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STDs and Pregnancy in Adolescents
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How do you treat an illness wHen your patient is tHe medical industry ?
The illness hasn’t been given a name, but it’s as ubiquitous as the common cold — and almost as untreatable. Almost. Ask just about any doctor and they’ll agree that the health care industry is sick. Why is it that day in and day out you’re forced to perform more like a CFO and less like an MD? Managing the books
Of course, these are only a few of the many ills Florida’s physicians face every day. We not only want to see things change. We want to see things truly get better. The Florida Medical Association isn’t in possession of a magic pill, but we are constantly working to protect physicians and improve the
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thejournal FloridaofMedical Association. Call 800.762.0233, or visit www.fmaonline.org. the florida medical association 2JoinThe
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contents CME Objectives A letter from the Florida Medical association Introductory Remarks by Russell W. Eggert, MD, MPH Epidemiology of STDs Among Underserved Populations in Florida, 2008 Health Disparities in Sexually Transmitted Diseases: Black Americans at Risk Sexually Transmitted Infections and Health care Providers: Young Adult Women Speak from Posters to PRISM: Physician Roles in STD Prevention and Control Efforts that Target Adolescents Self-Administered Adolescent Risk Survey CME POst-test CME POST-TEST ANSWER SHEET
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CME Objectives: After reviewing and completing this educational activity, participants should be able to: »» discuss the incidence and prevalence of STDs and pregnancy in Florida’s adolescents »» recognize the importance of communication with and counseling of adolescent patients to prevent pregnancy and STDs »» discuss pregnancy and STDs with their adolescent patients Pl a n ner a n d Auth o r Cr edenti al s a n d D isclosur e I nfo r m ati o n :
This information is being provided to CME learners in compliance with ACCME policies for disclosure and commercial support. The information below identifies planner and faculty relationships/affiliations and financial relationships with any commercial interest that produces health care goods or services related to the content of the educational material in which they are involved. As an accredited CME provider, the FMA is obligated to resolve to the best of its abilities any potential conflicts of interest that may arise from a planner’s or author’s financial relationships with commercial interests that produce health care goods or services related to the content of the educational presentation in which that planner or author is involved. The following biographical and disclosure information is provided for the learner’s benefit: Sherese Bleechington, MPH, CHES – Statewide Health Educator, Florida Department of Health, Bureau of STD Prevention & Control, Tallahassee, Florida Disclosure: No relevant financial relationships Toye Brewer, MD – STD Epidemiologist, Centers for Disease Control & Prevention, Field Epidemiology Unit, State of Florida Bureau of STD Prevention & Control/Miami Dade County Health Department, Miami, Florida Disclosure: No relevant financial relationships Adrian C. Cooksey, MPH – Epidemiologist, Florida Department of Health, Bureau of STD Prevention & Control, Tallahassee, Florida Disclosure: No relevant financial relationships Kevon-Mark Jackman, MPH – Public Health Apprentice, Centers for Disease Control and Prevention Disclosure: No relevant financial relationships Russell W. Eggert, MD, MPH, Colonel (Ret.), USAF, MC, SFS, Director, Division of Disease Control, Florida Department of Health Disclosure: No relevant financial relationships Karla Schmitt, PhD, MSN, MPH, ARNP – Chief, Bureau of STD Prevention and Control, Florida Department of Health, Tallahassee, Florida Disclosure: No relevant financial relationships Dionne Stephens, PhD – Assistant Professor, Department of Psychology and African & African Diaspora Studies Program, Florida International University, Miami, Florida Disclosure: No relevant financial relationships Tami Thomas, PhD, ARNP, RNC – Assistant Professor, Center for Nursing Research, Medical College of Georgia, Augusta, Georgia Disclosure: No relevant financial relationships The planners of this educational material have no relevant financial relationships.
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Financial Acknowledgments:
This educational activity was made possible by the receipt of funds from the Bureau of STD Prevention & Control, Florida Department of Health. S t a t e m e n t o f App r e c i a t i o n :
The Florida Medical Association Foundation is pleased to recognize the outstanding talent and commitment of the Bureau of STD Prevention & Control staff and the volunteer experts/authors. This publication would not have been possible without them. Accr ed itati o n / Cr ed it S tatement
The Florida Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical educational activities for physicians. The Florida Medical Association designates this educational activity for a maximum of two (2) AMA PRA Category 1 CreditsTM . Physicians should only claim credit commensurate with the extent of their participation in the activity. Estimated time to complete this educational activity: Two Hours Expiration Date for the Activity: April 30, 2011 INSTRUCTIONS FOR O B TAINING CME CREDIT
»»Read all of the educational articles included in this monograph »»Complete the post-test using the answer sheet provided. Participants must correctly answer at least 70% of the questions to receive credit. »»Complete the evaluation questions on the bottom of the answer sheet »»Mail the answer sheet/evaluation form to: Florida Medical Association ATTN: Nancy Wisham 123 South Adams Street Tallahassee, FL 32301 Feel free to call the FMA Education Department at 800.762.0233 or email education@medone.org if you have questions. Once the answer sheet is graded and a score of at least 70% is achieved, a certificate of credit will be emailed to you. Retain a copy of your certificate for your records. This publication was supported by Cooperative Agreement Number 1H25PS001372-01 from the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not represent the official views of the Centers for Disease Control and Prevention.
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A letter from
the Florida Medical association
Stephen R. West, MD
Bernd Wollschlaeger, MD
The Florida Medical Association
has again partnered with the Florida Department of Health to bring you another CME issue of the Journal of the Florida Medical Association. Within these pages, you will find detailed articles with clinical information regarding sexually transmitted diseases (STDs) that affect a disturbingly high percentage of our adolescent population here in Florida. These articles address epidemiology of STDs, important demographic information, and very importantly, the role physicians must often assume in disease prevention. Clearly the health and well-being of adolescents is crucial to the future of our great state. We are excited that the FMA is able to provide this collaborative enduring material and participate in the effort to reduce the adverse and costly effects of sexually transmitted infections in Florida. The FMA works on your behalf by partnering with regulatory agencies to keep you up-to-date on health matters that concern you and your patients. Throughout the year, FMA staff serves as your liaison to legislators to protect physicians and their practices. FMA members have access to experts knowledgeable in legal issues, Medicare/ Medicaid, Workers’ Compensation, and numerous other areas. The FMA also offers a tremendous amount of benefits, including complimentary continuing medical education, billing and coding advice, and practice management tools. By joining the efforts of the FMA, you will benefit your profession and your practice. If you are currently a member of the FMA, we appreciate your sustained support. You are the necessary element for the future growth of the FMA and organized medicine in Florida. Please consider becoming a member of the FMA if you have not yet joined our ranks. Simply call (800) 762-0233 to speak to the membership department or you may join online at www.fmaonline.org. Upon successful completion of the test located on page 35, you will be eligible to claim two CME credits. With the continued assistance of organizations like the Department of Health, we hope to continue to serve Florida physicians with opportunities for growth in knowledge and education. Sincerely,
Steve West, MD President, Florida Medical Association
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The journal of the florida medical association
Bernd Wollschlaeger, MD Chair, FMA Committee on CME & Accreditation
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Introductory Remarks by Russell W. Eggert, MD, M.P.H.
January 27, 2009
I would like to take
this opportunity to thank each of our Florida physicians for the contribution that they have made to our improved capacity to identify sexually transmitted infections and to our understanding of their distribution. In 2006, the Department of Health promulgated a significant revision to Florida Administrative Code 64D-3: Communicable Diseases and Conditions Which May Significantly Affect Public Health. Physicians had new requirements to report specific numerous sexually transmitted infections. Laboratories had requirements to transmit results electronically in altered timeframes. We observed a 28% increase in positive test notifications. We observed a 26% decrease in time from collection to report and subsequent confirmation of treatment completion. Clearly, the initiative has been a success. However, we now recognize the larger scope of disease burden in our communities. Your partnership remains very critical to our capacity to reduce this disease burden. The department projected the identification of over 5,000 mothers that would be infected with an STD during pregnancy when we rolled out the Florida Administrative Code changes in 2006. Thanks to our partners in the medical community and laboratories, we received 13,148 notifications during 2008. Our collective capacity to ensure timely treatment and management of these infections has been a public health gain. Thank you. Acquisition of STDs among those 15-24 years of age persists as indicators of health care access, economic disparity, personal behavior choices, and individual knowledge about risk prevention. During 2008, 70% of chlamydia and 61% of gonorrhea was reported in those 15-19 years of age. Moreover, since 2003, we observed a 4-fold increase of early syphilis in this age group of 15-24 years. Chlamydia, gonorrhea, and syphilis represent a gateway into the costly health care expenditures associated with chronic STDs: HIV, HPV, and genital herpes. We invite your partnership to enhance communication about STDs with the adolescent patients seen in your practice. We invite you to utilize our public health function through local health departments to interrupt the spread in the community among the most vulnerable and disparately affected. Together we can screen more youth, more minority populations, and reduce the adverse health outcomes and associated costs of sexually transmitted infections. Sincerely,
Russell W. Eggert, MD, MPH Director, Division of Disease Control Florida Department of Health
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Epidemiology of STDs
Among Underserved Populations in Florida, 2008 Adrian C. Cooksey, MPH and Karla Schmitt, PhD, MSN, MPH, ARNP
Research demonstrates
disparities exist in health care status and delivery of health services. Underserved populations may be characterized by low socioeconomic status, geography, language, and/or physical conditions. Disparate differences in racial and ethnic populations cause disproportionate cases of chronic disease, cancer, and infectious disease in these populations. Those who are typically underserved by the health system face greater debilitating conditions and circumstances. The personal cost of disparities can lead to significant morbidity, disability, and lost productivity at the individual level. At the societal level, distal costs follow from proximal opportunities that were missed to intervene and reduce the burden of illness1. The need to eliminate disparities in health care has been adopted by federal and state organizations. The federal government’s prevention agenda, “Healthy People 2010,” addresses the differences in health care for preventable and treatable chronic and infectious conditions. Some of the most common infectious diseases in the United States are sexually transmitted diseases (STDs). The Centers for Disease Control and Prevention estimates that approximately 19 million new infections occur each year with the burden falling on youth and women 2. In concert with age and gender, minorities also account for a disproportionate share of new AIDS, chlamydia, gonorrhea, and syphilis cases in Florida and the nation annually. This report will present incidence and prevalence of reportable sexually transmitted conditions in underserved populations who reside in Florida and focus on youth, women, and minorities. This report will also highlight select economic and geographic indicators of high rates of infection. Surveillance data (2008) obtained from Florida’s Department of Health STD case reports, census tables, and data obtained from the Florida Community Health Assessment Resource Tool Set (CHARTS) were used for analysis. C h l a m y d i a ( CT )
In 2008, there were 69,420 chlamydia cases reported among both males and females in Florida, or 367.4 cases per 100,000 total population. Close examination of the disease distribution reveals that 80% of all reported cases of chlamydia are reported in populations 26 and under; further, Chlamydia trachomatis is the most prevalent sexually transmitted bacterial infection reported among 15-24 year olds in Florida. Age as a risk factor for chlamydia is extremely important, as the prevalence of chlamydia is the highest among those under 25 years of age. Approximately 50% of all STD cases reported from 2000 to 2008 have an age of initial report of an STD at age 22 or under. Although 15-24 year olds represent 16% of the population 15 and over, this population represents approximately 70% of all reported chlamydia cases in Florida. A total of 49,036 chlamydia cases were reported in persons between the ages of 15-24 in 2008. From 2007 to 2008, reported cases in this population increased by 19.1%. Chlamydia cases in the 15-19 age group comprised 33.2% of all cases reported, and chlamydia cases in the 20-24 age group comprised 37.4% of all cases reported in 2008. The overall rate for 15-24 year olds
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Figure 1:
was 2,009.8 per 100,000 population. The mean age of all reported chlamydia cases was 22.8. However, at least 4,500 cases in each single age group were reported in 17-22 year olds. When single age groups are compared within the 15-24 age range, cases reported peaked at the age of 20 (mean=20.1) with a gradual decline of cases as single age in years increased.
Chlamydia cases by census Tracts
Legend County Line
Chlamydia Cases by Census Tracts Frequency 0-5 6 - 10 11 - 15 16 - 20 21 - 139
The burden of morbidity occurs in young women for several reasons. Young women may have an increased susceptibility to the bacterium Chlamydia trachomatis compared to mature women who may develop immune response and/or decreased target cell availability for infection. Consequently, these physiological differences make it common to observe a high number of infections before the age of 25. In 2008 and preceding years, the highest number of cases in females were reported in the 15-24 age group with the highest rate, regardless of gender, among females 15-19 (3,186.5 per 100,000 population). The rate for females in the 20-24 age group was slightly lower at 3,175.0 per 100,000 population. Florida specific trends parallel national data that indicates infection is most prevalent in women under the age of 25. Gender differences in health care services and health care seeking behaviors account for significant variation among rates between males and females. Although rates are considerably lower in males, disparities exist with men under the age of 25 as well. In 2008, 20-24 year olds had the highest rate among male populations (1,173.0 per 100,000 population). This rate was trailed by a rate of 635.6 per 100,000 population for males between the ages of 15-19. The peak age for male reported chlamydia infection was 21.3 for the 15-24 age cohort and 24.9 for all males with a reported infection. Chlamydia impacts adolescents and young women regardless of race and ethnic groupings. The distribution of race/ethnicity is vast among women; however nonHispanic Black females in adolescence and young adult populations have higher rates compared to White and
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Hispanic populations in Florida. Among women, the case rate for non-Hispanic Black 15-24 year olds (7,989.0 per 100,000) was nearly five times higher than the second highest rate in non-Hispanic White females 15-24 (1,603.1 per 100,000 population). In 2008, adolescents and young adults (15-24) who self reported as non-Hispanic Black accounted for 50.8% of the chlamydia cases in 2008. Persons who self reported as non-Hispanic White accounted for 21.8% of cases. Persons who self reported as Hispanic (White or Black) accounted for 8.9% of cases. Persons who self reported in other or unidentified racial-ethnic groups accounted for 18.5% of cases. G o n o r r h e a ( GC )
In 2008, there were 22,897 gonorrhea cases reported among both males and females in Florida, or a rate of 121.2 cases per 100,000 population. Close examination of the disease distribution reveals that over 75% of all reported cases of gonorrhea are reported in populations under the age of 30; further, gonorrhea is the second most prevalent sexually transmitted bacterial infection reported among 15-24 year olds in Florida. About 2/3 of the cases reported since 2000 had an STD at age 24 or younger and the other 1/3 had their initial report at age 25 or older. Over the past five years, the total number of reported gonorrhea cases reached a low of 18,580 cases in 2004 and increased to 23,976 cases in 2006; however, overall cases decreased in 2007 (23,366) and 2008 (22,897). More cases have been reported in the 20-24 age group for gonorrhea consistently since 1998; further, 15-24
STDs and Pregnancy in Adolescents
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year olds accounted for 61% of infections reported in 2008. The age specific case rate for 15-24 year olds was 572.2 per 100,000. The mean age of all reported gonorrhea cases was 24.9. However, when single age groups are compared within the 15-29 age range, cases peaked at the age of 20 with a gradual decline of cases as age in years increased. Adolescent and young adult populations had minimal change in the number of cases reported from 2006 to 2008. Although cases decreased 1.5% in 20-24 year olds from 2007, cases in 15-19 year olds increased by 2.5%. When comparing gender specific data in populations under 25, much like chlamydia trends, females under the age of 25 accounted for the largest proportion of cases reported (60%). Among females, the highest number of cases was reported in 15-19 year olds (4,460 cases) with a rate of 747.5 per 100,000 population. The second highest rate among females was in 20-24 year olds (682.3 per 100,000 population). Among males, the highest numbers of cases was reported in the 20-24 age group (3,319 cases) with age specific rate of 531.7 cases per 100,000 population. Males 25-29 had the second highest rate (343.5 per 100,000 population). Unlike chlamydia trends, males aged
25 and over had higher rates compared to females. The mean age of males with a reported gonorrhea infection was 27.5 compared to 22.2 for females. Nevertheless, all cases reported, regardless of gender, disproportionately occur in populations under 25 years of age. In 2008, the distribution of gonorrhea by race/ethnicity in the 15-24 age group disproportionately affected non-Hispanic Blacks. Non-Hispanic Black adolescents and young adults (15-24) have the highest rates by race/ethnicity and age group in Florida. In 2008, nonHispanic Black females age 15-19 had a case rate of 2,282.8 per 100,000 population. This rate was nearly eight times higher than the second highest rate in nonHispanic White females 15-19 (220.7 per 100,000 population). Non-Hispanic Black males age 15-19 had a case rate of 1,123.7 per 100,000 population. This rate was 23 times higher than the second highest rate in Hispanic males 15-19 (69.7 per 100,000 population). Males 25-29 years old had the highest age specific rates in males. E a r ly S y p h i l i s
Reported cases of total syphilis increased in all age groups from 2006 to 2008. Unlike chlamydia and gonorrhea trends,
Figure 2: Chl a m y d i a a n d Go n o r r he a Geospati al D isper si o n in Selec t Countie s, 2 0 0 8
Broward
Legend
Legend
County Line
County Line
Chlamydia Cases by Census Tracts Frequency 0-5
8
Broward
Gonorrhea Cases by Census Tracts Miami-Dade
Frequency 0-5
6 - 10
6 - 10
11 - 15
11 - 15
16 - 20
16 - 20
21 - 139
21 - 98
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early syphilis cases are more equally distributed among 15-49 year olds. However, there has been a four-fold increase of early syphilis cases reported in 15-24 year olds from 2003. In 2008, early syphilis trends in females indicate 59% of cases occur in those under 30 years of age compared to 35% in males in the same age cohort. However, males aged 30-49 account for 83% of reported early syphilis cases in both male and female populations over 30. The number of early syphilis cases has increased 8% from 2007. The ratio of male to female early syphilis cases was 3.2 to 1 in 2008. The distribution of early syphilis by race/ethnicity continues to disproportionately affect non-Hispanic Blacks. Persons who self reported as non-Hispanic Black accounted for 44.1% of the syphilis cases in 2008. Persons who self reported as non-Hispanic White accounted for 29.7% of the cases. Persons who self reported as Hispanic (White, Black, or other) accounted for 18.1% of the cases. Persons who self reported in other or unidentified racial and ethnic groups accounted for 8.1% of the cases. The rate per 100,000 for non-Hispanic Blacks was 33.1 per 100,000 population. This rate was six times greater than the second highest rate in non-Hispanic Whites (5.8/100,000). Economic and Geographic view of STD s b y c e n s u s t r a c t s
In highly impacted areas, STD rates, evaluated by census tract, may be an order of magnitude higher than that of surrounding areas3. In 2008, over 45% of all gonorrhea cases were reported from larger, more populous counties (Duval, Broward, Orange, Dade, and
Hillsborough) and unlike chlamydia dispersion, gonorrhea cases occurred in more tightly defined areas (Figure 2). While there is clearly considerable geospatial congruence between the two infections from the state perspective, the distributions of gonorrhea and syphilis (not shown) are more closely aligned than others. As of the 2000 Census, 33 of Florida’s 67 counties are considered rural based on the statutory definition of an area with a population density of less than 100 individuals per square mile or an area defined by the most recent United States Census as rural 4. Rates of infection in rural counties were slightly lower in comparison to rates in most urban areas. However, some of the highest rates of GC infection in 15-24 years olds were found in the following rural counties: Gadsden, Jackson, Calhoun, and Hamilton. From 2005-2008, 13% of people were in poverty in Florida and nearly 20% of Florida’s residents had no insurance of any kind. It is important to note that race and ethnicity in the United States are risk markers that correlate with other more fundamental determinants of health status such as poverty, access to quality health care, health care seeking behavior, and residence in communities with high prevalence of STDs 5 . Adults aged 19-29 are one of the largest groups without health insurance, according to a study sponsored by the Commonwealth Fund 6 . Sexually transmitted diseases, especially syphilis and gonorrhea, are associated with a host of adverse socioeconomic indicators. In the United States, these are often correlated
Figure 3: Mean Rates/1,000 By Census Tract Poverty Levels, 2008 (n=3,152) Percent Below Poverty Level
GC Rate/1,000
CT Rate/1,000
Early Syphilis Rate/1,000
0 - 5.9%
0.5
1.7
0.0
6 - 9.9%
0.7
2.2
0.1
10 - 17%
1.3
3.3
0.1
17.1 - 76.8%
3.6
6.9
0.3
Census Tract Average
1.5
3.5
0.1
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with residential housing patterns. The mean rates for census tract data shows a linear association between poverty level and STD infection rates (Figure 3). Chlamydia rates nearly doubled the average census tract rate when the poverty level was in the upper 4th quartile. Similarly early syphilis and gonorrhea rates increased as well. Pu b l i c H e a lt h I m pl i c at i o n s
In “Un-equal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” the Institute of Medicine notes that disparities in health care are substantial, even after accounting for characteristics typically associated with disparities, such as health insurance coverage and income. Although analysis reports applicable findings, more in-depth analysis is needed. Surveillance data was mapped over a large geographic area and may not reflect trends that occur in smaller sub populations. Census data for census tracks and poverty level are nearly ten years old. These rates may not account for birth, death, or migration changes in population. Data was also not explored by other characteristics such as race/ethnicity, location of STD clinics, and available medical resources for stronger geospatial associations. Further, analysis reflects only data that has been reported to the Florida Department of Health and represents only a small proportion of the true national and state burden of STDs. 2 The acquisition of STDs persists as indicators of health care access, economic disparity, personal behavior choices and individual knowledge about risk and preventive measures. Florida’s population between 15-24 years of age represents 16% of the total Florida population. For those 15-24 years of age, 2008 reported 70% of the total 19% increase in chlamydia, and 61% of the gonorrhea with 3.5% increase specific to this age group. And since 2003, we observed a four-fold increase of early syphilis among this age same group. Across race and ethnicity of all adolescents and young adults, and among specific minority populations the distribution of sexually transmitted infections persist disproportionately in our state.
references
National Health Care Disparities Report: Summary. February 2004. Agency for Health care Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/nhdr03/nhdrsum03.htm
1
Trends in Reportable Sexually Transmitted Diseases in the United States, 2008: National Surveillance Data for Chlamydia, Gonorrhea, and Syphilis. Centers for Disease Control and Prevention, Division of STD Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. http://www.cdc.gov/std/ stats07/default.htm 2
Nelson KE, Williams CM, Graham N. Infectious Disease Epidemiology Theory and Practice. Aspen Publishers, 2001. 3
Florida Office of Rural Health. Program Overview. Tallahassee, FL: Florida Department of Health. http:// www.doh.state.fl.us/workforce/RuralHealth/ruralhealthhome.html#Rural%20Health
4
Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2001. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, September 2002. 5
Young adults lack insurance. Cinical Psychiatry News 34.7 (July 2006: 74(1). General OneFile.Gale. State Library of Florida-Web Portal. 12 Jan. 2009. http://find.galegroup.com/ips/start.do?prodID=IPS>.
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Health Disparities
in Sexually Transmitted Diseases: Black Americans at Risk Toye H. Brewer, MD and Kevon-Mark Jackman, MPH
Introduction:
Sexually transmitted diseases (STDs) are among the most common of all infectious diseases. The Centers for Disease Control and Prevention (2008) recently estimated that one in four adolescent girls in the United States (U.S.) is infected with an STD. Treatment costs are estimated to be in the billions of dollars (Starnbach et al., 2008); sequelae of untreated and inadequately treated disease include infertility, adverse pregnancy outcomes, and enhanced efficiency of HIV transmission. In the United States, Blacks, or African Americans, are disproportionately affected by high rates of STDs (Steele et al., 2008). Given the potential sequelae of STDs as well as the national goal to eliminate health disparities in the United States (DHHS 2000), racial disparities in STD rates merit attention. In this report we will review the magnitude of racial disparities in STDs, discuss individual and systemic aspects of risks for STDs and finally discuss strategies to reduce racial disparities in STDs. Although racial disparities in health status in the U.S. are pervasive and span both chronic and infectious diseases, disparities in the prevalence of STDs are particularly striking (Steele et al., 2007). According to the CDC 2005 STD Surveillance Report (see Table 1), in that year chlamydia infection rates among Blacks were over eight times higher than among Whites and 2.7 times higher than among Hispanics. For gonorrhea, rates were nearly 18 times higher among Blacks compared to Whites, and eight times higher among Blacks compared to Hispanics. Finally for syphilis, the rate among Blacks was approximately five times higher than among Whites and three times that of Hispanics. In Florida, which follows the national pattern, Blacks have much higher rates of STDs than Whites, while the risk for Hispanics is modestly increased (Cooksey and Schmitt, this edition). Risk Factors for STD A c q u i s i t i o n
In an attempt to understand racial disparities in STDs, the first question that must be addressed is whether or not these differences can be attributed to higher risk sexual behaviors among Blacks. In fact, there is reliable data from the National Health and Nutrition Examination Study (NHANES) data (Fryar et al., 2007), which indicates that a higher proportion of Blacks initiate sexual activity before the age of 15 and a higher proportion had more than one sex partner in the 12
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months prior to the study than Mexican-Americans or Whites. However, differences in risk behaviors do not account for the difference in STD rates. Several welldesigned studies have shown that Blacks remain at a significantly increased risk for STDs compared to Whites, even after adjustment for sexual behaviors and socio-demographic factors (Ellen et al., 1998, Hallfors et al., 2007, Harawa et al., 2003). In the landmark study by Hallfors et al. (2007), data from wave III of the National Longitudinal Study of Adolescent Health (Add Health) was analyzed to determine whether individuals’ sexual and drug risk behaviors account for racial disparities in HIV and STDs. Data from over 8,500 non-Hispanic Black and White respondents, all between 18 and 26 years of age, were included in the analysis. As Table 2 shows, the research team found that across the spectrum of risk behaviors, from least risky to highest risk, Blacks had significantly higher odds ratios (OR) for HIV and STDs than Whites, even after adjustment for covariates. For example, among the lowest risk group (little alcohol or tobacco, few sex partners) Blacks had an OR of 7.1 for STDs or HIV compared to Whites of the same risk category. At the higher risk level of men having sex with men (MSM), Black MSM had an OR of 9.6 for STDs or HIV compared to Whites in the same risk category. These findings led the authors to conclude that “Black young adults are at very high risk for STDs, even when their behavior is normative,” whereas STD risk for Whites approached that of Blacks only among the highest risk groups.
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Table 1: Sexually transmitted disease rates by race and the ratio of black and hispanic case rates to whites: United States, 2005a Sexually Transmitted Disease
Rateb
Rate Ratioc
White, Non-Hispanic
1.8
1.0
Black, Non-Hispanic
8.8
4.9
Hispanic
3.3
1.8
U.S. Total
3.0
Infectious Syphilisd
Chlamydia White, Non-Hispanic
152.1
1.0
Black, Non-Hispanic
1247.0
8.2
Hispanic
459.0
3.0
U.S. Total
332.5
Gonorrhea White, Non-Hispanic
35.2
1.0
Black, Non-Hispanic
656.4
17.8
Hispanic
74.8
2.1
U.S. Total
115.6
Source: CDC, Sexually Transmitted Disease Surveillance, 2005 b Rate per 100,000 population c Represents the ratio of STD rates in Blacks and Hispanics to Whites d Primary and Secondary Syphilis a
Findings such as these have led to a shift in STD epidemiology concepts from an emphasis on individual risk behaviors to the analysis of social and structural determinants of health as well as social and sexual networks (Aral, 1999, Adimora, 2005, Farley, 2006). As STDs tend to concentrate in areas most affected by poverty and segregation (Cohen, 2000, Farley, 2006, Zenilman et al., 1999), increasingly these and other structural factors such as racism, policies and laws, educational opportunities, access to quality health care, and community prevalence of disease are being cited as determinants of racial disparities of STDs.
and health behaviors, as well as access to health care. Additionally racial segregation is linked to environmental factors like high rates of crime, homicide, and drug use (Williams and Collins, 2001). These factors generate conditions that make Black males six to seven times more likely to be incarcerated than White males (Harawa and Adimora, 2008, Steele et al., 2007). High rates of incarceration have a major impact on future educational and employment opportunities. Small numbers of males with stable employment within low income African American communities greatly impact stability in relationships (Harawa and Adimora, 2008). Qualitative research (Adimora et al., 2001) suggests that poverty, drug use and scarcity of Black men contribute to high rates of STDs and HIV among Black women by an imposition of structural barriers on women’s choices in partner selection.
Blacks are far more likely than other racial groups to live in segregated areas in the U.S. as well as to live in areas of concentrated poverty (Williams and Collins, 2001). Racial segregation and poverty interact to affect educational and employment opportunities, housing,
Another research area exploring racial disparities in STDs is the field of sexual networking. Lauman and Youm (1999) analyzed the 1992 National Health and Social Life Survey data, which consists of information on over 3,000 adults between 18 and 59 years of age,
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Table 2: Sexually Transmitted Disease And Hiv Infection Prevalence (95%, Ci) , By Race And Risk Behavior Pattern: National Longitudinal Study Of Adolescent Health Wave Iii, 2001-2002a Risk Behavior Pattern
White
Blackb
Substance Use and Sexual Activity
3.4 (1.6, 7.0)
22.0 (9.7, 42.6)
Multiple Sexual Partners
3.4 (1.4, 7.8)
9.7 (4.7, 18.9)
Injection Drug Use
7.8c (3.1, 18.4)
23.4 (4.8, 65.1)
Male-male sexual activity
6.7c (2.3, 18.1)
33.8 (14.3, 60.9)
Data derived from Hallfors et al. (2007) Sexual and Drug Behavior Patterns and HIV and STD Racial Disparities: The Need for New Directions All prevalence extimates were greater than the sample‘s overall prevalence (6%) c Greater than the sample’s overall prevalence (6%) a
b
selected using a national representative probability sample. They found that 1) sexual networking patterns among Blacks are more segregated, i.e., inter-racial mating is less common than among Whites and Hispanics, which increases the odds of exposure to an infected partner and that 2) within the Black community, members of high-risk core groups (drug users, persons with multiple sex partners) are more likely to have sex with persons who are at low risk (dissortative mating), which leads to more effective spread of HIV into the wider community. These patterns, shaped by the larger social determinants, predict that regardless of individual risk behaviors, Blacks are more likely to encounter an infected sexual partner than Whites. A d d r e s s i n g STD D i s p a r i t i e s
Aggressive campaigns aimed to reduce individual risk behaviors by encouraging adolescents to abstain from or delay the onset of sexual activity, use condoms and limit their number of sexual partners are of utmost importance. However, it is now clear that community level and structural interventions are also needed. Community level and structural interventions should incorporate entities outside of the traditional public health paradigm. As Steele et al. (2007) note, “Reducing and eliminating health disparities cannot be achieved by a single agency or group; rather the task will require partnerships from individuals, communities, agencies, community based organizations, policymakers, the public and private health care sectors, and others.” Such partnerships might address structural factors, outside of the traditional public health paradigm, that are associated with negative health outcomes, such as high school drop out rates and the impact of policies that lead to disproportionately high rates of incarceration among poor Blacks. Support for alternative drug policies that promote prevention and treatment rather
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than incarceration have increased over time and such efforts may be essential to improve local policies that disproportionately affect poor Blacks (McBride et al., 2008). Additionally it has been suggested that correctional facility based intervention could be used to reach incarcerated persons and their sexual partners for STD/ HIV interventions (Hammet and Jones, 2006). Traditional public health measures that include screenings of high risk populations and the provision of surveillance to provide data to direct resource expenditures are also critical. The traditional public health role to provide low cost STD services is also of key importance. Blacks are more likely than Whites to access health care services via public clinics, therefore decreased services and/or increased co-pays at these sites negatively impacts access to care among Blacks (Reitmejier et al., 2005). Conclusions
Racial disparities in STD rates are strongly influenced by structural and socio-economic determinants that contribute to disparities in socio-economic status and circumstances. To address these underlying structural determinants is a tremendous challenge which requires political will, partnerships, and commitments from multiple stakeholders if the gap is to be closed. Given the inability of public health programs alone to eliminate the cause of disparities, goals must be realistic (Steele et al, 2007). Among realistic goals of public health programs are the provision of timely surveillance to guide targeted interventions to those populations at highest risk and provision of affordable STD services, which includes screening, treatment, and risk reduction counseling. Development of partnerships with communities, the private sector, policy makers, and other partners is another essential step for public health programs to address health disparities.
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References Adimora AA (2005). Social context, sexual networks, and racial disparities in rates of sexually transmitted infections. Journal of Infectious Diseases, 191(suppl 1), 2115-122. Adimora AA, V. J. Schoenbach, F. E. Martinson, Donaldson KH, Fullilove RE,& Aral SO (2001). Social context of sexual relationships among rural African Americans. Sexually Transmitted Diseases. 28 (2), 69-76. Aral SO (1999). Sexual network patterns as determinants of std rates: paradigm shift in the behavioral epidemiology of STDs made visible. Sexually Transmitted Diseases, 26(5);262-264. Centers for Disease Control and Prevention (2006). Sexually Transmitted Disease Surveillance, 2005. Atlanta, GA:US Department of Health and Human Services. Centers for Disease Control and Prevention. Nationally Representative CDC Study finds 1 in 4 teenage girls has a sexually transmitted disease. Press release March 11, 2008. Available at: http://www.cdc.gov/stdconference/2008/media/release-11march2008.pdf. Accessed August 26 2008. Cohen D, Spear S., Scribner R., Kissinger P., Mason K,.& Wildgen, J. “Broken Windows” and the Risk of Gonorrhea. (2000). American Journal of Public Health, 90,230-236. Ellen JM, Aral SO, & Madger LS (1998). Do differences in sexual behavior account for the racial/ethnic differences in adolescents’ self reported history of a sexually transmitted disease? Sexually Transmitted Diseases 25(3), 125-129. Farley TA (2006). Sexually transmitted diseases in the Southeastern United States: location, race and social context. Sexually Transmitted Diseases 33(7), S58-64. Fleming DT & Wasserheit JN (1999). From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sexually Transmitted Infections 75(1), 3-17. Fryar CD, Hirsch R, Porter KS, Kottiri B, Brody DJ & Louis T.(2007) Drug use and sexual behaviors reported by adults: United States, 1999-2002. Advanced data from vital and health statistics; no.384. Hyattsville, MD: National Center for Health Statistics. Ford K & Norris A (1997). Sexual networks of African American and Hispanic youth. Sexually Transmitted Diseases, 24(6), 327-333. Hallfors DD, Iritani BJ, Miller WC, & Bauer DJ (2007). Sexual and Drug Behavior Patterns and HIV and STD Racial Disparities: The Need for New Directions. American Journal of Public Health, 97: 125-132 Hammett & Drachman-Jones (2006). HIV/AIDS, Sexually transmitted diseases and incarceration among women; National and Southern perspectives. Sexually Transmitted Diseases, 33 (7), S17S-22. Harawa NT & Admiora A (2008). Incarceration, African Americans and HIV: Advancing a research agenda. Journal of the National Medical Association, 100(1), 57-62. Harawa NT, Greenland S, Cochran SD, Cunningham WE & Visscher B. Do differences in relationship and partner attributes explain disparities in sexually transmitted disease among young White and Black women? Journal of Adolescent Health, 32(3), 187-91. Laumann EO & Youm Y (1999). Racial/ethnic group differences in the prevalence of sexually transmitted diseases in the United States: a network explanation. Sexually Transmitted Diseases, 26(5), 250-261. McBride D, Terry-McElrath Y., VanderWall C., Chiqui J. & Myllyluoma J. (2008). US Public Health Agency involvement in youth-focused illicit drug policy, planning, and prevention at the local level, 1999-2003. American Journal of Public Health, 98(2), 270-2. Rietmeijer CA, Alfonsi GA, Douglas JM, Lloyd LV, Richardson DB & Judson FN. (2005) Trends in clinic visits and diagnosed Chlamydia trachomatis and Neisseria gonorrhoeae infections after the introduction of a copayment in a sexually transmitted infection clinic. Sexually Transmitted Diseases, 32(4).243-6. Starnbach N. & Roan N. (2008). Conquering sexually transmitted diseases. Nature Reviews. Immunology, 8(4), 313-317. Steele CD, Melendez-Norales L, Campoluci R, DeLuca N & Dean H. Health Disparities in HIV/AIDS, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis: Issues, Burden and Response, A Retrospective Review, 2000-2004. Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Prevention, November 2007. Available at: http://www.cdc.gov/nchhstp/healthdisparities. Accessed August 26, 2008. U.S. Department of Health and Human Services. Healthy People 2010.2nd ed. With Understanding and Improving Health Objectives for Improving Health 2 vols. Washington, DC:U.S. Government Printing Office, November 2000. Available at: http://www.healthypeople.gov/Document/html/uih/ uih_1.htm. Accessed August 26 2008. Williams DR & Collins C.(2001) Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Reports, 116, 404-416. Zenilman JM, Ellish Nancy, Fresia Anne & Glass G (1999). The geography of sexual partnerships in Baltimore: Applications of core theory dynamics used in geographic information systems. Sexually Transmitted Diseases, 26(2), 75-81.
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Sexually Transmitted Infections and Health care Providers:
Young Adult Women Speak Tami Thomas, PhD, ARNP, RNC and Dionne Stephens, PhD
Introduction:
Despite widespread condom distribution and health education, sexually transmitted infections (STIs) in young adult women are on the increase. In an attempt to address these increasing rates of STIs, improve patient-provider interactions, increase access to sexual and reproductive health information and quality health services for young adult women, investigators from nursing and psychology collaborated on a joint research project. The purpose of this study was to describe sexual risk taking, access to sexual and reproductive health information and quality health services, and interactions with health care providers in a culturally diverse group of young adult women. This study also examined the impact of socio-cultural beliefs and values that surround sexual risk taking through the use of sexual scripting and the influence of these results on subsequent health seeking behavior. The result of this work provides valuable information for health care providers, as it allows them to understand how racial/ethnic minority women view themselves as sexual beings, and how the sexual behaviors they exhibit are manifestations of culturally unique values and beliefs about female sexuality.
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Background and Significance
STI rates have been examined and infections with few or no symptoms for women, such as chlamydia, can be highly problematic. Chlamydia is the most prevalent and the most common reportable STI in the United States (CDC, 2007; Sipkin, Gillam, Bissett & Grady, 2003). An estimated 28 million Americans are infected annually with chlamydia (CDC, 2006). The significant variations in incidence between different racial and ethnic groups are consistent within specific studies and CDC findings that report non-Whites tend to have a higher rate of infection than Whites (Einwalter, Ritchie, Ault, & Smith, 2005; Ford, Jaccard, Millstein, Bardsley & William, 2004; Klausner, et al., 2001; Sipkin, Gillam, Bissett & Grady, 2003). African-Americans are the heaviest burdened non-White racial/ethnic group, followed by American Indian/Alaska Natives, Hispanics, and then Asian/Pacific Islanders. In 2006, the chlamydia infection rate among African-Americans was eight times higher than Caucasians, and Hispanics had a rate 3.1 times higher than Caucasians. These STI data indicate that regardless of the variety and reach of educational programs focused on STI rates, rates of infection are on the increase. Sexually active college/university student populations are at particularly high risk due to the predominant age range of 18 to 24 years and often precarious behaviors that include sexual risk taking. These risky activities include inconsistent use or complete disregard of condoms, multiple sexual partners, serial monogamy, and the intake of alcohol and/or drugs during sexual acts. Furthermore, young adult women of ethnically diverse minority backgrounds frequently delay seeking treatment for gynecological symptoms, which puts them at increased risk for further morbidity such as pelvic inflammatory disease and infertility. The most common factor to delay young adults from seeking testing and treatment for a possible STI is perceived consequences (Barth, Cook, Downs, Switzer & Fischhoff, 2002). Young adults are concerned about what others will think, harsh criticism, stigma, perceived severity of a possible infection, and health care provider characteristics. Ethnicity and culture as suggested by one’s race can also be a factor in treatment delay, which creates a subsequent health care disparity. Prior research in this area suggests that cultural
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values transmitted through interactions with individuals and social contexts directly inform an individuals’ sexual health identity (LaPlante, McCormick, & Brannigan, 1980; Barth et al., 2002; Stephens & Phillips, 2005). Simon & Gagnon (1986) developed the sexual scripting theory, which posits that sexual interactions are guided by scripts, or schemas, that help individuals in the development of their sexual selves. Health care providers who encounter young adult African-American or Hispanic women must consider the sexual scripting processes and experiences that inform the sexual values of these young adult women. Recognition of this dynamic gives import to the fact that knowledge about sexual risks does not translate into a sexual behavioral change. Consequently, the meanings that emerge from sexual messages are important to understand how knowledge affects behavior (Longmore, 1998). Prior research has found that close friends play a significant role in decisions about sexual risk behavior (Caspi, Lynam, Moffitt & Silva, 1993; Harper, 2004; Prinstein, Meade & Cohen, 2003; Treboux & BuschRossnagel, 1995). Friends contribute to sexual socialization processes that shape behavioral outcomes, which includes the acquisition of new dating and sexual partners. Conversation and the information exchange between friends shape a young adult woman’s opinion of herself and her plans for sexual conduct. Friends also serve as a source of influence on sexual risk taking behaviors and intent to seek testing and treatment for gynecological complaints or concerns of STIs. Different sources of influence, such as sex education, family, and religion have been previously cited as important in the development of a racial/minority female’s sexual script (Raffaelli & Ontai, 2001; Bay-Cheng, 2003; Rouse-Arnett, Dilworth & Stephens, 2005). Since racial/ ethnic minority cultures tend to have traditional attitudes in regard to gender roles, such as female reticence and placing men’s pleasure at the center of a sexual scenario (sometimes at the cost of safe sex), racial/ethnic minority females are typically socialized into such reticence, which potentially decreases their ability to negotiate safe sex practices (Logan, Cole & Leukefeld, 2002; Dworkin, Beckford & Ehrhardt, 2007). Therefore, traditional scripts can act as a cultural barrier to racial/minority females’ sexual health.
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Health care providers can gain accurate and comprehensive knowledge about cultural messaging and meaning given to sexual behaviors among racial/ ethnic minority women when sexual scripting theory is used as a framework. This qualitative study explores the meaning of sexuality in this population of ethnic minority young adult women. The sexuality paradigm asserts that people develop a sense of their sexual selves through sexual messaging that takes place within continually changing cultural and social contexts (Simon & Gagnon, 1984, 1986). As such, sexuality is “socially scripted” in that it is a “part” that is learned and acted out within a social context, and different social contexts have different social scripts (Jackson 1996, 62). Prior research has found that sexual scripts, as frameworks of unique meanings given to sexual actions, differ across racial/ ethnic groups (Faulkner, 2003; Metts & Spitzberg, 1996; Stephens & Few, 2007; Zea, Reisen, & Diaz, 2003) and directly influence sexual behavioral outcomes (Emmers-Sommer & Allen, 2005; Ginsburg, 1988; Lear, 1995; Mahay, Laumann & Michaels, 2001; Nolan, 2006). A large body of research that examines sexual scripting theory exists in several populations: heterosexual White adolescents (e.g. Alksnis, Desmariais, & Wood, 1996; Rose & Frieze, 1993), gay and lesbian populations (e.g. Klinkenberg & Rose, 1994; Rose, 2000), and White young adult and gay/ lesbian populations. But there is limited research that examines racial/ethnic populations, particularly those in college or university settings. As the demographics of the United States continue to change with increased populations of ethnic minorities, a study focused on young adult women from ethnic minority backgrounds was timely and relevant.
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Study Design, Setting and Methodology Q ualitative D e s i g n
This study employed qualitative data collection techniques, which require an examination of the processes by which individuals and specific groups construct meaning, and a description of how those meanings are interpreted and expressed (Bogdan & Biklen, 1998). A growing body of qualitative research examined sexual risk behaviors among African American and Hispanic women, particularly those which use individual interviews or focus groups, to analyze various dynamics that shape sexuality, race, and gender interactions (Jarama, et. al, 2007; Morrow, Costello, Boland, 2001; Parrado, McQuiston & Flippen, 2005; Stephens & Few, 2007). Sixteen women, aged 18-25, participated in the study; all selfidentified as Hispanic (n=10), African American/ Caribbean (n=3) and Asian (n=3). Data were gathered from women at this phase of the lifespan because women enter more serious relationships, engage in sexual acts, and have an expanding pool of potential mates (Soet, Dudley & Dilorio, 1999). Methods
Participants were recruited from the psychology student research pool in a large Hispanic-serving institution in the southeastern part of the United States. We further employed purposeful sampling, which involved identification of participants who might give the most comprehensive and knowledgeable information about the meanings given to sexual scripting and health services utilization in racial/minority communities. Women between the ages of 18 and 25, self identified as a
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racial minority were eligible to participate. Three data collection techniques were used: 1) semi-structured audio-taped individual interviews, 2) the interviewers’ notes, and 3) the researchers’ notes. These techniques provided the framework for triangulation, confirmation of emergent themes, and detection of any data inconsistencies. Research assistants scheduled interviews at times selected by the participants. The interviews were conducted by research assistants in an office on campus, which made it more convenient for the students. After some initial discussion, the questioning process focused on skin color values in the context of dating. A questioning route provided a framework to develop and sequence a series of focused, yet flexible questions (Rubin & Rubin, 1995). Throughout this process, the interviewers made notes about participant-researcher interactions and salient issues that emerged through the interviews. Participant-researcher interactions, body language, subsequent interview questions, and outlines of possible categories, themes, and patterns were also included in the interviewers’ notes. Finally, two researchers read the interview transcripts twice to make notes that identified and highlighted key themes and points that were raised. Pseudonyms are used to identify the participants’ voices on the audio tapes.
A n a ly s i s
Principles of the constant-comparative method (Lincoln & Guba, 1985) were used to guide data analysis in this study. Simon and Gagnon’s (1984) sexual scripting levels were used to develop the coding schemes. Reissman’s (1993) levels of representation model guided continuing attempts through analysis to represent and interpret narrative data. The investigators read the transcripts three times. The analysis process began with independent open coding to develop categories of concepts, and themes that emerged from the data. Selective coding, where first level codes were condensed and placed in new categories, followed this procedure. Findings
Some questions included
These young adult women stated that they need to improve their sexual health knowledge and use of sexual and reproductive health services. Beliefs around sexually appropriate scripts disseminated directly influenced attitudes toward seeking screening and treatment for sexual health issues. These beliefs placed women in positions where they lacked knowledge about sexual health issues and felt that they could not take steps to become more empowered about their sexuality. Specifically, women felt that health care providers who discuss sexual health information/education within a safe/comforting environment would best meet their sexual health needs.
»» Tell me how you racially or ethnically define yourself, and particularly as a woman within that group? »» What kinds of expectations about sexual behaviors are associated with [insert ethnicity] women? »» What do you think are the most important sexual health issues affecting women your age today? »» Where do you or your friends go to get the most up to date and accurate information about HPV, chlamydia, and other sexual health issues? »» If you had to describe what an ideal health practitioner would be, what would you want his/her qualities to be? »» Have you had to go to a medical practitioner in the past 12 months specifically for anything related to your sexual health or reproductive needs? Who conducted the majority of the visit- a doctor, nurse, or nurse practitioner? »» Do you know what a nurse practitioner is?
1. Barriers to Treatment: Sexual Script Messages Familial and religious barriers emerged as the most influential sources of sexual scripting and influence on seeking screening and treatment among these women. Socialization by family was a significant influence in the formation of racial/ethnic minority females’ sexual scripts. This is consistent with prior research of familial influences on minority daughters (Raffaelli & Ontai, 2001). Most (79%) of the participants supported the stated “it’s not normal to go to family” to discuss sexual health issues, although familial values about sexuality are extremely important. In addition, families attempted to instill values that included female subservience towards men and no premarital sex. These values held true regardless of race/ethnicity.
Probes were prepared for each question to elicit further information from the participants if the responses given were not comprehensive or failed to provide understandable information.
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“I still believe that I need to serve whatever guy that I’m in a relationship with, so in a relationship I always feel like I’m sort of, like I guess the best way to put this is like a waitress,
Hispanic female :
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where I’m like, always putting them first and serving them because that’s like what I’ve seen with my family.” Similarly, indoctrination of religious influences was evident in the minority female participants. Religious influences promoted female chastity and silence on the topic of sex (Raffaelli & Ontai, 2001). Sexuality and contraception were not discussed unless it was to deter from sex. As a social institution, religion can indoctrinate feelings of guilt and an inability to disclose sexual information (Wyatt & Dunn, 1991): Caribbean female : “ [Caribbean
people] are religious, Christian, so you know the norm is that you’re heterosexual and sexuality isn’t accepted, [sexuality and sexual health] is not really spoken about.”
2. Health Care Providers as Educators The majority (87%) of the women in this study did not feel they had adequate sexual health education. They cited schools, peers, and female familial members (including sisters and cousins within their same age group) as possible sources of information, but were critical of the accuracy and the depth of knowledge gained from these sources. Often the information they received was focused on avoidance of sexual contacts, which ignores the need for protective actions. This supports prior research findings that racial/minority females are largely unaware of STI preventive measures. “I actually went to a passion party over the weekend and I thought I knew everything, and I realized I knew nothing. I was shocked by how little I actually knew, and I think education was something that was missing. I think that what’s taught in schools isn’t enough, it’s just kind of biased where not everything is taught in schools either.”
Hispanic female :
The females in the sample indicated a desire for health care providers to discuss with them preventive information in regard to sexual health. Nurse practitioners were viewed by the women as reliable resources for sexual health information. Their fears
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about inaccurate or limited information would not be of concern if they spoke with a health care provider, such as a nurse practitioner. This finding is supported by other research data that indicates medical professionals are often viewed as credible sources of medical information, particularly on topics traditionally viewed as taboo (Ginige, Chen & Fairley, 2006; Gott et al, 2004; Pavlin et al., 2008). African American female : ”It’s getting information from someone who knows about [sexual health issues]. I guess that’s what they do so they know - [Nurse Practitioner] would know the right things. She would have heard everything already from people coming in for things so nothing would be a big deal for her.”
Conversations about sexual and reproductive health information in a medical setting further helped women feel that sexual health conversations were held in a safe space. While women often hesitate to talk about personal health issues, prior research has shown that university medical setting, student health care centers are ideal spaces to help patients feel accurate information is being provided in an appropriate setting (Diebold, Chappell & Robinson, 2000; Dooris, 2001; Swinford, 2002). 3. Health Care Providers Creating Safe Environments Although women felt that nurse practitioners would be ideal sources of sexual health information, they also admitted to a delay in seeking practitioner assistance because of feelings of humiliation. Sexual scripts shaped by their cultural values significantly shaped this fear; any public acknowledgement of their sexuality could put them risk for being seen as a “loose” or “bad” woman. This is consistent with research conducted by Barth et. al. (2002), which stated that one of the main barriers to seeking testing for STIs is the perceived negative consequence of “What would others think?” Caribbean female : ”I think it’s an embarrassing thing for a woman, at least in the Caribbean, so by going to a practitioner, its kind of like you feel that everyone will find out pretty soon. I mean, here
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you are supposed to be virgin and you are going to a doctor for an STD or something else. The doctor may look down upon you. That’s how women of the culture think.” This need to recognize the sexual script messages within cultural contexts was viewed as an extremely important characteristic for health care providers. All the young adult women who participated in the study gave significant value to their racial/ethnic and cultural background. These young adult women, without exception, discussed the strong influence of the messages received from cultural sources on their own sexual behavior. Although critical of the sexual scripting expectations for females within their cultures, these women consistently spoke of the importance of having their unique cultural beliefs respected and integrated into sexual health communication. This finding is consistent with research that notes clients often fear that health providers use a comparative approach to review their sexual health experiences; a normalization of White/middle class cultural values, which leads to an inaccurate perception and possible misdiagnosis of racial/ethnic minority women’s sexual health needs (Jones, 1991; McLoyd, 1998; Stephens & Few, 2007). D i s cu s s i o n / Ap p li cati o n to C li n i cal Practice
Despite the valuable information uncovered, the study was not without limitations. Meaningful comparisons between the ethnicities of the sample were difficult, given that the majority of the sample was Hispanic. Future research should therefore include a larger sample with comparable sizes between the different ethnicities. In addition, the qualitative nature of the study did not allow for a large sample of participants, and the development of sexual scripts were based on participant recall. Saturation was achieved after the thirteen interviews were reviewed. However, this study was unique in that it integrated the disciplines of nursing and psychology to address increasing rates of STIs in minority young adult women. The use of qualitative methods, particularly interviews or narrative documents, have been instrumental to inform researchers of the various dynamics that shape sexuality, race, and gender interactions (Bell-Scott,
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1998; Few, Stephens, & Rouse-Arnett, 2003). In consideration of sexual health issues, prior research suggests the use of qualitative methods to provide the most direct window into young adults’ sexual experiences through rich descriptions that can detail facts that are not easily quantified (Brooks-Gunn & Paikoff, 1997; Few, Stephens, & Rouse-Arnett, 2003). Training and continuing education on cultural competence are essential for health care providers and support staff, as they are the first face most of these young adults see as they enter the primary care office or student health care clinic. Time spent to discuss the specific cultural needs of each patient is important to provide equitable care. These discussions would also foster an environment of acceptance, privacy, and safety. An emphasis on training can and does decrease patient-provider miscommunication and improves cultural competence of the health care provider. Cultural competence is one of the most effective factors to decrease health care disparities (Institute of Medicine, 2002). To provide effective sexual and reproductive health information, an understanding of culture and the context of sexual meanings for young adult women the provider serves is essential. The awareness by health care providers that young adult women require an environment that fosters communication and that a young adult woman’s knowledge on how to use a condom and awareness of sexually transmitted infections, does not necessarily translate to their use of condoms is paramount.(Sipkin, Gillam, & Bissett Grady, 2003). Therefore, readily available routine urine screening and treatment of chlamydia in both sexually active asymptomatic females and males is a good strategy to decrease chlamydia infections. Screening of males is important in reducing the incidence of
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infections and re-infection. Due to the silent nature of the disease, it is not enough to test only when there are symptoms. Females should be routinely screened at the time of a vaginal examination and pap smear either by vaginal swabbing or urine collection. Males and females should also be offered chlamydia screening when accessing student health care services on college and university campuses. In addition, the results of this research give evidence that clinical office settings and specific office routines must provide young adult women the time to discuss sexual health information. In an age of decreased reimbursement and increased patient visits on a daily basis this may seem untenable. One solution may be the use of internet and or text messaging between patient and health care providers. These technologies are available to most young adults and provide them anonymity and allow the provider to answer questions at convenient times. This is an upgrade from the old “telephone triage nurse system”. While this technology might not be available in all offices, it might be a reasonable step to improve the patients’ perception of privacy and safety. Conclusions
Through an understanding of the unique socialization factors that shape racially diverse young adult female populations and their health care experiences illustrated in the qualitative research results, health care providers of all types will gain accurate perceptions of these women’s sexual health information needs. Moreover, racial minority young adult women need, and more importantly, want nurse practitioners’ credible help to identify healthy and unhealthy sexual behaviors within a specific gender and racial context. Through the continued development of sexual scripting models to address unique cultural nuances during client-provider interactions, health care providers can strengthen their partnership with their racial minority clients and promote desirable sexual health behavioral outcomes. These data provide a foundational component for further research. They provide a framework for the development of a specific provider intervention to decrease the rates of STIs and decrease related morbidity, and thereby significantly decrease the health care dollar burden of these diseases.
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References Alksnis, C., Desmarais, S., & Wood, E. (1996). Gender difference in scripts for different types of dates. Sex Roles, 34, 499- 509. Barth, K.R., Cook, R.L., Downs, J.S., Switzer, G.E., & Fischhoff, B. (2002). Social stigma and negative consequences: factors that influence college students’ decisions to seek testing for sexually transmitted infections. Journal of American College Health. 50, 153-159. Bay-Cheng, L. Y. (2003). “The trouble of teen sex: the construction of adolescent sexuality through school-based sexuality education.” Sex Education, 3, 63-74. Bell-Scott, P. (1998). Flat footed truths: Telling Black women’s lives. New York: Henry Holt. Bogdan, R. C., & Biklen, S. K. (1998). Qualitative research for education: An introduction to theory and methods (3rd ed.). Boston, MA: Allyn & Bacon. Brooks-Gunn, J., & Paikoff, R. (1997). Sexuality and development transitions during adolescence. In J. Schulenburg, J. L. Maggs, & K. Hurrelmann (Eds.), Health risks and developmental transitions during adolescence (pp. 190-219). Boston: Cambridge University Press. Caspi, A., Lynam, D., Moffitt, T.E., Silva, P.A. (1993). Unraveling girls’ delinquency: Biological, dispositional, and contextual contributions to adolescent misbehavior. Developmental Psychology, 29, 19-30. CDC (2006). “Sexually transmitted diseases treatment guidelines, 2006.” CDC. CDC (2007). Human Papillomavirus: HPV Information for Clinicians. Atlanta, GA: Centers for Disease Control and Prevention. Retrieved June 8, 2008 http ://www.cdc.gov/std/hpv/hpv-clinicians-brochure.htm. Diebold, C.M., Chappell, H.W., Robinson, M.K. (2000), “A health promotion practicum targeting the college-age population”, Nurse Education, 25, 48-52. Dooris, M. (2001), “The ‘Health Promoting University’: a critical exploration of theory and practice”, Health Education, 101, 51-60. Dworkin, S.L., Beckford, S.T., & Ehrhardt, A.A. (2007). Sexual scripts of women: A longitudinal analysis of participants in a gender-specific HIV/ STD prevention intervention. Archives of Sexual Behavior. 36, 269-279. Einwalter, L.A., Ritchie, J.M., Ault, K.A., & Smith, E.M. (2005). Gonorrhea and chlamydia infection among women visiting family planning clinics: Racial variation in prevalence and predictors. Perspectives on Sexual Reproductive Health, 37, 135-140. Emmers-Sommer, T., & Allen, M. (2005). Safer sex in personal relationships: The role of sexual scripts in HIV infection and prevention. Mahwah, New Jersey: Erlbaum. Faulkner, S. L. (2003). Good girl or flirt girl: Latinas’ definitions of sex and sexual relationships. Hispanic Journal of Behavioral Sciences, 25, 174-200. Ford, C.A., Jaccard, J., Millstein, S.G., Bardsley, P.E., & William, W.C. (2004). Perceived risk of chlamydial and gonococcal infection among sexually experienced young adults in the United States. Perspectives on Sexual and Reproductive Health, 36, 258-264. Few, A., Stephens, D.P., & Rouse-Arnett, M. (2003). Sister-to-sister talk: Transcending boundaries in qualitative research with Black women. Family Relations, 52, 205-215. Ginsburg, G. P. (1988). Rules, scripts, and prototypes in personal relationships. In S. W. Duck (Ed.), Handbook of personal relationships (pp. 2339). London: Wiley. Gott, M., Galenan, E, Hinchliff, S. & Elford, H. (2004). Opening a can of worms: GP and practice nurse barriers to talking about sexual health in primary care. Family Practice, 21, 528- 536. Ginige, S., Chen, M.Y. & Fairley, C.K. (2006). Are patient responses to sensitive sexual health questions influenced by the sex of the practitioner? Sexually Transmitted Infections, 82, 321-322. Harper, D. M., Franco, E.L., Wheeler, C., et al (2006). “HPV Vaccine Study Group. Sustained efficacy up to 4.5 years of a bivalent L1 virus-like particle vaccine against human papillomavirus types 16 and 18: follow-up from a randomized controlled trial.” Lancet 367,9518, 1247-1255. Institute of Medicine ( 2002). Unequal treatment : What health care providers need to know about racial and ethnic disparities in health care. Retrieved July 9, 2008 http://www.nap.edu/catalog/10260.html. Jackson, S. (1996). The Social Construction of Female Sexuality. In S. Jackson & Sue Scott (Eds.), Feminism and Sexuality: A Reader (pp. 62- 73). New York, NY: Columbia University Press. Jarama, L. Belgrave, F. Z., Bradford, J., Young, M. & Honnold, J.A. (2007). Family, cultural and gender role aspects in the context of HIV risk among African American women of unidentified HIV status : An exploratory qualitative study. AIDS Care, 19, 307-317. Jones, J. M. (1991). Psychological models of race: What have they been and what should they be? In J. D. Goodchilds (Ed.), Psychological perspectives on human diversity in America (pp. 7-46). Washington, DC: American Psychological Association.
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Klinkenberg, D. & Rose, S. (1994). Dating scripts of gay men and lesbians. Journal of Heterosexuality, 26, 23- 35. LaPlante, M.N., McCormick, N., & Brannigan, G.G. (1980). Living the sexual script: College students’ views of influence in sexual encounters. The Journal of Sex Research. 16, 338-355. Lear, D. (1995). Sexual communication in the age of AIDS: The construction of risk and trust among young adults. Social Science and Medicine, 41, 1311-1323. Logan, T.K., Cole, J., Leukefeld, C. (2002). Women, sex, and HIV: social and contextual factors, meta-analysis of published interventions, and implications for practice and research. Psychological Bulletin, 128, 851–85. Lincoln, Y. S., & Guba, E. G. (1985). Naturalist inquiry. Beverly Hills, CA: Sage. Longmore, M.A. (1998). Symbolic Interactionism and the study of sexuality. Journal of Sex Research, 35, 44- 58. Mahay, J., Laumann, E. O., & Michaels, S. (2001). Race, gender, and class in sexual scripts. In E. O. Laumann & R. T. Michaels (Eds.), Sex, love, and health in America (pp. 197-238). Chicago: University of Chicago Press. McLoyd, V. C. (1998). Changing demographics in the American population: Implications for research on minority children and adolescents. In V. C. McLoyd & L. Steinberg (Eds.), Studying minority adolescents: Conceptual, methodological, and theoretical issues (pp. 167-182). Mahwah, NJ: Erlbaum. Metts, S., & Spitzberg, B. H. (1996). Sexual communication in interpersonal contexts: A script-based approach. In B. Burleson (Ed.), Communication yearbook, 19 (pp. 49-91). Mahwah, New Jersey: Erlbaum. Morrow, K., Costello, T., & Boland, R. (2001). Understanding the Psychosocial Needs of HIV-Positive Women: A Qualitative Study. Psychosomatics, 42, 497-503. Noland, C.M. (2006). Listening to the sound of silence: gender roles and communication about sex in Puerto Rico. Sex Roles: A Journal of Research, 55, 283-294. Parrado, E.A., McQuiston, C. & Flippen, C. (2005). Participatory Survey Research: Integrating Community Collaboration and Quantitative Methods for the Study of Gender and HIV Risks Among Hispanic Migrants. Sociological Methods & Research, 34, 204-239. Pavlin, N., Parker, R., Fairley, C.K, Gunn, J.M. & Hocking, J. (2008). Take the sex out of STI screening: Views of young women on implementing chlamydia screening in General Practice. BMC Infectious Diseases, 8, 62. Prinstein, M.J., Christina S. Meade, C.S. & Cohen, G.L. (2003). Adolescent Oral Sex, Peer Popularity, and Perceptions of Best Friends’ Sexual Behavior. Journal of Pediatric Psychology, 28, 4, 243-249. Rafaelli, M. O., L. L. (2001). “She’s 16 years old and there’s boys calling over to the house’: an exploratory study of sexual socialization in Latino families.” Culture Health and Sexuality 3(3): 295-310. Rubin, H. J. & Rubin, I. S. (1995). Qualitative Interviewing: the art of hearing data. Thousand Oaks, CA. Sage. Simon, W., & Gagnon, J. H. (1984). Sexual scripts. Society, 22, 52- 60. Simon, W., & Gagnon, J. H. (1986). Sexual scripts: Permanence and change. Archives of Sexual Behavior, 15, 97-120. Sipkin, D. L., Grady, L., Bissett, L., & Gillam, A. (2003). Risk factors for chlamydia trachomatis infection in California collegiate population. Journal of American College Health 52,65-72. Soet, J. E., Dudley, W. N., & Dilorio, C. (1999). The effects of ethnicity and perceived power on women’s sexual behavior. Psychology of Women Quarterly, 23, 707-723. Stephens, D.P. & Phillips, L. (2005). Integrating Black feminist thought into conceptual frameworks of African American adolescent women’s sexual scripting processes. Sexualities, Evolution and Gender. 7 37-55. Stephens, D.P. & Few, A.L. (2007). The Effects of Images of African American Women in Hip Hop on Early Adolescents’ Attitudes toward Physical Attractiveness and Interpersonal Relationships. Sex Roles, 56, 251- 264. Swinford, P.L. (2002), Advancing the health of students: a rationale for college health programs. Journal of American College Health, 50, 309-13. Thomas, T. L. (2006). Chlamydia screening: Population specific risk factors for female university students. Unpublished Doctoral Dissertation University of Florida. Treboux, D., & Busch-Rossnagel, N.A. (1995). Age differences in parent and peer influences on female sexual behavior. Journal of Research on Adolescence, 5, 469-487. Wyatt, G.E. & Dunn, K.M. (1991) Examining predictors of sex guilt in multiethnic samples of. women. Archives of Sexual Behavior , 20, 471-436. Zea, M.C., Reisen, C., & Diaz, R. (2003). Methodological Issues in Research on Sexual Behavior with Latino Gay and Bisexual Men. American Journal of Community, 31, 281-291.
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from Posters to PRISM:
Physician Roles in STD Prevention and Control Efforts that Target Adolescents Sherese J. Bleechington, MPH, CHES
Health care providers
are well known for their curative role in disease control, yet they also serve as a critical point of contact for prevention efforts. Few patients will deny that they almost unquestionably trust the advice obtained from a person donning a white coat and stethoscope. This is not to say that there are not a growing number of individuals with high levels of health literacy prepared to openly and consistently communicate with providers. Instead a reflection on patients’ confidence in the information supplied by providers is an opportunity to explore how patient-provider communications may be enhanced to reduce disease among target populations. Patient-provider communications are especially important as the Florida Department of Health, Bureau of STD Prevention and Control seeks partners to reverse the trend of increasing rates of STDs among adolescents in Florida. This article will discuss two physician roles that contribute to STD prevention among adolescents: disease reporting and patient communication.
S e x ua l ly T r a n s m i t t e d D i s e a s e s A m o n g A d o l e s c e n t s
Sexually transmitted diseases are a major health problem among adolescents. The highest reported rates of chlamydia and gonorrhea are found among persons ages 15-24. In the pursuit of primary prevention, which is the avoidance of the development of disease, health care providers are encouraged to talk with their young patients before the patients initiate sexual activities. Statistics from the 2007 Florida Youth Risk Behavior Survey (YRBS) indicated that 49.5% of adolescents in grades 9-12 had engaged in sexual intercourse (see Figure 1), with 8.2% engaging in intercourse before the age of 13.1 Approximately 16.4% of students reported they had sexual intercourse with four or more people during their life. The 2007 YRBS survey instrument introduced a new question to create a baseline for youth engagement in oral sex. Roughly 309,000 students (45.2%) had ever had oral sex in 2007. Males had a significantly higher prevalence of this behavior than females (50.6% and 39.9%, respectively).
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FIGURE 1: Percentage of students who have had sexual intercourse by gender, Florida, 2001 - 2007 70 60
percent
Additional data sources 50 suggest adolescents need 40 information about sexual 30 health and STDs. 20 Provisional data for 2008, 10 collected by the Florida 0 2001 2003 2005 2007 Department of Health, Bureau of STD Prevention FL Total 49.9 51.3 50.5 49.5 and Control, indicates FL Females 46.2 46.7 47.1 44.8 more than 23,000 cases of FL Males 53.5 56.1 53.5 54.3 chlamydia and 6,500 Source: Sexual Behaviors Among Florida Public High School Students: Results from the 2007 Florida Youth cases of gonorrhea were Risk Behavior Survey Report. (2007). Tallahassee, Florida. Available at http://www.doh.state.fl.us/disease_ reported for the 15-19 ctrl/epi/Chronic_Disease/YRBS/2007/2007_YRBS.html year old age group alone (see Table 1). Examination of the state’s STD data gathered from 2007 through Concerns include literacy levels among target popula2008 reveals a significant percent change in the tions with low educational attainment, printing costs number of cases reported for chlamydia and gonorthat create barriers to dissemination of printed health rhea (increase by 43% and 55% respectively) among information, and the spread of misinformation by the 15-19 age group in Florida. invalid, unscientific sources. 5 The concerns represent gaps that health care providers fill. Health care providers have been identified as primary sources of information and guidance for young adoHealth care providers continue from where the posters lescents and their parents. This is a critical health pro- and other prevention materials end. They are in a motion and prevention role. The American Academy unique and influential position. The American Academy of Pediatrics (Sexuality Education for Children and of Pediatrics provides the following recommendations: Adolescents) and the American Medical Association (Guidelines for Adolescent Preventive Services) en»» Integrate sexuality education into clinical practice with courage health care providers to discuss sexually children from early childhood through adolescence. transmitted diseases with their patients. 2,3 As parent This education should respect the family’s individual and cultural values. and child embark on the journey from childhood to »» Educational materials, such as handouts, pamphlets, adolescence, the role of health care providers is critior videos, should be available to reinforce officecal in the prevention of sexually transmitted diseases. based educational efforts. » » Be knowledgeable about community services that Posters and Other Prevention provide appropriate high-quality sexuality education M ater i al s and additional services that children, adolescents, or Posters are one of many ways to communicate health families need. information to multiple target populations. Marketing research is typically conducted to ensure vivid, relevant »» Consider participating in the development and implementation of sexuality education curricula for schools images and memorable phrases are used to attract or in public efforts to decrease the rates of unsafe readers and impart a succinct health promotion adolescent sexual behavior and adverse outcomes. message.4 Posters rarely stand alone. They are often »» Linguistically appropriate materials could be provided coupled with educational booklets or brochures that in the office or the health care provider should have a elaborate on the theme or messages presented in the way of helping children, adolescents, and their famiposter. There is great debate among public health prolies get information in their language of choice. fessionals regarding the use of printed materials.
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Table 1: Notifiable STD cases in 15-19 year olds, by gender Gender
Chlamydia
Gonorrhea
Syphilis
Total
Female
19,013
4,460
140
23,613
Male
3,961
2,086
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H e a lt h C a r e Pr ov i d e r s , Disease Reporting and Surveillance
6,172 In addition to their roles of providing inUnknown 81 16 0 97 formation, physicians across the state have a second role associated with their Total 23,055 6,562 265 29,882 disease reporting responsibilities under Source of data: Florida Department of Health, Division of Disease Control, Bureau of STD Prevention and Control data files as of January 2009. Florida Administrative Code 64D-3: Communicable Diseases and Conditions The multiple benefits in the use of PRISM include the Which May Significantly Affect Public Health. The inforexistence of a central statewide database and demation that they report complements data received creased timeframes between positive tests, diagnosis, from laboratories and enables efficient timely manageand treatment. The use of a central system allows for a ment in disease investigations to interrupt spread in comprehensive view of the treatment intervention and the community. This data stored in the Department of related STD activities of an individual in the context of Health’s PRISM (Patient Reporting, Investigation and statewide performance measures. Electronic laboratory Surveillance Manager) application actively monitors reporting per Florida Administrative Code 64D-3 has STD morbidity and disease trends in Florida. PRISM is shortened the length of time between a positive test utilized by over 500 users concurrently, varying from disease investigators, data analysts, and treatment pro- result and the initiation of STD prevention and control activities (such as investigation, case management, inviders. Introduced in 2007, PRISM is the only tervention, and treatment). Reduction in the duration of Department of Health statewide application available STDs among infected individuals will reduce the period from desktops, laptops, and via Blackberry. A profile, in of time that an individual is infectious, and consequently PRISM, is an individual. The individual’s profile contains his/her demographic information, laboratory results, in- reduce the numbers of partners exposed to infection. terview notes, treatment history, and other case investigation information unique to that individual. FIGURE 2 Measurable Improvements: Integration of ELR in to PRISM and into the business model of STD continues to produce measurable improvements in operations. These improvements will continue to translate into cost savings, operational expenditure reductions, and increasing efficiencies during economic times that demand programs do more with less.
160 140
Average (Days)
120
COL_INT = Collection of initiation date of field records COL_DIS = Collection of specimen to field disposition date REC_INT = Test result receive date to initiation date of field record REC_DIS = Test result receive date to disposition date.
100 80 60 40 20 0 1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
COL_INT
125
89
73
52
58
42
19
22
17
15
10
COL_DIS
140
130
87
65
70
49
11
10
10
24
19
REC_INI
12
6
12
7
11
17
16
17
13
12
7
REC_DIS
54
63
29
22
25
13
15
12
13
21
15
YEAR The journal of the florida medical association
The system’s use of automation allows laboratory results to be processed quicker and enables the field staff to ensure treatment or verify treatment with providers in a much more efficient manner. Figure 2 reveals an enormous reduction in test to treat intervals because of ELR and other efficiencies. Across the state, local health care providers and laboratories are the link between infected persons and our public health response to interrupt spread. Without reports of illness from local partners, the Florida Department of Health cannot fully identify and investigate STD outbreaks of public health significance. Health care providers’ partnership with representatives from the Department of Health that utilize PRISM is necessary to: »» identify clusters, outbreaks, and/or pandemics, »» enable preventive or mitigative treatments, and »» assist in national and international surveillance efforts to control the spread of STDs.
more extensive and intensive. The activities implemented to achieve the State goals are selected through a deliberate, logical approach and require health care providers’ engagement in order to be successful. The 2009 agenda for STD health promotion illustrates commitment to the use of science-based, theory driven frameworks that allow multiple stakeholders to use a shared rationale to achieve behavior change among target populations. Physicians are core stakeholders in the process of prevention of STDs among adolescents. STD health promotion activities may be organized by concepts of the Health Belief Model (HBM). The HBM is a behavior change theory. It is a psychological model that attempts to explain and predict health behaviors by focusing on the attitudes and beliefs of individuals (see Figure 3).6 It is one of the first behavior change theories developed. According to HBM, changes in behavior depend on six factors:
P o s t e r s t o P RISM : P o i n t s A l o n g t h e Sp e c t r u m
Although this article briefly introduces posters and PRISM as STD activities, the core activities that contribute to STD prevention and control efforts are much
»» Perceived susceptibility - the belief that one is at risk for contracting the illness or disease »» Perceived severity - the belief that a health problem is serious
Figure 3. Conceptual Model of the Health Belief Model Individual Perceptions
Perceived susceptibility/ seriousness of disease
ModIfying Factors
Likelihood of Action
Age, sex, ethnicity personality socio-economics knowledge
Perceived benefits versus barriers to behavioral change
Perceived threat of disease
Likelihood of behavioral change
Cues to action: education symptoms media information Source: Glanz, K., Rimer, B.K. & Lewis, F.M. (2002). Health Behavior and Health Education. Theory, Research and Practice. San Fransisco: Wiley & Sons.
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“Are you thinking about being sexually active with anyone sometime soon?” »» Perceived benefit - the belief that a change in one’s behavior will reduce the threat »» Perceived barriers - a perception of the obstacles to a change in one’s behavior »» Cues to action - strategies to activate “readiness” or reminders to engage in health protective behaviors »» Self efficacy - the belief that one has the ability to change one’s behavior
A Snapshot of the Role of P h y s i c i a n s A l o n g t h e Sp e c t r u m
Not sure where you can make a difference? The following small steps are important, easy ways health care providers influence patients’ decisions to engage in healthy behaviors. Provide Information
provides plain language brochures with basic facts about STDs. To order free STD educational materials, visit: https://www2.cdc.gov/nchstp_od/piweb/ stdorderform.asp.
The CDC
Table 2 compares key public health and physician prevention activities performed that address the concepts of the Health Belief Model. The list of activities can be conducted by health care providers in order to make the anticipated achievement of reduced STDs a shared success. There are many points along the STD spectrum from posters to PRISM and health care providers are key navigators for patients traveling from point A to point B. It is the patient-provider communication that does (or does not) occur that makes the greatest difference in health outcomes. Providers have the voice that posters and disease surveillance will never have. They activate the power in theory and enhance the practice of prevention. Health care providers are catalysts along the spectrum.
The AAP Adolescent Health Section offers one central, convenient location where pediatricians can turn for access to many adolescent health related handouts. Visit http://www.aap.org/sections/adolescenthealth/ handoutstools.cfm for more information. Parent Package (an AMA effort) - Designed to help physicians share important information about adolescence with parents and adolescent patients. Available at: http://www.ama-assn.org/ama/pub/category/7312.html.
TABLE 2
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Concept
Public Health Activities
Physician Activities
1. Perceived Susceptibility
Develop and disseminate materials containing morbidity data
Conduct a brief risk assessment and correct or confirm patient’s perception of individual risk
2. Perceived Severity
Intensify quantity and quality of STD information presented with interrelated topics (e.g. pregnancy prevention, HIV, and substance abuse)
Integrate STD prevention messages in conversations about other serious threats to adolescent and reproductive health (e.g. HPV, PID)
3. Perceived Benefits
Age-appropriate, reward centered DVDs for use during community health promotion events and school health presentations
Provide printed materials that describe tips for risk reduction and potential positive outcomes of STD prevention and early treatment
4. Perceived Barriers
Disseminate publications that provide tips for partner to partner communications and patient guides for provider-patient interactions
Start a dialogue with patients and parents about barriers described in the literature or presented by other patients
5. Cues to Action
Reminder cues for action in the form of health marketing items
Display age-appropriate and environment-friendly posters that contain reminder messages (such posters are available free of cost from the Bureau of STD)
6. Self-Efficacy
Support county health department staff in efforts (e.g. face-to-face client interviews, condom demonstrations, testing events) that build individual and community confidence
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Normalize the conversation of STDs; incorporate STD risk assessment and discussion as a component of an office visit Empower patients through readily available, judgmentfree testing
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Ask Questions
Screen for issues quickly by asking trigger questions:
7
»» “Are any of your friends sexually experienced? How about you?” »» “Have you ever had any sexual experiences?” »» “Are you thinking about being sexually active with anyone sometime soon?” A self-administered survey may expedite the process (see Self-Administered Adolescent Risk Survey, this edition). For sexually active patients, ask about lower abdominal pain, vaginal discharge, burning, itching, skin lesions, malodorous discharge, and difficulty and/or pain during urination.
provide pediatricians with information and tools to address challenges identified by providers 8, including: »» Lack of time »» Confidentiality issues »» Concerns over adolescent and parental comfort »» Concerns over risk reduction messages Information and tools are available in the form of sample risk assessment surveys, copies of state and federal policies and statutes, guides for sexual history taking, and science-based, age appropriate risk reduction educational materials. Summary
Know
the
Law
Title XXIX, Public Health, Chapter 384.30, Sexually Transmissible Diseases M i n o r s’ co n s e nt to tr eatm e nt
The department and its authorized representatives, each physician licensed to practice medicine under the provisions of chapter 458 or chapter 459, each health care professional licensed under the provisions of part I of chapter 464 who is acting pursuant to the scope of his or her license, and each public or private hospital, clinic, or other health facility may examine and provide treatment for sexually transmissible diseases to any minor, if the physician, health care professional, or facility is qualified to provide such treatment. The consent of the parents or guardians of a minor is not a prerequisite for an examination or treatment. Recognize
and
Reduce Barriers
The county health department and Florida Department of Health, Bureau of STD Prevention and Control can
There is an increase in reported number of cases among adolescents. Health care providers have been identified as the primary and preferred source of health information by adolescents. While a variety of public health STD activities are conducted, the effectiveness of STD interventions is dependent on health care providers engagement in dialogues with their patients about STDs. A risk assessment survey can serve as a conversation starter and help providers determine a patient’s probable risk and need for testing. Health care providers make a difference along the spectrum of prevention and control. They are the bridge from patient knowledge to patient action. April is national STD Awareness Month. Local activities will take place throughout the month of April to encourage Floridians to become informed and empowered about STD infections, methods of prevention, signs and symptoms, treatments available, and services offered to the local communities as part of public health. The physician has a critical role in the use of three T’s to prevent the spread of STDs: talk, test, and treat.
References 1. Florida Department of Health (2008). Sexual Behaviors Among Florida Public High School Students: Results from the 2007 Florida Youth Risk Behavior Survey Report. Retrieved from http://www.doh.state.fl.us/disease_ctrl/epi/Chronic_Disease/YRBS/2007/2007_YRBS.html. 2. American Academy of Pediatrics: Committee on Psychosocial Aspects of Child and Family Health and Committee on Adolescence. (2001). “Sexuality education for children and adolescents”, Pediatrics, 108(2), (498-502). 3. Elster AB, Kuznets NJ, eds. (1994). AMA guidelines for adolescent preventive services (GAPS): recommendations and rationale. Baltimore: Williams Wilkins. 4. Kotler, P., Ned, R., & Lee, N. (2002). Social marketing: Improving the quality of life. California: Sage. 5. Wurzbach, M. E. (2004). Community health education and promotion: a guide to program design and evaluation. Massachusetts: Jones and Bartlett. 6. Glanz, K., Rimer, B.K. & Lewis, F.M. (2002). Health Behavior and Health Education. Theory, Research and Practice. San Fransisco: Wiley & Sons. 7. Cavanaugh, R. M., (2007). Screening Adolescent Gynecology in the Pediatrician’s Office: Have a Listen, Take a Look. Pediatrics in Review, 28; 332-342. 8. Boekloo, B. O., Schamus, L. A., Simmens, S. J., et al. (1999). A STD/HIV Prevention Trial Among Adolescents in Managed Care. Pediatrics, 103; 107-115.
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&
Questions Answers for Parents of Pre-teens about Human Papillomavirus (HPV) and the HPV Vaccine
What is human papillomavirus (HPV)?
How common is cervical cancer?
HPV is a common virus that is spread through sexual contact. Most of the time HPV has no symptoms so people do not know they have it. There are many different strains or types of HPV. Some types can cause cervical cancer in women and can also cause other kinds of cancer in both men and women. Other types of HPV can cause genital warts in both males and females. In most people, HPV goes away on its own without any treatment and does not cause health problems. Experts do not know why HPV goes away in some cases, but not in others.
Cervical cancer is a serious health problem in the United States. The American Cancer Society estimates that in 2007, over 11,000 women will be diagnosed with cervical cancer and approximately 3,600 will die from it in the U.S.
This vaccine is the first vaccine developed to prevent cervical cancer and genital warts due to HPV. It works by protecting against the types of HPV that most commonly cause these diseases. The vaccine is given in 3-doses.
How common is HPV?
Who should get the HPV vaccine?
HPV is the most common sexually transmitted infection in the United States, with about 20 million people currently infected. Your daughter has an 80 percent chance of getting HPV by the time she is 50. Every year in the U.S., about 6.2 million people get a new HPV infection. HPV is most common in young people who are in their late teens and early 20s.
What is the HPV vaccine?
Doctors recommend this vaccine for 11 and 12 year old girls. If your teenage daughter missed getting this vaccine when she was 11 or 12, make an appointment for her to get it now. Ideally, girls should get this vaccine before their first sexual contact when they could be exposed to HPV. This is because the vaccine prevents disease in girls/women who have not previously gotten one or more types of HPV prevented by the vaccine. It does not work as well for those who were exposed to the virus before getting the vaccine. continued on back
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For more information on vaccines, ask your child’s healthcare provider or call 800-CDC-INFO (800-232-4636) The journal of the florida medical association Website: www.cdc.gov/vaccines/preteen/
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Is the HPV vaccine effective? This vaccine targets types of HPV that most commonly cause cervical cancer and genital warts. This vaccine is highly effective in preventing these types of HPV in young women who have not been previously exposed to them. The vaccine will not treat existing diseases or conditions caused by HPV.
Is the HPV vaccine safe?
girls/women would get if they receive only one or two doses of the vaccine. For this reason, it is very important that girls/women get all three doses of the vaccine.
Will the girls/women who have been vaccinated still need a Pap test, also called “cervical cancer screening”?
The vaccine has been licensed as safe. Before it was approved by the Food and Drug Administration (FDA), the vaccine was studied in thousands of girls and women in the U.S. and around the world. These studies have shown no serious side effects. The most common side effect is soreness where the shot is given (in the arm).
Yes, they will still need to see their healthcare provider for a Pap test. Regular Pap tests are recommended for all women starting within three years of when a girl/woman begins sexual activity or at age 21, whichever comes first. The vaccine will not provide protection against all types of HPV that cause cervical cancer, so women will still be at risk for some cancers.
Are there other ways, besides the vaccine, to prevent HPV?
Why is the vaccine only recommended for girls/women 9 through 26 years old?
The surest way to prevent genital HPV is to avoid sexual contact. For persons who are sexually active, condoms may lower their chances of getting HPV, if used all the time and the right way. Condoms may lower a person’s chances of developing genital warts and cervical cancer. But HPV can infect areas that are not covered by a condom—so condoms may not fully protect against HPV.
The vaccine has been widely tested in 9 through 26 year old females. But research on how well the vaccine works in older women has just recently begun. The FDA may consider licensing the vaccine for these women when there is research to show it is safe and effective for them.
Will girls/women be protected against HPV and related diseases, even if they don’t get all three doses of the vaccine?
What about vaccinating boys? We do not yet know if the vaccine is effective in boys or men. Studies are being done to find out if the vaccine is effective in males. When more information is available, this vaccine may be licensed and recommended for boys/men as well. CS112269
The HPV vaccine is recommended as a 3-dose vaccine. It is not yet known how much protection
For more information on vaccines, ask your child’s healthcare provider or call 800-CDC-INFO (800-232-4636) Website: www.cdc.gov/vaccines/preteen/ www.fmaonline.org
Department of Health and Human Services Centers for Disease Control and Prevention
STDs and Pregnancy in Adolescents
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Self-Administered Adolescent Risk Survey 1. Are you dating someone or going steady? Yes
No
Not Sure
2. Are you thinking about having sex (“going all the way “or “doing it”)? Yes
No
Not Sure
3. Have you ever had sex? Yes
No
Not Sure
4. Have any of your friends ever had sex? Yes
No
Not Sure
5. Have you ever felt pressured by anyone to have sex? Yes
No
Not Sure
6. Have you ever been told by a doctor or a nurse that you had a sexually transmitted disease like herpes, gonorrhea, or chlamydia? Yes
No
Not Sure
7. Would you like to receive information on abstinence (“how to say no to sex”)? Yes
No
Not Sure
8. Would you like to receive information or supplies to prevent pregnancy or sexually transmitted infections? Yes
No
Not Sure
9. Would you like to be tested for STDs? Yes
No
Not Sure
10. Do you have any questions or concerns that you would like to discuss today? Yes
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No
Not Sure
The journal of the florida medical association
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CME POst-test M u lt i pl e C h o i c e : C h o o s e t h e b e s t
True /False : Choose the correct
one response to each question.
response.
1. According to the Health Belief Model (HBM), changes in behavior depend on six factors. Which of the following is NOT one of these six factors:
6. Approximately 80% of all reported cases of chlamydia are reported in populations 26 and under.
1. Perceived barriers - a perception of the obstacles to a change in one’s behavior 2. Self efficacy - the belief that one has the ability to change one’s behavior 3. Perceived susceptibility - the belief that one is at risk for contracting the illness or disease 4. Perceived greatness - the belief that one can become a better person for having overcome the illness or disease 2. In early syphilis, there has been what increase of cases reported in 15-24 year olds from 2003. 1. three-fold 2. four-fold 3. five-fold 4. six-fold 3. Which theory posits that sexual interactions are guided by scripts, or schemas, that help individuals in the development of their sexual selves. 1. sexual scripting theory 2. sexual identity theory 3. schema theory 4. sexual self theory 4. Gonorrhea is the most prevalent sexually transmitted bacterial infection reported among 15-24 year olds in Florida.
1. True 2. False 7. The Centers for Disease Control and Prevention recently estimated that one in five adolescent girls in the United States is infected with an STD. 1. True 2. False 8. Racial disparities in STD rates are strongly influenced by structural and socio-economic determinants that contribute to disparities in socio-economic status and circumstances. 1. True 2. False 9. The most common factor to delay young adults from seeking testing and treatment for a possible sexually transmitted infection is fear. 1. True 2. False 10. PRISM (Patient Reporting, Investigation and Surveillance Manager) is the only Department of Health statewide application available from desktops, laptops, and via blackberry. 1. True 2. False
1. second 2. third 3. fourth 4. fifth 5. Which chapter in the Florida Statutes addresses minors’ consent to treatment? 1. Chapter 384.24 2. Chapter 384.26 3. Chapter 384.30 4. Chapter 384.32
www.fmaonline.org
STDs and Pregnancy in Adolescents
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CME POST-TEST ANSWER SHEET STDs & Pregnancy in Adolescents Expiration date of this activity and answer sheet: April 30, 2011 No cme credit granted for answer sheets received after this date. 1.
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Make a copy of your completed answer sheet for your files. EVALUATION
Do you better understand the incidence and prevalence of STDs and pregnancy in adolescents? Yes
No
Already knew the information covered
Do you recognize the importance of communication and counseling to prevent pregnancy and STDs in your adolescent patients? Yes
No
The articles were effectively written? Yes
No
Very Much
Somewhat
Not at all
Comments: Do you think that you will discuss pregnancy and STDs with your adolescent patients in the future? Yes
No
Have already been doing this
If not, why?
What CME topics would you like to see presented in future FMA journals?
P LEASE P RINT OR USE AN ADDRESS LA B EL
Name:
Degree:
Address: City/State/Zip: Phone:
Fax:
E-mail:
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The Florida Medical Association
Your source for CME in 2009
Mandatory CME courses, Prevention of Medical Errors and Domestic Violence, online at www.fmaonline.org
CME at FMA Annual Meeting, Friday, July 24th at the Boca Raton Resort & Club Best Practices Symposium: How to Succeed in the Business of Medicine and Safeguard Your Practice Prevention of Medical Errors Disaster Preparedness: Getting Ready the Right Way Immunizations: Science versus Populism Questions? Call the FMA Education Department at (800) 762-0233
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STDs and Pregnancy in Adolescents
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