Adolescent STI Epidemiology and Treatment Strategies

Adolescent STI Epidemiology and Treatment Strategies

Adolescent-Friendly Health Services Outline Stages of adolescence Barriers to health care faced by adolescents Adolescent-friendly health services Confidentiality HEEADSSS Resources

Objectives Identify three key barriers to health care access faced by adolescents. Describe three elements of adolescentfriendly health services. Utilize the HEEADSSS model of patient interviewing. When Do Adolescents Seek Sexual and Reproductive Health (SRH) Services? The average teen waits ? months after becoming sexually active to make her first family planning visit.

The pregnancy test is an admission of unprotected sexual activity and an indication of the need for appropriate reproductive counseling.* Guttmacher Institute (2000). Adolescents For the most part, adolescents are: Healthy Resilient Independent yet vulnerable

Adolescents are not: Big children Little adults The Culture of Adolescence Peer dependent Egocentric Distinct language and dress Popular culture influence Ongoing search for

identity Why Focus on Adolescent Health? Reduce death and disease, now and for the rest of their lives Fulfill the rights of adolescents to health care, especially reproductive health care Increase the chances for healthy adulthood Adolescence in Context Changes during adolescence are shaped by

Race/Ethnicity Religion Socioeconomic Status Family Peers Early Stages of Adolescence: 1114 Growth spurt Begin sexual maturation Increased interest in sexual anatomy Anxieties and

questions about size of genitals begins Self-exploration and evaluation Middle Stages of Adolescence: 15-17 Stronger sense of identity Relates more strongly to peer group More reflective thought Transitioning between dependence and

independence Late Stages of Adolescence: 18+ The body fills out and takes its adult form Distinct identity; ideas and opinions become more settled Focus on intimacy and formation of stable relationships Plans for future and commitments

External Barriers to Care Perceived lack of confidentiality and restrictions (parental consent/notification) Poor communication by providers Insensitive attitudes of care providers Lack of provider knowledge and skills Lack of money, insurance, and transportation Inaccessible locations and/or limited services Limited office hours External Barriers: Lack of Insurance

Young adults aged 19-25: 22.6% uninsured 2nd-highest uninsured age group under 26- to 34-year-olds (23.5%) Teens and children under 19: 7.6% uninsured Teens and children under 18: 7.3% uninsured US Census Bureau (2013) Lack of Insurance = Lack of Care

Uninsured adolescents are: Less likely to receive medical care Less likely to have a usual source of care More likely to experience long wait times More likely to be low-income and of color Insured adolescents visit a physicians office twice as often as uninsured teens. Adolescent-Friendly Health Services Include Establishing a comfortable, confidential, safe space maintained by office staff and providers.

Communicating respectfully and appropriately. Screening for high-risk behavior. Awareness of how: ability, age, culture, gender identity, sexual orientation, religion, or socioeconomic status can affect an adolescents reproductive health. Adolescent-Friendly Services Adolescent-specific Multi- and interdisciplinary

Accessible Financially affordable Adolescent-focused materials on display Peer educator component Adequate space Confidential Flexible scheduling Comprehensive services Continuity of care

Help transitioning into the adult medical care system Preparing for Clinical Visits Case Discussion Michelle is a 15-year-old woman who has come to your clinic with her mother complaining of an

ear infection. Her mother requests to remain in the room for the exam. Do you allow Michelles mother to stay? Rationale for Confidentiality Confidentiality in Adolescent Health Care Clinically Essential

Developmentally Expected Supported by Expert Consensus Clinically Essential In a clinical setting, confidentiality affects an adolescents Decision to seek care Disclosure of behaviors Follow-up for care

Confidentiality Assurances Enable Better Clinical Care High school students randomized to receive assurance of confidentiality or no assurance Students receiving assurance of confidentialit

y Students did not receive assurance of confidentialit y Ford C, et al. JAMA 1997;278:102934. 47% willing to disclose information 67% willing to follow-up

for care 39% willing to disclose information 53% willing to follow-up for care Confidentiality Assurances Enable Better Clinical Care 2000 study of 32 MA high schools 76% of students

wanted the ability to obtain confidential health care Only 45% perceived that confidential care was available to them Thrall J, et al. Arch Pediatr Adolesc Med. 2000;154:885892. Developmentally Expected Confidentiality is developmentally expected: Emotional need for increasing autonomy

Increasing intellectual capacity to give informed consent Opportunity to take responsibility for health Professional Consensus Professional organizations support confidential adolescent health care. ACOG 88 SAHM 92 AMA 92

AAFP 89 AAP 89 Confidentiality: Parental Perspective Parents are not the enemy. Parents are experiencing their own adjustment to their childs adolescence. Providers have an opportunity to educate parents about the need for confidentiality in the provider-patient encounter.

Discuss Confidentiality in Advance Inform parents about the confidentiality policy up front before a visit. Send a letter home: Detail when parent will or will not be included in the clinical visit. Discuss billing issues (e.g., routine STI testing, etc.). Display materials discussing importance of doctor/patient confidentiality. OUR POLICY ON CONFIDENTIALITY

Our discussions with you are private. We hope that you feel free to talk openly with us about yourself and your health. Information is not shared with other people unless we are concerned that someone is in danger. Sample statement developed by URMC Department of Pediatrics Develop Referral Network

Social worker Nutritionist Psychologist or counselor Abortion, adoption, and prenatal care services STD clinics Department of Health clinics Case 1 You have recently accepted a new position as

practitioner at a pediatric office. The clinic sees a small population of adolescents but wishes to expand its efforts with this population. What are some initial steps that you take to ensure that your office is adolescent friendly? The Clinical Interview Comprehensive HEEADSSS

H: Home E: Education/Employment E: Eating A: Activities D: Drugs S: Sexuality S: Suicide/depression

S: Safety *Additional questions: Strengths, Spirituality Klein DA, Goldenring JM & Adelman WP. Contemporary Pediatrics. 2014. SHEEADSSS

S: Strengths/Spirituality H: Home E: Education/Employment E: Eating A: Activities D: Drugs S: Sexuality S: Suicide/depression S: Safety

Klein DA, Goldenring JM & Adelman WP. Contemporary Pediatrics. 2014. Strengths-Based Approach Identify strengths early Look for examples of past difficulties that your patient has successfully overcome Praise Use reflective listening and pause Create a comfortable, trusting, nonjudgmental setting Share your concerns Strengths* Assess healthy behaviors and resiliency

throughout the interview Identify past difficulties that have been overcome Provide positive feedback and balance to the interview Spirituality* How do your beliefs influence your health and attitudes about sex and contraception? How important are your spiritual beliefs in your day-to-day life? How often do you participate in religious activities?

What do you consider to be your religion? Home U.S. Home Demographics (2013) Teens and children under 18: 22% live in poverty 35% live in single-parent households 31% live with families where no parent has fulltime, year-round employment 18-24 year olds:

25% live in poverty (2013) Home Where do you live and who lives there with you? What are relationships like at home? Can you talk to anyone at home about stress? Who? What are the rules like at home? Is there a gun in your home? Ever been homeless or in shelter care?

Ever been in foster care or group home? Education and Employment Education and Employment Young adults (18-24): 48% enrolled or completed college 16% not attending school, not working, and no degree beyond high school

Teens (16-19): 4% not enrolled in school and not high school graduates 8% not attending school and not working 72% unemployed (2013) Education Tell me about school. Do you feel connected to your school? Do you feel as if you belong? How many days have you missed in the past

year and what was the reason? Have you ever had any educational setbacks? Why? Have there been any recent school changes? What are your educational and life goals? Employment Are you working? Where? How much?

What type of work do you do? How many hours a week? Do you help to pay for things at home? What are your future career interests? Do you have any home chores? Allowance? Eating US High School Students: Weight, 2013 YRBS 100% 90%

Male 80% Female 70% 60% 50% 36.3% 40% 25.9% 30%

16.6% 20% 10% 10.8% 16.50% 16.60% 0% Obese Are Overweight

CDC. YRBS. MMWR. June 13, 2014. 63(4) Describe Selves as Overweight Controlling Weight, 2013 YRBS 100% 90% 80% 70% 60%

50% 40% 30% 20% 10% 0% Male Female 62.6% 33.0% 18.7%

7.4% Were Trying to Lose Weight Went 24 hours w/out Eating 3.4% 6.6% Took Diet Pills CDC. YRBS. MMWR. June 13, 2014. 63(4) 2.2%

6.6% Vomited or Took Laxatives Eating Does your weight or body shape cause you any stress? If so, tell me about it. Have there been any recent changes in your weight? Have you dieted in the past year? How? How often? What do you like and not like about your body? Tell me about your exercise routine.

Exercise Behaviors, 2013 YRBS 47.3% of students were physically active at least 60 minutes per day on 5 or more days 48% of students when to physical education (PE) classes on 1 or more days during the week 54% of students played on at least one sports team in past year Case 2

A 15-year-old female patient comes to your office. You notice that she has gained a bit of weight. When you ask her to stand on the scale, she begins to cry. What questions do you ask her regarding her health and body weight? How do you approach the subject sensitively?

Activities Activities, 2013 YRBS 54% reported having played on a sports teams in the past 12 months 32.5% reported watching 3 or more hours of television per day 41.3% reported using a computer for something not school related for 3 or more hours per day

CDC. YRBS. MMWR. June 13, 2014. 63(4) Activities How do you like to spend your free time? Hobbies, clubs, religious/spiritual activities? Do you play any sports? How many hours of television/computer per day? Per week? Drugs

Substance Use, 2013 YRBS Ever Used: 66.2% drank alcohol 20.8% reported episodic heavy drinking 40.7% used marijuana 8.9% inhalants 6.6% ecstasy (MDMA) 5.5% cocaine 3.2% methamphetamines 7.1% hallucinogenic drugs CDC. YRBS. MMWR. June 13, 2014. 63(4)

Drugs and Alcohol Does anyone you hang out with smoke, drink, or use drugs? How frequently and how much? Do you use tobacco? Do you use electronic cigarettes? Do you drink alcohol? What kind: beer, wine, hard liquor? Any blackouts? Ever pass out? Vomit? CRAFFT Questions: Identify Problem Use Have you ever ridden in a Car driven by

someone who was high or had been using alcohol or drugs? Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in? Do you ever use drugs or alcohol when you are Alone? Do you Forget things while using drugs or alcohol? Do your family or Friends ever tell you that you should cut down on your drinking or drug use? Have you ever gotten into Trouble while using Copyright Children's Hospital Boston. All rights reserved drugs or alcohol?

Sexuality Sexual Behavior Questions Dont Ask Are you sexually active? Use gender-biased pronouns when referring to sexual partners Use judgmental

language Use slang unless patient offers it first Do Assure confidentiality Explain why you are asking sensitive questions Ask patient to describe specific sexual behaviors Add second tier

questions to assess comfort with behaviors Most Males and Females Begin Sex at Age 17 Sexuality Have you ever been in a romantic relationship? Tell me about the people that youve dated. Have any of your relationships ever been sexual relationships (such as involving kissing or touching)?

Are you attracted to anyone now? Are you interested in boys? Girls? Both? Not yet sure? Suicide and Depression Suicide and Depression, 2013 YRBS 100% 90% 80% 70% 60%

50% 40% 30% 20% 10% 0% Male Female 34.5% 22.4% 19.7%

11.6% Felt Sad or Hopeless 10.3% 16.9% 5.4% 10.6% Seriously Made Suicide Plan Attempted Suicide Considered Suicide 1 or more Times

CDC. YRBS. MMWR. June 13, 2014. 63(4) Suicide and Depression Do you feel stressed or anxious more than usual? Do you feel sad or down more than usual? Have you ever received counseling and/or therapy? Are you having trouble getting to sleep? Tell me about a time when you felt sad while using social media sites like Facebook. Have you ever thought of hurting yourself or

someone else? Safety Sexual/Dating Violence 2013 YRBS 100% 90% Male 80% Female

70% 60% 50% 39.1% 40% 30% 20.8% 20% 10%

7.4% 14.40% 13.0% 6.20% 0% Physical Dating Violence Sexual Dating Violence Forced to Have Sexual

Intercourse Sexual and Physical Abuse Have you ever been forced to have sex or been touched in a way against your will? By whom and is this still going on? Who did you tell? How does it affect your day-to-day life? In what ways does that experience affect your sexual relationships now? Has anyone ever hurt you on a repeated basis? At home, in school, or in your neighborhood? Interpersonal Violence includes

Child abuse Battering Domestic violence Partner violence School, peer, community violence

Sexual harassment Sexual abuse Sexual assault Hate crime Drunk Driving, 2013 YRBS 100% 90% 80% 70% 60% 50% 40%

30% 20% 10% 0% Male 21.4% Female 22.4% 12.0% 7.8%

Rode w/ Driver Who Had Been Drove When Drinking Alcohol Drinking Safety Have you ever been seriously injured? (How?) How about anyone else you know? Do you always wear a seatbelt in the car? When was the last time you sent a text message while driving? Tell me about a time when you have ridden with a driver who was drunk or high. When? How often?

Wrap Up Emphasize that your approach is nonjudgmental and that you welcome future visits Im here for you, and I want you to feel comfortable confiding in me. If you have something personal to talk about, Ill try to give you my best advice and answer your questions

Provider Resources and Organizational Partners www.advocatesforyouth.orgAdvocates for Youth www.aap.orgAmerican Academy of Pediatricians American Civil Liberties Union Reproductive Freedom Project www.acog.orgAmerican College of Obstetricians and Gynecologists www.arhp.orgAssociation of Reproductive Health Professionals www.cahl.orgCenter for Adolescent Health and the Law Gay and Lesbian Medical Association

Provider Resources and Organizational Partners www.guttmacher.orgGuttmacher Institute Jane Fonda Center at Emory University Morehouse School of Medicine NARAL Pro-Choice New York Teen Outreach Reproductive Challenge (TORCH) North American Society of Pediatric and Adolescent Gynecology www.prh.orgPhysicians for Reproductive Health

Provider Resources and Organizational Partners www.siecus.orgSexuality Information and Education Council of the United States www.adolescenthealth.orgSociety for Adolescent Health and Medicine Planned Parenthood Federation of America Reproductive Health Access Project Spence-Chapin Adoption Services

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