Georgia prenatal care providers' perceptions of barriers to sexually transmitted disease screening.

Background: Evidence suggests that sexually transmitted disease (STD) screening during pregnancy is not optimal. No published studies have systematically examined barriers that hinder routine STD screening. This study examines prenatal care providers" perceptions about barriers to routine STD screening of pregnant women.

Methods: Using a conceptual framework, four a priori barrier categories were developed: provider, patient, organizational, and structural. Responses to a question on barriers to STD screening in a 1998 mail survey of Georgia prenatal care providers were qualitatively classified into one of these categories.

Results: Of the 293 providers who responded, 71% identified structural barriers, with 52% citing inadequate reimbursement. These respondents were most likely to name barriers categorized as structural, not patient, provider, or organization issues.

Conclusion: Efforts to improve STD screening of pregnant women should include a focus on structural level interventions, such as instituting health care policies that provide adequate reimbursement for routine STD screening during pregnancy.

Key Words: barriers, health care policy, pregnancy, prenatal care providers, sexually transmitted disease screening

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Providers of prenatal care play a critical role in preventing adverse outcomes of pregnancy associated with sexually transmitted diseases (STDs) by adhering to recommended screening, diagnosis, and treatment guidelines for routine prenatal care and by helping women to make informed decisions about screening for STDs during pregnancy, (1-4) Evidence indicates that screening for STDs during pregnancy is not optimal. (5,6) Available evidence also suggests that provider willingness to provide preventive care is crucial to improving the delivery of STD screening] Enlisting such support requires an understanding of providers' perspectives concerning the factors that may help or hinder the delivery of STD screening to pregnant women. However, there are no published studies that systematically examine battlers that may hinder routine STD screening tests by prenatal care providers. We developed a conceptual framework for determining possible barriers to STD screening, examined prenatal care providers' perceptions about the types of barriers to routine STD screening of pregnant women, and determined what factors were associated with identified barriers.

Methods

Conceptual Framework

Our conceptual framework is based on previous work on delivery of preventive care. (8,9) Walsh and McPhee's (8) "Systems Model of Clinical Preventive Care" focused on patient-provider interactions and on the predisposing, enabling, and reinforcing factors that influence the completion of prevention care activities at the provider, patient, and health care system levels. Makrides et al (9) delineated physician and patient categories of obstacles to preventive care. Obstacles to physicians' success are classified as personal, organizational, or structural, whereas obstacles to patients' success are classified as individual or socioenvironrnental (Table 1). For this study, we used an integrated conceptual framework, incorporating major elements of both models (Fig. 1).

On the basis of these models, we derived four a priori barrier categories: 1) structural, 2) organizational, 3) provider, and 4) patient. Structural barriers refer to obstacles to preventive care that pervade the entire health care system such as lack of insurance coverage for a particular preventive care procedure. Barriers at the structural level can be affected or changed by health care policy initiatives, for instance, by establishing a coverage benefit that reimburses for that procedure. Organizational barriers refer to qualities of a particular practice or office setting that interfere with preventive care, such as inadequate staffing. Barriers at the organizational level can be changed or affected by the system in which they exist, for instance, by hiring more personnel. Provider barriers rotor to qualities of individual providers that interfere with the provision of preventive care. For example, providers may not value preventive services or may forget to perform preventive measures. Patient barriers refer to concerns or expectations of the patient that act as obstacles to preventive care. For instance, patients may decline or not request preventive care because they do not perceive themselves to be at risk for a disease. Barriers at these two levels can be changed or affected by individual providers and patients (Fig. 1).

Participants and Procedures

Data for this study came from responses to a mailed survey of prenatal care providers licensed to practice in the state of Georgia who indicated that they were currently providing prenatal care. The survey was mailed to 3,082 Georgia-licensed obstetrician/gynecologists, family practitioners, and nurse-midwives. Of the 1,300 providers who returned the survey, 565 (44%) stated that they were currently providing prenatal care. (5) Study methods and prenatal care providers' STD screening rates, policies, and practices are discussed in detail elsewhere. (5) As part of this survey, providers were asked to describe and comment on barriers they encountered in screening pregnant women for STDs and other infections by answering the open-ended question, "What are some of the barriers to screening for STDs and other infections that you have encountered in your practice (eg, time constraints, billing, legal issues, please comment)?" Demographic information included race, sex, area of professional training (physicians [ie, obstetrics/gynecologists and family/general practice] versus nurse-midwives), number of years in prenatal care practice, and type(s) of setting(s) in which providers practiced (ie, private practice setting versus non-private practice setting). Non-private practice setting response categories were managed care organization, medical school-affiliated hospital, Veteran's Affairs or military-affiliated hospital/ clinic, county facility, community clinic, and other.

Written responses to the barrier question were analyzed by using standard qualitative techniques. (10) Two of the authors (RSB and LAA) identified recurring themes. One of the authors (RSB) classified the responses using this framework. A second author (LAA) independently classified a random sample of 36 responses (12% of responses) to establish and refine the classification framework. After three iterations, the two raters agreed on definitions of each barrier type. Interrater reliability for classification of the providers' responses was 97%. The classified responses were analyzed using EpiInfo version 6. (11)

Results

Of the 565 prenatal care providers who responded to the survey, 428 (75%) were white, 316 were male (57%), and 448 were physicians (80%). The median number of years for which respondents had provided prenatal care (excluding residency) was 12. Ninety-eight percent of providers reported that they routinely screened all pregnant women for syphilis and hepatitis B, 84% for human immunodeficiency virus (HIV) and for chlamydia, and 71% for gonorrhea. (5)

Providers were asked to check all the practice settings in which they worked. Four hundred sixty-nine (83%) providers checked only one practice setting, whereas 96 (17%) providers checked more than one practice setting. Providers checking more than one practice setting may have been indicating that they worked in more than one physical setting and/or that their patients used various methods to pay for health care (eg, self-pay, indemnity insurance plans, or managed care plans). More than half (n - 331 [59%]) of providers reported working exclusively in private practice settings, whereas another 96 (17%) reported working at least partly in private practice settings. Providers working either entirely or partly in private practice settings accounted for 427 (76%) of the respondents, including 82 (15%) who reported working in both private practice and managed care settings. The other 138 providers (24%) reported working exclusively in non-private practice settings (managed care organization, medical school-affiliated hospital, Veteran's Affairs/military hospital or clinic, county facility, community clinic, or other). Twenty-nine providers (5%) reported working exclusively in managed care settings.

Of the 565 prenatal care providers who returned the survey, 293 (52%) responded to the question on barriers to STD screening of pregnant women. Midwives were more likely to respond to the barrier question than physicians (63% versus 49%; P = 0.01). Providers working either wholly or partly in private practice settings were just as likely to

have made a response (51%) as their counterparts in other practice settings (55%). Providers who responded to the barrier question and providers who did not respond were equally likely to report routinely screening pregnant women for STDs (data not shown).

Providers identified from zero to five different barriers, with 76 (26%) reporting no barriers to STD screening. One barrier was identified by 168 (57%) of respondents and two or more by 49 (17%). The most frequently cited barriers were structural. Of the 217 providers who reported at least one barrier, 155 (71%) identified a structural barrier. Inadequate or lack of reimbursement for STD screening accounted for 133 (52%) of the responses. Individual responses illustrate the range of reimbursement barriers encountered by providers. One respondent wrote, "Medicaid does not pay for STD testing, especially HIV." Another provider wrote, "Insurance reluctant to pay for STD screening of asymptomatic patients." Yet another responded, "Billing is a hassle with some insurance [that] don't want routine screening, only [want screening of] high risk [patients]." Several providers noted a related concern about inadequate reimbursement as expressed in this response: "Many insurance carriers tag along all the costs of testing to our professional bill. As a result of labs being more expensive every year and more tests being done, our actual income has decreased abruptly." Few providers cited the other types of structural barriers set forth in the conceptual framework. Less than 10% of the respondents cited legal issues related to obtaining informed consent for HIV testing. Another 10% identified structural barriers such as lack of time, concerns about conflicting guideline recommendations, and the lack of safety net providers within the community to provide follow-up care for patients testing positive (ie, sparse community resources).

One provider mentioned an organizational barrier, specifically, lack of personnel to perform routine STD screening. Seven percent of respondents reported provider barriers. Provider barriers fell into two areas, lack of motivation to perform preventive care, mainly due to perceptions of patients as being at low risk for STDs and screening as being cost-ineffective, and lack of consensus of individual providers within a practice to provide STD screening. Patient barriers, which included issues of patient expectations or concerns, were the second most frequently cited barrier category (17.5%). Examples include patients' refusing STD screening (eg, patients were "offended" or "appalled"); patients not perceiving themselves to be at risk (eg, patients reported themselves as in "stable, monogamous relationship[s]"); or patients not sharing important sexual history information with providers (eg, "history/exposures/risks concealed by patients").

Sex of the provider was not associated with the types of barriers reported. Providers working either wholly or partly in private practice settings were more likely to report inadequate or lack of reimbursement as a barrier (49 versus 32%; P = 0.01) and were less likely to report no barriers (21% versus 40%; P = 0.002) compared with providers working in non-private practice settings. Compared with midwives, physicians were less likely to cite provider barriers (5% versus 17%; P = 0.003) and were more likely to cite patient barriers (20 versus 6%; P = 0.006). Proportions of providers who reported routine screening of pregnant women for specific STDs did not differ by type of barrier cited (data not shown).

Discussion

Lack of adequate reimbursement was the most commonly cited impediment to routine STD screening of pregnant women, reported by more than half of the respondents. Providers perceived lack of adequate reimbursement as a significant barrier to routine STD screening, regardless of provider type or sex. Most of the respondents worked at least partly in private practice settings, and these providers were more likely to report reimbursement as a barrier compared with those working in non-private practice settings. This study found that very few providers cited another structural barrier, lack of time. This contrasts with other studies that have found lack of time to be a commonly reported barrier to general preventive care. (12)

This study has some strengths and limitations. A major strength is that we used a conceptual framework to guide our analysis. The findings are limited by modest response rates to the survey as a whole (43%) (5) and to the specific question on barriers to screening. The 293 providers who responded to the barriers question represent a little more than hall" (52%) of all eligible respondents and less than a quarter (22%) of the total number of providers who returned the questionnaire. For this reason, we chose a conservative analytic approach by including only surveys in which some response to the barrier question was noted. We did not assume that respondents who did not answer the question had encountered no barriers to STD screening. The responses reflected providers' perceptions of barriers using a single, open-ended question that referred to "barriers to STDs and other infections." Although non-STD infections were referred to, none of the barrier responses referred to any conditions other than STDs and HIV. As with all self-reported data, responses may not accurately reflect the actual barriers or the degree of difficulty created by these barriers. Finally, use of specific barrier examples (eg, time constraints, billing, legal) within the open-ended question may have prompted respondents to give greater consideration to those barriers or to structural barriers in general. Respondents reported only one of the three examples given (billing) frequently, however.

Conclusions

These findings have practical implications for health policy and health care delivery. The conceptual framework indicates that the most commonly cited barrier, lack of reimbursement, is structural and can be addressed with health care policy interventions. Interventions targeted at the level of practice organizations, providers, or patients, even if well conceived and implemented, may not be appropriate for resolving structural barriers. Interventions targeting reimbursement issues may be especially relevant for providers working in private practice settings, given that those providers most frequently reported reimbursement as a barrier. Initial efforts to improve routine STD screening of pregnant women should focus on instituting policies in both private and public health care systems to provide adequate reimbursement for routine STD screening during pregnancy.

One example of such a strategy is in the area of chlamydia screening. In 1998, the Georgia General Assembly enacted legislation (HB 1565) mandating insurance reimbursement for providers who perform annual chlamydia screening for women younger than 30 years of age. This policy-level intervention may partially address providers' concerns about reimbursement for routine STD screening for some of their prenatal care patients. Further work needs to be done to assess this law's effect on actual screening practices and barrier perceptions. It would be important to reevaluate prenatal care providers' perceptions about barriers to routine STD screening of pregnant women after implementation of this policy to determine whether providers now perceive fewer barriers or whether providers now assign greater importance to other types of barriers to routine STD screening. Finally, this study presents useful initial data about provider perceptions of barriers to STD screening. Future work could benefit from a more comprehensive examination of barriers using a conceptual framework such as this to examine types of barriers and the degree to which different types of barriers interfere with providers' ability to routinely screen for STDs.

Table 1. Classification of preventive care barriers with examples
related to STD screening

Patient-initiated barriers
  Patient expectations/concerns
    Example: Patient who views STD testing as not relevant to her
      lifestyle, embarrassing, or intrusive may not be interested in
      screening
Provider barriers
  Provider lack of motivation
    Example: STD screening perceived as unnecessary, irrelevant, or not
      efficacious for patient population
  Provider lack of prevention service knowledge or skills
    Example: Lacks communication or technical skills to convey need for
      screening or to perform screening procedures
  Provider lack of consensus or recall
    Example: Lack of consensus of providers in a practice for providing
      STD screening or difficulty remembering to routinely provide
      screening
Organizational barriers
  Inadequate staff, facilities, or equipment
    Example: Personnel, facilities, or equipment needed to carry out
      STD screening is not available or difficult to access
  Medical care versus preventive care model
    Example: Practice is organized around medical treatment and
      acute, episodic care with lack of emphasis on STD screening
      services
  Negative staff attitude toward prevention
    Example: Support staff perceive STD screening as annoying or
      unnecessary part of their work
Structural barriers
  Inadequate or lack of reimbursement
    Example: Cost of STD screening is not covered or is incompletely
      covered by insurance or Medicaid
  Lack of time
    Example: STD screening cannot be completed in time allotted for
      patient appointment
  Sparse community resources
    Example: Infrastructure of safety net health care providers
      necessary to provide STD screening services is inadequate
  Legal or consent issues
    Example: Providers perceive separate consent process required
      for HIV testing as burdensome or as a legal liability

Key Points

* Prenatal care providers' perceptions about barriers to routine sexually transmitted disease (STD) screening of pregnant women can be classified into four a priori barrier categories: provider, patient, organizational, and structural.

* Most respondents to this survey, conducted among Georgia prenatal care providers in 1998, named barriers classified as structural.

* Appropriate interventions to improve routine STD screening of pregnant women should address the type of barriers identified by providers, in this case, structural barriers.

* An intervention that would address the most frequently cited structural barrier in this survey, inadequate reimbursement for routine STD screening during pregnancy, would be to institute a health care policy providing adequate reimbursement for this service.

References

(1). Watts DH. Brunham RC. Sexually transmitted diseases including HIV infection in pregnancy, in Holmes KK, Sparling PF, Mardh PA, et al (eds): Sexually Transmitted Diseases. New York, McGraw-Hill Health Professions Division, 1999, ed 3, pp 1089 1132.

(2.) (:enters for Disease Control and Prevention. 1998 guidelines far treatment of sexually transmitted diseases. MMWR Recomm Rep 1998: 471RR-1):1-111.

(3.) American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Human Immunodeficiency Virus Screening (RE9916): Joint Statement of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists (Policy Statement). Elk Grove Village. IL, American Academy of Pediatrics, July 1999. Available at: http://www.aap.org/policy/re9916.html. Accessed June 23, 2003.

(4.) American Academy of Pediatrics, American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. Elk Grove Village, II, American Academy of Pediatrics, and Washington, DC, American College of Obstetricians and Gynecologists, 2002, ed 5.

(5.) Weisbord JS, Koumans EH, Toomey KE, et al. Sexually transmitted diseases during pregnancy: Screening. diagnostic, and treatment practices among prenatal care providers in Georgia. South Med J 2001:94: 47-53.

(6.) Mills WA. Martin DL, Bertrand JR, ct al. Physicians' practices and opinions regarding prenatal screening for human immunodeficiency vials and other sexually transmitted diseases. Sex Transm Dis 1998:25: 169-175.

(7.) Cohen SJ, Halvorson IIW, Gosselink CA. Changing physician behavior to improve disease prevention. Prey Med 1994:23:284-291.

(8.) Walsh JM, McPhee SJ. A systems model of clinical preventive care: An analysis of factors influencing patient and physician. Health Educ Q 1992:19:157 175.

(9.) Makrides L. Veinot PL, Richard J, et al. Primary care physicians and coronary heart disease prevention: A practice model. Patient Educ Couns 1997;32:207 217.

(10.) Ary D, Jacobs LC, Razavieh A. Qualitative and historic research, in Introduction to Research in Education. Fort Worth, TX, Harcourt Brace College Publishers, 1996, ed 5, pp 474-496.

(11.) Centers for Disease Control and Prevention, Epidemiology Program Office, Division of Public Health Surveillance and Informatics. Epi Info version 6,04 [software program]. Atlanta, GA. Centers for Disease Control and Prevention. 1997.

(12.) Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999: 282:1458-1465.

From the Division of Sexually Transmitted Disease Prevention of the National Center for HIV, STD, and TB Prevention and the Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, GA; and the Division of Public Health, Georgia Department of Human Resources, Atlanta, GA.

This study was made possible by in-kind contributions from the Medical Association of Georgia, the Division of Public Health of the Georgia Department of Human Resources, and the Division of STD Prevention of the Centers for Disease Control and Prevention. We have no commercial. proprietary-, or financial interest in any item mentioned in this study. This study was exempted From CDC IRB review.

Reprint requests to Rheta S. Barnes, MSN, MPH, Division of STD Prevention, Centers for Disease Control and Prevention, Mail Stop E-44, 1600 Clifton Road NE, Atlatua, GA 30333. Email: [e-mail]

Accepted January 9, 2003. Copyright [c] 2003 by The Southern Medical Association 0038-4348/03/9609 0845