Exposure to domestic violence and abuse and consultations for emergency contraception: nested case-control study in a UK primary care dataset

Food Insecurity: A Barrier to Reproductive Justice Globally

Objective: Reproductive Justice identifies three core reproductive rights for all people: (1) the right to not have a child; (2) the right to have a child; and (3) the right to parent children in safe and healthy environments. We aim to illustrate that food insecurity infringes upon on all three of these rights and so is a pressing issue for reproductive justice and for sexual and reproductive health more broadly. Methods: Using a phenomenological approach, we outline potential pathways between food insecurity and reproductive justice. Results: There are numerous potential pathways between food insecurity and reproductive justice, including entry into sexual relationships for material support, links to sexually transmitted infections and infertility, structural violence, prioritization and spending tradeoffs between food and other basic necessities, biological impacts of malnutrition, restricted reproductive choices, population control measures, and social stigma and exclusion. Marginalized people are disproportionately impacted by food insecurity and its consequences, with implications for sexual health and pleasure and for reproductive justice. Conclusions:Meaningful and equitable collaboration between people with lived experience of food insecurity, human rights and reproductive justice activists, and academics is critical to sensitively contextualize this work and mobilize broader social change.

Barriers and facilitators to pharmacists' engagement in response to domestic violence: a qualitative interview study informed by the capability-opportunity-motivation-behaviour model

BACKGROUND

Domestic and sexual violence and abuse (DSVA) is a global public health problem resulting in health inequalities. Community pharmacies are uniquely placed to help people affected by DSVA. We examined factors that impact pharmacists' engagement in response to DSVA when providing public health services.

METHODS

Semi-structured qualitative interviews with community pharmacists (n = 20) were analyzed thematically, with inductive themes mapped to the Capability-Opportunity-Motivation Behaviour (COM-B) model.

RESULTS

Pharmacists were confident in providing public health services, but a lack of DSVA training meant there is a need to support their 'Capability' to respond to DSVA. Pharmacies were perceived as highly accessible healthcare providers on the high street, with sexual health consultations offering an ideal 'Opportunity' to enquire about DSVA in a private consultation room. Pharmacist's 'Motivation' to enquire about DSVA was driven by potential positive client outcomes and a desire to be more involved in public heath interventions, but organisation- and system-level support and remuneration is needed.

CONCLUSIONS

Community pharmacy offers opportunities for integrating DSVA work in existing public health services. Pharmacists need training on DSVA, ongoing support, allocated funding for DSVA work, and awareness raising campaign for the public on their extended public health role.

Self-harm risk in pregnancy: recurrent-event survival analysis using UK primary care data

BACKGROUND

Perinatal self-harm is of concern but poorly understood.

AIMS

To determine if women's risk of self-harm changes in pregnancy and the first postpartum year, and if risk varies by mental illness, age and birth outcome.

METHOD

This was a retrospective cohort study of 2 666 088 women aged 15-45 years from the 1 January 1990 to 31 December 2017 linked to 1 102 040 pregnancies and their outcomes, utilising the Clinical Practice Research Datalink and Pregnancy Register. We identified self-harm events and mental illness (depression/anxiety/addiction/affective/non-affective psychosis/eating/personality disorders) from clinical records and grouped women's age into 5-year bands. They calculated the rate of self-harm during discrete non-perinatal, pregnant and postpartum periods. We used a gap-time, stratified Cox model to manage multiple self-harm events, and calculated the unadjusted and adjusted hazard ratios (adjHR) of self-harm associated with pregnancy and the postpartum compared with non-perinatal periods. Pre-planned interactions tested if risk varied by mental illness, age and birth outcome.

RESULTS

The analysis included 57 791 self-harm events and 14 712 319 person-years of follow-up. The risk of self-harm shrank in pregnancy (2.07 v. 4.01 events/1000 person-years, adjHR = 0.53, 95% CI 0.49-0.58) for all women except for 15- to 19-year-olds (adjHR = 0.95, 95% CI 0.84-1.07) and the risk reduced most for women with mental illness (adjHR = 0.40, 95% CI 0.36-0.44). Postpartum, self-harm risk peaked at 6-12 months (adjHR = 1.08, 95% CI 1.02-1.15), at-risk groups included young women and women with a pregnancy loss or termination.

CONCLUSIONS

Maternity and perinatal mental health services are valuable. Family planning services might have psychological benefit, particularly for young women.

Uptake and provision of self-care interventions for sexual and reproductive health: findings from a global values and preferences survey

Self-care interventions hold the potential to improve sexual and reproductive health (SRH) and well-being. Yet key knowledge gaps remain regarding how knowledge and uptake vary across different types of self-care interventions. There is also limited understanding of health workers’ confidence in promoting SRH self-care interventions, and how this may differ based on personal uptake experiences. To address these knowledge gaps, we conducted a web-based cross-sectional survey among health workers and laypersons from July to November 2018. We investigated the following information about SRH self-care interventions: knowledge and uptake; decisions for use; and associations between health workers’ uptake and providing prescriptions, referrals, and/or information for these interventions. Participants (n = 837) included laypersons (n = 477) and health workers (n = 360) from 112 countries, with most representation from the WHO European Region (29.2%), followed by the Americas (28.4%) and African (23.2%) Regions. We found great heterogeneity in knowledge and uptake by type of SRH self-care intervention. Some interventions, such as oral contraception, were widely known in comparison with interventions such as STI self-sampling. Across interventions, participants perceived benefits of privacy, convenience, and accessibility. While pharmacies and doctors were preferred access points, this varied by type of self-care intervention. Health workers with knowledge of the self-care intervention, and who had themselves used the self-care intervention, were significantly more likely to feel confident in, and to have provided information or referrals to, the same intervention. This finding signals that health workers can be better engaged in learning about self-care SRH interventions and thereby become resources for expanding access.

Signs and symptoms of intimate partner violence in women attending primary care in Europe, North America and Australia: a systematic review and meta-analysis

BACKGROUND

Intimate partner violence (IPV) is a prevalent yet underdiagnosed health issue, and primary care practitioners are in a unique front-line position to provide care and counsel for the victims.

OBJECTIVE

To identify the signs and symptoms of women exposed to IPV who attended primary care, regardless motive of consultation.

METHODS

Systematic review and meta-analysis on Cochrane, PubMed, Embase and CINAHL between 1946 and 2020. Eligible studies had to be original quantitative research, on women aged >15 years, attending primary care settings in Europe, North America and Australia and interviewed on their status as victims of IPV and on their signs and symptoms.

RESULTS

Of 1791 articles identified, 57 were selected. Associations were found between IPV and signs and symptoms of depression [19 studies: overall odds ratio (OR) = 3.59, 95% confidence interval (CI; 2.7-4.7, I2 = 94.6%)], anxiety [9 studies: overall OR = 2.19, 95% CI (1.75-2.73, I2 = 84%)], gynaecological and/or sexually transmitted infections [6 studies: overall OR = 2.82, 95% CI (2.1-3.8, I2 = 41%)] and combination of somatic symptoms [5 studies: standard mean deviation = 0.795, 95% CI (0.62-0.97, I2 = 0%)].

CONCLUSIONS

Women exposed to IPV may present with clinical symptoms and signs other than bodily injury. Policy implications knowing these symptoms presented by women victims of IPV can help GPs identify and treat them.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018089857.

The sexual and reproductive health of women with mental illness: a primary care registry study

The purpose of this study is to characterise the sexual and reproductive health risks associated with mental illness among women. This was a retrospective cohort study of 2,680,149 women aged 14 to 45 years in the Clinical Practice Research Datalink, a UK primary care register, linked to 1,702,211 pregnancies that ended between the 1st January 1990 and 31st December 2017. Mental illness was identified in primary care and categorised into the following: common mental illness (depression/anxiety); addiction (alcohol/drug misuse); serious mental illness (affective/non-affective psychosis); other mental illness (eating/personality disorders). Logistic regression estimated the association between mental illness and subsequent risk of recurrent miscarriage and termination. Cox proportional hazards estimated the association between mental illness and time to gynaecological diseases, sexually transmitted infections, reproductive cancers, cervical screen, contraception and emergency contraception. Models were adjusted for calendar year, year of birth, smoking status and ethnicity, region and index of socioeconomic status. Compared to women without mental illness, exposed women were more likely to experience recurrent miscarriage (adjOR = 1.50, 95%CI 1.41 to 1.60), termination (adjOR = 1.48, 95%CI 1.45 to 1.50), gynaecological diseases (adjHR = 1.39, 95%CI 1.37 to 1.40), sexually transmitted infections (adjHR = 1.47, 95%CI 1.43 to 1.51), reproductive cancers (adjHR = 1.10, 95%CI 1.02 to 1.19), contraception (adjHR = 1.28 95%CI 1.26 to 1.29) and emergency contraception (adjHR = 2.30, 95%CI 2.26 to 2.34), and less likely to attend for cervical screening (adjHR = 0.91, 95%CI 0.90 to 0.92). Currently, the sexual and reproductive health needs of women with mental illness are unmet representing significant health inequalities. Clinicians must create opportunities to engage with women in primary care and mental health services to address this gap.

Women's expectations of healthcare providers in the context of reproductive abuse in Australia

Reproductive abuse is a poorly understood form of violence against women. It is defined as a deliberate attempt to interfere with or control a women's reproductive choices and is usually perpetrated by a male intimate partner. Reproductive abuse is associated with a range of poor health outcomes for women, increasing the likelihood that they will visit a healthcare provider. Despite this, there is a dearth of evidence to inform best practice in health settings, particularly research that highlights the voices of survivors. Qualitative studies to date have focused on intimate partner or sexual violence more broadly, yet it is likely that reproductive abuse presents its own nuance in terms of a supportive response. In this paper, we address this gap by reporting qualitative data from 14 women who self-identified as survivors of reproductive abuse. Findings suggest that healthcare providers have an important role to play in responding to reproductive abuse, focusing on taking the problem seriously, reinforcing that the behaviour is wrong, asking about other forms of violence and addressing women's needs and priorities for contraception and reproductive autonomy. This study has important implications for the development of best practice guidelines for healthcare providers responding to reproductive abuse in female patients.

How to identify, assess, and refer patients experiencing interpersonal violence across the lifespan: the role of US pharmacists in integrated pharmacy research and practice

Interpersonal violence is a public health crisis in need of multipronged interventions. Victims of violence experience both acute injuries and chronic illness and may seek acute self-care and/or have the need for chronic medication therapy. Thus, the community-based, ambulatory pharmacy setting can serve as a portal for identification of, and intervention for, victims of violence. This article provides background on four types of interpersonal violence, including intimate partner, child and elder abuse, in addition to sexual assault. This article briefly reviews the statutory reporting requirements for pharmacists in the United States, identifies educational needs for pharmacists with existing resources and suggests a method for the ambulatory pharmacist's intervention.

Trends in HIV testing in the UK primary care setting: a 15-year retrospective cohort study from 2000 to 2015

OBJECTIVES

To estimate trends in HIV testing, positivity and prevalence in UK primary care for 2000-2015 as part of a wider investigation into reasons for late diagnosis of HIV.

DESIGN

Retrospective cohort study using the Clinical Practice Research Datalink (CPRD) which is derived from computerised clinical records produced during consultations in primary care.

SETTING

404 general practices in England.

PARTICIPANTS

5 979 598 adults aged ≥16 years registered between 2000 and 2015 with 45 093 761 person years of observation.

OUTCOMES

Annual HIV testing rates, proportion of positive tests and prevalence of HIV-infected people recorded in primary care 2000-2015.

RESULTS

HIV testing in primary care increased from 2000 to 2010, but then declined. Testing was higher in females than in males and in those aged 16-44 years compared with older adults. Rates per 100 000 in women aged 16-44 years were 177 (95% CI 167 to 188); 1309 (95% CI 1282 to 1336); 1789 (95% CI 1757 to 1821) and 839 (95% CI 817 to 862) in 2000, 2005, 2010 and 2015, respectively, and for non-pregnant women: 22.5 (95% CI 19 to 26); 134 (95% CI 125 to 143); 262 (95% CI 250 to 275); 190 (95% CI 179 to 201). For men aged 16-44 years rates were: 26 (95% CI 22 to 29); 107 (95% CI 100 to 115); 196 (95% CI 185 to 206); 137 (95% CI 127 to 146). Over the study period, there were approximately two positive results per 1000 HIV tests. Men were eightfold more likely to test positive than women. The percentage of HIV diagnoses among adults recorded in CPRD may be as low as 55% in London and 67% in the rest of the UK.

CONCLUSIONS

HIV testing rates in primary care peaked in 2010 and subsequently declined. Access to testing was higher for women despite the prevalence of HIV being higher in men.

IMPLICATIONS AND FURTHER RESEARCH NEEDED

Opportunities remain in primary care for increasing HIV testing to prevent costly late diagnoses and decrease HIV transmission. Interventions to improve targeting of tests and increase adherence to HIV testing guidelines are needed in primary care.