Women In Primary Care Research Articles

Assessing Obstetrician-Gynecologists Understanding of Their Role Under the Affordable Care Act [8M

INTRODUCTION: A survey was sent to Colorado Section of ACOG members with the objective of assessing understanding and compliance with preventive care aspects of the Affordable Care Act (ACA). Obstetrician gynecologists are potentially uniquely positioned to serve as specialists in women's health and primary care providers although they are not specifically designated as primary care providers. METHODS: A REDCap linked survey containing questions on screening for cervical cancer, sexually transmitted infections, breast cancer, contraception, pregnancy intention, domestic violence, depression, vaccination provision, utilization of electronic medical records, activity within ACOG, and basic anonymous demographics was emailed to members. RESULTS: Over a four month period, 87 responses from 668 email addresses were obtained, reflecting approximately 14.5% of Colorado members. 98.9% of respondents considered themselves specialists in women's health and 64.4% of respondents also considered themselves to be primary care providers for women. Overall, respondents self reported high compliance with ACA screening guidelines: 86% reported screening for depression, and 96% for screening appropriately for cervical cancer, but 60.9% of respondents self-reported referral of patients who need vaccinations. CONCLUSION: ACOG members responding to this survey reported high levels of compliance with most of the ACA recommendations for preventive care except vaccination, providing an area for expanded education or analysis for reimbursement and other barriers. Although they consider themselves primarily as specialist in women's health, more than half still see themselves as primary care providers, which may have reimbursement implications.

Committee Opinion No. 661: Integrating Immunizations Into Practice.

Immunization against vaccine-preventable diseases is an essential component of women's primary and preventive health care. Despite the importance of vaccination and clear guidance from public health agencies, rates of vaccination lag behind national goals. Obstetrician-gynecologists can play a major role in reducing morbidity and mortality from a range of vaccine-preventable diseases, including pertussis, influenza, human papillomavirus, and hepatitis. Given demonstrated vaccine efficacy and safety, and the large potential for prevention of many infectious diseases that affect adults, pregnant women, and newborns, obstetrician-gynecologists should include immunizations as an integral part of their practice. To do so, they must embrace their role as important sources of information and advice on immunization for adults, adolescents, and pregnant women, and advance their patients' well-being with continued efforts to augment immunization services in their offices. Increasing awareness combined with the many suggestions in this document will work to enhance immunization uptake.

Primary care of women who have sex with women. Recommendations from the research.

Research on women who have sex with women has increased in the last decade. Attention has been brought to this group of women through the IOM report, which noted a lack of research related to their care. Most of the research has not been published in nursing literature. This article reviews this literature with recommendations for primary care practice.

The Clinical Learning Dyad Model: An Innovation in Midwifery Education.

There is a national shortage of women's health and primary care providers in the United States, including certified nurse-midwives and certified midwives. This shortage is directly related to how many students can be trained within the existing system. The current model of midwifery clinical training is based on apprenticeship, with one-on-one interaction between a student and preceptor. Thus, the number of newly trained midwifery providers is limited by the number of available and willing preceptors. The clinical learning dyad model (CLDM), which pairs 2 beginning midwifery students with one preceptor in a busy practice, addresses this problem. In addition, this model brings in a senior midwife student as a near-peer mentor when the students are first oriented into outpatient clinical practice. The model began as a pilot project to improve the quality of training and increase available student spots in clinical education. This article discusses the origins of the model, the specifics of its design, and the results of a midterm and one-year postintervention survey. Students and preceptors involved in this model identified several advantages to the program, including increased student accountability, enhanced socialization into the profession, improved learning, and reduced teaching burden on preceptors. An additional benefit of the CLDM is that students form a learning community and collaborate with preceptors to care for women in busy clinical settings. Challenges of the model will also be discussed. Further research is needed to evaluate the effectiveness of the CLDM. This article is part of a special series of articles that address midwifery innovations in clinical practice, education, interprofessional collaboration, health policy, and global health.

Provider Attitudes and Screening Practices Following Changes in Breast and Cervical Cancer Screening Guidelines.

Changes to national guidelines for breast and cervical cancer screening have created confusion and controversy for women and their primary care providers. To characterize women's primary health care provider attitudes towards screening and changes in practice in response to recent revisions in guidelines for breast and cervical cancer screening. In 2014, we distributed a confidential web and mail survey to 668 women's health care providers affiliated with the four clinical care networks participating in the three PROSPR (Population-based Research Optimizing Screening through Personalized Regimens) consortium breast cancer research centers (385 respondents; response rate 57.6 %). We assessed self-reported attitudes toward breast and cervical cancer screening, as well as practice changes in response to the most recent revisions of the U.S. Preventive Services Task Force (USPSTF) recommendations. The majority of providers believed that mammography screening was effective for reducing cancer mortality among women ages 40-74 years, and that Papanicolaou (Pap) testing was very effective for women ages 21-64 years. While the USPSTF breast and cervical cancer screening recommendations were widely perceived by the respondents as influential, 75.7 and 41.2 % of providers (for mammography and cervical cancer screening, respectively) reported screening practices in excess of those recommended by USPSTF. Provider-reported barriers to concordance with guideline recommendations included: patient concerns (74 and 36 % for breast and cervical, respectively), provider disagreement with the recommendations (50 and 14 %), health system measurement of a provider's screening practices that use conflicting measurement criteria (40 and 21 %), concern about malpractice risk (33 and 11 %), and lack of time to discuss the benefits and harms with their patients (17 and 8 %). Primary care providers do not consistently follow recent USPSTF breast and cervical cancer screening recommendations, despite noting that these guidelines are influential.

Public health agendas addressing violence against rural women - an analysis of local level health services in the State of Rio Grande do Sul, Brazil.

This study analyses health managers' perceptions of local public health agendas addressing violence against rural women in municipalities in the southern part of the State Rio Grande do Sul in Brazil. It consists of an exploratory descriptive study utilizing a qualitative approach. Municipal health managers responsible for planning actions directed at women's health and primary health care were interviewed. The analysis sought to explore elements of programmatic vulnerability related to violence in the interviewees' narratives based on the following dimensions of programmatic vulnerability: expression of commitment, transformation of commitment into action, and planning and coordination. It was found that local health agendas directed at violence against rural women do not exist. Health managers are therefore faced with the challenge of defining lines of action in accordance with the guidelines and principles of the SUS. The repercussions of this situation are expressed in fragile comprehensive services for these women and programmatic vulnerability.

Creating a roadmap for delivering gender-sensitive comprehensive care for women Veterans: results of a national expert panel.

Background:Women Veterans are a significant minority of users of the VA healthcare system, limiting provider and staff experience meeting their needs in environments historically designed for men. The VA is nonetheless committed to ensuring that women Veterans have access to comprehensive care in environments sensitive to their needs.Objectives:We sought to determine what aspects of care need to be tailored to the needs of women Veterans in order for the VA to deliver gender-sensitive comprehensive care.Research Design:Modified Delphi expert panel process.Subjects:Eleven clinicians and social scientists with expertise in women’s health, primary care, and mental health.Measures:Importance of tailoring over 100 discrete aspects of care derived from the Institute of Medicine’s definition of comprehensive care and literature-based domains of sex-sensitive care on a 5-point scale.Results:Panelists rated over half of the aspects of care as very-to-extremely important (median score 4+) to tailor to the needs of women Veterans. The panel arrived at 14 priority recommendations that broadly encompassed the importance of (1) the design/delivery of services sensitive to trauma histories, (2) adapting to women’s preferences and information needs, and (3) sex awareness and cultural transformation in every facet of VA operations.Conclusions:We used expert panel methods to arrive at consensus on top priority recommendations for improving delivery of sex-sensitive comprehensive care in VA settings. Accomplishment of their breadth will require national, regional, and local strategic action and multilevel stakeholder engagement, and will support VA’s national efforts at improving customer service for all Veterans.

Primary Care of Women Aging with HIV (2014/116)

Primary Care of Women Aging with HIV (2014/116)

Outcomes following implementation of symptom triggered diagnostic testing for ovarian cancer

ObjectivesUK is the first country to implement symptom triggered testing for suspected ovarian cancer (OC) following guidance from National Institute of Clinical Excellence in 2011. We evaluated its impact on cancer outcomes and implications on clinical practice. Study designThis is a cohort study and we analysed data for all new urgent referrals for suspected OC from two large teaching hospitals using a prospectively collected electronic referral database, supplemented with clinical data from electronic records. We evaluated outcomes prior to (2011) and after (2013) implementation of guidance to evaluate stage shift, referrals workload and surgical procedures generated. ResultsSecondary care received 2185 new referrals from primary care for women with suspected gynaecological cancer in post guideline cohort. Of these, 217 women were referred for suspected OC. 90% of primary care referrals were not compliant with guidance. Following implementation of guidance, more women with OC were diagnosed through urgent referral (rapid access clinics): Almost double, 21 of the total 67 (31.34%) OCs in 2013 (post guidance) in comparison to only 11 of 69 OCs (15.94%) were diagnosed in 2011 (pre guidance) through urgent referrals, p=0.03. The predictive value of detecting cancer through rapid access clinics increased, from 4.5% to 9.6%, p=0.04; however, no stage shift was noted. Over 25% of patients underwent surgeries for non-malignant conditions in the post-guideline cohort. No increase was seen in workload of cancer clinics. ConclusionImplementation of Symptom-triggered testing is challenging in clinical practice. Such testing results in more patients with OC accessing expedited care pathways leading to streamlined routes of diagnosis and care. However, current implementation does not lead to stage shift in diagnosis and may not achieve significant mortality benefit.

Dyspareunia in the Context of Psychopathology, Personality Traits, and Coping Resources: Results From a Prospective Longitudinal Cohort Study From Age 30 to 50.

Although dyspareunia has a major impact on sexual and general wellbeing, there are few data on the longitudinal development of its prevalence in representative study groups. Therefore, it was the aim of the present study to fill this gap by evaluating the prevalence of dyspareunia in a representative sample at age 30, 35, 41, and 50. Additional aims were to determine the association between dyspareunia, psychopathological covariates, personality characteristics, and coping resources. Semi-structured interviews with single-item questions on sexual problems in general as well as dyspareunia were used to gain information on 1-year as well as long-time prevalence rates. Psychopathological covariates were explored with the SCL-90-R. The Freiburger Personality Inventory (Freiburger Persönlichkeits Inventar, FPI) assessed personality characteristics. Scales of sense of mastery and self-esteem were used to investigate coping resources. Twelve months prevalence of dyspareunia varied between 4.5 and 6.4 % with a mean of 5.6 % and a long-time risk of 19.3 %. No relation between age and the prevalence rates was found. Dyspareunia was related to psychopathological covariates, especially depression. With respect to personality traits as measured with the FPI only nervousness showed a significant association with dyspareunia, whereas coping resources were unrelated. As dyspareunia is experienced by about 20 % of all women, it represents a frequent sexual problem. Therefore, assessment of dyspareunia should be integrated into primary care of women at any age and diagnostic as well as therapeutic strategies should be based on physiological and psychological factors.

Abstract A50: Educating women about cancer clinical trials: The impact of a community health educator intervention in a primary care clinic

Abstract Clinical trials information is often presented to patients at the time of diagnosis or during the course of treatment when patients have many barriers to acquiring new information, including stress on emotional, social, family, and/or functional well-being. We hypothesized that engaging the community about the importance of clinical trials is critical in order to increase enrollment when patients are faced with a diagnosis. We implemented an educational program based on the premise that general education about cancer clinical trials should begin independent of a cancer diagnosis in order to maximize message retention and acceptability. This pilot program aimed to educate low income, racially-diverse patients about clinical trials and evaluate acceptance and attitudes of incorporating these messages during a primary care visit. A Community Health Educator (CHE) funded through the NCI National Outreach Network was hired to work within a women's health primary care clinic in an urban safety net hospital to target women in need of cancer screening. The CHE identified women ages 50-69 more than 18 months overdue for routine breast cancer screening, scheduled mammograms, and educated these women about clinical trials to promote awareness about research. All women who met the criteria for overdue screening were provided with NCI-adapted educational materials and participated in discussions with the CHE about clinical trials. Women were invited to participate in follow up qualitative interviews about the educational materials until the evaluation sampling goal of 20 was reached. The evaluation interview consisted of both close- and open-ended questions. Likert and dichotomous responses were summarized using descriptive statistics. Qualitative responses were coded by the primary author and reviewed with two senior authors. The CHE identified 1,703 women eligible for mammograms in the clinic, of which 460 (27%) were overdue for screening. Through one-on-one interactions with these women, the CHE scheduled 324 mammograms to reduce the rate of overdue breast cancer screening to 8% over a one year period. The CHE delivered educational materials to 190 of these women. Of the twenty women in the evaluation sample, most were racial/ethnic minorities (65%), on public insurance (55%), and only half had education above a high school diploma. While all (100%) respondents agreed that clinical trials help find ways to prevent cancer, fewer (55%) women reported they would be willing to participate themselves. Compared to those who were willing to participate in a future clinical trial, participants who were unwilling were more likely to be non-white (45% vs. 89%; p=0.04). Qualitative responses indicated that most women recalled receiving the educational materials and topics discussed, but when probed regarding specific details about clinical trials, little information was retained. Women who were able to recall specifics typically related their knowledge to salient life circumstances such as a personal or family experience with cancer. This program demonstrates the viability of incorporating clinical trials messages into primary care encounters involving cancer screening discussions in a safety net population. Our use of a CHE was successful in engaging a diverse group of women and resulted in more than half reporting a willingness to consider clinical trial enrollment in the future. Although message retention was a challenge, using narratives to increase salience may be one way to overcome this barrier, especially for minority populations. Citation Format: Christine M. Gunn, Sharon K. Bak, Tracy A. Battaglia. Educating women about cancer clinical trials: The impact of a community health educator intervention in a primary care clinic. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr A50. doi:10.1158/1538-7755.DISP13-A50

Making the Most of the Affordable Care Act's Contraceptive Coverage Mandate for Privately-Insured Women

Under the Patient Protection and Affordable Care Act of 2010 (ACA), most women of reproductive age with private health insurance have, or will soon have, first-dollar coverage of contraception and contraceptive counseling. The need for contraceptive coverage is great, because most American families want two children, resulting in the average woman spending three decades of her reproductive life trying to avoid pregnancy (Guttmacher Institute, 2012; Finer & Philbin, 2014). Contraceptive coverage without cost sharing is a sea change in women’s health insurance. This policy change has the potential to dramatically shift contraceptive use patterns, to reduce the U.S. unintended pregnancy ratedwhich stands at approximately half of all pregnancies (Finer & Zolna, 2014)dand to improve the health of women and families. In this commentary, we argue that realizing the potential of this policy change requires more action on the part of public health practitioners, insurers, health care providers, and researchers than is currently evident, andwe offer some suggestions for making the most of first-dollar contraceptive coverage.

Primary care of women after gestational diabetes mellitus: mapping the evidence-practice gap.

To determine the extent to which preventive activities, including the ordering of an oral glucose tolerance test (OGTT) between 6 and 12 weeks of birth, are integrated into women's primary care postpartum visits after a gestational diabetes mellitus (GDM)-affected pregnancy. Prospective survey and retrospective chart audit of general practices that provide maternity shared care in south-east Queensland, July 2011 to June 2012. General practitioners (n = 38) and medical records of women to whom they provided care (n = 43 women). GPs' awareness and knowledge of GDM guidelines and delivery of postpartum preventive care. The response rate for the survey/chart audit was 47%. All respondents recommended an OGTT between 6 and 12 weeks; a variety of guidelines informed practice; and weight, blood pressure and infant feeding practices were regularly checked. Mental health status and diet and exercise were discussed less consistently. GPs surveyed knew guidelines around the timing and type of test for women who have experienced GDM, and the audit demonstrated that this knowledge is translated into practice. Adherence to preventive screening and advice was less consistent. This problem may exist due to the absence of a systems approach to care, resulting in a lost opportunity to systematically reduce the incidence of type 2 diabetes and promote the wellbeing of women and their infants.

Su1430 Risk of Congenital Anomaly in Children Born to Women With Coeliac Disease: A United Kingdom Population-Based Cohort Study

INTRODUCTION Several studies have raised the spectre of infertility being associated with coeliac disease. These have primarily been carried out in small groups of women attending infertility specialist services and subsequently screened for coeliac disease. Although nutritional deficits can contribute to infertility, such study designs are highly prone to produce biased estimates of the risk of fertility problems in women with coeliac disease in the general population. We carried out a large population-based study to compare clinical reporting of fertility problems in women with and without coeliac disease in the United Kingdom (UK). METHODS In the UK, any first contact or treatment from specialist infertility services requires referral from a women's primary care doctor, so this is the first clinical contact for assessment of fertility problems. Using The Health Improvement Network, a large primary care database of patients from across the UK, we estimated age-specific rates of new clinically recorded fertility problems in women with and without coeliac disease (CD) during their childbearing years between 1990 and 2013. These rates were then stratified by whether the fertility problem was recorded before or after the CD diagnosis and were compared to the general population rates using Poisson regression with adjustments for socioeconomic status and calendar time. RESULTS Out of the total population of 2,426,225 women, 6,506 (0.3%) women had a diagnosis of CD. The age specific-rates of new clinically recorded fertility problems in women with CD were very similar to the general population rates (11.6/1,000 person years in women with CD and 12.6/1,000 person years in the general population in the 30-34 year age group) (table 1). Incident fertility problems were recorded a median of 2 months (interquartile range: 4 years before, 2.7 years after). When stratified by the time of CD diagnosis the rates of clinically recorded fertility problems were very similar to the general population in both the time before and after CD diagnosis. However these rates were 50% higher after CD diagnosis in women aged 25-29 years compared to the same age group in the general population (IRR 1.50, 95% CI 1.10-2.04). Approximately 25% of the fertility problems were reported within a year before/after the CD diagnosis (Figure 1). CONCLUSION Women with coeliac disease do not have a substantially greater likelihood of reporting fertility problems than women without the condition. Rates were slightly higher in younger women with diagnosed CD, however as this effect did not hold for women of other age groups, increased ascertainment of the condition rather than a causal association may explain this. Table 1 Age specific rates of incident fertility problem reporting in women with and without coeliac disease

Su1429 Do Women With Coeliac Disease Clinically Present With Fertiliy Problems More Often Than Women in the General Population?

INTRODUCTION Several studies have raised the spectre of infertility being associated with coeliac disease. These have primarily been carried out in small groups of women attending infertility specialist services and subsequently screened for coeliac disease. Although nutritional deficits can contribute to infertility, such study designs are highly prone to produce biased estimates of the risk of fertility problems in women with coeliac disease in the general population. We carried out a large population-based study to compare clinical reporting of fertility problems in women with and without coeliac disease in the United Kingdom (UK). METHODS In the UK, any first contact or treatment from specialist infertility services requires referral from a women's primary care doctor, so this is the first clinical contact for assessment of fertility problems. Using The Health Improvement Network, a large primary care database of patients from across the UK, we estimated age-specific rates of new clinically recorded fertility problems in women with and without coeliac disease (CD) during their childbearing years between 1990 and 2013. These rates were then stratified by whether the fertility problem was recorded before or after the CD diagnosis and were compared to the general population rates using Poisson regression with adjustments for socioeconomic status and calendar time. RESULTS Out of the total population of 2,426,225 women, 6,506 (0.3%) women had a diagnosis of CD. The age specific-rates of new clinically recorded fertility problems in women with CD were very similar to the general population rates (11.6/1,000 person years in women with CD and 12.6/1,000 person years in the general population in the 30-34 year age group) (table 1). Incident fertility problems were recorded a median of 2 months (interquartile range: 4 years before, 2.7 years after). When stratified by the time of CD diagnosis the rates of clinically recorded fertility problems were very similar to the general population in both the time before and after CD diagnosis. However these rates were 50% higher after CD diagnosis in women aged 25-29 years compared to the same age group in the general population (IRR 1.50, 95% CI 1.10-2.04). Approximately 25% of the fertility problems were reported within a year before/after the CD diagnosis (Figure 1). CONCLUSION Women with coeliac disease do not have a substantially greater likelihood of reporting fertility problems than women without the condition. Rates were slightly higher in younger women with diagnosed CD, however as this effect did not hold for women of other age groups, increased ascertainment of the condition rather than a causal association may explain this. Table 1 Age specific rates of incident fertility problem reporting in women with and without coeliac disease

Abstract P119: Assessment of Cardiovascular Health among Older Women in Primary Care

In 2010, the American Heart Association (AHA) launched the groundbreaking Life’s Simple 7™ campaign to improve the cardiovascular health (CVH) of Americans. Five of the 7 [smoking, body mass index (BMI), blood pressure, cholesterol, and glucose] are commonly recorded in electronic medical records (EMRs). Although CVH components are often included in patient-provider discussions, to date there has been no formal attempt to characterize CVH from EMR data. We characterized the CVH of 160 female patients ages 65 and older seen in an Ohio State University primary care clinic from May 1 through July 31, 2013. We defined CVH according to AHA criteria, and assigned each behavior and factor to either an “ideal”, “intermediate”, or “poor” category. We calculated an overall CVH score ranging from 0 (worst) to 10 (best) by summing across behaviors and factors as follows: poor, 0; intermediate, 1; and ideal, 2. We calculated means and standard deviations (sd) of continuous variables and report frequencies within CVH categories. Patients were an average of 74.2 (sd=6.7) years old, and 35% were black. Among the 126 (79%) women who had data available on all 5 factors, mean CVH score was 6.0 (sd=1.3). Among all women, the mean fractional score (actual score/maximum possible) was 0.63 (sd=0.14), and it did not differ significantly by race. Greater than 10% of data were missing for BMI (13%) and cholesterol (11%). Figure 1 shows the distribution of ideal, intermediate, poor, and missing CVH values for each behavior and factor. We have demonstrated that a majority of Life’s Simple 7™ components are easily queried from EMRs. These data indicate that older female patients seen in the primary care setting have less-than-ideal CVH. There exists great potential to leverage the EMR for patient-provider communication and engagement around CVH. As such, we are implementing an automated assessment of CVH targeted to primary care providers and their older female patients. Following the intervention, CVH values will be compared to these baseline data. Figure 1. Percent of older female patients (n=160) who were seen in a primary care clinic by category of CVH: behaviors and factors*. *Diabetes was defined as either treated by a glucose-lowering medication (intermediate) or not (ideal), since over 90% of data were missing for fasting glucose or hemoglobin A1c.

Berek and Novak’s Gynecology 15th Edition

The gold-standard text in gynecology has been published in its 15th edition, thoroughly revised and updated and now in full color throughout. This edition continues to uphold the goals of Emil Novak’s original 1941 publication: to provide a comprehensive yet accessible overview of the expanding field of gynecology, serving as a gold-standard reference for private practitioners as well as an excellent teaching tool for those in training. In comparing this book to Stenchever’s Comprehensive Gynecology, 4th edition (Mosby, 2001), which has been touted by some as the “Bible” of gynecology for residents, Berek and Novak’s textbook seems to be at least as good as the former. The 15th edition is structurally sound, comprehensive, and accessible. The book covers the entire spectrum of women’s healthcare, tidily yet comprehensively, organized into eight sections. This comprehensive and general gynecological textbook provides guidance for the management of specific gynecological conditions. The first two sections cover principles of practice and initial assessment and the relevant basic science. The third section is on preventive and primary care for women, and the remaining five sections are directed at methods of diagnosis and management in general gynecology, operative general gynecology, urogynecology and pelvic reconstructive surgery, reproductive endocrinology, and gynecologic oncology. In this edition, there is an update on robotics in gynecology as well. The text covers the basics of anatomy and physiology of the female reproductive tract to the management of complicated gynecologic conditions. The book goes above and beyond the objectives to provide a thorough and current review of gynecology. The book covers a wide range of topics, from anatomy and embryology to gynecologic malignancies and everything in between. It is a fantastic review of the current literature, and the color art is a great complement to the text. This should be on every gynecologist’s bookshelf. It is an essential reference that covers all components of the practice. This edition’s structure represents an improvement over the 14th edition, appropriately mirroring the expansion of the field and its subspecialties over the past few years. Specifically, a separate section now covers urogynecology and three separate chapters now cover lower urinary tract disorders, pelvic organ prolapse, and anorectal dysfunction, topics previously compressed into one chapter. The family planning chapter now includes newer contraceptive options such as vaginal rings, subcutaneous depomedroxyprogesterone acetate, the implanon subdermal implant, and Essure sterilization. The addition of a complementary therapy chapter is unique, and will serve as an important reference as more and more patients make use of alternatives to mainstream healthcare. The addition of multicolored figures and tables will facilitate quicker access during a busy clinic and can serve as a teaching tool on the hospital floor. This will allow the book to continue to be of use for an increasingly Internet-savvy generation of physicians, while other books without these features may fall out of use.

Training of nurses in primary health of women

Objectives: To evaluate the influence of the nursing education process in primary care related to women's health. In addition, to analyze nursing training in primary care for women's health and as a National Policy for Comprehensive Care of Women's Health. Method: An exploratory study with 30 nurses from the Family Health Strategy. Data were generated through interviews, processed and analyzed in Alceste4.8 by Descending Hierarchical Classification. Results: The data were presented as dendrogram classes: training at the graduate level to work in the area of women's health; the work of nurses in primary care to women's health; the Program for Integral Attention to Women's Health in primary care and continuing education of nurses in primary health care of women. Final considerations: Permanent education of nurses is necessary for the promotion healthcare and public policy on care for women.

Stress Urinary Incontinence in Younger Women in Primary Care: Prevalence and Opportunistic Intervention

Stress urinary incontinence (SUI) is prevalent in females, even among young adults. Though their quality of life (QOL) is impaired and pelvic floor exercise is an effective treatment, not many affected women seek medical help. This study aimed to evaluate the feasibility of case finding and opportunistic intervention of SUI at a public Well Women Clinic in Macau, China. A convenience sample of 408 consecutive female patients aged 30-50 years filled in the Urogenital Distress Inventory Short Form and the Incontinence Impact Questionnaire Short Form. They were also asked reasons for not seeking for medical help. The patients with incontinence were educated on pelvic floor muscle exercise during the gynecological examination. SUI was reported by 153 (37.5%) women, of whom 47 (30.7%) had impaired quality of life despite mild symptoms. Of the SUI patients, 52.9% thought that incontinence was inevitable with age, 22.2% believed that they should cope with the problem themselves, 13.7% thought that no useful treatment was available, and 3.9% had sought medical advice before. After learning pelvic floor muscle exercise for 4 to 6 months, 9.8% of SUI patients had complete relief of the symptoms, 47% partial improvement, and 17.6% no significant change. SUI with impaired quality of life was common before menopause. Very few affected women sought medical help. Opportunistic case finding and education about pelvic floor exercise in a Well Women Clinic were effective in the detection and treatment of the silent SUI.

Women’s Health During Health Care Transformation

Women’s Health During Health Care Transformation