A professor asks a student nurse to explain the stage when an adolescent has prevalence

Am J Nurs. Author manuscript; available in PMC 2017 Jul 17.

Published in final edited form as:

PMCID: PMC5513155

NIHMSID: NIHMS847985

An evidence-based guide to delivering counseling and services to adolescents and parents.

Abstract

Nurses care for adolescents in a variety of settings, including communities, schools, and public health and acute care clinics, which affords them many opportunities to improve adolescents’ sexual and reproductive health and reduce the rates of unplanned pregnancy and sexually transmitted infections. To ensure that adolescents have access to sexual and reproductive health care (which includes both preventive counseling and treatment) in all nursing practice sites, nurses need to gain the knowledge and hone the skills required to deliver evidence-based counseling and services to adolescents and parents. Collectively, nurses can use their unique combination of knowledge and skills to make a positive impact on adolescent sexual and reproductive outcomes. Nurses have the capacity and opportunity to disseminate information about sexual and reproductive health to adolescents and their parents in communities, schools, public health clinics, and acute care settings. This article discusses the Society for Adolescent Health and Medicine’s goals and recommendations, which address adolescent sexual and reproductive health as both a health care and a human rights issue.

Keywords: adolescents, health care, reproductive health, sexual health, sexual and reproductive health care

Adolescents face a variety of critical sexual and reproductive health challenges, such as unplanned pregnancy and sexually transmitted infections (STIs), including HIV infection. While these conditions are readily preventable with access to adequate sexual and reproductive health care (including both preventive counseling and treatment), adolescents often lack easy access to condoms and other contraception as well as counseling; thus, their sexual health challenges go unaddressed and often lead to serious outcomes. Even in pediatric hospitals, which might afford the best opportunities to deliver preventive sexual and reproductive health, thereby reducing adolescent morbidity and mortality and improving birth outcomes, assessment of pregnancy risk is inconsistent.1

ADVERSE SEXUAL AND REPRODUCTIVE HEALTH OUTCOMES

Adolescent health is shaped by a complex variety of biological and social factors, but risky behavior at this age can often have a disproportionate effect on health across the life span.2 Many young people initiate sexual behavior in adolescence and experience adverse sexual and reproductive health outcomes.3 Yet, at the time when adolescents would benefit most from sexual and reproductive health behavior counseling, too often they don’t receive it. For example, a decade-long study of 700,000 adolescents enrolled in a Minnesota health plan found that a third of 13-to-17-year-olds with four or more years of continuous enrollment had no preventive care visits and 40% had only one.4 These findings highlight the importance of viewing all encounters with adolescents as opportunities to provide preventive care services.

The most appropriate time for initial preventive sexual and reproductive health counseling is before an adolescent’s first sexual experience or first experience of sexual intercourse (known in the literature as “sexual debut”); however, such counseling is often lacking, which contributes to immediate and long-term health consequences, including STIs and unplanned pregnancy. There was a 23% decline in U.S. adolescent pregnancies between 2008 and 2011; even so, in 2011, 562,000 women younger than 20 years of age became pregnant.5

The Centers for Disease Control and Prevention (CDC) estimates that half of the nearly 20 million new STIs that occur every year in the United States affect young people 15 to 24 years of age,6 costing $16 billion.7 Adolescents account for two-thirds of chlamydia and half of gonorrhea cases and experience the greatest disease burden.6 Young people 13 to 24 years of age account for 26% of all new HIV infections.8 One example of the potential for improvement in adolescent sexual and reproductive health is the prevention of human papillomavirus (HPV), an STI so common that nearly all sexually active men and women will acquire it at some point in their lives.9 National guidelines from the CDC recommend HPV vaccination for all young men and women in early adolescence. Medicaid-eligible families can obtain free vaccination from the Vaccines for Children Program (see www.cdc.gov/vaccines/programs/vfc/index.html).

In October 2016, the CDC changed its recommendation on the number of HPV vaccine doses to be administered to 11-to-12-year-olds; rather than the previously recommended three doses, the CDC now recommends two doses, the second to be given six to 12 months after the first.10 Those who begin the vaccination process between the ages of 15 and 26 should still receive three doses. All of the current studies on vaccine uptake and vaccination series completion rates are based on the three-shot recommendation. According to one recent study, the uptake and completion rates have remained low, with only 40% of girls and 22% of boys completing the full three-shot vaccination series.11

Barriers to adolescent vaccination uptake include limited knowledge among providers12 as well as a variety of parental factors, including fears about vaccine safety,13 the assumption that vaccination leads to increased sexual activity,14 and the beliefs that children are not sexually active15 and are too young for a vaccine against STIs.16 Another barrier is providers’ failure to make vaccination referrals, which disproportionately affects racial and ethnic minorities.17 According to one recent study, the strength and consistency of physicians’ recommendations on HPV vaccination are not in accordance with national recommendations.18 Thirty-nine percent of the physicians surveyed reported making strong and consistent recommendations to males between 13 and 17 years old; 31% made such recommendations to those 11 to 12 years old and 18 to 21 years old. Another recent study found that poor, less-educated, Spanish-speaking, rural, uninsured, and Hispanic parents reported less collaborative provider–parent communication, which is also a barrier to vaccine uptake.19 Such barriers and missed opportunities may be contributing to the failure to achieve the national Healthy People 2020 target of 80% vaccination coverage.20 Nurses can help meet the national goal by counseling and educating adolescents and parents at every adolescent health care visit across all care settings and strongly advocating for HPV vaccination.

CALLS FOR IMPROVEMENT

The United Nations Convention on the Rights of the Child declared that adolescents across the globe have the human right to receive sexual and reproductive health care.21 In response, the Society for Adolescent Health and Medicine (SAHM) issued a position paper that called for improvements in adolescent sexual and reproductive health care.22 The SAHM’s three core goals were accompanied by a number of recommendations to health care providers and other professionals who work with adolescents. The goals and recommendations align with those set forth by the American Academy of Pediatrics and the World Health Organization. This article highlights specific recommendations that nurses can follow to improve sexual and reproductive health care delivery and adolescent health outcomes.

Goal 1: Adolescents should have universal access to comprehensive sexual and reproductive health information and services that are evidence based, confidential, developmentally appropriate, and culturally sensitive.22

Because many adolescents do not get annual preventive health examinations, the CDC recommends screening adolescents for sexual and reproductive health and pregnancy risks at every encounter in all health care settings.23 Therefore, nurses should initiate conversations about sexual and reproductive health at every health care encounter, regardless of the clinical setting and the reason for the encounter; advocate for youth-friendly services, including private nurse–adolescent consultation time during each encounter; and maintain confidentiality within the parameters of state law. (For resources on adolescent sexual and reproductive health for nurses, see Table 1.)

Table 1

Resources on Adolescent Sexual and Reproductive Health Care

Romero and colleagues have compiled 31 evidence-based clinical practices that facilitate access to and delivery of sexual and reproductive health care; these include improving adolescents’ access to contraception and the provision of emergency contraception; providing quick-start methods to initiate the use of hormonal contraception and intrauterine devices; screening for cervical cancer and STIs, including HIV infection; and streamlining confidential billing practices.24 The following sections highlight some recommendations for providing sexual and reproductive health care.

Sexual and reproductive health across care settings

Adolescents use health services for well and sick visits, sports physicals, immunizations, and emergency care. While as many as 40% of U.S. adolescents have annual examinations, only 5% of 13-to-18-year-olds receive HIV/STI counseling during general medical–physical clinic visits; therefore, there’s a clear need to better integrate sexual and reproductive health screening and counseling with other nurse–patient interactions.25, 26 Each such interaction provides this opportunity. Nurses can and should offer developmentally appropriate sexual and reproductive health screening and counseling to adolescents and their parents as part of annual examinations. This approach is associated with reduced teen pregnancy and improved contraceptive use.27 The annual examination, which typically takes more time than acute care visits, can better accommodate nurse-led screening and anticipatory guidance about behavioral health topics. Outside of the annual examination, nurses can provide adolescent behavioral risk screenings during intake procedures and add automatic prompts to electronic health record systems to cue providers to conduct sexual and contraceptive history screening, counseling, and referrals for all adolescent patients.1, 28 As nurses become proactive in providing critical sexual and reproductive health services to adolescents, these patients may relay more accurate information to their peers.29

It is essential to the delivery of sexual and reproductive health services that nurses provide behavioral screenings to adolescent patients. Sexual and reproductive behavior screenings and risk assessments include appropriate testing; discussions about risk reduction and avoidance strategies; HPV vaccination; HIV preexposure prophylaxis (PrEP) eligibility screening; and safety assessments of home, school, and social environments to determine whether adolescents are subject to physical, emotional, or sexual abuse, bullying, or dating violence (see Table 2 for recommended talking points and discussion strategies for counseling both adolescents and parents). The CDC recommends using pregnancy screening checklists in all adolescent health care settings to assess the risk of unintended pregnancy.20 Researchers have demonstrated the feasibility and efficacy of using motivational interviewing techniques—designed to elicit the motivation to change behavior—with adolescents in the ED.30 Nurses can also increase the reach of sexual and reproductive health care to underserved adolescent populations through community-based sexual and reproductive health education and behavioral screenings in schools, hospitals, clinics, homeless shelters, and faith-based and community settings.31

Table 2

Recommended Counseling, Screening, Vaccination, and Testing Talking Points for Nurses

Youth-friendly health care

To address the ongoing burden of STIs and unplanned pregnancy among adolescents, it’s essential to remove barriers to health care access, prioritize youth-friendly health services, and ensure compassionate nurse–patient interaction.32, 33 Nurses can promote the adoption of adolescent-friendly sexual and reproductive health services by advocating for them within each health care setting and facilitating their implementation. According to focus group discussions conducted separately with adolescents and their parents, both groups reported that the most effective way to get adolescents to use available preventive care is “to directly address provider-level barriers related to the timeliness, privacy, confidentiality, comprehensiveness, and continuity” of preventive care.34 Nurses can help address these concerns by conducting practice-based assessments of services to determine whether they are youth friendly and making necessary changes to improve adolescent perceptions of care (see Table 335).35, 36 Nurses can assess for and promote accessibility (for example, after-school and evening hours of operation, convenient clinical locations in proximity to school and public transportation systems), staff friendliness, warm communication, competent and guideline-based care, inclusivity, and confidentiality. Nurses can also leverage adolescents’ already high use of mobile technology to promote the use of youth-friendly apps such as Bedsider, which allows users to search for nearby sexual and reproductive health care settings and providers based on current need and location. This has been shown to decrease unprotected sex and increase contraceptive use.37

Table 3

Assessing Youth Friendliness of Health Care Settings35

Confidential care

Protecting adolescents’ confidentiality is crucial to ensuring their access to sexual and reproductive health care and is also an essential component of that care.38, 39 Ensured confidentiality is associated with improved delivery of sexual and reproductive health services.27, 40 Therefore, to promote better outcomes, nurses should reassure adolescents that reproductive health care behavioral screenings and pregnancy and STI prevention counseling are confidential. Adolescents suggest that the best way to encourage nurse–adolescent discussions is to increase private consultation time with a nurse who has established trust and confidence.34 If possible, nurses should establish trusting and confidential relationships with children before they become adolescents, beginning with annual examinations when children are in primary and middle school; this may help parents and other adult caregivers view confidentiality as a standard of care for young people.

Adolescents who are afraid that confidentiality won’t be maintained by providers are more likely to delay or avoid needed sexual and reproductive health care and less likely to share information about sexual and reproductive health with providers.41 Concerns about confidentiality not only inhibit adolescents’ health care–seeking behaviors but are also associated with increased health care costs. For example, research conducted in Texas more than a decade ago indicated that state-required parental consent and reporting laws were projected to cost $44 million as a result of additional births, abortions, untreated STIs, and progression to pelvic inflammatory disease.42 A more recent study suggests that parental consent laws do not lead to positive changes in the sexual behaviors of minors.43 The specific provisions of state statutes that protect adolescent confidentiality with regard to sexual and reproductive health issues vary from state to state. Nurses can advocate for confidential health visits by posting state statutes in plain sight in waiting and examination rooms and reviewing them with adolescents and parents at each visit.

Parents have varying and sometimes conflicting perspectives on confidentiality in the context of adolescent sexual and reproductive health care. When asked, two-thirds of parents reported that it was very or somewhat important for adolescents to have private time with health care providers.44 However, in the same study, 46% of parents stated that they would like providers to disclose confidential information obtained during private counseling with adolescents. Nurses can advise parents on the importance of confidential access to sexual and reproductive health counseling and inform them of state policies and minor consent laws, reinforcing the idea that the provision of confidential care and private nurse–adolescent time improves sexual and reproductive health outcomes. Nurses who are unclear on how to navigate adolescent confidentiality issues or who see a small number of adolescents could benefit from identifying a skilled preceptor in adolescent sexual and reproductive health care delivery and learning effective strategies for explaining adolescents’ legal rights to confidential care. Nurses can access state laws regarding adolescent sexual and reproductive health care and confidentiality at www.guttmacher.org/statecenter/spibs/index.html.

Goal 2: Health care providers should have the knowledge and skills to deliver sexual and reproductive health services that have been proven effective in clinical settings.22

Although adolescents are often too embarrassed to initiate conversations with providers about sexual and reproductive health and risky sexual behavior,45 well-prepared nurses may be able to ease adolescents’ embarrassment and facilitate communication.46 Forty-two percent of a nationally representative sample of 5th to 12th graders said nurses, school nurses, and physicians were the first people they asked about health issues.45 When asked about specific health topics, 58% of boys and 65% of girls said providers should address STIs, but only 24% and 28%, respectively, said providers had actually done so.

To provide effective sexual and reproductive health care services to adolescents, nurses require knowledge and skills in counseling, behavioral screening, risk avoidance and reduction methods, and STI testing, as well as knowledge of treatment guidelines. Therefore, it’s important for nursing educators and education programs to be responsive to the demand for health care delivery redesign and emphasize health counseling and prevention, particularly in sexual and reproductive health care.47 One promising strategy to increase nurses’ knowledge of and skill in effective communication with parents and adolescents is integrating evidence-based sexual and reproductive health counseling curricula into nursing education. A recent study of nursing students who completed 16 hours of education in the Families Talking Together (FTT) training model—an evidence-based adolescent sexual health program for parents—found statistically significant improvements in sexual and reproductive health counseling self-efficacy, ability to address barriers to sexual and reproductive health communication, and skills in engaging both adolescents and their parents.48

It’s crucial that nurses have effective strategies for eliciting honest disclosure of information about sexual and reproductive behavior. Researchers showed that adolescents preferred behavioral screenings done with an audio computer-assisted self-interview system rather than provider interviews; techniques like this may enhance the disclosure of sensitive information such as sexual behaviors and therefore help identify youth at risk for STIs.49 Electronic behavioral screening tools are readily available and can be another valuable way to identify sexual and reproductive health risks; one such psychosocial assessment for youths is the HEADSS (home, education, activities, drug and alcohol use, sexuality, and suicide) tool.50 Incorporating behavioral screening, electronic or otherwise, at each visit will facilitate the nurse’s ability to follow STI screening and treatment guidelines, counsel adolescents accurately on the importance of dual-method contraception (using both a condom and a hormonal contraceptive, such as birth control pills), and navigate provider referrals for sexual and reproductive health services that are unavailable in their own practice settings.

Goal 3: Providers should encourage developmentally appropriate communication about sexual and reproductive health between parents and/or caregivers and their children.22

Nurses can and should counsel parents at every health care visit—beginning before their children become sexually active—on protective practices, including parent–child communication, parental involvement, and parental monitoring of behavior in order to delay sexual debut, decrease sexual activity, and increase condom and hormonal contraceptive use in sexually active adolescents.51–54 This can be done by counseling parents while the adolescent meets separately with the NP or physician.

Involving parents

Parent–child communication and parental monitoring have been shown to improve sexual and reproductive health outcomes.55, 56 Yet many parents do not communicate with adolescents because of embarrassment, lack of confidence, and uncertainty about what to say.57 Implementing a brief and effective intervention such as the FTT model is a way to improve parent–child communication and effectively monitor adolescent behavior, leading to delayed sexual debut and reduced frequency of sex.58, 59 FTT provides guidance to nurses on topics to cover with parents to facilitate effective parent–child sexual health communication that takes the youth perspective into consideration. Nurses should verbally endorse the importance of parent–child sexual health communication at each visit, particularly to promote communication prior to sexual debut for younger adolescents.

While there is no single method that will reach all parents, clinic and community delivery models have demonstrated success.58, 60–62 One study found that a computer-based six-hour intervention for Latino parents resulted in improved parent–adolescent communication.62 Computer-based sexual health education games have also been developed, primarily for use by young people. One recent study used focus groups with both parents and 11-to-14-year-olds to learn what kind of game features potential users would want in an intergenerational sexual health education game, to be played by parent–child dyads.63 Nurses can also encourage parents to explore the CDC’s sexual health communication resources (available at www.cdc.gov/teenpregnancy/parent-guardian-resources/index.htm).

By incorporating the effective strategies outlined here, nurses can help more adolescents receive appropriate sexual and reproductive health care based on the CDC’s clinical guidelines, facilitate adolescents’ navigation of the health care system, improve the reach of preventive education, and enhance access to contraception, STI testing and treatment, and HPV vaccination. Nurses can also increase their own knowledge and skills to improve delivery of evidence-based sexual and reproductive health services and initiate parent-based adolescent sexual and reproductive health counseling. Nurses should be encouraged to provide these services independently and also within collaborative interprofessional health care teams. Further research is needed to identify best practices in the effective implementation of these strategies to prepare practicing nurses and nursing students to incorporate adolescent sexual and reproductive health education across various health care delivery settings. We look forward to improved outcomes and better access to sexual and reproductive health care for all adolescents through nurse-driven health care delivery and advocacy for adolescent-friendly environments.

Footnotes

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Contributor Information

Diane Santa Maria, Assistant professor at the University of Texas Health Science Center at Houston.

Vincent Guilamo-Ramos, Professor and codirector of the Center for Latino Adolescent and Family Health in the Silver School of Social Work at New York University in New York City.

Loretta Sweet Jemmott, Vice president of health equity at Drexel University in Philadelphia.

Anne Derouin, Assistant professor at Duke University in Durham, NC.

Antonia Villarruel, Professor and the Margaret Bond Simon Dean of Nursing in the University of Pennsylvania School of Nursing, Philadelphia.

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