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STI service delivery in British Columbia, Canada; providers' views of their services to youth Masaro, Cindy L; Johnson, Joy; Chabot, Cathy; Shoveller, Jean Aug 6, 2012

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RESEARCH ARTICLE Open AccessSTI service delivery in British Columbia, Canada;providers' views of their services to youthCindy L Masaro1*, Joy Johnson2, Cathy Chabot3 and Jean Shoveller4AbstractBackground: Little is known about service providers’ knowledge, attitudes, and experiences in relation to theassessment, diagnosis, and treatment of individuals seeking care for sexually transmitted infections (STIs), and howthey influence the delivery of services. The purpose of this study was to explore the perceptions of STI careproviders and the ways they approached their practice.Methods: We used a qualitative approach drawing on methods used in thematic analysis. Individual semi-structured in-depth interviews were conducted with 21 service providers delivering STI services in youth clinics, STIclinics, reproductive health clinics, and community public health units in British Columbia (BC), Canada.Results: Service providers’ descriptions of their activities and roles were shaped by a number of themes includingspecialization, scarcity, and maintaining the status quo. The analysis suggests that service providers perceive, attimes, the delivery of STI care to be inefficient and inadequate.Conclusion: Findings from this study identify deficits in the delivery of STI services in BC. To understand thesedeficits, more research is needed to examine the larger health care structure within which service providers work,and how this structure not only informs and influences the delivery of services, but also how particular structuralbarriers impinge on and/or restrict practice.BackgroundThe diagnosed incidence of sexually transmitted infec-tions (STIs) continues to increase in Canada [1]. In theprovince of British Columbia (BC), the number ofpeople testing positive for an STI has more than doubledin the past decade [2]. For Chlamydia, the most com-monly reported STI in BC, the rate of diagnosed infec-tion increased from 122.4 per 100,000 in 1998 to 239.3per 100,000 in 2008 (a 96% increase). Among men andwomen during this same period, the highest rates ofdiagnosed Chlamydia were among those 20 to 24 yearsof age. Women in this age group had a rate (1743.3 per100,000) more than twice that of the men in this sameage group (832.3 per 100,000) [2]. Although the inci-dence of diagnosed STIs show a steady increase over thistime period, we must also acknowledge that changes inthe availability of STI testing, as well as changes in thepopulation of those testing may, in part, have contribu-ted to the rise in diagnosed incidence of these infections.Despite the increase in STIs, however, is concern thatdiagnosed cases far underestimate the number of peoplewho are truly infected, but who remain unaware becauseof the asymptomatic nature of many STIs. Undiagnosedand untreated STIs can evolve into serious sequelae, par-ticularly for young women, including pelvic inflamma-tory disease, infertility, chronic pelvic pain, ectopicpregnancy, and cervical cancer [3]. In addition, evidencenow indicates that STIs enhance the transmission ofhuman immunodeficiency virus (HIV) [4].Increasing the number of sexually active individualswho seek testing for STIs is an important public healthpriority. Early diagnosis and treatment are key elementsin preventing the transmission of STIs and reducingtheir sequelae. Several studies have identified barriersthat reduce STI testing among people at risk. Such bar-riers include concerns about confidentiality, perceivedstigma related to STIs [5,6], structural features related totesting (e.g., clinic location, hours of operation, availabil-ity of appointments), attitudes of health care providers* Correspondence: cindy.masaro@gmail.com1RN, MSN – Doctoral Candidate, University of British Columbia (UBC) Facultyof Applied Science/Nursing, 302 – 6190 Agronomy Road, Vancouver V6T 1Z3,CanadaFull list of author information is available at the end of the article© 2012 Masaro et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Masaro et al. BMC Health Services Research 2012, 12:240http://www.biomedcentral.com/1472-6963/12/240towards users, and providers’ lack of knowledge and lim-ited counseling skills [7,8]. Encounters with health careprofessionals represent opportunities for STI educationand counselling for those at risk, and offer the potentialto increase the uptake of STI services through theprovision of quality STI care. Research related to theprovision of STI services has focused on the screeningpractices of primary care physicians revealing a gap be-tween ideal and actual practice [9-11]. For example,many physicians do not routinely assess STI risk, offerSTI testing, or provide safer sex counselling to patients[12,13]. Barriers to providing appropriate STI servicesinclude inadequate training and specialization in thearea of STIs, a reluctance to obtain a full sexual historyto assess sexual risk because of discomfort in discussingthese topics with patients, and a lack of time to provideadequate education and counselling within the typicalencounter [6,9,14].STI clinics provide another option for those seekingSTI services. Weston et al.’s [7] systematic review of pa-tient satisfaction found that most studies reported highlevels of satisfaction among those attending STI clinics.In the United Kingdom (UK), the growing number ofpatients using STI clinics has resulted in increased pres-sure on those providing STI services [15]. As a result, anemerging issue in the literature concerns the expandedrole of nurses in the delivery of sexual health care. Overthe past two decades, nurses have taken on more re-sponsibilities for STI services; responsibility that hastraditionally been assumed by physicians [16,17]. InCanada (Achen, personal communication), the UnitedStates (US), the UK, the Netherlands, and Australia,nurse-led STI clinics have been in operation to meet therising demand for STI services and to reduce onwardtransmission of STIs [18,19]. Several studies have shownthat nurses perform as well, or better, than physicians inthe delivery of quality STI care and their care is oftenrated higher for overall patient satisfaction [20-23].Despite the growth in service provision related to STIs,little is known about STI service providers’ knowledge,attitudes, and experiences in providing care and, morespecifically, how these may influence their practices duringthe delivery of STI services to youth. Furthermore, weargue that service providers’ perspectives on STI testingare shaped by broader themes that inform their practices.The purpose of this study was to examine how STI serviceproviders working in British Columbia, Canada, viewedtheir roles and the services they provided to clients seek-ing care for STIs and how this in turn informed and influ-enced the delivery of STI services to clients.Context of STI service delivery in BCIn 2006 and 2007, when we conducted our interviews, STIservices in BC were provided in many sites, includingphysician offices, youth clinics, STI clinics, sexual repro-ductive health clinics,, hospitals, and community publichealth units. Although historically physicians have beenthe principal providers of STI care in BC, since the late1980’s, nurses employed at some facilities (e.g., youthclinics; public health units) also have been offering STIservices under a system of delegated medical function, in-cluding: sexual history taking, risk assessment, counselingand education, specimen collection, examinations, order-ing of diagnostic tests, and diagnosing and prescribingtreatments for some infections.MethodsSetting and participantsThis study builds on the work of Shoveller et al. whoinvestigated how socio-cultural influences (e.g., gender,culture and place) and structural features (e.g., clinichours, locations, institutional policies) affected youth’sexperiences accessing STI services [24]. For this study, weused a qualitative approach that drew on 21 individual in-depth ethnographic interviews conducted in 2006 and2007 with service providers (n= 21; 18 women; 3 men;23–65 years of age) who worked with youth in variouscapacities, including five physicians, 14 nurses, one admin-istrative assistant, and one youth worker. Half of thenurses interviewed had completed the five day BC Centrefor Disease Control (BCCDC) STI training course. Thiscourse was the only specialized training available to healthcare providers delivering STI services in BC at that time.Nurses delivering STI services were required to practiceunder delegated medical function. Completion of thiscourse signified that nurses were prepared to deliver STIcare to clients and practice in this capacity.Service providers from a variety of clinical settingswere interviewed, including: clinics that offered educa-tion, counseling, and a full range of STI testing; othersthat provided education and counseling only; and otherclinics that provided testing with limited counseling.Thirteen of the interview participants worked in clinicslocated in BC’s largest urban centre (Vancouver area,population > 720,000), three worked in clinics located ina mid-sized geographically isolated urban centre inNorthern BC (population ~ 85,000), and five worked in asmall rural community in Northern BC (population <10,000). The semi-structured individual interviews wereconducted by four qualitatively trained interviewers ran-ging in age from their mid-twenties to early thirties.Three of the interviewers were Euro-Canadian womenand one was a Euro-Canadian man. A more detailed de-scription of the study settings has been provided else-where [see 24].The semi-structured interviews with these service pro-viders included questions about their experiences in pro-viding STI services to youth, as well as the policies andMasaro et al. BMC Health Services Research 2012, 12:240 Page 2 of 10http://www.biomedcentral.com/1472-6963/12/240practice guidelines that informed their work with youth.We asked their perspectives on the type of STI servicesavailable to youth in their communities, their experi-ences in providing these services, and the socio-culturaland structural conditions influencing the uptake of suchservices by youth in their communities. We used aninterview guide consisting of semi-structured questionsthat were constructed to be open-ended allowing partici-pants the freedom to elaborate and respond to promptsto expand upon and/or clarify their views (see attached).The guide included questions about the types of servicesoffered, providers’ interactions with clients, STI assess-ment procedures, clients’ post-test responses, confidenti-ality issues, record keeping, and their satisfaction withthe services they offered to youth. Participants also com-pleted a brief socio-demographic questionnaire to obtaindata describing their age, education, professional back-ground, and current employment. All interviews wereconducted in private settings and lasted approximately60 to 90 minutes. Ethical approval for this study wasobtained from the University of British Columbia andUniversity of Northern British Columbia Research EthicsBoards, as well as the health authorities that overseeclinics in their regions.Analytical approachWe used a thematic analysis (TA) approach to analyzingour data. TA is a method that involves identifying and ana-lyzing patterns of meaning or themes within qualitative data[25-27]. At a basic level, TA assists researchers in organiz-ing and describing unstructured text-based data. Once abasic structure is identified, TA aids researchers in restruc-turing the data to develop an explanatory frameworkaccording to salient themes or aspects of the research topicthat is consistent with the text [25,27]. One of the criticismsof TA concerns the fact that there have been no clearguidelines developed on how to go about conducting thistype of analysis [27]. To fill this gap, Braun and Clarke [25]developed a step-by-step guide for conducting a TA (seeBraun and Clarke for details), which we used to guide ouranalysis. The first step in the process involved transcribingall interview tapes verbatim and then reading and re-reading the text from each transcript in an active waysearching for recurrent patterns, themes, topics, or relation-ships, which were identified manually by writing ideas ornotes on specific segments of text that were related to thephenomena of interest. The second step involved generat-ing initial codes from the ideas and notes identified in stepone. The codes generated were intended to capture import-ant aspects of the phenomena under study, and to repre-sent some level of patterned response or meaning in thedata set. In step three, we examined the codes and consid-ered which ones grouped together to form a broader theme.The next step then involved refinement and interpretationof the themes. In refining themes we were seeking to deter-mine if there was a clustering of themes and examinedwhether they formed a coherent pattern that adequatelycaptured the coded data. In the interpretation phase weexamined how the themes fit together, what was interestingabout them and why, and then considered the overall storythese themes conveyed about the data. The first author wasprimarily responsible for developing the initial codes andthemes. Selected excerpts of coded texts supporting eachtheme were passed on to the second author for independ-ent review. Refinement and interpretation of the themeswere discussed with the entire research team. In presentingthe findings we use pseudonyms, and identify the type ofclinic where the provider worked, in order to situate thedata.ResultsThe service providers’ descriptions of their activities androles in their clinics were shaped by three themes in-cluding specialization, scarcity, and maintaining the sta-tus quo. These thematic perspectives were reflected inthe way they explained the complexity of their work,how they practiced, and the challenges they faced. Whileone theme seemed to dominate the participants’ discus-sions, many of the service providers shifted betweenthemes in the context of the interview as they sought tosituate their practice in different ways. As we inter-viewed only those working in the province of BC, we ac-knowledge that our findings are not generalizable andlimited only to service providers delivering STI care inthis province.SpecializationThe theme of specialization was often invoked to set STIpractice apart from other forms of health care practice.Given the sensitive subject matter and stigma attachedto STI testing, service providers described their practiceas a specialty requiring a particular set of skills andunderstanding that not all service providers possess.Those who did not possess these specialized skills were“weeded out” and not afforded the opportunity of work-ing in these settings, as pointed out by Robert, a nurseworking in a busy urban STI clinic:“You can’t work in this program unless you’re coolwith gays. . .unless you’re cool with substance use.... Idon’t have to use heroin to work in this program, but Ihave to be non-judgmental. If you have a judgmentalthing happening. . .you’re weeded out in the interviewprocess.”Providers taking up this theme described themselvesas more knowledgeable and skilled at providing STIcare than those who do not specialize in sexual health.Masaro et al. BMC Health Services Research 2012, 12:240 Page 3 of 10http://www.biomedcentral.com/1472-6963/12/240Some providers, mainly nurses, positioned their prac-tice in opposition to primary care physicians, whomthey perceived as “generalists.” They described general-ists as those having some knowledge, but not an “in-depth” knowledge of STIs (primarily because they donot focus exclusively on sexual health and STIs). Itwas suggested by some that physicians were deficientin the knowledge and skills needed to adequately as-sess and test for STIs, as illustrated by Beth, a nurseworking in a youth wellness clinic, who recounted oneof her experiences:‘I mean I’ve had doctors at the walk-in clinic who havetreated somebody who’s symptomatic for Gonorrheawith the wrong medication. . .the one guy it happenedto, I think he went in four or five times, and he wastreated each time, and on the fourth or fifth time, hada urine test.... In the end it turned out he hadn’t beenadequately screened, hadn’t been adequately treated.”Providers who invoked the specialization theme alsoemphasized their ability to “spend time” with youthcompared to other providers. For the majority of STIproviders, time spent with a client was an important fac-tor that determined the quality of STI care. In general,service providers argued that the more time one has toestablish an environment conducive to the client’s dis-closure of sensitive information, the more comprehen-sive the assessment and the deeper the understanding ofboth the medical and psychosocial aspects of sexualhealth. Mary, a salaried STI physician working in a busyurban STI clinic specializing in STI care made the fol-lowing comment:‘We find people that have been to four or five differentwalk-in clinics and they finally come, you give themtime, sit them down, get the proper history and you’vesorted them out. . .I think that the medical systemshould provide the ability to spend time so you canactually listen to people and they would save a lot ofmoney in the long run. . .”Mary thought that health care delivery could beimproved by eliminating fee-for-service billing (FFS).She explained that because physicians bill FFS, theymust restrict the time they spend with each client inorder to maintain sufficient throughput in their dailybilling – making it difficult to perform a comprehen-sive assessment and/or counselling. Physicians in pri-mary care, who bill FFS, were most often perceived asnot having enough time with clients and were fre-quently described as providing ‘piecemeal’ STI services.Beth, a nurse working in a youth wellness clinicexplained:“They are providing Pap tests, and in addition to thatthey are doing screening but they are not doing thepre-counselling, they are not doing the HIV, not doingSyphilis or Hepatitis, so they’re doing a piece, butthey’re not doing STD testing.”This approach was said to be detrimental to the wel-fare of youth largely because vital aspects of sexualhealth are not addressed. Ultimately, it was maintainedthat this led to substandard care and inconvenience foryouth (e.g., requiring multiple clinic visits and furthertesting to resolve STI issues). FFS was described as theroot of these problems by those who did not bill forhealth services in this manner.Another aspect of the specialization theme was theparticular emphasis placed on the need for confidenti-ality. Confidentiality was a predominant topic amongSTI providers as they viewed the privacy needs ofyouth as being much different from those seeking ser-vices in other areas of health care. Some clinics,mainly those in the Vancouver area, had the ability toprovide testing that did not require youth to presenttheir provincial personal health number (PHN) or toshow ID. This was often contrasted with medicalclinics, including walk-in clinics that require a PHN inorder to bill the provincial Medical Services Plan(MSP) for services rendered. Several providers main-tained that producing a PHN is problematic for someyouth (e.g., their parents may have possession of theirPHN cards). Others maintained that youth are athigher risk of potential confidentiality breaches (ascompared to adults) because some providers, mainlyphysicians, were perceived not to be aware of or asunderstanding of the confidentiality issues associatedwith STIs. Valerie, a nurse working in an urban youthclinic explained, “There’s doctors who say things like ’Ifa kid comes in to me I have to tell their parents.”Thus, STI “specialists” distinguished themselves fromgeneralists by highlighting the privacy advantage theybelieve they offer to youth seeking STI services.The theme of specialization was also used toemphasize how providers were able to overcome the in-adequacies of current policies related to STI/HIV ser-vices/care in meeting the needs of youth seeking STIservices. Importantly, this theme was used to justify howproviders moved beyond the rules and policies in orderto meet youths’ needs. Erica, a physician in Vancouver,discussed how providers in her clinic offered youth theopportunity to opt out of having their names enteredinto the electronic record keeping system, despite thetension that this created with administration. Otherssuch as Beth, a nurse working in a youth clinic describedcircumventing policy if she felt it to be beneficial for theyouth. For example, although provincial policy (at theMasaro et al. BMC Health Services Research 2012, 12:240 Page 4 of 10http://www.biomedcentral.com/1472-6963/12/240time of this interview) was to swab for Gonorrhea, Bethrequested a urine test instead:“we’ve been telling doctors who have tested people[who receive a] positive [for a STI], ‘you know you maywant to confirm with a swab if this person isn’t highrisk’. But if they’re high risk, I’m not waiting for aswab to treat them because they could disappear andnever come back and. . .it could be too serious.”In some instances, the specialization theme appearedto override young people’s agency, as providers sug-gested they knew what was best for young people be-cause they were specialists. Difficulties experienced inproviding care were located with youth, rather than theapproach taken. In particular, STI care problems werethought to stem directly from youths’ lack of responsibilityand sense of entitlement, as highlighted by Dorothy, anurse working in a student health clinic:“They [the youth] have the sense of entitlement or asense of ‘someone is just going to give me condoms.’Whereas they don’t have the responsibility to sort ofsay ‘It's my job to go out to BUY them or get them anyway I CAN, that’s my responsibility, and not forsomeone to put them under my door, or given them tome for free.’"Ray, a nurse working in a STI clinic, indicated thatmany youth seemed unwilling to listen closely to mes-sages about safe sex and that "everything you say is virtu-ally irrelevant.“ Given the alleged lack of responsibility,these providers indicated that it was within their scopeof practice to employ extraordinary measures to ensurethat youth receive additional follow-up care. Dorothydescribed using whatever measures were required to lo-cate someone with an STI, and implied that many youthare not responsible enough to get their test results:“But if I’m concerned I also have ways of gettinginformation. . .because if it’s really risky I won’t let itbother me. If someone was a – had a positive HIVresult. . .I’ll use whatever devious means, ‘cause I’vedone that before with the STD clinic, as you can justfind some way around.”Ruth, a nurse working in a youth clinic, indicated that,in addition to sexual health issues, she also tries to helpyouth with other health issues. She stated that she is ableto consolidate her workload to deal with issues such aspoverty and mental illness and suggested she knowswhat is best for youth in relation to these issues: “I alsoknow who needs a little boost and who doesn’t along theway.“ When service providers override young people’sagency, they also appear to invoke a sense of “owner-ship” in relation to youth (e.g., the youth need to beencouraged to return to the clinic; and, particular tacticsare used because the providers know what is best). Per-haps most importantly, the providers describe talking toyouth in such a way that suggests they are taking on aparental role:Ruth - “and I had a fit one night because I had ayoung woman, obviously needed emergencycontraception. I said, ‘Under no circumstances do Iwant your mother pulling a wallet out to pay forsomething that you need and I consider completelyprivate. So let’s you and I make a little deal that I’mpresenting it to you as a gift and you can just quietlytell your mother nothing.‘"In this scenario, Ruth does not mention whether or notthe young woman had discussed the need for emergencycontraception with her mother. It may have been likelythat this young woman's mother knew why her daughterwas at the clinic, especially considering that the motherwas present at the clinic and willing to pay. Even whenyouth have made a decision, Ruth describes interveningbecause she believes she knows what is best:"I mean if I do a pregnancy options counselling, and eventhough I know they've pretty well made their decision butit's a little bit of roaring ambivalence that flies in. I said,‘Let's you and I make a deal. My role really does endhere. . .but let's follow up in two weeks. . .and so they'll geta phone call from me in two weeks’ time.’"Ruth went on to describe how she kept a detailed listof youth whom she perceived were in need of additionalsupport and follow up, even though their cases had beenresolved. Unless youth had specifically requested oragreed to be followed up, follow up in these situationmay be uncalled-for and create more anxiety or confi-dentiality concerns, especially if unwarranted voicemailmessages are left for health issues a young personthought were resolved. Efforts at maintaining unneces-sary relationships with the youth and a sense of"mothering" were invoked when Ruth suggested thatyouth must be physically present to discuss partner noti-fication, rather than discussing this over the phone. Dis-cussing partner notification can be conducted over thephone and does not necessarily require youth to bephysically present in the clinic setting. In her interviewRuth recounted telling some youth who required partnernotification:"’So why don't you come in tonight?’. . . I mean I've hadpeople say, 'Well it's not a good time.' ‘Well, it's neverMasaro et al. BMC Health Services Research 2012, 12:240 Page 5 of 10http://www.biomedcentral.com/1472-6963/12/240going to be a good time and what's going to make itpositive for you? How about we do it tomorrow?’"ScarcitySome providers made reference to notions of scarcity asthey emphasised what could not be achieved because ofa lack of resources, frequently describing themselves as‘overwhelmed’ and ‘frustrated’. These providers recog-nized that certain STI services were lacking, and thattheir practice could be improved by offering these ser-vices. The theme of scarcity was characterised by a rec-ognition that resources were lacking in the system, andan expression of frustration that things should changebut cannot, as Beth, a nurse in Northern BC explained:"We have always been really full.... We're at full capacityand we just don't have the resources to increase, whichwe need to do." In the end this theme emphasised thatSTI providers were “doing the best that they could do.”One of the main scarcity issues described concerned alack of human resources. Providers expressed frustrationwith not having enough staff to cover existing services,to expand these services, or to hire new personnel tomeet the needs of youth. For example, Ruth, a youthclinic nurse , told us:"we need more staff. We need more nurses. That wouldbe lovely if we had one more nurse doing moredelegation and that sense of flow. . .it would beincredible. That's a daydream."The theme of scarcity was also used in discussingpractitioners’ physical space. Several providers statedthat their clinics did not have enough space, or that theclinic location and hours of operation were not suitablefor meeting their clientele's needs. Some described notbeing able to offer services because of the lack of mater-ial supplies, as illustrated by Anne, a nurse in NorthernBC:"So when we went down to the STI training [offered bythe BCCDC], I came back, I still couldn't do women,even though we had been shown it. We didn't have aset up, we didn't have any means of doing it, we didn'thave any of the equipment, we didn't have any lights,nothing."Maintaining the status quoIn this third theme, STI providers, mainly nurses, recog-nized that there are inefficiencies within the system yet,for the most part, they appeared resigned to these ineffi-ciencies. A key element of this theme is an expression ofresignation and frustration over things that cannot bechanged, as evidenced by Helen, a public health nurse ,who spoke about the process for follow up on positivetest results: ". . .time-consuming, that's frustrating. And Idon't know if that's fixable or not." In their descriptionsof their practices, providers reflected this theme only in-directly. No practitioner indicated that they were infavour of the status quo, but this theme was hinted at asthe providers suggested that they follow the routines andpolicies of the clinics even when they led to questionableoutcomes.In many cases nurse providers were qualified andcompetent to carry out several of the same functions asphysicians. Clare, a youth clinic nurse explained:"All of us that work here have a degree in nursing andthen we've all taken extra courses at BCCDC, the STIclinic, that's one of the prerequisites."However, at some clinics these nursing activities wererestricted and not supported by administration or thephysicians working there. Interestingly, the nurses atthese clinics did not appear to dispute policies or guide-lines that unnecessarily restricted their practice, perhapsin part because they felt unsure about their nursing re-sponsibilities in relation to STI care, and what they were"allowed" to do and what they were "not allowed" to do.For example, Anne, a public health nurse discussed howshe was unaware what nurses were permitted to do interms of STI testing, diagnosis, and treatment until sheheard information from another nurse provider:"And so it's one of those. . .what you don't know, yousometimes don't question."Others could not envision operating a STI clinic with-out a physician present for consultations: "I couldn't im-agine sort of constantly having to operate that way,because some clinics do, you know, it's strictly nurse-run,but it is limiting in terms of how much you could provideand your sense of what it means to have a touchstone."(Ruth, a sexual and reproductive health clinic nurse).Many nurses who were qualified to perform specificfunctions (e.g., Pap tests and STI tests) were ‘tasked’with these responsibilities during busy time periods inclinics, but only completed these procedures when theclinic physician was too busy and there was a back up ofclients in the waiting room. In some clinics, thereappeared to be incorrect delineation of tasks betweenphysician and nurse, which in the following case resultedin a lengthy delay in following up with youth who havetested positive for a STI at a physician's office:"If Dr. X gets a gonorrhoea, we have--sometimes amonth delay before we're allowed to try and contactthat person. . .because we have to get permission fromhim to contact them. . . . If it was up to us, we couldMasaro et al. BMC Health Services Research 2012, 12:240 Page 6 of 10http://www.biomedcentral.com/1472-6963/12/240probably do it faster but that might interfere with thedoctor-client relationships, [which] we're not allowedto, so. . ." (Helen, public health nurse)Despite being qualified to provide STI care and beingaware of the problems and inefficiencies within the sys-tem, providers invoked the status quo and did not dis-cuss how their own skills or qualifications could be partof the solution. Anne, a public health nurse , began tounderstand this only after a new nurse, who questionedthe status quo, began working at her clinic:Julie is just very good at pushing it until it happens.You know, it made no sense that we couldn't give it[herpes, trichomoniasis, bacterial vaginosis treatment].They give it down at BCCDC. And then we found outthat they were giving it in [name of city] but it stilltook a lot–it's that whole getting through thepaperwork and the hierarchy to be allowed to actuallydo it. So we are now and she's phenomenal, that's howwe get so much going."DiscussionPerceptions about matters such as STI practice areshaped by institutional and social structures (e.g., formaland informal policies, practices, procedures, power dy-namics) that enforce particular ways of thinking and act-ing. In this study we sought to understand how certainlanguage and social processes around STI service deliv-ery influenced the ways in which service providersthought and talked about particular aspects of theirpractice, and how this influenced the care they providedto youth. Several features of the themes identified in thisstudy reflect service providers’ perceptions that the de-livery of STI care is at times inefficient and inadequate.Although these themes have been identified in relationto service providers' experiences delivering care toyouth, similar themes have been identified among thoseproviding STI services to adults [28]. Thus, our findingsmay be applicable to STI service delivery in BC in gen-eral. While it is tempting to “blame” the service provi-ders for these deficiencies, we must first look to thelarger health care structure within which the serviceproviders work, and give consideration to how thisstructure informs and influences practice and thus ser-vice delivery, as well as the structural barriers that limitpractice. In the following discussion we highlight keystructural factors that shape STI testing.The theme of specialization highlights the need felt bymany STI service providers to develop a specializedbody of knowledge in relation to the provision of STIservices. This specialized knowledge was required be-cause of the sensitivity associated with having an STI,the importance of spending time building rapport andobtaining an accurate sexual health history. Those whosediscussion reflected this theme perceived clients of STIservices to have needs that were quite different fromthose accessing other primary care services. The needfor a specialized approach may stem, to some extent,from society’s negative social judgment, which is oftenstigmatizing and discriminating, toward those who ac-quire STIs. Individuals receiving a STI diagnosis areoften viewed as dirty and promiscuous [29] and reportexperiencing shame, discomfort, anxiety, isolation, andrejection [30,31]. This results in the need for providersto break down barriers to open communication. Theneed for service providers to address these issues wasseen in sharp contrast to traditional STI services thatfocus on the diagnosis and treatment of the disease ra-ther than include the socio-cultural context that influ-ences and limits people's decision making in relation totheir sexual health.A key feature of the specialization theme was an em-phasis on the need to spend more time with clients. It wasargued that this enabled service providers' opportunitiesto understand and deal with the multifaceted psycho-social and socio-cultural aspects of their clients' sexualhealth, which they perceived as necessary for providing ahigher standard of care. Notably, this theme often involvedcontrasting the service providers remunerated by FFS withthose on a fixed salary. For example, service providers bill-ing FFS were deemed to provide substandard care becauseconsiderably less time was spent consulting with the clientabout the socio-cultural and structural conditions thatconstrain sexual health and well-being; the focus insteadwas on the medical-curative aspects. Indeed, researchdemonstrates that service providers who are not paid on aFFS basis spend more time providing patients with directpatient care (e.g., longer consultations, follow up) [32].According to Devlin and Samra, the FFS form of remuner-ation is a formidable tool for influencing physician behav-iour. For example, FFS physicians supplement theirincome by increasing the number of clients they see ratherthan by increasing the quality of the services they provide.Decisions regarding care are often determined by the de-sire to generate income rather than the desire to serve theneeds of the client [33]. The FFS model rewards rapid,technical procedures over the delivery of holistic care [3].Also apparent in the specialization theme is the existingtension between non-physician and physician STI serviceproviders, which may in part, stem from a lack of rec-ognition of the full role that non-physician providers(e.g., nurses) are able to play in relation to STI service de-livery. Indeed, expectations about the role STI service pro-viders play in the delivery of STI services shows anunderlying “tug-of-war” for power and ownership betweenphysicians and non-physician service providers in their at-tempt to shape the system. At the time of our interviews,Masaro et al. BMC Health Services Research 2012, 12:240 Page 7 of 10http://www.biomedcentral.com/1472-6963/12/240non-physician STI service providers were not formallyrecognized as specialists in this area. The specializationtheme was reinforced by the perceived need for non-physicians to establish credibility and decrease depend-ence on physicians. Jones [34] suggests that unclear roleexpectations underlie some healthcare providers’ negativeattitudes toward expanded practice roles. Turf battles andconcerns about whether service providers are practicingbeyond their scope of practice arise, especially when thereis an overlapping of roles [35]. Clients can also expressconcern. Rashid’s [36] findings show that when rolesformerly undertaken by physicians were carried out bynurses practicing in an expanded role, clients were morelikely to express concern about the nurses’ level of trainingand competency, particularly in relation to diagnostic test-ing and treatment.Although some service providers felt the need to ‘cre-ate a niche’ for themselves in the provision of STI ser-vices, what also needs to be considered is howspecialization can create obstacles for others to provideSTI care. At the time of our interviews service provi-ders could only attend the BCCDC STI training courseif they were nominated by their employers, and hadtheir time and expenses paid. This limited the numberof practitioners who were specially trained to provideSTI care. Another unintended obstacle created byspecialization is the tendency to disregard the know-ledge and experience of youth. Service providers whosecomments suggested a patronizing attitude may havebeen expressing their own disciplinary power, as know-ledge and specialization are recognized tools for exer-cising power over others [37].Notions of scarcity influence much of health care pol-icy [38]. As such, it is not surprising that it was used toposition STI testing. Federal and provincial governmentbudgets have become increasingly dominated by thehigh costs of health care. Providers readily describedhow they lacked appropriate human and physicalresources, and identified these as limitations in theprovision of care, but there was minimal discussionabout how these issues might be addressed. The know-ledge gained through training programs is a necessaryfactor for initiating change, but inadequate resources(e.g., support staff, technology, infrastructure) placeservice providers at an extreme disadvantage when try-ing to practice in an expanded role and have been fre-quently reported in the literature [32]. As evidenced insome settings, structural conditions (e.g., policies, proce-dures, practices) were such that implementing aspects ofan expanded STI service role was not possible. Coordin-ation and expansion of STI services pose major chal-lenges for provincial governments as they attempt toreconcile increasing demand with budgetary con-straints. This has resulted in much emphasis beingplaced on improving service delivery using existingresources [32].In recent years there has been an increasing demandon non-physician service providers to deliver quality STIcare [22]. The findings, however, reveal a lack of claritysurrounding the role of non-physician service providers,and a lack of support for STI education, training, andorganizational resources for those delivering this careand practicing in an expanded role. In some areas, thesestructural constraints have resulted in STI services thatare fragmented with little or no coordination. Accord-ing to Kumpers, van Raak, Hardy, and Mur [39], thiscauses waste and undersupply on the system’s side andundersupply and neglect for those using the services.In a systematic review by Jones [34], lack of role claritywas identified as one of the most important factorslimiting the implementation of an expanded practicerole. Lack of role clarity contributes to confusionamong other healthcare service providers about the ac-tivities performed by those practicing in an expandedcapacity [34]. This may limit the acceptance of theseroles by other providers, hinder innovation, and per-petuate the status quo. Providing well-defined goalsand expectations for expanded practice roles wouldprovide greater recognition for those practicing in theseroles [35].When people become worn down by the system, theyeventually give in and accept the status quo [2,40]. Inthis way, the system limits service providers in thinkingabout and initiating change. Some service providers mayhave disengaged from attempting to make changes dueto frustration experienced from confrontational situa-tions with physicians or administrators, especially insituations where they perceive themselves to have lim-ited power. Service providers in the current study fre-quently said they lacked the power to make structuralchanges and, as result, worried that they were inadvert-ently reinforcing the existing system. Because of theseconstraints, some service providers resorted to employ-ing strategies that offered innovations in practice be-cause they circumvented existing policy and procedures.Subsequently, service providers’ creative energies werediverted to overcoming barriers rather than in advocat-ing for change.Limitations of this study should be acknowledged. First,the study focused on a particular context and the findingsare not necessarily generalizable to other contexts. Sec-ond, we focused on the perspectives of care providers andthis understanding could be bolstered by consideration ofthe actual day-to-day actions and practices, which will bethe focus of a subsequent manuscript. Also, TA is inter-pretive and the themes that are described herein resultfrom a specific analytical orientation; other themes may berevealed by other analytic strategies.Masaro et al. BMC Health Services Research 2012, 12:240 Page 8 of 10http://www.biomedcentral.com/1472-6963/12/240ConclusionThe findings of this study provide valuable insightsregarding perspectives that shape STI service delivery toyouth. These findings call into question approaches thatfocus solely on educating individual practitioners andpoint to the need to also address important structuralfactors that limit STI service delivery.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsCLM conducted the data analysis and drafted the manuscript. JJ reviewedand provided feedback on the data analysis and the manuscript. CC and JSalso provided feedback both on the data analysis and manuscript. JSconceived of the original study. All authors read and approved the finalmanuscript.AcknowledgementsThis study and manuscript were made possible by funding from theCanadian Institutes of Health Research (CIHR), Institute of Gender and Health(grant number MOP-77574). Career support for JS is provided by a CIHRApplied Public Health Chair award and by a Michael Smith Foundation forHealth Research Senior Scholar award. We gratefully acknowledge theservice providers who participated in this study.Author details1RN, MSN – Doctoral Candidate, University of British Columbia (UBC) Facultyof Applied Science/Nursing, 302 – 6190 Agronomy Road, Vancouver V6T 1Z3,Canada. 2PhD, RN, FCAHS– Professor, School of Nursing, UBC and ScientificDirector, Canadian Institute of Health Research, Institute of Gender andHealth, 302 – 6190 Agronomy Road, Vancouver V6T 1Z3, Canada. 3MA –Research Manager, School of Population and Public Health, UBC, 2206 EastMall, Vancouver V6T 1Z3, Canada. 4PhD – Professor, School of Populationand Public Health, UBC, 2206 East Mall, Vancouver V6T 1Z3, Canada.Received: 14 October 2011 Accepted: 31 July 2012Published: 6 August 2012References1. Public Health Agency of Canada: Brief report on sexually transmittedinfections in Canada. Ottawa: Public Health Agency of Canada; 2007.2. BC Centre for Disease Control: Annual surveillance report HIV and sexuallytransmitted infections. 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BMC Health ServicesResearch 2012 12:240.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitMasaro et al. BMC Health Services Research 2012, 12:240 Page 10 of 10http://www.biomedcentral.com/1472-6963/12/240

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