Social determinants of health

To the Editor:Recent reports from the World Health Organization1 and from Australian agencies2,3 emphasise the urgency of improving health service response to family violence. Understanding the victim and survivor experience and perpetrator patterns is essential to improving health practitioners’ capacities for recognising and responding appropriately to family violence.1,3 Although there is an increasing awareness of the severity of health consequences of family violence,1,4 there is little standardisation of terminology within the national and international literature. The Royal Australian College of General Practitioners recognises physical, emotional, economic, social, sexual, psychological, verbal and spiritual abuse as forms of family violence.4 Family violence includes any violence or abuse that occurs within a family,4 including between partners, parents, children, siblings, uncles or aunts, cousins, grandparents and in-laws. Complexities arise because of the pervasive nature of violence when trying to differentiate the types of violence and individual victims. For example, studies show that 50% of children who experienced physical abuse and 40% of children who experienced sexual abuse have a mother who experienced intimate partner violence.5 “Domestic violence” emphasises the place of the violence, whereas “family violence” emphasises the relationships between the victim and the perpetrator. “Intimate partner violence” refers to the “behaviour within an intimate relationship” of current or former partners (including same-sex relationships) causing “physical, emotional, sexual, economic and social harm to those in the relationship”.4 Family violence (Box) encompasses domestic violence, intimate partner violence and sibling violence. Cases of child neglect, child abuse, child sexual abuse, sexual assault and rape may occur in the context of family violence; however, these forms of violence may also occur outside the context of the family, such as institutional abuse or stranger violence. Likewise, older people abuse, which can include sexual abuse and rape, may occur in the context of family violence and also in institutional contexts, in the context of service provision or between people who have no familial or institutional relationships. An increased understanding of the terminology used in the research literature enhances the capacity for delivering high quality care to women, children and men experiencing the health impacts of family violence. Box – Terminology for family violence Figure by Debbi Long and Serena Lee.

Debbi Long · Serena Lee · Jan Y Coles

Editor’s note: The Lancet recently published an important Australian randomised controlled trial of robotic and open prostatectomy. We publish the following non-commissioned correspondence by Hutchison and colleagues together with an invited response from the corresponding author of the trial, Robert Gardiner, because of the relevance of the debate to Australian health care. To the Editor: Robotic prostatectomy took off quickly, despite the cost. In Australia, most prostatectomies are now done with a robot that costs almost $10 000 in capital and maintenance per procedure, or between $442 and $3548 more than an open prostatectomy.1 The robotic option was meant to reduce side effects relating to impotence and incontinence; however, preliminary findings from the world’s first randomised controlled trial suggest that this is not the case.2 Uptake of innovative surgery tends to outpace evidence because it is hard to design and run randomised studies. In addition, placebo surgery is rare and controversial, and recruitment is challenging, as surgeons and patients often prefer one option. Trial results may also be difficult to interpret: if the same surgeon performs both operations, they may be better at one; or if different surgeons operate, one may be superior.3 Australia is not immune to these challenges, despite local initiatives to improve quality of care4 and evaluate the benefits of the robotic procedure.5 The industry understands this. Intuitive Surgical aggressively marketed its robot while the jury was still out on its comparative benefits. Celebrity stories have also driven demand; for instance, radio personality Alan Jones has been an outspoken advocate.6 But even when evidence commends a surgical innovation, introducing it to the public health care system may create or exacerbate inequity. Suppose that the robot, or some successor, eventually proves superior to alternatives. Expensive equipment and difficult procedures require high patient throughput to justify the costs and maintain surgeons’ skills, so they tend to be concentrated in the biggest, busiest hospitals. Therefore, patients in regional areas are often expected to travel for treatment, with little or no financial support; and the barrier is even higher for people who do not have the social and economic resources to get themselves to a big city hospital.7 We should resist the hype of a new technology and wait for good evidence before expending scarce health care dollars. This will sometimes mean lagging behind other countries and saying no to patients. However, it will also mean safeguarding patients and the public purse from innovations that turn out to be no better, or maybe worse, than existing options. Moreover, when a new technology is introduced, we should also fund the supports that people need to access it.

Katrina Hutchison · Drew Carter · Jane Johnson

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Robyn Hopkins · Kate A Dolan

In reply

Yuejen Zhao

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Uma Jatkar · Mitchell D Anjou · Hugh R Taylor

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Anna M Klinken Whelan · Jan E Ritchie · Carina Hickling

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Craig Cumming · Stuart A Kinner · David B Preen