Abstract
The purpose of this study was to quantify the rate of condom counseling (CC) among adolescent males at preventive (PV) and non-PV (NPV) clinic visits in order to identify missed opportunities for contraception counseling. Adolescent males attending an outpatient clinic at a tertiary children’s hospital from 2009 to 2013 were included. Patient demographics and provider responses to a postvisit electronic medical record questionnaire regarding CC were collected. Over 4 years, 2,439 males attended 6,123 visits; 33% were PVs. CC occurred at 92% PVs versus 43% NPVs (p < .001). Those receiving CC were more likely to be older (16.1 vs. 15.9 years; p < .001) and minority (odds ratio = 1.43; 95% confidence interval = 1.28-1.61). In conclusion, in this single-center study among adolescent males, CC occurred routinely at PVs but infrequently at NPVs. CC was more likely among older, minority males. Providing CC at NPVs and ensuring younger, White males receive CC are two strategies to increase rates of CC among adolescent males.
Introduction
Adolescence is a time of increased sexual activity for young males (Kann et al., 2014; Marcell, Klein, Fischer, Allan, & Kokotailo, 2002; Marcell, Wibbelsman, Seigel, & Committee on Adolescence, 2011), but it is also a time of decreased follow-up in health care, marked by a transition from scheduled preventive visits (PVs) to acute nonpreventive visits (NPVs; Marcell et al., 2002). The Society for Adolescent Health and Medicine recommends discussing contraception and sexually transmitted infection prevention strategies, including condom counseling (CC), during comprehensive adolescent well visits (Burke et al., 2014). Adolescent follow-up at well visits is poor, and in one study, less than one third of males self-reported receiving reproductive health services at routine office visits (Sonenstein, Stewart, Lindberry, Pernas, & Williams, 1997).
The primary aim of this study was to determine the frequency with which providers broached CC with male adolescents at PVs and NPVs by using an electronic medical record (EMR) postvisit contraception questionnaire. Secondary aims included identifying patient factors associated with CC receipt.
Method
The Colorado Multiple Institutional Review Board approved this study. The Children’s Hospital Colorado EMR database hosted by EPIC (Verona, WI) was queried to identify males 13 to 24 years old who attended the Adolescent Medicine Clinic between August 2009 and July 2013. This clinic serves patients from the cities of Denver and Aurora, populated with nearly 1,000,000 inhabitants, who self-describe as 50% White non-Hispanic, 30% Hispanic, 15% African American, and 5% other races. Nearly one third of families speak Spanish at home.
During the study period, providers were not instructed on CC delivery, although all providers completed a postvisit contraception questionnaire integrated in the patient record within the Children’s Hospital Colorado EMR (Table 1). Questionnaire responses, patient age, and patient race were abstracted from the EMR. Data were analyzed with SPSS software (Version 21, IBM, Sommers, NY) using descriptive statistics, t tests of means, and chi-square analyses of proportions.
Contraception Survey.
Note. Questions and possible responses as listed on the electronic medical record contraceptive survey mandated for providers following adolescent health care visits.
Results
Over 4 years, 2,439 adolescent males with a mean age of 16.0 ± 2.0 years attended 6,123 visits, 2,028 (33%) of which were PVs (Table 2). Male adolescents averaged 0.83 PVs and 1.68 NPVs per person over 4 years. CC occurred at 92% of PVs compared to 43% of NPVs (p < .001). Males who received CC were more likely to be older (mean age 16.1 vs 15.9 years; p < .001) and non-white (odds ratio = 1.43; 95% confidence interval = 1.28-1.61).
Demographics.
Note. Patient demographics include age, race, and visit type. P values are for comparisons between contraceptive counseling completed and missed opportunity groups.
Discussion
As in prior work (Kann et al., 2014; Marcell et al., 2002), adolescents in this project had scarce contact with the health care system, averaging 2.5 office visits per adolescent in 4 years. Males attended NPVs nearly twice as often as PVs, but providers broached contraception at NPVs less than half as often. This disparity may reflect a belief that CC is only part of a comprehensive PV or underscore the focused nature of NPVs. In 2005, Fairbrother and colleagues performed a survey of adolescents in New York City, finding that 22% of sexually active males and females with a health care encounter in the prior 12 months had not been counseled about condom use (Fairbrother et al., 2005). Burnstein and colleagues, citing the Youth Risk Behavior Surveillance (YRBS) data from 2003, reported that only one third of sexually experienced males who attended a preventive health care visit in the previous 12 months discussed sexually transmitted infections, human immunodeficiency virus, or pregnancy prevention (Burnstein, Lowry, Klein, & Santelli, 2003). Missed opportunities for CC abound, and providing CC at NPVs may help fill this gap.
Next, this study identified that minority and older patients were more likely to receive CC than their White, younger counterparts. This may be due to provider biases that young or non-White adolescents are unlikely to be sexually active. Per the 2013 YRBS data, Black and Hispanic males were more likely than White males to have ever had sex (68% and 52%, respectively), but 42% of White males reported initiating sexual activity in high school (Kann et al., 2014). Additionally, White males were less likely than Black males (62% vs. 73%) to have used a condom at last sex (Kann et al., 2014). Last, 8% of males reported having sex before age 13 (Kann et al., 2014). Missed opportunities for CC may be exaggerated among younger and White males. Regardless, providers should take care to remember all males when broaching CC at office visits.
There are limitations to this study. Health care professionals are under explicit and implicit pressures to provide CC at office visits, which may have biased the reported provision of CC at PVs and NPVs. Also, the current findings resulted from data collected in an urban, hospital-based adolescent clinic; such findings may not generalize well to other settings.
Despite these limitations, this study provides objective estimates of CC at NPVs and PVs in a single institution via an EMR-integrated questionnaire, reminds providers to initiate CC with all adolescent males, and suggests a feasible practice change to increase CC among adolescent males. Future work should explore standardized CC delivery models, corroborate data on larger scales, and utilize youth-reported post-CC practices to determine the impact of CC at NPVs.
Implications and Contribution
Condom counseling among adolescent males occurs frequently at preventive visits but infrequently at nonpreventive visits. Younger, White males may be overlooked. Condom counseling at nonpreventive visits may be an effective strategy to reduce missed counseling opportunities and increase condom use among adolescent males.
Footnotes
Authors’ Note
This work was presented in part as an oral platform presentation at the 2014 meeting of the Pediatric Academic Societies in Vancouver, British Columbia, Canada.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.