PEDIATRICS Vol. 111 No. 5 May 2003, pp. 996-1001
Missed Opportunities for Sexually Transmitted Diseases, Human Immunodeficiency Virus, and Pregnancy Prevention Services During Adolescent Health Supervision Visits
* Division of HIV and AIDS Prevention, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
Department of Pediatrics, University of Rochester, Rochester, New York
|| Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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ABSTRACT |
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Objective. To describe prevention counseling on pregnancy and sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV), received by sexually experienced youth in the primary care setting and to test associations between recent sexual risk behaviors and preventive counseling.
Methods. Using data from the 1999 Youth Risk Behavior Surveillance survey, a nationally representative survey (N = 15 349) of high school students, we analyzed responses to questions about sexual experience, time since last preventive health care visit, and discussion of STD, HIV, or pregnancy prevention with a doctor or nurse during their last preventive health care visit. Logistic regression was used to test associations; students’ demographic characteristics were controlled.
Results. More than half of the US high school students surveyed reported a preventive health care visit in the 12 months preceding the survey: 60.4% (95% confidence interval [CI]: 57.2%–63.6%) of female students and 57.5% (95% CI: 53.9%–61.1%) of male students. For female students, sexual experience was positively associated with a preventive health care visit (odds ratio [OR]: 1.3; 95% CI: 1.1–1.6), but for male students, sexual experience had a negative effect (OR: 0.8; 95% CI: 0.7–0.9). Of the students who reported a preventive health care visit in the 12 months preceding the survey, 42.8% (95% CI: 38.6%–47.1%) of female students and 26.4% (95% CI: 22.7%–30.2%) of male students reported having discussed STD, HIV, or pregnancy prevention at those visits. Sexual experience was associated with a higher likelihood of engaging in a dialogue about sexual health once a student entered the health care system: female students (OR: 3.8; 95% CI: 3.0–4.9) and male students (OR: 1.9; 95% CI: 1.3–2.7).
Conclusion. Primary care providers miss opportunities to provide STD, HIV, and pregnancy prevention counseling to high-risk youth.
Key Words: adolescence • health supervision visit • prevention counseling • sexually transmitted diseases • human immunodeficiency virus • teen pregnancy
Abbreviations: STD, sexually transmitted disease • HIV, human immunodeficiency virus • YRBS, Youth Risk Behavior Surveillance (survey) • CDC, Centers for Disease Control and Prevention • AIDS, acquired immune deficiency syndrome • OR, odds ratio • CI, confidence interval
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INTRODUCTION |
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Pregnancy and sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) infection, constitute important preventable health problems among adolescents. Biological and behavioral factors place adolescents at high risk.1–3 The highest rates of gonorrhea and chlamydia are those for females 15 to 19 years old.4 Half of new HIV infections occur among persons <25 years of age.5 Nearly 1 of 20 females 15 to 19 years old becomes pregnant every year,6 and >90% describe their pregnancies as unintended. More than 50% of those unintended pregnancies end in abortion.7
The primary care health supervision visit offers an important opportunity to provide counseling about responsible sexuality and condom use to all adolescents and to offer contraception management and HIV and other STD screening to sexually active patients. Primary care guidelines recommend annually screening adolescents for sexual activity and its sequelae.8–11 Pediatric and adolescent health care providers play an important role in discussing STDs and HIV infection, postponing sexual activity, and practicing safer sex.12–16 However, obstacles such as limited provider skills, time constraints, and lack of confidential care can limit the content of the discussion and the services delivered.
We assessed the use of preventive health care visits as an opportunity to provide reproductive health counseling and services. First, to establish that a health supervision visit is a practical strategy for reaching adolescents, we determined the proportion of high school students who receive annual clinical preventive health care visits. Then, to estimate the missed opportunities for adolescent reproductive health prevention counseling and services delivery at those visits, we determined the proportion of high school students who received STD, HIV, and pregnancy prevention counseling during those adolescent clinical preventive health care visits.
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METHODS |
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Study Design
We analyzed data from the 1999 national school-based Youth Risk Behavior Surveillance (YRBS) survey, part of the Youth Risk Behavior Surveillance System implemented by the Centers for Disease Control and Prevention (CDC) to monitor the prevalence of risky health behaviors among youth.17 For the 1999 YRBS, a 3-stage cluster sample design was used to produce a representative sample of public and private high school students in grades 9 through 12 in the United States. The first-stage sampling frame contained 1270 primary sampling units, consisting of large counties or groups of smaller adjacent counties. A total of 52 sampling units were selected from 16 strata formed according to the degree of urbanization and the relative proportions of black and Hispanic students in the unit. The sampling units were selected with probability proportional to the number of students enrolled in schools in the unit. During the second stage of sampling, 187 schools were selected with probability proportional to the size of school enrollment. To ensure that the sample contained sufficient numbers of students in racial and ethnic subgroups for subgroup analysis, more of the schools with substantial numbers of black and Hispanic students were sampled. The final stage of sampling consisted of randomly selecting 1 or 2 intact classes of a required subject, such as English or social studies, from grades 9 through 12 at each selected school. All students in the selected classes were eligible to participate in the survey. A weighting factor was applied to each student’s record to adjust for the varying probabilities of selection at each stage of sampling, student nonresponse, and the oversampling of black and Hispanic students. The final weights were scaled so that the weighted count of students equaled the total sample size, and the weighted proportions of students in each grade matched projections of the national population. Survey procedures were designed to protect student privacy and allow anonymous participation. Following local procedures, parental consent was obtained before the survey was administered. The questionnaire, comprising 92 items, was administered in the classroom by trained data collectors. Additional details of the 1999 YRBS methodology have been described elsewhere.18 The YRBS was approved by the CDC Institutional Review Board.
Data Analyses
The timing of the most recent preventive health care visit was determined by asking "When was the last time you saw a doctor or nurse for a check-up or physical examination when you were not sick or injured?" Response options ranged from during the past 12 months to never. Having a discussion about STDs, HIV, or pregnancy prevention was assessed by responses to the question "During your last check-up, did your doctor or nurse discuss ways to prevent pregnancy, acquired immune deficiency syndrome (AIDS), or other STDs?"
We assessed the following demographic and sexual behaviors as independent variables: 1) age, 2) race/ethnicity, 3) geographic area of residence, 4) having ever had sexual intercourse, 5) multiple lifetime sex partners, 6) condom use by the student or the partner during most recent sexual intercourse, and 7) method for pregnancy prevention by the student or the partner during most recent intercourse. After the question "Have you ever had sexual intercourse?" the other sexual behaviors were analyzed for the students who reported at least 1 sexual experience. Responses to "During your life, with how many people have you had sexual intercourse?" were stratified into 1, 2–3, and 4 or more. Separate questions concerned condom use and contraceptive use: "The last time you had sexual intercourse, did you or your partner use a condom?" and "The last time you had sexual intercourse, what one method did you or your partner use to prevent pregnancy?" Responses about the method of pregnancy prevention were dichotomized into hormonal contraception (oral contraceptive or Depo-Proveraa contraceptive injection; Pharmacia Corp, Peapack, NJ) versus no or some other method.
We used a series of logistic regression models, controlling background demographic factors, to assess the independent associations between sexual risk behaviors (independent variables) and receipt of preventive health services and HIV, STD, and pregnancy prevention counseling (dependent variables). Separate analyses were conducted for male and female students. For all students, we examined the relationship between sexual experience and a preventive health care visit within the past 12 months. Because US primary care guidelines recommend annual health care screening for adolescents, a preventive health care visit within the past 12 months was used as the dependent variable.8–11 Next, we examined the relationship between sexual behaviors and a preventive health care visit in the past 12 months for sexually experienced students. For all students who reported a preventive health care visit within the past 12 months, we analyzed the relationship between sexual experience and the likelihood of discussing STDs, HIV, or pregnancy prevention at that visit. Finally, for sexually experienced students who reported a preventive health care visit within the past 12 months, we examined the relationship between sexual behaviors and a discussion about STDs, HIV, or pregnancy prevention.
To account for the complex sample design, we calculated prevalence estimates, adjusted odds ratios (ORs), and corresponding 95% confidence intervals (CIs), using weighted data and SUDAAN statistical analysis software (Research Triangle Park, NC). Differences between prevalence estimates were considered statistically significant if 95% CIs did not overlap, and adjusted ORs were considered statistically significant if 95% CIs did not include 1.0 or P < .05. Independent variables that did not achieve statistical significance were not included in the final logistic regression models.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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Sample
A total of 187 schools were selected for the 1999 YRBS sample, and 144 (77%) agreed to participate. At the participating schools, a total of 15 349 students (86% of sampled students) completed the questionnaire, resulting in an overall response rate of 66%. Item nonresponse of questions analyzed in 1999 YRBS ranged from <1% to 7% of surveyed students.
Half of the US high school students surveyed had had sexual intercourse: 47.7% (95% CI: 43.5–51.9) of female students and 52.2% (95% CI: 47.6–56.5) of male students. Coitarche was 14.6 years (95% CI: 14.5–14.7) among female students and 13.9 years (95% CI: 13.8–14.1) among male students. Among sexually experienced students, male students were more likely to report 4 or more lifetime sex partners and condom use during most recent sexual intercourse (Table 1). Female students were more likely to have used a hormonal contraceptive method during most recent sexual intercourse.
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Preventive Health Care Visits
More than half of the US high school students surveyed reported a preventive health care visit in the 12 months preceding the survey: 60.4% (95% CI: 57.2%–63.6%) of female students and 57.5% (95% CI: 53.9%–61.1%) of male students. Of the total, female students living in the Northeast (OR: 1.7) were more likely to report a preventive health care visit; Hispanic female students (OR: 0.7) and male students (OR: 0.6) were less likely to do so (Table 2). Although for female students, sexual experience was positively associated with a preventive health care visit in the 12 preceding months (OR: 1.3), sexually experienced male students were less likely to report a visit (OR: 0.8).
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Of sexually experienced students, 63.6% (95% CI: 60.1%–67.2%) of female students and 53.6% (95% CI: 49.1%–58.1%) of male students reported a preventive health care visit in the 12 months preceding the survey. Sexually experienced female students (OR: 1.9) and male students (OR: 1.7) living in the Northeast, female students using a hormonal contraceptive method (OR: 2.6), male partners of female students who used a hormonal contraceptive method (OR: 1.5), and female students with 2 to 3 lifetime sex partners (OR: 1.6) were more likely to report a preventive health care visit in the preceding 12 months (Table 3).
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Dialogue About STD, HIV, or Pregnancy Prevention
Of all students who reported a preventive health care visit in the 12 months preceding the survey, 42.8% (95% CI: 38.6%–47.1%) of female students and 26.4% (95% CI: 22.7%–30.2%) of male students reported having discussed STD, HIV, or pregnancy prevention at those visits. Among female students, older age, (17 years; OR: 2.9;
18 years; OR: 4.3), black race (OR: 2.2), and sexual experience (OR: 3.8) were associated with having discussed STD, HIV, or pregnancy prevention at a preventive health care visit within the last 12 months; among male students, only sexual experience was correlated with such a discussion (OR: 1.9) (Table 4).
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Of sexually experienced students who reported a preventive health care visit in the 12 months preceding the survey, 61.4% (95% CI: 55.4%–67.4%) of female students and 33.5% (95% CI: 28.3%–38.6%) of male students reported having discussed STD, HIV, or pregnancy prevention at those visits. Among sexually experienced female students, older age (
18 years; OR: 3.5), black race (OR: 2.0), 4 lifetime sex partners (OR: 2.3), and hormonal contraception use during most recent sexual intercourse (OR: 4.4) were associated with reporting a discussion about STD, HIV, or pregnancy prevention with their provider. For sexually experienced male students, no variables reached statistical significance in the model (Table 5). However, age of 18 years approached significance in the model for sexually experienced male students (P = .05; data not shown).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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In our study, most of the high school students reported a preventive health care visit in the preceding 12 months. Although most students received some form of preventive health care annually, few had discussed STD, HIV, or pregnancy prevention at those visits. Perhaps because it was the reason for their visit, the students most likely to engage in such a dialogue were older female students who were already using hormonal contraception.
A variety of demographic and behavioral variables affected the students’ use of health care services. Hispanic students were 30% to 40% less likely than students of other race/ethnicities to report a preventive health care visit in the 12 months before the survey and female students in the Northeast were >1.5 times more likely than female students in other geographic regions to report a preventive health care visit in the 12 months before the survey. From the students’ demographic characteristics, these differences mirror the likelihood of health insurance coverage,19 which is a key determinant of adolescents’ use of health care services.20–22 Low-income youth—the population at substantial risk for limited access to health care—are also most at risk for STDs and unintended pregnancy.4,6
Sexually experienced female students were more likely to report a preventive health care visit in the 12 months preceding the survey, but sexually experienced male students were less likely to do so than were peers who were not sexually experienced. However, for both male and female students, having ever had sexual intercourse increased the likelihood of engaging in a dialogue about reproductive health issues once a student entered the health care system. Although all sexually experienced adolescents need reproductive health counseling, the opportunities for the counseling and care of male adolescents are very limited. Whereas female adolescents seek care at public sector and not-for-profit family planning clinics and from private sector obstetricians and gynecologists, reproductive health care for male adolescents, except for a limited network of STD clinics primarily located in urban areas, do not exist. The use of hormonal contraception compels female adolescents to use the health care system; male condom use bears no such prerequisites.
Although clinical preventive services and STD and HIV care are limited, male adolescents use them when they are more accessible (eg, located in school-based health centers or community-based organizations).23–26 The association between adolescent sexual activity and a discussion with a provider about reproductive health discussion could reflect provider recognition or an inquiry from the adolescent. This positive association emphasizes the importance of screening adolescents for sexual activity and encouraging patient-provider dialogue. Although providers should discuss STD, HIV, and pregnancy prevention with all adolescents, more focus should be directed toward sexually experienced male adolescents.
YRBS data also confirm that less than half of female and only a quarter of male students who reported having received preventive health care services had discussed the prevention of the outcomes of risky sexual behavior. The students most likely to have engaged in this dialogue were older, sexually experienced female students who had already entered the health system and were using hormonal contraception. Surveys of pediatric providers confirm that providers do not typically offer their adolescent patients reproductive health services.27–31 Adolescents view their primary care providers as valid reproductive health information sources32 and report a desire to discuss confidential issues with physicians.33 Although half of US high school students are sexually experienced, many do not receive guidance that could prevent the detrimental outcomes of risky sexual behavior.
Our study has several limitations. Our data relied on students’ self-report of confidential interactions. Although research on health services for adolescents has traditionally relied on parent reports, chart review, and administrative databases, these sources may not accurately reflect the care delivered. For adolescents, self-report has been shown to be a valid and reliable method for determining the content of preventive health services.34,35 In addition, the YRBS survey questions demonstrate good test-retest reliability.36
Our analysis is also limited by lack of data about the validity of recall of the specific timing of an adolescent’s last visit. Klein et al34 found that 94% of adolescents surveyed remembered having had a specific health care visit within 6 months. Although both adolescents and adults tend to ‘‘telescope’ events into more recent times when recalling encounters, studies in adults show that recent ambulatory physician visit report is accurate, but self-reported ambulatory physician visits in the previous year are biased toward underreporting at higher numbers of visits.37,38 Because adolescent ambulatory visits are relatively rare events, these issues are unlikely to have caused substantial bias in our data except for the small portion of respondents with chronic or high acuity illness resulting in high utilization.
Because these data are cross-sectional, we cannot conclude that there is a cause-and-effect relationship between risk behaviors and the health services received. These data also apply only to adolescents who attend high school. In 1999, 96% of persons 14 to 17 years old were enrolled in school.39 The health needs and risk behaviors described by these data probably underestimate the circumstances of the 5% of US adolescents who do not attend school.40
Finally, using data from the YRBS, we were able to analyze only a limited number of demographic and behavioral variables. Other pertinent information on health insurance, family income, usual source of medical care, satisfaction with the provider, and knowledge of and attitudes toward STD, HIV, and pregnancy prevention need further definition. Nonetheless, providing anticipatory guidance and screening for health-compromising conditions and behaviors make up the core of comprehensive pediatric health supervision.11 The use of a health services surveillance system to assess the content of primary care delivered to adolescents has the potential to improve the quality of the care they receive.
Implications
STDs, HIV infection, and pregnancy are preventable. Although 92% of adolescents have a usual source of care,19 many adolescents acquire STDs, and many female adolescents become pregnant. These data demonstrate that primary care providers miss opportunities to provide adolescents with STD, HIV, and pregnancy preventive services. Noninvasive sensitive and specific STD and HIV tests,41,42 effective methods of hormonal contraception,43 an effective STD and HIV brief counseling strategy,44 and a plethora of resources for patient information45 provide the opportunity for primary care providers to deliver effective reproductive health services as part of standard adolescent preventive care. Because the sequelae of risky sexual behaviors are preventable, we recommend that all primary care providers discuss HIV infection, STDs, and pregnancy with their adolescent patients before as well as after these young persons become sexually active.
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FOOTNOTES |
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Received for publication Aug 23, 2002; Accepted Nov 12, 2002.
Reprint requests to (G.R.B.) Division of HIV/AIDS Prevention-Surveillance and Epidemiology, National Center for HIV, STD, and TB Prevention, Centers for Disease Control and Prevention, Mail Stop E-46, 1600 Clifton Rd, NE, Atlanta, GA 30333. E-mail: gib5{at}cdc.gov
a The use of trade names does not imply endorsement by the Centers for Disease Control and Prevention or by the US Department of Health and Human Services. 
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