Parents and nurses during the immunization of children--where is the power? A conversation analysis.

BACKGROUND: Best practice for health care practitioners is considered patient-centred approaches which empower patients. Immunization of young children requires maintaining this approach while retaining professional management. OBJECTIVE: The objectives were to assess situations within the immunization event with discordance between health provider and caregiver and evaluate strategies used to empowering parents while obtaining the desired clinical outcome. METHODS: This was a qualitative study nested within a larger study of immunization rates in 124 randomly selected primary care practices. Interactions between immunizing practice nurses, caregivers and children were videotaped and transcribed and underwent conversation analysis. Six purposively sampled primary care practices in Auckland, New Zealand, served as the setting. The participants were eight practice nurses immunizing 10 children and their parents. Normative pattern of interactions and 'deviant cases' involving discordance between nurse and parent. RESULTS: A total of 168 minutes of video-recorded conversation from 10 immunization sessions provided strong 'typical' pattern and equally striking 'deviant cases'. Parents mostly treated nurses as 'experts' and accepted asymmetry of knowledge over medical matters. Nurses demonstrated skilful strategies in delineating their area of medical expertise from areas in which patients are expert-their knowledge of themselves and their children. CONCLUSION: While patient centredness and empowering patients are contemporary goals of primary health care delivery, these attributes are not precisely defined. Patients may wish to be informed, but many trust their health professionals to direct their decision making. Although health professionals may impart as much knowledge as they can, asymmetry of knowledge remains. However, patients hold expertise beyond their clinical situation in the social and economic world in which they live.

Aggressive acts and assaults in intimate relationships: towards an understanding of the literature.

Far more people in relationships are subjected to violent acts than those who receive injuries. The degree of damage sustained may not reflect the perpetrator's intent to deliberately harm a partner. Data documenting aggressive acts determines the population at risk and their prevention and early treatment requirements; whereas data focusing on harm and injury helps determine emergency medical and refuge services. Data from national crime surveys, police records, or clinical populations should not be generalized to the population at large. Even if men perpetrate the majority of serious partner attacks, addressing the issue of female violence will significantly reduce the overall level of domestic violence. Judicial, medical, and social services should take note that while male violence may be more problematic, violence is a relationship issue, not a male issue.

What is an 'intact' hymen? A critique of the literature.

The purpose of this study was to establish medico-legal guidelines based upon medical findings which support or refute allegations of sexual penetration, taking into account non-sexual explanations for positive physical findings. A review of the literature was undertaken to examine what has been determined about the range of usual findings which can be expected if the hymen has been penetrated. While a large body of literature is available on the topic, some findings are ambiguous, and further research is required to advance and clarify our knowledge base in these areas. In only a minority of non-acute cases can definitive statements be made as to whether an alleged molestation has occurred. A non-scarred hymen that will not admit a finger is 'intact'; a hymenal opening accommodating two fingers or a vaginal speculum, with evidence of a deficit or scarring at the lower pole, indicates past sexual or, possibly, non-sexual penetration. Other findings are not definitive and, at best, can estimate only relative probability of occurrence of penetration. Findings within the normal range should be presented as 'neither confirm nor deny abuse', not 'consistent with abuse'. Often, it is impossible to establish whether a hymen is 'intact' in regard to past sexual intercourse.

Parents and other relatives accused of sexual abuse on the basis of recovered memories: a New Zealand family survey.

AIM: To survey New Zealand families where an alleged perpetrator and/or other family member denies an accusation involving the childhood molestation of one family member by another, based on a memory recovered in adulthood. As the validity of such memories is crucial, our aim was to develop a profile of such families and to compare it with New Zealand epidemiological data. METHOD: Information was collected by questionnaire regarding family demographics, characteristics of the accuser, family life, events surrounding and leading up to the accusations, consequences of the accusations and details of the accuser's current life situation. The 73 subjects included fathers, mothers, siblings and other relatives of the accusing adults. RESULTS: Most accusers were highly educated white women, frequently first born or older children from relatively large families, statistically different proportions from those expected. Many accusations involved events of low base-rate probability including satanic ritual abuse. Proportions differed from those of another New Zealand prevalence survey of 1019 18-year-olds in almost every way. CONCLUSION: The data suggest that it is unlikely that many, if not most, of the memories of child sexual abuse recovered in adulthood are a true reflection of history. Memories recovered during therapy should be treated with respect as part of the patient's narrative truth, but not assumed to be factually accurate without corroborative evidence.

Can tampon use cause hymen changes in girls who have not had sexual intercourse? A review of the literature.

Since tampon availability has become ubiquitous, several authors have opined about their effect on the virginal hymen, but only one paper has scientifically addressed the subject of tampon use and clefts in the hymens of never-sexually-active adolescent girls. It naturally has become an authority used by the courts. The Emans et al. (1994) study asserts that 'for physicians testifying in court about sexual assault cases, complete clefts in adolescents cannot be attributed to prior tampon use'. On closer inspection, however, it appears that the authors have interpreted their statistical finding using a strict scientific convention (chi 2, P = 0.06 as not having statistical significance) that may mislead in a clinical or legal situation. Indeed, there is a definite possibility that tampon use compared to not having used tampons in their never-sexually-active sample was associated with an increased percentage of complete hymenal clefts (14% vs. 6%; P = 0.06). Nevertheless, clefts were found in both the sexually active and the never-active groups: 20 of their 200 never-sexually-active subjects possessed complete hymenal clefts, as did only 84 of their 100 sexually active subjects. Caution should be used by all physicians asked to testify in courts regarding possible causes of a hymenal cleft.

Memory recovery and repression: what is the evidence?

Both the theory that traumatic childhood memories can be repressed, and the reliability of the techniques used to retrieve these memories are challenged in this paper. Questions are raised about the robustness of the theory and the literature that purports to provide scientific evidence for it. Evidence to this end is provided by the authors which surveyed New Zealand families in which one member had accused another (or others) of sexual abuse on the basis of recovered memories. It is shown that a number of these allegations involve very low probability events. Since memory repression theory is not currently scientifically substantiated it is argued that care needs to be taken in the mental health, legal and insurance compensation arenas. Memories recalled during therapy may be treated as metaphorical but, in the absence of corroborative evidence, should not be considered factually true. Clinicians who wish to use memory recovery techniques should inform patients of their experimental and controversial nature, point out adverse effects, and obtain consent before proceeding.

Medical evaluation of sexual assault findings in the Auckland region.

A five year retrospective study of medical findings in sexual assault is presented. Data from examinations of 109 children and 81 adults were analysed. Results indicate that those at highest risk of sexual assault are Maori girls and young women, who were just over a quarter of the cases seen, although only 8.7% of the Auckland city population. Pacific Island children also appear to be at increased risk (19% of child victims but only 10.9% of Auckland population). Over a third of the women raped were intoxicated with alcohol. It seems likely that drinking is an important factor in sexual assault. Children are usually abused by acquaintances or family (only 15% were stranger rape) and often in their own home. Over a third of adults were also assaulted in their own homes. Sexual assault victims are predominantly girls and young women. Only 7.3% were older than 30 years, although 37.7% of the Auckland female population is in this age group. Well over half the women raped were physically restrained and three quarters of them had signs of trauma on examination. A weapon was involved in nearly a quarter of the women. Medical findings will not often prove the assault, and only a minority of cases examined (28%) proceeded to court hearings.