An overview of both quantitative and qualitative results and how the findings relate to each other can be found in Figure 1.
[Insert Figure 1 around here]
Quantitative results
In total, 43 medical interns signed up for the educational day but only 39 attended. Also, three participants came late or had technical problems answering the questionnaire and were therefore excluded from the study, i.e. 36 interns were eligible for inclusion. One person declined participation, leaving a sample of 35 who answered the baseline questionnaire (response rate 97%). Nineteen participants (54%) in the intervention group were lost to follow-up, leaving a sample of 16 (46%) who participated at both measurement points. Of the 67 medical interns asked to participate in the control group, 20 answered the baseline survey (response rate = 30%). Six participants in the control group (30%) were lost to follow-up, leaving a sample of 14 (70%) who participated at both measurement points. There was no significant difference in background characteristics between the intervention and control group in the sample retained at follow-up. However, the attrition analysis revealed that in the intervention group a higher proportion of those retained at follow-up reported education about violence in a close relationship at baseline, compared to those lost to follow-up (p=0.03) (Table 1).
[Insert Table 1 around here]
Aim 1
Propensity to ask questions: We found a significant increase in the frequency of asking questions in the intervention group at follow-up (p=0.047), i.e. more respondents reported having asked questions about abuse on several occasions at follow-up. The same pattern was not found for the control group (p=0.38) (Table 2). There was no significant change concerning the proportion of participants who reported asking patients questions about abuse, but the trend was towards an increase in the intervention group (baseline n=5; 31%; follow-up n=9; 56% p=0.13) and towards a decrease in the control group (baseline n=9, 64%; follow-up n=6, 44%, p=0.25) (Table 1).
[Insert Table 2 around here]
Table 1. Background characteristics of participants (intervention group n=16, control group n=14) and attrition analysis
|
Sample
|
Attrition analysis
|
Intervention
|
Control
|
Intervention
|
Control
|
n=16
|
n=14
|
Lost to follow-up
n=19
|
Retained
n=16
|
Lost to follow up
n=6
|
Retained
n=14
|
n
|
%
|
n
|
%
|
N
|
%
|
n
|
%
|
n
|
%
|
n
|
%
|
Sex
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Female
|
10
|
62.5
|
10
|
71.4
|
14
|
73.7
|
10
|
62.5
|
3
|
50.0
|
10
|
71.4
|
|
Male
|
6
|
37.5
|
4
|
28.6
|
5
|
26.3
|
6
|
37.5
|
3
|
50.0
|
4
|
28.6
|
Age
|
|
|
|
|
|
|
|
|
|
|
|
|
|
≤34 years
|
12
|
75.0
|
14
|
100
|
15
|
78.9
|
12
|
75.0
|
6
|
100
|
14
|
100
|
|
35-49 years
|
4
|
25.0
|
-
|
-
|
4
|
21.1
|
4
|
25.0
|
-
|
-
|
-
|
-
|
Medical school training about abuse at baseline
|
|
|
|
|
|
|
|
|
|
|
|
|
No, Do not remember
|
4
|
25.0
|
1
|
7.1
|
2
|
10.5
|
4
|
25.0
|
2
|
33.3
|
1
|
7.1
|
|
Yes, violence in close relationships
|
12
|
75.0
|
13
|
92.9
|
17
|
89.5
|
12
|
75.0
|
4
|
66.7
|
13
|
92.9
|
|
Yes, elder abuse
|
2
|
12.5
|
4
|
28.6
|
4
|
21.1
|
2
|
12.5
|
1
|
16.7
|
4
|
28.6
|
Other training about abuse at baseline
|
|
|
|
|
|
|
|
|
|
|
|
|
|
No, Do not remember
|
8
|
50.0
|
5
|
35.7
|
15
|
78.9
|
8
|
50.0
|
2
|
33.3
|
5
|
35.7
|
|
Yes violence in close relationships
|
8
|
50.0
|
9
|
64.3
|
3
|
15.8
|
8
|
50.0
|
4
|
66.7
|
9
|
64.3
|
|
Yes, elder abuse
|
2
|
12.5
|
3
|
21.4
|
1
|
5.3
|
2
|
12.5
|
2
|
33.3
|
3
|
21.4
|
Asked questions about abuse at baseline
|
|
|
|
|
|
|
|
|
|
|
|
|
|
No, Do not remember
|
11
|
68.8
|
5
|
35.7
|
15
|
78.9
|
11
|
68.8
|
3
|
50.0
|
5
|
35.7
|
|
Yes
|
5
|
31.3
|
9
|
64.3
|
4
|
21.1
|
5
|
31.3
|
3
|
50.0
|
9
|
64.3
|
Asked questions about abuse at follow up
|
|
|
|
|
|
|
|
|
|
|
|
|
|
No, Do not remember
|
7
|
43.8
|
8
|
57.1
|
|
|
|
|
|
|
|
|
|
Yes
|
9
|
56.3
|
6
|
42.9
|
|
|
|
|
|
|
|
|
Pearson’s chi square test, or when appropriate Fisher’s exact test, were used to compare differences in background characteristics between intervention and control group at baseline as well as differences between those lost to follow up and those retained in the intervention and control group respectively. Numbers in bold represent significant changes at p<0.05
Perceived ability to manage the response: We found a significant increase in self-efficacy between baseline and follow-up for managing the response (p=0.04) in the intervention group, but not the control group (p=0.14) (Table 3).
Table 3. Self-efficacy for asking older patients questions about abuse and managing the response.
|
Baseline
|
|
Follow-up
|
|
P-value
|
|
Mean
|
SD
|
Mean
|
SD
|
|
Intervention group (n=16)
|
|
|
|
|
|
Self efficacy asking questions
|
16.3
|
3.5
|
19.2
|
3.0
|
0.04
|
Self efficacy managing response
|
24.3
|
7.3
|
28.6
|
7.6
|
0.04
|
Control group (n=14)
|
|
|
|
|
|
Self efficacy asking questions
|
19.6
|
5.3
|
19.4
|
5.5
|
0.84
|
Self efficacy managing response
|
25.0
|
8.5
|
27.9
|
11.4
|
0.14
|
Significant changes (p<0.05) between baseline and 6 months follow-up are written in bold and have been calculated using paired t-tests.
Aim 2
Sense of responsibility and internal barriers and facilitators for asking questions about abuse and managing the response: Self-efficacy for asking questions was significantly increased between baseline and follow-up in the intervention group (p=0.04), but not in the control group (p=0.84) (Table 3). We found no significant changes in either the intervention or control group concerning estimation of own responsibility for asking questions at follow up. However, in both the intervention and control group most respondents reported a high sense of responsibility already at baseline (Table 2). Respondents in the intervention group attributed higher responsibility to the health care organization to ask questions about abuse at follow-up compared to baseline (p=0.046), which was not seen in the control group (p=0.16). Respondents in the intervention group were less likely to report their own lack of awareness as a barrier at follow-up (p=0.04), while there was no such difference in the control group (p=0.16) (Table 2). There were no significant changes between baseline and follow-up in either the intervention or control group concerning any of the causes for concern when asking questions about abuse. The higher levels of concern (rather worried and very worried) were commonly reported for concern about not being able to provide a proper follow-up, while concerns about negative reactions or negative effects on the patient-provider relationship were commonly reported at the lower levels of concern (not at all or little worried) at both measurement points in both groups (Table 3).
Organizational barriers to asking questions about abuse and managing the response: A majority of respondents in both the intervention and control group reported a lack of routines for managing cases as a barrier to some or a large extent at both baseline and follow-up. However, fewer respondents in the control group reported that a lack of routines for asking questions (p=0.03) and a lack of routines for managing the response (borderline significant, p=0.052) were barriers to asking questions at follow-up. No significant difference was seen in the intervention group for the same two variables (p=0.32 and p=0.37 respectively). No changes were seen for time restraints as a barrier in either the intervention or control group (Table 3).
Qualitative results:
Four participants were interviewed, all of whom were female. Analysis of the interviews resulted in four categories: Internal processes and new perspectives; Motivational processes; Area of responsibility; Feelings of insecurity and challenges in responding to elder abuse.
Internal processes and new perspectives:
The participants all described emotional reactions to the content of the educational day, e.g. frustration, discomfort and sadness, but also commitment and curiosity. Experiencing scenarios that were perceived as realistic was an important factor in evoking the emotional responses. Also, an increased awareness of elder abuse was articulated in all interviews. Participants reported finding the subject more important because of the educational day, as well as having more general knowledge and a more comprehensive understanding of the issue. Some participants stated that realizing how common and under-diagnosed elder abuse is, as a result of listening to the theoretical lecture, had made a particular impact on them.
“…I mean, I think the statistics were tough. Yes, that was really the toughest part. […] statistics and this information about… […] how unusual it is for health care providers to ask [about elder abuse], and how many people go unnoticed”. (Participant 4)
Participants expressed that they had made associations between what they were seeing and hearing during the educational day, and their own previous experiences. The portrayal of various abuse-related scenarios, particularly in the videos and in the forum theatre, made the participants reflect on their own experiences of similar situations. This prompted emotional reactions for some, e.g. when realizing they hadn’t asked questions about abuse in situations where they now thought it would have been relevant. In addition, such realizations made them start to apply their acquired knowledge of elder abuse to real life experiences.
“When we saw the videos and other [participants] started to talk about what they’ve seen in wards and primary care offices, you realized ‘Oh my god, so many things have been witnessed’. [...] You started to think about what you’ve seen and experienced yourself. That it [elder abuse] is much more common than you think and something you need to open your eyes to…” (Participant 2).
The participants also described that during the day, especially in the forum theatre and group exercises, discussions would continuously arise between participants, which allowed them to share their own thoughts and gain perspectives other than their own. Seeing and hearing their colleagues and the actors play out the scenes in the forum theatre made the participants reflect on their own choice of strategy, as well as providing them with the opportunity to learn lessons from others.
“And the thing about seeing…You learn from how your colleagues are managing it, what words they are using. And when they got stuck, someone else made a contribution. ‘Maybe you could do it [handle the situation] like this?’ Or ‘I would have done it like that’. Then you also learn from your colleagues’ mistakes” (Participant 2)
Motivational processes:
Most participants expressed that the educational day made them feel involved with and committed to care for victims of elder abuse. For instance, the forum theatre evoked a feeling of involvement and some participants described how they felt compelled to take action to make a difference for the better in the scene that was being played out. An increased awareness of the issue, as well as understanding that their actions could make a difference for the better, was mentioned as important in conveying motivation and interest.
“… having time to talk about the subject and seeing situations... that I hadn’t for example paid attention to before. And feeling that I could be of importance [when encountering victims of elder abuse]. That I could make a difference through my questions or behaviour, that it could improve things for these people… I felt like that created motivation” (Participant 3)
When asked about how their way of working had changed after the educational day, the participants particularly mentioned acting from the position of being more aware of elder abuse, e.g. paying attention to warning signs and symptoms, asking direct questions and not being afraid to ask about abuse, more routinely screening for elder abuse and considering types of abuse other than physical.
“…But I have to say that in those situations when it’s more of an unpleasant atmosphere, I have never had the courage to make a comment on that. But perhaps now…” (Participant 4)
Participants also mentioned being equipped with more tools to manage situations involving elder abuse, such as having the pamphlets that were handed out during the day that contained phone numbers and other contact information to supportive organizations and authorities. They also cited being provided with ideas and inspiration concerning how and when to ask questions about abuse and that they had learned strategies to manage situations where abuse could be suspected. However, some participants emphasized the importance of practising how to ask questions out loud about elder abuse, and that they perceived that there had been too little time to do that during the educational day.
Area of responsibility:
All the participants expressed the importance of the expectations on them as physicians and on their organizations. Some clearly felt that it was their responsibility to investigate suspected ongoing elder abuse, and to help patients who were suffering from abuse. However, the informants also stated that the extent of their professional responsibility needs to be more clearly defined and explained to them, that they needed to know where their responsibilities toward the patient ended and other health care professionals’ and social welfare authorities’ responsibilities started. Staying within their area of responsibility was important for the informants and they felt that stepping outside it would be difficult and could put them in a difficult position. For instance, some felt that they might be questioned for prioritizing the management of abuse-related problems if it took time away from their medically related tasks. All the participants also expressed how the patient had to take responsibility as well, e.g. taking action to make a change and accepting help that was offered to them.
“And I believe that if you talk about it more and establish a norm that it’s important that we assist and aid in a certain way, then I think we employees will… work for that and take more responsibility. The way things are now, I don’t feel like it is that way […] It is not our responsibility […] we are supposed to manage other things. And if it is about being exposed [to abuse] in a relationship, it’s the victim themselves or other professionals who must take responsibility.” (Participant 3).
Feelings of insecurity and challenges in responding to elder abuse:
Some participants felt that the education did not provide them with a solution to an important part of their insecurities, i.e. how to generally manage cases of elder abuse. Some respondents emphasized that they remain unsure of how to act in practice, and not being able to present the patient with a definite measure or solution left the participants with a feeling of inadequacy. For instance, one participant shared that her insecurities about how to manage the situation could influence her to avoid the subject all together and refrain from asking questions about abuse.
“Often it’s like…What we hear is: ‘Don’t order those lab tests, because it will result in incidental findings.’ And it is a bit the same situation here: ‘Don’t ask that question, because you will have a problem you can’t manage’. I think that is often the case. And I feel like that’s a shame, but sometimes I feel just like that: ‘What do I do with the answer?’.” (Participant 2).
Participants required information about structured and uncomplicated ways to manage situations and sought the possibility to offer concrete measures to the patient, e.g. offering an appointment to someone in charge of follow-ups or making referrals to responsible departments or resources. This would assure the health care provider involved that the issue wouldn’t end with just their contribution, which could provide a sense of security for them. Another approach to lessen their insecurities was to seek support. During the interviews, all the participants expressed a need for support to manage patients subjected to abuse. This support could be e.g. practical routines, consulting more experienced colleagues, social workers or for some a wish to hand over responsibility for following up and managing the situation to someone else.
“…I often feel insufficient not knowing what resources there are […] …Who can this person [the patient] make contact with? Who do we usually send referrals to? […] I wonder if there is something more I could do, that I’m not aware of.” (Participant 3).