Knowledge, attitudes, and beliefs of Emergency Care Practitioners to victims of domestic violence in the Western Cape.

Thesis (M.PH.)-University of KwaZulu-Natal, 2006.PURPOSE. Domestic violence has a significant prevalence in the world, and certainly in South Africa, yet Emergency Care Practitioner (ECP) training and practice does not have any particular focus on domestic violence intervention. The absence of any clear response protocol to domestic violence in a Health Professions Council of South Africa (HPCSA) regulated profession, suggests the reliance on health practitioner discretion in this regard. This is problematic as the profession is male dominated and focused on tertiary levels of care. ECP's may be positioned to screen for abuse early, yet there is no evidence of success or failure in this endeavour. This study aimed to ascertain what the prevailing ECP knowledge, attitudes and beliefs around domestic violence in the Western Cape are, so that any factors preventing or nurturing early identification and appropriate treatment of domestic violence may be mitigated or supported respectively. METHODS. Health Professions Council of South Africa (HPCSA) registered ECP's in the Provincial Government- Western Cape (PGWC)- Emergency Medical Service (EMS) Metropole region voluntarily completed a questionnaire. MAJOR RESULTS. Only 49% of respondents could correctly define domestic violence. ECP qualification was associated with domestic violence definition in that Basic ECP's were more likely to incorrectly define domestic violence than the advanced ECP's. Eighty-one percent of respondents recognized less than thirty domestic violence calls in the preceding six months. The majority of ECP's (89%) experienced no special handling of domestic violence victims. No significant association could be found (Chi-Square: p = 0.2298) between qualification and knowledge of domestic violence laws. An ECP's qualification is no predictor of his/her legal knowledge about abuse. Qualification could also not be positively associated with the referral of victims, although the majority of practitioners of all qualifications (78%), had only sometimes referred victims or not at all. The majority of respondents expressed inadequate assessment and management of domestic violence patients. The majority also indicated that their ECP training was inadequate in preparing them for domestic violence intervention. CONCLUSIONS DRAWN. The attitudes and beliefs of Emergency Care Practitioners elicited from this study suggest a poor level of understanding of the extent and nature of domestic violence. There is a probable low detection rate amongst the majority of ECP's. There exists harbouring of myths that may confound the implementation of a pre-hospital protocol for domestic violence management. There is an inadequacy of current ECP practice with respect to domestic violence crisis intervention with regards screening, management and referral. The EMS response to domestic violence should be congruent with an appropriate health sector response and should include universal screening (asking about domestic violence routinely); comprehensive physical and psychological care for those patients who disclose abuse; a safety assessment and safety plan; the documentation of past and present incidents of abuse; the provision of information about patients rights and the domestic violence act; and referral to appropriate resources. The ECP curriculum should emphasise the particular nature and treatment of domestic violence. The study supports the need for the introduction of a comprehensive ECP protocol, in training and in practice. This information should prove useful to all who attempt to design educational programmes and clinical strategies to address this public health issue

Scripting of Domestic-violence Simulations to Improve Prehospital Emergency-care Diagnostic Probity and Healthcare Responsiveness in Low- to Middle-income Countries

The global occurrence of domestic violence is a disturbing problem which leaves both victims and   interventionists with a sense of helplessness. Emergency-care providers have been identified as a critical contact point for victims. The interlude between the act of violence and the victim’s hospitalisation provides opportunities for screening, medical care and appropriate referral (primary, secondary and tertiary prevention). Both the current training of emergency-care providers and research on the domestic-violence response are unjustifiably minimal. Simulation training is not foreign to prehospital emergency care. However, the use of domestic-violence-related scripted scenarios (to promote diagnostic probity) is novel. Therefore, the primary research question was: How does the scripting of evidence-informed simulations of domestic-violence cases enhance practitioner responsiveness and patient safety among prehospital emergency-care students? The paradigm and methodology for this qualitative study was social constructivism and grounded theory respectively. The data collection comprised a literature review, focus-group discussions and participant observation during patient simulations. The data was analysed through the method of constant comparative analysis. It was found that the scripting of simulations with the use of peer-based training may be an effective method of achieving improved responsivity to domestic violence. Traditional EMS training with expensive manikins may not be as effective for this purpose, as students require a level of feedback and fidelity through which they can convey their empathy and history-taking skills. Further research should be conducted to determine the most effective methods for assessing standardised domestic-violence patient simulations

Keeping our heads above water : a systematic review of fatal drowning in South Africa

BACKGROUND: Drowning is defined as the process of experiencing respiratory impairment from submersion/immersion in liquid, and can have one of three outcomes - no morbidity, morbidity or mortality. The World Health Organization African region accounts for approximately 20% of global drowning, with a drowning mortality rate of 13.1 per 100 000 population. The strategic implementation of intervention programmes driven by evidence-based decisions is of prime importance in resource-limited settings such as South Africa (SA). OBJECTIVE: To review the available epidemiological data on fatal drowning in SA in order to identify gaps in the current knowledge base and priority intervention areas. METHODS: A systematic review of published literature was conducted to review the available epidemiological data describing fatal drowning in SA. In addition, an internet search for grey literature, including technical reports, describing SA fatal drowning epidemiology was conducted. RESULTS: A total of 13 published research articles and 27 reports obtained through a grey literature search met the inclusion and exclusion criteria. These 40 articles and reports covered data collection periods between 1995 and 2016, and were largely focused on urban settings. The fatal drowning burden in SA is stable at approximately 3.0 per 100 000 population, but is increasing as a proportion of all non-natural deaths. Drowning mortality rates are high in children aged <15 years, particularly in those aged <5. CONCLUSIONS: This review suggests that SA drowning prevention initiatives are currently confined to the early stages of an effective injury prevention strategy. The distribution of mortality across age groups and drowning location differs substantially between urban centres and provinces. There is therefore a need for detailed drowning surveillance to monitor national trends and identify risk factors in all SA communities

A critical ethnographic study of discriminatory social practice during clinical practice in emergency medical care

Background: Post-apartheid, South Africa adopted an inclusive education system that was intended to be free of unfair discrimination. This qualitative study examines the experiences and perceptions of racial discrimination between Emergency Medical Care (EMC) students, clinical mentors, and patients within an Emergency Medical Service (EMS) during clinical practice. Understanding the nature of such discrimination is critical for redress. Methods: Within the conceptual framework of Critical Race Theory, critical ethnographic methodology explored how discriminatory social practice manifests during clinical practice. Semi-structured interviews enabled thematic analysis. We purposively sampled 13 undergraduate EMC students and 5 Emergency Care (EC) providers. Results: EMC student participants reported experiences of racial and gender discrimination during work-integrated learning (WIL) as they were treated differently on the basis of race and gender. Language was used as an intentional barrier to isolate students from the patients during WIL because EC providers would intentionally speak in a language not understood by the student and failed to translate vital medical information about the case. This conduct prevented some students from engaging in clinical decision-making. Conclusions: Unfair discrimination within the pre-hospital setting have an impact on the learning opportunities of EMC students. Such practice violates basic human rights and has the potential to negatively affect the clinical management of patients, thus it has the potential to violate patient’s rights. This study confirms the existence of discriminatory practices during WIL which is usually unreported. The lack of a structured approach to redress the discrimination causes a lack of inclusivity and unequal access to clinical education in a public clinical platform

Paramedicine educators’ identity needs and impediments to professional emergence : A multiphase mixed-methods participatory approach

This research delves into how identity-needs and philosophies of paramedicine educators influence theoretical advancement and praxis in higher education. It examines the perceptions of paramedicine academics, their roles and the transitional challenges when moving from clinical practice to academia. It explores the potential of transformative pedagogy in fostering social consciousness, justice, and innovation. Challenges and benefits of a constructivist approach to paramedicine education and future-orientation is assessed. Employing a multiphase mixed-methods participatory approach, researchers reached consensus on the guided themes (Phase 1) for staff collaborative engagement (Phase 2) during the inaugural ‘Paramedicine Educators Forum’, which featured participation of academic leaders and staff from four universities and one jurisdictional ambulance service. The study unveils the intricate tapestry of paramedicine educators' identities and philosophies and their impact on theoretical advancements and practical applications in higher education. Conversations revolved around defining the role of paramedics in academia, the potential of transformative pedagogy, and the balance between producing competent paramedics whilst nurturing criticality. Discussions also addressed the shortcomings of current undergraduate degrees in preparing students for technological advancements and the potential for extended degree programs. The findings underscore the need to adapt paramedicine education to meet the evolving demands of the profession, with paramedicine educators playing a leading role in this transformation. These insights may be instructive in providing guidance for educational policies and practices that shape the future of paramedicine education and may have transferability for other allied health professions

Gender-based violence: strengthening the role and scope of prehospital emergency care by promoting theory, policy and clinical praxis

Gender-based Violence has a considerable prevalence globally, but it is South Africa that has recorded the highest femicide rate in the world. Prehospital Emergency Care providers appear to be well positioned (as first responders) to respond to abuse early. The aim was to understand and strengthen current/potential practice of domestic violence intervention by prehospital emergency medical systems in the context of global health-sector responses. The paradigm was critical theory and the methodology was exploratory sequential mixed methods. Interviews with managers/policy-makers, focus group discussions of clinician-educators and non-participant observation of simulated practice resulted in hypothesis generation. The quantitative phase involved a survey and cohort study with a screening intervention in a public emergency service. The qualitative phase found challenges and threats to responses require organisational/ideological change as paradoxical practice exists relative to the domestic violence behavioural pathology. Further, role-definition, identity and violence re-contextualisation is needed amidst ambivalent and contradictory positions. Emergent theoretical propositions include: typologies of victims, perpetrators and stakeholder responses; an eco-systemic relationship of state/societal expectations; and a 'conceptual compass' for preventing systemic research bias. The cohort study found bio-psycho-social responses and prehospital screening for domestic violence effective and that the evaluation of prehospital met/unmet need was prudent. The historical domestic violence detection rate was found to be 5,1/1000. A nine-fold increase in detection following the screening training and implementation translated to 47,9/1000 emergency care patients, with no adverse events. These rates are unprecedented for South African emergency care and support screening-policy implementation. The difference in domestic violence detection, quantifies the extent of the practice gap, with an alarming missed case detection of 42,8 per 1000 patients (females, 14 years plus). Conceptualisation of the emergency care burden of domestic violence and an awakening to the unacceptability of current practice is warranted. There is a risk of regulatory and organisational 'capture' mediated by masculine hegemony and resuscitation bias. Professionalization should enable a community of practice approach to violence prevention. Recommendations include the national implementation of screening policy; mitigation of regulatory capture risk and professionalising responses through curriculum-reform. The proposed Risk-Need-Responsivity practice-model promotes clinical coherence in Emergency Care. This elevation of the emergency care discourse is likely to benefit the victim and emergency medicine community. Research is warranted in the evolving epidemiology of domestic violence, the acute/clinical needs of victims/perpetrators and the role of emergency medical systems and surveillance, in promoting health and preventing the associated morbidity/mortality, both as a forensic emergency care burden and as a social determinant of health

From conception to coherence: The determination of correct research ‘posture’

Abstract(First 300 words) Introduction (from conception to philosophy)The first article in this series provided a brief conceptual understanding of research. It postulated that the many ways of acquiring knowledge included tradition, authority, logical reasoning, experience, intuition, borrowing and the scientific method. Of these, the scientific method is the most sophisticated and reliable. It is this sophistication, in the form of research philosophy and methodological paradigms that is the object of this article. How data are collected and interpreted depends on how one conceives of the “world” and its knowledge constructs, as scientific inquiry is defined not at the level of the methodology but at the level of the paradigm. This paradigmatic framing of research activity and philosophical posturing of the researcher provides the external coherence prerequisite of scientific research.Alternative research paradigms that determine ‘posture’In seeking an epistemological position (how we come to know), one needs to also consider the ontological lens (world view) and methodological paradigm most befitting the aims and objectives of the study. To determine the appropriate “posture” 1, some factors against which the alternative inquiry paradigms may be compared include: the nature of the knowledge sought, ways in which knowledge is accumulated (and accommodated), quality criteria and ethics.2 To demonstrate reflexivity and appropriateness of choice for a study, the paradigms positivism, interpretivism and critical theory are appraised against some of the factors mentioned above. Only fundamental dilemmas are discussed below. To contextualize the above paradigms and facilitate understanding, the topic of inter-personal violence prevention will be used as this is a global phenomenon burdening health care.3–5 To answer the research question: “What are the reciprocal meanings for inter-personal violence and emergency medicine?”, the further question is: “What is the paradigm that will best inform the researcher’s posture toward this question?

Risk factor management and perpetrator rehabilitation in cases of gender-based violence in South Africa: implications of salutogenesis

It has become an established socio-political reality that South Africa has evolved into a very violent society, the manifestations of which are seen over the last two decades, despite having transitioned to a post-apartheid context. A woman is reported to be killed every eight hours in South Africa (Sapa, ‘MRC says 3 women a day killed in SA’, 7 November 2012). The interpersonal nature of the violence is suggestive of societal fragmentation particularly where the perpetrator is known to the victim and where there are fatal or protracted consequences of abuse. The phenomenon of gender-based violence has reached virtually epidemic proportions and continues to manifest in various ways, such as domestic violence, rape, sexual assault, sexual harassment and the murder of intimate partners. As perpetrators or potential perpetrators of gender-based violence, South African men of have become central to the perpetuation of the problem and it is crucial that they be targeted for intervention measures. The health promotion model provides for interventions aimed at primary prevention, early detection and tertiary care or rehabilitation. Whilst tertiary interventions may be too little too late, the early detection interventions are a logical next step to advocacy and awareness campaigns. Whilst rehabilitation interventions are reactive, early detection fosters agency and reflection and is by design pro-active. This Briefing explores how a structured process of targeted interventions for men who may be prone to committing acts of gender-based violence through the model of salutogenesis (creation of wellness), as opposed to models of pathogenesis (creation of illness), could potentially become a key aspect of the solution towards attempting to bring down the overall rates of violence across the national spectrum. It draws on experiential work and theoretical knowledge that is resonant in various practitioner (and researcher) contexts such as the Advice Desk for the Abused, a non-governmental organisation (NGO) that deals with crisis intervention. Current practices are problematised and the implications of the salutogenesis model are presented in the context of gender-based violenc

Evaluating the role of paramedics in addressing the vulnerabilities of elderly populations in humanitarian crises and abusive contexts

This review aims to explore the roles of paramedics in identifying and responding to vulnerabilities of older people during humanitarian crises, and in abusive contexts. The review aims to scope available literature, and make recommendations for future research and practice