- Email: [email protected]
10: Consistency between face-to-face and survey reports of health-related behavior in adolescent females
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Abstracts / 40 (2007) S19 –S54
Results: The median age of the participants was 19 years (15-24 yrs). The median age for coitarche was 15 years (12-18 yrs). Ninety-point-six percent (90.6%), 65.5% and 15.6% of teens engaged in vaginal, oral, and anal sex respectively. Eighty-fourpoint-four percent (84.4%), 59.4%, and 12.5% reported engaging in vaginal, oral, and anal sex without barrier protection, respectively. While 100% of participants indicated that STI transmission could occur via vaginal sex and 90% reported that STIs could be transmitted via anal sex and fellatio, only 69% were aware of the transmission risk during cunnilingus. Significantly more adolescents who reported engaging in cunnilingus were unaware that fellatio could transmit STIs (p ⬍ 0.001). Although 93.8% of adolescents reported that STIs were a “big concern”, a large number of teens (43.8%) stated that it was difficult to discuss STIs with their partners. Conclusion: Risky non-coital sexual behavior occurs commonly among adolescent and young adult females. Teens who also engage in oral sex have less knowledge regarding STI transmission via oral sex. As this study is targeted to enroll 100 participants, preliminary findings suggest that knowledge and risk perception will be less among teens who engage in non-coital behaviors. Thus, it is essential that health care providers recognize that adolescents engage in anal and oral sex, and are willing to provide anticipatory guidance correcting misconceptions about STI transmission.
8. ANAL SEX IS PROXY OF A HIGH-RISK SEXUAL BEHAVIOR PROFILE FOR AFRICAN AMERICAN ADOLESCENT FEMALES Ralph DiClemente, PhD, Richard Crosby, PhD, and Laura Salazar, PhD. Emory University, Atlanta, Georgia Objective: To determine whether engaging in penile-anal sex is associated with a profile of sexual risk behaviors. Methods: Participants were 715 African American adolescent females. Data collection included a) an audio-computer assisted self-interview (A-CASI) lasting about 60 minutes and a selfcollected vaginal swab for NAAT to detect Trichomonas vaginalis, Chlamydia trachomatis, and Neisseria gonorrhoeae. Results: About one of every 10 adolescents (10.5%) reported engaging in anal sex, at least once, during the past 60 days. Of these, 40.0% tested positive for at least one of three laboratoryconfirmed STDs. This prevalence was significantly greater compared to the 27.5% prevalence among those not recently engaging in anal sex. Of the 10 outcomes comprising the sexual risk profile, 7 achieved bivariate significance, with each of the differences indicating greater risk for those who reported they had recently engaged in anal sex. In controlled analyses, those having anal sex were nearly twice as likely to test positive for STDs compared to those not having anal sex (AOR ⫽ 1.89). Also, 6 of the 10 measures comprising the sexual risk profile retained significance in these analyses. Conclusion: African American adolescent females who engage in penile-anal sex may experience an elevated risk of vaginallyacquired STDs. Indeed, the findings suggest that a host of sexual risk behaviors are significantly more likely to be reported among those having penile-anal sex. Thus, penile-anal sex may be an important proxy of overall sexual risk behaviors. Sources of Support: Funded by a grant from the National Institute of Mental Health, awarded to Dr. DiClemente.
9. PROVOCATIVE QUESTIONS IN A PAROCHIAL SEX EDUCATION CLASS: HIGHER INCIDENCE IN YOUNGER TEENS Megan A. Moreno, MD, MSEd, Cora C. Breuner, MD, MPH, and Paula Lozano, MD, MPH. Department of Pediatrics, University of Washington, Seattle, Washington Purpose: Recent data show US adolescents are engaging in sexual activity at earlier ages, however; little is known about young teens’ specific sexual attitudes and behaviors. Examining teens’ questions in sex education classes may provide insight into these attitudes and behaviors. This study examined 5th through 8th graders’ anonymously submitted questions in parochial sex education classes. Methods: Anonymous written questions were submitted by 5th/ 6th and 7th/8th grade students at the outset of sex education classes in a Seattle parochial school between 2003 and 2005 in this quasi cohort study. Questions were classified into topic categories. Three additional variables were then coded for each question. Ethics/guidance questions included requests for advice or value judgments. Prohibited questions included the topics: homosexuality, abortion, masturbation, and contraception. “Red flag questions” were those that suggested consideration of or engagement in sexual behavior. A modified Delphi procedure with three adolescent medicine physicians was used to identify red flag questions. Ten percent (10%) of the questions were coded for topic categories by a second rater with a 94% concordance. Results: Among 473 questions submitted by 410 students, the most popular topics for 5th/6th graders were: pregnancy, puberty, and menstruation and for 7th/8th graders: puberty, menstruation and general health. Forty-one (41) questions (8.6%) were prohibited. Twenty-nine questions (6.2%) asked about ethics/guidance. Eighteen questions (3.81%) were coded as red flag questions. A chi square analysis showed that 5th/6th graders asked significantly more questions in the ethics/guidance (8.3 versus 3.64%) and red flag question categories (5.53 versus 1.82%) (p ⬍ 0.05) than 7th/8th graders. Conclusions: Although provocative questions represent a minority of these middle students’ queries, these requests suggest the urgency of providing appropriate guidance to young teens, given the risks of sexual activity in this age group. Contrary to our expectations, younger students asked more questions than their older peers in two subcategories of provocative questions: ethics/ guidance and red flags. The role of school education programs, physicians and parents in addressing questions of this sort should be considered. Sources of Support: None.
10. CONSISTENCY BETWEEN FACE-TO-FACE AND SURVEY REPORTS OF HEALTH-RELATED BEHAVIOR IN ADOLESCENT FEMALES Jennifer Newman, PhD, Carmen Radecki Breitkopf, PhD, Abbey B. Berenson, MD. Department of Obstetrics & Gynecology, University of Texas Medical Branch, Galveston, Texas Purpose: To investigate the reliability (consistency) between two self-report methods (face-to-face interview with provider [FTFI] vs. self-administered questionnaire [SAQ]) with regard to sexual health indicators, substance use, and depressed mood among female adolescents of low socioeconomic status.
Abstracts / 40 (2007) S19 –S54
Methods: Consistency of responses was evaluated among 329 African American, Hispanic, and White females 13 to 18 years of age who attended a family planning clinic in southeast Texas. Questions included age at first sexual intercourse, lifetime number of sexual partners, history of a sexually transmitted disease (STD), tobacco use, drug use, and whether the adolescent often felt sad, blue, or depressed. Correlation coefficients and kappa statistics were used to determine reliability. Percent matching was included for each of the six health indicators across the total sample and separately for each race/ethnicity. Results: All consistency estimates except one achieved statistical significance (P ⬍ .05), however, the strength of agreement varied by health indicator and in some cases, by race/ethnicity. Reports of drug use and depressed mood agreed less frequently overall, than reports of STD history and tobacco use. With regard to age at first intercourse and lifetime number of sexual partners, the correlation coefficients were similar across the total sample (r ⫽ .84 and .85, respectively) however, they were significantly lower among African Americans relative to Hispanics and Whites (all P ⬍ .001). African Americans had the highest percent of matched responses for substance use and depressed mood relative to Hispanic and Caucasian adolescents. However, African Americans had the lowest percent of matched responses for sexual health indicators relative to Hispanics and Whites. Inconsistent reports generally reflected greater reporting of negative behaviors/mood states on the SAQ relative to the FTFI. Conclusions: FTFI and SAQ yield varying degrees of consistency for different health indicators. Consistency of reporting also differed by race/ethnicity. The results of this study suggest that a self administered questionnaire will reveal negative thoughts and behaviors more often among adolescents than a face-to-face interview. This suggests providers could use a self-administered questionnaire to assess these behaviors and reserve their face-toface time for counseling. Incorporating a well-designed SAQ into the adolescent visit has the advantage of easy administration in a busy clinic setting where health care providers have limited time for patient interaction. Sources of Support: This study was supported by the National Institute of Child Health and Human Development of the National Institutes of Health grant K24HD043659.
11. GETTING PERSONAL: WHAT PEDIATRICIANS ARE ASKING THEIR ADOLESCENT PATIENTS ABOUT SEX Melissa Pujazon, MD, MPH. Sarah Worley, MS, and Ellen Rome, MD, MPH. Department of General Pediatrics, Section of Adolescent Medicine, Children’s Hospital, Cleveland Clinic, Cleveland, Ohio Purpose: To determine the content of the sexual history performed by pediatric residents and pediatricians at the average adolescent well care visit. Methods: One-thousand-two-hundred (1,200) members of the American Academy of Pediatrics, Ohio Chapter, were randomly invited to participate and were emailed a link to an online questionnaire. Twenty-five questions addressed the practitioner’s demographics, typical sexual history content, and comfort level discussing and perceived education on various sexual issues. Data was analyzed with SAS using Chi-Square and Fisher’s Exact Tests (statistical significance p ⬍ 0.05). Results: The response rate was 22.8% (n ⫽ 278) with 61.3% (n ⫽ 166) ⱕ 35 yrs old and 38.7% (n ⫽ 103) ⱖ 36 yrs old. Fifty-two
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percent of respondents begin asking about sexual activity between the ages of 11-13 yrs. Fifty-seven percent reported always asking about sexual activity during the typical adolescent well visit, but only 26.3% always asked about type of sexual activity, 15.4% always asked about sexual attraction and 12.9% always asked about nonconsensual sex. Statistically significant differences occurred among all different demographic groups. For example, women were more likely than men to ask about sexual attraction (41.2% vs. 25.3%, p ⫽ 0.047), and number of lifetime partners (81.9% vs. 68.7%, p ⫽ 0.024). Respondents ⱕ 35 yrs old were more likely than those 36 and older to report they received adequate education on emergency contraception (60% vs. 20%, p ⬍ 0.001), STDs (97.6% vs. 85.6%, p ⬍ 0.001), oral sex (51.2% vs. 25.7%, p ⬍ 0.001) and issues related to gay, lesbian and bisexual youth (30.5% vs. 16.4%, p ⫽ 0.009). Non-U.S. born respondents “always or usually” worried about parental reaction to initiating a conversation with the patient on vaginal sex (40.5% vs. 16.9%, p ⫽ 0.021), anal sex (67.5% vs. 30.5%, p ⬍ 0.001) and oral sex (62.1% vs. 26.5%, p ⬍ 0.001) and were less likely to bring up vaginal sex (43.2% vs. 22.9%, p ⫽ 0.009) and oral sex (81.1% vs. 55.8%, p ⫽ 0.004). Respondents with children felt less adequately educated on emergency contraception (33.8% vs. 58.0%, p ⬍ 0.001), STDs (89.3% vs. 97.5%, p ⫽ 0.010) and oral sex (31.1% vs. 54.2%, p ⬍ 0.001) than those without children. Finally, personal beliefs affected the sexual history content and practitioner’s comfort level in counseling patients. For example, those who reported emergency contraception was bad and/or wrong felt less comfortable discussing emergency contraception with their patients (37.8% vs. 74.9%, p ⬍ 0.001). Conclusion: The content of the average sexual history varies among pediatric practitioners and is influenced by the practitioner’s personal beliefs and background.
12. THE ROLE OF RELATIONSHIP CONTEXT IN AFRICAN AMERICAN ADOLESCENT MALES’ CONDOM DECISIONMAKING Melissa Gilliam, MD, MPH, Aisha Reuler, BS, and Amy Berlin, MPH. Department of Obstetrics and Gynecology, The University of Illinois at Chicago, Chicago, Illinois Purpose: The purpose of this study is to gain insights into condom decision-making and behaviors of urban, African American male youth. Methods: We conducted 3 focus groups with young, African American males from the Southside of Chicago (n ⫽ 14). All sessions were tape-recorded and transcribed verbatim, Atlas ti/5.0 was used for data analysis. Through grounded theory methods and content analysis we identified major themes. A model of condom decision-making was developed. Results: Major themes presented are those which appeared in all sessions and were widely endorsed across sessions. Boys are motivated to use condoms based on perceived risk of STDs which is influenced by partner and relationship factors. They believe girls are clean or dirty. “Real girlfriends” or true girlfriends are considered clean. The perception of the female partner as “safe” and “trusted” as evidenced by her desire to wait to have sex or use a condom reduces his concern for STDs and motivation to use condoms. Conversely, casual sex partners are more likely to be “dirty” based on physical qualities and reputation as promiscuous or willing to have sex for drugs (e.g., “buzzards”). One boy said of “dirty” partners: “they dress a little bit nastier than all the other
Abstracts / 40 (2007) S19 –S54
Results: The median age of the participants was 19 years (15-24 yrs). The median age for coitarche was 15 years (12-18 yrs). Ninety-point-six percent (90.6%), 65.5% and 15.6% of teens engaged in vaginal, oral, and anal sex respectively. Eighty-fourpoint-four percent (84.4%), 59.4%, and 12.5% reported engaging in vaginal, oral, and anal sex without barrier protection, respectively. While 100% of participants indicated that STI transmission could occur via vaginal sex and 90% reported that STIs could be transmitted via anal sex and fellatio, only 69% were aware of the transmission risk during cunnilingus. Significantly more adolescents who reported engaging in cunnilingus were unaware that fellatio could transmit STIs (p ⬍ 0.001). Although 93.8% of adolescents reported that STIs were a “big concern”, a large number of teens (43.8%) stated that it was difficult to discuss STIs with their partners. Conclusion: Risky non-coital sexual behavior occurs commonly among adolescent and young adult females. Teens who also engage in oral sex have less knowledge regarding STI transmission via oral sex. As this study is targeted to enroll 100 participants, preliminary findings suggest that knowledge and risk perception will be less among teens who engage in non-coital behaviors. Thus, it is essential that health care providers recognize that adolescents engage in anal and oral sex, and are willing to provide anticipatory guidance correcting misconceptions about STI transmission.
8. ANAL SEX IS PROXY OF A HIGH-RISK SEXUAL BEHAVIOR PROFILE FOR AFRICAN AMERICAN ADOLESCENT FEMALES Ralph DiClemente, PhD, Richard Crosby, PhD, and Laura Salazar, PhD. Emory University, Atlanta, Georgia Objective: To determine whether engaging in penile-anal sex is associated with a profile of sexual risk behaviors. Methods: Participants were 715 African American adolescent females. Data collection included a) an audio-computer assisted self-interview (A-CASI) lasting about 60 minutes and a selfcollected vaginal swab for NAAT to detect Trichomonas vaginalis, Chlamydia trachomatis, and Neisseria gonorrhoeae. Results: About one of every 10 adolescents (10.5%) reported engaging in anal sex, at least once, during the past 60 days. Of these, 40.0% tested positive for at least one of three laboratoryconfirmed STDs. This prevalence was significantly greater compared to the 27.5% prevalence among those not recently engaging in anal sex. Of the 10 outcomes comprising the sexual risk profile, 7 achieved bivariate significance, with each of the differences indicating greater risk for those who reported they had recently engaged in anal sex. In controlled analyses, those having anal sex were nearly twice as likely to test positive for STDs compared to those not having anal sex (AOR ⫽ 1.89). Also, 6 of the 10 measures comprising the sexual risk profile retained significance in these analyses. Conclusion: African American adolescent females who engage in penile-anal sex may experience an elevated risk of vaginallyacquired STDs. Indeed, the findings suggest that a host of sexual risk behaviors are significantly more likely to be reported among those having penile-anal sex. Thus, penile-anal sex may be an important proxy of overall sexual risk behaviors. Sources of Support: Funded by a grant from the National Institute of Mental Health, awarded to Dr. DiClemente.
9. PROVOCATIVE QUESTIONS IN A PAROCHIAL SEX EDUCATION CLASS: HIGHER INCIDENCE IN YOUNGER TEENS Megan A. Moreno, MD, MSEd, Cora C. Breuner, MD, MPH, and Paula Lozano, MD, MPH. Department of Pediatrics, University of Washington, Seattle, Washington Purpose: Recent data show US adolescents are engaging in sexual activity at earlier ages, however; little is known about young teens’ specific sexual attitudes and behaviors. Examining teens’ questions in sex education classes may provide insight into these attitudes and behaviors. This study examined 5th through 8th graders’ anonymously submitted questions in parochial sex education classes. Methods: Anonymous written questions were submitted by 5th/ 6th and 7th/8th grade students at the outset of sex education classes in a Seattle parochial school between 2003 and 2005 in this quasi cohort study. Questions were classified into topic categories. Three additional variables were then coded for each question. Ethics/guidance questions included requests for advice or value judgments. Prohibited questions included the topics: homosexuality, abortion, masturbation, and contraception. “Red flag questions” were those that suggested consideration of or engagement in sexual behavior. A modified Delphi procedure with three adolescent medicine physicians was used to identify red flag questions. Ten percent (10%) of the questions were coded for topic categories by a second rater with a 94% concordance. Results: Among 473 questions submitted by 410 students, the most popular topics for 5th/6th graders were: pregnancy, puberty, and menstruation and for 7th/8th graders: puberty, menstruation and general health. Forty-one (41) questions (8.6%) were prohibited. Twenty-nine questions (6.2%) asked about ethics/guidance. Eighteen questions (3.81%) were coded as red flag questions. A chi square analysis showed that 5th/6th graders asked significantly more questions in the ethics/guidance (8.3 versus 3.64%) and red flag question categories (5.53 versus 1.82%) (p ⬍ 0.05) than 7th/8th graders. Conclusions: Although provocative questions represent a minority of these middle students’ queries, these requests suggest the urgency of providing appropriate guidance to young teens, given the risks of sexual activity in this age group. Contrary to our expectations, younger students asked more questions than their older peers in two subcategories of provocative questions: ethics/ guidance and red flags. The role of school education programs, physicians and parents in addressing questions of this sort should be considered. Sources of Support: None.
10. CONSISTENCY BETWEEN FACE-TO-FACE AND SURVEY REPORTS OF HEALTH-RELATED BEHAVIOR IN ADOLESCENT FEMALES Jennifer Newman, PhD, Carmen Radecki Breitkopf, PhD, Abbey B. Berenson, MD. Department of Obstetrics & Gynecology, University of Texas Medical Branch, Galveston, Texas Purpose: To investigate the reliability (consistency) between two self-report methods (face-to-face interview with provider [FTFI] vs. self-administered questionnaire [SAQ]) with regard to sexual health indicators, substance use, and depressed mood among female adolescents of low socioeconomic status.
Abstracts / 40 (2007) S19 –S54
Methods: Consistency of responses was evaluated among 329 African American, Hispanic, and White females 13 to 18 years of age who attended a family planning clinic in southeast Texas. Questions included age at first sexual intercourse, lifetime number of sexual partners, history of a sexually transmitted disease (STD), tobacco use, drug use, and whether the adolescent often felt sad, blue, or depressed. Correlation coefficients and kappa statistics were used to determine reliability. Percent matching was included for each of the six health indicators across the total sample and separately for each race/ethnicity. Results: All consistency estimates except one achieved statistical significance (P ⬍ .05), however, the strength of agreement varied by health indicator and in some cases, by race/ethnicity. Reports of drug use and depressed mood agreed less frequently overall, than reports of STD history and tobacco use. With regard to age at first intercourse and lifetime number of sexual partners, the correlation coefficients were similar across the total sample (r ⫽ .84 and .85, respectively) however, they were significantly lower among African Americans relative to Hispanics and Whites (all P ⬍ .001). African Americans had the highest percent of matched responses for substance use and depressed mood relative to Hispanic and Caucasian adolescents. However, African Americans had the lowest percent of matched responses for sexual health indicators relative to Hispanics and Whites. Inconsistent reports generally reflected greater reporting of negative behaviors/mood states on the SAQ relative to the FTFI. Conclusions: FTFI and SAQ yield varying degrees of consistency for different health indicators. Consistency of reporting also differed by race/ethnicity. The results of this study suggest that a self administered questionnaire will reveal negative thoughts and behaviors more often among adolescents than a face-to-face interview. This suggests providers could use a self-administered questionnaire to assess these behaviors and reserve their face-toface time for counseling. Incorporating a well-designed SAQ into the adolescent visit has the advantage of easy administration in a busy clinic setting where health care providers have limited time for patient interaction. Sources of Support: This study was supported by the National Institute of Child Health and Human Development of the National Institutes of Health grant K24HD043659.
11. GETTING PERSONAL: WHAT PEDIATRICIANS ARE ASKING THEIR ADOLESCENT PATIENTS ABOUT SEX Melissa Pujazon, MD, MPH. Sarah Worley, MS, and Ellen Rome, MD, MPH. Department of General Pediatrics, Section of Adolescent Medicine, Children’s Hospital, Cleveland Clinic, Cleveland, Ohio Purpose: To determine the content of the sexual history performed by pediatric residents and pediatricians at the average adolescent well care visit. Methods: One-thousand-two-hundred (1,200) members of the American Academy of Pediatrics, Ohio Chapter, were randomly invited to participate and were emailed a link to an online questionnaire. Twenty-five questions addressed the practitioner’s demographics, typical sexual history content, and comfort level discussing and perceived education on various sexual issues. Data was analyzed with SAS using Chi-Square and Fisher’s Exact Tests (statistical significance p ⬍ 0.05). Results: The response rate was 22.8% (n ⫽ 278) with 61.3% (n ⫽ 166) ⱕ 35 yrs old and 38.7% (n ⫽ 103) ⱖ 36 yrs old. Fifty-two
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percent of respondents begin asking about sexual activity between the ages of 11-13 yrs. Fifty-seven percent reported always asking about sexual activity during the typical adolescent well visit, but only 26.3% always asked about type of sexual activity, 15.4% always asked about sexual attraction and 12.9% always asked about nonconsensual sex. Statistically significant differences occurred among all different demographic groups. For example, women were more likely than men to ask about sexual attraction (41.2% vs. 25.3%, p ⫽ 0.047), and number of lifetime partners (81.9% vs. 68.7%, p ⫽ 0.024). Respondents ⱕ 35 yrs old were more likely than those 36 and older to report they received adequate education on emergency contraception (60% vs. 20%, p ⬍ 0.001), STDs (97.6% vs. 85.6%, p ⬍ 0.001), oral sex (51.2% vs. 25.7%, p ⬍ 0.001) and issues related to gay, lesbian and bisexual youth (30.5% vs. 16.4%, p ⫽ 0.009). Non-U.S. born respondents “always or usually” worried about parental reaction to initiating a conversation with the patient on vaginal sex (40.5% vs. 16.9%, p ⫽ 0.021), anal sex (67.5% vs. 30.5%, p ⬍ 0.001) and oral sex (62.1% vs. 26.5%, p ⬍ 0.001) and were less likely to bring up vaginal sex (43.2% vs. 22.9%, p ⫽ 0.009) and oral sex (81.1% vs. 55.8%, p ⫽ 0.004). Respondents with children felt less adequately educated on emergency contraception (33.8% vs. 58.0%, p ⬍ 0.001), STDs (89.3% vs. 97.5%, p ⫽ 0.010) and oral sex (31.1% vs. 54.2%, p ⬍ 0.001) than those without children. Finally, personal beliefs affected the sexual history content and practitioner’s comfort level in counseling patients. For example, those who reported emergency contraception was bad and/or wrong felt less comfortable discussing emergency contraception with their patients (37.8% vs. 74.9%, p ⬍ 0.001). Conclusion: The content of the average sexual history varies among pediatric practitioners and is influenced by the practitioner’s personal beliefs and background.
12. THE ROLE OF RELATIONSHIP CONTEXT IN AFRICAN AMERICAN ADOLESCENT MALES’ CONDOM DECISIONMAKING Melissa Gilliam, MD, MPH, Aisha Reuler, BS, and Amy Berlin, MPH. Department of Obstetrics and Gynecology, The University of Illinois at Chicago, Chicago, Illinois Purpose: The purpose of this study is to gain insights into condom decision-making and behaviors of urban, African American male youth. Methods: We conducted 3 focus groups with young, African American males from the Southside of Chicago (n ⫽ 14). All sessions were tape-recorded and transcribed verbatim, Atlas ti/5.0 was used for data analysis. Through grounded theory methods and content analysis we identified major themes. A model of condom decision-making was developed. Results: Major themes presented are those which appeared in all sessions and were widely endorsed across sessions. Boys are motivated to use condoms based on perceived risk of STDs which is influenced by partner and relationship factors. They believe girls are clean or dirty. “Real girlfriends” or true girlfriends are considered clean. The perception of the female partner as “safe” and “trusted” as evidenced by her desire to wait to have sex or use a condom reduces his concern for STDs and motivation to use condoms. Conversely, casual sex partners are more likely to be “dirty” based on physical qualities and reputation as promiscuous or willing to have sex for drugs (e.g., “buzzards”). One boy said of “dirty” partners: “they dress a little bit nastier than all the other