1. Sexually Transmitted Infections in the Adolescent Population By Marcie Chenette, Rita Daniels, Chelsea Melrose and Gary Webster

2. Problem Statement Risk of sexually transmitted infections (STIs) among 15 – 19 year olds related to high risk behavior as demonstrated in higher incidence rate of sexually transmitted infections (STIs) in Kent County, Michigan.

3. Data Analysis Kent County, MI has one of the highest rates of STI infections in the state. o The national goal is that only 84 (or less) out of 100,000 people will have a STI o In Michigan, 457 out of 100,000 people have an STI o In Kent County, 488 out of 100,000 people have an STI ("Kent County," 2012) Why???

4. Data Analysis Possible factors that contribute to Kent County's high numbers: Lack of prevention and treatment promotion due to stigma associated with STIs. Better record keeping and better reporting strategies. A county with more prevention and clinical testing programs may have a higher incidence number than a county without these resources.

5. Why are the numbers higher in Kent County? According to a 2011 health survey performed in Kent County, youth living in this county are more likely to have received yearly check-ups. This suggests that perhaps the higher disease rates in Kent County are a result of higher numbers of the population getting checked for STI’s and receiving treatment. Kent County boasts having a more proactive public health agency presence than other counties in Michigan. The higher rates of STI’s may be a result from the following: populations at risk receiving treatment for STIs, greater availability of STI screening programs, and more efficient reporting practices. These factors, along with the factors such as racial disparities, are likely to be the major contributors to Kent County’s large incidence of sexually transmitted infections.

6. Data Analysis According to Healthy People 2020, the spread of STI’s is directly affected by social, economic and behavioral factors. Racial and ethnic disparities have been correlated to higher incidences of poverty, limited access to healthcare, and decreased attempts to get treatment (Healthy People 2020, 2012). Research has shown that African-American, Hispanics and American Indians have higher incidence rates of sexually transmitted infections than Caucasians (Healthy People 2020, 2012).

7. Data Analysis GenderAll Ages0-14 years 15-19 years 20-24 years 25-29 years 30-44 years 45 years or older Both sexes 3,615561,2451,37553535548 Male1,0721127640320115327 Female2,5404496797233420221 What groups are affected by STIs? Source: Michigan Sexually Transmitted Diseases Database, Sexually Transmitted Disease Section, Division of HIV/AIDS-STD, Michigan Department of Community Health; Table prepared by the Division for Vital Records and Health Statistics, Michigan Department of Community Health.

8. Data Analysis “In the U.S., although 15–24-year-olds represent only 25% of the sexually active population, they account for nearly one-half of all new sexually transmitted infections, and rates are highest among young women and minorities “ (Kohler, Manhart, & Lafferty, 2008, p. 344)

9. Data Analysis What resources are available in Kent County to address the high incidence of STIs? Kent County Health Department Planned Parenthood Blodgett Outpatient Clinic Cherry Street Services, Inc The above listed clinics boast "potentially free" STD testing. Kent County Health Dept provides a 16-session research based curriculum that may be used to enhance sexual education programs already in place. Program is called "Reducing the Risk" and is targeted to youth ages 14-18 (accessKent, 2012).

10. Data Analysis Despite Kent County's proactive health department and higher access to healthcare, the number of STI incidence remains high, indicating a need for community nursing intervention. Potential Inter-disciplinary Partners: RNs, NPs, PAs and MD's from local health department, hospitals, clinics and doctors offices Sexual education teachers from local schools

11. Why are STIs a problem? Reproductive health problems Fetal and perinatal health problems Cancer Facilitation of the sexual transmission of HIV infections (Healthy People 2020, 2012)

12. Goal According to Healthy People 2020, the goal is to promote healthy sexual behaviors, strengthen community capacity, and increase access to quality services to prevent sexually transmitted diseases (STDs) and their complications. ( Healthy People 2020, 2012)

13. Possible Causative Factors Biological Factors o Gender disparities - women suffer more frequent and serious STI complications o Age disparities - sexually active adolescents ages 15-19 are at higher risk for getting STIs o No signs and symptoms - many STIs either have no symptoms or have a long lag time in between infection and symptoms Social and Economic Factors o Poverty - high risk sexual behavior is more common o Access to health care - limited health services (Healthy People 2020, 2012)

14. Possible Causative Factors Behavioral Factors Substance abuse - association of substance abuse and STDs o Sexuality and secrecy - stigma associated with STDs o Sexual networks - sex with partner that is participating in risky sexual behavior (Healthy People 2020, 2012)

15. Measurable Indicators STI testing Human Papillomavirus Vaccination Comprehensive Risk Reduction (CRR)

16. Interventions Abstinence (refraining from genital contact) is the only 100% effective method of contraception and STD prevention Abstinence, however, is difficult for many people to achieve. Abstinence, self-esteem programs, and accurate information regarding barrier prevention is the most effective primary prevention.

17. Primary Prevention STD prevention is the primary care strategy for improving reproductive health (Healthy People 2020, 2012). Promote safer sexual behavior (www.unaids.org) Increase knowledge, communication, and healthy/respectful attitudes regarding sexual health (Douglas, 2011) Increase healthy, responsible and respectful sexual behaviors and relationships (Douglas, 2011) Use of condoms for penetrative sexual acts (www.unaids.org)

18. Secondary Prevention Promotion of health care seeking behavior Increase use of high quality, coordinated and integrated education, programmatic, and clinical services that promote sexual health (Douglas, 2011) Provision of clinical services that are accessible, acceptable and effective Decrease adverse health outcomes, including HIV/STDs, viral hepatitis, unintended pregnancies, and sexual violence (Douglas, 2011) Support and counseling services (www.unaids.org) Social Support Theory

19. Geopolitical Issues and Implications Federal content requirements when sex education is taught indicates: 27 states require abstinence be stressed 9 states require abstinence be covered Michigan requires abstinence be stressed (Douglas, 2011)

20. Geopolitical Issues and Implications “A randomized controlled trial of four federally funded abstinence programs found no significant decrease in the number of partners or risk for STD and pregnancy, and no delay in sexual debut. Similarly, a systemic review of 13 trials found that abstinence-only programs were not associated with reductions in sexual risk behavior or in diagnosis of STDs. Another review showed that all but one of 11 programs that taught about contraception results in no increase in sexual activity. Other studies have shown that sexual activity is not increased with teaching about condoms and HIV/AIDS” (Kohler, Manhart, Lafferty, 2008, p. 350).

21. Evidence-Based Practices Federal government will: Support states, tribes and communities to implement evidence-based sexual health information Promote and disseminate national screening recommendations for HIV and other STIs Promote and disseminate best practices and tools to reduce behavioral risk factors that contribute to high rates of HIV/STIs and teen pregnancy (Reproductive and Sexual Health, 2011)

22. Resources Public sector Specialized STI clinics Outpatient departments First level care including emergency departments, dispensaries and health centers Reproductive health/maternal and child health clinics

23. Resources Private sector Private STD clinics Private physicians Pharmacists Workplace clinic services

24. Evaluation Evaluation is used to improve the effectiveness of public health programs. Multiple types of evaluations can be used three of which are: Traditional evaluations- assess the impact of a specific program Economic evaluations- costs and benefits Formative evaluations-focus groups to find best use of resources (Stoto & Closer, 2008)

25. Traditional Evaluation Monitoring the impact of interventions: Positive evaluation would be a decrease in number of STI cases in the target group Negative evaluation would be an increase in the number of cases or same number of cases in the target group

26. Economic evaluations Evaluating the cost to benefit ratio of interventions: Cost: staff wages, building overhead, printed materials, treatment supplies Benefits: amount of decrease in number of incidence, number of participants in classes, increased public awareness

27. Formative Evaluations Assessing best use of resources using target group input Seeking out the target group where they are Asking target group how they learn Questionnaires after presentations about content and/or methods that worked or did not

28. Evaluations Employing multiple evaluation techniques will allow for a dynamic program that will adjust to the changing needs of the target group, allowing for redistribution of resources to the most beneficial techniques and locations.

29. Summary With the numbers high in Kent County, our group proposes: Re-formatting sex education programs Social Support Theory Monitoring measurable indicators Evaluating outcomes Our goal is to decrease the number of reported cases of STIs in Kent County.

30. References accessKent. (2012). Health education programs. Retrieved from http://www.accesskent.com/Health/HealthDepartment/Health_Promotion/Health_Education.htm County health rankings and roadmaps: Kent county, mi. (2012). Retrieved from http://www.countyhealthrankings.org/app/michigan/2012/kent/county/1/overall Douglas, J. M. (2011). Advancing a public health approach to improve sexual health in the United States: A framework for national efforts. National Center for HIV/AIDs, Viral Hepatitis, STD, and TB Prevention. Centers for Disease Control and Prevention. Retrieved from: http://www.cdc.gov/sexualhealth/docs/DouglasNHPCHIVpx081611last Harkness, G., & DeMarco, R. (2012). Community and public health nursing. Philadelphia, PA: Lippincott Williams & Wilkins. Healthy People 2020. (2012). Sexually transmitted diseases. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=37 Healthy People 2020. 2020 Topics and Objectives. Sexually transmitted diseases. Retrieved from: http://www.healthpeople.gov/2020/objectives/overview Kent County, Michigan: county health rankings & roadmaps. (2012). Retrieved from http://www.countyhealthrankings.org/app/michigan/2012/kent/county/

31. References Kohler, R.N., Manhart, P., Lafferty, M.D. (2008). Abstinence-Only and comprehensive sex education and the initiation of sexual activity and teen pregnancy. Journal of Adolescent Health, 42(4). Doi: 10:1016/j.adohealth.2007.08.026 Reproductive and Sexual Health. (2011). National Prevention Strategy. Retrieved from: http://www.healthcare.gov/prevention/nphpphc/strategy/reproductive-sexual-health.pdf Santelli, J., Ott, M.A., Lyon, M., Roger, J., Summers, D., Schliefer, R. (2006). Abstinence and abstinence-only education: A review of U.S. policies and programs. Journal of Adolescent Health 38, p. 72–81. Retrieved from: http://www.moappp.org/Documents/articles/2006/SantelliAbstinenceonlyEducationReviewPaper.pdf Stoto, M.A. & Cosler, L.E. (2008). Evaluation of public health interventions. In Novick, L.F., Morrow, C.B. & Mays, G.P. (Eds), Public Health Administration Principles for Population-Based Management, 2nd edition (pp 495-544). Sudbury, MA. Jones and Bartlett Publisher. Retrieved from http://www.jblearning.com/samples/0763738425/38425_CH18_495_544.pdf World Health Organization. Joint United Nations Programme on HIV/AIDS. Sexually transmitted diseases: Policies and procedures for prevention and care. Retrieved from: http://www.unaids.org/en/media/unaids/contentassets/dataimport/publications/irc-pub04/una97-6_en.pdf