Adolescents, contraception and confidentiality: a national survey of obstetrician--gynecologists

The NERSH Questionnaire and Pool of Data from 12 Countries: Development and Description

Modern healthcare research has only in recent years investigated the impact of health care workers' religious and other values on medical practice, interaction with patients, and ethically complex decision making. So far, only limited international data exist on the way such values vary across different countries. We therefore established the NERSH International Collaboration on Values in Medicine with datasets on physician religious characteristics and values based on the same questionnaire. The present article provides (a) an overview of the development of the original and optimized questionnaire, (b) an overview of the content of the NERSH data pool at this stage and (c) a brief review of insights gained from articles published with the questionnaire. The pool at this stage consists of data from 17 studies from research units in 12 different countries representing six continents with responses from more than 6000 health professionals. The joint data pool suggests that there are large differences in religious and other moral values across nations and cultures, and that these values contribute to the observed differences in health professionals' clinical practices-across nations and cultures!

Caring for the Poor and Vulnerable: A Virtue Analysis of Mandated Health Insurance Compared with Healthcare Sharing Ministries

In the present time, what has been called the "medical-industrial insurance complex" in the United States needs reform. As health insurance in the United States remains inaccessible to millions of people, and as prices continue to rise, questions arise about the most moral ways to ensure delivery of health care especially to the most vulnerable populations. In this essay, I offer a virtue analysis of the moral implications of health insurance mandated by the US Government in contrast to an increasingly popular alternative to insurance, namely, healthcare sharing ministries. In part 1, I list some of the moral problems entangled with US Government-mandated health insurance, including injustice, disrespect for patient autonomy, limitations on patient freedom, exploitation of patients for profit, undermining of conscience rights, cooperation with evil, and scandal. In part 2, I discuss the issue of risk and then list some potential moral advantages to healthcare ministries, including respect for patient autonomy, conscience, and the religious freedom to witness to the Catholic faith in charity and solidarity.

Summary

Mandated health insurance the United States presents some moral challenges for conscientious Catholics, whereas healthcare sharing ministries appear to ameliorate some of these issues. Ultimately, the individual should have freedom to choose either insurance or healthcare sharing, given the different benefits and risks entailed by both.

Challenges of Confidentiality in Clinical Settings: Compilation of an Ethical Guideline

BACKGROUND

Respecting patients confidentiality and privacy are considered as the patients' rights. Confidentiality is the key virtue for trust building in physician-patient relationship. While law considers confidentiality as absolute except for legal situations, despite efforts to maintaining confidentiality, sometimes breaching confidentiality is unavoidable but not necessarily unethical. There is no Iranian unified ethical guideline to define clear approaches to patient confidentiality in clinical setting. To keep all medical data confidential it is necessary to identify the scope of the problem. In this study, we aimed at identifying the scope of the problem.

METHODS

This study was conducted in three phases including literature review, qualitative study (semi-structured interview) and focus group discussion. The literature review provided a framework for the second phase.

RESULTS

The content analysis of the interviews presented 3 main themes indicating problems in maintaining confidentiality in clinical setting including management issues, organizational ethics and physician-patient relationship.

CONCLUSION

Based on the results a draft guideline in confidentiality in clinical setting was prepared and finalized in focus groups discussions.

Influence of Contraception Use on the Reproductive Health of Adolescents and Young Adults

Oral contraceptives (OCs) are often prescribed to adolescents and young adults for the treatment of health problems and to avoid unwanted pregnancies. We hypothesized that the use of OCs, among adolescents and young adults, is associated with a greater likelihood of pregnancy, abortion, sexually transmitted diseases (STDs), pelvic inflammatory disease (PID), and sexual behaviors that will enhance those problems (i.e., earlier sexual debut and more sexual partners) than adolescents and young adults not using OCs. To test this hypothesis, data from 1,365 adolescents and young adults in the 2011-2013 National Survey of Family Growth (NSFG) were used to describe the influence of ever use of OCs on ever having sex, sexual debut, multiple sexual partners, STDs, PID, pregnancy, and abortion. A secondary purpose was to evaluate protective factors from unhealthy sexual practices like religiosity, church attendance, and intact families. We found that the "ever use" of OCs by US adolescents and young adults results in a greater likelihood of ever having sex, STDs, PID, pregnancy, and abortion compared with those adolescents and young adults who never used OCs. Furthermore, those adolescents who ever used OCs had significantly more male sexual partners than those who never used OCs, and they also had an earlier sexual debut by almost two years. Conversely, we found that frequent church attendance, identification of the importance of religion, and having an intact family among adolescents were associated with less likelihood of unsafe sexual practices. We concluded that the use of OCs by adolescents and young adults might be considered a health risk. Further research is recommended to confirm these associations. Summary: The purpose of this article was to show the correlation between contraceptive use in adolescents and negative sexual outcomes. We used data from the 2011-2013 NSFG and demonstrated that never married adolescents who used oral hormonal contraception were three times more likely to have an STD, have PID, and to become pregnant, and, surprisingly, ten times more likely of having an abortion compared to noncontracepting adolescents. These are outcomes that contraception is intended to prevent. These data also showed that the contraceptors had significantly more male partners than their contraceptive counterparts. Protective factors such as church attendance and family cohesiveness were associated with a decreased likelihood of sexual activity.

Privacy and Confidentiality Practices In Adolescent Family Planning Care At Federally Qualified Health Centers

CONTEXT

The confidentiality of family planning services remains a high priority to adolescents, but barriers to implementing confidentiality and privacy practices exist in settings designed for teenagers who are medically underserved, including federally qualified health centers (FQHCs).

METHODS

A sample of 423 FQHCs surveyed in 2011 provided information on their use of five selected privacy and confidentiality practices, which were examined separately and combined into an index. Regression modeling was used to assess whether various state policies and organizational characteristics were associated with FQHCs' scores on the index. In-depth case studies of six FQHCs were conducted to provide additional contextual information.

RESULTS

Among FQHCs reporting on confidentiality, most reported providing written or verbal information regarding adolescents' rights to confidential care (81%) and limiting access to family planning and medical records to protect adolescents' confidentiality (84%). Far fewer reported maintaining separate medical records for family planning (10%), using a security block on electronic medical records to prevent disclosures (43%) or using separate contact information for communications regarding family planning services (50%). Index scores were higher among FQHCs that received Title X funding than among those that did not (coefficient, 0.70) and among FQHCs with the largest patient volumes than among those with the smallest caseloads (0.43). Case studies highlighted how a lack of guidelines and providers' confusion over relevant laws present a challenge in offering confidential care to adolescents.

CONCLUSIONS

The organizational practices used to ensure adolescent family planning confidentiality in FQHCs are varied across organizations.

Confidentiality in Family Planning Services for Young People: A Systematic Review

CONTEXT

Family planning services are essential for reducing high rates of unintended pregnancies among young people, yet a perception that providers will not preserve confidentiality may deter youth from accessing these services. This systematic review, conducted in 2011, summarizes the evidence on the effect of assuring confidentiality in family planning services to young people on reproductive health outcomes. The review was used to inform national recommendations on providing quality family planning services.

EVIDENCE ACQUISITION

Multiple databases were searched to identify articles addressing confidentiality in family planning services to youth aged 10-24 years. Included studies were published from January 1985 through February 2011. Studies conducted outside the U.S., Canada, Europe, Australia, or New Zealand, and those that focused exclusively on HIV or sexually transmitted diseases, were excluded.

EVIDENCE SYNTHESIS

The search strategy identified 19,332 articles, nine of which met the inclusion criteria. Four studies examined outcomes. Examined outcomes included use of clinical services and intention to use services. Of the four outcome studies, three found a positive association between assurance of confidentiality and at least one outcome of interest. Five studies provided information on youth perspectives and underscored the idea that young people greatly value confidentiality when receiving family planning services.

CONCLUSIONS

This review demonstrates that there is limited research examining whether confidentiality in family planning services to young people affects reproductive health outcomes. A robust research agenda is needed, given the importance young people place on confidentiality.

Analysis of medical confidentiality from the islamic ethics perspective

Confidentiality is one of the old rules of the medical profession. While emphasizing the necessity of confidentiality in religious teachings, disclosure of other's secrets to commit sin deserves punishment hereafter known. Today, progress in medical science and invention of new diagnostic and therapeutic procedures, as well as the extent of information and disclosure of the secrets of the patients, have provided more than ever. After explaining the concepts and principles of confidentiality in medical ethics, the Islamic-oriented Virtue Ethics, in a comparative review, share the differences in these two sets of ethical review and explain the issue of confidentiality. In professional medical ethics, only the behaviors of health staff are evaluated and moral evaluation of the features cannot be evaluated, but in Islamic ethics, the moral evaluation of the features that are sensual, confidentiality is more stable, without any external supervision will maintain its efficiency.

Sex differences among obstetrician-gynecologists: a review of survey studies

Whether practice differences exist between the sexes is a question of clinical and educational significance. The obstetrician-gynecologist (ob-gyn) workforce has been shifting to majority women. An examination of sex differences in ob-gyn practice contributes to the discussion about how the changing workforce may impact women's healthcare. We sought to review survey studies to assess whether there are specific topics in which differences in attitudes, opinions, and practice patterns between male and female ob-gyns are apparent. We conducted a systematic review to identify all survey studies of ob-gyns from the years 2002-2012. A total of 93 studies were reviewed to identify statements of sex differences and categorized by conceptual theme. Sex differences were identified in a number of areas. In general, women report more supportive attitudes toward abortion. A number of differences were identified with regard to workforce issues, such as women earning 23% less than their male counterparts as reported in 1 study and working an average of 4.1 fewer hours per week than men in another study. Men typically provide higher selfratings than women in a number of areas. Other noted findings include men tending toward more pharmaceutical therapies and women making more referrals for medical conditions. Although a number of areas of difference were identified, the impact of such differences is yet to be determined. Additional research may help to clarify the reasons for such differences and their potential impact on patients.

TARGET AUDIENCE

Obstetricians and gynecologists, family physicians Learning Objectives: After completing this CME activity, physicians should be better able to determine how the relevance of studying sex differences among physicians, specifically ob-gyns, can help improve patient care, assess whether there are topical areas in which male and female ob-gyns have reported different beliefs, practices, attitudes, and opinions, and examine how the limitations of survey studies and systematic reviews can affect the findings of these studies and reviews.

General internists' preferences and knowledge about the care of adult survivors of childhood cancer: a cross-sectional survey

BACKGROUND

Adult childhood cancer survivors (CCSs) are at high risk for illness and premature death. Little is known about the physicians who provide their routine medical care.

OBJECTIVE

To determine general internists' self-reported attitudes and knowledge about the care of CCSs.

DESIGN

Cross-sectional survey.

SETTING

Mailed survey delivered between September 2011 and August 2012.

PARTICIPANTS

Random sample of 2000 U.S. general internists.

MEASUREMENTS

Care preferences, comfort levels with caring for CCSs (7-point Likert scale: 1 = very uncomfortable, 7 = very comfortable), familiarity with available surveillance guidelines (7-point Likert scale: 1 = very unfamiliar, 7 = very familiar), and concordance with Children's Oncology Group Long-Term Follow-Up Guidelines in response to a clinical vignette.

RESULTS

The response rate was 61.6% (1110 of 1801). More than half the internists (51.1%) reported caring for at least 1 CCS; 72.0% of these internists never received a treatment summary. On average, internists were "somewhat uncomfortable" caring for survivors of Hodgkin lymphoma, acute lymphoblastic leukemia, and osteosarcoma. Internists reported being "somewhat unfamiliar" with available surveillance guidelines. In response to a clinical vignette about a young adult survivor of Hodgkin lymphoma, 90.6% of respondents did not appropriately recommend yearly breast cancer surveillance, 85.1% did not appropriately recommended cardiac surveillance, and 23.6% did not appropriately recommend yearly thyroid surveillance. Access to surveillance guidelines and treatment summaries were identified as the most useful resources for caring for CCSs.

LIMITATION

Findings, based on self-report, may not reflect actual clinical practice.

CONCLUSION

Although most general internists report involvement in the care of CCSs, many seem unfamiliar with available surveillance guidelines and would prefer to follow patients in collaboration with a cancer center.

PRIMARY FUNDING SOURCE

National Cancer Institute.

Adderall for All: A Defense of Pediatric Neuroenhancement

I argue that young patients should be able to access neuroenhancing drugs without a diagnosis of ADHD. The current framework of consent for pediatric patients can be adapted to accommodate neuroenhancement. After a brief overview of pediatric neuroenhancement, I develop three arguments in favor of greater acceptance of neuroenhancement for young patients. First, ADHD is not relevantly different from other disadvantages that could be treated with stimulant medication. Second, establishing a legitimate framework for pediatric neuroenhancement would mitigate the bad effects of diversion and improve research on neuroenhancement and ADHD. Third, some pediatric patients have rights to access neuroenhancements. I then consider several objections to pediatric neuroenhancement. I address concerns about addiction, advertising, authentic development, the parent-child relationship and equal opportunity and conclude that these concerns may inform a framework for prescribing neuroenhancement but they do not justify limits on prescribing.

Counseling adolescents about contraception: towards the development of an evidence-based protocol for contraceptive counselors

Research on contraceptive counseling of adolescents in clinics and service delivery settings is considered. The provider context as well as the developmental context of adolescence is characterized and their implications for contraceptive counseling are explicated. After reviewing research on the effectiveness of contraceptive counseling, it was concluded there is little empirical evidence to support the efficacy of current practices considered as a totality. Twelve principles for effective contraceptive counseling were then derived as a basis for building an evidence-based contraceptive counseling protocol for adolescents.

Obstetrician-gynecologists' beliefs about safe-sex and abstinence counseling

OBJECTIVE

To examine obstetrician-gynecologists' beliefs about safe-sex and abstinence counseling.

METHODS

Between October 2008 and January 2009, a survey was mailed to a national randomized sample of 1800 practicing US obstetrician-gynecologists. Study variables were agreement with 2 statements. (1) "If physicians counsel patients about safe-sex practices, the patients will be less likely to engage in risky sexual behaviors". (2) "If physicians counsel patients about abstinence, the patients will be much less likely to engage in sexual activity". Covariates included demographic, clinical, and religious characteristics of the physician.

RESULTS

The response rate was 66% (1154/1760 eligible physicians). Most respondents somewhat (62%) or strongly (25%) agreed that counseling patients about safe-sex practices makes patients less likely to engage in risky sexual behaviors. Fewer agreed strongly (3%) or somewhat (28%) that counseling patients about abstinence makes patients less likely to engage in sexual activity. The belief that safe-sex counseling reduces risky behaviors was less common among males (odds ratio [OR] 0.6) and more common among immigrants (OR 2.0). Religious physicians were more likely to believe that abstinence counseling reduces sexual activity (OR 2.2-5.3).

CONCLUSIONS

Most obstetrician-gynecologists believed that counseling about safe sex is effective, and a significant minority endorsed abstinence counseling.