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Physician attitudes and practices related to providing reproductive and sexual health care to women with… Creighton, Zahra; Kuras, Martha; Vincze, Elizabeth 2014

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 Physician Attitudes and Practices Related to Providing Reproductive and Sexual Health Care to Women with Mobility DisabilitiesBackground: Studies show that women with physical disabilities have significant barriers to sexual and reproductive health care. There are several contributing factors to this disparity: health care provider attitudes towards disability and sexuality; health care provider lack of knowledge about sexuality and disability; limited education regarding sexual health and disabilities for health care providers; and inaccessible facilities and equipment. Currently, much of the research on the subject has been based in the United States. Limited research has been done to identify barriers and physician knowledge and attitudes towards sexuality and disability in British Columbia and Canada. Purpose: 1. Complete independent literature review on the reasons for the disparity in sexual and reproductive health care for women with physical disabilities. This research informed the development of physician survey questions. 2. Determine best physician survey methods based on most current evidence.3. Identify physician survey questions about views on sexual and reproductive health for women with disabilities which will identify potential gaps in knowledge and/or education. The results of this survey will help inform and shape a future education program for physicians about this topic, with the intention of reducing or eliminating the identified inequity.By: Zahra Creighton, Martha Kuras, Elizabeth VinczePhysician Response to Survey ? A primary purpose of this project was to develop a survey assessing physician?s attitudes, knowledge, and accessibility of their facilities to addressing the sexual and reproductive health care needs of women with physical disabilities. ? However, research has consistently shown low response rates to physician surveys, creating several challenges:? How generalizable are survey results? ? Potential for nonresponse bias; studies have shown systematic differences between respondents and nonrespondents? Why are physician response rates low? ? Research shows the main factors include: lack of time; perceived low value of the study; concerns about confidentiality; questions that appear biased and do not give a good range of options? With this in mind, we conducted a literature review to determine methods that may increase response rates to a physician survey? Contact participants prior to administering the survey ? A mailed survey has shown to produce the best response rates ? Design a mixed methods survey with options to respond by mail, internet, or fax? Mail survey with registered mail and include: a personalized cover letter explaining the importance of the study and the individual?s response, and stamped return envelopes ? All materials should be personalized as much as possible and endorsed by the organization conducting the research? If possible, include a small, immediate monetary incentiveSurvey QuestionsWe first conducted a literature review of research on sexuality and women with disabilities, which informed the physician survey questions. We designed our survey questions to address the following three themes identified in the literature: Theme: Physical barriers to accessible health care for women with disabilities Studies have shown the physical environment of facilities and exam rooms are a barrier for health exams for women with disabilities. For example, Drew and Short (2010) and McRee, Halpern, and Hayden (2010) found lower rates of pap testing among women with disabilities. Armour, Thierry, and Wolf (2008) similarly found lower rates of mammograms and pap tests among women with disabilities, and argued this is likely related to the physical environment of the health care facilities. Iezzoni, McCarthy, Davis, and Siebens (2000) also noted lower rate for mammograms, pap tests and immunizations, and attributed this disparity partly to the inadequacy of office equipment and inaccessibility of facilities. Specifically, Thierry (2000) identified physical barriers such as difficulty accessing transportation to get to the facility, difficulty mounting examination tables, and inadequate equipment in the exam room. Facilities may also lack ramps and elevators that make getting to the facility challenging for anyone with a disability (Drew & Short, 2010).  - Theme: Physician attitudes towards sexuality and reproductive health for women with physical disabilitiesPeople with disabilities are commonly perceived as asexual by society (Esmail, Darry, Walter, & Knupp, 2010). Research has shown physicians may also assume women with disabilities are asexual (Thierry, 2000). This influences their care for these women in a number of ways. For instance, health care providers may ignore the sexual and reproductive health needs of disabled women, which in addition to the physical barriers, also contributes to disparities in routine screening and prevention measures described above. Iezzoni et al. (2000) found that physicians focused more on the client?s condition that caused the disability rather than screening and prevention. Further, O?dea, Shuttleworth, and Wedgwood (2012) argue physician attitudes had a moderating effect on inhibiting sexual expression in women with neuromuscular disorders, which negatively affected the women?s quality of life. Based on their research on physicians as well as the general public?s attitude on sexuality and physical disability Esmail et al., (2010) concluded that more research needs to be done on how to educate society about sexuality and disability, because knowledge influences social attitudes including physicians attitudes to sexuality when working with this population.  Survey QuestionsSurvey QuestionsTheme: Lack of education and experience working with the disabled populationEven where physicians recognize the need to explore sexual and reproductive health, they may lack the necessary knowledge and experience to work with this population. For instance, when they presented residents at an urban medical facility with a case scenario about a woman with spinal cord injury Oshima, Kirschner, Heinemann, and Semik (1998) found that although the residents knew they needed to address issues of reproductive health, they did not know how to position the women, and did not have the correct equipment to examine the women in their office. O?dea et al. (2012) argue the need for more education opportunities to help physicians address sexual health in women with physical disabilities. Oshima et al. (1998) recommend that an alternative model of care be developed to address the sexual and reproductive health needs of women with disabilities, as primary care GPs often lack the knowledge and experience to adequately address the health needs of this population. How did these research themes influence our survey questions?Theme: Physical barriers to accessible health care for women with disabilitiesCorresponding survey questions:Question 3: In relation to the above case study, I feel that my office is well equipped to meet the reproductive health care needs of a woman with a SCI.This question directly asks if the physician?s office has any physical barriers for a woman with a SCI.Question 7: My office has the necessary equipment needed to transfer this patient from her wheelchair to the examination table.As previously discussed, inability to transfer to an examination table is a key physical barrier for women with a mobility disability. This question directly addresses this point in asking if a woman with MS could use a physician?s examination table.Question 9: In relation to the above case scenario, how could your office improve accessibility for patients with mobility disabilities?This question asks an open-ended question where respondents can comment in a text box. This provides physicians with the opportunity to reflect on what environmental barriers exist for those with mobility disabilities in their offices.Theme: Physician attitudes towards sexuality and reproductive health for women with physical disabilitiesCorresponding survey questions:Question 1: I feel comfortable with regards to providing reproductive health care for a woman with a SCI.This question addresses whether a physician is comfortable when providing care to a woman with a SCI, which is an attitude that the physical holds.Question 4: I feel comfortable with providing care to this patient. (A 13 year old with CP)Like the above question, this question addresses whether a physician is comfortable when providing care for an adolescent with CP.Question 10: In relation to the above case scenario, do you feel that increasing accessibility to patients with mobility disabilities is an issue that should be addressed further within our current healthcare system?This question allows the physician to state his opinion about how the current healthcare system addresses the needs of those with mobility disabilities.Theme: Lack of education and experience working with the disabled populationCorresponding survey questions:Question 2: In relation to the above case study, I feel that I have received adequate education and have sufficient knowledge in order to properly care for a woman with a SCI.This question directly asks if the physician has the knowledge and experience required to care for a woman with a SCI.Question 5: In relation to the above case study, I feel that I have received adequate education and have sufficient knowledge in order to properly care for an adolescent with CP.Like the above question, this question directly asks if the physician has the knowledge and experience to care for an adolescent with CP.Question 6: In relation to the above case study, how would you proceed to provide care to this patient?This is an open ended question that allows the physician to explain his plan of care for the adolescent with CP, which therefore directly inquires into the physician?s knowledge base and previous experience and education in this area.Question 8: In relation to the above case scenario, I would be able to perform a routine pap test on this individual. (42 year old with MS)This question directly asks if the physician has the knowledge and education in order to perform a procedure on a woman with MS.Outcome: SurveyWe created an online survey based on our evidence-based survey questions for the purpose of this presentation in order to demonstrate the format and question style of the survey. The link can be found here: we were to conduct an actual survey of physicians, it is important to note that the survey would be in multiple formats including a mailed paper survey and online survey. As well, if we were to mail surveys to physicians, we would want to include a cover letter detailing the purpose of the survey and, if possible,  a small incentive (such as an attractive pen or gift card) as this has also been shown in the literature to increase physician response rates. Our research shows these methods elicit the highest physician response rates. ? Two literature reviews provided by Lenore Riddell:? Nelson, M. (2012). Sexuality Education and Youth with Disabilities and/or Chronic Illnesses.? Fraser Health Authority. (2012). Engaging Marginalized Women in Health Care Decision-making.? Meetings and communications with Lenore Riddell? Online resources: PubMed, Google ScholarResources UsedNext StepsThere is currently enough evidence to show that there is indeed a disparity in sexual and reproductive health care for women with disabilities, and that this is based on multiple factors including the physical barriers and issues with physician attitudes towards, and knowledge of working with this population.Next, the list of physicians to be included into the survey sample will need to be compiled. The survey will be edited further, compiled into a final format and prepared to be mailed out. After the surveys are filled in and returned, the results will need to be compiled and analyzed. These results will then be used to inform the content of the educational program for physicians (and perhaps for other health care providers).The intention of the educational program is to both fill in any gaps in knowledge that may exist for physicians, but also to challenge any attitudes that may be influencing the care that this population is receiving.We also feel that it would be beneficial to create a modified version of the survey which could be filled in by the program participants after its completion. This survey would ask whether there were topics that were missing from the program, and also whether the participants felt that the information provided was useful and challenging, and would potentially translate into change in the participants? practice settings.References Andresen, E. M., Peterson-Besse, J. J., Krahn, G. L., Walsh, E. S., Horner-Johnson, W., & Iezzoni, L. I. (2013). Pap, mammography, and clinical breast examination screening among women with disabilities: A systematic review. Women's Health Issues, 23(4), 205-214.Armour, B.S., Thierry, J.M., & Wolf, L.A. (2008). State-level differences in breast and cervical cancer screening by disability status: United States, 2008. Women's Health Issues 19(6), 406-414.Bonevski, B., Magin, P., Horton, G., Foster, M., & Girgis, A. (2011). Response rates in GP surveys-trialling two recruitment strategies. Australian family physician, 40(6), 427-430.Cho, Y. I., Johnson, T. P., & VanGeest, J. B. (2013). Enhancing Surveys of Health Care Professionals A Meta-Analysis of Techniques to Improve Response. Evaluation & the health professions, 36(3), 382-407.Drew, J.A.R., & and Short, S.E. (2010).. Disability and pap smear receipt among US women, 2000 and 2005. Perspectives on Sexual and Reproductive Health 42(4), 258-266.DOI: 10.1363/4225810Drummond, F. J., Sharp, L., Carsin, A. E., Kelleher, T., & Comber, H. (2008). Questionnaire order significantly increased response to a postal survey sent to primary care physicians. Journal of clinical epidemiology, 61(2), 177-185.Edwards, J.P., Roberts, I., Clarke,M. J., DiGiuseppi, C., Wentz, R., Kwan, I., Cooper, R., Felix, L. M., & Pratap, S. (2009). Methods to increase response to postal and electronic questionnaires. Cochrane Database Systematic Review 3, MR000008. doi:10.1002/14651858 MR000008.pub4Esmail, S., Darry, K., Walter, A., Knupp, H. (2010).Attitudes and perceptions towards disability and sexuality. Disability & Rehabilitation 32(14), 1148-1155.Gibson, B.E., and Mykitiuk, R.(2012). Health care access and support for disabled women in Canada: Falling short of the UN Convention on the Rights of Persons with Disabilities: A qualitative study. Women's Health Issues 22(1), 111-118.Greydanus, D.E., & Omar, H.A. (2008). Sexuality issues and gynecologic care of adolescents with developmental disabilities. Pediatric Clinics of North America 55(6), 1315-1335.Heath, B., Flicker, S., Nepveux, D., & Proudfoot, D. (2013). A content analysis of youth sexual health websites: Exploring their relevance and accessibility for youth with disabilities." Health Tomorrow: Interdisciplinarity and Internationality 1. Retrieved from, L.I., McCarthy, E.P., Davis, R.P., & Siebens, H. (2000). Mobility impairments and use of screening and preventive services. American Journal of Public Health 90(6), 955.James, K.M., Ziegenfuss, J.Y., Tilburt, J.C., Harris, A.M., Beebe, T.J. (2011). Getting Physicians to Respond: The Impact of Incentive Type and Timing on Physician Survey Response Rates. Health Services Research 46(1), 232-242.References ContinuedLennox, N. G., Diggens, J.N. & Ugoni, A.M. (1997). The general practice care of people with intellectual disability: Barriers and solutions. Journal of Intellectual Disability Research 41(5), 380-390.Martins, Y., Lederman, C.L., Lowenstein, C.L., Joffe, S., Neville, B.A., Hastings, B.T., & Abel, G.A. (2012). Increasing response rates from physicians in oncology research: A structured literature review and data from a recent physician survey. British Journal of Cancer 106, 1021-1026. McLeod, C.C., Klabunde, C.N., Willis, G.B., & Stark, D. (2013). Health care provider surveys in the United States, 2000-2010: A review. Evaluation and the Health Professions 36(1), 107-127. doi: 10.1177/0163278712474001McRee, A-L., Haydon, A.A, and Halpern, C.T. (2010). Reproductive health of young adults with physical disabilities in the US. Preventive medicine 51(6), 502-504.Minniear, T.D., McIntosh, E.B., Alexander, N., Weidle, P.J., & Fulton, J. (2013). Using electronic surveys to gather information on physician practices during a response to a local epidemic - Rhode Island, 2011. Annals of Epidemiology 23(8), 521-523. Nicholls, K., Chapman, K., Shaw, T., Perkins, A., Sulllivan, M.M., Crutchfield, S., & Reed, E. (2011). Enhancing response rates in physician surveys: The limited utility of electronic options. Health Services Research 46(5), 1675-1682. Oshima, S., Kirschner, K.L., Heinemann, A., & Semik, P. (1998).Assessing the knowledge of future internists and gynecologists in caring for a woman with tetraplegia. Archives of physical medicine and rehabilitation 79(10), 1270-1276.O?Dea, S.M., Shuttleworth, R.P., & Wedgwood, N. (2012). Disability, doctors and sexuality: Do healthcare providers influence the sexual wellbeing of people living with a neuromuscular disorder? Sexuality and Disability 30(2), 171-185.Pit, S.W., Hansen, V., & Ewald, D. (2013). A small unconditional non-financial incentive suggests an increase in survey response rates amongst older general practitioners (GPs): A randomised controlled trial study. BMC Family Practice 14, 108.Recklitis, C.J., Campbell, E.G., Kutner, J.S., & Bober, S.L. (2009). Money talks: Non-monetary incentive and internet administration fail to increase response rates to a physician survey. Journal of Clinical Epidemiology 62(2), 224-226.Sprague, S., Quigley, L., Bhandari, M. (2009). Survey design in orthopaedic surgery: Getting surgeons to respond. Journal of Bone Joint Surgery 91(3), 27-34. Thorpe, C.,Ryan, B.,McLean, S. L., Burt, A., Stewart,M., Brown, J. B.,Reid, G. J., & Harris, S. (2009). How to obtain excellent response rates when surveying physicians. Family Practice 26(1), 65?68.VanGeest, J.B., Johnson, T.P., & Welch, V.L. (2007). Methodologies for improving response rates in surveys of physicians: A systematic review. Evaluation & the Health Professions 30(4), 303-321. Thierry, J. M. (2000). Observations from the CDC: Increasing breast and cervical cancer screening among women with disabilities. Journal of women's health & gender-based medicine, 9(1), 9-12.


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