Provider Perspectives“I Wouldn’t Be this Firm if I Didn’t Care”: Preventive clinical counseling for reproductive health
Introduction
Despite high rates of unintended pregnancy and sexually transmitted infection (STI) in the United States, and public health goals to reduce prevalence [1], surprisingly little research has identified effective counseling approaches for use in clinical settings to influence sexual risk behavior [2], [3]. A number of theory-driven interventions to reduce HIV/AIDS acquisition and transmission have been successful in community and clinic settings, but generally are implemented with specially trained study staff [4], [5]. Recent reviews of the literature on contraceptive and STI prevention counseling call for development and testing of interventions that can be applied in health care settings [2], [6], [7], [8].
Women's interactions with health care providers present important opportunities to educate, offer resources, and counsel patients to change risk behaviors [9]. Yet, we lack theory-driven research to inform patient counseling on unintended pregnancy, and consensus on the most effective messages for contraceptive counseling in clinical settings [3], [10]. Two fields of research provide context for our study of clinicians’ reproductive health counseling: (1) clinical interaction studies and the concept of patient-centered care and (2) health behavior change theory.
Observational studies of the clinical interaction from the patient and clinician perspective offer insight into the importance of interpersonal dynamics in quality of care. Clinical interaction research focuses on qualities of communication, such as empathy [11], [12], qualities of the relationship such as trust and respect [13], or personal characteristics, such as gender and race, that influence interactions [14]. The degree of patient-centered care, or shared decision-making, is a concept that has become increasingly important for evaluating clinical interactions. According to patient-centered models, psychosocial circumstances of individuals are relevant, in addition to biological processes and medical needs. Patient-centered communication is intended to increase patient disclosure and facilitate patient involvement in decision-making [15]. The approach has been used to improve care for a range of health conditions [16], [17], but few studies have examined the effectiveness of patient-centered care in reproductive health counseling [18].
Clinical interaction literature is not easily integrated with research on health behavior change. Clinical interaction studies have identified communication styles consistent with patient-centered care, but not mechanisms for eliciting health behavior change. An extensive literature has developed and tested theories of behavior change for diverse populations, settings, and health conditions. In a recent Cochrane Review of theory-based interventions for contraceptive counseling [10], social cognitive theory was widely used, with constructs focused on skills, cultural norms, self-efficacy, goals, and social support for protective health behaviors [19]. Yet, few interventions to increase effective contraceptive use were beneficial, and interventions using clinician counseling at health visits were uncommon.
There is not a well-tested and consistently applied theoretical model for counseling in preventative reproductive health care, leaving clinicians with little guidance on counseling that is most likely to be effective. Counseling approaches used by clinicians most likely are derived from a number of sources—professional education, clinical training, knowledge of behavior change theory, personal beliefs, and life experience [20]. Clinicians’ descriptions of efforts to bring about behavior change in their patients, and their views concerning what is effective, are considered in this study. We further analyze whether concepts that emerged from clinician interviews are consistent with leading behavior change theories or tenets of patient-centered care. The findings may inform the development of conceptual models for reproductive health counseling.
Section snippets
Setting and data collection
We conducted in-depth interviews with clinicians serving low-income women. The recruitment strategy was designed to obtain a diverse selection of approximately 30 clinicians serving women at heightened risk of unintended pregnancy and STI/HIV. Obstetrician–gynecologists, family medicine physicians, certified nurse-midwives, and nurse practitioners were included. Data from the Centers for Disease Control on HIV prevalence [21] and information from local health departments were used to identify
Results
Study participants were primarily women, reflecting a high concentration of women in nursing and reproductive health professions, and they were from varied racial/ethnic backgrounds (Table 2). The clinicians described their patient populations as racially and ethnically diverse, including immigrant and foreign-born patients. All accepted Medicaid, describing most patients as low-income. All cared primarily for women of reproductive age. Clinicians described a variety of strategies and messages
Discussion
In the absence of widely used, evidence-based approaches to preventive reproductive health counseling, clinicians describe a range of practices. Some approaches include components of behavior change theory, but many are not represented in current conceptual models, indicating a need for development of testable theories for use in clinical counseling for prevention of unintended pregnancy and STIs.
Most clinicians believed they influenced patient contraceptive choice, particularly with
Acknowledgements
This project was funded by NIH/NICHD R01 H10603-23636. Dr. Henderson's effort was also supported by an NIH/NICHD Mentored Research Scientist Development Award in Population Research (K01HD054495) and resources from NIH/NCRR/OD UCSF-CTSI (KL2 RR024130). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH. We are grateful for the thoughtful comments provided in peer-review.
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