Advanced Pharmacology: Metformin; Theoretical and nursing: Pregnancy and STD; Capstone project (Due 26 and 48 hours)

Adolescent Attitudes Towards Sexually Transmitted Infection Screening in the Emergency Department

Addison S. Gearhart, MD1, Gia M. Badolato, MPH2, Monika K. Goyal, MD, MSCE2,3

1Children’s Hospital of Orange County, Orange, CA

2Children’s National Health System, Washington, DC

3Departments of Pediatrics and Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC

Abstract

Objectives—Adolescents who seek care in emergency departments (EDs) are often at high risk

for sexually transmitted infections (STIs). The objective of this study was to assess adolescent

attitudes towards ED-based STI screening.

Methods—We conducted a secondary analysis of a cross-sectional study that evaluated STI

screening acceptability and prevalence when STI testing was universally offered to asymptomatic

adolescents presenting to the ED for care. Adolescents 14–21 years old completed a computerized

survey and answered questions regarding attitudes towards ED-based STI screening and sexual

behavior. We performed multivariable logistic regression to compare differences in attitudes

towards ED-based STI screening among patients who agreed versus declined STI testing.

Results—326 of 553 (59.0%) adolescents agreed to be tested for STIs. The majority (72.1%)

believed the ED was an appropriate place for STI screening. Patients who agreed to be tested for

STIs were more likely to positively endorse ED-based STI screening than those who declined STI

testing (77.0% vs 64.8%%; aOR 1.6, [95% CI 1.1, 2.4]). Most (82.6%) patients stated they would

feel comfortable getting tested for STI’s in the ED. There was no difference in comfort level of

ED-based STI testing between those who agreed and declined STI testing (83.5% vs 81.4% aOR

1.1, [95% CI 0.7, 1.8]).

Conclusion—Our results suggest that adolescents view the ED as an acceptable location for STI

screening. Therefore the ED may serve a role in increasing the accessibility of STI detection and

prevention resources for adolescents.

Keywords

Adolescents; Sexually Transmitted Infections; Emergency Department; Screening

Corresponding Author: Monika K. Goyal, MD, MSCE, Children’s National Health System, 111 Michigan Ave NW, Washington, DC 20010, PH: 202-476-5000, MGoyal@childrensnational.org, fax: 202-476-2100.

The authors have conflicts of interest to report.

HHS Public Access Author manuscript Pediatr Emerg Care. Author manuscript; available in PMC 2021 October 01.

Published in final edited form as: Pediatr Emerg Care. 2020 October ; 36(10): e573–e575. doi:10.1097/PEC.0000000000001387.

A uthor M

anuscript A

uthor M anuscript

A uthor M

anuscript A

uthor M anuscript

INTRODUCTION

Approximately half of the 20 million new cases of sexually transmitted infections (STIs) in

the United States (U.S.) occur in people between the ages of 15 and 24.1,2 One in four

sexually active adolescent females has an STI.3 The majority of STIs are asymptomatic, and

if left undiagnosed and untreated, can lead to serious complications such as infertility,

ectopic pregnancies or pelvic inflammatory disease.4

While there are national guidelines recommending routine-screening for sexually active

patients, physicians report adherence to screening guidelines less than a third of the time

during routine health visits.5–7 Furthermore, in 2003 only 30% of women age 25 years and

younger with commercial health care plans and 45% of women with Medicaid plans were

screened for chlamydia.8 One explanation for low STI screening rates among adolescents

may be STI screening efforts have traditionally been focused around primary care, and

adolescents have the lowest rates of primary care use compared to all other pediatric age

groups.9,10 Alternatively, adolescents frequently access the emergency department (ED) for

care, comprising 14.8 million ED visits annually.11 Furthermore, approximately 1.5 million

adolescents rely on EDs as their primary source of health care.11,12 Therefore, adolescent

patient encounters in the ED may offer a strategic opportunity to address missed

opportunities for STI screening, prevention and treatment efforts.

Elucidating barriers to the accessibility of STI services is crucial to the development of

effective prevention efforts.13 Established barriers to STI services include system level

obstacles such as cost, long waiting times, and unfavorable clinic schedules and hours.14

Given these barriers, patients often access the ED for care. EDs have a perceived quicker

wait time and are open 24 hours a day.14 Other documented reasons for not seeking STI

services include perceived interpersonal barriers such as fear of judgment from the doctor

and confidentiality.15 Furthermore, social barriers such as stigma attached to STIs and

increased sensitivity to other’s perception of themselves also play a role in hindering STI

screening efforts.16 As such, patients may be more inclined to select the ED for care because

they do not have an established relationship with the providers and have a lower likelihood

of seeing the provider again. However, STI testing is infrequently performed in the ED.17,18

We recently evaluated STI screening acceptability and prevalence when STI screening was

universally offered to an asymptomatic adolescent ED population.19 The goal of this

secondary analysis was to explore adolescent attitudes towards ED-based STI screening.

METHODS

Study Design and Population

We conducted a secondary analysis of a cross-sectional study that evaluated STI screening

acceptability and prevalence when STI screening was universally offered to asymptomatic

adolescents seeking care in a large, tertiary, urban pediatric hospital ED from December

2013 to July 2014. Patients between the ages of 14 to 21 presenting to the ED with non-STI

related complaints were eligible for participation. For the purposes of this study, STI related

complaints for females were described as: lower abdominal pain, concern for STI, vaginal

Gearhart et al. Page 2

Pediatr Emerg Care. Author manuscript; available in PMC 2021 October 01.

A uthor M

anuscript A

uthor M anuscript

A uthor M

anuscript A

uthor M anuscript

discharge with or without lesions, itching and or bleeding, hematuria, dysuria, flank pain,

pelvic pain and rectal or anal pain. STI related chief complaints for males were defined as:

penile, scrotal or testicular concerns, rectal or anal pain, urinary problems or dysuria.

Patients were excluded from participation if they were not literate in English, critically ill,

developmentally delayed, presented with altered mental status/psychiatric emergency, victim

of assault, or were in police-custody. The hospital’s Institutional Review Board approved the

study.

Data Collection

Patients who enrolled in this study completed a computerized survey (LimeSurvey

Software)20 through the use of a handheld tablet and answered questions regarding attitudes

towards ED-based STI screening during their ED visit. The survey also collected

information on demographics and sexual behavior.

Data Analysis

We assessed attitudes towards STI screening and compared them among adolescents who

agreed to and declined STI testing. Survey items consisted of 5-point Likert scale-type

questions (strongly agree to strongly disagree) and were dichotomized for analyses with

strongly agree and agree as one category. We performed multivariable logistic regression to

compare differences in attitudes towards ED-based STI screening among patients who

agreed versus declined STI testing. We included all variables with p-values of <0.2 on

bivariable analyses in our final multivariable models. Data were analyzed using STATA vs.

12.0.

RESULTS

A total of 553 adolescents were enrolled in this study. The study population had a mean age

of 16.1 (SD +/−1.8) years, was half female, primarily of non-Hispanic black race/ethnicity,

and publicly insured. Almost 50% of the population reported being sexually active (Table 1).

Of the 553 adolescents in the study, 326 (59.0%) agreed to be tested for STIs.

The majority of participants in the study (72.1%) believed the ED was an appropriate place

for STI screening. Patients who agreed to be tested for STIs were more likely to positively

endorse ED-based STI screening than those who declined STI testing (77.0% vs 64.8%%;

OR 1.8, 95% CI 1.2, 2.7). Most (82.6%) patients stated they would feel comfortable getting

tested for STI’s in the ED. There was no difference in comfort level of ED-based STI testing

between those who agreed (83.5%) and declined (81.4%) STI testing (OR 1.2, 95% CI 0.7,

1.8). One third of patients responded that they were worried about their parents finding out

about STI testing. However, there was no difference between confidentiality concerns

between those who agreed (34.3%) and declined (32.1%) STI testing (OR 0.9; 95% CI 0.6,

1.3) (Table 2).

In a multivariable model that adjusted for age, gender, insurance status, and sexual activity,

adolescents who agreed to be tested for STIs were more likely to believe that the ED was an

important venue for STI screening (aOR 1.6, 95% CI 1.1, 2.4) and were more likely to

believe doctors and nurses should ask adolescents in the ED about sexual health (aOR 1.5,

Gearhart et al. Page 3

Pediatr Emerg Care. Author manuscript; available in PMC 2021 October 01.

A uthor M

anuscript A

uthor M anuscript

A uthor M

anuscript A

uthor M anuscript

95% CI 1.0, 2.1). Participants who accepted testing were also more likely to believe the ED

served as a good place for adolescents to answer questions about sexual health (aOR 1.7,

95% CI 1.2, 2.5). However, there was no difference between those who agreed to be tested

versus those who declined and a belief that they would want doctors in the ED to ask

adolescents about their sexual activity (aOR 1.4, 95% CI 0.9, 2.0).

DISCUSSION

Our study found that most adolescents are comfortable discussing their sexual health with

ED clinicians and being screened for STIs in the ED even when they present for non-STI

related complaints. These results were seen amongst all participants including those who did

not consent to STI screening during the visit. This is an important finding, as access to

healthcare is a major barrier to reducing STIs among adolescents,10 and previous studies

demonstrate that adolescents report frequent use of the ED.11,12,21

Recent reports have revealed high rates of STI screening acceptance among adolescents in

the ED.19,22,23 Previous studies of clinicians reported perceived patient discomfort as the

reason for not conducting sexual histories or performing STI screening.24 Our study, which

explored adolescent attitudes towards ED-based STI screening found the majority believe

the ED is an appropriate place for STI screening, want to discuss their sexual health with

clinicians, and feel comfortable receiving STI services in the ED. These results suggest that

perceived discomfort is not a true barrier, and should not discourage clinicians from

screening patients for STIs in the ED.

The ED encounter may serve as the only opportunity for clinicians to screen and treat high-

risk, often asymptomatic adolescents.25 Our study demonstrates adolescents’ desire for ED

clinicians to engage in sexual health discussions, regardless of why they presented to the

ED. The majority of participants not only wanted the clinicians to initiate these discussions,

but they also believed the ED is an appropriate setting to respond to these questions.

Previous studies have shown similar results, with adolescents reporting they prefer the

clinician to initiate the conversation because they feel uncomfortable starting the

conversation; however, these studies were not conducted solely in the ED.30,31

Prior data have revealed that adolescents often cite perceived anonymity, confidentiality, and

privacy as factors influencing them to visit the ED in placed of a primary care clinic for non-

urgent health issues.11,15,26 Adolescents in other studies have previously reported that they

would stop receiving care or delay screening if their parents were notified.27 About one-third

of our sample indicated they were concerned about confidentiality when getting tested in the

ED; however, our results suggest that this concern did not affect their acceptance of

screening. These results demonstrate that adolescents have a desire for STI screening, and

innovative methods for confidential STI screening are warranted.

The results from this study should be considered in light of several potential limitations. We

used a convenience sampling strategy, so patients were only enrolled when research staff

were available. However, risk of missing patients was minimized because our research

assistants enrolled patients 7 days a week from 8 am until 11 pm. Furthermore this study

Gearhart et al. Page 4

Pediatr Emerg Care. Author manuscript; available in PMC 2021 October 01.

A uthor M

anuscript A

uthor M anuscript

A uthor M

anuscript A

uthor M anuscript

was conducted in a single pediatric ED with a high community prevalence of STIs.

Therefore, our results may not be generalizable to other geographical areas or healthcare

settings. The survey responses may be prone to social desirability bias because of the

sensitive nature of the topic. In order to decrease the risk for bias, we used a computerized

survey as literature suggests that adolescents are more likely to honestly report information

through computerized questionnaires when compared to face to face interviews.8,28 Finally,

the findings of this study may also be prone to responder bias as our survey relied on

participants to consent to the study, and therefore does not include the opinions of people

who declined participation.

In conclusion, adolescents find STI screening in the ED acceptable. Therefore, the ED could

potentially serve as a strategic venue for adolescent STI detection and treatment. Offering

STI services in the ED may reduce the morbidity, mortality, and further transmission of

STIs. Future studies should explore interventions that can study the impact of ED-based STI

screening on a population level, examine provider attitudes towards ED-based STI screening

and incorporate STI screening into the ED workflow.

Acknowledgments

Source of funding: This work was supported by award number K23HD070910 from NICHD (MKG.). The funding sources had no role in (1) study design; (2) the collection, analysis, and interpretation of data; (3) the writing of the report; or (4) the decision to submit the article for publication. This funding was not given for the production of this article. No other grants, honorariums, or other forms of payment were given to the authors of this manuscript.

References

1. Satterwhite CL, Torrone E, Meites E, et al. Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008. Sex Transm Dis. 2013; 40(3):187–193. DOI: 10.1097/OLQ.0b013e318286bb53. [PubMed: 23403598]

2. Centers for Disease Control and Prevention. Reported STDs in the United States: 2013 National data for chlamydia, gonorrhea, and syphilis. CDC Fact Sheet. 2014 Decembre;:1–3. DOI: 10.1037/ a0029416.Socioeconomic

3. Forhan SE, Gottlieb SL, Sternberg MR, et al. Prevalence of sexually transmitted infections among female adolescents aged 14 to 19 in the United States. Pediatrics. 2009; 124(6):1505–1512. DOI: 10.1542/peds.2009-0674 [PubMed: 19933728]

4. Trigg BG, Kerndt PR, Aynalem G. Sexually transmitted infections and pelvic inflammatory disease in women. Med Clin North Am. 2008; 92(5):1083–113, x. DOI: 10.1016/j.mcna.2008.04.011 [PubMed: 18721654]

5. American Academy of Pediatrics. Screening for Nonviral Sexually Transmitted Infections in Adolescents and Young Adults. Pediatrics. 2014; 134(1):e302–e311. DOI: 10.1542/peds.2014-1024 [PubMed: 24982099]

6. Sexually Transmitted Diseases Treatment Guidelines. 2015. http://www.cdc.gov/mmwr/preview/ mmwrhtml/rr6403a1.htm

7. Lee KC, Ngo-Metzger Q, Wolff T, Chowdhury J, Lefevre ML, Meyers DS. Sexually transmitted infections: Recommendations from the U.S. preventive services task force. Am Fam Physician. 2016; 94(11):907–915. [PubMed: 27929270]

8. Turner CF, Ku L, Rogers SM, Lindberg LD, Pleck JH, Sonenstein FL. Adolescent sexual behavior, drug use, and violence: increased reporting with computer survey technology. Science. 1998; 280(5365):867–873. [PubMed: 9572724]

9. Nordin JD, Solberg LI, Parker ED. Adolescent primary care visit patterns. Ann Fam Med. 2010; 8(6):511–516. DOI: 10.1370/afm.1188 [PubMed: 21060121]

Gearhart et al. Page 5

Pediatr Emerg Care. Author manuscript; available in PMC 2021 October 01.

A uthor M

anuscript A

uthor M anuscript

A uthor M

anuscript A

uthor M anuscript

10. Irwin CE, Adams SH, Park MJ, Newacheck PW. Preventive care for adolescents: few get visits and fewer get services. Pediatrics. 2009; 123(4):e565–72. DOI: 10.1542/peds.2008-2601 [PubMed: 19336348]

11. Ziv A, Boulet JR, Slap GB. Emergency Department Utilization by Adolescents in the United States. Pediatrics. 1998; 101(6)

12. Grove DD, Lazebnik R, Petrack EM. Urban emergency department utilization by adolescents. Clin Pediatr (Phila). 2000; 39(8):479–483. DOI: 10.1177/000992280003900806 [PubMed: 10961820]

13. Sangani P, Rutherford G, Wilkinson D. Population-based interventions for reducing sexually transmitted infections, including HIV infection. Cochrane Database Syst Rev. 2004; (1):CD001220.doi: 10.1002/14651858.CD001220.pub2 [PubMed: 15106156]

14. Moses S, Manji F, Bradley JE, Nagelkerke NJ, Malisa MA, Plummer FA. Impact of user fees on attendance at a referral centre for sexually transmitted diseases in Kenya. Lancet. 1992; 340(8817):463–466. [PubMed: 1354792]

15. Tilson EC, Sanchez V, Ford CL, et al. Barriers to asymptomatic screening and other STD services for adolescents and young adults: focus group discussions. BMC Public Health. 2004; 4(1):21.doi: 10.1186/1471-2458-4-21 [PubMed: 15189565]

16. Fortenberry JD, Brizendine EJ, Katz BP, Wools KK, Blythe MJ, Orr DP. Subsequent sexually transmitted infections among adolescent women with genital infection due to Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis. Sex Transm Dis. 1999; 26(1):26– 32. [PubMed: 9918320]

17. Musacchio NS, Gehani S, Garofalo R. Emergency Department Management of Adolescents with Urinary Complaints: Missed Opportunities. J Adolesc Heal. 2009; 44(1):81–83. DOI: 10.1016/ j.jadohealth.2008.05.011

18. Banas DA, Cromer BA, Santana M, et al. Comparison of Clinical Evaluation of Genitourinary Symptoms in Female Adolescents among Primary Care versus Emergency Department Physicians. J Pediatr Adolesc Gynecol. 2010; 23(2):71–76. DOI: 10.1016/j.jpag.2009.05.010 [PubMed: 19643640]

19. Goyal MK, Teach SJ, Badolato GM, et al. Universal Screening for Sexually Transmitted Infections among Asymptomatic Adolescents in an Urban Emergency Department: High Acceptance but Low Prevalence of Infection. J Pediatr. 2016; 171:128–132. DOI: 10.1016/j.jpeds.2016.01.019 [PubMed: 26846572]

20. Schmitz, C. Limesurvey: an open source survey tool. Limesurvey Proj Hamburg, Ger. 2012. http:// www.limesurvey.org

21. Weiss, A; D’Angelo, L; Rucker, A. Adolescent use of the emergency department instead of the primary care provider: who, why, and how urgent?. J Adolesc Heal. 2014. http:// hsrc.himmelfarb.gwu.edu/smhs_peds_facpubs/547. Accessed November 6, 2016

22. Schneider K, FitzGerald M, Byczkowski T, Reed J. Screening for Asymptomatic Gonorrhea and Chlamydia in the Pediatric Emergency Department. Sex Transm Dis. 2016; 43(4):209–215. DOI: 10.1097/OLQ.0000000000000424 [PubMed: 26967296]

23. Uppal A, Chou KJ. Screening adolescents for sexually transmitted infections in the pediatric emergency department. Pediatr Emerg Care. 2015; 31(1):20–24. DOI: 10.1097/ PEC.0000000000000322 [PubMed: 25526018]

24. Haley N, Maheux B, Rivard M, Gervais A. Sexual health risk assessment and counseling in primary care: How involved are general practitioners and obstetrician-gynecologists? Am J Public Health. 1999; 89(6):899–902. DOI: 10.2105/AJPH.89.6.899 [PubMed: 10358682]

25. Weisman J, Chase A, Badolato G, Teach SJ, Trent ME, Chamberlain JM. Adolescent Sexual Behavior and Emergency Department Use. Pediatr Emerg Care.

26. Ginsburg KR, Slap GB, Cnaan A, Forke CM, Balsley CM, Rouselle DM. Adolescents’ perceptions of factors affecting their decisions to seek health care. Jama. 1995; 273(24):H.doi: 10.1001/ jama.1995.03520480033036

27. McKibben L, Horan T, Tokars JI, et al. Guidance on Public Reporting of Healthcare-Associated Infections: Recommendations of the Healthcare Infection Control Practices Advisory Committee. Am J Infect Control. 2005; 33(4):217–226. DOI: 10.1016/j.ajic.2005.04.001 [PubMed: 15877016]

Gearhart et al. Page 6

Pediatr Emerg Care. Author manuscript; available in PMC 2021 October 01.

A uthor M

anuscript A

uthor M anuscript

A uthor M

anuscript A

uthor M anuscript

28. MacMillan HL. Computer survey technology: a window on sensitive issues. CMAJ. 1999; 161(9):1142. [PubMed: 10569103]

Gearhart et al. Page 7

Pediatr Emerg Care. Author manuscript; available in PMC 2021 October 01.

A uthor M

anuscript A

uthor M anuscript

A uthor M

anuscript A

uthor M anuscript

A uthor M

anuscript A

uthor M anuscript

A uthor M

anuscript A

uthor M anuscript

Gearhart et al. Page 8

Table 1

Descriptive Characteristics of Patients

Mean Age(SD) 16.1 (+/−1.8) years

N (%)

Female Gender 293 (52.4%)

Race/Ethnicity

White, Non-Hispanic 40 (7.3%)

Black, Non-Hispanic 376 (68.9%)

Hispanic 81 (14.8%)

Other 49 (9.0%)

Insurance status

Private 156 (28.2%)

Public 377 (68.2%)

Uninsured 20 (3.6%)

Sexually Active 264 (47.7%)

Pediatr Emerg Care. Author manuscript; available in PMC 2021 October 01.

A uthor M

anuscript A

uthor M anuscript

A uthor M

anuscript A

uthor M anuscript

Gearhart et al. Page 9

Ta b

le 2

Pa tie

nt A

tti tu

de s

To w

ar ds

E D

-b as

ed S

T I

Sc re

en in

g

To ta

l N

( %

) A

gr ee

d to

S T

I Te

st N

( %

) D

ec lin

ed S

T I

Te st

N (%

) O

R aO

R *

T he

E D

is a

g oo

d pl

ac e

to b

e te

st ed

f or

S T

Is 38

4( 72

.1 %

) 24

4( 77

.0 %

) 14

0( 64

.8 %

) 1.

8( 1.

2, 2.

7) 1.

6( 1.

1, 2

.4 )

C om

fo rt

ab le

g et

tin g

te st

ed f

or S

T Is

in th

e E

D 44

3( 82

.7 %

) 26

4( 83

.5 %

) 17

9( 81

.4 %

) 1.

2( 0.

7, 1.

8) 1.

1( 0.

7, 1.

8)

W an

t d oc

to rs

in th

e E

D to

a sk

a do

le sc

en ts

a bo

ut th

ei r

se xu

al a

ct iv

ity 30

0( 56

.9 %

) 19

0( 60

.7 %

) 11

0( 51

.4 %

) 1.

51 .(

0, 2.

1) 1.

4( 0.

9, 2.

0)

B el

ie ve

th e

E D

is a

g oo

d pl

ac e

fo r

ad ol

es ce

nt s

to a

ns w

er q

ue st

io ns

a bo

ut s

ex ua

l h ea

lth 34

8( 65

.3 %

) 22

1( 70

.2 %

) 12

7( 58

.3 %

) 1.

7( 1.

2, 2.

4) 1.

7( 1.

2, 2.

5)

W or

ri ed

a bo

ut p

ar en

ts f

in di

ng o

ut a

bo ut

S T

I te

st in

g 17

6( 33

.4 %

) 10

7( 34

.3 %

) 69

(3 2.

1% )

0. 9(

0. 6,

1. 3)

0. 8(

0. 6,

1. 2)

* A dj

us te

d fo

r ag

e, g

en de

r, in

su ra

nc e

st at

us a

nd s

ex ua

l a ct

iv ity

Pediatr Emerg Care. Author manuscript; available in PMC 2021 October 01.