Family Practice Vol. 18, No. 2, 214-216
© Oxford University Press 2001
Barriers in the care of patients who have experienced a traumatic event: the perspective of general practice
Department of General Practice, ExTra, Research Institute for Extramural and Transmural Care, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands.
van den Akker M, Mol SSL, Metsemakers JFM, Dinant G-J and Knottnerus JA. Barriers in the care of patients who have experienced a traumatic event: the perspective of general practice. Family Practice 2001; 18: 214–216.
Received 2 February 2000; Revised 12 July 2000; Accepted 30 October 2000.
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Abstract |
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Background. Previous research has indicated that GPs encounter barriers in the care of patients who have experienced a traumatic event.
Objectives. The aims of the present study were to map barriers GPs encounter in the care of patients who experience a traumatic event and solutions for these barriers, and to estimate the influence of GP characteristics on the number of barriers experienced.
Methods. Telephone interviews were conducted among a sample of 500 Dutch GPs stratified by sex. Topics covered barriers in the care of victims of: accidents, incest in the past, ongoing physical or sexual abuse of adults, and ongoing physical or sexual abuse of children.
Results. The response rate was 44%. GPs are regularly confronted with patients who have experienced a traumatic event. GPs experience 10% barriers in care of patients who have difficulties getting over an accident, 13% in the care of incest victims, 16% in the care of adults who are physically or sexually abused, and 20% in the care of physically or sexually abused children. Most of the GPs recently updated their knowledge of care of victims of traumatic events, but still the majority feel in need of additional expert training.
Conclusion. GPs experience the greatest number of barriers in the care of children who are abused. GP characteristics were not related to the number of barriers. However, seeing more victims was related to fewer barriers. To facilitate GP care of victims of traumatic events, GP training and continuing medical education should focus especially on skills education regarding the detection and initial treatment of traumatic events of ongoing physical or sexual abuse.
Keywords. Abuse, barriers, GPs, patient care, victims, violence..
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Introduction |
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Estimates of the incidence and prevalence of traumatic events vary, but most reports agree on the fact that primary care workers only identify a small proportion of cases.1 However, a large proportion of GPs state that it is a primary task to recognize and treat victims of traumatic events.2 Barriers that hinder recognition and treatment of patients who have experienced a traumatic event have been identified, including factors related to both the doctors' knowledge and skills and the patients' presentation.3
The aim of this study is to gain more insight into the current knowledge and skills of Dutch GPs with regard to violent traumatic events, the barriers they experience when confronted with these patients, characteristics of GPs that are related to these barriers, and possibilities of improving patient care.
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Methods |
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Out of the ~7500 GPs registered in The Netherlands, a random sample of 500, stratified by sex (1:1), was addressed for a telephone interview. GPs who did not want to take part in the interview were asked to fill in a postal questionnaire.
GPs were interviewed about the estimated incidence of traumatic events in their own practice, and the need for guidelines and refresher courses on the subject. GPs were asked about barriers in care regarding accidents (exemplary for incidental violent events), ongoing physical and sexual abuse of a child, incest in the past, and ongoing physical and sexual abuse of an adult. The interview covered two types of events, the questionnaire four.
Analysis
Non-response was analysed using the chi-square test and the chi-square test for trend. Relative sum scores of barriers per subject were calculated and are reported as percentages (‘barrier scores’). Multiple linear regression analysis was used to establish the relationship between the barrier score (dependent variable) and GP characteristics (sex, age, practice type, years in practice, number of patients per year with a new event).
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Results |
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Response
The total response was 44%; 134 GPs provided information regarding patients who had difficulties getting over an accident and children being physically and sexually abused at present, 127 GPs answered questions about barriers in the care of patients who experienced incest in the past and ongoing physical or sexual abuse of an adult. There were no significant relationships between response and any of the GP characteristics.
Background characteristics of the participating GPs and the yearly number of patients who experience a new traumatic event are reported in Table 1
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Accidents
GPs reported few barriers in helping patients who have difficulties getting over an accident. Barriers that were mentioned most often were the type or number of other care providers to whom to refer patients (70%), insufficient knowledge of signs and symptoms of difficulties in coping with the accident (22%) and insufficient skills to start treatment (29%). In answer to an open question, additional problems concerned patient's attitude, co-ordination of different care providers, and problems with insurance and legal settlements.
The barrier score was 10%, with 63% of the GPs not experiencing any barriers (Table 2). An increasing number of patients was related to a decreasing barrier score; no relationship was found with GP characteristics sex, age, years in practice and practice type.
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Incest
The main barriers are insufficient type or number of care providers to refer to (61%), insufficient skills to raise the subject (27%) and to start treatment (42%), and insufficient knowledge of signs (29%). Additionally, reported problems concern the patient's family (the perpetrator being one's patient, the fear that disclosure disrupts the family), patients' attitude (difficulty discussing, unwillingness to co-operate in therapy, claiming against the GP), financial problems for patients (referrals not refunded by insurance) and insufficient knowledge about male victims.
The barrier score was 13%, with 59% not experiencing any barriers. Again, only seeing a higher number of victims was related to experiencing fewer barriers.
Ongoing physical or sexual abuse of adults
The most frequently mentioned barriers were insufficient possibilities of referral (57%), insufficient knowledge of signs of abuse (46%) and of acute danger (59%), and lack of skills to raise the subject (31%). The mean barrier score was 16%, 52% of the GPs reporting none. No relationship was found between the barrier score and the GP characteristics.
Ongoing physical or sexual abuse of a child
The main barriers reported were insufficient referral possibilities (57%), insufficient skills to confront parents with suspected abuse (52%) and to start treatment (62%), and lack of knowledge of signs of child abuse (42%) and of acute danger (48%). The barrier score, only related to the number of new cases, was 20%, 40% not reporting any difficulties.
How to improve care
GPs mentioned possibilities of improving care by: increasing the number and availability of specialized care givers and their co-operation with them, and consultation of expert colleagues. Furthermore, despite an upgrade of knowledge reported by two-thirds, GPs would like education about skills for recognition and initiation of treatment.
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Discussion |
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GPs experienced most barriers in caring for abused children. There were fewer barriers for events which were less taboo subjects (such as accidents); they are of a more organizational and financial nature. For events which were more taboo subjects, more emotional and attitudinal barriers were mentioned.
In contrast to previous studies,3–5 we found GP characteristics not to be related to the barriers. Only a higher number of new victims in a practice per year was related to a smaller number of barriers.
Our response rate was 44%. Possibly, participating GPs are more interested in and therefore more acquainted with the subject, implicating a possible underestimation of barriers found. While the magnitude of possible bias is unknown, it is reassuring that respondents and non-respondents did not differ with regard to demographic and practice characteristics.
Our figures show that helping people to cope with the aftermath of traumatic events is difficult for GPs. Although two-thirds of the GPs had updated their knowledge and/or skills on this subject during the previous 3 years, a majority stated that they are in need of extra training. As seeing more new victims of a traumatic event was the only characteristic related to a lower level of barriers experienced, the most effective education may be through role-playing or standardized patients. Furthermore, an additional relationship may exist: GPs who know a lot about the topic might see more patients because they are more alert to the problem.
Our results emphasize the importance of further training of GPs. The most urgent areas are detection, assessing signs of acute danger and initiating treatment in ongoing abuse.
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References |
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1 Mol S, Dinant GJ, Metsemakers JFM, Knottnerus JA. Incidentieverschillen van (gewelddadige) ingrijpende gebeurtenissen in landelijke registratiesystemen, enquetes in de bevolking en onderzoek onder huisartsen; een literatuuroverzicht [Differences in incidence of (violent) traumatic events in the national registration systems, population surveys and studies from family practice; a review of literature]. NTvG 1999; 143: 1308–1314.
2 Reid S, Glasser M. Primary care physician's recognition of and attitudes toward domestic violence. Acad Med 1997; 72: 51–53.[Web of Science][Medline]
3 Easteal P, Easteal S. Attitudes and practices of doctors toward spouse assault victims: an Australian study. Violence and Victims 1992; 7: 217–228.[Medline]
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Gulbrandsen P, Hjortdal P, Fugelli P. General practitioners' knowledge of their patients' psychosocial problems: multipractice questionnaire survey. Br Med J 1997; 314: 1014–1018.
5 Gremilion D, Kanof EP. Overcoming barriers to physician involvement in identifying and referring victims to domestic violence. Ann Emerg Med 1996; 27: 769–773.[Web of Science][Medline]
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