Providers do not fully use adolescent well-care visits to discuss sexual health.

Although 58-60% of U.S. high school students make preventive health care visits, far lower proportions of those doing so--43% of females and 26% of males--discuss pregnancy or sexually transmitted disease (STD) prevention at one. According to an analysis using 1999 survey data from the Youth Risk Behavior Surveillance System, (1) primary care providers are thus missing opportunities to counsel their adolescent patients. Among sexually experienced females, the odds of having such a discussion are significantly elevated among users of a hormonal method (odds ratio, 4.4), those aged 18 or older (3.5), those who have had at least four sex partners (2.3) and blacks (2.0). Among sexually experienced adolescent males, however, no characteristic or sexual risk behavior is independently associated with the odds of having discussed STD or pregnancy prevention.

Using data from the nationally representative survey of more than 15,000 high school students in grades 9-12, the researchers performed a series of logistic regression analyses to assess the association between characteristics and behaviors and two outcomes--having visited a primary care provider for preventive health care in the past year and having discussed ways to prevent pregnancy or STDs, including HIV, at that visit.

Roughly half of the sample (48% of females and 52% of males) had had sexual intercourse by the time of the survey; males were slightly older than females the first time they had sex (14.6 years vs. 13.9 years). Among sexually experienced students, a higher proportion of males than of females had had at least four sex partners (37% vs. 27%) and had used a condom at last intercourse (66% vs. 54%). Use of a hormonal method (i.e., the pill or injectable) at last sex was more prevalent among females than among males (22% vs. 11%).

Overall, 58-60% of the students had visited a primary care provider for preventive health care in the past year (i.e., for a physical examination in the absence of sickness or injury). Among those who had made such a visit, 43% of females and 26% of males said they had discussed pregnancy or STD prevention with their provider. Among sexually experienced students, 64% of females and 54% of males had gone for preventive care; 61% of females receiving such care discussed pregnancy and STD prevention at their visit, as did 34% of similar males.

According to the logistic regressions, residence in the Northeast was independently and positively associated with having made a preventive health care visit among all females (adjusted odds ratio, 1.7), as was having initiated sexual activity (1.3); being Hispanic was associated with significantly reduced odds of having gone for preventive care (0.7). The odds of having discussed pregnancy and STD prevention at that visit were significantly elevated among females who had had intercourse (3.8), blacks (2.2) and older adolescents (odds ratios of 4.3 for those aged 18 or older and 2.9 for 17-year-olds).

Among sexually experienced females, residence in the Northeast was associated with increased odds of having made a preventive health visit (1.9), as was having had 2-3 sex partners (1.6) and having used a hormonal contraceptive at last sex (2.6). The odds of having discussed pregnancy and STD prevention at a recent visit were significantly elevated among sexually experienced females who had used a hormonal method at last coitus (4.4), who were aged 18 or older (3.5), who had had at least four partners (2.3) and who were black (2.0).

For males, being Hispanic and having initiated sexual activity were significantly associated with reduced odds of having seen a primary care provider for preventive care (0.6 and 0.8, respectively). The odds of having discussed ways to prevent pregnancy and STDs with a provider were significantly elevated among males who had initiated sexual activity (1.9).

Among sexually experienced males, those living in the Northeast had significantly increased odds of having received preventive care (1.7), as did those whose partner used a hormonal method (1.5). No characteristic or behavior of sexually active adolescent males had an independent association with the odds of discussing pregnancy or STD prevention with a provider.

The researchers note that although half of U.S. high school students are sexually active and even higher proportions have made a recent preventive health visit, primary care providers do not use these opportunities to routinely discuss sexual and reproductive health. The students most likely to have discussed sexual and reproductive health were older, sexually experienced females who had already entered the health system and were using a hormonal method. Efforts to better use these clinical opportunities should focus on adolescent male patients, because condom use does not draw sexually active males into the health care system. The researchers acknowledge that their study is limited by the data's cross-sectional nature, the sampling of in-school youth only and the lack of information on other potentially important factors. Because the consequences of risky sexual behaviors are preventable, the authors conclude by recommending that "all primary care providers discuss HIV infection, STDs and pregnancy with their adolescent patients."

REFERENCE

(1.) Burstein GR et al., Missed opportunities for sexually transmitted diseases, human immunodeficiency virus, and pregnancy prevention services during adolescent health supervision visits, Pediatrics, 2003, 111(5):996-1001.