Gynecologic Care for Women With Physical Disabilities: A Qualitative Study of Patients and Providers.

BACKGROUND: Women with physical disabilities have unmet gynecologic care needs, including disparities in cancer screening and contraceptive care, when compared with women without physical disabilities. Our objective was to qualitatively assess provider and patient perspectives regarding barriers to gynecologic health care for women with physical disabilities. METHODS: We used purposive sampling to recruit women with physical disabilities and gynecology providers who had experience caring for this population at two university hospitals. Patient and provider participants completed in-depth, semistructured interviews investigating their experiences with and barriers to receiving or providing gynecologic care. Transcripts were systematically analyzed by reviewing assigned codes and performing thematic analysis. We planned a sample size of at least 20 patient and provider participants to allow for saturation of thematic content. RESULTS: We interviewed 29 women with physical disabilities and 20 providers. Important themes for providers and patients centered around adequate time spent during appointments, challenges with the gynecologic examination, inadequate facilities, clinical space limitations, and lack of formal provider and staff training in caring for this population. CONCLUSIONS: Providers were motivated to provide quality care for women with disabilities, but encountered systems and training barriers. Patients and providers had concordant impressions of barriers that influenced equitable and patient-centered care, with structural barriers, including a lack of accessible space, closely related to perceptions of health care inequity between women with and without physical disabilities.

Pediatric Emergency Provider Sexually Transmitted Infection Screening Practices in Adolescents With Oropharyngeal or Anorectal Chief Complaints.

OBJECTIVES: Sexually transmitted infections (STIs) may present with oropharyngeal or anorectal symptoms. Little is known about the evaluation of adolescents with these complaints in the pediatric emergency department (PED). This study aimed to determine the frequency of and factors associated with STI consideration and testing in this population. METHODS: Retrospective chart review of patients aged 13 to 18 years who presented to an urban PED with oropharyngeal or anorectal chief complaints between June 2014 and May 2015. Sexually transmitted infection consideration was defined as sexual history documentation, documentation of STI in differential diagnosis, and/or diagnostic testing. Multivariate logistic regression models were used to identify factors associated with consideration. RESULTS: Of 767 visits for oropharyngeal (89.4%), anorectal (10.4%), or both complaints, 153 (19.9%) had STI consideration. Of the 35 visits (4.6%) that included gonorrhea and/or chlamydia testing, 12 (34.3%) included testing at the anatomic site of complaint. Of those 12 tests, 50.0% were the incorrect test. Patients with older age (adjusted odds ratio [aOR] = 1.5, 95% confidence interval [CI] = 1.3-1.7), female sex (aOR = 1.6, 95% CI = 1.03-2.5), or anorectal complaints (aOR = 2.4, 95% CI = 1.3-4.3) were more likely to have STI consideration. CONCLUSIONS: In an urban PED, only 20% of visits for adolescents with oropharyngeal or anorectal symptoms included STI consideration. Testing was performed in only 5% of cases and often at an inappropriate anatomic site or with the incorrect test. Interventions to increase awareness of appropriate STI consideration and testing for individuals presenting with possible extragenital complaints may help reduce STIs among adolescents.

Missed Opportunities for HIV Screening Among a Cohort of Adolescents With Recently Diagnosed HIV Infection in a Large Pediatric Hospital Care Network.

PURPOSE: Routine human immunodeficiency virus (HIV) screening reduces HIV progression and transmission. Our aims were to determine prevalence and factors associated with prior HIV screening among a cohort of youth living with HIV. METHODS: Retrospective chart review of youth living with HIV aged 14-26 at an HIV clinic comparing characteristics between those with and without HIV screening within the year prior to diagnosis RESULTS: Subjects (n = 301) were male (85%), African-American (87%), and men who have sex with men (84%). Subjects seen 1 year prior to diagnosis (n = 58) contributed 179 visits for missed opportunities with 59% having a documented sexual history in the electronic health record and 48% tested for HIV. Subjects with symptoms suggesting acute HIV infection (51%) were more likely to be tested (p = .04). In the adjusted model, documentation of sexual history and demographic factors was not associated with prior testing. CONCLUSION: We identified high rates of missed opportunities for HIV testing and sexual history documentation in the year prior to diagnosis, underscoring the need for routine HIV screening in adolescents.

Prevalence of 3 sexually transmitted infections in a pediatric emergency department.

OBJECTIVE: This study aimed to determine the prevalence of Chlamydia trachomatis, Neisseria gonorrheae, and Trichomonas vaginalis and to describe factors associated with sexually transmitted infection (STI) in a pediatric emergency department (ED). METHODS: Adolescents aged 14 to 19 years presenting to a Midwestern pediatric ED were asked to provide urine for STI testing and complete a survey about previous sexual activity (PSA), high-risk behaviors, demographics, and visit reason (reproductive: genitourinary complaints, abdominal pain, or a female with vomiting). Comparisons between subgroups were analyzed using Χ test. RESULTS: Among 200 subjects (64% of approached), mean age was 15.6 years; 63% were female. Eleven subjects (6%; 95% confidence interval, 2.3-8.7) tested positive for 1 or more STIs: 10 for C. trachomatis (one denied PSA), 3 for T. vaginalis (all coinfected with C. trachomatis), and 1 for N. gonorrheae. Half reported PSA; of these, 71% reported 1 or more high-risk behaviors, most commonly first sex before the age of 15 years (51%) and no condom at last sex (42%). Among those with PSA and nonreproductive visit (n = 73), 11.0% had 1 or more STIs (95% confidence interval, 3.4-18.1). Two factors were associated with greater likelihood of positive STI test result, namely, reporting PSA versus no PSA (10% vs 1%, P = 0.005) and last sex within 1 month or less versus more than 1 month (20% vs 0%, P = 0.001). In this sample, none of the following characteristics were associated with STI: insurance, race, high-risk behaviors, age, or ED visit reason. CONCLUSIONS: Approximately 1 in 10 sexually active adolescent ED patients without reproductive complaints had 1 or more STIs. This suggests the need for strategies to increase STI testing for this population.

How parents of children receiving pediatric palliative care use religion, spirituality, or life philosophy in tough times.

BACKGROUND: How parents of children with life threatening conditions draw upon religion, spirituality, or life philosophy is not empirically well described. METHODS: Participants were parents of children who had enrolled in a prospective cohort study on parental decision-making for children receiving pediatric palliative care. Sixty-four (88%) of the 73 parents interviewed were asked an open-ended question on how religion, spirituality, or life philosophy (RSLP) was helpful in difficult times. Responses were coded and thematically organized utilizing qualitative data analysis methods. Any discrepancies amongst coders regarding codes or themes were resolved through discussion that reached consensus. RESULTS: Most parents of children receiving palliative care felt that RSLP was important in helping them deal with tough times, and most parents reported either participation in formal religious communities, or a sense of personal spirituality. A minority of parents, however, did not wish to discuss the topic at all. For those who described their RSLP, their beliefs and practices were associated with qualities of their overall outlook on life, questions of goodness and human capacity, or that "everything happens for a reason." RSLP was also important in defining the child's value and beliefs about the child's afterlife. Prayer and reading the bible were important spiritual practices in this population, and parents felt that these practices influenced their perspectives on the medical circumstances and decision-making, and their locus of control. From religious participation and practices, parents felt they received support from both their spiritual communities and from God, peace and comfort, and moral guidance. Some parents, however, also reported questioning their faith, feelings of anger and blame towards God, and rejecting religious beliefs or communities. CONCLUSIONS: RSLP play a diverse and important role in the lives of most, but not all, parents whose children are receiving pediatric palliative care.

Impact of domestic violence posters on female caregivers' opinions about domestic violence screening and disclosure in a pediatric emergency department.

OBJECTIVES: The objectives of this study were to examine female caregivers' attitudes about the display of domestic violence (DV) resources in a pediatric emergency department (ED) and to explore whether these resources engendered positive feelings about DV screening and encouraged disclosure. METHODS: We conducted a cross-sectional survey in a pediatric ED during 2 distinct periods, comparing responses of female caregivers before (pre) and after (post) displaying DV posters and cards. Women were surveyed about (1) personal experience with DV, (2) the appropriateness of DV posters and screening in a pediatric ED, and (3) willingness to divulge DV, if abused. RESULTS: The 2 groups (pre, n = 133; post, n = 136) did not significantly differ with respect to age, race, education, or personal DV history. The majority endorsed that "it is appropriate to have DV posters," with the post group responding in this manner more often than the pre group (pre, 85%; post, 95%; odds ratio [OR], 3.3; 95% confidence interval [CI], 1.3-8.5). The post group was less likely to prefer pediatric ED DV screening (pre, 76%; post, 63%; OR, 0.5; 95% CI, 0.3-0.9) and tended to be less likely to say that they would divulge (pre, 85%; post, 75%; OR, 0.6; 95% CI, 0.3-1.1). In both groups, women with a DV history were less likely than women without this history to say that they would disclose DV to their pediatric ED provider (P < 0.001). CONCLUSIONS: These results suggest the need for further exploration of how to most effectively help and provide resources for abused women in this setting.

Prevalence of tubo-ovarian abscess in adolescents diagnosed with pelvic inflammatory disease in a pediatric emergency department.

OBJECTIVES: The rate of tubo-ovarian abscess (TOA) in adolescents with pelvic inflammatory disease (PID) is reported to range from 17% to 20%. However, no reports have focused specifically on the adolescent patient presenting to the emergency department (ED), regardless of whether they are treated in the inpatient or outpatient setting. Recent changes in the 2002 Centers for Disease Control and Prevention (CDC) Guidelines for the Treatment of Sexually Transmitted Diseases and sexually transmitted infection screening programs are likely to have impacted both the prevalence of PID and the rates of its complications, particularly TOA. Given that most patients with PID are treated as outpatients, it is imperative to accurately assess the prevalence of TOA in this population. Therefore, we sought to determine the rate of TOA in female adolescents diagnosed with PID in a large urban pediatric ED. METHODS: We performed a retrospective medical record review to assess the prevalence of TOA in adolescents diagnosed with PID in the ED by an attending physician in pediatric emergency medicine. All cases were identified on the basis of the clinical criteria from the 2002 CDC Guidelines for the Treatment of Sexually Transmitted Diseases. Data collected included historical and physical examination findings, and laboratory and radiological imaging results. RESULTS: Three (2.4%; 95% confidence interval, 0.5-6.7) of 127 patients diagnosed with PID in the ED who had imaging or clinical follow-up were also found to have a TOA. The mean age of the patients was 16 years. Most patients (89%) had imaging studies performed within 24 hours; most of these studies (97%) were pelvic ultrasounds. Eleven patients did not have imaging but had clinical follow-up within 72 hours. Four patients were diagnosed with PID during the study period and were lost to follow-up. CONCLUSION: The rate of TOA in adolescents diagnosed with PID in an urban pediatric ED is much lower than the rates previously reported in adolescents. This lower prevalence may be attributed to the broader 2002 CDC guidelines for diagnosing PID. In addition, community-based screening programs for Chlamydia trachomatis and Neisseria gonorrhoeae may help to identify young women at risk for developing PID earlier in the course of infection.

Screening for intimate partner violence using an audiotape questionnaire: a randomized clinical trial in a pediatric emergency department.

OBJECTIVE: To compare women's acceptability ratings of 2 different intimate partner violence screening methods, an audiotape questionnaire and a written questionnaire, in a pediatric emergency department. DESIGN: Randomized clinical trial. SETTING: An urban, pediatric, tertiary care center emergency department. PARTICIPANTS: Female caregivers of children. MAIN EXPOSURE: Intimate partner violence screening by either an audiotape or written questionnaire method. MAIN OUTCOME MEASURES: Perceptions of each screening method's safety, acceptability, and ease of use. RESULTS: Fifty (10%) of 497 participants reported intimate partner violence, 30 (11%) of 266 in the audiotape group and 20 (9%) of 231 in the written questionnaire group (P = .30). Women in the audiotape group were significantly more likely to report that the audiotape method did not put them at risk and was private. Women in both groups were satisfied with their screening method and were willing to use it again. Women in both groups preferred their given method over the idea of direct emergency department provider screening. CONCLUSIONS: Screening for intimate partner violence with an audiotape method appears to have several advantages compared with screening by a written questionnaire, and the audiotape method may be associated with slightly higher rates of disclosing intimate partner violence. TRIAL REGISTRATION: http://clinicaltrials.gov/show/NCT00122395.