Background 30% of UK primary care consultations relate to gynaecology. Servicewomen access healthcare in general more frequently than their NHS counterparts, so military medical professionals are thus more likely to be managing significant numbers of gynaecological conditions on deployed military operations. Little is known about their confidence and preparedness in managing female-specific complaints. This study aimed to assess clinicians' views as to their training and confidence in managing gynaecological conditions; to gauge the need for developing treatment guidelines and specific training opportunities and to establish the frequency and scope of female-specific presentations on a military deployment.
Method A retrospective questionnaire-based service evaluation of clinical practice was undertaken via an anonymised questionnaire, which was distributed to 44 randomly selected Afghanistan-based UK military medical professionals in May 2014. All clinicians with sick parade duties were eligible for inclusion.
Results 23 (57.5%) military medical professionals reported managing one or more gynaecological conditions per month while deployed and 4 (25%) doctors treated more than 5 per month. Of those questioned, 21 (52.5%) felt underprepared to manage gynaecological conditions confidently. Two-thirds would attend a short course on the subject, 13 (32.5%) thought gynaecology should be included in medical predeployment training (PDT) and 26 (65%) wanted management guidelines included within Clinical Guidelines for Operations (CGOs).
Conclusions Military medical professionals treat servicewomen with gynaecological problems on deployment. Half of the medical professionals questioned felt they had insufficient training and experience to do so confidently. Training packages, as part of PDT or stand alone, were reported as acceptable methods of improving confidence and knowledge. The common gynaecological acute presentations were suggested as topics to be included in CGOs.
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Gynaecological consultations are not uncommon on operational deployment.
Many military medical professionals feel they have insufficient training and experience to manage gynaecological presentations confidently.
Training packages are acceptable methods of improving confidence and knowledge.
Common acute gynaecological conditions were suggested as topics to be included in Clinical Guidelines for Operations.
Women represent nearly 10% of the UK Armed forces, with numbers steadily increasing.1
In general, women in the UK access primary healthcare (PHC) on average six times a year,2 while the UK military women seek healthcare consultation more frequently than this.3 In the PHC setting, gynaecological complaints account for up to one-third of consultations,4 in the deployed setting women's health has been noted to be responsible for up to 26% of female medical consultations.5 Women's health encompasses all common gynaecological conditions including, but not limited to, menstrual dysfunction, contraception, early pregnancy problems, pelvic pain and vaginal discharge and sexual health.
No data regarding the frequency or nature of gynaecological consultations among the UK Army females to PHC on operations are available in the literature. Generally, there is very limited useable data available regarding any aspect of deployed women's health or healthcare. EPINATO data do not divide information by gender, or provide breakdown by category of consultation problem. This knowledge gap was identified by the Women's Health Advisory Group (WHAG) in January 2014, at a time when operational deployment (Op HERRICK) was ongoing, but shortly due to end.
Currently, there are no military guidelines available for managing women’s health conditions on operations6 ,7 and obstetric and gynaecology (O&G) emergency guidelines are not currently included in Clinical Guidelines for Operations (CGOs).6 Little is known about the confidence and preparedness of deployed military medical professionals providing women's healthcare on operations.
The aims of this study were to assess clinicians' opinion regarding adequacy of training and perceived confidence in managing female-specific presentations; to assess the need and appetite for development of treatment guidelines or further training opportunities; to obtain a snapshot of gynaecological work being undertaken on an operational tour and to gauge the confidence with which it was being managed by military medical professionals across all employment groups (doctors, nurses and combat medical technicians (CMTs)).
A retrospective questionnaire-based service evaluation of current clinical practice was undertaken among the UK Medical Group clinicians. The structured questionnaire used a combination of binary option answers, Guttman scale with checkmark answers and unstructured questions with space for free text. Questions relating to provider demographics; training received; symptoms encountered; equipment and resources available were included.
Question type, content and wording, placement and response format were agreed within the WHAG. All military medical professionals with sick parade duties, across all three services (Army, Navy, Royal Air Force (RAF)) and all areas of employment (PHC, emergency department, wards and forward locations) were eligible for inclusion. This anonymous, voluntary, group administered questionnaire was distributed in May 2014 to a sample population of military medical practitioners on Op HERRICK 19B. Responses were collected both in paper and electronic form, and returned to the UK for analysis.
All 44 (100%) of the distributed questionnaires were returned and all bar one were complete; three (7.0%) were excluded as the respondents had no sick parade duties, leaving 40 questionnaires for analysis.
Demographic breakdown of practitioners
The 40 participants consisted of 13 (32.5%) CMTs (or Naval/RAF equivalent), 11 (27.5%) nurses and 16 (40.0%) doctors. In total, 20 (50%) of the respondents worked within PHC; 16 (40%) in large, well-established PHC settings (Camp Bastion, Camp Souter and Camp Qargha) and 4 (10%) were from forward (Role 1) locations; the rest were employed in the hospital setting.
Over half (23, 57.5%) of medical professionals had managed at least one gynaecological condition per month during their tour and four (80%) of those managing five or more gynaecological conditions a month were doctors (Table 1).
All common gynaecological conditions were seen (Figure 1). Menstrual disorders (menorrhagia, dysfunctional uterine bleeding, dysmenorrhoea) accounted for over 40% of all presenting complaints.
Training and resources
Of those questioned, 21 (52.5%) felt they had insufficient, or no training, to manage gynaecological conditions during their medical training or PDT; 26 (65%) stated they would attend a short course to improve their knowledge on the subject and 13 (32.5%) stated women's health should be part of PDT. Sources of clinical information were similarly available across the clinical employment groups (Table 2).
Nearly two-thirds (26, 65%) of respondents felt that a women's health section within CGOs would be beneficial and suggested topics have been tabulated (Table 3). Overall, 22 (55%) were satisfied they had sufficient equipment to adequately manage gynaecological conditions.
This service evaluation demonstrates that the UK servicewomen seek gynaecological advice from all military medical professionals while deployed. Many of those treating women feel underconfident to do so independently and seek specific guidance and training in advance of deployment.
With the lack of published information available to date, this questionnaire provides a broader overview of exposure to, and clinician attitude towards, gynaecological consultations in a deployed setting. The main theme identified by the authors was that the problems women face on deployment are largely those encountered at home but that medical professionals caring for them feel more vulnerable and need greater support.
This review of clinical practice did, however, contain several limitations. The response rate was unusually high (97.7%). Although the questionnaire was voluntary, there may have been a degree of perceived coercion as the distributor was a high-ranking Medical Officer, potentially questioning whether the responses were affected by acceptability bias or a true expression of personal opinion. However, as nearly all were completed fully, this might suggest that those responding were actually keen for their views on this topic to be known. The phraseology in questions may have been subconsciously loaded or biased as all members of WHAG have an interest in improving military women's health, although informal feedback from practitioners did not suggest this.
The results may be adversely influenced by the relative proportions of medical professionals questioned. Doctors were over-represented, compared with numbers deployed; however, relatively equal numbers of all medical professionals were included and subanalysis by employment group attempted to eliminate this, as well as identify group-specific trends.
Op HERRICK 19B was towards the end of the campaign; it was less kinetic than earlier tours, and a more mature theatre of operations with arguably the best medical provision to date. Presentation with gynaecological disorders might well have been more common than in previous tours, although determining this will now be impossible. A patient-based questionnaire would have been useful in understanding patient attitudes to gynaecological care provision as their experiences and expectations would have further aided understanding of how to improve the services provided.
At present, there is limited military guidance for managing women’s health conditions on operations; however, 14 (35%) responded that they used military policy as reference. CGOs6 do not cover O&G, there is little information in JSP-9507 and only three leaflets covering sexual health, chlamydia and cervical smears. It may be that respondents were referring to the ‘Medic’s Primary Healthcare Treatment Protocols’,8 which cover dysmenorrhoea, menorrhagia and vaginal discharge, but are intended for firm base consultations.
Even with these limitations, there is now a greater understanding of the problems military medical practitioners encounter on operational tour regarding women's health conditions.
Female military personnel deployed on operations will seek medical advice regarding women's health problems from all military medical professionals, many of whom feel they have insufficient training to deal with these presentations confidently. Most military medical professionals agree that inclusion of O&G within CGOs would be beneficial in guiding management. Standalone courses or specific training as part of PDT are seen as acceptable methods to increase skill, confidence and exposure to managing acute gynaecological presentations.
We thank Col S Dalal and Capt PE Wilson for questionnaire distribution on Op HERRICK 19B and the Women's Health Advisory Group for ratifying the questionnaire.
- Received July 27, 2016.
- Revision received March 22, 2017.
- Accepted March 26, 2017.
Contributors RS conceived the questionnaire objectives. MT and SE designed the questionnaire, contributed to data analysis and interpretation. MT reviewed literature, drafted all sections of the article. RS and SE provided critical and intellectual comment to revise the drafts. All authors approved the version of the article submitted for consideration.
Competing interests None declared.
Ethics approval Service evaluation registered and approved by the Academic Department of Military Emergency Medicine at the Royal Centre for Defence Medicine.
Provenance and peer review Not commissioned; externally peer reviewed.
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