REDUCING HEALTH DISPARITIES IN UNINTENDED PREGNANCIES AMONG LATINA ADOLESCENTS USING A PATIENT-CENTERED COMPUTER-BASED CLINIC INTERVENTION Kathleen Tebb, PhD, FSAHM1, Felicia Rodriguez, MA1, Lance Pollack, PhD1, Maryjane Puffer, MPA2, Sally Adams, PhD1, Loris Hwang, MD1, Rosario Rico, MPH4, Robert Renteria, HSD4, Elizabeth Ozer, PhD1, Claire Brindis, DrPH, MPH1, Sang Leng Trieu, DrPH2 1University of California, San Francisco (UCSF); 2The Los Angeles Trust For Children's Health; 3University of CA, Los Angeles; 4The Los Angeles Trust for Children's Health

BackgroundChlamydia trachomatis (CT) continues to be a major public health problem among sexually active adolescent and young adult females. Although annual CT screening is recommended, actual rates remain low. System-based interventions are an effective approach to improve clinical practice including CT screening.ObjectiveThere are two objectives: (1) To describe the sustainability of a systems-based, clinical practice improvement intervention to increase urine-based CT screening among adolescent girls (14–18 years old) during routine check-ups in a paediatric clinic setting (2) To describe and evaluate the translation of this intervention into control clinics.MethodsThe study randomised 10 paediatric clinics (5 experimental, 5 control) within a large Northern California health maintenance organization (HMO). Clinics in the experimental group received a systems-based clinical practice improvement intervention (CPI) and controls received a traditional provider education intervention. The original study took place between 2000 and 2002 (Shaferet al JAMA, 2002). After the study ended, the intervention was translated to the remaining clinics including to the five controls. Data were tracked for four additional years (2003–2006). The proportion of 14–18-year-old girls who had sexual intercourse and who were screened for CT during their routine checkups was calculated using the same methodology as the original study. We assessed changes in the rate variable over time, within sites and between the intervention and control groups using linear mixed effects models with random intercepts.ResultsThe average screening rate in the intervention group was sustained at an average of 60% during the 4-year follow-up period (CI 0.41 to 0.79) with no significant increases over time. Prior to translation activities, the proportion screened in controls was 21%. After translation activities, the control group exhibited statistically significant linear and quadratic effects of time (p=0.0019 by Wald χ2 test). The estimated rate for the controls was 0.42 (95% CI 0.25 to 0.59) at time 1, increased to a maximum of 0.69 (95% CI 0.55 to 0.83) at year 2.5, then declined to 0.52 (95% CI 0.35 to 0.70) at the end of year 4.ConclusionsThis CPI systems intervention was both translatable and sustainable to other paediatric clinics within this HMO.

Background STIs remain epidemic among teens. Parents have a powerful influence on their teens' sexual behaviours, yet their role in preventing adolescent STIs and unplanned pregnancies has been largely ignored in clinical practice and research. Objective To explore parental acceptability of different contraceptive methods, including condoms, offered to their teen during a confidential healthcare visit (CV). Methods A cross-sectional phone survey of 261 randomly selected parents/caregivers of girls 12–17 years enrolled in two large diverse clinic systems. Parental acceptability of 7 different contraceptive methods was assessed on a 4-point likert scale (1=very unacceptable to 4=very acceptable). We examined if parental acceptability varied according to a variety of demographic factors, perceived likelihood of teen's sexual activity, and parental knowledge of STIs using bivariate analyses (χ 2 for categorical correlates, t tests for continuous correlates). Results Parents surveyed were 27–69 years old (mean 45 yrs), 70% married; 86% female; and diverse (46% Latino, 23% White, 16% Black, 11% Asian, 3% Other). 15% of household incomes were $20 K or less and 25% over $100 K. 36% attended religious services at least once/week. When parents were asked about their own experiences as teens, 40% reported sexual intercourse, 4% had an STI, 14% had a teen pregnancy, and 25% used birth control. The majority of parents lacked STI knowledge (56% correctly answered 0-1 out of 5 basic knowledge questions). Overall acceptability of contraception provided to their teen was highest for oral contraceptive pills (OCP) 59% and condoms 51% and lowest for IUDs 18% (see Abstract P1-S2.05 table 1). Only 24% thought there was any likelihood their teen would have sexual intercourse in the next year. Acceptability of OCPs, condoms, and emergency contraception was higher among parents who report a likelihood their teen would have sex. Abstract P2-S1.05 Table 1 Parental acceptability of contraceptive methods Contraceptive method Overall parental acceptability (N=261) Parental acceptability if teen is very unlikely to have sex in next year (n=195) Parental acceptability if teen has any likelihood of having sex in next year (n=62) Differences in acceptability by likelihood of teen having sex Condom 51% 43% 76% p<0.001 Oral contraceptive pill (OCP) 59% 53% 75% p<0.01 Depot medroxyprogesterone Acetate (DMPA) 46% 42% 58% p<0.05 Patch 42% 39% 51% NS Implant 32% 30% 37% NS Intrauterine Device (IUD) 18% 17% 20% NS Emergency contraception (EC) 45% 39% 63% p<0.001 NS, not statistically significant. p>0.05. Discussion This is the first study to examine parental acceptability of contraception offered during a CV. This study shows that parents lack basic STI knowledge and underestimate their teens' sexual activity. Only half found condoms, the only method that offers both STI and contraception protection, to be acceptable. In the context of providing confidential health services for teens, these findings highlight the need to better understand influences on parental attitudes and to improve communication with parents about sexual health topics, STIs, and condom use.

Despite recommendations for annual screening of Chlamydia trachomatis (CT), the most commonly reported STI among adolescents, health care providers are falling short of meeting this goal. Since nearly 2/3 of teens who make contact with the health care system do so with an urgent care visit, the purpose of this study was to survey providers regarding their perceived barriers to screening adolescents for Chlamydia during urgent care visits. As part of a larger randomized control study to increase CT screening in 14-18 year olds, pediatric providers at 5 intervention clinics were given an anonymous survey to assess barriers to screening adolescents. Surveys were hand delivered to providers with a self-addressed envelope. Providers were asked to rate the frequency of 7 common barriers using a 4 point Likert scale where 1= very rarely to 4= very frequently. 82 pediatric providers from 5 clinics completed the self-report questionnaire (95% response rate). The top 4 barriers included: urine specimens not already obtained and in the room (mean 2.0), difficulty asking parents to leave the room (2.0), teen not able to urinate (1.9) and physician visit time constraints (1.7). Barriers to screening need to be identified and addressed at both the provider and the health care system levels before universal CT screening can be accomplished. Although some of the barriers may be difficult to overcome, there was no barrier that was ranked more than 2 on a scale of 1-4. Furthermore, there is a common misconception that lack of time is the most significant barrier to screening in urgent care. This study, shows that providers ranked several other barriers higher than time. Interventions need to address provider and system level barriers in order to achieve universal CT screening which includes the urgent care setting.

Purpose Despite recommendations for annual screening of Chlamydia trachomatis (CT), the most commonly reported STI among adolescents, health care providers are falling short of meeting this goal. Since nearly two-thirds of teens who make contact with the health care system do so with an urgent care visit, the purpose of this study was to survey providers regarding their perceived barriers to screening adolescents for Chlamydia during urgent care visits. Methods As part of a larger randomized control study to increase CT screening in 14-18 year olds, pediatric providers at 5 intervention clinics were given an anonymous survey to assess barriers to screening adolescents. Surveys were hand delivered to providers with a self-addressed envelope. Providers were asked to rate the frequency of 7 common barriers using a 4-point Likert scale where 1 = very rarely to 4 = very frequently. Results 82 pediatric providers from 5 clinics completed the self-report questionnaire (95% response rate). The top 4 barriers included urine specimens not already obtained and in the room (mean 2.0), difficulty asking parents to leave the room (2.0), teen not able to urinate (1.9), and physician visit time constraints (1.7). Conclusions Barriers to screening need to be identified and addressed at both the provider and the health care system levels before universal CT screening can be accomplished. Although some of the barriers may be difficult to overcome, there was no barrier that was ranked more than 2 on a scale of 1-4. Furthermore, there is a common misconception that lack of time is the most significant barrier to screening in urgent care. This study shows that providers ranked several other barriers higher than time. Interventions need to address provider and system-level barriers in order to achieve universal CT screening which includes the urgent care setting.

Purpose As many teens utilize only urgent care visits each year, these visits are an important opportunity to screen for sexually transmitted infections (STIs). This study looked at whether aspects of doctor communication in the urgent care setting were associated with teens9 reported acceptability of sexual health discussion and urine STI testing. Methods In this cross-sectional study of 211 adolescents, ages 14-18, attending urgent care visits in two HMO pediatric clinics, participants completed a confidential 22-item self-administered survey post urgent care visit. Teens were asked to rate their provider9s communication on a 4-point Likert scale (1 = strongly disagree, 4 = strongly agree). Statements included: “The doctor knows how to talk to teens like me”; “The doctor explained that what we talked about alone would be confidential (that is kept between us).” Teens were also asked to rate their acceptability of talking about sexual health during an urgent care visit and providing a urine sample for STI testing in urgent care visits using the same rating scale. For analysis 1, 2 = unacceptable and 3, 4 = acceptable. Results The overall reported acceptability of sexual health discussion and urine STI testing was 82% and 79% respectively. Using logistic regression analysis, teens9 reported acceptability of sexual health discussion was significantly associated with doctors explaining confidentiality to teens (OR 2.80, 95% CI 1.21-6.49, p value = .02), and having a doctor who “knows how to talk to teens like me” (OR 7.47, CI 2.12-26.39, p value = .002). Teens9 reported acceptability of urine STI testing was also significantly associated with having a doctor who “knows how to talk to teens like me” (OR 4.35, CI 1.31-14.51, p value = .02) but was not significantly associated with the doctor9s explanation of confidentiality. These associations did not vary by gender. Conclusions Sexual history taking and collecting urine samples for testing are components of screening for STIs and were reported as acceptable to most teens in the urgent care setting. Aspects of doctor communication were associated with reported acceptability of sexual heath discussion and urine STI testing and therefore represent an area that can be targeted for provider education as pediatric practices expand STI screening to urgent care visits.

As many teens utilize only urgent care visits each year, these visits are an important opportunity to screen for sexually transmitted infections (STIs). This study looked at whether aspects of doctor communication in the urgent care setting were associated with teens’ reported acceptability of sexual health discussion and urine STI testing. In this cross-sectional study of 211 adolescents, ages 14-18, attending urgent care visits in two HMO pediatric clinics, participants completed a confidential 22-item self-administered survey post urgent care visit. Teens were asked to rate their provider’s communication on a 4-point Likert scale (1=strongly disagree, 4=strongly agree). Statements included: “The doctor knows how to talk to teens like me”; “The doctor explained that what we talked about alone would be confidential (that is kept between us)”. Teens were also asked to rate their acceptability of talking about sexual health during an urgent care visit and providing a urine sample for STI testing in urgent care visits using the same rating scale. For analysis 1,2=unacceptable and 3,4=acceptable. The overall reported acceptability of sexual health discussion and urine STI testing was 82% and 79% respectively. Using logistic regression analysis, teens’ reported acceptability of sexual health discussion was significantly associated with doctors explaining confidentiality to teens (OR 2.80, 95% CI 1.21-6.49, p value=0.02), and having a doctor who “knows how to talk to teens like me” (OR 7.47, CI 2.12-26.39, p value=0.002). Teens’ reported acceptability of urine STI testing was also significantly associated with having a doctor who “knows how to talk to teens like me” (OR 4.35, CI 1.31-14.51, p value=0.02) but was not significantly associated with the doctors explanation of confidentiality. These associations did not vary by gender. Sexual history taking and collecting urine samples for testing are components of screening for STIs and were reported as acceptable to most teens in the urgent care setting. Aspects of doctor communication were associated with reported acceptability of sexual heath discussion and urine STI testing, and therefore represent an area that can be targeted for provider education as pediatric practices expand STI screening to urgent care visits.

Purpose Previous research has shown that frequent alcohol and drug use is associated with sexual intercourse at an earlier age, frequency of sex, and unprotected sex in teens. The goal of the current study was to examine if teens who report having had sex are more likely to also report using alcohol/drugs than teens who have not had sex. Methods This study was part of a larger randomized control study to increase Chlamydia screening in adolescents. Two N. California Kaiser Permanente pediatric clinics participated in the current study. Self-report surveys were administered to all 14-18 year old adolescents seen for urgent care visits. The survey was anonymous, voluntary, and brief with 12 questions in total (age, gender, ethnicity, sexual activity). Questions regarding the teen9s sexual activity, lifetime and 30-day use of drugs and alcohol were worded similarly to those on the national Youth Risk Behavior Survey. A research assistant approached teens after their urgent care visit, received verbal consent, and gave the survey to the teen; the teen completed the survey, dropped in a 1-way collection box, and received a coupon for an ice cream as a thank you for participation. Human Use Committees approved this study. Results A total of 81 teens completed the survey (48 F and 33 M). The response rate was 85%. The sample was ethnically diverse and was composed of 31% Latino/a, 19% mixed ethnicity, 17% Asian, 15% Pacific Islander, and 11% Caucasian. The mean age was 15.5 years for males and 15.6 years for females. Self-reported sexual activity rates were 25% for females and 36% for males. Teens who report ever having sex are also more likely to report having used alcohol (lifetime and 30-day) than those who did not (p = .001). Teens who report ever having sex are also more likely to report having used drugs (lifetime and 30-day) than those who did not (p = .001). No significant gender differences were found. Conclusions Teens who reported using alcohol (30-day and lifetime) also reported being sexually active. This is consistent with prior research showing that adolescent risk-taking behaviors cluster together. Since we have found that nearly two-thirds of teens who visit their pediatric provider in any given year do so in the context of an urgent care visit, more research is needed to identify strategies to assess adolescent health risks in the context of urgent care visits.

Purpose Fewer than 1/2 of the sexually active young females are being screened annually for C. trachomatis (CT). To address barriers to screening, this study examined gender, ethnicity, and age disparities in adolescents who are screened for CT during regularly scheduled pediatric health checks. Methods This study was part of a larger randomized controlled trial to increase CT screening among sexually active teens (14-18 years old) during their regularly scheduled health checks in 10 pediatric clinics at a large Northern California health maintenance organization. Teens attending the 5 intervention clinics were asked to complete an anonymous survey at the end of their visit to determine site specific sexual activity rates in order to monitor CT screening rates. The survey gathered basic demographic information on the teens9 age, gender, and race/ethnicity. In addition, the survey asked: “Have you ever had sexual intercourse?” and “Did you have a test for STDs today?” Results There were 4,368 (49.5% female, 46.4% male and 4.1% did not report gender). The response rate was 74%. The mean age was 15.4 years for females and 15.3 for males. The ethnicity of the overall population was: Asians 26.7%; Blacks 13.2%; Latino19.5%; Caucasian 25.5%; Multi-ethnic/other14.3%. Most teens (83%) were asked about sexual activity; 19.7% had had sex (20.4% for females and 19.0% for males); 7% had an STD test on the day of their visit, 80.1% were not tested for an STD, and 12.5% did not know whether they were tested for an STD. There was no difference in STD screening across gender, ethnicity, or age; yet, there were significant ethnic, age and gender differences in queries about sexual activity. Blacks were significantly more likely to report being asked than Asians (89% vs 81%, p≤0.001) and Latinos (89% vs 81%, p≤0.001). Older teens were more likely to be asked than younger teens (p≤0.05); and female adolescents were more likely than males to be asked about sex (85% vs 83%, p=0.01). Conclusions Data revealed that there were no differences in who is screened for CT once the sexual history is obtained: however, there are disparities in sexual history taking. While it is encouraging that so many teens were asked about their sexual history, African Americans, older teens, and females were more likely to be asked about sexual history than their counterparts. Providers should be wary of introducing their own bias into screening protocols when universal screening of all sexually active adolescent females is recommended.

Purpose Obesity and lack of fitness are national health “emergencies” especially among our racial/ethnic minority youth. After-school programs may be one venue to address these health issues. Therefore, this study evaluated the association between after-school program participation and physical and sedentary activity, and to describe racial/ethnic differences in the level of after-school program participation. Methods 691 fifth grade students attending 12 schools in Vallejo, CA (an ethnically diverse community in CA) were given a survey for their parent/guardian to fill out and to mail back in a self-addressed stamped envelope. Small incentives were provided to classes with the highest response rate. The 29-question survey asked parents about their child's sedentary activities such as television watching (hours/day), and current participation in after-school programs. If they did not participate, parents were asked to give the reasons for non-participation: “too expensive”, “no transportation”, “don't know of any”, “don't need to”, or “other”. Results There were 415 respondents (60% response rate). Participants' race/ethnicity reflected that of the overall school district with African-American 22%, American-Indian 2%, Asian 5%, Filipino 25%, Latino/a 20%, Native Hawaiian/Pacific Islander 2%, White 18%, and Multi-ethnic/Other 6%. Only 20% of the 5th graders currently participated in some after-school program; however, those who participated, watched significantly less television than children who did not participate (2.5 hrs/day vs. 2.2 hrs. respectively, p=0.03). After-school participation did not differ by race/ethnicity. Barriers to after-school participation included: cost (n=39), not knowing of any program (n=32) and lack of transportation (n=29). Conclusions This is one of the first studies to examine after-school program participation of an ethnically diverse population of fifth graders. This study found that participation in after school programs is associated with fewer hours spent watching television (a risk factor for childhood overweight/obesity); yet at the same time, fewer than 20% of students participate in after school activities. Although this study did not find significant ethnic differences in after school program participation, more research is needed to examine ethnic differences in after school participation while also examining factors such as socio-economic status and language spoken at home. It would also be important to examine these differences across multiple ages/grades as after-school participation has been shown to decrease as children age.

Chlamydia trachomatis (CT) screening of sexually active girls (15–25) is a performance standard in the Health Plan Employer Data Information Set (HEDIS) as part of the National Committee for Quality Assurance (NCQA) to monitor the quality of care in managed care organizations. There has only been one published study to date examining the validity of the HEDIS measure to identify sexually active females. However, this study did not specifically report on the teen data. Because of the lack of data and concern about the HEDIS measure for teens (e.g., oral contraceptive prescription use for acne & reproductive counseling as a preventive service), we compared two different methods for calculating CT Screening rates among sexually active adolescent females: HEDIS specifications vs. teens’ self-report survey data.

Purpose Chlamydia trachomatis (CT) screening of sexually active girls is a performance standard in the Health Plan Employer Data Information Set (HEDIS) to monitor the quality of care in managed care organizations. There has only been one study examining the validity of the HEDIS measure to identify sexually active females and this study did not specifically report on teen data. Because of the lack of data and concern about the HEDIS measure for teens (e.g., oral contraceptive prescription use for acne & reproductive counseling as a preventive service), we compared two different methods for calculating CT screening rates among sexually active adolescent females: HEDIS vs. teens9 self-report survey data. Methods This study was implemented in 10 ambulatory pediatric departments of a large California HMO as part of a larger randomized control trial designed to increase CT screening rates among sexually active 14-18 yo adolescent females (Shafer et al. 2002) during regularly scheduled health maintenance visits (HMVs). CT screening rates are the number of CT tests done in the past 12 months for a given teen divided by the estimated number of sexually active teens. Laboratory (CT tests) and HMVs data was compiled for three years (2001-2003). Two different methods were used to estimate the number of sexually active teens. First, HEDIS administrative data was used (as specified with ICD-9 and CPT-4 codes). Second, anonymous surveys at each of the pediatric clinics were administered to calculate sexual activity rates. Results Significantly more teens were estimated to be sexually active using the HEDIS specifications compared to self-reported survey data. The mean number of teens identified as sexually active via HEDIS across the 3 years was 337 compared to 140 using the self-reported survey data, p=0.008. Improvements in CT screening rates in intervention clinics compared to controls were detected in both methodologies; however, the difference was not as robust with the HEDIS measure. Conclusions There are many advantages for using administrative data to estimate sexual activity used to calculate CT screening rates; however, more research is needed to examine its validity especially for the young adolescent population. This issue is extremely important, as clinicians monitor the effectiveness of their interventions to progress towards the goal of universal CT screening of sexually active females.

Purpose Age-specific rates of Chlamydia trachomatis (CT) remain highest among youth. Most CT control efforts focus on screening. However, little is known about the management of teens, especially follow-up retesting after the initial (+) CT. CDC Guidelines state that a “test of cure” is usually not necessary in uncomplicated infections, but retesting is recommended at 3-4 months and up to 1 year after treatment. The current study describes the management and timing of follow-up retesting of CT(+) teens by gender. Methods A consecutive sample of teens 14-19 years testing CT (+) between 5/01-12/03 at 5 Northern California HMO pediatric clinics was identified using a centralized laboratory database. The first (+)CT result during study dates was defined as the index infection. Medical charts were reviewed for management, including antibiotic treatment and timing of retesting for CT within one year after treatment. Results The sample consisted of 122 teens with a mean age 16.7 years (SD ± 1.1 yrs). Antibiotics were successfully prescribed for 118 (97%) teens. Safer sex counseling was provided for 96 (79%) teens. Providers advised partner notification and treatment in 63 (52%) cases. HIV and/or RPR screening was advised in 44 (36%) cases. (Table) More males than females had no CT retesting at all during the 12 months post-index infection (77% vs. 51%, p=0.018). Conclusions Most teens received appropriate antibiotics. In sharp contrast, much fewer received other follow-up care, with males faring more poorly than females with regard to retesting. Only 10% received CT retesting according to guidelines (i.e. from 3-12 months after treatment of index infection) and 22% were inappropriately retested within 3 weeks post-treatment (i.e. nonculture tests remain positive for up to 3 weeks post-treatment). The current study describes inappropriately timed retesting and highlights important “missed opportunities” to target this at-risk population with follow-up prevention interventions.

OBJECTIVE:To assess sexually active adolescents' attitudes toward 3 screening collection techniques for detection of Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis using first-void urine (FVU), self-collected vaginal swab specimens, and pelvic examination with clinician-collected endocervical swab specimens.DESIGN:Participants completed a preexamination health survey, provided FVU and self-collected vaginal swab samples, and had a pelvic examination with endocervical swab specimen collection. In a confidential postexamination interview, patients ranked the 3 screening techniques according to preference and responded to qualitative positive and negative descriptors to evaluate each technique.SETTING:San Francisco area health maintenance organization and university clinics.PARTICIPANTS:A convenience sample of 155 ethnically diverse females aged 12 to 21 years, who were sexually active and were to have a pelvic examination.MAIN OUTCOME MEASURES:Adolescents' preferences for and evaluations of 3 sexually transmitted disease screening techniques.RESULTS:Participants preferred the FVU test for sexually transmitted disease screening over the pelvic examination and the self-administered vaginal swab test (P<.001). These results were consistent when controlling for potentially mitigating experiences, including previous pelvic examination, tampon or condom use, and prior pregnancy. In evaluating what they liked and disliked about each of the 3 screening methods, participants described the FVU most positively, the pelvic examination most negatively, and the vaginal swab technique slightly less positively than the FVU.CONCLUSION:Most sexually active adolescents attending clinics for pelvic examination prefer to be screened for sexually transmitted diseases first by the FVU, second by the self-collected vaginal swab test, and last by the pelvic examination.