Missed opportunities for intervening with adolescents during office visits

Background: Many adolescents often behave as if they were invincible, which may make them less likely to adhere to a healthy diet and properly exercise and more likely to engage in risky sexual behavior, substance use and interpersonal violence. Unprotected intercourse results in approximately 3 million new adolescent STIs, 1 million pregnancies, and 25% of new HIV cases annually. Among subpopulations in the United States, Latino teens are at high risk for these three sex-related conditions. Among self-reporting Latino high school students (YRBS), approximately 35% engage in sexual activity, but only 57% used a condom at their last sexual intercourse. In addition, approximately 57% of all Latino teens report having used tobacco products, 42% having ever used marijuana, and 79% ever using alcohol. These health risk behaviors are occurring in communities where access to health care is limited. Studies suggest that even when seen for medical visits, providers often miss health education and prevention opportunities. Yet teens have reported that they prefer to receive health information, especially related to sexual risks, from their physicians rather than from parents, friends or teachers.

Purpose: The purpose of this study was to determine the gaps between the high risk behaviors of predominantly Latino adolescents living in San Diego County and documentation of health risk behaviors and counseling by their health care provider.

Methods: This study is part of a larger intervention study of adolescents with latent tuberculosis. The baseline assessment of 265 participants was completed from 2004-2006. The teens in this study were predominantly Latino public school students ages 13 to 19, living in San Diego County, who tested positive for Latent Tuberculosis Infection (LTBI), and consented to participate in a medication adherence trial for treatment of LTBI. Bilingual college-aged research assistants conducted the baseline interviews using a predetermined standardized written script. Health behavior questions related to interpersonal violence, sexuality, substance abuse, exercise, diet, and unintentional injuries. If study participants did not have a heath provider with whom they received routine health care, they were connected to the most geographically proximate, federally-designated Community Clinic. All students in the study saw their provider at least once to start LTBI treatment. Medical records were reviewed to determine whether physicians documented attempts to elicit risk information, provided counseling, and whether there was documentation that the teens provided accurate information. This study was approved by the SDSU IRB.

Results: The study sample was 95% Latino, 60% Mexican born and 43% reported no health insurance. Among providers, 71% were physicians, with the majority pediatricians. Of the 60% of participants who reported ever using alcohol, only 28% had documented inquiries and none had documented counseling. Of the 20% who reported ever using tobacco, only 7% had documented screening and none had documented counseling. Illicit drug use was low in this group (6%), and none were asked or counseled. The majority (74%) ate less than three fruit and vegetables a day, but only 14% had documented dietary inquiries and only 4% had documented counseling. Many of the participants exercised less than 20 minutes a day (39%), but less than 10% of this group had documented inquiry about physical activity. Sexual activity was reported by 15%, the majority not using birth control, but only 20% of this group had documented inquiry about sexual behavior

Discussion: Health care providers evaluated participants in this study because they had recently tested positive for LTBI. Visits prompted by LBTI were used to evaluate whether providers used these as opportunities to address other known adolescent health risk behaviors. In this study, few documented attempts were made to solicit information about behavior, and even fewer counseling attempts seem to have been made. Our finding reinforce that there seem to be many missed opportunities for health care providers to counsel and intervene even during non-prevention visits. Providers working with adolescents need to use LTBI treatment and other office visits as health prevention and education opportunities.