The case for the green banana: Using fruit to improve tenaculum placement simulation.

OBJECTIVES: The purpose of this study was to identify a fruit that would resemble the 'feel' of a uterine cervix when compared to plastic pelvic models. STUDY DESIGN: A group of experienced clinicians tested six different fruits and evaluated their suitability as a cervical simulation for tenaculum placement. RESULTS: An unripe (green) banana was rated the highest in seven out of eight characteristics and was the only fruit to achieve a consensus for overall simulation above 70%. CONCLUSIONS: A green banana is an affordable and accessible option to simulate a cervix for procedures requiring tenaculum placement on a cervix.

Changes in HIV knowledge and interest among nursing and public health students at a large Midwest University: Outcomes of implementing the National HIV Curriculum.

BACKGROUND: Ending the HIV epidemic requires additional healthcare and public health workers who are competent in HIV prevention and treatment. The National HIV Curriculum was developed to increase competency in HIV among healthcare workers in the US. OBJECTIVES: The purpose of the current study was to examine the impact of implementing the National HIV Curriculum (NHC) for nursing and public health students. DESIGN: This study employed a single-arm, cohort intervention design. SETTING: This study was conducted at large, public university in the Midwestern United States of America in a state noted for high HIV transmission. PARTICIPANTS: Undergraduate nursing, graduate nursing, and undergraduate public health students participated in this study. METHODS: An online survey of nursing and public health students was conducted following implementation of the NHC at a large, public university in the Midwest. Students were assessed on knowledge and interest of HIV using a bootstrapped paired-samples t-test approach. RESULTS: Participants (N = 175) were enrolled in the undergraduate nursing program (n = 72, 41.14 %), graduate nursing (n = 37, 21.14 %) public health (n = 37, 21.14 %), medicine (n = 10, 5.71 %), and biological, biomedical, and health sciences discipline (n = 19, 10.86 %). Overall, results suggest a consistent gain in knowledge of working with individuals living with HIV of 1.42 points (on a 4-point scale). About half (47.43 %) of all students increased interest to work with individuals living with HIV in the future. CONCLUSION: The NHC increased knowledge and interest in students across a broad range of nursing, public health, medicine, and other disciplines. This study suggests that universities can integrate the curriculum across undergraduate and graduate programs. Students at varying degree levels may benefit from the NHC. Future longitudinal studies should be conducted on the career choices of those students exposed to the NHC.

Virtual Skills Training Format for Teaching Intrauterine Contraception Insertion During Coronavirus Disease 2019.

The coronavirus disease 2019 pandemic resulted in the curtailment of face-to-face clinical skills training in 2020. To meet Title X workforce needs, the National Clinical Training Center for Family Planning transitioned onsite intrauterine contraception training to a virtual format using online didactic material and livestreamed training and telementoring. Videos demonstrated the placement and removal of intrauterine contraceptives, and all necessary supplies were shipped directly to participants. Attendees reported a high level of skill uptake and impact on their practice. This pilot study suggests that virtual skills training is suitable for providers unable to travel to in-person events.

Barriers and Challenges to Making Referrals for Treatment and Services for Opioid Misuse in Family Planning Settings.

Background: In this opioid overdose epidemic, women are an overlooked group seeing increasing rates of overdose death. Implementation challenges have prevented evidence-based interventions from effectively reaching women who misuse opioids, with gaps in access to effective treatment and services. Family planning clinics could serve as important points of contact for referral to needed treatments and services. The study explores how family planning staff knowledge and attitudes related to opioid misuse serve as potential barriers and challenges in making referrals for evidence-based services and treatments. Methods: In 2018, we conducted a national online survey of family planning staff, assessing knowledge and attitudes of treatments and services for opioid misuse. Results: A total of 691 family planning staff completed the survey. Most respondents agreed that opioid misuse was a major problem in their community (86.0%) and identified challenges in responding to it, including a lack of treatment access (70.3%), the absence of in-house behavioral health staff (67.2%), and unfamiliarity with local treatment providers (54.1%). Respondents reported low levels of acceptability for syringe services programs (46.0%), medications such as methadone and buprenorphine (55.4%), and naloxone to reverse opioid overdose (60.1%). Controlling for other factors, race/ethnicity, urbanicity, workplace role, and substance use training were associated with differences in acceptability. Conclusions: Family planning settings could play a critical role in connecting women who misuse opioids to treatment and services. Strategies are needed to increase the acceptability of evidence-based interventions and the feasibility of having family planning staff play a linkage role.

"Far More than Just a Prescription": Focus Groups With U.S. Family Planning Providers and Staff About Integrating PrEP for HIV Prevention Into Their Work.

BACKGROUND: Cisgender women in the United States use pre-exposure prophylaxis (PrEP) for HIV prevention at lower rates relative to other groups. Advocacy groups and patients identify family planning clinics as the preferred sites to lead PrEP implementation for women in the United States. However, limited qualitative exploration exists of U.S. family planning practitioners' attitudes toward integrating PrEP into their work. METHODS: We conducted qualitative focus groups with a convenience sample of family planning clinicians, counselors, and clinic managers to explore barriers and facilitators to PrEP provision in U.S. family planning clinics. RESULTS: We conducted six focus groups (total participants = 37) with respondents who worked in family planning clinics in San Francisco, California; Kansas City, Missouri; and Philadelphia, Pennsylvania. Key themes emerged highlighting how PrEP at times runs contrary to other family planning agendas, including efficient clinic visits, condom promotion, and long-acting reversible contraception counseling. Throughout these discussions, participants expressed discomfort with HIV vulnerabilities rooted in social and structural determinants of health. CONCLUSIONS: Findings suggest that those seeking to implement PrEP for U.S. cisgender women may benefit from exploring 1) how to integrate patient/provider conversations about the structural determinants of health and their relationship to HIV and other sexual and reproductive health outcomes and 2) how to foster person-centered prevention conversations in the context of busy family planning visits.

A Mixed-Methods Assessment of Health Care Providers' Knowledge, Attitudes, and Practices Around Fertility Awareness-Based Methods in Title X Clinics in the United States.

Objective: To understand how Title X providers currently engage with fertility awareness-based methods (FABMs) for pregnancy prevention in Title X clinics across the United States. Materials and Methods: We developed a survey to assess knowledge of fertility for purposes of pregnancy prevention, attitudes toward FABMs use for pregnancy prevention, and practices when patients request FABMs for pregnancy prevention. Results: In total, 329 participants who met all inclusion criteria completed the survey. Respondents were generally highly knowledgeable on fertility, felt neutrally toward FABMs or thought they were a nonviable option for most women, and were likely to respond to patient requests for FABMs for pregnancy prevention by providing information. Qualitative responses included several barriers to provision of FABMs for pregnancy prevention and few successes to provision. Conclusions: Fertility knowledge and discussion of specific methods increased with the number of methods included in the clinic's written materials or with the number of different FABMs someone at that clinic had been trained on. Significant clinician or administrative barriers may exist to offering FABMs to patients. Incorporating up-to-date information on a range of FABMs-rather than treating them as one method-into contraceptive counseling represents an opportunity to increase the contraceptive offering for clients who want them, leading to increased patient satisfaction and successful family planning outcomes.

Family planning providers' role in offering PrEP to women.

Pre-exposure prophylaxis (PrEP) provides a radically different HIV prevention option for women. Not only is PrEP the first discrete, woman-controlled method that is taken in advance of exposure, but it is both safe and highly effective, offering over 90% protection if taken daily. While multiple modalities of PrEP are in development ranging from vaginal rings to injectables and implants, only PrEP with oral tenofovir/emtricitabine is currently FDA-approved. Family planning clinics provide key access points for many women to learn about and obtain PrEP. By incorporating PrEP services into family planning care, family planning providers have the opportunity to meet women's expectations, ensure women are aware of and offered comprehensive HIV prevention options, and reverse emerging disparities in PrEP access. Despite real and perceived barriers to integrating PrEP into family planning care, providing PrEP services, ranging from education to onsite provision, is not only possible but an important component of providing high-quality sexual and reproductive healthcare to women. Lessons learned from early adopters will help guide those in family planning settings initiating or enhancing PrEP services.

Development of a Mobile App for Family Planning Providers.

PURPOSE: To provide an overview of lessons learned during the development process of an app for iOS and Android based on national recommendations for providing quality family planning services. STUDY AND DESIGN: After a review of existing apps was conducted to determine whether an app of clinical recommendations for family planning existed, a team of clinicians, training specialists, and app developers created a resource app by first drafting a comprehensive content map. A prototype of the app was then pilot tested using smart tablets by a volunteer convenience sample of women's healthcare professionals. Outcomes measured included usability, acceptability, download analytics, and satisfaction by clinicians as reported through an investigator-developed tool. RESULTS: Sixty-nine professionals tested a prototype of the app, and completed a user satisfaction tool. Overall, user feedback was positive, and a zoom function was added to the final version as a result of the pilot test. Within 3 months of being publicly available, the app was downloaded 677 times, with 97% of downloads occurring on smart phones, 76% downloads occurring on iOS devices, and 24% on Android devices. This trend persisted throughout the following 3 months. CLINICAL IMPLICATIONS: Clinicians with an interest in developing an app should consider a team approach to development, pilot test the app prior to wider distribution, and develop a web-based version of the app to be used by clinicians who are unable to access smart devices in their practice setting.

Facilitating State-Wide Collaboration around Family Planning Care in the Context of Zika.

INTRODUCTION: Family planning providers have an important role to play in the response to the public health challenge posed by Zika. In the United States, there are high rates of unintended pregnancy, especially in states most at risk for mosquito-borne transmission of the Zika virus. This paper describes efforts by eight of these states (Arizona, California, Florida, Georgia, Louisiana, Mississippi, South Carolina, and Texas) to build capacity for quality family planning care in the context of Zika. METHODS: Drawing on resources developed by the Office of Population Affairs, including a toolkit for family planning care in the context of Zika, agencies and stakeholders involved in the family planning delivery system in Southern states at risk for mosquito-borne transmission met over several months in the summer of 2016 to coordinate efforts to respond to the risk of Zika in their jurisdictions. RESULTS: Through proactive communication and collaboration, states took steps to integrate Zika-related family planning care, including screening for Zika risk and providing appropriate, client-centered counseling. Challenges faced by the states included not having family planning included as a component of their state's Zika response effort, limited funding for family planning activities, and the need for robust communication networks between multiple state and federal agencies. CONCLUSIONS: The efforts described in this paper can help other states to integrate family planning into their Zika response. This is relevant to all states; even when mosquito-borne transmission is not occurring or expected, all states experience travel-related and sexually transmitted Zika infections.

Advanced Practice Registered Nurses and Long-Acting Reversible Contraception.

INTRODUCTION: Advanced practice registered nurses (APRNs) are in an excellent position to address the high rates of unintended pregnancy in the United States by providing long-acting reversible contraceptives (LARCs). These methods are significant in their effectiveness in preventing pregnancy in individual women and in having population-level effects on unintended pregnancy. The aim of this study was to learn more about APRN practices around long-acting reversible contraception and influences on those practices. METHODS: A cross-sectional survey of APRNs who provide women's health services was conducted during the summer of 2015 using an existing adapted instrument with items on personal and patient characteristics, opinions, practices, and training around LARC methods. Zero-inflated Poisson regression models were conducted to study the factors that influenced the number of LARC insertions in the past year. RESULTS: While 84% of the 390 respondents were inserting intrauterine devices (IUDs) and 77% single-rod implants, only 16% of these were inserting more devices than 5 years earlier. The most significant predictor of placement of these contraceptives was the clinical practice of requiring only one visit for completion. DISCUSSION: National guidelines and recommendations have been in place for several years stating that women should be able to receive the contraceptive method of their choice in just one clinic visit. Women's access to LARCs from APRNs may be less than optimal. Additional research is needed to understand if the limitations in accessibility of this important reproductive health service are a function of clinician practices or clinic policies.

SANE-A-PALOOZA: Logistical Development and Implementation of a Clinical Immersion Course for Sexual Assault Nurse Examiners.

SANE-A-PALOOZA, a continuing education program that utilizes hands-on practice with standardized patients and human simulators, was developed to fulfill a portion of the required supervised clinical experience for certification as a sexual assault nurse examiner. The program is designed to provide concentrated clinical skill practice application, eliminate the time gap between gaining and applying clinical knowledge, and decrease discontinuity among multiple preceptors. This article provides an overview of SANE-A-PALOOZA logistics, with the goal of aiding other organizations in developing skill-building experiences for new or less-experienced sexual assault nurse examiners.

United States family planning providers' knowledge of and attitudes towards preexposure prophylaxis for HIV prevention: a national survey.

OBJECTIVES: The Centers for Disease Control and Prevention defines HIV prevention as a core family planning service. The HIV community identified family planning visits as key encounters for women to access preexposure prophylaxis (PrEP) for HIV prevention. No studies explore US family planning providers' knowledge of and attitudes towards PrEP. We conducted a national survey of clinicians to understand barriers and facilitators to PrEP implementation in family planning. STUDY DESIGN: Family planning providers recruited via website postings, national meetings, and email completed an anonymous survey in 2015. Descriptive statistics were performed. RESULTS: Among 604 respondents, 495 were eligible for analysis and 342 were potential PrEP prescribers (physicians, nurse practitioners, midwives or physicians assistants). Among potential prescribers, 38% correctly defined PrEP [95% confidence interval (CI): 32.5-42.8], 37% correctly stated the efficacy of PrEP (95% CI: 32.0-42.4), and 36% chose the correct HIV test after a recent exposure (95% CI: 30.6-40.8). Characteristics of those who answered knowledge questions correctly included age less than 35 years, practicing in the Northeast or West, routinely offering HIV testing, providing rectal sexually transmitted infection screening or having seen any PrEP guidelines. Even among providers in the Northeast and West, the proportion of respondents answering questions correctly was less than 50%. Thirty-six percent of respondents had seen any PrEP guidelines. Providers identified lack of training as the main barrier to PrEP implementation; 87% wanted PrEP education. CONCLUSIONS: To offer comprehensive HIV prevention services, family planning providers urgently need training on PrEP and HIV testing. IMPLICATIONS: US family planning providers have limited knowledge about HIV PrEP and HIV testing, and report lack of provider training as the main barrier to PrEP provision. Provider education is needed to ensure that family planning clients access comprehensive HIV prevention methods.

SANE-A-PALOOZA: A Clinical Immersion Experience to Close the Gap for New Sexual Assault Nurse Examiners.

BACKGROUND: Traditional educational methods for new sexual assault nurse examiners (SANEs) have had a gap in time between didactic instruction and the application to forensic nursing practice. In this interval, which can take several months, SANE trainees must locate a preceptor and perform at least 10 pelvic examinations. Only then can they apply their didactic knowledge and pelvic examination skills to actual patients presenting for forensic examinations. In 2011, Kansas City educators developed SANE-A-PALOOZA, a program that eliminated this gap, facilitated a unified educational experience, and ensured rapid integration of knowledge and skills. OBJECTIVES: The aims of this study were to briefly describe an educational method for SANEs based on adult learning principles and constructivist learning theory and to provide preliminary quantitative evaluation data, which are limited in contemporary literature. METHODS: Immediately after the formal 40-hour didactic educational experience, trainees took part in an 8-hour SANE-A-PALOOZA, a clinically focused continuing education course that included standardized pelvic examination patients, skills immersion experience with advanced practice nurses and experienced sexual assault nurses, and a hands-on practicum with a crime scene photographer. Each of the 44 trainees performed 8-10 female pelvic and two male genital examinations on standardized patients and took forensic genital photographs in three of those examinations. Participants completed a variety of preevaluation and postevaluation instruments, including knowledge, clinical skills checklists, and confidence measures. RESULTS: SANE-A-PALOOZA participants' self-evaluations indicate high satisfaction with the educational program. Pretest/posttest scores indicate increased comfort, competence, and confidence after this immersion practicum. CONCLUSION: Skills education via a hands-on immersion experience can address the gap between didactic and hands-on clinical experience for SANEs.

The intention of advanced practice registered nurses to remain in positions at family planning clinics serving low-income women.

Federally funded Title X Family Planning Clinics are critical safety nets for reproductive health services in which advanced practice nurses (APRNs) provide the majority of care. The goal of this study was to identify factors affecting APRN's intention to remain in positions at these clinics. An Internet-administered survey was completed by 406 APRNs working in Title X clinics. The survey, based on a causal model of retention adapted for APRN practice, included 10 factors. Factor significance and model selection criteria were used to determine model fit. Intention to remain in current positions was associated with greater family responsibilities and lower levels of involvement in professional associations. Less routinization, more integration, and a greater sense of distributive justice were significant causal paths to job satisfaction (a significant mediator for intention to remain). Results provide Title X administrators information that can guide them in policy development to maximize APRN retention.

A randomized trial comparing the VIPON tampon and ibuprofen for dysmenorrhea pain relief.

BACKGROUND: This study was conducted to evaluate the therapeutic efficacy of a device designed to deliver high-frequency vibratory stimulation through direct intravaginal tampon application (VIPON) compared with a low-dose over-the-counter pharmacologic treatment of dysmenorrhea. METHODS: A randomized, open-label, prospective study comparing the investigational device to an oral self-administration of the over-the-counter dose of 200-400 mg of ibuprofen with the onset of menstrual discomfort was conducted at two academic medical centers in the Midwest region of the United States. Women age 18 and older with self-reported dysmenorrhea were treated with either VIPON or a single dose of 200-400 mg of ibuprofen, randomized for each of the next four menstrual cycles, and pain reduction from baseline was measured according to the Melzack-McGill pain scale. RESULTS: Overall, both ibuprofen and VIPON have significant effects on pain reduction according to the Melzack-McGill pain scale. However, the VIPON group achieved statistically significant greater, and more rapid, pain relief at every time point when compared with the ibuprofen. CONCLUSION: VIPON tampon is a viable, nonpharmacologic option to traditional low-dose over-the-counter pharmacologic therapies for menstrual pain management with more rapid onset of action.

High-fidelity simulation and legal/ethical concepts: a transformational learning experience.

Students in an undergraduate legal and ethical issues course continually told the authors that they did not have time to study for the course because they were busy studying for their clinical courses. Faculty became concerned that students were failing to realize the value of legal and ethical concepts as applicable to clinical practice. This led the authors to implement a transformational learning experience in which students applied legal and ethical course content in a high-fidelity human simulation (HFHS) scenario. A preliminary evaluation compared the new HFHS experience with in-person and online student groups using the same case. Based on both student and faculty perceptions, the HFHS was identified as the best of the three approaches for providing a transformational learning experience regarding legal and ethical content.

Clinician perceptions of providing natural family planning methods in Title X funded clinics.

INTRODUCTION: Natural family planning (NFP) methods are effective for contraception with proper and consistent use. However, only 1% of patients at federally funded Title X family planning clinics select NFP as a contraceptive method. The goal of this study was to understand from clinicians' perspectives the barriers and facilitators to providing NFP methods. METHODS: Six telephone focus groups were conducted with 29 clinicians from Title X clinics across the United States and Puerto Rico. A hermeneutic method was used to analyze data for related themes. RESULTS: The overarching theme from the study was that participants had a strong desire to teach their patients how their bodies work and to empower them to learn to control fertility. Four subthemes emerged: patient misinformation and misunderstanding about fertility; provider ideas about ideal types of candidates for NFP; inconsistent patient teaching strategies; and lack of time to teach NFP methods. DISCUSSION: There is a need for increased NFP training for providers and efficient NFP patient teaching strategies to meet the needs of patients with limited knowledge about fertility.

Silence is not golden: invisible Latinas living with HIV in the Midwest.

This qualitative study was conducted to better understand the health needs and concerns of immigrant HIV-infected Latinas residing in the Midwest United States. Individual interviews (n = 18) were conducted in Spanish with Latinas in Kansas, Oklahoma and Missouri. Women were at different stages of acceptance about their HIV diagnosis and four common themes emerged from the data: pregnancy as a death sentence, HIV is taboo, God as their only resource, and living in isolation. Silence was an over-arching theme present throughout all the narratives and many women had never shared their stories about HIV with anyone. Depressive symptoms and suicidal ideation were common. These findings have implications for strategies to address the HIV prevention and HIV-related healthcare needs of this population of women. Results from this study further suggest that efforts are needed to break the silence surrounding HIV and to reduce HIV-related stigma in smaller Midwestern Hispanic communities.

Development and feasibility of an HIV and IPV prevention intervention among low-income mothers receiving services in a Missouri Day Care Center.

This article outlines the development and feasibility of an HIV and IPV prevention intervention. Researchers formed a partnership with a group of women representative of the population that the intervention was intended to reach using methods derived from participatory action research. The use of health protective behaviors changed from pre- to postintervention in the clinically desirable direction. Results indicated that intervention delivery was feasible in the novel setting of a large urban day care center. This intervention has promise as a strategy to reduce HIV among low-income women; however, a controlled study is indicated to further examine intervention efficacy.

Health concerns of mature women living with HIV in the midwestern United States.

This study was performed to better understand the health concerns of mature Midwestern women living with HIV and to offer health care providers information about the spectrum of medical and psychosocial needs of this population. Individual interviews were conducted with 18 low-income women who were 41 to 68 years of age. Interviews showed multiple needs that encompassed both physical and emotional health: more frequent health screenings, the ability to differentiate symptoms of advancing HIV from those of aging, desire for knowledge about reasonable expectations for aging women with HIV, and attention to emotional health needs and social support. Interventions aimed at helping mature HIV-infected women cope as they age, education about the normal aging process, consumer information about appropriate timing of health care screenings, and mechanisms to facilitate the creation of social support networks to decrease isolation seem to be needed in this population.