Received: 19 June 2020 | Revised: 20 August 2020 | Accepted: 8 September 2020 DOI: 10.1002/nop2.641 RESEARCH ARTICLE Attitudes and beliefs of nurses and physicians about managing sexual health in primary care: A multi-site cross-sectional comparative study Juan M. Leyva-Moral1,2,3,4 | Mariela Aguayo-Gonzalez1,2 | Patrick A. Palmieri3,4,5,6 | Genesis Guevara-Vasquez3,7 | Nina Granel-Grimenez1,2 | Artur Dalfó-Pibernat8 1 Department d'Infermeria, Universitat Autonoma de Barcelona Facultat de Abstract Medicina, Barcelona, Spain Aim: To understand the attitudes and beliefs of nurses and physicians about manag- 2 Grupo de Investigación Enfermera en ing the sexual health of patients during office visits in primary care centres. Vulnerabilidad y Salud (GRIVIS), Universitat Autònoma de Barcelona, Barcelona, Spain Design: A questionnaire-based, cross-sectional multi-centre study. Methods: The study was performed in 15 primary care centres in Barcelona (Spain), 3 Nursing Research Group, EBHC South America: A Joanna Briggs Institute Affiliated Group, Lima, Perú from December 2017–February 2018. Obtained data were analysed with descriptive 4 Center for Global Nursing, Texas Woman's and bivariate statistics. University, Houston, TX, USA Results: Nearly half the participants believed they should manage sexual health in 5 Office of the Vice Chancellor for Research, primary care, but a third of them disagreed this is a priority. Participants also believed Universidad Norbert Wiener, Lima, Peru 6 College of Graduate Health Studies, A. T. patients are not comfortable speaking with them about sex. Statistically significant Still University, Kirksville, MO, USA differences were observed between the professions as nurses more often reported 7 Department of Research, Hospital Regional receiving sexual health questions from patients and believed they had enough knowl- Lambayeque, Chiclayo, Perú 8 Primary Care Center Horta, Institut Català edge to appropriately respond. Most participants wanted additional education to de la Salut, Barcelona, Spain speak with patients more comfortably and confidently about sex. Correspondence KEYWORDS Patrick A. Palmieri, Office of the Vice Chancellor for Research, Universidad attitude of health personnel, community health nursing, nurse practitioners, nurse–patient Norbert Wiener, Avenida Arequipa 440, relations, physician–patient relations, primary care physicians, primary health care, sexual Lima, Perú. health, Sexualidad en Atención Primaria Questionnaire, surveys and questionnaires Email: patrick.palmieri@uwiener.edu.pe Funding information This research did not receive any funding from entities or agencies in the public, commercial and/or not-for-profit sectors. The publication of this research is partially supported through a research dissemination grant received from the Universidad Norbert Wiener (VRI-D-07-001-RDG) by Prof. Dr. Patrick A. Palmieri This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. © 2020 The Authors. Nursing Open published by John Wiley & Sons Ltd 404 |  wileyonlinelibrary.com/journal/nop2 Nursing Open. 2021;8:404–414. LEYVA-MORAL et al. | 405 1 | I NTRO D U C TI O N to understand their physicians because theyused incomprehensi- ble terminology about sexual matters (Asociación Española para la Sexual health is generally defined as a state of physical, men- Salud Sexual, 2011). Likewise, these beliefs and behaviours were re- tal, and social well-being in relation to sexuality (World Health ported to prevent sexual health conversations in another small study Organization, 2015). This requires a positive and respectful ap- of Spanish nurses (Dalfó-Pibernat et al., 2015). Understanding the proach to sexuality and sexual relations, as well as the possibility attitudes and beliefs of primary care nurses and physicians about of having safe sexual experiences without coercion, discrimination managing the sexual health of patients is necessary to tailor inter- and/or violence (Edwards & Coleman, 2004). Discussions about sex- ventions that canincrease their engagement in the affective-sex- ual health during a primary care visit should be approached like any ual education noted to have a positive impact on patient outcomes other topic focused on health promotion. Yet, clinical professionals (Denno et al., 2015). The purpose of this study was to understand such as nurses and physicians report difficulties speaking with pa- the sexual health attitudes and beliefs of Spanish nurses and physi- tients about sexual health due to the multifactorial and multicultural cians working in primary care centres in Barcelona (Spain). context (Barragan, 1995; Gott et al., 2004). In addition, stereotypes and myths about sexual topics persist despite decades of reforms in health science curriculums (Bayer et al., 2017; Frenk et al., 2010; 3 | TH E S T U DY Kong et al., 2009; Saunamäki & Engström, 2014; Stevens, 2013) that should have contributed to a more contemporary and professional 3.1 | Design approach with modern social practices (Nair & Webster, 2010). There has been little change in the way nurses and physicians ad- This was a cross-sectional multi-site study with a questionnaire. dress sexual health, from older patients (Leyva-Moral, 2008) to pregnant women (O'Malley et al., 2015), during primary care visits. 3.2 | Participants 2 | BAC KG RO U N D A purposive sample of nurses and physicians was recruited from pri- mary care centres (PCCs) in Western Barcelona (Spain). From the 18 In the primary care setting, patients present with conditions com- PCCs in this region, 15 (83.3%) agreed provide access to their staff monly reported to have a negative impact on sexual health including, for this study. These PCCs represent the diversity of the city. Family depression and anxiety (Tijeras-Úbeda, 2010), hypertension (Latif physicians, paediatricians, nurses and interns/residents (physicians et al., 2014), menopause (Thornton et al., 2015), and diabetes (Bal and nurses) working in any of the PCCs were invited to participate. et al., 2015). However, clinicians report negative experiences when Only nurses and physicians not working in primary care, including managing sexual health problems, especially when the purpose of those with temporary incapacity for work, were excluded from par- the visit is not perceived to have a direct relationship to sexual health ticipation. An a priori power analysis was conducted to determine the (Fuzzell et al., 2016; Magnan & Norris, 2008; Magnan et al., 2005; proper sample size (N = 180) for the available population (N = 400), Rashidian et al., 2016). For example, only 8% of American ado- considering a 5% margin of error and a 95% confidence level. lescents (N = 253) were able to initiate a conversation with their physician, while the remaining were either embarrassed to share in- formation or they were fearful about judgement with unwelcomed 3.3 | Data collection comments (Alexander et al., 2014). The same authors also reported 65% of the adolescents received consultation or content related to Data were collected electronically between December 2017– sexual health during their visit, but the mean time was 36 s. Other February 2018 using a questionnaire. Each PCC was sent a stand- studies have similarly reported sexual health conversations during ardized email for their staff with the study information provided in primary care visits are low frequency with minimal depth (Donaldson a digital link to the questionnaire. The questionnaire was completed et al., 2013; Klein & Wilson, 2002). Although sexual health is a his- through a secure platform, Encuestafacil®, with submission confirm- torically important area for evidence-based practice (Reynolds & ing acceptance to participate. Magnan, 2005), sexual health is often neglected by nurses and phy- sicians (East & Hutchinson, 2013; Fennell & Grant, 2019; Tsimtsiou et al., 2006). Initiating sexual health discussions with patients has 3.3.1 | Questionnaire been described as opening a “can of worms” by Gott et al. (2004) due to the sensitivity, complexity, limited expertise and time constraints. The Sexualidad en Atención Primaria (SEX-AP), or Sexual Health in In Spain, little is known about sexual health in primary care. In Primary Care, questionnaire has 35 items, including 12 related to a survey study of Spanish men (N = 1,500), 80% reported no ex- sociodemographics, 12 related to attitudes and 11 related to be- periences speaking about sexual health with their physicians. liefs, with good reliability. The items in each domain were assessed From the 20% of men reporting experiences, most were unable with a five-point Likert scale (strongly disagree, somewhat disagree, 406 | LEYVA-MORAL et al. neither disagree nor agree, somewhat agree and strongly agree). The were not included in the analysis (Waltz et al., 2016). The study is Spanish version of the questionnaire is presented in File S1, and the reported in accordance with the Strengthening the Reporting of English version is presented in File S2. Observational Studies in Epidemiology (STROBE) statement (von Elm et al., 2007), with the completed checklist in File S3. 3.4 | Ethical considerations 4 | R E S U LT S After approval by the institutional ethics committee (# P17/230), the study protocol was presented to the PCC leaders for approval. Completed questionnaires were submitted by 178 clinicians, includ- Participation in this study was voluntary and without incentives. ing nurses (N = 85) and physicians (N = 93). Participants were mostly The data were managed with confidentiality, and no issues were women (79%) with a median age of 45 years (interquartile range of reported. 38–53 years). This sample represented 99% of the ideal sample size. The demographic data are presented in Table 1. Nearly all participants (93.8%) reported patients ask them about 3.5 | Data analysis sexual health concerns in a “few or some” of their visits. Not many participants (4.5%) reported asking patients about their sexual health At the conclusion of data collection, the data were downloaded into in “all or almost all" of their visits. Most participants responded they a Microsoft Excel (version 2010) spreadsheet to identify missing data were comfortable speaking with patients about sexual health, es- and to organize the data for statistical analysis. Any questionnaire pecially with women (69%; 124). But, only 8% of participants indi- with more than a 20% non-response rate (Dillman, 2007), or seven cated they were uncomfortable addressing patient questions about missing responses, was eliminated from analysis. No data imputation sexual health concerns. Similarly, 84% of the participants “strongly techniques were used. The statistical analysis was performed with disagreed” with feeling comfortable, compared with the 66% who the STATA (version 14). As the quantitative data may not be normally felt safe working with the sexual health of patients. Regarding clin- distributed, Kolmogorov–Smirnov test (Gravetter & Wallnau, 2016) ical management based on patient age, most participants (85%) was applied and these data were presented as medians and inter- “totally disagreed” with feeling uncomfortable about addressing quartile ranges. The qualitative data were presented as absolute and sexual health concerns with young patients, while only 21% “totally relative frequencies (Polit & Beck, 2017). The association between agreed” with being uncomfortable talking about sexual health with the nurses and physicians, including their attitudes and beliefs, was older patients. In the comparative analysis of nurses and physician analysed with the chi-square (χ2) statistic for the qualitative vari- attitudes, statistically significant differences were observed about ables at a 5% (p = .05) level of significance (Grove & Cipher, 2020). receiving questions from patients during visits (p = .020), as nurse more frequently reported receiving questions. Statistically signifi- cant differences were also found between male and female partic- 3.6 | Validity, reliability and rigour ipants in feeling comfortable managing sexual health problems of men (p = .001). The complete data for the attitudes, item by profes- When applying a cross-cultural adaptation process to measure a sion, are presented in Table 2. phenomenon reported in the literature from other countries and Regarding the beliefs of the participants, most (81%) reported cultures, researchers can either (a) develop a new instrument or (b) indifferently that physicians and nurses are the right people to modify a previously validated instrument (Guillemin et al., 1993). manage sexual health in primary care. Although almost half (46%) Instruments to measure sexual health attitudes and beliefs of nurses considered themselves appropriately prepared to manage issues, and physicians in the context of primary care and in Spain were not most participants (83%) reported they require more training to available. As such, a systematic process was completed to transition manage sexual health problems with greater confidence. In daily the existing knowledge from the primarily English literature into a clinical practice, about a third of the participants (31%) believed new instrument for application in Spain (Cha et al., 2007; Rattray & sexual health is a priority; however, most participants (79%) lack Jones, 2007). the time to speak with patients about their sexual health concerns. The five steps to develop the questionnaire included the follow- Furthermore, many participants (63%) believe patients are not ing: 1. literature review and variable abstraction, 2. variable defini- comfortable speaking with them about sexual health problems. tion and item construction, 3. item confirmation and domain review, The participants (64%) generally believed adolescents require 4. questionnaire evaluation and confirmation by experts (content more preventive education about sexual health than other age validity) and 5. pilot test with small sample from the intended pop- groups. Moreover, statistically significant differences were ob- ulation (Escobar-Pérez & Cuervo-Martínez, 2008; Lynn, 1986). The served between nurses and physicians about needing more infor- SEX-AP questionnaire was validated (V Aiken > 0.90) by 20 experts mation to safely discuss sexual topics with patients (p = .025) and (Aiken, 1980, 1985; Beaton et al., 2000) and successfully pilot-tested about having received enough training to address sexual health with 10 nurses and physicians from the target population; these data concerns (p = .008). In both cases, nurses reported having enough LEYVA-MORAL et al. | 407 TA B L E 1 Participant sociodemographic data 5 | D I S CU S S I O N Variables n % This study indicates most participants working in primary care cen- Sex tres believe patients seldomly ask them about sexual health as they Female 141 79.2 are not comfortable speaking about sex. Consequently, most par- Male 37 20.8 ticipants in this study do not ask their patients about their sexual Agea 45 [38–53] health. Similarly, a study from Denver (USA) reported almost two Occupation in three primary care physicians never or almost never addressed Nurse 85 47.8 sexual health topics with their patients (Bober et al., 2009). The Physician 93 51.2 same authors also found most participants consider physicians and Family and community specialist family nurse practitioners to be the right health professionalto ad- No 81 45.5 dress sexual health issues with patients. Contrary results have been Yes 95 53.4 reported by other studies as participants were uneasy or not clear about the right health professional responsible for initiating conver- Prefer not to answer 2 1.1 sations about sexual health with patients (Hordern & Street, 2007; Doctoral degree (PhD or ScD) Stead et al., 2003). No 164 92.1 In this study, about half the participants considered sexual health Yes 7 3.9 to be a lower level patient priority compared with other health areas, In process 7 3.9 indicating in most cases they lacked the time to speak about sexual Master's degree topics with patients. This finding evidences the challenges primary No 110 61.8 care professionals encounter as they are managing too many patients Yes 64 36.0 during extended working hours with shorter visits, resulting in little In process 4 2.2 time to address sexual health (Stead et al., 2001; Wiggins et al., 2007). Postgraduate courses This seems to be similar to the problems encountered by nurses No 61 34.3 working in hospital settings, as they reported not being inclined to Yes 115 64.6 spend time discussing sexual health issues with their patients (Arikan et al., 2015). Although the present study found participants believed In process 2 1.1 adolescents require more preventive sexual health education, similar Years of professional experiencea 15 [8–21] studies, although old and in different contexts, indicate conversa- Civil status tions about sexual health between physicians and adolescents rarely Married 102 57.3 occur (Alexander et al., 2014; Boekeloo, 2014; Maheux et al., 1995; Single 54 30.3 O'Keeffe & Clarke-Pearson, 2011; Schuster et al., 1996). When Divorced 19 10.7 the conversations do occur, they are on average 36 s (Alexander Prefer not to answer 3 1.7 et al., 2014) and focused on learning if the adolescents were sexually Children active (Fuzzell et al., 2016). Similar findings have been reported in the No 66 37.1 two other studies from Spain (Dalfó-Pibernat et al., 2015; Raya-Tena Yes 112 62.9 et al., 2019). Religion Previous studies also identified characteristics such as age, gen- Catholic 77 43.3 der, race and sexual orientation can discourage clinicians from dis- Atheist 81 45.5 cussing sexual health issues with their patients (Bober et al., 2009; Stead et al., 2003). In this study, almost all participants reported not Other 6 3.4 having concerns about managing sexual health issues with younger Prefer not to answer 12 6.7 patients, compared with most participants being uncomfortable Importance of religion in life discussing sex with older patients and other participants feeling None or very little 111 62.4 uncomfortable with LGTBI patients. Despite the geographical and Somewhat important 27 15.2 cultural differences, there is some resistance on the part of health Important or very important 35 19.7 professionals about discussing sexual health issues. Prefer not to answer 5 2.8 Although nurses consider sexual conversations to be private and Abbreviation: DK/DA, do not know/do not answer. intimate (Arikan et al., 2015), this study found half the participants a Median (ICR). are confident enough and willing to engage patients in discussions about sex. Generally, physicians felt insecure about how to discuss information and receiving the appropriate training. The complete sexual health, especially sexual orientation, with younger patients results are presented in Table 3. recognizing their ignorance about the availability of community 408 | LEYVA-MORAL et al. TA B L E 2 Participant attitudes by profession and gender Items and responses N (%) Physician (%) Nurse (%) p-value Female (%) Male (%) p-value Patients ask me about their sexual health… Somewhat or strongly 11 (6.2) 9 (81.8) 2 (18.2) .020* 7 (63.6) 4 (36.4) .243 disagree Somewhat or strongly 167 (93.8) 76 (45.5) 91 (54.5) 134 (80.2) 33 (19.8) agree I ask patients about their sexual health… Somewhat or strongly 14 (7.9) 7 (50.0) 7 (50.0) — 10 (71.4) 4 (28.6) .679 disagree Neither agree nor 156 (87.7) 70 (44.9) 86 (55.1) 124 (79.5) 32 (20.5) disagree Somewhat or strongly 8 (4.5) 8 (100.0) 0 (0.0) 7 (87.5) 1 (12.5) agree I feel comfortable discussing sexual health topics with male patients… Somewhat or strongly 29 (16.3) 18 (62.1) 11 (37.9) .124 28 (96.6) 1 (3.5) .001* disagree Neither agree nor 44 (24.7) 23 (52.3) 21 (47.7) 39 (88.6) 5 (11.4) disagree Somewhat or strongly 105 (59.0) 44 (41.9) 61 (58.1) 74 (70.5) 31 (29.5) agree I feel comfortable discussing sexual health topics with female patients… Somewhat or strongly 17 (9.6) 9 (52.9) 8 (47.1) .836 15 (88.2) 2 (11.8) .671 disagree Neither agree nor 38 (21.4) 19 (50.0) 19 (50.0) 29 (76.3) 9 (23.7) disagree Somewhat or strongly 123 (69.1) 57 (46.3) 66 (53.7) 97 (78.9) 26 (21.1) agree I feel comfortable discussing sexual health topics with LGBTIQ patients… Somewhat or strongly 30 (16.9) 15 (50.0) 15 (50.0) .793 28 (93.3) 2 (6.7) .089 disagree Neither agree nor 47 (26.4) 24 (51.1) 23 (48.9) 37 (78.7) 10 (21.3) disagree Somewhat or strongly 101 (56.7) 46 (45.5) 55 (54.5) 76 (75.3) 25 (24.8) agree I do not like when patients ask me about their sexual health… Somewhat or strongly 131 (73.6) 62 (47.3) 69 (52.7) .847 103 (78.6) 28 (21.4) .541 disagree Neither agree nor 33 (18.5) 17 (51.5) 16 (48.5) 28 (84.9) 5 (15.2) disagree Somewhat or strongly 14 (7.9) 6 (42.9) 8 (57.1) 10 (71.4) 4 (28.6) agree I am professionally interested in sexual health topics in clinical practice… Somewhat or strongly 12 (6.7) 5 (41.7) 7 (58.3) .713 7 (58.3) 5 (41.7) .149 disagree Neither agree nor 54 (30.3) 24 (44.4) 30 (55.6) 42 (77.8) 12 (22.2) disagree Somewhat or strongly 112 (62.9) 56 (50.0) 56 (50.0) 92 (82.1) 20 (17.9) agree I feel comfortable discussing sexual health topics with patients… (Continues) LEYVA-MORAL et al. | 409 TA B L E 2 (Continued) Items and responses N (%) Physician (%) Nurse (%) p-value Female (%) Male (%) p-value Somewhat or strongly 150 (84.3) 72 (48.0) 78 (52.0) .879 120 (80.0) 30 (20.0) .549 disagree Somewhat or strongly 28 (15.7) 13 (46.4) 15 (53.6) 21 (75.0) 7 (25.0) agree I feel confident discussing sexual health topics with patients… Somewhat or strongly 60 (33.7) 33 (55.0) 27 (45.0) .167 51 (85.0) 9 (15.0) .175 disagree Somewhat or strongly 118 (66.3) 52 (44.1) 66 (55.9) 90 (76.3) 28 (23.7) agree I feel comfortable discussing sexual health topics with young patients… Somewhat or strongly 152 (85.4) 70 (46.1) 82 (54.0) .272 119 (78.3) 33 (21.7) .605 disagree Somewhat or strongly 26 (14.6) 15 (57.7) 11 (42.3) 22 (84.6) 4 (15.4) agree I feel comfortable discussing sexual health issues with adult patients… Somewhat or strongly 145 (81.5) 65 (44.8) 80 (55.2) .155 112 (77.2) 33 (22.8) — disagree Neither agree nor 2 (1.1) 1 (50.0) 1 (50.0) 2 (100.0) 0 (0.0) disagree Strongly or somewhat 31 (17.4) 19 (61.3) 12 (38.7) 27 (87.1) 4 (12.9) agree I feel comfortable discussing sexual health topics with elderly patients… Somewhat or strongly 139 (78.1) 65 (46.8) 74 (53.2) .855 108 (77.7) 31 (22.3) — disagree Neither agree nor 2 (1.1) 1 (50.0) 1 (50.0) 2 (100.0) 0 (0.0) disagree Somewhat or strongly 37 (20.8) 19 (51.4) 18 (48.7) 31 (83.8) 6 (16.2) agree *Statistically significant median [ICR]. resources (Lena et al., 2002). In this regard, nurses consider speaking communication (Ha & Longnecker, 2010; Patel et al., 2019), including to patients about their sexual health is an important responsibility a lack of instruction for psychosocial concerns such as sexual health (Yip et al., 2015). Nurses considering this important feel more con- (Dennis & Elstein, 1980; Wagner, 2005). fident about their ability to handle issues and invite patients to talk Physician comfort with managing psychosocial concerns about sex (Arikan et al., 2015; Magnan & Reynolds, 2006). As most has been correlated to speaking with patients about their sex- physicians reported their sexual health knowledge was limited, they ual health (Tsimtsiou et al., 2006). Previous physician training in would like more education to manage the issue safely and effectively. communication was the strongest predictor for addressing sexual This study found a difference between nurses and physicians health. Grounded in a human caring ontology (Watson, 2009), about their comfort in engaging patients in sexual health conver- nursing curriculum emphasizes altruism, authentic presence, com- sations. For example, more often than physicians, the nurses in munication, and therapeutic care (Landers et al., 2014). For this this study felt safer discussing sexual matters with patients, re- reason, nurses are probably most capable of shifting the current ported more sufficient knowledge to address questions, and be- medical paradigm to welcome sexual health as a normal primary lieved they can effectively manage issues with either men or care conversation. women. A systematic review of sexuality in health care determined Finally, sexual health has long been noted to be an educational sexual health care is not viewed by physicians as a medical prob- priority for health science programmes, residency training, and lem (Fennell & Grant, 2019). Similarly, in addressing sexual health, practicing clinicians (Ford et al., 2013). Although clinicians are re- Klaeson et al. (2017) noted the medical paradigm needs to shift to quired to complete continuing education to maintain licensure in person-centred care to address sexual health with a more holistic many countries (Institute of Medicine, 2010; Karas et al., 2020; perspective similar to nurses. As medical curriculums are not fo- Sherwood & Shaffer, 2014), there are limited intervention studies cused on holistic caring, they are missing education and training in this area (Clark et al., 2012; Wazqar, 2020). Online continuing focused on important concepts such as empathy, compassion, and sexual health education (Bos-Bonnie et al., 2017; Win et al., 2015) 410 | LEYVA-MORAL et al. TA B L E 3 Participant beliefs by profession and gender Items and Responses N (%) Physician (%) Nurse (%) p-value Female (%) Male (%) p-value I believe the most appropriate health professional for patients to discuss sexual health topics with is/are… Family physician or nurse 144 (80.9) 62 (43.1) 82 (56.9) — 116 (80.6) 28 (19.4) — practitioner Nurse practitioner 14 (7.9) 13 (92.9) 1 (7.1) 9 (64.3) 5 (35.7) Family physician 7 (3.9) 2 (28.6) 5 (71.4) 4 (57.2) 3 (42.9) Other physicians 4 (2.2) 3 (75.0) 1 (25.0) 4 (100.0) 0 (0.0) Other professionals 6 (3.4) 4 (66.7) 2 (33.3) 5 (83.3) 1 (16.7) None of the above 2 (1.1) 0 (0.0) 2 (100.0) 2 (100.0) 0 (0.0) Prefer not to answer or do not 1 (0.6) 1 (100.0) 0 (0.0) 1 (100.0) 0 (0.0) know I believe the age group most needing preventive sexual health education is… Childhood 3 (1.7) 1 (33.3) 2 (66.7) – 2 (66.7) 1 (33.3) – Adolescence 113 (63.5) 54 (47.8) 59 (52.2) 89 (78.7) 24 (21.2) Adults 8 (4.5) 4 (50.0) 4 (50.0) 6 (75.0) 2 (25.0) Elders 53 (29.8) 26 (49.1) 27 (50.9) 43 (81.1) 10 (18.9) All of them 1 (0.6) 0 (0.0) 1 (100.0) 1 (100.0) 0 (0.0) I believe the age group least needing preventive sexual health education is… Childhood 25 (14.1) 14 (56.6) 11 (20.4) — 21 (75.0) 4 (25.0) — Adolescence 2 (1.1) 1 (50.0) 1 (50.0) 1 (50.0) 1 (50.0) Adults 13 (7.3) 6 (46.2) 7 (53.9) 8 (61.5) 5 (38.5) Elderly 65 (36.5) 30 (46.2) 35 (53.9) 49 (75.4) 16 (24.6) All of them 18 (10.1) 12 (66.7) 6 (33.3) 15 (83.3) 3 (16.7) None of the above 47 (26.4) 20 (42.6) 27 (57.5) 40 (85.1) 7 (14.9) Prefer not to answer or do not 8 (4.5) 2 (25.0) 6 (75.0) 7 (87.5) 1 (12.5) know I believe I am appropriately trained to discuss sexual health topics with patients… Somewhat or strongly disagree 46 (25.8) 27 (58.7) 19 (41.3) .226 39 (84.8) 7 (15.2) .465 Neither agree nor disagree 50 (28.1) 22 (44.0) 28 (56.0) 40 (80.0) 10 (20.0) Somewhat or strongly agree 82 (46.1) 36 (43.9) 46 (56.1) 62 (75.6) 20 (24.4) I believe I should receive more training to confidently discuss sexual health topics with patients… Somewhat or strongly disagree 12 (6.7) 8 (66.7) 4 (33.3) .025* 11 (91.7) 1 (8.3) .543 Neither agree nor disagree 19 (10.7) 4 (21.1) 15 (79.0) 14 (73.7) 5 (26.3) Somewhat or strongly agree 147 (82.6) 73 (49.7) 74 (50.3) 116 (78.9) 31 (21.1) I believe I received sufficient university training to discuss sexual health topics with patients… Somewhat or strongly disagree 130 (73.0) 56 (43.1) 74 (56.9) .008* 102 (78.5) 28 (21.5) .872 Neither agree nor disagree 23 (12.9) 18 (78.3) 5 (21.8) 18 (78.3) 5 (21.7) Somewhat or strongly agree 25 (14.0) 11 (44.0) 14 (56.0) 21 (84.0) 4 (16.0) I believe sexual health is a priority in my clinical practice… Somewhat or strongly disagree 55 (30.9) 31 (56.4) 24 (43.6) .210 43 (78.2) 12 (21.8) .543 Neither agree nor disagree 87 (48.9) 36 (41.4) 51 (58.6) 67 (77.0) 20 (23.0) Somewhat or strongly agree 36 (20.2) 18 (50.0) 18 (50.0) 31 (86.1) 5 (13.9) I believe my colleagues discuss sexual health topics with their patients… Somewhat or strongly disagree 90 (50.6) 43 (47.8) 47 (52.2) .695 70 (77.8) 20 (22.2) .654 Neither agree nor disagree 44 (24.7) 23 (52.3) 21 (47.7) 34 (77.3) 10 (22.7) Somewhat or strongly agree 44 (24.7) 19 (43.2) 25 (56.8) 37 (84.1) 7 (15.9) (Continues) LEYVA-MORAL et al. | 411 TA B L E 3 (Continued) Items and Responses N (%) Physician (%) Nurse (%) p-value Female (%) Male (%) p-value I believe I do not have enough time to discuss sexual health topics with patients… Somewhat or strongly disagree 28 (15.7) 12 (42.9) 16 (57.1) .365 21 (75.0) 7 (25.0) .829 Neither agree nor disagree 10 (5.6) 7 (70.0) 3 (30.0) 8 (80.0) 2 (20.0) Somewhat or strongly agree 140 (78.7) 66 (47.1) 74 (52.9) 112 (80.0) 28 (20.0) I believe patients are not comfortable discussing sexual health topics with health professionals… Somewhat or strongly disagree 64 (36.0) 30 (46.9) 34 (53.1) .938 49 (76.6) 15 (23.4) .343 Neither agree nor disagree 2 (1.1) 1 (50.0) 1 (50.0) 1 (50.0) 1 (50.0) Somewhat or strongly agree 112 (62.9) 54 (48.2) 58 (51.8) 91 (81.3) 21 (18.8) In clinical practice, I believe there are higher priority needs to discuss rather than sexual health topics… Somewhat or strongly disagree 82 (46.1) 45 (54.9) 37 (45.1) .199 65 (79.3) 17 (20.7) 1.000 Neither agree nor disagree 21 (11.8) 8 (38.1) 13 (61.9) 17 (81.0) 4 (19.0) Somewhat or strongly agree 75 (42.1) 32 (42.7) 43 (57.3) 59 (78.7) 16 (21.3) *Statistically significant median [ICR]. tailored for clinicians in a modular approach (Case beer et al., 2002) biases. Finally, this is one of the first sexual health studies comparing has been reported to increase knowledge and change clinical prac- nurses and physicians with a representative sample from multiple tice (Guy et al., 2011; Shabsigh et al., 2009). In this regard, cli- locations. nicians can access free and low-cost sexual health courses, two to six hours, or enroll in postgraduate certificate programs which are longer and more expensive. Several organizations provide cur- 6 | CO N C LU S I O N rent clinical practice resources for sexual health including links for external continuing education and university-based programmes This study found primary care nurses and physicians in Barcelona (Centers for Disease Control & Prevention, 2017, 2018, 2019; (Spain) do not generally feel comfortable speaking with their pa- Royal College of Nursing, 2020; World Association for Sexual tients about sexual health. They avoid asking questions about Health, 2020; World Organization of Family Doctors, 2019). sexual health despite recognizing their important role in helping patients achieve satisfaction with their sexual health. However, nurses are more willing, comfortable, and capable of engaging 5.1 | Limitations their patients in sexual health discussions than their physician col- leagues. Clearly, the work environment and self-reported knowl- Despite incorporating strategies to reduce bias and increase gener- edge deficits about addressing sexual health are the principle alizability (Malone et al., 2014), there are five study limitations that barriers to engaging patients in sexual discussions. Qualitative need to be discussed. First, response and information bias are pos- research may be helpful to unpacking the way participant atti- sible when using a questionnaire (Choi & Pak, 2005). To minimize tudes and beliefs manifest as barriers or facilitators to discussing this bias, the questionnaire was anonymous and sent through an ex- sexual health with patients. Applied nursing research is also nec- ternal web link (Keough & Tanabe, 2011). Second, despite the large essary to translate the current evidence into strategies to guide number of sampling locations, selection bias needs to be considered clinical practice and to inform nursing and medical curriculums. since the participants responding to the survey might have been Sexual health knowledge needs to be improved and communica- more familiar or motivated by the topic. Third, the non-probabilistic tion skills further developed through additional training to stimu- sampling can have an impact on the results (Polit & Beck, 2017). late more intentional discussions with patients. Other intervention However, the response rate for the present study was higher (Gök strategies focused on promoting person-centred care should be & Demir Korkmaz, 2018) than the previously cited studies. Fourth, considered to help patients initiate the conversations with clini- the questionnaire could have increased social desirability bias, as cians about their sexual health in a constructive and comfortable participants respond how they believed would be favourably viewed manner. by researchers (Waltz et al., 2016). This is not likely as there were multiple responses contrary to a favourable view. Fifth, the sample AC K N OW L E D G E M E N T S may be subject to participation biases due to non-response, but par- We are grateful for the assistance of Mr. Toni Lopez, Adjunct ticipation was high and the item summary is disclosed in the tables Director of Nursing at the Institut Catala de la Salut (Barcelona, (Badger & Werrett, 2005). Despite these five anticipated limitations, Spain) for coordinating the work with the primary care centres, the study was designed to minimize the potential for errors and including access and diffusion. Without his assistance, this study 412 | LEYVA-MORAL et al. would not have been possible. Furthermore, we want to recog- Badger, F., & Werrett, J. (2005). Room for improvement? Reporting response rates and recruitment in nursing research in the past nize the mentorship provided by Dr. Joan Edwards, Director of the decade. Journal of Advanced Nursing, 51(5), 502–510. https://doi. Center for Global Nursing, and Professor of Nursing at the Nelda org/10.1111/j.1365-2648.2005.03521.x C. Stark College of Nursing, Texas Woman's University, through- Bal, M. D., Yılmaz, S. D., Çelik, S. G., Dinçağ, N., Beji, N. K., & Yalçın, Ö. out this project and her continued support of the global collabora- (2015). Does the diabetes of type 2 affect the sexual functions of women? Journal of Sex & Marital Therapy, 41(1), 107–113. https://doi. tion that resulted in this project. Finally, we would like to thank Dr. org/10.1080/00926​23X.2013.842193 Jean Watson, Founder and Director of the Watson Caring Science Barragan, F. (1995). La educación sexual y la educación secundaria oblig- Institute, for her continued mentorship and scholarly guidance in atoria: enseñar a creer o aprender a crear [Sex education and high developing nursing research to improve the sexual health of peo- school: Teaching to believe or learning to create]. Temas transversales: ple by implementing human caring interventions. Documentos de apoyo (Vol. 5, pp. 93–153). Sevilla, Spain: Junta de Andalucía. Bayer, C. R., Eckstrand, K. L., Knudson, G., Koehler, J., Leibowitz, S., C O N FL I C T O F I N T E R E S T Tsai, P., & Feldman, J. L. (2017). Sexual health competencies for No conflict of interest has been declared by the authors. undergraduate medical education in North America. Journal of Sexual Medicine, 14(4), 535–540. https://doi.org/10.1016/j. jsxm.2017.01.017 AU T H O R C O N T R I B U T I O N S Beaton, D. E., Bombardier, C., Guillemin, F., & Ferraz, M. B. (2000). AD-P, GG-V, JML-M, MA-G, NG-G and PAP: Conception and design Guidelines for the process of cross-cultural adaptation of self-report of the study; acquisition of data; analysis and interpretation of data; measures. Spine, 25(24), 3186–3191. https://doi.org/10.1097/00007​ preparation of draft; critical revision for important intellectual con- 632-20001​2150-00014 Bober, S. L., Recklitis, C. J., Campbell, E. G., Park, E. R., Kutner, J. S., tent; final approval of the version to be published; and accountable Najita, J. S., & Diller, L. (2009). Caring for cancer survivors. Cancer, for all aspects of the work in ensuring that questions related to the 115(S18), 4409–4418. https://doi.org/10.1002/cncr.24590 accuracy or integrity of any part of the work are appropriately inves- Boekeloo, B. O. (2014). Will you ask? Will they tell you? Are you ready to tigated and resolved. hear and respond?: Barriers to physician-adolescent discussion about sexuality. JAMA Pediatrics, 168(2), 111–113. https://doi.org/10.1001/ jamap​ediat​rics.2013.4605 DATA AVA I L A B I L I T Y S TAT E M E N T Bos-Bonnie, L. H. A., van Bergen, J., Te Pas, E., Kijser, M. A., & van Dijk, The data that support the findings of this study are available from N. (2017). Effectiveness of an individual, online e-learning program the corresponding author upon reasonable request. about sexually transmitted infections: A prospective cohort study. BMC Family Practice, 18(1), 57. https://doi.org/10.1186/s1287​ 5-017-0625-1 ORCID Casebeer, L., Allison, J., & Spettell, C. M. (2002). Designing tailored Juan M. Leyva-Moral https://orcid.org/0000-0003-4241-4992 Web-based instruction to improve practicing physicians' chla- Mariela Aguayo-Gonzalez https://orcid. mydial screening rates. Academic Medicine, 77(9), 929. https://doi. org/0000-0002-5968-5214 org/10.1097/00001​888-20020​9000-00032 Centers for Disease Control and Prevention (2017). Sexual health and dis- Patrick A. Palmieri https://orcid.org/0000-0002-0765-0239 ease prevention. Retrieved from https://www.cdc.gov/nchhs​tp/sexua​ Genesis Guevara-Vasquez https://orcid. l-healt​h-topics.htm org/0000-0003-0329-3825 Centers for Disease Control and Prevention (2018). Discussing sexual Nina Granel-Grimenez https://orcid.org/0000-0001-7404-0564 health with your patients. Retrieved from https://www.cdc.gov/hiv/ clini​cians/​scree​ning/discu​ssing​-sexua​l-health.html Artur Dalfó-Pibernat https://orcid.org/0000-0002-2539-3715 Centers for Disease Control and Prevention (2019). Sexual health. Retrieved from https://www.cdc.gov/sexua​lheal​th/ REFERENCES Cha, E.-S., Kim, K. H., & Erlen, J. A. (2007). Translation of scales in cross-cul- Aiken, L. R. (1980). Content validity and reliability of single items or tural research: Issues and techniques. Journal of Advanced Nursing, questionnaires. Educational and Psychological Measurement, 40(4), 58(4), 386–395. https://doi.org/10.1111/j.1365-2648.2007.04242.x 955–959. https://doi.org/10.1177/00131​6 4480​0 4000419 Choi, B. C. K., & Pak, A. W. P. (2005). A catalog of biases in question- Aiken, L. R. (1985). Three coefficients for analyzing the reliability and naires. Preventing Chronic Disease, 2(1), A13. https://www.ncbi.nlm. validity of ratings. Educational and Psychological Measurement, 45(1), nih.gov/pmc/artic​les/PMC13​23316/ 131–142. https://doi.org/10.1177/00131​6 4485​451012 Clark, J., Brey, R., Banter, A., & Khubchandani, J. (2012). The delivery Alexander, S. C., Fortenberry, J. D., Pollak, K. I., Bravender, T., Davis, J. K., of sexuality-related patient education to adolescent patients: A Østbye, T., Tulsky, J. A., Dolor, R. J., & Shields, C. G. (2014). Sexuality preliminary study of family practice resident physicians. Journal talk during adolescent health maintenance visits. JAMA Pediatrics, of Family Medicine and Primary Care, 1(1), 34–38. https://doi. 168(2), 163–169. https://doi.org/10.1001/jamap​ediat​rics.2013.4338 org/10.4103/2249-4863.94449 Arikan, F., Meydanlioglu, A., Ozcan, K., & Canli Ozer, Z. (2015). Attitudes Dalfó Pibernat, A., Pelegrina Rodríguez, F. J., Dalfó Pibernat, E., Rosell and beliefs of nurses regarding discussion of sexual concerns of pa- Vidal, J., & Rosell Vidal, J. (2015). Is sexual health an issue in nursing tients during hospitalization. Sexuality and Disability, 33(3), 327–337. education? European Journal of Cardiovascular Nursing, 14(6), 466– https://doi.org/10.1007/s1119​5-014-9361-9 467. https://doi.org/10.1177/14745​15115​586710 Asociación Española para la Salud Sexual. (2011). Informe Lilly sobre sex- Dennis, K. J., & Elstein, M. (1980). Education in sexuality in the medical ualidad masculina [Lilly report about masculine sexuality]. Asociación curriculum. Clinical Obstetrics and Gynecology, 7(2), 183–191. Española de Andrología, Medicina Sexual y Reproductiva. http:// Denno, D. M., Hoopes, A. J., & Chandra-Mouli, V. (2015). Effective slide​player.es/slide/​27207​11/ strategies to provide adolescent sexual and reproductive health LEYVA-MORAL et al. | 413 services and to increase demand and community support. Journal of Karas, M., Sheen, N. J. L., North, R. V., Ryan, B., & Bullock, A. (2020). Adolescent Health, 56(1), S22–S41. https://doi.org/10.1016/j.jadoh​ Continuing professional development requirements for UK health ealth.2014.09.012 professionals: A scoping review. British Medical Journal Open, 10(3), Dillman, D. A. (2007). Mail and internet surveys: The tailored design method e032781. https://doi.org/10.1136/bmjop​en-2019-032781 (2nd ed.). John Wiley & Sons. Keough, V. A., & Tanabe, P. (2011). Survey research: An effective design Donaldson, A. A., Lindberg, L. D., Ellen, J. M., & Marcell, A. V. (2013). for conducting nursing research. Journal of Nursing Regulation, 1(4), Receipt of sexual health information from parents, teachers 37–44. https://doi.org/10.1016/S2155​-8256(15)30315​-X and healthcare providers by sexually experienced U.S. adoles- Klaeson, K., Hovlin, L., Guvå, H., & Kjellsdotter, A. (2017). Sexual health cents. Journal of Adolescent Health, 53(2), 235–240. https://doi. in primary health care – A qualitative study of nurses’ experiences. org/10.1016/j.jadoh​ealth.2013.03.017 Journal of Clinical Nursing, 26(11–12), 1545–1554. https://doi. East, L., & Hutchinson, M. (2013). Moving beyond the therapeutic rela- org/10.1111/jocn.13454 tionship: A selective review of intimacy in the sexual health encoun- Klein, J. D., & Wilson, K. M. (2002). Delivering quality care: Adolescents' ter in nursing practice. Journal of Clinical Nursing, 22(23–24), 3568– discussion of health risks with their providers. Journal of 3576. https://doi.org/10.1111/jocn.12247 Adolescent Health, 30(3), 190–195. https://doi.org/10.1016/S1054​ Edwards, W. M., & Coleman, E. (2004). Defining sexual health: A descrip- -139X(01)00342​-1 tive overview. Archives of Sexual Behavior, 33(3), 189–195. https://doi. Kong, S. K. F., Wu, L. H., & Loke, A. Y. (2009). Nursing students' knowl- org/10.1023/B:ASEB.00000​26619.95734.d5 edge, attitude and readiness to work for clients with sexual health Escobar-Pérez, J., & Cuervo-Martínez, A. (2008). Validez de contenido y concerns. Journal of Clinical Nursing, 18(16), 2372–2382. https://doi. juicio de expertos: Una aproximación a su utilización. Revista Avances org/10.1111/j.1365-2702.2008.02756.x en Medición, 6(1), 27–36. Landers, M. G., Weathers, E., McCarthy, G., & Fitzpatrick, J. J. (2014). Fennell, R., & Grant, B. (2019). Discussing sexuality in health care: A sys- Professional caring: Descriptions from student nurses' perspec- tematic review. Journal of Clinical Nursing, 28(17–18), 3065–3076. tives midway through their educational program. International https://doi.org/10.1111/jocn.14900 Journal Human Caring, 18(4), 52–58. https://doi.org/10.20467/​ Ford, J. V., Barnes, R., Rompalo, A., & Hook, E. W. (2013). Sexual health 1091-5710.18.4.52 training and education in the U.S. Public Health Reports, 128(2_ Latif, R. A., Muhamad, R., Ann, A. Y. H., Sidi, H., Jaafar, N. R. N., Midin, M., suppl1), 96–101. https://doi.org/10.1177/00333​54913​1282s111 Das, S., Seng, L. H., & Guan, N. C. (2014). Duration of hypertension Frenk, J., Chen, L., Bhutta, Z. A., Cohen, J., Crisp, N., Evans, T., Fineberg, and antihypertensive agents in correlation with the phases of female H., Garcia, P., Ke, Y., Kelley, P., Kistnasamy, B., Meleis, A., Naylor, sexual response cycle. Comprehensive Psychiatry, 55, S7–S12. https:// D., Pablos-Mendez, A., Reddy, S., Scrimshaw, S., Sepulveda, J., doi.org/10.1016/j.compp​sych.2012.10.008 Serwadda, D., & Zurayk, H. (2010). Health professionals for a new Lena, S. M., Wiebe, T., Ingram, S., & Jabbour, M. (2002). Pediatricians' century: Transforming education to strengthen health systems in an knowledge, perceptions and attitudes towards providing health care interdependent world. Lancet, 376(9756), 1923–1958. https://doi. for lesbian, gay and bisexual adolescents. Annals of the Royal College org/10.1016/S0140​-6736(10)61854​-5 of Physicians and Surgeons of Canada, 35(7), 406–410. Fuzzell, L., Fedesco, H. N., Alexander, S. C., Fortenberry, J. D., & Shields, Leyva-Moral, J. M. (2008). La expresión sexual de los ancianos. Una C. G. (2016). “I just think that doctors need to ask more questions”: sobredosis de falsos mitos [Elders sexual expression: An overdose Sexual minority and majority adolescents' experiences talking about of false myths]. Index De Enfermería, 17(2), 124–127. http://scielo. sexuality with healthcare providers. Patient Education and Counseling, isciii.es/scielo.php?scrip​t=sci_artte​x t&pid=S1132​-12962​0 0800​ 99(9), 1467–1472. https://doi.org/10.1016/j.pec.2016.06.004 0200010 Gott, M., Galena, E., Hinchliff, S., & Elford, H. (2004). “Opening a can Lynn, M. R. (1986). Determination and quantification of content validity. of worms”: GP and practice nurse barriers to talking about sexual Nursing Research, 35(6), 382–385. https://doi.org/10.1097/00006​ health in primary care. Family Practice, 21(5), 528–536. https://doi. 199-19861​1000-00017 org/10.1093/fampr​a/cmh509 Magnan, M. A., & Norris, D. (2008). Nursing students' perceptions of Gravetter, F. J., & Wallnau, L. B. (2016). Statistics for the behavioral health barriers to addressing patient sexuality concerns. Journal of Nursing sciences (9th ed.). Cengage Learning. Education, 47(6), 260–268. https://doi.org/10.3928/01484​834- Grove, S. K., & Cipher, D. J. (2020). Statistics for nursing research: A work- 20080​601-06 book for evidence-based practice (3rd ed.). Elsevier. Magnan, M. A., & Reynolds, K. (2006). Barriers to addressing patient Guillemin, F., Bombardier, C., & Beaton, D. (1993). Cross-cultural adapta- sexuality concerns across five areas of specialization. Clinical Nurse tion of health-related quality of life measures: Literature review and Specialist, 20(6), 285–292. https://doi.org/10.1097/00002​8 00- proposed guidelines. Journal of Clinical Epidemiology, 46(12), 1417– 20061​1000-00009 1432. https://doi.org/10.1016/0895-4356(93)90142​-N Magnan, M. A., Reynolds, K. E., & Galvin, E. A. (2005). Barriers to ad- Guy, R. J., Ali, H., Liu, B., Poznanski, S., Ward, J., Donovan, B., dressing patient sexuality in nursing practice. Medsurg Nursing, 14(5), Kaldor, J., & Hocking, J. (2011). Efficacy of interventions to in- 282–289. crease the uptake of chlamydia screening in primary care: A sys- Maheux, B., Haley, N., Rivard, M., & Gervais, A. (1995). STD risk as- tematic review. BMC Infectious Diseases, 11, 211. https://doi. sessment and risk-reduction counseling by recently trained fam- org/10.1186/1471-2334-11-211 ily physicians. Academic Medicine, 70(8), 726–728. https://doi. Ha, J. F., & Longnecker, N. (2010). Doctor-patient communication: A re- org/10.1097/00001​888-19950​8 000-00018 view. Ochsner Journal, 10(1), 38–43. https://www.ncbi.nlm.nih.gov/ Malone, H., Nicholl, H., & Tracey, C. (2014). Awareness and minimisa- pmc/artic​les/PMC30​96184/ tion of systematic bias in research. British Journal of Nursing, 23(5), Hordern, A. J., & Street, A. F. (2007). Communicating about patient 279–282. https://doi.org/10.12968/​bjon.2014.23.5.279 sexuality and intimacy after cancer: Mismatched expectations and Nair, M., & Webster, P. (2010). Education for health professionals in the unmet needs. Medical Journal of Australia, 186(5), 224–227. https:// emerging market economies: A literature review. Medical Education, doi.org/10.5694/j.1326-5377.2007.tb008​77.x 44(9), 856–863. https://doi.org/10.1111/j.1365-2923.2010.03747.x Institute of Medicine (2010). Redesigning continuing education in the health O'Keeffe, G. S., & Clarke-Pearson, K. (2011). The Impact of Social Media professions. National Academies Press. https://doi.org/10.17226/​ on Children. Adolescents and Families. Pediatrics, 127(4), 800–804. 12704 https://doi.org/10.1542/peds.2011-0054 414 | LEYVA-MORAL et al. O'Malley, D., Higgins, A., & Smith, V. (2015). Postpartum sexual health: A [Attitudes to sexuality in primary healthcare professionals: Analysis principle-based concept analysis. Journal of Advanced Nursing, 71(10), of predictive variables]. Anuario De Sexología, 12, 51–58. 2247–2257. https://doi.org/10.1111/jan.12692 Tsimtsiou, Z., Hatzimouratidis, K., Nakopoulou, E., Kyrana, E., Salpigidis, Patel, S., Pelletier-Bui, A., Smith, S., Roberts, M. B., Kilgannon, H., G., & Hatzichristou, D. (2006). Predictors of physicians' involvement Trzeciak, S., & Roberts, B. W. (2019). Curricula for empathy and com- in addressing sexual health issues. Journal of Sexual Medicine, 3(4), passion training in medical education: A systematic review. PLoS One, 583–588. https://doi.org/10.1111/j.1743-6109.2006.00271.x 14(8), e0221412. https://doi.org/10.1371/journ​al.pone.0221412 von Elm, E., Altman, D. G., Egger, M., Pocock, S. J., Gøtzsche, P. C., & Polit, D. F., & Beck, C. T. (2017). Nursing research. generating and assessing Vandenbroucke, J. P. (2007). Strengthening the reporting of obser- evidence for nursing practice (10th ed.). Wolters Kluwer. vational studies in epidemiology (STROBE) statement: Guidelines for Rashidian, M., Minichiello, V., Knutsen, S. F., & Ghamsary, M. (2016). reporting observational studies. BMJ, 335(7624), 806–808. https:// Barriers to sexual health care: A survey of Iranian-American physi- doi.org/10.1136/bmj.39335.541782.AD cians in California, USA. BMC Health Services Research, 16(1), 263. Wagner, G. (2005). Sexual medicine in the medical curriculum. https://doi.org/10.1186/s1291​3-016-1481-8 International Journal of Andrology, 28(s2), 7–8. https://doi. Rattray, J., & Jones, M. C. (2007). Essential elements of questionnaire org/10.1111/j.1365-2605.2005.00581.x design and development. Journal of Clinical Nursing, 16(2), 234–243. Waltz, C. F., Strickland, O. L., & Lenz, E. R. (Eds.) (2016). Measurement in https://doi.org/10.1111/j.1365-2702.2006.01573.x nursing and health research (5th ed.). Springer Publishing Company. Raya-Tena, A., García-Hernández, D., Blázquez-Gómez, C., Martínez- https://doi.org/10.1891/97808​26170620 Blanco, P., Tierz-Bartolomé, N., & Fernández San Martín, M. I. (2019). Watson, J. (2009). Caring science and human caring theory: Transforming Evaluación pre-post intervención de los conocimientos de infec- personal and professional practices of nursing and health care. ciones de transmisión sexual en adolescentes. Metas De Enfermería, Journal of Health and Human Services Administration, 31(4), 466–482. 22(1), 5–13. https://doi.org/10.35667/​Metas​Enf.2019.22.10030​ https://www.jstor.org/stabl​e/25790743 81348 Wazqar, D. Y. (2020). Sexual healthcare in cancer patients: A survey of Reynolds, K., & Magnan, M. A. (2005). Nursing attitudes and beliefs healthcare providers' knowledge, attitudes and barriers. Journal of toward human sexuality: Collaborative research promoting ev- Clinical Nursing, 1–9. https://doi.org/10.1111/jocn.15459. [Epub idence-based practice. Clinical Nurse Specialist, 19(5), 255–259. ahead of print]. https://doi.org/10.1097/00002​8 00-20050​9000-00009 Wiggins, D. L., Wood, R., Granai, C. O., & Dizon, D. S. (2007). Sex, in- Royal College of Nursing (2020). Sexual health education, training and timacy and the gynecologic oncologist. Journal of Psychosocial professional associations. Retrieved from https://www.rcn.org.uk/ Oncology, 25(4), 61–70. https://doi.org/10.1300/J077v​25n04_04 clini​c al-topic​s /publi​c-healt​h /sexua​l -healt​h /sexua​l -healt​h -educa​ Win, K. T., Hassan, N. M., Bonney, A., & Iverson, D. (2015). Benefits of on- tion-and-training line health education: Perception from consumers and health profes- Saunamäki, N., & Engström, M. (2014). Registered nurses' reflections sionals. Journal of Medical Systems, 39(3), 27. https://doi.org/10.1007/ on discussing sexuality with patients: Responsibilities, doubts and s1091​6-015-0224-4 fears. Journal of Clinical Nursing, 23(3–4), 531–540. https://doi. World Association for Sexual Health (2020). Sexual health and sexual org/10.1111/jocn.12155 rights for all. Retrieved from https://world​sexua​lheal​th.net/ Schuster, M. A., Bell, R. M., Petersen, L. P., & Kanouse, D. E. (1996). World Health Organization (2015). Sexual health, human rights and the Communication between adolescents and physicians about sex- law. WHO Press. https://www.who.int/repro​ducti​vehea​lth/publi​ ual behavior and risk prevention. Archives of Pediatrics & Adolescent catio​ns/sexual_healt​h/sexua​l-healt​h-human​-right​s-law/en/ Medicine, 150(9), 906–913. https://doi.org/10.1001/archp​ World Organization of Family Doctors (2019). European primary care edi.1996.02170​3 4002​0 004 group: Sexual health & reproduction. Retrieved from https://www. Shabsigh, R., Sadovsky, R., Rosen, R. C., Carson, C. C. 3rd, Seftel, A. D., & sexua​lheal​th.eu/ Noursalehi, M. (2009). Impact of an educational initiative on applied Yip, B.-H.-K., Sheng, X.-T., Chan, V.-W.-Y., Wong, L.-H.-L., Lee, S.-W.-Y., & knowledge and attitudes of physicians who treat sexual dysfunction. Abraham, A. A. (2015). ‘Let's talk about sex’ – A knowledge, attitudes International Journal of Impotence Research, 21(1), 74–81. https://doi. and practice study among paediatric nurses about teen sexual health org/10.1038/ijir.2008.65 in Hong Kong. Journal of Clinical Nursing, 24(17–18), 2591–2600. Sherwood, G. D., & Shaffer, F. A. (2014). The role of internationally ed- https://doi.org/10.1111/jocn.12869 ucated nurses in a quality, safe workforce. Nursing Outlook, 62(1), 46–52. https://doi.org/10.1016/j.outlo​ok.2013.11.001 Stead, M. L., Brown, J. M., Fallowfield, L., & Selby, P. (2003). Lack of S U P P O R T I N G I N FO R M AT I O N communication between healthcare professionals and women with Additional supporting information may be found online in the ovarian cancer about sexual issues. British Journal of Cancer, 88(5), 666–671. https://doi.org/10.1038/sj.bjc.6600799 Supporting Information section. Stead, M. L., Fallowfield, L., Brown, J. M., & Selby, P. (2001). Communication about sexual problems and sexual concerns in ovar- ian cancer: Qualitative study. BMJ, 323(7317), 836–837. https://doi. How to cite this article: Leyva-Moral JM, Aguayo-Gonzalez org/10.1136/bmj.323.7317.836 M, Palmieri PA, Guevara-Vasquez G, Granel-Grimenez N, Stevens, K. (2013). The impact of evidence-based practice in nursing and Dalfó-Pibernat A. Attitudes and beliefs of nurses and the next big ideas. Online Journal of Issues in Nursing, 18(2), 4. https:// doi.org/10.3912/OJIN.Vol18​No02M​an04 physicians about managing sexual health in primary care: Thornton, K., Chervenak, J., & Neal-Perry, G. (2015). Menopause and Multi-site cross-sectional comparative study. Nursing Open. sexuality. Endocrinology and Metabolism Clinics of North America, 2021;8:404–414. https://doi.org/10.1002/nop2.641 44(3), 649–661. https://doi.org/10.1016/j.ecl.2015.05.009 Tijeras-Úbeda, M. J. (2010). Actitudes hacia la sexualidad de profesio- nales sanitarios de atención primaria: análisis de variables predictoras