Womens Health: Strategies for Supporting Gynecologic Care

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Womens Health Strategies for Supporting
Gynecologic Care

• August 30, 2006
• Pamela Rothpletz-Puglia, EdD,RD
• Sandra Lewis, PsyD

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Womens Health

• Cervical cancer is an AIDS defining illness.
• Incidence and associated mortality rate is low
  with routine cervical cytologic screening.
• HRSA HAB identified cervical cancer screening as
  a priority for CARE act sites.
• Multi-site field study of gynecologic care and
  Pap screening

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Research Questions

• How do Title IV programs deliver gynecologic
  services and Pap screening?
• What are the patient, healthcare provider, and
  clinic procedural factors that impede or
  facilitate gynecologic services and Pap
  screening?

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Method

• Cross-sectional, multi-site, field study
• Study sites (n6)
• Participation limited to sites in the upper and
  lower quartiles of Pap screening rates
• Three sites from each group
• Researchers blinded to screening rates

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Method

• Study sites cont.
• Geographically diverse
• Varying levels of RWCA funding
• Participants
• Clients gt18 years English speaking
• Recruited through purposive sampling
• Paid 50.00 for participation
• Healthcare providers, administrators support
  staff

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Method

• Data Collection methods
• Chart reviews
• Interview with site coordinator or designee
• Recorded patient focus groups
• Recorded provider focus groups
• Site/clinic tour

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Method

• Ethical review and confidentiality
• IRB approved at all sites
• Patient informed consent was obtained by site
  staff
• Researchers were not aware of patients names
• Participants were instructed not to use names
  during focus groups

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Methods - Fishbone diagram from HRSA HAB,
Quality Management Technical Assistance Manual,
2003
Cause and Effect Diagram (Fishbone) Analysis
Perfomance of Pap Smears
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Data Analysis

• Transcription of interviews/focus groups
• NVivo
• Data coded within domains (provider, client,
  system, facility)
• Additional codes developed based upon the data
• Data were also coded as barriers or facilitators
• Matrices were constructed to examine variables
  within the four domains as barriers or
  facilitators
• Analysis conducted by two researchers working
  independently

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Data Analysis

• Major themes and links between concepts were
  established by examining consistencies in data
  within and between sites

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Major Themes

• Provider
• Barriers rapport or interest, expertise
• Facilitators rapport or interest, on-site GYN
  provider
• System
• Barriers scheduling, tracking, follow-up,
  caseload
• Facilitators on-site GYN provider, support
  staff, provider prompts

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Major Themes

• Client
• Barriers importance, multiple health problems,
  life
• Facilitators provider interest, genuineness,
  capacity to explain procedures, expertise,
  on-site GYN provider
• Facility
• Barriers insufficient equipment, lack of exam
  room specifically for GYN care
• Facilitators sufficient equipment and space for
  GYN care

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Model of Pap Screening
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Provider-Patient Relationship

• Patient comfort in relationship with provider
• Rapport sustained by genuineness interest
• Trust in the providers ability
• Clients circumstances

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Provider-Patient Relationship

• Female GYN Provider
• My doctor makes is comfortable. I like (my
  doctor) especially because she is a woman.
• You want to be comfortable to talk with your
  GYN. You may be having problems sexually at
  homeSo there are other reasons why it is better
  to have a female GYN

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Integrated Services

• On-site GYN care
• Designated GYN provider

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Integrated Services

• Providers off-site
• They didnt even ask me if it was okay for other
  people to come in. And like 10 people came into
  the room. The doctor came into the room and said
  this is such and such female and she is
  HIV-positive. I felt like a freak show. I was
  very uncomfortable, I got up and left.
• I could only imagine if the shoe were on the
  other foot. Would this be the same thing done if
  they went? I imagine she would want the same kind
  of treatment we would want.

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Integrated Services

• I think the biggest aspect of whatever you talk
  about GYN care is to just have easy access. When
  you are talking about HIV and GYN care it is
  important to have a provider that is dedicated to
  doing the GYN. . . . . as long as one or two
  individuals in a practice are doing it and people
  become comfortable and develop trust and bonds
  with the individuals so that they do come back.

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Integrated Services

• It is imperative that there is someone
  identified who will provide womens services
  inside an HIV setting because of the frequent
  isolation and the fear that people have of
  exposure of their disease and rejection.
• In a nutshell, it is a collaborative effort and
  I (RN) identify the clients that need GYN care
  and facilitate that they have it the same day as
  their primary care. If they come into our clinic
  it becomes one stop shopping. I target the
  physicians so they target the patient.

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Clinician Training and Expertise

• She explains what she is doing, what you can
  look for and what is going to happen and she is
  smooth. You are very, very comfortable with
  her.
• Most of them (residents) are not used to doing
  primary care. They are too busy. A Pap smear is
  not too difficult to do, but you have to have
  things set up right and you have to be trained in
  how to do it. Most people that go into adult
  infectious diseases are not trained and dont
  want to do it.

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Support Staff

• Nursing
• Case management
• Other support staff

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Facilities and Systems

• Nursing sets up the trays before each patient
  exam. I think that may be an incentive for
  clinicians and patients.
• Scheduling
• Provider prompts
• Room for GYN care

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Summary

• Patient-provider relationship
• Female GYN provider
• Interest and genuineness
• On-site GYN, designated GYN provider
• Provider training and expertise
• Support staff
• Facility and system

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Taking it Home Action Plan

• Provider
• System
• Client
• Facility