidents relating to accessing and utilising maternity services. Mapped to the underpinning theoretical framework, our findings show how the four domains of attitudes; knowledge; social norms; and perceived control are important factors shaping maternity care experiences. CONCLUSIONS: Positive staff attitude and empowering women to have control over their own care is crucial in influencing women's access to and utilisation of maternity healthcare services. Moreover these are cyclical, with the consequences and outcomes of healthcare use becoming part of the enabling or disabling factors affecting future healthcare decisions.Further consideration needs to be given to the development of strategies to access and recruit women in these circumstances. This will provide an opportunity for under-represented and silenced voices to be heard.

Access and utilisation of maternity care for disabled women who experience domestic abuse: a systematic review.

BACKGROUND: Although disabled women are significantly more likely to experience domestic abuse during pregnancy than non-disabled women, very little is known about how maternity care access and utilisation is affected by the co-existence of disability and domestic abuse. This systematic review of the literature explored how domestic abuse impacts upon disabled women's access to maternity services. METHODS: Eleven articles were identified through a search of six electronic databases and data were analysed to identify: the factors that facilitate or compromise access to care; the consequences of inadequate care for pregnant women's health and wellbeing; and the effectiveness of existing strategies for improvement. RESULTS: Findings indicate that a mental health diagnosis, poor relationships with health professionals and environmental barriers can compromise women's utilisation of maternity services. Domestic abuse can both compromise, and catalyse, access to services and social support is a positive factor when accessing care. Delayed and inadequate care has adverse effects on women's physical and psychological health, however further research is required to fully explore the nature and extent of these consequences. Only one study identified strategies currently being used to improve access to services for disabled women experiencing abuse. CONCLUSIONS: Based upon the barriers and facilitators identified within the review, we suggest that future strategies for improvement should focus on: understanding women's reasons for accessing care; fostering positive relationships; being women-centred; promoting environmental accessibility; and improving the strength of the evidence base.

Older women living and coping with domestic violence.

Although domestic violence is seen as a serious public health issue for women worldwide, international evidence suggests that women aged over 50 who are victims are suffering in silence because the problem is often ignored by health professionals. More U.K. research is needed to identify the extent of the problem, and services to meet the needs of older women. This study aims to bridge this gap by gaining a deeper understanding of how 'older women' cope with domestic violence and how it affects their wellbeing. Eighteen older women who were currently, or had been in an abusive relationship were recruited. Semi-structured interview schedules were used to discuss the personal nature of DV and its effects on wellbeing, ways of coping and sources of support. Findings suggest that living in a domestically violent context has extremely negative effects on older women's wellbeing leading to severe anxiety and depression. Three-quarters of the women defined themselves as in 'very poor' mental and physical health and were using pathogenic coping mechanisms, such as excessive and long-term use of alcohol, prescription and non-prescription drugs and cigarettes. This negative coping increased the likelihood of these women experiencing addiction to drugs and alcohol dependence and endangered their health in the longer term. Our findings suggest that health professionals must receive appropriate education to gain knowledge and skills in order to deal effectively and support older women experiencing domestic violence.

Safeguarding children and public health: midwives' responsibilities.

AIM: Using a healthy settings framework, this study aims to compare and contrast how midwives working in either hospital or community settings are currently responding to the co-occurrence of domestic and child abuse; their perceived role and willingness to identify abuse; record keeping; reporting of suspected or definite cases of child abuse; and training received. METHODS: A survey questionnaire was sent to 861 hospital and community midwives throughout Northern Ireland, which resulted in 488 midwives completing the questionnaire, a 57% response rate. Comparisons were made using descriptive statistics and cross-tabulation and the questionnaire was validated using exploratory factor analysis. RESULTS: Community midwives reported receiving more training on domestic and child abuse. Although a high percentage of both hospital and community midwives acknowledged a link between domestic and child abuse, it was the community midwives who encountered more suspected and definite (p < 0.001) cases of child abuse. More community midwives reported being aware of the mechanisms for reporting child abuse. However, an important finding is that although 12% of community midwives encountered a 'definite' case of child abuse, only 2% reported the abuse, leaving a 10% gap between reporting and identifying definite cases of child abuse. Findings suggest that lack of education and training was a problem as only a quarter of hospital midwives reported to have received training on domestic violence and 40% on child abuse. This was significantly less than that received by community midwives, where the figures were 57% and 62%, respectively. CONCLUSION: Midwives need training on how to interact with abused mothers using non-coercive, supportive and empowering mechanisms. Many women may not spontaneously disclose the issues of child or domestic abuse in their lives, but often respond honestly to a sensitively asked question. This issue is important as only 13% of the sample actually asked a woman a direct question about domestic violence.

Recognizing the co-occurrence of domestic and child abuse: a comparison of community- and hospital-based midwives.

This study aimed to compare and contrast how midwives working in either hospital or community settings are currently responding to the co-occurrence of domestic and child abuse (CA), their perceived role and willingness to identify abuse, record keeping, reporting of suspected or definite cases of CA and training received. A survey questionnaire was sent to 861 hospital and community midwives throughout Northern Ireland which resulted in 488 midwives completing the questionnaire, leading to a 57% response rate. Comparisons were made using descriptive statistics and cross-tabulation, and the questionnaire was validated using exploratory factor analysis. Community midwives reported receiving more training on domestic and CA. Although a high percent of both hospital and community midwives acknowledged a link between domestic violence (DV) and CA, it was the community midwives who encountered more suspected and definite (P < 0.001) cases of CA. More community midwives reported to be aware of the mechanisms for reporting CA. However, an important finding is that although 12% of community midwives encountered a definite case of CA, only 2% reported the abuse, leaving a 10% gap between reporting and identifying definite cases of CA. Findings suggest that lack of education and training was a problem as only a quarter of hospital-based midwives reported to have received training on DV and 40% on CA. This was significantly less than that received by community midwives, as 57% received training on DV, and 62% on CA. The study suggests that midwives need training on how to interact with abused mothers using non-coercive, supportive and empowering mechanisms. Many women may not spontaneously disclose the issues of child or domestic abuse in their lives, but often respond honestly to a sensitively asked question. This issue is important as only 13% of the sample actually asked a woman a direct question about DV.

A healthy settings framework: an evaluation and comparison of midwives' responses to addressing domestic violence.

OBJECTIVES: to compare and contrast how midwives working in either hospital- or community-based settings address domestic violence by evaluating their views on: prevalence of domestic violence; their role in addressing domestic violence; the acceptability of routine enquiry; and barriers encountered in asking clients questions about violence and abuse in pregnancy. DESIGN: a postal survey questionnaire. SETTING: Northern Ireland. STUDY POPULATION: 983 hospital and community midwives. FINDINGS: overall, 488 midwives returned a completed questionnaire; a 57% response rate. Comparisons were made using descriptive, inferential statistics and cross-tabulation. Although there were significant differences between hospital- and community-based midwives in relation to domestic violence, both groups of midwives tended to underestimate its prevalence. KEY CONCLUSIONS: the findings suggest that midwives per se identify and respond to a fraction of the cases of domestic abuse in pregnancy, due to lack of confidence, education and training. This reinforces the need for both hospital and community midwives to gain further confidence and an understanding of the many psychosocial factors that surround domestic violence. IMPLICATIONS FOR PRACTICE: healthy settings theory can be used effectively to identify good practice with women who experience domestic violence. Effective investment for health care requires the gaps between hospital- and community-based practice to be bridged, and for work to be integrated.

Overcoming health inequalities: a participative evaluation framework fit for the task.

AIMS: Healthcare providers are confronted with the claim that the distribution of health and healthcare provision is inherently unfair. There is also a growing awareness that the tools and methodologies applied in tackling health inequalities require further development. Evaluations as well as interventions usually focus on population-based indicators, but do not always provide guidance for frontline service evaluation and delivery. That is why the evaluation framework presented here focuses on facilitating local service development, service provider and user involvement, and the adequate representation of different population groups. METHODS: A participative evaluation framework was constructed by drawing on six common success characteristics extrapolated from the published literature and policies on health inequalities. This framework was then applied to an intervention addressing women's psychosocial health needs in order to demonstrate its utility in practice. RESULTS: The framework provides healthcare professionals with an evidence-based tool for evaluating projects or programmes targeting health inequalities in ways that are responsive to local contexts and stakeholders. CONCLUSION: This participative evaluation framework supports the identification of meaningful psychosocial and contextual indicators for assessing the diverse health and social needs of service users. It uses multi-dimensional indicators to assess health and social care needs, to inform local service development, and to facilitate the exchange of knowledge between researchers, service providers, and service users. The inherent responsiveness enables rigorous yet flexible action on local health inequalities.

Recognizing and reporting child physical abuse: a survey of primary healthcare professionals.

AIM: This paper reports a study of the self-reported ability and behaviours of primary healthcare professionals in Northern Ireland to recognise child physical abuse. A secondary aim was to assess the educational and training needs of these professionals. BACKGROUND: In the United Kingdom, 7% of children suffer serious physical abuse by a parent or carer, and two children aged under 15 years die from abuse each week. Recognizing child physical abuse depends on the knowledge and skills of a variety of healthcare professionals. METHODS: A stratified random sample of 979 nurses, doctors, and dentists working in primary care in Northern Ireland were sent a postal questionnaire; 419 responded, giving a 43% response rate. The data were collected in 2002-2003. FINDINGS: In their working lives 60% (251) said that they had seen a suspicious child physical abuse case; however, only 47% (201) had reported a suspicious case to the authorities, leaving a 13% gap in reporting. Although 74% (310) of respondents were aware of some of the mechanisms for reporting child physical abuse, 79% (332) requested further education on this topic. Ability to recognize and willingness to report abuse cases discriminated between the three professional groups. Compared with doctors or dentists, community nurses were statistically significantly more likely to recognize and report suspicions of child physical abuse, and were the group most aware of child abuse issues and the most willing to become involved in abuse cases. CONCLUSIONS: The findings suggest that professional fears and anxieties and lack of knowledge act as barriers to recognizing and reporting abuse and that more specific education and support for primary care professionals is required.

The use of exploratory factor analysis in evaluating midwives' attitudes and stereotypical myths related to the identification and management of domestic violence in practice.

OBJECTIVE: to investigate the suitability of the 'Midwives' Attitudes to Domestic Violence Scale' for evaluating midwives' attitudes and stereotypical myths related to the identification and management of domestic violence in practice. Other objectives were to assess midwives' perceived role and experience of raising the issue of domestic violence with their clients, and to assess their perceived prevalence of domestic violence in their current practice. DESIGN: survey using a postal quesnionnaire. The questionnaire included a scale on attitudes to, and stereotypical myths surrounding, domestic violence within maternity care, and assessed demographic details. SETTING: Northern Ireland. PARTICIPANTS: 861 hospital and community midwives. FINDINGS: 488 midwives returned a completed questionnaire leading to a 57% response rate. Exploratory factor analysis of the 22-item attitude questionnaire produced three factors that accounted for 36% of the variance: namely, factor 1: non-susceptible to myths; factor 2: training and information; and factor 3: confidence. In general, as indicated by the mean summary score, most of the midwives (82%) did not subscribe to the numerous stereotypical myths surrounding domestic violence. Similarly, there was general agreement with issues associated with factor 2: training and information (mean summary score 74%). Importantly, however, factor 3, associated with confidence levels, indicated that, in general, midwives lacked confidence in dealing with the issues addressing domestic violence (mean summary score 33%). KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the measure provides a reliable method for assessing midwives' attitudes and training needs for identifying and dealing with domestic abuse. It may also serve to evaluate training and policy interventions in domestic violence.

Making equity a reality: oral health promotion in a psychiatric setting.

The aim of the study addresses the inequity in oral health status of long stay psychiatric patients, by promoting an inter-disciplinary team approach to oral health promotion. A cross sectional study using a modified version of the oral health assessment guide (OHAG) (Eilers et al 1988, Sjorgen & Nordstrom 2000) was used by a nurse who received training and calibration at the School of Dentistry, Queen's University, Belfast, to assess the oral health status of long stay psychiatric patients. The paper provides an overview of the literature relating to oral health within the context of holistic health. It highlights the non-random distribution of oral health problems amongst psychiatric patients and the potential contribution of health needs assessment to the realization of equity. The study focused on 65 long stay patients in a psychiatric hospital, mean length of time patients had been in the hospital was 25.6 years; nine patients had been living in the hospital between 40 and 65 years. The study achieved a response rate of 82% and identified that oral health of the psychiatric patients was generally very poor, compared to the general population. Only one patient did not have calculus, decayed or fractured teeth and 12 of the patients were endentate and there was a conspicuous absence of health promoting behaviours amongst the patient group. A case study is used to highlight the lived reality of the patients and the need for a holistic and an inter-disciplinary approach to oral health promotion, for patients residing in a psychiatric setting. This preliminary investigation highlights the benefits of systematic assessment of need: in this instance the use of the OHAG as a tool, for promoting equity based care by making visible the non random distribution of oral health problems amongst the patients.

How to recognise a 'quality' grounded theory research study.

BACKGROUND: The quality of a research study is a key issue for clinical practitioners committed to the delivery of 'best-practice' patient care. With the increasing use of grounded theory in nursing research, attention is now focusing on the quality of studies using this research methodology. Indeed, within the growing body of grounded theory in nursing some methodological problems are emerging that raise questions about the quality of the research. AIM: This paper recognises that clinical practitioners need to be critical readers of grounded theory research, so that they recognise 'quality' research studies and can develop their clinical practice based on sound research findings. CONCLUSION: Grounded theory should be viewed as a package of research methods that includes the use of concurrent data collection and constant comparative analysis, theoretical sampling and memoing, all of which can create an awareness and an appreciation of the scientific merit required of grounded theory research and promote quality standards relating to research practices in grounded theory methodology.

Cognitive dissonance and undergraduate nursing students' knowledge of, and attitudes about, smoking.

BACKGROUND: Smoking is a major cause of morbidity and mortality. Although nurses have an important role in health promotion, and are well placed to see the harmful effects of tobacco smoking, studies suggest that they smoke at much the same rate as the general population. AIM: The aim of this paper is to report a study examining undergraduate nursing students' knowledge about the impact of smoking on health, and their attitudes towards smokers and smoking. METHODS: The study took place in 2001, using a non-probability sample of 366 undergraduate nursing students from an Australian university. Participants completed the Smoking and Health Promotion instrument. Festinger's theory of cognitive dissonance provided an explanatory framework for the findings. RESULTS: Most respondents who were still smoking began the habit while in high school. Students had greater generic than specialized knowledge about the effects of smoking on health, and there was no significant difference between second and third year students' knowledge. Those who still smoked had less favourable attitudes towards smoking-related health promotion than those who had never smoked or stopped smoking. Non-smokers were more supportive of non-smokers' rights than those who continued to smoke, while those who had stopped smoking were undecided. There was minimal association between levels of knowledge and attitudes about being sensitive to smoking-related health risks. CONCLUSION: The findings have implications for both high school education and undergraduate nursing education, and for the recruitment of students to undergraduate nursing programmes. More attention needs to be given in undergraduate nursing programmes to smoking and smoking-related illnesses, and to nurses' role in smoking health promotion.