Contraception 93 (2016) 438 445

Original research article

Core competencies in sexual and reproductive health for the

interprofessional primary care team,,
Joyce Cappiello a,, Amy Levi b , Melissa Nothnagle c
a
University of New Hampshire
b
University of New Mexico, 1 University of New Mexico, Albuquerque, NM, 87131
c
Alpert Medical School of Brown University, Providence, RI
Received 6 May 2015; revised 7 December 2015; accepted 9 December 2015

Abstract

Objective: A primary care workforce that is well prepared to provide high-quality sexual and reproductive health (SRH) care has the
potential to enhance access to care and reduce health disparities. This project aimed to identify core competencies to guide SRH training
across the primary care professions.
Study design: A six-member interprofessional expert working group drafted SRH competencies for primary care team members. Primary
care providers including family physicians, nurses, nurse practitioners and certified nurse midwives, physician assistants and pharmacists
were invited to participate in a three-round electronic Delphi survey. In each round, participants voted by email to retain, eliminate or revise
each competency, with their suggested edits to the competencies incorporated by the researchers after each round.
Results: Fifty providers from six professions participated. In Round 1, 17 of 33 draft competencies reached the 75% predetermined agreement level
to be accepted as written. Five were combined, reducing the total number to 28. Based on Round 2 feedback, 21 competencies were reworded, and 2
were combined. In Round 3, all 26 competencies reached at least 83.7% agreement, with 9 achieving 100% agreement.
Conclusion: The 33 core competencies encompass professional ethics and reproductive justice, collaboration, SRH services and conditions
affecting SRH. These core competencies will be disseminated and adapted to each profession's scope of practice to inform required curricula.
Implications: SRH competencies for primary care can inform the required curricula across professions, filling the gap between an established
standard of care necessary to meet patient needs and the outcomes of that care.
2015 Elsevier Inc. All rights reserved.

Keywords: Modified Delphi study; Interprofessional; Sexual health; Reproductive health; Core competencies

1. Introduction address the persistent sexual and reproductive health (SRH)

In 2013, an interprofessional group of leaders in reproduc-
tive health policy, advocacy and clinical care came together to
Funding: The ARHP Sexual and Reproductive Health Workforce
Project was funded by the New Morning Foundation, the David and Lucile
Packard Foundation, the William and Flora Hewlett Foundation and an
anonymous donor.
Authors Levi and Nothnagle have no conflicts of interest to report.
Author Cappiello reports a conflict of interest as a shareholder in Bioceptive,
a biomedical engineering company that has developed a novel IUD inserter.
The Investigational Review Board of the University of New Hampshire
#6031 approved the research.
Corresponding author. Tel.: + 1 603 833 0790.
E-mail addresses: joyce.cappiello@unh.edu (J. Cappiello),
amylevi@salud.unm.edu (A. Levi), melissa_nothnagle@brown.edu
(M. Nothnagle).
http://dx.doi.org/10.1016/j.contraception.2015.12.013
0010-7824/ 2015 Elsevier Inc. All rights reserved.
disparities and high rates of unintended pregnancies in the United
States. Convened by the Association of Reproductive Health
Professionals (ARHP), the group aims to increase the capacity of
US health care providers to provide high-quality SRH care to all
patients. The experts at this SRH Workforce Summit asserted
that the interprofessional primary care team should be able to
meet the majority of SRH needs of all patients and to coordinate
specialty referral as indicated [12].
A major outcome of the meeting was to organize Working
Groups to address three tasks:
1. Identification of core competencies in SRH for primary
care training programs;
2. Identification of SRH-related skills among practicing
primary care professionals;
3. Identification of quality metrics in SRH care.
 J. Cappiello et al. / Contraception 93 (2016) 438445
This article reports the work of the Core Competencies
Working Group. The Core Competencies Working Group's
tasks are:
1. to define the essential SRH competencies that primary
care professionals should attain during their training
and
2. to work collaboratively with the appropriate national
professional associations to adopt these competencies.
SRH care is sometimes narrowly considered to encom-
pass only maternalchild health, family planning or
women's health care. In the US context, this care is
sometimes seen as the purview of gynecologists and
specialized family planning clinics. However, to produce
optimal health outcomes, the World Health Organization
(WHO) states that the definition of primary care should
include the reproductive health of men and women
throughout their lifespan, including adolescence [3]. SRH
care cannot be relegated solely to specialty care providers
and needs to be included in the preparation of all health care
providers, particularly primary care professionals. Currently,
many primary care graduates report varying amounts of SRH
preparation in their programs [4]. The development of
interprofessional competencies in SRH will guide curricu-
lum development and thus assist educational programs to
better integrate SRH into primary care training. Interprofes-
sional core competencies to guide curricula have already
been developed in many fields, including gerontology and
genetics, but do not currently exist for SRH care in the US. A
core set of competencies is needed to guide the development
of educational content that can be incorporated across the
health professions.
A competent primary care workforce in SRH care will
only be achieved if professionals have comprehensive
education and training in SRH. The purpose of this study
was to identify core competencies for the provision of SRH
in primary care in order to provide a framework for
expanding SRH education for health professionals. We
focused specifically on the competencies needed by family
physicians, nurses, advanced practice nurses including nurse
practitioners and certified nurse midwives, physician
assistants and pharmacists.
2. Material and methods
To identify and refine a set of core competencies, we used
a modified Delphi method, as it allows for the maximum
amount of input from study participants. The Delphi method
is a structured process used to achieve consensus from a wide
range of individuals who are geographically dispersed on
topics that currently lack evidence. In the initial round of
questionnaires, expert opinion is solicited on a topic. The
researchers incorporate feedback from this first round into
the next round using the participants' feedback. Participants
have the option to reconsider their opinion in Round 2 of the
439
survey in view of their colleagues' comments. Each round
builds on the results of the previous round. Most Delphi
studies use a 75%80% level of agreement to confirm
concurrence with a proposed concept and allow the content
to be carried to the subsequent round; we used 75% as the
cutoff level. The modified Delphi is used extensively in
health care and social science research [5]. Most recently, a
Delphi study comprised of expert nurses, nurse educators
and advanced practitioner nurses identified unintended
pregnancy prevention and care competencies in nursing.
[6]. A Delphi study uses two to four rounds with three as the
norm, which corresponds to the model used here [78].
The Core Competencies Working Group included seven
experienced educators from the following primary care
professions: family medicine, nurse-midwifery, nurse practi-
tioners, pharmacists and physician assistants. This group
developed an initial draft of 31 competencies. Global and US
frameworks guided the initial set of SRH competencies. Both of
the core SRH competency frameworks from the WHO and the
United Kingdom build on health provider competencies for
primary care and public health service delivery. The WHO
model establishes a global approach to the provision of
competency-based education for all primary health care workers
in SRH based on a minimum package of SRH care that all clients
should be able to access, regardless of their social, physical and
mental status; sex; age; religion and country of origin. In the UK,
a coordinated system of competency-based SRH education,
training and certification has been established for primary care
providers (RNs, NPs, midwives and physicians) working in the
National Health Services.
Initially, the Working Group reviewed competencies that
met some or all of our criteria: (a) an interprofessional team
approach, (b) focus on primary care, (c) focus on SRH for
both men and women, (d) focus on sexual wellness as well as
disease-specific conditions, (e) articulation of a reproductive
justice approach and (f) professional ethics. The WHO
definition of SRH care that includes the reproductive health
of men and women throughout their life cycle, and
adolescents of both sexes formed the basis of the criteria.
The definition is not solely focused on reproduction and
infection but includes sexual health, which is defined as the
enhancement of life and personal relations. The definition
addresses associated sociocultural factors, gender roles and
the respect and protection of human rights. The WHO
competencies emphasize increasing the capacity of SRH
provision in primary care. See Tables 1A and 1B.
All of the competencies that we reviewed informed our initial
draft. For example, the discipline-specific competencies provided
the background for scope of practice and educational training for
the six professions. The WHO SRH Core Competencies in
primary care and the UK SRH competencies for nursing, the
generalist physician and the specialty obstetrician/gynecologist
met most of our criteria. However, neither was specific to the
unique needs of the US health care delivery system. After a
review of the available competencies, the Working Group
identified 33 initial competencies for Round 1.
440 J. Cappiello et al. / Contraception 93 (2016) 438445

Table 1A
Review of existing competencies by organization
Organization WHO UK SRH Healthy People 2020 US Centers for Disease Women's Health
Control/Office of Population Curriculum Health
Affairs Selected Practice Resources and Services
Recommendations Administration/Office
of Women's Health
Survey of existing Competencies Competencies Action plan Practice standard Women's health
standards curriculum
Core SRH Clinical competencies Basic SRH services/skills, National goals focus Guidelines for family Focus on women's
domains: included family planning, contraception, unplanned on unintended pregnancy, planning services. health care. Identifies
pregnancy spacing, pregnancy care, women's prenatal care, Focus on how key context for
infertility, STI, abortion health/common gynecology, adolescent health, contraceptive methods women's health
care, peripregnancy care. assessment of specialty STI & HIV detection. can be used and provide curricula.
gynecology problems, recommendations on
pregnancy care, genitourinary optimal use of contraceptive
conditions of men, sexual methods for persons
health promotion, public of all ages,
health, ethics including adolescents.
Review criteria
Team approach Professional primary Primary care Applies to all health Applies to all health Pharmacy, medicine,
health care team for SRH providers (midwives, care providers care providers nursing, dentistry,
(specified by country) nurses, physicians) public health.
Pharmacy not addressed.
Primary care focus Yes Yes Yes Yes Yes
Focus on men Men & women Men & women Men & women Men & women Women only
& women
Sexual wellness Yes Yes No No Yes
Articulates RJ Yes Yes Not part of document Not part of document Social determinants
approach of health
Articulates Yes Yes Not specifically addressed Not specifically addressed Yes
professional ethics
Review process SRH experts in Clinical Effectiveness Federal Interagency Systematic review Expert panel
research, education, Unit (National Workgroup, Institute by CDC, WHO meetings
policy, service. Health Services), of Medicine
Delphi research RCOG, RCN
Includes Yes Yes No Yes Yes
abortion care
US based No No Yes Yes Yes
Reference 3 10 11 12 13
STI, sexually transmitted infections; HIV, human immunodeficiency virus; RJ, reproductive justice; ACGME; Accreditation Council for Graduate Medical
Education.

The Round 1 Delphi survey was initially pilot tested by the
Working Group members to ensure clarity of the structure of the
survey. The Working Group members then identified expert
clinicians and educators in SRH through their professional
networks to invite for participation in the study. The Institutional
Review Board at the University of New Hampshire approved this
study. We invited 127 potential panelists via email using Survey
Monkey. There is no agreement in the literature on the ideal
sample size for Delphi surveys. In order to include adequate
representation from the six professions, we invited approximate-
ly 20 participants from each profession and sought participants
from diverse geographic regions. The invitation email contained
the consent form, which had to be completed before advancing to
the survey. Participants received no compensation for participa-
tion. After 3 weeks, we sent reminder emails. When the initial
response was lower than expected, we gave a 2-week extension,
with one email reminder sent by the survey administrator and
another email sent through the university email accounts of the
researchers. The dual-email approach increased participation
rates in each round. Data collection occurred from July 2014 to
January 2015.
We preserved anonymity among participants, and
between participants and their individual responses. To
provide additional layers of anonymity between participants
and their responses, an ARHP staff member rather than the
researchers administered the survey. The staff person
downloaded the anonymous results for each round from
the survey tool and compiled comments according to each
competency. A data analysis firm conducted the statistical
analysis of frequency and percentages for each competency.
We asked participants to provide feedback on each of 33
competencies by indicating that the competency was
sufficient as written, needed revision or should be dropped;
they could also provide edits to suggest improvement in the
competency. In order to give participants the opportunity to
review the input of the other participants in subsequent
 J. Cappiello et al. / Contraception 93 (2016) 438445 441

Table 1B
Review of existing competencies by profession
Organization Physician Registered nurse Certified nurse Nurse practitioner Family medicine Pharmacists
assistant midwife
Survey of existing Competencies Competencies Competencies Competencies ACGME program Competencies
standards requirements
Core SRH Broad professional 1. Broad professional Basic midwifery Population focused Well-woman care, Broad professional
domains: competencies with competencies competencies for professional family planning, competencies with
a focus on with a focus on beginning clinical competencies. contraception and a focus on
patient-centered care patient-centered care practice, including SRH included in options counseling patient-centered care
2. ROE Consortium well woman, selected populations for unintended
competencies specific antepartum, pregnancy
to SRH intrapartum,
postpartum
and neonatal care
Review criteria
Team approach Discipline specific Discipline specific Discipline specific Discipline specific Discipline specific Discipline specific
Primary care focus Yes Yes Yes Yes Yes Yes
Focus on men Men & women Men & women Men & women Men & women Women only Men & women
& women
Sexual wellness Nonspecific 1. Nonspecific Nonspecific Nonspecific Nonspecific Nonspecific
2. ROE Consortium
competencies
specific to SRH
Articulates RJ Uses general patient 1. Uses general Not part of document Uses general Not part of Uses general
approach centered care language patient centered patient centered document patient centered
care language care language care language
2. ROE Consortium
uses specific SRH language
Articulates Yes Yes Yes Yes Yes Yes
professional ethics
Review process National PA 1. Key stakeholders Key stakeholders Multiorganizational Family Medicine ACCP Task Force
organizations internal & external within the profession task force Residency Review
to nursing. Committee of
2. ROE Consortium-key ACGME
nursing stakeholder
Includes Broadly written, 1. Broadly written, No Inferred: support No Broadly written,
abortion care do not address do not address any a woman s right do not address
any specific specific health conditions to make her own any specific
health conditions 2. ROE Consortium decisions regarding health conditions
includes abortion care her health and
reproductive choices
within the context
of her belief system
US based Yes Yes Yes Yes Yes Yes
Reference 14 15, 6 16 17 18 19

rounds, competencies were combined but not eliminated
until Round 3. The percent agreement for accepting, revising
or dropping the competency as written was calculated for
each competency at the end of each round. The authors met
in person to review the Round 1 comments and incorporate
participant feedback into revised competencies. Round 2
participants received these revised competencies, accompa-
nied by a summary of all of comments received and an
explanation indicating how competencies were combined,
edited and reordered. In Round 2, survey participants again
had to choose whether each competency should be accepted,
dropped or revised. Following Round 2, two authors (J.C.,
M.N.) incorporated comments and sought additional input
from Working Group members to effectively incorporate the
additional feedback from all of the panelists. For Round 3,
participants either accepted or rejected each competency as
written; edits were no longer allowed.
3. Results
Fifty participants completed Round 1. Most were female
(90%), and most had been in practice for more than 10 years
(74%). As would be expected from the educational
requirements of their respective disciplines, 98% of
participants had master's degrees or higher. Most partici-
pants defined their primary professional practice as teaching
(42%) or clinical practice (36%). Of those primarily in
clinical practice, almost half were in academic practices
(47%). Forty-nine of the 50 participants identified a clinical
442 J. Cappiello et al. / Contraception 93 (2016) 438445

practice site; one participant had recently retired. Twenty- Table 2

two states across the country were represented. Physician Characteristics of participants
assistants, nurses and pharmacists were less well represented Frequency Percent
than physicians and advanced practice nurses (Table 2). Gender
In Round 1, only 17 of 33 competencies reached the Female 45 90.0
preset 75% agreement to accept as written. Participants Male 5 10.0
Total 50 100.0
suggested that the wording of some competencies was too
Number of years in practice
vague, was redundant, did not read as specific to SRH care 05 4 8.0
or required further editing. As a result of this feedback, 5 510 9 18.0
competencies were combined, reducing the total number of 1120 16 32.0
competencies to 28 for Round 2. The term sexual and 2130 10 20.0
Over 30 11 22.0
reproductive health care was added to five other compe-
Total 50 100.0
tencies, and each competency experienced at least some Professional background
minor editing. As a result of this feedback, we reworded 21 Certified nurse midwife 9 18.0
competencies and merged 2 competencies. The majority of Licensed nurse 3 6.0
the suggested edits in this round focused on using more Nurse practitioner 12 24.0
Pharmacist 7 14.0
succinct language (Fig. 1). In the final round, the lowest
Physician 17 34.0
level of agreement on a competency was 83.7%, with nine Physician assistant 2 4.0
competencies achieving 100% agreement. Forty-four Total 50 100.0
participants provided feedback on Round 3 to reach Highest educational degree
consensus on 26 competencies. The final competencies Bachelors 1 2.0
Masters 15 30.0
are listed in Table 3.
MD/DO 17 34.0
Participants in Round 1 stated that some competencies PhD 6 12.0
were too broad or that competencies were not specific to Total 50 100.0
SRH, thus overlapping with existing professional com- Primary professional responsibilities
petencies. We included concepts such as cultural Administration 3 6.0
Clinical practice 18 36.0
competency and patient centered care. Participants
Quality improvement 1 2.0
valued the concepts but felt that the terminology was Research 7 14.0
overused and lacking an agreed upon definition. The use Teaching 21 42.0
of terminology such as patient versus client lacked Total 50 100.0
agreement among respondents. Many comments focused Types of clinical settings
Academic practice 23 46.9
on concerns about whether a specific competency could be
Community-based practice 9 18.4
measured or not. There was solid agreement to include a Federal health department 1 2.0
competency on lesbian, gay, bisexual, queer/questioning Planned Parenthood Federation of America 1 2.0
and transgendered health care; however, the exact Private practice 9 18.4
wording produced many edits. Public health 1 2.0
Title X 2 4.1
The most challenging competency wording addressed the
Tribal health clinic 1 2.0
concept of reproductive justice. There were many and varied University health service 1 2.0
suggestions for edits. The Working Group members summa- Veteran's Administration 1 2.0
rized the comments with examples of wording for the Total * one participant retired 49 100.0
participants to review. In Round 2, many edits focused on Total number of participants in clinical practice 49 One retired
Primary professional responsibilities
screening and managing a condition that resonated with
Administration 3 6.0
professions who had the scope of practice to prescribe Clinical practice 18 36.0
treatments. Other professions felt that assessment and Quality improvement 1 2.0
counseling better described their competency. The participants Research 7 14.0
suggested using the term care, such as in provide screening Teaching 21 42.0
Total 50 100.0
and care. Because scope of practice differs significantly, for
example, between a registered nurse and a physician, the
language in the competencies is broad. Participants also
wanted the term referral included in selected competencies
to ensure that the language did not infer that a single health care 4. Discussion
provider or profession could meet all patient needs. Partici-
pants supported the inclusion of abortion care as a competen- This final set of competencies addresses the gaps in the
cy, and the continuing process of editing focused on the competencies that we initially reviewed, providing a US-in-
optimal way to state this competency. In Round 3, all formed set of SRH competencies. Each profession will need to
competencies met the 75% preset threshold level of agreement. take into account their specific scope of practice as they
 J. Cappiello et al. / Contraception 93 (2016) 438445
Round One
17 of 33
competencies
had 75%
agreement
50 participants
508 edits
Fig. 1. Three rounds of the Delphi survey.
incorporate the competencies into their profession-specific
education and training. In health care education, professional
competencies such as patient care and medical knowledge
serve as a framework for teaching and assessment. More
recently, health professions educators have introduced entrus-
table professional activities (EPAs) in order to better translate
competencies into clinical practice [9]. EPAs are the skills and
behaviors that demonstrate mastery of the ability to indepen-
dently provide specific components of patient care. Compe-
tencies establish the basic parameters for EPAs; in order to
demonstrate, for example, that a clinician is able to perform a
procedure safely and without discomfort to the patient, s/he
must first understand the components of the procedure and the
rationale for providing the procedure. Many of the competen-
cies generated by this group actually describe discrete
professional activities in SRH care and thus will fit well into
assessment systems that use EPAs to determine readiness for
independent performance.
Other models already exist which suggest a process for the
articulation of standards for the development of the knowledge,
attitude and skills required for a specific area of practice.
The Core Competencies in Genetics for all Health
Professional articulated broad genetic competencies for all
professions [10]. Each profession further identified curric-
ular guidelines and outcome indicators. Nursing developed
language to further specify competency at the registered
nurse and advanced practice level. Geriatrics followed a
similar process with the Multidisciplinary Competencies in
the Care of the Older Adult at the Completion of the
Entry-level Health Professional Degree [11]. Thirty profes-
sional organizations have endorsed the geriatric competen-
cies, and 10 health care disciplines have formally adopted the
competencies.
Following the example set by the geriatrics and
gerontology models, and the WHO and the UK SRH
models, we have identified these next steps: (a) dissemina-
tion of the competencies to the primary care professions
through their formal and informal organizational networks,
(b) endorsement from a variety of professional health care
organizations, (c) development of curricular tools to align
443
Round Two Round Three
5 competencies All competencies
combined for reached 75%
total of 28 agreement
39 participants 9 received 100%
227 edits agreement
44 participants
No further edits
possible
with the competencies, (d) development of continued
professional development modules to disseminate the
competencies and incorporate their use at all levels of
professional education, (e) evaluation of the use of the
competencies and (f) evaluation and refinement of the
competencies as they continue to be implemented. The
competencies are dynamic and will continue to evolve as
needed by each professional group and with the evolution of
interprofessional models of care delivery, as well as the
incorporation of SRH care into primary care.
In terms of limitations, the survey administrator and data
analyst ensured anonymity and accuracy but added more
time between each round, thus lengthening the data
collection period. This may have contributed to a loss of
momentum to the task of refining the competencies. In
addition, the software used could not filter out who had
already responded; thus, reminders were sent to all
participants in Round 3, including six participants who did
not respond to Round 2. Although representatives from all
professions were represented in the Working Group,
recruitment efforts were less successful in identifying
significant numbers of study participants from the profes-
sions of pharmacy and physician assistants.
In conclusion, using Delphi methods, a group of experts
identified 26 competencies in sexual and reproductive health
care for the interprofessional team. This comprehensive list
addresses the gaps in existing SRH competencies in health
professions education. Sexual and reproductive health
competencies for primary care can inform curricula across
health care professions, filling the gap between an
established standard of care necessary to meet patient
needs and the outcomes of that care.
Acknowledgments
We acknowledge the ARHP; the ARHP Working Group
on Core Competencies; Rana Suliman, Senior Program
Manager at ARHP, for managing the survey software; and
John Ogawa, PhD, of LTG Associates for his statistical
analysis support.
444 J. Cappiello et al. / Contraception 93 (2016) 438445

Table 3
Core competencies in SRH care for the interprofessional primary care team
Frequency Percent
Professional ethics and reproductive justice
1. Support patients' choices in sexual and reproductive 44 100.0
health care in a nonjudgmental and nondiscriminatory
manner, including their right to consent for or refuse care.
2. Act consistently in accordance with professional ethics and standards. 38 86.4
3. Incorporate knowledge of sexual and reproductive 39 90.7
anatomy and physiology and sex and age-specific
pharmacotherapeutic considerations into care.
4. Incorporate principles of the reproductive justice framework 37 86.0
when delivering sexual and reproductive health services.
Explanation: The reproductive justice framework recognizes
that the ability of any person to determine his/her reproductive
destiny is linked to the conditions in his/her community
and his/her full achievement of human rights.
5. Provide culturally sensitive sexual and reproductive care 43 97.7
with regard to race, ethnicity, class, gender identity and
expression, sexual orientation and disabilities.
6. Provide sexual and reproductive health care that meets 42 97.7
the needs of lesbian, gay, bisexual, queer/questioning
and transgender patients, with referral as needed.
Collaboration in SRH care
7. Collaborate with interprofessional team members through 43 97.7
shared goals, effective communication, mutual respect
and understanding of roles in the provision of
sexual and reproductive health care.
8. Provide referrals to community-based resources and/or 43 97.7
sexual and reproductive specialists when appropriate.
SRH services
9. Screen for pregnancy intention and provide 43 100.0
preconception care as indicated.
10. Provide counseling and/or referral for 40 93.0
reproductive health-related genetic screening.
11. Provide care for patients with fertility concerns. 36 83.7
12. Provide care for patients with early pregnancy loss, 43 100.0
ectopic pregnancy and other complications conditions
of early pregnancy with referral as needed.
13. Provide pregnancy testing and patient-centered pregnancy 43 97.7
options counseling that includes parenting, abortion and adoption.
14. Provide patient-centered contraceptive counseling, care and 43 100.0
management, including all appropriate methods and emergency contraception.
15. Provide abortion care including counseling, medication and 41 95.3
aspiration abortion, and follow-up care or referral if unable to provide these services.
16. Provide sexual and reproductive health care for postpartum patients. 43 100.0
17. Provide screening, diagnostic testing and treatment for 43 100.0
reproductive tract infections and sexually transmitted infections.
18. Provide screening, diagnostic testing and referral for reproductive tract cancers. 42 97.7
19. Provide care for patients with benign conditions of the reproductive tract. 42 97.7
20. Provide sexual and reproductive health care during the perimenopausal and postmenopausal period. 42 97.7
21. Provide counseling to promote sexual health and well-being across the lifespan. 43 100.0
22. Provide education and counseling regarding safer sex practices. 43 100.0
23. Provide screening and care for patients with sexual health concerns, including adolescents and older adults. 38 88.4
Conditions affecting SRH
24. Identify patients who have experienced sexual coercion, violence, 43 100.0
abuse or exploitation and provide counseling and/or referrals as needed.
25. Assess and provide counseling regarding environmental risk factors that affect reproductive health. 38 88.4
26. Provide screening, care and referral as needed for behavioral 41 95.3
and mental health concerns identified in the context of sexual and reproductive health care.
 J. Cappiello et al. / Contraception 93 (2016) 438445
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