Sexual health in primary health care settings in North West province
The researcher’s personal experiences and the literature review confirmed that sexual history taking (SHT) for sexual dysfunction (SD) is not common in primary care nor in routine consultations. Illness and medication can both contribute to sexual dysfunction and justify a patient-doctor encounter. Various barriers to sexual history taking have been identified in the past, including age, sex and cultural discordance, shyness or discomfort, lack of skill and knowledge, and time or treatment constraints. Few studies have been published on sexual dysfunction is South Africa. The observation of the interaction dynamics focussing on history taking of sexual dysfunction in real time consultations was an innovative research concept. The broader aim of this study was to describe the consultation process, associated factors and skills required for successful disclosure of sexual health issues during patient clinical encounters with doctors in primary health care settings in the North West Province, South Africa. The following objectives are reflected as aims in the six articles: 1) To quantify the observations and descriptions of sexual history taking during routine consultations in primary care settings and to identify if patients wanted to discuss sexual issues with doctors, and possible quantitative barriers to sexual history taking, as well as to assess the nature of communication and holistic practice of doctors in these consultations. 2) To describe sexual history taking as well as doctor-patient interaction regarding sexual history taking, during routine consultations in primary care settings in Dr. Kenneth Kaunda Health District, North West Province, South Africa. 3) To explore doctors’ and patients’ perspectives on sexual history taking during chronic primary healthcare consultations with patients at risk of sexual dysfunction, and to report how patients and doctors viewed talking about sexual matters, as well as their perspectives on barriers and facilitators of sexual history taking. 4) To assess the proportion of patients living with symptoms of sexual dysfunction that could have been elicited or addressed during routine chronic illness consultations. 5) To assess doctors’ clinical decision-making processes regarding sexual dysfunction risks and management in chronic illness patients in primary care, based on two hypothetical patient scenarios, by reviewing the doctors’ diagnostic perception and management of these case studies; to compare the scenario outcomes with a reference groups outcomes of the same scenarios; and to describe the clinical reasoning and decision-making process. 6) To identify barriers to and facilitators of sexual history taking that primary care doctors experience during consultations involving patients with chronic illnesses using reflective interviews. The research study was conducted in ten of the 36 primary care facilities in Dr Kenneth Kaunda Health District, North West Province, South Africa, where health care services are provided to nearly 800 000 individuals. This study used a grounded theory research design. A sample of 151 consultations involving patients with diabetes and hypertension who were consecutively sampled formed the core of this study. These patients were purposively selected based on their risk of sexual dysfunction due to their illness and medication. All the doctors in primary care, excluding the family physicians, were recruited to participate. Doctor data collection involved 151 visually recorded routine consultations by 21 doctors. Nineteen doctors completed the two hypothetical scenario vignettes. Patient data collection entailed patients completing sexual dysfunction questionnaires (FSFI and IIEF) to establish the proportion of patients living with sexual dysfunction symptoms. Patient records were reviewed to obtain data on co-morbidities, medication and presenting complaints. Field notes and memoing formed the third part of the data collection. Quantitative data such as patient and doctor characteristics were analysed using descriptive statistics and the Fischer Exact Test was used to elucidate the associations between patient and doctor characteristics and sexual dysfunction, and to compare the doctors’ responses with the reference group’s responses. The Shapiro-Wilk Test for normality was used to analyse the age distribution of the patient participants in the sample. Qualitative data such as recorded consultations, interviews, open-ended questions on the questionnaires, and field notes were analysed using the MaxQDA 2018 software. The initial coding was descriptive as well as in-vivo line-by-line coding naming concepts and developing provisional codes. Axial coding followed where relationships or connections were established between codes. These codes were selected in categories and named. Template analysis was performed for categorical variables that emerged from the interpreted data and existing assessment tools. The vignettes had a mixed method analysis using qualitative analysis to code the answers to the scenarios and then these codes became variables, which were quantitatively analysed. No sexual history taking for SD took place and doctors in only five of 151 consultations (3%) enquired about the patients’ HIV status and vaginal health. A total of 54 of the 151 consultations (36%) reflected a working relationship with the patient, focussing on the problem and not the person. Most of the consultations (66%) had insufficient evidence of holistic practice. Consultations were compromised by a lack of professionalism, doctor-centredness as well as poor communication skills. Doctors demonstrated lower levels of competence in clinical reasoning than expected at their level of experience, and they failed to identify or screen for sexual dysfunction risks. Patients wanted the doctors to ask about SD and the doctors were waiting for patients to talk about it. Generally, patients believed that nothing would stop them from discussing sexual challenges with their doctors, except if the doctor was rude, and did not listen, though they did not do so. Doctors, on the other hand, indicated there were too many other things to discuss during the consultation so that SD was not a priority, and that time constraints were an important barrier. Three themes summarised the multiple realities of the patient-doctor-system triad, namely, lack of patient centredness (doctor centredness and poor communication), a limiting consultation context (lack of privacy, interruptions, and poor filing systems) and consultation content (the scope of sexual history taking, no screening for sexual dysfunction and overall poor chronic care). A Theory of Dynamic Interaction emerged and strategies for change are suggested. In conclusion, a poor patient-doctor-system interaction led to a disconnect between patients and doctors which contributed to sub-standard consultations. The consultations observed in primary care suggested that doctors are stuck in a rut, with little professional fulfilment, and patients are consulting because they have no other option than to do so. The emerging theory of change is dynamic interaction, where communication and person-centredness are keys to modify the patient-doctorsystem relationship.
A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy to the Faculty of Health Sciences, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, 2021