Abstinence and teenagers: prevention counseling practices of health care providers serving high-risk patients in the United States

Counseling and provision of long-acting reversible contraception in the US: national survey of nurse practitioners

OBJECTIVE

Nurse practitioners (NPs) provide frontline care in women's health, including contraception, an essential preventive service. Their importance for contraceptive care will grow, with healthcare reforms focused on affordable primary care. This study assessed practice and training needs to prepare NPs to offer high-efficacy contraceptives - intrauterine devices (IUDs) and implants.

METHOD

A US nationally representative sample of nurse practitioners in primary care and women's health was surveyed in 2009 (response rate 69%, n=586) to assess clinician knowledge and practices, guided by the CDC US Medical Eligibility Criteria for Contraceptive Use.

RESULTS

Two-thirds of women's health NPs (66%) were trained in IUD insertions, compared to 12% of primary care NPs. Contraceptive counseling that routinely included IUDs was low overall (43%). Nurse practitioners used overly restrictive patient eligibility criteria, inconsistent with CDC guidelines. Insertion training (aOR=2.4, 95%CI: 1.10 5.33) and knowledge of patient eligibility (aOR=2.9, 95%CI: 1.91 4.32) were associated with IUD provision. Contraceptive implant provision was low: 42% of NPs in women's health and 10% in primary care. Half of NPs desired training in these methods.

CONCLUSION

Nurse practitioners have an increasingly important position in addressing high unintended pregnancy in the US, but require specific training in long-acting reversible contraceptives.

Evidence-based IUD practice: family physicians and obstetrician-gynecologists

BACKGROUND AND OBJECTIVES

Family physicians and obstetrician-gynecologists provide much of contraceptive care in the United States and have a shared goal in preventing unintended pregnancy among patients. We assessed their competency to offer women contraceptives of the highest efficacy levels.

METHODS

We conducted a national probability survey of family physicians and obstetrician-gynecologists (n=1,192). We measured counseling and provision practices of intrauterine contraception and used multivariable regression analysis to evaluate the importance of evidence-based knowledge to contraceptive care.

RESULTS

Family physicians reported seeing fewer contraceptive patients per week than did obstetrician-gynecologists and were less likely to report sufficient time for counseling. While 95% of family physicians believed patients were receptive to learning about intrauterine contraception, fewer than half offered counseling or the method. Only half were trained to competence to offer intrauterine contraception, while virtually all obstetrician-gynecologists were. Both family physicians and obstetrician-gynecologists were unlikely to have adequate knowledge of the women who would be good candidates for intrauterine contraception-as gauged by the Centers for Disease Control and Prevention Medical Eligibility Criteria for contraception-and consequently did not offer the method to a wide range of eligible patients.

CONCLUSIONS

Most family physicians providing contraceptive care were not offering methods with top-tier effectiveness, although they reported interest in updating contraceptive skills through training. Obstetrician-gynecologists had technical skills to offer intrauterine contraception but still required education on patient selection. Greater hands-on training opportunities for family physicians, and complementary education on eligible method candidates for obstetrician-gynecologists, can increase access to intrauterine contraception by women seeking contraceptive care.

Male circumcision for HIV prevention: clinical practices and attitudes among healthcare providers in South Africa and Zimbabwe

BACKGROUND

This study aimed to document the clinical practices and attitudes of health care providers in South Africa and Zimbabwe on male circumcision for human immunodeficiency virus (HIV) prevention.

METHODS

We conducted national surveys of physicians and nurses in both countries in 2008-2009 (N = 1444). Data on male circumcision for HIV prevention were analyzed; outcomes were patient counseling, provision of services, and desire for training. We used multivariable logistic regression to examine associations between these outcomes and clinician, practice, and attitudinal variables.

RESULTS

Overall, 57% of clinicians reported counseling male patients on male circumcision, 17% were offering services (49% referrals), and 61% desired training. In the multivariable analyses, provision of services was more common in South Africa (P ≤ 0.001) but desire for training higher in Zimbabwe (P ≤ 0.01). Provision of services was highest among physicians (P ≤ 0.01) and in hospital settings (P ≤ 0.001). However, nurses had greater desire for training (P ≤ 0.05) as did younger clinicians (P ≤ 0.001). Clinicians in rural and clinic settings were just as likely to express training interest. Clinician attitudes that patients would be upset due to cultural beliefs and would increase risky behaviors were associated with less counseling and service provision (P ≤ 0.05).

CONCLUSIONS

Many clinicians in South Africa and Zimbabwe showed willingness to integrate new HIV prevention evidence into practice and to become trained to offer the procedure to patients. Results suggest that both countries should consider involving nurses in male circumcision for HIV prevention, including those in rural areas, and should help clinicians to address cultural concerns.

Sexual Health Information Networks: What are Urban African American Youth Learning?

This qualitative study examined sexual health information networks among urban African American youth living in low-income communities. The authors identified sources, message content, and utility of messages about sex and sexual health in a sample of 15-17-year olds (N = 81). Youth received sexual health information from a variety of sources. Messages from parents and sex education had high utility, whereas messages from the Internet and religion had low utility. Four information network patterns were identified, suggesting considerable variation in how youth are socialized regarding sex. Findings suggest that sexual information networks have the potential to affect sexual health and development.

Pelvic examinations and access to oral hormonal contraception

OBJECTIVE

Requiring a pelvic examination before prescribing oral contraception poses an unnecessary barrier to contraceptive access. Medical guidelines have outlined the safety of oral contraception provision without a pelvic examination, yet little is known about the practices of clinicians providing reproductive health care. Our purpose was to investigate clinicians' requirements for pelvic examination and what may account for practice differences.

METHODS

We administered a mailed survey to a national probability sample of obstetrician-gynecologists (ob-gyns), family medicine physicians, and advanced practice nurses specializing in obstetrics and gynecology and women's health or family medicine in 2008-2009 (N=1,196), with a response rate of 65.3%.

RESULTS

Nearly one third of ob-gyns and family medicine physicians reported always requiring a pelvic examination when prescribing oral contraception (ob-gyns 29%; family medicine 33%). A higher proportion of advanced practice nurses in primary care (45%) and a markedly lower percentage of advanced practice nurses in reproductive health (17%) reported always requiring the examination. In adjusted analyses, older clinicians were more likely to require the pelvic examination (odds ratio [OR] 1.03, P<.01) and clinicians serving a higher proportion of Medicaid patients more likely (OR 1.62, P<.05). Providers in private practice were more than twice as likely as those working in family-planning or community clinics to require pelvic examinations (OR 2.30, P<.01).

CONCLUSION

One third of clinicians we surveyed require pelvic examinations before provision of oral contraceptives, despite guidelines indicating they are unnecessary and research suggesting they can pose a barrier to contraceptive access.