Portal de Periódicos da CAPES

Adolescent Health Care Providers

1997; Lippincott Williams & Wilkins; Volume: 24; Issue: 2 Linguagem: Inglês

10.1097/00007435-199702000-00006

1537-4521

Robert A. Gunn, ELIZABETH VEINBERGS, Lawrence S. Friedman,

Child and Adolescent Health

THE RISK OF ACQUIRING sexually transmitted infections (STIs) is great among adolescents in most areas of the United States with the incidence of gonorrhea (GC) and Chlamydia trachomatis (CT) being highest in 15- to 19-year olds.1 Sexual behavior that includes multiple partners and inconsistent use of condoms and physiologic factors such as endocervical ectopy, which facilitates chlamydia infection, all contribute to this high risk. Sexually transmitted disease (STD) prevention programs face the challenge of developing effective community-level intervention strategies to prevent STI among adolescents, as well as ensuring that clinical prevention services are delivered during health care visits. Visits for routine physicals or minor illness or injury provide opportunities for clinicians to assess sexual behavior, deliver health education, counsel high-risk clients, and obtain screening tests for chlamydia and, when indicated, for gonorrhea, syphilis, and human immunodeficiency virus. Adolescents traditionally have been underserved by the health care community. A national survey done in 1991 showed that the number of comprehensive health service programs for adolescents was vastly inadequate to serve their needs. The survey estimated that less than 5% of all teens were served by these programs.2 In San Diego County, California (population, 2.6 million), as in many localities, little was known about providers of adolescent health care, and it appeared that services were fragmented and difficult to access, especially for disadvantaged youth. To learn more about adolescent health care in San Diego and communicate with providers about STI prevention issues, we attempted to identify all health care providers who devoted at least 10% of their time to adolescent patients, produce an adolescent health care directory of providers and ancillary services, develop a coalition of adolescent health care and support services providers, publish a coalition newsletter, and sponsor continuing medical education conferences. In addition, we surveyed specialists of adolescents and other providers of adolescent health care regarding clinical preventive services and report here results pertaining to STI prevention and control practices. Methods Adolescent health care specialists, defined as providers who devoted more than 50% of their time to adolescent patients, were identified through membership lists of the Southern California Chapter of the Society for Adolescent Medicine and the San Diego Chapter of the American Academy of Pediatrics, listings in the San Diego County telephone directory, hospital-based referral services, and through professional knowledge of specialists. A listing of all college and university student health services also was obtained and, through advertisements and notices in professional societies' bulletins and newsletters, we sought primary care physicians who devoted more than 10% of their time to adolescent patients and wished to be listed in the provider directory. The percentage of adolescent patients seen by these self-identified primary care providers was not verified. During the period from November 1994 through May 1995, an adolescent health care coordinator (part-time grant-funded position) visited all adolescent specialists and directors of student health centers and completed a comprehensive survey through interviews with clinicians and their staff. In addition, an abbreviated survey with similar questions was mailed in March 1995 to self-identified primary care adolescent providers. The number of full-time equivalent (FTE) physicians was determined for adolescent specialists and student health center directors, and we estimated that each primary care physician provided 0.20 FTE of adolescent care. We calculated the ratio of adolescents (12–19 years old, 1993 San Diego County estimate) per physician providing adolescent health care (expressed as an FTE). Results Eleven adolescent specialty practices, 12 university student health centers, and 76 primary care (e.g., pediatrics, family medicine, internal medicine, and obstetrics-gynecology) adolescent providers were identified. The adolescent specialty practices were: four community clinics, two U. S. Navy dependent clinics, and one of each university hospital clinic, private practitioner, homeless youth clinic, high school clinic, and juvenile detention medical service. In the adolescent specialty practices, there were 28 physicians providing 10 FTEs of care. The university student health centers provided 14 FTEs of physician care, and we estimated that primary care practices provided 15.2 FTEs of physician care. The adolescent-to-physician ratio was 9,613 adolescents per FTE of physician adolescent health care. The primary care provider survey was returned by 64 (84%) physicians. Sexual behavior risk assessment was reported by all providers as part of routine care; however, an adolescentoriented risk assessment questionnaire or data recording form was used by only 64% of adolescent specialists, 58% of student health centers, and 31% of primary care providers. Among the adolescent specialists and student health centers using forms (N = 14), questions covered the following topics: STD history (79%), condom use (57%), contraception (57%), number of sex partners (43%), gender of partner (36%), sex for drugs or money or both (7%), and age of partners (0%). Providers routinely screened sexually active girls for chlamydia more frequently than boys (51% versus 28%), and adolescent specialists did more routine screening than either university student health centers or primary care providers (Table 1). Among those doing testing (routine or high-risk screening) for girls (N = 74), the DNA probe was the most commonly used test (43%), followed by Chlamydiazyme (14%), and other enzyme immunoassays (10%). Twenty-four percent were not sure what test they used, and only 2 (3%) primary care providers used a polymerase chain reaction test. For boys, providers used the same tests as for girls and used primarily urethral swab specimens. Of those doing testing for boys (N = 64), only three (5%) primary care providers used a urine polymerase chain reaction test. Of those providers who reported treating chlamydia (N = 76), 64 (84%) used doxycycline, and 30 (39%) used azithromycin (60% directly observed).TABLE 1: Chlamydia Screening Practices for Sexually Active Adolescents, by Provider Type, Adolescent Health Care Provider Survey, San Diego, California 1995Regarding sex partners of infected patients, many providers recommended that partners come to their service for treatment (72%), and 77% also referred partners to either their own physician (84%) or to the health department (65%). In most instances (89%), the patient was asked to contact their sex partner or partners regarding treatment. Written referrals were provided for approximately 48% of those referred. Only 25 (29%) providers had a mechanism to determine and record that a sex partner or partners had been treated. Primary care providers responding to this survey were interested in receiving information that would help them in their practice. We offered, and practitioners asked for, copies of the following: model risk assessment form (89%), 1993 Centers for Disease Control STD Treatment Guideline (73%), and the Adolescent Health Coalition Newsletter (97%). However, only 6% were interested in receiving information about becoming a member of the national Society for Adolescent Medicine. The adolescent health care provider directory was produced, and more than 2,000 copies were distributed to providers, school nurses, and a variety of agencies and programs. In collaboration with the Division of Adolescent Medicine, Department of Pediatrics, School of Medicine, University of California, San Diego, a coalition of professionals interested in adolescent health care was formed (more than 120 attended the initial meeting). From this group, a local chapter of the Society for Adolescent Medicine was formed (currently, 55 members; $20.00 local dues; national membership not required for local chapter members). The chapter has been publishing a quarterly newsletter (circulation, approximately 600 copies) that has included three STD-related articles: (1) new advances in chlamydia diagnosis and treatment, (2) utilizing urine tests for chlamydia screening, and (3) hepatitis B immunization strategies. The Chapter has sponsored two continuing medical education-approved conferences (topics, teenage depression and suicide; teen pregnancy). Discussion The survey showed, as expected, that adolescent specialists were doing more routine CT screening of sexually active adolescents than were other providers. The fact that less than 50% of the primary care adolescentoriented physicians were routinely screening all sexually active adolescent girls and less than 20% were screening boys suggests that more information regarding screening recommendations needs to be distributed to these and other primary care providers. Perhaps distributing information about the results of this survey, the utility of the polymerase chain reaction3 and recently licensed ligase chain reaction urine CT tests,4 and the current screening recommendations5 will encourage primary care providers to expand routine CT screening to all sexually active adolescents. Assessing sexual behavior is an important component of adolescent preventive health care. The survey indicated that all providers reported assessing adolescent sexual behavior, but there was variable use of a questionnaire or data form to record this information, suggesting that some areas of behavior could be missed when relying on open-ended questioning. Self-administered questionnaires are sometimes difficult to administer because accompanying parents or friends may interfere with the process unless a private area is available for completing the questionnaire. However, we recommend that some type of systematic questioning and recording process be used so that a complete assessment can be done, recorded, and progress (or lack of) easily determined. In addition, analyzing the patterns of sexual behaviors of the providers' teen clients can identify sexual health education and other prevention needs that can be addressed systematically. Providing partner treatment in settings other than public STD clinics always has been difficult. This survey, similar to another survey of chlamydia screening practices done in 1993 in San Diego,6 showed that fewer than one third of providers had a mechanism to determine and record whether a partner had been treated. Considering the number of CT-infected patients, patient-based methods of partner notification will be the only feasible method in most clinical settings. However, a recent study7 of adolescent girls with CT or gonorrhea infection showed that neither patient- nor clinic provider-based partner notification and treatment was successful (overall fewer than 20% of sex partners treated). Providers need to play an active and supportive role for patient-based approaches to be successful, and they will need to work with health department-based partner notification staff to develop effective patient-based notification and treatment strategies. Health department staff also should be available to provide direct assistance in difficult partner notification situations. Beyond the results of the survey, conducting the survey and developing the directory provided an opportunity to contact adolescent specialists as well as other providers who were delivering adolescent health care services. The health department STD control program now has an identifiable audience of professionals for distributing adolescent-specific STI prevention and control information. These professionals appear to be interested in working with the health department and other professional colleagues as evidenced by their request for guidelines and the newsletter. We think that a dialogue has been established that, over time, should lead to an expansion of preventive health services and an increase in STD screening among teens. However, it is difficult to quantitatively measure the impact of our activities. Periodic surveys may be helpful in assessing an impact, but, at a minimum, such surveys should help identify current practices and professional educational needs. We recommend that local STD control programs initiate a dialogue with adolescent specialists and primary care providers who have an interest in caring for adolescents and provide educational and other professional materials that should assist them in delivering STI prevention services. For those specialists and clinics that provide care for high-risk youth, collaborative approaches with the health department STD program regarding reporting, partner notification, client education-risk reduction, screening, and treatment should be developed. Finally, many adolescents, especially those living in inner city areas, infrequently access preventive health care services for a variety of reasons. For an STD prevention and control program to have an impact on the entire community, additional services need to be delivered through alternative approaches such as school health programs, peer teen outreach, and mobile clinics. Adolescents who are least likely to access traditional health care service are most likely to have STDs and be involved in STD transmission networks. We encourage STD programs to include an assessment of adolescent preventive health care services as a routine activity, and, in collaboration with community agencies and providers, to explore alternative methods to provide STD services on a community-wide basis to high-risk youth.