Sexually transmitted infections (STIs) and unplanned pregnancies are two common problems among adolescents and young adults. Approximately half of all new STIs occur in people between the ages of 15 and 24, even though this group makes up only 25% of those who are sexually active.1
Adolescents and young adults are considered more vulnerable to STIs for many reasons, including physiologic differences, inability to pay for healthcare services, limited access to age-appropriate care, and concerns about confidentiality.1 Besides the health risks associated with the diseases themselves, STIs can cause many secondary complications including cancer, transmission of HIV, problems with reproductive health, and fetal health problems in future pregnancies.2
Teen pregnancy rates are much higher in the U.S. than in other western industrialized nations, accounting for more than $9 billion in increased taxpayer costs each year.3 Although the detrimental effects of STIs and unplanned pregnancies on the teenage and young adult populations have been highly studied and publicized, many healthcare providers fail to address these problems with patients in these age groups.4
Multiple systematic reviews have been performed on the topic of STIs and unintended pregnancy, the majority of which showed the effectiveness of primary prevention on sexual health behaviors.5-8 Interventions varied greatly and included programs such as community-wide prevention campaigns, prison educational sessions, behavioral counseling in primary care settings and family planning clinics, and individual educational sessions.5-9
One systematic review showed that abstinence-plus interventions improved behavioral and/or biological outcomes of the participants without any increase in risk for the participants.5 Authors of one outlier study concluded that primary prevention efforts did not lead to sexual risk reduction, yet many of the study results included in the meta-analysis covered abstinence-only interventions, which could dramatically skew their conclusions.9 Several other systematic reviews showed that education combined with skills training (including behavioral counseling, proper use of contraception and sexual negotiation strategies) is more effective at positively affecting sexual health behaviors and outcomes than education alone, with little to no risk for the participants.6,7,8
The evidence that primary prevention has a positive impact on rates of STIs and unintended pregnancies in adolescents and young adults is apparent.5-8 Research clearly indicates that a multifaceted intervention including education and skills training is an effective approach.6-8 Because of the large amount of evidence (mostly level I evidence) that reports favorable outcomes, there is strong support for implementing primary prevention interventions for these populations. NPs and PAs can use these findings as support for practice and policy changes in a variety of settings. By implementing practice and policy changes that include the primary prevention of STIs and unintended pregnancies, patients would benefit from increased knowledge about sexual health behaviors and the potential negative outcomes of their choices. Our communities as a whole would also benefit from lower STI and unintended pregnancy rates.1
Quality Improvement Process
Project Design. This practice improvement project (PIP) was designed to change clinical practice in order to improve sexual health behaviors in a targeted population. Two separate institutional review boards deemed the project to be "not human subjects research," and no further approval was needed. The point of access included two family practice clinics located in rural South Carolina. Both practices are owned by a local community hospital system and serve people of all ages. The targeted population included all teenagers and young adults, ages 15 to 24, seen during the process improvement period at these two practices. The intended outcome for this project was to increase contraceptive use in the targeted patient population in order to prevent STIs and unwanted pregnancies.
The Precede/Proceed model was used as a guide to implement this program. During the first phase, the following four steps occurred: a social needs assessment, an epidemiologic assessment to identify behavioral and environmental factors contributing to STIs and pregnancy, an educational and ecological assessment, and an administrative and policy assessment.10 Throughout this process, providers were encouraged to help design and set goals for the program to increase buy-in and ownership of the improvement process.10 All four steps were completed prior to the implementation of the improvement process.
The second phase of the Precede/Proceed model was an implementation and policy assessment. During and after implementation, it was important to assess the extent to which the changes were adopted in the office as well as what effect the program had on the health and quality of life of the patients.10
Improvement Process. To begin the project, the participating providers and support staff underwent project training and were educated about the need for STI and pregnancy prevention education and skills training for the target population. The providers received educational materials and were reminded about support available for these patients, including free contraception at the local health department. During this session, providers helped brainstorm strategies for working the topic of STI/pregnancy prevention into routine visits.
After the training session, the process improvement project was initiated, and providers broached the subject of STI/pregnancy prevention at every visit for the target population. The nursing staff provided each patient with a standardized educational handout, and providers discussed the handout and answered any questions during the visit. If the teenager/young adult was interested and there was time during their visit, further education, skills training, prescriptions and referrals were provided. If there was not time in that visit, patients were encouraged to set up a follow-up visit to further discuss these topics.
After the improvement process was in place for 4 months, a survey period began. For 7 weeks, every 15- to 24-year-old seen in the clinic was asked to complete a survey about contraception use. The survey was created using questions from the National Survey of Family Growth. Patients received the survey from the front office staff at check-in and were asked to return the survey in a sealed envelope at checkout. The survey also asked patients if they had been seen in the office at any time during the last 4 months (the process improvement period). This allowed the surveys to be divided into two groups: patients who were provided with STI and pregnancy prevention education and patients who were last seen prior to the PIP. When the survey period ended, the survey results were compiled, and results from the two groups were compared.
Eighty-two surveys were collected from patients in the two participating family practice clinics, and the ages of the respondents ranged from 13 to 24. Twenty-seven (32.9%) respondents were men and 55 (67.1%) were women. The majority of respondents classified themselves as single (79.3%, n = 65), while 9.8% (n = 8) were married and 9.8% (n = 8) were single but living with a partner of the opposite sex. One respondent (1.2%) classified himself or herself as widowed or divorced. Of the 82 total respondents, 62.6% reported being sexually active. In the 13- to 17-year-old age range, 38.1% were sexually active; 80.0% of the 18- to 20-year-old respondents were sexually active. In the 21- to 24-year-old group, 100.0% were sexually active.
Among patients who were sexually active, reported ages of first sexual encounter ranged from 12 to 19, with the average being 15.6 years. Among respondents who were not sexually active, reasons for delaying sexual activity included: religion/morals, don't want to get pregnant, don't want to get STI, haven't found the right person, too young, don't want to, not part of life plan right now.
Of the respondents who answered the corresponding questions, 7.6% (6/79) had been diagnosed with an STI or HIV, 33.3% (18/54) had been pregnant (question marked as being for women only), and 4.1% (3/73) reported that they or their partner were currently trying to conceive.
Reported methods of contraception used by respondents included oral contraceptive pills, condoms, injectable hormones, pulling out, hormonal vaginal ring, rhythm method, hormonal implant, emergency contraception, hormonal patch, spermicide, and intrauterine device.
To determine the effectiveness of the project's improvement process, the results from the following survey questions were analyzed: "The last time you had intercourse, did you or your partner use any form of contraception, birth control or family planning?" and "How often would you say you use any form of birth control or family planning when you have sexual intercourse?" Of the 29 respondents who received education, 75.9% (n = 22) answered that contraception was used at their last sexual encounter. Of the 20 respondents who did not receive the education, 70.0% (n = 14) answered that contraception was used at their last encounter. In response to the second question, 62.1% (18/29) of those who received the education said they "always" use contraception, 13.8% (4/29) use contraception "most of the time," 20.7% (6/29) use contraception "sometimes," and 3.4% (1/29) "never" use contraception. Forty-five percent (9/20) of patients who did not receive the education reported that they "always" use contraception, 20.0% (4/20) use contraception "most of the time," 15.0% (3/20) use contraception "sometimes," and 20.0% (4/20) "never" use contraception.
In summary, 5.9% more of the patients seen during the PIP used contraception at their most recent encounter than patients not seen during the PIP, and 17.1% more of the patients who were seen during the PIP "always" used contraception than patients not seen during the PIP.
The results from this project indicate that patients who received education aimed at sexual risk reduction had better rates of contraception use than patients who did not receive any education. The results also indicate a further need for education aimed at the primary prevention of STIs and unwanted pregnancies in this population: 62.2% of respondents are sexually active, and many are not consistently using contraception. Similarly, many survey respondents indicated they had been diagnosed with an STI and/or had been pregnant at some point.
Limitations of this project may include the limited time frame used for the process improvement as well as the survey period. Because of the limited time frame, a relatively small sample size of survey respondents was used for data analysis. Appointments in these clinics are typically scheduled for only 15 minutes, so the time available for each visit may have limited the amount of education that could be provided. A possibility of self-report bias from the survey respondents also exists.
The participating providers recognized the need for increased education related to STI and pregnancy prevention, and they responded favorably to the idea of using an educational handout to save time during visits. The use of the standardized educational handout to start the conversation about STI and pregnancy prevention also ensured that all patients received the same basic information, no matter which provider they saw. Costs and training time for this project were minimal, therefore making it feasible for clinics of varying size and in a wide range of settings to implement similar practice improvement initiatives.
Healthcare providers can use the findings from the literature review and this PIP to support practice improvement initiatives aimed at reducing STIs and unplanned pregnancies in adolescents and young adults in a variety of settings. Further research specifically targeting primary care and PIPs with longer time frames could help strengthen the support for these types of initiatives. Further education in these practices could also be beneficial in helping to reduce rates of STIs and unwanted pregnancies, since many patients are not using contraception with every sexual encounter.
1. Centers for Disease Control and Prevention. STDs in adolescents and young adults. http://www.cdc.gov/std/stats11/adol.htm
2. HealthyPeople.gov. Sexually transmitted diseases. http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=37
3. Centers for Disease Control and Prevention. About teen Pregnancy. http://www.cdc.gov/TeenPregnancy/AboutTeenPreg.htm
4. Centers for Disease Control and Prevention. Sexually transmitted diseases guidelines, 2010. http://www.cdc.gov/std/treatment/2010/specialpops.htm#adolescents
5. Underhill K, et al. Abstinence-plus programs for HIV infection prevention in high-income countries. Cochrane Datab Syst Rev. 2008;(1):CD007006.
6. Shepherd J, et al. Interventions for encouraging sexual lifestyles and behaviours intended to prevent cervical cancer. Cochrane Datab Syst Rev. 2000;(2):CD001035.
7. Oringanje C, et al. Interventions for preventing unintended pregnancies among adolescents. Cochrane Datab Syst Rev. 2009;(4):CD005215.
8. Lin J, et al. Behavioral counseling to prevent sexually transmitted infections: a systematic review for the U.S. Preventive Services Task Force. 2008;149(7):497-508.
9. DiCenso A, et al. Interventions to reduce unintended pregnancies among adolescents: systematic review of randomised controlled trials. BMJ. 2002;324(7351):1426-1430.
10. Glanz K, et al. Health Behavior and Health Education: Theory, Research, and Practice. 4th ed. San Francisco, CA: Jossey-Bass; 2008.
Jessica Rivera is a family nurse practitioner at Medical Center Easly in Easly, S.C.