Advance provision of emergency contraception to young men: An exploratory study in a clinic setting.

PURPOSE: To explore the acceptability of advance provision of emergency contraceptive pills (ECPs) to young men seeking health care. METHODS: For this exploratory study in a clinic setting, we approached young men aged 16-35 to participate in a survey eliciting socio-demographics, sexual and contraceptive history, and knowledge about ECPs. We offered young men advance provision of ECPs and compared characteristics of 126 young men who did and did not accept the ECPs. RESULTS: Most (76%) of the participants accepted advance provision and left with an ECP pack, with even higher proportions among males whose sexual histories were suggestive of increased risk of involvement in an unintended pregnancy. CONCLUSIONS: This study holds promise to inform scale up of advance provision of ECPs among young men.

Longitudinal Analysis of Quality of Life, Clinical, Radiographic, Echocardiographic, and Laboratory Variables in Dogs with Preclinical Myxomatous Mitral Valve Disease Receiving Pimobendan or Placebo: The EPIC Study.

BACKGROUND: Changes in clinical variables associated with the administration of pimobendan to dogs with preclinical myxomatous mitral valve disease (MMVD) and cardiomegaly have not been described. OBJECTIVES: To investigate the effect of pimobendan on clinical variables and the relationship between a change in heart size and the time to congestive heart failure (CHF) or cardiac-related death (CRD) in dogs with MMVD and cardiomegaly. To determine whether pimobendan-treated dogs differ from dogs receiving placebo at onset of CHF. ANIMALS: Three hundred and fifty-four dogs with MMVD and cardiomegaly. MATERIALS AND METHODS: Prospective, blinded study with dogs randomized (ratio 1:1) to pimobendan (0.4-0.6 mg/kg/d) or placebo. Clinical, laboratory, and heart-size variables in both groups were measured and compared at different time points (day 35 and onset of CHF) and over the study duration. Relationships between short-term changes in echocardiographic variables and time to CHF or CRD were explored. RESULTS: At day 35, heart size had reduced in the pimobendan group: median change in (Δ) LVIDDN -0.06 (IQR: -0.15 to +0.02), P < 0.0001, and LA:Ao -0.08 (IQR: -0.23 to +0.03), P < 0.0001. Reduction in heart size was associated with increased time to CHF or CRD. Hazard ratio for a 0.1 increase in ΔLVIDDN was 1.26, P = 0.0003. Hazard ratio for a 0.1 increase in ΔLA:Ao was 1.14, P = 0.0002. At onset of CHF, groups were similar. CONCLUSIONS AND CLINICAL IMPORTANCE: Pimobendan treatment reduces heart size. Reduced heart size is associated with improved outcome. At the onset of CHF, dogs treated with pimobendan were indistinguishable from those receiving placebo.

Effect of Pimobendan in Dogs with Preclinical Myxomatous Mitral Valve Disease and Cardiomegaly: The EPIC Study-A Randomized Clinical Trial.

BACKGROUND: Pimobendan is effective in treatment of dogs with congestive heart failure (CHF) secondary to myxomatous mitral valve disease (MMVD). Its effect on dogs before the onset of CHF is unknown. HYPOTHESIS/OBJECTIVES: Administration of pimobendan (0.4-0.6 mg/kg/d in divided doses) to dogs with increased heart size secondary to preclinical MMVD, not receiving other cardiovascular medications, will delay the onset of signs of CHF, cardiac-related death, or euthanasia. ANIMALS: 360 client-owned dogs with MMVD with left atrial-to-aortic ratio ≥1.6, normalized left ventricular internal diameter in diastole ≥1.7, and vertebral heart sum >10.5. METHODS: Prospective, randomized, placebo-controlled, blinded, multicenter clinical trial. Primary outcome variable was time to a composite of the onset of CHF, cardiac-related death, or euthanasia. RESULTS: Median time to primary endpoint was 1228 days (95% CI: 856-NA) in the pimobendan group and 766 days (95% CI: 667-875) in the placebo group (P = .0038). Hazard ratio for the pimobendan group was 0.64 (95% CI: 0.47-0.87) compared with the placebo group. The benefit persisted after adjustment for other variables. Adverse events were not different between treatment groups. Dogs in the pimobendan group lived longer (median survival time was 1059 days (95% CI: 952-NA) in the pimobendan group and 902 days (95% CI: 747-1061) in the placebo group) (P = .012). CONCLUSIONS AND CLINICAL IMPORTANCE: Administration of pimobendan to dogs with MMVD and echocardiographic and radiographic evidence of cardiomegaly results in prolongation of preclinical period and is safe and well tolerated. Prolongation of preclinical period by approximately 15 months represents substantial clinical benefit.

Predictors of HPV vaccine uptake among women aged 19-26: importance of a physician's recommendation.

Among insured women, aged 19-26 years, those who discussed the HPV vaccine with their physician and received a recommendation were overwhelmingly more likely to be vaccinated. Student status and perception of the personal importance of vaccination were also predictive of vaccination. The strength of the physician's recommendation played a significant role in the decision to be vaccinated, resulting in a 4-fold greater likelihood of vaccination when women received a strong recommendation versus one that was not strong. Health care providers should be well-informed about HPV vaccination and recognize that the strength of their recommendation to patients will foster appropriate uptake.

Intent to accept and acceptance of herpes testing in adolescents and young adults.

OBJECTIVES: Understanding the intention-behaviour association with HSV-2 testing is important because it can inform interventions that might be needed to support an effective HSV-2 control programme. This study aims to understand attitudinal, symptomatic and historical precursors to intent to accept, and acceptance of, HSV-2 testing. METHODS: The sample included 900 individuals recruited from four sites located in two US cities. Participants completed self-report questionnaires. Expressed intent to accept HSV-2 testing was assessed with an item that asked about acceptance of a test with the same characteristics as the test offered later. The health behaviour outcome was acceptance of the HSV-2 test when it was offered. Predictors examined were STI history, genital symptoms, anxiety and STI-related stigma. RESULTS: Expressed intent significantly predicted test acceptance. However, a number of participants made testing decisions which were at odds with their stated intent. Genital symptoms and STI history significantly predicted both greater intent and test acceptance. STI stigma only predicted lower intent, whereas anxiety only predicted greater acceptance. Intent fully mediated the relationship between genital symptoms and test acceptance, but did not mediate the relationship between STI history and test acceptance. CONCLUSIONS: This study suggests that intent does not always predict behaviour, even when the two are measured within close temporal proximity. There are factors that may predict intent only or behaviour only, or may predict behaviour, but solely through influencing intent. Understanding how these various relationships work may be important to efforts designed to maximise acceptance of HSV-2 testing.

The psychosocial impact of serological diagnosis of asymptomatic herpes simplex virus type 2 infection.

OBJECTIVES: To evaluate the impact of a positive herpes simplex virus type 2 (HSV-2) serological test on psychosocial functioning among people with no known history of genital herpes. METHODS: Individuals (age 14-30 years) without a history of genital herpes were recruited from an urban university setting and sexually transmitted diseases (STD), primary care, and adolescent clinics. Participants completed a questionnaire addressing psychological functioning, psychosocial adjustment, and perceived quality of sex and were offered free HSV-2 antibody testing. 33 HSV-2 positive people and 60 HSV-2 negative people demographically matched from the same source of recruitment were re-evaluated at a 3 month follow up visit. HSV-2 positive participants also completed a genital herpes quality of life (GHQOL) measure. RESULTS: Of the 33 who were HSV-2 seropositive, four did not recall their diagnosis. In comparing those who were HSV-2 positive with those who were negative, repeated measures analysis of variance indicated there were no significant differences over time on any of the measures. None the less, many HSV-2 positive individuals indicated that the diagnosis had a notable impact on their quality of life. Also, among the HSV-2 positive people, lower GHQOL at the 3 month follow up was predicted by higher interpersonal sensitivity (r = -0.44, p<0.05), lower social support (r = 0.40, p<0.05), and quality of sex (r = 0.62, p<0.01) at baseline. CONCLUSIONS: A diagnosis of asymptomatic HSV-2 infection does not appear to cause significant lasting psychological difficulties. Those for whom the diagnosis had the greatest impact were interpersonally vulnerable before the diagnosis. These results suggest that assessment of interpersonal distress may be important to include as part of pretest and post-test counselling.

Attitudes about human papillomavirus vaccine among family physicians.

STUDY OBJECTIVE: Human papillomavirus (HPV) vaccines will soon be available for clinical use, and the effectiveness of vaccine delivery programs will depend largely upon whether providers recommend the vaccine. The objectives of this study were to examine family physicians' attitudes about HPV immunization and to identify predictors of intention to recommend immunization. DESIGN: Cross-sectional survey instrument assessing provider and practice characteristics, knowledge about HPV, attitudes about HPV vaccination, and intention to administer two hypothetical HPV vaccines. PARTICIPANTS: Surveys were mailed to a national random sample of 1,000 American Academy of Family Physicians (AAFP) members. MAIN OUTCOME MEASURE: Intention to administer two hypothetical HPV vaccines (a cervical cancer/genital wart vaccine and a cervical cancer vaccine) to boys and girls of different ages. RESULTS: One hundred fifty-five surveys (15.5%) were returned and 145 were used in the final sample. Participants reported higher intention to recommend both hypothetical HPV vaccines to girls vs. boys (P < 0.0001) and to older vs. younger adolescents (P < 0.0001). They were more likely to recommend a cervical cancer/genital wart vaccine than a cervical cancer vaccine to boys and girls (P < 0.001). Variables independently associated with intention (P < 0.05) included: female gender of provider, knowledge about HPV, belief that organizations such as the AAFP would endorse vaccination, and fewer perceived barriers to vaccination. CONCLUSIONS: Female gender, knowledge about HPV, and attitudes about vaccination were independently associated with family physicians' intention to recommend HPV vaccines. Vaccination initiatives directed toward family physicians should focus on modifiable predictors of intention to vaccinate, such as HPV knowledge and attitudes about vaccination.

Acceptability of human papillomavirus self testing in female adolescents.

OBJECTIVES: To develop scales assessing acceptability of human papillomavirus (HPV) testing in adolescents, to compare acceptability of self to clinician testing, and to identify adolescent characteristics associated with acceptability. METHODS: Female adolescents 14-21 years of age attending a hospital based teen health centre self collected vaginal samples and a clinician, using a speculum, collected cervicovaginal samples for HPV DNA. Acceptability of and preferences for self and clinician testing were assessed at baseline and 2 week visits. RESULTS: The mean age of the 121 participants was 17.8 years and 82% were black. The acceptability scales demonstrated good internal consistency, reliability, test-retest reliability, and factorial validity. Scores were significantly lower for self testing than clinician testing on the acceptability scale and three subscales measuring trust of the test result, confidence in one's ability to collect a specimen, and perceived effects of testing (p < 0.01). Of those who reported a preference, 73% preferred clinician to self testing. Acceptability scores for both self and clinician testing increased significantly pre-examination to post-examination (p < 0.01). Multivariable analyses demonstrated that race was independently associated with pre-examination and post-examination acceptability of self testing, and that sexual behaviours and gynaecological experiences were associated with specific acceptability subscales. CONCLUSIONS: This sample of adolescents found clinician testing for HPV to be more acceptable than self testing and preferred clinician to self testing. If self testing for HPV is offered in the future, clinicians should not assume that adolescent patients will prefer self testing. Instead, they should educate adolescents about available testing options and discuss any concerns regarding self collection technique or accuracy of test results.

Prevention and control of sexually transmitted infections among adolescents: the importance of a socio-ecological perspective--a commentary.

The sexually transmitted infection (STI) epidemic among adolescents in the USA is inextricably tied to individual, psychosocial and cultural phenomena. Reconceptualizing the epidemic within an expanded socio-ecological framework may provide an opportunity to better confront its challenges. In this article, we use a socio-ecological framework to identify determinants of adolescents' sexual risk and protective behaviours as well as antecedents of their STI acquisition. The goal is to provide a synthesis of several discrete categories of research. Subsequently, we propose an integrated strategy that addresses the STI epidemic among adolescents by promoting a socio-ecological perspective in both basic research and intervention design. This approach may expand the knowledge base and facilitate the development of a broader array of intervention strategies, such as community-level interventions, policy initiatives, institutionally based programmes, and macro-level societal changes. Although there are inherent challenges associated with such an approach, the end result may have reciprocal and reinforcing effects designed to enhance the adoption and maintenance of STI-preventive practices among adolescents, and further reduce the rate of STIs.

Gender-specific predictors of genital herpes vaccine acceptance in a college population.

Vaccines represent one promising method for reducing the sexually transmitted disease (STD) epidemic. This study evaluated whether influences on the decision to accept a genital herpes vaccine differed by gender. In all, 518 college students completed a questionnaire on sexual history, health beliefs, and acceptance of a potential genital herpes vaccine. Each predictor variable plus a gender interaction term were analysed in separate logistic regression models. Follow-up analyses were performed by gender for outcomes that displayed significant interactions. Results indicated that a prior history of an STD and increased perception of risk for acquiring genital herpes were significant predictors of vaccine acceptance for men, while younger age and concerns about vaccine safety were significant predictors for women. Endorsement of a vaccine strategy targeting sexually experienced people was an influential factor for both genders, but was a much stronger one for women. Results suggest that gender-specific strategies may be crucial to genital herpes vaccine acceptance.

Patient satisfaction with care for genital herpes: insights from a global survey.

OBJECTIVE: To describe patient experiences and views regarding genital herpes management. METHODS: Between February 2002 and January 2003, subjects with genital herpes were recruited via the International Herpes Alliance website and through banners on additional sites. Surveys were available in English, French, Spanish, Italian, and German and assessed views on access to care, diagnosis, related emotional experiences, educational resources, counselling, pharmacotherapy, and satisfaction with care. RESULTS: 2075 patient responses from 78 countries were analysed. 49% reported their diagnosis was by culture (or other direct detection) and 9% by antibody test, while 34% reported they had been diagnosed by examination alone. 65% used a prescription antiviral therapy, 18% a topical antiviral therapy, and 17% an alternative therapy. Of 901 subjects who reported on frequency of antiviral use, only 30% reported a frequency consistent with a suppressive regimen while 59% of respondents said they would be likely to take daily therapy if it reduced the frequency of outbreaks. Patient satisfaction with management of physical symptoms was independently associated with duration of initial visit >or=15 minutes (adjusted odds ratio (OR) = 4.52), receiving a prescription (adj OR = 2.34) and receipt of a brochure/fact sheet (adj OR = 2.14). Satisfaction with attention to emotional issues also correlated with the first two of these factors. CONCLUSIONS: Genital herpes management may be improved by including the use of confirmatory laboratory testing, employing a full range of antiviral therapy options, providing educational materials, and committing more time to counselling at the initial visit.

Adolescents' attitudes and experiences regarding levonorgestrel 100 mcg/ethinyl estradiol 20 mcg.

STUDY OBJECTIVE: Oral contraceptive pills (OCs) are a commonly prescribed method of birth control for sexually experienced adolescents. The purpose of the current study was to describe anticipated parental involvement and adolescent compliance with pill taking, and to describe experiences with a 20-mcg OC regarding satisfaction and side effects after six cycles. DESIGN: Anticipated parental involvement and anticipated compliance, and experiences with an OC, were assessed at baseline, and after the first and sixth cycles during a clinical trial of oral contraceptives, which required parental consent. SETTING: Three adolescent medicine clinics in New York, NY; Cincinnati, OH; and San Juan, Puerto Rico. PARTICIPANTS: The sample consisted of 43 female adolescents with a mean age of 17 years. RESULTS: The majority of adolescents living with a parent anticipated parental involvement, and few adolescents anticipated difficulties with consistent pill taking. For two side effects (weight and mood changes), more than 30% of the adolescents anticipated the occurrence or worsening of side effects. However, few adolescents actually experienced increases in any of the nine side effects assessed. Ninety-seven percent of adolescents in this trial reported being satisfied with a 20-mcg OC. CONCLUSIONS: Health care providers can assess adolescents' anticipated difficulties with compliance with daily pill taking, and desire for help from their parents. This information can be incorporated into counseling to promote consistent and correct use.

A preliminary examination of adolescent girls' perceptions of the parental knowledge of their boyfriends.

STUDY OBJECTIVE: The purpose of this study was to describe adolescent girls' perceptions of their parents' contact with and knowledge of the girls' boyfriends. A second objective was to determine if knowledge was related to demographic characteristics of the girls or aspects of the relationship with their boyfriend. DESIGN: Cross-sectional analysis of data from an interview with adolescent girls enrolled in a longitudinal study. SETTING: Urban adolescent medicine clinic. PARTICIPANTS: Adolescent girls (n = 109) with a mean age of 17.6 (range 14.9-19.3 yr). Eighty percent were African-American and 20% were Caucasian. RESULTS: Most girls reported that their parents had some contact (either in person or on the phone) with their boyfriends. Thirteen girls reported that their parents did not know their boyfriends well, 40 reported that their parents knew their boyfriends somewhat, and 56 reported that their parents knew their boyfriends well. Age, race, and sexual experience were not related to how well the parents knew the boyfriend. Girls who had been involved with their boyfriends longer, believed that their relationship would last longer, were more satisfied, were more likely to tell their boyfriends private information and were more likely to describe their parents as knowing their boyfriends well. CONCLUSIONS: These results provide an initial description of girls' perceptions of their parents' relationships with their boyfriends. It would be important to understand how to utilize the information regarding these parental-boyfriend relationships to further adolescent girls' development of healthy (both psychologically and physically) relationships.

Sexual initiation: predictors and developmental trends.

BACKGROUND: Early initiation of sexual intercourse is associated with increased risk for acquiring sexually transmitted diseases. GOAL: To examine variables related to sexual initiation and developmental changes in the reasons why adolescent girls have sexual intercourse. STUDY DESIGN: A longitudinal study of girls recruited from an adolescent medicine clinic was performed. RESULTS: Logistic regression showed that girls who described their families as being expressive, having a moral-religious emphasis, providing supervision, and having greater maternal education, and who experienced menarche at an older age were older at sexual initiation. On the basis of contingency analyses, younger girls were less likely to report attraction or love, and more likely to report peers having sex as a reason for sexual intercourse at initiation. A generalized estimating equation analysis indicated that girls at younger ages are more likely to report curiosity, a grown-up feeling, partner pressure, and friends having sexual intercourse as reasons for intercourse. Girls at older ages are more likely to report a feeling of being in love, physical attraction, too excited to stop, drunk or high partner, and feeling romantic as reasons for having sexual intercourse. CONCLUSIONS: Prevention programs should include a focus on familial characteristics and susceptibility to peer norms. They should be conducted with sensitivity to the developmental changes in intimate relationships that occur during adolescence.

Adolescent girl's coping with an STD. Not enough problem solving and too much self-blame.

STUDY OBJECTIVE: Approximately three million teenagers are infected with an STD each year. The ways in which an adolescent girl copes with an STD may have implications for future risk and for psychological adjustment. The purpose of the current study was to compare whether coping with an STD was similar to coping with other stressors. SETTING: Urban, hospital-based adolescent medicine clinic. DESIGN AND PARTICIPANTS: Sixty-seven girls with a mean age of 15.9 (sexual debut was 13.8) yr completed the KIDCOPE in response to both an STD acquisition and an interpersonal stressor within the previous 6 months. RESULTS: Problem solving was used less often, and self-blame was used more often, in response to an STD acquisition. Frequency of use of self-blame was not correlated with perceived helpfulness. CONCLUSIONS: These findings suggest that clinicians need to help adolescent girls manage STD acquisition from the perspective of problem solving rather than self-blame.

Factors influencing condom use and STD acquisition among African American college women.

To identify factors that influence condom use and the risk of acquiring sexually transmitted diseases (STDs) among African American college women, the authors surveyed a sample of 123 sexually experienced undergraduate women at a state university. The college women who were older, had initiated sex earlier, or had more recent sexual partners were more likely than others in the study to report a history of an STD. The findings have implications for prevention and intervention programs for African American college women.

Improving rheumatologists' screening for alcohol use and sexual activity.

OBJECTIVES: To design, implement, and assess the impact of an office-based intervention designed to improve rheumatologists' identification of risk behaviors, especially alcohol use and sexual activity, among adolescents and young adults with chronic rheumatologic conditions. DESIGNS: Prospective intervention study. SETTING: Midwestern academic pediatric rheumatology practice. PARTICIPANTS: Ten attending rheumatologists and fellows and 178 patients (mean age, 18.1 years; 67% female; 88% white; 69% with juvenile rheumatoid arthritis) seen in the practice during the baseline and intervention years. MAIN OUTCOME MEASURES: Change in the rate of screening for alcohol use and sexual activity from the baseline to the intervention year, and physician perceptions of the intervention. RESULTS: Screening for alcohol use increased from 4.2% (9/208) at baseline to 31.6% (56/177) after the intervention (P<.001). Of those patients undergoing screening at follow-up, 20 (36%) of 56 patients reported any alcohol use and 11 (20%) reported current alcohol use. Of those reporting current use, 7 (64%) were counseled or referred. Methotrexate use increased the likelihood of alcohol screening (43% [33/76] vs 26% 123/871; P = .02). Screening for sexual activity increased from 12.4% (27/ 218) to 36.2% (64/177) (P<.001) from baseline to follow-up. Of 52 females undergoing screening at follow-up, 31 (60%) were sexually active. Eleven (41%) of 27 sexually active females were not using contraception other than condoms (4 were not asked about contraception); 7 (82%) of these were referred for contraceptive counseling. Seven rheumatologists completed in-depth semistructured interviews after the intervention. All reported time as a main barrier to screening. Other barriers included logistical problems, discomfort with the subject area, ambivalence about whether risk behavior screening is the province of pediatric rheumatologists, and perceived lack of applicability to their patients. CONCLUSIONS: Despite knowledge and concern about the interaction of immunosuppressive therapy and risk behaviors, few rheumatologists adequately screen the behavior of their adolescent and young adult patients. Time constraints, organizational issues, and physician beliefs remain barriers to widespread screening.

Adolescents' knowledge of human papillomavirus and cervical dysplasia.

STUDY OBJECTIVE: This study examined adolescents' knowledge of human papillomavirus (HPV) and cervical dysplasia (CD). Factors associated with knowledge and self-reported change in health-related behaviors were identified. DESIGN: Interviews were conducted at an average of 2.5 years following the diagnosis of HPV/CD. Medical charts were reviewed. SETTING: The study was conducted at a university-based adolescent dysplasia clinic. PARTICIPANTS: Fifty females, ages 15-23 participated in the study: 88% African-American, 12% Caucasian. RESULTS: On average, participants responded correctly to 86% of the questions regarding HPV/CD. However, the following key points were routinely missed: 52% did not know cigarette smoking increased the risk for cervical cancer; 42% believed that HPV/CD was always symptomatic; and 22% did not know condoms decreased the transmission of HPV. According to participants, their health care provider explained the diagnosis and treatment of HPV/CD using words they understood "some" or "most of the time." Higher academic skills significantly correlated with greater knowledge of HPV/CD. Forty-one percent of participants with a smoking history reportedly increased their smoking since the diagnosis, and only 40% used condoms "most of the time." However, 90% had maintained or increased their frequency of Pap tests. CONCLUSIONS: Adolescent girls had knowledge of most factors related to HPV/CD, but many did not understand the risks of cigarette smoking and failure to use condoms. To improve understanding and compliance, health care providers should tailor educational strategies to the functional level of adolescents.

Attitudes regarding vaccinations of STDs and other diseases.

The purpose of this study was to examine, among 2 groups of individuals with different risk profiles, the similarity of their attitudes towards vaccines for sexually transmitted diseases (STDs) and non-STDs. Subjects were recruited from an undergraduate psychology class at an urban university (n=518) or were participants in genital herpes vaccine trials (n=87). The participants were asked to complete a questionnaire regarding their attitudes about vaccines for selected diseases. The results of this study revealed that, in general, both groups supported vaccination for most diseases. There were differences, however, between groups regarding 3 diseases: measles, genital warts, and chlamydia. The vaccine trial participants were more likely to accept vaccines for measles and the college students were more likely to accept vaccines for chlamydia and genital warts. The results of this study suggest that negative attitudes regarding vaccination to control STDs may not be a significant barrier to use.