OBJECTIVE: In the United States, 15- to 24-year-olds represent ∼14% of HIV cases diagnosed in 2006 and almost 50% of the 19 million sexually transmitted infections (STIs) reported annually. This survey assessed pediatricians' practices regarding preventive health care screening, provision of reproductive health services including HIV and STI screening and counseling, and barriers to providing these services.
METHODS: A random-sample mailed survey of 1626 US members of the American Academy of Pediatrics in 2005.A total of 752 completed questionnaires were returned (46% response rate). Analysis was limited to the 468 pediatricians who provided health supervision visits to patients who were older than 11 years.
RESULTS: Most pediatricians discussed sexual activity at preventive care visits; similar numbers discuss abstinence (62%), condoms (61%), and STIs (61%) with slightly fewer discussing HIV (54%). Pediatricians occasionally or rarely/never discussed homosexuality/sexual identity (82%). Most (71%) identified adolescents with high-risk behaviors by clinical interviews. Approximately 30% prescribed condoms, 22% distributed condoms, and 19% provided condom demonstrations. Whereas 46% of pediatricians recommended STI tests for all sexually active teens, only 28% recommended HIV testing for this population. Hospital/clinic-based and inner-city practitioners were more likely to prescribe, provide, and demonstrate condoms and recommend HIV/STI tests for sexually active teens. The most frequently identified barrier to HIV and STI prevention counseling was lack of time.
CONCLUSIONS: Pediatricians believed it is important to deliver reproductive health services, and most addressed adolescent sexual activity at preventive care visits but did not routinely address homosexuality/sexual identity. Counseling and testing practices varied by physician characteristics.
WHAT'S KNOWN ON THIS SUBJECT:
Adolescents often engage in high risk behaviors such as sexual activity and are at risk for acquiring sexually transmitted infections includung HIV. Pediatricians are encouraged to address sexual activity as part of annual preventive care visits.
WHAT THIS STUDY ADDS:
This survey of Pediatricians providing care to adolescents indicates that sexually active adolescents are more likely to be tested for sexually transmitted infections, and that most pediatricians do not routinely address HIV testing, or homosexuality/sexual identity.
Adolescence is frequently associated with risk-taking behaviors that are a natural reflection of normal adolescent physical and social development. Experimentation with substance use and sexual activity, for example, is most commonly encountered during middle and late adolescence (age 14–21 years). Among a national representative survey by the Kaiser Family Foundation of >1800 youth aged 13 to 24, almost one-third of 15- to 17-year-olds reported pressure to have sex.1 The 2007 Youth Risk Behavior Survey, a national high school–based survey conducted by the Centers for Disease Control and Prevention (CDC), illustrates the association of increasing sexual experience with age, with “ever having sexual intercourse” reported by 33%, 44%, 56%, and 65% of ninth- through 12th-graders, respectively. Slightly more than one-third (38.5%)of youth reported not using condoms at last intercourse, and 15% reported ≥4 lifetime sexual partners.2
Significant risks are associated with sexual activity, including unintended pregnancy and sexually transmitted infections (STIs), including HIV. Adolescents/young adults aged 15 to 24 account for almost 50% of the estimated 19 million new cases of STIs reported annually in the United States.3,–,5 Adolescents aged 13 to 24 years represented 14.2% of all HIV/AIDS cases diagnosed in 2006,6 and among young men who have sex with men (MSM) aged 13 to 24 years, the incidence of HIV cases increased 12.4% between 2001 and 2006.7
The American Academy of Pediatrics (AAP), Department of Health and Human Services Maternal and Child Health Bureau, and the American Medical Association promote the delivery of annual clinical preventive health care visits and have developed materials for use in office practices that include developmentally focused anticipatory guidance topics for adolescents and their parents.8,9 The US Preventive Services Task Force also recommends screening for HIV and other STIs and counseling to prevent STIs for all sexually active adolescents and for adults who are at increased risk (www.ahrq.gov/clinic/uspstf05/hiv/hivrs.htm). The objectives of our study were to examine the extent to which pediatricians identify adolescents who are at risk and offer reproductive health services (RHS), including prescribing and distributing condoms and recommending STI/HIV testing and to identify barriers to providing these services.
Data for this study were obtained from the 63rd Periodic Survey of Fellows, conducted by the AAP Department of Research. This survey, conducted from May through September 2005, consisted of an 8-page self-administered questionnaire mailed to 1626 randomly selected nonretired AAP members who were residing and working in the United States. Approximately 80% of all US board-certified pediatricians are members of the AAP. The original mailing was followed by up to 6 additional mailings to nonrespondents.
Survey content was informed by the AAP Committee on Pediatric AIDS. AAP institutional review board approval was obtained before study initiation. The survey is available on request from the AAP (). All respondents were asked a broad range of questions including demographic and practice characteristics. Pediatricians who answered the adolescent health supervision questions were asked to do so for their main practice, defined as the location where they spend most of their time. Specific questions related to office policies and to individual practices regarding confidentiality, prevention care counseling, and identification of high-risk behaviors.
High-risk behaviors were defined as those generally associated with transmission of HIV and other STIs. These include vaginal, anal, or oral sex without the use of condoms or other barrier protection; a history of previous STIs; multiple sexual partners; and illicit oral or intravenous drug use. A clinician's office was determined to have the capability for delivering RHS when any of the following was routinely offered: pelvic examinations, STI screening, provision of contraception prescriptions, or administration of injectable contraception.
χ2 analyses were used to compare differences in counseling and screening practices by pediatricians' characteristics, including age (≤/>45 years), gender, practice type (solo/2-physician practice, group/staff model health maintenance organization practice, hospital/clinic practice), practice location (urban inner city, other urban area, suburban, and rural), and patient insurance source (<50% of patients with public health insurance, ≥50% with public insurance). McNemar's test was used with nonparametric data. Multivariate logistic regression was used to assess associations between pediatricians' demographic and practice characteristics and their self-report of whether they offer RHS or distribute condoms in their offices. The logistic models included variables whose bivariate relationships were significant at the .05 level or have been previously shown to have an effect on pediatrician counseling behaviors. All statistical tests were performed using SPSS 14.0 (SPSS Inc, Chicago, IL).
A total of 752 completed questionnaires were returned, a response rate of 46%, consistent with other AAP Periodic Surveys conducted during this time. On the basis of comparison by using AAP membership file data, respondent pediatricians were similar to nonrespondents with respect to gender, age, and practice locations (data not shown).
Almost all (92%) responding pediatricians reported providing patient care. These results are limited to the 468 pediatricians (62% of respondents) who reported that they provided preventive health care to patients who were aged ≥11 years. These physicians reported working an average of 49 hours per week. Fifty-four percent reported that their primary practice setting was a group practice (including staff model health maintenance organizations); 18% were in solo or 2-physician practices; and 26% were in a medical school, hospital, or clinic practice setting. Forty-five percent practiced in suburban areas and 43% in urban areas including 17% who practiced in inner-city environments. Fifty-five percent were female, and the average age was 45 years. Fewer than 2% of respondents to our survey indicated that their specialty was adolescent medicine.
Eighty percent of respondents reported recommending yearly preventive care visits for their adolescent patients; 16% recommended biannual visits. More than three-fourths of pediatricians reported always discussing most general health care topics at well/preventive care visits (Table 1). Approximately 6 of 10 pediatricians reported always discussing abstinence, contraception, and STIs during these visits, and slightly more than half discussed HIV. Fewer than 40% of pediatricians surveyed reported always including discussions of sensitive topics such as violence prevention, sexual or physical abuse, or homosexuality/sexual identity as part of their routine practice. The infrequent discussion of homosexuality/sexual identity is noteworthy; <1 in 5 pediatricians always discussed this topic during well/preventive care visits, and slightly more than one-third rarely or never broached this topic.
Although the data are not presented, pediatricians were also queried about frequency of discussions with parents on preventive health topics. Puberty/reproductive health and sexually activity were always or occasionally discussed by almost three-fourths (73%) of respondents, and abstinence, condoms, contraception, sexual/physical abuse, and HIV/STIs were each discussed by approximately two-thirds of respondents.
Overall, 58.3% of pediatricians said that their practice has a standardized office protocol for confidentiality (ie, policies that address when confidentiality may be waived, guidelines for reimbursement for services, medical record access and appointment scheduling, and office policies for information disclosure).
Reproductive Health Services
Overall, 55.6% of pediatricians routinely offered at least some RHS in their main practice. The specific services offered by pediatricians who provided RHS are shown in Table 2. Routine provision for oral contraceptives was reported by 85% of these pediatricians, yet among all respondents, only 22% distributed or made condoms available in their office and 10% had condoms available in public areas. Among pediatricians who made condoms available, 5.9% always provided demonstration of their proper use, 55.4% sometimes did so, and 39% never provided demonstrations.
Provision of RHS varied by physician and practice characteristics (Table 3). Younger age, female gender, practice in hospital or clinic settings and inner city location, and having a standardized protocol for confidentiality were associated with greater delivery of RHS. In multivariate analysis, younger age (adjusted odds ratio [aOR]: 1.67 [95% confidence interval (CI): 1.04–2.68]), female gender (aOR: 1.65 [95% CI: 1.05–2.60]), practice in the inner city (aOR: 3.10 [95% CI: 1.46–6.61]), and having an office protocol for confidentiality (aOR: 2.79 [95% CI: 1.77–4.41]) remained as predictors of offering these services.
Similarly, in bivariate analysis, younger age, practice in the inner city or hospital/clinic setting, and having a standardized office protocol for confidentiality were associated with distributing condoms, as was having a majority (≥50%) of patients covered by public insurance (Table 3); however, in multivariate analysis, only practice in a hospital or clinic setting (aOR: 2.95 [95% CI: 1.36–6.40]), practice in an inner city (aOR: 4.24 [95% CI: 1.89–9.51]), and having a standardized office protocol for confidentiality (aOR: 3.45 [95% CI: 1.82–6.52]) were predictive of making condoms available to adolescent patients.
Identification and Testing of Adolescents with High-risk Behaviors
Most pediatricians reported identifying high-risk behaviors by clinical interview. Pediatricians (64.1%) reported that they were more likely than the patient (7.0%) to initiate dialogue about high-risk behaviors. Twenty percent used a standardized risk assessment tool with all or some adolescents; the majority (64%) of these pediatricians relied on a tool that they or other members of their practice developed. More than 93% of all pediatricians surveyed responded that once an adolescent with high-risk behaviors was identified, 69.4% and 65.7% recommend testing for STIs and HIV, respectively. Only 46% routinely recommended testing all sexually active patients for STIs, and 28% routinely recommended testing all sexually active patients for HIV (Table 4). Pediatricians who recommended that all high-risk patients be tested for STIs and HIV were more likely both to offer RHS and to provide condoms (P < .01 for all comparisons).
Among pediatricians who offered routine RHS as part of their practice, 74% provided on-site HIV testing and the remainder referred elsewhere for HIV testing. Only 7% of those who provided on-site testing for HIV had access to oral or rapid antibody tests. Fewer than 9% of pediatricians reported that they were very familiar with either the AAP policies on STI and HIV testing of adolescents or the 2003 CDC recommendations to routinize HIV testing. Most of the 91% remaining were “somewhat” or “vaguely” familiar with AAP policies (80%) and CDC recommendations (70%). Approximately 25% of responding pediatricians did not know whether their state law allowed HIV or STI testing of adolescents without parental consent.
Attitudes and Barriers
Nearly all (>90%) pediatricians agreed that alcohol and drug use contributes to high-risk sexual behavior among adolescents and believed that pediatricians should discuss sexual and other high-risk behaviors and HIV prevention with their adolescent patients. Most thought that lack of information about HIV transmission contributes to high-risk sexual behaviors (69%) and believed that personalized preventive counseling is effective in reducing these behaviors (64%). Few (7%) pediatricians thought that HIV tests should be limited to adolescents with STIs.
The most common barriers to providing STI/HIV counseling included lack of sufficient time to conduct personalized HIV prevention counseling (76%), cultural or language differences between the pediatrician and the patient (69%), adolescents' inaccurate responses to inquiries about sexual behaviors (68%), physicians' discomfort discussing sexual issues (66%), and adolescents' fear of parental notification about sexual and/or high-risk behaviors (60%). More than half of respondents identified lack of adequate reimbursement for HIV prevention counseling (58%), lack of interest in adolescent health issues (58%), and insufficient training in how to talk to adolescents about STIs/HIV (55%) as barriers to delivery of these services.
Our survey indicates that although most pediatricians ascribed to current recommendations for annual preventive health care visits during adolescence, the content of these visits frequently failed to address important sexuality and reproductive health care needs. Although two-thirds of pediatricians thought that personalized preventive counseling is effective in reducing high-risk behaviors among adolescents, 3 of 4 believed that they did not have sufficient time to provide such counseling. Regrettably, lack of interest in adolescent health was reported by more than half of respondents.
On the basis of our survey results, inner-city practices were more likely than their counterparts both to routinely provide RHS and to have an office-wide standardized protocol for confidentiality. Failure to provide an assurance of confidentiality may lead adolescents to forgo health care10,11 and may also result in adolescents' being less forthcoming about their true health concerns.12,13 Pediatricians are encouraged to develop confidentiality protocols, discuss confidentiality with adolescents and their parent/legal guardians, and be knowledgeable about state laws regarding health care to minors. Both Bright Futures8 and Guidelines for Adolescent Preventive Services9 recommend meeting with parents to discuss issues that are commonly encountered during each stage of adolescent development. The majority of pediatricians surveyed engaged parents in dialogue about reproductive health and sexual activity, although topics related to sexual activity such as condoms, contraception, STIs, and HIV were less frequently discussed.
The availability of RHS is both important and necessary for sexually active youth. The finding that the majority of pediatricians who provided RHS were most likely to practice in inner-city sites raises concerns about perceptions of “risk.” These practice sites may be more likely to encounter ethnic minorities of lower socioeconomic status, who, on the basis of current STI and HIV surveillance, are more likely to be positive for an STI or HIV. In 1 randomized, controlled trial of 116 unmarried white and black sexually active girls aged 15 to 19 years, white girls were more likely to engage in more frequent high-risk sexual behaviors including more sexual partners, more partners that used intravenous drugs, less condom use, and more frequent alcohol use before sex; however, black girls were more likely to be tested for HIV.14 It is critical that pediatricians understand that all adolescents who engage in sexual or other risky behavior(s) are at risk for STIs and HIV.
Our survey results indicate that 7 of 10 pediatricians recommend STI and HIV testing for “all” patients who screen at high risk. This testing is supported by a recent report that one-fourth of adolescent girls tested positive for at least 1 STI, the most common being human papillomavirus (18%) and Chlamydia (4%).15 Current guidelines recommend annual screening for Chlamydia and gonorrhea with retesting of girls with Chlamydia within 3 to 12 months of treatment.16 Testing should be accompanied by prevention education that addresses abstinence, limiting the number of sexual partners, and emphasizing safer sexual practices (correct and consistent condom use) for nonabstinent adolescents.
A minority of pediatricians made condoms available, and most did not demonstrate proper use. This is concerning, because knowing how to use condoms properly may result in less STI/HIV transmission and unintended pregnancy. Two studies surveyed condom use errors among female and heterosexual male college students and found placement of the condom after initiating sexual activity, not leaving space at the tip of the condom, and placing the condom on backward were frequently reported.17,18 Data from the National Longitudinal Study of Adolescent Health of >16 000 adolescents identified misconceptions that included not needing to leave space at the tip of the condom and petroleum jelly as an acceptable lubricant.19 To ensure that adolescents are equipped with the knowledge and skill to use condoms correctly, information about proper use accompanied by condom demonstrations is encouraged.20
All adolescents can benefit from knowing how condoms can prevent transmission of HIV and other STIs. One subpopulation at significant risk for HIV is MSM, the leading exposure category for HIV infection. Our survey found that one-third (35.6%) of pediatricians rarely or never discussed homosexuality/sexual identity with patients.
Adolescents who self-identify as gay, lesbian, bisexual, or transgender may be at increased risk for depression, substance use, promiscuity, victimization, and suicidal ideation/attempts.21,–,23 In a study by Meckler et al24 of gay adolescents, nearly two-thirds reported that if a physician asked them about being gay, they would be more comfortable discussing their sexual orientation. The AAP, the American Medical Association, and the Society for Adolescent Medicine recommend discussing sexual orientation as part of routine health care.
Whereas equivalent numbers of pediatricians recommended both STI and HIV testing in “high risk” patients, almost twice as many pediatricians would screen “all” sexually active patients for an STI compared with HIV. In addition, <9% of pediatricians surveyed were very familiar with either AAP or CDC recommendations on STI and HIV counseling and testing. During the time this survey was conducted, the CDC HIV testing guidelines encouraged screening patients for HIV-related risk factors and making HIV testing routine, accessible, and available. The CDC strengthened their recommendations for HIV testing of adults, adolescents, and pregnant women in September 2006. These recommendations (1) encourage medical providers to incorporate consent for HIV testing into their general care consent, (2) waives requirements for pretest counseling and written consent as a prerequisite to HIV testing, and (3) strongly recommends that all individuals between the ages of 13 and 64 be tested for HIV.25 Screening for HIV is specifically recommended for any person who seeks treatment for STIs, pregnant women, and MSM.25
Some of the barriers to providing STI/HIV counseling cited by pediatricians in this survey must be addressed if successful implementation of the current CDC recommendations and improvements in the delivery of RHS to adolescents are to occur. Pressure must be brought to insurance companies and other third-party payers to provide confidential reimbursement codes and adequate reimbursement for prevention education and RHS. Insufficient training in talking with adolescents about STIs/HIV and discomfort discussing sexual issues need to be addressed, through educational programs. Formally established office guidelines to address confidentiality may encourage adolescents to discuss sensitive topics more openly.
There are several limitations to our study. The survey included only members of the AAP, so the findings may not be generalizable beyond this group. Because of social desirability, respondents may be biased toward overreporting counseling; however, if this is so, then the low reports of counseling on the high risk-taking behaviors are all the more concerning. Fewer than half of the sample responded to the survey, introducing the possibility of nonresponse bias; however, respondents were similar to nonrespondents on key variables, and studies of nonresponse bias among relatively homogeneous professional groups including an analysis of response rates to AAP surveys suggested minimal nonresponse bias.26,27 Last, it is also possible that the number of respondents to our survey overestimated the actual proportion of pediatricians who care for youth.
Our survey shows that pediatricians believed in the importance of RHS, and most addressed adolescent sexual activity. Although they believed that individualized counseling can reduce risky behaviors and that testing for HIV and other STIs should be considered part of a package of care, only a subset of physicians had implemented these activities. The data indicate that additional training to address identified barriers is needed and could result in improved health for adolescents.
This study was supported by the AAP and funded in part by a grant from the CDC as part of the HIV Prevention with National Medical and Nursing Associations project (cooperative agreement U65/CCU524395-02).
We thank Sanford Sharp for assistance with data collection and analysis.
- Accepted January 5, 2010.
- Address correspondence to Lisa M. Henry-Reid, MD, Stroger Hospital of Cook County, 1st Directory-Office, Administration Bldg, Room 1111, 1900 W Polk St, Chicago, IL 60612-3834. E-mail:
The views expressed in this article are those of the authors and do not represent policies of the American Academy of Pediatrics.
FINANCIAL DISCLOSURE: Dr Henry-Reid is on the speakers Bureau of Merck, Bristol-Myers-Squibb; and GlaxoSmithKline; Dr Flynn has clinical research agreements with Tibotec and Medimmune; Dr Futterman has received a Gilead Pharmaceuticals education grant and funded research project from Orasure Technologies; and Ms O'Connor, Dr Klein, and Ms Cooper have no financial relationships relevant to this article to disclose.
- CDC =
- Centers for Disease Control and Prevention •
- STI =
- sexually transmitted infection •
- MSM =
- men who have sex with men •
- AAP =
- American Academy of Pediatrics •
- RHS =
- reproductive health services •
- aOR =
- adjusted odds ratio •
- CI =
- confidence interval
- Henry J,
- Kaiser Family Foundation,
- Hoff T,
- Greene L,
- Davis J
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- 15.↵Department of Health and Human Services. 2008 National STD Prevention Conference, Chicago, March 10–13, 2008. Available at: www.cdc.gov/stdconference/2008/press/release-11march2008.htm. Accessed August 7, 2008
- 20.↵American Academy of Pediatrics: Committee on Psychosocial Aspects of Child and Family Health and Committee on Adolescence. Sexuality education for children and adolescents. Pediatrics. 2001; 108(2): 498–502
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- Copyright © 2010 by the American Academy of Pediatrics