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.. . , ELIZABETHJMEACHAM
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6/01 c:/ClFiC/DateDue.p65.p.15

 

 

A RISK ASSESSMENT TOOL FOR SCREENING FEMALE ADOLESCENTS
PERCEPTION OF RISK FOR, KNOWLEDGE OF, AND LIKELIHOOD OF ACTION
TO PREVENT SEXUALLY TRANSMITTED DISEASES
By

Elizabeth J. Meacham

A SCHOLARLY PROJECT

Submitted to
Michigan State University
In partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE

College of Nursing

1998

ABSTRACT

A RISK ASSESSMENT TOOL FOR SCREENING FEMALE ADOLESCENTS
PERCEPTION OF RISK FOR, KNOWLEDGE OF, AND LIKELIHOOD OF ACTION
TO PREVENT SEXUALLY TRANSMITTED DISEASES
By

Elizabeth J. Meacharn

Adolescents are at higher risk of acquiring a sexually transmitted disease (STD)
than any other age group. Data on the prevalence of STDs among adolescents indicates
that the highest rates occur in younger adolescent females. A variety of unique factors
contribute to the higher risk of STDs in the female adolescent population. Among these
factors are biological vulnerability, cognitive and psychosocial factors, inadequate
knowledge about the symptoms of STDs and the asymptomatic nature of some infections.
The purpose of this scholarly project was to develop a screening tool that can be used in a
primary care setting to assess female adolescents' perception of risk for, knowledge of,
and likelihood of taking action to prevent STDs. The Health Belief Model (HBM) was
the conceptual fi'amework utilized in this scholarly project. The questions developed for
the risk assessment tools were derived from a review of the literature and encompassed
the specific health beliefs of the HBM: perceived susceptibility, perceived severity,
perceived benefits and perceived barriers. Information obtained fi'om this scholarly
project can assist the APN (Advanced Practice Nurse) in determining if the female
adolescent has risk factors for acquiring an STD based upon perceptions of her own

personal risk for and knowledge of STDs.

This project is lovingly dedicated to my husband, Robert, who has inspired, supported
andencouragedmetodomybest.

iii

ACKNOWLEDGMENTS

This author gratefirlly acknowledges the skilled guidance of Jackie Wright, RN.,
M.S.N. Her assistance in the process of selection and fine-tuning of this project was
invaluable. Thanks are also due to Mildred A. Omar, RN.C., PhD., and Linda Beth
Tiedje, RN, PhD., for their collaborative assistance. Their combined efi‘orts to make
this project applicable and useable were greatly appreciated. It truly was a learning
experience for us all.

This author would also like to recognize the encouragement and support fi'om
family, friends and colleagues while awaiting the completion of this project, without

which it would not have been possible.

iv

TABLE OF CONTENTS

LIST OF FIGURES ..................................................................... vii
INTRODUCTION ...................................................................... 1
Background of the Problem ..................................................... 1
Problem Statement ............................................................... 3
DEFINITION OF CONCEPTS ....................................................... 6
PURPOSE ................................................................................ 7
CONCEPTUAL FRAMEWORK ..................................................... 7
Overview of the Health Belief Model ......................................... 8
Health Belief Model Dimensions .............................................. 9
Perceived Susceptibility .................................................. 11
Perceived Seriousness .................................................... 11
Perceived Benefits ........................................................ 12
Perceived Barriers ......................................................... 12
Knowledge ................................................................. 13
Integration/Application of the Health Belief Model
with Incorporated Review of Literature ................................ 14
Summary of Integration/Application of the Risk
Assessment Tool within the HBM ...................................... 22
Health Belief Model Related Studies .......................................... 23
REVIEW OF THE LITERATURE ................................................... 27
Biological Risk for STDs ....................................................... 27
Cognitive Risk for STDs ........................................................ 28
Psychosocial Risk for STDs .................................................... 29
Current and Emerging Concerns of STDs .................................... 31
Critique of the Literature Review .............................................. 33

PROJECT DEVELOPMENT ......................................................... 34

Approach and Procedures ....................................................... 34
Target Group ...................................................................... 38
Tool Development ............................................................... 38
Early Adolescent (10-13 years) Risk Assessment Tool .............. 39
Middle Adolescent (14 —16years) Risk Assessment Tool ........... 41
Late Adolescent (17-19 years) Risk Assessment Tool ............... 41
Pilot ................................................................................ 44
DISCUSSION ........................................................................... 44
Evaluation of Tool ............................................................... 44
Implications for the Advanced Practice Nurse ............................... 46
APPENDICES ........................................................................... 52
Appendix A. Guidelines for Administration of Tool ........................ 52
Appendix B. A Risk Assessment Tool for Sexually Transmitted
Diseases Early Adolescent Females (10-13 years) ........... 54
Appendix C. A Risk Assessment Tool for Sexually Transmitted
Diseases Middle Adolescent Females (14-16 years) ........ 56
Appendix D. A Risk Assessment Tool for Sexually Transmitted
Diseases Late Adolescent Females (17-19 years) ........... 58
LIST OF REFERENCES ............................................................... 6O

LIST OF FIGURES

Figure 1: The Health Belief Model ................................................. 10
Figure 2. Integration of the STD Risk Assessment Tool
within the Health Belief model .......................................... 15

vii

INTRODUCTION

The purpose of this scholarly project was to develop a screening tool that can be
used in a primary care setting to assess female adolescents' perception of risk for,
knowledge of and likelihood of taking action to prevent sexually transmitted diseases.
Adolescents are at higher risk of acquiring a sexually transmitted disease (STD) than any
other age group (Townsend, 1996). A variety of unique factors contribute to the
increased risk of STDs in adolescents. Among these factors are biological vulnerability,
such as extension of columnar epithelium to the exocervix; behavioral aspects, such as
risk taking; cognitive and psychological factors, such as perceived lack of risk; and
inadequate knowledge about the symptoms of STDs and the asymptomatic nature of
some infections (Biro, Rosenthal & Stanbery, 1994; Cates 1991; MacDonald, Wells &
Fisher, 1990)

Background of Problem

To change behaviors that put adolescents at risk for HIV infection or STDs or to
maintain safe behavior adolescents must perceive that they could become infected (Janz
& Becker, 1984). Furthermore, even though adolescents are developing the cognitive
abilities to perceive health risks accurately, some observers believe that adolescents often
do not weigh the relevant risks in making decisions. (Office of Technology Assessment
[OTA], 1991). Even though many adolescents worry about getting infected with a STD,

they like adults, may be more concerned about satisfying needs (e.g., peer acceptance,

2
having a sexual relationship, being attractive to members of the opposite sex) than about
preventing possible HIV or STD infection (OTA, 1991).

Sexually transmitted diseases are hidden epidemics of tremendous health and
economic consequences in the United States (Institute of Medicine [IOM], 1996). They
are hidden from public view because many Americans are reluctant to address sexual
health issues in an open way and because of the biological and social factors associated
with these diseases. In addition, the scope, impact, and consequences of STDs are under
recognized by the public and health care professionals (IOM, 1996).

Of the top ten most fi‘equently reported diseases in 1995 in the United States, five
are STDs (IOM, 1996). Rates of curable STDs in the United States are the highest in the
developed world and are higher than in some developing regions (IOM, 1996).
Approximately 12 million new cases of STDs occur annually, and 3 million of these
occur among adolescents (Centers for Disease Control [CDC], 1993). The estimated
annual direct and indirect costs of selected major STDs are approximately $10 billion or,
if sexually transmitted HIV infections are included, $17 billion (IOM, 1996). Along with
the human suffering associated with STDs, this cost is shared by all Americans through
higher health care costs and taxes. STDs represent a growing threat to the nation's health,
it affects all people in every aspect of society (IOM, 1996).

Sexually transmitted diseases are a major problem in the adolescent population.
Over one half of the adolescents in the United States are sexually active, and the rates of
sexual activity have increased among younger age groups (CDC, 1992). Sexually active
adolescents have the highest rates of SIDS of any sexually active age group. Annually

2.5 to 3 million adolescents will have a STD; this corresponds to one out of six sexually

3
active teenagers (Braverman & Strasburger, 1994). It has been estimated that 25% of
adolescents will develop a STD by the time they graduate from high school (Committee
on Adolescence, 1994).

The female adolescent is at higher risk for developing a STD for a number of
reasons: 1) biologically the female adolescent cervix is immature, STD pathogens can
easily colonize the columnar cells causing pathology to occur and they lack antibodies of
adult women which increases their susceptibility; 2) the age of initiation of sexual
activity has decreased, and the age of first marriage has increased, resulting in increased
premarital sexual experience for the female adolescent (CDC, 1996); 3) psychological
vulnerability and lack of assertiveness which can influence their ability to negotiate
condom use. The risk of acquiring a STD also increases if the female adolescent is
involved in substance use, either drugs or alcohol (OTA, 1991). Analyses of the National
Longitudinal Survey of Youth have attempted to further understand the relationship of
substanceuseandsexualactivity. Theirresultstendtoindicatethatearly alcoholusein
females is more predictive than use in males of early sexual activity (Mott & Haurin,

1 987).
W

The health profession considers health care providers responsible for
incorporating the promotion of sexual health into adolescent care. The US Preventative
Task Force (U SPTF) recommends that primary health care providers take a sexual
history, discuss risk prevention and provide confidential care (within legal limits) for all
adolescent patients (U SPTF , 1996). However, it has been noted that primary health care

providers do not always follow these recommendations. One study of physician belnvior

4
found that most physicians (84%) say they usually or always ask new adolescent pmients
about cigarette smoking, but far fewer ask about STDs (56%), condom use (52%),
number of sexual partners (34%), and sexual orientation (27%) (CDC, 1992). The few
relevant published studies suggest that discussions about SIDS and adolescent sexual
health are uncommon. One study found that about four-fifths of first year college
students reported that physicians had never provided them with counseling on STDs
(79%) and contraception (81%) (Igra & Millstein, 1993). Another study suggested that at
most 6% of adolescents' general medical and physical examination visits include
counseling on transmission of STDs and HIV (Hingson, Stunin, Berlin & Heeren, 1990).
No studies were found regarding Advanced Practice Nurses (APN) and their discussions
with adolescent patients about sexual health.

In general, American adolescents have a fairly high level of factual knowledge
regarding HIV transmission and methods of preventing its transmission (OTA, 1991).
Data fi'om the National Adolescent Student Health Survey suggest, however, that many
American adolescents lack information or are misinformed about many aspects of
transmission, prevention, and treatment of other STDs (OTA, 1991). Approximately
30% of a nationally representative sample of 8th and 10th graders did not know that most
STDs are acquired through sexual intercourse, and a substantial minority did not know or
were unsure that a sore on the sex organs (33%) and a discharge of pus from a sex organ
(44%) were signs ofan STD infection (OTA, 1991). It is apparent that in recent years,
adolescents generally have been informed about the risk and prevention of HIV/AIDS; in

contrast, they have not been well informed about STDs (Boyer, Shafer & Tschann, 1997).

S

It has been noted by may researchers that more thanjust knowbdge ofsexually
transmitted diseases is needed by adolescents to promote STD prevention (OTA, 1991).
Some researchers (Scales, 1983) maintain that education that provides only facts does not
address the fimdamental needs of the adolescent. Understanding an adolescent's
worldview or perception is crucial for developing efl‘ective strategies to promote STD
prevention. Adolescents have often been perceived as risk takers. The term, risk taker,
has fi'equently been misused. A risk taker is one who knowingly risks harm by engaging
in a particular activity (Cates, 1991). If the adolescent does not view (perceive) the
activity as harmful, then engaging in it cannot be labeled as risktaking. For example, ifa
female adolescent desires to become pregnant and has unprotected intercourse, she is not
from her viewpoint (perception) risking any harm She may be labeled by some as being
unwise but she is not a risk taker. Any approach designed to provide information to
adolescents about STDs must also address the issue of the adolescent's perception that
she/he is invulnerable to harm.

The approachofienusedto screenforrisk factorsregarding sexually transmitted
diseases is the routine history and physical, which might not include a complete sexual
history. A systenntic approach to screening all adolescents' perception of risk for,
knowledge of; and likelihood of action to prevent a STD is lacking. The APN in a
prirnarycare setting providedwiththe correcttool should be abletoassess female
adolescents' perceptiom of risk, knowledge of and likelihood of taking action to prevent a
STD. This tool should be convenient, practical and incorporated into the history and

physical portion of the examination. The APN is in an excellent position to provide

 

6
accurate, comprehensive and nonjudgmental information about sexually transmitted
diseases and prevention’s tailored to the female adolescents needs.

Adolescent females were selected as the population of focus for this scholarly
project because of the unique factors that place them at risk for acquiring a STD and data
on the prevalence of STDs among adolescents indicate that the highest rates occur in
younger adolescent females (Townsend, 1996). The adolescent female is biologically at
risk because ofan immature cervixthat can be easily colonized with pathogens. The
female adolescent is also cognitively at risk for acquiring a STD because of her unique
sense of invulnerability to harm and denial of personal risk. Also the female adolescent's
age of initiating sexual intercourse is steadily declining, which in turn increases the
number of lifetime. partners an enlarging the pool of adolescent females at risk for
acquiring a STD.

Definition of Concepts

For this scholarly project adolescence was defined as the time of transition from
childhood to adulthood. Specifically, early adolescence is defined as those females
between the ages of 10 and 13 years, middle adolescence between the ages of 14-16 years
and late adolescence between the ages of 17-19 years. Perception of risk was defined as
the ability of the female adolescent to understand the chance of injury/harm to herself.
Knowbdge was defined as the ability to understand and process information. Likelihood
of action was defined as the ability of the female adolescent to perceive a STD as a threat
to personalhealthand believethatthe benefits oftaking actionto protectherhealth

outweigh the barriers that will be encountered.

7
Purpose

The purpose of this scholarly project was to develop a screening method (tool)
that can be easily implemented in the primary care setting to assess female adolescents'
perception of risk for, knowledge of and likelihood of action to prevent a sexually
transmitted disease. This project focused on the female adolescent population. The
primary use of this tool is for screening the female adolescent's perception of risk
associated with acquiring an STD, her knowledge of SIDS and also the likelihood of
action she will take to prevent an STD. This screening tool can be used with all
adolescent females who present for primary care such as routine annual exams, those
seeking family planning, screening for pregnancy or sports physicals. This screening tool
needs to be incorporated with a complete sexual history as well as with a routine medical
and family history so all the patient's background information can be incorporated.

This tool was developed to assist the APN in determining more extensively the
female adolescent’s perception of risk for current knowledge of STDs, and likelihood of
taking action to prevent SIDS and thus identifying those patients at higher risk for
infection.

Conceptual Framework

Adolescence is a period of significant life transition during which children enter
into adulthood. Behaviors and beliefs established during this period are often carried into
adult life. Health behaviors established prior to adulthood can significantly influence
health and longevity, both in the short term and later in life (Adams & Schoenborn,

1995). Adolescents pose unique challenges in terms of measurement of health and health

8
related behaviors and in terms of strategies nwded to promote healthful habits and
discourage behaviors demonstrated to have deleterious health consequences.

During adolescence, changes in the social environment allow adolescents greater
decision making power in areas such as health. It is important to understand the firctors
that are related to these decisions. In adults, health beliefs have been shown to be
important mediators of health related behaviors (Meyer, Leventhal, & Gutmann, 1985).
A better understanding of the specific health beliefs held by adolescents and their direct
effects on behavior can also facilitate the communication between patients and providers,
a factor that is known to improve patient outcomes (Hulka, 1979).

The following sections provide: (a) an overview of the Health Belief Model
(HBM); (b) specific I-IBM dimensions with conceptual definitions to guide this project;
(0) integration / application of the HBM incorporated with a review of the literature; ((1)
HBM related studies; and (e) review of the literature and critique.

Overview of the Health Belief Model

The Health Belief Model was used in this scholarly project as the conceptual
fi'amework for assessing psychological variables. The HBM was developed in the early
1950's by a group of social psychologists, and is derived from the Social Cognitive
TMory. The HBM was designed as a framework for exploring why some people who are
illness the take actions to avoid illness, while others fail to take protective actions. The
model was viewed as potentially useful to predict those individuals who would or would
mt use preventive measures and suggest interventions that might increase predisposition

of resistant individuals to engage in health protecting behaviors (Pender, 1996).

9

The HBM is most applicable with voluntary, health-related actions that involve an
element of uncertainty. Because it is a psychological model, it is applicable only to
behavior that can be explained by a person's attitudes and beliefs. The HBM
encompasses a ”value expectancy" approach which attributes behavior to the value an
individual places on the expected outcome of the action and also to the perception by the
individual that the specific behavior will result in the expected outcome (Janz & Becker,
1984).

The HBM hypothesizes that health related behavior occurs as a result ofthe
interactive and combined effects of (a) readiness to comply with recommended action/s,
and (b) modifying and enabling factors. The fictors that influence readiness to act
include those dimensions known as the health beliefs, which include susceptibility,
seriousness, benefits and barriers. The perception of a threat to health is conceptualized,
as a combination of how susceptible the individual perceives him/herselfto be to an
illness and how severe of an effect he/she believes the illness would have on his/her life.
The beliefalso mustexistthattheactionthe individual takeswillresult inthe expected
outcome and that there are not insurmountable barriers that preclude goal attainment (see
Figurel).

H 1i Model imens'

Specifically, the HBM consists of the following dimensions known as the health
beliefs, which provide the basis for the questions of the screening tool: perceived
susceptibility, perceived severity, perceived benefits and perceived barriers. To
determine the female adolescents' perception of risk for acquiring a STD the concepts of

perceived susceptibility and perceived seriousness are used to develop screening

 

 

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INDIVIDUAL PERCEPTIONS MODIFYING FACTORS LIKELIHOOD OF ACTION
Demographic variables Perceived benefits of
(Age, sex, race, ethnicity, etc.) preventive action.
Sociopsychological variables . Minus
(Personality, social class, peer
and reference-group pressure, Perceived barriers to
etc.) preventative action.
Structural variables
(Knowledge about the disease,
prior contact with the disease,
etc.)

. J.

Perceived susceptibility to
disease X

Perceived seriousness
(severity) of disease X

 

 

 

 

‘ . Perceived threat of disease X

 

*— preventive health

 

 

 

 

Cues to action

Mass media campaigns

Advice from others

Reminder postcard from physician
Illness of family member or fiiend
Newspaper or magazine article

 

 

 

Likelihood of taking
recommended

action.

 

 

 

Figtge 1. The Health Belief Model. Selected psychosocial models and correlates of individual health-
related behaviors. Becker, M.H., Haefirer, D.P., Kasl, S.V., et al. (1977). Medical Care 15:27

 

10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INDIVIDUAL PERCEPTIONS MODIFYING FACTORS LIKELIHOOD OF ACTION
Demographic variables Perceived benefits of
(Age, sex, race, ethnicity, etc.) preventive action.
Sociopsychological variables . Minus
(Personality, social class, peer
and reference-group pressure, Perceived barriers to
etc.) preventative action.
Structural variables
(Knowledge about the disease,
prior contact with the disease,
etc.)
V V
fiercerve; susceptibility to Likelihood of l .
_, Perceived threat of disease X ‘_ recommended

Perceived seriousness WWW health

(severity) of disease x ““0“-
Cues to action
Mass media campaigns
Advice from others
Reminder postcard from physician
Ilhress of family member or friend
Newspaper or magazine article

Figrgg 1. The Health Belief Model. Selected psychosocial models and correlates of individual health-

related behaviors. Becker, M.H., Haefi'rer, D.P., KasL S.V., et a1. (1977). Medical Care 15:27

11
questions. The screening questions designed to determine the likelihood that the female
adolescent will take action to prevent a sexually transmitted disease are based upon the
concepts of perceived benefits and barriers. The modifying factor, knowledge was also
used to determine the female adolescents' understanding of sexually transmitted diseases.
These dimensions are further defined as follows.
Per iv S 'bi '

This dimension of the HBM reflects the individuals' feelings of personal
vulnerability to a specific health problem. Individuals vary widely in their feelings of
personal vulnerability to a condition (Pender, 1996). Some individuals may not feel
susceptible to illnesses in general or have no belief whatsoever in the given diagnosis.
For this scholarly project perceived susceptibility was defined as the female adolescent's
subjective perception of the risk of acquiring a sexually transmitted disease. The
adolescent must view herself as vulnerable to contracting a STD. For example, if the
female adolescent has sexual activity with more than one partner she is vulnerable and
susceptible to acquiring a STD. The female adolescent must consider herselfat risk.
Perceived Seriousness

Feelings concerning the seriousness of contracting an illness, or leaving it
untreatedalso vary frompersonto person. Thisdimensionofthe HBM includes
evaluations of both medical/clinical consequences and also social consequences of the
illness. The medical/clinical consequences can include death, disability, and pain. The
social consequences can include efiects of the illness on work, family life and social
relationships. Perceived seriousness of a given health problem can be judged either by a

degree of emotional arousal created by the thought of having the disease or by the

1 2

medical/clinical or social difliculties that individuals believe a given health condition
would create for them (Pender, 1996). For this scholarly project perceived seriousness
was defined as the perceived implications to the individual (both medically and socially)
of acquiring a sexually transmitted disease.
Perceived Benefits

While acceptance of personal susceptibility to a condition also believed to be
serious was held to produce a force leading to behavior, it did not define the particular
cornse of action that was likely to be taken. This was hypothesized to depend upon
beliefs regarding the efi‘ectiveness of the various actions available in reducing the disease
threat. Thus, a "sufficiently threatened" individual would not be expected to accept the
recommended health action unless it was perceived as feasible and beneficial (Janz &
Becker, 1984). For this scholarly project perceived benefits were defined as the belief
about the effectiveness of taking recommended actions to prevent sexually transmitted
diseases. The female adolescent must believe that using condoms will prevent her fiom
acquiring a STD. The female adolescent must also believe this particular method of
prevention will work, is something that she can do and it is beneficial to her overall
health.
Perceived Barriers

The potential negative aspects of a particular health action may act as
impediments to undertaking the recommended behavior. This dimension of the HBM
involves a kind of cost-benefit amlysis where in the individual weighs the action's
effectiveness against perceptions that it my be expensive, dangerous, unpleasant,

inconvenient and time consuming. For this scholarly project perceived barriers were

1 3
defined as the negative consequences of taking the prescribed health actions to prevent a
sexually transmitted disease.

The modifying and enabling factors of the HBM include demographic, socio-
psychological and structural variables. Some of these factors may function as cues to
action, also characterized as "triggering mechanisms". These factors are considered to
have an indirect influence on health behavior by their effect on an individual's health
motivation and perceptions. Examples of the modifying and enabling factors include a)
demographic characteristics, such as age, sex, race, and income; b) socio-psychological
variables such as personality, social class, and reference-group pressure; and c) structural
variables which includes knowledge about the disease and prior contact with the disease.
The only modifying/enabling factor this project examined was knowledge.

Knowledge

Knowledge is a concept that is frequently explicated for specific measurement in
health behavior research. The HBM was originally conceived with knowledge
recognized as a significant determinant ofhealth related behaviors and as having the
potential to influence individual's readiness to undertake a specific action. According to
Rosemtock (1974),"both perceived susceptibility and severity have a strong cognitive
component and are at least partly dependent upon knowledge" (p.330). Because of it's
potential significanceasamodifierofthe healthbeliefsandbecause it isanareathat
nursing can impact, knowledge of sexually transmitted diseases was one of the variables

examined in this project.

14
Integrgion/Application of the HBM with Incormrated Review of Literature

As identified in Figure 2, the screening and prevention of risk behaviors
associated with acquiring a STD can be integrated into the HBM. The basic premise of
the HBM is that behavioral change results fi'om knowledge related to health when three
conditions are met. The first condition requires the female adolescent to believe that she
is threatened by a particular health risk, whether because of her personal susceptibility or
because of the severity of the risk itself. In other words, if a female adolescent is
sexually active she is at risk for acquiring an STD; and if she is sexually active with more
than one partner, this fact alone increases the severity of the risk involved in being
sexually active (CDC, 1996). Sexually transmitted diseases are often asymptomatic; thus
prevention measures have no immediate apparent effect. The long term seriousness and
complications of STD infections including pelvic inflammatory disease, infertility and
cervical cancer may seem to abstract or improbable to the adolescent.

Many studies have looked at the relationship between the adolescent’s perceived
personal risk for STDs and subsequent condom use. These studies are often related to an
individual's perceived risk of acquiring AIDS. In a study of 585 sexually active
adolescents, Strunin and Hignson (1987) found that only 15% reported changing their
sexual behavior because of concern about contracting AIDS. I-Iingson, Strunin, Berlin
and Heeren (1990) found that adolescents were more likely to report always using a
condom if they felt susceptible to AIDS. However, only 31% of the 1,080 sexually active
respondents reported always using a condom. A study conducted by Ricket, Jay, Gottlieb
and Bridges (1989) of 99 adolescent women at a comprehensive adolescent clinic, found

that although 62% of the women reported that a fear of AIDS had influenced their

15

INDIVIDUAL PERCEPTIONS MODIFYING FACTORS LIKELIHOOD OF ACTION
OF RISK FOR STD: TO PREVENT STD!

    
   

  
 

  

Perceived benefits of
prevmtive action (not

acqurrmg a sexually

Demographic variables

   
  
 

    
      
   
  

   
   
 
  

 

    
  
 
     
   

Sociopsychological I in ed disease)

variables Minus
Perceived barriers to

Structural variables preventative action

(Knowledge about (mconvenrarce &

sexually transmitted m)

diseases, prior contact

with sexually

transmitted diseases

etc.)

 

 
     
   
     
   

 

Female adolescent’s

perceived susceptibility to
sexually transmitted

   

 

    
     

  
 

 

 

 

    
   

 

diseases Female adolescent’s Likelihood oftaking
perceived threat ofa rm?

Female adolescent’s sexually transmitted disease gem acti
perceived seriousness on.
(severity) of sexually
transmitted diseases

Cues to action

Mass media campaigns

Advice from others

Illness of family member or friend

Newspaper or magazine article

 

 

 

F igrge 2. Integration of the STD Risk Assessment Tool within the Health Belief Model. Selected
psychosocial models and correlates of individual health-related behaviors. Becker, M.H., Haefner, D.P.,
Kasl, S.V., et al. (1977). Medical Care 15:27

l6

behavior, less than 18% reported asking their partner to use a condom to prevent AIDS.
Several other studies have found no significant relationship between perceived

susceptibility for STDs and self -reported use of condoms (Potter & Anderson, 1993;
Weisman, Plichta, Nathanson, Ensminger& Robbinson, 1991). A recent study conducted
by Ellen, Boyer, Tschann and Shafer (1996) of 231 sexually experienced urban teenagers
found that adolescent's perception of risk appear to be related to anxiety about STDs and
HIV and their behaviors may be related to peer influences and attitudes toward using
condoms. This study also concluded that little is known about the determinants of
adolescent’s perceptions of personal risk for STDs and HIV; it appears that sexually
active adolescents know they are at risk for STDs and HIV but they continue practicing
sexual risk taking behavior without prevention.

The second condition that must be met to produce behavioral change is the risk
reducing action must be viewed as providing a greater potential benefit than its potential
cost. The female adolescent must believe in the effectiveness of the strategies to prevent
STDs and that prevention in the long term is more beneficial to her overall health than
any negative consequences or inconvenience that she might encounter. Although the
most effective method for prevention of STDs is to abstain fiom sexual intercourse many
adolescents do not practice abstinence. For those adolescents that cannot abstain the use
of latex condoms is the most effective way to lower the risk of STD infection. The HBM
proposes that thinking that condoms are effective at preventing STDs should correlate
positively with their consistent use. However, knowledge about STDs and belief in the
efl'ectiveness of condom has not appeared to increase their use (Agyei, Epema &Lubega,

1992). Ricket, Jay, Gottlieb and Bridges, (1989) found that although 74% of the females

17
knew that condom use provided efl‘ective protection fi'om STDs and AIDS, less than 20%
reported using a condom for that purpose.

Knowledge gained from health education does not always translate into
subsequent health behaviors. This suggests that more detailed knowledge of the
mediators of these behavioral changes is meded. Therefore in order to gain a deeper
understanding of health behaviors associated with STD risk assessment and prevention, it
is important for the APN to consider the psychological variables that can affect belnvior
change. Identification of such variables could enhance the individualization of risk
assessment strategies.

The HBM proposes that the perceived negative consequences of carrying out the
health behaviors will inhibit their use. Perceived barriers are not only associated with the
use ofcondoms but also access to health care services for adolescents. Perceived barriers
to condom use include perceived inconvenience of use, a belief that condo-s decrease
sexual pleasure and are embarrassing to use (Pendergrast, DurRant & Gaillard, 1992;
Hingson et aL, 1990). Pendergrast et a1. (1992) and Keegles, Adler and Irwin (1989)
found that health considerations played a minor role in determining condom use
compared to other immediate consequences such as perceived inconvenience of use and
perceived partner attitude. Therefore, although adolescents demonstrate an awareness of
STD risk, their behavior rennins essentially unchanged.

The decade ofthe 1990's has witnessed a concerted effort towards improving
accessto healthcare for adolescents. The literature onbarriers to care forthe adolescent
has recognized such problems as inadequate health insurance, transportation and service

site. These factors are known to affect adolescent’s utilization of services. The female

 

 

 

.ab

tort

 

 

l8
adolescent might also view parents as a barrier. Most often adolescents must use his/her
parent's health insurance to pay for services. The adolescent female could also be
concerned about confidentially and obtaining parental consent for treatment of STDs.
Health care providers need to negotiate with parents to provide confidential services and
inform adolescent patients that parental consent is not need for treatment.

Other barriers have been identified as unique concerns to the adolescent and
influence the adolescent's decision to seek health care. These barriers include cleanliness
of the health care site, issues involving infection control, confidentiality and provider
characteristic such as honesty and fiiendliness (Gingsburg, Slap, Cnaan, Forke, Balsey &
Rouselle, 1995). There are also barriers that are associated with the health care provider.
Health care providers fail to provide preventive messages for many reasons including
both environmental factors and factors related to the clinician. Environmental factors
include poor reimbursement for counseling activities, insufl'rcient time, lack of health
education resources specific to adolescents in many offices and lack of preventive
services reminder systems (Kottke, Brekke & Solberg, 1993). Clinician factors include
feeling inadequately trained, not believing in the effectiveness of such interventions and
feeling personally uncomfortable with such discussions of sensitive topics (Igra &
Millstein, 1993). When health care services are not accessible or are perceived as a
barrier to the adolescent the result is a missed opportunity for STD prevention.

The third condition to promote behavioral change is environmental cues to action.
These cues to action must be present to stimulate the decision to reduce the health risk
specifically the risk of acquiring a STD. Many attempts have been made to reduce sexual

activity among adolescents; hundreds of sexuality education curricula have been

19
developed and implemented in junior and senior high schools in past 15 years. Since the
mid 1980's when concern about AIDS began to grow a search for educatioml programs
to reduce behaviors associated with the transmission of the virus also increased. These
cues to action also include mass media campaigns such as the "Just Say No" campaign.
In 1981, Congress passed the Adolescent Family Life Act sometimes called the "chastity
act" because it stressed teaching abstinence until marriage as and important part of
pregnancy and STD prevention. Other cues to action include advice from others, illness
of a family member or friend and newspaper/magazine articles.

The HBM conceptualizes knowledge as a modifying variable and thus is
characterized as having an indirect effect upon behavior by mediating the major health
beliefs. Studies using the IBM as a fiamework often also examine knowledge. No
studies were found that used the HBM as a fi'amework to examine knowledge and STD
preventative behaviors. A review of the literatme in relation to knowledge and health
behavior indicates that although knowledge plays a significant role in behavior, its efi'ect
is probably indirect. Studies in which the role of knowledge is examined as an influence
ofthe health beliefs seem to hold the most promise for additional research utilizing the
variable. The HBM provides an appropriate framework for examining knowledge and
can effect one or more of the health beliefs.

Given the fact that risk sexual behaviors are directly related to the transmission of
HIV and STDs the ultimate goal of education based prevention efforts is to decrease risky
behaviors. Preventive behaviors for example would be 1) abstinence, 2) monogamous
relationships in which neither partner has a STD, 3) use of condoms, 4) limit number of

sex partners, and 5) know the signs and symptoms of STDs. Education based prevention

20
programs often used in schools, attempt to influence students' behavior by increasing
knowledge about AIDS and, to a lesser extent, knowledge about ST'Ds (including
methods of transmitting and preventing infection) and to change student’s
attitudes/behavioral intentions with respect to preventive behaviors. There is little
evidence to suggest that increased knowledge alone will result in behavioral change
(OTA, 1991). Very few studies have evaluated how educational interventions affect
risky behavior related to the transmission of STDs and HIV infection.

Some available evidence suggests that brief educational instruction can
significame increase adolescent’s knowledge about HIV and STD infection. A study
evaluation the impact of a 3 hour AIDS prevention curriculum taught in San Francisco
middle and high school classes, for example, found that students receiving the cm'riculum
(including knowledge that condoms could reduce the risk of HIV transmission during
sexual intercourse) showed significantly more knowledge than students who received no
instruction (OTA, 1991). Because student’s knowledge was not assessed afier a long
period of time, however, it is possible that the increases of knowledge may not have
remained strong. One study demonstrated that student’s knowledge about STDs
increased significantly immediately following a CDC sponsored curriculum and then
decreased six weeks later (OTA, 1991).

Breaking the chain of STD transmission is crucial to STD control. Any hope of
slowing the progression of STDs and the consequences to society will require that all
people, especially young people, learn and practice skills to protect themselves and others
fi'om STD risks and transmission ("Assessing and counseling ", 1994). Education must

be geared at the particular group being taught. Creating positive attitudes related to

21
reducing sexual risk requires increasing the client's knowledge and changing beliefs and
feelings (Marion, 1990). Thus, educational efforts to improve knowledge and change
attitudes and belnvior are a necessary component of STD prevention. The HBM can be
incorporated into a STD prevention program and be utilized in identifying: 1) those
individuals who do not perceive themselves as susceptible to STDs, 2) those individuals
that would not use condoms or other preventive measures such as abstinence and 3) to
suggest interventions that might increase resistant adolescents to engage in health
protecting behaviors.

The HBM model can be applied in the screening and prevention of risk behaviors
associated with acquiring a STD as indicated by the following examples relative to each
of the HBM variables. If the female adolescent's responses to the screening tool indicate
that she perceives herself as being susceptible, she will see herself as being likely to
acquire a STD. The perception of severity is a combination of an emotional arousal
createdbythethoughtofhaving a STD andperceptions ofthekindsofdiflicultiesthat
having a STD represent to the female adolescent. For example, the female adolescent
mightperceivethathavingaSTDwouldresultinasocial stigma. Oncediagnosedwitha
STD she could have concerns related to her partner's fidelity, body image, sexuality and
relationships. In regard to the benefits variable, if abstinence or use of condom is
perceived as beneficial, she will believe that these preventive strategies will decrease her
susceptibility to a STD. Examples of barriers that might be perceived by a female
adolescent with regard to prevention of STDs include (a) viewing the purchase of
condoms embarrassing, (b) inability to enjoy sex with condoms, (c) believing that

condoms are inconvenient and (d) feeling powerless to negotiate condom use with her

22
partner. The female adolescent must be knowledgeable about the transmission and
prevention of STDs, but knowledge will only be affective in changing behaviors if the
female adolescent perceives herself susceptible to acquiring a STD.
Sm of the Integrfl' n/Application of the Risk Assegment Tool within the EM

The HBM provides a logical framework to allow the APN the ability to assess
adolescent female's perceptions of acquiring and knowledge about STDs. Using the
model the APN may better understand the female adolescent's perceptions of STDs
including the barriers encountered that might prevent them from taking the recommended
health action. Because the IBM emphasizes individual perceptions it enables the APN
to comprehend what factors influence the female adolescent's behavior. The APN must
look at the female adolescent's needs and determine how her present behavior is firlfilling
them. After assessing what the female adolescent perceives her risk to be based upon the
health beliefs and her knowledge of STDs the APN can intervene. Using the model to
identify risk behaviors the APN can assess each female adolescent individually and
design specific interventions to encourage healthy sexual behavior.

There are other factors associated with female adolescents and STDs that this
author's tool does not address. Dma on the prevalence of STDs indicates that the highest
STD rates occur among younger adolescent females, demographically- inner city, and
minority teens. Factors such as poor role models lack of economic and educational
opportrmities (such as life goals and expectations), low self esteem and family formation
also contribute to early sexual activity and increased risk of STDs for the female

adolescent.

23
Health Belief Mggl Related Studies

The most widely tested formal model describing the relationships of health beliefs
to health behavior is the HBM (Becker, 1974). The HBM has generated prolific research
regarding behaviors related to disease detection and prevention of disease in
asymptomatic subjects (Janz & Becker, 1984). Janz and Becker (1984) reviewed 29
HBM- related studies that were designed to investigate preventive health behavior and
disease detection behaviors. These studies used the "traditioml" health beliefs of
susceptibility, seriousness, benefits and barriers. Most of the research supported a
statistically significant association between health beliefs and behaviors. Barriers were
found to account for the largest percent of variance, followed closely by susceptibility,
benefits and seriousness. Janz and Becker (1984) concluded that substantial empirical
evidence supports the importance of the HBM dimensions in explaining and predicting a
person's health behaviors. However, it was noted that, for the most part, studies using the
HBM as the conceptual fi'amework have lacked consistent operationalization and
measurement of the variables. The variability in measures was noted to make
interpretation and comparison of findings across studies difficult. Refinement and
standardization of tools directed toward the measurement of condition-specific beliefs
was recommended for future studies.

Champion (1984), who was concerned with the inconsistency in application of the
model and the lack of valid and reliable instruments for measming the constructs,
developed and tested an instrument designed specifically for the study of the HBM
variables as they related to self breast examination (BSE). In addition to the four

traditional HBM variables, health motivation was included. The five variables

24
representing the health beliefs accounted for statistically significant amount of the
variance (26 percent) in BSE practice. Barriers accounted for the largest portion of
variance (23 percent) for a single HBM construct, and health motivation accounted for 2
percent of the variance in BSE practice. Women perceiving more barriers tend to
examine their breasts less frequently. Champion's subsequent research of 1985 and 1986,
also revealed a correlation between the HBM constructs and BSE practice. Another
study conducted by Champion in 1987, included knowledge as a variable and results
revealed that along with knowledge, barriers and susceptibility were correlated with the
frequency of BSE

Research regarding the influence of the HBM variables in disease prevention
behavior also supports the conceptualization of the model (Aho, 1979; Allard, 1989;
Becker, 1985; Knight & Hay, 1989; Tirrell & Hart, 1980). Allard's study (1989) adapted
Champion's (1984) scale to investigate disease preventive practices and beliefs about
AIDS. The HBM was formd to be a good theoretical approach to obtain data on AIDS
related behaviors. Perceived susceptibility to AIDS and perceived severity of the disease
were formd to be significamly correlated with AIDS prevention practices. Using the
HBM was also found to be useful for the development of health education programs to
promote behavior change to reduce the risk of contracting AIDS.

A more recent study conducted by Hittabiddle (1996) investigated factors
associated with adolescent condom use for the prevention of STDs. Using the HBM as a
theoretical fiamework, the researcher was able to identify unique risk factors related to
adolescents and their risk for STDs, barriers to and facilitators of condom use, and

provide suggestions for health care providers to increase condom use among adolescents.

25
TheresearcherconcludedthatalthoughtheHBMmayhadsome weaknesses initsuse
with the adolescent population, its emphasis on the individual's perceptions my be a key
in influencing adolescent behavior. Further research is mded in understanding how
adolescents view their sexual belmvior, what do they feel vulnerable to and who
influences their health making decisions, especially peer groups and values.

The results of research using the HBM with disease detection and preventive
behaviors have been varied, but suggest that certain HBM variables are useful in
predicting specific belmviors. Much of the support for the HBM has come fiom studies
in which data on beliefs and behaviors were collected at the same time. These studies
have shown strong correlation between beliefs and behavior, but it is difficult to judge if
beliefs produce behavior or vice versa. A problem with retrospective design is tlmt
causality can not be implied as there is evidence to show that individuals sometimes
rationalize their beliefs and feelings to fit their behavior (McKinaly, 1972).

Another problem with many HBM studies relates to the self-administration of the
questionnaire and self-report of the behavior. Also, problems with inconsistency
regarding measurement of the health belief variables limits interpretation of many of the
studies. Jette, Cummings, Brock, Phelps and Naessens (1981) reported that scales
comprised of items that refer to a specific health problem (e.g. sexually transmitted
diseases) lmve higher reliability than scales comprised of items that fail to mention the
disease of interest. The development of consistent, reliable and valid measures have been
recommended. Ideally, separate scales should be constructed as the HBM is applied to
each new health problem (Champion, 1984; Given, Given, Gallin & Condon, 1983; Janz

& Becker, 1984; Jette et al., 1981; Maiman, Becker, Kirscht, Haefner & Drachman,

26
1977). Champion (1984) suggests if the IBM is found to be theoretically sound and if
reliable instruments are available, the study results can be used to structure individualized
health promotion nursing strategies.

The I-BM also has specific limitations when dealing with the adolescent
population. Models that only emphasize disease related variables have been criticized as
being insufficient for mounting efi‘ective behavioral interventions. Other cognitive and
attitudinal variables affect sexual behavior and these must be addressed as well
(Levinson, Jaccard & Beamer, 1995). The IBM fails to recognize the "positive"
motivators for adolescents engaging in sexual behaviors. Some adolescents find it
physically pleasurable. Other adolescents might believe that it nukes them more
attractive to others. Yet other adolescents believe that engaging in sex brings them an
emotional intimacy that otherwise they cannot achieve (Levinson, et aL, 1995). Disease
related models such as the I-BM tend to ignore these "positive" types of motivations.
The implicit assumption is that preventive behavior is driven by the fear of negative
events (e.g. STDs and unintended pregnancy) when, in fact, the behavior may be heavily
influenced by the "positive" motivations to engage in risk behaviors.

The I-BM has also been criticized for not incorporating peer group influence,
emotional factors, or the cognitive level of adolescents, which impairs their ability to
evaluate personal risks objectively in decision making. The adolescent's preoccupation
with the immediate consequences of his or her actions hinders the rational decision

making skills on which this model is based (Brown, DiClemente & Reynolds, 1991).

27
Review of the Literature
Sexually transmitted diseases are a major problem in the adolescent population.
Over one lmlfof the adolescents in the United States are sexually active, and the rates of
sexually activity have increased among younger age groups (CDC, 1992). Sexually
active adolescents have the highest rates of STDs of any sexually active age group.
Annually 2.5 million adolescents will lmve a STD; this corresponds to one out of six
sexually active teenagers (Braverman & Strasburger, 1994). In general, STD rates appear
to vary by sex and race, there being more STDs reported among adolescent females than
males and more among nonwhite than among whites. When considering possible
explanations for this high rate of infection, a variety of biological, cognitive and
psychosocial risk factors unique to the female adolescent need to be examined.
Biological Risk for STDs
In general, adolescents have had less lifetime exposure to STDs then adults and
therefore have not developed either systemic or local antibodies to infection. The
presence of such antibodies presumably would provide some protection to the female
adolescent (Braverman & Strasburger, 1994). As previously mentioned the female
adolescent cervix is immatrn'e. The cervix has an ectropian in which columnar cells are
present on the exocervix and the transformation zone between columnar and squamous
cells, which is exposed to the vaginal environment. STD pathogens can colonize these
columnar cells causing pathology in the area of the transformation zone leading to an

increased morbidity from STDs (CDC, 1991).

28

Cogn_rt' ive Risk for STDs

Cognitive changes involve the adolescent moving fi'om concrete operations to
formal operations. Early adolescent girls are in concrete operations as identified by
Piaget (1969). Decisions made by the early adolescent are based on experience, time
orientation is almost exclusively past or present. Little or no forethought goes into
activities with which the young female is not eagerly absorbed or genuinely comfortable
with. The firture, if considered, is perceived as uncertain or idealized. Few teens at this
stage of early adolescence look much beyond a few weeks or months into their fixture.
Since development of adult values and a sexual value system require abstract cognition
and conceptualization, early adolescents whose thought processes are still "concrete" are
unlikely to articulate clear values with regard to sexuality, sexual behavior or to plan for
sexual intercourse (Proctor, 1986).

Formal operations according to Piaget (1969) allow the individual to plan
realistically for the future, transfer information fiom one situation to another, and
conceptualize abstract ideas such as health and prevention. Formal operations include the
ability to manipulate abstractions such as algebraic expressions, to reason fi'om known
principles, to weigh multiple points of view according to varying criteria and to think
about the process of thinking itself. Formal operational thought, which implies an ability
to treat possibilities as real entities, may be related to critical decisions, such as whether
or not to lmve unprotected intercourse or engage in other risk taking behaviors. As the
adolescent begins to move toward abstract reasoning the process may be selfdirected and

lead to day dreaming and increased self interest and fantasy (Neinstein, 1991).

29

Adolescents believe others are constantly focused on them. This egocentrism
contributes to the notion of a "personal fable", identified by Elkind (1979). The personal
fable isthe "beliefthattheindividualisspecialandnot subjecttothenatmallawsthat
pertain to others" (p.95). He describes adolescents' belief that he or she is an exception to
the rules because of his or her own uniqueness or special qualities. This aspect of
cognition may influence the female adolescents' perception of STD risk. This sense of
invulnerability results in a denial of personal risk of exposure or negative health
consequences related to acquiring a STD.

Adolescence also is characterized by risk taking behavior valued by the
adolescent, who believes risks prepare him/her for adult status. The perceived secondary
gains of increased self-confidence, attainment of adult status, popularity among peers, or
affection encourages adolescents to engage in behaviors they acknowledge as dangerous.
Adolescents with limited experience engage in behaviors with expectation of benefit
and/or without understanding the immediate or long-term harmful consequences of their
actions. Risktaking insexual activity isonearea inwhichthistypeofbehavioris
evident.

W

The adolescent strives for autonomy and independence developing a separate
identity fi'om the family and the peer group increases in importance. Identification with
peers and fitting in with the group's values and behaviors are important aspects of
adolescent development. Language, dress and values are reflective of the peer group. As
a result, adolescents may engage in sexual activity to obtain peer acceptance and approval

(Scott, 1996).

30

The adolescent shifts from same sex fiiendships to dating and heterosexual or
homosexual relationships. Sexual experimentation and intercourse are likely to occur.
Sexual romanticism is common rather than real intimacy. The sexual encounters of
adolescents tend to be unplanned and sporadic. Their sexual relationships tend to be non-
monogamous or to involve serial monogamy (Boyer, 1990). As the early initiation of
sexual intercourse increases the chance of more sexual partners over one's lifetime also
increases, and therefore intensifies the risk of STDs. Such relationship patterns increase
the adolescent’s risk of acquiring a STD.

Female adolescents are also psychologically vulnerable to older men often do to
their low self-esteem These relationships with older men often make negotiation of
condom use difficult for the adolescent female. The female adolescent lacks
assertiveness to insist that her older male partner use condoms for STD prevention.

On the basis of interviews with a large number of adolescent women, Thompson
(1990) reported that they began sexual activity in one of two scenarios: (a) intercomse
"just happened" and (b) intercourse was planned. Lesbian adolescents began sexual
activity in either scenario, often their first sexual relationship being heterosexual and then
lesbian relationships develop. Because the STD rate is high in gays, many people
assumed it would be high in lesbian women also. However, researchers found that
lesbian women had very low rates of STDs (Johnson, Smith &Guenther, 1987; Robertson
& Schachter, 1981). No current data was found on lesbian adolescents and their rates of

STDs.

3 1
Current and Em’ Concerns of STDs

Current and emerging concerns that make the prevention of STDs difl‘icult
include such problems as the huge number of infected individuals with no symptoms, the
synergy between STDs and human immunodeficiency virus (HIV) infection and the
particular vulnerability of females to STDs based on their biology. The STD field has
expanded from a "narrow group of 'Classic Venereal Diseases' to multiple bacteria,
fungi, ectoparasites, protozoans and viruses" (Shulman, Phair & Sommers, 1992 p.238).
In three decades, more than 50 organisms or syndrome combinations have been identified
as sexually transmitted (Cates, 1991). The societal, physical and psychological impacts
ofthe STD crisisare staggering. The fiscalcost ofcaring forpatientswithSTDs is
soaring. Billions are spent each year for the treatment of SIDS and their consequences
(Alexander, 1992). In 1990, the estimated cost of pelvic inflammatory disease and its
sequale was more than 8 4.2 billion ("Contraception and the STD epidemic", 1992).

A crucial concern to be conscious of in the prevention and detection of STDs is
that significant proportions of persons with STDs have no symptoms. Most new
infections are acquired from individuals who are unaware that they have a transmissible
disease. In general, STDs are transmitted primarily by individuals who either lack '
symptoms of infection or do not perceive the importance of mild manifestations. Most
people with such symptoms as urethral or vaginal discharge, dysuria, genital sores or
pelvic pain are less likely to be sexually active than persons without such symptoms.
Therefore,thepersonwhotransmitsaSTDto hisorherpartnerisunlikelyto have

symptoms that will cause him or her to seek medical attention (Hansfield, 1996).

32

Even infections that are usually symptomatic such as gonorrhea or trichomoniasis
can be present for extended periods without the development of symptoms or signs. The
critical point then, is that every STD can be asymptomatic. It is a mistake, especially for
the female patients, to assume that they can easily identify possibly infected partners, or
for clinicians to expect all patients with STDs to have visible signs of infection.

All sexually transmitted diseases are behaviorally and clinically interrelated, and
the term "epidemiological synergy" has been applied to interactions between HIV
infections and the other STDs (Wasserheit, 1992 p.61). The presence of STDs facilitates
the HIV spread because the lesions or inflammation in the genital tract make ready points
of entry for the virus. In addition, the presence of HIV influences the natural course,
diagnosis, clinical manifestations and response to therapy of STDs. Coinfection may
amplify the transmission and progression of each disease, indicating the treatment of the
non-HIV infections to decrease HIV risks (Hansfield, 1996).

Women carry the greatest burdens of STDs biologically (Aral, 1992). This is
known as "biological sexism" (Hatcher, Trussel, Stewart, Stewart, Kowal, Guest, Cates &
Policar, 1994). Many infections are transmitted more efficiently fiom men to women
than the reverse. Women have more asymptomatic infections that lead to delayed and
often difficult diagnosis and more serious sequale with irreversible damage to the
reproductive system or serious illness. One coital episode carries a higher risk of
infection for the female than the male. In addition, STDs carry a greater social stigma for
the female. Fear or embarrassment may keep the female patient from seeking medical

care, thus increasing the risks of infection (Hatcher et al., 1994).

33
91:11 E. ue of the M Review

Reviewing the literature on adolescents and STDs proved to be quite extensive,
but few articles were found relating specifically to adolescent’s perceptions of acquiring a
STD. Many articles addressed adolescents in general, not just females, and the alarming
incidence rates of STDs in this population. Those articles that did address the female
patient often focused upon the risk of pregnancy and not STDs. Research and non-
research articles written by physicians as well as APN's often related to the diagnosis and
treatment of STDs. Several articles addressed adolescent's development both biologically
and psychologically as well as the social factors that place adolescents at increased risk
for STDs. Informtion regarding early screening and detection of adolescents that are at
high risk of acquiring a STD was quite often ignored.

There was also little information available on how providers feel about discussing
STDs and sexual behavior with adolescents. It was noted that the adolescent patient and
health care providers were both uncomfortable with discussing sexual issues and often
the conversations about these subjects were not brought up or did not occur at all. A
misconception also noted was health care providers perceive adolescents do not want to
discuss issues of sexuality, when in fact they really do.

Many of the articles and studies proposed the need to further evaluate adolescent's
perceptions and how they impact their sexual behavior. In the growing body of research
about adolescent's sexual behavior, which is based generally on survey methods, there is
scant in-depth information about how adolescents feel and what their perceptions are
regarding their own sexual behavior. It was mentioned numerous times that a shift was

needed fiom just teaching the facts (knowledge) about STDs to addressing the

34
adolescent's developmental needs and perceptions. Projects such as this one are needed
to stimulate the discussion of STDs and also to understand how the female adolescent
views her own personal risk and whether or not she will be likely to prevent a STD.
Project Development

Mach and Procedures

Often the approach used to screen for STDs in the primary care setting is the
routine history and physical questionnaire. Many practitioners devise their own
screening tools for assessment of risk of acquiring a STD and they improvise according
to the age or sex of the patient. There are no specific tools available that screen female
adolescent’s perception of risk for, knowledge of and likelihood of taking action to
prevent a STD. The tools to assess the female adolescent’s risk for STDs must be
concise, age appropriate and easy to use. This tool will be used in a primary care setting,
given by the APN in a guided interview type format and then the findings reviewed with
the female adolescent patient (see Appendix A). It is the belief of this author the female
adolescent will answer the questions more honestly in a guided interview type format
than if she were to fill out the tool as a questionnaire. This screening tool maybe costly
in administration, but if the answers are more realistic and truthfirl of the female
adolescent's actual behavior than the overall costs may be less secondary to prevention.

The clinical strategies used to prevent the spread of STDs are often classified by
the stage of illness they target. The least expensive and most effective approach to
prevent STDs is primary prevention or avoidance of exposure (Kassler, Wasserheit &
Cates, 1996). Prinmry prevention strategies are implemented before the sexually

transmitted infection occurs and involve reducing or eliminating risk factors. Secondary

35

prevention consists of organized, direct screening efi‘orts or education of the public to
promote early case findings of individuals with disease (sexually transmitted disease) so
that prompt intervention can be instituted to halt pathologic processes and limit disability
(Pender, 1996). This screening tool is to be implemented as a secondary prevention
technique. It is not the intent of this author that only the tool should be used. This author
recommends that this tool be used in conjunction with the routine health and lirmily
history form. It will be important for the APN to use his/her assessment and interviewing
skills to complete a more in depth assessment. The tool will help to screen for
misperceptions of risk and inaccurate information about STDs. If the patient has not ever
been sexually active, or perhaps is contemplating becoming sexually active the screening
tool may be used as a way to open discussion, allow for teaching and counseling
regarding sexually transmitted diseases.

Makingsurethefemaleadolescentisnotansweringthequestionsinthetoolina
manner that would under estimate personal risk is important. The tendency to
systematically underestimate personal risk has been termed "optimistic bias" (Weinstein,
1989). Moore and Rosenthal (1992) found that college students are optimistically biased
in their perceptions of relative risk for STDs. Little is known about early adolescent’s
perception of risk for STDs, one study conducted suggests that they too have optimistic
bias in their perceptions of risk for STD outcomes (Millstein, 1989). When the APN is
using the tool with the female adolescent patient it will be very important to clarify any
questions that would tend for the patient to answer in such a way that would

rmderestimate personal risk for acquiring a STD.

36

Many clinicians would recommend that all sexually active adolescents be
screened for STDs yearly, especially since asymptomatic infections are common (Holmes
& Mardh, 1990). The absence of definitive symptoms or physical findings does not rule
out an infection. This tool is designed to help the APN teach the adolescent female
patient about the signs and symptoms of STDs and also modes of disease transmission.
Because of the asymptomatic nature of these infections it is crucial that the APN provide
accurate information and assess those patients that are at potential risk for acquiring a
STD.

In this time of health care constraint, the cost of providing adolescent health care
is viewed by some as an impediment. Because of the very complex issues that
adolescents face, both developmental and societal, health care visits may be time
consuming if comprehensive care is to be provided (Scott, 1996). A comprehensive
initial database is essential in providing care even for facilities that treat only STDs.
Thirty to forty-five minutes has been recommended as the time necessary for an initial
adolescent visit (Scott, 1996). Currently, 49% of adolescent visits with physicians last 10
minutes or less and 23% of these visits are first encounters (Society for Adolescent
Medicine, 1992). The use of this screening tool with the adolescent female is realistic in
view of the current time constraints in primary care. It is the intent of this author that the
APN can, with the use of this tool, complete an accurate assessment of the female
adolescent within a thirty to forty-five minute time period. As mentioned previously the
costs of not screening the female adolescent is more than the initial cost of STD

prevention.

37

If sufficient personal perception of risk or lack of information is identified while
using this screening tool in conjunction with the routine health and family history, it will
be the APN's responsibility to initiate appropriate medical management of the patient.
Treatment of patients with STDs involves tertiary prevention strategies. These strategies
are implemented to prevent adverse outcomes once an infection has occurred and are
directed in minimizing residual disability from disease (sexually transmitted disease) and
helping the female patient live productively with limitations. There are no strict
guidelines as to the number of questions the patient has to answer that would indicate risk
for a STD, when using the screening tool. The APN must rely on his/her knowledge of
STDs, clinical skills and follow recommended standards ofcare when assessing the
female adolescent’s responses to the tool. The APN can also collaborate with fellow
practitioners and nuke appropriate referrals as needed.

This screening tool was developed to better understand the female adolescent
patient’s perception of personal risk for, knowledge of and the likelihood of taking
preventative action for STDs. This tool was not designed to specifically address the
female adolescent's sexual behavior. It is this author's belief that as a result of using this
tool with the female adolescent patient the discussion of her sexual behavior will occur.
AstheAPN becomesmore familiarwiththeuseofthetool, itisthisauthorsbeliefthat
the APN will also become more comfortable with discussing STDs and a sense of
confidence in this area of adolescent sexuality will develop over time. The ultimate goal
of STD prevention is to modify the risky sexual behavior that places the female

adolescent patient at risk for acquiring a STD. It is this author's conviction tint by

38

incorporating this screening tool into use with the routine history and physical, areas of
sexuality that are often ignored and seldom addressed will be discussed by the APN.
Target Group

Adolescent females were chosen as the p0pulation of focus for this scholarly
project screening tool. The female adolescent population was the obvious target group
because they have been identified as the population of greatest risk for acquiring a STD
and suffering long-term consequences as a result. For this scholarly project the female
adolescence is defined as early (10-13 years), middle (14-16 years) and late (17-19). For
this scholarly project the adolescent female must be between the ages of 10 and 19, but
this tool could be modified to be relevant for those female patients over 20 years of age.
For purposes of this scholarly project the female adolescent patients must be able to
speak and understand English.
Tool Development

The screening tool for the female adolescent was compiled for this scholarly
project consisting of a series of questions pertaining to five content areas: (a) perception
of susceptibility to STDs, (b) perception of seriousness related to acquiring a STD, (c)
knowledge of STDs, (d) benefits of taking action to prevent a STD, and (e) barriers
encountered in the process of taking action to prevent a STD. The first three sections of
the screening tool are composed of four questions and the last two sections have three
questions each, bringing the total number of questions to 18. Each section of the
screening tool is to be evaluated separately, since each section identifies a specific area of

risk.

39

This author developed all questions on each of the age-appropriate risk
assessment tools after conducting a literature search on female adolescents and STDs.
The questions are to be administered by the APN in a guided interview type format. It
was this authors intent that by administering the tool in this manner it would facilitate
further discussion by the APN and the female adolescent patient. The following
discussion will describe the questions, possible responses and includes the rationale for
question selection on all three screening tools.
m Adolescent (10-13 years) Risk Assessmem Tool

The first section of questions of the screening tool is related to the early
adolescent females perceived risk of contracting a STD (see Appendix B). The patient's
responses to these four questions will help the APN determine if the adolescent: (a) has
been sexually active, (b) sees herself at risk for acquiring a STD, and (c) has an older
boyfiiend that has been sexually active in the past. If the patient answers "yes" to all the
questions except for number three then she would be seen as at risk for acquiring a STD
and also misguided in her perception of personal risk. A "red flag" question in this
section would be if the patient has an older boy friend tlmt has been sexually active.
Even ifthe patient has statedtlmt shehasneverhad sex before she should stillbe seenas
at risk for acquiring a STD. The APN must take into account that adolescent boys of this
same age group are intensely curious about sex, but few are sexually active (Alan
Guttrnacher Institute, 1981). Therefore most sexual partners of young adolescent females
willnot beyoung menoftheir ownage as is still noted inthecurrent literaturetoday.

The second section of questions is related to how serious does the early

adolescent female perceive a STD to be and how will it afl‘ect her. If the patient answers

40
"no" to all the questions except for number three than she does not perceive the serious
nature or complications of SIDS. Because the early adolescent at this cognitive level
does not generally think beyond the next several weeks or months there were no
questions directed at the future or long term consequences of STDs. It will also be
important for the APN to impart to the patient that pills and shots do not always cure
everything and some diseases you will have for the rest of your life.

The third section of questions is related to knowledge of STDs. These questions
are designed to determine what information about STDs the patient aheady has obtained.
The APN can also use these questions to clarify any misinformation the patient might
have been given. One question was designed to give the patient possible options as to
modes of transmission of STDs. It was discovered during the literature search that many
adolescents do not tmderstand how people can get STDs and many believed that STDs
were transmitted by swimming pools (OTA, 1991). Education will be an important area
for the APN to concentrate on when dealing with the early female adolescent patient.

The last two sections ofthe screening tool are the perceived benefits and barriers
to STD prevention. The benefits questions for the early adolescent are constructed to
help the APN understand if the patient believes that she can do something to prevent a
STD. These questions were also designed to promote the concept of abstinence with the
female adolescent. The APN needs to emphasize the firct that abstinence is the only way
to prevent STDs tmless condo-s are consistemly used every time intercourse occurs.
Delayingtheage offirstintercom'seisafactthatisalsoknownto decreasetheriskof
acquiring a STD among female adolescents (OTA, 1991). It is hoped that if the female

adolescent response to the questions in a manner indicating she understands the benefits

41
of not acquiring a STD that she would be more likely to be abstinent, delay the age of
first intercourse or always use a condom.

Based upon the review of the literature many adolescents are concerned about
confidentiality and their parents finding out they have a STD. The questions regarding
barriers are based upon these findings. The early adolescent because of age is still under
the care and supervision of her parents. The female adolescent might answer the
questions in such a manner that demonstrates her reluctance and fear oftelling her
parents that she has been sexually active or possibly has a STD. It is important that the
APN informthe female adolescent patient whom she can tell ifshe thinks she has a STD,
stresstothepatientmattersofconfidentialityandalso thatmost clinicsdo notrequire
parental consent for treatment of STDs.

Middl 14-1 . -:u s m; = e 17-1' ear Atol~ en ’ '. 2;,- ohm m

The questions formulated by this author for these screening tools are very similar
in content, therefore, they will be discussed together with the subtle differences noted
(see Appendix C for middle adolescents (14-16) and Appendix D for late adolescents
(17-19) for tools with specific questions). The first set of questions on both tools is
related to the female adolescent's perception of susceptibility (risk) for acquiring a STD.
These questions are constructed to help the APN determinezl) if the female adolescent
hasbeensexuallyactive, 2) howmanypartners shehasbeenwith, 3) ifshethinks shehas
a STD and 4) whether or not she uses condoms consistently. If the female adolescent in
either age group has been with more than one partner or inconsistently uses condoms she
is at risk for acquiring a STD. The questions of susceptibility designed by this author for

the (14-16 years) middle adolescents group differ fiom their younger counterparts by the

 

 

Ir
«a

42
fact that they are more sexually experienced, not just physically experienced but socially
as well. The late female adolescent is even more sexually experienced. By the 12th
grade nearly 70% of adolescents have had sexual intercourse and approximately one-
quarter of all students have had sex with four or more partners (IOM, 1996). Thus, when
the APN questions the late adolescent female about the number of partners she has had
withinthepast year, the answer shouldbe furtherquestioned bythe APN ifthe patient
states only one.

The second set of questions on the screening tools is related to how serious does
the middle/late adolescent female perceive STDs to be. The 14-16 year old adolescent
female is cognitively going through the process of developing more future oriented
thinking. Because of this change in cognitive thinking of the middle adolescent female
the questions for this age group were to designed to reveal the long-term complications of
STDs. If the female adolescent answers "no" to questions 2, 3, and 4 and "yes" to
question 1, than she is misguided in her perception of how serious STDs really are. The
denial of personal risk is a factor that the APN must expect fiom these age groups. Thus,
any endeavor undertaken by the APN should recognize the denial factor in attempting to
influence the adolescent patient.

The third section of the screening tool is questions related to knowledge of STDs.
Many females in both middle and late adolescence are concermd only with prevention of
pregnancy and little thought is given to prevention of STDs (OTA, 1991). The questions
regarding knowledge of STDs allows the APN to address this issue with the female
patient. Question #1 asks if birth control pills or the shot prevent STDs; if the patient

answers "yes" than she has been misinformed about what birth control does and how

43
STDs are prevented. The remaining questions provide the basis for the APN to further
educate the female adolescent patient. These questions encourage discussion by the APN
ofthe asymptomatic natureofSTDsandhow treatment willbe meded even ifthe
symptoms do go away.

The final two sections of the risk assessment tool for the middle and late
adolescent femalearequestions onthebenefitsandbarriers inundertakingthe
recommended action to prevent STDs. The benefit questions will enable the APN to
assess if the ferrule adolescent believes that she can prevent STDs. The third question in
the benefits section of the tool differs slightly for the middle adolescent than the late
adolescent. The middle adolescent female is asked if she believes that by delaying
intercourse it could help prevent a STD. If the patient answers "no, I don't believe this" it
willbe a "red flag" areathattheAPNwillneedto assess further. Asmentioned
throughout this scholarly project, if the female adolescent delays having intercourse until
she is older it will biologically allow her cervix to mature and also time to develop
antibodies to protect her fiom infection. The third question for the late adolescent in the
benefits section is an attempt to recognize the fact that late adolescent females pursue a
sexual life for reasons such as the physical pleasure, emotional intimacy or being
attractive to others. The APN when using this screening tool must not ignore these
factors when assessing the older adolescent female. The patient might perceive that it is
more important to satisfy one's sex drive and disregard the benefits of not acquiring a
STD.

The last section of questions addresses the issue of barriers that the middle and

late adolescent female might encounter in preventing STDs. In reviewing the literature

44
for question development the most common barriers encountered by the adolescent
population were related to condoms. If the female adolescent answers the questions in
the barriers section by saying that she or her partner does not enjoy using condoms, or
they are inconvenient to use, then it is likely she is not going to protect herself fi'om a
STD. It will be important for the APN to assist the female adolescent to overcome the
obstacles to condom use since it is essential in preventing STDs. The middle adolescent
like the early adolescent might also perceive that parental permission is a barrier to
obtaining treatment for STDs. The APN will nwd to inform the middle adolescent
femalethatparentalconsent isnotneededforthetreatment ofSTDsandalso
confidentially will be maintained.
File!

A pilot of the tool was not conducted for this scholarly project; instead the tool
was given to the following persons for them to review. The tool was given to a Women's
Health Nurse Practitioner working in a Family Planning and Obstetrics Clinic, a Family
Nurse Practitioner and also two different OB/GYN physicians. After reading the
questions, they spoke with the author and gave insight on other possible questions and
their own comments on the usability of the tool in practice.

Discussion
Evaluation of Tool

The peer review of the tool proved to be less effective than what was originally
expected. It is this author's belief that the peers who reviewed the tool did not want to
upset the author with any negative comments. The APN working in a family practice

ofi'rce felt the tool was practical and could be incorporated into the history a physical

45
forms. The APN working in the family planning and obstetric clinic gave the best
comments since adolescent females are her clientele. This APN thought that some of the
questions on the middle and late adolescent tools should be changed to difl‘erent sections
such as from knowledge to perceived susceptibility. Her overall comments were very
positive and she thought the questions were relevant to the female population and
addressed areas that are often overlooked by the provider. The two OB/GYN physicians
thought the questions "looked good" and were interested in using the tool on some of
their female adolescent patients.

A pilot test of the tool must be done with a diverse population of adolescent
females. A meeting would need to be conducted between this author and the staffto
familiarize everyone involved with the screening tool. The pilot study would be
conducted first on a small sample of female adolescents and based upon the
responses/reactions and overall impression of the tool refinements and revisions shall be
made. This author would like to pilot the tool at the Women's Health Center clinic and
also haveanotherpractitionerusethetoolwithasimilarpopulationandsee ifthe results
are similar. The author could then determine ifthere is any reliability ofthe screening
tool. Using the tool over a period of time, which will help to prove its reliability, will
also assess the tool’s stability.

Thisauthorwouldalso liketo givethetoolto PractitionersattheCountyHealth
Department working in a STD clinic. The tool would be reviewed by Practitioners this
author does not personally know, with the hope of receiving objective comments. This
author would also be more direct in asking about feedback on specific questions such as;

do you think the client will understand the questions, did the Practitioner find it difficult

46
to use, or is it too long or short? This objective feedback will also help in making
revisions of the tool.

It will also be necessary to provide the tool to an expert in the field of adolescents
and STDs. This expert could verify content validity. This author has begun to establish
content validity by documenting the literature, which represents the concepts and
questions.

I lications for Adv Practice Nurse

Since the APN working in a primary care setting has the specific task ofhealth
promotion and illness prevention it is the perfect time to screen for perceived risks that
can lead to poor health. The APN is in an excellent position to screen for female
adolescent’s perception of risk for, knowledge of and the likelihood of taking action to
prevent a STD. The APN can incorporate this screening tool into the routine health
history and physical exam, family planning services, sports physicals and perhaps some
acute care visits. This author believes that the screening tool should be used with all
adolescent females who are seeking primary care services.

The APN will determine if the patient has risk factors for acquiring a STD based
upon perceptions of her own personal risk for and knowledge about STDs. For those
adolescent females who are not identified as at risk for acquiring a STD, the APN will be
able to use the screening tool to open discussion on STDs as well as sexual behavior.
Using the tool in this manner will provide the female adolescent with knowledge
regarding STDs and a personalized risk assessment, hopefully preventing her from

acquiringaSTDinthefiiture.

47

The APN is in a position to provide education regarding STDs to small groups
within a specific practice or health system Group sessions for females at high risk to
correct misconceptions about risks and ways to reduce them, as well as practice and
training in these skills, lmve been found to reduce risk behaviors associated with STDs
(Kelly, 1994) The APN could provide information through interactive small groups
designed to help the female adolescent role play on how to handle awkward sexual
situations. This would allow the APN to reach many adolescent females at one time
instead of only focusing on the one on one relationship. For example, the APN could use
the screening tool with a small group of female adolescent patients, identifying perceived
barriers that might be encountered, such as negotiating condom use with a male partner
or pmchasing condoms. The APN could then assist the female adolescent patients in role
playing how each of their perceived barriers would be overcome.

ThisscreeningtoolwasdesignedtobeusedbytheAPNasasecondary
prevention strategy. It is this author's belief that this screening tool will provide the APN
with a theoretical framework from which to discuss many primary prevention techniques
and many aspects ofST'Ds with the female adolescent patient. This screening tool can
promote the discussions of: abstinence; knowing partners well before sexual
relationships; use of drugs and alcohol with sex; decreasing the number of sexual
partners; and methods of protection to prevent a STD.

IfitlmsbeendeterminedbytheAPNafierusingthescreeningtoolthatthefemale
adolescent patient is at risk for acquiring a STD, then tertiary prevention strategies will
be implemented. The specific plan of care or interventions will be based upon

appropriate standards of care and each office policies and procedures for treating patients

48
with STD infections. Those female adolescents identified at risk will require general
screening cultures for STDs and a pelvic exam performed by the APN. If the female
adolescent patient had a STD she will be diagnosed and treated appropriately. The APN
will also participate, if needed in partner notification and request these individuals to
come into the office/clinic to be treated as well.

It is this author’s belief that once the screening tool has been tested, revised and
refined it will have the potential for broader application. As mentioned earlier in this
scholarly project this screening tool could be modified for use in women over 19 years
oldandbeyond. Sexuallytransmitteddiseasesdo not stop atage l9;there are infact
many women at risk for acquiring a STD tlmt might never be questioned or diagnosed
due to lack of proper screening techniques. This screening tool could also be altered to
be used with the adolescent male population as well.

Anareathatmdstobeaddressedandhasnotyet beendiscussed bythisauthor,
isthe facttlnttheenvironmentalso oontributesto STD risk. Themassrmdiahas
glorified sex without counterbalancing prevention messages (OTA, 1991). Children and
adolescents are particularly exposed and susceptible to explicit and implicit messages in
such media (IOM, 1996). Many adolescents are not receiving appropriate information
regarding STDs and sexual behavior from their parents or other sources (IOM, 1996). It
is this author's belief that something should be done including writing letters to local TV
stations and the larger networks encouraging them to broadcast inforrmtion regarding
STDs and healthy sexual behaviors, including delaying sexual intercourse and using
condoms, with a special focus on reaching adolescents and young adults. Another small

step, but one that all APN's could participate in is to have educational programs about

49
STDs and prevention shown on the office waiting room TV instead of the usual afternoon
soap operas.

The HBM does have limitations when applied to the adolescent population. The
female adolescent must perceive that she is at risk for acquiring a STD and often because
of her sense of invulnerability and stage of development this perception is distorted. In
order for prevention to occur the female adolescent must perceive a STD as a health
threat. The HBM also fails to acknowledge the "positive" motivators of adolescents
having sexual relationships. Although the HBM may have some weaknesses in its use
with the adolescent population, its emphasis on the individual's perceptions may be the
key to influencing adolescent behavior. Educators in the field of sexual health must look
at the female adolescent’s needs and determine how their present behavior is fulfilling
them. After assessing what the female adolescent perceives as barriers be it
misconceptions or lack of information, the APN can intervene. Using the findings from
the screening tool as a guide, the APN can assess each female individually and design
specific interventions to encom'age healthy sexual behavior.

Education should continue to focus on teaching modes of STD transmission and
efi‘ective means of protection. The often-asymptomatic nature of STD infections and the
seriousness of the sequale of PID, ectopic pregnancy, and infertility should also be
stressed. Instruction on decision making skills and negotiating condom use should be
included. The APN should also encourage a return demonstration of condom use on a
model to instill a sense of self-confidence in the adolescent patient. It is the hope of this
author that with the introduction of the screening tool into the clinical setting, it will

stimulate and open discussion among the various health care providers on how to

50
approach the subject of STDs and how to counsel adolescents on such a sensitive topic.
It has been identified that my clinicians and adolescents do not feel comfortable talking
about sexual issues but these conversations do need to occur and over time with the use
of tools such as this one, a sense of confidence will be developed in the APN.

Although many of the severe health consequences of STDs manifest themselves
among adults, these complications usually result from infections or health behaviors
initiated during adolescence (IOM, 1996). Adolescent females are at great risk of STDs
because they fiequently have unprotected intercourse, are biologically more susceptible
to infection, and are likely to have social problems that significantly increase their risk
(IOM, 1996). The APN working in a primary care setting provided with the proper
screening tool can design interventions tailored specifically to the female adolescents
needs. Interventions by the APN include targeting misconceptions and perceptions of
personal vulnerability and assisting the female adolescent to make a more realistic STD
risk assessment. Attitudinal studies of adolescents have suggested that clinician
fi'iendliness, understanding and willingness to take their time are important to
adolescent’s compliance with the STD treatment regime (OTA, 1991). The APN
embodies all of these unique qualities and can make a difference in the health and overall
well being of the female adolescent patient.

Finally, further research is needed to examine the meaning of sexuality and sexual
intercourse for the female adolescent, as well as the influences on her sexual behavior
and sense of vulnerability. Most research to date has not shown significant changes in

adolescent’s behavior alter the introduction of STD prevention campaigns. A shift is

51

needed fi'om teaching just the facts about STDs to addressing the female adolescent's

developmental needs and perceptions and maybe this approach will be more successful.

APPENDICES

APPENDIX A

APPENDIX A

Guidelines for Administration of Screening Tool

The screeningtoolwasdesignedtobeadministeredbytheAPN inaguided
interview type format with the female adolescent patient. The APN will ask the
questions directly. The APN should conduct the interview in a quiet, comfortable place
and allow at least thirty minutes to conduct the interview. The APN must inform the
patient that all answers to the questions are kept confidential and parental consent is not
needed for treatment of STDs.

The APN will need to use interviewing and assessment skills to stimulate further
discussion, specifically asking the client to tell more about each specific question. The
APNwillalsoneedtomake surethattheclientdoesnot answerthequestionsinsuch
mannerthatwouldunderestimateherpersonalrisk. TheAPNwillneedtoclarify
questions to prevent this underestimating of personal risk.

There are specific questions that will require more in depth evaluation by the
APN. These questions are considered to be potential "red flags" to indicate the female
adolescent would be at higher risk of acquiring a STD. The contents of the questions
requiring further assessment by the APN are as follows:

1. Patient has an older boyfriend that has been sexually active.

2. Patient is misinformed of the treatment and general knowledge of STDs.

3. Patient thinks parental consent is needed for treatment.

4. Patient has multiple partners.

5. Patient does not believe that delaying intercourse would be beneficial to her.
6. Patient does not consisteme or refitses to use condoms.

52

53
There are no specific guidelines as to the number ofquestions the patient has to
answer that would indicate risk for a STD, when using the screening tool. The APN must
rely on his/her knowledge of STDs, clinical skills and follow recommended standards of

care when assessing the female adolescent’s responses to the tool.

APPENDIX B

APPENDIX B

A Risk Assessment Tool for Sexually Transmitted Diseases
Early Adolescent Females (lO-l3years)

Susceptibility to Sexually Transmitted Diseases

1.

2
3.
4

Have you ever had sex with another person?

Have you ever heard of sexually transmitted diseases?

Do you think that you can get a sexually transmitted disease?

Has your boyfriend ever had a sexual relationship with someone else?

Seriousness of Sexually Transmitted Diseases

1.
2.
3.

4.

Will having a sexually transmitted disease cause you pain?
Will a pill or a shot always cure a sexually transmitted disease?
Will having a sexually transmitted disease make your body look different?

If you have sex with somne just once do you have to worry about getting a
sexually transmitted disease?

Knowledge of Sexually Transmitted Diseases

1.

How do you get a sexually transmitted disease?

Objects Kissing Sex Don‘t Know
What do you think are signs/symptoms of sexually transmitted diseases?
Can you always tell if somne has a sexually transmitted disease?

Are sores on genital (private areas) a sign of a sexually transmitted disease?

54

55

Benefits of Preventive Action

I.

Do you believe it would be good for you if you did not get a sexually transmitted
disease?

Do you believe that if you wait until you are older to have sex this will help you
not get a sexually transmitted disease?

If you knew that you could prevent a sexually transmitted disease would you do
something?

Barriers to Preventive Action

1.
2.

3.

Who would you tell if you thought you had a sexually transmitted disease?
Do you know where you could get condoms?

Will you need your parents permission to get treated for a sexually transmitted
disease?

APPENDIX C

APPENDIX C

A Risk Assessment Tool for Sexually Transmitted Diseases
Middle Adolescent Females (14-16 years)

Susceptibility to Sexually Transmitted Diseases

1.

2.

In your whole life how many people have you had sex with?

How afi'aid are you that you might have a sexually transmitted disease in your
body now?

How many times out of the last ten times that you have had sex, did you use a
condom?

How sure are you that you can tell if someone you would like to have sex with
has a sexually transmitted disease?

Seriousness of Sexually Transmitted Diseases

1.

2.

Will a pill or shot always cure a sexually transmitted disease?
Will having sexually transmitted diseases affect your fitture sexual relationships?

Could having a sexually transmitted disease prevent you fi'om having children
some day?

Could you get cancer some day from having a sexually transmitted disease?

Knowledge of Sexually Transmitted Diseases

1.

Will taking birth control pills prevent you from getting a sexually transmitted
disease?

Does using condoms prevent all sexually transmitted diseases?
Can you always tell if you have a sexually transmitted disease?

Should you still be concerned about a sexually transmitted disease if the
symptoms clear up in one to two weeks?

56

57

Benefits of Preventive Action

1.

Do you believe that it is beneficial to you to avoid sexually transmitted diseases?

2. Do you believe it will be beneficial to you to use condoms?

3. Do you believe if you waited until you were older, to have intercourse, it could
help you prevent getting a sexually transmitted disease?

Barriers to Preventive Action

1. Are you embarrassed to use condoms?

2. Are condoms easy for you and your partner to use?

3. Will most clinics require permission from your parents to get treatment for a

sexually transmitted disease?

APPENDIX D

APPENDIX D

A Risk Assessment Tool for Sexually Transmitted Diseases
Late Adolescent Females (17-19 years)

Susceptibility to Sexually Transmitted Diseases

1.

How afi‘aid are you that you might have a sexually transmitted disease in you
body now?

How many partners have you had sex with in the past year?

Are you confident that you can tell if someone that you would like to have sex
with had a sexually transmitted disease?

How many times in the last 10 times that you had sex did you use a condom?

Seriousness of Sexually Transmitted Diseases

1.

2.

Will a pill or a shot always cure a sexually transmitted disease?
Could you get cervical cancer fi'om having a sexually transmitted disease?

Could having a sexually transmitted disease prevent you fi'om having children
someday?

Will having a sexually transmitted disease affect your fitture sexual relationships?

Knowledge of Sexually Transmitted Diseases

1.

Will taking birth control pills or the “shot” prevent you fi'om getting a sexually
transmitted disease?

Is the only way that you can catch a sexually transmitted disease is by having sex
with someone who has one?

Can you always tell if you have a sexually transmitted disease?
Does using condoms always prevent you from getting a sexually transmitted

disease?

58

59
Benefits of Preventive Action
1. Do you believe it is beneficial to use condoms?
2. Do you believe it is beneficial to avoid sexually transmitted diseases?
3. Which is more important to you lmving intercourse or not getting a sexually
transmitted disease?
Barriers to Preventive Action
1. Are condoms easy for you and your partner to use?
2. When you use condoms do you enjoy sex?

3. Are you embarrassed to use condoms?

LIST OF REFERENCES

LIST OF REFERENCES

Adams, P. F. & Schoenborn, CA. (1995). Health-risk behaviors among our
nation's youth: United States, 1992. Vital and Health Statistics 192 1-34.

 

Agyei, W.K., Epema, E.J., & Lubega, M. (1992). Contraception and prevalence of
sexually transmitted diseases among adolescents and young adults in Uganda.
International Jomnal of Epidemiology, 21, 981-988.

Aho, W.R. (1979). Participation of senior citizens in the swine flu inoculation
program: An analysis of health belief model variables in preventive health behavior.
Journfl of Gerontology 34, 201-208.

Alexander, L. (1992). STD: Perspective on this growing epidemic. Mug;
Mitioner, 12(10), 31-42.

Allard, R. (1989). Belief about AIDS; A determination of preventive practices and
support for coercive measures. American Journal of Public HEM; 79, 448-452.

Aral, S. (1992). Sexual behavior as a risk factor for sexually transmitted disease.
In A. Germain, K. Holmes, & J. Wasserheit (Eds.), Reproductive tract infections.
(pp. 185-198). New York : Plenum Press.

Assessing and counseling patients at risk of STDs and HIV. (1994). STD Update:

'93 : STDs in the '908. In the Association of Remoductive Health Professionals clinical
proceedings (p.13). Washington DC : AHRP.

Becker, M.H. (1985). Patient adherence to prescribed therapies. Medical Cm, 23,
539-555.

Becker, M.H. (Ed). (1974). The health belief model and personal health behavior.
Health Education Monomh, 2, 324-508.

Biro,F.M., Rosenthal, S.L.& Stanberry, LR. (1994). Knowledge of gonorrhea in
adolescent females with a history of STD. Clinical Pediatrics 33 (1),601

60

61

Boyer, C. B. (1990). Psychosocial, behavioral, and educational factors in

reventing sexually transmitted diseases. Adolescent Medicig' e: State of me An Reviews,
1, 597-613.

Boyer, C.B., Shafer, M.A., & Tschann, J.M. (1997). Evaluation of a knowledge
and cognitive behavioral skills building intervention to prevent STDs and HIV infection
in high school students. W (125), 25-41.

Braverman, P.K. & Strasburg, V.C. (1994). Sexually transmitted diseases.
W (1), 26-37.

Brown, L. K., DiClemente, R.J., & Reynolds, L. A. (1991). HIV prevention3 for

adolescents: Utility of the Health Belief Model. AIDS Educatiog en_dPreve 31199.3 ,
50-59.

Cates, W. (1991). Teenagers and sexual risk taking: The best oftimes and the
worst of times. WM 84-94-

Centers for Disease Control. (1991). Pelvic inflammatory disease: Guidelines for
prevention and management. Morbidity and Mortality Weekly Report, 40, RR 5, 1-25.

Centers for Disease Control. (1992). Sexual behavior among high school students
-United States 1990 WALL 885- 888

Centers for Disease Control. (1992). Health risk behaviors among persons aged
12-21 years - United States 1992. JAMA 1924: 271: 1311.

Centers for Disease Control. (1993). Sexually transmitted disease treatment

guidelines. Morbidgy' and Mortality Weekly Remg, 42, RR-l4, i-10, 19-46, 49-75,
83-93.

Centers for Disease Control. (1996). Sexually transmitted disease surveillance

 

Champion, V.L. (1984). Instrument development for health belief model
constructs. We in Nursin' g ch' ace, 6 (3), 73-85.

Champion, V.L. (1985). Use of the health belief model in determining fiequency
of breast self-examination WW 373-379.

Champion, V. L. (1987). The relationship of breast self-examination to health
belief model variables WW 375- 382

62

Committee on Adolescence. (1994). Sexually transmitted diseases. W,
568-572.

Contraception and the STD epidemic (1992). W (1).
5-11.

Elkind, D. (1979). The child and society: Essays in epplied child development.
New York: Oxford University Press.

Ellen, M. J., Boyer, C.B., Tschann, J.M. & Shafer, MA. (1996). Adolescents'
perceived risk for STDs and HIV infection. Jogmel of Adolegnt Health, 18, 177-181.

Gingsburg, K.G., Slap, G.B., Cnaan, A., Forke, C.M., Balsey, C.M & Rouselle,
D.M. (1995). Adolescents' perceptions of factors affecting their decision to seek health
care. 1% 273, 1913-1918.

Given, C. W, Given, B. A., Gallin, R.S. & Condon, J. W. (1983). Development of

scales to measure beliefs of diabetic patients. W 127-
147.

Hansfield, HR (1996} W New
York: McGraw-Hill.

Hatcher, R., Trussel, J., Stewart, F., Stewart. G., Kowal, D., Guest, F ., Cates, W.
& Policar, M. (1994). Contrmive technology, 16th revised ed. New York: Irvington
Publishers.

Hingson, R.W., Strunin, L., Berlin, B.M. & Heeren, T. (1990). Beliefs about
AIDS, use of alcohol and drugs, and unprotected sex among Massachusetts adolescents.
American Journal of flhlic Hflh, 80, 295-299.

Hittabiddle, SJ. (1996). Adolescent condom use, the health belief model, and the
prevention of sexually transmitted disease. JOGNN 25 (1), 61-66.

 

Holmes, KK, & Mardh P.A.(l990). W 2nd ed. New
York , NY: McGraw-Hill.

Hulka, BS. (1979). Patient and clinician interactions and compliance. In R.B.

Haynes, D.W.Taylor, & D.L. Sackett (Eds). Ware, (pp.63-77). Johns
Hopkins University Press.

63

Igra, V. & Millstein, S.G. (1993). Current status and approaches to improving
preventive services for adolescents. JMA, 269, 1408-1412.

Institute of Medicine (1996). WWWM
Wflommittee on Prevention and Control of Sexually Transmitted
Diseases) Washington, DC.

Janz, N.K. & Becker, M.H. (1984). The health belief model: A decade later.
Health Education Merly, 11, 1-47.

Jette, AM, Cummings, M., Brock, B.M., Phelps, MC. & Naessens, J. (1981).
The structure and reliability of health belief indices. Mb Services Research 16, 81-97.

Johnson, SK, Smith, B.M., & Guenther, S.M(1987). Comparison of
gynecological health problems between lesbian and bisexual women: A survey of 2345
women. Journal of Repeeductive Medicine, 32, (1 1), 805-811.

Kassler, W.J., Wasserheit, J .N., & Cates, W. (1996). Sexually transmitted
diseases. In Health promotion and disease prevention in clinical mtice. Eds S. Wolf, S.
Jonas, & R.S. Lawrence. New York, NY: McGraw-Hill.

Keegles, S.M., Adler, N.E. & Irwin, CE. (1988). Sexually active adolescents and
condoms: Changes over one year in knowledge, attitudes and use. American Journal of

Public Health, 78, 460-462.

Kelly, J. (1994). Sexually transmitted disease prevention approaches that work.
Sexually Transmitted Diseases, 21, (2,Suppl.), s73-s75.

Knight, R.S., & Hay, DA (1989). The relevance of the health belief model to
Australian smokers. Social Science Medicine 28 1311-1314.

 

Kottke, T.E., Brekke, M.L., & Solberg, LL (1993). Making "time" for preventive
services. Mayo Clinic Proe,68 785-791.

Levinson, R.A., Jaccard, J., & Beamer, L. (1995). Older adolescents' engagement
in causal sex: Impact of risk perception and psychosocial motivations. Journal of Youth
and Adolescence 24(3), 349-364.

 

Maiman, L.A., Becker, M.H., Kirscht, J.P., Haefiier, D.P. & Drachman, RH.
(1977). Scales for measuring health belief model dimensions: A test of predictive value,
internal consistency, and relationships among beliefs. Health Education Mommhs, 5,
215-23 1.

64

Marion, L.(l990). Risky and risk reducing sexual behaviors in women:
Determinants and interventions. Ngee Practitiog Pong, l (1), 47-55.

MacDonald, N.E., Wells, G.A., & Fisher, WA. (1990). High risk STD/HIV
behavior among college students. 1% ,263 3155-3160.

McKinlay, J.B.(l972). Some approaches and problems in the study of the use of
services: An overview. 19ml of Health SociaLl Behavior, 13, 115-118.

Meyer, D. Leventhal, H. & Gutrnann, M. (1985). Common sense models of
illness: The example of hypertension. Hgljh Psychelogy, 4, 115-132.

Millstein, S.G.(l989). Perceiv bil' to sexuall .
MW Presented at the 97th Annual Convention of the American

Psychological Association at New Orleans, August.

Moore, S.M.& RosenthaL DA. (1992). Australian adolescents' perceptions of
health related risks. J fAdo nt e 7 177-191.

Mott, F .L. & Haurin, RJ. (1987). The inter-relatedness of age at first intercourse,
early pregnancy and dnig use among American adolescents: W

natioeaj longitudinal survey of youth lebor flket em’ence. Paper presented at annual
meeting of the population association of America. Chicago: IL.

Neinstein, LS. (1991). Adolescent health care. (2nd ed.). Baltimore, MD:
Williams & Wilkins.

Pender, NJ. (1996). Health promotion in nursing pmfice. (3rd ed.). Stamford,
CN: Appleton & Lange.

Pendergrast, R.A., DuRant, R.H. & Gaillard, G.L. (1992). Attitudinal and

behavioral correlates of condom use in urban adolescent males. gem of Adolescem
thh, 13,133-139.

Piaget, J. (1969). The memlegy 9f Q ehild. New York, Basic Books.

Potter, L .B. & Anderson, J. E. (1993). Patterns of condom use and sexual behavior
among never-married women W20. 201-208

Proctor, SE. (1986). A developmental approach to pregnancy prevention with
early adolescent females. 10pm pf Semel Health, 56, (10), 313-316.

65

Ricket, V.I., Jay, S., Gottlieb, A. & Bridges, C. (1989). Adolescents and AIDS:
Females' attitudes and behaviors toward condom purchase and use. Journal of Adolescent
Health Care 10 313-316.

 

Robertson, P. & Sclmchter, J. (1981). Failure to identify venereal disease in a
lesbian population. Sexually Transmitted Diseases, 8, (2) 7 5-76.

Rosenstock, I.M. (1974). Historical origins of the health belief model. Health
Mion Mononghe, 2, 228-335.

Scales, P. (1983). Sense and nonsense about sexuality education: A rejoinder to
Shornack's critical view. Family Relations, 32, 287-296.

Scott, MK. (1996). Reducing the risks: Adolescents and sexually transmitted
diseases. Nurse gem iemr Eogm, 7 (1), 23-29.

Shulman, S., Phair, J. & Sommers, H. (1992). The biological m clinieg b_a§is fer
infectious diseases. (4th ed.). Philadelphia: WB Saunders.

Society for Adolescent Medicine (1992). Access to health care for adolescents: A
position paper of the society for adolescent mdicine. Journal of Adolescent Hefl 13,
162-1 70.

Strasburger, V.C. & Brown, RT. (1991). Adolescgt medicine e ppaetical gm’de.
Boston MA: Little & Brown.

Strunin, L. & Hingson, R. (1987). Acquired immunodeficiency syndrome and
adolescents' knowledge, beliefs attitudes and behavior. Pediatrics 79 825-828.

 

Teenage pregnancy : The problem hasn't gone away. New York, The Alan
Guttmacher Emil—1t. e, (1981). pp 6-21.

 

Tirrel. B.E. & Hart, L.K. (1980). The relationship of health beliefs and knowledge
to exercise compliance in patients after coronary bypass. Heart & Lu, 9, 487-493.

Townsend, V.B.(1996). STDs: Screening, therapy and long-term implications for
the adolescent patient. International Journal of Fertility, 41 109-114.

US. Congress, Office of Technology Assessment. (1991). Adolescent health

volume II : Backgrpund and the effectiveness of selected prevention and treatment
_ser_vige_s_. (OTA-H 466). Washington, DC: US Government Printing Office.

 

66

US Preventive Services Task Force. (1996). Guide to clinical preventive serviees.
(2nd ed.). Baltimore MI): Williams & Wilkins.

Wasserheit, J. (1992). Epidemiological synergy: Interrelationships between HIV
and other sexually transmitted diseases. Sexually Transmitted Diseases,l9 (2), 61-77.

Weinstein, N.D.(1989). Perceptions of personal susceptibility to harm. In Mays
V.M., Albee, G.W., Schneider, S.F. eds. Prim_ary Prevention of AIDS: Psycholegical
approaches. Vol XII. Newbury Park, CA. Sage Publications Inc., 142-167.

Weisman, C.S., Plichta, S., Nathanson, C.A, Ensminger, M., & Robinson, J.C.
(1991). Consistency of condom use for disease prevention among adolescent users of oral

contraceptives. Family Planning Pemtives, 23, 71-75.

 

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