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Adolescent Reproductive Health Data. Objectives. By the end of this presentation, participants will be able to: Discuss trends in adolescent sexuality and reproductive health. Characterize patterns in adolescent contraceptive use.

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objectives
Objectives
  • By the end of this presentation, participants will be able to:
    • Discuss trends in adolescent sexuality and reproductive health.
    • Characterize patterns in adolescent contraceptive use.
    • Assess study and data quality in response to “Practice-Based Learning and Improvement” core competency.
the growing diversity of the adolescent population
The Growing Diversity of the Adolescent Population
  • Most minority populations are growing faster than white populations. By 2050, it is projected that:
    • Percentage of adolescent non-Hispanic whites will fall from 75.7% in 1990 to 52.7%
    • Non-Hispanic blacks will increase from 11.8% to 15%.
    • Asians will increase 3% to 10%.
    • Hispanics* will increase from 9% to 21.1%.
    • Indigenous groups will remain constant at about 1%.
    • Asian/Pacific Islanders, though small in number, are growing at the fastest rate.
    • The American Indian/Alaska Native population is projected to remain largely unchanged.
prevalence of gay lesbian bisexual and youth 2005 vermont yrbs
Prevalence of Gay, Lesbian, Bisexual, and Youth: 2005 Vermont YRBS
  • Of 8,636 9th to 12th graders:
    • 1% of students described themselves gay or lesbian
    • 3% described themselves as bisexual
    • 3% are not sure
    • 2% reported having had same-sex intercourse
adolescents and insurance
Adolescents and Insurance
  • 3.3 million (1 in 8) adolescents ages 12-17 lack health insurance
  • 8 million (1 in 4) youths ages 18-24 are uninsured
    • The risk of being uninsured doubles when a teen turns 19
u s children home demographics 2004
U.S. Children: Home Demographics, 2004
  • 33% live with families where no parent has full-time, year-round employment
  • 31% live in single-parent households
  • 18% live in poverty
  • 21% of 18-24 year olds live in poverty
u s teenagers education and employment
U.S. Teenagers:Education and Employment
  • In 2005, of U.S. 8th graders:
    • 32% scored below basic math level
    • 29% scored below basic reading level
  • In 2004:
    • 9% did not attend school and did not work
    • 15% ages 18-24 did not attend school, did not work, and had only a high school degree
adolescent sexual experience nsfg 2002
Adolescent Sexual ExperienceNSFG 2002

Percent of males and females ages 15-19 who have ever had sexual intercourse

slide12

Percent of High School Students Who Have Ever Had Sexual Intercourse, 2005 YRBS

After declining in the 1990s, sexual experience appears to be leveling out.

percentage of hs students who have had sexual intercourse by race and grade 2005 yrbs
Percentage of HS Students Who Have Had Sexual Intercourse By Race and Grade, 2005 YRBS

9th 10th 11th 12th

W B H O

male adolescents and sexual experience nsfg 2002
Male Adolescents and Sexual Experience, NSFG 2002

Percentage of Men Who Have Had Intercourse

Ages

percentage of males and females ages 15 19 reporting ever having had oral sex 2002 nsfg
Percentage of Males and Females Ages 15-19 Reporting Ever Having Had Oral Sex: 2002 NSFG

*With partner of the opposite sex

female and male contraceptive use at last intercourse nsfg 2002
Female and Male Contraceptive Use at Last Intercourse,NSFG 2002

Other

7%

No Method

9%

Hormonal

Only

13%

Condom Only

47%

Dual Use

30%

Female

Male

female contraceptive use at first intercourse by year of first premarital intercourse n sfg 2002
Female Contraceptive Use at First Intercourse by Year of First Premarital Intercourse,NSFG, 2002
scope of sexually transmitted infections
Scope of Sexually Transmitted Infections
  • 18.9 million new cases of STIs each year
    • half of which occur in people ages 15-24
    • Most are asymptomatic and remain undiagnosed
  • By age 25, at least one in two sexually active people will have contracted an STI
  • Economic costs of treatment ~ $6.5 billion/ year
gonorrhea rates ages 15 19 1996 2006
Gonorrhea Rates, Ages 15-19 1996-2006

Rate (per 100,000 population)

declining teenage pregnancy rates
Declining Teenage Pregnancy Rates

Guttmacher Institute, 2005

disparities persist between racial minorities and whites
Disparities Persist Between Racial Minorities and Whites

Pregnancies per 1,000 women aged 15-19, 2002

pregnancy outcomes for teenagers 15 19 years by race and hispanic origin 1990 and 2002
Pregnancy Outcomes for Teenagers 15-19 Years by Race and Hispanic Origin, 1990 and 2002

Rates per 1,000 women

223.8

134.2

169.1

131.5

116.3

98.8

75.4

65.0

Hispanic

All Races

White

Black

americans opinions regarding sexuality education
Americans Opinions Regarding Sexuality Education

Public opinion

Guttmacher Institute, 2004

abstinence only education programs evaluated
Abstinence-Only Education Programs Evaluated
  • Few studies on abstinence-only programs
  • Evaluation of four federally funded programs found:
    • Slight improvements in attitudes regarding abstinence
    • Ineffective at improving communication with parents or intentions to remain abstinent
  • Majority of other studies had methodological limitations
    • Measuring short-term behaviors
    • Small sample sizes
the content of federally funded abstinence only programs
The Content of Federally Funded Abstinence-Only Programs
  • 80% of curricula contain false, misleading, or distorted information, including:
    • False information about effectiveness of contraception
    • False information about the risks of abortion
    • Blur religion and science
    • Treat gender stereotypes as scientific facts
    • Contain other scientific errors
virginity pledge data
Virginity Pledge Data
  • Pledgers:
    • Delayed onset of intercourse for up to 18 months (not until marriage)
    • 1/3 less likely to use contraception at eventual intercourse
    • Had same STIs rates as non-pledgers
    • 88% had intercourse before marriage
  • Pledge neither significantly decreased nor increased the chances of pregnancy
follow up virginity pledge data
Follow-Up Virginity Pledge Data
  • Pledgers vs. Non-pledgers: Sexual Debut
    • Pledgers had sexual intercourse later
    • 61% of pledgers and 79% of inconsistent pledgers had sex before marriage
  • Pledgers vs. Non-pledgers: Condom Use
    • Less likely to use condoms at most recent intercourse
  • Pledgers and STI Rates:
    • Did not differ from non-pledgers
    • Were less aware of STI status
  • Pledgers and Oral and Anal Sex:
    • More likely to have oral/anal sex but no vaginal sex
comprehensive sex education
Comprehensive Sex Education
  • Review of 28 well designed experimental studies found most programs do not adversely affect
    • Initiation or frequency of sexual activity
    • Number of partners
  • Many programs shown to:
    • Significantly improve condom use and other contraceptive methods
institute of medicine s findings
Institute of Medicine’s Findings
  • IOM study investigated the ability of sexuality education programs to prevent STIs, including HIV.
  • Findings included:
    • Comprehensive sexuality education programs can be effective in reducing high-risk behavior and do not increase sexual activity.
    • There is insufficient evidence to support abstinence-only-until-marriage programs.
slide46
Understanding the Data:

Epidemiology 101

the practice based learning and improvement core competency
The “PRACTICE-BASED LEARNING AND IMPROVEMENT” Core Competency
  • Residents must be able to:
    • Investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices
    • Analyze practice experience and perform practice-based improvement activities using a systematic methodology
    • Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems
residents must be able to
Residents must be able to:
  • Obtain and use information about their own population of patients and the larger population from which their patients are drawn
  • Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness
  • Use information technology to manage information, access online medical information, and support their own education
  • Facilitate the learning of students and other healthcare professionals
study design
Study Design
  • Randomized Controlled Study
    • There are two groups: a treatment and control group
      • The treatment group receives the treatment under investigation, and the control group receives either no treatment or some standard default treatment
    • Patients are randomly assigned to all groups
    • Advantages
      • Assigning patients at

random reduces risk

of bias and increases the

probability that differences

between groups can be attributed

to the treatment

  • Disadvantages
    • Study takes a long time to complete
    • Researchers need to recruit two study populations: treatment and control
    • Costly
study design1
Study Design
  • Cohort Studies
    • Patients who presently have a certain condition and/or receive a particular treatment are followed over time and compared with another group who are not affected by the condition.
    • Advantages
      • More flexible re: ethical considerations
      • Valuable for studying diseases that take years to manifest
  • Disadvantages
    • Not as reliable
    • All variables not controlled
    • Can take a long time—have to wait until conditions of interest develop
study design2
Study Design
  • Prospective Cohort Study
    • Identifies the original population at the beginning of the study
    • Accompanies subjects concurrently until disease develops or does not develop
  • Retrospective Cohort Study
    • Use historical data to telescope the frame of calendar time for the study and obtain their results sooner
study design3
Study Design
  • Case Control Studies
    • Patients who already have a certain condition are compared with patients who do not
    • Advantages
      • Can be done quickly
      • Researchers do not

use special methods

  • Disadvantages
    • Less reliable than either randomized controlled studies or cohort studies
    • No control groups
    • Issues of association vs. causation
relative risk
Relative Risk
  • Relative Risk =
    • Risk of developing STI in exposed population

Risk of developing STI in non-exposed population

Incidence Rates

of Disease

Disease Develops

Disease Does Not Develop

Totals

__a__

a + b

__c__

c + d

relative risk what does it mean
Relative Risk: What Does It Mean?
  • If RR = 1
    • No evidence exists for any increased risk in exposed individuals or for any association of the disease with the exposure.
  • If RR is greater than 1
    • The risk in the exposed person is greater than the risk in the non-exposed person.
  • If the RR is less than 1
    • The risk in the exposed person is less than the risk in the non-exposed person.
odds ratio
Odds Ratio
  • Odds Ratio in a Cohort Study
    • Probability that exposed person develops STI

Probability that non-exposed person develops STI

Develops Does Not

Disease Develop Disease

Exposed

Not

Exposed

odds ratio1
Odds Ratio
  • Odds Ratio in a Case-Control Study
    • Odds that a case was exposed

Odds that a control was exposed

Cases Controls

(With Disease) (Without Disease)

History

Of

Exposure

No History

Of Exposure

odds ratio what does it mean
Odds Ratio: What Does It Mean?
  • If exposure is not related to the disease, the OR = 1.0
  • If exposure is positively related to the disease, the OR > 1.0
  • If exposure is negatively related to the disease, the OR < 1.0
condom use and relative risk and odds ratio
Condom Use and Relative Risk and Odds Ratio
  • If condom users have = risk for STI as non-condom users, the RR or OR would = 1.
  • If the RR and OR < 1.0 -> association is “protective”
    • Condom users had a lower risk of STIs
  • If the RR or OR >1.0 -> “harmful” effect
    • Condom users had a higher risk of STI than non-users
statistical significance
Statistical Significance
  • Term refers to the likelihood that the observed associations were due to chance alone.
  • Tests of significance are often reported using p-values or confidence intervals.
  • A p-value of 0.05 is often used as a cutoff point for statistical significance.
  • A p-value of less than 0.05 means that the likelihood that the observed association is due to chance alone is less than 5%.
confidence interval ci
Confidence Interval (CI)
  • Quantifies the uncertainty in measurement
  • Usually reported as 95% CI
    • Range of values within we can be 95% sure that the true value for the whole population lies
  • Consists of values of the RR or OR consistent with the data a particular level of confidence
  • An interval that includes 1.0 is not statistically significant because it is consistent with an RR=1.0 (no effect)
provider resources adolescent reproductive healthcare
Provider Resources: Adolescent Reproductive Healthcare

Resources:

  • www.prch.org- Physicians for Reproductive Choice and Health
  • www.aap.org - The American Academy of Pediatrics
  • www.acog.org - The American College of Obstetricians and Gynecologists
  • www.adolescenthealth.org- The Society for Adolescent Medicine
  • http://www.aclu.org/reproductiverights/- The Reproductive Freedom Project of the American Civil Liberties Union
  • www.advocatesforyouth.org – Advocates for Youth
  • www.guttmacher.org – Guttmacher Institute
  • www.cahl.org/ - Center for Adolescent Health and the Law
  • www.gynob.emory.edu - The Jane Fonda Center of Emory University
  • www.siecus.org - The Sexuality Information and Education Council of the United States
  • www.arhp.org - The Association of Reproductive Health Professionals
provider resources adolescent reproductive health care cont
Provider Resources: Adolescent Reproductive Health Care, Cont.
  • PRCH’s Minors’ Access to Confidential Reproductive Healthcare Cards and Emergency Contraception: A Practitioner’s Guide
  • ARHP Reproductive Health Model Curriculum
  • AMA Guidelines for Adolescent Preventive Services (GAPS)
  • The American College of Obstetricians and Gynecologists:
    • Confidentiality in Adolescent Health Care
    • Primary and Preventive Health Care for Female Adolescents
    • Tool Kit for Teen Care—available at:
      • http://www.acog.org/bookstore/Tool_Kit_for_Teen_Care_P348C84.cfm
  • For emergency contraception, call 1-888-NOT-2-LATE
provider resources adolescent reproductive healthcare c ont
Provider Resources: Adolescent Reproductive Healthcare, cont.
  • Centers for Disease Control and Prevention. Sexually Transmitted Diseases Treatment Guidelines 2002: www.cdc.gov/std/treatment/rr5106.pdf
  • Building Emergency Contraception Awareness Among Adolescents, A ToolKit, Academy for Educational Development: http://www.aed.org/Publications/upload/ECtoolkit3283.pdf
  • Henry J. Kaiser Family Foundation: public health policy, broken down by area (e.g., reproductive, state-specific, Medicaid, HIV/AIDS): www.kff.org.
  • The Young Men’s Clinic of Columbia University: http://www.cumc.columbia.edu/dept/sph/popfam/
  • Mount Sinai Adolescent Health Center: http://www.mountsinai.org/msh/msh_program.jsp?url=clinical_services/ahc.htm