Sheila Macdonald

Factors associated with suspected drug-facilitated sexual assault

Background: There has been little systematic investigation of widespread reports of drugging and sexual assault. We sought to determine the prevalence of and factors associated with suspected drug-facilitated sexual assault. Methods: Between June 2005 and March 2007, a total of 977 consecutive sexual assault victims underwent screening for suspected drugging at 7 hospital-based sexual assault treatment centres. We defined victims of drug-facilitated sexual assault as those who presented to a centre within about 72 hours of being assaulted and who provided at least 1 valid reason for suspecting that she or he had been drugged and sexually assaulted. We used logistic regression modelling to compare victims of suspected drug-facilitated sexual assault with other sexual assault victims, controlling for covariates. Results: In total, 882 victims were eligible for inclusion in the study. Of these, 855 (96.9%) were women, and 184 (20.9%) met the criteria for suspected drug-facilitated sexual assault. Compared with other victims, victims of drug-facilitated sexual assault were more likely to have presented to a large urban centre for care (odds ratio [OR] 2.31, 95% confidence interval [CI] 1.47–3.65), to be employed (OR 1.92, 95% CI 1.34–2.76), to have consumed over-the-counter medications (OR 3.97, 95% CI 2.47–6.38) and street drugs (OR 1.71, 95% CI 1.12–2.62) in the 72 hours before being examined and to have used alcohol before the assault (OR 4.00, 95% CI 2.53–6.32). Interpretation: Suspected drug-facilitated sexual assault is a common problem. Sexual assault services should be tailored to meet the needs of those experiencing this type of victimization.

Being "at fault" in traffic crashes: does alcohol, cannabis, cocaine, or polydrug abuse make a difference?

Objective: To compare associations of alcohol, cannabis, and cocaine abuse and traffic crash risk for “at fault” crashes and all crashes. Design: A historical cohort study. Setting: Toronto, Ontario. Patients or subjects: Subjects beginning treatment at the Centre for Addictions and Mental Health (CAMH) in 1994 for abuse of alcohol, cannabis, cocaine, and all combinations of these substances (n = 590, with 411 drivers). A control group consisted of 518 records from the Ontario registry of registered drivers, frequency matched for age and sex and residence. Interventions: CAMH subjects took part in therapeutic programs. Pre-intervention (11 115 driver-years) and post-intervention intervals (8550 driver-years) were defined and compared. Main outcome measures: Crash and collision rates, adjusted relative risks (ARRs) of crash involvement and of “at fault” crashes were computed using Poisson regression to control for variations in time at risk, age, and sex of participants. Results: Pre-treatment, significant ARRs of 1.49 to 1.79 for all crashes were found for abusers of cannabis, cocaine, or a combination. ARRs increased by 10%–15% for “at fault” crashes. Post-treatment, all associations were very modest for all abuse types. Only younger and male drivers had a significantly increased risk, which was stronger for “at fault” than for all crashes. Conclusions: Abuse of cannabis and cocaine pre-treatment was more strongly related to “at fault” crashes than to all crashes. Interaction between these substances means that the effects of combined abuse cannot be predicted from simple main effects.

Alcohol and injury: a comparison of emergency room populations in two Canadian provinces.

The few comparative emergency room (ER) studies reported have found alcohols role in injury occurrence to vary and suggest that regional and cultural differences in drinking patterns may account, in part, for this variation. To further this research, a probability sample of 1708 ER patients was interviewed regarding the role of alcohol in the event, usual drinking patterns, and alcohol-related problems and a urine sample was obtained to estimate blood alcohol concentration (BAC). The sample was from ERs in two Canadian provinces with distinctly different cultures: primarily English-speaking Alberta and French-speaking Quebec. While differences in demographic and drinking characteristics between injured and noninjured in both the Alberta and Quebec ERs were similar to those in other ER studies, the injured in the Alberta ER were more likely to be positive for estimated BAC; to have higher BAC levels; to report drinking prior to the event; and, among those reporting drinking, to have consumed a larger number of drinks and to report feeling drunk at the time of injury compared to those in Quebec. These differences may be associated with cultural differences in typical drinking patterns, with higher rates of abstinence reported in the Alberta ER, but also with higher rates of heavy drinking and alcohol-related problems, while those in the Quebec ER were more likely to report consuming smaller quantities with greater frequency (typical of wine-drinking cultures). Additional research is needed to explicate further alcohols role in injury occurrence for planning effective prevention strategies that are both culturally relevant and specific.

Male Victims of Adult Sexual Assault: A Descriptive Study of Survivors’ Use of Sexual Assault Treatment Services

This descriptive study aims to provide new information about the services used by sexually assaulted men and adolescent boys presenting to specialized hospital-based sexual assault programs and further insight into the factors that may be associated with their victimization. Information was collected from 38 male clients aged 12+ presenting to 29 sexual assault treatment centers in Ontario, Canada over 12 months. Variables were examined across 6 domains: time to presentation, client sociodemographics, assailant characteristics, assault characteristics, physical health consequences, and service delivery and utilization. A substantial minority of participants reported vulnerabilities such as young age; being Aboriginal; being transgendered, unemployed and/or on disability; working in the sex trade; and living on the streets, in a rehabilitative center, or in a correctional facility. Almost one-third identified or were documented as having a disability and, for most of these victims, it was either psychiatric in nature or developmental delay. All participants accepted at least one service offered; 86% used five or more services, most commonly those related to health care on-site such as crisis counseling, treatment of injuries, and referral for follow-up care for supportive counseling, injury redocumentation, and testing for sexually transmitted infections. These findings reveal that male clients’ uptake of specialized sexual assault services is significant and it is, therefore, important to provide access to a comprehensive range of psychological, medical, and forensic treatment options and referrals to other community services for ongoing support. Implications for future research and practice are discussed.

A comparative analysis of victims of sexual assault with and without mental health histories: acute and follow-up care characteristics.

ABSTRACT Sexual assault is a common and serious health issue that is underreported and has low follow-up rates. The myriad of psychological sequelae of sexual assault are well documented; however, there is a dearth of literature on the prevalence of preexisting mental health issues in survivors of sexual assault. This exploratory study compares victims seen at a sexual assault treatment center with and without preexisting self-reported mental health histories. The rates of preexisting mental illness in sexual assault victims are significant. Implications for clinical practice and research are discussed.

Client satisfaction with nursing-led sexual assault and domestic violence services in Ontario.

Introduction: There is still little known about survivors’ experiences of and satisfaction with comprehensive nursing-led hospital-based sexual assault and domestic violence treatment programs. Method: To address this gap, we surveyed and collected information from clients/guardians presenting to 30 of 35 of Ontario’s Sexual Assault/Domestic Violence Treatment Centres across seven domains: presentation characteristics, client characteristics, assailant characteristics, assault characteristics, health consequences, service use, and satisfaction with services. Results: One thousand four hundred eighty-four clients participated in the study, 96% of whom were women/girls. Most were White (75.3%), 12–44 years old (87.8%), and living with family (69.6%); 97.9% of clients used at least one service. The most commonly used service was assessment and/or documentation of injury (84.8%), followed by on-site follow-up care (73.6%). Almost all clients/guardians reported that they received the care needed (98.6%), rated the overall care as excellent or good (98.8%), and stated that the care had been provided in a sensitive manner (95.4%). Concerns and recommendations to improve care expressed by a small proportion of clients/guardians focused on long wait times, negative emergency department staff attitudes, issues of privacy and confidentiality, and difficulty with accessing services. Discussion: The high uptake and positive evaluation of services provided by Ontario’s Sexual Assault/Domestic Violence Treatment Centre programs confirms the value of nursing-led, hospital-based care in the aftermath of sexual assault and domestic violence. Ongoing evaluation of such services will ensure the best care possible for this patient population.

Sustainability of an HIV PEP Program for Sexual Assault Survivors: "Lessons Learned" from Health Care Providers.

This study explored challenges to continuing an HIV post-exposure prophylaxis (PEP) program of care provided to sexual assault survivors in the province of Ontario, Canada. Data were collected as part of an implementation and evaluation of a universal offering of HIV PEP (known as the HIV PEP Program) at 24 of 34 provincial hospital-based sexual assault treatment centres. Experienced health care providers were surveyed (n = 132) and interviewed in four focus groups (n = 26) about their perceptions of what, if any, factors threatened their ability to maintain the HIV PEP Program. All focus groups were audio-recorded and the recordings transcribed. The transcriptions and open-ended survey responses were analyzed using content analysis. Administrator, nurse, physician, social worker, and pharmacist respondents perceived important barriers to sustainability of the HIV PEP Program. Eight constructs were identified within four broad themes: resources (inadequate funds, overworked and unacknowledged staff), expertise (insufficient external supports, insufficiently trained and knowledgeable staff), commitment (lack of institutional support, physician resistance to offering HIV PEP), and accommodation (lack of flexibility in addressing specific client and community needs, inaccessibility and lack of clarity of tools). We discuss the implications of these findings and the actions that were taken to address the challenges.

Development of a comprehensive hospital-based elder abuse intervention: an initial systematic scoping review.

Introduction Elder abuse, a universal human rights problem, is associated with many negative consequences. In most jurisdictions, however, there are no comprehensive hospital-based interventions for elder abuse that address the totality of needs of abused older adults: psychological, physical, legal, and social. As the first step towards the development of such an intervention, we undertook a systematic scoping review. Objectives Our primary objective was to systematically extract and synthesize actionable and applicable recommendations for components of a multidisciplinary intersectoral hospital-based elder abuse intervention. A secondary objective was to summarize the characteristics of the responses reviewed, including methods of development and validation. Methods The grey and scholarly literatures were systematically searched, with two independent reviewers conducting the title, abstract and full text screening. Documents were considered eligible for inclusion if they: 1) addressed a response (e.g., an intervention) to elder abuse, 2) contained recommendations for responding to abused older adults with potential relevance to a multidisciplinary and intersectoral hospital-based elder abuse intervention; and 3) were available in English. Analysis The extracted recommendations for care were collated, coded, categorized into themes, and further reviewed for relevancy to a comprehensive hospital-based response. Characteristics of the responses were summarized using descriptive statistics. Results 649 recommendations were extracted from 68 distinct elder abuse responses, 149 of which were deemed relevant and were categorized into 5 themes: Initial contact; Capacity and consent; Interview with older adult, caregiver, collateral contacts, and/or suspected abuser; Assessment: physical/forensic, mental, psychosocial, and environmental/functional; and care plan. Only 6 responses had been evaluated, suggesting a significant gap between development and implementation of recommendations. Discussion To address the lack of evidence to support the recommendations extracted in this review, in a future study, a group of experts will formally evaluate each recommendation for its inclusion in a comprehensive hospital-based response.

Determining Possible Professionals and Respective Roles and Responsibilities for a Model Comprehensive Elder Abuse Intervention: A Delphi Consensus Survey

Objective We have undertaken a multi-phase, multi-method program of research to develop, implement, and evaluate a comprehensive hospital-based nurse examiner elder abuse intervention that addresses the complex functional, social, forensic, and medical needs of older women and men. In this study, we determined the importance of possible participating professionals and respective roles and responsibilities within the intervention. Methods Using a modified Delphi methodology, recommended professionals and their associated roles and responsibilities were generated from a systematic scoping review of relevant scholarly and grey literatures. These items were reviewed, new items added for review, and rated/re-rated for their importance to the intervention on a 5-point Likert scale by an expert panel during a one day in-person meeting. Items that did not achieve consensus were subsequently re-rated in an online survey. Analysis Those items that achieved a mean Likert rating of 4+ (rated important to very important), and an interquartile range<1 in the first or second round, and/or for which 80% of ratings were 4+ in the second round were retained for the model elder abuse intervention. Results Twenty-two of 31 recommended professionals and 192 of 229 recommended roles and responsibilities rated were retained for our model elder abuse intervention. Retained professionals were: public guardian and trustee (mean rating = 4.88), geriatrician (4.87), police officer (4.87), GEM (geriatric emergency management) nurse (4.80), GEM social worker (4.78), community health worker (4.76), social worker/counsellor (4.74), family physician in community (4.71), paramedic (4.65), financial worker (4.59), lawyer (4.59), pharmacist (4.59), emergency physician (4.57), geriatric psychiatrist (4.33), occupational therapist (4.29), family physician in hospital (4.28), Crown prosecutor (4.24), neuropsychologist (4.24), bioethicist (4.18), caregiver advocate (4.18), victim support worker (4.18), and respite care worker (4.12). Conclusion A large and diverse group of multidisciplinary, intersectoral collaborators was deemed necessary to address the complex needs of abused older adults, each having important roles and responsibilities to fulfill within a model comprehensive elder abuse intervention.

Introducing the model of cognitive-communication competence: A model to guide evidence-based communication interventions after brain injury

ABSTRACT Primary objective: Communication impairments associated with acquired brain injury (ABI) are devastating in their impact on family, community, social, academic, and vocational participation. Despite international evidence-based guidelines for communication interventions, evidence practice gaps include under identification of communication deficits, infrequent referrals, and inadequate treatment to realize functional communication outcomes. Evidence-informed communication intervention requires synthesis of abundant interdisciplinary research. This study describes the development of the model of cognitive-communication competence, a new model that summarizes a complex array of influences on communication to provide a holistic view of communication competence after ABI. Research design: A knowledge synthesis approach was employed to integrate interdisciplinary evidence relevant to communication competence. Methods and procedures: Development of the model included review of the incidence of communication impairments, practice guidelines, and factors relevant to communication competence guided by three key questions. This was followed by expert consultation with researchers, clinicians, and individuals with ABI. Main outcomes and results: The resulting model comprises 7 domains, 7 competencies, and 47 factors related to communication functioning and intervention. Conclusion: This model could bridge evidence to practice by promoting a comprehensive and consistent view of communication competence for evidence synthesis, clinical decision-making, outcome measurement, and interprofessional collaboration.