An Integrative Review of the Health Care
Needs of Female Adolescents
ABSTRACT
Female adolescents have multifaceted health care needs.The
needs of adolescent females include addressing sexual activity,
substance and tobacco use, psychosocial issues, chronic dis-
eases, and behavior.The purpose of this integrative review is
to identify current needs of the female adolescent within a
primary care setting. Although some of the issues identified
are common to all adolescents, the female adolescent risk is
compounded due to additional health risks related to sexual
activity.These needs may be best met by an advanced prac-
tice nurse who is able to focus time specific to the health
care of the adolescent female.
Keywords: adolescent, female health care, health care needs,
primary health care
274 The Journal for Nurse Practitioners - JNP
Michael G. Jaskiewicz
A dolescents face various issues; many of which can be
addressed by their primary care provider (PCP).
However, teenagers state that there is a lack of communication
skills with their PCP.1,2 Female adolescents have an elevated
awareness of the quality of communication with their PCP
compared to males.2 The female adolescent may be at increased
risk related to the issues she faces because many of them are
compounded in this particular group. Consequently, this also
increases her need for quality communication within the
primary care setting.
In a study of adolescents and their preferences for PCPs,
over half of the female adolescents preferred a female health
care provider. Girls who had a female provider were more likely
to have private time with their PCP, and the majority of ado-
lescents in the study preferred this.3 Based on 2004 data, there
April 2009
are approximately 884,974 practicing physicians in the United
States. Of this number, 27% are female.4 Comparatively, nursing
is 94% female, with 13% being in the advance practice realm.5
Half of all adolescents in the United States are sexually
active.2 Risky sexual behaviors may result in pregnancy, and
may place the female adolescent at risk for obtaining sexually
transmitted diseases (STDs).These STDs may place her in dan-
ger of future sequelae, which are specific to females, such as
Human Papilloma Virus (HPV), putting her at risk for cervical
cancer.While the issue of sexual activity is especially risky for
the adolescent female, there are many other health issues that
these girls face.
Healthy People 2010 focuses on 21 Critical Health Objectives
for Adolescents and Young Adults. Other authors have identified
these issues as well. Objectives include reducing adolescent
deaths, unintentional injuries, violence, substance abuse, depres-
sion, suicide, pregnancies, HIV/AIDS, STDs, sexual activity,
tobacco use, obesity, and increasing physical activity and con-
dom use if sexually active.6-16
Current guidelines have been established to screen adoles-
cents to meet these objectives.17 The guidelines suggest that
adolescents have an annual preventative/well care visit, which
includes a complete physical with health guidance, screening
history, diagnostic tests, and immunizations. Much of this “well
care,” however, is performed during shorter, acute visits as
opposed to visits dedicated to wellness.18 Based on 1997-2000 visits,
prenatal care, as opposed to well care, was the number one rea-
son female adolescents accessed healthcare.19
While the well-care guidelines vary by age, there are several
interventions that are based on proper verbal screening and
counseling.17 To meet these objectives, there must be commu-
nication between adolescent and provider. Building a trustful
adolescent/provider relationship is necessary in the medical
management of this patient population.20
Current evidence shows that health care providers are
screening slightly more than half of their adolescent females for
gonorrhea and chlamydia, and about a quarter of providers are
failing to take sexual histories on their patients. Female
providers’ statistics are better, with 87.2% taking a health his-
tory, 81.5% discussing STDs, and a higher rate engaging in risk
discussions.21,22 Compared with generalists, nurse practitioners
were more likely to take a sexual history as well as screen for
gonorrhea and chlamydia.22,23 Based on this evidence, we may
conclude that nurse practitioners are more likely to offer health
screening than physicians.
Adolescent females should be seen for the concerns that
are specific to them, as well as for those issues that are statisti-
cally shown to cause the highest incidences of morbidity and
www.npjournal.org
mortality among this population.Those issues should be
addressed by providers with whom the adolescent female can
best communicate.
The purpose of this integrative review is to determine what
the primary care needs of the female adolescent are, to identify
if the female adolescents’ needs are being addressed in the pri-
mary care setting, and are they congruent with those of the
published guidelines?
METHOD
An integrative review was performed; the model of integra-
tive review as developed by Ganong guided this research.24 A
search for research articles was conducted using Ovid
Journals Full Text, Medline, and CINAHL. Keywords
included health care, female, adolescent, health care needs,
and primary health care. Studies that took place in specialized
settings or outside the United States were excluded. The
focus of this review was on the primary care setting and the
relationship of the adolescent/provider within the cultural
milieu of the United States.
Provider/adolescent relationship, and research examining
female needs, was not a specific target for this integrative review.
The author believed a general search for all research related to, or
utilizing primary care, may provide more concise definition as to
why adolescents are being seen within the primary care setting. It
was also the hope of this author to identify themes within these
studies that involve the provider/adolescent relationship.
Studies involving adolescents but not including data specific
to the female were excluded. Because of the need to look at
current issues of the female adolescent, the search was limited
to articles published within the last 5 years.
Eleven quantitative studies met these criteria and were
included in this review. Each article was read and the survey
instrument (Table 1) was completed by the author.
RESULTS
The 11 articles included in this review contained different
methods and sampling.The age of adolescents was not set as a
criterion, as it was evident that there were various age ranges
utilized within the research of adolescents.The youngest to
oldest adolescents within this body of research was 9 to
21 years, respectively.
Five articles utilized a theoretical base and 2 used a medical
basis or guideline to direct their research. Eight of the studies
used sampling from within a primary care setting.The remain-
ing 3 articles recruited samples from either a school or hospital
and continued with the sample through a follow-up in the
primary care setting.
The Journal for Nurse Practitioners - JNP 275
 Three of the articles had subject matter different than the The second article revealed that household rules had the
other studies within this sample. One of these addressed a greatest influence on the healthy dietary intake of adolescents,
decrease in primary care utilization following a traumatic even more so than peer group influence, which only
injury,25 another looked at frequent wheezing in adolescents approached statistical significance. Household rules is the only
and the lack of diagnosis when being seen in the primary care variables that affected female teens’ dietary decisions.33
setting.26 The third focused on adolescent violence as it The first of 3 studies that looked at issues related to sexual
relates to parental expectations, discipline, and modeling.27 behaviors compared adolescents testing negative for an STD to
The remaining 9 articles could be grouped based on those testing positive and related this to their subsequent infec-
common themes: tobacco use, substance use, nutrition, and tion rate. Reaching statistical significance were the adolescents
sexual behaviors. who had a positively diagnosed STD and were more likely to
28
Two articles examined tobacco use. Ozer et al conducted abstain as well as report condom use with sex. However, these
an intervention study on screening and prevention within a pri- adolescents were also more likely to have multiple sex partners
mary care setting.Tobacco was included within the term “risky as well as test positive for trichomoniasis and chlamydia.34
health behaviors.” In the intervention group, providers were Ozer et al28 also addressed sexual behavior within their
educated as well as provided with instruments to assist with the research content of “risky health behaviors” and found that
screening and counseling of adolescents engaging in tobacco use female screening and counseling in this area increased after an
and other risk-taking behaviors. A decline in tobacco use intervention of provider education.28
reached statistical significance within In another study, data from the
the intervention group. 28 Youth Risk Behavior Surveillance
Hollis29 researched tobacco Adolescent females should (YRBS) were analyzed to monitor
specifically and the patterns, needs, be seen for the concerns that the prevalence of risky behaviors of
behaviors, and attitudes of the ado- adolescents. In this study, half of the
lescents who smoke, as well as those
are specific to them as well adolescents in grades 9 through 12
who do not.This study found that as for those issues that are had been sexually active, with
smoking in the month prior to the statistically shown to cause 47.7% of them being female. Of
study was higher among female the highest incidences of those surveyed, half of them had
teens as well as older teens. Smoking reported a visit in the primary care
was significantly associated with peer
morbidity and mortality setting within the previous 12
smokers, smokers in the home, and a among this population. months and, of these, 42.8% of the
positive depression screen. females reported discussing an STD,
Three studies focused on the lack of communication HIV/AIDS, or pregnancy.These discussions were positively
between provider/adolescent about alcohol. In the first study, associated demographically to older age, black race, and sexual
priming of the adolescent and prompting of the provider in the experience.35
final intervention group significantly increased the discussion Within Ozer et al’s previously mentioned study, safety was
30
on all alcohol topics, and in the second intervention study, also addressed. As with the other “subcategories,” seatbelt and
alcohol screening and counseling also increased significantly helmet use screening and counseling was improved and reached
within the intervention group.28 statistical significance within the intervention group.28
Shrier found that there was a correlation between alcohol The 3 remaining studies within this sample were those that
use and associated psychiatric symptoms. Both boys and girls were not categorized. In the first, adolescents were involved in
reported higher psychiatric symptoms with substance use an unspecified traumatic injury.These adolescents were initially
compared to those with no substance use.These data are recruited into the study through their hospital stay (setting).
specific to substance use problems not yet classified as a The research then followed up with these adolescents to obtain
substance use disorder.31 data on primary care referral, primary care follow-up, and
Physicians’ counseling/screening on diet and health-related appropriateness of primary care screening for post-traumatic
topics was the focus of one of the 2 nutrition-related topics. It stress (PTS), depression, and alcohol use. Significance in this
was found that providers discussed diet, weight, and nutrition study included 39.4% of adolescents who did not have a PCP
more often with those at risk rather than as a screening process. at discharge and of those that did, only 36.6% were seen for a
These data reached statistical significance.32 follow-up 4 to 6 months after hospital discharge.Thirty percent

276 The Journal for Nurse Practitioners - JNP April 2009

represented those that screened PTS positive within that same
4- to 6-month timeframe and were undiagnosed.25
Research on undiagnosed wheezing and the diagnosis of
asthma focused on the associated factors.These were compared
with asymptomatic children.This study found that female ado-
lescents, smokers, smoke exposure, low socioeconomic status,
and race were associated with the undiagnosed frequent
wheezer. Six percent of the sample was undiagnosed; 59% of
these were female.26
The final study within the sample included adolescents
who scored positive on a psychosocial screening within a pri-
mary care setting.This was an intervention study that included
an interview of the adolescent as well as his/her parent. Forty
percent of this study’s population was female. More than half of
the total sample had reported being in a physical fight the year
prior to the study. Eighty-four percent of the adult sample
were mothers. Nearly 40% of the adult sample stated that they
would tell their child to hit if another person pushed them.
Lack of corporal punishment and parental disapproval of vio-
lence were the greatest determinates of nonviolence vs vio-
lence in these adolescents.6
Based on these studies, adolescents need to have more
primary care visits that address sexual behaviors, substance use,
violence, tobacco, safety, and diet/nutrition. Furthermore,
primary care providers are not diagnosing wheezing appropri-
ately, and better referral and follow-up is necessary for post-
traumatic injury.
DISCUSSION
Many resources indicate the primary care needs of adolescents. In
addition, there are guidelines available to assist in directing care of
this specific population.This guidance includes the female adoles-
cent, but it does not address why the majority of adolescents are
only seen for sick visits, and why prenatal care continues to be
the number one reason for female health visits.19 With decreasing
adolescent pregnancy being one objective in the fight to improve
adolescent health, why does pregnancy continue to be the most
often treated diagnosis in the primary care setting? And why is
screening and counseling to prevent it, not?
Based on the results of this study, the objectives of Health
People 2010, as well as our guidelines, are correct in their focus
on substance use including tobacco, safety, issues related to sex-
ual behaviors, violence, and nutrition.Topics of research related
to primary care that were not expected were the amount of
undiagnosed wheezing, as well as the lack of follow-up after
traumatic injury.
The follow-up for screening after a traumatic injury is
of special interest because we know that injury is one of the
www.npjournal.org
leading causes of death within the adolescent population.6
This research was nonspecific, but it did mention motor
vehicle accidents (MVAs) and intentional injury.25 If injury is a
leading killer of our teens, then appropriate follow-up is nec-
essary to help us lower these statistics and meet our goals.
Follow-up, along with proper communication and screen-
ing, comprise the themes that have emerged from this integra-
tive review.There is a deficit in the follow-up primary care of
adolescents as well as in their general well-care and
counseling.25,26,28,30,32,35 The information in this sample is sup-
ported by other studies that did not meet the criteria of this
review.2,15,18-21,30,36,37
IMPLICATIONS
There continues to be a deficiency in female adolescent well
care, screenings, counseling, and provider communication.
Several research articles attribute this to adolescent/provider
gender differences and a lack in provider training.3,22,36 Studies
have also shown that nurse practitioners feel comfortable in
their training on the screening/counseling process and they are
more frequently providing the screening/counseling serv-
ice.22,23,36 Practically, provider training and time makes more
sense than gender preference but it could not be ignored based
on the what the review found.The nurse practitioner back-
ground/education has given them the ability to see the impor-
tance of prevention and wellness and focus on this as well as
communicate with what is often a difficult population to com-
municate with and often needs additional time. In studies that
looked specifically at nurse practitioners, there was not a separa-
tion between female and male.
Based on studies identifying the nurse practitioner’s com-
fort, ability, training, and the knowledge obtained through this
integrative review on the primary care needs of the female ado-
lescent, an advanced practice nurse such as a clinical nurse spe-
cialist, pediatric, women’s health, or family nurse practitioner
may help to improve the primary care of our adolescent
females.With the ability to focus on screening, prevention, and
education, advanced practice nurses (APNs) often having the
ability to provide longer time frames for patient visits, and con-
sidering it is a predominantly female profession, the APN may
be the best primary care provider to afford focused female ado-
lescent healthcare.
Limitations to this integrative review included the general-
ization of the sample mostly due to age.This sample can lend
information to several areas of adolescent health care, including
prevention and maintenance. However, a sample more specific
to female adolescent/provider communication and types of
office visits may have better answered the research question. A
The Journal for Nurse Practitioners - JNP 277
Table 1. continued
Author/ Method/ Theory/
Year Purpose Limitations Sample Framework
Hollis et al To identify predictors Particular HMO in Pacific Northwest. Cross-sectional survey of 2456 Healthy People 2010
2003 of tobacco use and Specific age group of adolescents. teenagers (1496 females), initiatives
describe attitudes and aged 14–17 in pediatric family
Not randomized and a third refused.
behaviors of those practice settings. Convenience
using tobacco and Self-reports of smoking. Did not independently sample, through recruitment
those not within a validate instruments. based on appointment.
primary care setting.

Sabin et al To determine an Possibility of too small of sample size to reach Prospective cohort. DSM-IV
2006 adolescent’s contact statistical significance. Random, adolescents 12-18
and level of contact/ Half return on mailings. Self-report utilized. years admitted to trauma
communication with center in western U.S. after
primary care and unintentional or intentional
school 4-6 months injury.
after a traumatic injury. n ⫽ 105 (99), (34.3% female).
Focus on ? assessment
and appropriate
determination of PTS,
ETOH, depression,
and communication
between hospital and
PCP.

Zabinski Psychosocial correlates Limited generalizability to those with health Health promotion intervention Social Cognitive
et al of fruit, veggie, dietary care due to recruitment through PCP offices. trial Theory and Trans-
fat intake in adolescent Adolescents in regions in the U.S. may not be n ⫽ 839 (458 girls) theoretical Model of
2006 girls and boys. represented. Behavior Change
11–15-year olds recruited
Hypotheses include
through their PCP in San Diego
a family and peer
County.
influence on choices,
household rules,
decisional balance,
self-efficacy, parent
strategies for a healthy
lifestyle, and child
strategies for change.

Crosby et al Identify associations Possibility of respondents not being
2004 between STD infections representative of the population of primary
and subsequent care physicians, those who did not respond
infections. may have different attitudes.
From a single state and may limit
generalizability.
Use of self-reporting.
Cross-sectional study limits the ability to draw
cause/effect conclusions.
All patients and STDs together in groups, a
physician may feel differently about one type
of patient compared with another.
Cohort Study None
Adolescents aged 15–21 years
from primary care and outreach
clinics, Atlanta, Providence,
and Miami
n ⫽ 1867 (1412) (analytic sample
of 455 after appropriate follow-
up)
Convenience
(females 59.6% of sample).

278 The Journal for Nurse Practitioners - JNP April 2009


Instrument
38-item questionnaire, developed
for this study, included demographic
information, exercise, and a 3
depression survey. Validity established
only on the data resulting from the
specific smoking questions, not the
tool.
Self-report of symptoms and
identification of PCP, The University ratios and confidence
of California at Los Angelas Post
Traumatic Stress Disorder Reaction
Index, Center for Epidemiologic
Studies Depression Scale, Alcohol Use
Disorders Identification test, modified
RI Trauma-History screen, and a
Program transferring medical code
into injury severity scale.
Minnesota Nutrition Data System for
Research, pros and cons of change,
self-efficacy scales for health-related
diet and exercise, Amhurst health
and Activity Study (scales developed
from), Transtheoretical and Social
Cognitive helped to develop child
change strategies tool. Test-retest
was generally high although could
be improved, they determined that
reliability for all was sufficient.
No internal consistency established
for the questionnaires completed by
parents.
30-min questionnaire with audio
computer assisted self-interviewing
technology, no other reliability or
validity was described.
www.npjournal.org
Statistical
Analysis Major Findings
Multiple logistic Higher prevalence of smoking within the last 30 days among older teens and
regression used to females.
predict smoking in the - Varied significantly between race.
last 30 days.
- There was a positive correlation among teens who smoke with having a
x2, although not stated smoker in the house, friends that smoke, and a positive depression screen.
- Prevalence increased in teens who had less educational aspirations, less
exercise, and trying to lose weight in the last year.
Comparison with odds Intentional injury (although it stated this was an exclusion criteria) accounted
for 10.5%.
intervals - “Pre-injury” ETOH by 13.6%.
- 30% reported greater than 4 previous trauma events, and previous psych
symptoms in 12.4% (skews the data).
- 39.4% did not have PCP at hospitalization.
- 36.6% of those with a PCP (60) did not see them in the 4-6 months after injury.
- Those with PCP were less likely to have intentional injury.
- At 4-6 months after injury, 30% had high PTS symptoms
- 11.1% reported depressive symptoms and 16.6% with problem ETOH use.
- Referral to PCP only reported as “low.” 54.8% of adolescents experiencing
symptoms were seen by PCP and not diagnosed.
- Increased support within the schools (counselors, etc).
Bivariate correlations Household rules and strategies for change are only variables associated with
for demographics and food choices. Peer influence approached significance (p 0.07).
dependant variables,
multivariate linear
regression, stratified
regression with age,
Spearman’s rho, and
Pearson product(r)
Chi-squared, bivariate Adolescents with STD are more likely to practice safer sex than those who have
testing and logistic never been diagnosed with an STD (supporting testing and diagnosis).
regression - 15.6% were diagnosed with STD before study, Chlamydia 7.5% at baseline of
study, Gonorrhea 1.3%, and Trichomoniasis 4.0%.
- A tenth of the total had at least one STD.
- 30% engaged in sex with a casual partner.
The Journal for Nurse Practitioners - JNP 279
Table 1. continued
Author/ Method/ Theory/
Year Purpose Limitations Sample Framework
Yeats et al Frequent wheezing and Not able to validate questionnaire. May be a 12–18-year olds None
2003 those with a frequent difference in demographics and health care (n 122,829).
wheeze not diagnosed due to relying on recall.
All students within grade levels
with asthma.
of public education, urban
and rural, North Carolina (7th
and 8th compared with older
adolescents.

Ohene et al The effect of parental Majority mothers. (n 134) Social cognitive

2006 punishment and Self-report. No causality or directionality due All 10- to 15-year-olds (41.5% theory
violence and modeling to cross-sectional. female) seen in 8 outpatient
and the attitudes pediatric settings during the
Select group of adolescents decreasing
of their children to timeframe and scoring positive
generalizability
violence. on a psychosocial screening
test, Minneapolis-St. Paul area.

Shrier et al Examine gender- Single adolescent clinic in urban area, Comparison None
2003 specific associations non-white. Possible selection bias due to 14- to 18-year-olds from an
between SUPs and convenience sample. urban hospital-based adolescent
SUDs and correlated Berkson’s bias. clinic for primary care.
psych symptoms.
Providers may have been more likely to refer Convenience sample
due to knowledge of study. n 538 (Females 368)
Bias to null hypothesis because those in
emotional crisis were excluded. Sample size
restricted differentiation between alcohol and
other substances.
Self-report was utilized.
Burstein To describe prevention Self-report. Data from YRBS survey. Grades None
et al counseling in the PCP Limited analysis due to lack of data about how 9–12, both public and private
2003 setting for pregnancy valid the adolescent recall is as to the date of schools, 3-stage cluster sample,
and STDs. Is there an last visit. (n 15,349)
association between
preventative counseling Only able to analyze some of the demographic
and behavioral variables.
and sexual risk
behaviors? Cannot conclude cause and effect relationship
due to cross-sectional design.
Ozer et al Goal of intervention Conducted within a group-model HMO. Intervention study, Precede/
2005 study to increase 13- to 17-year-olds, 4 outpatient proceed model
clinician screening as pediatric clinics, Northern
well as counseling of California, (37 offices in
the adolescent patient intervention and 39 in the
in the specific areas of comparison). 53/59% female
tobacco, ETOH, sexual adolescents from each group
behavior, seatbelt use, respectively. 89% MD vs NP
helmet use, and drugs provider from each group.

280 The Journal for Nurse Practitioners - JNP April 2009


Instrument
Used from ISAAC, a steering
committee for asthma, no mention
of the establishment of reliability or
validity.
Used a validated screening test.
Substance abuse scale from POSIT
and a structured adolescent interview
for substance use. Has been tested in
several studies, reliability and validity
has been previously established.
Survey implemented by the CDC
(YRBS), several previous and ongoing
studies have utilized.
Regional health education department
developed screening tools; the
questionnaire to adolescents has
been previously used and stated it had
adequate construct validity.
www.npjournal.org
Statistical
Analysis Major Findings
χ test
2
Frequent wheezing associated with female, smoking, smoke exposure, low
Spearman’s rho socioeconomics, allergies, African Americans, Native American, and Mexican
American. Adolescents need to be asked about wheezing specifically.
- Females 59% of undiagnosed frequent wheezers.
- Females are also a larger percent of diagnosed asthmatics as well as mild
respiratory symptoms.
- Allergies related to frequent wheezers.
Cronbach’s alpha Adolescents who had parents disapproving of violence were more prosocial
and less likely to participate in a violent situation; corporal punishment was
a predictor of a tendency toward violence, less prosocial attitude, and more
claims of victimization.
- 56% were in a fight within the previous year. We cannot assume that all
parents advocate not using violence.
- almost 40% of these parents stated that they believed their child should hit
another if they are provoked.
Bivariate and Increased psychiatric symptoms in adolescents with substance use opposed
multivariate analyses to those without. Continued addressing of the issue in primary care with
complaints that may not fall under the DSM-IV initially. The DSM-PC suggests
response by a PCP even in those who do not meet criteria. Sixty percent
reported at least one psych symptom in the last 12 months, with girls more likely
to report.
- Girls more often reported depression and eating disorders.
Calculation of -60.4% of the sexually active received some type of preventative care within the
prevalence estimates, last 12 months but did not speak to their health care provider about HIV, STDs, or
adjusted odds ratios, prevention of pregnancy.
logistic regression - 54.4% of females reported condom use with last intercourse.
for those that
- 42.8% reported talking about STD or pregnancy at last visit with PCP.
reached statistical
significance - Half of the students in study had sexual intercourse, 47.7% of females.
Descriptive statistics, Strong support for the need of increased training of PCP to address/screen/
ANCOVA counsel adolescents in the risk areas.
- Screening increased from 58% to 83% and counseling from 52% to 78% based
on the combination of the groups.
The Journal for Nurse Practitioners - JNP 281
Table 1. continued
Author/ Method/ Theory/
Year Purpose Limitations Sample Framework
Boekeloo Does prompting (of May not be representative sample. Higher risk Exploratory sub-study of Social Cognitive
et al adolescent and/or families may have been excluded for follow-up longitudinal study. Theory and Health
2003 provider) increase due to early appointment times. Providers may Randomized, controlled Belief Model
the communication also not be representative. Possibly biased
about alcohol sample (those adolescents who drank may 12- to 17-year-olds
between provider and have refused to participate). (n 444, 199 females) being
adolescent? seen in 5 primary care clinics,
Experimental design could have reduced
the differences in adolescent/provider. Washington D.C. and Maryland/
communication. Pediatricians (n 22) and
family practitioners
(n 4)
(5 of these providers were NP).
Klein et al Have adolescents Self-reported height and weight used to 14- to 18-year-olds in primary Body Image
2006 who are at risk for determine BMI. care who were seen for Construct
becoming overweight 5th percentile BMI used to classify “at risk” preventive visits, randomized,
or developing an eating but there are not current guidelines saying western New York
disorder had screening/ this. Used “misclassification” of body image (n 8382)
counseling by rather than “distorted.” Possibility of sample females 56.8%.
their primary care and response bias.
physicians?

sample more specific to adolescent/provider communication
may not have been possible, considering that the sample in this
study included only 11 studies, and further sampling procedure
beyond inclusion/exclusion criteria was not needed to limit the
sample size.These same limitations may also be a benefit
because this sample seems to be representative of what primary
care providers are seeing in the adolescent female population.
Considering the findings in this integrative review, qualita-
tive research on provider and adolescents’ perceptions of com-
munication barriers could add to the body of knowledge on a
female adolescent’s needs. Further recommendations for
research would include studies specifically examining the
advanced practice nurse and the type and quality of health care
provided to the female adolescent. Additionally, further research
on how gender affects the care of this population, specifically
care by nurse practitioners, would improve our view on how to
better care for these young women.
References
1. (Grunbaum J A Kann L Kinchen S A Williams B Ross J G Lowry R et al 2001
Youth Risk Behavior Surveillance-United States)Grunbaum JA, Kann L,
Kinchen SA, Williams B, Ross JG, et al. Center for Disease Control (2001).
Youth risk behavior surveillance-United States. Available at: http://www.cdc.
Accessed November 25, 2006.
2. Klein JD, Hedberg VA, Graff C, Allan MJ, Elster AB, et al. Adolescent voices:
teens recommendations for their routine healthcare. Pediatr Res. 1997;41(4):.
Available at: OVID Full Text database. Accessed November 25, 2006.
3. Kapphahn CJ, Wilson KM, Klein JD. Adolescent girls’ and boys’ preferences
for provider gender and confidentiality in their healthcare. J Adolesc Health.
1999;25:131-142. Available at: CINAHL database. Retrieved November 25,
2006.
4. American Medical Association. Minority Affairs Consortium.
5. The Department of Health and Human Services, Health Resources and
Services Administration, and Bureau of Health Professionals. Preliminary
findings,National Sample Survey of Registered Nurses. 2004.
6. U.S. Department of Health and Human Services Center’s for Disease Control
and Prevention (CDC). Twenty-one critical health objectives for adolescents
and young adults. Healthy people 2010. Atlanta, GA: CDC; 2000.
7. Byrne C, Browne G, Roberts R, Gafni A, Bell B, et al. Adolescent
emotional/behavioral problems and risk behavior in Ontario primary care:
comorbidities and cost. Clin Excellence Nurse Pract. 2004;8(3):135-144.
8. Brown JD, Melchiono MW. 2006. Health concerns of sexual minority
adolescent girls. Curr Opin Pediatr. 2006;18:359-364. Available at: OVID Full
Text. Retrieved September 27, 2006.
9. Burstein GR, Workowski KA. Sexually transmitted diseases treatment
guidelines. Curr Opin Pediatr. 2003;15:391-397.
10. De la Torre AM, Perez-Garcia A, De la Torre EM, Silleras BD. Is an integral
nutritional approach to eating disorders feasible in primary care? Br J Nutr.
2006;96(Suppl):S82-S85.
11. Farand L, Renaud J, Chagnon F. Adolescent suicide in Quebec and prior
utilization of medical services. Can J Public Health. 2004;95:357-360.
12. Lebrun C, Rumball JS. Female athlete triad. Sports Med Arthrosc
2002;10(1):23-32.
13. Lee MT, Garnick DW, Miller K, Horgan CM. Adolescents with substance
abuse: Are health plans missing them? Psychiatric Serv. 2004;55(2);116.
14. Roye CF, Nelson J, Stanis P. Evidence of the need for cervical cancer
screening in adolescents. Pediatr Nurs. 2003;29(3):224-225, 232.
15. Seimer BS. Intimate violence in adolescent relationships recognizing and
intervening. Am J Matern Child Nurs. 2004;29(2):117-121.
16. Stevens C. Being healthy: voices of adolescent women who are parenting.
JSPN. 2006;11(1):28-40.
17. American Medical Association (1997). Guidelines for adolescent
preventative services. Department of Adolescent Health.
18. Rand CM, Auinger P, Klein JD, Weitzman M. Preventative counseling at
adoelscent ambulatory care visits. J Adolesc Health. 2005;37(2):87-93.
19. Ma J, Wang Y, Stafford RS. U.S. adolescents receive suboptimal
preventative counseling during ambulatory care. J Adolesc Health.
2005;36:441.c1-441e.7.
20. Hardoff D, Schonmann S. Training physicians in communication skills with
adolescents using teenage actors as simulated patients. Med Educ.
2001;35:206-210.

282 The Journal for Nurse Practitioners - JNP April 2009

 Statistical
Instrument Analysis Major Findings
Two questionnaires, pre and post visit; Pearson x2 Priming of both/either increased the provider patient communication on the
no reliability or validity established. Linear mixed- topic of alcohol consumption.
model regression, - 76% Discussed avoiding alcohol before intervention and 89.1% after.
logistic regression, - Resisting peer pressure to drink, 66.4% and 79.6%.
descriptive analysis
- Dangers of drinking and driving, 58.7% and 76.9%.
- Risk of combining drinks and sex, 52.7 and 70.1%.

Adapted from CDC, youth risk behavior
survey, and evaluated on a pilot group.
χ2 and t-tests PCPs discussed weight and nutrition, but “at risk” adolescents need more. Body
image, weight loss, nutrition, and dieting should be discussed at well visits.
- 29% of adolescents were “at risk” based on BMI.
- Exercise discussed with 83% of adolescents.
- Nearly a third of all the adolescents incorrectly classified their BMI.
- 65.9% of females have attempted weight loss.

21. Klein JD, Wilson KM. Delivering quality care: adolescents’ discussion of
health risks with their providers. J Adolesc Health. 2003;30:190-195.
22. Torkko KC, Gershman K, Crane LA, Hamman R, Baron A. Testing for
chlamydia and sexual history taking in adolescent females: results from a
statewide survey of Colorado primary care providers. Pediatrics. 2000;106:
e32. Available at: http://pediatrics.aappublications.org/cgi/content/abstract/
106/3/e327. Accessed December 4, 2006.
23. (Boekeloo B O Snyder M H Bobbin M Burstein G R Conley D Quinn T C et al
2002 Provider willingness to screen all sexually active adolescent for
chlamydia)Boekeloo BO, Snyder MH, Bobbin M, Burstein GR, Conley D, et
al. Provider willingness to screen all sexually active adolescents for
chlamydia. Sex Transm Infect. 2002;78:369-373. Available
at:http://sti.bmjjournals.com. Accessed September 27, 2006.
24. (Ganong L H 1987 Integrative reviews of nursing research)Ganong LH.
Integrative reviews of nursing research. Res Nurs Health. 1987;10:1-11.
25. Sabin JA, Zatzick DF, Jurkovich G, Rivara FP. Primary care utilization and
detection of emotional distress after adolescent traumatic injury: identifying
an unmet need. Pediatrics. 2006;117:130-138.
26. Yeatts K, Johnston-Davis K, Sotir M, Herget C, Shy C. Who gets diagnosed
with asthma? Frequent wheeze among adolescents with and without a
diagnosis of asthma. Pediatrics. 2003;111:1046-1054.
27. Ohene SA, Ireland M, McNeely C, Wagman-Borowsky I. Parental
expectations, physical punishment, and violence among adolescents who
score positive on a psychosocial screening test in primary care. Pediatrics.
2006;117:441-447.
28. (Ozer E M Adams S H Lustig J L Gee S Garber A K Rieder-Gardner L et al
2005 Increasing the screening and counseling of asolescents for risky health
behaviors: A primary care intervention)Ozer EM, Adams SH, Lustig JL, Gee
S, Garber AK, et al. Increasing the screening and counseling of adolescents
for risky health behaviors: a primary care intervention. Pediatrics.
2005;115:960-968.
29. Hollis JF, Polen MR, Lichtenstein E, Whitlock EP. Tobacco use patterns and
attitudes among teens being seen for routine primary care. Am J Health
Promot. 2003;17:231-239.
30. Boeckeloo BO, Bobbin MP, Lee WI, Worrell KD, Hamburger EK, et al. Effect
of patient priming and primary care provider prompting on adolescent-
provider communication about alcohol. Pediatr Adolesc Med.
2003;157:433-439.
31. Shrier LA, Harris SK, Kurland M, Knight JR. Substance use problems and
associated psychiatric symptoms among adolescents in primary care.
Pediatrics. 2003;111:699-675.
32. Klein JD, Postle CK, Kreipe RE, Smith SM, McIntosh S, et al. Do physicians
discuss needed diet and nutrition health topics with adolescents? J Adolesc
Health. 2005;38:608.e1-608.e6.
33. Zabinski MF, Daly T, Norman GJ, Rupp JW, Calfas, KJ, et al. Psychosocial
correlates of fruit, vegetable, and dietary fat intake among adolescent boys
and girls. J Am Diet Assoc. 2006;106:814-821.
34. Crosby RA, Diclemente RJ, Wingood GM, Salazar LF, Rose E, et al.
Associations between sexually transmitted disease diagnosis and
subsequent sexual risk and sexually transmitted disease incidence among
adolescents. J Am Sex Transm Dis Assoc. 2004;31(4):205-208.
35. Burstein GR, Lowry R, Klein JD, Santelli JS. Missed opportunities for
sexually transmitted diseases, human immunodeficiency virus, and
pregnancy prevention services during adolescent health supervision visits.
Pediatrics. 2003;111:996-1001.
36. Ashton MR, Cook RL, Wiesenfeld HC, Krohn MA, Zamborsky T, et al. Primary
care physician attitudes regarding sexually transmitted diseases. Sex
Transm Dis. 2002;29:246-251.
37. Jacobsen L, Richardson G, Parry-Langdon N, Donovan C. How do teenagers
and primary healthcare providers view each other? An overview of key
themes. Br J Gen Pract. 2001;51:811-816.
Michael G. Jaskiewicz, MSN, FNP, is employed at Cass
Family Clinic in Cassopolis, MI. She can be reached at
milekmbubek@sbcglobal.net. In compliance with national
ethical guidelines, the author reports no relationships with busi-
ness or industry that would pose a conflict of interest.
1555-4155/09/$ see front matter
© 2009 American College of Nurse Practitioners
doi:10.1016/j.nurpra.2008.05.016

www.npjournal.org The Journal for Nurse Practitioners - JNP 283