HIV preventive services to adolescents by primary care physicians

JOURNAL OF ADOLESCENTHEALTH 1996;19:249-257

ORIGINAL ARTICLE

Delivery of STD/HIV Preventive Services to Adolescents by Primary Care Physicians SUSAN G. MILLSTEIN, PH.D.,* VIV1EN IGRA, M.D.,* AND JANET GANS, PH.D.**

Purpose: To document the rates of STD/HIV preventive services delivered to adolescents by primary care physicians in California, and to identify variation owing to physician and practice-related factors. Methods: A stratified random sample of California internists, family physicians, obstetrician-gynecologists, and pediatricians was drawn from the AMA Masterfile and surveyed by mail about their practices with regard to STD/HIV prevention for 15-18-year-old adolescent patients. Sixty percent of eligible physicians responded; the final sample was 1217 physicians. Results: Results showed that 40% of physicians reported screening all of their adolescent patients for sexual activity and 31% reported educating all of their adolescent patients about STD/HIV transmission. F o r their sexually active adolescent patients, 36% of physicians always provided STD/HIV education, 17% always screened for number of previous sexual partners; 12% always screened for sexual orientation; and 10% always screened for frequency of casual sex. Four percent of the physicians reported that they always provided condoms for their sexually active adolescent patients; 81% never provided condoms. Higher levels of preventive services delivery were associated with female physician gender, specialization in obstetrics-gynecology, and more recent date of medical school graduation. Physicians practicing in health maintenance organizations reported providing significantly higher rates of preventive services to sexually active adolescents than did physicians in private practice. Conclusions: Primary care physicians provide STD/ HIV preventive services to adolescents at rates far below

From the *School of Medicine, University of California, San Francisco, California;and **AmericanMedical Association, Chicago, Illinois. Address reprint requests to: Susan G. Millstein, Ph.D., Division of Adolescent Medicine, Box 0374, Rm. AC-O1, Department of Pediatrics, 400 Parnassus Ave., University of California--SF, San Francisco, CA 94143. Manuscript acceptedJanuary 16, 1996.

those recommended by current guidelines. Areas where additional research would be informative are highlighted.

KEY WORDS:

Sexually transmitted disease HIV Preventive services Practice parameters Clinical guidelines Health care delivery Adolescents

Sexually transmitted diseases (STD) are a significant source of potentially preventable morbidity in the adolescent population. Prevalence rates for most STD agents peak d u r i n g adolescence and y o u n g a d u l t h o o d (1,2). Current data underestimate the actual prevalence rates, since the most frequently occurring STDs in adolescents, chlamydia and h u m a n papilloma viral infection, are not routinely reported to the Centers for Disease Control (CDC). Furthermore, m a n y of the AIDS cases reported a m o n g 20-25-year-olds are the result of HIV infection that occurred during adolescence (1). The role and responsibility of physicians in preventive services delivery has been well articulated (3,4). Recent guidelines and r e c o m m e n d a t i o n s concerning the delivery of preventive services to adolescents have also been developed, including Bright Futures, from the Bureau of Maternal and Child Health (5) and the American Medical Association's Guidelines for Adolescent Preventive Services ( G A P S )

(6). GAPS r e c o m m e n d s that physicians screen all adolescents for S T D / H I V risk behaviors, educate all adolescent patients about S T D / H I V transmission,

© Societyfor AdolescentMedicine,1996 Published by ElsevierScienceInc,,655 Avenueof the Americas,New York,NY 10010

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and counsel adolescents about reducing their risk for contracting STDs, including HIV. Guidelines and recommendations do not, however, assure compliance. For example, recent studies of STD/AIDS preventive services delivered to adults report rates of service delivery well below levels recommended by the Public Health Service (4). Primary care physicians frequently fail to take sexual histories from new patients (7,8), and a minority of primary care physicians ask for more sensitive information, such as number of sexual partners or sexual orientation, or counsel patients about reducing the risk of contracting AIDS (8). Even among physicians who acknowledge having a "very important" role in AIDS prevention, a minority routinely assess their adult patients' risk for HIV (9). The few studies that have examined physicians' provision of services to adolescent patients also show rates below recommended levels. Nationally, 56% of primary care physicians report "usually or always" asking their adolescent patients about STDs, 34% ask about the number of sex partners, and 27% ask about sexual orientation (10). Similar findings were reported in a regional study (11). While informative, these studies did not examine sources of variation in service delivery patterns. Studies using adult populations have shown significant variation in STD/HIV preventive services as a function of factors, such as physician gender, specialty, practice setting, knowledge, and attitudes (7-9,11-13). No studies have examined the relationship between these types of physician characteristics and the provision of STD/ HIV preventive services to adolescents. Given the vulnerability of the adolescent population, such research is warranted. The current study examines primary care physicians' delivery of a range of STD/HIV preventive services, including risk assessment, counseling, and condom distribution to adolescents. In addition to documenting rates of service delivery, the study also examines sociodemographic factors and practice factors that have been shown or hypothesized to influence physicians' delivery of preventive services to adult patients.

Methods Study Participants Study participants were recruited by mail using a sample drawn from the American Medical Association Masterfile, which provides the most complete listing of physicians in the United States who have

JOURNALOF ADOLESCENTHEALTHVol. 19, No. 4

completed requirements to practice medicine. A stratified random sample containing equal numbers of primary care physicians in family practice, internal medicine, obstetrics-gynecology, and pediatrics was drawn from the Masterfile. Female physicians were oversampled in order to evaluate potential gender-related differences in rates of preventive services delivery. Eligibility for the sampling frame required that physicians: (1) be actively practicing in California, (2) have primary specialty and board certification in family practice, internal medicine, obstetrics-gynecology, or pediatrics, (3) indicate that their major professional activities were patient care related, and (4) not be practicing in a subspecialty. This last criterion was used to eliminate physicians practicing in specialized areas such as emergency medicine, who do not see adolescent patients for routine visits. Physicians who completed surveys but who reported seeing, on average, fewer than one adolescent patient per week were also excluded.

Study Procedures Physicians who fulfilled study entry criteria were mailed packets containing a cover letter describing the study, a letter endorsing the study from the professional organization (state or national) associated with their specialty, the study questionnaire, a stamped, addressed return envelope, and a ten dollar bill as a token of appreciation for their time and effort. One week after the initial mailing, reminder postcards were sent to all potential subjects. Four weeks after the initial mailing, nonresponders were sent a second questionnaire.

Sample Response Rate Of the 2952 questionnaires mailed, 181 were undeliverable because the physician had moved and left no forwarding address, or was deceased. Another 683 physicians (23%) failed to meet study criteria leaving an eligible pool of 2088 physicians. Among these 2088 physicians, 1253 (60%) returned surveys, 6% actively refused to participate, and 34% failed to respond to repeated requests for information. Owing to missing data on essential data elements, 37 respondents (less than 3%) were eliminated from all analyses, leaving a final sample size of 1217 physicians. Given the relatively large sample size and our desire to detect clinically relevant results, levels for statistical significance were set at p < .01 for all

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analyses. Using this criterion, there were no significant differences in response rates as a function of physician gender, (X2 -- 2.5; p = .11), year of medical school completion (F = .08, p = .77), or practice setting (solo private practice versus other settings; (×2 = 2.5; p = .11). Other settings could not be included in this analysis due to differences in the coding of practice specialty in the AMA Masterfile and on our survey. Response rates were significantly lower among internists (43.7%) than among family physicians (61.9%), obstetrician-gynecologists (62.3%), or pediatricians (66.5%; X2 = 50.4; p < .001).

Study Measures The first portion of the study questionnaire asked for

sociodemographic information, including the physician's age, gender, type of practice setting (private solo practice, private group practice, university based clinic, public/community clinic, free standing HMO, or other institutional setting), the percentage of time spent in direct patient care, and the number of adolescent patients seen per week (< 1, 1-5, 6-10, or > 10). The AMA Masterfile was used to identify the physician's specialty and the year of graduation from medical school. Physicians were then queried about their provision of preventive services to adolescent patients (ages 15-18 years) during routine visits. Routine visits were defined as "nonacute care visits, such as routine checkups, sports exams, school or employment physicals." Physicians were asked to note the percentage of their adolescent patients for whom they provided each of the following seven STD/HIV-related services: (1) screening for sexual activity, (2) asking about sexual orientation, (3) asking about the frequency of casual sex, (4) asking about the number of previous sexual partners, (5) educating about STD/ HIV transmission, (6) educating sexually active adolescents about STD/HIV transmission, and (7) providing sexually active adolescents with condoms. Physicians responded on a scale of percentages that were presented in deciles, from 0-100%.

Data Analysis Since we oversampled female physicians and aimed for approximately equal numbers of physicians in each specialty, the sample, by design, does not represent the gender or specialty distribution of physicians within California. We therefore used weighted analyses to describe how the prevalence of

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services delivered to adolescents would look had we obtained a more representative sample. Using the same exclusion criteria used to select the original sampling frame, we created sample weights based on the number of eligible California physicians practicing within each specialty, and the proportion of male and female physicians within each specialty. Eight different sample weights were developed, one for subjects in each of the specialty/gender subgroups. Weighted data were only used when reporting prevalence rates. For examining variations in preventive services delivery as a function of physician demographic and practice factors, a series of regression analyses were conducted. Because of the significant associations among the four physician factors of interest, interpreting differences in service delivery rates as a function of any one physician factor required that we first control for the other three factors. This was accomplished by entering the control factors at the first step of the regression equation and entering the physician factor of interest at the second step. Interactions were entered in the third step of each equation. Regression analyses were conducted using unweighted data. Analyses were conducted using SPSS-PC.

Results Description of Sample The final sample (Table 1) consisted of 1217 physicians, 66% (n = 798) were male and 34% (n -- 419) were female. Approximately equal numbers of physicians were family physicians (29.3% of the sample), obstetrician-gynecologists (29.8%), and pediatricians (28.4%). Internists represented only 12.4% of the final sample owing to their lower response rates, as well as higher rates of ineligibility, which were primarily owing to the small number of adolescent patients they saw per week. Most of the sample participants had graduated from medical school within the past 2 decades. Breaking the sample into approximate quartiles, 23% of the sample had graduated from medical school before 1968, 24% graduated from 1968-76, 27% graduated from 1977-82, and 26% graduated from medical school from 1984-89. Analysis of variance indicated that female physicians were more recent graduates than male physicians (F = 139.8, p < .0001), and that physicians in private practice were less likely to be recent graduates (F = 16.8, p < .0001). Internists and family physicians graduated more

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Table 1. Characteristics of Study Participants Specialty

Total sample (n) Practice setting (%) Private HMO Other Graduation year (Mean) Males (n) Practice setting (%) Private HMO Other Graduation year (Mean) Females (n) Practice setting (%) Private HMO Other Graduation year (Mean)

Family Practice (357)

Inernal Medicine (151)

ObstetricsGynecology (363)

Pediatrics (346)

Total (1217)

67 19 14 1977 (240)

60 27 14 1978 (93)

74 20 6 1972 (230)

66 26 8 1973 (235)

68 22 10 1975 (798)

73 18 9 1976 (117)

68 23 10 1976 (58)

75 19 6 1969 (133)

69 25 6 1972 (111)

72 21 7 1972 (419)

54 21 25 1981

47 33 21 1982

73 22 5 1978

61 28 11 1977

61 25 14 1979

recently than did obstetrician-gynecologists and pediatricians (F = 24.0, p < .0001). Physicians in the sample were actively involved in patient care; 93% of the sample reported spending 80% or m o r e of their time in direct patient care; 51% of the sample reported spending all of their time p r o v i d i n g direct patient care. Most of the physicians s u r v e y e d (51%) saw 1-5 adolescent patients (ages 15-18 years) per week; 31% saw 6-10 adolescents per week, and 18% saw more than 10 adolescents per week. Family physicians and pediatricians saw the greatest n u m b e r of adolescent patients; internists saw the fewest X2 = 56.6, p < .0001). A majority of the physicians (68%) were practicing in private g r o u p or solo practices; 22% were emp l o y e d b y freestanding health maintenance organizations (HMOs). The remaining 10% of physicians practiced in other settings, including public health clinics, university based settings, or other institutional settings, such as the Veterans Administration, student health services, or corporate health entities. Male physicians were m o r e likely to be in private practice settings than were female physicians (×2 = 20.1, p < .0001). Obstetrician-gynecologists were overrepresented in private practice settings, while internists and pediatricians were overrepresented in H M O settings (X2 = 28.5, p < .0001).

Delivery of STD/HIV-Related Preventive Services Table 2 shows the percent of physicians w h o reported providing specific STD/HIV-related preven-

tive services to their 15-18-year-old adolescent patients. Physicians reported screening, on average, 73% of their adolescent patients for sexual activity, and educating, on average, 69% about S T D / H I V transmission. Only 40% of physicians reported screening all of their 15-18-year-old patients for sexual activity. Thirty-one percent of physicians reported educating all of their adolescent patients about S T D / H I V transmission; a slightly higher percentage (36%) educated all of their sexually active adolescents patients. Physicians asked, on average, 45% of their sexually active adolescent patients about their n u m b e r of previous sexual partners; 17% of the physicians never conducted such screening. Physicians reported even lower rates of screening for the frequency of casual sexual experiences (32% of patients, on average), or sexual orientation (31%). The lowest rates were f o u n d for c o n d o m distribution (10%); 80% of the physicians reported that they never p r o v i d e d condoms to their sexually active adolescent patients.

Variations in Service Delivery by Physician Factors A series of regression analyses were conducted to examine variations in preventive services delivery as a function of four physician factors: (1) specialty, (2) gender, (3) year of medical school completion, (4) and practice setting. We focused on three measures of preventive services delivery. Screening for sexual activity and educating about S T D / H I V transmission

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Table 2. Weighted Prevalence of Physicians' Provision of STD/HIV Preventive Services to Adolescent Patients 15-18Years-of-Age Percent of Physicians Who Provide Service

Service Provided Screen for sexual activity Educate about STD/H1V transmission Services for sexually active patients Educate about STD/H1V transmission Ask about numbers of previous partners Ask about the frequency of casual sex Ask about sexual orientation Provide condoms

To None of Their Teen Patients

To All of Their Teen Patients

Mean Percent (SE) of Teen Patients to Whom Physicians Provide Service

2.5 3.2

39.7 30.9

72.6 (0.89) 69.1 (0.89)

4.9 19.9

36.3 17.2

69.2 (0.97) 44.9 (1.07)

32.9 37.4 81.4

10.4 11.9 4.2

31.9 (1.00) 31.0 (1.03) 9.6 (0.7l)

are services that are r e c o m m e n d e d for all adolescents, these w e r e a n a l y z e d separately. The third m e a s u r e w a s a c o m p o s i t e of p r e v e n t i v e services that are especially i m p o r t a n t for the sexually active adolescent. These included screening for specific H I V risk factors (e.g., sexual orientation, n u m b e r of previous sexual partners, frequency of casual sex), e d u cating a b o u t S T D / H I V transmission, a n d p r o v i d i n g condoms.

greater p e r c e n t a g e of their adolescent patients than did their m a l e colleagues (Table 4). T h e y r e p o r t e d higher rates of screening for sexual activity (R 2 change = .05, beta = .25, p < .001), e d u c a t i n g a b o u t S T D / H I V transmission (R 2 change = .04, beta = .21, p < .001), a n d p r o v i d i n g services to sexually active adolescents (R 2 change .04, beta -- .21, p < .001). H o w e v e r , these overall g e n d e r differences varied in different practice settings. Differences in screening rates b e t w e e n m a l e s a n d females a p p e a r e d to be m o r e p r o n o u n c e d in p r i v a t e practice settings than in

Specialty Controlling for other physician factors, specialty w a s associated w i t h significant differences in r e p o r t e d rates of screening for sexual activity (R 2 change = .19, p < .001), e d u c a t i n g a b o u t S T D / H I V transmission (R 2 change = .08, p < .001), a n d p r o v i d i n g services to sexually active adolescents (R 2 change = .08, p < .001; Table 3). C o m p a r e d to physicians in other specialties, o b s t e t r i c i a n - g y n e c o l o g i s t s rep o r t e d significantly higher rates of screening for sexual activity (beta = .45, p < .001), e d u c a t i n g a b o u t S T D / H I V infection (beta = .30, p < .001), a n d p r o v i d i n g services to sexually active adolescents (beta .25, = p < .001). Differences in screening for sexual activity b e t w e e n o b s t e t r i c i a n - g y n e c o l o g i s t s and other specialties w e r e particularly p r o n o u n c e d in m a l e s (beta = - . 1 8 , p < .0001). Specialty differences w e r e also f o u n d b e t w e e n family physicians a n d pediatricians, with family physicians reporting significantly higher rates of service p r o v i s i o n to sexually active adolescents (beta = .12, p < .001).

Gender Controlling for other physician factors, female p h y sicians r e p o r t e d p r o v i d i n g p r e v e n t i v e services to a

Table 3. Effects of Physician Specialty on Delivery of Preventive Services to Adolescent Patients DEPENDENT VARIABLE Independent Variables SCREENING ALL TEENS FOR SEXUAL ACITVITY Control factorsa Specialty Interactions EDUCATING ALL TEENS ABOUT STD/HIV TRANSMISSION Control factorsa Specialty Interactions SERVICES FOR SEXUALLY ACTIVE ADOLESCENTSb Control factorsa Specialty Interactions

R (model)

(model)

R2 (change)

.31 .54 .57

.10 .29 .32

.10"* .19"* .03**

.27 .40 .42

.07 .16 .17

.07** .08** .02+

.29 .40 .41

.08 .16 .17

.08** .08** NS

R2

a Controls include physician gender, graduation year, and practice setting. b Services include screening for sexual orientation, number of previous sexual partners, and frequency of casual sex, educating about STD/HIV transmission, and providing condoms. **p ~< .001. * p < .005. + P < .01.

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Table 5. Effects of Physician Year of Graduation on Delivery of Preventive Services to Adolescent Patients

Table 4. Effects of Physician Gender on Delivery of Preventive Services to Adolescent Patients D E P E N D E N T VARIABLE

Independent Variables SCREENING ALL TEENS FOR SEXUAL ACTIVITY Control factorsa Physician gender Interactions EDUCATING ALL TEENS ABOUT STD/HIV TRANSMISSION Control factorsa Physician gender Interactions SERVICES FOR SEXUALLY ACTIVE ADOLESCENTS b Control factorsa Physician gender Interactions

R

R2

(model) (model)

R2

(change)

.49 .54 .57

.24 .29 .32

.24** .05** .03**

.34 .40 .41

.12 .16 .17

.12"* .04** .01 +

.35 .40 .41

.12 .16 .17

.12"* .04** NS

a Controls include p h y s i c i a n specialty, g r a d u a t i o n year, a n d practice setting. b Services include screening for sexual orientation, n u m b e r of p r e v i o u s sexual partners, a n d frequency of casual sex, e d u c a t i n g about STD/HIV transmission, and providing condoms. ** p -< .001. * p < .005. + p < .01.

D E P E N D E N T VARIABLE

Independent Variables SCREENING ALL TEENS FOR SEXUAL ACTIVITY Control factors a G r a d u a t i o n year Interactions E D U C A T I N G ALL TEENS ABOUT STD/HIV TRANSMISSION Control factors a G r a d u a t i o n year Interactions SERVICES FOR SEXUALLY ACTIVE ADOLESCENTS b Control factors a G r a d u a t i o n year Interactions

R

R2

R2

(model)

(model)

(change)

.53 .54 .55

.28 .29 .31

.28** .01"* .02**

.38 .40 .40

.14 .16 .16

.14"* .01"* NS

.39 .40 .41

.15 .16 .16

.15"* .01"* NS

a Controls include p h y s i c i a n specialty, gender, a n d practice setting. b Services include screening for sexual orientation, n u m b e r of p r e v i o u s sexual partners, a n d frequency of casual sex, e d u c a t i n g a b o u t S T D / H I V transmission, a n d p r o v i d i n g c o n d o m s . ** p ~ .001. * p < .005.

Practice Setting H M O settings (beta = .08, p < .01), a n d there w e r e no g e n d e r differences in rates of educating (beta = .07, p = .06) or p r o v i d i n g services to sexually active adolescents (beta = .10, p = .24) a m o n g physicians w h o practiced in H M O settings. Screening for sexual activity also yielded a significant g e n d e r b y g r a d u a t i o n date interaction; while rates of screening in m a l e physicians w e r e higher a m o n g m o r e recent graduates, females s h o w e d no similar variation (beta = - . 2 1 , p = .01).

Graduation Year As s h o w n in Table 5, w h e n controlling for other physician factors, m o r e recent g r a d u a t e s w e r e significantly m o r e likely to screen for sexual activity (R 2 change = .01, beta = .13, p < .001). The effects of g r a d u a t i o n y e a r on screening differed b y specialty and, as n o t e d earlier, b y gender. A m o n g obstetrician- g y n e c o l o g i s t s these effects w e r e less evident t h a n they w e r e for other specialists (beta = - . 2 6 , p < .001). M o r e recent g r a d u a t e s w e r e also m o r e likely to educate adolescents a b o u t S T D / H I V transmission (R 2 change = .01, beta = .12, p < .001), and to p r o v i d e services to sexually active adolescents (R 2 change = .01, beta = .11, p < .001).

Controlling for all other physician factors, practice setting w a s not associated with differences in rep o r t e d rates of screening for sexual activity (R 2 change = .003) or rates of p r o v i d i n g S T D / H I V education (R 2 change = .001; Table 6). There w a s a borderline interaction of setting b y g e n d e r for rates of e d u c a t i n g w h e n c o m p a r i n g private practice settings to n o n p r i v a t e practice settings (R 2 change = .01, p = .015) a n d a significant interaction w h e n c o m p a r i n g p r i v a t e practice a n d H M O settings (R 2 change = .02, p < .005). Separate analyses b y g e n d e r revealed o p p o s i t e trends. A m o n g m a l e s (n = 796), rates of e d u c a t i n g a b o u t S T D / H I V t e n d e d to be greater a m o n g those practicing in H M O s t h a n a m o n g those in private practice (R 2 change = .01, p = .017; beta = - . 0 9 , p < .01). In contrast, females (n = 418) in private practice t e n d e d to report higher rates t h a n those in H M O settings (R 2 change = .02, p = .027; beta = .13, p < .01). Preventive services p r o v i d e d to sexually active adolescents did v a r y b y setting (R2 change = .01, p < .001). Physicians in p r i v a t e practice r e p o r t e d significantly l o w e r rates than did physicians in n o n p r i v a t e practice (beta = - . 1 1 , p < .001) or those in H M O s (beta = - . 0 8 , p < .01).

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Table 6. Effects of Practice Setting on Delivery of Preventive Services to Adolescent Patients D E P E N D E N T VARIABLE I n d e p e n d e n t Variables SCREENING ALL TEENS FOR SEXUAL ACTIVITY Control factors a Practice setting b Interactions E D U C A T I N G ALL TEENS ABOUT STD/HIV TRANSMISSION Control factors a Practice setting b Interactions SERVICES FOR SEXUALLY ACTIVE ADOLESCENTS adolescents b Control factors a Practice setting b Interactions

R (model)

R2 (model)

R2 (change)

.54 .54 .54

.29 .29 .29

.29** NS NS

.40 .40 .41

.16 .16 .l 7

.16"* NS NS

.39 .40 .41

.15 .16 .17

.15"* .01"* NS d

Controls include p h y s i c i a n specialty, gender, a n d g r a d u a t i o n year. b Private practice v e r s u s n o n p r i v a t e practice. c Services include screening for sexual orientation, n u m b e r of p r e v i o u s sexual partners, a n d f r e q u e n c y of casual sex, e d u c a t i n g a b o u t S T D / H I V transmission, a n d p r o v i d i n g c o n d o m s . a Interactions do e m e r g e w h e n c o m p a r i n g private practice a n d H M O settings. ** p ~ .001. * p ~ .005.

Summary of Effects of Physician Factors on Delivery of Preventive Services Taken together, physician gender, specialty, practice setting, and year of medical school graduation accounted, overall, for 29% of the variance in screening for sexual activity, 16% of the variance in educating about STD/HIV transmission, and 16% of the variance in providing services to sexually active adolescents. When we compare the R 2 change that occurs in the regression model when a particular physician factor of interest enters the equation (Tables 3-6), we can see that the unique (nonshared) variance attributable to physician factors for each outcome variable appears to be largest for specialty (19%, 8%, and 8% of the variance, respectively) and gender (5%, 4%, and 4% of the variance, respectively). However, these comparisons may not be the best w a y to assess the influence of specialty, relative to other factors, on preventive services delivery. With one exception, all of the specialty differences emerged between obstetrician-gynecologists and other primary care physicians. Obstetrician-gynecologists, by nature of their specialty, differ from the other specialties in two important ways: they exclusively see female patients,

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and they deal with more sensitive, sexuality-related issues on a day-to-day basis. In order to better understand the relative importance of specialty to other factors influencing practice variations we reanalyzed the data without the obstetrician-gynecologist subsample. These analyses, which included relevant physician factors as controls, indicated that specialty accounted for only 1% of the unique variance in screening for sexual activity, none of the variance in educating about STD/ HIV transmission, and 2% of the variance in providing services to sexually active adolescents. In contrast, gender accounted for 9%, 5%, and 5% of the variance in the three outcome measures, respectively.

Discussion The results of the current study indicate that physicians provide STD/HIV-related preventive services at levels far below those recommended by current guidelines. The AMA Guidelines for Adolescent Preventive Services and the United States Preventive Services Task Force recommend that all adolescents be screened for sexual activity, yet fewer than onehalf of the primary care physicians we surveyed reported doing so. Even more disturbing is the fact that when physicians know that an adolescent is sexually active, they often fail to screen further for behaviors or attributes that indicate increased risk for HIV transmission, such as multiple sexual partners, casual sexual experiences, or sexual orientation. Furthermore, sexually active adolescents were rarely provided with condoms. The lower rates of screening for more sensitive behaviors is not surprising. Previous studies have found that physicians who experience personal discomfort discussing sexual issues with their adult patients are less likely to provide AIDS related preventive services to those patients (11,12). Differences in physician discomfort may explain w h y we found, across all of the STD/HIV-related preventive services, significantly higher prevalence rates for obstetrician-gynecologists than for other primary care providers. Given the focus of their specialty, obstetrician-gynecologists deal regularly with these sensitive issues, and are therefore likely to be far more comfortable with them. It is important to note that these specialty differences were not only statistically significant, but also striking. Obstetriciangynecologists reported screening, on average, 96% of their patients and educating, on average, 85% of their

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patients. Corresponding prevalence rates in the other primary care specialists were 67% (for both services). Although we did not examine differences in the delivery of services to male and female adolescents, these specialty differences raise concerns about the provision of services to males, since obstetriciangynecologists see only female patients. These concerns are compounded by the fact that male adolescents are less likely than their female peers to seek health care in general, and would therefore have relatively fewer opportunities to be exposed to clinically-based STD/HIV preventive services even if they were optimally provided (14). In addition, condoms, which provide the best protection against STD/HIV transmission in sexually active adolescents, require the participation of male partners. Gender differences among physicians in the delivery of preventive services were striking. Female physicians, across all of the services we examined, reported higher rates of service delivery than male physicians. These differences are consistent with those reported for the delivery of health promotion and disease prevention services to adults (15). Yet we also saw evidence that gender differences in screening vary considerably in different cohorts and in different situational contexts. We found significant increases in screening among males who were more recent graduates, but not for females, suggesting that male physicians may be, over time, practicing more like female physicians. Differences between males and females also appeared to be less marked among physicians who practiced in HMO settings than among those in private practice. If this is due to differences in the degree of autonomy physicians have in these practice settings, it provides additional support to the idea that gender differences can be influenced by external sources, and are not immutable to change. We were particularly interested in the delivery of preventive services among physicians practicing in different settings. H M O practice settings, for example, are often promoted as more prevention oriented. In terms of provision of services to sexually active adolescents, our results confirm this, finding physicians in HMO settings reporting significantly higher rates than physicians in private practice. H M O settings also appeared to promote less pronounced gender differences in screening, higher rates of education among male physicians, and to eliminate gender differences in the provision of services to sexually active adolescents. Given the increasing prevalence of managed care settings for the delivery of primary care, future studies should examine more

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closely how, and by what mechanisms, the practice setting influences health care delivery patterns. The overall higher rates of providing STD/HIV preventive services among more recent medical school graduates is consistent with trends found in the delivery of adult preventive services in general (16) and HW-related services specifically (7,12,13). These findings may reflect a trend toward increased emphasis on prevention in medical education. However, although prevention education may be incorporated into some clinical rotations, only 25% of accredited American medical schools include a required course in preventive medicine in their curricula, and those that do average fewer than 40 hours of total instruction time (17). Nevertheless, the fact that both practice specialty and year of graduation were related to levels of preventive service suggests that training may have a role in increasing physicians' delivery of preventive services. Studies are needed to evaluate the potential impact of medical school course work as well as residency training specifically designed to enhance preventive services delivery. As with any study utilizing self-reports, data obtained from physicians on screening and counseling practices may not be a fully accurate reflection of their actual behavior. It is reasurring that the rates we report are consistent with studies that have used telephone interviews (15), suggesting that the questionnaire did not cue physicians as to what the "correct" response was. Previous research, however, has shown that physicians tend to overestimate their delivery of many preventive services (15). If our results reflect a similar bias, it would indicate that the rates of actual preventive services delivery to adolescents are likely to be even lower than those that we report, which serves to increase our concerns about the adequacy of preventive services delivery to adolescents. Life-style choices made during adolescence have enduring effects on health and well-being. The exploration and experimentation that characterizes adolescence creates both vulnerability to engaging in unhealthy life-styles, as well as opportunities for physicians to promote healthy alternatives. In addition to professional recommendations for physician involvement, there are other reasons for physicians to provide adolescent health promotion and disease prevention services. A majority of adolescents see a physician at least once a year and the average adolescent has three visits during the year; most of these visits are to family physicians, pediatricians, internists, and obstetrician-gynecologists (14). In addition, adolescents view physicians as credible, and

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preferred sources of health related information, especially AIDS-related information (17,18). As such, physicians are in a unique position to intervene to reduce STD/HIV related morbidity among adolescents. This research was supported by funds from: State of California, Universitywide Taskforce on AIDS (R93-SF-052), the California Wellness Foundation (#94-79), the American Medical Association through a grant from the Division of School and Adolescent Health, Centers for Disease Control and Prevention (U63CCU503075-01), the University of California (San Francisco) Committee on Research (504195-34935), and the Maternal and Child Health Bureau (MCJ000978). The authors gratefully acknowledge the contributions of research associates Maria Freebairn-Smith, B.A. and Jeanette Koshar, M.S.N., Ph.D. (Candidate) and thank Saul Kanowitz, M.P.H. for conducting statistical analyses.

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