Volume 33, Number 2, March/April 2001
Providers Who See Sexually Active Teenagers Often Fail To Test Them for Chlamydia
Although nearly three-quarters of primary care providers regularly take a sexual history from female adolescents during annual and new visits, only about half routinely screen those who are sexually active for chlamydia.1 Women practitioners are far more likely than their male counterparts both to take a sexual history and to routinely test sexually active young women for chlamydia. Providers who are comfortable talking about sex have a greater likelihood than those who are not of taking a sexual history. Additionally, practitioners who regularly discuss with adolescents strategies for preventing sexually transmitted diseases (STDs) are more likely than those who do not to test sexually active females for chlamydia.
From July to November 1998, a total of 576 physicians (including family practitioners, internists, obstetrician-gynecologists and pediatricians), nurse practitioners and physician assistants who provide any gynecologic care to adolescents aged 13-19 and who practice in Colorado responded to an anonymous, self- administered mail survey. The questionnaire requested demographic data and information on sexual history-taking, prevention activities and screening practices during annual and new visits. The survey also asked about knowledge of chlamydia. The majority of respondents were physicians (66%) and were women (58%). Sixty-one percent of physician assistants, 59% of nurse practitioners and 44% of physicians said that they see six or more adolescent females per week.
Using a five-point Likert scale, respondents indicated how frequently they take a sexual history from a female patient and how often they test sexually active teenagers for chlamydia. While 72% of respondents reported that they regularly (i.e., always or often) take a sexual history, only 54% said that they regularly test sexually active female adolescents for chlamydia. Providers most likely to test for chlamydia were those who reported that they routinely take a sexual history.
In univariate analyses, women pro-viders were more likely than men to report both regularly taking a sexual history (85% vs. 53%) and regularly testing sexually active teenagers for chlamydia (64% vs. 39%). Other variables associated with these outcomes were the provider's profession; whether the practitioner is knowledgeable about adolescent females' risk of chlamydia, initiates discussion of STDs, is comfortable discussing sex and regularly talks about STD prevention; and whether 5% or more of the provider's patients are on Medicaid.
Because the provider's gender was strongly associated with both outcomes, the researchers stratified responses regarding sexual history-taking, risk assessment and chlamydia testing by gender. The results show that larger proportions of women than men are comfortable discussing sex with their patients (93% vs. 73%) and initiate discussions about STDs (80% vs. 69%). Women also are more likely than men to regularly discuss a range of preventive behaviors and to regularly test for chlamydia on the basis of a variety of findings from their discussion with the patient and their examination of her.
The researchers used variables that were significant in the univariate analyses to construct multiple logistic regression models assessing factors in providers' sexual history-taking and testing practices. In these analyses, women were more likely than men to routinely take a sexual history from adolescent females (odds ratio, 5.5). Compared with physicians, physician assistants were less likely to take a sexual history (0.4). Obstetrician-gynecologists were more likely than physicians in family practice to routinely take a sexual history (4.0), while internists were less likely to do so (0.4). Furthermore, pro-viders who reported being comfortable talking about sex were more likely than those who did not to take a sexual history (4.9), as were those who said they initiate conversations about STDs (2.7). Finally, providers with a Medicaid pop- ulation of 5% or more were more likely than those with a lower proportion of Medicaid clients to report taking a sexual history (2.0).
Women were also more likely than men to regularly screen those who are sexually active for chlamydia (2.8). Providers who reported routinely discussing prevention strategies with female adolescents were more likely than those who did not to test sexually active patients for chlamydia (2.1). Similarly, practitioners who said that they regularly discuss limiting the number of sex partners as a part of their prevention message were more likely than those who did not to test for chlamydia (2.4). Although providers' age was not a significant factor in the univariate analyses, the investigators considered it an important variable and included it in the regression analyses. Interestingly, they found that the older providers were, the more likely they became to report testing sexually active females for chlamydia (1.1).
Although the Centers for Disease Control and Prevention (CDC) recommends that all sexually active adolescents be regularly screened for chlamydia, only about half of Colorado's primary care providers are doing so. Furthermore, the researchers suggest that their findings may reflect a nationwide pattern, because comparable studies conducted elsewhere have achieved similar results and because many respondents are likely to have received their training outside Colorado. In conclusion, they advocate for both wider dissemination of the CDC recommendation of routine screening and improved provider training in sexual history- taking, risk assessment and STD testing practices.--L. Schreck
1. Torkko KC et al., Testing for chlamydia and sexual history taking in adolescent females: results from a statewide survey of Colorado primary care providers, Pediatrics, 2000, 106(3), <www.pediatrics.org/cgi/content/full/ 106/3/e32>.