The Dynamics of Partner Violence and Alcohol Use in Couples: Research Methods.

OBJECTIVE: This research team uses complexity science to gain a deeper understanding of daily dynamics of intimate partner violence (IPV). This report describes research methods for gathering daily information about patterns of partner violence and alcohol use from couples in near-real time, and addresses recruitment and retention, adherence to study protocol, data validity, and participant safety. METHODS: Researchers enrolled 20 heterosexual couples with violent relationships from a primary healthcare center. Every day for 8 weeks, participants telephoned an interactive voice response (IVR) system and responded to 33 survey questions assessing violence, alcohol use, and household environment. They also completed baseline and end-of-study surveys. RESULTS: Of 20 enrolled couples, 15 completed the study, providing 90% adherence to daily reporting. Participants reported verbal aggression on an average of 11-13 days over 8 weeks, and physical abuse on an average of 2-4 days. Alcohol use was modest and infrequent. Women and men differed in their reports of women's physical aggression. No reports of physical violence were correlated with social desirability. CONCLUSIONS: We demonstrated the feasibility of enrolling and engaging both women and men in daily longitudinal research about partner violence and described advantages of IVR in daily longitudinal research.

Modeling Outcomes of Partner Violence Using Cusp Catastrophe Modeling.

Research suggests that intimate partner violence (IPV) is a complex, nonlinear phenomenon. In addition to the violence trajectory itself, IPV decision-making, help-seeking and leaving are nonlinear processes as well. The purpose of this study was to determine whether outcomes were best modeled as cusp catastrophic phenomena with measures of violence nonlinearity and wife-perpetrated violence serving as bifurcation variables. This 12-week time series study was conducted among 200 adult women in violent relationships. Women completed daily assessments of household environment and marital relationship using Interactive Verbal Response; missing violence data was imputed using TISEAN software to maintain its nonlinear characteristics. LZ complexity, approximate entropy, and largest Lyapunov exponents were used as measures of violence nonlinearity. Asymmetry variables included violence frequency and severity as well as its onset and duration. Factor-analyzed outcomes included coping and appraisals, hope and support, symptomatology, functional status, readiness-for-change, and medical utilization. When severity of wife's violence and nonlinearity of husband's violence were used as bifurcation variables, cusp catastrophe modeling helped explain positive and negative coping as well as readiness-for-change. In conclusion, measures of nonlinearity of husband's violence and wife's violence contributed to the variance of three outcomes in cusp catastrophe modeling. Sudden changes in coping and readiness-for-change in IPV should be expected and knowledge of violence nonlinearity may have applications when working with violent couples.

Systems and complexity thinking in the general practice literature: an integrative, historical narrative review.

PURPOSE: Over the past 7 decades, theories in the systems and complexity sciences have had a major influence on academic thinking and research. We assessed the impact of complexity science on general practice/family medicine. METHODS: We performed a historical integrative review using the following systematic search strategy: medical subject heading [humans] combined in turn with the terms complex adaptive systems, nonlinear dynamics, systems biology, and systems theory, limited to general practice/family medicine and published before December 2010. A total of 16,242 articles were retrieved, of which 49 were published in general practice/family medicine journals. Hand searches and snowballing retrieved another 35. After a full-text review, we included 56 articles dealing specifically with systems sciences and general/family practice. RESULTS: General practice/family medicine engaged with the emerging systems and complexity theories in 4 stages. Before 1995, articles tended to explore common phenomenologic general practice/family medicine experiences. Between 1995 and 2000, articles described the complex adaptive nature of this discipline. Those published between 2000 and 2005 focused on describing the system dynamics of medical practice. After 2005, articles increasingly applied the breadth of complex science theories to health care, health care reform, and the future of medicine. CONCLUSIONS: This historical review describes the development of general practice/family medicine in relation to complex adaptive systems theories, and shows how systems sciences more accurately reflect the discipline's philosophy and identity. Analysis suggests that general practice/family medicine first embraced systems theories through conscious reorganization of its boundaries and scope, before applying empirical tools. Future research should concentrate on applying nonlinear dynamics and empirical modeling to patient care, and to organizing and developing local practices, engaging in community development, and influencing health care reform.

Association of knowledge, attitudes, and behaviors for colon cancer screening in Hispanic patients.

PURPOSE: The purpose of our cross-sectional study was to examine the association between sociodemographic, knowledge, attitude and behavior factors with colon cancer screening among low-income Hispanic patients from an urban family medicine clinic in San Antonio, Texas. METHODS: Using random stratified sampling, 804 patients were surveyed with 274 Hispanic patients meet the eligibility criteria for colon cancer screening (aged > or = 50 years). A 10-page self-administered questionnaire in Spanish or English completed in the clinic waiting room included self-reported colonoscopy, sociodemographic characteristics, health status, knowledge, attitudes, and behaviors toward colon cancer screening. Associations between colonoscopy and patient characteristics were assessed using logistic regression. RESULTS: 62% of patients reported having been tested for colonoscopy. Older Hispanics (age mean=59 + 6.1 SD) were more likely to have a colonoscopy than younger Hispanics (age mean = 56 +/- 4.8 SD) (P < .001). Bivariate analysis showed that patients who discussed colon cancer risk with their doctor (P = .001), did not smoke (P = .004), or encouraged family members or friends to be tested for colon cancer (P < .001) were more likely to be screened. Multiple variable logistic regression analysis showed that older age, having cancer, discussing the risk factors with their doctor, and encouraging family members or friends to get tested were significant predictors for colonoscopy testing in Hispanics. CONCLUSIONS: Colonoscopy screening in a sample of low-income Hispanic patients differed by age and health experience. Intervention programs that increase colon cancer screening in Hispanics patients should concentrate on those aged < 60. Patient education for knowledge, positive attitude, and behaviors may improve colon cancer screening.

Chemical intolerance in primary care settings: prevalence, comorbidity, and outcomes.

PURPOSE: This study extends previous community-based studies on the prevalence and clinical characteristics of chemical intolerance in a sample of primary care clinic patients. We evaluated comorbid medical and psychiatric disorders, functional status, and rates of health care use. METHODS: A total of 400 patients were recruited from 2 family medicine clinic waiting rooms in San Antonio, Texas. Patients completed the validated Quick Environmental Exposure and Sensitivity Inventory (QEESI) to assess chemical intolerance; the Primary Care Evaluation of Mental Disorders (PRIME-MD) screen for possible psychiatric disorders; the Dartmouth-Northern New England Primary Care Cooperative Information Project (Dartmouth COOP) charts for functional status; and the Healthcare Utilization Questionnaire. RESULTS: Overall, 20.3% of the sample met criteria for chemical intolerance. The chemically intolerant group reported significantly higher rates of comorbid allergies and more often met screening criteria for possible major depressive disorder, panic disorder, generalized anxiety disorder, and alcohol abuse disorder, as well as somatization disorder. The total number of possible mental disorders was correlated with chemical intolerance scores (P <.001). Controlling for demographics, patients with chemical intolerance were significantly more likely to have poorer functional status, with trends toward increased medical service use when compared with non-chemically intolerant patients. After controlling for comorbid psychiatric conditions, the groups differed significantly only regarding limitations of social activities. CONCLUSIONS: Chemical intolerance occurs in 1 of 5 primary care patients yet is rarely diagnosed by busy practitioners. Psychiatric comorbidities contribute to functional limitations and increased health care use. Chemical intolerance offers an etiologic explanation. Symptoms may resolve or improve with the avoidance of salient chemical, dietary (including caffeine and alcohol), and drug triggers. Given greater medication intolerances in chemical intolerance, primary care clinicians could use the QEESI to identify patients for appropriate triage to comprehensive nonpharmacologic care.

Is Perceived Need for Action Among Women in Violent Relationships Nonlinear and, If So, Why?

Despite the prevalence and impact of partner violence, we understand little about women's action taking except that it seems an unpredictable, nonlinear process. This article determines the degree of nonlinearity in perceived need for help, legal action, or leaving among women in violent relationships. The participants included 143 women who experienced violence in the previous month, enrolled from six primary care clinics. Baseline surveys assessed background characteristics and factors which may affect perceived need for action. Multiple times series assessments of violence and need for action were collected daily for 8 weeks via telephone Interactive Voice Response. Measures of nonlinearity of violence, perceived need for help, legal action, and leaving were computed. Repeated measures ANOVA assessed differences across measures of nonlinearity. To identify factors contributing to nonlinearity, staged multiple regression assessed the relationship between nonlinearity measures and outcomes. Ninety-three women completed sufficient time series for nonlinearity assessment. Measures of nonlinearity were lower for need for legal action compared with needs for help and leaving. Regression analysis suggested that isolation, social networks, and lack of awareness contribute to nonlinearity. Women's perceived need for legal action and its level of nonlinearity were lowest compared with those of help seeking and leaving. Although its relative linearity suggests that the need for legal action may be the most predictable, its lower mean rating suggests that legal action is a low priority. Although need for help and leaving are of higher priorities, their nonlinearity suggests that intervention will not yield predictable results.

He Said, She Said: Comparing Men's and Women's Descriptions of Men's Partner Violence.

More than one in three women and one in four men in the United States report victimization by intimate partner violence. Women and men often disagree about the frequency or severity of violent acts, and researchers have proposed various reasons for discordant reports. Using daily surveys and qualitative interviews, we compared men's and women's reports about men's partner aggression and examined language they used to describe their experiences. Fifteen heterosexual couples in violent relationships completed an 8-week study that involved daily telephone surveys about violent behaviors and household environment; baseline and end-of-study surveys addressing predictors and outcomes of violence; and qualitative end-of-study interviews to provide perspective about their relationships. Most participants were Latinos with low income. Relationship length was 5.5 years, median. In daily surveys, both partners reported similar frequencies of men's physical violence (4% of days), but men reported more physical violence by women than women did (8% vs. 3% of days). The qualitative analysts compared men's and women's accounts of male-to-female violence and observed gender-specific variations in style of reporting. Men used indirect language to describe their violent behavior, implied definitions of abuse, and justified their aggression. These findings have implications for clinical guidelines to screen and intervene with victims and perpetrators of intimate partner violence in primary care and emergency settings. Future research should focus on perpetrators of violence and examine effective ways for health care providers to identify and manage their care.

Modeling Women's Need For Action in Violent Relationships.

We are beginning to understand that intimate partner violence (IPV) and women's decision-making about that violence are nonlinear phenomena. IPV and decision-making are influenced by variables feedforwarding upon themselves with multiple interconnected predictors and circularly causal relationships. Computer models can help us gain a systems perspective on these relationships and enable hypothesis-testing without engendering risk to women in these relationships. The purpose of this study was to develop a mathematical model of women's decision-making concerning her violent relationship and assess the impact of random stress and her controllable behaviors on violence and decision-making. An agent-based model was created using data from couples with history of violence, based upon results of multiple time series of partner violence. To explore factors that may alter model results, eight continuous variable parameters were created based upon significant (p ≤ .05) but discrepant (opposite directions) results from two prior time series studies. Overall, 13 unique patterns of violence in five categories were identified, but none of these categories included his violence alone without some additional influence (i.e., marital distance leading to marital distance the following day). To assess the potential impact that random stress and behaviors under her control (arguments, forgiveness, alcohol use, violence) could have on need-for-action and actions taken, the effects of variable parameter settings on these outcomes were also assessed. While random stress had little effect on outcomes, her interventions could have an impact but were pattern-specific. Her daily participation in arguments correlated with more violence. The need-for and actually taking action were at times independent of each other. This mathematical model yielded results that generally involved her violence with or without his violence. Thus, modeling partner violence and women's decision-making is possible, yielding diverse patterns. However, the complexity of interdependent predictors unique to each relationship means that targeted interventions will need to be couple-specific.

A method for estimating relative complexity of ambulatory care.

PURPOSE: We wanted to demonstrate a method for calculating the relative complexity of ambulatory clinical encounters. METHODS: Measures of complexity should reflect the complexity of the typical encounter and across encounters. If inputs represent the information transferred from the patient to the physician, then inputs include history, physical examination, testing, diagnoses, and patient demographics. Outputs include medications prescribed and other therapies used, including education and counseling, procedures performed, and disposition. The complexity of each input/output is defined as the mean input/output quantity per clinical encounter weighted by its inter-encounter diversity (range of possibilities used) and variability (visit-to-visit change). In complex systems, as the information in the input increases linearly, the complexity of the system increases exponentially. To assess the impact of the complexity of the encounter on the physician, we adjusted the estimated complexity by the duration-of-visit. RESULTS: Using the 2000 NAMCS database, we calculated input and output complexities for 3 specialties. Construct validity was affirmed by comparing the relative rankings of complexity against relative rankings using other complexity-related measures. Although total relative complexity was similar for family medicine (44.04 +/- 0.0024 SE) and cardiology (42.78 +/- 0.0004 standard error [SE]), when adjusted for duration-of-visit, family medicine had a greater complexity density per hour (167.33 +/- 0.0095 SE) than either cardiology (125.4 +/- 0.0117 SE) or psychiatry (31.21 +/- 0.0027 SE). CONCLUSIONS: This method estimates complexity based on the amount of care provided weighted by its diversity and variability. Such estimates could have broad use for interphysician comparisons as well as longitudinal applications.

Psychosocial effects of physical and verbal abuse in postmenopausal women.

PURPOSE: The purpose of this study was to examine the psychological effects of physical and verbal abuse in a cohort of older women. METHODS: This observational cohort study was conducted at 40 clinical sites nationwide that are part of the Women's Health Initiative (WHI) Observational Study. We surveyed 93,676 women aged 50 to 79 years using the mental health subscales and the combined mental component summary (MCS) score of the RAND Medical Outcomes Study 36-item instrument. RESULTS: At baseline, women reporting exposure to physical abuse only, verbal abuse only, or both physical and verbal abuse had a greater number of depressive symptoms (1.6,1.6, and 3 more symptoms, respectively) and lower MCS scores (4.6, 5.4, and 8.1 lower scores, respectively) than women not reporting abuse. Compared with women who had no exposure to abuse, women had a greater increase in the number of depressive symptoms when they reported a 3-year incident exposure to physical abuse only (0.2; 95% confidence interval [CI], -0.21 to 0.60), verbal abuse only (0.18; 95% CI, 0.11 to 0.24), or both physical and verbal abuse (0.15; 95% CI, -0.05 to 0.36); and they had a decrease in MCS scores when they reported a 3-year incident exposure to physical abuse only (-1.12; 95% CI, -2.45 to 0.12), verbal abuse only (-0.55; 95% CI, -0.75 to -0.34), and both physical and verbal abuse (-0.44; 95% CI, -1.11 to -0.22) even after adjustment for sociodemographic characteristics. CONCLUSION: Exposure to abuse in older, functionally independent women is associated with poorer mental health. The persistence of these findings suggests that clinicians need to consider abuse exposure in their older female patients who have depressive symptoms. Clinicians caring for older women should identify women at risk for physical and verbal abuse and intervene appropriately.

Is Readiness to Take Action Among Women in Violent Relationships a Catastrophic Phenomenon?

Taking action among women in violent relationships appears to involve sudden changes and reversals after periods of building stress, suggesting that decision making is a "catastrophic" phenomenon. This study sought to determine whether readiness-to-change is best modeled as a cusp catastrophic (CCM) phenomenon among women in violent relationships. A total of 143 women who experienced violence in the previous month completed baseline and end-of-study interviews assessing her hope, coping strategies, social network, and readiness-for-action (seeking help, taking legal action, and leaving) concerning the violence. Daily assessments of his violent behavior, forgiveness sought and given, and her perceived need-for-action were collected via telephone Interactive Voice Response for 8 weeks. Using regression analysis, the impact of factor-analyzed asymmetry (violence burden) and bifurcation (hope and cope, support, forgiveness, and number of children) variables on the outcomes (readiness-for-help, legal action, and leaving) was modeled, comparing the CCM against linear models to determine which model accounts for the most variance in each outcome. Cusp catastrophe models for all three actions accounted for more variance than either linear model comparison, but violence burden was only relevant to readiness-for-help and different bifurcation variables were at work for each action. While forgiveness was an important bifurcation factor in readiness-for-help and number of children served as the bifurcation factor for readiness-for-legal-action, readiness-to-leave was more complex with both number of children and hope-and-cope as bifurcation factors. Not only should we expect sudden changes in readiness but efforts to facilitate decision making should focus on addressing the bifurcation factors that may distort her interpretation of reality.

Psychometrics of the Violence Nonlinear Dynamics Scale.

OBJECTIVE: The trajectory of daily partner violence generally demonstrates nonlinear dynamics, and this nonlinearity is important to patient outcomes, as it is sometimes a stronger predictor of outcomes than violence frequency or severity. However, measurement of such dynamics is difficult, requiring complete time series data of sufficient length to yield stable measures. The purpose of this study was to develop a pencil-and-paper instrument to estimate violence nonlinearity and assess its psychometrics. METHODS: Adult women (N = 143) who experienced violence in the previous month were enrolled from 6 primary care clinics. Baseline surveys assessed factors known to correlate with nonlinearity (partner's control strategies, violence appraisal, hope, social support, coping style) and violence dynamics using a 30-item instrument based on traditional characteristics of complex adaptive systems. Participants completed daily assessments of the previous day's violence using interactive voice response via telephone for 8 weeks, with data collection occurring between August 2013 and March 2015. Three different measures of nonlinearity were computed: LZ complexity (algorithmic complexity), approximate entropy (lack of regularity), and Lyapunov exponent (sensitivity to initial conditions). RESULTS: Using factor analysis and reliability measures, the final 10-item Violence Nonlinearity Dynamics Scale (VNDS) was identified. The VNDS was found to have both internal consistency (0.817) and split-half reliability (0.796). In addition, the instrument demonstrated concurrent (correlating with both the combined nonlinearity factor score [r = 0.267] and Grassberger-Procaccia entropy [r = 0.338]) and construct (correlating with 9 of 13 previously identified nonlinearity correlates) validity. CONCLUSIONS: The VNDS has both reliability and validity and could facilitate the inclusion of nonlinearity assessment in both intimate partner violence research and clinical work.

Predictors of Perceived Need for and Actual Action Taking Among Women in Violent Relationships.

Decision-making of women in violent relationships is poorly understood. The study seeks to identify predictors of need-for-action and actions taken by women in violent relationships. The participants were 143 women who experienced violence in previous month from 6 primary care clinics. The methods involved multiple times series using daily assessments of household environment, marital relationship, concerns, violence, and need-for-action collected via telephone interactive voice response for 8 weeks. Outcomes include daily need-for-action and reports of actions taken. Same-day correlates and prior-day associations using vector autoregressions were sought, combined across subjects using meta-analytic techniques. Need for help depended on stalking, concern for child safety, forgiveness, and low perceived control; actually seeking help depended on sense of control with same-day stress and need for help. Need for legal action depended on concern for child safety and finances with desire to keep family together; actually taking legal action, correlated only with prior-day stalking and concerns about child safety but less about effects of violence on child. Need to leave depended on his violence, with concern about its effect on child, her forgiveness, and a low desire to keep family together, while actually leaving was primed by a day of his drinking, and triggered by same-day stress and need to leave, but lower levels of her drinking or his seeking forgiveness. Once gone, prior-day stalking and his alcohol use correlated with returning to the relationship. Taking action depends upon few prior- and same-day factors unique to each action.

Impact of spiritual symptoms and their interactions on health services and life satisfaction.

PURPOSE: Recent work suggests that the biopsychosocial model should be expanded to include the spiritual dimension as well. The purpose of this study was to assess the independent effects of spiritual symptoms and their interactions with biopsychosocial symptoms on health care utilization, extreme use of services, and life satisfaction among primary care patients. METHODS: Three hundred fifty-three adult waiting room patients at 2 primary care clinics completed the Biopsychosociospiritual Inventory (BioPSSI) as well as measures of life satisfaction and health care use. Hierarchical logistic regression analysis was performed with each outcome to determine whether adding spiritual symptoms and their interaction terms better accounted for outcomes than demographics, functional status, and chronic medical problems alone. RESULTS: Spiritual symptoms (alone or in interaction) were associated with 7 of the 10 outcomes and were particularly important to extreme use of health care services and life satisfaction. Among best-fit models, spiritual symptoms alone were significantly associated with any mental health use (beta =0.694, P < or = .05), fair-poor health status (beta =0.837, P < or = .05), and life lacking meaning (beta =1.214, P < or = .001). CONCLUSIONS: This study has shown the relevance of spiritual symptoms and their interactions to understanding health outcomes. Extreme utilization outcomes were related to the number of chronic problems, as well as to the social-spiritual interaction. Satisfaction outcomes were associated with physical and spiritual symptoms. These findings may have important implications for providing comprehensive, outcome-based care, as well as for modeling of research findings.

Chest pain and its importance in patients with panic disorder: an updated literature review.

CONTEXT: Chest pain is a common symptom in primary care settings, associated with considerable morbidity and health care utilization. Failure to recognize panic disorder as the source of chest pain leads to increased health care costs and inappropriate management. OBJECTIVE: To identify characteristics of the chest pain associated with the presence of panic disorder, review the consequences and possible mechanisms of chest pain in panic disorder, and discuss the recognition of panic disorder in patients presenting with chest pain. DATA SOURCES: Potential studies were identified via a computerized search of MEDLINE and PsycINFO databases and review of bibliographies. MeSH headings used included panic disorder with chest pain, panic disorder with coronary disease or cardiovascular disorders or heart disorders, and panic disorder with cholesterol or essential hypertension or tobacco smoking. STUDY SELECTION: The diagnosis of panic disorder in eligible studies was based on DSM criteria, and studies must have used objective criteria for coronary artery disease and risk factors. Only case control and cohort studies were included. DATA SYNTHESIS: Although numerous chest pain characteristics (believed to be both associated and not associated with coronary artery disease) have been reportedly linked to panic disorder, only nonanginal chest pain is consistently associated with panic disorder (relative risk = 2.03, 95% CI = 1.41 to 2.92). CONCLUSION: Chest pain during panic attacks is associated with increased health care utilization, poor quality of life, and phobic avoidance. Because the chest pain during panic attacks may be due to ischemia, the presence of panic attacks may go unrecognized. Ultimately, the diagnosis of panic disorder must be based on DSM criteria. However, once panic disorder is recognized, clinicians must remain open to the possibility of co-occurring coronary artery disease.

The association between panic disorder and coronary artery disease among primary care patients presenting with chest pain: an updated literature review.

CONTEXT: Although panic disorder is linked to hypertension and smoking, the relationship between panic disorder and coronary artery disease (CAD) is unclear. OBJECTIVE: To extend our understanding about the strength of the association between panic disorder and coronary artery disease and known cardiovascular risk factors. DATA SOURCES: Potential studies were identified via a computerized search of MEDLINE and PsycINFO databases and review of bibliographies. MeSH headings used included panic disorder with chest pain, panic disorder with coronary disease or cardiovascular disorders or heart disorders, and panic disorder with cholesterol or essential hypertension or tobacco smoking. STUDY SELECTION: The diagnosis of panic disorder in eligible studies was based on DSM-IV criteria, and studies must have used objective criteria for CAD and risk factors. Only case-control and cohort studies were included. DATA SYNTHESIS: Concerning the relationship between panic disorder and CAD, studies conducted in emergency departments found a relative risk [RR] of 1.25 (95% CI = 0.87 to 1.80), while those conducted in cardiology settings found an inverse relationship (RR = 0.19, 95% CI = 0.10 to 0.37). However, there is an inverse relationship between the prevalence of CAD in the study and the RR (r = -.554, p = .097), suggesting that, in primary care settings in which the prevalence of CAD is low, there may be a significant association between panic disorder and CAD. CONCLUSION: The association between panic disorder and CAD has several implications for primary care physicians managing patients with chest pain. When comorbid, the panic attacks may cause the patient with coronary disease to seek care but could also provoke a cardiac event. If one condition is recognized, a search for the other may be warranted because of the potential consequences if left undetected. The treatment approach to the panic disorder should be adjusted in the presence of comorbid CAD.

Community effects on mental health outcomes in subjects with and without panic attacks: results from a population-based study in san antonio, Texas.

OBJECTIVE: The purpose of this study was to determine the proportion of variance in mental health outcomes accounted for by census tract in community-dwelling adults with and without panic attacks. METHOD: This is a secondary analysis of a population-based study (conducted from August 1989 through December 1991) of subjects with and without panic attacks (DSM-III-R criteria) from 18 census tracts in San Antonio, Texas. All subjects completed measures of symptomatology, health care utilization, substance use, and quality of life. Subjects with panic attacks completed measures of panic-related disability and health care utilization, as well as measures of sense of control and secondary mental disorders. Hierarchical modeling was used to estimate the proportion of the variance of each outcome accounted for by census tract. RESULTS: Census tract accounted for less than 4% of the variance in psychiatric symptomatology and quality of life. However, census tract contributed to the proportional variance in panic-related outcomes, accounting for 13% of the variance of mental health utilization for panic symptoms when compared with individual-level variance. CONCLUSIONS: The use of more homogeneous levels such as block group could increase the measured multilevel effects found in this study. Studies of disease-specific mental health outcomes in multiple neighborhoods or clinics should consider whether multilevel effects are present.

It is complicated! - misunderstanding the complexities of 'complex'.

Terminology matters - as Lakoff emphasised, words and phrases evoke powerful images and frames of understanding. It is for that reason that we need to discern and use appropriately the term complex/complexity in the health science/professional/policy domain. Complex is the fashionable term used when in reality one means 'complicated', 'difficult to understand' or 'multiple simultaneous actions'. However, this is not what complex means. The Latin term means 'entwined/interwoven' - a structural characteristic describing systems. Complexity arises from the interactions between structurally connected entities - a functional characteristic of a system. The basis of scientific rigor is a clear understanding of a discipline's epistemology. Complexity refers to the emergence of outcomes from the interactions of a system's constituent components (and thus has nothing in common with the colloquial meaning of complicatedness).

Research or intervention or both? Women's changes after participation in a longitudinal study about intimate partner violence.

INTRODUCTION: The tensions between risk and benefit in research are particularly evident in studies about intimate partner violence. Recalling and relating traumatic experiences may deepen posttraumatic stress or relieve the burden of terrible events long borne in secret. In this article, we examine the effects of study participation in a longitudinal investigation of intimate partner violence using both qualitative and quantitative data. METHOD: Researchers enrolled 200 women in moderately violent intimate relationships and asked them to report about their relationships every day for 12 weeks. Daily, participants telephoned an automated survey and responded to 34 survey questions. They also completed baseline and end-of-study surveys and maintained telephone contact with 1 researcher weekly. Forty-2 participants completed qualitative end-of-study interviews to describe their relationships and their experiences in the study. RESULTS: Over 12 weeks, participants showed improvements in coping strategies, hope, and mental health, and increased readiness to leave their partners. In qualitative interviews, women reported gaining insight, feeling better emotionally, making behavioral changes, finding comfort in daily surveys, learning resources for help, and taking action to improve their lives. Fourteen percent left their partners by end-of-study; 35% sought counseling. DISCUSSION: The study's daily survey invited the participant to become more reflective about her relationship, which changed how she saw herself and her situation. The study methods also included weekly conversations with a compassionate researcher, allowing women to tell their stories. These 2 strategies may be incorporated into brief interventions for intimate partner violence in primary care settings. (PsycINFO Database Record

Randomized trial of the effect of research design and publication characteristics on physician change.

BACKGROUND: The primary barrier to translation of research into practice relates to physician use of research. If we are to succeed at translating research into practice, we must understand to which research characteristics and publication formats practitioners attend. OBJECTIVE: To determine which characteristics of research design (sample characteristics, study design) and publication (type of publication) are most influential on the acquisition of knowledge and change in behavior of family practitioners. METHOD: This randomized clinical trial was conducted in family practice offices on the 305 family physicians who scored lowest on a survey of knowledge about management of major depressive disorder (MDD), panic disorder, and generalized anxiety disorder (GAD). Subjects were randomly assigned to receive 1 of 3 MDD abstracts differing in study site, 1 of 3 panic disorder abstracts differing in study design, and 1 of 3 GAD communications differing in format. The main outcome measures (knowledge and management strategies) were assessed immediately following the intervention and again 6 months later. Data for the intervention survey were gathered in November 2002. RESULTS: This study found significant increases in knowledge level and use of first-line agents with all interventions; however, knowledge declined again after 6 months for both panic disorder and GAD. The only statistically significant interoption difference was that the POEM (patient-oriented evidence that matters) was associated with better retention of knowledge of the treatment of GAD. CONCLUSION: In conclusion, all interventions were associated with immediate increases in knowledge and use of first-line treatments. However, such gains were not retained for panic disorder and GAD. Except for better knowledge retention associated with POEM use, no consistent differences between intervention options were noted.