Brief alcohol intervention and alcohol assessment do not influence alcohol use in injured patients treated in the emergency department: a randomized controlled clinical trial.

AIMS: To evaluate the effectiveness of brief alcohol intervention (BAI) in reducing alcohol use among hazardous drinkers treated in the emergency department (ED) after an injury; in addition it tests whether assessment of alcohol use without BAI is sufficient to reduce hazardous drinking. DESIGN: Randomized controlled clinical trial with 12-month follow-up conducted between January 2003 and June 2005. SETTING: Urban academic emergency department (ED) of the Lausanne University Hospital, Lausanne, Switzerland. PARTICIPANTS: A total of 5136 consecutive patients attending ED after an injury completed a seven-item general and a three-item alcohol screen and 1472 (28.7%) were positive for hazardous drinking according to the National Institute on Alcohol Abuse and Addiction definition; of these 987 (67.1%) were randomized into a BAI group (n = 310) or a control group with screening and assessment (n = 342) or a control group with screening only (n = 335) and then a total of 770 patients (78.0%) completed the 12-month follow-up procedures. INTERVENTION: A single 10-15-minute session of standardized BAI conducted by a trained research assistant. MEASUREMENTS: Percentage of participants who have changed to low-risk drinking at follow-up. FINDINGS: Data obtained at 12 months indicated that similar proportions were low-risk drinkers in BAI versus control groups with and without assessment (35.6%, 34.0%, 37.0%, respectively, P = 0.71). Data also indicated similar reductions in drinking frequency, quantity, binge drinking frequency and Alcohol Use Disorders Identification Test (AUDIT) scores across groups. All groups reported similar numbers of days hospitalized and numbers of medical consults in the last 12 months. A model including age groups, gender, AUDIT and injury severity scores indicated that BAI had no influence on the main alcohol use outcome. CONCLUSIONS: This study provides the evidence that a 10-15-minute BAI does not decrease alcohol use and health resource utilization in hazardous drinkers treated in the ED, and demonstrates that commonly found decreases in hazardous alcohol use in control groups cannot be attributed to the baseline alcohol assessment.

Qualit�� et ��conomies: vont-elles de pair [Quality and saving: do they run together?]

In the healthcare debate, it is often stated that better quality leads to savings. Quality systems lead to additional costs for setting up, running and external evaluations. In addition, suppression of implicit rationing leads to additional costs. On the other hand, they lead to savings by procedures simplification, improvement of patients' health state and quicker integration of new collaborators. It is then logical to imagine that financial incentives could improve quality. First evidences of pay for performances initiatives show a positive impact but also some limitations. Quality and savings are linked together and require all our attention.

Violence in primary care: prevalence and follow-up of victims.

BACKGROUND: Primary care physicians underestimate the prevalence of domestic violence and community violence. Victims are therefore at risk of further episodes of violence, with psychological and physical consequences. We used an interview to assess the prevalence of domestic and community violence among Swiss natives and foreigners. In a follow-up study, we evaluated the consequences of the interview for the positive patients. METHODS: We evaluated the prevalence of violence by use of a questionnaire in an interview, in an academic general internal medicine clinic in Switzerland. In a follow-up, we evaluated the consequences of the interview for positive patients. The participants were 38 residents and 446 consecutive patients. Questionnaires were presented in the principal language spoken by our patients. They addressed sociodemographics, present and past violence, the security or lack of security felt by victims of violence, and the patients' own violence. Between 3 and 6 months after the first interview, we did a follow-up of all patients who had reported domestic violence in the last year. RESULTS: Of the 366 patients included in the study, 36 (9.8%) reported being victims of physical violence during the last year (physicians identified only 4 patients out of the 36), and 34/366 (9.3%) reported being victims of psychological violence. Domestic violence was responsible for 67.3% of the cases, and community violence for 21.8%. In 10.9% of the cases, both forms of violence were found. Of 29 patients who reported being victims of domestic violence, 22 were found in the follow-up. The frequency of violence had diminished (4/22) or the violence had ceased (17/22). CONCLUSION: The prevalence of violence is high; domestic violence is more frequent than community violence. There was no statistically significant difference between the Swiss and foreign patients' responses related to the rates of violence. Patients in a currently violent relationship stated that participating in the study helped them and that the violence decreased or ceased a few months later.

A reabilita����o psicossocial no atendimento em sa��de mental: Estrat��gias em constru����o

This study aims to identify the representations about Psychosocial Rehabilitation by Mental Health professionals working in open services, and also the difficulties they have met in the process of turning the care effective for the population. The study uses a qualitative methodology, collecting data by means of semistructured interviews with 15 subjects. The professionals identify the rehabilitation process as complex, meeting several obstacles and requiring their dedication and a flexible attitude to achieve the expected results.

A identidade do agente comunit��rio de sa��de: Uma abordagem fenomenol��gica

The structure of Brazil's National Health System (SUS) is being firmed up through programs adding a new element to its multi-professional healthcare teams: Community Healthcare Agents. This study examines psycho-social factors that are significant for the construction of this identity, from the standpoint of these Community Healthcare Agents, using the hermeneutic phenomenology of Paul Ricoeur as its reference methodology. The subjects of this survey were seven Community Healthcare Agents who were asked during interviews (with informed consent and after approval by the Research Ethics Committee) to: 'Tell me about your experience as Community Healthcare Agent'. The analysis of their replies indicated the following topics: previous experience; capacity-building for the job; bonding; building up expertise; gratifying experience; feelings of power(lessness); communications; daily work routines, personal growth; criticisms of the institution; user-agent experiences; and insertion into the social reality. The overall analysis disclosed the phenomenon through the convergence and divergence of the grouping of these topics, viewed from the standpoint of these Community Healthcare Agents and the psycho-social aspects constructing their identity.

Childhood trauma in substance use disorder and depression: An analysis by gender among a Brazilian clinical sample

Objective: In this study, we compared the frequency and intensity of childhood traumas in alcohol- or other drug-dependent patients, in patients with depression, and in a control group without psychiatric diagnoses. Methods: The study had a retrospective design of a clinical sample of men and women from the groups listed above. They were evaluated by the same standardized instrument: the Childhood Trauma Questionnaire.. Results: A higher frequency and intensity of emotional, physical, and sexual abuse were found in alcohol- and other drug-dependent patients than in patients with depression, who, in turn, presented significantly higher proportions than the control group. In all of the cases, the frequency was higher among women than men. Conclusion: Because of the high frequency and intensity of childhood traumas among alcohol- or other drug-dependent patients and depressed patients, the assessment of problems due to childhood traumas among these patients is essential to a better understanding of the etiology of those disorders and to their treatment. �� 2010 Elsevier Ltd. All rights reserved.

Express��es utilizadas por familiares ao relatarem experi��ncias de conviver com o adoecimento mental

OBJETIVO: Identificar as express��es usadas por familiares para descrever a experi��ncia de conviver com o adoecimento mental. M��TODOS: Tratase de pesquisa que realizou an��lise dos relatos de familiares por meio do software Analyse Lexicale par Contexte d'um Ensemble de Segments de Texte (ALCESTE), contendo metodologia de an��lise de dados qualitativos que se adapta a qualquer dom��nio de investiga����o, em que se pretenda tratar material textual. RESULTADOS: A an��lise realizada pelo ALCESTE forneceu quatro classes agrupadas duas a duas: Classe 2 -- in��cio da doen��a e Classe 4 -- in��cio do tratamento; Classe 1 -- conviv��ncia e Classe 3 - cotidiano. CONCLUS��O: Os momentos descritos pelos familiares foram identificados por express��es, palavras e termos usados pelos mesmos em suas narra����es. A principal contribui����o deste estudo foi trazer a linguagem dos familiares para descrever os momentos do adoecimento por meio de uma metodologia de an��lise mais distante do pesquisador.

Towards a hybrid method to categorize interruptions and activities in healthcare.

OBJECTIVE: Interruptions are known to have a negative impact on activity performance. Understanding how an interruption contributes to human error is limited because there is not a standard method for analyzing and classifying interruptions. Qualitative data are typically analyzed by either a deductive or an inductive method. Both methods have limitations. In this paper, a hybrid method was developed that integrates deductive and inductive methods for the categorization of activities and interruptions recorded during an ethnographic study of physicians and registered nurses in a Level One Trauma Center. Understanding the effects of interruptions is important for designing and evaluating informatics tools in particular as well as improving healthcare quality and patient safety in general. METHOD: The hybrid method was developed using a deductive a priori classification framework with the provision of adding new categories discovered inductively in the data. The inductive process utilized line-by-line coding and constant comparison as stated in Grounded Theory. RESULTS: The categories of activities and interruptions were organized into a three-tiered hierarchy of activity. Validity and reliability of the categories were tested by categorizing a medical error case external to the study. No new categories of interruptions were identified during analysis of the medical error case. CONCLUSIONS: Findings from this study provide evidence that the hybrid model of categorization is more complete than either a deductive or an inductive method alone. The hybrid method developed in this study provides the methodical support for understanding, analyzing, and managing interruptions and workflow.

The association of HIV counseling and testing with HIV risk behaviors in a random population-based survey in Kisumu, Kenya.

HIV testing has been promoted as a key HIV prevention strategy in low-resource settings, despite studies showing variable impact on risk behavior. We sought to examine rates of HIV testing and the association between testing and sexual risk behaviors in Kisumu, Kenya. Participants were interviewed about HIV testing and sexual risk behaviors. They then underwent HIV serologic testing. We found that 47% of women and 36% of men reported prior testing. Two-thirds of participants who tested HIV-positive in this study reported no prior HIV test. Women who had undergone recent testing were less likely to report high-risk behaviors than women who had never been tested; this was not seen among men. Although rates of HIV testing were higher than seen in previous studies, the majority of HIV-infected people were unaware of their status. Efforts should be made to increase HIV testing among this population.

"I don't know how you are" or indirect questioning in oncology interviews: an ongoing exploratory study

Background: The exploratory study is part of an evaluation of the pre-graduate teaching of communication skills (Lausanne Medical School). It is based on the data of a project highlighting the impact of individualized vs. group training for medicine students in breaking bad news to simulated patients who are diagnosed with cancer. The analysis of the video-taped interviews of the students (N=63) with the RIAS has shown a current usage of utterances such as I don't know if -you have any plans for the future / you have already heard about chemotherapy / ... or I don't know how -you are feeling today after this surgery / you like that all this stuff takes place / ...Aim: The present study questions the specificity of these assertive utterances used as questions (indirect), the specificity of their content, and their intentionality - specific vs. exploratory.Methods: The mentioned utterances are qualitatively analyzed (content analysis, intentionality analysis, etc).Results: 26 students (41%) used 1 to 6 times I don't know utterances during the interviews that contain 53 of such utterances in total. In contrast, they are atypical in an oncologist sample who conducted similar interviews (N=31; 4 oncologist used them 1 to 2 times). In more than half of the cases (29/53), simulated patients interpret I don't know questions as giving them a space to speak (open responses). Conclusions: The atypicality of the I don't know utterances in the oncologist sample may have linguistic explanations in terms of generational marker, but the specificity of the content suggests psychological explanations in terms of defense mechanism as well (marker of "toning down" or insecurity as regards the discussed topic).Keywords: Breaking bad news, communication skills, oncology, pre-graduate medical education, indirect questioning

How (not) to interview children : interviews with young children in sexual abuse investigations in Finland

The present thesis had two main objectives: The first was to assess how child sexual abuse (CSA) interviews in Finland are conducted through analysing the interviewing techniques applied and the language used by the interviewers, as well as to suggest ways to improve interviews if they were found to have deficiencies. The second main aim was to contribute to the growing research corpus concerning CSA interviews, in particular, by addressing how interviewers follow up information provided by the child, by analysing whether child health care professionals would use childadapted language, and by studying the kind of modifications in the verbal behaviour of interviewers and children that were associated with a) repeated interviews, b) a support person���s presence at the interview, and c) the use of anatomically detailed dolls. Two complementary samples of CSA interviews were analysed. The first one was composed of child interviews with 3-12-year-old children (N = 27) that had been considered problematic by lawyers or other involved professionals (Studies I and IV). The second sample consisted of unselected interviews (N = 43) with children aged 3 to 8 years conducted in a number of hospitals in different parts of the country (Studies II and III). Study I: The verbal interaction between interviewer and child was analysed in a sample of interviews that had been considered to be problematic by involved professionals. Results showed that interviewers used inappropriate questioning techniques, relying on option-posing, specific suggestive and unspecific suggestive questions to a significant extent, these comprising around 50% of all interviewer utterances. The proportion of invitations, which the research community recommends interviewers to rely on, was strikingly low. Invitations and directive utterances were associated with an increase in informative responses by the child in terms of response type, number of new details reported, as well as length of response. The opposite was true for option-posing and suggestive utterances. Longer questions by the interviewer (in number of words) often rendered no reply from the child, whereas shorter questions were followed by descriptive answers. Even after the child had provided an informative answer, interviewers failed to follow up the information in an adequate way and instead continued to rely on focused and leading questions. Study II: Due to the possible bias of the sample analysed in Study I, the most important analyses were rerun with the unselected sample and reported separately. Results were quite similar between the two studies, indicating that the problems observed in Study I, with interviewers relying on option-posing and suggestive questions to a significant extent, are likely to be general and not specific for those interviews. Even if suggestive questions were slightly less and invitations slightly more common in this sample than in the previous study, almost half of the interviewer questions were still optionposing or suggestive, and also in this sample, interviewers failed to follow up information by the child in a facilitating manner. Differentiating between judicial and contextual details showed that while facilitators, invitations, and directive utterances elicited more contextual than judicial details, the opposite was true for specific suggestive utterances. These results might be explained by the reluctance of children to describe sexual details related to the abuse events. Alternatively, they may also be due to children describing incorrect sexual details as a result of suggestive interviewing techniques. Study III: This study examined features of the language used by the interviewers. Interviewer utterances included multiple questions, long statements, complicated grammar and concepts, as well as unclear references to persons and situations. More than a fifth of the interviewer utterances were coded as belonging to at least one of these categories. The results suggest that even professionals who are experienced in interacting with children may have difficulties in using a child-sensitive language, adding to the pool of studies showing similar problems to occur in legal hearings with children conducted by lawyers. As children rarely comment on, or even recognise, their lack of comprehension, the use of a language that is too complex can have detrimental consequences for the outcomes of investigative interviews. Interviewers used different approaches to introduce the topic of abuse. While 15% of the children spontaneously addressed the topic of abuse, probably indicating that they felt confident with the interviewer and the situation, in almost 50% of the cases, the interviewer introduced the topic of abuse in a way that can be considered leading. Interviews were characterised by a lack of structure, apparent in frequent rapid switches of topic by the interviewer. This manner was associated with a decrease in the number of new details provided by the children. Study IV: This study analysed possible changes in the interview dynamics associated with repeated interviewing, the presence of a support person (related to the child), and the use of anatomically detailed (AD) dolls. Repeated interviewing, in combination with suggestive questions, has previously been found to seriously contaminate children���s accounts. In the present material, interviewers used significantly more suggestive utterances in the repeated condition, thus endangering the reliability of the children���s reports. Few studies have investigated the effects of a support person���s presence at the interview. The results of the present study showed that interviewers talked more and children provided less information when a support person was present. Supporting some earlier findings regarding the use of AD dolls, the present results showed that using AD dolls was associated with longer interviewer utterances and shorter, less responsive, and less detailed child responses. Interviewers used up to five times more unspecific suggestive utterances when dolls were used, for instance through repeatedly asking the child to show ���what really happened��� with the dolls. Conclusion: The results indicate that CSA interviews in Finland are not conducted in a manner that follows best practice as defined by the research community and as stated in a number of guidelines. When comparing these questioning strategies with the recommendations, which have been predominant in the field for more than ten years now, it can be concluded that the interviews analysed were conducted in a manner that undermines the possibility to elicit an uncontaminated and accurate narrative from the children. A particularly worrying finding was the fact that interviewers did not follow up relevant information by the children in an adequate way. A number of clinical implications can be drawn from the results, particularly concerning the need for improvement in the quality of CSA interviews. There is convincing research regarding how to improve CSA interviews, notably through training forensic child interviewers to use a structured interviewing protocol, and providing them with continuous supervision and feedback. Allocating appropriate resources to improve the quality of forensic child interviews is a matter of protecting the rights of all persons involved in CSA investigations, in particular those of the children.

Medical students are afraid to include abortion in their future practices : in-depth interviews in Maharastra, India

BACKGROUND: Unsafe abortions are estimated to cause eight per-cent of maternal mortality in India. Lack of providers, especially in rural areas, is one reason unsafe abortions take place despite decades of legal abortion. Education and training in reproductive health services has been shown to influence attitudes and increase chances that medical students will provide abortion care services in their future practice. To further explore previous findings about poor attitudes toward abortion among medical students in Maharastra, India, we conducted in-depth interviews with medical students in their final year of education. METHOD: We used a qualitative design conducting in-depth interviews with twenty-three medical students in Maharastra applying a topic guide. Data was organized using thematic analysis with an inductive approach. RESULTS: The participants described a fear to provide abortion in their future practice. They lacked understanding of the law and confused the legal regulation of abortion with the law governing gender biased sex selection, and concluded that abortion is illegal in Maharastra. The interviewed medical students' attitudes were supported by their experiences and perceptions from the clinical setting as well as traditions and norms in society. Medical abortion using mifepristone and misoprostol was believed to be unsafe and prohibited in Maharastra. The students perceived that nurse-midwives were knowledgeable in Sexual and Reproductive Health and many found that they could be trained to perform abortions in the future. CONCLUSIONS: To increase chances that medical students in Maharastra will perform abortion care services in their future practice, it is important to strengthen their confidence and knowledge through improved medical education including value clarification and clinical training.

Exploring types and functions of questions in police interviews

There is a proliferation of categorization schemes in the scientific literature that have mostly been developed from psychologists��� understanding of the nature of linguistic interactions. This has a led to problems in defining question types used by interviewers. Based on the principle that the overarching purpose of an interview is to elicit information and that questions can function both as actions in their own right and as vehicles for other actions, a Conversational Analysis approach was used to analyse a small number of police interviews. The analysis produced a different categorization of question types and, in particular, the conversational turns fell into two functional types: (i) Topic Initiation Questions and (ii) Topic Facilitation Questions. We argue that forensic interviewing requires a switch of focus from the ���words��� used by interviewers in question types to the ���function��� of conversational turns within interviews.

Da natureza do espa��o ao espa��o da natureza : reflex��es sobre a rela����o corpo-natureza em parque publicos urbanos

Universidade Estadual de Campinas. Faculdade de Educa����o F��sica