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
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22
respeedvdy). Female PCPs aged 3 MO in family pracli„ fpr, „
sex practices the least. AH of the nurse practitioners discussed ord sex practices with

their patients.

The patient partner risk assessment topics were the topics discussed by the fewest
PCPs. Twenty nine percent of the PCPs performed an adequate patient partner risk
assessment (Table 1). The topics STD history' and condom use were the topics discussed
by the most PCPs. yet only 58.8% of the PCPs discussed these topics. Sexual orientation

and oral sex practices were the topics discussed by the fewest PCPs (23% and 21%

respectively). PCPs who were male, over 50 years old and in practice over 20 years did

not discuss the oral sex practices of their patient’s partner with their patients.
Risk Reduction Topics

Adequate use of risk reduction topics was defined as using nine (70%) or more of
the 13 risk reduction topics. Sixty five percent of the PCPs adequately discussed the risk

reduction topics (Table 1). The topics entitled how to use condoms and where to get
condoms were the topics discussed by the fewest PCPs (58% and 53% respectively).

Interaction Skills
Adequate use of interaction skills was defined as using 12 (75%) or more of the

16 interaction skills. The interaction skills were utilized by 100% of the PCPs in this
study (Table 1). Eleven of the 16 interaction skills were used by all of the PCPs. All of

the nurse practitioners used 100% of the skills (Table 4). The topics provided educational

material and indicated other sources of information were the topics covered by the fewest
PCPs (44% and 40% respectively).

Coiinseled/Did Not Counsel
To meet the criteria lor counseling the PCP must have discussed six or more (70%
Or higher) of the eight risk assessment topics and nine or more (70% or higher) ofthe risk
reduction topics. Fifty nine percent ofthe PCPs in this stud, counseled (Table 1). Netther

23
males nor females in this study met the goal set by Healthy People 2000 (U.S. Public

Health Service. 1991) which aimed at increasing to 75% the number of PCPs counseling

adolescents about STDs (Table 1).

Topics;Jlbknf Contracting an STD and Sexual Abstinence for Prevention
One hundred percent of PCPs covered the risk reduction topic entitled risk of

contracting an STD regardless of gender, age. years in practice or specialty. One hundred
percent of the following PCPs discussed the topic sexual abstinence for prevention: (a)

females, (b) aged 31 to 40. (c) in practice under five years and 11 to 15 years and (d)

family practitioners and nurse practitioners. Sexual abstinence for prevention was also
discussed by (a) 83.3% of age group 41-50. (b) 66.6% of age group over 50. (c) 85.7% of

PCPs in practice six to 10 years, (d) 80% of PCPs in practice over 20 years, (e) zero

pediatricians and 75% of internists.
Summary

Chapter four presented the data. The participants were described based on

demographic data. The topics: (a) risk assessment, (b) patient partner risk assessments, (c)
risk reduction, (d) interactions skills and (e) counsel/did not counsel were discussed in

relationship to the total respondents and based on the demographic data. The risk
reduction topics risk of contracting a STD and sexual abstinence for prevention were
discussed in relationship to the demographic data.

24

Chapter V

Discussion and Recommendations
The purpose of this study was to determine if PCPs

are counseling adolescents

about STDs and their prevention. Fifty seven topics were

used to determine who was
counseling and who was not counseling based on gender, age, years in practice and
specialty. Specific aims were to determine if PCPs are adequately (a) performing risk

assessments, (b) discussing risk reduction topics, (c) using interaction skills and (d)
discussing the risk reduction topics: STD risk assessment and sexual abstinence for

prevention. A discussion of the results of this study and how they relate to the review of
literature is presented. Recommendations for future studies and suggestions to assist
PCPs in improving their abilities to counsel adolescents are offered.

Discussion

Fifty nine percent of the participants in this study met the criteria for counseling.
This percentage is similar to the percentage of nurses (60%) who counseled in the study

by Wall-Haas (1991). Nearly the same percentage of males (57%) and females (60%)
counseled. This is in contrast to the study by Millstein, Igra, & Gans (1996) who found

that female physicians counseled more frequently. Neither males nor females met the goal
set by Healthy People 2000 (U.S. Public Health Service, 1991) which aimed at increasing

to 70% the number of PCPs counseling adolescents about STDs.
The PCPs with the most years in practice (11 to 15 and over 20) had the highest
percentage of members meeting the requirements for counseling (lOO/o and 80/o

respectively). PCPs in practice six to 10 years had the lowest percentage of members

meeting the criteria for counseling (29%). This is in contrast to the study done by
Millstein, Igra, & Gans (1996) who found that the physicians with the fewest years

Practice did the most counseling. PCPs aged 31 to 40 had the fewest members
criteria for counseling while PCPs aged 41 to 50 had the most members

25
for counseling. Analysis of the specialties revealed that the nurse practitioner group had
the highest percentage of members meeting the criteria for counseling (75%).
The results of the specific aims of this study revealed that one hundred percent of

the PCPs in this study reported feeling adequately prepared to counsel adolescents about

STD prevention. Review of the literature revealed that PCPs do not feel adequately
prepared to counsel adolescents about STD prevention (Maheux et al., 1995; Schuster et
al.. 1996: Nussbaum et al.. 1989: & Wall-Haas. 1991). One hundred percent of the PCPs

met the criteria for adequate use of interaction skills. Sixty seven percent performed an
adequate patient risk assessment. Only 29% performed an adequate patient partner risk

assessment. Sixty five percent adequately discussed the risk reduction topics. Overall
PCPs aged 31 to 40 and in practice six to ten years had the poorest performance in this
study as they had the fewest members meet the criteria for counseling, performing an
adequate risk assessment, and for adequately discussing the risk reduction topics.
The following topics were the topics discussed by the fewest PCPs: (a) oral sex

practices, (b) anal sex practices, (c) blood transfusions, (d) sexual orientation, (e) how to
use condoms and (f) where to get condoms. The topic sexual abstinence for prevention

was discussed by 100% of the PCPs aged 31 to 40 but by only 67% of the PCPs over age

50.

Becker’s Health Belief Model
Becker's Health Belief Model was used as the theoretical framework for this

study. It helped in this study to evaluate the PCPs in their ability to counsel adolescents
about STD prevention. In practice, using the model would assist PCPs to thoroughly

counsel adolescents and increase the likelihood of the adolescents preventing STDs.
There are three main components of Becker's Health Belief Model (Becker 1974):
individual perceptions, modifying factors and likelihood of action. Individual perceptions

include a person's perceived seriousness of a disease and perceived susceptibility to a

26

disease. The mod.iying factors Wude demographic v.rl.bles,

of

and eues to action. Likelihood of action includes perceived benefits and barriers to

preventative action and likelihood of taking recommended preventative health action.

Based on Becker's Health Belief Model

order to prevent contracting an STD

adolescents need to realize they are al risk of contracting an STD before they will take
action to prevent contracting an STD. One hundred percent of the subjects reported
counseling adolescents about factors associated with STDs. Adolescents need to be

provided with cues to action which involves advertising, advice and reminders. Forty four
percent of the PCPs provided educational materials and 40% indicated other sources of

information to the adolescent. To increase the likelihood that adolescents will take action

to prevent contracting an STD the need to (a) realize the benefits of STD prevention, (b)
be aware of the barriers to STD prevention and (c) be offered solutions to overcome the

barriers. Ninety four percent reported counseling on the benefits of STD prevention.

Seventy six percent reported counseling on the barriers to STD prevention. Seventy

percent reported they offer solutions to help the adolescent overcome the perceived

barriers to STD prevention.
Recommendations
A larser study needs to be done because (a) this study was small in size
and (b) it only included one pediatrician and no OB/GYN subjects. A larger study would
be generalizable to the larger population.

Research needs to be done to determine (a) why less than 75% of PCPs are
counseling adolescents about STDs, (b) if the youngest populations ot PCPs are doing

less counseling (and why if they are found to be doing less counseling), (c) why PCPs are
adequately counsel on the patient partner risk assessment topics and (d) if nurse

practitioners are counseling adolescents more frequently than other subgroups of PCPs as
was found in this study. It would be interesting to deletmme why the younger PCPs are

27
more willing io advocate sexual abstinence for prevention of STDs than the older

population of PCPs.
Adolescents need more counseling on (a) the importance of knowing their
partner s risk of contracting STDs, (b) risk assessment and risk reduction topics, (c) their

perceived barriers to STD prevention and (d) arriving at solutions to overcome their
perceived barriers to STD prevention.

28

References
Alexander. E. & Hickner. J. (1997). First coitus for adolescents: Understanding

why and when. Journal of American Board of Family Practice. 10 (?) 96-103
Andersson-Ellstom. A. & Forssman. L. & Melsom, I. (1996). The relationship
between knowledge about sexually transmitted diseases and actual sexual behavior in a

group of teenage girls. Genituourinary Medicine. 72. (1). 32-36.
Becker. M.H. (1974). The Health Belief Model and Personal Health History.

Thorofare. NJ: Charles B. Slack. Inc.

Boekeloo. B.O.. Marx. E.S.. Karl. A.H.. Coughlin, S.C., Bowman, M., & Rabin,
D.L. (1991). Frequency and thoroughness of STD/HIV risk assessment by physicians in a

high-risk metropolitan area. American Journal of Public Health, 81 (12). 1645-1648.

Boekeloo. B.O.. Schamus. L.A.. Cheng. T.L.. & Simmens. S.J. (1996). Young

adolescents' comfort with discussion about sexual problems with their physician.
Archives of Pediatric Medicine, 150, 146-1152.

Bowman. M.A., Russell. N.K.. Boekeloo. B.O., Rafi, I.Z.. & Rabin, D.L. (1992).
The effect of educational preparation on physician performance with a sexually

transmitted disease-simulated patient. Archives of Internal Medicine, 152, 1823-1828.
Carney.P.A.. & Ward. D.H. (1998). Using unannounced standardized patients to

assess the HIV preventive practices of family nurse practitioners and family physicians.
The Nurse Practitioner, 23 (2), 57-76.
Centers for Disease Control and Prevention. (1998a) Youth Risk Behavior

Surveillance- United States. 1997. imMUJUSSU l 1-77.
Centers for Disease Control, and Prevention (1998b) Provisional cases of selected
notifiable diseases. United States, weeks ending Septenrber 5. .998 and August 30. 1997.

MMWIL47_(35). 733-748.

29
Donovan. P. (1997) Confronting a hidden epidemic: the Institute of Medicine’s
report on sexually transmitted diseases. EamikElanning Perspective. 2.9 (7) 87-89.

Ford. C.A.. Millstein. S.G.. Halpren-Felsher. B.L., & Irwin. C.E. (1997). Influence

of physician confidentiality assurances on adolescents’ willingness to disclose
information and seek future health care. Journal of the American Medical Association
278 (12). 1029-1034.

Guralnik, D. B.. et al. (1996). Webster s New World Dictionary of the American
Language (1966 ed.). Tenn: The Southwestern Company.

Hiltabiddle. S.J.. (1996). Adolescent condom use, the health belief model and the
prevention of sexually transmitted disease. Journal of Obstetrics, Gynecological and
Neonatal Nursing. 25 (1), 61 -65.

Keller. M.L.. (1993). Why do not young adults protect themselves against sexual
transmission of HIV? Possible answers to a complex question. AIDS Education and

Prevention, 5 (3), 220-233.

Leland. N.L. & Barth, R.P. (1992). Gender differences in knowledge, intentions
and behaviors concerning pregnancy and sexually transmitted disease prevention among
adolescents. Journal of Adolescent Health, 13.589-599.

Maheux. B.. Haley. N.. Rivard. M. & Gervais. A. (1995). STD risk assessment
and risk reduction counseling by recently trained family physicians. Academic Medicine.

2Q(8). 726-728.
Manning, D. Balson, P.M., Barenberg. N., Moore, T.M. (1989). Susceptibility to
AIDS: What college students do and do not believe. Collegddealth^ 67-72.

„ ,
w „ Panc j ,1096) Delivery of STD/HIV preventive
Millstien. S.G.. Igra. V., & Gans. J. (
)
Journal of Adolescent Health, 12,
services to adolescents by primary care physicians,
249-257.

30
Moscicke, A.B., Winkler,. B
C F x,
u u J. (1989), Differences in
o., Irwin
Irwin, C.E.
& «Schachttr.
biologic maturation, sexual behavior and sexually transmitted disease between

in

adolescents with and without cervical intraepithelial neoplasia. Journal of Pedin,no, ,)s

(3).487-493.

Mott. S.R. (1990). Adolescence. In D.S. Hunter, J. Spencer. A. Padial, & D.

Osnowitz (Eds.), Nursing care of children and families (n 302-303) California:
Addison-Wesley Nursing.
Nussbaum. M.P., Shender. I.D.. & Feldman. J.G. (1989). Attitudes versus
performance in providing gynecologic care to adolescents by pediatricians. Journal of

Adolescent Health Care, 10 (3). 203-208.
Polit. D.F. & Hungler. B.P. (1995). Nursing Research-Principles and Methods
(Fifth ed.) (p. 104). Philadelphia: J.B. Lippencott Company.

Rosenthal. S.L., Lewis. L.M.. Succop. P.A.. Burdlow, K.A., & Biro, F.M. (1997).
Adolescent girls’ perceived prevalence of sexually transmitted diseases and condom use.
Developmental and Behavioral Pediatrics, 18 (3), 158-161.
Schuster. M.A.. Bell, R.M., Peterson. L.P. & Kanouse, D.E. (1996).

Communication between adolescents and physicians about sexual behavior and risk

prevention. Archives of Pediatrics & Adolescent Medicine. lifl(9), 906-908.
Sieving, R„ Resnick. M.D., Bearinger. L„ Remafedi, G„ Taylor, B.A., & Hannon,

B. (1997). Cognitive and behavioral predictors of sexually transmitted disease risk
behavior among sexually active adolescents. Archives of Pediatric ft Adolescent
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emotion and disease

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Pediatric nursing. 17 (6). 549-554.

32

Appendix A
Demographic Information

Please answer the following six demographic questions by circling the correct

answer.

1. Do you treat adolescent patients in your office?

Yes

No

2. Do you counsel adolescents about sexually transmitted diseases?

Yes

No

3. Do you feel adequately prepared to counsel adolescents?

4. Which age group are you in?

Yes

No

under 30

31-40

41-50

Over 50

5. Are you male or female?

male

female

6. Number of years in practice.

under 5

6-10

16-20

over 20

7. Specialty

pediatrician family practice internist
OB/GYN nurse practitioner

Following is a list of risk assessment topics. Please circl
topic and no to indicate you do not cover the topic
£

Patient

• .
33
t0 indlcate you do cover the

Partner of Patient

No. of Partners

Yes

No

Yes

No

STD History

Yes

No

Yes

No

Condom Use

Yes

No

Yes

No

IV Drug Use

Yes

No

Yes

No

Blood Transfusion

Yes

No

Yes

No

Sexual Orientation

Yes

No

Yes

No

Sex Practices

Yes

No

Yes

No

Oral Sex Practices

Yes

No.

Yes

No

34

Following is a list of risk reduction topics. Please answer yes to indicate you do
cover the topic and no to indicate you do not cover the topic.

Risk of Contracting a STD

Yes

No

Risk of Contracting HIV

Yes

No

Sexual Abstinence for Prevention

Yes

No

Condoms for Prevention

Yes

No

Condoms With All Partners

Yes

No

Know Partner Better,

Yes

No

Limiting No. of Partner

Yes

No

How to Make Condoms Part of Sex

Yes

No

How to Use Condoms

Yes

No

Where to Get Condoms

Yes

No

Benefits of STD Prevention

Yes

No

Barriers to STD Prevention

Yes

No

Yes

No

Solutions to Barriers

35

Following is a list of patient interaction skills. Please answer yes to indicate you

that you utilize the skill and no to indicate you do not utilize the skill
Appropriate Eye Contact

Yes

No

Appropriate Body Language

Yes

No

Private Environment

Yes

No

Communication Nonjudgmental

Yes

No

Direct Routine Approach

Yes

No

Patient Discomfort Acknowledged

Yes

No

Confidentiality Assured

Yes

No

Initiated Sensitive Issues

Yes No

Listened to Concerns

Yes

No

Provided Information in Manageable Doses

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Tailored Advice to Pts Risk
Checked Understanding of Facts
Provided Educational Materials
Indicated Other Sources of Information

36

Appendix B
November 09, 1999

Dear Primary Care Provider.

Hi, my name is Kathy Foltz. I am a registered nurse in the Master of Science/

Nurse Practitioner program at Edinboro University, Pa. I am conducting a descriptive
study to fulfill the requirements of the program.
The purpose of the study is to determine if primary care providers are counseling

adolescents about sexually transmitted diseases. I became interested in the topic because

I may soon be in the position to counsel adolescents myself and because I am the mother

of a adolescent.
A small pilot study was conducted in a nearby county. The results of the study
indicated that, on average, it takes 6 minutes to complete the study. Do not sign the study.

Please enclose the study in the self addressed stamped envelope provided and return it by
March 23,1999. Confidentiality and anonymity is guaranteed.

Results of the study will be available in the Edinboro University Library in

Edinboro Pa. in the fall of 1999.1 sincerely hope you will participate in the study. Thank
you for your time and assistance.

Sincerely

Kathy Foltz

37

Appendix C

Dear Primary Care Provider.
Hi. I recently sent you a study to complete for the fulfillment of my graduation

requirements at Edinboro University. If you have returned the study then I would like to
take this opportunity to say thank-you. If you have not returned the study then I would

greatly appreciate it if you would do so.
Sincerely,
Kathy Foltz