Adolescent Health: Sexually Transmitted Infections. By: Amina Hossain Alicia Yang Andrea Vera Zambrano Melissa Ip Marisela Chan Liu. Adolescent Health: STIs.
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Adolescent Health: Sexually Transmitted Infections
Andrea Vera Zambrano
Marisela Chan Liu
We decided to focus our project on “Sexually Transmitted Diseases” using the objective of Healthy People 2020, in relation to adolescents.
We found important to address the disparities that this group faces. As stated by Crosby & Danner (2008), “about 48% of nearly 19 million cases of STDs occurring annually in the United States are acquired by persons aged 15-24 years” (p. 311).
Factors such as peer influence, gender, socioeconomic status, health care access and substance abuse have been found to be influence(Champion & Collins, 2010, p. 739).
Teenagers see their peers as “role models” and may imitate their friends on what they do and how they act (Kim & Free, 2008, p. 89).
Gender also plays an important role. Females are more susceptible to serious and irreversible complications from STDs.
The complications may include infertility, pelvic inflammatory disease and/or ectopic pregnancy as a consequence of a sexually acquired infection.
Adolescents’ socioeconomic status may also impact their intimate relationship decisions. The poorer may engage for monetary gain, while the wealthier are reckless and uncaring.
Poverty may not only limit the amount and quality of education a teenager may receive about safe behaviors but also about resources available for him/her.
“Poverty and barriers to quality health care system have been correlated with higher rates of STI” (p. 740).
Lastly, it has been also reported that higher sexual risk behaviors are associated with alcohol and substance abuse among people between 15-24 years old (p. 739).
This type of substances can alter a person’s ability to judge and make rational decisions; placing adolescents are at higher risk to engage in risky sexual behaviors that leads to STD.
Despite the factual prevalence and increasing number of cases of adolescents infected with HIV, Chlamydia, gonorrhea, syphilis, etc.; concrete solutions have not yet been found.
Part of the problem is that many cases of STDs are not being reported to the Centers for Disease Control and Prevention (CDC) and therefore, go unnoticed and with no actions taken to avoid or prevent their further spread.
This can subsequently lead to a variety of problems; as have been reported by Healthy People 2020, “undiagnosed and untreated STDs cause at least 24,000 women in the United States each year to become infertile” (U.S. Department of Health and Human Service, 2012).
We will analyze five research articles that explore interventions and possible solutions to combat this health disparity affecting young people.
One is a study conducted by Crosby & Danner (2008), of which the purpose was to evaluate whether adolescents’ attitude about protecting themselves from STDs can help predict their vulnerability and actual status (whether they are infected or not) (p. 310).
Another study sought to evaluate the effectiveness of a community-based STD risk-reduction program in which the main goal was to motivate adolescents and provide them with knowledge about these diseases and how to prevent acquiring them (Jemmot, Jemmott, Fong & Morales, 2010, p. 720).
A third study done by Sznitman, Stanton, Vanable, Carey, Valois, Brown, DiClemente, Hennessy, Salazar &Romer (2011) examined the long-term effects of two interventions created to help reduce risky sexual behaviors among members of this age.
The fourth study describes health, psychosocial and economic aspects that must be taken into consideration when assessing or implementing an intervention with the objective of promoting healthy sexual behaviors among adolescents (Champion & Collins, 2010, p. 739).
Finally, a research done by Kim & Free (2008) examines the efficacy of a peer-led approach used to educate adolescents about sexual health (p. 89).
As a group, we chose five articles that examined the issue of suggested approaches on how to effectively change adolescents’ behaviors preventing the acquirement of sexually transmitted infections. One study explored the teenager’s attitudes towards protecting themselves against STDs (Crosby & Danner, 2008). Adolescents were asked to complete a self-reported measure that required them to rate from 5 options ranging from “strongly disagree” to “strongly agree” to the statement, “It would be a big hassle to completely protect myself from getting an STD.”
Results showed that the adolescents who considered protecting themselves from STDs to be a hassle had an increased chance of testing positive for an STD in early adulthood (Crosby & Danner, 2008). These results also indicated that adolescents’ attitudes about STD protection are carried over beyond adolescence ages, therefore, emphasizing the importance of intervention during adolescent years. In order to change adolescents’ risky behaviors, we need to change their attitudes towards protecting themselves.
Another reason why the adolescent population needs intervention regarding STD prevention is shown in the Jemmott III, Jemmott, Fong, and Morales (2010) research report. Authors stated that “in the United States, although youths aged 15-24 constitute only 25% of the sexually active population, they account for about half of new STD cases (Jemmott et al., 2010). This clear disparity calls for special attention because the adolescent population is particularly a vulnerable population when it relates to STDs. Programs that need to be developed have to appeal and mold to this particular population. One study looks at modifying an existing program called Project Safe (Champion & Collins, 2010).
The study aims to change the intervention already placed in Project Safe and adapts these interventions to an at risk population (African- and Mexican- American) within the adolescent group. Culturally relevant factors that were taken into consideration were, for example, understanding that females in African- and Mexican American culture were not likely say “no” to unsafe sex for risk of losing their partner, or “the threat of violence or the loss of a partner may be worse than the possible contraction of another STI” (Champion & Collins, 2010).
Also, pretest examination revealed that this population needed special intervention and education regarding the continuous contraceptive use, where and how to get tested for STDs, difference between pap smear and HPV and results implications, asking men to use condoms, substance use during sexual encounters, pregnancy preventions was not supported by some partners, concerns about break through-bleeding, and lack of understanding about dyspareunia. After all these factors were considered, a program was set to address all this concerns through counseling, workshops, and support groups. Findings showed desirable outcomes such as fewer barriers to medical care, higher contraceptive use, and lower sexual risk behaviors, substance use, abuse, unwanted pregnancies and STI rates than other studies (Champion & Collins, 2010).
The previous study aims to mold its interventions to a particular at risk adolescent population while in another report by Sznitman et. al, “Long-term Effects of Community-Based STI Screening and Mass Media HIV Prevention Messages on Sexual Risk behaviors of African American Adolescents,” tries to appeal to the adolescent population by reaching them through television and radio ads. In this study, mini-dramas in popular channels among African American adolescents depicting “adolescents resolving dilemmas regarding sexual risk behavior and modeling appropriate responses to such problems” in a culturally sensitive manner (Sznitman et. al, 2011).
Participants were composed of African American STI-positive adolescents. The control group received risk reduction counseling while the intervention group had counseling as well as exposure to TV and radio ads modeling STD preventative behaviors. The effects observed from the study were that STI- positive adolescents that were not exposed to the media campaign reduced their number of sex partners and the probability of unprotected sex in the first 6 months but returned to their previous risk taking levels equal or higher to the recruitment period (Sznitman et. al, 2011).
The adolescents who were exposed to the ads showed steady reductions in unprotected sex for at least 18 months. These results are crucial for the community nurse to know in order to establish a program that will produce long-term change in high risk behaviors in adolescents since it was proven that counseling only had an effect on reducing sexual high risk behaviors in adolescents only for the first 6 months.
Another issue that will aid the community health nurse while creating an effective program to reach adolescents regarding to STDs is whether or not the peer-led approach in adolescent sexual health education have been proven successful in influencing teenagers to reduce high risk sexual behaviors leading to STDs. Kim & Free found that in 13 articles assessing the success of peer-led groups, none of the studies showed consistent condom use, another reported reduction in testing positive for Chlamydia, but another study found no effect on the incidence for STD after peer-led sexual education was given (2008).
Another study demonstrated an increase in the odds that female participants have never had sex, while there was no effect on males. However, 10 studies reported positive effects in knowledge, intentions, and attitudes (Kim & Free, 2008). To sum up, there is no clear evidence that peer-led sex education is successful; on the other hand, this does not mean that this approach should not be p used. The aim of peer-led education is to create an environment where adolescents feel they are understood and accepted in a group of cohorts. Kim & Free suggest further utilization of peer-led sex educational groups with better designs.
As researchers, community health nurses have the role of investigating what has worked in the community setting before they can implement any interventions to increase the chance of successful outcomes. One study examines the efficacy of a program called “Be Proud! Be Responsible!” delivered in community-based organizations. “Be Proud! Be Responsible!” was a program that aimed to give adolescents the skill, knowledge, and motivation necessary to decrease their risk for STDs (Jemmott et al., 2010). This program has been proven to be efficacious but its effects in the community have not yet been studied.
Adolescents who received this intervention in the community setting reported using condoms consistently and this rate did not vary throughout the 3 follow-up assessments of 3-, 6-, and 12-months compared to groups who received health promotion information. This study demonstrated that programs effective in other areas of health care can be easily translated to the community. This is especially important when health care promotion is mostly provided in the community as a preventative measure for the relatively healthy population.
The adolescent population and the incidence of STDs is an issue that needs to be stressed. The alarming statistics indicate they are in need of interventions to decrease the rate of STD cases. The analysis of this issue suggests that attitudes ought to be assessed and a positive change of attitudes can prevent adolescents’ chance of contracting an STD in early adulthood. Also, adjusting programs to adolescents’ cultural and molding interventions into something that is familiar to them can aid health care providers to reach and influence adolescents’ attitudes and behaviors. Furthermore, health care providers have the responsibility to investigate what programs are effective to reduce high risk sexual behaviors in adolescents, and what approaches need adjustments, so mistakes are not repeated.
Because adolescents are at such high risk for contracting STIs it is important to implement appropriate interventions to reduce this risk. One recommended solution already discussed by Champion & Collins (2010) would be educational classes focused on health promotion. By incorporating STI prevention strategies into the students’ curriculum adolescents can gain additional knowledge to help keep them protected. Including information such as how to properly use a condom, discussing the differences between STIs, and identifying ways to protect oneself would be the key issues taught. If adolescents become more knowledgeable and confident in their skills they can become more proactive in reducing their risk of STIs.
According to Crosby & Danner (2008) a study found that adolescents who reported that they agree with the statement, “it would be a big hassle to completely protect yourself from getting an STD” were more likely to acquire an STI. The implications suggested that adolescent’s perception and attitudes towards safe sex could influence their chances of getting an STI. Therefore, with this school program, an area of focus would be to improve attitudes towards safer sex. The program would teach easy and practical ways of having safe sex.
It would aim to improve attitudes towards using condoms so that adolescents did not consider these healthy behaviors as a “hassle.” Also, Sznitman (2011) confirms that by adjusting to the adolescence culture, it can aid to get the message through, thus including fun activities that interest adolescents will help improve attitudes towards healthy sexual behaviors. The use of games and group activities where adolescents interact with one another can be a great attempt at raising awareness. Role-playing in groups is a great way to get critical information across in a fun and educational way.
At this age, adolescents are highly influenced by their peers; therefore incorporating teaching in an environment that involves their peers can help improve attitudes. Although there has been no recent evidence regarding the advantages of peer-led education interventions it is still important to consider its effects. Assigning adolescents their own mentor or peer to help guide them and support them would be a great approach to reaching teens.
The role of the community health nurse in this situation would definitely be the educator. It would be his/her duty to put together important health information to present to adolescents. Using all available resources to gather as much data as possible would be essential. For instance, making sure to have diagrams of the male and female genitourinary tract to properly explain how STIs affect the body. Also having access to video clips that show how HIV is spread and demonstrating how to properly use condoms.
The CHN can also provide adolescents with surveys to figure out their preferences to learning. For example, if most adolescents’ state they learn best visually it would be best to provide information that includes pictures. If others prefer a more hands on approach, then it would best to teach proper condom use where adolescents can practice on a mannequin and demonstrate their skills.
Another recommendation would be to offer couples counseling for adolescents engaged in sexual relationships. This “counseling session” could help identify misconceptions as well as help partners feel confident enough to make the right choices. For example in the Project Safe program African and Mexican American adolescents would say “no” to safe sex if it meant not having to lose their partner (Champion & Collins, 2010). Also the threat of violence from a partner that could occur if they did say “no” was another factor hindering these adolescents from making safer sexual decisions.
During the “couples counseling” adolescents can come with their sexual partner and openly discuss their concerns and questions to a qualified educator such as a nurse. During this interaction, the nurse can also choose to meet one-on-one with girls who report feeling afraid of saying “no” to their partners. It would be essential for the nurse to explain the possible consequences and long-term effects unprotected sex may have on their life. The nurse can also help the couple come up with solutions that are easy to use in order to prevent STIs. Acting as a mediator and instilling knowledge into the youth would be the aim of this intervention.
The role of the CHN in this case would be to ensure that he or she is fostering an open and welcoming environment. Adolescents need to feel safe and assured that this personal information will not be disclosed to others, as this will hinder their attempts at receiving care. The CHN has to display honesty and will have to gain the trust of these adolescents in order to have them open up. The nurse will also have the responsibility of keeping in mind how cultural differences among adolescents impact their access to healthcare. By becoming culturally competent and understanding the stage of development adolescents are going through, the nurse can provide effective care and possibly help reduce the incidence of STIs among this vulnerable population.
The AIDS Risk Reduction Model was an adaptation from Project Safe, an intervention that was designated in the Centers for Disease Control (CDC) as an effective intervention for the prevention of STI/HIV among adolescent minority women (Champion & Collins, 2010). In many cultures, there is the idea of “machismo”, in which the male has the power in the relationships. The woman may choose to participate in sexual intercourse due to her fears of the risk of losing her partner or the possibility of being subject to physical abuse. Because this population may be subject to poverty, self-esteem deficits, or substance abuse issues, as well as other situation factors like job skills or support systems, these women may view the threat of losing a partner or risk of abuse as greater than contracting STIs/HIV (Champion & Collins, 2010).
To appeal to the African-and-Mexican-American culture’s value of childbearing and children, the emphasis of the possible loss of fertility, harm to the fetus, and emotional or physical hardships to the existing children of their mother contracts an STI or AIDS can remind to the adolescents of the benefits of reducing risky sexual behaviors. A good recommendation for effective interventions would be to encourage adolescents to use these resources would be to offer free access to resources such as STI testing and treatments, pregnancy testing, contraceptives, and physical examinations. Project Safe is an example of this behavioral intervention in which women have access to workshop session, individual counseling, and support group sessions (Champion & Collins, 2010).
The role of the community health nurse would be to act as an educator and a care provider. She would have to stress the use of contraceptives and counsel the groups to reconsider their choice of partners and to learn skills that would help meet new supportive partners with whom they can have a healthy relationship with as a couple and as a family. Support groups and workshop groups are to be strictly confidential and voluntary.
The groups can be designed to be small and to consist of the same members so that participants would be more comfortable while discussing sensitive topics and other personal information. Topics can include anything from relationships, parenting, lifestyle changes, decision-making, abuse, and recognition of STI symptoms so that proper and timely interventions can be initiated.
In addition to community-based STI testing and interventions, another program that can be initiated is a media program in which television and HIV-prevention messages can be delivered to promote safe sex practices in the adolescent population. Condom use and messages to delay sexual intimacy with new partners can be promoted in these media campaigns. According to a study conducted by Sznitman et. al (2011), culturally and developmentally sensitive mass media messages can potentially promote a reduction in risky sexual behaviors.
These messages can be presented in various ways such as mini-series dramas in which the main characters resolve dilemmas regarding sexual behaviors and also act upon appropriate responses to these problems. The uses of modeling and dramas have shown to be more effective in changing behaviors than didactic public health messages (Sznitman et. al, 2011).
The role of the community health nurse in this situation would also be as an educator. STI knowledge would increase, which would hopefully lead to a decrease in risky sexual practices such as unprotected sex. Over time, these messages can potentially reach more of the community than community-based STI testing or standard treatment of care and counseling. Although there may not be any face-to-face interactions, adolescents may still be able to learn and make better choices that will improve their health and lifestyles.
To conclude, the incidence and prevalence of sexual transmitted diseases/infections among adolescents are issues that need to be addressed with great intensity in this country, and community health nurses can help to make a difference through innovative educational efforts at prevention and management of these diseases. With the focus on empowering youths to engage in safer sexual practices through primary, secondary and tertiary preventive educational measures and recognizing the lifelong and devastating effects these diseases may have on their lives, it is our belief that the problem can not only be drastically reduced from pandemic proportions, but indeed eradicated.
Champion, J., & Collins, J. (2010). The Path to Intervention: Community Partnerships and Development of a Cognitive Behavioral Intervention for Ethnic Minority Adolescent Females. Mental Health Nursing, 31, 739-747
Crosby, R., & Danner, F. (2008). Adolescents' sexually transmitted disease protective attitudes predict sexually transmitted disease acquisition in early adulthood. Journal Of School Health, 78(6), 310-313.
Jemmott, J., Jemmott, L., Fong, G., & Morales, K. (2010). Effectiveness of an HIV/STD risk-reduction intervention for adolescents when implemented by community-based organizations: a cluster-randomized controlled trial. American Journal Of Public Health, 100(4), 720-726.
Kim, C., & Free, C. (2008). Recent Evaluations of the Peer-Led Approach In Adolescent Sexual Health Education: A Systematic Review. International Family Planning Perspectives, 34, 89-96Kim, C., & Free, C. (2008). Recent evaluations of the peer-led approach in adolescent sexual health education: a systematic review. International Family Planning Perspectives, 34(2), 89-96.
Sznitman, S., Stanton, B., Vanable, P., Carey, M., Valois, R., Brown, L., & ... Romer, D. (2011). Long Term Effects of Community-Based STI Screening and Mass Media HIV Prevention Messages on Sexual Risk Behaviors of African American Adolescents. AIDS & Behavior, 15(8), 1755-1763.
U.S. Department of Health and Human Service (2012, September 06). 2020 Topic & Objectives: Adolescent Health. Healthy People 2020 Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=2