SGarrett - STDJournal (see pages 26 through 31)

www.fmaonline.org STDs and Pregnancy in Adolescents 1
Journalof the florida medical Association
The
STDs and
Pregnancy
in Adolescents
Helping Physicians Practice Medicine
FLORIDAMEDI
CAL ASSOCIATIO
N,INC.
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The journal of the florida medical association www.fmaonline.org2Join the Florida Medical Association. Call 800.762.0233, or visit www.fmaonline.org.
The illness hasn’t been given a name, but it’s as ubiquitous as the
common cold — and almost as untreatable. Almost.
Ask just about any doctor and they’ll agree that the health care
industry is sick. Why is it that day in and day out you’re forced to
perform more like a CFO and less like an MD? Managing the books
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spent your young
adult life with your
head buried in medical
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a doctor to care for
people, not to just care
for your bottom line.
Moreover:
Malpractice premiums
are much too high,
forcing many good
physicians to leave
Florida or curtail their
practice altogether. Medicare payments have only increased a mere
1.1% over the past few years. Medicaid payments haven’t increased
at all — not even to support cost-of-living increases. And truth be
told, there will never be a paperweight big enough to hold down
your reams upon reams of critical documentation.
Of course, these are only a few of the many ills Florida’s physicians
face every day. We not only want to see things change. We want to
see things truly get better.
The Florida Medical Association isn’t in possession of a magic pill,
but we are constantly working to protect physicians and improve the
practice of medicine in Florida.
The FMA offers many services
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Although the state of
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Ho w do y ou t r e at a n il l ne s s w Hen
y our pat ien t i s t He me dic a l indu s t r y ?
Knowledge is vital. It is important that physicians understand they
have the power to shape the future of medicine in Florida.
James Howard Rubenstein, MD, Radiation Oncologist, Ft. Myers

CME Objectives
A letter from the Florida Medical association
Introductory Remarks by Russell W. Eggert, MD, MPH
Epidemiology of STDs Among Underserved Populations
in Florida, 2008
Health Disparities in Sexually Transmitted Diseases:
Black Americans at Risk
Sexually Transmitted Infections and Health care Providers:
Young Adult Women Speak
from Posters to PRISM: Physician Roles in STD Prevention
and Control Efforts that Target Adolescents
Self-Administered Adolescent Risk Survey
CME POst-test
CME POST-TEST ANSWER SHEET
contents

The journal of the florida medical association www.fmaonline.org2
CME Objectives:
After reviewing and completing this educational activity,
participants should be able to:
discuss the incidence and prevalence of STDs and pregnancy in Florida’s adolescents»»
recognize the importance of communication with and counseling of adolescent patients»»
to prevent pregnancy and STDs
discuss pregnancy and STDs with their adolescent patients»»
P l a n n e r a n d A u t h o r C r e d e n t i a l s a n d D i s c l o s u r e I n f o r m a t i o n :
This information is being provided to CME learners in compliance with ACCME policies for disclosure and com-
mercial support. The information below identifies planner and faculty relationships/affiliations and financial rela-
tionships with any commercial interest that produces health care goods or services related to the content of the
educational material in which they are involved.
As an accredited CME provider, the FMA is obligated to resolve to the best of its abilities any potential conflicts
of interest that may arise from a planner’s or author’s financial relationships with commercial interests that
produce health care goods or services related to the content of the educational presentation in which that
planner or author is involved.
The following biographical and disclosure information is provided for the learner’s benefit:
Sherese Bleechington, MPH, CHES – Statewide Health Educator, Florida Department of Health, Bureau of STD Prevention & Control,
Tallahassee, Florida
Disclosure: No relevant financial relationships
Toye Brewer, MD – STD Epidemiologist, Centers for Disease Control & Prevention, Field Epidemiology Unit, State of Florida Bureau of STD
Prevention & Control/Miami Dade County Health Department, Miami, Florida
Adrian C. Cooksey, MPH – Epidemiologist, Florida Department of Health, Bureau of STD Prevention & Control, Tallahassee, Florida
Kevon-Mark Jackman, MPH – Public Health Apprentice, Centers for Disease Control and Prevention
Russell W. Eggert, MD, MPH, Colonel (Ret.), USAF, MC, SFS, Director, Division of Disease Control, Florida Department of Health
Karla Schmitt, PhD, MSN, MPH, ARNP – Chief, Bureau of STD Prevention and Control, Florida Department of Health, Tallahassee, Florida
Dionne Stephens, PhD – Assistant Professor, Department of Psychology and African & African Diaspora Studies Program, Florida International
University, Miami, Florida
Tami Thomas, PhD, ARNP, RNC – Assistant Professor, Center for Nursing Research, Medical College of Georgia, Augusta, Georgia
The planners of this educational material have no relevant financial relationships.

F i n a n c i a l A c k n o w l e d g m e n t s :
This educational activity was made possible by the receipt of funds
from the Bureau of STD Prevention & Control, Florida Department
of Health.
S t a t e m e n t o f App r e c i a t i o n :
The Florida Medical Association Foundation is pleased to recognize
the outstanding talent and commitment of the Bureau of STD
Prevention & Control staff and the volunteer experts/authors. This
publication would not have been possible without them.
A c c r e d i t a t i o n / C r e d i t S t a t e m e n t
The Florida Medical Association is accredited by the Accreditation
Council for Continuing Medical Education to provide continuing
medical educational activities for physicians.
The Florida Medical Association designates this educational activity
for a maximum of two (2) AMA PRA Category 1 CreditsTM
. Physicians
should only claim credit commensurate with the extent of their par-
ticipation in the activity.
Estimated time to complete this educational activity: Two Hours
Expiration Date for the Activity: April 30, 2011
INSTRUCTIONS FOR O B TAINING CME CREDIT
Read all of the educational articles included in this monograph»»
Complete the post-test using the answer sheet provided. Par-»»
ticipants must correctly answer at least 70% of the questions to
receive credit.
Complete the evaluation questions on the bottom of the an-»»
swer sheet
Mail the answer sheet/evaluation form to:»»
Florida Medical Association
ATTN: Nancy Wisham
123 South Adams Street
Tallahassee, FL 32301
Feel free to call the FMA Education Department at 800.762.0233 or
email education@medone.org if you have questions.
Once the answer sheet is graded and a score of at least 70% is
achieved, a certificate of credit will be emailed to you. Retain a copy
of your certificate for your records.
This publication was supported by Cooperative Agreement Number 1H25PS001372-01 from the
Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors
and do not represent the official views of the Centers for Disease Control and Prevention.

The Florida Medical Association has again partnered with the Florida
Department of Health to bring you
another CME issue of the Journal of the Florida Medical Association. Within these pages, you will find detailed articles with clinical information
regarding sexually transmitted diseases (STDs) that affect a disturbingly high percentage of our adolescent population here in Florida. These
articles address epidemiology of STDs, important demographic information, and very importantly, the role physicians must often assume in
disease prevention. Clearly the health and well-being of adolescents is crucial to the future of our great state. We are excited that the FMA is
able to provide this collaborative enduring material and participate in the effort to reduce the adverse and costly effects of sexually transmitted
infections in Florida.
The FMA works on your behalf by partnering with regulatory agencies to keep you up-to-date on health matters
that concern you and your patients. Throughout the year, FMA staff serves as your liaison to legislators to protect
physicians and their practices. FMA members have access to experts knowledgeable in legal issues, Medicare/
Medicaid, Workers’ Compensation, and numerous other areas. The FMA also offers a tremendous amount of
benefits, including complimentary continuing medical education, billing and coding advice, and practice man-
agement tools. By joining the efforts of the FMA, you will benefit your profession and your practice.
If you are currently a member of the FMA, we appreciate your sustained support. You are the necessary element
for the future growth of the FMA and organized medicine in Florida.
Please consider becoming a member of the FMA if you have not yet joined our ranks. Simply call (800) 762-0233
to speak to the membership department or you may join online at www.fmaonline.org.
Upon successful completion of the test located on page 35, you will be eligible to claim two CME credits. With
the continued assistance of organizations like the Department of Health, we hope to continue to serve Florida
physicians with opportunities for growth in knowledge and education.
Sincerely,
Steve West, MD
President, Florida Medical Association
A letter from
the Florida Medical association
Stephen R. West, MD Bernd Wollschlaeger, MD
Bernd Wollschlaeger, MD
Chair, FMA Committee on CME & Accreditation

January 27, 2009
I would like to take this opportunity to thank each of our Florida physicians for the contribution that
they have made to our improved capacity to identify sexually transmitted infec-
tions and to our understanding of their distribution. In 2006, the Department of Health promulgated a significant revision to Florida
Administrative Code 64D-3: Communicable Diseases and Conditions Which May Significantly Affect Public Health. Physicians had new require-
ments to report specific numerous sexually transmitted infections. Laboratories had requirements to transmit results electronically in altered
timeframes. We observed a 28% increase in positive test notifications. We observed a 26% decrease in time from collection to report and sub-
sequent confirmation of treatment completion. Clearly, the initiative has been a success. However, we now recognize the larger scope of disease
burden in our communities. Your partnership remains very critical to our capacity to reduce this disease burden.
The department projected the identification of over 5,000 mothers that would be infected with an STD during
pregnancy when we rolled out the Florida Administrative Code changes in 2006. Thanks to our partners in the
medical community and laboratories, we received 13,148 notifications during 2008. Our collective capacity to
ensure timely treatment and management of these infections has been a public health gain. Thank you.
Acquisition of STDs among those 15-24 years of age persists as indicators of health care access, economic dispar-
ity, personal behavior choices, and individual knowledge about risk prevention. During 2008, 70% of chlamydia
and 61% of gonorrhea was reported in those 15-19 years of age. Moreover, since 2003, we observed a 4-fold in-
crease of early syphilis in this age group of 15-24 years. Chlamydia, gonorrhea, and syphilis represent a gateway
into the costly health care expenditures associated with chronic STDs: HIV, HPV, and genital herpes. We invite your
partnership to enhance communication about STDs with the adolescent patients seen in your practice. We invite
you to utilize our public health function through local health departments to interrupt the spread in the commu-
nity among the most vulnerable and disparately affected. Together we can screen more youth, more minority pop-
ulations, and reduce the adverse health outcomes and associated costs of sexually transmitted infections.
Sincerely,
Russell W. Eggert, MD, MPH
Director, Division of Disease Control
Florida Department of Health
Introductory Remarks
by Russell W. Eggert, MD, M.P.H.

Research demonstrates disparities exist in health care status
and delivery of health services.
Underserved populations may be characterized by low socioeconomic status, geography, language, and/or physical con-
ditions. Disparate differences in racial and ethnic populations cause disproportionate cases of chronic disease, cancer,
and infectious disease in these populations. Those who are typically underserved by the health system face greater de-
bilitating conditions and circumstances. The personal cost of disparities can lead to significant morbidity, disability,
and lost productivity at the individual level. At the societal level, distal costs follow from proximal opportunities that
were missed to intervene and reduce the burden of illness1
.
The need to eliminate disparities in health care has been adopted by federal and state organizations. The
federal government’s prevention agenda, “Healthy People 2010,” addresses the differences in health care for
preventable and treatable chronic and infectious conditions. Some of the most common infectious diseases in
the United States are sexually transmitted diseases (STDs). The Centers for Disease Control and Prevention esti-
mates that approximately 19 million new infections occur each year with the burden falling on youth and women2
.
In concert with age and gender, minorities also account for a disproportionate share of new AIDS, chlamydia,
gonorrhea, and syphilis cases in Florida and the nation annually.
This report will present incidence and prevalence of reportable sexually transmitted conditions in underserved
populations who reside in Florida and focus on youth, women, and minorities. This report will also highlight
select economic and geographic indicators of high rates of infection. Surveillance data (2008) obtained from
Florida’s Department of Health STD case reports, census tables, and data obtained from the Florida Community
Health Assessment Resource Tool Set (CHARTS) were used for analysis.
C h l a m y d i a ( CT )
In 2008, there were 69,420 chlamydia cases reported among both males and females in Florida, or 367.4 cases
per 100,000 total population. Close examination of the disease distribution reveals that 80% of all reported
cases of chlamydia are reported in populations 26 and under; further, Chlamydia trachomatis is the most preva-
lent sexually transmitted bacterial infection reported among 15-24 year olds in Florida.
Age as a risk factor for chlamydia is extremely important, as the prevalence of
chlamydia is the highest among those under 25 years of age. Approximately 50%
of all STD cases reported from 2000 to 2008 have an age of initial report of an
STD at age 22 or under. Although 15-24 year olds represent 16% of the popula-
tion 15 and over, this population represents approximately 70% of all reported
chlamydia cases in Florida. A total of 49,036 chlamydia cases were reported in
persons between the ages of 15-24 in 2008. From 2007 to 2008, reported cases in
this population increased by 19.1%. Chlamydia cases in the 15-19 age group com-
prised 33.2% of all cases reported, and chlamydia cases in the 20-24 age group
comprised 37.4% of all cases reported in 2008. The overall rate for 15-24 year olds
Epidemiology of STDs
Among Underserved Populations
in Florida, 2008
Adrian C. Cooksey, MPH and Karla Schmitt, PhD, MSN, MPH, ARNP

was 2,009.8 per 100,000 population.
The mean age of all reported chla-
mydia cases was 22.8. However, at
least 4,500 cases in each single age
group were reported in 17-22 year
olds. When single age groups are
compared within the 15-24 age
range, cases reported peaked at
the age of 20 (mean=20.1) with a
gradual decline of cases as single
age in years increased.
The burden of morbidity occurs in
young women for several reasons.
Young women may have an increased susceptibility to
the bacterium Chlamydia trachomatis compared to
mature women who may develop immune response
and/or decreased target cell availability for infection.
Consequently, these physiological differences make it
common to observe a high number of infections
before the age of 25. In 2008 and preceding years, the
highest number of cases in females were reported in
the 15-24 age group with the highest rate, regardless
of gender, among females 15-19 (3,186.5 per 100,000
population). The rate for females in the 20-24 age
group was slightly lower at 3,175.0 per 100,000 popula-
tion. Florida specific trends parallel national data that
indicates infection is most prevalent in women under
the age of 25.
Gender differences in health care services and health
care seeking behaviors account for significant variation
among rates between males and females. Although
rates are considerably lower in males, disparities exist
with men under the age of 25 as well. In 2008, 20-24
year olds had the highest rate among male populations
(1,173.0 per 100,000 population). This rate was trailed
by a rate of 635.6 per 100,000 population for males
between the ages of 15-19. The peak age for male re-
ported chlamydia infection was 21.3 for the 15-24 age
cohort and 24.9 for all males with a reported infection.
Chlamydia impacts adolescents and young women re-
gardless of race and ethnic groupings. The distribution
of race/ethnicity is vast among women; however non-
Hispanic Black females in adolescence and young adult
populations have higher rates compared to White and
Hispanic populations in Florida. Among
women, the case rate for non-Hispanic Black
15-24 year olds (7,989.0 per 100,000) was
nearly five times higher than the second highest rate in
non-Hispanic White females 15-24 (1,603.1 per 100,000
population). In 2008, adolescents and young adults
(15-24) who self reported as non-Hispanic Black ac-
counted for 50.8% of the chlamydia cases in 2008.
Persons who self reported as non-Hispanic White ac-
counted for 21.8% of cases. Persons who self reported
as Hispanic (White or Black) accounted for 8.9% of
cases. Persons who self reported in other or unidenti-
fied racial-ethnic groups accounted for 18.5% of cases.
G o n o r r h e a ( GC )
In 2008, there were 22,897 gonorrhea cases reported
among both males and females in Florida, or a rate of
121.2 cases per 100,000 population. Close examination
of the disease distribution reveals that over 75% of all
reported cases of gonorrhea are reported in popula-
tions under the age of 30; further, gonorrhea is the
second most prevalent sexually transmitted bacterial
infection reported among 15-24 year olds in Florida.
About 2/3 of the cases reported since 2000 had an
STD at age 24 or younger and the other 1/3 had their
initial report at age 25 or older.
Over the past five years, the total number of reported
gonorrhea cases reached a low of 18,580 cases in 2004
and increased to 23,976 cases in 2006; however, overall
cases decreased in 2007 (23,366) and 2008 (22,897).
More cases have been reported in the 20-24 age group
for gonorrhea consistently since 1998; further, 15-24
Legend
County Line
Chlamydia Cases by Census Tracts
Frequency
0 - 5
6 - 10
11 - 15
16 - 20
21 - 139
F i g u r e 1 :
C h l a m y d i a c a s e s b y c e n s u s T r a c t s

year olds accounted for 61% of infections reported in
2008. The age specific case rate for 15-24 year olds was
572.2 per 100,000. The mean age of all reported gonor-
rhea cases was 24.9. However, when single age groups
are compared within the 15-29 age range, cases
peaked at the age of 20 with a gradual decline of cases
as age in years increased.
Adolescent and young adult populations had minimal
change in the number of cases reported from 2006 to
2008. Although cases decreased 1.5% in 20-24 year olds
from 2007, cases in 15-19 year olds increased by 2.5%.
When comparing gender specific data in populations
under 25, much like chlamydia trends, females under the
age of 25 accounted for the largest proportion of cases re-
ported (60%). Among females, the highest number of
cases was reported in 15-19 year olds (4,460 cases) with a
rate of 747.5 per 100,000 population. The second highest
rate among females was in 20-24 year olds (682.3 per
100,000 population). Among males, the highest numbers
of cases was reported in the 20-24 age group (3,319 cases)
with age specific rate of 531.7 cases per 100,000 popula-
tion. Males 25-29 had the second highest rate (343.5 per
100,000 population). Unlike chlamydia trends, males aged
25 and over had higher rates compared to females. The
mean age of males with a reported gonorrhea infection
was 27.5 compared to 22.2 for females. Nevertheless, all
cases reported, regardless of gender, disproportionately
occur in populations under 25 years of age.
In 2008, the distribution of gonorrhea by race/ethnicity
in the 15-24 age group disproportionately affected
non-Hispanic Blacks. Non-Hispanic Black adolescents
and young adults (15-24) have the highest rates by
race/ethnicity and age group in Florida. In 2008, non-
Hispanic Black females age 15-19 had a case rate of
2,282.8 per 100,000 population. This rate was nearly
eight times higher than the second highest rate in non-
Hispanic White females 15-19 (220.7 per 100,000 popu-
lation). Non-Hispanic Black males age 15-19 had a case
rate of 1,123.7 per 100,000 population. This rate was 23
times higher than the second highest rate in Hispanic
males 15-19 (69.7 per 100,000 population). Males 25-29
years old had the highest age specific rates in males.
E a r l y S y p h i l i s
Reported cases of total syphilis increased in all age groups
from 2006 to 2008. Unlike chlamydia and gonorrhea trends,
Broward
Miami-Dade
Legend
County Line
Chlamydia Cases by Census Tracts
Frequency
0 - 5
6 - 10
11 - 15
16 - 20
21 - 139
Broward
Miami-Dade
Legend
County Line
Gonorrhea Cases by Census Tracts
Frequency
0 - 5
6 - 10
11 - 15
16 - 20
21 - 98
F i g u r e 2 :
C h l a m y d i a a n d G o n o r r h e a G e o s p a t i a l D i s p e r s i o n i n S e l e c t C o u n t i e s , 2 0 0 8

early syphilis cases are more equally distributed among
15-49 year olds. However, there has been a four-fold increase
of early syphilis cases reported in 15-24 year olds from 2003.
In 2008, early syphilis trends in females indicate 59% of
cases occur in those under 30 years of age compared to
35% in males in the same age cohort. However, males aged
30-49 account for 83% of reported early syphilis cases in
both male and female populations over 30. The number of
early syphilis cases has increased 8% from 2007. The ratio of
male to female early syphilis cases was 3.2 to 1 in 2008.
The distribution of early syphilis by race/ethnicity continues
to disproportionately affect non-Hispanic Blacks. Persons
who self reported as non-Hispanic Black accounted for
44.1% of the syphilis cases in 2008. Persons who self re-
ported as non-Hispanic White accounted for 29.7% of the
cases. Persons who self reported as Hispanic (White, Black,
or other) accounted for 18.1% of the cases. Persons who self
reported in other or unidentified racial and ethnic groups
accounted for 8.1% of the cases. The rate per 100,000 for
non-Hispanic Blacks was 33.1 per 100,000 population. This
rate was six times greater than the second highest rate in
non-Hispanic Whites (5.8/100,000).
E c o n o m i c a n d G e o g r a p h i c v i e w o f
STD s b y c e n s u s t r a c t s
In highly impacted areas, STD rates, evaluated by
census tract, may be an order of magnitude higher than
that of surrounding areas3
. In 2008, over 45% of all gon-
orrhea cases were reported from larger, more populous
counties (Duval, Broward, Orange, Dade, and
Hillsborough) and unlike chlamydia dispersion, gonor-
rhea cases occurred in more tightly defined areas
(Figure 2). While there is clearly considerable geospatial
congruence between the two infections from the state
perspective, the distributions of gonorrhea and syphilis
(not shown) are more closely aligned than others.
As of the 2000 Census, 33 of Florida’s 67 counties are
considered rural based on the statutory definition of
an area with a population density of less than 100 in-
dividuals per square mile or an area defined by the
most recent United States Census as rural4
. Rates of
infection in rural counties were slightly lower in com-
parison to rates in most urban areas. However, some
of the highest rates of GC infection in 15-24 years olds
were found in the following rural counties: Gadsden,
Jackson, Calhoun, and Hamilton.
From 2005-2008, 13% of people were in poverty in
Florida and nearly 20% of Florida’s residents had no
insurance of any kind. It is important to note that race
and ethnicity in the United States are risk markers that
correlate with other more fundamental determinants
of health status such as poverty, access to quality
health care, health care seeking behavior, and resi-
dence in communities with high prevalence of STDs5
.
Adults aged 19-29 are one of the largest groups
without health insurance, according to a study spon-
sored by the Commonwealth Fund6
. Sexually transmit-
ted diseases, especially syphilis and gonorrhea, are
associated with a host of adverse socioeconomic indi-
cators. In the United States, these are often correlated
Figure 3: Mean Rates/1,000 By Census Tract
Poverty Levels, 2008 (n=3,152)
Percent Below Poverty Level GC Rate/1,000 CT Rate/1,000 Early Syphilis Rate/1,000
0 - 5.9% 0.5 1.7 0.0
6 - 9.9% 0.7 2.2 0.1
10 - 17% 1.3 3.3 0.1
17.1 - 76.8% 3.6 6.9 0.3
Census Tract Average 1.5 3.5 0.1

with residential housing patterns. The mean rates for census tract data shows a linear association between
poverty level and STD infection rates (Figure 3). Chlamydia rates nearly doubled the average census tract
rate when the poverty level was in the upper 4th quartile. Similarly early syphilis and gonorrhea rates in-
creased as well.
P u b l i c H e a l t h I m p l i c a t i o n s
In “Un-equal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” the Institute of Medicine
notes that disparities in health care are substantial, even after accounting for characteristics typically associ-
ated with disparities, such as health insurance coverage and income. Although analysis reports applicable
findings, more in-depth analysis is needed. Surveillance data was mapped over a large geographic area and
may not reflect trends that occur in smaller sub populations. Census data for census tracks and poverty level
are nearly ten years old. These rates may not account for birth, death, or migration changes in population.
Data was also not explored by other characteristics such as race/ethnicity, location of STD clinics, and avail-
able medical resources for stronger geospatial associations. Further, analysis reflects only data that has been
reported to the Florida Department of Health and represents only a small proportion of the true national and
state burden of STDs.2
The acquisition of STDs persists as indicators of health care access, economic disparity, personal behavior
choices and individual knowledge about risk and preventive measures. Florida’s population between 15-24
years of age represents 16% of the total Florida population. For those 15-24 years of age, 2008 reported 70%
of the total 19% increase in chlamydia, and 61% of the gonorrhea with 3.5% increase specific to this age
group. And since 2003, we observed a four-fold increase of early syphilis among this age same group. Across
race and ethnicity of all adolescents and young adults, and among specific minority populations the distribu-
tion of sexually transmitted infections persist disproportionately in our state.
r e f e r e n c e s
1
National Health Care Disparities Report: Summary. February 2004. Agency for Health care Research and
Quality, Rockville, MD. http://www.ahrq.gov/qual/nhdr03/nhdrsum03.htm
2
Trends in Reportable Sexually Transmitted Diseases in the United States, 2008: National Surveillance Data
for Chlamydia, Gonorrhea, and Syphilis. Centers for Disease Control and Prevention, Division of STD
Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. http://www.cdc.gov/std/
stats07/default.htm
3
Nelson KE, Williams CM, Graham N. Infectious Disease Epidemiology Theory and Practice. Aspen
Publishers, 2001.
4
Florida Office of Rural Health. Program Overview. Tallahassee, FL: Florida Department of Health. http://
www.doh.state.fl.us/workforce/RuralHealth/ruralhealthhome.html#Rural%20Health
5
Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance, 2001. Atlanta, GA:
U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, September 2002.
6
Young adults lack insurance. Cinical Psychiatry News 34.7 (July 2006: 74(1). General OneFile.Gale. State
Library of Florida-Web Portal. 12 Jan. 2009. http://find.galegroup.com/ips/start.do?prodID=IPS>.

Introduction: Sexually transmitted diseases (STDs) are among the most common of all
infectious diseases. The Centers for Disease Control and Prevention
(2008) recently estimated that one in four adolescent girls in the United States (U.S.) is infected with an STD.
Treatment costs are estimated to be in the billions of dollars (Starnbach et al., 2008); sequelae of untreated and in-
adequately treated disease include infertility, adverse pregnancy outcomes, and enhanced efficiency of HIV transmis-
sion. In the United States, Blacks, or African Americans, are disproportionately affected by high rates of STDs (Steele
et al., 2008). Given the potential sequelae of STDs as well as the national goal to eliminate health disparities in the
United States (DHHS 2000), racial disparities in STD rates merit attention. In this report we will review the magnitude
of racial disparities in STDs, discuss individual and systemic aspects of risks for STDs and finally discuss strategies
to reduce racial disparities in STDs.
Although racial disparities in health status in the U.S. are pervasive and span both chronic and infectious dis-
eases, disparities in the prevalence of STDs are particularly striking (Steele et al., 2007). According to the CDC
2005 STD Surveillance Report (see Table 1), in that year chlamydia infection rates among Blacks were over eight
times higher than among Whites and 2.7 times higher than among Hispanics. For gonorrhea, rates were nearly 18
times higher among Blacks compared to Whites, and eight times higher among Blacks compared to Hispanics.
Finally for syphilis, the rate among Blacks was approximately five times higher than among Whites and three
times that of Hispanics. In Florida, which follows the national pattern, Blacks have much higher rates of STDs than
Whites, while the risk for Hispanics is modestly increased (Cooksey and Schmitt, this edition).
R i s k F a c t o r s f o r
STD A c q u i s i t i o n
In an attempt to understand
racial disparities in STDs, the
first question that must be ad-
dressed is whether or not
these differences can be at-
tributed to higher risk sexual
behaviors among Blacks. In
fact, there is reliable data
from the National Health and
Nutrition Examination Study
(NHANES) data (Fryar et al.,
2007), which indicates that a
higher proportion of Blacks
initiate sexual activity before
the age of 15 and a higher
proportion had more than
one sex partner in the 12
Health Disparities
in Sexually Transmitted Diseases:
Black Americans at Risk
Toye H. Brewer, MD and Kevon-Mark Jackman, MPH

months prior to the study than Mexican-Americans or
Whites. However, differences in risk behaviors do not
account for the difference in STD rates. Several well-
designed studies have shown that Blacks remain at a
significantly increased risk for STDs compared to
Whites, even after adjustment for sexual behaviors and
socio-demographic factors (Ellen et al., 1998, Hallfors
et al., 2007, Harawa et al., 2003). In the landmark study
by Hallfors et al. (2007), data from wave III of the
National Longitudinal Study of Adolescent Health (Add
Health) was analyzed to determine whether individuals’
sexual and drug risk behaviors account for racial dis-
parities in HIV and STDs. Data from over 8,500 non-His-
panic Black and White respondents, all between 18 and
26 years of age, were included in the analysis. As Table
2 shows, the research team found that across the spec-
trum of risk behaviors, from least risky to highest risk,
Blacks had significantly higher odds ratios (OR) for HIV
and STDs than Whites, even after adjustment for cova-
riates. For example, among the lowest risk group (little
alcohol or tobacco, few sex partners) Blacks had an OR
of 7.1 for STDs or HIV compared to Whites of the same
risk category. At the higher risk level of men having sex
with men (MSM), Black MSM had an OR of 9.6 for STDs
or HIV compared to Whites in the same risk category.
These findings led the authors to conclude that “Black
young adults are at very high risk for STDs, even when
their behavior is normative,” whereas STD risk for
Whites approached that of Blacks only among the
highest risk groups.
Findings such as these have led to a shift in STD epide-
miology concepts from an emphasis on individual risk
behaviors to the analysis of social and structural deter-
minants of health as well as social and sexual networks
(Aral, 1999, Adimora, 2005, Farley, 2006). As STDs tend
to concentrate in areas most affected by poverty and
segregation (Cohen, 2000, Farley, 2006, Zenilman et al.,
1999), increasingly these and other structural factors
such as racism, policies and laws, educational opportu-
nities, access to quality health care, and community
prevalence of disease are being cited as determinants
of racial disparities of STDs.
Blacks are far more likely than other racial groups to
live in segregated areas in the U.S. as well as to live in
areas of concentrated poverty (Williams and Collins,
2001). Racial segregation and poverty interact to affect
educational and employment opportunities, housing,
and health behaviors, as well as access to health care.
Additionally racial segregation is linked to environmen-
tal factors like high rates of crime, homicide, and drug
use (Williams and Collins, 2001). These factors gener-
ate conditions that make Black males six to seven times
more likely to be incarcerated than White males
(Harawa and Adimora, 2008, Steele et al., 2007). High
rates of incarceration have a major impact on future
educational and employment opportunities. Small
numbers of males with stable employment within low
income African American communities greatly impact
stability in relationships (Harawa and Adimora, 2008).
Qualitative research (Adimora et al., 2001) suggests
that poverty, drug use and scarcity of Black men con-
tribute to high rates of STDs and HIV among Black
women by an imposition of structural barriers on
women’s choices in partner selection.
Another research area exploring racial disparities in
STDs is the field of sexual networking. Lauman and
Youm (1999) analyzed the 1992 National Health and
Social Life Survey data, which consists of information on
over 3,000 adults between 18 and 59 years of age,
Table 1: Sexually transmitted
disease rates by race and the ratio of
black and hispanic case rates to whites:
United States, 2005a
Sexually Transmitted
Disease
Rateb Rate
Ratioc
Infectious Syphilisd
White, Non-Hispanic 1.8 1.0
Black, Non-Hispanic 8.8 4.9
Hispanic 3.3 1.8
U.S. Total 3.0
Chlamydia
Hispanic 459.0 3.0
U.S. Total 332.5
Gonorrhea
Hispanic 74.8 2.1
U.S. Total 115.6
a
Source: CDC, Sexually Transmitted Disease Surveillance, 2005
b
Rate per 100,000 population
c
Represents the ratio of STD rates in Blacks and Hispanics to Whites
d
Primary and Secondary Syphilis

selected using a national representative probability
sample. They found that 1) sexual networking patterns
among Blacks are more segregated, i.e., inter-racial
mating is less common than among Whites and
Hispanics, which increases the odds of exposure to an
infected partner and that 2) within the Black commu-
nity, members of high-risk core groups (drug users,
persons with multiple sex partners) are more likely to
have sex with persons who are at low risk (dissortative
mating), which leads to more effective spread of HIV
into the wider community. These patterns, shaped by
the larger social determinants, predict that regardless
of individual risk behaviors, Blacks are more likely to
encounter an infected sexual partner than Whites.
A d d r e s s i n g STD D i s p a r i t i e s
Aggressive campaigns aimed to reduce individual risk
behaviors by encouraging adolescents to abstain from
or delay the onset of sexual activity, use condoms and
limit their number of sexual partners are of utmost im-
portance. However, it is now clear that community level
and structural interventions are also needed.
Community level and structural interventions should in-
corporate entities outside of the traditional public
health paradigm. As Steele et al. (2007) note, “Reducing
and eliminating health disparities cannot be achieved
by a single agency or group; rather the task will require
partnerships from individuals, communities, agencies,
community based organizations, policymakers, the
public and private health care sectors, and others.”
Such partnerships might address structural factors,
outside of the traditional public health paradigm, that
are associated with negative health outcomes, such as
high school drop out rates and the impact of policies
that lead to disproportionately high rates of incarcera-
tion among poor Blacks. Support for alternative drug
policies that promote prevention and treatment rather
than incarceration have increased over time and such
efforts may be essential to improve local policies that
disproportionately affect poor Blacks (McBride et al.,
2008). Additionally it has been suggested that correc-
tional facility based intervention could be used to reach
incarcerated persons and their sexual partners for STD/
HIV interventions (Hammet and Jones, 2006).
Traditional public health measures that include screen-
ings of high risk populations and the provision of sur-
veillance to provide data to direct resource expendi-
tures are also critical. The traditional public health role
to provide low cost STD services is also of key impor-
tance. Blacks are more likely than Whites to access
health care services via public clinics, therefore de-
creased services and/or increased co-pays at these sites
negatively impacts access to care among Blacks
(Reitmejier et al., 2005).
C o n c l u s i o n s
Racial disparities in STD rates are strongly influenced by
structural and socio-economic determinants that con-
tribute to disparities in socio-economic status and cir-
cumstances. To address these underlying structural de-
terminants is a tremendous challenge which requires
political will, partnerships, and commitments from mul-
tiple stakeholders if the gap is to be closed. Given the
inability of public health programs alone to eliminate
the cause of disparities, goals must be realistic (Steele
et al, 2007). Among realistic goals of public health pro-
grams are the provision of timely surveillance to guide
targeted interventions to those populations at highest
risk and provision of affordable STD services, which in-
cludes screening, treatment, and risk reduction counsel-
ing. Development of partnerships with communities,
the private sector, policy makers, and other partners is
another essential step for public health programs to
address health disparities.
Table 2: Sexually Transmitted Disease And Hiv Infection Prevalence
(95%, Ci) , By Race And Risk Behavior Pattern:
National Longitudinal Study Of Adolescent Health Wave Iii, 2001-2002a
Risk Behavior Pattern White Blackb
Substance Use and Sexual Activity 3.4 (1.6, 7.0) 22.0 (9.7, 42.6)
Multiple Sexual Partners 3.4 (1.4, 7.8) 9.7 (4.7, 18.9)
Injection Drug Use 7.8c (3.1, 18.4) 23.4 (4.8, 65.1)
Male-male sexual activity 6.7c (2.3, 18.1) 33.8 (14.3, 60.9)
a
Data derived from Hallfors et al. (2007) Sexual and Drug Behavior Patterns and HIV and STD Racial Disparities: The Need for New Directions
b
All prevalence extimates were greater than the sample‘s overall prevalence (6%)
c
Greater than the sample’s overall prevalence (6%)

R e f e r e n c e s
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Introduction: Despite widespread condom distribution and health education, sexually
transmitted infections (STIs) in young adult women are on the increase.
In an attempt to address these increasing rates of STIs, improve patient-provider interactions, increase access to
sexual and reproductive health information and quality health services for young adult women, investigators from
nursing and psychology collaborated on a joint research project. The purpose of this study was to describe sexual
risk taking, access to sexual and reproductive health information and quality health services, and interactions with
health care providers in a culturally diverse group of young adult women. This study also examined the impact of
socio-cultural beliefs and values that surround sexual risk taking through the use of sexual scripting and the influ-
ence of these results on subsequent health seeking behavior. The result of this work provides valuable information
for health care providers, as it allows them to understand how racial/ethnic minority women view themselves as
sexual beings, and how the sexual behaviors they exhibit are manifestations of culturally unique values and beliefs
about female sexuality.
Sexually Transmitted Infections
and Health care Providers:
Young Adult Women SpeakTami Thomas, PhD, ARNP, RNC and Dionne Stephens, PhD

B a c k g r o u n d a n d S i g n i f i c a n c e
STI rates have been examined and infections with few
or no symptoms for women, such as chlamydia, can be
highly problematic. Chlamydia is the most prevalent
and the most common reportable STI in the United
States (CDC, 2007; Sipkin, Gillam, Bissett & Grady,
2003). An estimated 28 million Americans are infected
annually with chlamydia (CDC, 2006). The significant
variations in incidence between different racial and
ethnic groups are consistent within specific studies
and CDC findings that report non-Whites tend to have
a higher rate of infection than Whites (Einwalter,
Ritchie, Ault, & Smith, 2005; Ford, Jaccard, Millstein,
Bardsley & William, 2004; Klausner, et al., 2001; Sipkin,
Gillam, Bissett & Grady, 2003). African-Americans are
the heaviest burdened non-White racial/ethnic group,
followed by American Indian/Alaska Natives,
Hispanics, and then Asian/Pacific Islanders. In 2006,
the chlamydia infection rate among African-Americans
was eight times higher than Caucasians, and Hispanics
had a rate 3.1 times higher than Caucasians.
These STI data indicate that regardless of the variety
and reach of educational programs focused on STI
rates, rates of infection are on the increase. Sexually
active college/university student populations are at
particularly high risk due to the predominant age range
of 18 to 24 years and often precarious behaviors that
include sexual risk taking. These risky activities include
inconsistent use or complete disregard of condoms,
multiple sexual partners, serial monogamy, and the
intake of alcohol and/or drugs during sexual acts.
Furthermore, young adult women of ethnically diverse
minority backgrounds frequently delay seeking treat-
ment for gynecological symptoms, which puts them at
increased risk for further morbidity such as pelvic in-
flammatory disease and infertility.
The most common factor to delay young adults from
seeking testing and treatment for a possible STI is per-
ceived consequences (Barth, Cook, Downs, Switzer &
Fischhoff, 2002). Young adults are concerned about
what others will think, harsh criticism, stigma, per-
ceived severity of a possible infection, and health care
provider characteristics. Ethnicity and culture as sug-
gested by one’s race can also be a factor in treatment
delay, which creates a subsequent health care dispar-
ity. Prior research in this area suggests that cultural
values transmitted through interactions with individu-
als and social contexts directly inform an individuals’
sexual health identity (LaPlante, McCormick, &
Brannigan, 1980; Barth et al., 2002; Stephens &
Phillips, 2005). Simon & Gagnon (1986) developed the
sexual scripting theory, which posits that sexual inter-
actions are guided by scripts, or schemas, that help in-
dividuals in the development of their sexual selves.
Health care providers who encounter young adult
African-American or Hispanic women must consider
the sexual scripting processes and experiences that
inform the sexual values of these young adult women.
Recognition of this dynamic gives import to the fact
that knowledge about sexual risks does not translate
into a sexual behavioral change. Consequently, the
meanings that emerge from sexual messages are im-
portant to understand how knowledge affects behav-
ior (Longmore, 1998).
Prior research has found that close friends play a signif-
icant role in decisions about sexual risk behavior
(Caspi, Lynam, Moffitt & Silva, 1993; Harper, 2004;
Prinstein, Meade & Cohen, 2003; Treboux & Busch-
Rossnagel, 1995). Friends contribute to sexual social-
ization processes that shape behavioral outcomes,
which includes the acquisition of new dating and sexual
partners. Conversation and the information exchange
between friends shape a young adult woman’s opinion
of herself and her plans for sexual conduct. Friends
also serve as a source of influence on sexual risk taking
behaviors and intent to seek testing and treatment for
gynecological complaints or concerns of STIs.
Different sources of influence, such as sex education,
family, and religion have been previously cited as im-
portant in the development of a racial/minority female’s
sexual script (Raffaelli & Ontai, 2001; Bay-Cheng, 2003;
Rouse-Arnett, Dilworth & Stephens, 2005). Since racial/
ethnic minority cultures tend to have traditional atti-
tudes in regard to gender roles, such as female reti-
cence and placing men’s pleasure at the center of a
sexual scenario (sometimes at the cost of safe sex),
racial/ethnic minority females are typically socialized
into such reticence, which potentially decreases their
ability to negotiate safe sex practices (Logan, Cole &
Leukefeld, 2002; Dworkin, Beckford & Ehrhardt, 2007).
Therefore, traditional scripts can act as a cultural barrier
to racial/minority females’ sexual health.

Health care providers can gain accurate and compre-
hensive knowledge about cultural messaging and
meaning given to sexual behaviors among racial/
ethnic minority women when sexual scripting theory is
used as a framework. This qualitative study explores
the meaning of sexuality in this population of ethnic
minority young adult women. The sexuality paradigm
asserts that people develop a sense of their sexual
selves through sexual messaging that takes place
within continually changing cultural and social con-
texts (Simon & Gagnon, 1984, 1986). As such, sexuality
is “socially scripted” in that it is a “part” that is
learned and acted out within a social context, and dif-
ferent social contexts have different social scripts
(Jackson 1996, 62). Prior research has found that
sexual scripts,
as frameworks
of unique
meanings given
to sexual
actions, differ
across racial/
ethnic groups
(Faulkner, 2003;
Metts &
Spitzberg,
1996; Stephens
& Few, 2007;
Zea, Reisen, &
Diaz, 2003) and
directly influ-
ence sexual be-
havioral out-
comes (Emmers-Sommer & Allen, 2005; Ginsburg,
1988; Lear, 1995; Mahay, Laumann & Michaels, 2001;
Nolan, 2006). A large body of research that examines
sexual scripting theory exists in several populations:
heterosexual White adolescents (e.g. Alksnis,
Desmariais, & Wood, 1996; Rose & Frieze, 1993), gay
and lesbian populations (e.g. Klinkenberg & Rose,
1994; Rose, 2000), and White young adult and gay/
lesbian populations. But there is limited research that
examines racial/ethnic populations, particularly those
in college or university settings. As the demographics
of the United States continue to change with in-
creased populations of ethnic minorities, a study
focused on young adult women from ethnic minority
backgrounds was timely and relevant.
S t u d y D e s i g n , S e t t i n g a n d
M e t h o d o l o g y
Q u a l i t a t i v e D e s i g n
This study employed qualitative data collection tech-
niques, which require an examination of the pro-
cesses by which individuals and specific groups con-
struct meaning, and a description of how those
meanings are interpreted and expressed (Bogdan &
Biklen, 1998). A growing body of qualitative research
examined sexual risk behaviors among African
American and Hispanic women, particularly those
which use individual interviews or focus groups, to
analyze various dynamics that shape sexuality, race,
and gender interactions (Jarama, et. al, 2007;
Morrow, Costello,
Boland, 2001;
Parrado,
McQuiston &
Flippen, 2005;
Stephens & Few,
2007). Sixteen
women, aged
18-25, partici-
pated in the
study; all self-
identified as
Hispanic (n=10),
African American/
Caribbean (n=3)
and Asian (n=3).
Data were gath-
ered from women
at this phase of the lifespan because women enter
more serious relationships, engage in sexual acts,
and have an expanding pool of potential mates
(Soet, Dudley & Dilorio, 1999).
M e t h o d s
Participants were recruited from the psychology
student research pool in a large Hispanic-serving insti-
tution in the southeastern part of the United States. We
further employed purposeful sampling, which involved
identification of participants who might give the most
comprehensive and knowledgeable information about
the meanings given to sexual scripting and health ser-
vices utilization in racial/minority communities. Women
between the ages of 18 and 25, self identified as a

racial minority were eligible to participate. Three data
collection techniques were used: 1) semi-structured
audio-taped individual interviews, 2) the interviewers’
notes, and 3) the researchers’ notes. These tech-
niques provided the framework for triangulation, con-
firmation of emergent themes, and detection of any
data inconsistencies.
Research assistants scheduled interviews at times selected
by the participants. The interviews were conducted by re-
search assistants in an office on campus, which made it
more convenient for the students. After some initial discus-
sion, the questioning process focused on skin color values
in the context of dating. A questioning route provided a
framework to develop and sequence a series of focused,
yet flexible questions (Rubin & Rubin, 1995). Throughout
this process, the interviewers made notes about partici-
pant-researcher interactions and salient issues that
emerged through the interviews. Participant-researcher in-
teractions, body language, subsequent interview ques-
tions, and outlines of possible categories, themes, and
patterns were also included in the interviewers’ notes.
Finally, two researchers read the interview transcripts twice
to make notes that identified and highlighted key themes
and points that were raised. Pseudonyms are used to iden-
tify the participants’ voices on the audio tapes.
S o m e q u e s t i o n s i n c l u d e d
Tell me how you racially or ethnically define yourself,»»
and particularly as a woman within that group?
What kinds of expectations about sexual behaviors are»»
associated with [insert ethnicity] women?
What do you think are the most important sexual health»»
issues affecting women your age today?
Where do you or your friends go to get the most up to»»
date and accurate information about HPV, chlamydia,
and other sexual health issues?
If you had to describe what an ideal health practitioner»»
would be, what would you want his/her qualities to be?
Have you had to go to a medical practitioner in the past»»
12 months specifically for anything related to your sexual
health or reproductive needs? Who conducted the ma-
jority of the visit- a doctor, nurse, or nurse practitioner?
Do you know what a nurse practitioner is?»»
Probes were prepared for each question to elicit
further information from the participants if the re-
sponses given were not comprehensive or failed to
provide understandable information.
A n a l y s i s
Principles of the constant-comparative method (Lincoln
& Guba, 1985) were used to guide data analysis in this
study. Simon and Gagnon’s (1984) sexual scripting levels
were used to develop the coding schemes. Reissman’s
(1993) levels of representation model guided continuing
attempts through analysis to represent and interpret
narrative data. The investigators read the transcripts
three times. The analysis process began with indepen-
dent open coding to develop categories of concepts,
and themes that emerged from the data. Selective
coding, where first level codes were condensed and
placed in new categories, followed this procedure.
F i n d i n g s
These young adult women stated that they need to
improve their sexual health knowledge and use of
sexual and reproductive health services. Beliefs
around sexually appropriate scripts disseminated di-
rectly influenced attitudes toward seeking screening
and treatment for sexual health issues. These beliefs
placed women in positions where they lacked knowl-
edge about sexual health issues and felt that they
could not take steps to become more empowered
about their sexuality. Specifically, women felt that
health care providers who discuss sexual health infor-
mation/education within a safe/comforting environ-
ment would best meet their sexual health needs.
1. Barriers to Treatment: Sexual Script Messages
Familial and religious barriers emerged as the most in-
fluential sources of sexual scripting and influence on
seeking screening and treatment among these
women. Socialization by family was a significant influ-
ence in the formation of racial/ethnic minority females’
sexual scripts. This is consistent with prior research of
familial influences on minority daughters (Raffaelli &
Ontai, 2001). Most (79%) of the participants supported
the stated “it’s not normal to go to family” to discuss
sexual health issues, although familial values about
sexuality are extremely important. In addition, families
attempted to instill values that included female sub-
servience towards men and no premarital sex. These
values held true regardless of race/ethnicity.
Hispanic female: “I still believe that I need to
serve whatever guy that I’m in a relationship with,
so in a relationship I always feel like I’m sort of, like
I guess the best way to put this is like a waitress,

where I’m like, always putting them first and
serving them because that’s like what I’ve seen
with my family.”
Similarly, indoctrination of religious influences was
evident in the minority female participants. Religious
influences promoted female chastity and silence on
the topic of sex (Raffaelli & Ontai, 2001). Sexuality and
contraception were not discussed unless it was to
deter from sex. As a social institution, religion can in-
doctrinate feelings of guilt and an inability to disclose
sexual information (Wyatt & Dunn, 1991):
Caribbean female: “[Caribbean people] are reli-
gious, Christian, so you know the norm is that
you’re heterosexual and sexuality isn’t accepted,
[sexuality and sexual health] is not really spoken
about.”
2. Health Care Providers as Educators
The majority (87%) of the women in this study did not
feel they had adequate sexual health education. They
cited schools, peers, and female familial members (in-
cluding sisters and cousins within their same age
group) as possible sources of information, but were
critical of the accuracy and the depth of knowledge
gained from these sources. Often the information
they received was focused on avoidance of sexual
contacts, which ignores the need for protective
actions. This supports prior research findings that
racial/minority females are largely unaware of STI pre-
ventive measures.
Hispanic female: “I actually went to a passion
party over the weekend and I thought I knew ev-
erything, and I realized I knew nothing. I was
shocked by how little I actually knew, and I think
education was something that was missing. I think
that what’s taught in schools isn’t enough, it’s just
kind of biased where not everything is taught in
schools either.”
The females in the sample indicated a desire for
health care providers to discuss with them preventive
information in regard to sexual health. Nurse practi-
tioners were viewed by the women as reliable re-
sources for sexual health information. Their fears
about inaccurate or limited information would not be
of concern if they spoke with a health care provider,
such as a nurse practitioner. This finding is supported
by other research data that indicates medical profes-
sionals are often viewed as credible sources of
medical information, particularly on topics tradition-
ally viewed as taboo (Ginige, Chen & Fairley, 2006;
Gott et al, 2004; Pavlin et al., 2008).
African American female: ”It’s getting informa-
tion from someone who knows about [sexual
health issues]. I guess that’s what they do so they
know - [Nurse Practitioner] would know the right
things. She would have heard everything already
from people coming in for things so nothing
would be a big deal for her.”
Conversations about sexual and reproductive health
information in a medical setting further helped
women feel that sexual health conversations were
held in a safe space. While women often hesitate to
talk about personal health issues, prior research has
shown that university medical setting, student health
care centers are ideal spaces to help patients feel ac-
curate information is being provided in an appropriate
setting (Diebold, Chappell & Robinson, 2000; Dooris,
2001; Swinford, 2002).
3. Health Care Providers Creating Safe
Environments
Although women felt that nurse practitioners would
be ideal sources of sexual health information, they
also admitted to a delay in seeking practitioner assis-
tance because of feelings of humiliation. Sexual
scripts shaped by their cultural values significantly
shaped this fear; any public acknowledgement of their
sexuality could put them risk for being seen as a
“loose” or “bad” woman. This is consistent with re-
search conducted by Barth et. al. (2002), which stated
that one of the main barriers to seeking testing for
STIs is the perceived negative consequence of “What
would others think?”
Caribbean female: ”I think it’s an embarrassing
thing for a woman, at least in the Caribbean, so by
going to a practitioner, its kind of like you feel that
everyone will find out pretty soon. I mean, here

you are supposed to be virgin and you are going
to a doctor for an STD or something else. The
doctor may look down upon you. That’s how
women of the culture think.”
This need to recognize the sexual script messages
within cultural contexts was viewed as an extremely
important characteristic for health care providers. All
the young adult women who participated in the study
gave significant value to their racial/ethnic and cultural
background. These young adult women, without ex-
ception, discussed the strong influence of the mes-
sages received from cultural sources on their own
sexual behavior. Although critical of the sexual script-
ing expectations for females within their cultures,
these women consistently spoke of the importance of
having their unique cultural beliefs respected and inte-
grated into sexual health communication. This finding
is consistent with research that notes clients often fear
that health providers use a comparative approach to
review their sexual health experiences; a normalization
of White/middle class cultural values, which leads to
an inaccurate perception and possible misdiagnosis of
racial/ethnic minority women’s sexual health needs
(Jones, 1991; McLoyd, 1998; Stephens & Few, 2007).
D i s c u s s i o n / A p p l i c a t i o n t o C l i n i c a l
P r a c t i c e
Despite the valuable information uncovered, the study
was not without limitations. Meaningful comparisons
between the ethnicities of the sample were difficult,
given that the majority of the sample was Hispanic.
Future research should therefore include a larger
sample with comparable sizes between the different
ethnicities. In addition, the qualitative nature of the
study did not allow for a large sample of participants,
and the development of sexual scripts were based on
participant recall. Saturation was achieved after the
thirteen interviews were reviewed.
However, this study was unique in that it integrated the
disciplines of nursing and psychology to address in-
creasing rates of STIs in minority young adult women.
The use of qualitative methods, particularly interviews
or narrative documents, have been instrumental to
inform researchers of the various dynamics that shape
sexuality, race, and gender interactions (Bell-Scott,

1998; Few, Stephens, & Rouse-Arnett, 2003). In con-
sideration of sexual health issues, prior research sug-
gests the use of qualitative methods to provide the
most direct window into young adults’ sexual experi-
ences through rich descriptions that can detail facts
that are not easily quantified (Brooks-Gunn & Paikoff,
1997; Few, Stephens, & Rouse-Arnett, 2003).
Training and continuing education on cultural compe-
tence are essential for health care providers and
support staff, as they are the first face most of these
young adults see as they enter the primary care office
or student health care clinic. Time spent to discuss
the specific cultural needs of each patient is impor-
tant to provide equitable care. These discussions
would also foster an environment of acceptance,
privacy, and safety. An emphasis on training can and
does decrease patient-provider miscommunication
and improves cultural competence of the health care
provider. Cultural competence is one of the most ef-
fective factors to decrease health care disparities
(Institute of Medicine, 2002). To provide effective
sexual and reproductive health information, an un-
derstanding of culture and the context of sexual
meanings for young adult women the pro-
vider serves is essential.
The awareness by health care providers
that young adult women require an en-
vironment that fosters communication
and that a young adult woman’s
knowledge on how to use a condom
and awareness of sexually transmit-
ted infections, does not necessarily
translate to their use of condoms is
paramount.(Sipkin, Gillam, &
Bissett Grady, 2003). Therefore,
readily available routine urine
screening and treatment of chla-
mydia in both sexually active as-
ymptomatic females and males
is a good strategy to decrease
chlamydia infections.
Screening of males is im-
portant in reducing the
incidence of
infections and re-infection. Due to the silent nature of
the disease, it is not enough to test only when there
are symptoms. Females should be routinely screened
at the time of a vaginal examination and pap smear
either by vaginal swabbing or urine collection. Males
and females should also be offered chlamydia screen-
ing when accessing student health care services on
college and university campuses.
In addition, the results of this research give evidence
that clinical office settings and specific office routines
must provide young adult women the time to discuss
sexual health information. In an age of decreased re-
imbursement and increased patient visits on a daily
basis this may seem untenable. One solution may be
the use of internet and or text messaging between
patient and health care providers. These technolo-
gies are available to most young adults and provide
them anonymity and allow the provider to answer
questions at convenient times. This is an upgrade
from the old “telephone triage nurse system”. While
this technology might not be available in all offices, it
might be a reasonable step to improve the patients’
perception of privacy and safety.
C o n c l u s i o n s
Through an understanding of the unique socialization
factors that shape racially diverse young adult female
populations and their health care experiences illus-
trated in the qualitative research results, health care
providers of all types will gain accurate perceptions of
these women’s sexual health information needs.
Moreover, racial minority young adult women need,
and more importantly, want nurse practitioners’ credi-
ble help to identify healthy and unhealthy sexual behav-
iors within a specific gender and racial context.
Through the continued development of sexual script-
ing models to address unique cultural nuances during
client-provider interactions, health care providers can
strengthen their partnership with their racial minority
clients and promote desirable sexual health behavioral
outcomes. These data provide a foundational compo-
nent for further research. They provide a framework
for the development of a specific provider interven-
tion to decrease the rates of STIs and decrease
related morbidity, and thereby significantly decrease
the health care dollar burden of these diseases.

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from Posters
to PRISM:
Physician Roles in STD Prevention
and Control Efforts
that Target Adolescents
Sherese J. Bleechington, MPH, CHES
Health care providers are well known for their curative role in
disease control, yet they also serve as a
critical point of contact for prevention efforts. Few patients will deny that they almost unquestionably trust the
advice obtained from a person donning a white coat and stethoscope. This is not to say that there are not a
growing number of individuals with high levels of health literacy prepared to openly and consistently communicate
with providers. Instead a reflection on patients’ confidence in the information supplied by providers is an opportu-
nity to explore how patient-provider communications may be enhanced to reduce disease among target populations.
Patient-provider communications are especially important as the Florida Department of Health, Bureau of STD
Prevention and Control seeks partners to reverse the trend of increasing rates of STDs among adolescents in
Florida. This article will discuss two physician roles that contribute to STD prevention among adolescents: disease
reporting and patient communication.
S e x u a l l y T r a n s m i t t e d D i s e a s e s A m o n g A d o l e s c e n t s
Sexually transmitted diseases are a major health problem among adolescents. The highest reported rates of
chlamydia and gonorrhea are found among persons ages 15-24. In the pursuit of primary prevention, which is
the avoidance of the development of disease, health care providers are encouraged to talk with their young
patients before the patients initiate sexual ac-
tivities. Statistics from the 2007 Florida Youth
Risk Behavior Survey (YRBS) indicated that
49.5% of adolescents in grades 9-12 had
engaged in sexual intercourse (see Figure 1),
with 8.2% engaging in intercourse before the
age of 13.1
Approximately 16.4% of students re-
ported they had sexual intercourse with four or
more people during their life. The 2007 YRBS
survey instrument introduced a new question
to create a baseline for youth engagement in
oral sex. Roughly 309,000 students (45.2%) had
ever had oral sex in 2007. Males had a signifi-
cantly higher prevalence of this behavior than
females (50.6% and 39.9%, respectively).

Additional data sources
suggest adolescents need
information about sexual
health and STDs.
Provisional data for 2008,
collected by the Florida
Department of Health,
Bureau of STD Prevention
and Control, indicates
more than 23,000 cases of
chlamydia and 6,500
cases of gonorrhea were
reported for the 15-19
year old age group alone
(see Table 1). Examination
of the state’s STD data gathered from 2007 through
2008 reveals a significant percent change in the
number of cases reported for chlamydia and gonor-
rhea (increase by 43% and 55% respectively) among
the 15-19 age group in Florida.
Health care providers have been identified as primary
sources of information and guidance for young ado-
lescents and their parents. This is a critical health pro-
motion and prevention role. The American Academy
of Pediatrics (Sexuality Education for Children and
Adolescents) and the American Medical Association
(Guidelines for Adolescent Preventive Services) en-
courage health care providers to discuss sexually
transmitted diseases with their patients.2,3
As parent
and child embark on the journey from childhood to
adolescence, the role of health care providers is criti-
cal in the prevention of sexually transmitted diseases.
P o s t e r s a n d O t h e r P r e v e n t i o n
M a t e r i a l s
Posters are one of many ways to communicate health
information to multiple target populations. Marketing
research is typically conducted to ensure vivid, relevant
images and memorable phrases are used to attract
readers and impart a succinct health promotion
message.4
Posters rarely stand alone. They are often
coupled with educational booklets or brochures that
elaborate on the theme or messages presented in the
poster. There is great debate among public health pro-
fessionals regarding the use of printed materials.
Concerns include literacy levels among target popula-
tions with low educational attainment, printing costs
that create barriers to dissemination of printed health
information, and the spread of misinformation by
invalid, unscientific sources.5
The concerns represent
gaps that health care providers fill.
Health care providers continue from where the posters
and other prevention materials end. They are in a
unique and influential position. The American Academy
of Pediatrics provides the following recommendations:
Integrate sexuality education into clinical practice with»»
children from early childhood through adolescence.
This education should respect the family’s individual
and cultural values.
Educational materials, such as handouts, pamphlets,»»
or videos, should be available to reinforce office-
based educational efforts.
Be knowledgeable about community services that»»
provide appropriate high-quality sexuality education
and additional services that children, adolescents, or
families need.
Consider participating in the development and imple-»»
mentation of sexuality education curricula for schools
or in public efforts to decrease the rates of unsafe
adolescent sexual behavior and adverse outcomes.
Linguistically appropriate materials could be provided»»
in the office or the health care provider should have a
way of helping children, adolescents, and their fami-
lies get information in their language of choice.
FIGURE 1: Percentage of students who have had
sexual intercourse by gender, Florida, 2001 - 2007
percent
2001 2003 2005 2007
FL Total 49.9 51.3 50.5 49.5
FL Females 46.2 46.7 47.1 44.8
FL Males 53.5 56.1 53.5 54.3
Source: Sexual Behaviors Among Florida Public High School Students: Results from the 2007 Florida Youth
Risk Behavior Survey Report. (2007). Tallahassee, Florida. Available at http://www.doh.state.fl.us/disease_
ctrl/epi/Chronic_Disease/YRBS/2007/2007_YRBS.html
70
60
50
40
30
20
10
0

The journal of the florida medical association
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
COL_INT 125 89 73 52 58 42 19 22 17 15 10
COL_DIS 140 130 87 65 70 49 11 10 10 24 19
REC_INI 12 6 12 7 11 17 16 17 13 12 7
REC_DIS 54 63 29 22 25 13 15 12 13 21 15
160
140
120
100
80
60
40
20
0
Average(Days)
YEAR
H e a l t h C a r e P r o v i d e r s ,
D i s e a s e R e p o r t i n g a n d
S u r v e i l l a n c e
In addition to their roles of providing in-
formation, physicians across the state
have a second role associated with their
disease reporting responsibilities under
Florida Administrative Code 64D-3:
Communicable Diseases and Conditions
Which May Significantly Affect Public Health. The infor-
mation that they report complements data received
from laboratories and enables efficient timely manage-
ment in disease investigations to interrupt spread in
the community. This data stored in the Department of
Health’s PRISM (Patient Reporting, Investigation and
Surveillance Manager) application actively monitors
STD morbidity and disease trends in Florida. PRISM is
utilized by over 500 users concurrently, varying from
disease investigators, data analysts, and treatment pro-
viders. Introduced in 2007, PRISM is the only
Department of Health statewide application available
from desktops, laptops, and via Blackberry. A profile, in
PRISM, is an individual. The individual’s profile contains
his/her demographic information, laboratory results, in-
terview notes, treatment history, and other case investi-
gation information unique to that individual.
The multiple benefits in the use of PRISM include the
existence of a central statewide database and de-
creased timeframes between positive tests, diagnosis,
and treatment. The use of a central system allows for a
comprehensive view of the treatment intervention and
related STD activities of an individual in the context of
statewide performance measures. Electronic laboratory
reporting per Florida Administrative Code 64D-3 has
shortened the length of time between a positive test
result and the initiation of STD prevention and control
activities (such as investigation, case management, in-
tervention, and treatment). Reduction in the duration of
STDs among infected individuals will reduce the period
of time that an individual is infectious, and consequently
reduce the numbers of partners exposed to infection.
Table 1: Notifiable STD cases
in 15-19 year olds, by gender
Gender Chlamydia Gonorrhea Syphilis Total
Female 19,013 4,460 140 23,613
Male 3,961 2,086 125 6,172
Unknown 81 16 0 97
Total 23,055 6,562 265 29,882
Source of data: Florida Department of Health, Division of Disease Control, Bureau of STD Prevention and
Control data files as of January 2009.
FIGURE 2
Measurable Improvements: Integration of ELR in to
PRISM and into the business model of STD continues to produce
measurable improvements in operations. These improvements will
continue to translate into cost savings, operational expenditure re-
ductions, and increasing efficiencies during economic times that
demand programs do more with less.
COL_INT = Collection of initiation date of field records
COL_DIS = Collection of specimen to field disposition date
REC_INT = Test result receive date to initiation date of field record
REC_DIS = Test result receive date to disposition date.

The system’s use of automation allows laboratory
results to be processed quicker and enables the field
staff to ensure treatment or verify treatment with pro-
viders in a much more efficient manner. Figure 2 reveals
an enormous reduction in test to treat intervals because
of ELR and other efficiencies. Across the state, local
health care providers and laboratories are the link
between infected persons and our public health re-
sponse to interrupt spread.
Without reports of illness from local partners, the
Florida Department of Health cannot fully identify and
investigate STD outbreaks of public health signifi-
cance. Health care providers’ partnership with repre-
sentatives from the Department of Health that utilize
PRISM is necessary to:
identify clusters, outbreaks, and/or pandemics,»»
enable preventive or mitigative treatments, and»»
assist in national and international surveillance efforts to»»
control the spread of STDs.
P o s t e r s t o P RISM : P o i n t s A l o n g
t h e Sp e c t r u m
Although this article briefly introduces posters and
PRISM as STD activities, the core activities that con-
tribute to STD prevention and control efforts are much
more extensive and intensive. The activities imple-
mented to achieve the State goals are selected
through a deliberate, logical approach and require
health care providers’ engagement in order to be suc-
cessful. The 2009 agenda for STD health promotion il-
lustrates commitment to the use of science-based,
theory driven frameworks that allow multiple stake-
holders to use a shared rationale to achieve behavior
change among target populations. Physicians are core
stakeholders in the process of prevention of STDs
among adolescents.
STD health promotion activities may be organized by
concepts of the Health Belief Model (HBM). The HBM
is a behavior change theory. It is a psychological model
that attempts to explain and predict health behaviors
by focusing on the attitudes and beliefs of individuals
(see Figure 3).6
It is one of the first behavior change
theories developed.
According to HBM, changes in behavior depend on
six factors:
Perceived susceptibility - the belief that one is at risk»»
for contracting the illness or disease
Perceived severity - the belief that a health problem is»»
serious
Figure 3. Conceptual Model of the Health Belief Model
Individual Perceptions ModIfying Factors Likelihood of Action
Perceived susceptibility/
seriousness of disease
Age, sex, ethnicity
personality
socio-economics
knowledge
Perceived benefits
versus barriers to behav-
ioral change
Perceived threat
of disease
Likelihood of
behavioral change
Cues to action:
education
symptoms
media information
Source: Glanz, K., Rimer, B.K. & Lewis, F.M. (2002). Health Behavior and Health Education. Theory, Research and Practice. San Fransisco: Wiley & Sons.

Perceived benefit - the belief that a change in one’s»»
behavior will reduce the threat
Perceived barriers - a perception of the obstacles to a»»
change in one’s behavior
Cues to action - strategies to activate “readiness” or»»
reminders to engage in health protective behaviors
Self efficacy - the belief that one has the ability to»»
change one’s behavior
Table 2 compares key public health and physician pre-
vention activities performed that address the concepts
of the Health Belief Model. The list of activities can be
conducted by health care providers in order to make
the anticipated achievement of reduced STDs a shared
success. There are many points along the STD spec-
trum from posters to PRISM and health care providers
are key navigators for patients traveling from point A
to point B. It is the patient-provider communication
that does (or does not) occur that makes the great-
est difference in health outcomes. Providers have the
voice that posters and disease surveillance will never
have. They activate the power in theory and enhance
the practice of prevention. Health care providers are
catalysts along the spectrum.
A S n a p s h o t o f t h e R o l e o f
P h y s i c i a n s A l o n g t h e Sp e c t r u m
Not sure where you can make a difference? The follow-
ing small steps are important, easy ways health care
providers influence patients’ decisions to engage in
healthy behaviors.
P r o v i d e I n f o r m a t i o n
The CDC provides plain language brochures with basic
facts about STDs. To order free STD educational ma-
terials, visit: https://www2.cdc.gov/nchstp_od/piweb/
stdorderform.asp.
The AAP Adolescent Health Section offers one central,
convenient location where pediatricians can turn for
access to many adolescent health related handouts.
Visit http://www.aap.org/sections/adolescenthealth/
handoutstools.cfm for more information.
Parent Package (an AMA effort) - Designed to help
physicians share important information about ado-
lescence with parents and adolescent patients.
Available at: http://www.ama-assn.org/ama/pub/cat-
egory/7312.html.
TABLE 2
Concept Public Health Activities Physician Activities
1. Perceived Susceptibility
Develop and disseminate materials containing mor-
bidity data
Conduct a brief risk assessment and correct or confirm
patient’s perception of individual risk
2. Perceived Severity
Intensify quantity and quality of STD information
presented with interrelated topics (e.g. preg-
nancy prevention, HIV, and substance abuse)
Integrate STD prevention messages in conversations
about other serious threats to adolescent and reproduc-
tive health (e.g. HPV, PID)
3. Perceived Benefits
Age-appropriate, reward centered DVDs for use
during community health promotion events and
school health presentations
Provide printed materials that describe tips for risk reduc-
tion and potential positive outcomes of STD prevention
and early treatment
4. Perceived Barriers
Disseminate publications that provide tips for
partner to partner communications and patient
guides for provider-patient interactions
Start a dialogue with patients and parents about barriers
described in the literature or presented by other patients
5. Cues to Action
Reminder cues for action in the form of health mar-
keting items
Display age-appropriate and environment-friendly
posters that contain reminder messages (such posters
are available free of cost from the Bureau of STD)
6. Self-Efficacy
Support county health department staff in efforts
(e.g. face-to-face client interviews, condom demon-
strations, testing events) that build individual and
community confidence
Normalize the conversation of STDs; incorporate STD
risk assessment and discussion as a component of an
office visit
Empower patients through readily available, judgment-
free testing
“Are you thinking about being sexually active with anyone
sometime soon?”

SGarrett - STDJournal (see pages 26 through 31)

SGarrett - STDJournal (see pages 26 through 31)

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