- Email: [email protected]
Older Adults and HIV and STI Screening: The Patient Perspective
FEATURE ARTICLE Older Adults and HIV and STI Screening: The Patient Perspective Monica S. Slinkard, MSN, APRN, ANP-BC, WHNP-BC Meredith Wallace Kazer, PhD, CNL, APRN, A/GNP-BC
To explore patient provider interactions regarding human immunodeficiency virus (HIV) and sexually transmitted infection (STI) screening of older adults in Connecticut through a focus group approach. Older adults were defined as individuals over 64 years old. Two focus groups convened. The data analysis revealed that the majority of participants had not been screened for HIV or STIs and had not talked with their health care providers about sexual health in recent years. The lack of conversation about sexual health and sexual health screening was the major barrier to sexual health screening. Instigation of the conversation of sexual health and a positive relationship with the health care provider were suggested to overcome these barriers. Health care providers have an important role in initiating conversation about and screening patients for STIs, including HIV. The media, specifically television, was identified as a potential avenue for successful health education. (Geriatr Nurs 2011;32:341-349) esearch supports that many older adults continue to be sexually active throughout all decades of life.1 While there are many documented positive outcomes of continued sexual activity, the risk for sexually transmitted infections (STIs), such as human immunodeficiency virus (HIV), is a significant concern among older adults. As the population of older adults in the United States is expected to increase and the incidence of HIV and acquired immunodeficiency syndrome (AIDS) is growing faster among individuals 50 and older compared to those under 40,2,3 health care providers must be prepared to identify individuals at risk and screen accordingly to prevent disease morbidity and mortality. But, health care providers, including nurses, nurse practitioners, and physicians, are not routinely discussing sexual health with their older patients. A recent study by the University of Chicago revealed that few older men (38%) and even
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fewer women (22%) had discussed sex with a physician since age 50.1 More information is needed to enhance understanding about how older adults and health care providers engage in dialogue about sexual health and HIV screening. The purpose of this focus group study was to explore older patient experiences around sexual health assessment, as well as screening and communication about HIV and STIs, to improve screening practices of older adults. This article concludes with suggestions for improving STI risk assessment screening and education among older adults.
Background The at-risk population for HIV among community dwelling older adults has shifted since the 1980s. Receiving a potentially HIV-contaminated blood transfusion was a prominent risk factor for the development of AIDS in older adults for many years.4 However, as blood transfusion has posed little risk of HIV transmission in the United States for over 2 decades, older adults now have a much more similar risk profile for the development of HIV to the majority of the U.S. population. For older women, heterosexual transmission remains the greatest risk factor for HIV, as it is for women internationally.4,5 Women may be at increased risk of transmission of HIV in older age due to the physiological change of vaginal atrophy, allowing for the potential of more body fluid exposure to mucosa with impaired integrity.6 For older men, men having sex with men (MSM) is the greatest risk factor, as it is for men in the United States of all ages, followed by injection drug use.4,7 However, older adults who are injection drug users have been found to have less risky sexual behaviors and needle-sharing practices than their younger counterparts.8 Ethnic minorities continue to be at greatest risk for HIV infection and show greater incidence of AIDS.9
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African Americans are the most vulnerable, with Hispanics/Latinos as the second most vulnerable group for HIV and AIDS infection across the U.S. population, throughout midlife and old age, for both men and women.10 Older adults’ general lack of knowledge about STIs and HIV leaves this population particularly vulnerable to STIs and makes communication with health care providers that much more important.11 A survey of 135 physicians found that 60.8% of physicians rarely or never discuss HIV or AIDS with patients over the age of 50, while 72% of physicians regularly discuss HIV risk factors with individuals under 30 years old.12 A survey of 335 adults over the age of 50 in the United Kingdom reported that approximately 65% had received “not very much” or “hardly anything” with regard to information about HIV and STIs from any source.13 Furthermore, “individuals 50 years or older are one-sixth as likely to use condoms and one-fifth as likely to have been tested for HIV as individuals in their 20’s.”14 Teaching about safe sex practices and risk factors for STIs, including HIV, and the importance of HIV testing is critical for the older adult population, and screening must be emphasized.15-17 The revised HIV screening protocol put forth by the Centers for Disease Control and Prevention (CDC) in 2006 recommends routine, voluntary, opt-out screening tests for all adolescents, adults, and pregnant women in a wide range of health care settings.18 However, these recommendations exclude routine opt-out testing for older adults over the age of 64.18 The prevalence of HIV over the age of 64 is perceived to be below the level that would allow for cost effective screening. Health care providers, therefore, are expected to screen and test older adults age 65 and above at their discretion. In 2009, the American College of Physicians (ACP) Clinical Practice Guidelines suggest that screening patients up to age 75 for HIV would be cost effective among sexually active older adults, as the evidence, though limited, suggests that the prevalence among older adults may be as high as 0.5%, which is above the often cited threshold for cost-effectiveness (0.1%).19 Of note, several studies provide evidence to support HIV screening even when the prevalence of HIV in a population is 0.1% to 0.2% and as low as 0.05%.19 Repeat screening is left to the provider’s discretion.19 The U.S. Preventive Services Task Force (USPSTF) HIV screening guidelines were revised 342
in 2007 to incorporate new literature but ultimately held to the original guidelines, which recommend that clinicians screen for HIV in all adolescents and adults at increased risk for HIV infection.20 However, health care providers are not routinely asking about the sexual activity of older adults,12 and therefore not assessing their risk, making these guidelines difficult to apply. Because older adults were not routinely being screened or tested for HIV infection in recent history, many older adults may present with late stages of AIDS disease. Additionally, as antiretroviral therapy continues to extend the life span, many older adults will be presenting to clinics with longstanding HIV treatment. These 2 populations differ as to the course of their disease progression and, therefore, the clinical approach to their care. Older adults presenting with late stage AIDS may present with opportunistic infections like Pneumocystis carinii pneumonia (PCP) and esophageal candidiasis.21As noted in Tangredi et al., HIV-infected adults over age 50 are also more likely to report symptoms such as peripheral neuropathy, weight loss, or hair loss, and less likely to report headaches, depressed mood, white oral patches, and diarrhea, which are reported among their younger counterparts.22,23 Tangredi et al. also note that HIV/AIDS dementia (HAD) may be the only presenting complaint of older adults and should be included in the differential diagnosis of any older adult presenting with cognitive changes.22 Comorbidities must also be a focus for patients with longstanding treated HIV infection. A recent study comparing matched noninfected and HIV-infected adults over the age of 50 revealed, “Older HIV-infected persons have a higher prevalence of hypertension, hypertriglyceridemia, low BMD, and lipodystrophy than matched controls, suggesting that HIV and treatment-related factors exceed ‘normal’ aging in the development of those problems.”24 This finding deserves more research to determine if the difference in developing problems is related to highly active antiretroviral therapy (HAART) treatment or the course of HIV infection. More extensive guidelines are needed for primary care providers on how to address the needs of older adults infected with HIV. What is known is that older age is an independent risk factor for the progression of HIV to AIDS and to death, and HIV may accelerate the progression of comorbidities.4,25 In order to continue to Geriatric Nursing, Volume 32, Number 5
decrease the mortality rates of HIV-infected individuals, the focus must shift to also aggressively treating noneAIDS-related conditions.26 Early recognition and treatment of HIV/AIDS and surrounding comorbidities are critical to slowing the disease process. The realities of the disease progression once again highlight the importance of screening and detection of HIV/AIDS in older adults. Though the number of older adults that are actually being screened for HIV/AIDS is not known, the barriers to patienteprovider interactions surrounding sexual assessment and risk assessment for HIV/ AIDS and STI screening in older adult populations have been explored to a certain extent. Limited research has been done in the United States, but studies in Europe may offer insight. In a 2004 study by researchers at the University of Sheffield, United Kingdom, 22 general practitioner physicians (GPs) and 35 practice nurses (similar to advanced practice nurses in the United States) were interviewed to explore barriers of sexual health discussion with patients in the primary care setting.27 The main barriers that the providers revealed were differences between the patient and the provider, specifically related to gender, ethnicity, sexual orientation, and age discrepancies.27 Suggestions to overcoming barriers included longer patient visits, provider training, better patient information pamphlets to give patients, and more use of the practice nurse, who theoretically has more time with patients.27 A survey of 163 women of the age of 65 in the United States likewise revealed that older adults did not want to initiate discussion but would have liked to have discussed sexual health had their physician introduced the subject.28 This study also noted that older women were significantly less likely to talk about sexual concerns with their physician than their younger counterparts.28 Overall, only some providerepatient barriers to sexual assessment have been identified. In summary, older adults are vulnerable to STIs, specifically HIV/AIDS, and sexual assessment often does not occur. Though some research has been conducted on clinicians’ perceived barriers to sexual screening in older adults and guidelines have been laid out with regard to the usefulness of screening of older adults, little has been published regarding the older adults perspective of the screening process. Gaining the older adult’s perspective into the screening process may give useful insight into how providers can effectively and sensitively approach screening. Geriatric Nursing, Volume 32, Number 5
Methods This qualitative focus group study was designed to explore patient experiences around screening of and communication about HIV, STIs, and sexuality, in order to improve the ability to screen older adults. Two focus groups were held at 2 different senior centers. Inclusion criteria were of age greater than 64, English speaking, and willing to talk about sensitive subjects such as sexuality. Each focus group was recruited to have 6 to 12 individuals based on Kruger and Casey’s guidelines for focus group size.29 The result was 5 men and 9 women participants over the age of 64 and English speaking. Each group convened for up to 1 hour and was guided through a demographic questionnaire and a series of focus group questions (Table 1). The 2 groups of older adults were divided by gender, due to the sensitivity of the subject matter and the desire to facilitate open discussion. The focus group sessions were observed, audio recorded, transcribed, and analyzed. Institutional review board approval was granted through the Human Subjects Research Review Committee in combination with the Hospital/ Nursing Research Committee. Focus group participants were recruited through flyers distributed at local universities, senior centers, and assisted living communities. The recruitment flyer stated the purpose of the study and advised potential participants to contact the researcher if he had questions or was interested in participating in the study. When the potential participant contacted the investigator, the purpose and description of the study were discussed and the participant was given the opportunity to decline participation or was scheduled for a focus group. Participants were also asked if they had friends who may also be interested in participating. Thus, snowball sampling continued until enough participants for 1 male and 1 female focus group were obtained. Focus group questions were developed following the focus group question guidelines set forth by Krueger and Casey.29 Two advanced practice nurses with experience in focus groups and 2 older adults reviewed the set of questions with attention to clarity, readability, and content using a modified Delphi technique by email. Two rounds of modifications were made: 1 round of comments and corrections, then another round of comments on corrections, with the principal 343
Table 1.
Focus Group Questions Type of Question
Opening Question
Introductory Questions
Transition Questions
Key Questions
Ending Questions
Older Adult Group Briefly: What kind of health care provider do you normally see and where do you see them? (Do you go to a Doctor, Nurse Practitioner, or Physician’s Assistant? Do they come to your home, do you go to their office, clinic, health care center, or do you mostly receive health care in a hospital setting?) How do you learn about health and disease? Reading? Television? Radio? Internet? Your Nurse or Physician Assistant? Senior Centers? Religious Centers? Does your health care provider talk to you about ways to stay healthy? When is it appropriate to talk about sexual health with your health care provider? How has your health care provider talked to you about sexually transmitted diseases, such as HIV/AIDS? What has made this type of discussion comfortable? What has made this kind of discussion difficult? What did your provider do that helped you to learn about sexually transmitted diseases? Through conversation? Handouts? Offer brief oral summarydIs this an accurate summary of our discussion? Did we miss anything?
investigator as facilitator, with full agreement achieved. A fundamental qualitative content analysis method was used to analyze the results of the focus groups.30 Analysis was focused on identifying and categorizing each participant’s comments, as well as the general comments of the group. The investigator proofed the focus group audiotape transcriptions. Field notes taken by the trained observer were incorporated into the transcript. The investigator read the transcription, while listening to the audiotapes, coding the data in the margin of the transcript as appropriate and organizing the responses into possible categories as described in Basics of Qualitative Research, 3rd edition.31 Words and phrases related to the same content were grouped together with consideration to nonverbal communication, such as power dynamics, body language, emotional charge, and tone, and then subcategories, categories, patterns, regularities, and themes were extracted. A total of 7 main codes were identified. The coding and organizing were used to determine an initial consensus regarding the essential themes of 344
the focus groups by noting the frequencies of similar messages and agreement among participants. A straight descriptive summary was made of the informational content of the data organized by focus group question topic. An expert in qualitative data analysis reviewed and verified the analysis, categories, and the descriptive summary.
Results Participants in this study ranged in age from 66 to 90. There were 5 male participants in group 1 with a mean age of 82 and 9 female participants in group 2 with a mean age of 77 years. All participants identified themselves as white. Ten participants had a high school education, 2 had some college, and 2 did not complete high school. One participant had an advanced practice nurse as a primary care provider and the rest had physicians. Six of the total number of participants saw their health care providers monthly, 2 participants visited every 3 months or 6 months, respectively, and the rest saw their providers once a year or less. Geriatric Nursing, Volume 32, Number 5
Data were organized by three main themes: perceptions of sexual health care and HIV/AIDS screening, seeking health care information, and patienteprovider dynamic. Perceptions of Sexual Health Care and HIV/AIDS Screening When asked, “How has your health care provider talked to you about sexually transmitted diseases, such as HIV/AIDS?” both groups of men and women expressed that their providers did not ask about sexual health in general or talk about STIs. With respect to talking about STIs, half of the men made comments similar to: “There isn’t a reason unless you had a scare or something and seek their advice. I don’t think they volunteer it,” “I’ve never received anything from a doctor pertaining to any kind of sexuality,” and “No, none of my physicians have ever talked to me about sex.” Though all of the women initially said they had never been asked, later in the discussion 2 of the women mentioned that they may have been asked about sexually transmitted diseases on initial intake questionnaires years ago, but 1 could not remember for sure. A comment from the women’s group summed up the sentiments regarding STI screening in older age: “They [doctors] look at the white hair and stopped asking.” Another comment by a woman: “Another doctor we go to, a gynecologist, OB/ GYN once a year, and they don’t even talk to you about it [STI or HIV]. They just do their thing.” Furthermore, the women noted that they were not educated about HIV when they were younger, commenting, “You know, the HIV wasn’t around when we were younger . maybe crabs or something like that, but that was it,” and another added, “not anything really serious that you could die from it.” However, 1 woman had been screened for HIV because she had experienced persistent, challenging health problems, and she noted that she had not been asked before she was screened for HIV/AIDS, nor was told much about it once she tested negative for the virus. As the participants’ health care providers had not broached the topic of STIs and HIV/AIDS, none of the participants had received any information about the topics from their providers. In response to the question, “What did your provider do that helped you learn about sexually transmitted diseases?” the consensus between both groups was “nothing.” Geriatric Nursing, Volume 32, Number 5
Neither focus group saw an overall need for discussions surrounding sexual health unless there was a problem that needed to be addressed. This perspective is consistent with the general attitude that one goes to a provider when there is a problem. The men’s group commented, “Well, if you’re bringing that up, you probably have some kind of problem or if there’s a member of the family or someone you know. .” Similar comments were made, including “I’ve never had a problem sexual wise, so I never had to discuss anything with him [doctor].” Another man commented: “I can’t ever recall discussing sex with any doctor or any nurse or anybody in the medical field, I guess since my wife had a baby and that was 45 years ago.” Many of the women in the focus group were widowed or with a partner who had health conditions that hindered the ability to perform sexually. Not having a sexual partner appeared to make the topic irrelevant: “Without a man in your life, it [talking about sexual health] just doesn’t seem like it’s necessary,” which was received with head nods all around the table. One woman said, “We’re all pretty much past that time [to talk about sexual health].” Seeking Health Care Information Interestingly, both focus groups cited the media, specifically radio and televisiondnot primary care providersdas their primary sources of health care information. Furthermore, both groups mentioned, “Those doctor [television] shows,” where doctors give general medical advice. The participants also learned from friends, family, and word of mouth. The term “advice” came up multiple times in the men’s focus group and some men cited their “doctor” as a place where they learn about health and disease. When consulting others, friends or physicians, both men and women sought information with relation to problems, not general medical issues: “Your aches and pains make you thirst for knowledge” and “You ask [your provider] a lot of questions when you go . it’s my body and I want to know what’s going on.” The women’s group also read books regarding their health care conditions. PatienteProvider Dynamic Throughout both focus group discussions there were many comments made about the challenges in communicating effectively with health care 345
providers. The men’s group made many comments related to being at the mercy of their physicians, such as: “Whatever he finds, he sends me to a specialist,” “From my own personal experience, for all the doctors I’ve seen, they volunteer very little information unless they are 100% sure of what’s going on. Otherwise, it’s all supposition . they don’t want to open themselves up to liabilities,” and “What’s the result? I haven’t the slightest idea . so like I said, I’m in the dark . I’ve taken hundreds and hundreds of tests. Tell me what’s wrong! Give me an idea of what’s wrong.” There were also various comments made related to the power dynamic between patient and provider: “They’re the doctor, you’re the patient,” “You should always question . sometimes you have to let the doctor know you disagree,” and “You know you got to take the approach when listening to a patient that sometimes they’re right.” There were comments about a general sense of trial and error the men had experienced with medical providers and confusion about navigating the health care system. These sentiments were expressed through comments like: “I also feel . that doctors aren’t always right. They’ll put you on something, and it’s all experimental how your body’s going to react to it,” “It’s not easy for them and it’s not easy for you. It’s just a guessing game, to be truthful,” and “This is the sickness, this is the cure.now, how it affects you, we’ll wait and see.” There was discussion in the men’s group about the complexity of knowing if one should take medication that is prescribed due to the side effect profiles and the potential for interactions with other medications. Three older men commented on keeping track of medications: “I have four doctors I go to and the correlation between the four is all the medication I’m taking,” “.And then you got one doctor and he’ll say, ‘Stop that (medication).’ And you go to the other doctor and he’ll say, ‘Stop this (medication),” and “it’s very confusing sometimes to know how to balance that [side effects of medications], when to take it.” Only 1 woman made a similar comment with regard to receiving what she suggested to be futile blood tests, stating: “.And he says, ‘Well, I want you to go to Yale.’ I said, ‘What for? They’re going to do the same things you did plus another bone marrow, which I totally hate, and come up with absolutely nothing.’” The women’s group did not make many comments about the patienteprovider relationship in 346
general, while much of the men’s group discussion was framed around this topic.
Discussion This focus group study was conducted to describe how older adults and their health care providers are discussing sexual health and screening practices for STIs and HIV. In general, it appears that health care providers did not ask older adults about their sexual health or talk about sexually transmitted infections or HIV/AIDS. This is consistent with the findings of previous studies.1,32,33 The focus group participants also did not bring up the topic of sexual health, as the general attitude was that unless there was a problem, sexual health was not something that warranted discussion. The lack of sexual health assessment and risk screening found in this study and the literature underscores the great need for all health care providers to be educated about addressing sexual health and risk for STIs among older adults. This education should be initiated in basic baccalaureate, graduate nursing, and medical school educational programs and continue as part of required education throughout practice careers. Important issues to address related to sexuality in older adults include safe sex practices, physical and emotional comfort level of sexual activity, and how a patient’s medical conditions and/ or medications are affecting his or her sexual desire and/or performance.34 Sexuality is a continued human need that does not stop as individuals enter older adulthood.34 Thus, it should be assumed that all older adults are sexually active and appropriate sexual history questions should be asked during all health assessments.34 As the CDC does not recommend opt-out HIV testing for adults 65 years and older,18 it is essential that providers discuss sexual health and sexual risk factors with older adult patients in order to screen for HIV/AIDS. The men’s focus group also suggested that a nonjudgmental and open attitude would facilitate discussion about sexual health with their health care provider. The women’s group offered that they would be open to talking about it if they were only asked. Provider initiation of the conversation of sexual health was found to be a key factor in facilitating discussion in other studies as well.28,35 The PLISSIT model, acknowledged by Geriatric Nursing, Volume 32, Number 5
Annon in 1976, may be a useful framework from which to not only address sexual dysfunction concerns but also open the door for further discussion relating to sexual activity and highrisk behaviors.36 An incidental finding discovered through the focus group process is that participants in this study also indicated that they had difficulty navigating the health care system. This was demonstrated through comments about confusion regarding medications, testing, and patient-provider communication and continuity. In a similarly designed focus group study by the National Eye Institute (2003) designed to determine information needs and improve health care systems for older adults, numerous challenges to understanding medical issues and management of health care problems were also identified.37 Participants in the National Eye Institute focus groups suggested that brief screening questions and increased information sharing between health care providers and patients would improve health care quality.37 Both focus groups cited the media, specifically radio and television, as a means by which they obtain health information. Furthermore, “those doctor [television] shows,” where doctors give general medical advice, were highlighted. Television may be a promising avenue that could be used to teach about screening for HIV and STI screening in older adults. The average age of the television viewing population is on the rise and television occupies the greater part of leisure time for older adults age 70 to 105 years.38-40 Television is often used as a means of education, and within health care it has been successfully argued to be a means of patient education by pharmaceutical industries as a basis for direct-to-consumer advertising.39-41 Raising awareness of this issue through the media may also influence older adults to ask their providers about the screening, as well as potentially informing health care providers. Limitations As with any research, this study has some limitations. The most obvious limitations were in the composition of the sample. First, it would have been ideal to recruit older adults who were at high risk for HIV and STIs, such as intravenous drug users or older men who have sex with men (MSM). However, recruitment of such a population into a focus group setting would have been Geriatric Nursing, Volume 32, Number 5
very challenging and require resources beyond the scope of this study. Second, with 5 participants in 1 group and 9 in the other, there is clearly a very limited sample size that impacts the generalizability of the study. Sample saturation was not achieved and may have yielded results that could further the understanding of patient experiences around screening of and communication about HIV, STIs, and sexuality. The study used a convenience sampling procedure that resulted in a primarily white sample of middle-older adults (i.e., 75 to 85 years old). Thus, the results limit the ability to apply the findings to members of other ethnic groups or younger, more sexually active adults. Furthermore, specific information about whether participants were engaged in sexual behavior was not gathered. This information would have been useful in putting participant’s responses into context. Despite these limitations, the study provides important patient perspectives on screening practices regarding sexuality, HIV, and STIs that nurses may use in practice with older patients. Recommendations and Conclusions for Nursing Practice The purpose of this focus group study was to explore patient experiences around sexual health assessment as well as screening and communication about HIV and STIs. The study was innovative in its approach to access an understudied population in order to gather information to improve screening practices for older adults. The study participants shared that sexual health and HIV risk discussions never occurred with their health care providers, a finding that is supported in the literature and underscores the need to enhance sexual health assessment and screening of high risk patients. Moreover, participants shared perspectives regarding health care practices that would enhance sexual discussions including initiating discussions in a nonjudgmental manner. Results of this study provide information that health professionals can use in patient education and screening practices to detect HIV and STIs at an earlier, more treatable stage. Furthermore, keeping up with healthdirected television and radio programs and incorporating what is being projected in the media into the patient’s visit may be an effective educational tool. Health care providers may also consider using the avenue of media as a way to share health information with older adults. For example, 347
providers might consider including videos or audio recordings into the educational component of the patient’s care plan. The participants in this study also indicated that they had difficulty navigating the health care system. Increased information sharing may help build patients’ confidence in navigating the health care system. In the future, it may be helpful to obtain the perspective of physicians, advanced practice nurses, and physician assistants themselves as to how they approach screening older adults for sexual health issues, STIs, and HIV/AIDS. More research about perceived barriers and successes as described by health care providers may be helpful in developing and promoting screening tools, as well as giving perspective on screening guidelines. The older men expressed varying degrees of discontent with the way that they have been involved in the health care process by their health care providers; it appears that much of this discontent stems from issues of communication with their health care providers. More focused assessment of the interaction between older adults and their providers, as well as implementation of these findings, is needed. For now, this focus group study reveals that not all older adults are being engaged in conversation about sexual health or being screened for STIs such as HIV/ AIDS. Improved patient assessment, education, and screening for high-risk patients are needed at the clinical level.
References 1. Lindau ST, Schumm P, Laumann EO, et al. A study of sexuality and health among older adults in the United States. N Engl J Med 2007;357:762-74. 2. Karlovsky M, Lebed B, Mydlo JH. Increasing incidence and importance of HIV/AIDS and gonorrhea among men aged $50 years in the US in the era of erectile dysfunction therapy. Scand J Urol Nephrol 2004;38: 247-52. 3. Patel D, Gillespie B, Foxman B. Sexual behavior of older women: results of a random digit-dialing survey of 2000 women in the United States. Sex Transm Dis 2003;216-20. 4. Nguyen N, Holodniy M. HIV infection in the elderly. Clin Interv Aging 2008;3:453-72. 5. National Institute of Allergy and Infectious Disease: HIV Infection in Women. Department of Health and Human Services, National Institute of Health. 2008. Available at http://www.niaid.nih.gov/topics/hivaids/understanding/ population%20specific%20information/pages/womenhiv. aspx. Cited December 11, 2010. 6. Catania JA, Turner H, Kegeles SM, et al. Older Americans and AIDS: transmission risks and primary prevention research needs. Gerontologist 1989;29:373-81.
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24. Onen NF, Overton ET, Seyfried W, et al. Aging and HIV infection: a comparison between older HIV-infected persons and the general population. HIV Clin Trials 2010; 11:100-9. 25. Effros RB, Fletcher CV, Gebo K. Workshop on HIV infection and aging: what is known and future research directions. Clin Infect Dis 2008;47:542-53. 26. Lau B, Gange S, Moore RD. Risk of non-AIDS related mortality may exceed risk of AIDS-related mortality among individuals enrolling into care with CD4+ counts greater than 200 cells/mm3. J Acquir Immune Defic Syndr 2007;44:179-87. 27. Gott M, Galena E, Hinchliff S, et al. "Opening a can of worms": GP and practice nurse barriers to talking about sexual health in primary care. Fam Pract 2004;21:528-36. 28. Nusbaum M, Singh A, Pyles A. Sexual healthcare needs of women aged 65 and older. J Am Geriatr Soc 2004;52:117-22. 29. Krueger R, Casey M. Focus groups: a practical guide for applied research. 4th ed. Thousand Oaks, CA: SAGE Publications; 2009. 30. Sandelowski M. What happened to qualitative description? Res Nurs Healt 2000;23:334-40. 31. Corbin J, Strauss A. Basics of qualitative research: techniques and procedures for developing grounded theory. 3rd ed. Los Angeles: SAGE Publications; 2008. 32. Lindau ST, Leitsch SA, Lundberg K, et al. Older women’s attitudes, behavior and communication about sex and HIV: a community-based study. J Women’s Health 2006;6:747-53. 33. Gott M, Hinchliff S. Barriers to seeking treatment for sexual problems in primary care: a qualitative study with older people. Fam Pract 2003;20:690-5. 34. Arena JM, Wallace M. Issues regarding sexuality. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, eds. Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008. p. 629-47.
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35. Gott M, Hinchliff S, Galena E. A qualitative study to explore GP attitudes to discussing sexual health issues with older people. Soc Sci Med 2004;58:2093-103. 36. Annon JS. The PLISSIT model: a proposed conceptual scheme for the behavioral treatment of sexual problems. J Sex Educ Ther 1976;2:1-15. 37. National Eye Institute, National Institutes of Health (2003). Final older adult needs assessment, final focus group report. 2003. Available at http://www.nei.nih.gov/ nehep/research/older_adult_needs_assessment_final. pdf. Cited August 3, 2010. 38. Mundorf N, Brownell W. Media preferences of older and younger adults. Gerontologist 1990;30:685-91. 39. Schneider M. TV viewers’ average age hits 50. Variety 2008. Available at http://www.variety.com/article/ VR1117988273.html?categoryid51275&cs51. Cited August 3, 2010. 40. Horgas AL, Wilms HU, Baltes MM. Daily life in very old age: everyday activities as expression of successful living. Gerontologist 1998;38:556-68. 41. Frosch DL, Krueger PM, Hornik RC, et al. Creating demand for prescription drugs: a content analysis of television direct-to-consumer advertising. Ann Fam Med 2007;5:6-13. MONICA S. SLINKARD, MSN, APRN, ANP-BC, WHNP-BC, is a recent graduate from the Yale School of Nursing, New Haven, CT and is currently working at Mary’s Center for Maternal and Child Care in Washington, DC, as an APRN. MEREDITH WALLACE KAZER, PhD, CNL, APRN, A/GNP-BC, is an Associate Professor at Fairfield University School of Nursing, Fairfield, CT. 0197-4572/$ - see front matter Ó 2011 Mosby, Inc. All rights reserved. doi:10.1016/j.gerinurse.2011.05.002
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To explore patient provider interactions regarding human immunodeficiency virus (HIV) and sexually transmitted infection (STI) screening of older adults in Connecticut through a focus group approach. Older adults were defined as individuals over 64 years old. Two focus groups convened. The data analysis revealed that the majority of participants had not been screened for HIV or STIs and had not talked with their health care providers about sexual health in recent years. The lack of conversation about sexual health and sexual health screening was the major barrier to sexual health screening. Instigation of the conversation of sexual health and a positive relationship with the health care provider were suggested to overcome these barriers. Health care providers have an important role in initiating conversation about and screening patients for STIs, including HIV. The media, specifically television, was identified as a potential avenue for successful health education. (Geriatr Nurs 2011;32:341-349) esearch supports that many older adults continue to be sexually active throughout all decades of life.1 While there are many documented positive outcomes of continued sexual activity, the risk for sexually transmitted infections (STIs), such as human immunodeficiency virus (HIV), is a significant concern among older adults. As the population of older adults in the United States is expected to increase and the incidence of HIV and acquired immunodeficiency syndrome (AIDS) is growing faster among individuals 50 and older compared to those under 40,2,3 health care providers must be prepared to identify individuals at risk and screen accordingly to prevent disease morbidity and mortality. But, health care providers, including nurses, nurse practitioners, and physicians, are not routinely discussing sexual health with their older patients. A recent study by the University of Chicago revealed that few older men (38%) and even
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fewer women (22%) had discussed sex with a physician since age 50.1 More information is needed to enhance understanding about how older adults and health care providers engage in dialogue about sexual health and HIV screening. The purpose of this focus group study was to explore older patient experiences around sexual health assessment, as well as screening and communication about HIV and STIs, to improve screening practices of older adults. This article concludes with suggestions for improving STI risk assessment screening and education among older adults.
Background The at-risk population for HIV among community dwelling older adults has shifted since the 1980s. Receiving a potentially HIV-contaminated blood transfusion was a prominent risk factor for the development of AIDS in older adults for many years.4 However, as blood transfusion has posed little risk of HIV transmission in the United States for over 2 decades, older adults now have a much more similar risk profile for the development of HIV to the majority of the U.S. population. For older women, heterosexual transmission remains the greatest risk factor for HIV, as it is for women internationally.4,5 Women may be at increased risk of transmission of HIV in older age due to the physiological change of vaginal atrophy, allowing for the potential of more body fluid exposure to mucosa with impaired integrity.6 For older men, men having sex with men (MSM) is the greatest risk factor, as it is for men in the United States of all ages, followed by injection drug use.4,7 However, older adults who are injection drug users have been found to have less risky sexual behaviors and needle-sharing practices than their younger counterparts.8 Ethnic minorities continue to be at greatest risk for HIV infection and show greater incidence of AIDS.9
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African Americans are the most vulnerable, with Hispanics/Latinos as the second most vulnerable group for HIV and AIDS infection across the U.S. population, throughout midlife and old age, for both men and women.10 Older adults’ general lack of knowledge about STIs and HIV leaves this population particularly vulnerable to STIs and makes communication with health care providers that much more important.11 A survey of 135 physicians found that 60.8% of physicians rarely or never discuss HIV or AIDS with patients over the age of 50, while 72% of physicians regularly discuss HIV risk factors with individuals under 30 years old.12 A survey of 335 adults over the age of 50 in the United Kingdom reported that approximately 65% had received “not very much” or “hardly anything” with regard to information about HIV and STIs from any source.13 Furthermore, “individuals 50 years or older are one-sixth as likely to use condoms and one-fifth as likely to have been tested for HIV as individuals in their 20’s.”14 Teaching about safe sex practices and risk factors for STIs, including HIV, and the importance of HIV testing is critical for the older adult population, and screening must be emphasized.15-17 The revised HIV screening protocol put forth by the Centers for Disease Control and Prevention (CDC) in 2006 recommends routine, voluntary, opt-out screening tests for all adolescents, adults, and pregnant women in a wide range of health care settings.18 However, these recommendations exclude routine opt-out testing for older adults over the age of 64.18 The prevalence of HIV over the age of 64 is perceived to be below the level that would allow for cost effective screening. Health care providers, therefore, are expected to screen and test older adults age 65 and above at their discretion. In 2009, the American College of Physicians (ACP) Clinical Practice Guidelines suggest that screening patients up to age 75 for HIV would be cost effective among sexually active older adults, as the evidence, though limited, suggests that the prevalence among older adults may be as high as 0.5%, which is above the often cited threshold for cost-effectiveness (0.1%).19 Of note, several studies provide evidence to support HIV screening even when the prevalence of HIV in a population is 0.1% to 0.2% and as low as 0.05%.19 Repeat screening is left to the provider’s discretion.19 The U.S. Preventive Services Task Force (USPSTF) HIV screening guidelines were revised 342
in 2007 to incorporate new literature but ultimately held to the original guidelines, which recommend that clinicians screen for HIV in all adolescents and adults at increased risk for HIV infection.20 However, health care providers are not routinely asking about the sexual activity of older adults,12 and therefore not assessing their risk, making these guidelines difficult to apply. Because older adults were not routinely being screened or tested for HIV infection in recent history, many older adults may present with late stages of AIDS disease. Additionally, as antiretroviral therapy continues to extend the life span, many older adults will be presenting to clinics with longstanding HIV treatment. These 2 populations differ as to the course of their disease progression and, therefore, the clinical approach to their care. Older adults presenting with late stage AIDS may present with opportunistic infections like Pneumocystis carinii pneumonia (PCP) and esophageal candidiasis.21As noted in Tangredi et al., HIV-infected adults over age 50 are also more likely to report symptoms such as peripheral neuropathy, weight loss, or hair loss, and less likely to report headaches, depressed mood, white oral patches, and diarrhea, which are reported among their younger counterparts.22,23 Tangredi et al. also note that HIV/AIDS dementia (HAD) may be the only presenting complaint of older adults and should be included in the differential diagnosis of any older adult presenting with cognitive changes.22 Comorbidities must also be a focus for patients with longstanding treated HIV infection. A recent study comparing matched noninfected and HIV-infected adults over the age of 50 revealed, “Older HIV-infected persons have a higher prevalence of hypertension, hypertriglyceridemia, low BMD, and lipodystrophy than matched controls, suggesting that HIV and treatment-related factors exceed ‘normal’ aging in the development of those problems.”24 This finding deserves more research to determine if the difference in developing problems is related to highly active antiretroviral therapy (HAART) treatment or the course of HIV infection. More extensive guidelines are needed for primary care providers on how to address the needs of older adults infected with HIV. What is known is that older age is an independent risk factor for the progression of HIV to AIDS and to death, and HIV may accelerate the progression of comorbidities.4,25 In order to continue to Geriatric Nursing, Volume 32, Number 5
decrease the mortality rates of HIV-infected individuals, the focus must shift to also aggressively treating noneAIDS-related conditions.26 Early recognition and treatment of HIV/AIDS and surrounding comorbidities are critical to slowing the disease process. The realities of the disease progression once again highlight the importance of screening and detection of HIV/AIDS in older adults. Though the number of older adults that are actually being screened for HIV/AIDS is not known, the barriers to patienteprovider interactions surrounding sexual assessment and risk assessment for HIV/ AIDS and STI screening in older adult populations have been explored to a certain extent. Limited research has been done in the United States, but studies in Europe may offer insight. In a 2004 study by researchers at the University of Sheffield, United Kingdom, 22 general practitioner physicians (GPs) and 35 practice nurses (similar to advanced practice nurses in the United States) were interviewed to explore barriers of sexual health discussion with patients in the primary care setting.27 The main barriers that the providers revealed were differences between the patient and the provider, specifically related to gender, ethnicity, sexual orientation, and age discrepancies.27 Suggestions to overcoming barriers included longer patient visits, provider training, better patient information pamphlets to give patients, and more use of the practice nurse, who theoretically has more time with patients.27 A survey of 163 women of the age of 65 in the United States likewise revealed that older adults did not want to initiate discussion but would have liked to have discussed sexual health had their physician introduced the subject.28 This study also noted that older women were significantly less likely to talk about sexual concerns with their physician than their younger counterparts.28 Overall, only some providerepatient barriers to sexual assessment have been identified. In summary, older adults are vulnerable to STIs, specifically HIV/AIDS, and sexual assessment often does not occur. Though some research has been conducted on clinicians’ perceived barriers to sexual screening in older adults and guidelines have been laid out with regard to the usefulness of screening of older adults, little has been published regarding the older adults perspective of the screening process. Gaining the older adult’s perspective into the screening process may give useful insight into how providers can effectively and sensitively approach screening. Geriatric Nursing, Volume 32, Number 5
Methods This qualitative focus group study was designed to explore patient experiences around screening of and communication about HIV, STIs, and sexuality, in order to improve the ability to screen older adults. Two focus groups were held at 2 different senior centers. Inclusion criteria were of age greater than 64, English speaking, and willing to talk about sensitive subjects such as sexuality. Each focus group was recruited to have 6 to 12 individuals based on Kruger and Casey’s guidelines for focus group size.29 The result was 5 men and 9 women participants over the age of 64 and English speaking. Each group convened for up to 1 hour and was guided through a demographic questionnaire and a series of focus group questions (Table 1). The 2 groups of older adults were divided by gender, due to the sensitivity of the subject matter and the desire to facilitate open discussion. The focus group sessions were observed, audio recorded, transcribed, and analyzed. Institutional review board approval was granted through the Human Subjects Research Review Committee in combination with the Hospital/ Nursing Research Committee. Focus group participants were recruited through flyers distributed at local universities, senior centers, and assisted living communities. The recruitment flyer stated the purpose of the study and advised potential participants to contact the researcher if he had questions or was interested in participating in the study. When the potential participant contacted the investigator, the purpose and description of the study were discussed and the participant was given the opportunity to decline participation or was scheduled for a focus group. Participants were also asked if they had friends who may also be interested in participating. Thus, snowball sampling continued until enough participants for 1 male and 1 female focus group were obtained. Focus group questions were developed following the focus group question guidelines set forth by Krueger and Casey.29 Two advanced practice nurses with experience in focus groups and 2 older adults reviewed the set of questions with attention to clarity, readability, and content using a modified Delphi technique by email. Two rounds of modifications were made: 1 round of comments and corrections, then another round of comments on corrections, with the principal 343
Table 1.
Focus Group Questions Type of Question
Opening Question
Introductory Questions
Transition Questions
Key Questions
Ending Questions
Older Adult Group Briefly: What kind of health care provider do you normally see and where do you see them? (Do you go to a Doctor, Nurse Practitioner, or Physician’s Assistant? Do they come to your home, do you go to their office, clinic, health care center, or do you mostly receive health care in a hospital setting?) How do you learn about health and disease? Reading? Television? Radio? Internet? Your Nurse or Physician Assistant? Senior Centers? Religious Centers? Does your health care provider talk to you about ways to stay healthy? When is it appropriate to talk about sexual health with your health care provider? How has your health care provider talked to you about sexually transmitted diseases, such as HIV/AIDS? What has made this type of discussion comfortable? What has made this kind of discussion difficult? What did your provider do that helped you to learn about sexually transmitted diseases? Through conversation? Handouts? Offer brief oral summarydIs this an accurate summary of our discussion? Did we miss anything?
investigator as facilitator, with full agreement achieved. A fundamental qualitative content analysis method was used to analyze the results of the focus groups.30 Analysis was focused on identifying and categorizing each participant’s comments, as well as the general comments of the group. The investigator proofed the focus group audiotape transcriptions. Field notes taken by the trained observer were incorporated into the transcript. The investigator read the transcription, while listening to the audiotapes, coding the data in the margin of the transcript as appropriate and organizing the responses into possible categories as described in Basics of Qualitative Research, 3rd edition.31 Words and phrases related to the same content were grouped together with consideration to nonverbal communication, such as power dynamics, body language, emotional charge, and tone, and then subcategories, categories, patterns, regularities, and themes were extracted. A total of 7 main codes were identified. The coding and organizing were used to determine an initial consensus regarding the essential themes of 344
the focus groups by noting the frequencies of similar messages and agreement among participants. A straight descriptive summary was made of the informational content of the data organized by focus group question topic. An expert in qualitative data analysis reviewed and verified the analysis, categories, and the descriptive summary.
Results Participants in this study ranged in age from 66 to 90. There were 5 male participants in group 1 with a mean age of 82 and 9 female participants in group 2 with a mean age of 77 years. All participants identified themselves as white. Ten participants had a high school education, 2 had some college, and 2 did not complete high school. One participant had an advanced practice nurse as a primary care provider and the rest had physicians. Six of the total number of participants saw their health care providers monthly, 2 participants visited every 3 months or 6 months, respectively, and the rest saw their providers once a year or less. Geriatric Nursing, Volume 32, Number 5
Data were organized by three main themes: perceptions of sexual health care and HIV/AIDS screening, seeking health care information, and patienteprovider dynamic. Perceptions of Sexual Health Care and HIV/AIDS Screening When asked, “How has your health care provider talked to you about sexually transmitted diseases, such as HIV/AIDS?” both groups of men and women expressed that their providers did not ask about sexual health in general or talk about STIs. With respect to talking about STIs, half of the men made comments similar to: “There isn’t a reason unless you had a scare or something and seek their advice. I don’t think they volunteer it,” “I’ve never received anything from a doctor pertaining to any kind of sexuality,” and “No, none of my physicians have ever talked to me about sex.” Though all of the women initially said they had never been asked, later in the discussion 2 of the women mentioned that they may have been asked about sexually transmitted diseases on initial intake questionnaires years ago, but 1 could not remember for sure. A comment from the women’s group summed up the sentiments regarding STI screening in older age: “They [doctors] look at the white hair and stopped asking.” Another comment by a woman: “Another doctor we go to, a gynecologist, OB/ GYN once a year, and they don’t even talk to you about it [STI or HIV]. They just do their thing.” Furthermore, the women noted that they were not educated about HIV when they were younger, commenting, “You know, the HIV wasn’t around when we were younger . maybe crabs or something like that, but that was it,” and another added, “not anything really serious that you could die from it.” However, 1 woman had been screened for HIV because she had experienced persistent, challenging health problems, and she noted that she had not been asked before she was screened for HIV/AIDS, nor was told much about it once she tested negative for the virus. As the participants’ health care providers had not broached the topic of STIs and HIV/AIDS, none of the participants had received any information about the topics from their providers. In response to the question, “What did your provider do that helped you learn about sexually transmitted diseases?” the consensus between both groups was “nothing.” Geriatric Nursing, Volume 32, Number 5
Neither focus group saw an overall need for discussions surrounding sexual health unless there was a problem that needed to be addressed. This perspective is consistent with the general attitude that one goes to a provider when there is a problem. The men’s group commented, “Well, if you’re bringing that up, you probably have some kind of problem or if there’s a member of the family or someone you know. .” Similar comments were made, including “I’ve never had a problem sexual wise, so I never had to discuss anything with him [doctor].” Another man commented: “I can’t ever recall discussing sex with any doctor or any nurse or anybody in the medical field, I guess since my wife had a baby and that was 45 years ago.” Many of the women in the focus group were widowed or with a partner who had health conditions that hindered the ability to perform sexually. Not having a sexual partner appeared to make the topic irrelevant: “Without a man in your life, it [talking about sexual health] just doesn’t seem like it’s necessary,” which was received with head nods all around the table. One woman said, “We’re all pretty much past that time [to talk about sexual health].” Seeking Health Care Information Interestingly, both focus groups cited the media, specifically radio and televisiondnot primary care providersdas their primary sources of health care information. Furthermore, both groups mentioned, “Those doctor [television] shows,” where doctors give general medical advice. The participants also learned from friends, family, and word of mouth. The term “advice” came up multiple times in the men’s focus group and some men cited their “doctor” as a place where they learn about health and disease. When consulting others, friends or physicians, both men and women sought information with relation to problems, not general medical issues: “Your aches and pains make you thirst for knowledge” and “You ask [your provider] a lot of questions when you go . it’s my body and I want to know what’s going on.” The women’s group also read books regarding their health care conditions. PatienteProvider Dynamic Throughout both focus group discussions there were many comments made about the challenges in communicating effectively with health care 345
providers. The men’s group made many comments related to being at the mercy of their physicians, such as: “Whatever he finds, he sends me to a specialist,” “From my own personal experience, for all the doctors I’ve seen, they volunteer very little information unless they are 100% sure of what’s going on. Otherwise, it’s all supposition . they don’t want to open themselves up to liabilities,” and “What’s the result? I haven’t the slightest idea . so like I said, I’m in the dark . I’ve taken hundreds and hundreds of tests. Tell me what’s wrong! Give me an idea of what’s wrong.” There were also various comments made related to the power dynamic between patient and provider: “They’re the doctor, you’re the patient,” “You should always question . sometimes you have to let the doctor know you disagree,” and “You know you got to take the approach when listening to a patient that sometimes they’re right.” There were comments about a general sense of trial and error the men had experienced with medical providers and confusion about navigating the health care system. These sentiments were expressed through comments like: “I also feel . that doctors aren’t always right. They’ll put you on something, and it’s all experimental how your body’s going to react to it,” “It’s not easy for them and it’s not easy for you. It’s just a guessing game, to be truthful,” and “This is the sickness, this is the cure.now, how it affects you, we’ll wait and see.” There was discussion in the men’s group about the complexity of knowing if one should take medication that is prescribed due to the side effect profiles and the potential for interactions with other medications. Three older men commented on keeping track of medications: “I have four doctors I go to and the correlation between the four is all the medication I’m taking,” “.And then you got one doctor and he’ll say, ‘Stop that (medication).’ And you go to the other doctor and he’ll say, ‘Stop this (medication),” and “it’s very confusing sometimes to know how to balance that [side effects of medications], when to take it.” Only 1 woman made a similar comment with regard to receiving what she suggested to be futile blood tests, stating: “.And he says, ‘Well, I want you to go to Yale.’ I said, ‘What for? They’re going to do the same things you did plus another bone marrow, which I totally hate, and come up with absolutely nothing.’” The women’s group did not make many comments about the patienteprovider relationship in 346
general, while much of the men’s group discussion was framed around this topic.
Discussion This focus group study was conducted to describe how older adults and their health care providers are discussing sexual health and screening practices for STIs and HIV. In general, it appears that health care providers did not ask older adults about their sexual health or talk about sexually transmitted infections or HIV/AIDS. This is consistent with the findings of previous studies.1,32,33 The focus group participants also did not bring up the topic of sexual health, as the general attitude was that unless there was a problem, sexual health was not something that warranted discussion. The lack of sexual health assessment and risk screening found in this study and the literature underscores the great need for all health care providers to be educated about addressing sexual health and risk for STIs among older adults. This education should be initiated in basic baccalaureate, graduate nursing, and medical school educational programs and continue as part of required education throughout practice careers. Important issues to address related to sexuality in older adults include safe sex practices, physical and emotional comfort level of sexual activity, and how a patient’s medical conditions and/ or medications are affecting his or her sexual desire and/or performance.34 Sexuality is a continued human need that does not stop as individuals enter older adulthood.34 Thus, it should be assumed that all older adults are sexually active and appropriate sexual history questions should be asked during all health assessments.34 As the CDC does not recommend opt-out HIV testing for adults 65 years and older,18 it is essential that providers discuss sexual health and sexual risk factors with older adult patients in order to screen for HIV/AIDS. The men’s focus group also suggested that a nonjudgmental and open attitude would facilitate discussion about sexual health with their health care provider. The women’s group offered that they would be open to talking about it if they were only asked. Provider initiation of the conversation of sexual health was found to be a key factor in facilitating discussion in other studies as well.28,35 The PLISSIT model, acknowledged by Geriatric Nursing, Volume 32, Number 5
Annon in 1976, may be a useful framework from which to not only address sexual dysfunction concerns but also open the door for further discussion relating to sexual activity and highrisk behaviors.36 An incidental finding discovered through the focus group process is that participants in this study also indicated that they had difficulty navigating the health care system. This was demonstrated through comments about confusion regarding medications, testing, and patient-provider communication and continuity. In a similarly designed focus group study by the National Eye Institute (2003) designed to determine information needs and improve health care systems for older adults, numerous challenges to understanding medical issues and management of health care problems were also identified.37 Participants in the National Eye Institute focus groups suggested that brief screening questions and increased information sharing between health care providers and patients would improve health care quality.37 Both focus groups cited the media, specifically radio and television, as a means by which they obtain health information. Furthermore, “those doctor [television] shows,” where doctors give general medical advice, were highlighted. Television may be a promising avenue that could be used to teach about screening for HIV and STI screening in older adults. The average age of the television viewing population is on the rise and television occupies the greater part of leisure time for older adults age 70 to 105 years.38-40 Television is often used as a means of education, and within health care it has been successfully argued to be a means of patient education by pharmaceutical industries as a basis for direct-to-consumer advertising.39-41 Raising awareness of this issue through the media may also influence older adults to ask their providers about the screening, as well as potentially informing health care providers. Limitations As with any research, this study has some limitations. The most obvious limitations were in the composition of the sample. First, it would have been ideal to recruit older adults who were at high risk for HIV and STIs, such as intravenous drug users or older men who have sex with men (MSM). However, recruitment of such a population into a focus group setting would have been Geriatric Nursing, Volume 32, Number 5
very challenging and require resources beyond the scope of this study. Second, with 5 participants in 1 group and 9 in the other, there is clearly a very limited sample size that impacts the generalizability of the study. Sample saturation was not achieved and may have yielded results that could further the understanding of patient experiences around screening of and communication about HIV, STIs, and sexuality. The study used a convenience sampling procedure that resulted in a primarily white sample of middle-older adults (i.e., 75 to 85 years old). Thus, the results limit the ability to apply the findings to members of other ethnic groups or younger, more sexually active adults. Furthermore, specific information about whether participants were engaged in sexual behavior was not gathered. This information would have been useful in putting participant’s responses into context. Despite these limitations, the study provides important patient perspectives on screening practices regarding sexuality, HIV, and STIs that nurses may use in practice with older patients. Recommendations and Conclusions for Nursing Practice The purpose of this focus group study was to explore patient experiences around sexual health assessment as well as screening and communication about HIV and STIs. The study was innovative in its approach to access an understudied population in order to gather information to improve screening practices for older adults. The study participants shared that sexual health and HIV risk discussions never occurred with their health care providers, a finding that is supported in the literature and underscores the need to enhance sexual health assessment and screening of high risk patients. Moreover, participants shared perspectives regarding health care practices that would enhance sexual discussions including initiating discussions in a nonjudgmental manner. Results of this study provide information that health professionals can use in patient education and screening practices to detect HIV and STIs at an earlier, more treatable stage. Furthermore, keeping up with healthdirected television and radio programs and incorporating what is being projected in the media into the patient’s visit may be an effective educational tool. Health care providers may also consider using the avenue of media as a way to share health information with older adults. For example, 347
providers might consider including videos or audio recordings into the educational component of the patient’s care plan. The participants in this study also indicated that they had difficulty navigating the health care system. Increased information sharing may help build patients’ confidence in navigating the health care system. In the future, it may be helpful to obtain the perspective of physicians, advanced practice nurses, and physician assistants themselves as to how they approach screening older adults for sexual health issues, STIs, and HIV/AIDS. More research about perceived barriers and successes as described by health care providers may be helpful in developing and promoting screening tools, as well as giving perspective on screening guidelines. The older men expressed varying degrees of discontent with the way that they have been involved in the health care process by their health care providers; it appears that much of this discontent stems from issues of communication with their health care providers. More focused assessment of the interaction between older adults and their providers, as well as implementation of these findings, is needed. For now, this focus group study reveals that not all older adults are being engaged in conversation about sexual health or being screened for STIs such as HIV/ AIDS. Improved patient assessment, education, and screening for high-risk patients are needed at the clinical level.
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24. Onen NF, Overton ET, Seyfried W, et al. Aging and HIV infection: a comparison between older HIV-infected persons and the general population. HIV Clin Trials 2010; 11:100-9. 25. Effros RB, Fletcher CV, Gebo K. Workshop on HIV infection and aging: what is known and future research directions. Clin Infect Dis 2008;47:542-53. 26. Lau B, Gange S, Moore RD. Risk of non-AIDS related mortality may exceed risk of AIDS-related mortality among individuals enrolling into care with CD4+ counts greater than 200 cells/mm3. J Acquir Immune Defic Syndr 2007;44:179-87. 27. Gott M, Galena E, Hinchliff S, et al. "Opening a can of worms": GP and practice nurse barriers to talking about sexual health in primary care. Fam Pract 2004;21:528-36. 28. Nusbaum M, Singh A, Pyles A. Sexual healthcare needs of women aged 65 and older. J Am Geriatr Soc 2004;52:117-22. 29. Krueger R, Casey M. Focus groups: a practical guide for applied research. 4th ed. Thousand Oaks, CA: SAGE Publications; 2009. 30. Sandelowski M. What happened to qualitative description? Res Nurs Healt 2000;23:334-40. 31. Corbin J, Strauss A. Basics of qualitative research: techniques and procedures for developing grounded theory. 3rd ed. Los Angeles: SAGE Publications; 2008. 32. Lindau ST, Leitsch SA, Lundberg K, et al. Older women’s attitudes, behavior and communication about sex and HIV: a community-based study. J Women’s Health 2006;6:747-53. 33. Gott M, Hinchliff S. Barriers to seeking treatment for sexual problems in primary care: a qualitative study with older people. Fam Pract 2003;20:690-5. 34. Arena JM, Wallace M. Issues regarding sexuality. In: Capezuti E, Zwicker D, Mezey M, Fulmer T, eds. Evidence-based geriatric nursing protocols for best practice. 3rd ed. New York (NY): Springer Publishing Company; 2008. p. 629-47.
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35. Gott M, Hinchliff S, Galena E. A qualitative study to explore GP attitudes to discussing sexual health issues with older people. Soc Sci Med 2004;58:2093-103. 36. Annon JS. The PLISSIT model: a proposed conceptual scheme for the behavioral treatment of sexual problems. J Sex Educ Ther 1976;2:1-15. 37. National Eye Institute, National Institutes of Health (2003). Final older adult needs assessment, final focus group report. 2003. Available at http://www.nei.nih.gov/ nehep/research/older_adult_needs_assessment_final. pdf. Cited August 3, 2010. 38. Mundorf N, Brownell W. Media preferences of older and younger adults. Gerontologist 1990;30:685-91. 39. Schneider M. TV viewers’ average age hits 50. Variety 2008. Available at http://www.variety.com/article/ VR1117988273.html?categoryid51275&cs51. Cited August 3, 2010. 40. Horgas AL, Wilms HU, Baltes MM. Daily life in very old age: everyday activities as expression of successful living. Gerontologist 1998;38:556-68. 41. Frosch DL, Krueger PM, Hornik RC, et al. Creating demand for prescription drugs: a content analysis of television direct-to-consumer advertising. Ann Fam Med 2007;5:6-13. MONICA S. SLINKARD, MSN, APRN, ANP-BC, WHNP-BC, is a recent graduate from the Yale School of Nursing, New Haven, CT and is currently working at Mary’s Center for Maternal and Child Care in Washington, DC, as an APRN. MEREDITH WALLACE KAZER, PhD, CNL, APRN, A/GNP-BC, is an Associate Professor at Fairfield University School of Nursing, Fairfield, CT. 0197-4572/$ - see front matter Ó 2011 Mosby, Inc. All rights reserved. doi:10.1016/j.gerinurse.2011.05.002
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