ADOLESCENTS AND SEXUALLY TRANSMITTED DISEASES: ARE PRIMARY CARE PROVIDERS COUNSELING ADOLESCENTS? By Kathy Sue Foltz Submitted in Partial Fulfillment of the Requirements for the Masters of Science in Nursing Degree Edinboro University of Pennsylvania Approved by: Mary l/0u ^feller, PhD, CRNP Committee Chairperson Dare Janet Geisel, PhD, RN Committee Member Date ^3 -7/ Karen Bugaj, MSN; C^NP, RNC Committee Member Adolescents and sexually transm i tted diseases : Are primary care prov i ders counsel ing adolescents / by Kathy... Thesis Nurs. 1999 F6?la c .2 Date Abstract Adolescents and sexually transmitted diseases: Are primary care providers counseling adolescents? Sexually transmitted diseases (STDs) and their sequelae are very important problems in the adolescent population. There are 3 million adolescents that contract STDs each year (Donovan, 1997). The purpose of this study was to determine if primary care providers are counseling adolescents about STDs. The study is a quantitative descriptive study in rural northwestern Pennsylvania. It consisted of six demographic questions and 37 yes and no questions to determine the percentage of PCPs (a) providing adequate STD counseling, (b) performing adequate risk assessments, (c) using adequate interaction skills, and (d) who indicated they cover the topics risk of contracting a STD and sexual abstinence for prevention. Forty eight questionnaires were mailed to primary care providers, 23 were returned, and 17 were entered into the study. Fifty nine percent of the subjects counseled. Nearly the same percentage of males and females counseled. PCPs aged 41-50, in practice 11-15 years, and were nurse practitioners did the most counseling. PCPs aged 31 to 40, in practice six to 10 years, and were a pediatrician did the least amount of counseling. All primary care providers who counseled (a) performed adequate risk assessments, (b) adequately discussed the risk reduction topics, and (c) covered the risk reduction topics entitled risk of contracting an STD and sexual abstinence for prevention. All primary care providers used adequate interaction skills. i Table of Contents Content Abstract.. List of Tables iv Chapter I: Introduction 1 Background of the Problem 1 Statement of the Problem .2 Theoretical Framework 2 Purpose of the Study 3 Definitions of Terms 3 Assumptions 3 Limitations ,4 Summary Chapter II: Review of Literature 5 Primary Care Provider Counseling 5 Adolescent Knowledge 7 Adolescent Development 9 Adolescent Condom Usage 10 Adolescent Confidentiality 10 Healthy People 2000 11 Summary 11 Chapter III: Methodology Research Design Operational Definitions Setting and Sample 15 Instrumentation... ii Pilot Study 15 Data Collection 16 Procedure For Data Analysis 16 Summary 16 Chapter IV: Results 17 Description of Participants 17 Risk Assessment Topics 17 Risk Reduction Topics ,22 Interaction Skills 22 Counseled/Did Not Counsel ,22 Topics: Risk of Contracting an STD and Sexual Abstinence for Prevention...23 Summary 23 Chapter V: Discussion and Recommendations Discussion ,24 Becker’s Health Belief Model ,25 Recommendations 26 References 28 Appendixes 32 A. Instrument 32 B. Cover Letter, 36 C. Postal Card 37 List of Tables Table 1. Number of PCPs Who Adequately Discussed the Topics Based on Gender.... 18 2. Number of PCPs Who Adequately Discussed the Topics Based on Age........ 19 3. Number of PCPs Who Adequately Discussed the Topics Based on Years in Practice............................................................................................................ 20 4. Number of PCPs Who Adequately Discussed the Topics Based on Specialty..21 1 Chapter 1 Introduction This chapter is a brief introduction to the problem of sexually transmitted diseases in adolescents. It provides the background of the problem, the theoretical framework, purpose of the study, statement of the problem and research questions. The terms used in this study are defined and the underlying assumptions and limitations are identified. Background of the Problem In 1997 the Centers for Disease Control and Prevention (CDC) (1998b) conducted a national school based survey of 16,262 students in grades 9 through 12. This survey found that during their lifetime 7,875 (48.4%) of these students had ever had sexual intercourse, 1,170 (7.2%) of students had initiated sexual intercourse before age 13 and 2,601 (16.0%) of the students had sexual intercourse with a total of 4 or more sex partners. Only 9,236 (56.8%) respondents reported a condom was used during their most recent intercourse. For the week ending August 30, 1997, the CDC (1998a) reported 304,137 cases of Chlamydia trachomatis in the United States, 192,129 cases of Neisseria gonorrhoeae, 5,773 cases of syphilis and 40,204 cases of Acquired Immune Deficiency Syndrome (AIDS). For the week ending September 5, 1998, nearly one year later, the CDC reported 356,718 cases of Chlamydia trachomatis, 215,231 cases of Neisseria gonorrhoeae, 4,779 cases of syphilis and 31,523 cases of AIDS. Sexually transmitted diseases (STDs) infect people of every age, culture and socioeconomic background. People under the age of 25 are an important subgroup because they account for nearly two-thirds of all reported cases of STDs. There are three million adolescents that contract STDs each year (Donovan, 1997). 2 Statement of the Problem Adolescents are engaging in sexual activity without knowledge of the incidence, implications and transmission modes of STDs (Manning, Balson, Barenberg, & Moore, 1998). Adolescents are psychologically and physically more vulnerable to the contraction of STDs (Mott, 1990; Hiltabiddle, 1996; Moscicke, Winkler, Irwin, & Schachter, 1989). Primary care providers (PCPs) are uncomfortable with counseling adolescents on sexual issues and feel they lack the knowledge to counsel adolescents (Maheux et al., 1995; Schuster et al., 1996; Nussbaum et al., 1989; & Wall-Haas, 1991). As a result, adolescents are not provided with the information they need to prevent contraction of STDs (Manning, Balson, Barenberg & Moore, 1989). Theoretical Framework Becker’s (1974) Health Belief Model was used as the theoretical framework for this study. There are three main components of the Health Belief Model: individual perceptions, modifying factors and likelihood of action. Individual perceptions include a person’s perceived seriousness of a disease and perceived susceptibility to a disease. Perceived susceptibility involves the realization that one is at risk of contracting an STD and the degree of that risk. Polit and Hungler (1995) stated that perceived seriousness refers to the impact a person perceives the disease will have on his/her life. Action to prevent the disease will not occur unless the severity of the disease is high enough to cause serious organic or social implications. The modifying factors (Becker, 1974) include demographic variables, perceived threat of disease and cues to action. Perceived threat of disease results from the combination of perceived susceptibility and perceived seriousness. Cues to action include advertising, advice and reminders. Likelihood of action includes perceived benefits and 3 barriers to preventative action and likelihood of taking recommended preventative health action. Using the Health Belief Model the PCP counsels the adolescent about STDs. Counseling increases the adolescent’s perceived susceptibility to STDs and increases his/her awareness of the consequences of contracting an STD. Counseling by the PCP provides cues to action. The PCP and adolescent need to discuss the adolescent’s perceived benefits and barriers to STD prevention and the need to arrive at proposed solutions to overcome those barriers. All of these efforts are to increase the adolescent’s likelihood of participating in preventative health actions. Purpose of the Study The purpose of this study was to determine if primary care providers are counseling adolescents about sexually transmitted diseases. The specific aims were to determine if the primary care provider: (a) explained the risk factors associated with sexually transmitted diseases, (b) used patient interaction skills to increase the likelihood of the adolescent preventing the contraction of an STD and (c) explained to the adolescent that she/he can choose to abstain or participate in sexual relations. Definition of Terms The following terms are defined in the context used in this study. 1. Primary care provider (PCP) includes nurse practitioners, family physicians, pediatricians, obstetricians/gynecologists and internists. 2. Sexually Transmitted Diseases (STDs) are a broad category of diseases acquired from sexual contact with an infected person (Thomas, 1989). 3. Adolescent is a person in his or her teens (Guralnik et al., 1966). Assumptions The following assumptions of this paper included: 4 1. That the primary care provider: (a) answered the survey questions honestly and (b) had the knowledge and skills required to counsel adolescents about STDs. 2. Adolescents have the capacity to understand and the desire to know what the primary care providers teach about STDs. Limitations The limitations of this study are as follows: 1. The sample was a small convenience sample from a rural population and may not be applicable to the general population. 2. The content of the questionnaire required self-recall of the respondent. Summary The CDC (1998a) reports as many as 48% of students in grades 9 through 12 have engaged in sexual intercourse. While adolescents engage in sexual intercourse, they lack the knowledge to prevent STDs (Manning et al., 1989). Consequently there are 3 million teens who contract an STD each year (Donovan, 1997). The purpose of this study was to determine if PCPs are counseling adolescents about STD prevention. The theoretical framework used in the study was Becker’s Health Belief Model (Becker 1974). Applying this model to prevent STDs in adolescents the PCP must counsel the adolescent to (a) perceive themselves as susceptible to STDs and (b) perceive the illnesses to have a serious impact on their lives. The PCP, through counseling, can provide cues to action to increase the likelihood of preventing STDs. 5 Chapter II Review of the Literature This chapter provides a review of the literature concerning the multiple variables influencing whether or not adolescents practice STD prevention. Numerous studies are presented to show the frequency with which PCPs are providing STD counseling to adolescents, as well as the areas of STD counseling being covered by the PCPs. Studies are provided to illustrate the levels of knowledge about STDs and their prevention that adolescents possess. Variables that effect the contraction of STDs by adolescents such as, condom use and adolescent physical and psychological development, are also discussed. Primary Care Provider Counseling A study by Carney and Ward (1998), of eleven nurse practitioners and eleven family physicians, was done with unannounced standardized patients to assess human immunodeficiency virus (HIV) preventative practices. The participants were informed that unannounced standardized patients would come to their offices and audiotape their appointments, in an attempt to assess the levels of health service delivery. The participants were unaware of the identities of the standardized patients. The standardized patients all played out the same scenario. They were all first time patients who had recently moved to the community. They were happily divorced heterosexuals. They had been engaging in unprotected sex with one steady partner for the previous 9 months and had an incident of a one night stand with an unknown partner one month prior to visiting the PCP. The results revealed that physicians recommended condom use to 45% of their standardized patients and nurse practitioners recommended condom use to 72% of their patients. None of the physicians and 9% of the nurse practitioners spoke of the difference in effectiveness between animal skin and latex condoms. Only 9% of the physicians and 27% of the nurse practitioners recommended limiting sexual partners. Very few nurse 6 practitioners or physicians assessed the patient’s history in terms of past STDs, number of current or past sex partners, or bisexual/homosexual practices. A questionnaire was used to determine the difference between pediatricians’ attitudes versus performances (Nussbam, Shender, & Feldman, 1998). Sixty pediatricians in a suburban area reported it was important to take a sexual history from teenage girls. However, only 73% (44) reported they had done so by the time the patient was 16. Only 50% (30) of the pediatricians reported doing external genital exams. Only 28% (17) reported they performed an internal exam for complaints of vaginal discharge. Sixty percent (36) did not feel they had sufficient training to do an internal speculum exam (Nussbam et al., 1998). Wall-Haas (1991) studied 39 hospital based nurses to determine their attitudes towards adolescent sexuality. It was a descriptive study using a 61 item questionnaire. The study revealed that the nurses did not feel comfortable or adequately prepared to counsel adolescents. When confronted with the situation, 60% (24) took the opportunity to do so. Boekeloo et al. (1991) assessed 961 Washington, DC physicians using standardized telephone interviewers, to determine frequency and thoroughness of STD/HIV risk assessments. It was found that many physicians only assessed a patient’s STD/HIV risks if they had reason to believe the patient was in a high risk group. Sixty percent (577) reported asking new adolescent patients about their sexual practices. A California study consisted of a mailed questionnaire to 1,217 randomly selected internists, obstetricians, gynecologists and pediatricians (Millstein, Igra, & Gans, 1996). Forty percent of the physicians reported screening all of their adolescent patients for sexual activity and 31% counseled all of their adolescent patients about STD transmission. Of the adolescents known to be sexually active, 17% of the physicians always screened for number of sexual partners and 10% screened for frequency of casual 7 sex. It was found that female physicians and physicians with fewer years of practice counseled more frequently. An urban California school district allowed Schuster, Bell, Peterson and Kanouse (1996) to survey 2,026 students regarding communication with their physicians about sexual behavior and risk prevention. The students completed a self-administered survey. The results indicated fewer than 40% of the students had discussed with their physicians how to prevent AIDS and the need to use condoms. Fewer than 20% had discussed:(a) sexual histories, (b) condom use and (c) abstinence. An alarming 51% of the students reported they had never spoken with their physicians about any of the topics covered in the survey. Researchers, such as Maheux et al. (1995), Nussbaum et al. (1989), Schuster et al. (1996), & Wall-Haas (1991), have surveyed PCPs to ascertain why they aren’t providing adolescents with the counseling they need to prevent STDs. The following is a summary of their findings: primary care providers reported they do not counsel because they: (a) lack the training, (b) lack the knowledge and (c) feel uncomfortable. In the studies by Maheux et al. (1995), Schuster et al. (1996), & Wall-Haas (1991), the PCPs also reported they perceived that the adolescent patient did not desire counseling. The study by Maheux et al. (1995) reported PCPs do not counsel adolescents because they underestimate the adolescents’ risk behaviors. Adolescent Knowledge A study by Manning, Balson, Barenberg and Moore (1989) demonstrated that adolescents do not have the knowledge needed to prevent STDs. These researchers studied 122 college freshman, initially with a quantitative questionnaire, then with a qualitative discussion using the nominal group technique. They found that the students ■ions -------about their susceptibility to AIDS. These included: (a) reported numerous misconceptions come from good backgrounds so they will girls should use birth control pills, (b) students 8 not get AIDS, (c) condoms may cause injury, (d) you can only get AIDS from sex with gross people and (e) no one our age gets AIDS. Leland and Barth (1992) conducted a study of 1,033 high school students. Their study contained 90 questions to assess pregnancy and STD knowledge. Twenty questions specifically addressed pregnancy and STD prevention. An average of 11 of the 20 questions were answered correctly. Of the 20 questions, there were 8 that specifically asked about STD prevention. Seven hundred thirty five (71.2%) of the respondents reported that condoms protect against STDs. When asked if condoms are the most effective way to prevent STDs only 23.3% answered correctly. Two questions to evaluate knowledge related to proper use of condoms, when averaged, were correctly answered by 53.7% of the respondents. Keller (1993) studied 272 college students (average age 19.3 years) using 125 closed ended questions. He found that 20% of the participants did not know whether or not animal skin condoms prevent STDs and 21% did not know if a vasectomy prevents STDs. Of the students who reported at least one episode of unprotected sex, 50% reported doing so because they “just knew” their partner was free of HIV. Andersson-Elstrom et al. (1996) conducted a Swedish study over a two year period in which 88 girls ages 16 to 18, reported to a clinic every six months for a total of five visits each. Structured verbal interviews were used on visits 2, 3 and 4 and written standardized questionnaires on visits 1 and 5. They found that d4% of the girls had an STD during the course of the study. When the girls were questioned, almost all of them denied the possibility of having sexually acquired or transmitted an infection. Although adolescents are reporting insufficient communication with their physicians regarding STD prevention, self administered questionnaires by Schuster et al. (1996) and Boekeloo et al. (1996) demonstrated that adolescents are receptive to communication. In both studies almost 90 percent stated that they valued their physicians’ 9 opinions and felt it would be helpful to talk with them about sexual issues. In addition, the study (Boekeloo et al.) reported (a) 50% of the adolescents felt comfortable discussing sexual issues with their PCP, (b) adolescents felt more comfortable talking with their PCP if the PCP had discussed STD prevention with them at routine health visits and (c) the adolescents felt more comfortable discussing intimate issues when the physicians openly discussed their policies on confidentiality and disclosure of information to parents. Adolescent Development During adolescence cognitive development progresses from concrete thinking to formal operational thought processing (Mott, 1990). Adolescents with formal operational thought processes have the ability to (a) learn to hypothesize, (b) imagine alternative explanations for the same phenomenon, (c) see things from another person’s point of view, (d) understand and foresee the relationship between cause and effect and (e) anticipate possibilities prior to actual experimentation. Although the transition from concrete to formal operations occurs in adolescence, some never achieve formal operational thinking and most only have a limited ability to use formal operational skills. Adolescence is a time when peer approval and a separate identity from family are important (Hiltabiddle, 1996). The adolescent feels tom between peer pressure to engage in sex and parental pressure to abstain from sex. This creates guilt which can inhibit teens from utilizing STD prevention. STD prevention requires anticipating sexual activity and the teen is not always willing to mentally accept that he/she has planned to engage in sexual activity. A year long Michigan study by Alexander & Hickner (1997) involved 218 adolescents. The study consisted of a self administered questionnaire and assessed why and when adolescents engage in first coitus. This study demonstrated that 13 and 14 year-olds, who believed some of their friends were nonvirgins, were six times more likely to have initiated intercourse than the 13 and 14 year olds who believed their friends wem 10 not sexually active. The adolescents who believed their friends were sexually active were more than twenty times more likely to be nonvirgins. The physiologic immaturity of the adolescent cervix predisposes the adolescent to contraction of STDs (Moscicki, Winkler, Irwin, & Schachter, 1998). The adolescent cervical epithelium consists of columnar and metaplastic cell types which are more penetrable by pathogens than mature squamous epithelium (Moscicki et al., 1998). Adolescent Condom Usage Many Researchers (Hiltabiddle, 1996; Keller, 1993; Leland et al., 1992; Manning et al., 1998; & Sieving et al., 1997) have evaluated why adolescents do not use condoms. Following is a summary of the reported barriers of condom usage: (a) condoms do not feel good (Hiltabiddle, 1996; Manning et al., 1998; & Sieving et al., 1997), (b) interrupt the mood (Leland et al., 1992; Manning et al.; & Sieving et al.), (c) fit poorly and fall off (Keller, 1993), (d) break easily (Sieving et al.), (e) are embarrassing to use and purchase, (f) are not always available (Hitabiddle, Keller, Leland et al., Manning et al., & Sieving et al.) and (g) are expensive (Manning et al.). Other barriers included: (a) sex was not planned (Keller), (b) alcohol and drug usage (Keller, & Manning et al.), (c) partner refused to use (Leland et al., & Sieving et al.), (d) lack of knowledge related to usage (Hiltabiddle, & Sieving et al.), (e) and low perceived susceptibility to STDs (Keller, Manning et al., Rosenthal et al, 1997; & Sieving et al.). Adolescent Confidentiality In a study done by Ford, Millstein, Halpem-Felsher and Irwin (1997) 562 adolescents were enrolled in a social issues class and randomly assigned to one of three groups. They listened to one of three standardized audiotapes of office visits. In the audiotapes, the physician assured either unconditional confidentiality, conditional confidentiality or didn’t approach the issue. The study results indicated that if adolescents are assured of confidentiality, they are more willing to disclose personal information, seek 11 health care and return to the physician. No significant difference was found between the group assured of unconditional confidentiality and conditional confidentiality in respect to disclosing personal information, but it was found that the adolescents exposed to unconditional confidentiality were more willing to return for future health needs. Healthy People 2000 Healthy People 2000 (U.S. Public Health Service, 1991) acknowledges the numerous complications of STDs such as death, pelvic inflammatory disease, sterility, blindness, cancer, fetal death and birth defects including retardation. Because of the high incidence of STDs among the adolescent population, Healthy People 2000 has set the following goals: 1. Reduce the number of nonvirgin adolescents to 15% by age 15 and 40% by age 17. 2. Increase the percent of condom use to 60% for partners of adolescent females and to 75% for adolescent males themselves. 3. Increase to 75% the number of PCPs providing STD counseling. 4. Increase to 90% the proportion of PCPs who correctly treat STDs. 5. Provide curricula on STDs in all schools preparing students for careers in health care and ensure that they can demonstrate knowledge of STDs. 6. Provide continuing education on STDs to health care workers. Summary Preventing STDs in the adolescent population is a multifaceted problem. Adolescents: (a) do not have the knowledge needed to prevent STDs (Leland & Barth, 1992), (b) are at an increased risk of contracting an STD because of their psychological (Mott,1990) and physiological (Moscicke, Winkler, Irwin, & Schachter, 1989) immaturity and (c) are not receptive to using condoms (Keller, 1993). Primary care providers are not adequately counseling adolescents because they: (a) feel uncomfortable (Wall-Hmrs, 12 1991), (b) lack the knowledge and skills needed (Bowman, Russel, Boekeloo, Rafi & Rabin, 1992), (c) fear they will embarrass the adolescent (Schuster et al., 1996) and (d) underestimate the adolescent’s risk behaviors (Maheux et al., 1995). 13 Chapter III Methodology This chapter describes the methodology utilized to determine what percentage of PCPs were counseling adolescents about STDs. Included in this chapter is the research design, setting and sample, instrumentation and procedures for collection and analysis of data. Research Design This study used a nonexperimental descriptive research design. The study was to determine if PCPs are counseling adolescents about STDs. Specific aims were to determine if PCPs (a) perform adequate patient STD risk assessments (b) use adequate interaction skills to increase the likelihood of the adolescent following the PCP’s recommendations, (c) explain the risk factors associated with contraction of STDs to the adolescent and (d) bring to the attention of the adolescents that they can choose to participate in or abstain from sexual relations. Operational Definitions 1. A risk assessment was a health history of the patient taken by the PCP which included discussion of STD transmission modes. For the purpose of this study counseling on six (70%) or more of the following risk assessment topics constituted an adequate risk assessment. The topics were: (a) number of partners, (b) sexually transmitted disease history, (c) condom use, (d) IV drug use, (e) blood transfusions, (f) sexual orientation, (g) anal sex practices and (h) oral sex practices. 2. Risk reduction topics were information provided by the PCP to the adolescent to reduce the adolescent’s risk of contracting an STD. For the purpose of this study adequate use of risk reduction topics was defined as counseling on nine (70%) or more of the following 13 risk reduction topics: (a) risk of contracting an STD, (b) risk of contracting HIV, (c) sexual abstinence for prevention, (d) condoms for prevention, 14 (e) condoms with all partners, (f) know partner better, (g) limiting number of partners, (h) how to make condoms part of sex, (i) how to use condoms, (j) where to get condoms, (k) benefits of STD prevention, (1) barriers to STD prevention and (m) solutions to overcome the barriers. 3. Interaction skills were actions taken by the PCP to (a) increase the comfort level of the adolescent, (b) facilitate conversation and learning and (c) evaluate the adolescents understanding of what has been discussed. For the purpose of this study utilizing 12 (75 /o) or more of the following interaction skills constituted adequate use of interaction skills. The interaction skills were: (a) appropriate eye contact, (b) appropriate body language, (c) private environment, (d) communication nonjudgmental, (e) direct routine approach, (f) patient discomfort acknowledged, (g) confidentiality assured, (h) initiated sensitive issues, (I) listened to concerns, (j) encouraged patients to ask questions, (k) asked about concerns, (1) provided information in manageable doses, (m) tailored advice to patients risk, (n) checked understanding of facts, (o) provided educational materials and (p) indicated other sources of information.. 4. Counseling was the PCP discussing with and advising the adolescent on risk assessment and risk reduction topics. For the purpose of this study counseling took place if the PCP discussed six (70%) or more risk assessment topics and nine (70%) or more of the risk reduction topics. Setting and Sample The setting for this study was a rural county in northwestern Pennsylvania. The sample consisted of PCPs who were currently treating adolescents in the setting chosen for the study. The nurse practitioner sample consisted of known nurse practitioners to be practicing in the sample setting. The physician sample was obtained from the listing of PCPs in the telephone directory. 15 Instrumentation The instrument (Appendix A) was developed by this researcher based on the results of the study conducted by Bowman et al.( 1992). It was a 44 item self administered questionnaire with a cover letter introducing the researcher and the purpose of the study. It contained (a) seven demographic questions, (b) eight risk assessment topics, (c) 13 risk reduction topics and (d) 16 patient interaction skill topics. All of the questions in the instrument, with the exception of the demographic questions, were answered with a yes or no answer. The PCP reported if he/she does or does not (a) discuss the risk assessment topics, (b) discuss the risk reduction topics and (c) utilize the patient interaction skills listed on the instrument. The cover letter requested the instrument (a) not be signed to ensure anonymity and (b) be returned within 14 days. By return of the instrument, the researcher assumed that informed consent had been given. Pilot Study A pilot study of the research project was done in nearby Erie County, Pennsylvania. Twelve physicians, randomly chosen from the telephone directory, were mailed the questionnaire. The pilot study requested that the physicians include the amount of time it took them to complete the questionnaire and provided a space to make comments. Fourteen days after the pilot study questionnaires were mailed, the researcher followed with a telephone call. The researcher stated “ If you have returned your survey, I would like to take this opportunity to say thank-you. If you have not returned your survey, I would like to encourage you to return it.” A stamped self addressed envelope was included for the PCP to return the instrument to the researcher. Of the 12 instruments mailed, one was returned to the researcher by the post office stamped "unable to forward”. Four completed questionnaires were received by the researcher. The average time reported to complete the questionnaire was six minutes. One comment was made. It stated that the physician did not have time in his office to do 16 complete STD counseling and he/she felt it was the responsibility of the parents and schools. Data Collection Data were collected by mailing an instrument to each PCP. A stamped self addressed envelope was included for the PCP to return the instrument to the researcher. Twelve days after the instrument was mailed, 47 postcards (Appendix C) were sent to thank the PCPs who had responded to the instrument and to encourage the remainder of the PCPs to return their surveys. Procedure For Data Analysis The data were analyzed to determine the percentage of PCPs who (a) provided adequate STD counseling, (b) performed adequate risk assessments, (c) used risk reduction topics, (d) used interaction skills and (e) indicated they discussed the topics: risks of contracting an STD and sexual abstinence for prevention of STDs. The number of yes and no answers were tallied for each question overall and for each of the specific aims. They were categorized and analyzed based on the demographic data. Summary The research design, the purpose of the study and the specific aims were discussed in this chapter. Risk assessments, interaction skills, adequate use of risk reduction topics and counseling were operationally defined. The setting and instrument were described. Finally, data collection and analysis were explained. 17 Chapter IV Results Review of literature on STDs and the adolescent population reveals that adolescents are sexually active and do not have the knowledge needed to prevent contraction of STDs. The literature also reveals that PCPs are not adequately counseling adolescents on STDs and their prevention. This descriptive study was to determine if PCPs are counseling adolescents on STDs. The results of this study are presented in this chapter. Description of Participants A total of 47 instruments were mailed by the researcher, 42 to physicians and 5 to nurse practitioners. Two instruments were returned by the post office stamped “unable to forward**. Twenty-three instruments were returned in the stamped self addressed envelopes. One of the 23 instruments returned contained a note stating the physician was no longer at that address. Two instruments were deleted from the study because the PCPs had indicated that they do not treat adolescents in their offices. Three instruments were deleted from the study because they were incomplete. Seventeen were completed by PCPs who treated and counseled adolescents in their offices and were entered into the study. Risk Assessment Topics Adequate patient risk assessment was defined as discussing six (70%) or more of the eight risk assessment topics. The risk assessment topics were subdivided into patient risk assessment topics and partner of patient risk assessment topics. Seventy six percent of the PCPs performed an adequate patient risk assessment (Table 1). Tables 1 through 4 illustrate the number and percent of PCPs who met the criteria for an adequate risk assessment based on the demographic data. The patient risk assessment topics STD history and condom use were discussed by all the PCPs. The topics entitled anal sex practices and oral sex practices were discussed by the fewest PCPs (46% and 60% 18 -u £ ”o 04 a o H > £ CM 'O o C/3 $3 C/3 o z 20 'O CM CM £ o o £ o oo CM GO UQ 6s O O a oJ o o3 £ o £ o o o o CM in ox° x x° 0s cn o o x° 0s cc CM o cn o in c _o o a o a3 • r—< c T3 £ o 3 £ CM S & 3o GO (D GQ < cn II & in o o Z £o Z 21 HD JD "aS 09 o § o O £ £ o in £ in r^ in (N x® £ o £ o o o 00 ^r ^r £ in x? 0s x© GO C/3 x® a o o o •4—^ 0s o o o a3 a> a c o o » r-M □ 'O *o