Healthcare Clinician and Staff Perspectives on Facilitators and Barriers to Ideal Sexual Health Care to High-Risk Depressed Young Women: A Qualitative Study of Diverse Clinic Systems

Abstract

Study Objective

This study identified clinician and clinic staff perspectives on facilitators and barriers to providing sexual and reproductive health (SRH) care to depressed young women, a population at increased risk for adverse SRH outcomes.

Design

We conducted in-person semi-structured qualitative interviews, which were audio-recorded, transcribed, and coded by two researchers. We used thematic analysis to identify themes pertaining to care facilitators and barriers within a socio-ecological framework.

Setting

This study was conducted in seven diverse clinics in the U.S. New England region.

Participants

Participants were 28 clinicians and staff (4/clinic), including behavioral health clinicians (n = 9), nurse practitioners (n = 7), nurses (n = 3), medical doctors (n = 3), administrative associates (n = 2), practice managers (n = 2), family planning counselor (n = 1), and medical assistant (n = 1).

Main Outcome Measures

We queried how clinicians and clinic staff identify and manage depression and sexual risk, and what they perceive as facilitators and barriers affecting provision of ideal SRH care to depressed young women.

Results

Themes represented facilitators of and barriers to providing ideal SRH care to high-risk depressed young women at five socio-ecological levels: individual (facilitator: trust in providers; barrier: stigma experiences), interpersonal/provider (facilitator: frequent patient–provider communication; barrier: lack of time during clinic visits to build trust), clinic (facilitator: integration of care; barrier: lack of scheduling flexibility), organization/community (facilitator: training for providers; barrier: funding constraints), and macro/societal (facilitator: supportive policies; barrier: mental health stigma).

Conclusion

Optimizing SRH care to high-risk depressed young women necessitates attention to factors on all socio-ecological levels to remove barriers and bolster existing facilitators of care.

Introduction

Adolescent and young adult women (“young women”) with depression are at increased risk for sexually transmitted infections (STIs) and unintended pregnancy related to engaging in behaviors such as lack of contraception, lack of condom use, unprotected intercourse, casual sexual relationships, multiple partners, and engaging in sex while under the influence of substances.1, 2, 3, 4, 5, 6 Many cognitive and emotional factors can contribute to increased sexual and reproductive health (SRH) risk behaviors in depressed young women, including efforts to regulate affect,2, 3, 4^,7 stress,⁸ substance-related sexual enhancement expectations,⁵ and pregnancy ambivalence.⁹ Young women with depression may also have diminished power in relationships^10,11 and difficulties negotiating condom use with a partner,¹⁰ and are more likely than their non-depressed peers to experience reproductive coercion¹² and intimate partner violence.¹³

Primary care clinicians must consider the distinct constellation of psychological and relational challenges to SRH facing young women with depression. In addition, depression can result in impaired information processing and risk perception,¹⁴ as well as difficulties with medical decision making and adherence,¹⁵ all of which can influence depressed young women's engagement with care and response to treatment. Professional guidelines for primary care clinicians treating young women encourage recognition and management of depression.¹⁶ However, guidelines regarding depression care do not focus on SRH care, and formal interventions addressing both SRH and depression in primary care have not been tested. Identifying barriers to SRH care that are particular to depressed young women may inform implementation of strategies to address their unique needs.

A socio-ecological perspective¹⁷ is valuable in understanding the multiple and interacting factors influencing the health of people across levels, from intrapersonal (individual) and interpersonal, to factors within systems of care and the larger social and policy environment.¹⁸ For a young woman with depression, her SRH decisions and behaviors may be affected by her knowledge, attitudes, and values about sexual behavior and emotional well-being (individual level); her relationships with family, peers, intimate partners, and health care providers (interpersonal level); organizations such as schools, neighborhoods, and healthcare agencies, which both influence and respond to young women's SRH and behavior (community/organizational level); and her societal context, such as policies pertaining to sexual and mental health problems among young women (macro/societal level). Although the socio-ecological perspective is often discussed theoretically, more research is needed that operationalizes this perspective to develop interventions aimed at changing individual behaviors and health outcomes while recognizing the multilevel contexts in which these behaviors are nested.^19,20

We have developed an SRH risk reduction intervention for depressed young women seen in primary care clinics.²¹ To inform integration of this and similar interventions into existing systems of care, we examined perspectives of clinicians and staff from diverse clinics on ideal SRH care for depressed young women and what facilitates or impedes delivery of this ideal care in primary care clinics. Although depressed young women have their own personal experiences and perspectives about accessing and receiving care, clinicians and clinic staff have perspectives on systems of care and SRH care delivery for these women. Therefore, for this study, we focused on health care providers’ perspectives, which may be particularly relevant for optimizing approaches to introducing and sustaining effective interventions at multiple socio-ecological levels across diverse clinic settings.