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community-based health clinics, operated by community-based health professionals or agencies that usually receive public funds; and
private health care settings, including private physician offices, health-plan-affiliated facilities, private clinics, and private hospital emergency rooms.
The public, community-based, and private settings for STD-related care serve somewhat different, albeit overlapping, population groups, each of which has different needs related to STD prevention.
Health Care Professionals and Prevention Activities
There is a broad range of health care professionals involved in STD-related care. Most clinicians who provide STD-related care in public or private settings emphasize diagnosis and treatment and, to a lesser extent, management of sex partners rather than other approaches to STD prevention (Bowman et al., 1992). Most clinicians do not provide adequate STD risk assessment, prevention counseling, or other STD-related education, despite the fact that they may include some STD screening in their patients' medical evaluation (Lewis and Freeman, 1987; Lewis et al., 1987; Gemson et al., 1991; Bowman et al., 1992; Russell et al., 1992). In a 1986 survey of California internists, only 10 percent reported asking new patients questions that were specific enough to assess their risk of STDs (Lewis and Freeman, 1987). In a more recent national survey of primary care physicians and other health care providers (registered nurses, nurse practitioners, nurse midwives, and physician assistants), only 39 percent of physicians and 49 percent of other primary care providers reported conducting risk assessment for STDs for all or most of their new adult patients (ARHP and NANPRH, 1995). A survey of 961 physicians in the Washington, D.C., area found that only 37 percent of respondents reported regularly asking new adult patients about their sexual practices and that 60 percent did so for new adolescent patients (Boekeloo et al., 1991). Reasons typically cited for these deficits, as mentioned elsewhere in this report, include (a) health professionals' common skepticism of the efficacy of health education and behavioral interventions; (b) pressures to see large numbers of patients in a brief amount of time; (c) personal discomfort regarding taking accurate, nonjudgmental sex and STD histories, attributed to lack of training and other reasons; and (d) a widespread misconception that STDs and issues related to sexuality are too "sensitive" to discuss. The last perception is not correct; one study found that patients who were asked questions about sexual and STD histories at their initial visit to primary health care providers tended to leave those interactions with a greater sense of confidence that their providers would provide high-quality care compared to patients who did not have such histories taken (Lewis and Freeman, 1987). It has been suggested that simulated patients be used to improve clinician skills in risk assessment and counseling (Rabin et al., 1994).