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Missed Opportunities for Sexually Transmitted Diseases, Human Immunodeficiency Virus, and Pregnancy Prevention Services During Adolescent Health Supervision Visits Gale R. Burstein, MD, MPH*, Richard Lowry, MD, MS, Jonathan D. Klein, MD, MPH and John S. Santelli, MD, MPH|| PEDIATRICS Vol. 111 No. 5 May 2003, pp. 996-1001 http://pediatrics.aappublications.org/cgi/content/full/111/5/996 * 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      ABSTRACT   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      INTRODUCTION   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.      METHODS   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.      RESULTS   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. TABLE 1. Proportion of Sexually Experienced High School Students Reporting Risky Sexual Behaviors, by Gender: United States, 1999 Variables Female Students   Male Students   % (95% CI) % (95% CI)   Lifetime partners      1 37.3 (33.7–40.9) 32.5 (28.4–36.6)  2–3 35.3 (31.9–38.8) 30.5 (28.4–32.7)  4 27.4 (24.0–30.8) 37.0 (31.5–42.5) Condom use at last sex 54.4 (50.0–58.7) 66.1 (62.9–69.4) Hormonal contraceptive* use at last sex 21.6 (18.9–24.3) 10.7 (7.7–13.6)   * Oral contraceptive pill or Depo-Provera injectable contraceptive.   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). TABLE 2. Association Between Characteristics of High School Students and a Preventive Health Care Visit Within the Past 12 Months: United States, 1999 Variables Female Students   Male Students   % OR (95% CI) % OR (95% CI)   Age (y)              18 63 1.0 (0.6–1.6) 49 0.7 (0.4–1.1)      17 62 1.0 (0.6–1.5) 58 0.9 (0.6–1.4)      16 59 0.8 (0.5–1.3) 59 1.0 (0.7–1.4)      15 58 0.8 (0.5–1.2) 59 0.9 (0.6–1.5)      14 62 1.0 (ref) 61 1.0 (ref)     Race/ethnicity              Black 63 1.0 (0.9–1.2) 54 0.8 (0.6–1.2)      Hispanic 51 0.7 (0.6–0.9)* 48 0.6 (0.5–0.8)*      Other 58 0.9 (0.6–1.3) 56 0.9 (0.6–1.2)      White 62 1.0 (ref) 60 1.0 (ref)     Geographic region              Northeast 70 1.7 (1.2–2.3) 67 1.3 (1.0–1.7)      Midwest 57 0.9 (0.6–1.3) 55 0.8 (0.6–1.1)      South 59 0.9 (0.7–1.2) 53 0.7 (0.5–1.1)      West 56 1.0 (ref) 60 1.0 (ref)     Sexually experienced              Yes 64 1.3 (1.1–1.6) 54 0.8 (0.7–0.9)*      No 57 1.0 (ref) 62 1.0 (ref)       * P < .001. P < .01. P < .05. 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). TABLE 3. Association Between Characteristics of Sexually Experienced High School Students and a Preventive Health Care Visit Within the Past 12 Months: United States, 1999 Variables Female Students   Male Students   % OR (95% CI) % OR (95% CI)   Age (y)               18 68 1.2 (0.7–2.3) 48 0.7 (0.4–1.4)      17 67 1.2 (0.7–2.1) 55 1.0 (0.6–1.9)      16 62 1.1 (0.6–1.9) 55 1.0 (0.6–1.6)      15 59 1.0 (0.5–2.0) 54 1.0 (0.5–2.1)      14 57 1.0 (ref) 59 1.0 (ref)     Race/ethnicity              Black 57 1.2 (0.9–1.6) 55 1.1 (0.8–1.5)      Hispanic 51 0.7 (0.5–1.0) 48 0.9 (0.7–1.1)      Other 65 1.0 (0.6–1.6) 59 1.2 (0.8–1.8)      White 64 1.0 (ref) 53 1.0 (ref)     Geographic region              Northeast 74 1.9 (1.3–2.8)* 64 1.7 (1.1–2.6)      Midwest 62 1.0 (0.6–1.6) 52 1.0 (0.7–1.5)      South 60 1.0 (0.6–1.6) 49 0.9 (0.6–1.4)      West 59 1.0 (ref) 53 1.0 (ref)     Lifetime sex partners (no.)              4 64 1.2 (0.8–1.8) 52 0.8 (0.6–1.0)      2–3 69 1.6 (1.2–2.2) 50 0.7 (0.5–1.0)      1 58 1.0 (ref) 58 1.0 (ref)     Hormonal contraception use              Yes 80 2.6 (1.8–3.7)* 61 1.5 (1.0–2.1)      No 59 1.0 (ref) 52 1.0 (ref)       * P < .001. P < .01. P < .05.   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). TABLE 4. Association Between Characteristics of High School Students Reporting a Preventive Health Care Visit Within the Past12 Months and Discussion of Pregnancy, STDs, or HIV Prevention: United States, 1999 Variables Female Students   Male Students   % OR (95% CI) % OR (95% CI)   Age (y)              18 68 4.3 (2.3–8.0)* 28 1.2 (0.7–1.9)      17 56 2.9 (1.8–4.7)* 29 1.3 (1.0–1.7)      16 37 1.5 (0.9–2.5) 26 1.1 (0.8–1.5)      15 31 1.4 (1.0–1.9) 26 1.1 (0.8–1.7)      14 21 1.0 (ref) 22 1.0 (ref)     Race/ethnicity              Black 63 2.2 (1.5–3.2)* 36 1.5 (1.0–2.4)      Hispanic 36 0.9 (0.6–1.4) 33 1.4 (0.9–2.2)      Other 39 1.1 (0.6–2.1) 32 1.5 (0.8–2.7)      White 40 1.0 (ref) 23 1.0 (ref)     Geographic region              Northeast 48 1.5 (0.8–2.7) 33 1.4 (0.9–2.2)      Midwest 48 1.3 (0.9–2.0) 24 0.9 (0.6–1.3)      South 42 1.0 (0.6–1.6) 23 0.8 (0.5–1.2)      West 33 1.0 (ref) 26 1.0 (ref)     Sexually experienced              Yes 61 3.8 (3.0–4.9)* 33 1.9 (1.3–2.7)*      No 24 1.0 (ref) 19 1.0 (ref)       * P < .001. 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). TABLE 5. Association Between Characteristics of Sexually Experienced High School Students Reporting a Preventive Health Care Visit Within the Past 12 Months and Discussion of Pregnancy, STDs or HIV Prevention: United States, 1999 Variables Female Students   Male Students   % OR (95% CI) % OR (95% CI)   Age (y)              18 81 3.5 (1.3–9.4) 26 0.5 (0.3–1.0)      17 67 2.0 (0.8–5.1) 35 0.7 (0.4–1.3)      16 49 1.1 (0.6–2.2) 34 0.6 (0.3–1.4)      15 49 1.1 (0.5–2.2) 36 0.8 (0.4–1.8)      14 48 1.0 (ref) 41 1.0 (ref)     Race/ethnicity