Does physician bias affect the quality of care they deliver? Evidence in the care of sexually transmitted infections

Facilitators, Barriers, and Opportunities to Implementing Sexual History Screening and Human Immunodeficiency Virus Pre-Exposure Prophylaxis at a Federally Qualified Health Center

Sexual history screening (SHS) is recommended to determine risk for acquisition of human immunodeficiency virus (HIV) and eligibility for pre-exposure prophylaxis (PrEP). SHS and PrEP are underutilized, sequential screening, and prevention practices. This study aimed to understand factors impacting the implementation of SHS and PrEP at a multi-site federally qualified health center (FQHC) in Connecticut. Guided by the Consolidated Framework for Implementation Research, semistructured interviews were conducted on Zoom with primary care providers (PCPs), medical assistants, clinical leadership, and PrEP navigators. Convenience and purposive sampling took place via email until thematic saturation was achieved. Thematic analysis was conducted. Twenty-two participants were interviewed for this study. PCPs lacked knowledge and reported limited or no use of SHS to determine patients' level of HIV risk, which may explain why most PCPs relied on patients to request PrEP. While PCPs perceived organizational support to prescribe PrEP, clinical staff were unaware of structural resources. Lastly, participants described a vertical trajectory of influence from external sources (policies and insurance) to time allocated to appointments that limits their ability to implement SHS and PrEP, further complicated by the electronic health record and disparities in structural resources across clinical sites. This study provides foundational evidence for future research on implementation strategies to improve HIV prevention through universal, comprehensive SHS to identify patients for PrEP. Overcoming barriers to SHS and PrEP, particularly in clinical settings such as FQHCs that care for vulnerable populations, may improve identification, prevention, and treatment of HIV and aid in ending the HIV epidemic.

Unravelling Delay in Care for Sexually Transmitted Infections-Related Symptoms in a Developing Country Setting (Jamaica)

BACKGROUND

Sexually transmitted infections (STIs) and STI treatment remain a challenge in public health. There is little understanding of related factors influencing health seeking behaviour and delay of care among clinic attendees in Jamaica.

AIM

To determine socio-demographic profile of clinic attendees with STI and identify factors associated with delay in seeking care for STI-related symptoms.

METHODS

A cross-sectional study was done. 201 adult patients presenting with STI symptoms from four health centres in Kingston and St Andrew were selected. A 24-item interviewer-assisted questionnaire was used to obtain data on socio-demographic characteristics, patients' symptoms and duration, previous STIs, knowledge of complications and seriousness of STIs, and factors influencing decision to seek medical care.

RESULTS

Almost 75% delayed seeking care for STIs. Recurrent STIs was identified in 41% of patients. 'Could not find time' was the most commonly reported reason for delay in seeking care (36%). Females were 3.4 times more likely to delay seeking care for STI symptoms than males (OR 3.42, 95% CI: 1.73-6.73). Those with primary level education and below were 5 times more likely to delay seeking care for STI symptoms than those with at least secondary level education (OR 5.05, 95% CI: 1.09-23.46). Participants viewed staff as confidential (68%) and 65% thought health-care workers spent adequate time during consultations.

CONCLUSION

Lower education level and the female gender are associated with delay in seeking care for STI-related symptoms. These factors should be considered when developing interventions to reduce delay in care for STI-related symptoms.

What sexual and reproductive health issues do young people want to discuss with a doctor, and why haven't they done so? Findings from an online survey

OBJECTIVE

Young people are a priority group for sexual and reproductive health (SRH) care. We considered which SRH topics young Australians want to discuss with a general practitioner (GP) and explored barriers they encounter to discussing these issues.

METHODS

We conducted an online survey (2nd May - 21st June 2022) of Australians aged 16-29 years. Participants were asked to identify from a list of SRH topics which they wanted to discuss, but never had, with a GP. Those who selected any topic/s (with 'undiscussed SRH issues') were asked a free-text follow-up question about what prevented them from discussing issues. We explored characteristics associated with having undiscussed issues using multivariate logistic regression. Free-text comments were analysed using content analysis.

RESULTS

A total of 1887 people completed relevant survey questions. Most (67.1 %) were women and 48.5 % were heterosexual. Two-thirds (67.0 %) had a usual GP. Nearly half (45.6 %) had undiscussed issues. Most commonly, women wanted to discuss cervical screening and sexual problems, and men wanted to discuss sexual problems and STIs. Participants who were male, older, heterosexual, and with a usual GP were least likely to have undiscussed issues. Barriers to accessing care for SRH were identified from free-text comments, including discomfort, lack of opportunity, fear of negative outcomes, low priority of SRH issues, and perceptions about the role and expertise of GPs.

CONCLUSIONS

Many young people would welcome more preventative SRH care. Young people may be reassured that all issues, including sexual difficulties and dysfunction, are appropriate to discuss with a GP.

Patient and Provider Demographics and the Management of Genitourinary Tract Infections in the Emergency Department

Introduction

Urinary tract infections (UTIs) and sexually transmitted infections (STIs) can have overlapping signs, symptoms, and findings on urinalysis. Our objective was to determine if patient or provider demographics are associated with differences in the diagnosis and management of UTIs and STIs in the emergency department (ED).

Methods

We analyzed 38,062 ED patient encounters from a single healthcare system between April 18, 2014, and March 7, 2017. All encounters were women ≥18 years of age and not admitted to the hospital. We performed logistic regression using patient and provider demographics, laboratory testing results, ED triage data, and ED diagnoses.

Results

The patient's age, race, and marital status were not associated with having an ED UTI diagnosis with a urine culture ≥10,000 colony forming units (CFUs)/mL (vs. <10,000 CFUs/mL). Patient race and the sex of the ED provider were not associated with differences in empiric antibiotic treatment for gonorrhea and chlamydia during the ED encounter. Patient's race and the sex of the ED provider were also not associated with discordance between empiric antibiotic therapy given in the ED and the results of gonorrhea and chlamydia tests that resulted following the ED encounter.

Conclusion

In our multivariate analyses, we did not observe that the patient's race resulted in significant differences in the diagnosis of UTIs with bacteriuria ≥10,000 CFU/mL or differences in the empiric treatment of gonorrhea and chlamydia infections among those tested for the infection in the ED. The patient's age and marital status, but not the provider's sex, were significantly associated with differences in the management of gonorrhea and chlamydia.

Associations Between Sexual History Documentation in Electronic Health Records and Referral to Pre-Exposure Prophylaxis Navigator on Prescription of Pre-Exposure Prophylaxis at a Multi-Site Federally Qualified Health Center

This cross-sectional study examined the relationships between sexual history screening (SHS) and referrals to a pre-exposure prophylaxis (PrEP) navigator (non-clinical staff member who assists patients in overcoming structural barriers to PrEP) on the proportion of days covered by PrEP for adult patients at a federally qualified health center. Patients' sociodemographics, PrEP prescriptions, referral to a PrEP navigator, and SHS data were extracted from the electronic health record (EHR). The analytic sample was 214 adult patients who were human immunodeficiency virus (HIV) negative and taking PrEP to prevent infection from January 2016 to December 2019. Mixed-effects negative binomial models were conducted accounting for clustering by patients' primary care providers. Documentation of SHS was associated with a higher proportion of days covered by PrEP (incidence rate ratio = 1.44, 95% confidence interval: 1.17-1.77). There was no significant effect of having a referral to the PrEP navigator on the proportion of days covered by PrEP, nor did having a referral to the PrEP navigator moderate the relationship between having SHS documented in the EHR and the proportion of days covered by PrEP. This study is the first to investigate the relationship between having sexual history documented in the EHR, referrals to a PrEP navigator, and their combined effect on the proportion of days covered by PrEP. Results of this study provide foundational evidence for future studies examining SHS as an opportunity to improve PrEP access and adherence and indicate the need for additional research exploring the value of PrEP navigators as an implementation strategy to overcome social and structural barriers to care.

Review of current 2SLGBTQIA+ inequities in the Canadian health care system

Gender identity and sexual orientation are determinants of health that can contribute to health inequities. In the 2SLGBTQIA+ community, belonging to a sexual and/or gender minority group leads to a higher risk of negative health outcomes such as depression, anxiety, and cancer, as well as maladaptive behaviors leading to poorer health outcomes such as substance abuse and risky sexual behavior. Empirical evidence suggests that inequities in terms of accessibility to health care, quality of care, inclusivity, and satisfaction of care, are pervasive and entrenched in the health care system. A better understanding of the current Canadian health care context for individuals of the 2SLGBTQIA+ community is imperative to inform public policy and develop sensitive public health interventions to make meaningful headway in reducing inequity. Our search strategy was Canadian-centric and aimed at highlighting the current state of 2SLGBTQIA+ health inequities in Canada. Discrimination, patient care and access to care, education and training of health care professionals, and crucial changes at the systemic and infrastructure levels have been identified as main themes in the literature. Furthermore, we describe health care-related disparities in the 2SLGBTQIA+ community, and present available resources and guidelines that can guide healthcare providers in narrowing the gap in inequities. Herein, the lack of training for both clinical and non-clinical staff has been identified as the most critical issue influencing health care systems. Researchers, educators, and practitioners should invest in health care professional training and future research should evaluate the effectiveness of interventions on staff attitudinal changes toward the 2SLGBTQIA+ community and the impact on patient outcomes.

Are Medical Students More Prejudiced? Comparison of University Students' Attitudes Towards Sexual Minorities by Faculties and Cultural background: A Study From Hungary

Sexual and gender minorities often experience discrimination or stigmatization during health encounters. When patients feel stigmatized, they are more likely to delay seeking help and it affects patient cooperation and compliance, thus undermining therapeutic efficacy itself. We examined knowledge and attitude toward LGBT+ people among Hungarian (n = 743) and foreign (n = 130) medical students of the four Hungarian medical universities and 188 students from other faculties. Homonegativity and inadequate knowledge about sexual minority individuals are correlated with male gender, conservative political views, religiosity, religious behavior, and the absence of LGBT+ acquaintance. Medical students show more negative attitudes than students from other disciplines, although foreign medical students were more accepting than Hungarian program students. Further investigation of sexual minority-related content of the Hungarian medical education and revising the written and hidden curriculum would be desired, as well as collecting data from postgraduate students, physicians, and wide range of university faculties.

"It's Always among Us. I Can't Act Like It's Not.": Women College Students' Perceptions of Physicians' Implicit Bias

Physicians have an opportunity to provide accurate and timely information about sexual behavior to individuals in their care. However, many young people, and in particular college women, are reticent to talk to their physicians about sexual behavior. One explanation for this reticence may be the fact that physicians' implicit bias has the potential to denigrate communication between physicians and patients. However, little is known about how patients perceive physicians' implicit bias, or to what extent it shapes a patient's beliefs about communicating with their physician. Qualitative analysis of in-depth, semi-structured interviews was used to describe and explain the way women college students perceive issues concerning physicians' implicit bias. Results were interpreted through the lens of Communication Privacy Management theory and revealed that participants either avoided or limited communication with a physician as a result of anticipating implicit bias. Major themes included "untangling identity and the effects of physicians' implicit bias" and "seeking to understand physicians' cognition and emotion." These findings have the potential to improve communication interventions both for women college students and healthcare professionals by introducing evidence of patients' perceptions of implicit biases along the intersection of race, young age, sexuality, and female gender in physician-patient communication about sexual behavior.

[Evaluation of the approach to sexuality in primary care consultations in Spain: A multicentre comparative study (2004-2017)]

OBJECTIVE

To describe how sexuality is addressed in general practitioners' (GP) consultations, as well as to compare the results of a questionnaire carried out in 2017 that updated the data obtained from a 2004 survey.

MATERIAL AND METHODS

Descriptive, analytical, multicentre study with 2cross-sections. Of the 3,500 GP who met the selection criteria (holding current accreditation as a resident tutor and being an active worker at the time of the study), 598 doctors participated in the survey in 2017 and 357 in 2004.

RESULTS

In both studies, the majority (98.6% in 2017 and 96% in 2004) consider that the sexual sphere is an important component in people's health, but less than half (40, 6% in 2017 and 21.6% in 2004) systematically recorded it in their clinical history. The main source of training in sexuality in both studies were continuing education courses (50.6% in 2017 and 31.4% in 2004). The main barriers found in both studies were lack of time (85.5% in 2017 and 82.1% in 2004) and lack of training (75.2% in 2017 and 74.5% in 2004).

CONCLUSIONS

GP are aware of the importance of sexuality in people's health, despite this, few professionals systematically record it in their medical records. The main source of training in sexuality is continuing education courses, which has increased in recent years. The main barriers in both studies are lack of time and poor training.

Digital Scarlet Letters: Sexually Transmitted Infections in the Electronic Medical Record

ABSTRACT

The harms of implicit bias in clinical settings are acknowledged but poorly understood and difficult to overcome. We discuss how structural components of electronic medical record (EMR) user interfaces may contribute to sex and gender-based discrimination against patients via constant, duplicative presentation of stigmatizing sexually transmitted infection (STI) data irrespective of clinical significance. Via comparison with symbolism and representative quotes in Hawthorne's 1850 novel The Scarlet Letter, we propose a metaphor to examine how EMRs function as a platform for moral judgment, which may display an indelible "scarlet letter" for pregnant patients with STI history. We consider whether current depictions of STIs in EMRs are structurally unjust and may contribute to biased treatment by directing attention to violations of hegemonic sex/gender norms regarding sexual behavior and thus triggering moral judgments of maternal fitness. We conclude with recommendations for how to address these challenges to improve ethical stewardship of sensitive sexual/reproductive health data.

Citizenship and Social Responsibility in Surgery: A Review

Importance

Social determinants of health have been shown to be key drivers of disparities in access to surgical care and surgical outcomes. Though the concept of social responsibility has received growing attention in the medical field, little has been published contextualizing social responsibility in surgery. In this narrative review, we define social responsibility as it relates to surgery, explore the duty of surgeons to society, and provide examples of social factors associated with adverse surgical outcomes and how they can be mitigated.

Observations

The concept of social responsibility in surgery has deep roots in medical codes of ethics and evolved alongside changing views on human rights and the role of social factors in disease. The ethical duty of surgeons to society is based on the ethical principles of benevolence and justice and is grounded within the framework of the social contract. Surgeons have a responsibility to understand how factors such as patient demographics, the social environment, clinician awareness, and the health care system are associated with inequitable patient outcomes. Through education, we can empower surgeons to advocate for their patients, address the causes and consequences of surgical disparities, and incorporate social responsibility into their daily practice.

Conclusions and Relevance

One of the greatest challenges in the field of surgery is ensuring that surgical care is provided in an equitable and sustainable way. Surgeons have a duty to understand the factors that lead to health care disparities and use their knowledge, skills, and privileged position to address these issues at the individual and societal level.

Differences by sexual orientation in treatment outcome and satisfaction with treatment among inpatients of a German psychiatric clinic

A wealth of research suggests that sexual minority individuals experience stigma and lack of sexual minority specific competencies in mental health care, which could lead to less optimal treatment outcome. However, most related research suffers from methodological limitations, such as selected samples, retrospective design, or not assessing treatment outcome. To overcome some of these limitations, we explored if sexual minority patients have poorer treatment outcome and are less satisfied with treatment in a mental health care setting not specialized in sexual minority issues. The analytical sample comprised 5609 inpatients, including 11% sexual minority patients, from a German psychiatric clinic. Outcomes were improvement in well-being and depression from admission to discharge, and satisfaction with treatment judged at discharge. Nearly all sexual orientation differences were in a direction hinting at less improvement of depression and well-being and less satisfaction among sexual minority compared to heterosexual patients. However, the differences were generally small and not statistically significant. Stigma and lacking sexual orientation specific competency in healthcare may not be universally present or not as severe as studies with other research designs suggested. However, this needs to be investigated in more clinical settings by including sexual orientation as part of the routine assessment. Moreover, adequate sexual-minority specific competencies are important in any case, not just to prevent that sexual minority patients benefit less from treatment.

Barriers and Facilitators to Cancer Screening Among LGBTQ Individuals With Cancer

PROBLEM IDENTIFICATION

Cancer screening may reduce mortality and frequency of the disease. Lesbian, gay, bisexual, transgender, or queer (LGBTQ) individuals are less likely than non-LGBTQ individuals to present for cancer screening.

LITERATURE SEARCH

A literature search was performed using CINAHL®, PsycINFO®, and PubMed®. Articles were included if they were published in English from 2008 to 2018 and addressed barriers or facilitators to cancer screening in LGBTQ populations.

DATA EVALUATION

Data were organized by thematic matrix and classified according to the multilevel influences on the cancer care continuum framework.

SYNTHESIS

This integrative review found that the lack of cancer screening data and knowledge about screening guidelines by LGBTQ populations and providers were major barriers to cancer screening adherence. Provider-created welcoming environments and caregiver inclusion were facilitators.

IMPLICATIONS FOR PRACTICE

Determinants of health-seeking behavior included patients' and providers' lack of cancer screening knowledge, as well as perceived discrimination. Nurses are in a unique position to provide cancer screening information and culturally sensitive care for LGBTQ populations with adequate education.

(Mis)perceptions of HIV and HPV among female college students: a qualitative study

Background This study aims to investigate college women's misperceptions about the human papillomavirus virus (HPV) and the human immunodeficiency virus (HIV).

METHODS

Twenty college women from an urban, Midwestern university in the United States were recruited to participate in interviews exploring their beliefs about HIV and HPV. In-depth interviews were conducted and analysed via interpretive methods.

RESULTS

The college women in this study often conflated or confused HPV and HIV and revealed misperceptions about the severity and prevalence of HPV and HIV.

CONCLUSION

The results have important implications for understanding college women's sexual risk behaviour and, as a result, can inform the practices of both healthcare providers and public health professionals.

Are Services Inclusive? A Review of the Experiences of Older GSD Women in Accessing Health, Social and Aged Care Services

The review aimed to examine the views and experiences of ageing gender and sexually diverse (GSD) women-a triple minority in relation to their age, gender and sexual orientation-in accessing health, social and aged care services. Eighteen peer reviewed articles identified from seven electronic databases in health and social sciences were evaluated according to predefined criteria and a thematic review methodology drawing upon socio-ecological theory was used to analyse and interpret the findings. Four major themes were identified from the analysis: "The Dilemma of Disclosure", "Belonging/Connection", "Inclusiveness of Aged Care" and "Other Barriers to Access Care". In the dilemma of disclosure, older GSD women consider factors such as previous experiences, relationship with the provider and anticipated duration of stay with the provider before disclosing their sexual identifies. The review also revealed that aged care services lack inclusiveness in their policies, advertising materials, aged care spaces and provider knowledge and attitude to provide sensitive and appropriate care to GSD women. Overall, older GSD women experience multiple and multilevel challenges when accessing health, aged and social services and interventions are needed at all levels of the socio-ecological arena to improve their access and quality of care.

Preparing Medical Students to Address the Needs of Vulnerable Patient Populations: Implicit Bias Training in US Medical Schools

Little is known about how medical students are trained to identify and reduce their own biases toward vulnerable patient groups. A survey was conducted among US medical schools to determine whether their curricula addressed physician implicit biases toward three vulnerable patient groups: lesbian, gay, bisexual, transgender, and questioning (LGBTQ) individuals, persons experiencing homelessness, and migrant farmworkers. Of 141 US medical schools, 71 (50%) responded. Survey respondents indicated that implicit bias is not routinely addressed in medical education, and training specific to vulnerable populations is infrequent. Recommendations for incorporating implicit bias training in medical school curricula are discussed.

Training to reduce LGBTQ-related bias among medical, nursing, and dental students and providers: a systematic review

BACKGROUND

Lesbian, gay, bisexual, transgender and questioning (LGBTQ) individuals experience higher rates of health disparities. These disparities may be driven, in part, by biases of medical providers encountered in health care settings. Little is known about how medical, nursing, or dental students are trained to identify and reduce the effects of their own biases toward LGBTQ individuals. Therefore, a systematic review was conducted to determine the effectiveness of programs to reduce health care student or provider bias towards these LGBTQ patients.

METHODS

The authors performed searches of online databases (MEDLINE/PubMed, PsycINFO, Web of Science, Scopus, Ingenta, Science Direct, and Google Scholar) for original articles, published in English, between March 2005 and February 2017, describing intervention studies focused on reducing health care student or provider bias towards LGBTQ individuals. Data extracted included sample characteristics (i.e., medical, nursing, or dental students or providers), study design (i.e., pre-post intervention tests, qualitative), program format, program target (i.e., knowledge, comfort level, attitudes, implicit bias), and relevant outcomes. Study quality was assessed using a five-point scale.

RESULTS

The search identified 639 abstracts addressing bias among medical, nursing, and dental students or providers; from these abstracts, 60 articles were identified as medical education programs to reduce bias; of these articles, 13 described programs to reduce bias towards LGBTQ patients. Bias-focused educational interventions were effective at increasing knowledge of LGBTQ health care issues. Experiential learning interventions were effective at increasing comfort levels working with LGBTQ patients. Intergroup contact was effective at promoting more tolerant attitudes toward LGBTQ patients. Despite promising support for bias education in increasing knowledge and comfort levels among medical, nursing, and dental students or providers towards LGBTQ persons, this systematic review did not identify any interventions that assessed changes in implicit bias among students or providers.

CONCLUSIONS

Strategies for assessing and mitigating implicit bias towards LGBTQ patients are discussed and recommendations for medical, nursing, and dental school curricula are presented.

Nurses' perceptions of their relationships and communication with lesbian women seeking perinatal care

AIMS AND OBJECTIVE

To examine whether nurses' assessment of their relationships and communication with lesbian women seeking perinatal care is associated with their personal and professional characteristics and knowledge of homosexuality.

BACKGROUND

Recently, there has been a growing incidence of same-sex parenthood. Nurses administer health care to lesbian women from pregnancy planning through birth, providing consultation. Although there has been a shift in attitudes towards homosexuality, discrimination is still quite common.

DESIGN

This research is part of a larger cross-sectional study carried out at women's healthcare centres, concerning nurses' perceived quality of perinatal care provided to lesbian women.

METHODS

The study was conducted from December 2015-April 2016 at women's health centres in Israel encompassing 184 registered nurses who completed self-report questionnaires. They were assessed as to their knowledge of homosexuality and nurse-patient relationships and communication. The Squire checklist was used.

RESULTS

Most (73.4%) had prior acquaintance with lesbian women; only 17.9% had been educated as to lesbian women's unique health needs; of these, 66.7% thought that they had been given professional tools for working with lesbian women; 60.4% were unaware of the importance of knowing the patient's sexual orientation. The average score on a homosexuality knowledge questionnaire was 10.4 on a scale of 0-17, indicating moderate levels of factual knowledge about homosexuality. A significant positive correlation was found between nurses' knowledge of homosexuality and assessment of their relationships and communication with lesbian women seeking perinatal care. In addition, nurses' personal and professional characteristics, such as place of birth, religiosity and familiarity with lesbian women, were related to their assessment of their relationships and communication.

CONCLUSION

Nurses' knowledge of homosexuality and personal and professional characteristics were associated with their perceptions regarding relationships and communication with lesbian women seeking perinatal care.

RELEVANCE TO CLINICAL PRACTICE

Further training might broaden, refine rigid perceptions and contribute to advancing equal perinatal nursing care of lesbian women.

Reproductive Health Considerations in Sexual and/or Gender Minority Adolescents

Disparities exist in the area of reproductive health for lesbian, gay, bisexual (LGB), and transgender and gender nonconforming (TGNC) adolescents compared with cisgender, heterosexual adolescents, particularly related to pregnancy and pregnancy risk factors. Review of the literature indicates an estimated increased risk of adolescent pregnancy involvement between 2 and 10 times higher for LGB youth compared with heterosexual youth. This might be explained by a broad spectrum of sexual health risks experienced, including an earlier age of sexual debut, exposure to sexual abuse, and a higher number of sexual partners. TGNC youth face conflict with their gender identity and potentially their sexual orientation. It is likely that their experience is similar to cisgender LGB adolescents as it pertains to reproductive health considerations. TGNC adolescents additionally confront the added challenge of fertility preservation. Health care providers play an important role in identifying and addressing these risk factors to improve the health of LGB and TGNC adolescents. Unfortunately, whether implicit or explicit, bias among health care providers exists and affects patient care. We believe it is the responsibility of health care providers to be informed about the increased needs of these patients and to provide appropriate risk-reducing management while using inclusive and sensitive history-taking and language.

Factors Affecting Sexual History Taking in a Health Center Serving Homeless Persons

Low rates of documentation of sexual histories have been reported and research on sexual history taking (SHT) has focused on the content of, barriers to collecting, and interventions to improve documentation of sexual histories. Absent from this literature is an understanding of the contextual factors affecting SHT. To address this gap, a focused ethnography of one health center was conducted. Data were collected through observations of health care encounters and interviews with health care providers (HCPs). No SHT was observed and this was likely influenced by patients' characteristics, communication between patients and HCPs, the prioritization of patients' basic needs, and time constraints imposed upon encounters. Given that the health center studied serves patients experiencing homelessness, behavioral health concerns, and opioid use disorder, findings illuminate areas for future inquiry into a patient population affected by social as well as physiologic determinants of health and potentially at high risk for adverse sexual health outcomes.

Blended learning to teach gender in medical school

BACKGROUND

Teaching gender and sexuality in medical school is critical to prepare students for future clinical practice. Yet curriculum gaps exist in teaching these topics in medical schools. To address this, medical schools are integrating gendered perspectives into their curricula.

CONTEXT

Acknowledging the need to teach gender and sexuality, Western Sydney University School of Medicine introduced a lecture on 'Gendered Perspectives on Health' in 2015. However, the delivery of the content took more time than anticipated, as some students lacked a basic understanding of gender and sexuality. Engagement with the didactic teaching method was low.

INNOVATION

Using blended learning techniques, a flipped classroom workshop on gender and sexuality was developed in 2016. The workshop had online components that gave basic information on gender and sexuality, which students viewed prior to the face-to-face session. Students then discussed specific gender-related topics with expert facilitators using a timed multi-station approach during the face-to-face session. A plenary session provided students with the opportunity to address any remaining questions. Evaluation suggests that the workshop increased the students' self-reported knowledge on gender and sexual health topics and services. Students also found the workshop useful and engaging. Teaching gender and sexuality in medical school is critical to prepare students for future clinical practice IMPLICATIONS: The workshop provided an engaging and informative way for students to discuss gender and sexuality. The workshop also created a safe learning environment for students to clarify their perceptions of gender and sexuality. Increasing students' knowledge and understanding of gender and sexuality promoted a gender-sensitive approach to patient care, which can help students to avoid stereotyping and to provide comprehensive care to gender-diverse groups.

Sexual orientation differences in treatment expectation, alliance, and outcome among patients at risk for suicide in a public psychiatric hospital

BACKGROUND

Sexual minority (SM) individuals (gay, lesbian, bisexual, or otherwise nonheterosexual) are at increased risk for mental disorders and suicide and adequate mental healthcare may be life-saving. However, SM patients experience barriers in mental healthcare that have been attributed to the lack of SM-specific competencies and heterosexist attitudes and behaviors on the part of mental health professionals. Such barriers could have a negative impact on common treatment factors such as treatment expectancy or therapeutic alliance, culminating in poorer treatment outcomes for SM versus heterosexual patients. Actual empirical data from general psychiatric settings is lacking, however. Thus, comparing the treatment outcome of heterosexual and SM patients at risk for suicide was the primary aim of this study. The secondary aim was to compare treatment expectation and working alliance as two common factors.

METHODS

We report on 633 patients from a suicide prevention inpatient department within a public psychiatric hospital. Most patients were at risk for suicide due to a recent suicide attempt or warning signs for suicide, usually in the context of a severe psychiatric disorder. At least one indicator of SM status was reported by 21% of patients. We assessed the treatment outcome by calculating the quantitative change in suicide ideation, hopelessness, and depression. We also ran related treatment responder analyses. Treatment expectation and working alliance were the assessed common factors.

RESULTS

Contrary to the primary hypothesis, SM and heterosexual patients were comparable in their improvement in suicide ideation, hopelessness, or depression, both quantitatively and in treatment responder analysis. Contrary to the secondary hypothesis, there were no significant sexual orientation differences in treatment expectation and working alliance. When adjusting for sociodemographics, diagnosis, and length of stay, some sexual orientation differences became significant, indicating that SM patients have better outcomes.

CONCLUSIONS

These unexpected but positive findings may be due to common factors of therapy compensating for SM-specific competencies. It may also be due to actual presence of SM competencies - though unmeasured - in the department. Replication in other treatment settings and assessment of SM-specific competencies are needed, especially in the field of suicide prevention, before these findings can be generalized.

Is the Lack of Specific Lesbian, Gay, Bisexual, Transgender and Queer/Questioning (LGBTQ) Health Care Education in Medical School a Cause for Concern? Evidence From a Survey of Knowledge and Practice Among UK Medical Students

Lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) people frequently report negative health care encounters. Medical professionals may inadequately manage LGBTQ persons' health if they have not received training in this area. An anonymous survey measuring efficacy in health situations among LGBTQ persons was answered by 166 medical students across all years of a UK university. Results show that 84.9% of participants reported a lack of LGBTQ health care education, with deficits in confidence clarifying unfamiliar sexual and gender terms, deciding the ward in which to nurse transgender patients, finding support resources, and discussing domestic abuse with LGBTQ patients. Most participants reported that they would not clarify gender pronouns or ask about gender or sexual identity in mental health or reproductive health settings. Participants reported infrequently observing doctors making similar inquiries. Participants held positive attitudes toward LGBTQ patients, with attitude scores positively correlating with LGBTQ terminology knowledge scores (r_s = 0.5052, p < .01). Addressing gender identity and sexuality issues within medical curricula may remove barriers to accessing health care and improve encounters for LGBTQ patients.

Working at the interface in Aboriginal and Torres Strait Islander health: focussing on the individual health professional and their organisation as a means to address health equity

Background

Aboriginal and Torres Strait Islander people experience inequity in health outcomes in Australia. Health care interactions are an important starting place to seek to address this inequity. The majority of health professionals in Australia do not identify as Aboriginal and/or Torres Strait Islander people and the health care interaction therefore becomes an example of working in an intercultural space (or interface). It is therefore critical to consider how health professionals may maximise the positive impact within the health care interaction by skilfully working at the interface.

Methods

Thirty-five health professionals working in South Australia were interviewed about their experiences working with Aboriginal people. Recruitment was through purposive sampling. The research was guided by the National Health and Medical Research Council Values and Ethics for undertaking research with Aboriginal communities. Critical social research was used to analyse data.

Results

Interviews revealed two main types of factors influencing the experience of non-Aboriginal health professionals working with Aboriginal people at the interface: the organisation and the individual. Within these two factors, a number of sub-factors were found to be important including organisational culture, organisational support, accessibility of health services and responding to expectations of the wider health system (organisation) and personal ideology and awareness of colonisation (individual).

Conclusions

A health professional’s practice at the interface cannot be considered in isolation from individual and organisational contexts. It is critical to consider how the organisational and individual factors identified in this research will be addressed in health professional training and practice, in order to maximise the ability of health professionals to work with Aboriginal and Torres Strait Islander people and therefore contribute to addressing health equity.

Narrative review of the barriers and facilitators to chlamydia testing in general practice

As the cornerstone of Australian primary health care, general practice is a setting well suited for regular chlamydia testing but testing rates remain low. This review examines the barriers and facilitators to chlamydia testing in general practice. Six databases--Medline, PubMed, Meditext, PsycInfo, Scopus and Web of Science--were used to identify peer-reviewed publications that addressed barriers and facilitators to chlamydia testing in general practice using the following terms: 'chlamydia test*', 'STI test*' 'general practice', 'primary care', 'family medicine', 'barriers', 'facilitators' and 'enablers' from 1997 until November 2013. Data about the study design and key findings were extracted from the publications. A framework method was used to manage the data and organise publications into three categories -patient, general practitioner, and general practice. Key findings were then classified as a barrier or facilitator. Sixty-nine publications were included, with 41 quantitative studies, 17 qualitative studies, and 11 using mixed methods. Common barriers identified in all three groups included a lack of knowledge, awareness or training, demands on time and workload, and the social context of testing. Facilitators included the normalisation of testing, the use of nurses and other practice staff, education and incentives. Numerous barriers and facilitators to chlamydia testing in general practice have been identified. While the barriers are well studied, many of the facilitators are not as well researched, and highlight areas for further study.

Collecting and registering sexual health information in the context of HIV risk in the electronic medical record of general practitioners: a qualitative exploration of the preference of general practitioners in urban communities in Flanders (Belgium)

Background and aim Current health-care delivery requires increasingly proactive and inter-professional work. Therefore, collecting patient information and knowledge management is of paramount importance. General practitioners (GPs) are well placed to lead these evolving models of care delivery. However, it is unclear how they are handling these changes. To gain an insight into this matter, the HIV epidemic was chosen as a test case.

METHODS

Data were collected and analysed from 13 semi-structured interviews with GPs, working in urban communities in Flanders. Findings GPs use various types of patient information to estimate patients' risk of HIV. The way in which sexual health information is collected and registered, depends on the type of information under discussion. General patient information and medical history data are often automatically collected and registered. Proactively collecting sexual health information is uncommon. Moreover, the registration of the latter is not obvious, mostly owing to insufficient space in the electronic medical record (EMR).

CONCLUSIONS

GPs seem willing to systematically collect and register sexual health information, in particular about HIV-risk factors. They expressed a need for guidance together with practical adjustments of the EMR to adequately capture and share this information.

Health Care Providers' Implicit and Explicit Attitudes Toward Lesbian Women and Gay Men

OBJECTIVES

We examined providers' implicit and explicit attitudes toward lesbian and gay people by provider gender, sexual identity, and race/ethnicity.

METHODS

We examined attitudes toward heterosexual people versus lesbian and gay people in Implicit Association Test takers: 2338 medical doctors, 5379 nurses, 8531 mental health providers, 2735 other treatment providers, and 214,110 nonproviders in the United States and internationally between May 2006 and December 2012. We characterized the sample with descriptive statistics and calculated Cohen d, a standardized effect size measure, with 95% confidence intervals.

RESULTS

Among heterosexual providers, implicit preferences always favored heterosexual people over lesbian and gay people. Implicit preferences for heterosexual women were weaker than implicit preferences for heterosexual men. Heterosexual nurses held the strongest implicit preference for heterosexual men over gay men (Cohen d = 1.30; 95% confidence interval = 1.28, 1.32 among female nurses; Cohen d = 1.38; 95% confidence interval = 1.32, 1.44 among male nurses). Among all groups, explicit preferences for heterosexual versus lesbian and gay people were weaker than implicit preferences.

CONCLUSIONS

Implicit preferences for heterosexual people versus lesbian and gay people are pervasive among heterosexual health care providers. Future research should investigate how implicit sexual prejudice affects care.

Neurosyphilis Update: Atypical is the New Typical

Syphilis has reemerged as an important cause of neurological disease, affecting any part of the neuraxis at any stage of infection. What was once a dwindling diagnosis is now redoubling, particularly in the HIV-positive and in men who have sex with men populations. In the era of antibiotics and HIV coinfection, neurosyphilis presentations are protean, making diagnosis notoriously challenging. Advanced disease may be irreversible, and so early detection and treatment are ideal. Herein, we review recent advances in understanding neurosyphilis.

Sexual minorities in England have poorer health and worse health care experiences: a national survey

BACKGROUND

The health and healthcare of sexual minorities have recently been identified as priorities for health research and policy.

OBJECTIVE

To compare the health and healthcare experiences of sexual minorities with heterosexual people of the same gender, adjusting for age, race/ethnicity, and socioeconomic status.

DESIGN

Multivariate analyses of observational data from the 2009/2010 English General Practice Patient Survey.

PARTICIPANTS

The survey was mailed to 5.56 million randomly sampled adults registered with a National Health Service general practice (representing 99 % of England's adult population). In all, 2,169,718 people responded (39 % response rate), including 27,497 people who described themselves as gay, lesbian, or bisexual.

MAIN MEASURES

Two measures of health status (fair/poor overall self-rated health and self-reported presence of a longstanding psychological condition) and four measures of poor patient experiences (no trust or confidence in the doctor, poor/very poor doctor communication, poor/very poor nurse communication, fairly/very dissatisfied with care overall).

KEY RESULTS

Sexual minorities were two to three times more likely to report having a longstanding psychological or emotional problem than heterosexual counterparts (age-adjusted for 5.2 % heterosexual, 10.9 % gay, 15.0 % bisexual for men; 6.0 % heterosexual, 12.3 % lesbian and 18.8 % bisexual for women; p < 0.001 for each). Sexual minorities were also more likely to report fair/poor health (adjusted 19.6 % heterosexual, 21.8 % gay, 26.4 % bisexual for men; 20.5 % heterosexual, 24.9 % lesbian and 31.6 % bisexual for women; p < 0.001 for each). Adjusted for sociodemographic characteristics and health status, sexual minorities were about one and one-half times more likely than heterosexual people to report unfavorable experiences with each of four aspects of primary care. Little of the overall disparity reflected concentration of sexual minorities in low-performing practices.

CONCLUSIONS

Sexual minorities suffer both poorer health and worse healthcare experiences. Efforts should be made to recognize the needs and improve the experiences of sexual minorities. Examining patient experience disparities by sexual orientation can inform such efforts.

Don't ask, sometimes tell. A survey of men who have sex with men sexual orientation disclosure in general practice

Despite advances in lesbian, gay, bisexual and transgender equality in recent years, some men who have sex with men remain at increased risk of ill-health. Positive interventions in primary care include psychological support and strategies for risk reduction. It is important that men who have sex with men can disclose sexual orientation in primary care. To quantify disclosure of sexual orientation by men who have sex with men attending general practice and identify barriers to disclosure we surveyed a group of Scottish men. A questionnaire was distributed by voluntary organisations and the National Health Service in the West of Scotland, to rural and urban populations. Two hundred and four gave evaluable responses, with all ages represented. A total of 199 (98%) were registered with a General Practitioner and 167 (83%) attended in the previous year. A total of 81 (40%) stated staff were aware of their sexual orientation. A total of 93/121 (75%) men who have sex with men whose GP was unaware stated this was because they had never been asked. A total of 36/81(44%) men who have sex with men rated support from practices since disclosure as 'excellent' and qualitative responses were positive. It is reassuring that almost all respondents were registered with GPs and attending primary care services. However, only 40% had disclosed sexual orientation. This was not because of fear of negative impact on care but because men who have sex with men felt it was irrelevant to their attendance. GPs appear to be reluctant to raise the issue of sexual orientation without prompting.

Physicians' perceived barriers to management of sexually transmitted infections in Vietnam

Background

Sexually transmitted infections (STIs) are a public health problem in Vietnam with sub-optimal care in medical practice. Identifying practitioners’ perceived barriers to STI care is important to improve care for patients with STIs.

Methods

A cross-sectional survey was conducted among 451 physicians. These physicians were dermatology and venereology (D&V) doctors, obstetrical/gynaecological (Ob/Gyn) doctors, general practitioners, and assistant doctors working in health facilities at provincial, district and communal levels in three provinces in Vietnam.

Results

Almost all (99%) respondents mentioned at least one barrier to STI care. The barriers were “lack of STI training” (57%), “lack of professional resources” (41%), “lack of time” (38%), “lack of reimbursement” (21%), “lack of privacy/confidentiality” (17%), “lack of counselling” (15%), and “not the role of primary care provider” (7%). Multivariable logistic regression analysis showed that “lack of professional resources” was associated with respondents being in medical practice for ten years or under (vs. 11–20 years), and working at district or communal health facilities (vs. provincial facilities); “lack of time” were associated with respondents being female, seeing more than 30 patients a week (vs. <15 patients/week); and “lack of privacy/confidentiality” was associated with physicians’ seeing more than 30 patients a week (vs. <15 patients/week).

Conclusion

The study has identified several barriers to STI care in medical practice in Vietnam. Results of the study can be used to improve areas in STI care including policy and practice implications.

Sexual history taking in general practice: managing sexually transmitted infections for female sex workers by doctors and assistant doctors in Vietnam

Sexually transmitted infections (STIs) in Vietnam have been increasing. Control of STIs among female sex workers (FSWs) is important in controlling the epidemic. Effective STI control requires that physicians are skilful in taking sexual history for FSW patients. Three hundred and seventy-one physicians responded to a survey conducted in three provinces in Vietnam. The respondents were asked whether they asked FSW patients about their sexual history and information asked during sexual history taking. The respondents were also asked about their barriers for taking sexual history. Over one-fourth (27%) respondents always, over half (54%) respondents sometimes and 19% respondents never obtained a sexual history from FSW patients. Multivariable analysis revealed that factors associated with always taking a sexual history were being doctor, training in STIs and working at provincial level facilities. Physician’s discomfort was found to be inversely associated with training on communication with patients, seeing 15 or fewer patients a week, working at provincial level facilities. Issues in sexual history taking among FSW patients in general practice in Vietnam were identified. These issues can help STI control for FSW patients and need due attention in order to improve STI management in Vietnam.

Lesbians on Medical Encounters: Tales of Heteronormativity, Deception, and Expectations

The experiences of lesbian women in medical encounters prove particularly relevant for understanding their difficulties in their relationship with professionals and health services. We carried out semistructured interviews with 30 women aged 21 to 63 years, who define themselves as lesbian. The analysis highlights the difficulties experienced in disclosure of sexuality in medical encounters, the tendency for doctors to come across as heteronormative, and also medical practices experienced as appropriate by interviewees. Analysis of participant experiences demonstrates the need for reflection and decision making to promote the recognition of the sexual citizenship of lesbian women and their empowerment.

HIV testing in primary care: feasibility and acceptability of provider initiated HIV testing and counseling for sub-Saharan African migrants

Provider-initiated HIV testing and counseling (PITC) is recommended to reduce late HIV diagnoses, common among Sub-Saharan African migrants (SAM) residing in Europe. Primary care represents an ideal entry point for PITC. To support Flemish general practitioners (GPs), we developed a culturally sensitive PITC tool. Over a 12-week period, 65 GPs implemented PITC to assess acceptability and feasibility of PITC. The qualitative evaluation showed high acceptability among physicians. Routine PITC was challenged by physicians' personal discomfort, assumptions of patients' sexual risk, perceived incoherence with reasons for consultation, and time pressure. The best opportunity for PITC was an indicated blood analysis for other medical reasons. Counseling skills improved during the implementation, but participants still advocated for reduced counseling requirements. PITC proved to be feasible in primary care settings, but the up-scaling requires a reformulation of counseling guidelines, a policy stipulating the role of GPs in the prevention-care continuum, and an investment in (continuous) training.

Perceptions of barriers to discussing and testing for sexually transmitted infections in a convenience sample of general practice patients

We aimed to identify patient perceptions of barriers to discussing sexually transmitted infections (STIs) at the primary care level. An anonymous questionnaire was available to patients (16–70 years) in the waiting room of four metropolitan Perth general practices. Results are based on 370 participant views (9.5% of the potential target population). Patients felt comfortable discussing STIs with their general practitioner (GP) and their level of comfort would be enhanced if they knew their GP had a special interest or qualification in sexual health. Willingness to discuss issues increased or remained unchanged if the GP took time to explain it to them or was a good listener. Patients were willing to discuss STIs if they were a new patient and irrespective of the GP’s gender and age. Fewer patients were willing to discuss STIs if they knew the GP socially. Patients who had sex with a new partner were willing to request a STI test from their GP. Patients were not embarrassed if discussion was initiated in a consultation unrelated to sexual health and did not mind discussing the topic in the presence of a partner or parent, though this depended on circumstances. Waiting room STI test advertising did not affect patient comfort level. Patients would involve their GP when seeking information about STIs. Patients have fewer barriers to discussing sexual health matters than perceived by GPs.

Disparities in safe sex counseling & behavior among individuals with substance dependence: a cross-sectional study

Background

Despite the vast literature examining disparities in medical care, little is known about racial/ethnic and mental health disparities in sexual health care. The objective of this study was to assess disparities in safe sex counseling and resultant behavior among a patient population at risk of negative sexual health outcomes.

Methods

We conducted a cross-sectional analysis among a sample of substance dependent men and women in a metropolitan area in the United States. Multiple logistic regression models were used to explore the relationship between race/ethnicity (non-Hispanic black; Hispanic; non-Hispanic white) and three indicators of mental illness (moderately severe to severe depression; any manic episodes; ≥3 psychotic symptoms) with two self-reported outcomes: receipt of safe sex counseling from a primary care physician and having practiced safer sex because of counseling.

Results

Among 275 substance-dependent adults, approximately 71% (195/275) reported ever being counseled by their regular doctor about safe sex. Among these 195 subjects, 76% (149/195) reported practicing safer sex because of this advice. Blacks (adjusted odds ratio (AOR): 2.71; 95% confidence interval (CI): 1.36,5.42) and those reporting manic episodes (AOR: 2.41; 95% CI: 1.26,4.60) had higher odds of safe sex counseling. Neither race/ethnicity nor any indicator of mental illness was significantly associated with practicing safer sex because of counseling.

Conclusions

Those with past manic episodes reported more safe sex counseling, which is appropriate given that hypersexuality is a known symptom of mania. Black patients reported more safe sex counseling than white patients, despite controlling for sexual risk. One potential explanation is that counseling was conducted based on assumptions about sexual risk behaviors and patient race. There were no significant disparities in self-reported safer sex practices because of counseling, suggesting that increased counseling did not differentially affect safe sex behavior for black patients and those with manic episodes. Exploring the basis of how patient characteristics can influence counseling and resultant behavior merits further exploration to help reduce disparities in safe sex counseling and outcomes.

Trial registration

NCT00278447

"It is not easy": challenges for provider-initiated HIV testing and counseling in Flanders, Belgium

This study identified physicians' HIV testing practices and their barriers toward implementing provider-initiated HIV testing and counseling (PITC) for Sub-Saharan African migrants (SAM) in Flanders, Belgium. In-depth interviews were conducted on a purposive sample of 20 physicians (ten GPs and ten internists). GPs performed mainly patient-initiated tests, while internists carried out tests based on disease indicators and risk behavior. For the most part, World Health Organization (WHO) guidelines were not followed. Study participants were not in favor of implementing PITC. Reasons included lack of information on the HIV epidemic among SAM, fear of stigmatizing patients, perceiving testing as unethical for undocumented patients, questionable relevance of pre-test counseling, lack of expertise in discussing sexuality, language barriers, lack of time, and the absence of a national or regional HIV testing policy. Implementing PITC will require appropriate training of service providers. Also, supporting policies should be developed with the participation of stakeholders encouraging "normalization" of HIV testing.

Comparison of sexual behavior and HIV risk between two HIV-1 serodiscordant couple cohorts: the CHAVI 002 study

BACKGROUND

The CHAVI002 study was designed to characterize immune responses, particularly HIV-specific T-cell responses, amongst 2 cohorts of HIV-exposed seronegative (HESN) individuals. The absence of a clear definition of HESNs has impaired comparison of research within and between such cohorts. This report describes two distinct HESN cohorts and attempts to quantify HIV exposure using a 'HIV risk index' (RI) model.

METHODS

HIV serodiscordant couples (UK; 24, Uganda; 72) and HIV unexposed seronegative (HUSN) controls (UK; 14, Uganda; 26 couples, 3 individuals) completed sexual behavior questionnaires every 3 months over a 9 month period. The two cohorts were heterogeneous, with most HESNs in the UK men who have sex with men (MSM), while all HESNs in Uganda were in heterosexual relationships. Concordance of responses between partners was determined. Each participant's sexual behavior score (SBS) was estimated based on the number and type of unprotected sex acts carried out in defined time periods. Independent HIV acquisition risk factors (partner plasma viral load, STIs, male circumcision, pregnancy) were integrated with the SBS, generating a RI for each HESN.

RESULTS

96 HIV serodiscordant couples completed 929 SBQs. SBSs remained relatively stable amongst the UK cohort, whilst decreasing from Visit 1 to 2 in the Ugandan cohort. Compared to the Ugandan cohort, SBSs and RIs in the UK cohort were lower at visit 1, and generally higher at later visits. Differences between the cohorts, with lower rates of ART use in Uganda and higher risk per-act sex in the UK, had major impacts on the SBSs and RIs of each cohort. There was one HIV transmission event in the UK cohort.

CONCLUSIONS

Employment of a risk quantification model facilitated quantification and comparison of HIV acquisition risk across two disparate HIV serodiscordant couple cohorts.

Sex trade among young women attending family-planning clinics in Northern California

OBJECTIVE

To describe the prevalence and nature of sex trade in a clinic-based sample of young women and to evaluate associations with sexual and reproductive health.

METHODS

A cross-sectional survey was conducted with women aged 16-29 years (n=1277) presenting to family-planning clinics in Northern California, USA.

RESULTS

Overall, 8.1% of respondents indicated a lifetime history of trading sex for money or other resources. Sex trade was associated with unintended pregnancy (adjusted risk ratio [ARR] 1.27; 95% confidence interval [CI], 1.09-1.48), multiple abortions (ARR 1.63; 95% CI, 1.19-2.23), STI diagnosis (ARR 1.46; 95% CI, 1.27-1.68), and unwanted sex (vaginal ARR 3.64; 95% CI, 2.39-5.56; anal ARR 4.99; 95% CI, 2.17-11.50). Of the women ever involved in sex trade, 12 (37.3%) reported that their first such experience was before they were 18 years of age.

CONCLUSION

Approximately 1 in 12 participants had been involved in sex trade, illustrating the presence of patients with this history within the family-planning clinical setting. Sex trade was associated with multiple indicators of poor sexual and reproductive health. Family-planning clinics may represent an underused mechanism for engaging this high-risk population.

Assessment of knowledge and stigmatizing attitudes related to human papillomavirus among Hong Kong Chinese healthcare providers

OBJECTIVE

To assess knowledge and stigmatizing attitudes related to human papillomavirus (HPV) and HPV testing among Chinese healthcare providers in Hong Kong.

METHODS

Between May and September 2010, an anonymous self-administered questionnaire was sent to 247 doctors, nurses, and smear-taking trainees providing cervical screening in Hong Kong.

RESULTS

In total, 137 questionnaires were returned. Most participants had basic knowledge about HPV infection and HPV vaccination. Only about 33% knew that high-risk HPV does not cause genital warts, infection is most common among young women, or infected individuals might not have any identifiable sexual risk factors. Regarding HPV testing, 6 of 7 knowledge items were answered incorrectly by many participants (≥ 50%), highlighting a lack of understanding of the indications for HPV testing and the implications of a positive result. About 30% of participants agreed that individuals with HPV infection were sexually easy, responsible for their infection, or had more than 1 sexual partner. More knowledge about HPV infection predicted less stigmatizing attitudes.

CONCLUSION

Continued education on HPV and HPV testing is needed for frontline healthcare providers of screening in Hong Kong. The stigmatizing attitudes toward HPV-infected individuals warrant further exploration of the impact of HPV infection on patient care and interventions.

A social work perspective: attitudes toward end-of-life planning

This research examined social workers' attitudes toward end-of-life planning and related factors in a cross-sectional study (N = 844). Data were gathered on completion of a health care proxy, personal comfort, training experiences of social workers, and demographics. Attitudes toward end-of-life planning were related to personal completion of the health care proxy, personal comfort, and years of social work experience. These measures remained significant in all steps of the regression, regardless of practice grouping (health and aging or other than health and aging), suggesting the relative importance of personal rather than professional aspects. Respondents in the health and aging fields are older than those in other than health and aging, underscoring concerns about workforce issues in the field of aging.

Primary health care and equity: the case of lesbian, gay, bisexual, trans and intersex Australians

The current period of health reform in Australia offers an opportunity for positive actions to be taken to address the significant challenges that lesbian, gay, bisexual, trans, intersex and other sexuality, sex and gender diverse (LGBTI) people face in the health system. This paper provides analysis of why this group should be considered a priority health group using a social determinants of health framework, which has, to date, largely been ignored within primary health care policy reform in Australia. Several key areas of the primary health care reform package are considered in relation to LGBTI health and well-being. Practical suggestions are provided as to how the primary health care sector could contribute to reducing the health inequities affecting LGBTI people. It is argued that care needs to be taken to ensure the reform process does not further marginalise this group.

Impact of physicians' personal discomfort and patient prognosis on discussion of fertility preservation with young cancer patients

OBJECTIVE

This study sought to determine if physician's personal discomfort with the topic of FP and a patient's prognosis would have an impact on the likelihood of discussing FP with cancer patients.

METHODS

Data from larger studies of qualitative semi-structured interviews with pediatric and adult oncologists were analyzed using grounded theory and crystallizing immersion method to examine the themes of "personal comfort" and "patient prognosis" in relation to discussion.

RESULTS

Results showed that, across both physician types, the majority of respondents' personal comfort with the topic of FP was related to the likelihood of discussion. Personal discomfort manifested as: (a) lack of knowledge; (b) language/cultural barriers; (c) perception that subject of FP adds more stress to situation; (d) general uncertainty about success of FP methods. Data also indicate physicians do not feel discussions are appropriate for patients with poor prognosis.

CONCLUSION

Despite the ASCO guidelines suggesting physicians should discuss FP with all patients, the majority of physicians are not following these guidelines.

PRACTICE IMPLICATIONS

Improved training on recognition of such biases and communication strategies may improve the quality and frequency of such discussions. Involving the entire healthcare team in discussions may alleviate the need for physicians to have sole responsibility.

Lesbian women's experiences with health care: a qualitative study

BACKGROUND

Although the social situation for gay, lesbian, and bisexual people has improved over the last decades, lesbian women still face unique challenges when seeking healthcare services.

OBJECTIVES

To explore lesbian women's healthcare experiences specifically related to sexual orientation to achieve knowledge which can contribute to increased quality of healthcare for lesbian women.

METHODS

Qualitative study based on written stories, with recruitment, information, and data sampling over the internet. Data consisted of 128 anonymously written answers to a web-based, open-ended questionnaire from a convenience sample of self-identified lesbian women. Data were analysed with systematic text condensation. Interpretation of findings was supported by theories of heteronormativity. Main outcome measures. Patients' histories of experiences where a lesbian orientation was significant, when seeing a doctor or another healthcare professional.

RESULTS

Analysis presented three different aspects of healthcare professionals' abilities, regarded as essential by our lesbian participants. First, the perspective of awareness was addressed--is the healthcare professional able to think of and facilitate the disclosure of a lesbian orientation? Second, histories pointed to the attitudes towards homosexuality--does the healthcare professional acknowledge and respect the lesbian orientation? Third, the impact of specific and adequate medical knowledge was emphasized--does the healthcare professional know enough about the specific health concerns of lesbian women?

CONCLUSION

To obtain quality care for lesbian women, the healthcare professional needs a persistent awareness that not all patients are heterosexual, an open attitude towards a lesbian orientation, and specific knowledge of lesbian health issues. The dimensions of awareness, attitude, and knowledge are interconnected, and a positive direction on all three dimensions appears to be a necessary prerequisite.

Attitudes and practices of obstetric care providers in Kabul, Afghanistan regarding antenatal testing for sexually transmitted infection

OBJECTIVE

To determine attitudes toward and utilization of testing for HIV, syphilis, and hepatitis B among obstetric care providers in Kabul, Afghanistan.

DESIGN

Cross-sectional survey.

SETTING

Three public maternity hospitals in Kabul, Afghanistan.

PARTICIPANTS

One hundred and fourteen (114) doctors and midwives.

MAIN OUTCOME MEASURE

Prevalence and correlates of ever having tested patients for HIV, syphilis, and hepatitis B and agreement with statements concerning attitudes toward testing and care.

RESULTS

Less than half of the patient care providers surveyed had previously tested a patient for HIV, syphilis, or hepatitis B. Presumed rarity of these infections in Afghanistan was the most frequently stated reason for not testing, although many midwives stated that they did not have the authority to order tests. Most providers supported testing to promote neonatal health, but some midwives expressed concern regarding patient and family perceptions.

CONCLUSIONS

Due to logistical and cultural barriers, obstetric care providers underutilize testing for antenatal patients in Afghanistan. Improved training, empowerment of female providers, and availability of rapid testing are needed.

Preventing sexually transmissible infections in Australian general practice

Summary

The aims of the present study were to explore aspects of sexually transmissible infections (STI) prevention in general practice and to examine general practitioners' (GPs) perceived barriers to sexual-health promotion. The data from a postal survey of 409 GPs practising in New South Wales, Australia (response rate 45.4%) are analysed to explore the prevention of STI in general practice and to examine practitioners' perceived barriers to sexual-health promotion. About 49% of GPs reported having STI leaflets/pamphlets for patients in their clinic, while 21% had posters on STI displayed in their waiting room. Two-third (67%) of GPs provided STI-specific printed materials/leaflets to patients with STI. Female GPs were more likely to be proactive in STI prevention. Time and funding appear to be the major barriers to sexual-health promotion, followed by inadequate access to counselling. One-fifth (22%) of GPs felt that they had little influence in changing patients' risk behaviour, while about 28% emphasized the need for further preventive care training. The present study identifies inconsistencies in STI-prevention activities in general practice along with barriers to undertake sexual-health promotion. This area warrants further attention if GPs are to contribute fully to the control of STI.