To Improve Motivational Barriers to Retention in High Resolution Anoscopy, Patients and Providers Recommend Social and Environmental Changes: A Sequential Explanatory Mixed-Methods Pilot Study in a Federally Qualified Health Center.

Loss to follow-up (LTFU) in high-resolution anoscopy (HRA) programs jeopardizes the procedure's potential to help prevent anal cancer. We explored quality improvement factors to understand how to address this LTFU. Using the transtheoretical COM-B Model (Capability, Opportunity, Motivation, and Behavior) and a sequential explanatory mixed-methods design, we surveyed and interviewed 13 patients who remained engaged in HIV care but who delayed their HRA monitoring or treatment visits in the same community clinic, and 6 HRA clinicians and medical assistants. Analyses involved descriptive statistics and rapid qualitative analysis. Patients were racially, ethnically, and economically representative of the LTFU population, and were generally experienced with HRA (Mean HRA visits = 4.6, SD = 2.8, mdn = 3). Providers were experienced clinicians and medical assistants (Mean years providing HRA = 6.0, SD = 2.2). Analyses revealed two primary, related barriers: (A) motivational barriers such as physical pain, discomfort, embarrassment, and anxiety; which were largely borne from (B) opportunity barriers such as difficulties with scheduling, inconsistent after-care (particularly for pain and discomfort), anxiety-inducing exam rooms and equipment, and internalized and anticipated stigma. Capability barriers, such as limited health literacy about HRA, were less common and, like motivational barriers, linked to opportunity barriers. Participants recommended potential facilitators, including easier scheduling, standardization of pain management and after-care services, and examination room modifications to reduce anxiety. To retain HRA patients in community settings, interventions should address social and physical opportunity barriers that strongly determine motivational and capability barriers. Improving convenience, standardizing pain management, and introducing stigma interventions specific to HRA, could alleviate both motivational and capability barriers.

RESUMEN: La pérdida de seguimiento (LTFU) en los programas de anoscopia de alta resolución (HRA) pone en peligro el potencial del procedimiento para ayudar a prevenir el cáncer anal. Exploramos factores de mejora de la calidad para comprender cómo abordar este LTFU. Utilizando el modelo COM-B transteórico (Capacidad, Oportunidad, Motivación y Comportamiento) y un diseño de métodos mixtos explicativos secuenciales, encuestamos y entrevistamos a 13 pacientes que permanecieron involucrados en la atención del VIH pero que retrasaron sus visitas de seguimiento o tratamiento de la HRA en la misma clínica comunitaria y 6 médicos y asistentes médicos de la HRA. Los análisis involucraron estadísticas descriptivas y análisis cualitativo rápido. Los pacientes eran representativos de la población LTFU en cuanto a raza, etnia, y estatus económico. En general, tenían experiencia con HRA (visitas HRA media = 4,6, DE = 2,8, mdn = 3). Los proveedores eran médicos y asistentes médicos con experiencia (promedio de años proporcionando HRA = 6,0, DE = 2,2). Los análisis revelaron dos barreras principales relacionadas: (A) barreras motivacionales como el dolor físico, la incomodidad, la vergüenza y la ansiedad; que se debieron en gran medida a (B) barreras de oportunidad, como dificultades con la programación, cuidados posteriores inconsistentes (particularmente para el dolor y el malestar), salas de examen y equipos que inducen ansiedad, y estigma internalizado y anticipado. Las barreras a la capacidad, como la limitada alfabetización sanitaria sobre la HRA, fueron menos comunes y, al igual que las barreras motivacionales, estaban vinculadas a las barreras de oportunidades. Los participantes recomendaron posibles facilitadores, incluida una programación más sencilla, la estandarización del manejo del dolor y los servicios de cuidados posteriores, y modificaciones en la sala de examen para reducir la ansiedad. Para retener a los pacientes de HRA en entornos comunitarios, las intervenciones deben abordar las barreras de oportunidades sociales y físicas que determinan fuertemente las barreras motivacionales y de capacidad. Mejorar la conveniencia, estandarizar el manejo del dolor e introducir intervenciones de estigma específicas para la HRA podría aliviar las barreras tanto motivacionales como de capacidad.

Gay and Bisexual Men Who Report Anal Sex Stigma Alongside Discomfort Discussing Anal Sex with Health Workers Are Less Likely to Have Ever Received an Anal Examination or Anal Swab.

Purpose: We sought to determine whether stigma toward anal sexuality was associated with having ever received an anal examination or anal swab among gay and bisexual men (GBM). Methods: In 2017, we conducted a cross-sectional online survey with 1513 adult cisgender GBM living in the United States. We used structural equation modeling to test whether the Anal Sex Stigma Scales (a validated measure comprising provider stigma, self-stigma, and silence) was negatively associated with lifetime receipt of anorectal examination or anal swabbing by a medical provider. The model assessed mediation by respondents' comfort discussing anal sex practices with health workers and adjusted for possible confounders. Results: As hypothesized, anal sex stigma was associated with less comfort discussing anal sex (ß = -0.44, 95% confidence interval [CI]: -0.50 to -0.38, p < 0.001), and greater comfort was associated with greater likelihood of screening (ß = 0.28, 95% CI: 0.19 to 0.37, p < 0.001). The model demonstrated good fit (root mean square error of approximation = 0.045, comparative fit index, and Tucker-Lewis index each = 0.99) and adjusted for everyday discrimination, social support specific to anal sex, age, income, education, medical coverage, outness, and ethnic/racial identification. Collectively, model variables accounted for 48% of the variance in screening (p < 0.001). Conclusion: GBM who endorsed less anal sex stigma reported greater comfort discussing anal sex with health workers and were more likely to have ever received anal health screening by a medical provider. To improve anal health and cancer prevention among GBM, anal sex stigma and related discomfort discussing anal sex with health workers are targets for intervention.