advanced pharmacology: metformin; theoretical and nursing: pregnancy

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Part 1: Advanced Pharmacology

Topic: Metformin

Purpose: Educate your colleagues on the drug you have selected. The presentation must include information about the:

1. Describe drug pharmacology  and: (One paragraph)

a. Pharmacokinetics

2. Name (One paragraph)

a. Brand name

b. Generic name

c. Dosing

3. Indications for use and: (One paragraph)

a. Side effects

4. Contraindications (One paragraph)

a. Children

b. Mild-age

c. Elderly

5. Use during pregnancy (One paragraph)

6. Perform a cost analysis of the drug (One paragraph)

a. Local (Miami)

b. Regional (USA)

c. Global

7. Case (Three paragraphs)

a. Provide a patient case study on a patient in which you would utilize the drug you have selected (One paragraph)

b. Describe the appropriate patient education.(One paragraph)

c. What is your role as a Nurse Practitioner for prescribing this medication to this patient on your case study presentation? (One paragraph)

i. Describe the monitoring and follow-up.

Part 2: Theoretical and nursing

Topic: Pregnancy and STD

Goal: The purpose of this assignment is to identify a theory or model which can be used as a framework for a future evidence-based project

 

1. Describe the topic (One paragraph) and include

a. Static data in USA

i. Florida

ii. Miami

2. Describe why Health Belief Model (HBM) is relevant to your selected topic of advanced practice nursing (Two paragraphs)

3. Explain how the Health Belief Model (HBM) can be used as a framework to guide evidence-based practice to address the issue or concern  (One paragraph) and 

a. Give an briefly example (One paragraph)

4. Discuss the unique insight or perspective offered through the application of this theory or model (One paragraph) and 

a. What are the benefits for APNs if they use the model selected to apply t the topic (One paragraph)

 5. Describe why the topic is relevant for evidence-based practice (One paragraph) and 

a. Describe why the model is relevant for evidence-based practice (One paragraph) 

Part 3: Capstone

 

 Theoretical framework:  Watson’s Caring Theory 

Picot question:  Is it possible that in the ICU unit with patients aged 65 years or more,  the rate of errors due to incompatibility of intravenous medications is reduced by implementing a training program for nurses for 8 weeks, compared to the rate of errors before training?

 It should not reflect your opinion, but rather Evidence Based Practice should be applied

1. Review of Literature (This is a synthesis rather than a study by study review) (Ten paragraphs: One paragraph per article)

a. Review and discuss literature Synthesize the10 research studies attached

b. Describe quality and applicability to your PICOT question

c. Address the similarities

i. Differences

ii. Controversies

2. Analyze and apply knowledge directly to your PICOT (Two paragraphs)

a. The studies that you cite in this section must relate directly to your PICOT question.

3. Provide precise body of evidence for your Practice Change (One paragraph)

4. Discuss objectives for your practice change (One paragraph)

5. Discuss where the problem exists and (One paragraph)

a. Why it exists

b. What is the preposition for change

6. Describe Pros vs Cons, current state of problem (One paragraph)

7. Evaluates the strengths and weaknesses of all the sources you have found. (Two paragphs)

Part 4: Capstone

 

Theoretical framework:    health belief model (HBM)  

Picot question: Can the implementation of a 2-month program on sexually transmitted diseases in adolescents aged 14 to 17 years improve their knowledge about the prevention of sexually transmitted diseases compared to their knowledge before the program’s implementation?

 It should not reflect your opinion, but rather Evidence Based Practice should be applied

1. Review of Literature (This is a synthesis rather than a study by study review) (Ten paragraphs: One paragraph per article)

a. Review and discuss literature Synthesize the10 research studies attached

b. Describe quality and applicability to your PICOT question

c. Address the similarities

i. Differences

ii. Controversies

2. Analyze and apply knowledge directly to your PICOT (Two paragraphs)

a. The studies that you cite in this section must relate directly to your PICOT question.

3. Provide precise body of evidence for your Practice Change (One paragraph)

4. Discuss objectives for your practice change (One paragraph)

5. Discuss where the problem exists and (One paragraph)

a. Why it exists

b. What is the preposition for change

6. Describe Pros vs Cons, current state of problem (One paragraph)

7. Evaluates the strengths and weaknesses of all the sources you have found. (Two paragphs)

Part 5: Capstone

 

Theoretical framework:    Orem’s self-care model  

Picot question:   Is it possible that the turnover rate due to burnout is reduced after implementing a mental health program for 10 weeks, compared to the nurses’ turnover rate before the program? 

 It should not reflect your opinion, but rather Evidence Based Practice should be applied

1. Review of Literature (This is a synthesis rather than a study by study review) (Ten paragraphs: One paragraph per article)

a. Review and discuss literature Synthesize the10 research studies attached

b. Describe quality and applicability to your PICOT question

c. Address the similarities

i. Differences

ii. Controversies

2. Analyze and apply knowledge directly to your PICOT (Two paragraphs)

a. The studies that you cite in this section must relate directly to your PICOT question.

3. Provide precise body of evidence for your Practice Change (One paragraph)

4. Discuss objectives for your practice change (One paragraph)

5. Discuss where the problem exists and (One paragraph)

a. Why it exists

b. What is the preposition for change

6. Describe Pros vs Cons, current state of problem (One paragraph)

7. Evaluates the strengths and weaknesses of all the sources you have found. (Two paragphs)

Copyright 2018

This content is licensed
under a Creative Commons
Attribution 4.0 International License.

ORIGINAL ARTICLE

ISSN: 1679-4508 | e-ISSN: 2317-6385

Official Publication of the Instituto Israelita
de Ensino e Pesquisa Albert Einstein

1
einstein (São Paulo). 2018;16(3):1-6

Types and frequency of errors
in the preparation and administration
of drugs
Tipos e frequência de erros no preparo e na
administração de medicamentos endovenosos
Josiane Ribeiro Mendes1, Maria Carolina Barbosa Teixeira Lopes1,
Cássia Regina Vancini-Campanharo1, Meiry Fernanda Pinto Okuno1, Ruth Ester Assayag Batista1

1 Universidade Federal de São Paulo, São Paulo, SP, Brazil.

DOI: 10.1590/S1679-45082018AO4146

❚ ABSTRACT
Objective: To identify compatibility, types and frequency of errors in preparation and
administration of intravenous drugs. Methods: A cross-sectional and descriptive study performed
at the emergency department of a university hospital in the city of São Paulo (SP). The sample
consisted of 303 observations of the preparation and administration of intravenous drugs by
nursing aides, nursing technicians and registered nurses, using a systematized script, similar
to a checklist. The following variables were collected: errors related to dispensing, omission,
schedule, unauthorized administration, dosage, formulation, incompatibility, preparation and
administration. Results: In the preparation stage, the following errors were identified: no
hand hygiene (70.29%), and no use of aseptic technique (80.85%). Upon administration, no
hand hygiene (81.18%), and no use of aseptic technique (84.81%). In 31.35% of observations,
there was more than one medication at the same time for the same patient, of which 17.89%
were compatible, 56.84% were incompatible and 25.26% were not tested, according to the
Micromedex database. Conclusion: In both preparation and administration stages, the most
frequent errors were no hand hygiene and no use of aseptic technique, indicating the need to
develop and implement education programs focused on patient safety.

Keywords: Emergency nursing; Patient safety; Medication errors; Administration, intravenous

❚ RESUMO
Objetivo: Identificar a compatibilidade, os tipos e a frequência de erros no preparo e na
administração de medicamentos endovenosos. Métodos: Estudo transversal e descritivo,
realizado em um serviço de emergência de um hospital universitário da cidade de São Paulo (SP).
A amostra foi constituída por 303 observações do preparo e administração de medicamentos
endovenosos por auxiliares, técnicos de enfermagem e enfermeiros, tendo como instrumento
um roteiro sistematizado, do tipo checklist. As variáveis coletadas foram: erro de dispensação,
omissão, horário, administração não autorizada, dose, apresentação, incompatibilidade, e erros
de preparo e administração. Resultados: Na etapa de preparo, foram identificados os seguintes
erros: não higienização das mãos (70,29%) e não usar técnica asséptica (80,85%). Na etapa de
administração, 81,18% não higienizaram as mãos, e 84,81% não usaram a técnica asséptica.
Em 31,35% das observações, existia mais de uma medicação no mesmo horário para o mesmo
paciente; destas 17,89% eram compatíveis, 56,84% incompatíveis e 25,26% não foram testadas,
conforme análise feita na base de dados Micromedex. Conclusão: Tanto na etapa do preparo
quanto na de administração, os erros mais frequentes foram a não higienização das mãos e o não
uso de técnica asséptica, apontando para a necessidade de desenvolvimento e implantação de
programas de educação centrados na segurança do paciente.

Descritores: Enfermagem em emergência; Segurança do paciente; Erros de medicação; Administração
intravenosa

How to cite this article:
Mendes JR, Lopes MC, Vancini-Campanharo
CR, Okuno MF, Batista RE. Types and
frequency of errors in the preparation and
administration of drugs. einstein (São Paulo).
2018;16(3):eAO4146. https://doi.org/10.1590/
S1679-45082018AO4146

Corresponding author:
Josiane Ribeiro Mendes
Rua Pageú, 48, Vila Mariana
Zip code: 04139-000 – São Paulo, SP, Brazil
Phone: (55 11) 95904-6817
E-mail: [email protected]

Receveid on:
June 30, 2017

Accepted on:
Feb 14, 2018

Conflict of interest:
none.

Mendes JR, Lopes MC, Vancini-Campanharo CR, Okuno MF, Batista RE

2
einstein (São Paulo). 2018;16(3):1-6

INTRODUCTION
Emergency departments are settings specialized in
care of patients with acute clinical picture, which
might be life-threatening conditions.(1) Overcrowding
in these departments is a worldwide phenomenon,
resulting mainly from inadequacy of the demand due
to insufficient structuring of the healthcare network,
in addition to the increased number of accidents and
urban violence.(2)

Over the past decades, overcrowding at emergency
departments has been associated with worsening of
quality of care, due to stress, absenteeism, and lack of
professionals at these sites; to high patient turnover
rate, and excessive workload, which can lead to adverse
events.(3,4)

The prevention of adverse events, with the
consequent increase of patient safety, gained greater
visibility after the publication of “To err is human:
Building a safer health system”, by the Institute of
Medicine (IOM), in 1999. In this work, data related
to the number of healthcare-related deaths in the
United States were presented, drawing attention of
governmental organizations to quality of care and
patient safety.(5)

A culture of safety is a set of values, competences
and behaviors, which determine the commitment to
management of health and safety; hence, it replaces
guilt and punishment by the opportunity to learn from
failures and improve healthcare.(6)

Patient safety is a serious public health problem all
over the world. In developed countries, it is estimated
that one in every ten patients is harmed while receiving
care at hospital. Amidst this care, administration of
medications can pose risks to the individual’s safety.(5)

A medication error is defined as “any avoidable
event that can cause or induce the inappropriate use
of medication or harm the patient, at any phase of
drug therapy.”(7) Medication errors are among the
most frequent failures in healthcare and can cause
complications in the clinical picture, require new
interventions, increase length of hospital stay, or even
permanent disabilities and death.(5)

A study conducted in the United States demonstrated
that every patient admitted to a North American
hospital is subject to one medication error a day.
Approximately 400 thousand avoidable medication-
related adverse events are reported per year at these
sites.(8) It is estimated that medication errors in hospitals
cause more than 7,000 deaths per year in the United
States, leading to significant costs.(9)

In Brazil, statistics as to deaths by medication errors
are still scarce. Data from the Instituto para Práticas
Seguras no Uso de Medicamentos (ISMP) [Institute for

Safe Practices in Medication Use] showed that at least
8,000 deaths per year are attributable to medication
errors, in which failures or adverse reactions resulting
from administration of medications corresponded to
7.0% of admissions to the health system, accounting
840 thousand cases/year.(10)

Promoting safe practices in administration of
medications should be a constant concern of the
nursing team, since it is one of the tasks more often
performed by these professionals.(11) Some factors,
such as insufficient quantity of professionals, excess
work, exhausting working hours, lack of materials,
high number of medications to be given, interruptions
during preparation and administration of medications,
precarious lighting, and excessive noise predispose towards
the occurrence of errors.(10)

Even if many medication errors do not cause serious
consequences to patients, they should be notified and
studied to avoid their recurrence, and to strengthen a
safe drug administration system.(12) Identification of
medication errors is fundamental, since it supports
the decisions necessary to avoid them. The presence
of a punitive culture towards the professional who
made the error leads to underreporting, reflects this
responsibility is not shared between the employee
and the organization, which should foresee and offer
adequate working conditions for its team.(13)

The emergency department, due to the dynamics
of its care, is characterized by some factors, such as
stress and the scarcity of professionals. It is considered
a high-risk area for the occurrence of medication-
related adverse events, such as adverse reactions,
interactions, allergic reactions, and medication errors.
The risk potential for medication errors in this
department is observed, primarily, by the quantity of
medications prescribed and administered by various
routes including intravenous route, which requires the
addition of electrolytes and the calculation of drip rates
during critical phases of care. However, this risk can
occur in other phases of the medication process, and
even worsen due to the quantity of patients seen at
these sites.(14)

❚ OBJECTIVE
To identify types and frequency of errors in the preparation
and administration of intravenous medications at an
emergency department.

❚METHODS
This was a cross-sectional and descriptive study,
approved by the Research Ethics Committee of the

Types and frequency of errors in the preparation and administration of drugs

3
einstein (São Paulo). 2018;16(3):1-6

Universidade Federal de São Paulo, under official
opinion number 1.463.028, CAAE number: 52035115.
0.0000.5505.

The study was conducted at the emergency department
of Hospital São Paulo (HSP), a large high-complexity
tertiary hospital that mainly cares for patients from
the Sistema Único de Saúde (SUS) [Brazilian National
Health System].(15)

The convenience sample was composed of
opportunities for preparation and administration of
intravenous medications, performed by the emergency
department nursing professionals, during the data
collection period.

The professionals authorized participation in the
investigation before the start of data collection, and
the professional did not know when the observation
would occur.

Data collection was performed from April to
September 2016, in the four work shifts of the nursing
team, by means of a structured instrument for observation
with the following variables: category of professional
who administered the medication, drug class and expiry
date of medications, and errors found in the process of
preparation and administration of the drugs.

In this study, the errors were classified according to
clinical severity as serious or mild. The mild incidents
had a small or no effect on the patient, and serious
errors caused a reduction or permanent loss of organ
function of the patient, and those that lead to death.(16)

As to the drug therapy phase, the errors were
classified as(17) dispensing error – when there was
incorrect distribution of the medication prescribed;
omission error – when the medication prescribed was not
administered, or there was no record of administering
medication; time error – when the medication was
administered out of the time interval established by
the organization; non-authorized administration of the
medication – in case of administration of non-prescribed
drug, to the wrong patient, or wrong medication, or
use of an outdated prescription; dosage error – in
cases of administration of a dose greater or smaller
than what is prescribed; formulation error – when
the medication formulation prescribed was different
from what was administered; preparation error – when
there were failures in dilution, inadequate storage,
failure in asepsis technique, incorrect identification
of the drug, and inappropriate choice of infusion
lines; and administration errors – such as failure in
asepsis technique of the venous lines and connecting
devices, administration through a route other than that
prescribed, incorrect infusion rate, administration of
medication that is expired or with compromised physical

or chemical integrity, and association of medications
that are physically or chemically incompatible.

In order to verify incompatibility among medications,
the Truven Health Analytics, Micromedex (Greenwood
Village, Colorado, United States) software was used.
Since dipyrone is not a part of this software and was
one of the most medications more often observed in
this study, its incompatibility was analyzed according to
information contained on the package insert.

Due to ethical and patient safety issues, when
the investigator identified a potential or real error,
observation was immediately interrupted and the
investigator intervened by means of orientation of the
employee as to the correct practice.

Statistical analysis
Descriptive analysis was used. For continuous variables,
the mean, standard deviation, median, minimum and
maximum values were calculated; for categorical variables,
frequency and percentage.

❚ RESULTS
The study sample comprised 303 observations of
preparation and administration of intravenous
medications. The professional categories observed were
60.0% nursing aides, 32.6% nurse technicians, and
7.2% registered nurses.

The drug classes administered by these professionals
were antimicrobials (24.7%), non-opioid analgesics
(23.1%), anti-inflammatory agents (10.5%), anti-eme tics
(9.5%), opioid analgesics (8.9%), antacids (5.6%), anti-
arrhythmic agents (3.6%), diuretics (3.3%), anticonvulsants
(2.9%), vasodilators (1.6%), antispasmodic agents (1.3%),
cardiotonic agents (0.9%), splenic vasoconstrictors (0.6%),
antidiabetics (0.6%), vasopressors (0.6%), vitamins (0.3%),
and bone catabolism inhibitors (0.3%).

All medications administered during the observations
were within the expiry period.

As to the medication errors, no note was made
of omission errors, non-authorized medication
administration, or formulation and dispensing. Regarding
dosage errors, 2.6% of medications were administered
at a dose higher or lower than the dose prescribed. As
to timing errors, 5.6% of medications were not given,
respecting the recommendation of not exceeding 30
minutes more or less relative to the time at which the
medication was scheduled.

During the preparation of medications, the following
errors were identified: lack of hand hygiene before
preparation (70.2%); not using an aseptic technique

Mendes JR, Lopes MC, Vancini-Campanharo CR, Okuno MF, Batista RE

4
einstein (São Paulo). 2018;16(3):1-6

for preparation (80.8%); incorrectly identification of
the medication (47.9%); not checking the patient’s
identification (62.3%), and dilution of the medication
in a volume smaller than that recommended by the
manufacturer (1.6%).

In the administration stage, the identified failures
were no hand hygiene before administration (81.1%);
not using an aseptic technique in administration
(84/8%), and incorrect administration infusion rate
(4.0%). Of the total of medications administered, in
10.8%, checking the pulse rate was recommended, but
in 24.3% of the times, this measure was not taken.

In 31.3% of observations, there was more than one
medication for the same timepoint and patient: 56.8%
of them were incompatible, 25.2% had not yet been
tested, and 17.8% were compatible.

❚ DISCUSSION
Error in the process of preparation and administration of
medications can result in serious consequences to the
patient and their family, besides generating disabilities,
prolonging hospital stay and recovery, demanding new
procedures and interventions, delaying or impeding
the patient of reassuming their social function, and
even leading to death.(18)

In this study, most opportunities of preparation and
administration of medications were of antimicrobials
and non-opioid analgesics; the most observed and most
prone to error professional category was that of nursing
aides. A study conducted at the emergency department of
the State of Paraná, with the objective of characterizing
the administration of injectable medications, identified
that the majority of prescriptions was of analgesic
(29.1%), followed by anti-inflammatory agents (26.3%).(19)
The prescription of analgesics of any drug class that
have the relief of pain as secondary effect, is common
in emergency departments and first aid units since pain
is the most frequent complaint at these places; this
fact could justify the finding.(20) The fact of the most
observed professionals in this study having been the
nursing aides, corroborates the literature findings, since
the preparation and administration of medications are
activities that can be shared among the nursing team
and are usually delegated to these professionals.(21)

In this study, the administration of medications at
a dose higher or lower than that prescribed was noted.
In most cases, dosage errors can be attributed to the
writing of medical prescriptions, such as the use of
acronyms and/or abbreviations, absence of the patient’s
registration, lack of dosing schedule, and omission of
the date. Administration of incorrect doses can result

in ineffective treatment, prolonged hospital stay and
compromise quality of care delivered.(22)

As to timing errors, in this study, medications were
administered outside the recommended timepoint.
Brazilian studies have found alarming data relative to
this finding: 57.2% of medications were prepared more
than one hour before their administration,(7) and up to
69.7% of medications were administered at the wrong
time.(23) Often, the preparation and administration
of medications happen at incorrect times due to the
frequent practice of optimizing or advancing the
activities, which should be supervised and deterred,
since efficacy of medications can be compromised when
diluted and not immediately administered. Moreover,
they are exposed to contamination, light, heat, and
humidity. Another relevant factor is the time and
duration of action of the drugs, which can be impaired
when not given at the correct time, compromising the
patient’s recovery.(24)

In this investigation, during preparation and
administration of medications, we frequently identified
failures in hand hygiene of professionals and in asepsis
of materials. A descriptive study aiming to verify and
characterize errors in the administration of antibiotics
at an intensive therapy unit of a Brazilian teaching
hospital, identified absence of disinfection of vials
of medications to be given by intravenous route in
58.4% of the times, followed by lack of hand hygiene
in 29.2% of nursing team professionals before doing
the procedure.(24) This individual measure is simple,
low-cost, and prevents spread of healthcare-related
infections.(24)

Incorrect identification of the medication, and
not checking the patient’s identification before
administration of medication were errors found in the
observations of this study. These two steps – confirming
if the patient is correct and the medication correct − are
crucial for safe administration of medications.(25) The
findings of this research can be attributed to the fact of
being carried out at an emergency department, a site
where the demand for care often exceeds the physical,
human resource and material capacities. Additionally,
due to the serious status of the patient and risk of death,
many medications need to be given rapidly, even with
a verbal prescription. Despite this scenario, strategies
should be implemented, such as double-checking by the
medical and nursing teams, so that safety in medical
treatment is improved at these locations.

In this study, the dilution of medication at volume
lower than recommended by the manufacturer was
identified. A study conducted in a public hospital in
the interior of the state of São Paulo, with the objective

Types and frequency of errors in the preparation and administration of drugs

5
einstein (São Paulo). 2018;16(3):1-6

of identifying the frequency of errors that occurred
in the dilution process of intravenous medications, in
a critical care unit, showed that out of 180 doses, 125
(69.5%) presented with at least one dilution error, and
recording, evaluation and/or monitoring of these errors
were not detected.(26) These failures should be identified
and corrected, such as with educational and reference
materials, since these failures can compromise the
therapeutic efficacy of said medications.

Another important aspect regarding safety in
administration of medications is infusion rate, which in
this investigation, was incorrect in some observations. In
a literature review aiming at investigating the scientific
production on medication administration errors in
nursing care practice, the main medication error was
associated with the incorrect infusion rate.(27) When
using the infusion pump, this finding can be associated
to programming errors or inadequate handling. When
gravitational infusion was used, incorrect drip calculation
and lack of supervision by part of the team were noted,
indicating the need to train professionals involved in
this practice.

In 10.8% of medications administered, checking
patient’s pulse was recommended, but this measure
was not taken in 24.3% of cases. Some medications
have the potential of causing modification in vital
signs, worsening the patient’s health status. In this way,
the good practices in administration of medications
include ongoing vigilance and monitoring of patients
at risk, which could be emphasized at the emergency
department, site of our study, since the patients are
already, in most cases, in a severe state of health.(25)

In 31.3% of the observations, there was more
than one medication at the same time for the same
patient, as to the compatibility of medications that were
administered concomitantly during the collection of
data of this study, more than half were incompatible
and one fourth had not yet been tested. Because of
the clinical conditions of patients at the emergency
department, treatment with intravenous medications
is common, and can result in numerous risks, due to
complexity of intravenous pharmacotherapy, especially
administration of the medication.(28)

Incompatibility is an unexpected physical and/or
chemical interaction between two or more substances
when in a mixture, which can compromise the safety
and efficacy of treatment with the product formed.
Additionally, incompatibility can imply consequences
that go from a simple obstruction of a catheter
to an individual’s death. It is necessary that the
multiprofessional team be attentive to this problem,
primarily due to the lack of knowledge and the lack of
training of the professionals.(28)

This study has the limitation the fact of having been
conducted at a single center, with a reduced sample
size, which could hinder the comparison with other
realities and generalization of the results. In addition,
the intervention of the investigator, in case of potential
or real error, could have caused interference in the
findings of the research. Nevertheless, the results of
this study can contribute so that individual failures or
those in the process of preparation and administration
of medications are identified, and that measures for
prevention are implemented, such as in training and
permanent education of the team, which results in
increased quality of care and safety of the patient.

❚ CONCLUSION
The primary errors related to preparation and
administration of intravenous medications were lack of
hand hygiene in the preparation and administration of
medications, and lack of asepsis of the materials used
for the infusion.

❚ AUTHORS’ INFORMATION
Mendes JR: https://orcid.org/0000-0001-8823-8213
Lopes MC: https://orcid.org/0000-0002-8989-4404
Vancini-Campanharo CR: https://orcid.org/0000-0002-7688-2674
Okuno MF: https://orcid.org/0000-0003-4200-1186
Batista RE: https://orcid.org/0000-0002-6416-1079

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medications: errors made by the nursing staff]. Rev Bras Farm Hosp Serv
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26. Marini DC, Pinheiro JT, Rocha CS. [Errors on dilution of intravenous medication
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27. Nascimento MA, Freitas K, Oliveira CG. Erros na administração de medicamentos
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Ciencias Biologicas Saude Unit. 2016;3(3):241-56.

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See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/269283147

Incidence of intravenous drug incompatibilities in intensive care units

Article  in  Biomedical papers of the Medical Faculty of the University Palacky, Olomouc, Czechoslovakia · November 2014

DOI: 10.5507/bp.2014.057 · Source: PubMed

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Incidence of intravenous drug incompatibilities in intensive care units
Ondrej Machotkaa, Jan Manakb, Ales Kubenac, Jiri Vlceka

Aims. Drug incompatibilities are relatively common in inpatients and this may result in increased morbidity/mortal-
ity as well as add to costs. The aim of this 12 month study was to identify real incidences of drug incompatibilities in
intravenous lines in critically ill patients in two intensive care units (ICUs).
Methods. A prospective cross sectional study of 82 patients in 2 ICUs, one medical and one surgical in a 1500-bed uni-
versity hospital. One monitor carried out observations during busy hours with frequent drug administration. Patients
included in both ICUs were those receiving at least two different intravenous drugs.
Results. 6.82% and 2.16% of drug pairs were found to be incompatible in the two ICUs respectively. Among the most
frequent incompatible drugs found were insulin, ranitidine and furosemide.
Conclusions: The study showed that a significant number of drug incompatibilities occur in both medical and surgi-
cal ICUs. It follows that the incidence of incompatibilities could be diminished by adhering to a few simple rules for
medication administration, following by recommendations for multiple lumen catheter use. Future prospective studies
should demonstrate the effect of applying these policies in practice.

Key words: medical error, medical, medication safety, drug administration, drug incompatibilities, intensive care
units

Received: April 12, 2014; Accepted with revision: October 16, 2014; Available online: November 6, 2014
http://dx.doi.org/10.5507/bp.2014.057

aDepartment of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University in Prague, Hradec Kralove, Czech
Republic
bDepartment of Gerontology and Metabolism, University Hospital Hradec Kralove
cThe Institute of Information Theory and Automation, Academy of Sciences of the Czech Republic, Prague
Corresponding author: Ondrej Machotka, e-mail: [email protected]

INTRODUCTION

During the treatment of inpatients, medication errors
and unintended side effects are two relatively common
drug-related problems which may result in increasing
morbidity / mortality as well as add to the cost of the
therapy1,2. Medication errors have been identified as the
main factor limiting the effectiveness and safety of phar-
macotherapy3. The types and frequency of drug related
problems, especially medication errors in preparation and
administration, have dramatic implications for the overall
quality of nursing care4.

Currently only a limited number of physicians and
pharmacists have concerned themselves with monitoring
these problems in the Czech Republic, with even fewer
doing so outside the hospital environment. The authors of
early studies and analyses were concentrated on prescrip-
tion and dispensing errors as well as mistakes caused by
patient non-compliance. In contrast, our study was con-
ducted in the hospital environment of an ICU.

Especially in the ICU, rapid response to an emergency
is often crucial. For this reason, drugs are usually admin-
istered parenterally. Other reasons for this are that drugs
are often poorly absorbed via the oral route or patients are
unable to receive drugs in other ways. Poorly prepared or
wrongly administered parenteral therapy can cause inter
alia thrombus formation, severe hypersensitivity reactions

and infections5. Several studies have specifically focused
on intravenous medication administration errors and in-
vestigated the incidence6-10.

Physicochemical incompatibility is a typical medi-
cation error in the administration of parenteral drugs.
Incompatibility is defined as the reaction of intravenous
drugs resulting in solutions that are no longer optimal for
the patient after they are mixed – the stability or structure
of the drugs is altered by physical or chemical reactions.
Changes in stability can cause changes in drug effec-
tiveness; the increased size of microparticles has been
frequently linked to consequences such as therapeutic fail-
ure, catheter occlusion, or, in the worst cases, embolism11.

A number of studies confirm that this is a significant
and increasing problem. Taxis and Barber7 have shown
that about half of all ward-based intravenous drug prepara-
tions and administrations are incorrect. These incompat-
ibilities produce about 20% of all medication errors and
almost 89% of the overall errors in the administration of
drugs8,12.

The aim of this study was to survey the incidence and
extent of the incompatibilities in a hospital in the Czech
Republic and in Eastern Europe with the ultimate goal
of making recommendations for reducing the risk of in-
compatibilities.

Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2015 Dec; 159(4):652-656.

653

METHODS

The study was carried out as a comparison of two
ICUs at the 1500-bed University Hospital Hradec Kralove.
The first was a 20-bed medical ICU specializing in geron-
tology and metabolism, the second a 12-bed surgical ICU
treating adult patients after major surgeries and accidents.

The prospective study led to the identification of real
situations of drug incompatibilities. Data collection was
conducted gradually from January 2011 to December
2011. 50 patients in the medical ICU and 32 patients in
the surgical ICU were assessed prospectively. Only pa-
tients who were administered at least two different intra-
venous drugs were included. The data were collected by
the direct observation of nurses administering intravenous
medication. For this study we focused on drug incom-
patibilities excluding both TPN and drugs not found in
the database13. The observation was performed by one
monitor (an independent graduate student in the clini-
cal pharmacy doctoral program) during busy hours with
frequent drug administration (6-10 a.m.). The observation
was undisguised: nurses and doctors who had previously
been informed about the goals of the study, the first of its
kind in the Czech Republic. Nurses were clearly informed
they would not be identified in to ensure anonymity.

As the source of incompatibilities, Trissel’s Handbook
on Injectable Drugs13 was used. This database contains
incompatibility information on 359 different intravenous
active ingredients and is often mentioned as the gold
standard in IV drug incompatibilities14. We focused only
on Y-site incompatibilities, indicating two separate drug

infusions which are incompatible when infused through
the same IV line15. There were no standard operating pro-
cedures regarding the incompatibilities in the University
Hospital Hradec Kralove during the data collection.

For analysis of the data in the prospective studies, we
used graph coloring theory16. The averages of lumens per
patient in both ICUs were compared using t-tests.

The study was approved by the hospital Ethics
Committee.

RESULTS

The results are shown in Table 1.
The first prospective study (n=50; mean ± S.D. age;

59.3 ± 15.0 years; 54% female) was performed in the medi-
cal ICU. The patients were maintained on a total of 318
IV drugs (mean ± S.D., 6.3 ± 3.0) featuring 64 different
brands of medications on day two of their ICU stay. Out
of a total of 318 IV drugs, 88.7% (n=282) were found in
the database of drug incompatibilities. Out of 220 drug
pairs given to the patients through one intravenous line
which were found in the database, 6.82% (n=15) of the
pairs were incompatible, the most frequent compounds
being insulin, ranitidine, furosemide and ciprofloxacin
(see Table 2).

The second prospective study (n=32; mean ± S.D. age;
58.3 ± 17.2 years; 28% female) was performed in the surgi-
cal ICU. The patients were maintained on a total of 207
IV drugs (mean ± S.D., 6.5 ± 2.4) featuring 48 different
brands of medications on day two of their ICU stay. Out

Table 1. Results of our study.

Medical ICU Surgical ICU

No. patients 50 32
No. total administered IV drugs 318 207
Mean of administered drug/patient 6.3 6.5
No. administered drugs found in the database (%) 282 (88.7) 177 (85.5)
No. brands of medications 64 48
No. drug pairs 220 139
Mean (median) of lumens of catheters per patient 1.88 (1.50) 2.41 (3.00)
Incompatible pairs (%) 15 (6.82) 3 (2.16)

Table 2. Incompatible drug pairs coinfused through a common IV line.

Drug combinations (brand names) No. incompatibilities

Drug A Drug B Medical ICU Surgical ICU

Insulin (Humulin) Ranitidine (Ranital) 5 0
Vancomycin (Edicin) Omeprazole (Helicid) 2 0
Furosemide (Furosemid Biotika) Ciprofloxacin (Ciprofloxacin Kabi) 2 1
Furosemide (Furosemid Biotika) Fluconazole (Mycomax) 2 0
Insulin (Humulin) Noradrenalin (Noradrenalin Leciva) 2 0
Ciprofloxacin (Ciprofloxacin Kabi) Hydrocortisone (Hydrocortison Valeant) 1 0
Potassium chloride (Kalium chloratum Leciva) Methylprednisolone (Solu-Medrol) 1 0
Magnesium sulfate (Magnesium sulfuricum Biotika) Amiodarone (Cordarone) 0 1
Midazolam (Midazolam B. Braun) Omeprazole (Helicid) 0 1

Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2015 Dec; 159(4):652-656.

654

of a total of 207 IV drugs, 82.9% (n=145) of them were
found in the database of drug incompatibilities. Out of
139 drug pairs found in the database and given to the
patients through one intravenous line, 2.16% (n=3) of the
pairs were incompatible, the most frequent compounds
being ciprofloxacin, furosemide, midazolam, omeprazole,
amiodarone and magnesium sulfate (see Table 2).

DISCUSSION

Errors in the administration of intravenous drugs have
been analyzed in a number of studies7-10,17,18, with intrave-
nous drug incompatibilities comprising one subgroup of
these problems. Especially in intensive care, during which
parenteral drug administration is often complicated by
the fact that the number of the concurrently administered
drugs exceeds the number of available infusion lines, in-
travenous drug incompatibilities represent a significant
problem.

Our study was designed to identify the real state of
intravenous drug incompatibilities at one University hos-
pital in the Czech Republic. The incompatibilities dis-
covered could suggest a lack of interest in the described
problem, knowledge deficiencies and/or the absence of a
clear strategy or effective tools for reducing the frequency
of incompatibilities.

Although the frequency of the incompatibilities does
not seem particularly high, the substances found most fre-
quently were often vital drugs like insulin, antibiotics, an-
tiarrhythmics and catecholamines. Even a small decrease
in the efficiency of these drugs can cause a significant
impact on patients in ICUs.

Comparing the two ICUs involved in our study, the
differences in the results are quite interesting. The discrep-
ancies may simply be caused by the differing number of

catheter lumens used for the administration of IV drugs
in the two different ICUs. The average lumens per patient
used in the gerontology and metabolism ICU (1.88) was
significantly (P=0.008) lower than the average in the surgi-
cal ICU (2.41).

The differences in the types of IV drugs administered
in the ICUs could be another reason for the dissimilar
results. Although the total amount of administered drugs
per patient was higher in both studies conducted in the
surgical ICU, the number of brands of used medication
was always lower in the surgical ICU in comparison with
the medical ICU.

Other studies7,9,10,15,19 focused on intravenous drug
incompatibilities show an error rate of incompatibilities
similar to the results observed in our study (3%, 18.6%,
0.53%, 5.8%, 3.4%). On the other hand, for reasons such
as differences in sources of incompatibilities, study sam-
ples, types of incompatibilities, methods of collecting data
as well as interpretation methods, our results cannot be
compared with those in the literature (see Table 3).

Despite differences between studies, the incidence of
incompatibilities may still be seen as comparable with
other studies made in this field.

Based on a comparison with Bertsche et al.15 it is
possible to show relatively clear strategies towards im-
provement; the establishment of standard operational
procedures, the institution of compatibility charts and
the education of ICU nurses in this area have been dem-
onstrated to show promising results.

On the other hand, the establishment of new SOPs
can lead to other types of complications, e.g. the shown
link between switching to multi-lumen catheters and a
subsequent rise in catheter infections20, the increase in
the volume of drug solvent influencing fluid balance in
critically ill patients, as well as the escalating economic
burden and increasing demands on ICU staff. These phe-

Table 3. Comparison of similar studies focused on intravenous incompatibilities.

Our study Bertsche et al.15 Taxis, Barber7 Gikic, Paolo19 Tissot, Cornette9 Westbrook et al.10

No. patients
involved

82 25 106 19 26 Undocumented

No. total
administered IV
drugs

525 160 430 Undocumented Undocumented 568

Mean of
administered drug/
patient

6.4 6.4 4.1 6.5 Undocumented Undocumented

No. drug pairs 359 516 Undocumented 175 102 Undocumented

Database of
incompatibilities

Trissel’s
Handbook13

KIK database Manufacturer’s
instructions

More database
sources

Data
systematically
researched

Data systematically
researched

Incompatible pairs
(%)

18 (5.01) 30 (5.8) 12 (3.0) 6 (3.4) 19 (18.6) 3 (0.53)

Method of data
collecting

Undisguised
bedside
observation

Undisguised
bedside
observation

Disguised
bedside
observation

Undisguised
bedside
observation

Undisguised
bedside
observation

Undisguised bedside
observation

Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2015 Dec; 159(4):652-656.

655

Table 4. Possible distribution of IV drugs in different lumens of a catheter.

Medical ICU Surgical ICU

Lumen 1 Lumen 2 Lumen 1 Lumen 2

Ciprofloxacin Phenytoin Ciprofloxacin Phenytoin
Clindamycin Furosemide Amiodarone Furosemide
Metoclopramide Omeprazole Metoclopramide Insulin
Vancomycin Hydrocortisone Dobutamine Midazolam
Insulin Potassium phosphate Omeprazole Teicoplanin
Potassium chloride Magnesium sulfate Potassium chloride Piperacillin/tazobactam
Clarithromycin Noradrenalin Noradrenaline
Midazolam Ranitidine Propofol
Fluconazole Ceftriaxone Ranitidine

Methylprednisolone Sufentanil
Fluconazole

nomena will be monitored in our next study, which will be
focused on the assessment of the new SOPs in practice.

In our study we have partially addressed the prob-
lem of switching to multi-lumen catheters. Taking into
consideration all of the medications administered in the
prospective studies in both ICUs in terms of graph color-
ing theory11, it seems that only the two-lumen catheter
remains a viable solution for preventing the problem of
incompatibilities, thus switching to multi-lumen catheters
should be eliminated as an option. Table 4 shows an exam-
ple of the potential distribution of IV drugs in our study in
terms of excluding the possibility of incompatibilities. The
other IV drugs can be added arbitrarily to any one of the
groups without presenting problems. The only exceptions
are with patients on total parenteral nutrition. For the
sake of simplicity for nursing staff, one guideline should
be that a single catheter with one lumen designated only
for parenteral nutrition is recommended.

Our study has some limitations. First, the prospective
observational studies provided real data regarding e.g. spe-
cific routes of administration. Nevertheless, some disad-
vantages of prospective observational studies are the long
time needed for data collection, additional demands on
the data collectors and ICU staff, as well as difficulty of
ensuring that studies are blind. In choosing to use this
type of study we kept in mind these advantages and dis-
advantages. The use of prospective observational studies
is in our opinion necessary to identify the real state of
incompatibilities.

On the other hand, this could present the problem of
the observer interfering with the administering nurse. In
our opinion, attempting a totally blind collection of these
data is unrealistic. Disguised observation seems to be the
optimal method but we chose undisguised observation
with the hope of the possibility of only limited interfer-
ence with the duties of the nurses who cooperated with
our study. It is significant that the nurses in our study were
in fact unaware of how to solve problems with incompat-
ibilities, most likely due to difficulties in obtaining data
about the compatibility and incompatibility of adminis-
tered IV drugs (lack of information in SPC).

Another limitation of our study is the fact that we did
not observe the clinical implications for patients. This
would have been very difficult in a routine clinical en-
vironment due to the difficult recognition and differen-
tiation of symptoms of incompatibilities. For example a
decrease in the activity of one particular drug is difficult
to establish in the complexity of the treatments used in
the ICU.

The recurrent simplification of medicines to active
substances was a drawback as well. Thus it was also nec-
essary to limit the medicines studied to those listed in
the selected database. Despite the fact that our database
– Trissel’s Handbook13 is primarily designated for the
market in the United States, it is often taken as the gold
standard among incompatibility databases14. The reasons
for exclusion of TPN in the prospective studies were the
variability in nutrients composition, the dependence of
the incompatibility of individual components on their
concentration, and the lack of data on incompatibility of
parenteral nutrition solutions.

Working toward the detection and elimination of drug
incompatibilities and other drug related problems has
been acknowledged as a key goal for the clinical pharma-
cist21. Employing pharmacists with this specialization has
still not become sufficiently widespread in Czech hospi-
tals, but it has been on the rise in recent years.

This study has demonstrated that although a signifi-
cant number of drug incompatibilities occur in both medi-
cal and surgical ICUs, in fact only a limited number of
medications are involved in these interactions. Besides
the amount and type of medications, the most important
determinant of the incidence of medication incompatibili-
ties is the usage of single- or multiple lumen intravenous
catheters.

CONCLUSION

Based on our results, the incidence of drug incompat-
ibilities could be theoretically diminished by adhering to a
few simple rules for medication administration and follow-
ing a set of recommendations for multiple lumen catheter

Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2015 Dec; 159(4):652-656.

656

use. Future prospective studies should demonstrate the
effect of applying these policies in practice.

Acknowledgement: The authors would like to thank all
participating nurses for the successful collaboration.

This work was supported by grant No 53410-C-2010
of the Charles University Grant Agency and supported
in part by grant SVV 267 005 administered by Charles
University in Prague.
Author contributions: OM: study conception and design,
data collection, analysis and interpretation, drafting and
manuscript revision; JM: study design, data interpretation,
manuscript revision; AK: data analysis and interpretation;
JV: study conception, data interpretation, manuscript revi-
sion; all authors: final approval.
Conflict of interest statement: None declared.

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12. Taxis K, Barber N. Causes of intravenous medication errors: an eth-
nographic study. Qual Saf Health Care 2003;12:343-8.

13. Trissel LA. Handbook on Injectable Drugs, 15th edition: American
Society of Health-System Pharmacists 2008.

14. De Giorgi I, Guignard B, Fonzo-Christe C, Bonnabry P. Evaluation of
tools to prevent drug incompatibilities in paediatric and neonatal
intensive care units. Pharm World Sci 2010;32:520-9.

15. Bertsche T, Mayer Y, Stahl R, Hoppe-Tichy T, Encke J, Haefeli WE.
Prevention of intravenous drug incompatibilities in an intensive
care unit. Am J Health-Syst Pharm 2008;65:1834-40.

16. Harris JM, Hirst JL, Mossinghoff MJ. Combinatorics and Graph
Theory: Springer 2008.

17. Tissot E, Cornette C, Limat S, Mourand JL, Becker M, Etievent JP,
Dupond JL, Jacquet M, Woronoff-Lemsi MC. Observational study
of potential risk factors of medication administration errors. Pharm
World Sci 2003;25:264-8.

18. Han PY, Coombes ID, Green B. Factors predictive of intravenous
fluid administration errors in Australian surgical care wards. Qual
Saf Health Care 2005;14:179-84.

19. Gikic M, Di Paolo ER, Pannatier A, Cotting J. Evaluation of physico-
chemical incompatibilities during parenteral drug administration in
a paediatric intensive care unit. Pharm World Sci 2000;22(3):88-91.

20. Reed CR, Sessler CN, Glauser FL, Phelan BA. Central venous cath-
eter infections: concepts and controversies. Intensive Care Medicine
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21. Wiffen P, Mitchell M, Snelling M, Stoner N. Oxford handbook of clini-
cal pharmacy. Oxford, UK: Oxford University Press 2012.

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O R I G I N A L R E S E A R C H

open access to scientific and medical research

Open Access Full Text Article

http://dx.doi.org/10.2147/IPRP.S125085

Prevalence of intravenous medication
administration errors: a cross-sectional study

Tezeta Fekadu1

Mebrahtu Teweldemedhin2

Eyerusalem Esrael1

Solomon Weldegebreal
Asgedom1

1School of Pharmacy, Department
of Clinical Pharmacy, College of
Health Sciences, Mekelle University,
Mekelle, 2Unit of Biomedical Science,
School of Medicine, College of Health
Sciences and Referral Hospital, Aksum
University, Aksum, Ethiopia

Background: Intravenous medication administration errors (MAEs) may be accompanied by

avoidable undesirable effects, which might result in clinical complications.

Objective: The aim of the study was to determine the prevalence of MAEs and to identify the

factors associated with such errors.

Methods: A hospital-based cross-sectional study was conducted from March to April 2015.

Data were collected by direct observation using a pretested data collection tool. Simple random

sampling was used, and bivariate logistic regression model was used to identify the factors

associated with MAEs. P value <0.05 was considered statistically significant.

Results: A total of 134 patients were found to be eligible for the study. More than half of the

study participants were males (76 [56.7%]). The rate of MAE was 46.1%, with the missed

dose (n=162, 95.8%) being reported as the most common error. The age groups of 60–79 years

(adjusted odds ratio = 2.166, confidence interval = 1.532–8.799) and 80–101 years (adjusted

odds ratio = 1.52, confidence interval = 1.198–5.584) were the determinants of MAEs.

Conclusion: A high prevalence of MAEs was found. Enhancing the knowledge and practical

skills of clinical nurses might minimize such errors.

Keywords: prevalence, medication, administration, error

Background
Preparation and intravenous (IV) administration of medications is a crucial clinical

activity in provision of health care for hospitalized patients.1,2 In health care systems, the

medication administration processes represent an advanced technology and a complex

process.3,4 Infusion therapy is one of the medication administration processes used in

the treatment of many hospitalized patients; however, it is associated with high risk of

causing harm for patients.5,6 Administration of medications may be accompanied by

avoidable undesirable effects which sometimes are life threatening, especially when

administered in error.7,8

Medication errors are among the major clinical issues in the health care settings.9–11

Although IV therapy benefits patients, it also represents a source of risks. The complex-

ity of the procedures, multiplicity of professionals and services involved, rapid intro-

duction of new drugs, and diagnostic and therapeutic technologies frequently provoke

errors, jeopardizing care security and quality and generating an increase in cost.3,12

Medication errors are the eighth leading cause of death in the US, and they rep-

resent the single largest cause of errors in the hospital setting, accounting for >7000

deaths annually.13,14 In the US, 60% of serious and life-threatening medication errors

that occur in patients involved IV drugs; in the UK approximately 56% of the errors

Correspondence: Solomon Weldegebreal
Asgedom
School of Pharmacy, Department of
Clinical Pharmacy, College of Health
Sciences, Mekelle University, Mekelle
1871, Ethiopia
Tel +251 9 2087 1964
Email [email protected]

Journal name: Integrated Pharmacy Research and Practice
Article Designation: ORIGINAL RESEARCH
Year: 2017
Volume: 6
Running head verso: Fekadu et al
Running head recto: Medication administration errors
DOI: http://dx.doi.org/10.2147/IPRP.S125085

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48

Fekadu et al

administered with IV drugs. Although only a few medica-

tions are administered IV in the hospital setting, the IV

drugs account for the majority of medication errors.15,16 A

high incidence of medication errors related to IV therapy

was found in Germany, where 23% of the total medication

errors occur during IV administration.16,17 In Ethiopia, the

prevalence of medication administration errors (MAEs) was

reported to be 55%.18

MAEs can affect patient morbidity and mortality. They

can also influence patients, familiesm, and health care provid-

ers indirectly by cost implication, prolonged hospital stays

and psychological impact.11 Although medication errors are

well investigated in many developed countries, research on

the issue has rarely been conducted in developing countries,

including Ethiopia. Therefore, the aims of this study, which

was conducted at Ayder Referral Hospital (ARH), are to

determine the prevalence of MAEs and identify the factors

associated with them.

Methods and participants
The study was conducted at ARH, which is located in Mekelle

city, Tigray, Ethiopia. The hospital is affiliated to Mekelle

University and is the only referral hospital in the region.

It has a total capacity of 500 inpatient beds and serves

250–400 cases per day. We conducted an institutional-based

cross-sectional study. The sample size needed was deter-

mined using single mean population proportion formula.

Considering 1.96 for the standard normal variable with 5%

level of significance (α-value), 95% confidence interval, 5%

margin of error and 10% contingency for loss, the sample

size was calculated to be 384. Because the hospital has 206

beds in the three wards (medical, surgical, and gynecologi-

cal), the minimum sample size needed was estimated to be

134. Simple random sampling was used to select the study

participants. The study included patients aged 18 years and

above; patients administered with two or more IV medica-

tions during their stay in the ward; and patients admitted to

the three wards during the study period. Patients treated with

oral or topical medications were excluded from the study.

Data were collected by directly observing medication

administrations, and the medical records were reviewed using

the pretested data collection format, which was developed

by reviewing reputable literatures. All relevant data were

collected prospectively from patients’ medical records and

by direct observation. Demographic information about the

patients was obtained from their medical cards and medica-

tion administration records. Data on medication administra-

tion were collected by directly observing all day-time (6:00

am to 6:00 pm) medication administration. Along with the

day time observations, medication chart review was carried

out to collect data on the off duty (7:00 pm to 6:00 am) drug

administration. The observations and the information recorded

in the medication charts were documented during the data

collection, including all details about the patient’s medica-

tion regimen. The data were collected by two undergraduate

pharmacists employed outside of ARH. Pretest was done on

ten patients who were randomly selected from the hospital.

These were then excluded from the analysis and amendment

was done in the data abstraction format. MAEs were identi-

fied by comparing medication administration observed/found

as per the order of prescribers. The primary outcome of the

study was presence of MAE; age, comorbidity, number of

medications per patient, regimen complexity, sex, diagnosis,

and dose and frequency of medications were the independent

variables studied.

The data were coded, cleaned and checked for complete-

ness. They were entered in Epidata version 3.1 and analyzed

using Statistical Package for Social Sciences version 20.

Bivariate logistic regression analysis was used to find the

association between MAE and independent variables. Vari-

ables with P<0.05 in the binary logistic regression were

reanalyzed using multivariate logistic regression analysis

to identify the determinants of MAE. A P value <0.05 was

considered to be statistically significant. Ethical clearance

was obtained from the Institutional Review Board of College

of Health Sciences, Mekelle University. Oral consent were

obtained from the patients before the data were collected.

Operational definitions
MAE is a deviation from the physician’s medication order

as written on the patient’s chart. It includes poor medica-

tion administration record on the patient chart and failure

to comply with the prescription order (drug, dose, dosage

regimen, dosage form and length of therapy).19

Complex regimen is the prescription of three or more drugs

to one patient at the same time.19

Results
Demographic characteristics
In our study, 134 patients were included, making up a 100%

response rate. More than half of the study participants were

males 76 (56.7%) and 58 (43.3%) were in the age group of

40–59 years. The mean age of the participants was 35±15.5

years (Table 1).

IV medication usage information
More than half of the patients (64.2%) were admitted to the

emergency department before they were transferred to one

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Medication administration errors

of the three wards, and 73 (54.5%) patients were admitted

to the medical ward. Concerning the number of drugs per

prescription, 67 (50%), 43 (32.1%) and 17 (12.7%) patients

received two, three and four drugs per prescription, respec-

tively (Table 2). An average of 2.73 (2.73±1.34: mean ± stan-

dard deviation [SD]) drugs were prescribed at the same time

and 37 (27.6%) patients were diagnosed with comorbidities

including infection and abscess (Table 3).

MAE
A total of 366 medication administration interventions had

occurred in the studied wards of ARH. Out of the 366 medi-

cation administration interventions, 169 (46.1%) medica-

tions administered were labeled as MAE. Among all MAEs,

missed dose and wrong dose contributed to 162 (95.8%) and

7 (4.2%) errors, respectively. The MAEs were observed in

each study site: 89 (52.6%) in the medical ward, 51 (30.1%)

in the surgical ward and 29 (17.1%) in the gynecology ward.

Factors associated with IV MAE
Binary logistic regression analyses showed that age groups

60–79 years (crude odds ratio [COR] = 1.31, 95% confidence

interval [CI] = 0.47–3.68) and 80–101 years (COR = 1.13, 95%

CI = 1.02–4.03) were significantly associated with MAEs. Mul-

tivariate binary logistic analyses of factors showed that patients

in the age group of 60–79 years (adjusted odds ratio [AOR] =

2.17, CI = 1.532–8.78) and 80–101 years (AOR = 1.52, CI =

1.198–5.58) were determinants of MAE (Table 4). Patients in

the age group of 60–79 years were two times more likely to have

MAE than those in the age group of 18–39 years. Moreover,

patients in the age group of 80–101 years were 1.5 times more

likely to have MAE than those in the age group of 18–39 years.

Discussion
In this study, the prevalence of MAEs was found to be 46.1%.

Among the total medication errors in intervention, missed

dose and wrong dose accounted for 95.8% and 4.2%, respec-

tively. Multivariate binary logistic analyses of factors showed

that patients in the age group of 60–79 years (AOR = 2.17,

95% CI = 1.53–8.78) and 80–101 years (AOR = 1.52, 95%

CI = 1.19–5.58) were the determinants of MAE.

The rate of MAEs was found to be lower in this study

than that conducted at the Jimma University Specialized Hos-

pital (JUSH), Southwest Ethiopia, where 51.8% MAEs was

reported.11 The plausible justification for the difference might

be the difference in study setting. This study was conducted at

the surgical, gynecology and medical wards, whereas the study

from JUSH was conducted in the intensive care unit (ICU),

where the number of drugs given per patient was more as com-

pared to that administered to patients admitted in the medical

wards of ARH because IV administration is highly followed

for patients admitted to the ICU in comparison to other wards.

Besides, a much lower rate of MAE was found in our

study as compared to that in a prospective observational study

conducted at a tertiary care hospital, HospSel, Malaysia,

where the rate of MAE was 88.6%. The reason for this dif-

ference could be due to the high number (ten or more) of IV

drugs prepared and administered at that point of time and

the lack of staff nurses (three or less) at the particular ward

of the tertiary care hospital.15

The rate of MAEs in our study was higher than that in

the findings reported from an observational study conducted

Table 1 Age and sex distribution of patients (N=134)

Variables Frequency (%)

Sex
Male 76 (56.7)
Female 58 (43.3)
Age (years)
18–39 28 (20.9)
49–59 58 (43.3)
60–79 33 (24.6)
80–101 15 (11.2)

Table 2 Characteristics and IV medication usage of patients

Variables Frequency (%)

Admission ward
Medical ward 73 (4.5)
Surgical ward 35 (26.1)
Gynecology ward 26 (19.4)
Regimen taken
Simple 68 (50.7)
Complex 66 (49.3)
Number of drugs
Two drugs 67 (50.0)
Three drugs 43 (32.1)
Four drugs 17 (12.7)
Five drugs 7 (5.2)

Abbreviation: IV, intravenous.

Table 3 Comorbidities

Comorbidities Frequency (%)

DM 5 (3.7)
HIV/AIDS 4 (3)
TB 9 (6.7)
Cardiac disease 11 (8.2)
Hypertension 2 (1.5)
Cancer 10 (7.5)
Renal and liver disease 12 (9)
Infection and abscess 37 (27.6)
Accident 5 (3.7)
Others 39 (29.1)

Abbreviations: AIDS, acquired immunodeficiency syndrome; DM, diabetes
mellitus; HIV, human immunodeficiency virus; TB, tuberculosis.

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Fekadu et al

at three large teaching hospitals in the UK and Germany,

which showed 93 (34%) administration errors from 278

IV interventions observed.19 This might be due to the less

knowledge, skill and attitude of the health care providers

and the difference in provision of health care services to

the patients in ARH, as compared to those of UK and Ger-

man hospitals. The other plausible reason could be due to

the involvement of drug supply and pharmacy services in

medication administration process in the three large teach-

ing hospitals which resulted in lower frequency of MAE,19

as compared to our study in which there was no pharmacist

involved in IV administration.

In this study, missed dose was found to be the common

type of administration error. The prevalence of missed dose

was much higher than that reported in JUSH (18.3%). This

might be due to the difference in study setting. The study

from JUSH was conducted at the ICU, wherein patients are

kept under close supervision as compared to those in other

wards.11 Poor availability of medications and poor logistic

system of the hospital might also account for the health care

professionals missing the medication doses, which could

ultimately increase the prevalence of missed dose.

Multivariate binary logistic analyses of factors showed

that patients in the age group of 60–79 years (AOR = 2.166,

CI = 1.532–8.799) and 80–101 years (AOR = 1.52, CI =

1.198–5.584) are determinants of MAEs. Patients in the

age group of 60–79 years were two times more likely to

have MAEs than patients aged 18–39. Moreover, patients in

the age group of 80–101 years were 1.5 times more likely

to have MAEs than patients aged 18–39 years. These find-

ings strengthens the fact that elderly people under chronic

medication and with insufficient control of their medication

level are one of the risk groups for MAE.20,21

Limitations
This study has some limitations. As this is a cross-sectional

study, it might lead to recall bias. Further, the study was

conducted at a single center with a small sample size, which

might limit the generalization of the findings.

Conclusion
This study reports a high prevalence of MAEs, of which missed

dose was the most common type of error. In addition, it was

found that MAEs were influenced by a patient’s age. These find-

ings emphasize that health care providers could pay due atten-

tion to the risks of MAEs and the factors associated with them.

Acknowledgments
We would like to acknowledge Mekelle University for cooperat-

ing with us to conduct the study. Our deepest gratitude also goes

to the staff of Ayder Referral Hospital who helped us in collect-

ing data. The authors received no specific funding for this work.

TF and EE are assistant lecturers in Mekelle University.

MT is a microbiologist in Aksum University. SWA is a clini-

cal pharmacist and lecturer in Mekelle University.

Author contributions
TF was involved in the conception and design of the study,

developed data collection tools and analyzed data. SWA,

MT and EE were involved in manuscript writing, analysis

and editing. All authors contributed toward data analysis,

drafting and revising the paper and agree to be accountable

for all aspects of the work.

Disclosure
The authors report no conflicts of interest in this work.

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Table 4 Multiple logistic regression analysis of different variables with IV medication administration error in medical, surgical and
gynecology wards of ARH from March to April 2015

Variables Medication administration errors COR (95% CI) AOR (95% CI)

Yes (%) No (%)

Age categories (years)
18–39 12 (42.9) 16 (57.1) 1 1
40–59 12 (20.7) 46 (79.3) 2.875 (1.077–7.674) 4.501 (0.300–15.578)
60–79 12 (36.4) 21 (63.6) 1.312 (0.47–3.681) 2.166 (1.533–8.799)
80–101 6 (40.0) 9 (60.0) 1.125 (1.02–4.029) 1.52 (1.198–5.584)

Abbreviations: AOR, adjusted odds ratio; ARH, Ayder Referral Hospital; CI, confidence interval; COR, crude odds ratio; IV, intravenous.

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  1. Publication Info 4:
  2. Nimber of times reviewed 4:

_______________________________________________________________________________________________________________________________

Open Access Maced J Med Sci. 2019 Nov 15; 7(21):3579-3583. 3579

ID Design Press, Skopje, Republic of Macedonia
Open Access Macedonian Journal of Medical Sciences. 2019 Nov 15; 7(21):3579-3583.
https://doi.org/10.3889/oamjms.2019.722
eISSN: 1857-9655
Clinical Science

Medication Errors and Their Relationship with Care Complexity
and Work Dynamics

Zahra Sabzi

1
, Reza Mohammadi

2
, Razieh Talebi

3*
, Gholam Reza Roshandel

2

1
Nursing Research Center, Golestan University of Medical Sciences, Gorgan, Iran;

2
Sayyad Medical and Educational

Center, Golestan University of Medical Sciences, Gorgan, Iran;
3
Nursing Research Center, Golestan University of Medical

Sciences, Gorgan, Iran;
4
Golestan Research Center of Gastroenterology and Hepatology, Golestan University of Medical

Sciences, Gorgan, Iran

Citation: Sabzi Z, Mohammadi R, Talebi R, Roshandel
GR. Medication Errors and Their Relationship with Care
Complexity and Work Dynamics. Open Access Maced J
Med Sci. 2019 Nov 15; 7(21):3579-3583.
https://doi.org/10.3889/oamjms.2019.722

Keywords: Child; Drug Incompatibility; Hospital;
Medication Errors; Workplace

*Correspondence: Razieh Talebi. Nursing Research
Center, Golestan University of Medical Sciences, Gorgan,
Iran. E-mail: [email protected]

Received: 17-May-2019; Revised: 29-Sep-2019;
Accepted: 30-Sep-2019; Online first: 10-Oct-2019

Copyright: © 2019 Zahra Sabzi, Reza Mohammadi,
Razieh Talebi, Gholam Reza Roshandel. This is an open-
access article distributed under the terms of the Creative
Commons Attribution-NonCommercial 4.0 International
License (CC BY-NC 4.0)

Funding: This research was financially supported by the
Deputy of Research and Technology of Golestan
University of Medical Sciences, Iran

Competing Interests: The authors have declared that no
competing interests exist

Abstract

BACKGROUND: Medication errors are currently known as the most common medical errors. Research shows
that work environment and organisation management, in addition to the role of nurses, contribute to the
occurrence of an error.

AIM: Therefore, the present study was conducted to determine the rate of nurses’ medication errors and its
relation to the care complexity and work dynamics in the Taleghani Pediatric Hospital of Gorgan in 2017.

MATERIAL AND METHODS: This was a descriptive-correlational and cross-sectional study. Sampling was done
through census method (N = 100). The data collection tools consisted of four questionnaires of demographic
information, Salyer work dynamics, Medication Administration Errors, and Velasquez Nursing Care Complexity.
Data were analysed in SPSS V.16 software using descriptive and inferential statistical methods including
independent t-test and Pearson’s correlation.

RESULTS: Medication calculation errors, wrong dose and wrong medication were the most common non-
injectable medication errors, respectively. Drug incompatibility, wrong infusion rate and medication calculation
errors were the most common injectable medication errors, respectively. There was a positive correlation between
medication calculation errors (P = 0.02, r = 0.23), wrong solvent (P = 0.04, r = 0.21), and drug incompatibility (P =
0.01, r = 0.25) with amount of work dynamics. Also, there was a positive correlation between medication
calculation errors (P = 0.03, r = 0.22) and wrong medication (P = 0.00, r = 0.31) with the nursing care complexity.

CONCLUSION: Regarding the irrefutable impact of working conditions on the occurrence of errors, it appears that
the study and complete recognition of nurses’ working conditions and their adjustment would lead to a reduction in
medication errors.

Introduction

Medication errors are currently known as the
most common medical errors [1]. The US National
Coordinating Council for Medication Error Reporting
and Prevention (NCC MERP) defines medication
errors as follows: “A medication error is any
preventable event that may cause or lead to
inappropriate medication use or patient harm while the
medication is in the control of the healthcare
professional, patient, or consumer”[2]. Studies show
that medication errors occur three times more
frequently in admitted children than adults, and most
of these errors are harmful [3]. Because of the wide
variation in body mass, children need a unique

dosage calculation based on their weight, body
surface, age, and clinical status, which increases the
risk of medication errors [4]. Reports from the National
Patient Safety Agency (NPSA) in the UK found that
medication errors that occur during drug treatments
include 16% prescription writing errors, 18%
prescription preparation errors and 50% medication
administration errors. These errors are estimated at 3-
37% prescription errors, 5-15% prescription
preparation errors and 72-75% medication
administration errors for children [5].

In studies on the type of medication errors,
the wrong dose was the most common type of
medication error in children [6], [7] while using the
wrong medication was the most common medication

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error in adults [8]. These findings have been approved
by studies conducted in Iran [9], [10], [11], [12]. Based
on developed modules of medication errors, errors
arise from the interaction among several different
factors, including the administrative environment
(monitoring), leadership and organisational
commitment, management policies and procedures,
the complexity of tasks, work culture, and physical
environment [13], [14], [15]. Recent studies revealed
that the wrong medication was the most common
error of injectable medications and 51.5% of the errors
were related to the work environment [16]. It was also
identified that better nursing work conditions lead to a
lower frequency of medication errors [17] and
providing proper organisational conditions and work
environment can help nurses provide high-quality care
based on professional standards. Therefore, work
environment conditions can facilitate or hinder nursing
[18]. Work dynamics and care complexity were
considered as work environment factors in preceding
studies [13], [15].

Nurses’ activity in the hospital environment is
physically and psychologically difficult and can lead to
burnout, stress, and error. Busy work environments
can contribute to stress in employees, which
increases the risk of medication errors [14]. On the
other hand, effective and safe medication
management for children ensures good health and
provides social and economic benefits [19]. Therefore,
one of the important aspects of effective and safe
medication management is the evaluation of
medication errors and their properties to identify and
implement preventive strategies [20], [21].

Work environment and its variables can vary
in different care centers and consequently the amount
and type of medication errors can also vary, this study
aimed to determine the rate of medication errors of
nurses and its relationship with care complexity and
work dynamics in Taleghani Pediatric Hospital of
Gorgan in order to provide the grounds for
understanding the work environment of nurses in
pediatric units and to take an effective step toward
defining and implementing preventive strategies of
medication errors in pediatric units.

Material and Methods

This study was a descriptive-correlational,
cross-sectional survey. The study population
consisted of all nurses working in different units of
Taleghani Pediatric Hospital (N = 100). Sampling was
done through census method, and all nurses who had
inclusion criteria participated in the study. The
inclusion criteria were: The tendency and consent of
nurses to enter the study, employment at the time of
the studies, having at least six months of work
experience in the pediatric units, having at least a

bachelor’s degree, and working in different working
shifts. Data were collected by self-report and
questionnaires. Data collection tools were a
demographic questionnaire (age, sex, educational
level, type of employment, work experience, ward,
number of working shifts), Salyer Work Dynamics
Scale, Velasques Nursing Care Complexity Scale and
Medication Administration Error Questionnaire.

The 7-item Salyer’s was used to measure the
work dynamics of nurses. This tool is scored base on
a 6-point Likert scale (strongly disagree to agree
strongly) with a total score ranging between 7 and 42.
A low score indicates a lack of dynamics and a high
score indicates high dynamics. The content, structure
and face validity of the scale have been approved in
the studies. In Iran, a study by Pazoukian et al. (2014)
reported its high reliability (Cronbach’s alpha
coefficient = 0.81) and stability over time [22]. In the
present study, the Cronbach’s alpha coefficient was
0.80.

Care complexity scale was used to measure
this variable in the nurses’ work environment. This
scale was developed by Dona Maria Velasques in
2005 and had 15 items scored based on a 4-point
Likert scale (never to always) with a total score
ranging from 15 to 60. In Iran, Pazoukian et al., (2015)
reported its reliability with Cronbach’s alpha of 0.61,
and its correlation coefficient using test-retest as r =
0.88, indicating that the scale has acceptable validity
and reliability for use in Iran’s health system [23]. In
the present study, the Cronbach’s alpha coefficient for
consistency was 0.77.

The Medication Administration Error
questionnaire was used to determine the amount and
type of medication errors. The first part provides
information on the number of medication errors
occurring in the past 6 months and the working shift
with the highest number of mistakes. The second part
of the questionnaire consists of the questions related
to the type of medication errors categorized into two
groups of non-injectable medication errors (9 items)
and injectable medication errors (12 items) scored by
the percentage of medication errors (0-25, 25-50, 50-
75 and 75-100) with total score ranging between 0
and 100. The content validity and reliability of the
scale have been approved in different studies [11],
[12]. In the present study, the questionnaire’s
Cronbach’s alpha coefficient was 0.88.

The researchers started collecting data after
obtaining the approval of the Ethics Committee of the
Golestan University of Medical Sciences (the ethics
code of IR.GOUMS.REC.1395.207) and necessary
permits, and coordinating with the research setting
authorities. After briefing the participants about the
research goals and their rights, and answering their
questions, written informed consent was obtained
from them. The participants were assured that their
information would be confidential. Data were analysed
in SPSS v. 16 using descriptive and inferential

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statistics. That is, nominal qualitative variables were
described by frequency distribution and quantitative
variables by the mean and standard deviation.
Pearson’s correlation and student t-test were used to
analysing the data, taking into account a significance
level of less than 0.05.

Results

A total of 91 nurses from different parts of the
Taleghani Pediatric Hospital were enrolled.
Demographic characteristics of the study participants
are presented in Table 1.

Table 1: Frequency distribution of demographic characteristics
of the nurses in Taleghani Pediatric Hospital in 2017

Percent Frequency Classification Variable

48.27
51.73

42
45

< 35
> 35

Age (years)

20
80

18
72

Single
Married

Marital status

98.9
1.1

90
1

Bachelor’s degree
Master’s degree

Educational level

53.93
46.07

48
41

Permanent (official-
permanent contract)
Temporary (obliged
service, temporary
contract, through service
companies)

Employment Status

16.5
83.5

14
71

Fixed
Rotating

Working shifts

The most common types of medication errors
for non-injectable medications were respectively
medication calculation errors (37.25 ± 09.37), wrong
dose (34.22 ± 89.01), wrong medication (30.15 ±
49.72) and wrong time (30.15 ± 22.59). Furthermore,
the most common types of medication errors for
injectable medications were respectively drug
incompatibility (43.29 ± 41.09), wrong infusion rate
(43.26 ± 13.37), medication calculation errors (38.25 ±
46.08), wrong dose (38.24 ± 46.80) and wrong solvent
(37.24 ± 91.54) (Table 2).

Table 2: The mean and standard deviation of types of errors in
injectable and non-injectable medication in the Taleghani
Pediatric Hospital in 2017

Mean and standard
deviation (percent)

Injectable medication
errors

Mean and standard
deviation (percent)

Non-injectable
medication errors

28.85 ± 16.21
Wrong administration

technique
27.75 ± 16.85

Wrong
administration
technique

29.67 ± 12.86 Wrong Time 30.22 ± 15.59 Wrong Time
29.40 ± 12.68 Wrong patient 27.20 ± 9.60 Wrong patient

31.32 ± 13.74 Wrong medication 30.49 ± 15.72
Wrong
medication

38.46 ± 24.80 Wrong dose 34.89 ± 22.01 Wrong Dose

38.46±25.08
Medication calculation

errors
37.09±25.37

Medication
calculation errors

28.02±15.29
Administration without a

physician’s order
25.27±4.55

Administration
without a
physician’s order

28.85 ± 13.90

Administration after a
physician’s order to

discontinue the
medication

29.12 ± 14.07

Administration
after a
physician’s order
to discontinue
the medication

25.55 ± 6.43
Medication administration

to a newborn with a
known allergy

28.02 ± 26.57

Medication
administration to
a newborn with a
known allergy

37.91 ± 24.54 Wrong solvent – –
43.13 ± 26.37 Wrong infusion rate – –
43.41 ± 29.06 Drug incompatibility – –

The results showed no significant relationship
between demographic characteristics of study
participants and the number and type of medication
errors. However, there was a significant correlation
between types of shift work (fixed and rotating) and
the wrong medication error (non-injectable) (P-value =
0.009). That is, this error occurred more in the rotating
shift schedule.

The mean number of medication errors by
nurses during the past six months was less than once
(0.84). Furthermore, most nurses (59.68%) reported
that most of the medication errors occurred in the
morning, evening and morning-evening shifts,
respectively, as the administration without a
physician’s order (P-value = 0.03) for injectable
medications, and wrong dose (P-value = 0.05) for
non-injectable medications had a significant
relationship with these working shifts.

The results revealed a relatively high level of
work dynamics (28.94 ± 6.24) and the care complexity
(43.75 ± 5.004) in the study units.

A positive correlation exised in the
relationship between work dynamics and medication
calculation errors (r = 0.23, P = 0.02) wrong solvent (r
= 0.21, P = 0.04) and drug incompatibility (r = 0.25, P
= 0.01). Also, a positive correlation showed in the
relationship between care complexity and the
medication calculation errors (r = 0.22, P = 0.03) and
wrong medication (r = 0.31, P = 0.00).

Discussion

Today, patients’ safety is one of the most
important goals of health systems and based on that
goal, reducing the incidence of adverse events and
medical errors has received a lot of attention as it is
the most important one.

According to the results of the study,
medication calculation errors, wrong dose, wrong
medication and wrong time were the most common
types of non-injectable medication errors by nurses,
respectively. In line with these results, Ramezani et al.
also showed that the most common types of non-
injectable medication errors in the neonatal unit and
NICU were medication calculation errors and wrong
dose, respectively [24].

In the present study, drug incompatibility,
wrong infusion rate, medication calculation errors,
wrong dose, and wrong solvent were the most
common types of injectable medication errors by
nurses, respectively. Consistent with the results of the
present study, several studies reported wrong dose,
wrong infusion rate and wrong solvent as the most
common injectable medication errors [25], [26], [27].

In the present study revealed that the wrong

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medication error (non-injectable (occurred more in the
rotating shift schedule. Also, the results of the study
showed that the rate of the administration without a
physician’s order for injectable medications and wrong
dose for non-injectable medications significantly
increased in the morning, evening and morning-
evening working shifts, respectively. In line with these
results, Bagheri Nesami et al., reported that the
highest non-injectable medication errors (34.5%)
occurred at evening shift, (33.1%) at morning shift
(32.4%) and night shift [16]. In a study by Mohammadi
et al., in Kermanshah teaching centres, most
medication errors occurred at morning shift [28].
Unlike the results of the present study, Yousefi et al.,
showed that the mean number of medication errors
was higher at night shift than that of the morning shift,
and there was no difference between the morning shift
and the rotating shift [29]. Seki et al. did not report
significant differences in the occurrence of medication
errors between the three working shifts [30]. It
appears that the reason for these inconsistent results
can be due to different policies in different hospitals
about the ratio of nurses to patients, the duration of
each shift, the number of personnel in each unit, and
how the forces are assigned to each shift concerning
background and work experience.

The results of the present study showed that
an increase of work dynamics in the study units is
accompanied by an increase in the number of
medication calculation errors, wrong solvent, and drug
incompatibility. Contrary to these results, Chang &
Mark showed that in an appropriate work environment
with a high dynamic, a low degree of distraction and
confusion, the probability of medication errors is
relatively lower [31]. Therefore, the occurrence of
these medication errors in an environment that is
highly dynamic and desirable can be due to other
reasons, such as lack of pharmacological knowledge,
inappropriate communication among the members of
the treatment team and low work experience.
Developed medication errors model in recent studies
show that error-producing conditions include work
environment, team, and individual factors, in which,
care complexity and work dynamic are the work
environment factors, the physician-nurse relationship
is the team factor, and age and nursing work
experience are the personal factors [32]. Also, this
study released the greater care complexity in the
study units resulted in a greater number of medication
calculation errors and wrong medication. In line with
these findings, the results of Chang and Mark study
indicated that care complexity was positively
associated with medication errors [31]. Jolaee et al.
also reported a statistically significant relationship
between the occurrence of medication errors and the
working conditions of nurses such that the mean
number of medication errors can be reduced by
changing the working conditions from unfavourable to
favourable conditions [33]. Other studies also reported
inadequate staff in the unit, working load and fatigue
as the main reasons for medication errors [24], [29],

[34]. Inappropriate working conditions such as high
workload, disorder, lack of staff, distraction,
inappropriate patient-nurse ratio, and delayed
execution of patient’s medication orders can lead to
increased medication errors [30], [35]. Complicated
conditions make nurses spend more time taking care
of the patient, and this, even with skilled staff, can
lead to defects in the care process [36].

Limitations: The self-reporting nature of the
questionnaire was a limitation. In this regard,
researchers tried to gather real data by creating a
friendly atmosphere and mutual trust, and by
describing the objectives of the study. Also, the cross-
sectional nature of the study cannot determine the
causal relationships between the variables, so the
interpretation of the findings of the study should be
made with caution.

In conclusion, regarding the irrefutable impact
of working conditions on the occurrence of errors, it
appears that the study and complete recognition of
nurses’ working conditions and their adjustment would
provide a basis for reducing medication errors.
Nursing managers and health care providers should
identify the causes of medication errors and
implement strategies to reduce them. Medication
errors occur more often in the children and infant units
as the patients in these wards are more vulnerable
and need more care. Therefore, paying attention to
medication errors and the process of medication
administration is highly important. It is suggested that
studies be conducted on the occurrence of nursing
medication errors in other units and their related
factors. Therefore, an efficient error reporting and
recording system may reduce medication errors by
minimising reporting barriers.

Acknowledgement

The present study was approved by the
Research Council of Golestan University of Medical
Sciences with the ethics code of
IR.GOUMS.REC.1395.207. The researchers sincerely
thank the support of the Deputy of Research and
Technology of Golestan University of Medical
Sciences and the participation of the personnel and
authorities of Taleghani Pediatric Hospital of Gorgan.

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OR I G I N A L R E S E A R C H

Survey on Polypharmacy and Drug-Drug

Interactions Among Elderly People with

Cardiovascular Diseases at Yekatit 12 Hospital,

Addis Ababa, Ethiopia
This article was published in the following Dove Press journal:

Integrated Pharmacy Research and Practice

Yelbeneh Abayneh Assefa1

Ansha Kedir1

Wubayehu Kahaliw 2

1Department of Pharmacology and

Clinical Pharmacy, School of Pharmacy,

College of Health Sciences, Addis Ababa

University, Addis Ababa, Ethiopia;
2Department of Pharmacology, School of

Pharmacy, College of Medicine and

Health Sciences, University of Gondar,

Gondar, Ethiopia

Background: Elderly people are most commonly associated with cardiac disease.

Cardiovascular diseases are interlinked with co-morbidities which require multiple drug therapy

in addition to cardiovascular drugs. This results to polypharmacy which carries a high risk of

potential drug-drug interactions. Elderly patients are at a particular risk of drug related problems

because of increased level of polypharmacy and the physiological changes which accompany

aging. This study was aimed to assess polypharmacy and potential drug-drug interactions (DDIs)

among elderly people with cardiovascular diseases at Yekatit 12 hospital.

Methodology: A retrospective cross-sectional study using patients chart review was con-

ducted on all elderly people with cardiovascular diseases at Yekatit 12 hospital in the period

between March 2018 and March 2019. The types, seriousness and level of potential DDIs

were checked using Medscape online drug interaction checker.

Results: The mean number of drugs per prescription was 4.25 ± 1.754 and the prevalence of

polypharmacy (concurrent use of 5 and more drugs) was 42.7%. Polypharmacy and potential

DDIs were significantly associated with polymorbidity (P = 0.000), being hospitalized (P =

0.047) and congestive heart failure (P = 0.016). A total of 850-potential DDIs were

identified, the mean number of potential DDIs was 3.37 per prescription. The potential

DDIs were mainly significant (73.29%) in nature and pharmacodynamics (73.06%) in

mechanism. The prevalence of total and serious potential DDIs were 84.3% and 17.3%,

respectively. Most commonly interacting drug combination was aspirin + enalapril (30.2%).

Conclusion: A higher incidence of polypharmacy and increased risk of potential DDIs in

elderly people with cardiovascular disease are major therapeutic issues at Yekatit 12

hospital.

Keywords: polypharmacy, drug-drug interaction, cardiovascular diseases, elderly

Background
In many countries of the world, elderly people are significant in number and 60% of

them are found in developing countries.1 Elderly people in Ethiopia account 9.5%

from the total population.2 One-cardiovascular disease can occur as co-morbidity

with another one. Non-cardiovascular diseases are also highly associated with

cardiovascular diseases which impart complications to the heart. These complica-

tions cause several dysfunctions resulting in the use of many drugs

(polypharmacy).3

Correspondence: Wubayehu Kahaliw
Department of Pharmacology, College of
Medicine and Health Sciences, University
of Gondar, P.O, Box 196, Gondar, Ethiopia
Tel +251910532412
Email [email protected]

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open access to scientific and medical research

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Polypharmacy is defined as the concurrent use of

five or more drugs.4–8 It is associated with suboptimal

prescribing, increase in risk of falls and has a significant

effect on increasing health expenditures. Therefore, it is

a matter of interest for prescribers since it may be

regarded as irrational prescribing and it is a significant

problem among older adults.9,10 The practice of poly-

pharmacy leads to drug interactions and this in turn

causes adverse drug reactions and deterioration of func-

tional status.11–14

Drug-drug interaction (DDI) is defined as the change

in the drugs effect when a second drug is taken concur-

rently. As a result of drug-drug interaction synergistic or

additive, antagonistic or subtractive and idiosyncratic

effects may occur.15 Drug-drug interactions can be clas-

sified as pharmacokinetic, pharmacodynamics and phar-

maceutical interactions. Pharmacokinetic interactions are

the result of altered drug delivery to the site of action and

can occur at the level of absorption, distribution, meta-

bolism or clearance of the affected agent whereas

Pharmacodynamic interactions are the result of altered

drug effect at the site of action. Pharmaceutical interac-

tion is the interaction of incompatible drugs which occur

outside of the body during mixing.16

Studies indicated that there is an increased level of

multiple medications and hence drug-drug interaction

among the elderly part of the population.3 The drug-drug

interaction rate is higher in cardiovascular diseases com-

pared to other disease. The possible reason behind higher

DDI rate in cardiovascular disease may include elder age,

polypharmacy and pharmacokinetic or pharmacodynamics

nature of drugs used in cardiology.17 People in old age are

highly vulnerable to drug adverse effects because of multi-

ple drugs and aging.19,20 Physiological alterations asso-

ciated with aging make the elderly susceptible to

drug-interactions. The physiological alterations which

accompany aging are renal insufficiency and liver meta-

bolism abnormality, gut function alterations and poor

nutritional status.11

In addition, elderly patients suffering from chronic

diseases and taking sedatives/hypnotics without indication

and those with hypertension or atrial fibrillation are at high

risk of exposure to multiple drugs and potential drug-drug

interaction.3 In elderly patients, drug-drug interactions

play a significant role in the deterioration of the general

health condition, leading to affliction, poor quality of life,

prolonged hospital stays, a greater need for ambulatory

services and increased health-care costs.13

Although polypharmacy and drug interactions

reported to be common, there is sparse data on the

prevalence of polypharmacy and drug-drug interactions

in Yekatit12 hospital, Addis Ababa, Ethiopia. Hence this

study was aimed to evaluate prevalence of polyphar-

macy and types and severity of possible drug-drug inter-

actions in ambulatory and hospitalized elderly

cardiovascular patients.

Methods
Description of Study Setting
Yekatit 12 hospital is a referral hospital owned by Addis

Ababa Health Council. The hospital is a teaching hospital

associated with Addis Ababa University Black Lion

Hospital. It is one of the public hospitals in Ethiopia.

The hospital provides services for a population of approxi-

mately 4 million. It consists of nine departments and six

units and has 265 beds. Yekatit 12 hospital has excellent

laboratory facilities that perform most categories of rou-

tine diagnostics.

Study Design, Sample Size and Data

Collection
A retrospective cross-sectional study was carried out

from March 2018 to March 2019 in Yekatit 12

Hospital. All elderly (age 50 years and above) patients’

charts of cardiovascular disease and with adequate doc-

umentation were included in the study. All cardiovascu-

lar patients’ charts age 49 years and below as well as

charts recording non-cardiovascular disease were

excluded from the study. Data were collected from 255

patients’ charts using structured data collection format

(Patient data abstraction format). The format was pre-

pared with different sections important to fill basic

demographic information like age and sex, drugs admi-

nistered, and co-morbidities or diseases identified. The

interactions between the drugs were assessed using

Medscape online drug interaction checker.18

Ethical Considerations
Approval of the research ethics was obtained from School

of Pharmacy, Addis Ababa University Ethics Review com-

mittee. Prior information was sent to the administrative

authorities of the Yekatit 12 hospital about the nature and

purpose of the study through a letter from school of

Pharmacy, Department of pharmacology and clinical phar-

macy, Addis Ababa University. The data were accessed

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only by the researchers and data collector and every pre-

caution was considered for keeping confidentiality of

patient data.

Patient written informed consent form to review

their medical records was waived due to the following

justifications: personal identifiers of prescriptions were

not used in the data collection process and the institu-

tional review board of school of pharmacy, Addis

Ababa University believed that this study will not

adversely affect the rights and welfare of the subjects.

In addition, the research involves no more than mini-

mal risk.

Statistical Analysis
Data were entered using Epi Info version 3.5.1 and ana-

lyzed using the Statistical Package for Social Sciences

(SPSS) version 20.0 for Windows. Results were expressed

as means ± standard deviation (SD), frequencies, and

percentages. Chi-square test was used to compare the

means of different groups among the study population

while the Mann–Whitney U-test was used to compare

continuous variables in two groups. Values of P < 0.05

were considered as significant.

Results
Socio-Demographic and Related Profiles
In the current study, medical charts of 255 patients with

cardiovascular disease were collected and analyzed. The

mean age was 63.54 ± 9.248 years. From the medical

charts reviewed, majority of patients were above 60

years of age. More than half (57.3%) of prescriptions

were orders for males and almost 80% of the patients

were ambulatory (Table 1).

Diagnosis, Commonly Prescribed Drugs

and Drug-Drug Interactions
The most common cardiovascular diseases identified were

hypertension (46.6%), congestive heart failure (14.5%) and

stroke (13.3%). Most frequent co-morbid conditions were

endocrine disorders (24.7%), followed by respiratory pro-

blems (10.6%) and chronic kidney diseases (9%). The data

revealed that at least one co-morbid condition occurred in a

majority of patients (68.8%) (Table 2). As indicated in

Figure 1, the prevalence of polymorbidity was 71.8% with

1–3 co-morbidity (68.6%) and ≥4 co-morbidities (3.2%).

Table 1 Socio-Demographic and Related Profiles

Variable No. of Patients (%)

Gender Male 146 (57.3)

Female 109 (42.7)

Age 50–59 years 87 (34.1)

60–69 years 87 (34.1)

70 years and above 81 (31.8)

Mean age±SD 63.54 ± 9.248

Patient category Ambulatory (Outpatient) 201 (78.8)

Inpatient (Hospitalized) 54 (21.2)

Table 2 Diagnosis, Number of Prescribed Drugs and Potential

Drug-Drug Interactions

Variable No. of

Patients (%)

Number of drugs

prescribed

1 14 (5.5)

2–4 132 (51.8)

5 and more 109 (42.7)

Mean±SD 4.25 ± 1.754

Number of pDDIs No pDDI 40 (15.7)

1–3 120 (47.1)

4–6 49 (19.2)

7 and more 46 (18)

Mean ± SD 3.33 ± 3.05

Main cardiovascular diseases

diagnosed

Hypertension 124 (48.6)

Congestive Heart

Failure

37 (14.5)

Stroke 34 (13.3)

Ischemic Heart

Disease

22 (8.6)

Deep vein

thrombosis

16 (6.3)

Valvular heart

disease

9 (3.5)

Acute Coronary

Syndrome

6 (2.4)

Arrhythmia 6 (2.4)

Dyslipidemia 1 (0.4)

Other co-morbidities Endocrine

Abnormalities

63 (24.7%)

Respiratory

problems

27 (10.6 %)

CNS related 6 (2.4 %)

Chronic disease 11 (4.3%)

CKD, UTI and

Anemia

23 (9%)

Miscellaneous 8 (3.1%)

Abbreviations: pDDIs, potential drug-drug interactions; CKD, chronic kidney

disease; UTI, urinary tract infection; CNS, central nervous system.

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The occurrence of polymorbidity was more frequent in

males (76%) than in females (70.4%).

Most frequently prescribed drugs were aspirin 127

(49.8%), enalapril 122 (47.8%) furosemide 91 (35.7%),

nifedipine 90 (35.3%) and spironolactone 82 (32.2%) fol-

lowed by atenolol 79 (31%) (Figure 2). As shown in

Table 2, the average drugs prescribed per prescription was

4.25 ± 1.754 which indicated the practice of polypharmacy

in the hospital. Mean number of potential drug-drug

interactions was 3.33 ± 3.05 and almost half (47.1%) of

the study subjects encountered 1–3 interactions.

Prevalence of Polypharmacy
From 255-medical chart records assessed, 5 or more

drugs were prescribed in each of the 109 (42.7%) patient

charts which indicated the occurrence of polypharmacy in

Yekatit 12 hospital. Among 109 patients who took ≥5
drugs concurrently, 65 (44.5%) were males and 44

(40.4%) were females. The prevalence of polypharmacy

was high at advanced age; however, the association

between polypharmacy and age was statistically insignif-

icant (chi-square; χ2 = 1.291, p = 0.524, phi = 0.071)

(Table 3). According to chi-square test for independence,

statistically significant association between sex and poly-

pharmacy was not observed (χ2 = 0.287, p = 0.592, phi =

−0.042) (Figure 3).

The assessment of medical records of hospitalized

patients revealed that 55.6% of the patients received ≥5
drugs concurrently whereas 39.3% of ambulatory patients

received equal number of medications. Polypharmacy was

significantly associated with hospitalized patients (chi-

square test; χ2 = 3.954, p = 0.047, phi = 0.134) (Figure 3).

The number of medications prescribed per prescription

(≥5 drugs per prescription) was higher with polymorbidity

(≥4 co-morbidities). According to Mann–Whitney U-test the

number of cases of polypharmacy was significantly higher in

the presence of polymorbidity (p < 0.001). Forty-five

(36.3%) medical charts of hypertensive patients were

No co-
morb

idity

1-3
Co-m

orb
idity

4 com
orb

idity
0

20

40

60

80

24%
33.9%

28.2%

71.9%

64.3%

68.6%

4.1%
1.8%

3.2%

Level of co-morbidity

Pe
rc

en
t

Figure 1 Prevalence of Co-morbidity in gender. = Male, = Female,

= Total.

0 5 10 15 20 25 30 35 40 45 50 55 60
Diclofenac

Amlodipine

Clarithromycin

Metformin

Prednisolone

Vitamin B1

Simvastatin

Lovastatin

Ceftriaxone

Warfarin

Omeprazole

NPH insulin

Glibenclamide

Hydrochlorothiazide

Digoxin

Atenolol

Spironolactone

Nifedipine

Furosemide

Enalapril

Aspirin 49.8%

47.8%

35.7%

35.3%

32.2%

31%

18%

15.3%

11%

10.6

8.2%

7.8%

7.1%

6.3%

5.9%

5.9%

5.5%

5.1%
4.3%

3.5%

3.5%

Frequency distrribution of a single drug prescribed in medical charts of patients

D
ru

g
s

Figure 2 Specific drugs prescribed for the management of cardiovascular diseases.

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identified with polypharmacy. However, hypertension was

not significantly associated with polypharmacy (χ2 = 3.612,

p=0.057, phi= −0.127). On the other hand, 23 (62.2%) con-

gestive heart failure patients’ medical charts were identified

with polypharmacy and a chi-square test for independence

showed a significant association between congestive heart

failure and polypharmacy (χ2 = 5.772, p = 0.016, phi = 0.162)

(Figure 3).

Nature and Mechanism of Drug-Drug

Interactions
The nature and mechanisms of DDIs are summarized in

Tables 3 and 4. Among 850-potential DDIs, pharmacody-

namic interactions were the most common constituting

73.06%, followed by pharmacokinetic (21.29%) and

mixed (5.65%) interactions. Significant DDIs were most

common constituting 73.29%, followed by minor

(19.41%) and serious (7.3%) interactions.

Demographic variables and nature of potential DDIs

are illustrated in Table 4. In 125 (85.6%) male and 90

(82.6%) female patients’ prescriptions potential DDIs

were present. The number of potential DDIs in 60–69

years old age group, ambulatory and hospitalized patients’

medical charts were 77 (88.5%), 171 (85.1%) and 44

(81.5%), respectively. However, the association between

DDIs and demographic variables (gender, age and ambu-

latory or hospitalized patients) was not statistically signif-

icant using chi-square test. On the other hand, potential

DDIs in patients with congestive heart failure and four-co-

morbid conditions and polypharmacy were 100% and

98.2%, respectively. The association between DDIs and

congestive heart failure, four-co-morbid conditions

and polypharmacy were statistically extremely significant

(P = 0.001) using Mann–Whitney U-test (Table 4).

Common Drug Groups
The most frequent potential drug-drug interactions with

their respective importance and possible risks are

Table 3 Nature and Mechanisms of Potential Drug-Drug

Interactions

Nature of

Interactions

Frequency (%

per Total

Patient)

Frequency (%

per Total

pDDIs)

Mechanism of interaction

Pharmacodynamic

interaction

193 (75.7) 621 (73.06)

Pharmacokinetic

interaction

103 (40.6) 181 (21.29)

Unknown or mixed

mechanism of

interaction

45 (17.6) 48 (5.65)

Clinical types of potential

DDIs

Serious drug

interaction

44 (17.3) 62 (7.3)

Significant drug

interaction

195 (76.5) 623 (73.29)

Minor drug interaction 115 (45.1) 165 (19.41)

Abbreviations: DDIs, drug-drug interactions; pDDIs, potential drug-drug

interactions.

Age
50

-59
ye

ars

Age
60

-69
ye

ars

Age
>70

ye
ars Male

Fem
ale

Ambulat
ory

pati
en

ts

Hosp
ita

liz
ed

pati
en

ts

No c
o-m

orb
idity

1-3
co

-m
orb

idity

4 c
o-m

orb
idity

Hyp
ert

en
sio

n

Con
ges

tiv
e h

ear
t fa

ilu
re

0

50

100

150

62.1%

37.9%

54%

46%

55.6%

44.4%

55.5%

44.5%

59.6%

40.4%

60.7%

39.3%

44.4%
55.6%

1

90.3%

9.7%

46.3%
53.7%

100%
3

63.7%

36.3% 37.8%

32.2%
1

Different variables

Pe
rc

en
t

Figure 3 Polypharmacy status among different variables. = No polypharmacy, = polypharmacy. 1p = 0.05, 3p = 0.001.

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presented in Table 5. The most common drug groups

identified were angiotensin-converting enzyme (ACE)

inhibitors (enalapril), NSAIDs (low dose aspirin), diuretics

(furosemide, hydrochlorothiazide and Spironolactone), ß-

blockers (Atenolol), digoxin and calcium channel blocker

(Nifedipine), lipid lowering agents (Simvastatin and

Lovastatin), proton pump inhibitors (Omeprazole) and

prednisolone.

Themost commonly identified combination of drugs with

potential dug-drug interactions were Aspirin + Enalapril

(30.2%), Enalapril + furosemide (21.6%), Aspirin +

Furosemide (19.6%), Enalapril + Spironolactone (18.4%),

Aspirin + Atenolol (18%), Aspirin + Spironolactone

(16.1%), Digoxin + Spironolactone (16.1%) and Digoxin +

Furosemide (15.7%).

Discussion
In this study, medical charts of elderly (aged 50 year and

above) people with cardiovascular diseases were examined

and analyzed for the prevalence of polypharmacy and

potential drug-drug interactions. In addition, the nature

and mechanisms of drug-drug interactions, most com-

monly involved combination of drugs and the most fre-

quently occurred potential drug-drug interactions were

assessed. The majority of patients with cardiovascular

diseases were males (57.3%), which is in line with the

fact that men are more prone to heart disease compared to

women of a similar age.3 The most common diagnosis

identified was hypertension (48.6%) followed by conges-

tive heart failure and stroke. Similarly, hypertension

(57.8%) was the most frequent diagnosis found on the

study done in Italy on general elderly patients.21 The

prevalence (71.8%) of co-morbidity in our study is in

line with the prevalence of co-morbidity (35–80%) in

other studies on elderly populations.5 The most commonly

identified co-morbidities were cardiovascular disease,

endocrine abnormalities (diabetes mellitus II) and respira-

tory problems (pneumonia and chronic obstructive pul-

monary disease), which is in line with the previous study

in Bosnia and Herzegovina.22 In this study, the mean

number of co-morbidity in hospitalized patients was 4.8.

The finding of this study is lower than hospitalized

patients in Japan which depicted 7.7 mean number of co-

morbidity.8

The mean number of drugs per prescription was 4.25

with standard deviation of 1.754 which is comparable to

the data reported from previous studies in southern Brazil

(4.4 drugs per prescription) and Nigeria (3.8 drugs per

prescription).23 The mean number of prescribed drugs in

this study is lower than the study in South Africa (7.7) and

Bangladesh (7.34).1,24 The maximum number of drugs

recorded per patient were 10 which is comparable to the

finding of similar studies done in Nigeria and southern

Brazil which show a maximum of 8 and 11 drugs pre-

scribed per patient, respectively.1,23

In the current study, prevalence of polypharmacy

(42.7%) is comparable with the polypharmacy prevalence

reported from previous studies in Indian teaching hospitals

(45%), Japan (49%) and southern Brazil (43.1%).7,8,23 The

data revealed that prevalence of polypharmacy was not

significantly associated with age (P = 0.524) and gender

(P = 0.592). However, it was significantly associated with

inpatients (P = 0.047) which indicated that hospitalized

patients are at a higher risk of polypharmacy compared to

ambulatory patients.

Coming to DDIs, both ambulatory and hospitalized

patients are at higher risk of potential drug-drug interac-

tions. Majority of potential DDIs were significant

(73.29%) in nature and pharmacodynamic (73.06%) in

Table 4 Different Variables and Potential Drug-Drug Interactions

Variables Patients Without

DDIs on Their

Prescription

Patients with

DDIs on Their

Prescription

Age

50–59 years 17 (19.5%) 70 (80.5%)

60–69 years 10 (11.5%) 77 (88.5%)

≥70 years 13 (16%) 68 (84%)

Gender

Male 21 (14.4%) 125 (85.6%)

Female 19 (17.4%) 90 (82.6%)

Patient category

Ambulatory 30 (14.9%) 171 (85.1%)

Inpatient 10 (18.5%) 44 (81.5%)

Number of Drugs

Prescribed

<5 38 (26%) 108 (74%)

≥5 2 (1.8%) 107 (98.2%)

Co-Morbid

Condition

No co-morbidity 22 (30.6%) 50 (69.4%)

1–3 co-morbidity 18 (10.3%) 157 (89.7%)

4 co-morbidity 0 (0%) 8 (100%)

Hypertension 20 (16.1%) 104 (83.9%)

Congestive heart

failure

0 (0 %) 37 (100%)

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Table 5 Potential Drug-Drug Interactions Identified from Medical Records in Yekatit 12 Hospital

Drug Combinations pDDIs

(%)

Clinical Types of

pDDIs

Mechanism of

pDDIs

Potential Risk

Aspirin + Enalapril 77 (30.2) Significant PD, antagonism Aspirin may attenuate the vasodilator and hypotensive

effects of Enalapril.

Enalapril + Furosemide 55 (21.6) Significant PD, synergism Risk of acute hypotension, renal insufficiency.

Aspirin+ Furosemide 50 (19.6) Minor PD, antagonism Blunting of the diuretic effect of furosemide

Enalapril + Spironolactone 47 (18.4) Significant PD, synergism Risk of hyperkalemia

Aspirin + Atenolol 46 (18) Significant PD, antagonism Blunting of the antihypertensive effect of Atenolol and

risk of hyperkalemia

Aspirin + Spironolactone 41 (16.1) Significant PD Risk of hyperkalemia

Digoxin + Spironolactone 41 (16.1) Significant PK and PD Digoxin toxicity and increase serum potassium

Digoxin + Furosemide 40 (15.7) Significant PD, synergism Digoxin toxicity

Atenolol + Nifedipine 27 (10.6) Significant PD Both increase anti-hypertensive channel blocking

Atenolol + Spironolactone 27 (10.6) Significant PD Risk of hyperkalemia

Aspirin + Digoxin 25 (9.8) Significant PD Risk of hyperkalemia

Aspirin + Glibenclamide 17 (6.7) Minor PK Risk of hypoglycemia

Aspirin + NPH insulin 16 (6.3) Minor PD, synergism Risk of hypoglycemia

Enalapril + Glibenclamide 16 (6.3) Significant PD, synergism Risk of hypoglycemia

Aspirin + Hydrochlorothiazide 13 (5.1) Minor PK Risk of bleeding

Enalapril + NPH insulin 11 (4.3) Significant PD, synergism Risk of hypoglycemia

Atenolol + Digoxin 9 (3.5) Significant PD, synergism Enhanced bradycardia and increase in serum potassium

Spironolactone + Prednisolone 9 (3.5) Significant PK Increase in the level or effect of Prednisolone.

Furosemide + Prednisolone 8 (3.1) Minor PD, synergism Risk of hypokalemia

Furosemide + Ceftriaxone 8 (3.1) Minor PD, synergism Increased risk of nephrotoxicity

Aspirin + Ceftriaxone 8 (3.1) Minor PK Risk of bleeding

Aspirin + Prednisolone 6 (2.4) Significant PK and PD Increased risk of GI ulceration

Nifedipine + Digoxin 6 (2.4) Significant PK Digoxin toxicity

Enalapril + Carbamazepine 5 (2) Significant PK Increases levels of carbamazepine

Spironolactone + Lovastatin 5 (2) Significant PK Increases level of Lovastatin

Nifedipine + Simvastatin 8 (3.1) Serious PK Musculoskeletal toxicity

Digoxin + Omeprazole 7 (2.7) Serious PK Digoxin toxicity

Digoxin + Clarithromycin 4 (1.6) Serious PK Digoxin toxicity

Nifedipine + Lovastatin 4 (1.6) Serious PK Musculoskeletal toxicity

Rifampin + Warfarin 3 (1.2) Serious PK Decreased anticoagulation effect of warfarin

Heparin + Warfarin 3 (1.2) Serious PD Risk of bleeding

Abbreviations: PD, pharmacodynamic; PK, pharmacokinetic; pDDIs, potential drug-drug interactions.

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mechanism. According to the present study, prevalence of

potential DDIs were not associated with age (P = 0.343)

and gender (P = 0.626) which is in agreement with other

studies at different settings.23 This study showed that a

significant association was observed between congestive

heart failure and potential DDIs (P = 0.01). This indicated

that patients diagnosed and treated for congestive heart

failure are at higher risk of suffering from the adverse

effects of DDIs. The prevalence of potential DDIs were

also significantly associated with polypharmacy (P =

0.000) and four co-morbidities (P = 0.000) which showed

multiple medications and polymorbidity (≥4 co-morbid-

ities) are significant predictors of potential DDIs.23

With respect to specific drugs prescribed, aspirin, ena-

lapril, furosemide, nifedipine and spironolactone were the

most frequent which is in line with previous study in

Italy.23 The most commonly identified potential DDIs

were mainly due to aspirin, enalapril, furosemide, spiro-

nolactone, atenolol, digoxin and nifedipine in combination

with each another or with other drugs.

The majorities of identified interactions were of sig-

nificant in nature, pharmacodynamic in mechanism and

mainly related to drugs acting on cardiovascular system

which is in agreement with findings elsewhere.23 In fact,

there are DDI reports in the literature, but there is little

agreement among them with respect to the type, nature and

clinical importance of interactions. From potential interac-

tion with minor intensity, aspirin and furosemide combina-

tion was the most frequently identified one in which the

diuretic effect of furosemide could be blunted by the

pharmacodynamic antagonism caused by aspirin. An inter-

action between aspirin with antidiabetic agents

(Glibenclamide and NPH insulin) was also common and

lead to possible risk of hypoglycemia. In addition, minor

interaction was identified between aspirin and hydrochlor-

othiazide which is pharmacokinetic in mechanism and

might lead to bleeding.

The data revealed that significant DDIs were pharma-

codynamic in mechanism. Among medication combina-

tions, Aspirin + enalapril, enalapril + furosemide, aspirin

+ atenolol, aspirin + spironolactone and digoxin + furose-

mide were the most commonly encountered combination

with significant interactions. Such types of interaction

require close monitoring of the clinical outcome or possi-

ble risks. Aspirin might attenuate vasodilator and hypoten-

sive effects of enalapril while an interaction between

enalapril and furosemide might have a combined risk of

acute hypotension and renal insufficiency.

Even though diuretics are widely used to optimize

therapeutic effects and diminish adverse events, loop and

thiazide diuretics largely contribute to moderate intensity

interactions. The interaction between loop and thiazide

diuretics is pharmacodynamic interaction and leads to

loss of drug efficacy.

Nifedipine + simvastatin, digoxin + omeprazole and

digoxin + clarithromycin combinations were the most

common serious intensity pharmacokinetic interactions.

A combination of nifedipine and simvastatin affects the

metabolism and increases the level of simvastatin which

lead to musculoskeletal toxicity while those interactions

between digoxin and omeprazole or clarithromycin

increase level of digoxin and lead to digoxin toxicity.

Another serious pharmacodynamic interaction identified

was between heparin and warfarin which ultimately lead

to increased anticoagulation (higher incidence of bleed-

ing). Co-administration of drugs which are potentially

interacting might increase the number of adverse events

which can be confused with the severity of co-morbidities.

The consequences of such interactions include a longer

duration of treatment period with administration of more

drugs to patients, resulting in a higher probability of drug-

drug interactions.

Conclusion
The prevalence of polypharmacy was found associated

with increased number of co-morbidity and inpatient pre-

scriptions. The prevalence of total and serious potential

drug-drug interactions were 84.3% and 17.3%, respec-

tively. The majority of interactions were pharmacody-

namic in mechanism (73.06%) and significant in nature

(73.29%). The prevalence of potential drug-drug interac-

tions were significantly associated with polypharmacy and

polymorbidity (≥4 co-morbidities). Based on the finding in

the current study, drugs acting on cardiovascular system

including low dose aspirin, diuretics, angiotensin-convert-

ing enzyme inhibitors, calcium channel blockers, beta-

blockers and digoxin were most commonly and frequently

implicated in potential drug-drug interactions. A higher

incidence of polypharmacy and increased risk of potential

drug-drug interactions in elderly people with cardiovascu-

lar disease are major therapeutic issues at Yekatit 12

hospital.

Disclosure
The authors have no conflict of interest to disclose.

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Medication incompatibility in intravenous lines in a Paediatric Inten-sive

Care Unit (PICU) of Indonesian hospital

Article  in  Critical Care and Shock · August 2018

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Crit Care Shock (2018) 21:114-123

Medication incompatibility in intravenous lines in a Paediatric Inten-
sive Care Unit (PICU) of Indonesian hospital
Suci Hanifah, Patrick Ball, Ross Kennedy

Abstract
Objectives: Currently, little is documented con-
cerning the patterns of multiple concurrent med-
ication use utilising single intravenous line. The
in-line compatibility issues in Paediatric Inten-
sive Care Units (PICUs) are not as well docu-
mented as in adult patients either. This study
closely examined the combination of medications
used concurrently in a PICU, recorded how med-
ications were used, and then investigated the in-
line potential compatibility.
Methods: This study was a mixed model designed
first to identify retrospectively the patterns of
multiple medication use at any single time of ad-
ministration (STA). Secondly, a questionnaire
was distributed to practitioners to elucidate their
perceptions about incompatibility.
Results: From a single lumen peripheral line in-
vitro simulation, it was observed that three infu-
sions typically met in sequential Y-sites and had
the potential to interact. The combinations iden-
tified were morphine+midazolam, midazo-
lam+fentanyl+morphine, morphine+fenta-
nyl+dobutamine, morphine+midazolam+keta-
.

mine, and midazolam+dobutamine+norepineph-
rine. Compatibility data covering simultaneous
administration of three-or-more intravenous
drugs was not found in 97.5% (n=120) of the
cases. Most practitioners (92.9%) recognized in-
compatibility. Many (46.4%) said they observed
>3-10 in-line incompatibilities in a month. Most
nurses (78.5%) reported using the manufacturer
as their reference source for compatibility data.
Flushing with clear fluid between doses was the
most used method to prevent incompatibility
(45.5%).
Conclusions: It was a common practice to con-
currently administer three or more medications:
analgesics, sedatives, inotropes, and others,
through the same port with major potential for
incompatibility issues. Most of the literature is
based on two drug comparisons with minimal in-
formation on using combinations of three or
more. Most practitioners’ understanding of the
implications of the terminology of “incompatibil-
ity not known or possible” for their patients ap-
peared lacking.

Key words: Intravenous, drug utilization, drug incompatibility, critical care, paediatrics.

114 Crit Care Shock 2018 Vol. 21 No. 3

Address for correspondence:
Suci Hanifah
Jalan Kaliurang Km 14.4 Sleman, Yogyakarta 55582, Indonesia
Tel: +6285643958700
Emails: [email protected], [email protected]

From Pharmacy Department, Faculty of Science, Universitas
Islam Indonesia (UII), Yogyakarta, Indonesia (Suci Hanifah),
School of Pharmacy, Faculty of Science and Engineering, Wol-
verhampton University, England, UK (Patrick Ball), and
School of Biomedical Science, Charles Sturt University, New
South Wales, Australia (Ross Kennedy).

Introduction
In critical care, the majority of medications (>70%)
are administered parenterally for faster action or due
to patient’s inability to swallow oral medications. It
is known that many patients will receive an average
of 10 different medications in multiple doses during
.

a single admission. (1) In paediatric practice, the re-
quirement for multiple parenteral medications with
limited venous access and fluid volume restriction
frequently leads to concurrent administration of
combinations of intravenous (IV) medications
through a single line. Based on pharmaceutical for-
mulation principles, this has the potential for physi-
cal and chemical reactions, which when occurring
in-line and directly entering the patient circulation,
may lead to morbidity or mortality. (2,3) Anecdotal
evidence suggests that insufficient attention is paid
to this, which seems to be multifactorial and may
include knowledge, time, workforce, and cost con-
straints. (4)
Literature reports on medication use have concen-
trated on a single agent and infusion fluids or per-
haps in combination with another, making it diffi-
cult to evaluate in the context of multiple medica-
tions being added at different access points into a
single infusion system. (5,6) Also, laboratory mod-
.

Crit Care Shock 2018 Vol. 21 No. 3 115

els where two medications have been mixed to-
gether at fixed concentrations in a test tube poorly
reflect the way in which medications may also in-
teract with residuals of another before or after, the
IV fluids, and the infusion system (tubing, connect-
ors, etc.), or for various periods of time at variable
concentration gradients resulted from flow effects.
Also, the role of pharmaceutical excipients in the
formulation makes it impossible to extrapolate in-
formation from one manufacturer’s formulation to
an alternative product from a different manufac-
turer. (7) A recent study has suggested that pharma-
cists, who are usually consulted when information
about incompatibility is not available, need to be
aware of medication compatibility issues and that
“no data available” should not be interpreted as safe
to minimize such errors in their hospitals. (8)
This preliminary study was used as the basis for
identifying the problem of incompatibility in paedi-
atric critical care setting in in-vitro real time simu-
lated IV lines by closely observing and recording
the practice and gathering information about ward
staff experiences and reactions to what has been ob-
served by pharmacists as incompatibility.

Methods
Study approach
The setting of this research was the PICU in a teach-
ing hospital in Java, Indonesia, which is considered
a centre of excellence within the province. It is a
leading centre from which other hospitals look for
guidance. After a comprehensive review of litera-
ture, a retrospective prescription chart review was
conducted to establish the most common combina-
tions of medications and the problems incurring
during their administration. This was followed by a
prospective observational study of medication ad-
ministration practice and administration of a simple
questionnaire on the perceptions of nursing and
medical staff in relation to the problem of drug in-
compatibility.
Ethics approval for this study was obtained from the
Charles Sturt University Human Research Ethics
Committee (CSU HREC) on 18 September 2013
(2013/173). In addition, approval was also granted
by Universitas Gadjah Mada Human Ethics Com-
mittee (GMU HEC) on 31 July 2013
(KE/FK/733/EC). Hospital staff participation was
voluntarily, and the return of completed question-
naire was considered as an implied consent to par-
ticipate.

Data collection
As an initial step, medical records for the period be-
tween 1 June 2012 and 30 September 2013 were re-
.

viewed to gain an adequate sample of medication
usage patterns in the PICU and any recorded issues
regarding incompatibility. Then, bedside observa-
tions were undertaken for one month to confirm pat-
terns of how medications were prescribed, prepared
and administered as well as where medications were
administered simultaneously. No staff information
or identifiers were collected, and only the process
sequence was recorded. Thirdly, a questionnaire
was administered to nurses and resident doctors in-
volved in drug preparation and administration. This
was used to understand their perspective on incom-
patibilities and to identify whether they perceived
them as serious problems. The collected infor-
mation was then analysed to establish an under-
standing of the level of incompatibility problem and
current prevention strategies in the PICU facility.
All data collected in this phase was anonymous and
no personal identifiers were used.

Operational definitions adopted for drug admin-
istration
“Single time of administration (STA)” refers to the
administration of more than one medication at a spe-
cific timing, such as 8.00 o’clock in the morning or
in the evening. The term “infusion-infusion” refers
to the simultaneous administration of two medica-
tions by infusion via a two-way connector. At any
STA, if an intermittent or single bolus IV medica-
tion is injected sequentially through a port into infu-
sion tubing, the term “infusion-injection” will be
used.

Data analysis
Data collected from the medical records was tran-
scribed into a Microsoft Excel™ spreadsheet. To
ensure that there was no missing data, the spread-
sheet was crosschecked several times in sequence
and randomly. The data regarding medication use
and questionnaire responses were qualitatively ana-
lysed.

Results
The retrospective medical record search yielded in-
formation on 231 patients. There were 19 patients
excluded due to missing measurable data fields in
their records, and 212 patient records were consid-
ered for further analysis, including the name of the
medication, route, dose, administration time, and
any reported incompatibility medication-related
problems.

Profile of multiple intravenous
Patients in this PICU were administered an average
of 1-6 drugs at one STA, mostly (89%) through a
.

116 Crit Care Shock 2018 Vol. 21 No. 3

peripheral venous cannula (PVC). Over one third of
the patients (32.5%) received three infused medica-
tions concurrently through one line with other med-
ications administered by a bolus injection merged
into the infusion line at a ‘Y’-site. Therefore, a med-
ication group was defined as the combination of
medications administered simultaneously through
one line (infusion-infusion) or consecutively at one
STA through one extension (infusion-injection).
From a review of the medical records, it was found
that there were more than 100 different groups of
infusion-infusion and infusion-injection amongst
the 212 sample patients. Figure 1 shows the fre-
quency of the top 20 groups of drugs by frequency
of occurrence among the study samples.
The top 20 medication groups included various an-
algesic, sedative, and inotropic drugs. The most fre-
quent groups were morphine+midazolam (15.6%
frequency), morphine+fentanyl+midazolam (9.4%
frequency), and morphine+fentanyl+dobutamine
(6.6% frequency).
In one STA, infusions met injections (intermittent
medications) in the following descending order of
frequency: paracetamol, cefotaxime, furosemide,
ranitidine, meropenem, ampicillin, phenobarbital,
phenytoin, metronidazole, chloramphenicol, acy-
clovir, fluconazole, gentamicin, and methylpredni-
solone.

Potential problem of incompatibility
Incompatibility is defined as the potential for a
chemical reaction, displacement of particles, precip-
itation, jell formation, or other interactions arising
from medications coming together in the tubing,
such as drug-solution or drug-drug including infu-
sion-infusion and infusion-injection or drug-equip-
ment. Using recent literature, a two-dimensional
compatibility chart could be developed (Figure 2),
which shows that 73.6% of medications had their
information available on the PICU hospital website
database; of these, 57.3% appeared compatible,
while 16.2% were incompatible in solution.
To identify the compatibility of co-infusions with
simultaneous administration in a ‘Y’-site, a chart
was developed which more closely resembled the
practice. Table 1 was developed to represent a pos-
sible compatibility chart (infusion-injection) based
on actual experience in practice. Unlike the two-di-
mensional chart, using recent literature, many
frames were missing (97.5%; n=120) from this
chart.

Problem of IV drug incompatibility faced by health
practitioners
During the one-month period of bedside observa-
.

tion of practitioners’ practice in administering par-
enteral infusion, it was found that practitioners did
not appear to pre-consider IV drug compatibility, in-
cluding definitions, prior to commencing admin-
istration. Some nurses asked for an explanation of
what incompatibility is and how it occurs. Other
nurses asked how to distinguish incompatibility
from thrombophlebitis and the differences between
incompatibility and drug interaction. There were
also questions about when flushing should be used
in relation to medication administration.
The questionnaire was administered to nurses
(n=22) and resident medical doctors (n=6) who
were in charge of the preparation and administration
of IV drugs in PICU for more than a month, and all
staff (n=28) returned the completed survey. There
was no consultation with or input from clinical phar-
macists in the ward on the preparation or admin-
istration of drugs. The answers from nursing staff
and resident medical doctors to the questionnaire
are shown in Table 2.
All the nurses reported that they had observed drug
incompatibilities during their employment at PICU.
Only four of the doctors reported observing incom-
patibilities. The doctors reported that they had ob-
served less than three incompatibilities in the month
prior to the survey, whereas about 59% of nurses re-
ported observing 3-10 incompatibilities in the same
period. In this context, incompatibility refers to a
visible colour change in the line or the appearance
of a ‘flash’ of powder, as medications come to-
gether, but not other possible incompatibility, which
does not cause physical characteristic changes.
Although the doctors reported observing less than
three occlusions in the previous month, about 45.5%
of nurses observed 3-10 occlusions and about
54.5% observed more than 10 occlusions. However,
all the doctors and nurses had reported that their per-
ceived occlusions were not due to drug incompati-
bilities. The staff had linked the occlusion to having
been caused by a technical problem or blood clot-
ting occlusion.
With respect to prevention of incompatibility, prac-
titioners (78.6%) usually referred to pharmaceutical
manufacturers although some (21.4%) reported that
they used the “Handbook on Injectable Drugs”
(Trissel, 2014) instead; however, on investigation,
the book was found to be located in the pharmacy
not readily accessible in the ward. Most (45.5%)
managed incompatibility by flushing with sodium
chloride 0.9%. However, most nurses (68%) and all
the medical doctors reported that they considered
drug incompatibility issues as beyond their respon-
sibilities.
A range of drugs was reported to be involved in the
.

Crit Care Shock 2018 Vol. 21 No. 3 117

incompatibilities observed (Figure 3). The most
frequent medications involved, reported by both
doctors and nurses, were phenytoin and phenobar-
bital. Interestingly, inotropic drugs were also
viewed as problematic by the doctors (66.7%) but
less so by the nurses (22.7%).

Discussion
The likelihood of incompatibility increases with the
increasing number of medications at any STA. Re-
ducing the number of drugs per STA may be possi-
ble by spacing the administration of injections, but
this may fit poorly into nursing routines and is com-
plicated for slow or continuous concurrent infu-
sions. This is more complicated in paediatrics pop-
ulation when only a small volume of fluids can be
infused and multiple access sites are not possible
due to the age of patients. This may increase cost
and workload of ward staff and lead to medication
errors. (9)
When a single lumen PVC is utilized, a rule to use
separate lumen for each drug may become impossi-
ble. Additionally, in one single PVC, several infu-
sions flow in each piece of tubing and meet with the
other infusions or injections at a 3-way stopcock or
other connector where incompatibility reactions can
occur. In contrast, incompatibility seems rarely to
be reported when two IV drugs are administered
concurrently in critical care. The potential for in-
compatibility between consecutive IV injections ap-
pears to be avoidable if practitioners are accustomed
to flushing with clear fluid before and after medica-
tion delivery provided that the solution and volume
used have been validated for the system in use; how-
ever, in small infants, the volume and electrolyte ad-
ministered with the flushes may be significant.
Though rare, it may still occur as a fixed route for
three common groups: amine/cardioactive drugs,
analgesic/sedative, and parenteral nutrition in sepa-
rated lumen that cannot be implemented because of
the non-availability of multi lumen catheters in this
unit. However, the frequency of this occurrence is
not known and missing from the chart mimicking
practice (Table 1). This study’s finding regarding
the increased risk of incompatibility between three
or more medications concurs with that of other
works being understudied. (7,10) Therefore, the de-
velopment of a three-dimensional (or more) chart
for each infusion group administered in conjunction
with an injection is a benefit to the current body of
knowledge in the area of parenteral therapy for pae-
diatric patients.
Based on the questionnaires, nurses were more
likely to encounter and observe drug incompatibili-
ties and occlusion of the infusion line than doctors
.

as this is an inherent part of their practice responsi-
bilities as drug administration specialists. However,
most of the nurses felt that, even though they are
drug administration specialists, managing compati-
bility is beyond their expertise and responsibility.
Therefore, the lack of ward pharmacy services in
this PICU appears to be an integrated part of the in-
compatibility problems. Fahimi (2015) found that
drug incompatibility problems are frequent and
need to be dealt with as they are one of the leading
medication errors. (11)
On further investigation, it was found that manufac-
turer information sheets were commonly used as a
reference by nurses though they actually provided
insufficient information on compatibility. This is
also in accordance with a previous study which dis-
covered that many practitioners lacked awareness of
compatibility and how to source trusted information
about it. (8) In addition, Kanji (2010) stated that
nurses often ran concomitant drugs without suffi-
cient understanding of drug compatibility. (12)
Another finding was that the PICU practitioners
have insufficient training on how to manage incom-
patibility issues effectively. This study also identi-
fied vast variation in medication groups and admin-
istration protocols, which seems to be confusing for
nurses, leaving them at the risk of causing admin-
istration errors. Camire (2010) found a correlation
between a higher level of knowledge and a reduc-
tion in errors. (13)
Incompatibility is commonly classified by nurses as
relating to the medication injected rather than the
process. Most injections, such as acyclovir, ampicil-
lin, furosemide, phenobarbital, phenytoin and mero-
penem, have a basic pH (>7) or high pKa and will
theoretically cause precipitation when in low pH so-
lutions such as 5% glucose (pH 4-4.5). It is well
known that the high pKa of these drugs means that
relatively high pH levels are required to sustain
drugs in solution and they are very prone to precip-
itation during dilution if the pH is allowed to drift
too low. (14) Considering this, it is deemed neces-
sary to undertake assays of compatibility to fill in
the missing frame of the chart (Table 1). Bertsche
(2008) found that having a protocol reduced incom-
patibility from 5.8% to 2.4%. (8) Thus, the provi-
sion of IV compatibility data is a fundamental phar-
macy service in critical care. (15)
Overall, these present findings have illustrated the
recurrent problems of incompatibility and lacked
recognition and understanding. The lack of a ward
pharmacist in PICU may contribute to the low
awareness level. This appears to differ from hospi-
tals in some developed countries where pharmacist
contribution is considered helpful in two-thirds of
.

118 Crit Care Shock 2018 Vol. 21 No. 3

compatibility cases (16) and can reduce errors by
66%. (17) Accordingly, the current study supports
the need for clinical pharmacists to be involved in
the development of infusion protocols in PICU. The
role of pharmacists should be extended to critical
care services. (18,19) According to the international
guidance on competency from the Society of Criti-
cal Care Medicine, the prevention of incompatibil-
ity falls within the competency and responsibility of
clinical pharmacists. (20)
This study has provided preliminary information on
the incompatibility problems in PICU and ad-
dressed the urgency of incompatibility assays for
three and more concurrent medications. The identi-
fication of incompatibility must be interpreted with
caution as the numbers and percentages do not ex-
press the actual frequency of incompatibility in
every single case, but they are based on the most
frequently listed medications and conditions, which
have the potential for incompatibility. This study
may be limited to reflect incompatibility problems
in Indonesia, which can be different from other
countries.
Based on the findings, the current study proposes
that hospitals should provide staff with education
sessions in the area of parenteral drug compatibility
to raise the level of awareness regarding this critical
issue. Appropriate professional development short
courses can also relay information, refresh the
knowledge, and increase awareness of practitioners
concerning incompatibility. (21)

Conclusions
Based on the medical records of 212 paediatric pa-
tients, the majority were administered multiple
medications using three simultaneous infusions and
an injection. The five main drug groups in this PICU
were morphine+midazolam, midazolam+fenta-
nyl+morphine, morphine+fentanyl+dobutamine,
morphine+midazolam+ketamine, and midazo-
lam+dobutamine+norepinephrine. Additional med-
ications may also be administered as bolus or inter-
mittent, including ampicillin, acyclovir, cefotaxime,
chloramphenicol, gentamicin, phenytoin,
methylprednisolone, metronidazole, meropenem,
phenobarbital, phenytoin, and ranitidine.
‘Y’-site incompatibility occurred during the dwell
time with other infusions and injections as they were
administered with a one-lumen catheter (no separate
line). Based on a review of the literature, much in-
formation (97.5%, n=120) is missing from the infu-
sions-injections compatibility chart with regard to
the most frequently administered combinations.
The responses from the questionnaires have shown
that most practitioners (92.9%) encountered incom-
patibility during observation, mainly with pheny-
toin, although most did not have sufficient under-
standing of incompatibility problems and manage-
ment. The 78.5% practitioners used manufacturer
information to check the compatibility data. To pre-
vent incompatibility, flushing was used by 45.5%
nurses, while 39.3% chose to change drugs, and
17.9% reported to the doctors.

Table 1. Compatibility amongst medication groups, infusion with injection

Infusion
Drug groups

W
ith

ou
t i

nj
ec

tio
n

Injection drugs Intermittent

A
cy

cl
ov

ir

A
m

pi
ci

lli
n

C
ef

ot
ax

im
e

C
hl

or
am

ph
en

ic
ol

D
ex

am
et

ha
so

ne

Fu
ro

se
m

id
e

G
en

ta
m

ic
in

M
er

op
en

em

Ph
en

ob
ar

bi
ta

l

Ph
en

yt
oi

n

R
an

iti
di

ne

Pa
ra

ce
ta

m
ol

M
et

ro
ni

da
zo

le

Fl
uc

on
az

ol
e

Midazolam, morphine C ? ? ? ? ? ? ? ? ? ? ? ? ? ?
Morphine, midazolam,
fentanyl

C ? ? ? ? ? ? ? ? ? ? ? ? ? ?

Morphine, fentanyl, do-
butamine

? ? ? ? ? ? ? ? ? ? ? ? ? ? ?

Midazolam, morphine,
ketamine

C ? ? ? ? ? ? ? ? ? ? ? ? ? ?

Fentanyl, dobutamine,
norepinephrine

? ? ? ? ? ? ? ? ? ? ? ? ? ? ?

Midazolam, dobuta-
mine, norepinephrine

? ? ? ? ? ? ? ? ? ? ? ? ? ? ?

Legend: C=compatible; ?=no data available (no recent compatibility study or information in the literature
to answer).

Crit Care Shock 2018 Vol. 21 No. 3 119

Table 2. Incompatibility problem according to health practitioners based on questionnaires

Questions and choice of answers Responses to questions

Nurses (n=22) Doctors (n=6)
Duration of work in PICU
– <1 year 0 6
– 1 to <5 years 2 0
– 5 to <10 years 13 0
– ³10 years 7 0
Occurrence of incompatibility
– Have you ever observed drug incompabilities at PICU Sardjito?
• Yes 22 4
• No 0 2
– How often have you observed drug incompatibilities within the last month?
• <3 4 6
• 3-10 13 0
• >10 4 0
• No answer 1 0
– Have you observed an infusion line occlusion?
• Yes 22 5
• No 0 1
– How often did you observe an occlusion within last month?
• <3 0 6
• 3-10 10 0
• >10 12 0
– Were those occlusions associated with incompatibility?
• Yes 0 0
• No 22 6
– What medications have you observed

drug incompatibilities with?
Various answers given; see Figure 3

– What incompatibilities have proved hard
to manage?

Phenytoin (22) Phenytoin (4)
Phenobarbital (20) No answer (2)
Diazepam (2)

Prevention of incompatibility
– Is there any protocol for preventing in-

compatibility?
Yes (10), flushing
No (12)
Did not know (0)

Yes (0)
No (6)
Did not know (0)

– What reference do you use to have a look
at information regarding incompatibility?

Manufacturers (16)
Book* (6)

Manufacturers (6)

– How can you manage the incompatibility
or line occlusion?

Spooling or aspira-
tion (10)

Spooling or aspira-
tion (0)

Changing with the
other (8)

Changing with the
other (3)

Reporting to senior
or doctor (4)

Reporting to senior
or doctor (1)

No answer (2)

Legend: *=Trissel’s “Handbook on Injectable Drugs”.

120 Crit Care Shock 2018 Vol. 21 No. 3

Figure 1. Top 20 simultaneous infusions in PICU

Crit Care Shock 2018 Vol. 21 No. 3 121

0 5 10 15 20 25 30 35

Morphine+Midazolam
Morphine+Fentanyl+Midazolam

Morphine+Fentanyl+Dobutamine
Morphine+Midazolam+Ketamine

Midazolam+Dobutamine+Norepinephrine

Fentanyl+Dobutamine+Norepinephrine
Morphine+Midazolam+Dopamine

Morphine+Fentanyl
Morphine+Dobutamine+Norepinephrine

Midazolam+Dopamine
Fentanyl+Midazolam

Fentanyl+Midazolam+Ketamine
Morphine+Midazolam+Dobutamine+Epinephrine

Morphine+Dopamine
Morphine+Dobutamine+Norepinephrine

Morphine+Fentanyl

Morphine+Midazolam+Dopamine+Norepinephrine
Morphine+Midazolam+Ketamine+Epinephrine

Morphine+Ketamine
Morphine+Norepinephrine+Ketamine

Number of Patients

Figure 2. Two-dimensional compatibility chart of the 22 top drugs in PICU

Legend: C=compatible; I=incompatible; ?=no data available.

Figure 3. Frequency of reported drug incompatibility occurrences

122 Crit Care Shock 2018 Vol. 21 No. 3

0,0

20,0

40,0

60,0

80,0

100,0

120,0

Phenyto
in

Phenobarb
ita

l

Fu
rosemide

Ampicil
lin

Inotro
pic D

rug

Gen
tam

yci
n

Meropenem
/Im

ipen
em

Diaz
epam

Intra
lip

id

Propofol

Insu
lin

Calc
ium Gluco

nate

Fr
eq

ue
nc

y
of

re
po

rt
in

g
(%

)

Nurses Doctors

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4. Almasdy D, Siregar CJP. Evaluasi Teknik
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puran Intravena pada Ruangan Rawat bedah di
Suatu Rumah Sakit Pemerintah. Jurnal Sains
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5. Biswal S, Mishra P, Malhotra S, Puri G, Pandhi
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1834-40.

9. Dabaghzadeh F, Rashidian A, Torkamandi H,
Alahyari S, Hanafi S, Farsaei S, et al. Medica-
tion Errors in an Emergency Department in a
Large Teaching Hospital in Tehran. Iran J
Pharm Res 2013;12(4):937-42.

10. Trissel LA. Handbook on Injectable Drugs.
16th ed. Maryland: Bethesda MD, American
Society of Health-System Pharmacists; 2011.

11. Fahimi F, Forough AS, Taghikhani S,
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15. Mühlebach S. Incompatibility Reactions in IV
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106  2020 Journal of Research in Pharmacy Practice | Published by Wolters Kluwer – Medknow

Objective: The main aim of the study was to identify the physical and chemical
incompatibilities among the drugs administered intravenously to patients
admitted to the Intensive Care Unit (ICU) of a 1000 bedded hospital. The study
also envisaged establishing pharmaceutical guidelines for the administration of
incompatible medications. Methods: This prospective cross-sectional study was
conducted from January to July 2018 in the ICU after getting approval from the
Hospital Ethics Committee. A total of 104 medication charts were collected, and
their data were analyzed. Compatibility of the selected drug with a second drug,
when given together, was then analyzed using the Micromedex health-care series,
Trissel’s handbook of injectable drugs, and Manufacturer’s product information. The
pharmaceutical intervention was performed by preparing. The drug compatibility
chart of selected drugs and the same was reported to the study department.
Findings: Of 104 medication charts reviewed, 66 charts had incompatibility,
accounting for 90 incompatibilities. Incompatibility between two intravenous (IV)
bolus drugs constituted 68.8% with pantoprazole and ondansetron (85.4%) being
the most frequent combination. Incompatibility between infusion-bolus was found
to be 26.6%. Meropenem (infusion) and pantoprazole (bolus) constituted 16.6%.
Incompatibility between two infusions in the same IV line was found to be
4.4%. A drug compatibility chart containing 19 selected drugs was prepared and
submitted to the study department for their perusal. Conclusion: The current study
showed that a significant number of drug incompatibilities occur in hospitalized
critically ill patients in our tertiary care hospital. These incompatibilities could
generally be prevented by adhering to proper medication administration techniques
like flushing the line using compatible fluid or through a multi‑lumen catheter or
multiple IV access.

Keywords: Critically ill patients, drug‑related problems, intensive care unit,
intravenous drug incompatibilities

Intravenous Drug Incompatibilities in the Intensive Care Unit of a
Tertiary Care Hospital in India: Are they Preventable?
Shanmugam Sriram1, S. Aishwarya2, Akhila Moithu2, Akshaya Sebastian2, Ajith Kumar2

Address for correspondence:
Prof. Shanmugam Sriram,

E-mail: [email protected]

18.6% of the total medication errors (MEs) belong to
the category physicochemical incompatibility.[4]

Drug incompatibility results from the simultaneous
dilution and/or administration of two or more drugs
that interfere with the therapeutic efficacy of the
medications and patient safety, visually evidenced by

Original Article

Introduction

T he Intensive Care Unit (ICU) presents
substantial patient safety challenges.[1] In ICU,

intravenous (IV) therapy is preferred over oral therapy. It
is complex and error-prone hence requiring strategies to
reduce the risk and complications.[2] Infusion therapy is
associated with a high risk of causing harm for patients.
The administration of IV medications may be associated
with undesirable effects, especially when administered
in error.[3] In a study by Tissot et al., it is reported that

1Department of Pharmacy
Practice, Sri Ramakrishna
Institute of Paramedical
Sciences, Coimbatore,
Tamil Nadu, India

2Department of Pharmacy
Practice, PharmD Intern,
Sri Ramakrishna Institute
of Paramedical Sciences,
Coimbatore, Tamil Nadu,
India

A
bs

tr
ac

t

This is an open access journal, and articles are distributed under the terms of the
Creative Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as long as
appropriate credit is given and the new creations are licensed under the identical terms.

For reprints contact: [email protected]

How to cite this article: Sriram S, Aishwarya S, Moithu A, Sebastian A,
Kumar A. Intravenous drug incompatibilities in the intensive care unit of
a tertiary care hospital in India: Are they preventable? J Res Pharm Pract
2020;9:106-11.

Access this article online
Quick Response Code:

Website: www.jrpp.net

DOI: 10.4103/jrpp.JRPP_20_11

Received: 06-11-2019.
Accepted: 17-02-2020.
Published: 26-06-2020.

107

Sriram, et al.: Intravenous drug incompatibilities in ICU

107107Journal of Research in Pharmacy Practice ¦ Volume 9 ¦ Issue 2 ¦ April-June 2020

change of solution color, precipitation, or turbidity.[5]
Physical reactions of drugs usually refer to either phase
separation or precipitation due to a shift in the relation
between ionization and nonionization and solubility. In
chemical incompatibility, the medicine may undergo
many chemical degradation pathways such as oxidation,
reduction, hydrolysis, photolysis, or racemization. It
can be perceived as turbidity, precipitation, and color
changes. Therapeutic incompatibility may occur when
two or more drugs are administered concurrently
resulting in undesirable antagonistic or synergistic
pharmacological activity.

These incompatibilities generally occurs between
drugs and inappropriate diluents, two drugs: drug-drug
incompatibility, when these are mixed in the same
infusion line or the same IV container when these are
administered one after the other within the same infusion
line, drugs and adjutants such as stabilizer and solvent
and drugs and materials of IV containers like polyvinyl
chloride.

Probable mechanisms for these incompatibilities
may be due to medicines that precipitate on dilution,
precipitation of medications due to pH change on
mixing, ionic reactions forming insoluble substances,
and denaturation of biological molecules.

The extent and severity of the damage caused by
incompatibility depend on the patient’s condition and the
type of drug administered. Significant consequences are
multiorgan failure, severe liver dysfunction, toxic shock,
local embolus, myocarditis, respiratory difficulties,
systemic allergic reactions, local allergic reactions,
thrombosis, thrombophlebitis, phlebitis, and local
redness.[6-12]

Recent studies showed or recommended the following
preventive strategies for preventing the IV drug
incompatibilities as helpful: the usage of multiple lumen
catheter, use of in‑line infusion filters,[13,14] separate IV
infusion by time and place, flushing the IV line with
a fluid compatible to the drug administered,[15] and the
color-coding system for drug pH.[16]

The main objective of this study was to identify and
document the physical and chemical incompatibilities
among the drugs administered intravenously to patients
admitted to the ICU of a tertiary care hospital in India
and to establish pharmaceutical guidelines for the
administration of incompatible drugs.

Methods
This cross-sectional study was conducted at a
1000-bedded, private tertiary care multi-specialty
teaching hospital located at Coimbatore. The study was

conducted in the ICU of the hospital for a length of
6 months (January 2018–June 2018).

The study protocol was prepared and submitted to
the Institutional Ethical Committee of the study
hospital. The approval from the committee was
obtained as a letter (SRH/EC.12‑14/2017‑18 dated
28th December 2017).

The inclusion criteria of our study were all inpatients
of age 18 years and above, of either sex, getting
admitted to the study site during the study, with length
of stay equal to or longer than 24 h, prescriptions with
4 or more IV drugs and patients who were willing to
participate were included in the study. We also excluded
inpatients who were younger than 18 years, and who
are not willing to participate in the study were excluded
from the study.

Medication charts of 104 consecutive patients admitted
in the ICU and treated with four or more IV drugs were
analyzed. The patient baseline characteristics such as
age, sex, the reason for hospitalization, comorbidities,
laboratory investigations, diagnosis, and medication
charts were obtained.

Compatibility of selected drugs with a second
drug was analyzed using MICROMEDEX DRUG
DATABASE which is available with the Department
of Pharmacy Practice and TRISSEL’S HANDBOOK
OF INJECTABLE DRUGS. A two-dimensional
compatibility chart was then prepared to indicate the
compatibility of a selected drug with a co-administered
drug. Furthermore, the analysis of high alert
medications, drug-drug interactions (DDI) was also
analyzed.

Results
The total number of patients included in the study and
had fulfilled the inclusion criteria was 104 of which
72 (69.23%) were male and 32 (30.77%) were female.
The result of gender categorization revealed that the
overall study population was predominantly male
population. The most dominant group was middle
adulthood which accounts for 41.3% of the whole
study population. The average age of the whole study
population was found to be 58.03 ± 17.49 years.

The analysis showed that, out of 104 prescriptions, 66
prescriptions had incompatibility, summing to 90. IV
incompatibility of continuous infusions and bolus doses
when administered one after the other using the same
line was 26.6% (n = 24) [Figure 1].

The analysis of drugs prescribed to the study population
revealed that a minimum of 5 medicines and a

Sriram, et al.: Intravenous drug incompatibilities in ICU

108 Journal of Research in Pharmacy Practice ¦ Volume 9 ¦ Issue 2 ¦ April-June 2020

maximum of 24 drugs were found. The average number
of medications prescribed was found to be 11.2 ± 3.8.
Our analysis showed that the average ratio of IV drugs
per patient were 7.74 ± 2.84. The majority of the
study population has received antibiotics, anti-ulcer
medications and anti-emetics.

Of 104 prescriptions analyzed, 42 prescriptions had
DDIs. The results showed that there was a total of 65
DDIs of which 76.9% were major, and 16.9% were of
moderate severity. Minor DDI constituted to 3.1% of the
total DDI. One contraindicated pair was observed which
is fluconazole and ondansetron combination which
would result in QT interval prolongation.

Based on our observation and results, IV drug
compatibility-alert card was prepared to enhance the
rational use of IV medication and patient safety.

Discussion
Errors in the administration of IV drugs are numerous,
with IV drug incompatibility being a significant
problem. The current study provides information about
the incompatibility of IV drugs administered in patients
admitted to ICU.

In the study by Machotka et al., they have
analyzed 50 medication charts within 12 months
(January 2011–December 2011) comprising 54% females
and 46% males, with a total of 318 IV drugs.[17] In the
present study, 104 medication charts were analyzed.
The study revealed that the male population was
predominant, with 69.25% and 30.77% females. The
average age of the study population was found to be
69.38 ± 5.25 years.

Most of the patients were hospitalized in the ICU
due to Nervous System disorders comprising of
35.5%followed by respiratory system disorders (20.1%).
Poisoning (11.5%) and road traffic accidents (RTA)
(7.68%) cases were also seen.

The study on incompatibilities in the adult ICU conducted
by Marsilio et al. analyzed 100 medication charts and
found 68% of incompatibility.[18] In the present study,
63.4% of incompatibilities were found on analysis of
104 medication charts. Although a decreased prevalence
of incompatibilities was found in the present study,
this rate nevertheless remains high. This high rate of
incompatibilities in the present study is correlated with
multiple IV medications prescribed to critically ill patients.

26.6%

4.4%

68.8%

Continous infusion/bolus
dose

Continous infusion/Continous
infusion

Bolus dose/bolus dose

Figure 1: The frequency of IV drug incompatibilities by different types
of infusion in the study patients (n = 104)

Table 1: Drug type frequency of intravenous incompatibilities between continuous infusion and bolus dose
Number Continuous infusion Bolus dose Effect/result n (%)
1 Meropenem Pantoprazole Precipitation 4 (16.6)
2 Clindamycin Pantoprazole Red precipitation 3 (12.5)
3 Piperacillin/tazobactam Pantoprazole Precipitation 3 (12.5)
4 Metronidazole Pantoprazole Reddish-brown discoloration and cloudy precipitation 3 (12.5)
5 Meropenem Ondansetron White precipitation 2 (8.3)
6 Amikacin Pantoprazole Precipitation 2 (8.3)
7 Ceftriaxone Ondansetron Haziness with micro precipitation 2 (8.3)
8 Glycopyrrolate Pantoprazole Orange discoloration 1 (4.1)
9 Fluconazole Pantoprazole Haziness and micro precipitation 1 (4.1)
10 Levofloxacin Pantoprazole Orangish-yellowish discoloration 1 (4.1)
11 Piperacillin/tazobactam Midazolam White haze 1 (4.1)
12 Thiamine Furosemide Haze/turbidity/particulate matter 1 (4.1)

Table 2: Drug type frequency of intravenous incompatibilities between continuous infusions at the same time
Number Infusion-1 Infusion-2 Effect/result n (%)
1 Paracetamol Metronidazole Turbidity 1 (25)
2 Meropenem Acyclovir Precipitation 1 (25)
3 Paracetamol Acyclovir Particulate formation 1 (25)
4 Meropenem Calcium gluconate Yellow color 1 (25)

109

Sriram, et al.: Intravenous drug incompatibilities in ICU

109109Journal of Research in Pharmacy Practice ¦ Volume 9 ¦ Issue 2 ¦ April-June 2020

Kahmann et al. found 15% of incompatible combinations
from the analysis of 78 different medication
regimes.[19] The present study also analyzed 78 different
IV drug regimes and found 26.9% of combinations tested
exhibited drug incompatibility reactions. This difference
in prevalence might be due to the diversity of morbidity
profiles among the patients that might change the drug
therapy regimen to be used. Most of the patients in the
present study had comorbidities with either sustained
hypertension (SHT) and diabetes mellitus or SHT alone
of about 10.9%.

In this study, the frequency of intravenous incompatibilities
between continuous infusion and bolus dose (26.6%)
is depicted in Table 1 and the frequency of intravenous
incompatibilities between continuous infusions at
the same time (4.4%) is tabulated in Table 2 and the
incompatibilities occurred between two bolus drugs
(68.8%) is shown in Table 3. Among these, incompatibility
between pantoprazole and ondansetron (58.8%) was
commonly observed. Moraes et al. (2011)[20] found that
the most common drug incompatibility occurred between
piperacillin-tazobactam and midazolam. In another
study conducted by Marsilio et al.,[18] midazolam and
cefepime were the most common drug incompatible pair.
This between‑studies difference might be due to the less
prevalence of the incompatible pair piperacillin-tazobactam
and midazolam (1.1%). Unlike the studies mentioned
above, cefepime was not available in the drug regimes
analyzed, consequently the difference in the results.

Pantoprazole was the most common drug involved
in incompatibilities in the present study, followed by
ondansetron and meropenem. The high frequencies
of these drugs in incompatibilities might be relative
because they are widely used in the ICU and are
therefore present in numerous prescriptions.

In this study, pantoprazole was widely used for treating
drug-induced gastrointestinal disturbances accounting
for 9.3% of total IV medications administered. As
this medication is available as a powder for solution,
reconstitution must be done with D5W, Normal Saline
or Ringer Lactate normal saline or ringer lactate (NS, or
RL). The manufacture recommends the administration
of pantoprazole through a dedicated line and avoids
co-administration with other IV solutions.[21]

Acute nature of patients in ICU necessitates the use of
antibiotics frequently, and sometimes multiple antibiotic
therapies need to be initiated.[22] Nearly, 20%–40% of
patients are documented to receive antimicrobial agents
during hospitalization to treat and prevent nosocomial
infections.[23] In the present study, 24.5% of total IV
medications were antibiotics with meropenem (5.2%),
Piperacillin-Tazobactam (4.8%), and linezolid (3.2%)
the frequently prescribed and the one to be involved in
incompatibility.

Some medications are prone to show a higher risk
of ME. These high-risk drugs can cause devastating
consequences when misused.[24] According to Tyynismaa
et al., the most common human rights defenders
(HRDs) were oxycodone (5%), enoxaparin (3%), and
noradrenaline (3%).[25] In the present study, of 24
different HRDs observed, enoxaparin (20.7%) occurred
the most, followed by insulin (12.2%) and amikacin
(10%). As these medications are at heightened risk for
ME, their safe use in clinical practice must be ensured.

In the study by Rodrigues et al. conducted in ICU,
observed 67% major and 74% moderate interactions in
the prescriptions analyzed. They identified the interaction
between dipyrone, and enoxaparin (35.8%) was the most
prevalent.[26] In our study, we noticed, 76.9% major and
16.9% moderate DDIs. Most of the significant drug
interactions occurred with ondansetron comprising 38%.
One contraindicated pair was observed between fluconazole
and ondansetron resulting in QT interval prolongation,
requiring electrocardiogram monitoring, though its clinical
occurrence was not found in our study. The number of
potential DDIs has a positive correlation with the number
of prescribed drugs. Conceding the potential for higher risk
of DDIs in ICU is essential in enhancing patient safety.

There were some limitations in our study, such as the
analysis of incompatibilities involves the combination of
only two drugs, unavailability of specific medication in
the databases, inability to observe the clinical implication
for patients. Although a pharmaceutical intervention
in the form of the drug-incompatibility chart was
developed, the adherence of health-care professionals to
it was not evaluated.

Incompatibilities are an issue of concern, especially
in patients admitted to the ICU because of the large

Table 3: Drug type frequency of intravenous incompatibilities between bolus doses at the same time
Number Bolus 1 Bolus 2 Effect n (%)
1 Ondansetron Pantoprazole Turbid precipitation + yellow discoloration 53 (85.4)
2 Furosemide Pantoprazole Haze/turbidity/particulate matter 3 (4.8)
3 Ketorolac Pantoprazole Haze, microparticulates, yellow discoloration 3 (4.8)
4 Dexamethasone Pantoprazole Precipitation 2 (3.2)
5 Fentanyl Pantoprazole Haze and micro precipitation 1 (1.6)

Sriram, et al.: Intravenous drug incompatibilities in ICU

110 Journal of Research in Pharmacy Practice ¦ Volume 9 ¦ Issue 2 ¦ April-June 2020

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111

Sriram, et al.: Intravenous drug incompatibilities in ICU

111111Journal of Research in Pharmacy Practice ¦ Volume 9 ¦ Issue 2 ¦ April-June 2020

number of parenteral drug applications. As there is
a limited number of independent IV lines and the
need for constant drug concentration, assessing their
physicochemical compatibility is necessary to avoid
negative consequences such as therapeutic failure,
micro-embolisms, or even toxicity.

This study substantiated that a significant number
of drug incompatibilities occur in ICU, clinical
pharmacists have a crucial role in the detection and
elimination of drug incompatibilities and other DRPss.
The current study showed that a significant number of
drug incompatibilities occur in hospitalized critically ill
patients whom we studied. These incompatibilities could
generally be prevented by adhering to proper medication
administration techniques like flushing the line using
compatible fluid, through a multi‑lumen catheter,
through multiple IV access, using in-line infusion
filters, a spacing of medication or color‑coding system.
Pharmaceutical intervention by clinical pharmacists, in
the form of drug compatibility chart [Table 4] for the
common incompatible pair of drugs that was prepared
and submitted, will enable the Physicians in the ICUs to
be alert during the administration of such drugs.

Authors’ Contribution
Authors have made substantial contributions to
conception and design, acquisition of data, analysis and
interpretation of data and participated in drafting and
revising.

Financial support and sponsorship
Nil.

Conflicts of interest
There are no conflicts of interest.

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Clinical Interventions in Aging

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/dcia20

Evaluation of pharmacist interventions and
commonly used medications in the geriatric ward
of a teaching hospital in Turkey: a retrospective
study

Elif Ertuna, Mehmet Zuhuri Arun, Seval Ay, Fatma Özge Kayhan Koçak,
Bahattin Gökdemir & Gül İspirli

To cite this article: Elif Ertuna, Mehmet Zuhuri Arun, Seval Ay, Fatma Özge Kayhan Koçak,
Bahattin Gökdemir & Gül İspirli (2019) Evaluation of pharmacist interventions and commonly used
medications in the geriatric ward of a teaching hospital in Turkey: a retrospective study, Clinical
Interventions in Aging, , 587-600, DOI: 10.2147/CIA.S201039

To link to this article: https://doi.org/10.2147/CIA.S201039

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Clinical Interventions in Aging 2019:14 587–600

Clinical Interventions in Aging

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Clinical Interventions in Aging

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open access to scientific and medical research

Open Access Full Text Article

http://dx.doi.org/10.2147/CIA.s201039

evaluation of pharmacist interventions and
commonly used medications in the geriatric
ward of a teaching hospital in Turkey:
a retrospective study

elif ertuna1

Mehmet Zuhuri Arun1

seval Ay2

Fatma Özge Kayhan Koçak2

Bahattin gökdemir2

gül İ spirli2

1Department of Clinical Pharmacy,
Faculty of Pharmacy, ege University,
Izmir, Turkey; 2Department of Internal
Medicine, Division of geriatrics,
Faculty of Medicine, ege University,
Izmir, Turkey

Purpose: Aging increases the prevalence of diseases. The elderly population is consequently

often exposed to complex medication regimens. Increased drug use is one of the main reasons

for drug-related problems (DRPs). The primary objective of this study was to define and classify

DRPs, pharmacist interventions, and frequently prescribed medications in relation to possible

DRPs in patients admitted to the geriatric ward of a teaching hospital in Turkey.

Patients and methods: Pharmacist medication review reports for 200 orders of 91 patients

(mean age: 80.33±0.46) were analyzed retrospectively.

Results: A total of 1,632 medications were assessed and 329 interventions were proposed for

possible DRPs in 156 orders. A total of 87.5% of the patients used five or more drugs (mean:

8.17±0.23). The number of DRPs per order was higher when polypharmacy was present

(1.04±0.15 vs 1.66±0.11, P,0.05). In 71.31% of the cases, adverse drug events were recog-

nized as the problem. The principal cause of possible DRPs was determined as drug interactions

(40.12%). Only 22 potentially inappropriate medications were prescribed. The most common

interventions included monitoring drug therapy (31.0%), stopping the drug (20.06%), and chang-

ing dosage (13.98%). The acceptance rate of pharmacist interventions by treating geriatrician

was 85.41%. The most frequently prescribed drugs were for the nervous system, alimentary

tract and metabolism, and cardiovascular system (n=358, 314, and 304, respectively). The

pharmaceutical forms of 23 drugs were deemed inappropriate by pharmacists.

Conclusion: Clinical pharmacy services are still not properly implemented in Turkey. The

study highlights ways in which clinical pharmacy services can be instrumental in a geriatric

ward. The high acceptance rates of pharmacist recommendations concerning a wide variety of

DRPs and different classes of drugs indicate that advanced collaboration among geriatricians

and pharmacists is possible in interdisciplinary geriatric assessment teams in Turkey.

Keywords: pharmaceutical care, clinical pharmacy, elderly, medication review, polypharmacy,

potentially inappropriate medication

Introduction
According to the United Nations’ World Population Prospects report, population

aging is occurring throughout the world and the number of older persons in the world

is projected to be 2.1 billion in 2050. In Turkey, life expectancy at birth is estimated

to be 82.5 and 89.1 years by the end of 2050 and 2100, respectively.1 With aging,

the prevalence of diseases and geriatric syndromes increases; as a consequence, the

elderly population is more frequently exposed to complex medication regimens and

Correspondence: elif ertuna
Department of Clinical Pharmacy,
Faculty of Pharmacy, ege University,
35040 Bornova, Izmir, Turkey
Tel +90 532 672 5988
Fax +90 232 388 5258
email [email protected]

Journal name: Clinical Interventions in Aging
Article Designation: Original Research
Year: 2019
Volume: 14
Running head verso: Ertuna et al
Running head recto: Ertuna et al
DOI: 201039

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588

ertuna et al

increased drug use.2–5 Polypharmacy increases the risk of

drug-related problems (DRPs), potentially inappropriate use

of medications (PIMs), and hospitalizations, all of which are

common among elderly people.2,3,6,7

A DRP is defined as “an event or circumstance involv-

ing drug therapy that actually or potentially interferes with

desired health outcomes”.8 In addition to clinical impact,

DRPs also increase health expenditure, which causes eco-

nomic burden.9,10 Several studies have found that pharmacists

provide added value in resolving and preventing DRPs in

settings such as outpatient clinics, acute care in inpatients,

nursing homes, and palliative care.5,11–18 Studies from inpa-

tient settings have also shown that including a pharmacist

as a member of the interdisciplinary health care team may

improve outcomes and decrease drug-related readmissions

and mortality in geriatric patients.2,17,19–21 As team members,

pharmacists offer an additional perspective in the application

of medication reviews, resulting in an increase in detec-

tion of DRPs and a reduction of polypharmacy in elderly

inpatients.21

Pharmaceutical care, described as the pharmacist’s

contribution to the care of individuals in order to optimize

medicines use and improve health outcomes, is the founda-

tion of clinical pharmacy. In the past decade, changes in

pharmacy undergraduate education and new legislations in

the Turkish health care system have indicated increasing

recognition of the pharmaceutical care practice. However,

the provision of clinical pharmacy services is still a fairly

new concept. Therefore, the need to establish basic standard

operating procedures for ward-based pharmacy services and

improving efficiently delivered quality of care has emerged.

The primary objective of this study was to define and clas-

sify the DRPs and pharmacist interventions in the geriatric

ward of a teaching hospital in Turkey. The paper’s secondary

objective was to determine frequently prescribed medications

and pharmaceutical forms in relation to possible DRPs in the

study population.

Patients and methods
settings and data collection
The study was conducted between December 2017 and

July 2018 in the acute geriatric ward (10 beds) of a

government-run 1,800-bed tertiary university hospital in

Turkey. Patients aged 65 or over admitted to the outpatient

geriatric clinic or emergency department of the same hospital

with typical acute geriatric problems were hospitalized.

Referrals from other smaller district hospitals (primary or

secondary care) were also accepted. Patients were cared for

by an interdisciplinary team of geriatricians, nurses, and dieti-

cians. Medical care and discharge planning were provided.

Two licensed pharmacists working at the Department

of Clinical Pharmacy, Faculty of Pharmacy at the Ege

University began to participate in the weekly interdisciplinary

geriatric rounds in December 2017, and a medication review

service is provided routinely once a week thereafter. Phar-

macists reviewed medication orders, medication history,

and/or clinical data (such as vitals and biochemical markers)

in the medication review process to detect possible DRPs

and prepare a report of possible DRPs and interventions for

each order 1 day before weekly interdisciplinary rounds.

The reports were discussed and reviewed with a geriatrician

during the weekly interdisciplinary rounds. The acceptance

status of the proposals was then noted by pharmacists.

In the medication review process, the latest medication

orders of patients were evaluated for DRPs by software-

based, guideline-based, or knowledge-based approach by

the pharmacist. Drug–drug, food–drug, and disease–drug

interactions and intravenous incompatibilities were analyzed

with RxMediaPharma® Interactive Drug Database.22 PIM or

potentially inadequate medication use in geriatric patients

was determined using Beers criteria,23 Screening Tool of

Older Persons’ potentially inappropriate Prescriptions

(STOPP) criteria, and Screening Tool to Alert doctors to

the Right Treatment (START) criteria.24 The latest clinical

practice guidelines for specific diseases were used to support

clinical decisions when necessary.

Data analysis
The pharmacist reports for 200 medication orders of

91 patients were examined retrospectively. Problem type,

cause of problem, proposed intervention, and acceptance

status for the proposed interventions were classified accord-

ing to Pharmaceutical Care Network Europe’s (PCNE)

definitions and DRP classifications (the PCNE Classifica-

tion V 8.02).8 As using standard terms would facilitate the

comparison of the results of studies, PCNE recommends the

utilization of standard pharmaceutical care terms in European

countries.8,25,26 Detailed classification of data is shown in

Table S1 with subcategories and frequencies. One DRP may

have more than one cause and may lead to the proposition

of more than one intervention.

Definitions
A problem is defined as “the expected or unexpected event

or circumstance that is, or might be wrong, in therapy

with drugs”.8 As per definition, both manifest and possible

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589

ertuna et al

problems are included in this study. Problems of a tech-

nical nature (logistic, computer error, etc.) are specified

accordingly.

The cause is defined as “the action (or lack of action) that

leads up to the occurrence of a potential or real problem”.8

The intervention is the proposed measures to be taken

to overcome the cause of the problem by the pharmacist to

prevent or solve a problem. The proposed course of action

is deemed to improve and/or maintain patients’ health and

well-being.

Acceptance is defined as the acceptance status of the

pharmacist intervention proposals evaluated by physicians.

statistical analysis
The normality of the data was analyzed using the

Kolmogorov–Smirnov test. Continuous data were described

by mean ± standard error of mean. Categorical data were

described in terms of frequencies. Correlation between the

number of DRPs and total medications per order was assessed

using Pearson’s correlation test. The number of DRPs in

orders according to age and gender and the absence or pres-

ence of renal impairment and polypharmacy were analyzed

using Student’s t-test. Data were analyzed using SPSS ver-

sion 25.0 (IBM SPSS Statistics for Windows, Version 25.0;

IBM Corp., Armonk, NY, USA). A P-value #0.05 was

considered significant.

ethical considerations
This study was approved by the Ethics Committee for

Clinical Research of Faculty of Medicine at Ege University

(Date: October 2, 2018; No: 18-10/4). All patients or their

substitute decision maker gave written informed consent for

their participation.

Results
The pharmacists’ reports for 200 medication orders of 91

patients were analyzed. A total of 55 of these patients were

admitted to the hospital for two to six consecutive weeks,

and seven patients were readmitted two to three times within

6 months after discharge. Characteristics of the patients are

presented in Table 1.

Pharmacists detected 329 possible DRPs in 156 orders

and no problem was detected in 44 orders. The PCNE cat-

egories of possible DRPs and their frequencies are shown

in Figure 1. The number of medications and DRPs per order

was not different across different age groups, genders, or

in the absence or presence of renal impairment (Table 1).

There was a significant weak positive correlation between

the number of total drugs used and the number of DRPs

per order (P,0.05, r=0.2819; Pearson’s correlation test).

Polypharmacy, described as using five or more drugs, was

present in 175 (87.5%) orders. The number of DRPs was

higher when polypharmacy was present (P,0.05; Table 1).

One DRP may have had more than one cause that led to

the recommendation of more than one intervention. A com-

plete list of combinations of causes and interventions for

each DRP is presented in Table S1. In brief, most causes

of possible DRPs were drug interactions (including IV

incompatibilities), inadequate monitoring, and a high drug

dose (Table 2).

A total of 329 interventions were proposed and/or dis-

cussed by pharmacists – 282 (85.71%) of these interventions

were proposed to the prescribers, and on 47 (14.28%) occa-

sions, the prescriber was only informed, or the intervention

was discussed with the prescriber. The most frequently

recommended intervention was monitoring, which was fol-

lowed by stopping the drug and changing dosage or instruc-

tions for use (Figure 2). A full list of PCNE categories of

the interventions is presented in Table S1. The acceptance

rate of pharmacist interventions was 85.41% (n=281). Inter-

vention was accepted and fully implemented in 223 cases

(67.78%), partially implemented in 40 cases (12.16%),

Table 1 Characteristics of patients, number of medications, and
DrPs

Medication
(mean ± SEM)

DRP
(mean ± SEM)

Patient’s age (n=200;
80.33±0.46)

8.17±0.23 1.58±0.098

65–79 years (n=78) 7.95±0.33 1.59±0.15

$80 years (n=122) 8.32±0.31 1.58±0.13

Patient’s gender

Male (n=69) 7.65±0.35 1.41±0.14

Female (n=131) 8.45±0.29 1.68±0.13

renal function

egFr .60 ml/min/1.73 m2
(n=84)

8.45±0.36 1.42±0.13

egFr #60 ml/min/1.73 m2
(n=83)

8.13±0.36 1.76±0.17

Unknowna (n=33) 7.58±0.44 1.58±0.23

number of medication per order

0–4 (n=25) 3.40±0.20 1.04±0.15

$5 (n=175) 8.86±0.21 1.66±0.11b

Notes: aUnknown at the time of medication review due to new admission of the
patient and/or biochemistry results being incomplete at the time of interdisciplinary
round. bP#0.05; student’s t-test (number of medications per order; 0–4 vs $5).
Abbreviations: DrPs, drug-related problems; egFr, estimated glomerular
filtration rate; SEM, standard error of mean.

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not implemented in 12 cases (3.65%), and implementation

status was not known in 6 cases (1.82%). Only 38 (11.55%)

of the proposed interventions were rejected by the physician

due to being not feasible (n=19, 5.78%), unknown reasons

(n=1, 0.3%), and other reasons (n=18, 5.47%), such as the

patient being closely monitored, prior recommendations of

another specialist (psychiatry/infectious disease/cardiology),

or patient record error in hospital information system leading

to misinformation but patient receiving the correct drug form/

dosage. The acceptance status of ten intervention proposals

(3.04%) was unknown due to the physician not making the

decision during rounds and referring the patient to other

physicians for further consultations. In one case, written

information was provided only to the physician. On account

of this study being performed in a teaching hospital, medical

students also participated in the routine rounds. Pharmacist

intervention proposals led to educational discussions on six

different cases and were noted as separate interventions.

Detailed acceptance rates with respect to intervention cat-

egory are presented in Figure 2.

During this study, 1,632 medications were ordered.

Medications were coded following the WHO–Anatomical

Therapeutic Chemical (WHO–ATC) classification. ATC

groups of the most ordered drugs were N (nervous system,

358), A (alimentary tract and metabolism, 314), C (cardio-

vascular system, 304), B (blood and blood-forming organs,

197), and J (anti-infectives for systemic use, 151) (Table 3).

The number of possible DRPs for each prescribed drug in

the geriatric ward was analyzed, and the ten medications

with overall highest DRP counts and the medications with

the highest DRP counts in each ATC class were determined

(Table 3).

Pantoprazole, enteral nutrition products, enoxaparin, furo-

semide, metoprolol, sertraline, quetiapine, insulin glargine,

Figure 1 PCne categories of possible drug-related problems and their frequencies.
Abbreviations: PCne, Pharmaceutical Care network europe; DrPs, drug-related problems.

No problem

Not suitable strength

Wrong administration route
Ty

pe
o

f p
os

si
bl

e
D

R
P

Unnecessary drug treatment

Untreated symptom/indication

Effect not optimal

Adverse drug event possible

0 20 40 60

Percentage of possible DRPs (%)
80

Total counts

44

2

2

20

21

44

266

Table 2 PCne categories of most encountered causes of possible DrPs and their frequencies

PCNE code PCNE category Total counts (n, %)

C 1.4 Inappropriate combination of drugs or drugs and herbal medication (includes intravenous incompatibility) 132 (40.12%)

C 8.1 no or inappropriate outcome monitoring 47 (14.29%)

C 3.2 Drug dose too high 41 (12.46%)

C 1.2 Inappropriate drug (within guidelines but otherwise contraindicated) 30 (9.12%)

C 8.2.1 Patient education required 28 (8.51%)

C 6.6 Drug administered via wrong route 27 (8.21%)

C 1.6 no drug treatment in spite of existing indication 23 (6.99%)

C 2.1 Inappropriate drug form (for this patient) 23 (6.99%)

C 1.1 Inappropriate drug according to guidelines/formulary 22 (6.69%)

Abbreviations: PCne, Pharmaceutical Care network europe; DrPs, drug-related problems.

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ertuna et al

Figure 2 PCne categories of interventions proposed by the pharmacist and their acceptance rates.
Abbreviation: PCne, Pharmaceutical Care network europe.

Table 3 Total number of ordered medications, most frequently ordered medications, and medications with the highest number of
possible DrPs in each ATC class

ATC class Number of ordered
medications

Most frequently ordered medication
(n, % in related ATC group)

Medications with highest DRP (possible)
counts (n, % in related ATC group)

A 314 Pantoprazole (107, 34.08%) Pantoprazole (19, 6.05%)

B 197 enoxaparin (60, 30.46%) Enoxaparin (15, 4.93%)

C 304 Furosemide (57, 18.75%) Furosemide (15, 7.61%)
Metoprolol (12, 6.09%)

D 34 silver sulfadiazine (10, 29.41%) –

g 44 Tamsulosin (19, 43.18%) silodosin (3, 6.82%)

h 53 levothyroxine (20, 37.74%) Methylprednisolone (13, 24.53%)

J 151 Ceftriaxone (26, 17.22%) Ciprofloxacin (11, 7.28%)

l 10 Methotrexate (2, 20.00%) Mycophenolate (3, 30.00%)

M 11 Allopurinol (3, 27.27%) Allopurinol (2, 18.18%)
Colchicine (2, 18.18%)

n 358 sertraline (45, 12.57%) Quetiapine (41, 11.45%)
Donepezil (27, 7.54%)
Sertraline (19, 5.31%)
Escitalopram (12, 3.35%)

P 2 Metronidazole (2, 100.00%) Metronidazole (1, 50.00%)

r 65 salbutamol + Ipratropium (26, 40.00%) Salbutamol + Ipratropium (11, 16.92%)

s 11 Brimonidine + Timolol (4, 36.36%) –

V 78 enteral nutrition (61, 78.21%) enteral nutrition (6, 7.69%)

Total 1,632

Note: Boldface medications are the 10 medications with overall highest possible DrP counts.
Abbreviations: DrPs, drug-related problems; ATC, Anatomical Therapeutic Chemical.

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acetylsalicylic acid (ASA), and parenteral nutrition were the

most frequently prescribed medications in 200 orders among

elderly patients (Figure 3). Possible drug–drug, drug–herbal

medication, food–drug interactions, and intravenous incom-

patibilities related to these medications were represented as

a percentage of possible clinically significant interactions

encountered per total number of times prescribed (Figure 3).

Only 22 PIMs, according to the Beers criteria, STOPP/

START criteria, or latest clinical practice guidelines were

prescribed during the study period. PIMs ordered on more

than one occasion were ipratropium, lorazepam, haloperidol,

ASA, and dimenhydrinate (prescribed 3, 2, 2, 2, and 2 times,

respectively). Adverse events were deemed possible in

20 of these cases, 10 of which were due to inappropriate

combinations of drugs and excessively high dosages.

On two occasions, medication was regarded unnecessary

by the pharmacist. Intervention proposals to stop or change

drugs, monitor effects, or educate patients were accepted in

19 (86.36%) occasions (Table S1).

The appropriateness of the drug formulation for each

patient was also evaluated and coded following NFC

(EphMRA [The European Pharmaceutical Market Research

Association] New Form Code) classification. Only 23 drug

formulations were interpreted as inappropriate by phar-

macists. For the most part, swallowing difficulties among

patients or crushing or splitting of oral solid ordinary film-

coated tablets (ABC, n=15), oral solid retard film-coated

tablets (BBC, n=3), oral solid ordinary enteric-coated tablets

(ABD, n=2), and oral solid retard tablets (BAA, n=2) caused

the problem. Finally, as intramuscular injection is not a favor-

able route of administration in the elderly, prescription of a

parenteral ordinary IM ampoule (FMD) instead of an oral

pharmaceutical form led to intervention in one order. How-

ever, on 14 of these occasions, suitable drug formulation was

not available in the hospital pharmacy, and three occasions

resulted from an error in the hospital information system, and

the patient was administered the correct form of the drug.

Discussion
This study found that pharmacists contribute to health care

provisions, as members of interdisciplinary geriatric teams

in Turkey, by proposing a large number of accepted inter-

ventions to a wide variety of DRPs, different classes, and

pharmaceutical forms of drugs.

Aging is associated with an increase in medication use

parallel to the increase in chronic diseases and geriatric

syndromes.3,7,27 Based on this paper’s findings, patients’

orders consisted of an average of 8.17 medications. This

paper supports previous studies reporting an average of

7.2–9 medications taken by patients daily.17,19,28,29 A slightly

high number (mean 11.4 drugs) was reported in a study in

Belgium.20

While pharmacotherapy contributes to a patient’s general

state of well-being, all medications also have a risk of adverse

or unwanted effects. Although the number of prescribed

drugs or possible DRPs was not different in patients with

renal impairment, pharmacists must focus on drug doses as

both aging and poor renal functions may alter drug metabo-

lism leading to untoward consequences and interactions.

The number of DRPs was not different in older patients

(65–79 years vs $80 years) in our study, which matches the

previous findings that age does not have a direct effect on

Figure 3 Most frequently ordered medications and possible interaction or incompatibility risk in function of their prescription frequency. (numbers above each bar
represent total counts.)

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adverse drug events (ADEs).30 It is widely accepted that the

higher the number of drugs, the higher the number of DRPs,

and polypharmacy is a known risk factor in the development

of DRPs.2,3,6,7 In accordance, this study found a positive

correlation between the number of medications and DRPs.

Polypharmacy was present in most of the orders (87.5%), and

the DRP count was higher in the presence of polypharmacy.

DRPs have a significant impact on health, and ADEs

are an important component of DRPs. It is estimated that,

one in every ten elderly patients experience ADEs during

or leading to their hospital stay.31 In our study, in 71% of

the cases, ADE possibility was recognized as a problem.

The main cause of this possible problem was determined

as drug interactions (44.4%). This study’s results indicate

that geriatric patients’ orders must be reviewed by focus-

ing on drug interactions. Regardless of the problem type,

drug interactions were also the leading cause of problems

(40.1%) in all DRPs. Clinically significant interactions were

the main factor in pharmacist interventions in a geriatric day

unit and orthogeriatric wards in another study with rela-

tive compatibility to our results (21.1% and 30.4% of the

interventions, respectively).2 In another study conducted in

Turkey, inappropriate combination of drugs was accounted

as the reason for 29.5% of the overall DRPs in the general

internal medicine ward.11

A total of 329 interventions were recommended by the

pharmacist, and 85.4% of these interventions were accepted

by the treating physician in this study. Comparable accep-

tance rates were reported in a study focused on the imple-

mentation of ward-based pharmacy services in Belgium.17

The high acceptance rates indicate that, although clinical

pharmacy is a new concept in Turkey, the physicians in the

geriatric ward of the hospital is open to collaboration with

pharmacists. The most common interventions were moni-

toring drug therapy (monitoring ECG, serum electrolytes,

bleeding risk, vitals, anticholinergic side effects; 31%),

stopping drug use (20.1%), and changing dosage (14%) or

instructions for use (13.4%) in this study. Interestingly, the

most common interventions were cessation or dose alteration

of drugs in three studies, where an average of 9.6–11.5 medi-

cations was used,15,20,32 and monitoring drug therapy was the

second most prevalent intervention in one of them.15 Taken

these results into account, it may be assumed that, when the

number of drugs used by patients increases, pharmacists’ and

geriatricians’ efforts to simplify patients’ therapy outweigh

the need for monitoring.

According to the ATC classification system, drugs

affecting the nervous system (N), alimentary tract and

metabolism (A), cardiovascular system (C), and blood and

blood-forming organs (B) were the most frequently ordered

drugs. In a study from Brazil, N-, A-, and C-class drugs were

mostly prescribed for patients above 60 years.33 Likewise,

Recoche et al34 and Somers et al20 reported that C-, N-,

A-, and B-class drugs were the most frequently prescribed

drugs for frail elderly inpatients. Pantoprazole was the most

frequently ordered medication in this study (53.5% of total

orders). The reason for this high rate may be due to concurrent

enoxaparin, ASA, or sertraline use (30%, 16%, and 22.5% of

total orders) and the presence of conditions that can increase

the risk of bleeding. Accordingly, monitoring bleeding risk

was proposed by the pharmacist as an intervention when the

medications were prescribed.

Delirium incidences increase in patients over 65 years,

and in selected patients, haloperidol or second-generation

antipsychotics can be used to reduce agitation and

hyperactivity.35,36 In this study, quetiapine was ranked first

among medications with the highest possible DRP count

among nervous system drugs and was also found to almost

always (97.5%) cause possible drug interactions when

prescribed. As polypharmacy is a factor known to increase

mortality in patients with delirium,36 pharmacists should

control quetiapine orders for interactions and other DRPs.

Depression is common in older individuals and selective

serotonin reuptake inhibitors (SSRIs) are prescribed as

first-line treatment, though drug interactions are common

in patients with polypharmacy.37 Consistent with this find-

ing, sertraline was the overall sixth most prescribed drug in

this study. This drug was also among medications with the

highest possible DRP count and deemed to cause possible

drug interaction 31% of the times that it was prescribed. This

paper recommends that particular attention be paid to the

prescription of SSRIs in elderly patients when polypharmacy

is present. The most noted interaction with either quetiapine

or sertraline was the possibility of QTc prolongation in this

study. The categories of intervention recommendations

(monitoring serum electrolytes and ECG, or stopping or

reducing the dosage of the drug) were similar to those of

another study investigating drug-induced QT prolongation.38

Therefore, this paper suggests that pharmacists perform a

thorough medication review and recommends monitoring

ECG in patients using drugs with known risk of QT interval

prolongation taking additional risk factors such as advanced

age, gender, and electrolyte derangements into consideration

in elderly population.38

Potentially inappropriate prescribing is highly preva-

lent among geriatric patients.3 Di Giorgio et al39 reported

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that 49% and 27% of the geriatric patients had at least one

PIM during hospitalization period according to Beers and

STOPP criteria, respectively. In a study from Turkey, PIMs

were found in 19.5% of elderly patients admitted to internal

medicine ward.19 Conversely, only 22 PIMs were present

in 21 orders (10.5%) in this study. The reason for this low

prevalence may be due to patients’ treatment being under-

taken by geriatric specialists. Indeed, a study reported that

patients discharged from geriatric wards were found to have

lower prevalence of PIMs compared to those discharged

from an internal medicine ward.28 The acceptance rates of

intervention recommendations for resolving PIMs (patient

counseling, dosage change, monitoring therapy, and stop-

ping drug) were high (86.36%) in this study. Pharmacists in

Turkey should ensure that their knowledge is up-to-date and

follow current guidelines to ensure that they make accurate

and valid contributions to geriatric patient care as members

of the interdisciplinary team.

Swallowing difficulties have particular importance in

clinical pharmacy practice as oral solid pharmaceutical forms

are usually needed to be split or crushed. As a result, the

pharmacokinetics and stability of these drugs may alter

causing ADEs or undertreatment. The need for giving the

drugs via nasogastric tube is further complicated, as drugs

can cause clogging of the feeding tube or drug-enteral nutri-

tion interactions.40 According to this study’s results, only 23

drug formulations’ pharmaceutical form was deemed inap-

propriate by pharmacists. Swallowing difficulties and the need

for dosage reduction resulted in crushing or splitting of oral

solid ordinary/retard film-/enteric-coated tablets and oral solid

retard tablets in 22 cases. Recommended pharmaceutical form

change could not be accepted in 14 of these cases because the

suitable form was not available in the hospital formulary. This

paper suggests that hospital pharmacists’ awareness of this

geriatric syndrome should be extended in Turkey. Consider-

ing the needs of special populations, more than one choice

of pharmaceutical form (oral liquid, oral immediate release,

or patch formulations) for each highly prescribed active

ingredient should be made available to hospital pharmacies.

Finally, making comparisons with other studies was dif-

ficult, mainly because most of the previous studies did not

report DRPs, their causes, or recommended intervention

categories in accordance with standardized classification

systems. This study supports the use of the PCNE classifica-

tion systems for documenting clinical pharmacy activities,

both for standard record keeping and facilitating scientific

data sharing and comparison across Turkey and Europe.

Limitations
In this study, pharmacist interventions were evaluated retro-

spectively. The pharmacists assessed and defined the DRPs

prior to ward rounds. Therefore, DRPs were not classified

as possible or actual (manifest) problems. Although the

acceptance status of the recommended interventions was

recorded, the outcomes were not determined with follow-up

evaluations due to time and resource restrictions. As par-

ticipation of pharmacists in geriatric assessment teams is a

fairly new practice in Turkey, this study was conducted in

one hospital. This setting resulted in a relatively small sample

size and may be considered another limitation of the study.

Based on this study’s findings, it may be more beneficial to

reassess frequently encountered DRPs and associated drugs

in subgroups of patients with the outcome analysis of phar-

macist interventions.

Conclusion
The present study highlights the ways in which clinical

pharmacy services can be instrumental in a geriatric ward.

Pharmacists must be vigilant about ADEs and drug interac-

tions as these issues are the most frequently encountered

problems and the most common causes of problems,

respectively. This study found that pharmacists may

need to suggest monitoring drug therapy, stopping drugs,

and changing dosages or instructions for use frequently.

Raising awareness of the lack of available pharmaceutical

form choices for highly prescribed medications in hospital

formularies can reduce the problems associated with

splitting or crushing of oral solid pharmaceutical forms.

Polypharmacy, alterations in pharmacokinetics and phar-

macodynamics of drugs, is largely unavoidable in many

geriatric inpatients. The participation of pharmacists in

geriatric assessment teams can assist geriatric specialists

in rational therapeutic decision-making and improving care

quality. The findings of this study suggest that advanced

collaboration among geriatricians and pharmacists as

well as other health care professionals is possible and

preferable in an interdisciplinary geriatric team in Turkey.

Pharmacists’ recommendations on a wide variety of DRPs

and different classes and pharmaceutical forms of drugs

have been accepted by physicians. The results may also

be used to extrapolate and construct a feasible standard

operating model that defines both the role of the pharmacist

and the pharmacist’s relationship with other health care

professionals, leading to the effective use of resources in

the Turkish health care system.

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Acknowledgments
The authors would like to thank Prof Fehmi Akçiçek, MD

(Head of the Department), for permitting them to conduct this

study in the Division of Geriatrics, Department of Internal

Medicine, Faculty of Medicine, Ege University, Izmir,

Turkey. The authors would also like to thank Prof Fulden

Saraç, MD, and Assoc Prof Sevnaz Şahin, MD, for their kind

help and encouragement.

Disclosure
The authors report no conflicts of interest in this work.

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38. Buss VH, Lee K, Naunton M, Peterson GM, Kosari S. Identification of
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Supplementary material

Table S1 Types and causes of problems, proposed interventions, and acceptance status for proposed interventions

Cause Intervention Acceptance

Problem: none (n=44)

Problem: effect of drug treatment not optimal (n=20)

Inappropriate combination of drugs* (n=6) Drug changed (n=1) Fully accepted (n=1)

Dosage changed (n=1) Accepted; implementation
unknown (n=1)

Monitoring required (n=4) Fully accepted (n=2)

not accepted: not feasible (n=1)

not accepted: other (n=1)

Inappropriate combination of drugs* + inappropriate timing of
administration and/or dosing intervals (n=2)

Instructions for use changed (n=2) Fully accepted (n=1)

Partially accepted (n=1)

Inappropriate combination of drugs* + patient education
required (n=5)

Patient (drug) counseling (n=1) Fully accepted (n=1)

Patient (drug) counseling + instructions
for use changed (n=3)

Fully accepted (n=3)

spoken to family member/caregiver (n=1) Fully accepted (n=1)

Inappropriate drug form (n=1) Drug changed (n=1) Fully accepted (n=1)

Drug dose too low (n=1) Dosage changed (n=1) Fully accepted (n=1)

Drug dose too low + patient education required (n=1) Patient (drug) counseling (n=1) Fully accepted (n=1)

Dosage regimen not frequent enough (n=1) educational discussion started during
routine rounds (n=1)

Fully accepted (n=1)

Wrong drug administered (n=1) Drug changed (n=1) Partially accepted (n=1)

Patient stores drug inappropriately + patient education required
(n=1)

Patient (drug) counseling (n=1) Fully accepted (n=1)

Addition of new drug might be needed due to microbial
resistance (n=1)

new drug started (n=1) Fully accepted (n=1)

Problem: effect of drug treatment not optimal + adverse drug event (possibly) occurring (n=24)

Inappropriate combination of drugs* (n=2) Monitoring required (n=1) Partially accepted (n=1)

Drug stopped (n=1) Partially accepted (n=1)

Drug administered via wrong route (n=22) Instructions for use changed (n=22) Fully accepted (n=22)

Problem: untreated symptoms or indication (n=20)

no drug treatment in spite of existing indication (n=20) new drug started (n=20) Fully accepted (n=9)

Partially accepted (n=2)

not accepted: not feasible (n=5)

not accepted: other (n=4)

Problem: untreated symptoms or indication + adverse drug event (possibly) occurring (n=1)

Inappropriate combination of drugs* + no drug treatment in spite
of existing indication (n=1)

new drug started (n=1) Partially accepted (n=1)

Problem: adverse drug event (possibly) occurring (n=240)

Inappropriate drug according to guidelines/formulary (n=10) Drug stopped (n=10) Fully accepted (n=4)

Partially accepted (n=2)

Accepted; not implemented (n=1)

not accepted: other (n=2)

Acceptance status unknown (n=1)

(Continued)

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Table S1 (Continued)

Cause Intervention Acceptance

Inappropriate drug according to guidelines/
formulary + inappropriate combination of drugs (n=5)

Drug stopped (n=2) Partially accepted (n=2)

Drug stopped + monitoring required
(n=2)

Fully accepted (n=1)

Partially accepted (n=1)

Monitoring required (n=1) Fully accepted (n=1)

Inappropriate drug according to guidelines/formulary + drug
dose too high (n=5)

Dosage changed (n=2) Partially accepted (n=2)

Drug stopped (n=2) Fully accepted (n=1)

Partially accepted (n=1)

Monitoring required (n=1) Fully accepted (n=1)

Inappropriate drug (within guidelines but otherwise
contraindicated) (n=23)

Drug changed (n=2) Fully accepted (n=1)

Acceptance status unknown (n=1)

Dosage changed (n=6) Fully accepted (n=2)

not accepted: not feasible (n=4)

Instructions for use changed (n=2) Fully accepted (n=2)

Drug stopped (n=10) Fully accepted (n=4)

Partially accepted (n=2)

not accepted: not feasible (n=2)

not accepted: other (n=1)

Acceptance status unknown (n=1)

Monitoring required (n=3) Fully accepted (n=3)

Inappropriate drug (within guidelines but otherwise
contraindicated) + drug dose too high (n=4)

Dosage changed (n=3) Fully accepted (n=3)

Drug stopped (n=1) Partially accepted (n=1)

Inappropriate drug (within guidelines but otherwise
contraindicated) + drug dose too high + no or inappropriate
outcome monitoring (n=1)

Dosage changed + monitoring required
(n=1)

Fully accepted (n=1)

Inappropriate drug (within guidelines but otherwise
contraindicated) + dosage regimen too frequent (n=1)

Drug stopped (n=1) Fully accepted (n=1)

Inappropriate drug (within guidelines but otherwise
contraindicated) + no or inappropriate outcome monitoring (n=1)

Monitoring required (n=1) Fully accepted (n=1)

Inappropriate combination of drugs* (n=67) Written information provided only (n=1) Fully accepted (n=1)

Drug changed (n=4) Fully accepted (n=1)

Partially accepted (n=1)

not accepted: not feasible (n=1)

Acceptance status unknown (n=1)

Drug changed + monitoring required
(n=2)

Partially accepted (n=1)

not accepted: not feasible (n=1)

Dosage changed (n=3) Fully accepted (n=2)

not accepted: other (n=1)

Instructions for use changed (n=2) Fully accepted (n=1)

not accepted: not feasible (n=1)

Drug stopped (n=11) Fully accepted (n=3)

Partially accepted (n=5)

not accepted: not feasible (n=1)

not accepted: other (n=2)

Monitoring required (n=44) Fully accepted (n=42)

not accepted: other (n=1)

not accepted: unknown reason
(n=1)

(Continued)

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Table S1 (Continued)

Cause Intervention Acceptance

Inappropriate combination of drugs* + too many drugs
prescribed for indication (n=1)

Drug stopped + monitoring required
(n=1)

Partially accepted (n=1)

Inappropriate combination of drugs* + too many drugs
prescribed for indication + no or inappropriate outcome
monitoring (n=2)

Drug stopped + monitoring required
(n=1)

Partially accepted (n=1)

Monitoring required (n=1) Fully accepted (n=1)

Inappropriate combination of drugs* + drug dose too high (n=1) Dosage changed (n=1) Fully accepted (n=1)

Inappropriate combination of drugs* + no or inappropriate
outcome monitoring (n=27)

Drug changed + monitoring required
(n=1)

Fully accepted (n=1)

Drug stopped + monitoring required
(n=5)

Fully accepted (n=2)

Partially accepted (n=3)

Monitoring required (n=21) Fully accepted (n=21)

Inappropriate combination of drugs* + patient education
required (n=11)

Patient (drug) counseling (n=6) Fully accepted (n=4)

Accepted; implementation
unknown (n=1)

Acceptance status unknown (n=1)

spoken to family member/caregiver (n=5) Fully accepted (n=5)

Inappropriate duplication of therapeutic group or active
ingredient (n=1)

Drug stopped (n=1) not accepted: not feasible (n=1)

Inappropriate duplication of therapeutic group or active
ingredient + too many drugs prescribed for indication (n=1)

Drug stopped (n=1) Partially accepted (n=1)

Inappropriate duplication of therapeutic group or active
ingredient + drug dose too high (n=1)

Drug stopped (n=1) Fully accepted (n=1)

no drug treatment in spite of existing indication (n=2) new drug started (n=2) Fully accepted (n=1)

not accepted: not feasible (n=1)

Inappropriate drug form (n=19) Drug changed (n=2) Fully accepted (n=1)

not accepted: other (n=1)

Formulation changed (n=13) Fully accepted (n=1)

Partially accepted (n=1)

Accepted; not implemented (n=7)

Accepted; implementation
unknown (n=3)

Acceptance status unknown (n=1)

Instructions for use changed (n=4) Fully accepted (n=2)

not accepted: not feasible (n=1)

Acceptance status unknown (n=1)

Inappropriate drug form + prescribed drug not available (n=1) Instructions for use changed (n=1) Accepted; not implemented (n=1)

Drug dose too low (n=2) Dosage changed (n=1) Fully accepted (n=1)

Dosage changed + new drug started
(n=1)

Acceptance status unknown (n=1)

Drug dose too high (n=26) Dosage changed (n=22) Fully accepted (n=14)

Partially accepted (n=6)

not accepted: other (n=1)

Acceptance status unknown (n=1)

Instructions for use changed (n=1) Fully accepted (n=1)

new drug started (n=1) Fully accepted (n=1)

Monitoring required (n=2) Fully accepted (n=2)

Drug dose too high + no or inappropriate outcome monitoring
(n=1)

Drug stopped + monitoring required
(n=1)

Fully accepted (n=1)

(Continued)

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Table S1 (Continued)

Cause Intervention Acceptance

Dosage regimen too frequent (n=3) Dosage changed (n=2) not accepted: other (n=2)

Instructions for use changed (n=1) Fully accepted (n=1)

Dose timing instructions wrong, unclear or missing + no or
inappropriate outcome monitoring (n=1)

Monitoring required (n=1) Partially accepted (n=1)

Drug administered via wrong route (n=3) Instructions for use changed (n=3) Fully accepted (n=2)

Acceptance status unknown (n=1)

Patient uses/takes less drug than prescribed or does not take the
drug at all + patient education required (n=2)

Patient (drug) counseling (n=1) Fully accepted (n=1)

spoken to family member/caregiver (n=1) Fully accepted (n=1)

Patient takes food that interacts + patient unable to use drug/
form as directed + patient education required (n=1)

Patient (drug) counseling (n=1) Fully accepted (n=1)

no or inappropriate outcome monitoring (n=11) Drug changed (n=1) Partially accepted (n=1)

educational discussion started during
routine rounds (n=5)

Fully accepted (n=5)

Monitoring required (n=5) Fully accepted (n=5)

no or inappropriate outcome monitoring + patient education
required (n=2)

Patient (drug) counseling (n=1) Fully accepted (n=1)

Patient (drug) counseling + monitoring
required (n=1)

Fully accepted (n=1)

Patient education required (n=4) Patient (drug) counseling (n=4) Fully accepted (n=4)

Problem: adverse drug event (possibly) occurring + unnecessary drug-treatment (n=1)

Inappropriate combination of drugs* (n=1) Drug stopped (n=1) Fully accepted (n=1)

Problem: unnecessary drug treatment (n=19)

Inappropriate drug according to guidelines/
formulary + inappropriate combination of drugs* (n=1)

Drug stopped (n=1) Fully accepted (n=1)

Inappropriate drug according to guidelines/formulary + patient
education required (n=1)

Patient (drug) counseling + drug stopped
(n=1)

Fully accepted (n=1)

no indication for drug (n=3) Drug stopped (n=3) Fully accepted (n=3)

Inappropriate duplication of therapeutic group or active
ingredient (n=6)

Instructions for use changed (n=1) not accepted: other (n=1)

Drug stopped (n=5) Fully accepted (n=3)

Accepted; implementation
unknown (n=1)

not accepted: other (n=1)

Too many drugs prescribed for indication (n=4) Drug stopped (n=4) Fully accepted (n=4)

Drug dose too high (n=2) Dosage changed (n=2) Fully accepted (n=2)

Duration of treatment too long (n=2) Monitoring required (n=2) Fully accepted (n=2)

Problem: more suitable drug strength is available (n=2)

Inappropriate drug form (n=2) Formulation changed (n=2) Accepted; not implemented (n=2)

Problem: wrong administration route (n=2)

Drug administered via wrong route (n=2) Instructions for use changed (n=2) Fully accepted (n=2)

Note: *Includes intravenous incompatibility.

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Vol. 5 | Issue 2 | March-May 2014 Journal of Basic and Clinical Pharmacy 49 

A clinical study on drug-related problems associated with
intravenous drug administration

Abstract

Background: Infusion therapy through intravenous (IV) access is a therapeutic option used in the treatment of
many hospitalized patients. IV therapy is complex, potentially dangerous and error prone. The objectives were
to ascertain the drug‑related problems (DRPs) involved in IV medication administration and further to develop
strategies to reduce and prevent the occurrence of DRPs during IV administration.
Materials and Methods: A prospective observational study was carried out for a period of 4 months. Patients
receiving more than two medications through IV route were included and studied.
Results: Of 110 patients, 76 (69.09%) were male and the rest were female. Nearly, half of the patients (46.3%, n = 51)
were reported with DRPs. Of the 80 DRPs (72.72%) documented, 61 problems (55.4%) were seen in patients
given IV medications through peripheral line. Among the DRPs majority seen were incompatibilities (40.9%,
n = 45), followed by complications developed (12.7%, n = 14), errors in rate of administration (10.9%), and
dilution errors (8%). To study the association of DRPs among gender, statistical analysis was performed and
significant association was seen between DRPs and gender (P = 0.03).
Conclusion: Among the reported DRPs, simultaneous IV administration of two incompatible drugs was the main
predicament faced.

Key words:
Drug‑related problems, error, intravenous

A. Vijayakumar, E. V. Sharon, J. Teena, S. Nobil, I. Nazeer
Drug and Poison Information Center, Department of Pharmacy Practice,

KMCH College of Pharmacy, Coimbatore, Tamil Nadu, India

Address for correspondence:
Mr. A. Vijayakumar,

Drug and Poison Information Center, Department of Pharmacy Practice,
KMCH College of Pharmacy, Coimbatore ‑ 641 048, Tamil Nadu, India.

E‑mail: [email protected]

Introduction

Intravenous (IV) therapy is complex, potentially dangerous
and error prone, thus the need for strategies to reduce the risk
and complications.[1] Infusion therapy through IV access is a
therapeutic option used in the treatment of many hospitalized
patients.[2] Infusion medications are associated with high risk
of harm. Once injected, reversal is almost impossible unless an
antidote exists.[3] The IV route of medication administration
has many advantages and benefits. The most important are
the immediate therapeutic effect of medications. It can sustain
high plasma drug levels and may be used when a person has
difficulty in swallowing.[4] The drug when given intravenously
will reach the target rapidly.[5] Thus, IV route is the preferred
route when the patient is critically ill. However, there are
also a lot of possible direct and negative side effects such as
pulmonary complications, thrombophlebitis, and infection
with the possibility of sepsis.[4] There have been reports of

death and harm following medication errors such as wrong
dose drug diluents and cross contamination errors. Thus,
the primary focus should be to identify IV therapy associated
drug‑related problems (DRPs).[3]

Drug‑therapy problems in intravenous
administration
Drug‑therapy (related) problem can be defined as an event
or circumstance involving drug treatment that actually
or potentially interferes with the patient experiencing an
optimum outcome of medical care.[6] DRPs can originate when
prescribing, dispensing or administering medications. It may
lead to substantial morbidity and mortality as well as increase
the health care expenditure, thus affecting both patients and
the society.[7]

Wrong diluents
In the German and French hospitals, the most frequent error
was preparing the medicine with the wrong diluents. The use

Original Article

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Quick Response Code

DOI:

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Vijayakumar, et al.: Drug related problems in IV administration

Journal of Basic and Clinical Pharmacy Vol. 5 | Issue 2 | March-May 2014 50 

of the wrong diluents may cause a reduction in the solubility
of the medicine powder being reconstituted that can lead to
powder particulates being administered to the patient. The use
of the wrong diluents can also lead to a reduction in the stability
and activity of medicine and possible drug precipitation.[8]

Incompatibilities
Intravenous access is usually limited and often need to
have medications administered simultaneously through the
same line. This is facilitated by a y‑site connector where the
medications mix in the lumen of the tubing for up to 1 min
prior to being infused into the patient. Not all medications
can be mixed together as all are not compatible with each
other.[9] Incompatibility is an undesirable reaction that occurs
between the drug and the solution, container or another drug.
Administering incompatible medications together through
the same line can result in negative consequences and even
death in some extreme cases.[10] The three incompatibilities
associated with IV administration are physical, chemical and
therapeutic incompatibility.[11]

Wrong rate and wrong time errors
It was reported that at UK hospitals, the most frequent IV
medication errors were related to the administration rate,
usually higher than that recommended. The administered
drug characteristics, fast rates of drug administration are
associated with pain, phlebitis, and other complications.[8]

Complications of intravenous therapy
Intravenous therapy presents a potential risk to patient safety
with associated risks varying from minor complications to
death. As more number of patients are becoming acutely ill,
the numbers of patients requiring IV therapies are increasing.
Maintaining the patient’s vascular access throughout treatment
is difficult because a number of complications including phlebitis,
infiltration, extravasations, and infections may occur.[12]
Complications increase hospital stays, duration of therapy, and
can also put the patients at risk of other medical problems.[13]

Pharmacist role in intravenous administration
The mission of the profession of pharmacy is to improve public
health through ensuring safe, effective, and appropriate use of
medications.[14] Clinical Pharmacist can play a significant role
in nurse training as an effective method to reduce the rate of
errors in the hospital. One obvious solution to aid in the process
of DRPs could be considering pharmacy services in IV product
preparation by implementing protocol prepared by Clinical
Pharmacist and establishment of reporting error systems.[15]

Pharmacist role to provide expert advice on compatibility
and stability for the use of multiple drugs if required for
IV administration, update staff on new clinical practice
guidelines and help to interpret guidelines as they apply to
patients with advanced illness. Thus, permanent supervision
and involvement of Clinical Pharmacist is important.[16]

Materials and Methods

A prospective observational study was carried out over the
duration of 4 months from April, 2013 to July, 2013 at Private

Corporate Hospital, Coimbatore, India and the study was
approved by Institutional Ethics Committee. The patients
who received more than two IV medications irrespective of
their age and gender were enrolled in our study. Patients from
Intensive Care Unit (ICU) and Oncology Department were
excluded from the study.

Definition, assessment, and description of
intravenous drug‑related problems
Intravenous DRP was defined as an error of using wrong
rate or dilution in the context of administering medications
intravenously. We addressed DRPs as wrong rate, wrong
dilution procedure, incompatibility complications developed
after IV administration. The subjects in this study were
classified based on their diagnosis into various departments
(Neurology, Cardiology, Endocrinology, Nephrology, Ortho
etc.). DRPs were further categorized based on type of IV
administration (IV bolus, continuous IV infusion).

Data collection
For each patient, basic demographic characteristics as
well as occurrence and descriptive factors of each IV
DRPs were documented into a structured case record
form. DRPs documented include incompatibilities, rate of
administration errors, dilution errors, and complications
developed. Incompatibilities were categorized into actual
and observed. Actual incompatibilities were referred
to those incompatibilities documented on a theoretical
basis from the medication chart, whereas observed
incompatibilities were referred to those incompatibilities
that were seen in patients. Confidentiality of the entire
patient’s data was maintained.

Statistical analyses
Drug‑related problems and its impact on gender and venous
access site, since patients were treated with central and
peripheral line were investigated. Data were analyzed by
using SPSS software version 14.0.1 manufactured by SPSS
Inc., Chicago, IL.

Results

A total of 110 patients were involved in this study during
the period of 4 months. The male (69.09%) population was
predominant when compared with the female population
[Table 1]. Majority of the male were seen in the age group of
60‑69 (15.45%) years, whereas female were seen mainly in the
age group of 40‑49 (9.09%) years.

The DRPs seen in our study population receiving IV
medications were incompatibilities, complications, rate
of administration error and dilution errors. Among the
110 patients, nearly half of the patients (46.3%, n = 51)
were reported with DRPs. Patients receiving IV medications
through peripheral line (82.72%, n = 91) was predominant
than those receiving central lines (17.27%, n = 19). Out of 80
DRPs (72.72%), 61 problems (55.4%) were seen in patients
given IV medications through peripheral line, whereas
19 (17.27%) DRPs were seen in patients given medications
through the central line [Table 2].

Vijayakumar, et al.: Drug related problems in IV administration

Vol. 5 | Issue 2 | March-May 2014 Journal of Basic and Clinical Pharmacy 51 

Among the DRPs majority were incompatibilities
(40.9%, n = 45), followed by complications developed
(12.7%, n = 14) after IV administrations, errors in the rate of
administration were accounted for 12 patients (10.9%) and
errors in the dilution accounted for nine patients (8%). The
incompatibilities documented were categorized into observed
and actual incompatibilities. Among the 45 incompatibilities
documented, 11.8% (n = 13) of the incompatibilities
were observed [Figure 1] and 29% (n = 32) were actual
incompatibilities. From the observed incompatibilities, the
most common reason for the cause of incompatibility was
the development of precipitate (10.9%, n = 12). Only one
incompatibility was attributed to color change over time.
The most common drugs involved in incompatibilities were

Pantoprazole, Phenytoin, Mannitol and Pipercillin. Based
on our observation and results, IV drug compatibility‑alert
card was prepared in order to enhance the rational use of IV
medication and patient safety [Figure 2].

The most common IV incompatibilities were reported
from Neurology Department (10.9%, n = 12), out
of which three were observed and nine were actual
incompatibilities. It was followed by Cardiology Department
(7.2%, n = 8), Endocrinology (5.4%, n = 6), Nephrology. Of
45 incompatibilities, majority of the incompatibilities were
seen between one bolus and an infusion (57.7%, n = 26),
incompatibilities between two IV bolus drugs were seen
in 35.55% of the incompatibilities (n = 16) and only three
incompatibilities involved two infusion drugs.

Discussion

This study was carried out to determine the DRPs involved in
IV medication administration and develop strategies to reduce
and prevent the occurrence of DRPs during administration of
IV medications. Such strategies will improve the quality of
preparation and administration of IV medications and reduce
the DRPs in the long run.

The predominance of patients receiving more than two IV
medications were male (69.09%, n = 76) and female receiving
more than two medications were only 30.90% (n = 34).
Our study results are more similar to the study conducted by
Ponni et al., results.[17]

Studies have reported that IV administration of drugs has a
higher risk and severity of errors than any other medication
administration.[18] The DRPs seen in our study population
receiving IV medications were incompatibilities, rate of
administration errors, dilution errors, and complications.
Incompatibilities were dominant than all other DRPs. Among
the 110 patients, nearly half of the patients (46.3%, n = 51)
were reported with DRPs. When compared to other European
studies,[18] it was observed that our study results indicated less
number of DRPs.

In a randomized control trial,[19] majority patients received IV
medications through peripheral line, but the DRPs were seen
mainly in patients with IV medications through the central
line. Whereas in our study, patients receiving IV medications
through peripheral line (82.72%, n = 91) was predominant
than those receiving central lines (17.27%, n = 19). Out of
the 80 DRPs (72.72%) seen, 61 problems (55.4%) were seen
in patients given IV medications through peripheral line,
whereas 19 (17.27%) DRPs were seen in patients given
medications via central line. Since, the study was carried out
only at general and specialty wards, not in ICU.

Direct observational studies performed in the United Kingdom
and Germany revealed overall error rates of 49% and 48%,
respectively.[18] Whereas among the DRPs in our study
majority seen were incompatibilities (40.9%, n = 45),
followed by complications developed (12.7%, n = 14) after
IV administrations, errors in the rate of administration were

Table 1: Gender wise association of variables in study
population
Variables Males Females Relative

risk
95% CI P value

Central line
No error 5 3 1.455 0.823‑2.568 0.1337
Error 10 1

Drug related
problems

Yes 41 11 1.307 1.016‑1.681 0.0360*
No 35 23

Infusion rate error
Yes 8 4 0.9608 0.6305‑1.464 0.8473
No 68 30

Error in dilution
Yes 8 1 1.320 1.010‑1.726 0.1798
No 68 33

Incompatibility
Yes 37 8 1.370 1.070‑1.740 0.0130*
No 39 26

Complications
Yes 13 1 1.410 1.153‑1.730 0.0390*
No 63 33

*P<0.05, CI: Confidence interval

Table 2: Intravenous access site association with
variables in study population
Drug‑related
problems

Central
line

Peripheral
line

Relative
risk

95% CI P value

Complications
Yes 4 10 1.829 0.7072‑4.728 0.2312
No 15 81

Error in dilution
Yes 1 8 0.6235 0.0937‑4.148 0.6098
No 18 83

Infusion rate error
Yes 3 9 1.531 0.5211‑4.500 0.4531
No 16 82

Incompatibilities
Yes 11 34 1.986 0.8679‑4.545 0.0978
No 8 57

CI: Confidence interval

Vijayakumar, et al.: Drug related problems in IV administration

Journal of Basic and Clinical Pharmacy Vol. 5 | Issue 2 | March-May 2014 52 

accounted for 12 patients (10.9%) and errors in the dilution
accounted for nine patients (8%). In contrast, another study
revealed that wrong rate of administration was the most
frequent error, followed by omissions and wrong dose.[20]

Administering incompatible medications together through
the same line can result in negative consequences or death
in extreme cases.[9] The large number of incompatibilities
seen in our study may be due to lack of knowledge
regarding drug incompatibility and their consequences for
the patient.

Among the 45 incompatibilities documented, 11.8% (n = 13)
of the incompatibilities were observed and 29% (n = 32) were
actual incompatibilities. From the observed incompatibilities,
the most common reason for the cause of incompatibility
was the development of precipitate (10.9%, n = 12). Only
one incompatibility was attributed to color change over time.
The most common drugs involved in incompatibilities were
pantoprazole, phenytoin, mannitol, and piperacillin. The
study conducted by Kanji et al., were matched with our study
results.[9]

Results from different studies are difficult to compare
because of differing methods of analysis. Further to study
the significance of DRPs among gender, statistical analysis
was performed. Our results revealed that the relative
risk for all DRPs were >1. It indicates that there is a large
difference between the groups compared. Furthermore,
significant association was observed between total DRPs
and gender (P = 0.03). Similarly, when comparing DRPs
individually significant association was observed in case of
incompatibilities (P = 0.013) and complications (P = 0.039).
Increased complications seen in men possibly are due to the
high number of incompatibilities in men.

Even though, there was a difference between central and
peripheral line, we have performed statistical analysis to
know the risk of individual DRPs among patients with central
and peripheral line. It reveals that there was a significant
difference in cases of infusion rate error, complications and
incompatibilities. However, no significant association was

Intravenous drug incompatibility alert card
Dr

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Acyclovir • C N C I C C C C C N I I C I C C
Amikacin C • I C C C C C C C C I I C C C C
Azithromycin N I • N I I N I N N N C N I I N N
Calciumgluconate C C N • N C I C N C C I I C C I C
Ciprofloxacin I C I N • I I I I N C I I C I I N
Clindamycin C C I C I • C C C C C I I C C C C
Dexamethasone C C N I I C • C C C C I I C C C N
Furosemide C C I C I C C • C C N I I C C C I
Hydrocortisone C C N N I C C C • C C I I C C C N
Mannitol C C N C N C C C C • C I I C C C C
Metaclopramide N C N C C C C N C C • I I C C C C
Pantoprazole I I C I I I I I I I I • I C I N I
Phenytoin I I N I I I I I I I I I • I I I I
Potassiumchloride C C I C C C C C C C C C I • C C C
Pippercillin tazobactam I C I C I C C C C C C I I C • C N
Sodiumbicarbonate C C N I I C C C C C C N I C C • N
Vancomycin C C N C N C N I N C C I I C N N •

C: Compatible, I: Incompatible, N: No data available •: Same Drug

Figure 1: Intravenous Drug Incompatibility Alert Card

Figure 2: Intravenous drug incompatibility

Vijayakumar, et al.: Drug related problems in IV administration

Vol. 5 | Issue 2 | March-May 2014 Journal of Basic and Clinical Pharmacy 53 

3. Cousins DH, Upton DR. Medication error 79: How to prevent IV
medicine errors. Pharm Pract 1997;7:310-1.

4. Bernaerts K, Evers G, Sermeus W. Frequency of intravenous medication
administration to hospitalised patients: Secondary data‑analysis of the
Belgian nursing minimum data set. Int J Nurs Stud 2000;37:101‑10.

5. Ong WM, Subasyini S. Medication errors in intravenous drug
preparation and administration. Med J Malaysia 2013;68:52-7.

6. Mil FV. Drug related problems: A cornerstone for pharmaceutical care.
J Malta Pharm Pract 2005;10:5-8.

7. Ruths S, Viktil KK, Blix HS. Classification of drug‑related problems.
Tidsskr Nor Laegeforen 2007;127:3073‑6.

8. Cousins DH, Sabatier B, Begue D, Schmitt C, Hoppe‑Tichy T.
Medication errors in intravenous drug preparation and administration:
A multicentre audit in the UK, Germany and France. Qual Saf Health
Care 2005;14:190-5.

9. Kanji S, Goddard R, Kanji S, Goddard R, Donnelly R, McIntyre,
Turgeon A, Coons P, et al. Physical Compatibility of Drug Infusions
used in Canadian Intensive Care Units: A Program of Research.
Canadian Patient safety Institute 2010.

10. Newton DW. Drug incompatibility chemistry. Am J Health Syst Pharm.
2009; 66 (4): 348-357.

11. Cayo L. Compatibility of Commonly Used Intravenous Drugs. In:
Pharmacy Practice News. 2010: 41-46.

12. Ingram P, Lavery I. Peripheral intravenous therapy: Key risks and
implications for practice. Nurs Stand 2005;19:55‑64.

13. Complications of peripheral iv therapy. NMIE. 2008; 6 (1): 14-18.
14. Council on Credentialing in Pharmacy, Albanese NP, Rouse MJ.

Scope of contemporary pharmacy practice: Roles, responsibilities,
and functions of pharmacists and pharmacy technicians. J Am Pharm
Assoc (2003) 2010;50:e35-69.

15. Majid AK. The roles of clinical pharmacy in reducing medication
errors. Int Res J Pharm 2012;3:76-83.

16. Abbasinazari M, Zareh‑Toranposhti S, Hassani A, Sistanizad M,
Azizian H, Panahi Y. The effect of information provision on reduction
of errors in intravenous drug preparation and administration by nurses
in ICU and surgical wards. Acta Med Iran 2012;50:771-7.

17. Ponni J, Acthyuth KY, Mohanta GP, Kabalimurthy J. Studies
on the use of intravenous fluid management in the first week of
post-operative period of gastrointestinal surgery. Indian J Pharm
Pract 2012;5:16-20.

18. Westbrook JI, Rob MI, Woods A, Parry D. Errors in the administration
of intravenous medications in hospital and the role of correct procedures
and nurse experience. BMJ Qual Saf 2011;20:1027‑34.

19. Wilson D, Verklan MT, Kennedy KA. Randomized trial of percutaneous
central venous lines versus peripheral intravenous lines. J Perinatol
2007;27:92-6.

20. Wirtz V, Taxis K, Barber ND. An observational study of intravenous
medication errors in the United Kingdom and in Germany. Pharm
World Sci 2003;25:104‑11.

21. Taxis K, Barber N. Causes of intravenous medication errors: An
ethnographic study. Qual Saf Health Care 2003;12:343‑7.

seen in patients receiving IV medications through central and
peripheral line (P > 0.05).

A European study reported that effective strategies are
needed to reduce the harmful errors during IV drug
administration.[21] Based on our observation and results,
IV drug compatibility‑alert card was prepared in order to
enhance the rational use of IV medication and patient safety.

Limitations
The study has certain limitations. Since it was a pilot
study, it was carried out in wards and did not include ICU.
Longer period of data collection from ICU, will definitely be
associated with other IV administration related DRPs. The
time of administration of certain IV medications was different
from the time of data collection. Such data were collected from
patient records and verbally from nurses. Further studies may
be carried out in a large sample size to predict more DRPs.

Conclusion

Although the majority of the DRPs do not cause significant
harmful clinical outcomes to patients, training needs as well
as plans should be proposed to reduce such complexity.
Among the DRPs, simultaneous IV administration of two
incompatible drugs was the main predicament faced. As
the outcome from the study, an IV drug compatibility‑alert
card was prepared and distributed to the wards to help and
minimize any confusion regarding the commonly used IV
drugs. It is recommended that check list should be introduced
in wards to encourage monitoring dilution and administration
rate of IV infusions. Thus, permanent supervision and
involvement of Clinical Pharmacist will improve the quality
of preparation and administration of IV medications and will
also reduce the DRPs.

Acknowledgments

The authors are gratefully thankful to Dr. Nalla G. Palaniswami,
Chairman and Managing Director of Kovai Medical Center and
Hospital, Coimbatore and Dr. Thavamani D. Palaniswami, Trustee,
Kovai Medical Center Research Cancer and Educational Trust,
Coimbatore for providing necessary facilities and continuous
encouragement.

References

1. McDowell SE, Mt‑Isa S, Ashby D, Ferner RE. Where errors occur in the
preparation and administration of intravenous medicines: A systematic
review and Bayesian analysis. Qual Saf Health Care 2010;19:341‑5.

2. Summa‑Sorgini C, Fernandes V, Lubchansky S, Mehta S, Hallett D,
Bailie T, et al. Errors associated with IV infusions in critical care. Can
J Hosp Pharm 2012;65:19‑26.

How to cite this article: Vijayakumar A, Sharon EV, Teena J, Nobil S, Nazeer I.
A clinical study on drug-related problems associated with intravenous drug
administration. J Basic Clin Pharma 2014;5:49-53.

Source of Support: Nil, Conflict of Interest: None declared.

R E S E A R CH

Co-administration of multiple intravenous medicines: Intensive
care nurses’ views and perspectives

Mosopefoluwa S. Oduyale MPharm1 | Nilesh Patel PhD, BPharm (Hons)1 |

Mark Borthwick MSc, BPharm (Hons)2 | Sandrine Claus PhD, MRSB, MRSC3

1Reading School of Pharmacy, University of

Reading, Reading, UK

2Pharmacy Department, John Radcliffe

Hospital, Oxford University Hospitals NHS

Foundation Trust, Oxford, UK

3LNC Therapeutics, Bordeaux, France

Correspondence

Mosopefoluwa S. Oduyale, Reading School of

Pharmacy, University of Reading, Harry

Nursten Building, Room 1.05, Whiteknights

Campus, Reading RG6 6UR, UK.

Email: [email protected]

Funding information

University of Reading

Abstract

Background: Co-administration of multiple intravenous (IV) medicines down the

same lumen of an IV catheter is often necessary in the intensive care unit (ICU) while

ensuring medicine compatibility.

Aims and objectives: This study explores ICU nurses’ views on the everyday practice

surrounding co-administration of multiple IV medicines down the same lumen.

Design: Qualitative study using focus group interviews.

Methods: Three focus groups were conducted with 20 ICU nurses across two hospi-

tals in the Thames Valley Critical Care Network, England. Participants’ experience of

co-administration down the same lumen and means of assessing compatibility were

explored. All focus groups were recorded, transcribed verbatim, and analysed using

thematic analysis. Functional Resonance Analysis Method was used to provide a

visual representation of the co-administration process.

Results: Two key themes were identified as essential during the process of co-admin-

istration, namely, venous access and resources. Most nurses described insufficient

venous access and lack of compatibility data for commonly used medicines (eg, anal-

gesics and antibiotics) as particular challenges. Strategies such as obtaining additional

venous access, prioritizing infusions, and swapping line of infusion were used to man-

age IV administration problems where medicines were incompatible, or of unknown

or variable compatibility.

Conclusions: Nurses use several workarounds to manage commonly encountered

medication compatibility problems that may lead to delays in therapy. Organizations

should review and tailor compatibility resources towards commonly administered

medicines using an interdisciplinary approach. Developing a clinical decision-making

pathway to minimise variability while promoting safe co-administration practice

should be prioritised.

Relevance to clinical practice: This study highlights several ways ICU nurses are able

to manage challenges associated with co-administration and the need for the devel-

opment of a more robust and comprehensive compatibility resource that is relevant

to everyday practice through collaboration between nurses and pharmacists.

Received: 17 July 2019 Revised: 25 November 2019 Accepted: 20 December 2019

DOI: 10.1111/nicc.12497

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium,

provided the original work is properly cited.

© 2020 The Authors. Nursing in Critical Care published by John Wiley & Sons, Ltd on behalf of British Association of Critical Care Nurses.

156 Nurs Crit Care. 2020;25:156–164.wileyonlinelibrary.com/journal/nicc

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K E YWORD S

co-administration, compatibility, functional resonance analysis method, intravenous

1 | BACKGROUND

Patients admitted to intensive care units (ICU) are prescribed numerous

medicines delivered by continuous intravenous (IV) infusion. The num-

ber of prescribed IV infusions usually exceeds the number of venous

access sites or available lumens. Intensive care nurses are then forced to

request additional venous access, or alternatively co-administer either

continuous or intermittent infusions down the same lumen using a

Y-site connector, meaning the medicines mix in the venous access

lumen before entering the bloodstream. Medicines administered in this

way are at risk of physicochemical incompatibilities. Medicine incompat-

ibilities are considered to be in vitro physical or chemical reactions that

occur between two or more IV medicines combined in the same cathe-

ter lumen.1 Physical incompatibilities cause visible changes, often pre-

senting as precipitates, whereas chemical incompatibilities are not

visible and are considered significant when more than 10% degradation

of one or more of the medicines in solution occurs.2

Physicochemical reactions may impair the therapeutic efficacy of

the medicines or result in venous catheter occlusion, toxic compound

formation, embolism, or local/systemic inflammatory reactions.1,3-6

There are cases of life threatening pulmonary embolism, ventricular

failure, and ineffective therapy in humans, prompting the Food and

Drug Association to issue safety alerts.7-11 These adverse effects

harm patients and increase costs for hospitals.12 Thus, compatibility

must be assured prior to the co-administration of medicines.

Nurses are at the forefront of co-administration practice; however,

the majority of co-administration studies focus on frequencies of com-

bining incompatible medicines, generation of compatibility data, and

clinical complications of incompatibilities13-16 (Benlabed et al, 2018).

There is an evidence gap regarding nurses’ experience of processes

involved in co-administration of multiple medicines down the same

lumen and potential challenges experienced. Because the problem is

common,17 an understanding of the process based on nurse experiences

could prove useful by improving our knowledge, and revealing potential

practical interventions. This could help make patient care more efficient,

minimise challenges encountered by nurses during the process of co-

administration, and ultimately promote safer co-administration practice.

Co-administration of multiple medicines down the same lumen can

be viewed as a complex socio-technical system involving interaction

between people, technology, and devices in a physical and organisational

environment. Viewed like this, outcomes of services provided are inter-

connected and non-linear,15 and so can be investigated using a non-linear

method such as Functional Resonance Analysis Method (FRAM).16 The

FRAM results in a model that is a visual representation of all the activities

connected to the process of co-administration of medicines. Using FRAM

reveals interconnections and adjustments made within work processes

that a linear approach may be unable to discover. A key advantage of

FRAM is that it can be used to assess how things go right as well as how

things go wrong. This helps to identify not only what happens in the pro-

cess, but also the “how” and “why” aspects of the process.17 Several

studies show FRAM to be useful in exploring the effectiveness of work

systems and in understanding everyday performance in health care

processes to inform guideline implementation.17,21,22

Therefore, FRAM may provide new perspectives on the process

of co-administration which can then be used to improve the system

of work, quality, and safety of patient care.

2 | AIM

The overall aim was to explore the everyday practices surrounding co-

administration of multiple IV medicines by ICU nurses down the same

lumen, the challenges encountered during the process of co-administration,

and investigate how compatibility is assessed andmanaged in practice.

WHAT IS KNOWN ABOUT THIS TOPIC

• Co-administration of multiple medicines down the same

lumen is a common practice in ICUs.

• There are several potential complications associated with

co-administering incompatible medicines down the same

lumen, and so compatibility must be determined prior to

co-administration.

WHAT THIS PAPER ADDS

• This study indicates that nurses adopt several

workarounds to manage the challenges associated with

co-administration through requesting additional venous

access, prioritising infusions, and spacing out doses

• This study has used the Functional Resonance Analysis

Method (FRAM) to visualise the process of co-

administration which can be adapted to develop a user

friendly decision-making pathway for co-administration

to minimise variability in practice

• This study shows that resources available have limited

compatibility data on commonly used medicines. Future

compatibility studies should focus on providing data

based on current clinical practice.

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3 | DESIGN AND METHODS

This study used a qualitative research design through the use of focus

groups to explore how ICU nurses simultaneously co-administer medi-

cines down the same lumen and the means by which compatibility is

determined in practice. Focus groups were undertaken to allow peo-

ple with similar experiences (ie, nurses) and to identify shared and

common knowledge. Encouraging comments and sharing of views

with each other can provide more in-depth responses and also enable

participants to reflect on their practice.23,24

3.1 | Setting and sample

Three focus groups were conducted with ICU nurses across two hos-

pitals with adult ICUs in the Thames Valley Critical Care Network. An

estimate of 65 ICU nurses were invited to participate in the study.

Within the nursing group, purposeful sampling was employed to

ensure that only qualified ICU nurses with work experience in an ICU

setting were invited because of their experience and knowledge in co-

administration of IV medicines (Table 1). We aimed for four to eight

ICU nurses for each focus group because this is shown to be the most

appropriate size.23 All ICU nurses at each hospital were invited to take

part in the study via email using ICU pharmacists and matrons as con-

tacts at both hospitals. The ICU nurses that indicated interest in par-

ticipating were contacted by the first author—(M.S.O.) directly and

convenient times were arranged for the focus groups.

3.2 | Data collection tools

A focus group schedule consisting of semi-structured questions was

used to guide the discussion, allowing for probing questions and clari-

fication where appropriate.23,25 Focus groups were conducted

between October 2017 and July 2018. Each focus group discussion

took place in a meeting room at the hospital away from the ICU wards

and lasted between 40 and 60 minutes. Each focus group was facili-

tated by M.S.O. The main questions asked were (a) “Can you tell me

about a time where you have had to combine multiple IV drugs down

the same lumen?” and (b) “How do you check for IV compatibility?”

Each focus group was audio recorded with consent from participants,

anonymised, and transcribed verbatim by M.S.O. Field notes were

made after each focus group by M.S.O.

3.3 | Data analysis

3.3.1 | Thematic analysis

The transcribed data were entered into the qualitative data analysis

software NVivo 12 (NVivo qualitative data analysis software; QSR

International Pty Ltd. Version 12, 2018) for data management, and

analysed thematically for codes and themes. Thematic analysis of data

followed six steps as described by Braun and Clarke; familiarizing one-

self with the data, generating initial codes, searching for themes,

reviewing themes, naming, and defining themes.26 Two researchers

(M.S.O. and N.P.) were involved in the thematic analysis of the data.

The initial codes were developed inductively, in that they were driven

from the data and not by any pre-existing theory or coding frame-

work. The initial codes were identified by M.S.O., iteratively refined

within the research team, and collated into potential, and final themes

by both M.S.O. and N.P. Codes were not returned to nurses for

validation.

3.3.2 | FRAM: Building the FRAM model

The FRAM model was built using the FRAM model Visualiser tool.

There are five steps involved in developing a FRAM model. The first

step is to identify the primary purpose of the FRAM analysis and iden-

tify functions that are essential for work to be carried out. In this case,

FRAM was used to demonstrate co-administration practice. The sec-

ond step is to identify the functions that are required for everyday

activities and how each function relates to another. Functions in this

context refer to people’s actions to achieve or perform a specific task

either individually or collectively. The functions were identified by

TABLE 1 Participants’ demographics

Job role

Years of work
experience in
ICUs (year) Department of ICU

Staff nurse 3 years Adult and Cardiothoracic

Staff nurse 2 years Adult (general)

Staff nurse 6 years Adult and Cardiothoracic

Staff nurse 2 years Adult

Senior sister 17 years Adult

Staff nurse 1 year Adult and Cardiothoracic

Registered

nurse

4 years Adult

Staff nurse 1 year Adult

Staff nurse 2 years Adult

Staff nurse 1 year Adult and Cardiothoracic

Deputy

sister

18 years Adult

RAF nurse 2 years Adult

Staff nurse 1 week Adult

Staff nurse 8 months Adult

Staff nurse 8 years Neuro, Trauma, Cardio and

General

Deputy

sister

13 years General

Staff nurse 8 months Adult

Staff nurse 2 years and

8 months

Adult

Abbreviations: ICU, intensive care unit; RAF, royal air force.

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M.S.O., by thematically analysing the data and identifying codes that

were integral to the process of co-administration. The codes gener-

ated are represented as functions in the FRAM model. The third step

involves identification of performance variability, the reason for vari-

ability, and potential impact on a work system. The fourth step

involves determining how variability can spread throughout the sys-

tem leading to either an unexpected or expected outcome known as

functional resonance. The final step is to develop recommendations

for monitoring and managing performance variability to diminish the

possible occurrence of unwanted outcomes.

3.3.3 | Respondent validation

Nurses who participated in the focus groups were invited to assess

the accuracy and reliability of the resulting FRAM model (respondent

validation). Participants were requested to review the model, and a

meeting time was arranged. Participants were asked to verify the

model’s accuracy and to indicate whether important elements were

missing or insignificant elements had been included.

4 | ETHICAL AND RESEARCH APPROVALS

Ethical approval from University of Reading Ethical Committee was

received on 04/08/2017 (Ref number 17/37). Study participation was

voluntary, no financial incentives were given. Written consent

was obtained from all participants before taking part. Each participant

was allocated a number to ensure anonymity during coding processes,

and all data kept confidential.

5 | RESULTS

A total of 20 ICU nurses participated in the study, 18 of which pro-

vided demographic data. Focus groups consisted of two to eight ICU

nurses. The years of ICU experience ranged from 1 week to 13 years.

Adult ICUs were the most common wards that nurses worked in

(Table 1).

Thematic analysis highlighted two major themes, namely, venous

access and resources.

The FRAM model represents the activities carried out by ICU

nurses from the moment a patient is admitted into the ICU to the

point of IV administration. The model ends when IV administration

has occurred and shows that co-administration is a complex process

with several interdependencies.

A total of 21 functions were identified as important for co-

administration in the FRAM model. A visual representation of the

model can be found in Figure S1, and shows many interrelationships

between several functions.

6 | VENOUS ACCESS

6.1 | Creating venous access

Participants reported that the type of catheter inserted for continuous

IV delivery was dependent on the number of medicines prescribed

and their strength. The use of multi-lumen central venous catheters

was found to be the most advantageous as they consolidate infusions

of more than one medicine independently while limiting the number

of invasive devices on the patient, in turn minimising the risk of

infection.

You want to restrict the amount of invasive devices

you have on the patient – so you don’t want to have

4 cannulas in the patient plus a central lumen unless

you have a really good reason – because the more inva-

sive devices, the more risk of infection… (Partici-

pant 9)

6.2 | Availability of venous access

A major concern was the availability of sufficient venous access, espe-

cially in patients who have been prescribed a multitude of medicines

requiring continuous infusions. Participants stated a preference for

the administration of one medicine per lumen. This was not always

possible as the number of prescribed medicines for continuous infu-

sions sometimes exceeded the available lumens.

I would rather have just the one on one lumen and… so

yeah if I have enough lumen… I’ll just split everything

up… (Participant 19)

Participants explained that there were certain medicines prescribed

for continuous infusions that can neither be disrupted (eg, vasopres-

sors) nor combined with other medicines (eg, blood products, total

parenteral nutrition). These medicines must be allocated to a desig-

nated lumen in order to prevent accidental bolusing or withdrawal of

the infusion, limiting the number of lumens available for continuous

infusion.

You have your inotropes and vasopressors you have

them specifically on one port….to avoid any accidental

blousing…. So it’s kinda like one dedicated lumen…this

is for ionotropes or vasopressants only (Participant 2)

6.3 | Additional venous access

Requesting the insertion of an additional cannula was described by

participants as the easiest and quickest option for administration

when venous access was limited.

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But most of the time when we have that many medi-

cines that you have no entry point on the patient then

it’s normally quicker to ask the doctor if they can just

put another cannula for you… (Participant 18)

However, they described that this could become a difficult solution,

especially when doctors were not readily available. One participant

mentioned that sometimes doctors had to be approached multiple

times before the request could be granted. In desperate circum-

stances, some participants mentioned that they had to go higher up

and ask a consultant for assistance, which could take up to a couple of

hours.

Just being persistent with the doctors that I need a

venflon, I haven’t given the antibiotics– it was due like

half an hour ago and… I don’t want to delay it… or if

that person is not going to do it, you just have to go to

higher up (Participant 20)

Despite strategies to maximise venous access, participants sometimes

ran out of sufficient venous access. They reported that when venous

access was limited or compatibility information was unavailable, some

continuous infusions (insulin, electrolyte fluids, or vitamins) were

stopped to allow for the administration of intermittent medicines per-

ceived to be of higher priority, such as antibiotics and analgesics. Partici-

pants expressed that this can be frustrating and results in disruption in

prescribed administration times, as each medicine had to be adminis-

tered one at a time through a designated lumen after flushing with

saline at every interval because of the uncertainty of compatibility.

If you have medicines which are urgent, say… antibi-

otics. You’d end up having to stop other infusions and

prioritising which ones more important (Partici-

pant 15)

Administering one medicine after the other meant that the partici-

pants had to space out doses, sometimes causing a delay in adminis-

tration of other medicines. One participant reported that making

changes to administration times is one of the reasons administration

errors are made.

Infusions take a long time and we are constantly

supplementing these things…” (Participant 11)… “and

we are delaying medicines as a result, and it ruins it for

the rest of the medicine charts and then errors are

made (Participant 7)

However, the majority of participants were not overly concerned

about delays in administration, and did not think that this would affect

patient care or recovery. This was because of their perception that

delayed administration can be compensated for by adjusting adminis-

tration times to ensure the correct dose is given within the minimum

time frame. Additionally, there was the view that because patients are

constantly monitored, and with their knowledge about medicines,

adverse effects can be identified early and reversed quite quickly.

Well maybe if afternoon dose is like delayed for 2 hours

then we’ll delay the evening one with an hour… but we

sort of do makeup in the 24hrs that they do get the

exact same amount (Participant 19)

The majority of participants reported that some medicines can be

administered peripherally instead of centrally. If these medicines were

being administered centrally, they could be swapped to a peripheral

catheter to create space for medicines that can only be administered

centrally.

7 | RESOURCES

Participants highlighted the importance of checking compatibility prior

to co-administering multiple medicines through Y-site connectors. For

familiar medicine combinations, compatibility was largely confirmed

from nurse experience rather than using a compatibility resource. For

example, propofol and fentanyl were described as routine combina-

tions known to be compatible; therefore, participants felt it unneces-

sary to check compatibility using a resource.

I don’t use it (compatibility chart) that often if it is a

fairly standard set of drugs that I normally know,

because you get into the experience of which things

go in which things (Participant 9)

However, for unfamiliar medicines, compatibility was checked for

potential medicine combinations using a reference source. Partici-

pants reported a variety of resources for checking compatibility such

as a locally produced compatibility chart, drug monographs, the phar-

macy team, a more experienced nurse, or an in-house medicines man-

agement policy guide as can be seen in the extracted FRAM model in

Figure 1.

The compatibility chart was the preferred reference source

because of availability, and was described as easy to use with the abil-

ity to check compatibility multiple times for a variety of medicine

combinations.

The chart is quicker because you look at it straight

away… (Participant 20)

Participants identified a limitation of the chart being a restricted num-

ber of medicines, with little to no information available for some regu-

larly used medicines. They also mentioned that the resources available

report two medicine combinations but on some occasions may want

to combine three medicines down the same lumen for which they

confirm compatibility by cross-referencing medicine pairs on the com-

patibility chart. However, participants stated that they would not

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combine medicines that resources reported to be incompatible,

unknown, or variable as per advice from the pharmacy team.

I find smaller medicines like the paracetamol, metroni-

dazole and things like that, they are not on our com-

patibility chart (Participant 2)

…Say you have Hartmann’s, propofol and fentanyl….

you would have to do Hartmann’s against propofol,

Hartmann’s against fentanyl and propofol against fen-

tanyl (Participant 8)

The way in which participants made their decisions sometimes varied

and this can be seen in Figure 1. For example, should a participant not

find information on the chart, they might next check the drug mono-

graph followed by a request for additional venous access before

administration and vice versa.

8 | RESPONDENT VALIDATION

Responses were received from six ICU nurses, five of which were

involved in the original focus groups. Respondents thought that

the FRAM model was comprehensive and an accurate representa-

tion of work as performed in everyday practice. However, two

new functions were added to the FRAM model as advised by the

nurses; <to assess number of infusions> and <drug monograph> as

some participants mentioned using the drug monograph to check

compatibility.

9 | DISCUSSION

Our findings suggest that the absence of compatibility data and insuf-

ficient venous access appear to be the main challenges associated

with IV medicine co-administration. Participants managed these

through workarounds such as requesting additional venous access,

prioritising infusions, swapping line of infusion, and changing the form

of medicine. These have also been identified in other studies.14,27

F IGURE 1 Extract from the Functional Resonance Analysis Method model showing the various ways compatibility can be assessed

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Workarounds are alternative work procedures devised to circumvent

a perceived workflow block, which may become necessary for tasks

to be accomplished safely in variable environments such as health

care.28,29 However, there are concerns that workarounds may create

new pathways to error and decrease patient safety by increasing the

likelihood of administration errors.30-33 Koppel et al31 examined medi-

cines administration by nurses using a Barcode Medication Adminis-

tration system, identifying 15 types of workarounds with potential for

administering the wrong medications and at wrong times. A possible

consequence of workarounds in our study is medicine administration

delays, which the National Patient Safety Agency considers to be a

significant patient safety issue.34 Administration delay can have a det-

rimental impact on patient recovery, especially with medicines such as

antibiotics.34 Future work could use the FRAM model to identify areas

of potential safety risks associated with workarounds.35,36

Each workaround involved a clinical decision-making process which

was variable and depended on nurses’ experience and organisational

factors. The vast majority of participants used experience to confirm

compatibility, only using other resources with medicines unfamiliar to

them. Pattern recognition could be a possible explanation for this, where

nurses were able to make a clinical decision based on previous knowl-

edge of using similar medicine combinations in patients they had cared

for.37 However, a drawback is that participants may be relying on mem-

ory cues associated with inaccurate information, thereby risking combin-

ing incompatible medicines. Organisational factors such as

institutionalised routines, resource and staff availability can influence

the development of workaround behaviours.38,39 In this study,

workarounds appear to have become embedded into everyday nursing

practice. While it is unclear if these workarounds are without risks, their

constant use can be used to highlight areas within organisations that

require practical interventions to improve work efficiency. For example,

we found that obtaining additional venous access was heavily depen-

dent on doctor availability, which sometimes delayed medicine adminis-

tration. This could be resolved by promoting peripheral cannulation by

senior nurses within organisations.

Given the complexity of co-administration of medicines in the

ICU setting, a clinical decision-making pathway or tool for assessing

compatibility prior to co-administration that includes steps to follow

when compatibility is unknown, variable or incompatible should be

made available. This could be especially useful for new members of

staff unfamiliar with different co-administration practices, and to stan-

dardise the workarounds utilised to reduce the chances of creating

new, more harmful workarounds. The FRAM model can be used to

inform a simplified user-friendly decision-making pathway as it

reflects everyday work as performed in practice. Clay-Williams et al40

used FRAM to develop guidelines compatible with how staff work,

and through this found that the need to create workarounds that

compromised safety and quality of care could be reduced.

Although the compatibility chart was described as useful, there

was a need for more comprehensive compatibility data to be included

in the chart.41 This is supported by findings from a systematic review

investigating the availability of physical and chemical compatibility

data for commonly used medicines in ICU.42 Virtually no data exists

for three medicine combinations, and participants reported reluctantly

co-administering three medicines if they had been previously adminis-

tered without reports of clinical complications. This approach is largely

based on physical compatibility, but there are concerns that not all

incompatibility is physical. It would be worthwhile exploring and con-

firming the chemical compatibility of IV medicines alongside physical

compatibility. Additionally, future compatibility studies should explore

providing compatibility data for potential three medicine combina-

tions to minimise the risk of combining incompatible medicines and

help to improve work efficiency.

Our findings suggest that the compatibility chart in use requires

an update. Because of the possibility of numerous medicine combina-

tions, compiling and producing an updated chart can be arduous.

Nurses’ input in updating the chart would likely be beneficial to

develop a resource that is relevant to current practice. Strategies such

as including physicochemical properties (eg, pH) within the chart with

additional training on the significance of the values included may help

bedside care givers with predicting incompatibilities. However, pH

reactions are not always definitive in measuring compatibility and so

visual monitoring of lines for precipitates is still likely to be required.

A strength of this study is that it directly takes into consideration

the experiences and perspectives of ICU nurses in understanding the

practice surrounding co-administration of multiple medicines down

the same lumen, alongside identifying key challenges associated with

co-administration. The use of FRAM highlights the interrelations

within the process and how variability occurs within the system.

Limitations of the study include being conducted within two hospi-

tals in the same critical care region, and therefore, perspectives and

experiences of the ICU nurses may not reflect practice across all

hospitals. More research to obtain an overall understanding of

co-administration practice across a wider range of hospitals is required.

The presence of senior staff members in the focus groups could have

prevented some junior nurses from expressing their opinions and co-

administration practice freely. A regional compatibility chart was the

main resource used by participants in this study. However, the chart may

not be a standard resource in all hospitals. Further research to investi-

gate resources used in other hospitals, their effectiveness, and potential

limitations, in comparison with the compatibility chart is warranted.

10 | IMPLICATIONS AND
RECOMMENDATIONS FOR PRACTICE

The FRAM can be used to inform a user friendly decision-making

pathway to potentially standardise workarounds in practice, promot-

ing safer patient care.

Organisations should consider reviewing and designing compati-

bility charts of commonly used medicines using an interdisciplinary

approach to create a comprehensive tool that is relevant to everyday

practice.

Future compatibility studies should consider compatibility assess-

ment of three medicine combinations.

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ACKNOWLEDGEMENTS

The authors would like to thank all the ICU nursing staff who partici-

pated in the focus groups for sharing their views and experiences.

Funding was received from the University of Reading PhD

studentship.

AUTHOR CONTRIBUTIONS

M.S.O. designed the focus group questions, arranged and conducted

the focus groups, and analysed and interpreted the study data. The

data analysis and interpretation was reviewed by N.P. M.S.O. drafted

the paper and all authors contributed to the subsequent drafts and

final version of the manuscript.

11 | CONCLUSION

The majority of nurses described lack of sufficient venous access and

compatibility data for commonly used medicines as challenges associ-

ated with co-administration of multiple medicines down the same

lumen. The use of FRAM highlighted workarounds used to facilitate

administration of IV medicines that may sometimes lead to delays in

therapy. The FRAM model can be used to develop a user friendly clini-

cal decision-making pathway for co-administration of multiple medi-

cines for use in organisations, which could standardise workaround

behaviours while improving efficiency and safety of patient care.

Future work should consider reviewing and designing compatibility

resources with input from ICU nurses to create robust and compre-

hensive compatibility resources that are relevant to everyday practice.

ORCID

Mosopefoluwa S. Oduyale https://orcid.org/0000-0003-1482-7239

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SUPPORTING INFORMATION

Additional supporting information may be found online in the

Supporting Information section at the end of this article.

How to cite this article: Oduyale MS, Patel N, Borthwick M,

Claus S. Co-administration of multiple intravenous medicines:

Intensive care nurses’ views and perspectives. Nurs Crit Care.

2020;25:156–164. https://doi.org/10.1111/nicc.12497

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  • Co-administration of multiple intravenous medicines: Intensive care nurses’ views and perspectives
    • 1 BACKGROUND
    • 2 AIM
    • WHAT IS KNOWN ABOUT THIS TOPIC
    • WHAT THIS PAPER ADDS
    • 3 DESIGN AND METHODS
      • 3.1 Setting and sample
      • 3.2 Data collection tools
      • 3.3 Data analysis
        • 3.3.1 Thematic analysis
        • 3.3.2 FRAM: Building the FRAM model
        • 3.3.3 Respondent validation
    • 4 ETHICAL AND RESEARCH APPROVALS
    • 5 RESULTS
    • 6 VENOUS ACCESS
      • 6.1 Creating venous access
      • 6.2 Availability of venous access
      • 6.3 Additional venous access
    • 7 RESOURCES
    • 8 RESPONDENT VALIDATION
    • 9 DISCUSSION
    • 10 IMPLICATIONS AND RECOMMENDATIONS FOR PRACTICE
    • ACKNOWLEDGEMENTS
    • AUTHOR CONTRIBUTIONS
    • 11 CONCLUSION
    • REFERENCES

Adolescent Attitudes Towards Sexually Transmitted Infection
Screening in the Emergency Department

Addison S. Gearhart, MD1, Gia M. Badolato, MPH2, Monika K. Goyal, MD, MSCE2,3

1Children’s Hospital of Orange County, Orange, CA

2Children’s National Health System, Washington, DC

3Departments of Pediatrics and Emergency Medicine, The George Washington University School
of Medicine and Health Sciences, Washington, DC

Abstract

Objectives—Adolescents who seek care in emergency departments (EDs) are often at high risk

for sexually transmitted infections (STIs). The objective of this study was to assess adolescent

attitudes towards ED-based STI screening.

Methods—We conducted a secondary analysis of a cross-sectional study that evaluated STI

screening acceptability and prevalence when STI testing was universally offered to asymptomatic

adolescents presenting to the ED for care. Adolescents 14–21 years old completed a computerized

survey and answered questions regarding attitudes towards ED-based STI screening and sexual

behavior. We performed multivariable logistic regression to compare differences in attitudes

towards ED-based STI screening among patients who agreed versus declined STI testing.

Results—326 of 553 (59.0%) adolescents agreed to be tested for STIs. The majority (72.1%)

believed the ED was an appropriate place for STI screening. Patients who agreed to be tested for

STIs were more likely to positively endorse ED-based STI screening than those who declined STI

testing (77.0% vs 64.8%%; aOR 1.6, [95% CI 1.1, 2.4]). Most (82.6%) patients stated they would

feel comfortable getting tested for STI’s in the ED. There was no difference in comfort level of

ED-based STI testing between those who agreed and declined STI testing (83.5% vs 81.4% aOR

1.1, [95% CI 0.7, 1.8]).

Conclusion—Our results suggest that adolescents view the ED as an acceptable location for STI

screening. Therefore the ED may serve a role in increasing the accessibility of STI detection and

prevention resources for adolescents.

Keywords

Adolescents; Sexually Transmitted Infections; Emergency Department; Screening

Corresponding Author: Monika K. Goyal, MD, MSCE, Children’s National Health System, 111 Michigan Ave NW, Washington, DC
20010, PH: 202-476-5000, [email protected], fax: 202-476-2100.

The authors have conflicts of interest to report.

HHS Public Access
Author manuscript
Pediatr Emerg Care. Author manuscript; available in PMC 2021 October 01.

Published in final edited form as:
Pediatr Emerg Care. 2020 October ; 36(10): e573–e575. doi:10.1097/PEC.0000000000001387.

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INTRODUCTION

Approximately half of the 20 million new cases of sexually transmitted infections (STIs) in

the United States (U.S.) occur in people between the ages of 15 and 24.1,2 One in four

sexually active adolescent females has an STI.3 The majority of STIs are asymptomatic, and

if left undiagnosed and untreated, can lead to serious complications such as infertility,

ectopic pregnancies or pelvic inflammatory disease.4

While there are national guidelines recommending routine-screening for sexually active

patients, physicians report adherence to screening guidelines less than a third of the time

during routine health visits.5–7 Furthermore, in 2003 only 30% of women age 25 years and

younger with commercial health care plans and 45% of women with Medicaid plans were

screened for chlamydia.8 One explanation for low STI screening rates among adolescents

may be STI screening efforts have traditionally been focused around primary care, and

adolescents have the lowest rates of primary care use compared to all other pediatric age

groups.9,10 Alternatively, adolescents frequently access the emergency department (ED) for

care, comprising 14.8 million ED visits annually.11 Furthermore, approximately 1.5 million

adolescents rely on EDs as their primary source of health care.11,12 Therefore, adolescent

patient encounters in the ED may offer a strategic opportunity to address missed

opportunities for STI screening, prevention and treatment efforts.

Elucidating barriers to the accessibility of STI services is crucial to the development of

effective prevention efforts.13 Established barriers to STI services include system level

obstacles such as cost, long waiting times, and unfavorable clinic schedules and hours.14

Given these barriers, patients often access the ED for care. EDs have a perceived quicker

wait time and are open 24 hours a day.14 Other documented reasons for not seeking STI

services include perceived interpersonal barriers such as fear of judgment from the doctor

and confidentiality.15 Furthermore, social barriers such as stigma attached to STIs and

increased sensitivity to other’s perception of themselves also play a role in hindering STI

screening efforts.16 As such, patients may be more inclined to select the ED for care because

they do not have an established relationship with the providers and have a lower likelihood

of seeing the provider again. However, STI testing is infrequently performed in the ED.17,18

We recently evaluated STI screening acceptability and prevalence when STI screening was

universally offered to an asymptomatic adolescent ED population.19 The goal of this

secondary analysis was to explore adolescent attitudes towards ED-based STI screening.

METHODS

Study Design and Population

We conducted a secondary analysis of a cross-sectional study that evaluated STI screening

acceptability and prevalence when STI screening was universally offered to asymptomatic

adolescents seeking care in a large, tertiary, urban pediatric hospital ED from December

2013 to July 2014. Patients between the ages of 14 to 21 presenting to the ED with non-STI

related complaints were eligible for participation. For the purposes of this study, STI related

complaints for females were described as: lower abdominal pain, concern for STI, vaginal

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discharge with or without lesions, itching and or bleeding, hematuria, dysuria, flank pain,

pelvic pain and rectal or anal pain. STI related chief complaints for males were defined as:

penile, scrotal or testicular concerns, rectal or anal pain, urinary problems or dysuria.

Patients were excluded from participation if they were not literate in English, critically ill,

developmentally delayed, presented with altered mental status/psychiatric emergency, victim

of assault, or were in police-custody. The hospital’s Institutional Review Board approved the

study.

Data Collection

Patients who enrolled in this study completed a computerized survey (LimeSurvey

Software)20 through the use of a handheld tablet and answered questions regarding attitudes

towards ED-based STI screening during their ED visit. The survey also collected

information on demographics and sexual behavior.

Data Analysis

We assessed attitudes towards STI screening and compared them among adolescents who

agreed to and declined STI testing. Survey items consisted of 5-point Likert scale-type

questions (strongly agree to strongly disagree) and were dichotomized for analyses with

strongly agree and agree as one category. We performed multivariable logistic regression to

compare differences in attitudes towards ED-based STI screening among patients who

agreed versus declined STI testing. We included all variables with p-values of <0.2 on

bivariable analyses in our final multivariable models. Data were analyzed using STATA vs.

12.0.

RESULTS

A total of 553 adolescents were enrolled in this study. The study population had a mean age

of 16.1 (SD +/−1.8) years, was half female, primarily of non-Hispanic black race/ethnicity,

and publicly insured. Almost 50% of the population reported being sexually active (Table 1).

Of the 553 adolescents in the study, 326 (59.0%) agreed to be tested for STIs.

The majority of participants in the study (72.1%) believed the ED was an appropriate place

for STI screening. Patients who agreed to be tested for STIs were more likely to positively

endorse ED-based STI screening than those who declined STI testing (77.0% vs 64.8%%;

OR 1.8, 95% CI 1.2, 2.7). Most (82.6%) patients stated they would feel comfortable getting

tested for STI’s in the ED. There was no difference in comfort level of ED-based STI testing

between those who agreed (83.5%) and declined (81.4%) STI testing (OR 1.2, 95% CI 0.7,

1.8). One third of patients responded that they were worried about their parents finding out

about STI testing. However, there was no difference between confidentiality concerns

between those who agreed (34.3%) and declined (32.1%) STI testing (OR 0.9; 95% CI 0.6,

1.3) (Table 2).

In a multivariable model that adjusted for age, gender, insurance status, and sexual activity,

adolescents who agreed to be tested for STIs were more likely to believe that the ED was an

important venue for STI screening (aOR 1.6, 95% CI 1.1, 2.4) and were more likely to

believe doctors and nurses should ask adolescents in the ED about sexual health (aOR 1.5,

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95% CI 1.0, 2.1). Participants who accepted testing were also more likely to believe the ED

served as a good place for adolescents to answer questions about sexual health (aOR 1.7,

95% CI 1.2, 2.5). However, there was no difference between those who agreed to be tested

versus those who declined and a belief that they would want doctors in the ED to ask

adolescents about their sexual activity (aOR 1.4, 95% CI 0.9, 2.0).

DISCUSSION

Our study found that most adolescents are comfortable discussing their sexual health with

ED clinicians and being screened for STIs in the ED even when they present for non-STI

related complaints. These results were seen amongst all participants including those who did

not consent to STI screening during the visit. This is an important finding, as access to

healthcare is a major barrier to reducing STIs among adolescents,10 and previous studies

demonstrate that adolescents report frequent use of the ED.11,12,21

Recent reports have revealed high rates of STI screening acceptance among adolescents in

the ED.19,22,23 Previous studies of clinicians reported perceived patient discomfort as the

reason for not conducting sexual histories or performing STI screening.24 Our study, which

explored adolescent attitudes towards ED-based STI screening found the majority believe

the ED is an appropriate place for STI screening, want to discuss their sexual health with

clinicians, and feel comfortable receiving STI services in the ED. These results suggest that

perceived discomfort is not a true barrier, and should not discourage clinicians from

screening patients for STIs in the ED.

The ED encounter may serve as the only opportunity for clinicians to screen and treat high-

risk, often asymptomatic adolescents.25 Our study demonstrates adolescents’ desire for ED

clinicians to engage in sexual health discussions, regardless of why they presented to the

ED. The majority of participants not only wanted the clinicians to initiate these discussions,

but they also believed the ED is an appropriate setting to respond to these questions.

Previous studies have shown similar results, with adolescents reporting they prefer the

clinician to initiate the conversation because they feel uncomfortable starting the

conversation; however, these studies were not conducted solely in the ED.30,31

Prior data have revealed that adolescents often cite perceived anonymity, confidentiality, and

privacy as factors influencing them to visit the ED in placed of a primary care clinic for non-

urgent health issues.11,15,26 Adolescents in other studies have previously reported that they

would stop receiving care or delay screening if their parents were notified.27 About one-third

of our sample indicated they were concerned about confidentiality when getting tested in the

ED; however, our results suggest that this concern did not affect their acceptance of

screening. These results demonstrate that adolescents have a desire for STI screening, and

innovative methods for confidential STI screening are warranted.

The results from this study should be considered in light of several potential limitations. We

used a convenience sampling strategy, so patients were only enrolled when research staff

were available. However, risk of missing patients was minimized because our research

assistants enrolled patients 7 days a week from 8 am until 11 pm. Furthermore this study

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was conducted in a single pediatric ED with a high community prevalence of STIs.

Therefore, our results may not be generalizable to other geographical areas or healthcare

settings. The survey responses may be prone to social desirability bias because of the

sensitive nature of the topic. In order to decrease the risk for bias, we used a computerized

survey as literature suggests that adolescents are more likely to honestly report information

through computerized questionnaires when compared to face to face interviews.8,28 Finally,

the findings of this study may also be prone to responder bias as our survey relied on

participants to consent to the study, and therefore does not include the opinions of people

who declined participation.

In conclusion, adolescents find STI screening in the ED acceptable. Therefore, the ED could

potentially serve as a strategic venue for adolescent STI detection and treatment. Offering

STI services in the ED may reduce the morbidity, mortality, and further transmission of

STIs. Future studies should explore interventions that can study the impact of ED-based STI

screening on a population level, examine provider attitudes towards ED-based STI screening

and incorporate STI screening into the ED workflow.

Acknowledgments

Source of funding: This work was supported by award number K23HD070910 from NICHD (MKG.). The funding
sources had no role in (1) study design; (2) the collection, analysis, and interpretation of data; (3) the writing of the
report; or (4) the decision to submit the article for publication. This funding was not given for the production of this
article. No other grants, honorariums, or other forms of payment were given to the authors of this manuscript.

References

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Symptoms in Female Adolescents among Primary Care versus Emergency Department Physicians.
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19. Goyal MK, Teach SJ, Badolato GM, et al. Universal Screening for Sexually Transmitted Infections
among Asymptomatic Adolescents in an Urban Emergency Department: High Acceptance but
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primary care provider: who, why, and how urgent?. J Adolesc Heal. 2014. http://
hsrc.himmelfarb.gwu.edu/smhs_peds_facpubs/547. Accessed November 6, 2016

22. Schneider K, FitzGerald M, Byczkowski T, Reed J. Screening for Asymptomatic Gonorrhea and
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10.1097/OLQ.0000000000000424 [PubMed: 26967296]

23. Uppal A, Chou KJ. Screening adolescents for sexually transmitted infections in the pediatric
emergency department. Pediatr Emerg Care. 2015; 31(1):20–24. DOI: 10.1097/
PEC.0000000000000322 [PubMed: 25526018]

24. Haley N, Maheux B, Rivard M, Gervais A. Sexual health risk assessment and counseling in
primary care: How involved are general practitioners and obstetrician-gynecologists? Am J Public
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25. Weisman J, Chase A, Badolato G, Teach SJ, Trent ME, Chamberlain JM. Adolescent Sexual
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26. Ginsburg KR, Slap GB, Cnaan A, Forke CM, Balsley CM, Rouselle DM. Adolescents’ perceptions
of factors affecting their decisions to seek health care. Jama. 1995; 273(24):H.doi: 10.1001/
jama.1995.03520480033036

27. McKibben L, Horan T, Tokars JI, et al. Guidance on Public Reporting of Healthcare-Associated
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Table 1

Descriptive Characteristics of Patients

Mean Age(SD) 16.1 (+/−1.8) years

N (%)

Female Gender 293 (52.4%)

Race/Ethnicity

White, Non-Hispanic 40 (7.3%)

Black, Non-Hispanic 376 (68.9%)

Hispanic 81 (14.8%)

Other 49 (9.0%)

Insurance status

Private 156 (28.2%)

Public 377 (68.2%)

Uninsured 20 (3.6%)

Sexually Active 264 (47.7%)

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Pediatr Emerg Care. Author manuscript; available in PMC 2021 October 01.

  • Abstract
  • INTRODUCTION
  • METHODS
    • Study Design and Population
    • Data Collection
    • Data Analysis
  • RESULTS
  • DISCUSSION
  • References
  • Table 1
  • Table 2

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https://doi.org/10.1177/2150131917730210

Journal of Primary Care & Community Health
2017, Vol. 8(4) 332 –337
© The Author(s) 2017
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Pilot Studies

Introduction

Adolescents have the highest rates of sexually transmitted
infections (STIs) of any age group in the United States.
Despite a downward trend, US adolescents continue to have
higher rates of unintended pregnancies compared with other
developed countries.1,2 Access to adolescent-friendly health
care is integral to addressing sexual health behaviors and
preventing poor outcomes, including STIs/human immuno-
deficiency virus (HIV) and unintended pregnancies.3-5
However, little is known about how adolescents define
“adolescent-friendly” services or about their experiences
communicating with providers regarding sexual health.

There is a growing body of evidence that the quality of
adults’ experience with health care providers impacts both
patient satisfaction and health outcomes, including adher-
ence to prescribed medication and utilization of preventive
care services.6,7 Patients who perceive “good communica-
tion” with their provider are more adherent to diabetes self-
management and cancer screening.8-10

Although the impact of provider communication on
health outcomes for adolescents is unknown, there is evi-
dence that communication affects their health care experi-
ence.11 A systematic review of studies examining adolescent
perspectives on general adolescent health care identified
feeling welcome, trust in clinicians, understanding health
information, and involvement in health care decisions criti-
cal to adolescents’ perception of health care quality.11 A
minority of studies in this review specifically addressed
sexual health services. Survey studies have demonstrated
that when providers initiate sexual health discussions,
adolescents have a more positive perception of providers

730210 JPCXXX10.1177/2150131917730210Journal of Primary Care & Community HealthHoopes et al
research-article2017

1Kaiser Permanente Washington, Bellevue, WA, USA
2University of Washington School of Medicine, Seattle, WA, USA
3Fred Hutchinson Cancer Research Center, Seattle, WA, USA

Corresponding Author:
Andrea J. Hoopes, MD, MPH, Kaiser Permanente Washington
Adolescent Center, 13451 SE 36th Street, Bellevue, WA 98006, USA.
Email: [email protected]

Adolescent Perspectives on
Patient-Provider Sexual Health
Communication:
A Qualitative Study

Andrea J. Hoopes1, Samantha K. Benson2, Heather B. Howard2,
Diane M. Morrison2, Linda K. Ko3, and Taraneh Shafii2

Abstract
Background: Adolescents in the United States are disproportionately affected by sexually transmitted infections and
unintended pregnancy. Adolescent-centered health services may reduce barriers to health care; yet, limited research has
focused on adolescents’ own perspectives on patient-provider communication during a sexual health visit. Methods:
Twenty-four adolescents (14-19 years old) seeking care in a public health clinic in Washington State participated in one-on-
one qualitative interviews. Interviews explored participants’ past experiences with medical providers and their preferences
regarding provider characteristics and communication strategies. Results: Interviews revealed that (1) individual patient
dynamics and (2) patient-provider interaction dynamics shape the experience during a sexual health visit. Individual patient
dynamics included evolving level of maturity, autonomy, and sexual experience. Patient-provider interaction dynamics
were shaped by adolescents’ perceptions of providers as sources of health information who distribute valued sexual health
supplies like contraception and condoms. Participant concerns about provider judgment, power differential, and lack of
confidentiality also emerged as important themes. Conclusions: Adolescents demonstrate diverse and evolving needs for
sexual health care and interactions with clinicians as they navigate sexual and emotional development.

Keywords
community health, patient-centeredness, pediatrics, risky sexual behavior, qualitative methods

Hoopes et al 333

and increased STI testing.12,13 Despite these benefits, many
adolescent health care visits do not address sexual health,
and those that do are very brief, lasting on average 36 sec-
onds.14 Barriers to effective and realistic sexual health com-
munication strategies for providers remain elusive.

Qualitative studies using focus groups have explored the
adolescent patient experience when accessing confidential
sexual health services.15-18 Concerns raised by adolescents
include judgment by providers, lack of confidentiality, and
impersonal patient-provider interactions. While focus
groups provide insight into social norms, they are limited in
the ability to elicit personal experiences from individuals on
sensitive topics like sexual health. For this reason, this
study used one-on-one, in-depth interviews to explore ado-
lescents’ perspectives on patient-provider interactions dur-
ing a sexual health visit and how these shape their
preferences for patient-provider communication.

Methods

Eligibility and Recruitment

Adolescents seeking care in an urban public health STI
clinic were recruited from September 2008 to January 2009.
The clinic serves more than 6000 unique patients annually
and provides services for STI management, pregnancy test-
ing, and contraception, prevention counseling, and linkages
to community support resources for adolescents and adults
at sliding scale costs. Services are provided by advanced
practice providers (nurse practitioners and physician’s
assistants) with physician support when indicated. Among
10- to 19-year-old patients, approximately 45% identify as
women and 55% as men. Among older patients, approxi-
mately 30% identify as women and 70% as men. Race/eth-
nicity distribution for 14- to 19-year-olds utilizing the clinic
during the study period was 50% non-Hispanic White, 32%
non-Hispanic Black, 8% Asian, and 10% other, as deter-
mined by self-report at time of service. This is largely con-
sistent with the race/ethnicity distribution of all-aged
patients seeking care.

Patients were approached by a research assistant during
regular clinic operation hours within the recruitment period
and invited via a standard script to learn more about the
study. The research assistant recruited 10 to 20 hours per
week, primarily during afternoon hours to reach more
young people. If participants were interested, they com-
pleted a 6-item paper survey in the waiting room to deter-
mine eligibility. Inclusion criteria were age 14 to 19 years,
ability to speak and read English, vaginal sex in the past 12
months and at least one of the following: 1 episode of
unprotected (no condom or no birth control) vaginal sex in
the past 2 months, more than 1 vaginal sex partner in the
past 2 months, or history of STI or unintended pregnancy in
self or partner.

Eligible participants learned about the study in a private
clinic room and completed standard written informed con-
sent with the research assistant. The University of
Washington Human Subjects Division approved this study
and waived parental permission for participants aged 14 to
17 years, which aligns with the age of consent for sexual
health care in Washington.

Study Procedures

A research team member (HBH) interviewed all partici-
pants using in-depth, semi-structured interviews. The inter-
views lasted 45 to 60 minutes and included questions about
preferences in provider communication styles and experi-
ences with providers when discussing sexual health. To
ensure confidentiality, the only demographic information
collected was gender and age. On completion of the inter-
view, participants received $25 cash. Interviews were
recorded with a digital audio recorder, transcribed by a
research team member (HBH), and reviewed for accuracy
by the interviewer.

Analysis

Transcribed interviews were managed using the ATLAS.ti
version 7 (Berlin, Germany) qualitative data software pro-
gram. The research team generated tentative labels to capture
the essence of each idea and compared and contrasted their
notes.19 Two members of the research team (TS and HBH)
independently reviewed the first 3 transcripts to cluster simi-
lar ideas and generate preliminary codes. Two different
research team members (AJH and SKB), oriented to the pre-
liminary codes, independently coded all interviews and com-
pared and contrasted notes as new codes emerged. Any
coding discrepancies were reconciled verbally between AJH
and SKB until 100% agreement was reached. Atypical cases
that did not fit patterns for the majority were evaluated and
discussed by AJH, SB, and TS, and freehand domain charts
were created to map the interrelationship between concepts.

Results

Of 43 patients approached, 10 did not meet eligibility crite-
ria and 9 declined to participate. Twenty-four of 33 (72.7%)
participated: 15 females and 9 males. Average age was 17.3
years. Emerging themes around patient-provider experience
and communication revealed a distinction between individ-
ual patient dynamics and patient-provider interaction
dynamics.

Individual Patient Dynamics

Comfort in Discussing Sex. Participants described feeling
uncomfortable talking about sexual health topics with their

334 Journal of Primary Care & Community Health 8(4)

provider. However, being older (more “mature”) and hav-
ing more romantic relationship experience eased their
discomfort.

The doctor asked me “am I sexually active” and I didn’t feel
comfortable. It was probably two years ago. I was probably 17
years old. I did not feel comfortable, because I thought, “This
is wrong.” . . . But, I’ve matured now and it’s okay. (Female, 18
years)

Interviews revealed a common sentiment of “embarrass-
ment” when discussing sexual health with adults. This was
in contrast with how participants described discussing sex
with friends:

Most kids just get embarrassed to talk to an adult about sex,
’cause they can talk to their friends all day about it and it won’t
be embarrassing, but once there is an adult . . ., it’s just like, I
don’t know. (Gender, age unrecorded)

Lack of Trust and Confidentiality. Participants described feel-
ings of being caught off guard or offended when an unfa-
miliar health care provider asked questions about sexual
health and clinical symptoms, suggesting a misunderstand-
ing of why providers elicit such information. One partici-
pant described feeling unprepared for sexual history
questions in an interaction with a provider that felt
impersonal:

Well, I guess it’s like I don’t really know her as a person, so it’s
kinda like, “Hello stranger, tell me about your body,” you
know, so . . . (Female, 19 years)

Participants voiced concerns that confidentiality might be
violated by providers:

[. . .] I know it’s supposed to be confidential [. . .] But I think
some doctors, like, be telling, like, the children’s parents what
they talk about. (Female, 18 years)

Fear of Judgment From Providers. Many interviewed
expressed fear of being judged by providers for their sexual
behaviors:

Some doctors are like, “[sigh] You’re disgusting.” They don’t
say that, but they’re basically, like, “Shame on you. How could
you not expect this to happen?” (Female, 19 years)

Personal Responsibility Regarding Health Needs and Self-Effi-
cacy. Some adolescents demonstrated a sense of personal
responsibility for their sexual health:

I don’t really think I need anything from my doctor, I think it’s
more myself. Like, I need to go there and get checked, I need to
use condoms, I need to be on birth control. (Female, 16 years)

In fact, some participants believed safer sex practices are
not dependent on health care services at all, but rather on
personal choices:

[. . .] Yeah, but when it boils down to it, in the heat of the
moment sometimes it doesn’t happen like that. So you just
have to be smart and just know this is important to my body
and I want to use a condom. (Female, 18 years)

Patient-Provider Interaction Dynamics

Sensitivity to Confidentiality and Patient Comfort. Participants
raised concerns that providers ask them about sexual activ-
ity in front of their parents, creating an environment that
dissuades accurate responses and negatively affects patient-
provider rapport:

[. . .] I went to get a check-up, and um, my dad was in the room
with me, believe it or not. And the doctor asked me “am I
sexually active” [. . .] So, um, I answered falsely so that I don’t
have my dad look at me bad or the doctor look at me bad.
(Female, 18 years)

Many interviewed commented on the impersonal and
automated nature with which providers asked very sensitive
sexual behavior questions:

[. . .] it’s just, like, okay you talk to your everyday doctor,
and he’s on the computer asking you questions. Like, “Okay,
well do you have Chlamydia? Do you have this?” and there’s
no contact, he’s just asking you questions. That doesn’t
seem like he cares, he’s just doing his job. (Gender, age
unrecorded)

Adolescents alluded to a power differential between
themselves and the provider where they were asked to
divulge sensitive information while the provider remains
closed and impersonal.

You know how they say that we’re not going to answer personal
questions kind of makes you feel, you know, unequal. It’s like
you’re a human giving information out, but the doctor’s not
sharing their experience with you. (Male, 17 years)

Preferred Communication Styles. Several participants shared
preferred communication styles of providers based on posi-
tive experiences; however, these preferences were notably
varied. Some expressed appreciation when providers had a
straightforward style:

They don’t beat around the bush with it, which is a good thing.
I don’t like when people, like, say something to try to start the
conversation. I just like when they go, “How are you doing?”
And then, “Have you been using condoms,” and “How is your
sex life,” and stuff like that. (Female, 18 years)

Hoopes et al 335

Others particularly appreciated providers who acknowl-
edged their concerns about being normal and contextual-
ized sexuality as a part of routine health care.

Treating it like anything else . . . saying, “Yeah, like it can kind
of be nerve-wracking, but don’t worry, I’m not attacking you, I
ask all my patients this” [. . .] I think that’s good, ’cause teenagers
are always afraid of “being the only one.” (Female, 15 years)

Provider Adaptation to Patient’s Maturity Level. Participants spoke
apprehensively about sexual health discussions that did not
feel appropriate for their knowledge and maturity level. One
participant described going to a doctor at 10 years for birth
control pills to treat heavy and painful menstrual periods:

And, like, they were like, “Well, you know if you do decide to
have sex, blah, blah, blah.” … and I was like, why are you
telling me all this? It was so uncomfortable. I was like, okay,
I’m not going to have sex right now. And like, even if I was, or
something like, it was like waaay too much information.
(Female, 15 years)

Some referenced the frustration of providers’ failing to rec-
ognize a patient’s capacity to make autonomous decisions.

Me and my partner took a long time before we had sex . . . Took
a while for her to be ready, for me to be ready, to be able to trust
each other. And sometimes I think the doctors forget that
teenagers can think too. We have brains. (Male, 17 years)

Provider as Source of Sexual Health Expertise
and Services

Participants referred to providers as sexual health experts
and resources for accurate information.

Because I’m not really gonna talk to anybody else about it, so
I’d rather talk to the person who knows about it the most, and
is gonna keep everything . . . like not judge me, and is gonna
actually help me with it (Gender, age unrecorded)

Adolescents recognize providers as the gateway for health
care services and supplies such as condoms, contraception,
and STI testing. These offerings were described as key
aspects of the health care encounter and emphasized by
some as more valuable than provider counseling:

Give me protection. Give me condoms and saying maybe if I
don’t use condoms, try using birth control, or something of that
sort. (Female, 19 years)

Discussion

Using the words and experiences of adolescent patients in a
public health clinic, this study identified specific individual

dynamics and patient-provider interaction dynamics that
shape communication during sexual health visits.
Adolescents’ perspectives provided insights into how their
level of maturity and sexual experience influence their pref-
erences for providers broaching sexual health discussions.
Level of emerging autonomy was a major factor in their
comfort and willingness to discuss sexual health. Some
identified providers as resources for health information and
supplies, but others emphasized concerns about confidenti-
ality, judgment, and the power imbalance. While prefer-
ences about communication style varied, preferred attributes
included nonjudgmental and straightforward providers able
to normalize sexual health issues.

Participants in our study expressed themes consistent
with prior studies; they were less comfortable discussing
sexual health when concerned about confidentiality or with
providers perceived as highly judgmental.15,20 Our study
findings further reinforced the importance of patient-pro-
vider communication.21,22 The literature suggests that ado-
lescents with chronic illness,23 young men who have sex
with men,13 and adolescents seeking preventive health
care12,24 have a more favorable experience and are more
engaged in their health care when there is higher quality
patient-provider communication.

This study adds new insights into how level of maturity
and sexual experience factor into patient preferences and
needs within a patient-provider interaction. Our findings
suggest differences between patient and perceived provider
goals for the sexual health visit. Some adolescents perceive
the provider as primarily a resource for sexual health sup-
plies and services. They find the sexual health interview
invasive, rather than recognizing its purpose to assess risk
and determine sexual health needs. Therefore, providers
should communicate why they ask questions about sexual
behaviors to tailor their approach to the adolescent’s matu-
rity level.

Despite the importance of risk screening, providers face
challenges in discussing sexual health due to shortened
clinic visits, increasing number of preventive health topics,
and discomfort or lack of training in sexual health care.
Prior studies have found that providers miss opportunities
to screen and provide sexual health services and counseling
to adolescents, even those with known high-risk behav-
iors.25-27 It is clear that providers need adequate resources
and innovative strategies to carry out recommended screen-
ing and management guidelines.

This study was qualitative and exploratory and subject to
limitations of participants living in one geographical region
attending one clinic and is not generalizable to all adoles-
cents. Interview responses may be influenced by social desir-
ability and potentially reflective of their public health clinic
experiences rather than experiences in other clinical settings.
The demographic information collected was limited to age
and gender, which excludes understanding responses in the

336 Journal of Primary Care & Community Health 8(4)

context of specific demographic characteristics. Of note,
individual gender and age was unintentionally not recorded
for 2 participants’ audio files, limiting our ability to attribute
age and gender to quotations by those participants. The clinic
serves a high-risk population and these findings may not
reflect experiences of adolescents in the primary care setting.
Furthermore, inclusion criteria were limited to participants
who reported penile-vaginal intercourse and therefore the
experiences and preferences of adolescents engaging in other
sexual activities were not captured in this study. Although the
interviews were conducted from 2008 to 2009, the model of
clinic-based, adolescent sexual health services that existed
during data collection has not substantially changed since
that time, specifically that confidential services are provided
at sliding-scale cost in an ambulatory setting requiring a clin-
ical history, examination, laboratory tests, and provision of
medications, counseling, and preventive supplies such as
condoms. For this reason, findings are considered still rele-
vant and applicable to providers seeing adolescents in outpa-
tient clinical setting currently.

This study offers valuable insights into the adolescent
experience during a sexual health visit. The data reflect the
evolving and fluctuating health care needs of adolescents as
they navigate sexual and emotional development and gain
confidence in accessing and utilizing health care services.
Our findings highlight the importance of providers’ ability
to assess a patient’s developmental stage and prior experi-
ences and to tailor their communication style and health
messages accordingly. There is a clear need for innovative
tools that support providers to rapidly assess and adjust to
an adolescent’s stage of psychosocial development, level of
sexual experience, and risk behaviors to facilitate more ado-
lescent-friendly interactions. Next steps might involve
development and study of tools and interventions that sup-
port providers in these activities. Since these findings reflect
only the perspectives of the patients, further research that
includes provider interviews or patient-provider observa-
tion might elucidate more comprehensive insights.
Subsequent studies should also explore patient-provider
communication in other health care settings serving adoles-
cents, such as school-based health or acute care settings,
and among adolescents who have special health care needs.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
study was funded by Eunice Kennedy Shriver National Institute of
Child Health and Human Development 5K23HD052621 (PI
Taraneh Shafii, MD, MPH) NIH Mentored Patient-Oriented
Research Career Development Award (K23).

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Author Biographies

Andrea J. Hoopes, MD, MPH, is an adolescent medicine physi-
cian at Kaiser Permanente Washington in Seattle, Washington.
Her research focuses on improving sexual and reproductive health
services for adolescents in resource-limited communities.

Samantha K. Benson, MPH, received her MPH from the
University of Washington in 2012 with a focus on Maternal and
Child Health. She has since worked at the University of
Washington and is currently an educator with a program works
with US health departments to adapt to changes in the HIV pre-
vention landscape.

Heather B. Howard has expertise in patient-centered program
design, sexual and reproductive health, health systems strengthen-
ing, and health innovation among vulnerable populations in
domestic, development, and humanitarian settings. Ms. Howard
earned her MPH from the University of Washington in 2010.

Diane M. Morrison, PhD, is Professor Emerita at the University
of Washington School of Social Work. Her research interests
focus on adolescent and young adult sexual behavior and decision
making.

Linda K. Ko, PhD, is a behavioral scientist with expertise in the
development, testing, and evaluation of health communication
strategies. Dr. Ko is an Assistant Member in the Division of Public
Health Sciences at the Fred Hutchinson Cancer Research Center
and Associate Professor in the Department of Health Services at
University of Washington.

Taraneh Shafii, MD, MPH is an Associate Professor of Pediatrics
in the Department of Pediatrics, Division of Adolescent Medicine
at the University of Washington School of Medicine. Dr. Shafii’s
research focus is the development and testing of interactive, com-
puter-based interventions to promote sexual health and prevent
STI/HIV and unintended pregnancy in adolescents and young
adults. She serves as Director of the Inpatient Service at Seattle
Children’s Hospital and is Director of Quality Improvement in the
Division of Adolescent Medicine.

International Journal of

Environmental Research

and Public Health

Article

Lack of Knowledge about Sexually Transmitted
Diseases (STDs): Implications for STDs Prevention
and Care among Dermatology Patients in an Urban
City in Vietnam

Sau Huu Nguyen 1,2, Anh Kim Dang 3, Giang Thu Vu 4, Cuong Tat Nguyen 3, Thu Hoai Thi Le 1,2,
Nu Thi Truong 5, Chi Linh Hoang 5, Tung Thanh Tran 4, Tung Hoang Tran 6, Hai Quang Pham 3,
Nam Gia Dao 4, Bach Xuan Tran 7,8,* , Carl A. Latkin 8 , Cyrus S. H. Ho 9 and
Roger C. M. Ho 5,10,11

1 National Hospital of Dermatology and Venereology, Hanoi 100000, Vietnam;
[email protected] (S.H.N.); [email protected] (T.H.T.L.)

2 Department of Dermatology and Venereology, Hanoi Medical University, Hanoi 100000, Vietnam
3 Institute for Global Health Innovations, Duy Tan University, Da Nang 550000, Vietnam;

[email protected] (A.K.D.); [email protected] (C.T.N.); [email protected] (H.Q.P.)
4 Center of Excellence in Evidence-Based Medicine, Nguyen Tat Thanh University, Ho Chi Minh City 700000,

Vietnam; [email protected] (G.T.V.); tu[email protected] (T.T.T.);
[email protected] (N.G.D.)

5 Center of Excellence in Behavioral Medicine, Nguyen Tat Thanh University, Ho Chi Minh City 700000,
Vietnam; [email protected] (N.T.T.); [email protected] (C.L.H.)

6 Institute of Orthopaedic and Trauma Surgery, Vietnam—Germany Hospital, Hanoi 100000, Vietnam;
[email protected]

7 Institute for Preventive Medicine and Public Health, Hanoi Medical University, Hanoi 100000, Vietnam
8 Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, MD 21205, USA;

[email protected]
9 Department of Psychological Medicine, National University Hospital, Singapore 119074, Singapore;

[email protected]
10 Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore,

Singapore 119077, Singapore; [email protected]
11 Biomedical Global Institute of Healthcare Research & Technology (BIGHEART), National University of

Singapore, Singapore 119228, Singapore
* Correspondence: [email protected]; Tel.: +84-982228662

Received: 30 January 2019; Accepted: 22 March 2019; Published: 26 March 2019
����������
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Abstract: Sexually transmitted diseases (STDs) are a substantial global burden of diseases, especially
in developing countries. Lack of awareness of STDs may lead to a delay in treatment. This study
aimed to assess knowledge about STDs and the associated factors among dermatological patients.
A cross-sectional study was conducted among 622 patients at Vietnam National Hospital of Dermatology
and Venereology (NHD). Structured questionnaires were used to investigate the knowledge about STDs.
A multivariate Tobit regression was employed to determine factors associated with knowledge about
STDs. The percentage of patients knowing that syphilis was an STD was highest (57.8%), followed
by herpes warts (57.7%) and HIV/AIDS (57.4%). By contrast, 26.6% and 17.2% of patients knew that
chlamydia and hepatitis C were STDs. The most commonly stated symptom of STDs was purulent
genital (53.5%). Nearly two-thirds of participants were aware of the curability of STDs, and 34.7% knew
about vaccines for STDs. Living with partners, young age, and acquired knowledge of STDs via the
Internet, social networks, and health staff were positively related to having better knowledge about
STDs. Based on the results of this study, peer education, informal conversations within clusters, mass
community campaigns through the Internet and social networks, and the use of online health care
providers should be promoted in order to improve awareness of STDs.

Int. J. Environ. Res. Public Health 2019, 16, 1080; doi:10.3390/ijerph16061080 www.mdpi.com/journal/ijerph

Int. J. Environ. Res. Public Health 2019, 16, 1080 2 of 9

Keywords: STIs; STDs; sexually transmitted infections; dermatology; Vietnam

1. Introduction

Sexually transmitted diseases (STDs) are considered one of the major causes for the global
burden of diseases. According to a report from the World Health Organization (WHO), there are
approximately one million new cases of sexually transmitted diseases (STDs) every day worldwide [1].
In addition, each year it is estimated that there are 357 million new infections consisting of one of
four types of STDs including chlamydia, gonorrhea, syphilis, and trichomoniasis [1,2]. Beyond the
immediate impact of the infections, STDs may have severe repercussions on physical health as well
as the psychological and social well-being of patients [3]. Mother-to-child transmissions of STDs can
occur during pregnancy and childbirth. Syphilis in pregnancy can lead to stillbirth, neonatal deaths,
congenital deformities as well as increasing risk of dying from prematurity [1,4]. Women experiencing
Human Papillomavirus (HPV) infection may suffer from cervical cancer as a result, and women
with gonorrhea and chlamydia are at higher risk of undergoing pelvic inflammatory disease, female
infertility, and preterm delivery [1,3].

However, the management of STDs is still limited due to asymptomatic or mild cases that case
can be make detection difficult [5]; the diversity of pathogens, and social stigma on patients [1,6].
The imperative for enhancing knowledge of STDs is a strategic measure of the WHO to address the
burden of disease [3,7]. A previous study conducted among young students indicated that most of
them had heard about sexually transmitted infection (STIs), but primarily human immunodeficiency
virus/acquired immunodeficiency syndrome (HIV/AIDS) rather than other types of STDs. It was
reported that the students mainly obtained STD information through the Internet, newspapers,
or magazines [7]. Moreover, many people do not perceive that they are at risk of becoming infected
by STDs and do not have adequate knowledge about STDs, especially in developing countries [8].
Acquiring adequate knowledge of symptoms and about the prevention of STDs is critical in order to
reduce the risk of sexual transmission and the prevalence of STDs [9].

The prevalence of STDs in urban areas and megacities is increasing [10]. Previous studies have shed
light on the association between the spreading of STDs and mass urbanization and migration [10–12].
Additionally, among developing countries, STIs have been shown to directly negatively influence
reproductive health and indirectly increase the risk of sexual transmission of HIV and have a heavy
impact on both morbidity and mortality rates [13]. Because many symptoms of STDs are presented on
the skin, a large proportion of patients showing signs of STDs tend to visit Dermatology and Venereology
Hospital [14]. In Vietnam, the prevalence of STDs (excluding HIV/AIDS) has risen rapidly in the last ten
years and reached 17.3% in 2017, resulting in approximately 28,654 disability-adjusted life years [15].
This study aimed to assess knowledge about STDs as well as the associated factors among dermatological
patients in an urban city in Vietnam (a developing country).

2. Materials and Methods

2.1. Study Design and Setting

Our cross-sectional study was conducted at the Vietnam National Hospital of Dermatology and
Venereology (NHD) from September to November 2018. NHD is the specialized national hospital
that is the leader in dermatology in the country, and this is the main center for research, diagnosis,
treatment, prevention, and functional rehabilitation of STDs across different illness severity levels.
The techniques and tests performed at the hospital follow the standard procedures and protocols
provided or recommended by the Ministry of Health, WHO, and CDC (Centers for Disease Control
and Prevention).

Int. J. Environ. Res. Public Health 2019, 16, 1080 3 of 9

A convenience sampling technique was used to choose participants for the study among the
pool of patients attending the hospital. The eligibility criteria for selecting participants were (1) aged
18 years old or above; (2) having the ability to answer the questionnaire coherently; (3) agreeing to
be involved in the study by providing written consent. Participants suffering from serious illnesses
during the interview time were excluded. All participants were clearly informed about the purpose,
benefits, and disadvantages of the study prior to becoming involved in the study. Upon agreeing to
participate in the study, all participants signed a written informed consent form. Participants were
invited into a private room at the hospital in order to ensure the confidentiality of their responses
as well as the quality of the answers. Six hundred and twenty-two patients agreed to participate in
the study.

2.2. Measurements and Instruments

A pilot study was conducted among 20 patients in August 2018. Only a few comments
regarding logic and wording of the questionnaire were noted and corrected before conducting the
survey. Participants were invited to complete 20-minute face-to-face interviews using structured
questionnaires. The individuals who collected data were well-trained medical students at Hanoi
Medical University. Data regarding the socioeconomic status of participants and their knowledge
about STDs are specified below.

2.2.1. Socioeconomic Characteristics

Patients self-reported data about gender, age, educational level, marital status, occupation, living
area, age, monthly income, and health insurance.

2.2.2. Sexually Transmitted Disease (STD)-Related Characteristics

We collected information about each participant’s current diagnosis of STDs and about whether
they had ever suffered from any STDs or venereal diseases, especially STDs presented on the skin.

2.2.3. Knowledge Regarding Sexually Transmitted Diseases (STDs)

Seven multiple choice questions were asked to assess participants’ knowledge of STDs. Regarding
types of common STDs, signs and symptoms of STDs, and measures to prevent STDs, participants
were able to choose more than one answer. We prepared a list of featured signs and symptoms of STDs
and participants were queried about whether they knew each of them. Participants were asked to
choose one correct answer only about the curability and availability of vaccinations for STDs. Sources
of information on the prevention of STDs were also examined.

2.3. Statistical Analysis

Data was analyzed by STATA version 15.0 (StataCorp. LP, College Station, TX, USA). Descriptive
statistics were utilized to examine the socioeconomic variables and STD-related characteristics. For each
correct answer on STDs knowledge 1 point was scored. The total score of STDs knowledge was
calculated by summing all correct answers. A multivariate Tobit regression model was employed to
determine associated factors with knowledge about STDs (censored continuous variable). Independent
variables were socioeconomic characteristics (age, gender, marital status, educational level, occupation,
income level, and living areas), and methods by which the participants accessed information on the
prevention of STDs. In order to identify a reduced multivariate regression model, stepwise backward
selection strategies were performed with the minimum p-value for variable selection of 0.2. A p-value
under 0.05 was regarded as statistically significant. Listwise deletion was used to handle missing data,
whereby missing data were simply omitted and the remaining data was analyzed [16].

Int. J. Environ. Res. Public Health 2019, 16, 1080 4 of 9

2.4. Ethical Approval

The protocol of the study was approved by the Institutional Review Board of the Vietnam National
Hospital of Dermatology and Venereology (code 855/HDDDDBVDLTU).

3. Results

In our study, the percentage of female participants was 46.7%. The majority of participants
received high school education or higher (88.2%). More than two-thirds of patients lived with
spouses/partners (68.4%). In terms of employment status, 39.4% of the participants were white-collar
workers, followed by freelancers (28.5%). The mean age was 35.7 years (SD = 12.5).

Table 1 shows the information about the clinical characteristics of the patients. Most participants
did not suffer from any STDs. The percentage of patients having genital mycosis was the highest
(2%), followed by gonorrhea and syphilis (1.6%). About 9.3% of participants had STDs, and only
1% of participants had STDs related to dermatology. Approximately 10% of participants had
dermatological diseases.

Table 1. Clinical characteristics of respondents. STDs: sexually transmitted diseases.

Characteristic n %

Gonorrhea 10 1.6
Syphilis 10 1.6
Genital mycosis 12 2.0
Chlamydia 6 1.0
Hepatitis B 5 0.8
Human immunodeficiency virus (HIV) 6 1.0
Herpes 3 0.5
Others 7 1.1
Ever had dermatology STDs (n = 620) 10 1.6
Currently have STDs related to dermatology (n = 600) 6 1.0
Currently have STDs (n = 620) 58 9.3
Have more than 1 dermatological disease (n = 622)

Healthy 564 90.3
One disease 42 6.8
More than 1 disease 16 2.6

Table 2 presents the knowledge of participants regarding STDs. The number of patients who
were knowledgeable about syphilis was the highest, followed by herpes warts (57.7%) and HIV/AIDS
(57.4%). By contrast, only 17.2% of patients knew that hepatitis C is a STD and about 26.6% of
participants considered chlamydia to be an STD. Patients reported that the common symptoms of
STDs were purulent genital (53.5%), genital rash (49.6%), and genital ulcers (48.8%). In terms of the
curability of STDs, 68% of participants were aware that not all STDs can be cured, and 34.7% of patients
knew that several STDs had vaccines. Regarding preventive measures that can be taken against STDs,
80.7% mentioned using condoms.

Table 2. Knowledge of participants towards STDs.

Characteristics n %

Types of STDs
Syphilis 354 57.8
Herpes warts 353 57.7
Chlamydia 163 26.6
Hepatitis B 172 28.1
Hepatitis C 105 17.2
Human immunodeficiency virus/
acquired immunodeficiency syndrome (HIV/AIDS) 351 57.4

Genital mycosis 258 42.2
Gonorrhea 299 48.9

Int. J. Environ. Res. Public Health 2019, 16, 1080 5 of 9

Table 2. Cont.

Characteristics n %

Symptoms of STDs
Painful or leaky urine 274 44.8
Purulent genital 327 53.5
Genital ulcers 298 48.8
Genital rash 303 49.6
Inguinal lymph nodes 109 17.8

Preventive measure against STDs
Have only one sexual partner 348 56.9
Use condom 494 80.7
Vaccination 143 23.4
Periodic health examination 210 34.3

Curability of STDs (n = 603)
Every STD can be cured 48 8
No STD can be cured 28 4.6
Some can be cured, some cannot 410 68
Unknown 117 19.4

STDs vaccine availability (n = 603)
Every STD has vaccines 125 20.7
No STDs have vaccines 43 7.1
Some have vaccines, some do not have vaccines 209 34.7
Unknown 226 37.5

Participants’ sources of information about STDs are depicted in Table 3. Patients mainly got
information about STDs via the Internet (46.1%), friends/relatives (31.9%), and health staff (27.3%).
Only 5.1% of participants received information through short message service (SMS)/mobile phone
and 8.5% via the local speaker.

Table 3. Sources of STDs information.

Characteristics N %

Friends/relatives 195 31.9
Poster/banner 60 9.8
Internet 282 46.1
Short message service (SMS)/mobile phone 31 5.1
Local speaker 52 8.5
Paper/book 146 23.9
Health staff 167 27.3
Social network 154 25.2

Table 4 reveals the factors associated with knowledge about STDs of dermatological patients.
Participants who were younger or blue-collar workers were less likely to have adequate knowledge
about STDs compared to those who were unemployed or were older. Additionally, participants living
with partners had higher scores of STDs knowledge. In terms of information sources, attendants
received better information on STDs via the Internet, social networks and health staff compared with
those do not use the Internet and/or commute with healthcare providers.

Int. J. Environ. Res. Public Health 2019, 16, 1080 6 of 9

Table 4. Factors associated with participants’ knowledge of STDs.

Characteristics Coef. 95% CI

Employment (vs. Unemployed)
Blue collar worker −0.34 ** −0.66; −0.03

Education (vs. Under high school)
University/Postgraduate 0.20 * −0.03; 0.42

Family income (vs. Lowest)
Medium −0.27 ** −0.51; −0.02

Marital status (vs. Single/divorce)
Living with partners 0.32 ** 0.07; 0.58

Age −0.01 ** −0.02; −0.00
Source of information (Yes vs. no)

Internet 0.96 *** 0.74; 1.18
Local speaker 0.20 * −0.00; 0.41
Paper/book 0.24 * −0.00; 0.48
Health workers 0.41 *** 0.19; 0.63
Social network 0.24 ** 0.01; 0.48

Currently have STDs (Yes vs. no) 0.23 −0.12; 0.57

*** p < 0.01, ** p < 0.05, * p < 0.2.

4. Discussion

Our study indicated valuable information about knowledge on STDs of dermatological patients
in an urban city in Vietnam. The findings showed that a low percentage of participants had adequate
knowledge about the common types and symptoms of STDs and about vaccinations against STDs.
The majority of patients were aware of the measures of prevention and curability of STDs. Living
with partners, having a lower age, and being unemployed (compared to being a blue-collar worker)
were positively related to having adequate knowledge about STDs. The Internet, social networks, and
health staff were likely to be the most informative sources.

In this study, the percentage of participants who were aware of common types of STDs was
relatively low, as opposed to a previous study in which nearly one hundred percent of the participants
mentioned HIV/AIDS as being an STD [7]. Compared to the findings of a study conducted among
healthcare providers in rural Vietnam, our results also showed a lower rate of knowledge about all
common types of STDs [17]. Patients in our study demonstrated a higher level of knowledge about
STDs caused by bacteria, such as syphilis and gonorrhea, than STDs caused by viruses (HIV/AIDS
and hepatitis). This could be explained by a common belief that viral infections can spread more easily
via consuming contaminated food or sharing the same needles rather than sexually [18]. In terms of
knowledge about STD symptoms, the majority of patients mentioned purulent genital discharge as
being a symptom of STDs, whereas inguinal lymph nodes were often neglected. These findings are
consistent with a previous study that revealed that the percentage of participants who were able to
correctly provide answers about suspected symptoms was relatively low, and they only identified
symptoms presented on the skin [9,19,20].

The majority of patients were aware that using condoms is an effective measure of preventing STDs
and HIV. This proportion is higher than the results of previous studies performed in Vietnam [19,21]
and a study conducted among young girls in India [22]. However, a study in Ho Chi Minh City showed
that approximately 92% of participants were aware that condoms use protects against HIV [23]. There
was a disproportion of participants who had adequate knowledge about HIV/AIDS compared to
other STDs, and this can be explained by the unbalanced effort and financial resources allocated to
combating HIV/AIDS compared to STI control activities in general [24]. This may put patients at a
higher risk of becoming infected with other STDs due to inadequate knowledge. The percentage of
patients who had misunderstandings about the curability of STDs and the availability of vaccines for

Int. J. Environ. Res. Public Health 2019, 16, 1080 7 of 9

STDs was relatively high. A number of STDs are incurable, and the Center for Disease Control and
Prevention (CDC) recommends that vaccines are an effective way to prevent hepatitis B and HPV [25].

Our study shows that having a younger age and/or living with a spouse/partner were strongly
associated with having better knowledge of STDs. Women who get married typically have more
frequent reproductive health examinations [26,27], and are thus more likely to be provided information
regarding common symptoms of STDs and STD prevention measures by healthcare providers [19].
Also, unmarried women often hesitate to talk about sexual practices and STDs, probably due to their
sensitive nature [26]. A large proportion of STD-infected patients are adolescents [28], since many of
them do not perceive themselves to be at risk of becoming infected by an STD [9] and they tend to be
more likely to have unprotected sex as well as multiple sexual partners [29]. Therefore, a lot of health
promotion campaigns and sex education programs have been established in order to enhance the
approachability of STDs information for adolescence. These interventions may increase the knowledge
about STDs for young people compared to older people.

Our study also revealed that the Internet, social media, and health care providers were common
channels that participants seek for STDs information. This result is similar to a previous study that
indicated that the Internet was the most popular source of STDs information [7]. The Internet has
upgraded the way that people search for health information, as it can be easily retrieved and passed
on [30]. Additionally, the proportion of people using social networks to seek health information
also dramatically increased thanks to the ability to receive and respond to information rapidly [31].
A previous study demonstrated that adolescents usually use the Internet to search for their private
sexual health problems and collect information on health topics [32]. Nevertheless, as not all the
information on the Internet is scrutinized by health professionals, incorrect information may mislead
patients and pose the threat of delaying treatments [33].

Several implications can be drawn from our study. In terms of clinical implications, since the lack
of understandings about STDs may lead to delays in treatment, health professionals should carefully
assess their patients’ knowledge of common types and presentations of STDs, particularly beyond
those with skin-related symptoms. Secondly, unmarried women should receive more information
about such preventive healthcare service as vaccines in order to protect themselves from STDs and
ensure their reproductive health. Several interventions based on the Internet and social media should
be undertaken in order to enhance knowledge of STDs, such as peer education, informal conversations
within clusters, and/or mass community campaigns. Our findings also provide empirical evidence
for decision-makers to assess the effectiveness of current health policies and monitor appropriate
adjustments in the future.

Some limitations should be acknowledged. The convenience sampling technique used in this
study may limit the ability to interpret the findings from our study. Some of the data that was collected
could be incorrect due to recall bias and social desirability bias. In addition, a causal relationship
between knowledge of STDs and associated factors cannot be established due to the cross-sectional
study design. There was also incomplete data on some variables, which may affect the results of
the study.

5. Conclusions

This study revealed that there was a low percentage of participants who were adequately aware
of the common types, symptoms, and vaccinations available for STDs. Living with spouse/partners
and having a younger age were both positively related to having better knowledge about STDs.
The use of peer education, informal conversations within clusters, mass community campaigns via
the Internet and social networks, and online health care providers should be taken into consideration
when designing and implementing interventions.

Author Contributions: Conceptualization, A.K.D.; Data curation, C.T.N., N.T.T., T.H.T., B.X.T. and C.A.L.; Formal
analysis, G.T.V., C.L.H., T.T.T., H.Q.P., N.G.D. and C.A.L.; Funding acquisition, S.H.N., A.K.D., G.T.V., T.H.T.L.,
N.T.T., T.T.T., T.H.T., B.X.T., C.A.L. and R.C.M.H.; Investigation, A.K.D., C.T.N., T.H.T.L., N.G.D., C.A.L. and

Int. J. Environ. Res. Public Health 2019, 16, 1080 8 of 9

C.S.H.H.; Methodology, S.H.N., A.K.D., G.T.V., C.L.H., T.T.T., H.Q.P., B.X.T., C.S.H.H. and R.C.M.H.; Resources,
C.T.N., C.L.H., T.H.T., C.S.H.H. and R.C.M.H.; Software, S.H.N., N.T.T., H.Q.P. and N.G.D.; Supervision, G.T.V.,
T.H.T.L., N.T.T., C.L.H. and N.G.D.; Validation, S.H.N., C.T.N., T.T.T., T.H.T. and R.C.M.H.; Visualization, T.H.T.L.,
H.Q.P. and C.S.H.H.; Writing—original draft, B.X.T., C.A.L. and C.S.H.H.; Writing—review & editing, S.H.N.,
A.K.D., G.T.V., C.T.N., T.H.T.L., N.T.T., C.L.H., T.T.T., T.H.T., H.Q.P., N.G.D., B.X.T. and R.C.M.H.

Funding: No funding was received for this study.

Acknowledgments: Our thanks to Vietnam National Hospital of Dermatology and Venereology that gave me
permission and supported me to conduct this study. Besides, I am grateful to all the participants who gave me
their time and willing to participate in this study.

Conflicts of Interest: The authors declare no conflict of interest.

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© 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).

  • Introduction
  • Materials and Methods
    • Study Design and Setting
    • Measurements and Instruments
      • Socioeconomic Characteristics
      • Sexually Transmitted Disease (STD)-Related Characteristics
      • Knowledge Regarding Sexually Transmitted Diseases (STDs)
    • Statistical Analysis
    • Ethical Approval
  • Results
  • Discussion
  • Conclusions
  • References

Technology-Based Interventions to Reduce Sexually Transmitted
Infections and Unintended Pregnancy Among Youth

Laura Widman, PhD1, Jacqueline Nesi, MA2, Kristyn Kamke, MS3, Sophia Choukas-
Bradley, PhD4, and J. L. Stewart, BFA5

1North Carolina State University, Department of Psychology, Campus Box 6740, Raleigh, NC
27695

2University of North Carolina at Chapel Hill, Department of Psychology and Neuroscience,
Campus Box 3270, Chapel Hill, NC 27599

3North Carolina State University, Department of Psychology, Campus Box 6740, Raleigh, NC
27695

4University of Pittsburgh, Department of Psychology, 3413 Sennott Square, 210 S. Bouquet St,
Pittsburgh, PA 15260

5North Carolina State University, Department of Psychology, Campus Box 6740, Raleigh, NC
27695

Abstract

Purpose—Technology-based interventions to promote sexual health have proliferated in recent

years, yet their efficacy among youth has not been meta-analyzed. This study synthesizes the

literature on technology-based sexual health interventions among youth.

Methods—Studies were included if they: 1) sampled youth ages 13-24; 2) utilized technology-

based platforms; 3) measured condom use or abstinence as outcomes; 4) evaluated program effects

with experimental or quasi-experimental designs; and 5) were published in English.

Results—16 studies with 11,525 youth were synthesized. There was a significant weighted mean

effect of technology-based interventions on condom use (d=.23, 95% CI [0.12, 0.34], p<.001) and

abstinence (d=.21, 95% CI [0.02, 0.40], p=.027). Effects did not differ by age, gender, country,

intervention dose, interactivity, or program tailoring. However, effects were stronger when

assessed with short-term (1-5 months) compared to longer-term (greater than 6 months) follow-

ups. Compared to control programs, technology-based interventions were also more effective in

Corresponding Author: [email protected]; 919-513-2546.

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Implications and Contributions: This meta-analysis demonstrates that technology-based interventions can effectively promote
sexual health among youth. Compiling data from 16 studies, technology-based interventions were shown to improve condom use,
abstinence, safer-sex knowledge, and safer-sex attitudes and norms. Effects were robust across many factors (e.g., age, gender, dose)
but were stronger with shorter-term follow-up.

HHS Public Access
Author manuscript
J Adolesc Health. Author manuscript; available in PMC 2019 June 01.

Published in final edited form as:
J Adolesc Health. 2018 June ; 62(6): 651–660. doi:10.1016/j.jadohealth.2018.02.007.

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increasing sexual health knowledge (d=.40, p<.001) and safer sex norms (d=.15, p=.022) and

attitudes (d=.12, p=.016).

Conclusions—After 15 years of research on youth-focused technology-based interventions, this

meta-analysis demonstrates their promise to improve safer sex behavior and cognitions. Future

work should adapt interventions to extend their protective effects over time.

Keywords

adolescent sexual health; sex education; technology-based interventions; eHealth; mHealth; digital
health; sexually transmitted diseases; HIV prevention

Introduction

The risk of unplanned pregnancy and sexually transmitted infections (STIs), including HIV,

is high among youth. Youth ages 13-24 comprise nearly half of the 20 million new STI cases

and more than 20% of new HIV diagnoses each year in the United States [1, 2]. Worldwide,

adolescents and young adults account for 45% of all new HIV infections [3]. Rates of

unintended pregnancy are also elevated among youth, with girls ages 15-19 having higher

rates of unintended pregnancy than girls and women in any other age group [4, 5]. Further,

complications from childbirth are the second leading cause of death among 15-19 year old

girls worldwide [5].

Efforts to provide youth with sexuality education to reduce HIV/STIs and unintended

pregnancy have been underway for decades.[6, 7]. Only recently, however, has a movement

emerged toward utilizing technology-based platforms for sexual health program delivery [8–

10]. Technology-based interventions have been alternatively referred to as eHealth, mHealth,

digital media, or new media interventions, and typically utilize computers, smart phones,

text messaging, and/or other web-based platforms. As digital tools have become increasingly

accessible and sophisticated in their functionalities, many researchers have heralded the

promise of technology-based interventions to improve sexual health [8–10]. Compared to

traditional interventions, new media approaches may allow for broad reach at relatively low

costs, improved fidelity during intervention delivery, greater privacy and comfort for teens

learning about sensitive topics, and increased capacity for individually tailoring prevention

messages [11, 12]. Additionally, such tools may provide fruitful means for engaging today’s

digitally native youth, among whom the ubiquitous use of technology plays a central role in

key developmental tasks [13, 14].

The promise of new media tools has prompted a recent proliferation of technology-based

interventions targeting sexual health among youth. While recent systematic reviews have

highlighted potential impacts and limitations of these interventions [15–17], little is known

regarding their combined efficacy. Determining whether and through what mechanisms

technology-based interventions promote youth sexual health is critical, as such knowledge

can inform future interventions and justify the allocation of resources to their development.

To date, there have been only three published meta-analyses across adolescent and adult

populations that provide insights into the efficacy of technology-based interventions for

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sexual health. The first focused on interventions to reduce HIV infection and included 12

randomized controlled trials published between 2002-2008 with participants of any age [18].

This study found a small but significant overall increase in condom use among participants

who completed a technology-based intervention compared to those who were randomized to

a control group, with an effect size that was comparable to similar in-person interventions (d
across studies = .26). These effects were stronger when interventions included individualized

tailoring (i.e., materials matched to the needs of specific participants) and had a greater

number of sessions. The second meta-analysis focused exclusively on programs employing

computer-based administration, finding that such interventions were effective in improving

sexual health knowledge, sexual self-efficacy, safer sex intentions, and safer sexual behavior

among adolescents and adults [19]. The third meta-analysis identified significant effects of

new media interventions for increasing condom use and STI testing within non-clinical

populations [20]. Importantly, this meta-analysis found that interventions produced the

largest effect sizes when they targeted female adolescents [20].

Despite these preliminary findings, at least three critical gaps inhibit our ability to draw

conclusions about the overall efficacy of technology-based sexual health programs for youth.

First, there are currently no meta-analyses focused exclusively on youth, even though youth

are at heightened risk for unplanned pregnancies and STIs [3, 4, 21, 22] and are also some of

the most frequent users of new media technologies [13, 23]. Second, no meta-analyses have

included abstinence as a behavioral outcome. Abstinence can be a developmentally-

appropriate objective of comprehensive sexuality education—particularly in programs

targeting early adolescent populations. Third, prior meta-analyses and systematic reviews of

technology-based sexual health programs have only included studies published through 2014

[15, 16, 18–20, 24]. Given the rapidly changing landscape of technology and the many new

interventions introduced each year, an updated review of the literature is warranted.

Thus, the goal of this meta-analysis is to synthesize the growing literature on technology-

based sexual health interventions among youth ages 13-24 and to determine their overall

efficacy on two key behavioral outcomes: condom use and abstinence. Additionally, we will

examine a number of secondary outcomes identified as important components of safer

sexual decision-making within health behavior theories [25] that have guided many

intervention efforts in this area. These outcomes include safer sex attitudes, norms, self-

efficacy, behavioral intentions, and sexual health knowledge. Finally, we will examine

whether characteristics related to the intervention recipients (age, gender, country) or the

intervention design (delivery method, use of tailoring, program interactivity, follow-up

duration) moderate the effectiveness of technology-based interventions on sexual health

outcomes.

Methods

Search Strategy

We conducted a comprehensive search of Medline, PsycINFO, and Communication Source
databases to extract relevant studies published through May 2017. We used the following

combination of key words, with asterisks used as “wild cards” to find any variations:

(adolescen* or teen* or youth or middle school or high school) AND (sexual health or safe*

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sex or sex* education or sexually transmitted disease or sexually transmitted infection or

STD or STI or HIV or AIDS or pregnancy or reproductive health or condom* or contracept*
or protected sex or unprotected sex) AND (intervention or program or education or trial)
AND (technology or internet or web-base* or computer-base* or online or social media or

social network* or SNS or eHealth or mHealth or electronic health or mobile health or

texting or text messag* or digital media or new media or gaming or SMS or mobile phone or

cell phone or phone app* or Facebook or Twitter or Instagram or instant message or web 2.0
or media 2.0). Additional studies of potential relevance were located by examining prior

reviews and meta-analyses [15–20, 24]. We also examined the reference lists of all included

articles to search for additional studies. This search produced an initial 1,932 scientific

articles.

Selection Criteria

Studies were included if they met the following criteria: 1) focused on youth between the

ages of 13-24 (i.e., mean sample age 13-24 and no participant older than 29); 2) utilized

technology as the primary mode of delivering an HIV/STI or pregnancy prevention

intervention (studies that utilized technology but also included extensive in-person

components were excluded [26, 27]); 3) included a behavioral outcome measure of either

condom use/unprotected sex (referred to as “condom use” in this paper; the effect sizes for

unprotected sex were recoded so that the direction of effect always indicated greater

protection) or abstinence/delayed intercourse (referred to as “abstinence”); 4) evaluated

program effects with an experimental or quasi-experimental design; 5) were published in

English; and 6) provided sufficient statistics to calculate effect sizes. These selection criteria

resulted in a final sample of 16 articles (see Supplemental Figure 1). In total, we calculated

16 independent effect sizes for condom use, 8 for abstinence, 6 for safer sex attitudes, 5 for

norms, 5 for self-efficacy, 5 for behavioral intentions, and 9 for sexual health knowledge.

Data Extraction

Two of the authors (K.K. and J.L.S.) independently coded the primary studies. The

following data were abstracted: 1) demographic and sample characteristics; 2) intervention

characteristics (e.g., type of technology used, number of sessions, program interactivity); 3)

methodological characteristics (e.g., length of follow-up, type of comparison group); and 4)

type of outcome measurement(s). The mean percentage agreement across all coding

categories was 88%. Discrepancies between coders were resolved through discussion with

the first author (L.W.). Additionally, three of the authors (L.W., K.K., and J.L.S.) rated the

16 studies for quality and risk of bias using the Cochrane Collaboration’s tool for assessing

risk of bias (see Supplemental Table 1).

Calculation of Effect Sizes

The standardized mean difference, d, was used as the indicator of effect size (i.e., the

treatment group and control group means divided by the pooled standard deviation).

According to Cohen [28], effect size d can be interpreted as small (.20), medium (.50), or

large (.80). When ds were reported in an article, they were directly extracted. If ds were not

reported, other statistics that could be converted to ds (e.g., summary statistics, odds ratios)

were calculated using Comprehensive Meta-Analysis V2.0 [29]. When no statistics in the

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study could be converted to a d, study authors were contacted and appropriate data were

requested. When more than one follow-up time point was reported, effect sizes were

calculated based on data from the longest follow-up for which data were available. To ensure

the consistency and interpretability of effect sizes, higher values always indicate the

technology-based intervention group performed better than the control group.

We used random effects meta-analytic procedures for the primary analyses across all

independent effect sizes; this procedure allowed for the possibility of differing variances

across studies [30]. The Q statistic and I2 were used to examine whether significant

heterogeneity existed among effect sizes. Effect sizes for hypothesized moderators were

calculated along with their 95% confidence intervals, and those effect sizes were compared

using the Qb statistic. For these analyses, mixed effects models were utilized to allow for the

possibility of differing variances across subgroups. These models employ random effects

assumptions, while stratifying the effect sizes by fixed factors such as age and study dose

[30]. Analyses were conducted using Comprehensive Meta-Analysis V2.0 [29].

Results

Study Characteristics

Table 1 provides a summary of the studies included in this meta-analysis, including sample

characteristics and moderator variables. A total of 11,525 participants (mean age=18.42)

were enrolled across 16 technology-based interventions for youth. The majority of studies

were conducted in the United States (k=11). Many studies used combined samples of boys

and girls (k=9); however, a few studies analyzed data from boys (k=3) and girls (k=4)

independently.

The delivery of program content varied widely across different digital media technologies.

Specifically, 5 programs were delivered exclusively via computer programs; 2 were

delivered exclusively through internet websites; 1 was delivered exclusively through texting;

1 was delivered exclusively through social media; and nearly half of programs (7 of 16) were

delivered with more than one method, such as an Internet website with email follow-up [31–

33] or a combination of text messaging and email delivery ([34]). It was common for

interventions to be interactive (i.e., accept input from the user as the program progressed;

k=12) and to utilize tailoring (i.e., include program components that were matched

specifically to the user based on user characteristics; k=10). The dose of intervention varied

widely across studies, with k=5 programs including 1-2 sessions and k=8 programs

including 7 or more sessions.

Primary Outcomes

Condom Use—While individual effect sizes ranged from d=−.07 to .67, the weighted

mean effect size for condom use across these studies was d=0.23 (95% CI [0.12, 0.34];

p<0.001), indicating that technology-based interventions have a small but significant

protective effect on condom use behavior among youth (see Figure 1). To examine whether

publication bias may have inflated the effect size of the interventions on condom use, a fail-

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safe N was calculated. This fail-safe N was 92, suggesting 92 non-significant studies would

need to exist in order to reduce the effect size to a trivial level (p>.05).

Statistical testing indicated marginal heterogeneity among studies with regard to the condom

use outcome (Q=24.27, p=.061, I2=38.19). Thus, we examined the potential impact of

several moderating variables. As shown in Table 2, there was only one marginally significant

difference based on the duration of follow-up assessment, with shorter follow-ups (less than

6 months) producing stronger effects (d=0.32, p<.001) than programs with follow-ups of

longer duration (6 months or more; d=0.14, p=.093). No significant differences were found

by participant age, gender, study dose, program interactivity, program tailoring, or whether

the study was conducted in the U.S.

Abstinence—Individual study effect sizes for abstinence/delayed sex ranged from d=.01

to .65, with an overall weighted mean effect size for abstinence across studies of d=.21 (95%

CI [0.02-0.40]; p=.027). This indicates that technology-based interventions have significant

protective effects on abstinence over time (see Figure 1). To examine whether publication

bias may have inflated the effect size of the interventions on abstinence, a fail-safe N was

calculated. This fail-safe N was 18, suggesting 18 non-significant studies would need to

exist in order to reduce the effect size to a trivial level (p>.05).

Statistical testing indicated significant heterogeneity among studies with regard to the

abstinence outcome (Q=16.93, p=.018, I2=58.65); thus, we examined the potential impact of

several moderating variables. As shown in Table 3, the only significant moderator was the

duration of follow-up. Similar to the effects on condom use, intervention effects on

abstinence were significantly stronger for short-term follow-ups (i.e., less than 6 months; d=.

45, p<.001) than those with long-term follow-ups (d=.07, p=.321). No significant differences

were found by gender, age, intervention dose, tailoring, or country of study. Of note, all 8

studies that included abstinence as a primary outcome were interactive interventions; thus,

we could not examine the effects of interactive versus static programs for abstinence.

Secondary Outcomes

We examined 5 secondary outcomes, including safer sex attitudes, social norms for safer

sexual activity, self-efficacy, behavioral intentions to practice safer sex, and sexual health

knowledge. As shown in Table 4, compared to control programs, technology-based

interventions were efficacious in increasing sexual health knowledge (d=.40, p<.001), social

norms for safer sexual activity (d=.15, p=.022), and safer sex attitudes (d=.12, p=.016)

among youth. Compared to controls, there were no significant differences in the effect of

technology-based interventions on safer sex intentions or perceived self-efficacy to engage

in safer sexual behavior.

Data Quality

The majority of study designs were rigorous (14 RCTs) and there was limited evidence of

attrition bias, with retention rates across studies generally exceeding 80%. However, some

uncertainty was noted in whether studies had utilized best practices for concealing the

allocation of participants into study conditions. For 8 studies, it was also unclear if selective

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reporting of outcomes could have been an issue since these studies had not been

preregistered. However, overall data quality across studies was deemed to be high, and most

studies were found to have a low risk of bias (see Supplemental Table 1).

Discussion

Results of the current meta-analysis, which synthesize nearly 15 years of research on the

development and evaluation of youth-focused technology-based interventions, highlight the

great promise of these approaches to improve safer sex behaviors among youth. Pooling data

from 16 studies with over 11,000 adolescents, this meta-analysis found a significant positive

effect of technology-based sexual health interventions for improving two key sexual

behaviors among youth: increasing consistent condom use (effect size d=.23) and delaying

sexual activity (effect size d=.21). Across studies, technology-based programs also led to

increases in sexual health knowledge, safer sex attitudes, and positive norms surrounding

safer sexual activity. Importantly, these effect sizes are comparable or even exceed the

effects of in-person interventions, with generally small to moderate intervention effects

noted for in-person programs (effect size d=.13 for condom use and d=.11 for abstinence in

a meta-analysis by Johnson et al [6]).

Technology-based interventions offer many possible benefits over traditional, face-to-face

interventions [11, 35, 36]. Most notably, these programs can be administered with high

fidelity without extensive facilitator training. This may result in cost-effective programs that

are capable of reaching a greater number of youth than are in-person programs. These

approaches can also increase youths’ openness to learning by providing a safe, controlled,

and familiar environment to receive sexual health knowledge and skills. This may be

especially salient for sexual minority youth who, in traditional face-to-face interventions

(e.g., school-based), may receive sexual education that is stigmatizing, inaccurate, or

irrelevant to their specific needs [37]. Further, technology-based programs offer ample

opportunities for customizability, interactivity, and individual tailoring [11, 35, 36].

Technology-based interventions also have the potential to reach adolescents in resource-

limited areas as worldwide access to mobile phones and internet technologies is rapidly

increasing among young people, even in low- and middle-income countries and rural areas

[23, 38].

Results suggest that the positive effects of technology-based interventions on sexual health

may be robust across a number of different factors. Several potential moderating factors did

not impact the efficacy of technology-based programs for youth, including the age and

gender of participants and the intervention interactivity, tailoring, and dose. For example,

while intervention dose varied from a single 15-minute session [39] to a full 12 months of

content delivery [31, 34], intervention dose did not influence effect sizes for condom use or

abstinence across studies. This finding differs from a previous systematic review of in-

person sexual health programs, which found that programs with higher duration and

intensity produced the greatest treatment effects [40]. However, our findings are consistent

with a more recent analysis of new media interventions [20], which found that the program

duration did not influence the size of effects on condom use. Indeed, the effects of

technology-based program dose on youth sexual health outcomes may be complex. On the

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one hand, the lack of association between intervention dose and outcomes could simply

reflect the challenges of differentiating between the dose intended and the dose received
within some technology-based programs [41]. On the other hand, this finding may reflect the

growing potency of technology-based interventions. As technology has become increasingly

available, interactive, and customizable in recent years, these interventions have clearly

shown effectiveness, even at small doses. Future work could investigate whether such

intervention impacts vary by how actively youth engage with technology on an everyday

basis.

One crucial insight gleaned from this meta-analysis is that the effects of current technology-

based programs tend to decrease over time. Specifically, for both condom use and

abstinence, stronger effects were found in the short-term (i.e., 1-5 month follow-up)

compared to studies that evaluated intervention effects over 6 months or more. Adolescent

sexual behavior is complex, and it is perhaps not surprising that program effects appear to

diminish over time. The lack of long-term sustainability is a problem that has also plagued

many programs delivered to youth in-person [42]. The knowledge and skills adolescents

learn in specific programs may fail to adequately prepare them for long-term changes in

their dating and sexual relationships and their evolving sexual interests and desires. Given

the initial promise of technology-based programs, an exciting extension of this work would

be to evaluate longer-term, adaptive interventions utilizing Sequential Multiple Assignment

Randomized Trial (SMART) designs [43]. These designs will allow investigators to examine

the impact of added program components (e.g., booster sessions) over time to target the

specific youth for whom treatment effects are diminishing. In fact, SMART designs may be

particularly amenable to technology-based interventions, given unprecedented opportunities

to automate assignment to intervention options (i.e., tailoring) based on participants’

responses at critical decision points [44].

Limitations and Future Directions for Intervention Efforts

A number of important limitations in the studies included in this meta-analysis are worthy of

future research attention. First, it is worth noting that there was substantial variation across

studies in the way that the outcome measures were defined. For example, for both condom

use and abstinence, some investigators focused exclusively on acts of vaginal sex [45–47] or

anal sex [48], whereas others included acts of vaginal, anal, and oral sex in their definitions

[41] or referred only to “sex” or “intercourse” without a definition [32, 39]. Additionally, the

timeline for measuring these behaviors differed. For example, some studies measured

condom use at last sex [45, 47], whereas others measured the frequency of condom use over

a specified period of time [49, 50]. Likewise, for the outcome measure of abstinence/delayed

sex, some studies focused on whether youth had ever initiated sexual activity [41, 47]

whereas others focused on abstaining from sexual activity over a specified period of time

[49]. Similar variation was observed in the definitions of the secondary outcomes under

investigation. It is clear that the sexual health intervention literature lacks a “gold standard”

for measuring sexual risk behavior and related attitudes and cognitions. This lack of

consistency in measurement has been observed in other meta-analyses examining sexual risk

behavior [6, 18, 51–53]. The measurement variation across studies could be obscuring our

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ability to detect the most precise estimates of intervention success, including which

behaviors are most effectively addressed by technology-based interventions.

Second, only one of the included studies measured a biological outcome (i.e., Chlamydia

infection [49]) and no programs assessed intervention effects beyond one year. These issues

raise important questions about the long-term clinical impacts of these programs; however,

they are not unique to technology-based programs. In fact, a recent systematic review of all

school-based (i.e., in-person) sexual health programs among youth in the U.S. [54] found

only seven interventions that measured HIV/STI incidence or HIV/STI testing as outcomes.

Further, among the 98 in-person interventions reviewed by Johnson et al. [6], the average

outcome assessment occurred at 13 weeks. Future efforts to evaluate technology-based

programs would be enhanced by data on HIV/STI testing and/or diagnosis among program

recipients, as well as long-term follow-up to measure the longitudinal impacts of these

programs.

Another potentially fruitful avenue for efforts to improve adolescent sexual health outcomes

will be to identify the specific, replicable behavioral change techniques that are utilized in

technology-based interventions to enhance behavior change, as is increasingly being done

for in-person interventions [55]. It also will be critical for researchers to identify common

design elements that are specific to technology-based interventions going forward (for

examples, see [36, 56]). As technology rapidly evolves, recognizing common design features

across programs (e.g., tailoring, online social support and communication, automatic

feedback) will be essential for comparing interventions delivered across a range of

technological platforms. In this meta-analysis, we tested several possible technological

design features that could serve as moderators of intervention effectiveness, such as whether

the program was interactive and whether personal tailoring was utilized. However, there

were too few studies to examine further design elements that may increase program impact,

such as self-monitoring or personalized reminders [36]. These remain interesting avenues for

future work as new technology-based programs continue to emerge [57, 58]

As previously discussed, technology-based interventions may be a beneficial avenue for

delivering non-stigmatizing, accurate, and relevant sexual health education to sexual

minority youth. However, with the exception of one intervention targeting young men who

have sex with men [48], no study included in this meta-analysis specifically reported

tailoring intervention content to be inclusive of this population. Sexual minority youth

experience disproportionate rates of sexual risk [59], and face a number of stressors that may

impact their overall sexual health. Researchers should more explicitly consider the unique

needs of sexual minority youth in the development and evaluation of sexual health

programming, in addition to providing needed services at various levels of societal and

individual intervention [60]. Technology-based approaches may be particularly valuable

within this population, as sexual minority youth are more likely than heterosexual youth to

use the internet to look for sexual health information [61].

Future studies also should consider the potential moderating role of other important

demographic factors, including race/ethnicity, gender, and socio-economic status, given that

these group comparisons were not possible in the current study. Sexual health disparities

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among racial and ethnic minorities have been well documented, with rates of reported STIs

higher among some groups (e.g., Black and Hispanic individuals), compared to White

individuals [62]. Although a “digital divide” remains in terms of access and use of

technology in the United States [63], recent statistics suggest that rates of smartphone access

are comparable among Hispanic and White adolescents, and that Black youth are more
likely to have smartphones compared to other racial/ethnic groups [13]. Even among low

income youth (i.e., household income less than $30,000), 91% of adolescents report that

they access the Internet via a mobile device [13]. Thus, sexual health interventions delivered

via technology may hold particular promise for reaching these at-risk groups.

Finally, there is a need for greater attention to the comparative effects of content delivered

in-person versus through technology. Only one study in our meta-analysis compared a

technology-based intervention to an in-person control [64]. However, the structure and

quality of technology-based interventions may differ from in-person treatments in important

ways, including the possibility for anonymous communication (e.g., discussion boards), the

provision of unique forms of social support and skills practice (e.g., using avatars or

simulated person-to-person communication), and possibilities for different types of self-

monitoring [36]. Additionally, with advancements in technology and incorporation of

tailored, interactive features (e.g., “ask the expert”), technology-based interventions may

offer the opportunity for personalized, rich communication and support from intervention

personnel that once was limited to in-person interventions [36, 65]. However, interventions

delivered in-person may increase the perceived credibility of information sources and

provide a sense of accountability or connection [65]. Thus, although this meta-analysis

suggests that technology-based interventions are effective compared to no-treatment or

attention-matched controls, their relative efficacy in relation to traditional, in-person sexual

health interventions remains a question for future work.

Summary and Implications

After nearly 15 years of research on youth-focused technology-based interventions, this

meta-analysis demonstrates the great promise of these approaches to improve the safer sex

behavior and cognitions of youth. Pooling data from 16 studies with over 11,000 adolescents

and young adults, we found that technology-based interventions were more effective than

control programs at improving condom use, abstinence, sexual health knowledge, safer-sex

attitudes, and safer-sex norms. However, effects were stronger in studies with shorter-term

follow-ups compared to follow-ups of 6 months or more. Future work should focus on

intervention adaptations and supplements that may extend their protective effects over time.

Future work should also move beyond program development and into the realm of

implementation science to ensure these programs are broadly disseminated for maximum

impact [66].

Supplementary Material

Refer to Web version on PubMed Central for supplementary material.

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Acknowledgments

This research was supported in part by the following National Institutes of Health grants: R00 HD075654 and T32
MH018269. This work was also supported in part by a National Science Foundation Graduate Research Fellowship
DGE-1144081. The content, interpretations, and conclusions of this study are those of the authors and do not
necessarily reflect the views of the National Institutes of Health or the National Science Foundation.

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Figure 1.
Forest Plots for Primary Outcomes

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tu

de
nt

s
fr

om
U

.S
.;

71
%

f
em

al
e;

r
ac

e/
et

hn
ic

ity
:

81
%

W
hi

te
, 5

%
B

la
ck

, 6
%

H
is

pa
ni

c;
s

ex
ua

l o
ri

en
ta

tio
n:

9
8%

he

te
ro

se
xu

al
; r

ec
ru

ite
d

fr
om

p
sy

ch
ol

og
y

st
ud

en
t p

ar
tic

ip
an

t
po

ol
; i

nt
er

ve
nt

io
n

vi
a

co
m

pu
te

r

18
.9

(
nr

)
L

ow
Y

es
Y

es
1

C
on

do
m

U
se

; A
tti

tu
de

s;
N

or
m

s;

In
te

nt
io

ns
; K

no
w

le
dg

e

L
ig

ht
fo

ot
e

t a
l [

64
]

13
3

ad
ol

es
ce

nt
s

fr
om

U
.S

.;
45

%
f

em
al

e;
r

ac
e/

et
hn

ic
ity

: 4
9%

B

la
ck

, 4
7%

H
is

pa
ni

c;
r

ec
ru

ite
d

fr
om

a
lte

rn
at

iv
e

hi
gh

s
ch

oo
ls

;
in

te
rv

en
tio

n
vi

a
co

m
pu

te
r

16
(

14
-1

8)
M

od
Y

es
Y

es
3

C
on

do
m

U
se

; A
bs

tin
en

ce

L
im

e
t a

l [
34

]
99

4
yo

un
g

ad
ul

ts
f

ro
m

A
us

tr
al

ia
; 5

8%
f

em
al

e;
r

ec
ru

ite
d

fr
om

m

us
ic

f
es

tiv
al

; i
nt

er
ve

nt
io

n
vi

a
te

xt
in

g
an

d
em

ai
l

19
(

16
-2

9)
H

ig
h

N
o

N
o

12
C

on
do

m
U

se
; K

no
w

le
dg

e

L
ou

e
t a

l [
33

]
13

37
a

do
le

sc
en

ts
f

ro
m

C
hi

na
; 4

5%
f

em
al

e;
r

ec
ru

ite
d

fr
om

hi

gh
s

ch
oo

ls
a

nd
u

ni
ve

rs
iti

es
; i

nt
er

ve
nt

io
n

vi
a

w
eb

si
te

a
nd

em

ai
l

nr
(

15
-1

9)
H

ig
h

Y
es

Y
es

2.
5

A
bs

tin
en

ce
; A

tti
tu

de
s;

N
or

m
s;

K

no
w

le
dg

e

M
ev

is
se

n
et

a
l [

68
]

17
1

yo
un

g
ad

ul
ts

f
ro

m
th

e
N

et
he

rl
an

ds
; 6

1%
f

em
al

e;
s

ex
ua

l
or

ie
nt

at
io

n:
1

00
%

h
et

er
os

ex
ua

l;
in

te
rv

en
tio

n
vi

a
w

eb
si

te
20

.8
(

18
-2

5)
L

ow
Y

es
Y

es
3

C
on

do
m

U
se

; A
tti

tu
de

s;
N

or
m

s

M
us

ta
ns

ki
e

t a
l [

48
]

10
2

se
xu

al
ly

a
ct

iv
e

yo
un

g
ad

ul
t m

en
f

ro
m

U
.S

.;
ra

ce
/

et
hn

ic
ity

: 2
5%

W
hi

te
, 1

3%
B

la
ck

, 4
6%

H
is

pa
ni

c;
s

ex
ua

l
or

ie
nt

at
io

n:
1

00
%

m
en

w
ho

h
av

e
se

x
w

ith
m

en
; r

ec
ru

ite
d

fr
om

H
IV

te
st

in
g

ce
nt

er
; i

nt
er

ve
nt

io
n

vi
a

w
eb

si
te

a
nd

v
id

eo

ga
m

e

21
.3

(
18

-2
4)

M
od

Y
es

Y
es

3
C

on
do

m
U

se
; A

tti
tu

de
s;

N
or

m
s;

Se

lf
-E

ff
ic

ac
y;

I
nt

en
tio

ns
;

K
no

w
le

dg
e

N
or

to
n

et
a

l [
46

]
19

8
se

xu
al

ly
-a

ct
iv

e
co

lle
ge

s
tu

de
nt

s
fr

om
U

.S
.;

70
%

w
om

en
;

ra
ce

/e
th

ni
ci

ty
: 8

5%
w

hi
te

; s
ex

ua
l o

ri
en

ta
tio

n:
1

00
%

he

te
ro

se
xu

al
; r

ec
ru

ite
d

fr
om

p
sy

ch
ol

og
y

st
ud

en
t p

ar
tic

ip
an

t
po

ol
; i

nt
er

ve
nt

io
n

vi
a

co
m

pu
te

r
D

V
D

18
.6

(
nr

)
L

ow
N

o
N

o
2

C
on

do
m

U
se

J Adolesc Health. Author manuscript; available in PMC 2019 June 01.

A
uthor M

anuscript
A

uthor M
anuscript

A
uthor M

anuscript
A

uthor M
anuscript

Widman et al. Page 18

A
ut

ho
rs

Sa
m

pl
e

an
d

St
ud

y
D

es
cr

ip
ti

on
A

ge
M

(
ra

ng
e)

D
os

e
In

te
ra

ct
iv

e
Ta

ilo
ri

ng
F

ol
lo

w
-U

p
(m

on
th

s)
O

ut
co

m
e(

s)

Pe
sk

in
e

t a
l [

41
]

15
71

a
do

le
sc

en
ts

f
ro

m
U

.S
.;

59
%

f
em

al
e;

r
ac

e/
et

hn
ic

ity
: 1

7%

B
la

ck
, 7

4%
H

is
pa

ni
c;

r
ec

ru
ite

d
fr

om
u

rb
an

m
id

dl
e

sc
ho

ol
s

in

Te
xa

s;
in

te
rv

en
tio

n
vi

a
co

m
pu

te
r

14
.3

(
nr

)
H

ig
h

Y
es

Y
es

12
C

on
do

m
U

se
; A

bs
tin

en
ce

;
A

tti
tu

de
s;

S
el

f-
E

ff
ic

ac
y;

In

te
nt

io
ns

; K
no

w
le

dg
e

R
ob

er
to

e
t a

l [
47

]
32

6
10

th
g

ra
de

a
do

le
sc

en
ts

f
ro

m
U

.S
.;

56
%

f
em

al
e;

r
ac

e/
et

hn
ic

ity
: 9

7%
W

hi
te

; r
ec

ru
ite

d
fr

om
r

ur
al

h
ig

h
sc

ho
ol

s;

in
te

rv
en

tio
n

vi
a

co
m

pu
te

r

15
.6

(
nr

)
H

ig
h

Y
es

Y
es

2.
5

C
on

do
m

U
se

; A
bs

tin
en

ce
;

A
tti

tu
de

s;
N

or
m

s;
S

el
f-

E
ff

ic
ac

y;

K
no

w
le

dg
e

Su
ff

ol
et

to
e

t a
l [

45
]

52
s

ex
ua

lly
-a

ct
iv

e
yo

un
g

ad
ul

t w
om

en
f

ro
m

U
.S

.;
ra

ce
/

et
hn

ic
ity

: 6
5%

B
la

ck
, 6

%
H

is
pa

ni
c;

s
ex

ua
l o

ri
en

ta
tio

n:
1

00
%

he

te
ro

se
xu

al
; r

ec
ru

ite
d

fr
om

e
m

er
ge

nc
y

ro
om

s;
in

te
rv

en
tio

n
vi

a
te

xt
m

es
sa

ge
s

21
.4

(
18

-2
5)

H
ig

h
Y

es
Y

es
3

C
on

do
m

U
se

; A
bs

tin
en

ce

Y
ba

rr
a

et
a

l [
69

]
36

6
se

xu
al

ly
-a

ct
iv

e
ad

ol
es

ce
nt

s
fr

om
U

ga
nd

a;
1

6%
f

em
al

e;

re
cr

ui
te

d
fr

om
h

ig
h

sc
ho

ol
s;

in
te

rv
en

tio
n

vi
a

w
eb

si
te

16
.1

(1
3-

19
)

M
od

Y
es

Y
es

6
C

on
do

m
U

se
; A

bs
tin

en
ce

N
ot

e.
D

os
e

=
H

ig
h

(7
o

r
m

or
e

se
ss

io
ns

),
M

od
er

at
e

(3
-6

s
es

si
on

s)
, L

ow
(

1-
2

se
ss

io
ns

).
n

r =
n

ot
r

ep
or

te
d.

S
ex

ua
l o

ri
en

ta
tio

n
is

in
cl

ud
ed

in
th

e
sa

m
pl

e
de

sc
ri

pt
io

n
w

he
ne

ve
r

it
w

as
r

ep
or

te
d

in
th

e
te

xt
; m

an
y

st
ud

ie
s

di
d

no
t r

ep
or

t t
he

s
ex

ua
l o

ri
en

ta
tio

n
of

th
ei

r
pa

rt
ic

ip
an

ts
.

J Adolesc Health. Author manuscript; available in PMC 2019 June 01.

A
uthor M

anuscript
A

uthor M
anuscript

A
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anuscript
A

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anuscript

Widman et al. Page 19

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J Adolesc Health. Author manuscript; available in PMC 2019 June 01.

A
uthor M

anuscript
A

uthor M
anuscript

A
uthor M

anuscript
A

uthor M
anuscript

Widman et al. Page 20

Ta
b

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3

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J Adolesc Health. Author manuscript; available in PMC 2019 June 01.

A
uthor M

anuscript
A

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anuscript

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Table 4

Effect Sizes for Safer Sex Related Supplemental Outcomes

Variable k d 95% CI p

Safer Sex Attitudes 6 .12 [−0.02, 0.23] .016

Safer Sex Norms 5 .15 [0.02, 0.29] .022

Safer Sex Self-Efficacy 5 .07 [−0.05, 0.19] .249

Safer Sex Intentions 5 .06 [−0.02, 0.14] .158

Sexual Health Knowledge 9 .40 [0.25, 0.55] <.001

Note. Random effects models are presented. k = number of studies; d = weighted mean effect size; CI = confidence interval.

J Adolesc Health. Author manuscript; available in PMC 2019 June 01.

  • Abstract
  • Introduction
  • Methods
    • Search Strategy
    • Selection Criteria
    • Data Extraction
    • Calculation of Effect Sizes
  • Results
    • Study Characteristics
    • Primary Outcomes
      • Condom Use
      • Abstinence
    • Secondary Outcomes
    • Data Quality
  • Discussion
    • Limitations and Future Directions for Intervention Efforts
    • Summary and Implications
  • References
  • Figure 1
  • Table 1
  • Table 2
  • Table 3
  • Table 4

Research Article
Assessing and Improving the Knowledge of Sexually Transmitted
Infections among High School Adolescents

Itisha S. Jefferson ,1 S. Kayo Robinson,1 Eleanor Tung-Hahn ,2 Roan Schumann,3

Synthia Marrero-Conti,4 Jasmine M. Walton,5 Eileen Golden,6 Emily Poon ,7

Murad Alam ,7 and Rebecca Tung 8

1Stritch School of Medicine, Loyola University, Chicago, IL, USA
2College of Public Health, e University of South Florida, Tampa, FL, USA
3Robins School of Business, University of Richmond, Richmond, VA, USA
4East Ridge High School, Clermont, FL, USA
5Oak Street Health, Chicago, IL, USA
6Department of Obstetrics and Gynecology, Cleveland Clinic, Cleveland, OH, USA
7Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
8Florida Dermatology and Skin Cancer Centers, Winter Haven, FL, USA

Correspondence should be addressed to Itisha S. Jefferson; [email protected]

Received 12 November 2020; Accepted 26 March 2021; Published 9 April 2021

Academic Editor: Markus Stucker

Copyright © 2021 Itisha S. Jefferson et al. )is is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.

Background. According to the Center for Disease Control and Prevention (CDC), half of the 20 million new sexually transmitted
infections (STIs) occur annually in youth aged 15 to 24. It is critical for dermatologists to be able to provide young patients with
accessible education about how to identify, prevent, and treat these conditions. Our pilot study sought to assess the impact of a live
presentation about STIs in high school students and to evaluate students’ baseline and acquired knowledge about common STIs
using a before and after survey.Methods.)is survey study was conducted as part of the health education curriculum at a suburban
high school. An interactive scenario-based presentation about STIs was given to participants. Identical, deidentified pre-
intervention and postintervention surveys were completed by subjects to assess their baseline and acquired knowledge of STIs.
Each question was worth 1 point, for a total of 8 points. Results. 74 high school students were surveyed. Overall, there was a mean
improvement of 1.85 points in the posttest score in comparison to pretest score with a standard deviation of 1.58 (p< 0.0001).
Among all participants, the mean pretest score was 1.07 (SD� 0.75) and the mean posttest score was 2.92 (SD� 1.59). Conclusions.
)is study demonstrated that many young adults are unaware of the common types of STIs, symptoms, and potential com-
plications. While our scenario-based presentation was effective at providing understandable content to help improve students’
knowledge regarding STIs, additional educational resources in varied formats could likely further these gains.

1. Introduction

)e Center for Disease Control and Prevention (CDC)
estimates that half of the 20 million new sexually transmitted
infections (STIs) occur annually in youth aged 15–24, who
make up just over one quarter of the sexually active pop-
ulation in the United States [1]. Prevalence of STIs is higher
in sexually experienced young females compared to males

[2]. )is marked difference is thought to be due to anatomic
differences and relatively fewer bothersome symptoms in
females who are infected with common STIs such as chla-
mydia and gonorrhea [3]. Although STIs can affect people of
all ages, they can have more dire consequences and long
reaching effects in young adults.

As a group, young people are more likely to participate in
high-risk behaviors, sex without protection and having

Hindawi
Dermatology Research and Practice
Volume 2021, Article ID 6696316, 6 pages
https://doi.org/10.1155/2021/6696316

multiple sex partners [4]. )ese risky behaviors are more
evident in this cohort due to evolving brain development
and executive decision making [4, 5]. Additionally, teens are
less likely to seek medical attention and utilize sexual health
services than adults due to multiple barriers: lack of ac-
cessibility to services, concerns about confidentiality, stigma
attached to seeking STI services, and limited knowledge
about STIs, their signs and symptoms and delayed treatment
complications [6, 7].

Although STIs are commonly perceived as purely gy-
necologic or urologic conditions, many STIs have derma-
tologic manifestations [8]. Since many STIs can result in
severe medical consequences such as infertility, chronic
pain, adverse pregnancy outcomes, cancer, and, in some
cases, death [4], it is critical for the dermatologist to be able
to have an open dialogue with young patients about STIs as
well as being able to provide meaningful and accessible
education about how to identify, treat, and prevent these
same conditions.

)e aims of our pilot study are to assess the impact of an
interactive scenario-based presentation about STIs and
dermatologic skin manifestations in high school students
and to evaluate students’ baseline and acquired knowledge
about common sexually transmitted infections using a be-
fore and after survey.

2. Methods and Statistical Analyses

)is study was conducted as a part of the health education
curriculum in collaboration with educators at a suburban
high school. All parents were notified in advance and were
given the opportunity to opt in or to opt out their child’s
attendance and participation in this sexually transmitted
infections (STIs) lecture and study.

An identical, deidentified pre- and postintervention
survey (10 questions with multiple choice answers—2
questions focused on demographics and 8 questions per-
tained directly to the lecture content) was given to partic-
ipants to assess both their baseline and acquired knowledge
of STIs (Supplement 1). Questions relating to types of
common STIs, signs and symptoms of STIs, and compli-
cations of STIs allowed for choice of more than one answer.
During their scheduled class time, students first completed
the before survey (10 minutes), viewed the interactive 25-
minute PowerPoint live presentation lesson, and then took
the after survey. Each content question was worth 1 point,
for a total of 8 points for the before survey as well as the after
survey. )is curriculum was taught to three classes of stu-
dents, comprised of 11th and 12th graders. Content for this
lesson was drawn from multiple sources and highlighted the
most common STIs, major signs and symptoms of STIs,
treatment of STIs, and complications if left untreated. To
introduce each STI condition, students were informally
queried as a group as to whether they were aware of the
typical disease presentation and any questions were an-
swered. After the presentation, an identical survey ques-
tionnaire was administered. We chose to include one
question which elicited where students had previously re-
ceived information on STIs.

Data was analyzed by SAS Studio 3.8 (Enterprise Edi-
tion). All statistics were generated using this program.
Analysis consisted of paired sample t-test comparing nu-
merically rated answers on the before test and after test. For
all two-tailed tests, significance was set at 0.05.

3. Results

74 students (57 eleventh graders and 16 twelfth graders and 1
unspecified) participated in this educational intervention
study (Table 1). Mean age was 16.48 [standard deviation
(SD) of 0.58]. Students reported their knowledge on STIs
prior to the educational session (Table 2). Among partici-
pants, 95% had heard of STIs before, while 4% had never
heard about STIs, and 1% indicated they do not know. With
regard to sources where students stated they had received
information about STIs, the majority identified school (91%)
followed by the Internet (72%) and family (60%). Few
students cited periodicals including magazines (4%) and
television/radio (5%) as sources of STI information. For this
question, students could select multiple sources, if
applicable.

Table 3 demonstrates that survey scores of all students
significantly improved after viewing this presentation. )e
maximum score attainable on the pre- and posttest eval-
uation was 8. Participants were given a score of 1 for
answering a single question correctly or a score of 0 for
answering a single question incorrectly. No partial credit
was given. Overall, there was a mean improvement of 1.85
points in their posttest score as compared to their pretest
score with a standard deviation of 1.58 (p< 0.0001). For all
participants regardless of grade, the mean pretest score was
1.07 (SD � 0.75) and the mean posttest score was 2.92
(SD � 1.59).

Subgroup analysis revealed the mean overall pre- and
posttest scores for Grade 11 participants were 1.09
(SD� 0.79) and 3.11 (SD� 1.62), respectively, with a mean
improvement of 2.02 (SD� 1.65) (p< 0.0001). Average
percentage improvement in scores was 185% for Grade 11
students. For students in Grade 12, the mean overall pre-
and posttest scores were 1.00 (SD� 0.63) and 2.25
(SD� 1.34) with a mean improvement of 1.25 (SD� 1.18)
(p � 0.0007).)e average percentage improvement in scores
was 125% for Grade 12 participants.

Finally, with respect to the before versus after answers
for each individual question, all students significantly im-
proved in their ability to answer correctly following par-
ticipation in the STI session. However, with regard to
questions 3 (what are the main signs and symptoms of
sexually transmitted infections/diseases?) and 8 (which of
the following conditions can be treated with cryosurgery
(freezing)?), score improvement was noted, yet it was not
significant (Table 4). Students achieved a mean pretest score
of 0.44 (SD� 0.5) and posttest score of 0.58 (SD� 0.5)
(p � 0.06) on question 3. Most students answered question 8
(regarding Human Papillomavirus treatment) incorrectly.
On this question, students achieved a mean pretest score of
0.05 (SD� 0.23) and posttest score of 0.14 (SD� 0.34)
(p � 0.08).

2 Dermatology Research and Practice

4. Limitations

)e primary limitation of this study is that it was a small
pilot study conducted at a single site. )e results found
herein may not be representative for other institutions or
geographic locations. Educational institutions have different
requirements regarding presentation and format of sexual
education topics.

Although statistically significant improvement in the
overall score amongst all students in both grades was
noted, the mean increase (1.85) was still relatively low
following participation in the session. )is suggests that
there is room for further refinement and modification of
the content and delivery of the information presented.
Possibilities include emphasizing take-home points in a
summary slide following each disease topic, incorporating
a final review slide at the conclusion of the session, either
condensing or dividing the education session into two or
more separate sessions given the density of the content
material, and making the presentation available elec-
tronically for later retrieval and reference. Furthermore,
gathering feedback from the students following the ses-
sion could also provide insight on ways future educational
sessions could be improved. As described earlier, students
achieved only modest improvement in their scores for
questions 3 and 8. Further simplification and repetition of
the specific content may be helpful for learners. Addi-
tionally, the question format could also be altered to better
capture whether or not knowledge about these conditions
was acquired. As a whole, the information covered in the
STI presentation may have been new for our participants.
Allowing students to have electronic access to the pre-
sentation after the session for review could also be
beneficial.

We recognize that Grade 11 students were more highly
represented compared to Grade 12 students. Certainly,
equal representation would further strengthen our study.
We have reported the immediate effects of knowledge
improvement following our session by utilizing the before
test, but do not have data on the long-term impact sec-
ondary to pandemic-related school closures. Finally, it
may be advantageous to assess whether or not gender
differences affect study results. Comparing various de-
livery methods of STI education (live presentation, online
video format, and written material) may also prove useful
for optimizing teaching about this subject. It is also im-
portant to keep in mind that administration and teacher
collaboration as well as parental agreement are always
needed in conducting any type of study with minors on
this topic.

5. Discussion

Half of the annual STI cases in the United States occur in
adolescents and young adults [1]. Because this population is
disproportionately affected by STIs, we created an educa-
tional workshop in hopes of educating students about these
potentially life altering conditions. In 2016, the CDC re-
ported that 81.6% of high school districts had adopted a
policy to teach specific health topics including STI pre-
vention [9]. Districts were required to teach about substance
use prevention, mental health, nutrition, and violence
prevention in addition to STI education. )is policy was
enforced by requiring assessments measuring student
achievement based on the health education program.
However, only 51.6% of these districts actually implemented
a school-based health program for their high school students
[9]. It was reported that increased staffing and professional
development of health teachers could further improve the
current state of high school health education and ensure
students are being taught these topics. In addition, the CDC
recommended adjunctive resources such as )e National
Health Education Standards, the National Sexuality Edu-
cation Standards, and the Division of Adolescent and School
Health (DASH) that could be utilized by health educators for
teaching STI prevention, knowledge, and skills [10].

In an interview format study, Almeida et al. found that
preventative sexual health education implemented in the
school system is beneficial for young adults [11]. )ey
interviewed 22 high school students about their knowledge
of STIs, AIDS, pregnancy, and the role of school in sex
education. )ey found that students reported their teachers
to be their first choice as a source of STI information [11].
Students also recognized the role of their school lectures and
family cooperation in health promotion. Similarly, in our
study, participants stated that their school served as the
primary source of information on STIs. Taken together,
these findings underscore the important role that schools
have in providing much needed education about STIs.

In a structured questionnaire format study, Nguyen et al.
investigated knowledge about STIs among adult Vietnamese
dermatology patients. )ey found that participants had
limited knowledge about STIs including common present-
ing symptoms and available prevention strategies [12]. Of
interest, their study revealed that younger participant age
and residential status of living with a spouse or a partner
were associated with increased knowledge about STIs.
Further, they found that the Internet, social media, and
healthcare providers were primary sources of STI infor-
mation [12]. )is speaks to the important role that
healthcare providers such as dermatologists can play as
educators to raise awareness about STIs in patients and
community members. Harnessing technology such as the
Internet and social media platforms can also extend the
reach of a health care team to provide accessible, accurate,
and always available content about STIs to all.

Jones and colleagues suggested that social media and text
messaging may be promising approaches for effectively
increasing STI knowledge among both young men and
women [13]. Out of the 11 studies that were evaluated, seven

Table 1: Demographics (grade and age).

Grade Count %
11 57 77.02703
12 16 21.62162
N/A 1 1.351351

Age Mean SD
16.48 0.58

Dermatology Research and Practice 3

studies examined the effectiveness of social media or texting
interventions on STI knowledge. All of them showed sig-
nificant increases in STI knowledge, including increased
understanding of sexual protection methods and trans-
mission modes, following an instructional intervention [13].
Although social media is an easy and effective way to cir-
culate information, there are some potential concerns to
consider if it is used for a teaching platform about this topic.
Some potential issues include but are not limited to in-
formed consent to participate by either the subject or parents
if the subject is a minor, participant privacy and confi-
dentiality, protection of site content and prevention of in-
appropriate postings, and secure storage of participant
contact information for future followup [13, 14].

Information dissemination is one thing but making
content “stick” in the minds of learners is quite another.

Malik and colleagues sought to determine whether a lecture
accompanied by pretest/posttest teaching model versus a
post-test-only model was more advantageous in terms of
learning outcomes. )ey found that a pretest/posttest model
was more effective than a lecture followed by a posttest alone
[15]. )ey concluded that students, when given the op-
portunity to identify difficult topics beforehand with the
pretest, were better able to adjust their attention to facilitate
comprehension during the lecture, which ultimately resulted
in improved knowledge acquisition outcomes [15].With this
in mind, our study utilized the pretest/posttest teaching
model for the dual purposes of achieving effective learning
outcomes and assessing students’ baseline knowledge about
STIs.

Another effective teaching method, termed spaced
repetition, has been shown to improve learning outcomes
and long-term retention [16, 17]. Spaced repetition is a
memorization technique in which educational content is
reviewed repeatedly on a particular schedule, which is based
on a spaced repetition algorithm [17]. Kang highlighted
using spaced repetition in the classroom setting. )ey found
that when content was repeated over months as part of
teaching curriculums, students were better learners. Addi-
tionally, they concluded that computerized instruction could
provide an ideal means for delivery of spaced repetition
within the classroom [16]. In the case of STI education,
combining in-person interactive STI teaching models with
follow-up e-learning, which incorporates virtual presenta-
tion of the material multiple repetitions over a period of
time, could optimize students’ learning outcomes. )e

Table 2: Prior STD and STI knowledge.

Answer Count %
Have you ever heard of Sexually
Transmitted Diseases (STDs) or
Sexually Transmitted Infections (STIs)?

Yes 70 94.59459
No 3 4.054054

Don’t know 1 1.351351

From where have you received
information on STDs or STIs?

School 67 90.54054
Internet 53 71.62162
Family 44 59.45946
Friends 38 51.35135

Hospital/Clinic 31 41.89189
Television 23 31.08108
Youth club 6 8.108108

Radio 4 5.405405
Magazine 3 4.054054

N/A 2 2.702703

Table 3: Participant group scores before and after STI presentation.

Participant groups n
Pretest score Posttest score

Mean diff SD of mean diff p value
Mean SD Mean SD

Grade 11 57 1.09 0.79 3.11 1.62 2.02 1.65 <0.0001
Grade 12 16 1 0.63 2.25 1.34 1.25 1.18 0.0007
All participants 74 1.07 0.75 2.92 1.59 1.85 1.58 <0.0001

Table 4: Scores of each individual question before and after STI
presentation.

Question
Pretest
score

Posttest
score Mean

diff
SD of

mean diff p value
Mean SD Mean SD

1 0 0 0.23 0.42 0.23 0.42 <0.0001
2 0 0 0.16 0.34 0.14 0.34 0.0012
3 0.44 0.5 0.58 0.5 0.14 0.6 0.06
4 0.08 0.27 0.62 0.49 0.54 0.5 <0.0001
5 0.35 0.48 0.66 0.48 0.28 0.59 <0.0001
6 0.01 0.12 0.19 0.39 0.18 0.42 0.0005
7 0.09 0.29 0.38 0.49 0.28 0.51 <0.0001
8 0.05 0.23 0.14 0.34 0.08 0.4 0.08

4 Dermatology Research and Practice

challenge, of course, is having allocated time to permit this
type of multimodal instruction.

Because STIs commonly present with cutaneous mani-
festations and can have serious health ramifications if left
unidentified and untreated, we in dermatology can extend
our reach beyond the clinical setting by collaborating with
educators to chart a new course for young adults by pro-
viding effective accessible education which promotes STI
awareness, prevention, detection, and treatment. McCaw
highlighted the longstanding connection between derma-
tology and venereology dating back to the sixteenth century.
At that time, it was Syphilis, often first recognized by its
cutaneous findings, that propelled the expanding frontier of
dermatology. Two centuries later, another STI, Herpes, was
recognized in the dermatologic realm as a communicable
disease with cutaneous manifestations [18].

Historically, the specialty of dermatology was previously
known as dermatology and syphilology [19, 20], but syph-
ilology was dropped due to effective treatment regimens and
the evolving broader scope of dermatologic practice [19].
)e profound impact of dermatology on STI disease char-
acterization and treatment should not be lost. Rather, it is
important for modern dermatologists not only to be com-
fortable with the diagnosis and treatment of STIs but also to
advocate for and advance STI education among young adults
with the goals of prevention and early detection.

6. Conclusion

)is pilot study demonstrated that many young adults are
unaware of the common types of STIs, symptoms, and
potential complications. Although students’ knowledge of
STIs did increase after participating in our live interactive
scenario-based presentation, more can be done on this
educational front. Design of future educational tools could
also incorporate other teaching modalities such as e-learning
in some form, which can promote longer-term retention of
STI content and may ultimately influence behaviors that
impact health of both the individual and the public.

Data Availability

Data are available on request. Requests for access to data
should be made to Dr. Rebecca Tung, MD, at drrebecca-
[email protected]

Disclosure

)e study was presented at the 45th Annual Meeting Virtual
Poster Presentations, July 2020, by the Society for Pediatric
Dermatology.

Conflicts of Interest

)e authors declare that there are no conflicts of interest.

Acknowledgments

)e authors acknowledge and thank the Society for Pediatric
Dermatology (SPD) for giving them the opportunity to

present their research at the 45th Annual Meeting Virtual
Poster Presentations, July 2020.

Supplementary Materials

An identical, deidentified preintervention and post-
intervention survey (10 questions with multiple choice
answers—2 questions focused on demographics and 8
questions pertained directly to the lecture content) was given
to participants to assess both their baseline and acquired
knowledge of STIs (Supplement 1). (Supplementary
Materials)

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Dermatology Research and Practice 5

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6 Dermatology Research and Practice

Reducing HIV/STI Risk Among Adolescents Aged 12 to 14 Years:
a Randomized Controlled Trial of Project Prepared

Laurie J. Bauman1
& Dana Watnick2 & Ellen Johnson Silver2 & Angelic Rivera2 & Jamie Heather Sclafane3 &

Caryn R. R. Rodgers2 & Cheng-Shiun Leu4

Accepted: 4 January 2021
# The Author(s) 2021

Abstract
Despite calls for evidence-based HIV/STI prevention programs for youth aged 12 to 14 transitioning to adolescence, few
effective programs exist. In a two-group intent-to-treat randomized trial in the Bronx, NY, 397 participants were randomly
assigned to Project Prepared or an attention control, TEEN. Participants completed surveys at baseline, 6 months, and 12months.
Prepared had two components, an 11-session program and a 3-week internship. Content covered sexual risk behavior, social
cognitions, gender norms, relationships, and resilience. TEEN built communication skills and had the same intensity and
structure as Prepared but no sexual content. In both, boys and girls were trained together in mixed groups of ~ 11 teens.
Primary outcomes were HIV knowledge, self-efficacy, condom outcome expectancy, and behavioral intentions. Secondary
outcomes were relationship expectations and endorsement of risky gender norms. Generalized estimating equation analyses
showed youth randomized to Prepared had significant improvements compared to TEEN at T2 in HIV knowledge, sexual self-
efficacy, and outcome expectancy for condom use. At T3, there were significant differences favoring Prepared in outcome
expectancy for condom use, sexual self-efficacy, and intention for partner communication about HIV/AIDS or STIs. Analyses
by gender showed program effects in both boys (intention to talk to a partner about condom use, abstinence self-efficacy, sexual
self-efficacy, and condom outcome expectancy) and girls (gender norms, and abstinence outcome expectancy). Prepared effec-
tively reduced risk in young adolescents. ClinicalTrials.gov ID: NCT01880450, Protocol ID: 2008-551

Keywords Adolescents . HIV prevention . STI prevention . Randomized controlled trial

Background

Problem of Sexual Risk in Early Adolescents Over half (57%)
of US high school students engage in sexual intercourse by the
time they graduate (Witwer et al., 2018). Early sexual initia-
tion increases risk for HIV/STIs (CDC 2015) and unintended

pregnancy (Heywood et al., 2015). Few (6%) high school
students report sexual debut before age 13; males more than
females report early coitus (8.3% vs. 3.1%) and Black males
report the highest rate of early coitus (24%) compared to
Latino (9.2%) and white (4.4%) males (Kann et al., 2014).

Predictors of Sexual Risk in AdolescentsMany factors predict
sexual risk in adolescence (Brown and Larson, 2009; Kirby
et al., 2005; Kourtis et al., 2006; Parkes et al., 2011; Widman
et al., 2016). Kirby and Lepore 2007’s review of over 400
studies identified several hundred potentially important vari-
ables. Older age, male gender, economic disadvantage, Black
race, and Hispanic ethnicity predict sexual activity (CDC,
2015). Family characteristics can be both protective (close
parent relationship; good parent-teen sexual communication
(Kirby and Lepore, 2007; Parkes et al., 2011; Widman et al.,
2016)) and risk factors (single-parent family structure; low
parental education (Silver and Bauman, 2006)). Sexual risk
is higher in youth who use substances, have poor academic
performance, and poor psychosocial adjustment, and lower in

* Laurie J. Bauman
[email protected]

1 Preventive Intervention Research Center, Department of Pediatrics,
Albert Einstein College of Medicine, 1300 Morris Park Avenue
VE6B25, Bronx, NY 10461, USA

2 Department of Pediatrics, Albert Einstein College of Medicine,
Bronx, NY, USA

3 Division of Public Health, William Paterson University, Wayne, NJ,
USA

4 Mailman School of Public Health, Columbia University, New York
City, NY, USA

https://doi.org/10.1007/s11121-021-01203-0

/ Published online: 19 February 2021

Prevention Science (2021) 22:1023–1035

those with positive school attitudes, college aspirations, and
participate in after-school activities (Kirby and Lepore, 2007;
Silver and Bauman, 2006). Developmentally, peer relations
become more salient in adolescence (Brown and Larson,
2009). Social acceptance and social status become more im-
portant and peer pressure and willingness to conform are es-
pecially strong (Brown and Larson, 2009). Thus, attitudes and
values of romantic partners, friends, and other peers and be-
liefs about sexual activity of close friends are influential
(Kirby and Lepore, 2007).

Emotional competence, resilience, and self-efficacy beliefs
are also associated with risk, as are structural factors described
in theories of gender and power (DePadilla et al., 2011).
Gender norms, the attitudes and behaviors that a culture or
society associates with each sex, are important determinants
of health behavior (Fleming and Agnew-Brune, 2015). Gender
norms about sexual behavior for males typically suggest that
they should be knowledgeable and in control and should ini-
tiate and pursue all sexual opportunities, while female sexual-
ity is relationship-centered and associated with emotional
commitment; women are expected to resist sex in situations
where such motives are not sufficiently powerful (Marston and
King, 2006; Silver and Bauman, 2014; Tolman et al., 2003).
Risky gender norms may conflict with safer sex practices;
however, there is little systematic research on this topic among
young adolescents (Silver and Bauman, 2014).

Relationship beliefs and expectations also impact sexual
risk (Ellen et al., 2002; Rosengard et al., 2005; Misovich
et al., 1997; Rosenthal et al., 1998). Being in a committed
and loving relationship can increase risk for unprotected sex
because condom use is lower in committed than casual rela-
tionships (Ellen et al., 2002; Rosengard et al., 2005, Bauman
and Berman, 2005). Condom use is inconsistent with ideals of
romance, trust, and love, especially for girls (Rosenthal et al.,
1998; Bauman and Berman, 2005). Although young adoles-
cents may not be in this kind of relationship yet, many are
involved in the precursors, including being in love
(Montgomery and Sorell, 1998; Bauman and Berman,
2002). Serious adolescent relationships are fairly short-lived,
many engage in “serial monogamy (Misovich et al., 1997),
and many youth have concurrent partners during an ostensibly
exclusive relationships (Rosenberg et al., 1999); thus, adoles-
cents may expose themselves to considerable risk.

Theoretical Frameworks Research on HIV prevention among
adolescents has employed several different theoretical frame-
works. Social Cognitive Theory emphasizes efficacy expecta-
tions and outcome expectancies (Bandura, 1986; Bandura,
1989). The Theory of Reasoned Action posits that intention
to perform a behavior is key to whether it will occur, which is
related to perceptions of how the action might be perceived by
others (“subjective norms”) (Ajzen and Fishbein, 1980;
Bandura, 1989). The Theory of Planned Behavior extends

the Theory of Reasoned Action by adding degree of perceived
personal control over it (Ajzen, 1991). Sexual risk reduction
programs based only on these cognitive theories have small,
short-term effects, prompting researchers to apply socio-
ecological perspectives (Bronfenbrenner, 1977; Miller et al.,
2000; Kotchick et al., 2001; Coates et al., 2008; Protogerou
and Johnson, 2014; Atkiss et al 2011; Mason-Jones et al.,
2016) that emphasize positive youth development, gender
norms, relationship status, and developmental stage. Eco-
developmental Theory (Perrino et al., 2000; Pantin et al.,
2004) adds a developmental perspective—the person and con-
text change over time (Pantin et al., 2004). Adolescents expe-
rience many cognitive changes in the ways they view them-
selves and the world, some of which affect their processing of
health-related messages and their engaging in risk behaviors
for HIV/STIs (Serovich and Greene, 1996). A cognitive phe-
nomenon called the “personal fable” has been proposed as a
partial explanation for the tendency of adolescents to engage
in risky behavior (Serovich and Greene 1996). Adolescents
display egocentric thinking and believe both in the uniqueness
of their emotional experience and in their immortality or
invincibility. Elkind (1967) suggests that egocentricism re-
sults from the transition into formal operational stages of
thought, whereas Vartanian (2000) believes that the personal
fable reflects changes in social perspective-taking and inter-
personal understanding.

Positive youth development (PYD) is an effective strategy to
promote adolescent sexual health. Developmental assets such as
family connectedness and communication, parental monitoring,
school connectedness, cognitive and social competence, belief
in the future, and self-efficacy are associated with sexual health
(Catalano et al., 2010; Gloppen et al., 2010; House et al., 2010a;
House et al., 2010b). Accurate, evidence-based sex education
combined with PYD approaches can build resilience (Gavin
et al., 2010). Advocates of the assets-based approach have noted
the critical importance of social/relational factors for sexual be-
havior and recommend that these should be addressed in pre-
ventive interventions (Romeo and Kelley, 2009).

From the literature on adolescent sexual risk behavior and
the theories that guide interventions, we identified the content
of Project Prepared. Because young people 12–14 years of age
have not yet initiated sexual risk behavior, we chose a preven-
tion approach rather than a behavior change approach. Thus,
the intervention provided the tools and resources young peo-
ple would need to guide choices in their future sexual behav-
ior. These were (1) knowledge about sexuality, how STIs are
transmitted, and pregnancy prevention; (2) strategies to reduce
risk (e.g., condom use and contraception, refusal skills, con-
dom use negotiation); (3) cognitions (e.g., self-efficacy) to
assure confidence in using risk reduction strategies; (4) under-
standing of gender norms and how they influence sexual be-
havior; (5) understanding of how relationship factors and
power differentials influence behavior and skills in partner

1024 Prev Sci (2021) 22:1023–1035

communication; (6) motivation to adopt risk reduction behav-
iors; and (7) intention to engage in safer sex behaviors.

Experience of Interventions with Youth Aged 12–14
Interventions for 12–14 year olds demonstrate mixed results
(Coyle et al., 2004; Mason-Jones et al., 2016; Nelson et al.,
2016). “For Keeps” (Borawski et al., 2005) increased HIV-
related knowledge and decreased intentions to have inter-
course but did not influence sexual initiation or condom use.
“Postponing Sexual Involvement” (Kirby et al., 1997) dem-
onstrated a few small effects at 3 months; none was sustained
over time, and the program did not delay age at first coitus.
Others have found positive effects on HIV knowledge but not
on self-efficacy, intention, attitudes, delayed sexual initiation,
or condom use (Clark et al., 2005; Flay et al., 2004). “Wise
Guys” (Gruchow and Brown, 2011) showed positive effects
on knowledge, attitudes, and behavior but was designed for
boys only; others have shown effects on knowledge and effi-
cacy only for girls (Noia and Schinke, 2007). “Focus-on-
Kids” (Gaydos et al., 2008) showed early effects on condom
use and condom use intentions in 9–15-year-old youth that did
not persist. Jemmott, Jemmott & Fong (1998) showed de-
creased intercourse and increased condom use in 6th and 7th
graders, but only for sexually experienced teens.

Project Prepared is an intensive and comprehensive group-
based intervention for adolescents aged 12–14. Our conceptu-
al model is based on the literature and theory (Fig. 1). Each
conceptual element determined the content of the intervention
curriculum. Cognitions were drawn from Social Cognitive
Theory and included HIV knowledge, abstinence self-effica-
cy, and abstinence and condom use outcome expectancies.
For gender norms, a construct in developmental and social-
ecological theory, we helped youth recognize the generally
held beliefs about what behaviors are appropriate based on
gender, and how they influence having sexual intercourse,
having sex by a certain age, or having multiple partners.
Resilience is personal attributes that are critical for overcom-
ing life obstacles. We focused general self-efficacy, related-
ness (including trust and support), and emotional reactivity
and relied on Positive Youth Development for curriculum
exercises. Relationship factors are beliefs about romantic

relationships that can increase the likelihood of early sexual
initiation or unprotected sex, and how feelings of love and
trust and assumptions of monogamy can lead to risky behav-
ior. The entire curriculum was informed by developmental
theory and how 12–14-year-olds learn and behave (e.g., ego-
centric thinking, short attention span, limited use of role
plays). The conceptual model guided the main hypotheses,
that those randomized to Prepared, compared to the control
group, would have improved knowledge and social cogni-
tions; increased recognition of risky gender norms; more re-
silient attributes; healthier relationship beliefs; and stronger
intentions to engage in safer sex behavior (abstinence, talking
to partners about HIV/AIDS, condom use).

Methods

A two-group intent-to-treat randomized controlled trial of
Project Prepared was implemented in the Bronx, NY.
Adolescents were recruited from primary care practices at
Montefiore Medical Center (MMC) over 3 years beginning
in 2011 (see Fig. 2). These primary care practices provide
routine preventive care as well as manage youth with chronic
health conditions. Each year, 2 cohorts of 66 youth were re-
cruited and randomized to Prepared (the experimental condi-
tion) or TEEN (the attention control condition) (Bauman et al.,
1997). Primary outcomes were HIV knowledge, self-efficacy,
condom outcome expectancy, and behavioral intentions.
Secondary outcomes were relationship expectations, resil-
ience, and identifying gender norms.

Eligibility, Recruitment, and Randomization Participants were
identified using MMC’s computerized patient database.
Patient names, addresses, and age were generated with no
health data to preserve confidentiality. Parents of youth re-
ceived a letter from MMC indicating their child would be
invited to complete a computer-assisted questionnaire called
the “Teen Lifestyle Survey” (TLS) at The Preventive
Intervention Research Center at the Albert Einstein College
of Medicine, unless parents opted out. Of 981 initial invita-
tions, 247 were undeliverable and 38 parents opted out. The
remaining 696 were mailed an invitation to TLS; another 26%
were undeliverable and 54 parents refused (11%). Parent con-
sent and youth assent were obtained for participation in TLS.
The target sample size of 400 was selected to detect small to
moderate effects assuming a 20% loss to follow-up. Eligibility
criteria were (1) age 12–14 inclusive; (2) physical ability to
travel independently to the program site; (3) 5th grade reading
ability on the reading subtest of the Wide-range Achievement
Test (Jastak and Wilkinson, 1984) (required to read program
materials and complete TLS); and (4) spoke and understood
English. A total of 397 youth was enrolled and randomized
after completing TLS and having eligibility verified. Youth

PROJECT
PREPARED

Cognitive
Factors

Gender Norms Resilience

Relationship
Factors

Fig. 1 Project Prepared conceptual model

1025Prev Sci (2021) 22:1023–1035

were enrolled over the course of 3 years in 6 cohorts averaging
66 adolescents each to assure ~ 30 teens per condition in each
cohort. Following randomization, youth were re-enrolled with
a new parental consent and child assent describing the pro-
gram being offered and requirements for participation. To
assure between-group equivalence in age and gender, each
cohort of ~ 66 was stratified at recruitment by gender and
age into 6 groups of n ~ 11 youth: females ages 12, 13, and
14; males ages 12, 13, and 14. Before recruiting each cohort,
assignment lists were created; the field supervisor assigned
each eligible adolescent to the next slot in their subgroup.

Intervention Project Prepared had two parts. An 11-week
interactive classroom-style intervention was followed imme-
diately by a 3-week internship, for a total of 14 sessions. The

internship was a pedagogical tool in which participants used
what they had learned in Prepared and taught it to others. The
~ 33 youth randomized to both TEEN and Prepared were di-
vided in half for an ideally sized group of 12–15 participants.
For the internship, each group of 12–15 was split again into 2,
each producing their own poster presentation. The internship
began the week following the classroom intervention. The
goal of the internship was for participants to use their new
expertise through creating a poster presentation to educate
other teens about the topics in the Prepared program. In the
first week, participants chose a poster topic; in the second
week, they designed their poster and practiced their presenta-
tion; and in the third week, a panel of experts in sexuality
education attended their poster presentations and gave feed-
back. Youth then presented the poster to peers who voted to

Assessed for eligibility (n = 459)

Excluded (n=62)
• Did not meet inclusion criteria (n=6)
• Used for pilot (n=56)

Randomized (n = 397)

Follow-up at T2 (n=171)
• Lost to Follow-up (n=29)
o agreed but no show (n=4)
o unreachable (n=19)
o other obligations (n=1)
o parent unable to take child (n=3)
o passive refusal (n=2)

Follow-up at T3 (n=162)
• Lost to Follow-up(n=38)
o agreed but no show (n=5)
o unreachable (n=28)
o other obligations (n=3)
o parent unable to bring child (n=1)
o passive refusal (n=1)

Completed 11 of 14 sessions (n=120)

Did not complete 11 of 14 sessions
(n=19)

o unknown (n=19)

Allocated to Project Prepared (n=200)
• Attended at least one session (n=139)
• Did not attend (n=61)
o Agreed but no show (n=42)
o too busy (n=11)
o moved (n=3)
o unreachable (n=2)
o Parent refusal – program content (n=3)

Allocated to TEEN (n=197)
• Attended at least one session (n=155)
• Did not attend (n=42)
o Agreed but no show (n=29)
o too busy (n=10)
o moved (n=1)
o unreachable (n=2)

En
ro

llm
en

t
A
llo

ca
tio

n
Fo

llo
w
-u
p

A
na

ly
si
s

Analyzed (n = 200) Analyzed (n = 197)

Follow-up at T2 (n=157)
• Lost to Follow-up (n=40)
o agreed but no show

no show (n=3)

(n=4)
o unreachable (n=28)
o other obligations (n=6)
o parent unable to take child (n=1)
o passive refusal (n=1)

Follow-up at T3 (n=147)
• Lost to Follow-up(n=50)
o agreed but
o unreachable (n=36)
o other obligations (n=6)
o parent unable to bring child (n=2)
o passive refusal (n=3)

Completed 11 of 14 Sessions (n=115)

Did not complete 11 of 14 sessions
(n=40)

o unknown (n=40)

Fig. 2 CONSORT diagram of
participant flow

1026 Prev Sci (2021) 22:1023–1035

select the winning poster presentation; winners each received
a $10 gift card.

Prepared met once weekly for 2¼ hours. It included large
and small group discussions, separate gender group discus-
sions, icebreakers, and role plays. It covered information
about sexuality, including STIs, HIV, and condom use; aware-
ness of gender and relationship norms; perceived and actual
peer pressures that influence the ways in which people behave
and how these can increase sexual risk-taking; and skills in
communication, decision-making, and building healthy rela-
tionships. Risk reduction strategies included abstinence; cor-
rect, consistent condom use; limiting number of partners; and
recognizing healthy/unhealthy relationships. Adolescents re-
ceived $15 each week for participating. Each Prepared group
was led by one facilitator, with an assistant facilitator who
documented fidelity to the intervention manual and assisted
with logistics (e.g., attendance, food, pay) and small group
work. The internship was run by 4 facilitators; each was
assigned to one of the 4 poster groups.

TEEN was similarly structured as an 11-week commu-
nication and social skills program, and a 3-week internship
(14 total sessions) in which adolescents created a poster
presentation to teach peers about communication and social
skills. TEEN was a perfect attention control intervention: it
was successful in enhancing self-esteem and reducing dis-
tress (Bauman et al., 1997), and it was as intensive as
Prepared, but had no HIV/STD, gender norm, or relation-
ship content.

All facilitators had strong skills in sexuality education,
HIV/STI risk reduction, and group facilitation with degrees
in health education, public health, or health psychology, and
were experienced in working with adolescents. They were
trained in cultural competence, the intervention protocol, pro-
tocol manuals, and to adhere strictly to the protocols.

Acceptability of both programs was high. Satisfaction data
for both programs was collected at the end of each cohorts.
The 39-item survey asked about comfort with the program,
development fit, satisfaction with the content, and satisfaction
with the facilitator. Satisfaction ratings for both programs
were very high; this ceiling effect precluded formal analysis,
but visual inspection showed no gender, race, or program
differences.

Data Collection and Measures Adolescents completed data
collection three times between the years 2011 and 2015: at
T1, baseline; T2, 6 months later, after the programs were
completed; and T3, 1 year after baseline via self- and
interviewer-administered tools. Participants completed sur-
veys at private Computer-Assisted Personal Interview
(CAPI) terminals. Trained interviewers administered a survey
on school attendance, family structure, and personal back-
ground. Youth received $25 for completing each interview
(Table 1).

Table 1 Measures

Construct/measure Description Notes

Cognitive factors: social cognitions

HIV knowledge
(Volpe et al.
2007)

18 items, answered yes,
no, do not know

Means are reported

Abstinence
self-efficacy
(Diiorio et al.
2002, 2006)

12 items answered on a
7-point scale, “not
sure at all” to
“completely sure”

Items included staying
out of situations that
lead to pressure to
have sex

Abstinence outcome
expectancy
(Diiorio et al.
2001,2002, 2006)

19 items answered on a
5-point Likert scale.
Alpha reliability was
.85

The perceived
consequences of
enacting risk
reduction behavior

Sex-related
self-efficacy
(Diiorio et al.,
2001)

12 items answered on a
7-point scale “not
sure at all” to
“completely sure”

Self-efficacy for safer
sex behavior, e.g.,
using a condom,
negotiating condom
use

Condom use
outcome
expectancy
(Diiorio et al.,
2001)

9-item measure
answered on a
5-point Likert scale;
summed (higher =
more favorable atti-
tudes)

Self-evaluative,
physical, and social
expectancies of
condom use (e.g., I
will feel more
responsible if I use a
condom)

Cognitive factors: behavioral intentions

Behavioral
intentions (Diiorio
et al., 2002)

yes/no items e.g., intention to have
sex, limit sexual
partners, talk to
partners about HIV,
use condoms every
time

Behavioral
intentions (CAPS,
1994)

2 items answered on a
5-point scale from “I
would definitely” to
“I would definitely
not”

Whether they would
refuse to have sex
without a condom
and whether they
would insist even if
partner disagreed

Behavioral
intentions
(developed for the
study)

Future plans, answered
on a 5-point scale
from “never” to “will
definitely do fre-
quently”

Having sexual
intercourse, having
condoms available,
using condoms,
talking to sexual
partners

Gender norms

Gender norms
(Silver et al.,
2014)

6 items answered on a
4-point Likert scale;
parallel versions for
boys and for girls;
higher = higher en-
dorsement of risk
behaviors for that
gender

Having sexual
intercourse, having
sex by certain ages,
or having multiple
partners make
someone “cool” or
“popular”

Relationship factors

Romantic Beliefs
Scale
(Marin,Coyle,
Gomez, Carvahal
& Kirby, 2000)

5-items answered on a
Likert scale

Adolescent beliefs
about a romantic
love relationship.,
e.g., If I love
someone, I know I
can make the

1027Prev Sci (2021) 22:1023–1035

Statistical Analysis Preliminary analyses included inspection
of frequency distributions and dispersion of data as well as
calculations of summary statistics (mean, standard deviations,
and percentages). ANOVA (continuous measures) and chi-
square tests (categorical variables) were used to test whether
baseline characteristics/measures were similar between
Prepared and TEEN groups. The analyses followed an
intent-to-treat principle; all data were analyzed by initial as-
signment to the treatment group, regardless of intervention
exposure. Rubin’s multiple imputationmethod with 11 repeat-
ed imputations was employed to impute the missing endpoint
for conducting the intent-to-treat analysis. Generalized linear
models (GLMs) with the identity link function were used to
compare Prepared and TEEN. The analysis models included

an intercept term, an indicator for Prepared (vs. TEEN), time
indicators for the 6-month and 12-month follow-up visits (vs.
baseline), and an intervention-by-time interaction term.
Generalized estimating equation (GEE) methods with identity
working correlation matrix were selected to account for
within-subject correlation due to multiple assessments for
the same subject as well as the effect of clustering caused by
the conduct of the interventions in groups (Paik, 1997). GEE,
a population average model, was selected over a subject-
specific model, such as random effects models, because we
were interested in the impact of Prepared on overall risk re-
duction of HIV acquisition at the population level. If, on av-
erage, Prepared wasmore effective than TEEN over time, then
it will be beneficial from the public health point of view to
implement it in the target population. We are less interested in
knowing the weighted average intervention effect while hold-
ing all the random effect variables fixed, which is the question
that the subject-specific model aims to answer. Although the
estimated intervention effect from two methods may be sim-
ilar, their interpretations are very different. In addition, with
non-normal distributions in the dependent variables, GEE is
often superior to random effects models. Therefore, GEE is a
preferable method for analyzing the data from both practical
and statistical standpoints. The regression coefficient corre-
sponding to the intervention-by-time interaction term esti-
mates the difference in population mean change in outcome
(from baseline to follow-up) between Prepared and TEEN,
which represents the Prepared intervention effect.
Intervention effects are reported with their p values and cor-
responding 95% confidence intervals. The Holm step-down
procedure was employed to adjust for multiple comparisons
within each domain (such as knowledge, beliefs) at each
follow-up assessment. We also examined effectiveness by
gender to explore whether the Prepared intervention is bene-
ficial overall or just for a specific subgroup. We conducted
such analyses to help interpret the findings from the analysis
of the whole sample.

Results

Of the 200 randomized to Prepared, 69.5% participated;
86.3% of these completed it (Fig. 2). Of the 197 randomized
to TEEN, 78.7% participated and 74.2% completed it. In
Prepared, 85.5% completed the T2 survey and 81% completed
T3; in TEEN, 79.7% completed T2 and 74.6% completed T3.
Rates of program participation and completion, as well as
sample retention to T3, did not differ by gender or age.

Baseline Characteristics

The mean age of youth was 13.4 years; half (50%) were fe-
male (Table 2). The sample was mostly Black (44%) and

Table 1 (continued)

Construct/measure Description Notes

relationship work,
despite any obstacles

Relationship
expectations
(Watnick et al.,
2011)

12 items answered on a
4-point Likert scale;
two subscales.
Relationship moni-
toring & control;
emotional openness
& availability. Items
summed; higher =
more positive expec-
tations

e.g., when I have a
girl/boyfriend…
s/he will want to
know where I am at
all times;…“I will
tell my partner how I
feel about her/him”

Resilience

Resiliency scales for
adolescents,
profile of personal
strengths
(Prince-Embury,
2007)

Both raw scores and
T-scores for norma-
tive groups by age
and gender are
available using a
standardization sam-
ple of 200 teens
matched to the US
Census on ethnicity
and parent education
within sex and age
bands

Measures personal
attributes critical for
overcoming life
obstacles. Subscales
are sense of mastery
(optimism,
self-efficacy,
adaptability); sense
of relatedness (trust,
support, comfort,
tolerance); and
emotional reactivity
(sensitivity,
recovery,
impairment)

Behavior

Sexual behavior
(Diiorio et al.,
2002, 2006)

Items include ever
having had sexual
intercourse, age at
initiation, # of
partners, and
condom use (for
those reporting
initiation)

1028 Prev Sci (2021) 22:1023–1035

Latino (50%), and over 80% lived in poverty (received
Medicaid or public assistance excluding those who could
not answer). 44% lived with both biological parents and
40% lived in single-parent households. HIV knowledge was
low (mean = 5.7/18). Intention to have sex in the next
6 months also was low (14%), and most (85%) reported they
would definitely/probably refuse sex without a condom. Few
had engaged in oral, anal, or vaginal sex (12%), and fewer
(5%) had engaged in unprotected sex in the prior 6 months.

Baseline Differences Between Groups

Randomization was successful with only one significant dif-
ference between groups: TEEN started out higher on outcome
expectancy for condom use.

Change Over Time

In the longitudinal analyses comparing changes by group
(GEE), those in Prepared demonstrated significantly greater
improvements over those in TEEN at T2, 6 months post-inter-
vention, in HIV knowledge (p < .001), sexual self-efficacy
(p < .05), and outcome expectancy for condom use (p < .05).
At T3, 12 months post-intervention, we found significant dif-
ferences in improvement over time favoring Prepared in out-
come expectancy for condom use (p < .001), sexual self-
efficacy (p < .001), and intention to talk to one’s partner about
HIV (p < .05). There were no significant differences in absti-
nence self-efficacy or outcome expectancies, recognizing risky
gender norms, relationship expectations, or in intention to have

sex, to refuse sex without a condom or to carry a condom by
group at either T2 or T3 (Table 3).

Both boys and girls benefitted from Project Prepared.
Girls showed greater positive changes in abstinence out-
come expectancies at T2 (p < .05) and reduced endorsement
of risky female sexual behavior at T3 (p < .05) . Sexual self-
efficacy improved for girls in Prepared; however, TEEN
girls’ scores also improved, and the groups did not differ
significantly. Boys in Prepared improved in abstinence self-
efficacy (p < .001) and condom outcome expectancy at T3
(p < .001); and sexual self-efficacy (p < .001) and intention
to talk to one’s partner about HIV at T2 and T3 (p < .001)
(see Table 4). Condom outcome expectancy declined over
time for TEEN boys, especially at T3, but boys in Prepared
maintained T2 program effects. There was no parallel de-
cline in outcome expectancies for girls in either TEEN or
Prepared. TEEN girls improved more in resilience
(mastery) at T2 (p<.05) and abstinence self-efficacy at T3
(p<.05).

Sexual Behavior

Sexual risk behavior was not an outcome because we judged it
unlikely that many participants would initiate/engage in inter-
course during the project. As expected, only 53 teens reported
having intercourse between months 6 and 12, too few to have
the power to assess whether observed differences by group
were statistically significant. However, these findings were
suggestive: those randomized to Prepared reported fewer ep-
isodes of unprotected sex on average than those in TEEN (2.7
vs. 5.4).

Table 2 Participant
characteristics overall and by
group assignment

TEEN (n=197)
49.6%

Prepared (n=200)
50.4%

Total (n=397) p value

Age, mean (SD) 13.4 (.8) 13.5 (.8) 13.4 (.8) 0.26

% female 99 (50.3%) 98 (49.0%) 197 (49.6%) 0.80

Race/ethnicity 0.72

Black 84 (42.6%) 92 (46.0%) 176 (44.3%)
Latino 101 (51.3%) 96 (48.0%) 197 (49.6%)

White/Asian 2 (1.0%) 4 (2.0%) 6 (1.5%)

Mix/other 10 (5.1%) 8 (4.0%) 18 (4.5%)

Household member receives public
assistance

0.36

Yes 98 (49.7%) 108 (54.0%) 206 (51.9%)
No 18 (9.1%) 23 (11.5%) 41 (10.3%)

Do not know 81 (41.1%) 69 (34.5%) 150 (37.8%)

Participants’ family structure
(cohabitants)

0.11

Both biological parents 77 (39.1%) 97 (48.5%) 174 (43.8%)
Single biological parent 86 (43.7%) 73 (36.5%) 159 (40.1%)

Biological parent plus parent’s
partner

31 (15.7%) 23 (11.5%) 54 (13.6%)

All others 3 (1.5%) 7 (3.5%) 10 (2.5%)

1029Prev Sci (2021) 22:1023–1035

Limitations

This study has several limitations. First, we are skeptical
about the ability of 12–14-year-olds with no sexual expe-
rience to answer self-efficacy or intention questions. For
example, if youth say they have no intention of discussing
condom use with a partner, they may mean that they have
no intention to have sex. Second, our 1-year follow-up
window was too short to observe effects of Prepared on
sexual risk behavior. Third, this single-site study in one
city may not be generalizable to other populations.
Fourth, the study recruited participants who had primary
care visits and may under-represent youth who do not have
access to or use health care.

Discussion

Project Prepared aimed to address cognitions, gender norms,
resilience, and relationship factors that had been shown in the
literature to influence early sexual initiation. It relied on social
cognitive theories of Reasoned Action and Planned Behavior
to identify the specific cognitions that were covered in the
curriculum; it addressed gender norms and relationship beliefs
that were associated in the literature with sexual risk behavior
and identified resilience attributes that could be enhanced to
provide ongoing protection against risk. Given the acknowl-
edged sexual naiveté of the population, the curriculum covered
basic information—howHIV and STIs are transmitted, how to
use a condom and barriers to use, how risky sexual behavior is

Table 3 Model predicted mean and proportion for each group at each time point as well as the group comparisons in change over time (i.e., d2 and d3)
for the Full Sample

Baseline T2: 6 months T3: 12 months d2* p
value
d2

d3* p
value
d3

TEEN
(n=197)

Prepared
(n=200)

TEEN
(n=157)

Prepared
(n=171)

TEEN
(n=147)

Prepared
(n=162)

Relationship factors

Romantic Beliefs Scale 9.5 9.5 9.5 9.9 9.8 10.0 0.23 .40 0.16 .57

Monitoring/control 12.7 12.7 12.9 13.1 12.7 12.8 0.14 .48 0.12 .68

Openness 10.1 10.3 10.0 10.4 10.2 10.3 0.21 .31 0.04 .85

Gender norms

Endorse male sexual risk behaviors 11.8 11.2 12.3 12.2 12.7 12.4 0.35 .47 0.24 .81

Endorse female sexual risk
behaviors

9.7 9.5 8.8 9.1 9.1 8.6 0.27 .37 −0.10 .86

Resilience (T-scores)

Mastery (high = better mastery) 48.1 48.0 48.8 48.4 47.8 48.6 −0.24 .78 0.92 .27

Interpersonal relationships (high =
better relationships)

47.0 46.8 46.9 48.3 46.7 46.9 1.50 .24 0.33 .82

Emotional reactivity (high = worse
reactivity)

50.9 49.9 50.9 49.2 51.5 51.1 −0.68 .53 0.71 .65

Cognitive factors: behavioral intentions

Plan to have vaginal, anal, or oral
sex (“sex”)+

30 (15%) 27 (14%) 34 (22%) 29 (17%) 34 (23%) 34 (21%) 0.85 .60 1.02 .96

Plan to talk to a partner about
HIV/STIs +

63 (32%) 58 (29%) 49 (31%) 59 (35%) 40 (27%) 60 (37%) 1.34 .24 1.81 .02

Would refuse sex without a condom 169 (86%) 168 (84%) 136 (87%) 144 (84%) 126 (86%) 140 (86%) 0.95 .87 1.22 .60

Plan to carry a condom 57 (29%) 66 (33%) 62 (40%) 79 (46%) 61 (42%) 75 (46%) 1.09 .70 1.01 .98

Cognitive factors: social cognitions

HIV knowledge 5.6 5.8 7.2 8.3 7.6 8.9 0.99 .00 1.10 .14

Abstinence outcome exp. 58.6 58.8 58.1 58.9 58.4 58.8 0.51 .55 0.12 .92

Abstinence self-efficacy 62.3 63.2 67.1 66.9 67.0 68.7 −1.13 .28 0.77 .47

Sexual self-efficacy 61.0 60.7 64.9 66.8 63.8 67.3 2.27 .03 3.27 .00

Condom outcome exp. 35.9 34.6 35.2 35.4 34.6 35.1 1.38 .02 1.67 .00

+, includes those not planning to have sex

*d2 and d3 represent the Prepared intervention effect for T2 and T3 respectively. For continuous outcomes, they are mean difference (between Prepared
and TEEN) in change over time whereas for the dichotomous variables, they represent the ratio (between Prepared and TEEN) of two odds ratios (i.e., the
change over time for Prepared and for TEEN)

Text in bold indicates statistical significance at p < .05

1030 Prev Sci (2021) 22:1023–1035

Table 4 Model predicted mean and proportion for each group at each time point as well as the group comparisons in change over time (i.e., d2 and d3)
by each of the two gender subgroups

Females only

T1: Baseline T2: 6 months T3: 12 months d2* p value
d2

d3* p value
d3

TEEN
(N=99)

Prepared
(N=98)

TEEN
(N=80)

Prepared
(N=80)

TEEN
(N=78)

Prepared
(N=79)

Relationship expectations

Romantic Beliefs Scale 9.3 9.5 9.8 10.0 9.9 10.5 − 0.05 .90 0.44
.28

Monitoring/control 12.9 13.0 13.2 13.1 13.0 13.0 − 0.14 .64 −0.07
.84

Openness 10.5 10.5 10.5 10.8 10.3 10.7 0.15 .27 0.19 .50

Gender norms

Endorse male sexual risk
behaviors

11.0 10.9 11.9 12.1 13.5 12.5 0.12 .90 − 0.66

.64

Endorse female sexual risk
behavior

7.8 8.2 7.9 7.7 9.5 8.1 − 0.51 .21 −1.37

.02

Resilience (T-scores)

Mastery 48.2 48.3 48.6 47.2 48.3 47.9 − 1.50 .03 −0.51
.46

Interpersonal relationships 47.7 47.3 46.8 47.1 46.7 46.5 0.60 .59 0.13 .94

Emotional reactivity 51.7 50.0 50.2 51.5 52.2 52.3 3.05 .12 1.83 .52

Cognitive factors: behavioral intentions, N (%)

Plan to have sex+ 12 (12%) 9 (9%) 14 (18%) 10 (13%) 11(14%) 13 (17%) 0.92 .86 1.64 .31

Plan to talk to partner about
HIV/STIs+

27 (27%) 25 (26%) 26 (33%) 19 (24%) 22 (28%) 19 (24%) 0.71 .35 0.88 .74

Would refuse sex without a
condom

97 (98%) 92 (94%) 77 (96%) 76 (95%) 74 (95%) 73 (92%) 2.34 .43 2.08 .48

Plans to carry a condom 21 (21%) 21 (21%) 29 (36%) 26 (33%) 29 (37%) 23 (29%) 0.84 .61 0.69 .33

Cognitive factors: social cognitions

HIV knowledge 6.0 6.2 8.3 9.3 8.7 9.5 0.80 .07 0.53 .51

Abstinence outcome exp. 65.7 63.7 63.5 63.0 64.5 61.9 1.58 .02 − 0.53
.69

Abstinence self-efficacy 66.9 68.9 72.8 73.6 74.0 73.7 − 1.30 .31 −2.35
.04

Sexual self-efficacy 61.5 61.4 66.7 67.9 67.6 68.1 0.87 .65 0.26 .88

Condom outcome exp. 36.5 34.6 36.2 35.9 36.1 35.3 1.27 .10 0.90 .26

Males only

T1: Baseline T2: 6 months T3: 12 months d2* p value
d2

d3* p value
d3

TEEN
(N=98)

Prepared
(N=102)

TEEN
(N=77)

Prepared
(N=91)

TEEN
(N=69)

Prepared
(N=83)

Relationship expectations

Romantic Beliefs Scale 9.7 9.6 9.2 9.8 9.7 9.6 0.52 .12 0.52 .12

Monitoring/control 12.5 12.4 12.7 13.1 12.4 12.5 0.40 .10 0.32 .39

Openness 9.8 10.0 9.5 10.1 10.0 10.0 0.27 .48 − 0.11
.65

Gender norms

Endorse male sexual risk
behaviors

12.5 11.4 12.7 12.2 12.1 12.3 0.59 .29 1.17 .23

Endorse female sexual risk
behaviors

11.5 10.6 9.8 10.3 8.6 9.1 1.05 .03 1.23 .14

Resilience (T-scores)

Mastery 48.0 47.7 49.0 49.6 47.2 49.4 0.85 .47 2.56 .16

1031Prev Sci (2021) 22:1023–1035

rooted in gender norms, and how to identify healthy and un-
healthy relationships. The intensive intervention included an
internship designed to put teens in the role of expert to their
peers, which we believed would reinforce ownership of the
content, and enhance commitment to safer sex behaviors.

Prepared demonstrated statistically significant improve-
ments compared to TEEN in social cognitions and gender
norms, which is evidence that Prepared was successful in ma-
nipulating the factors it was designed to affect. In addition, we
noted improvement in behavioral intentions to engage in safer
sex. Program effects were shown for both boys and girls, with
effects a bit stronger for boys. Previous HIV/STI prevention
programs that examined program effects by gender have re-
ported mixed results, with some benefitting boys and others
helping girls. Our data show that both girls and boys random-
ized to Prepared improved post-intervention, but girls in
TEEN improved on some outcomes as well (with the notable
exception of perspectives on risky female gender norms). This
research further demonstrates that an HIV/STI intervention for
early adolescents could be effectively implemented for boys
and girls together. The Prepared curriculum was designed to
provide lessons appropriate to both boys and girls and includ-
ed lessons on gender norms and messages targeted to both
male and female perspectives.

Suggestions for Future Research

Research is needed onwhy boys benefited more strongly from
Prepared. Girls in Prepared also improved on key variables,

but girls in TEEN were nearly as likely as girls in Prepared to
improve as well. It is unlikely that this is due to unintended
effects of TEEN, which provided no sexual or reproductive
health information. It is possible that girls in this age range are
more likely than boys to receive formal or informal instruction
on HIV, STIs, and relationships in school, from their families,
or elsewhere. Although statistically the benefits of Prepared
accrued more to boys, girls’ scores improved as much as boys’
over time, therefore, we believe that it is warranted to recom-
mend the use of Prepared for both genders. There is a notable
lack of published successful interventions with adolescent
boys, indicating the promise of Prepared to fill an important
gap; however, further research is necessary to identify suc-
cessful mediators within interventions with this population
(Picot et al., 2012).

A large literature reports attenuation of the effects of HIV/
STI prevention programs. Prepared demonstrated significant
effects on cognitive factors over 12 months—social cogni-
tions and behavioral intentions. However, given the develop-
mental changes in adolescence; the variety in experiences be-
tween younger and older boys and girls in dating, sex, and
condom use; and the challenges adolescents have in making
healthy choices concerning their sexual and reproductive risk,
we believe that interventions for young teens may not be suf-
ficient to guide youths’ sexual decisions as they enter middle
adolescence. Sexual risk reduction interventions are offered
on an “immunization” model; i.e., once the skills and knowl-
edge are delivered in a program, it is assumed that the teen is
protected long term. However, this assumption should be test-
ed; research is needed on the utility of long-term, sustained

Table 4 (continued)

Interpersonal relationships 46.3 46.3 47.0 49.3 46.7 47.3 2.21 .20 0.48 .81
Emotional reactivity 50.2 49.8 51.7 47.1 50.7 50.0 −

4.16
.11 −

0.26
.90

Cognitive factors: behavioral intentions, N (%)
Plan to have sex+ 18 (18%) 18 (18%) 20 (26%) 19 (21%) 23 (33%) 21 (25%) 0.79 .56 0.71 .43
Plan to talk to partner about HIV
or STIs+

36 (37%) 33 (32%) 23 (30%) 40 (44%) 18 (26%) 41 (49%) 2.24 .02 3.36 .00

Would refuse sex without a
condom

72 (74%) 76 (75%) 59 (77%) 68 (75%) 52 (75%) 67 (81%) 0.86 .70 1.30 .57

Plan to carry a condom 36 (37%) 45 (44%) 33 (43%) 53 (58%) 32(46%) 52 (63%) 1.37 .28 1.43 .28
Cognitive factors: social cognitions
HIV knowledge 5.2 5.4 6.0 7.5 6.4 8.4 1.33 .07 1.82 .10
Abstinence outcome exp. 51.3 54.1 52.5 55.2 51.6 55.8 −

0.10
.92 1.45 .37

Abstinence self-efficacy 57.6 57.7 61.2 61.0 59.0 63.9 −
0.20

.90 4.78 .00

Sexual self-efficacy 60.6 60.1 62.9 65.8 59.5 66.5 3.69 .02 6.33 .00
Condom outcome exp. 35.2 34.7 34.2 35.0 32.9 35.0 1.51 .07 2.45 .00

+, includes those not planning to have sex

*d2 and d3 represent the Prepared intervention effect for T2 and T3 respectively. For continuous outcomes, they are mean difference (between Prepared
and TEEN) in change over time whereas for the dichotomous variables, they represent the ratio (between Prepared and TEEN) of two odds ratios (i.e., the
change over time for Prepared and for TEEN)

Text in bold indicates statistical significance at p<.05

1032 Prev Sci (2021) 22:1023–1035

intervention that evolves developmentally with teens, and tar-
gets information to the sexual evolution of adolescents’ expe-
rience (Dinaj-Koci et al., 2015). These interventions would
begin early, emphasizing basic information and anticipatory
guidance and over time offer increasingly sophisticated sexual
and reproductive health information; condom and communi-
cation skills; relationship skills; and access to teen-friendly
medical care, including STI and HIV testing and pre-
exposure prophylaxis. Research on the benefits of a K through
12 approach to sexual education might be the solution to the
problem that effects of risk reduction programs attenuate after
the programs end.

Supplementary Information The online version contains supplementary
material available at https://doi.org/10.1007/s11121-021-01203-0.

Funding The trial was funded by the National Institute of Child Health
and Human Development to Laurie J. Bauman (PI) 5R01HD062079 and
is registered at ClinicalTrials.gov ID: NCT01880450, Protocol ID: 2008-
551.

Compliance with Ethical Standards

Conflict of Interest The authors declare that they have no conflict of
interest.

Ethical Approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institu-
tional research committee and with the 1964 Helsinki declaration and its
later amendments or comparable ethical standards. The study protocol
was reviewed and approved by the Institutional Review Board of the
Albert Einstein College of Medicine.

Informed Consent Informed consent was obtained from all individual
participants.

Open Access This article is licensed under a Creative Commons
Attribution 4.0 International License, which permits use, sharing,
adaptation, distribution and reproduction in any medium or format, as
long as you give appropriate credit to the original author(s) and the
source, provide a link to the Creative Commons licence, and indicate if
changes weremade. The images or other third party material in this article
are included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in the
article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

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1035Prev Sci (2021) 22:1023–1035

  • Reducing HIV/STI Risk Among Adolescents Aged 12 to 14 Years: a Randomized Controlled Trial of Project Prepared
    • Abstract
    • Background
    • Methods
    • Results
      • Baseline Characteristics
      • Baseline Differences Between Groups
      • Change Over Time
      • Sexual Behavior
    • Limitations
    • Discussion
    • Suggestions for Future Research
    • References

International Journal of

Environmental Research

and Public Health

Article

Education of Adolescents in the Prevention of HIV/AIDS in the
Czech Republic

Petra Macounová 1 , Hana Tomášková 1,2,* , Anna Šnajdrová 2, Markéta Stanovská 1, Martina Polochová 1,
Ivan Tomášek 2 and Rastislav Mad’ar 1

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Citation: Macounová, P.; Tomášková,

H.; Šnajdrová, A.; Stanovská, M.;

Polochová, M.; Tomášek, I.; Mad’ar, R.

Education of Adolescents in the

Prevention of HIV/AIDS in the

Czech Republic. Int. J. Environ. Res.

Public Health 2021, 18, 6148. https://

doi.org/10.3390/ijerph18116148

Academic Editor: Laura Dallolio

Received: 30 April 2021

Accepted: 2 June 2021

Published: 7 June 2021

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Copyright: © 2021 by the authors.

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This article is an open access article

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Attribution (CC BY) license (https://

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4.0/).

1 Department of Epidemiology and Public Health, Faculty of Medicine, University of Ostrava,
709 00 Ostrava, Czech Republic; [email protected] (P.M.); [email protected] (M.S.);
[email protected] (M.P.); [email protected] (R.M.)

2 Public Health Institute Ostrava, 702 00 Ostrava, Czech Republic; [email protected] (A.Š.);
[email protected] (I.T.)

* Correspondence: [email protected]; Tel.: +420-553-461-788

Abstract: The number of HIV-positive people in the Czech Republic has trebled over the last decade.
An educational programme aimed at the prevention of HIV and STDs in adolescents between 13 and
19 years of age is underway in the Moravian-Silesian Region in the Czech Republic. All schools in
the region have been offered the chance to participate in the programme (on a voluntary basis). The
programme consists of an educational lecture and a game with interactive elements; the students
perform various tasks in groups. An anonymous paired questionnaire (input/output) was used
to assess the efficacy of the programme. In order to evaluate the programme efficacy, descriptive
statistics, non-parametric Wilcoxon paired test at the level of significance of 5%, and a model of
logistic regression for a dichotomous variable were used. A total of 1210 students took part in
the programme. The students’ knowledge improved, on average, by 15.5%. The highest efficacy
was observed in the age group of 13–14-year-olds, where the improvement reached 17.9%. The
educational programme was effective in raising awareness about STDs. Due to the observed increase
in knowledge especially among the youngest participants (13–14 years old), we recommend aiming
further interventions at the youngest age groups.

Keywords: HIV; health promotion; health education; sexually transmitted diseases; primary preven-
tion; preventive programs

1. Introduction

Although many years have passed since the discovery of the HIV/AIDS disease,
it still represents a significant global problem [1,2]. At the end of 2018, approximately
37.9 million people worldwide were infected with HIV. Despite the worldwide availability
of testing, 21% of all HIV+ patients are not aware of their condition [3]. The Czech Republic
counts among countries with a relatively low incidence of this disease; nevertheless, it
belongs, at the same time, to the list of countries with a rapid increase in the number of
new cases of HIV infection over the last few years [4,5]. The number of new cases has
grown approximately three times from 1186 in 2008 to 3368 in 2018 [6]. HIV infection
remains, despite significant advancements in treatment, an incurable disease, which is not
preventable by vaccination. Hence, primary prevention of HIV infection plays an important
role and, at the same time, remains the most effective and most economical preventive
measure. Raising awareness among the youth, general public, and specific populations
with a high risk of infection using training and education about sexually transmitted
diseases (hereinafter referred to as STDs), including HIV/AIDS, is the cornerstone of
primary prevention measures [7–11].

In addition to the education of pupils and students of primary and secondary schools,
educational events, peer programmes, and lectures with an HIV+ lecturer, primary HIV/AIDS

Int. J. Environ. Res. Public Health 2021, 18, 6148. https://doi.org/10.3390/ijerph18116148 https://www.mdpi.com/journal/ijerph

Int. J. Environ. Res. Public Health 2021, 18, 6148 2 of 12

prevention also includes services of AIDS counselling, contact centres, and exchange of
used injection needles as a part of the harm reduction programme [12–15]. In the area of
raising awareness and education, it is necessary to apply preventive measures especially
towards the youth (in particular, in the areas of prevention of disease transmission, risk
behaviour, and promotion of safe sex); it is also important to motivate and encourage
responsibility for one’s acts, using condoms, and healthy behaviour [16].

The Public Health Institute in Ostrava has implemented educational events for schools,
including the interactive programme Playfully about STDs (PaSTDs), the aim of which is
to raise awareness about the possibilities of preventing the transmission of the HIV virus
and other sexually transmitted diseases in young people, and to support the development
of responsible and desirable behaviour in the area of STD prevention, including HIV, and,
thus, to reduce risky behaviour [17,18].

The aim of the study is to present students’ knowledge of HIV/AIDS and the ef-
fectiveness of the PaSTDs educational programme in raising awareness and knowledge
regarding prevention of HIV and STDs in adolescents. The basic hypothesis is that this
programme represents an effective tool of primary prevention and that after its completion,
the participants’ knowledge about the problems of HIV and STDs increases.

2. Materials and Methods
2.1. Design

An educational programme aimed at the prevention of HIV and STDs in adolescents
between 13 and 19 years of age is underway in the Moravian-Silesian Region in the Czech
Republic. All grammar and secondary schools (a total of 457 schools) in the region have
been offered the possibility to take part in the programme; their participation was voluntary.
Over 2 years (2018–2019), students from 31 schools in the Moravian-Silesian Region, Czech
Republic, participated in the programme. A total of 1264 students aged 13 to 19 present on
the day of the educational programme at the school participated in the programme.

The programme consists of an educational lecture (two lessons) and a game with
interactive elements, during which the pupils from each class are divided into 4 groups
and perform 8 tasks with various educational tools (magnetic board and magnetic cards,
samples of contraception methods, models of penis for training of condom handling), for
which they receive points in the form of special “bouncing balls” [17]. A more detailed
description of the course of the programme can be found in Appendix A.

2.2. Measures

An anonymous paired questionnaire (input/output) was used to assess the efficacy of
the programme. The input questionnaire, with a unique ID, was distributed among the
students prior to commencement of the educational programme; this questionnaire served
as the baseline evaluation of participants’ knowledge about the problems of HIV before
education. The questionnaire contains 12 questions, beginning with the data about the
participant—sex and age. The student subsequently answers 10 test questions on sexually
transmitted diseases, choosing from multiple-choice options (the answer “I don’t know” is
always one of the options). After education, the students filled in the output questionnaire
with the same ID and with questions identical to those in the input questionnaire, supple-
mented with the possibility to evaluate the programme on a scale from 1 to 5 and to add an
open comment.

The questionnaire used in this study was based on the one published in our previous
pilot study about the educational programme [17]. In addition, two questions (8, 9, see
Appendix A) in the questionnaire were changed during data collection.

2.3. Data and Variables

A total of 1264 students participated in the preventive programme; 54 students were
excluded from the analysed sample due to incomplete/incorrect filling of the questionnaires
(e.g., ticking multiple options in single-choice questions or using ambiguous indicators).

Int. J. Environ. Res. Public Health 2021, 18, 6148 3 of 12

The questionnaire was also excluded from analysis if the pair (input and output part of the
questionnaire) was incomplete. The final sample consists of 1210 students.

Data about sex, age (age groups 13–14 years, 15–16 years, 17 and older) and the type
of school—a grammar school (GS), a secondary school (SS), or a lower secondary school
(LSS)—were collected. Test questions were awarded one point for each correct answer. The
maximum was 22 points. The total score was expressed as a percentage of the maximum.
The two questions that were changed over the course of data collection (questions 8, 9—
Appendix A) were excluded from the total score. The total score was calculated separately
for the input and output questionnaire. Students’ evaluation of the programme quality
was on a scale from 1 (the best) to 5 (the worst).

EpiData Software was used for the electronisation of the data from paper questionnaires.

2.4. Data Analysis

Descriptive statistics was used for the basic presentation of the results. The changes
in the proportions of correct answers in each of the test questions were evaluated via the
McNemar test. The non-parametric Wilcoxon paired test was used to test the changes in
the total score (before and after education). The power of the mean difference between
total scores before and after education was calculated based on a one-sample mean test for
a one-sided alternative hypothesis (Ha: mean difference > 0). The comparison of the total
score by sex, age, and school type was performed using Mann–Whitney and Kruskal–Wallis
tests. A model of logistic regression for dichotomous variables was used to evaluate the
most significant factors affecting the participants’ knowledge. Low knowledge was defined
as a total score of less than 70%. The basic (reference) categories were set as: men (for the
sex variable), the youngest students (13–14 years; age variable), and grammar school (the
type of school). The results were expressed as odds ratio (OR) with standard error (SE) and
95% confidence interval (CI). Statistical tests were evaluated at the 5% significance level.
The Stata software, version 14, was used to analyse the data.

2.5. Ethical Considerations

The study was approved by the Ethics Committee of the Faculty of Medicine of the
University of Ostrava on the basis of the EC Consent Opinion No. 04/2020.

3. Results

The age span of participants was 13–19 years, with a mean age of 14.6 years; 4 par-
ticipants did not state their age. The representation of boys and girls in the group was
almost even, with a slightly higher number of boys. Thirteen participants did not fill in the
information about their sex. The analysed group consisted of a total of 1210 pupils, with
987 pupils from lower secondary schools (LSS), 137 pupils from secondary schools (SS),
and the remaining 86 students from grammar schools (GS) (Table 1).

Table 1. Description of the sample (n = 1210).

Variable Category Number %

Gender
Male 609 50.9

Female 588 49.1

School

Grammar school 86 7.1

Secondary school 137 11.3

Lower secondary school 987 81.6

Age (years)
13–14 648 53.7

15–16 466 38.7

17+ 92 7.6

Int. J. Environ. Res. Public Health 2021, 18, 6148 4 of 12

3.1. Questionnaire Results

The principal question in the questionnaire related to the awareness of pupils about
what HIV is; only 48.7% of pupils selected the correct answer in the questionnaire. The
number of correct answers increased to 84.7% after the completion of the course, clearly in-
dicating an increase in the correct answers by more than 36.0%. Almost 80% of participants
responded correctly to the question “What disease is caused by the HIV virus?” before the
programme. Only less than 10% of the participants selected an incorrect disease; however,
it is important to note that a relatively high number of students, 10.8%, chose the option “I
don’t know” (see enclosed Table 2) at that stage.

Table 2. Selected questions and correct answers before and after education (n = 1210).

Question/Statement (the Correct Answer)
% Correct Answers

Change p-Value *
Before Education After Education

1. What is HIV? 48.7% 84.7% 36.0% <0.001

2. What disease is caused by HIV? 77.1% 87.4% 10.3% <0.001

3. HIV modes of transmission:
Insect sting or bite (NT) 91.2% 98.4% 7.1% <0.001
Kissing (NT) 88.2% 97.1% 8.9% <0.001
From HIV+ mother to child (T) 66.7% 89.9% 23.2% <0.001
Sharing a toilet (NT) 92.6% 95.0% 2.4% 0.008
Sharing needles and syringes (T) 71.9% 89.8% 17.9% <0.001
Blood (transfusion) (T) 67.9% 80.3% 12.4% <0.001
Hug, handshake (NT) 98.9% 99.3% 0.3% 0.371
Sneezing and coughing (NT) 89.9% 97.5% 7.6% <0.001
Sexual transmission (T) 96.3% 96.9% 0.6% 0.354

4. HIV vaccination exists (NT) 56.5% 83.1% 26.5% <0.001

5. Hormonal contraception acts as HIV
prevention (NT)

61.9% 90.2% 28.2% <0.001

6. Complete cure of HIV is possible (NT) 72.2% 92.5% 20.3% <0.001

7. HIV in Czechia is more common among men 47.9% 84.4% 36.5% <0.001

8. (original 1) Trend in the number of HIV+ in the
Czech Republic over the last 10 years: rising

60.4% 92.5% 32.1% <0.001

9. (original 1) City with the largest number of HIV+
in Czech Republic: Prague

33.1% 84.2% 51.1% <0.001

10. (new 2) Condom as a protection against HIV:
is significant

80.0% 94.6% 14.6% <0.001

11. (new 2) Period to valid testing after a risky contact
(2 to 3 months)

16.5% 75.4% 58.9% <0.001

* McNemar test; NT = not true; T = true. 1 These questions were not included in the total score (n = 949); 2 These questions were not
included in the total score (n = 261). The bold in the table is a significant output that should be made visible.

The knowledge of pupils in the area of transmission and spreading of the HIV virus
was relatively satisfactory even before education. A high number of respondents correctly
answered the question regarding the transmission of HIV through sexual intercourse; the
answers did not differ significantly in this area between the input and output questionnaires
(more than 95% in both cases). The lowest degree of knowledge was recorded regarding
HIV transfer from a positive mother to her child, with only 66.7% of correct answers before
and 89.9% after education (i.e., with a significant increase of more than 23%). A significant
increase in knowledge after education was also observed in the questions concerning
the means by which HIV cannot be transmitted, i.e., common kissing or insect bites (see
Table 2).

Unsatisfactory results prior to education were observed in several very important
HIV-related issues—namely, whether there is a vaccination against HIV (only 56.5% of

Int. J. Environ. Res. Public Health 2021, 18, 6148 5 of 12

correct answers before the educational programme significantly increasing to 83.1% after
the programme). A limited number of respondents believed that an effective vaccination
against HIV exists (23%), and a relatively higher number of students selected the option “I
don’t know” (20%). Similar results were also seen where the knowledge of hormonal con-
traception in the sense of HIV prevention was concerned. The success rate of answers was
also very low in this question, reaching only 62.0% before the programme and increasing
to 90.2% after education.

Two questions of a predominantly informative character (the town with the highest
number of HIV-positive individuals within the Czech Republic and the trend in the number
of HIV-positive patients) were answered by 949 students and, subsequently, substituted
with more important questions that can be used internationally. These new questions were
answered by 261 students. The question about the time interval for HIV testing after a
risky situation needed to obtain a valid result was correctly answered by 16.5% of students
prior to education and by 75.4% of students after the programme. The question of whether
a condom is considered an important protection means against HIV infection was correctly
answered by 80.0% of respondents before, and 94.6% after the education.

The median total point score before education was 17 points (range 6–22 points,
average % score 74.9%); after education, the total point score increased to 21 points (range
8–22 points, average total % score 89.4%). The mean difference between the total % scores
after and before education was 15.5%. The difference between total % scores was statistically
significant, and the power of the test was high (p < 0.001; power = 100) (see Table 3).

Table 3. Total scores before and after education (n = 1210).

Total Score Period Median Mean SD p-Value 2/Power 3

Points
Before education 17 16.3 3.17

<0.001
After education 21 19.7 2.69

%
Before education 73.9 74.9 14.42

<0.001
After education 95.5 89.4 12.23

Difference 1 13.4 15.5 14.50 100%

r1 Difference = total % score after education—total % score after education; 2 Wilcoxon paired test. 3 The power
for the mean difference was calculated based on a one-sample mean test for one side alternative hypothesis (Ha:
mean difference > 0).

3.2. What Factors Affect Knowledge?

Factors significantly influencing the participants’ knowledge about HIV/AIDS were
also analysed. Table 4 presents the results of comparing the scores before and after the
programme divided by sex, age, and type of school. Significant differences were observed
prior to education, with the exception of male-to-female comparison. After education, girls’
knowledge was higher (average success rate 91.4%) than boys’ (87.8%). The lowest mean
values before education were observed in lower secondary school pupils (72.6%); after
education, students at secondary schools manifested the lowest scores (87.7%). The level of
knowledge before education increased with age before education, while after it, the worst
results were recorded in the oldest students. Hence, the highest effect of education was
observed in the age group of 13–14-year-olds, with an improvement of the questionnaire
results by almost 18% (from 71.1% to 89.0%). In comparison, the average improvement in
the 17+ group, where the knowledge level was the highest already at the beginning, was
only 8.1%; nevertheless, the improvement was still statistically significant.

3.3. Which of These Factors Are Significant?

A low level of knowledge (a total score < 70%) was identified in 36% of students before
education and in 8% of students after education. Statistically significant factors—age and
type of school—were identified in the fully adjusted model before education. The age group
of 15–16-year-olds already showed significantly higher knowledge before education than

Int. J. Environ. Res. Public Health 2021, 18, 6148 6 of 12

the group of 13–14-year-olds (OR = 0.58; SE = 0.81; 95% CI: 0.44–0.76). Lower secondary
school pupils achieved statistically significantly worse point scores when compared with
grammar school students (OR = 2.73; SE = 0.87; 95% CI: 1.46–5.09). After education, the
differences according to age and type of school were no longer significant (see Figure 1);
however, a significantly greater improvement of the knowledge level was observed in girls
than in boys (OR = 0.41; SE = 0.10; 95% CI: 0.26–0.66).

Table 4. Average values of total scores (%) before and after education by sex, age, and type of school.

Variable Category n
Total % Score Before Education Total % Score After Education

p-Value 3

Median Mean SD Median Mean SD

Gender
Male 609 75 73.1 14.27 91.7 87.8 13.23 <0.001

Female 588 75 74.9 13.68 95.7 91.4 9.99 <0.001

p-value 1 0.0351 0.001

School
GS * 86 85.4 81.1 14.37 100 95.2 8.78 <0.001

SS ** 137 83.3 79.7 13.12 91.7 87.7 14.34 <0.001

LSS *** 987 75 72.6 13.80 91.7 89.2 11.74 <0.001

p-value 2 0.001 0.001

Age (years)
13–14 648 70.8 71.1 13.94 91.7 89.0 11.54 <0.001

15–16 466 79.2 77.1 13.29 95.8 90.7 12.03 <0.001

17+ 92 83.3 78.4 14.52 91.7 86.5 14.24 <0.001

p-value 1 0.001 <0.001
1 Mann–Whitney test; 2 Kruskal–Wallis; 3 Wilcoxon paired test; * GS—grammar school; ** SS—secondary school; *** lower secondary
school. The bold in the table is a significant output that should be made visible.

Int. J. Environ. Res. Public Health 2021, 18, x 7 of 12

Figure 1. Results of models monitoring the influence of gender, age, and type of schools on the low knowledge of
HIV/AIDS (1: Total % score < 70). OR—odds ratio; baseline—male, age 13–14 years, grammar school. Model (before edu-
cation) fully adjusted: p = 0.025; model (after education) fully adjusted: p < 0.001.

4. Discussion
In addition to the PaSTDs programme, there is also another project in the Czech Re-

public educating young people and forming their attitudes in the field of HIV/AIDS pre-
vention. This project is organised by the National Institute of Public Health under the
name “Playing Against AIDS”. In this project, all information regarding HIV is presented
to students only by means of oral presentations using available tools, and the programme
does not include any educational “hands-on” presentation. Participants work in five indi-
vidual groups, and the significant gaming character is missing. Each group of participants
has their own lecturer, and the programme is more personally demanding when com-
pared with the PaSTDs project, requiring only one lecturer for the whole intervention. The
PaSTDs project uses an educational game to present the subject and input and output
questionnaires to determine the effectiveness of the programme. Nevertheless, based on
available sources, both programmes are of high quality, effective, and positively evalu-
ated [18]. The educational information of PaSTDs was evaluated positively by the stu-
dents; their interest in the HIV issue manifested especially through the increase in aware-
ness about this problem by more than 15%.

The knowledge level increased in a vast majority of the 1210 participants; therefore,
we can consider the programme effective. The programme was most effective in the
youngest age group of 13–14-year-olds, where the improvement in the knowledge level
was almost 18%. This is most probably caused by the fact that the youngest participants
do not have much information and experience yet (as corroborated by their lowest initial
result); this result may have also been due to the gaming/competitive character of the pro-
gramme, which seems to be more attractive to younger participants. The average im-
provement observed in the 15–16-year-olds was 13.66%. Compared to that, the oldest age
group of 17–19-year-olds achieved an average improvement of a mere 8.1%, which is most
likely due to the already high level of knowledge the students had before completing the

Female

Age 15-16 years

Age 17+ years

Secondary school

Lower secondary school

0 2 4 6

95% Confidence Interval
OR before education OR after education

Factors influencing a low knowledge of HIV/AIDS

1

Figure 1. Results of models monitoring the influence of gender, age, and type of schools on the low knowledge of HIV/AIDS
(1: Total % score < 70). OR—odds ratio; baseline—male, age 13–14 years, grammar school. Model (before education) fully
adjusted: p = 0.025; model (after education) fully adjusted: p < 0.001.

Int. J. Environ. Res. Public Health 2021, 18, 6148 7 of 12

In the final part of the output questionnaire, the participants evaluated the programme
on a scale from 1 (best) to 5 (worst); the average evaluation was 1.23, which means that
the students rated the programme highly positively; however, the evaluation decreased
with age.

4. Discussion

In addition to the PaSTDs programme, there is also another project in the Czech
Republic educating young people and forming their attitudes in the field of HIV/AIDS
prevention. This project is organised by the National Institute of Public Health under the
name “Playing Against AIDS”. In this project, all information regarding HIV is presented
to students only by means of oral presentations using available tools, and the programme
does not include any educational “hands-on” presentation. Participants work in five
individual groups, and the significant gaming character is missing. Each group of partic-
ipants has their own lecturer, and the programme is more personally demanding when
compared with the PaSTDs project, requiring only one lecturer for the whole intervention.
The PaSTDs project uses an educational game to present the subject and input and output
questionnaires to determine the effectiveness of the programme. Nevertheless, based on
available sources, both programmes are of high quality, effective, and positively evalu-
ated [19]. The educational information of PaSTDs was evaluated positively by the students;
their interest in the HIV issue manifested especially through the increase in awareness
about this problem by more than 15%.

The knowledge level increased in a vast majority of the 1210 participants; therefore,
we can consider the programme effective. The programme was most effective in the
youngest age group of 13–14-year-olds, where the improvement in the knowledge level
was almost 18%. This is most probably caused by the fact that the youngest participants
do not have much information and experience yet (as corroborated by their lowest initial
result); this result may have also been due to the gaming/competitive character of the
programme, which seems to be more attractive to younger participants. The average
improvement observed in the 15–16-year-olds was 13.66%. Compared to that, the oldest
age group of 17–19-year-olds achieved an average improvement of a mere 8.1%, which is
most likely due to the already high level of knowledge the students had before completing
the programme. The highest increase in the knowledge level was observed, in particular, in
the most important questions, such as what HIV is, whether there is a vaccination against
HIV, or whether hormonal contraception provides protection against HIV infection. It is
also possible to evaluate the knowledge with respect to sex, which shows that compared
to boys, girls not only performed better before the education, but the increase in their
knowledge was also higher.

Although most educational programmes dealing with the problem of HIV/AIDS
infection and other STDs are primarily aimed at children and youth, these interventions
are also important for other population groups. For example, a positive influence of
the intervention has been previously confirmed among drug users [20]. Educational
programmes and their implementation play an important role in increasing knowledge
and awareness about HIV/AIDS. Although HIV/AIDS infection is not going to disappear
completely as a result of these programmes, they may help to reduce the number of new
cases of these infections; it is, therefore, appropriate to continue with such programmes, to
develop them further and adjust them to the ever-changing requirements [16].

The positive effect of educational programmes is also supported by a meta-analysis
summarising 83 studies from various countries (developed as well as developing), aiming
at sex education and the prevention of HIV and other sexually transmitted diseases. The
results of the analysis show a positive impact of educational programmes in this area on
the behaviour of the adolescent population [21].

Current findings show that these interventions are effective worldwide. According to
a systematic review examining the effect of interventions on the prevention of unwanted
pregnancy from 2016, multiple interventions combining education and promotion of con-

Int. J. Environ. Res. Public Health 2021, 18, 6148 8 of 12

traceptive methods significantly reduce the risk of unintentional pregnancy in adolescents.
The review further revealed that educational interventions alone will most probably not
result in postponing the beginning of sexual life in adolescents; however, the frequency
of condom use increases significantly when compared to individuals who have not been
through such an intervention [22]. This is also why our programme emphasises the impor-
tance of using a condom as well and why it also contains a practical demonstration of its
use. Another part of the programme is a demonstration of other contraceptive methods,
including hormonal contraception, for which it is always clearly emphasised that they
provide protection only against unwanted pregnancy but not against HIV and STDs.

This may also be the reason preventive programmes encouraging only sexual absti-
nence have been lately criticised as ineffective and, in addition, principally not promoting
the strategy of safer sex in the sense of STDs prevention (use of condoms) and protection
against unwanted pregnancy (use of condoms and other methods of contraception). This
criticism is also supported by the findings of a previous study on the effectiveness of
interventions aimed solely at sexual abstinence as prevention of HIV infection, which
concluded that such programmes are ineffective. The results did not show that these pro-
grammes reduce the risk of HIV infection; moreover, these programmes failed to influence
the incidence of unprotected vaginal sex, frequency of vaginal sex, number of partners,
sexual initiation, or use of condoms [23].

Thus, it is clearly apparent that it is more effective to lead adolescents towards re-
sponsible sexual behaviour than trying to force them into sexual abstinence as the only
means of prevention. This is also indicated by the meta-analysis published in 2011, which
concentrated directly on interventions intended to reduce the sexual risks of HIV infec-
tion in adolescents. A total of 98 interventions from 67 studies were included in this
meta-analysis; these were completed in total by 51,240 adolescents aged 11–19 years. The
findings show that the incidence of sexually transmitted diseases decreased among those
who completed the education when compared with controls; additional results included
more frequent use of condoms, delaying sexual intercourse or decreasing its frequency,
and upgrading the skills required for applying the principles of safe sex and obtaining
prophylactic protection [24].

Another study performed in Tanzania investigated the degree to which education
based on games and gamification (i.e., using gaming elements and principles in education)
could improve the education of adolescent students on sexual health when compared
with the traditional style of education. A total of 120 students from secondary schools
took part in the programme. The average score after completing the test for education
based on games and gamification, which reached 79% in both these educational methods,
was significantly higher than in the control group, where it reached only 51%. This study
suggests that the investigated innovative approaches to education may improve education
on sexual health in the adolescent population. These methods may potentially contribute,
in particular, to improving behaviour in the area of sexual health and increasing the
knowledge of adolescents, especially in contexts where discussions concerning sexual
problems present a taboo [25]. This is also why involving gaming elements is used in
our programme—the intention is to increase the attractiveness of the programme and to
eliminate possible shame and shyness in the participants.

Should we consider the generalisability of the results, it is likely that a similar effect in
the form of improving the participants’ knowledge could also be observed in the target
age group of 13–19-year-olds in other regions of the Czech Republic. Possible use of
the programme in other countries clearly depends on the contents of the educational
programmes at schools in individual countries, especially the inclusion of subjects similar
to the Health Education subject taught in the Czech Republic. However, this subject is
taught at schools for one year only and, considering the answers to some questions in
the questionnaire, it is possible to claim that the problems of HIV and STDs are not given
sufficient attention in the course of standard school education. Similar findings were also
observed in the questionnaire survey performed by the National Institute of Public Health

Int. J. Environ. Res. Public Health 2021, 18, 6148 9 of 12

in 2015, which revealed that adolescents are not sufficiently educated in this area and that
more attention needs to be paid to these topics in the future [26]. According to another
study from 2014, school educational programmes about HIV/AIDs are an important and
effective means of influencing the knowledge, attitudes, and behaviour of young people
regarding health issues related to sex. The study showed that educational programmes
about HIV/AIDS at schools may effectively reduce the risky behaviour of young people.
The authors also propose that education in the area of HIV/AIDS prevention should ideally
start before puberty, or, at the latest, before the first sexual intercourse [15]. We also tend to
support this conclusion, considering the highest effectiveness observed in the youngest
age group of our programme.

The PaSTDs programme should be based on the principle of double transmission of
information—the first time during the educational lecture, and the second time during the
game. In addition, the effectiveness is also supported by the initial questionnaire before
the programme as students who did not know answers to individual test questions were
more likely to extract the answers from the given lecture.

Limitations: The greatest limitation of this programme may be the fact that it rep-
resents a one-off intervention only and there is no further monitoring, for example, of
the length of knowledge persistence, or of possible effects on the future risky behaviour
of the participants. However, these drawbacks are mainly caused by a lack of financial
means invested in the area of prevention and, in our case, also the limited staffing of the
programme. The first and greatest obstacle in the implementation of the programme was
the lack of interest in the programme at some schools. We propose performing a repeated
intervention in the already educated pupils in order to discover whether the knowledge
persists on a long-term basis. The programme is currently interrupted due to the complete
closure of schools in the Czech Republic caused by the coronavirus pandemic; nevertheless,
we expect it to continue when the situation permits.

5. Conclusions

Taking into consideration the presented results, it is possible to conclude that the
programme leads to increased knowledge in the participants and, as such, can be considered
an effective tool of primary prevention in the sense of increasing awareness about the
problem of HIV and STDs by 15.5% on average (from 74.0% to 89.5%).

The programme was observed to be more effective in lower age categories (the score in
the age group of 13–14-year-olds improved by 17.92%). Evaluation of knowledge according
to sex (M/F) shows that girls achieved a higher success rate of answers before education
and, at the same time, manifested a higher increase in knowledge after education than boys.

The participating students showed great sympathy with the educational programme;
their interest in this problem corresponds to a significant increase in knowledge observed
especially among the youngest participants. This is also why we propose to focus further
interventions, in particular, on this youngest age group of 13–14-year-olds.

Author Contributions: Conceptualisation, P.M. and H.T.; methodology, P.M. and H.T.; software,
H.T.; validation, P.M. and H.T.; formal analysis, H.T.; investigation, P.M., H.T., A.Š., M.S., and M.P.;
resources, P.M.; data curation, H.T.; writing—original draft preparation, M.S.; writing—review
and editing, P.M. and H.T.; visualisation, P.M.; supervision, I.T. and R.M.; project administration,
P.M.; funding acquisition, R.M. All authors have read and agreed to the published version of
the manuscript.

Funding: This research was funded by a specific university research grant by the University of
Ostrava No. SGS06/LF/2020, with the support of the HIV/AIDS Counseling Center project of Public
Health Institute Ostrava and RBP, a health insurance company in the Czech Republic.

Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki and approved by the Ethics Committee of the Faculty of Medicine of the
University of Ostrava on the basis of the EC Consent Opinion No. 04/2020.

Int. J. Environ. Res. Public Health 2021, 18, 6148 10 of 12

Informed Consent Statement: Informed consent was obtained from all subjects involved in the
study. Written informed consent has been obtained from the participants to publish this paper.

Data Availability Statement: The data presented in this study are available on request from the
corresponding author. The data are not publicly available due to their quantum.

Conflicts of Interest: The authors declare no conflict of interest. The funders had no role in the design
of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or
in the decision to publish the results.

Appendix A

The programme description: The programme was implemented directly in individual
schools and classes, where the data were also collected.

The input questionnaire, with a unique ID, is distributed among the students prior
to the implementation of the educational programme; the aim of this questionnaire is to
reveal knowledge on HIV-related issues before education. The questionnaire contains
12 questions, the first 2 of which identify basic data regarding the respondent—sex and
age. The student subsequently answers test questions pertaining to sexually transmitted
diseases, choosing from multiple-choice options, which are always supplemented with
the answer “I do not know”. Two questions in the questionnaire were changed during
data collection.

The list of the test questions and their maximum scoring points are detailed in the
table below:

Table A1. The list of the test questions.

1. What is HIV? (1 point)

2. Which disease is caused by HIV? (1 point)
3. HIV modes of transmission: (10 points, 1 for each correct answer)

Insect stings or bite; Kissing; From HIV+ mother to child; Sharing a toilet; Sharing needles and syringes;
Blood (transfusion); Hug; Handshake; Sneezing and coughing; Sexual transmission.

4. HIV vaccination does/does not exist. (1 point)
5. Can hormonal contraception prevent HIV? (1 point)
6. Is HIV completely curable? (1 point)
7. In which sex does HIV occur more frequently in the Czech Republic?(1 point)
8. (old) What is a trend in the number of HIV+ in the Czech Republic over the last 10 years? (0 points)
9. (old) Which city has the largest number of HIV+ individuals in the Czech Republic? (0 points)
10. (new) Does a condom provide protection from HIV? (0 points)
11. (new) What is the time interval from a risk contact, after which HIV test is valid? (0 points)
12. Which of the diseases are not STDs? (6 points) Smallpox; Syphilis; Gonorrhoea; Tetanus; AIDS; Measles.

After filling in the input questionnaire, the students complete the programme itself,
which consists of an educational lecture and a game, and takes 2 lessons, i.e., 90 min. The
educational lecture is a presentation bringing information about HIV/AIDS and STDs,
which helps the students with solving tasks during the following educational games. The
lecture starts with an initial question of the lecturer in the form of brainstorming, where
the lecturer asks the students about their first thoughts upon hearing the term “sexually
transmitted diseases”.

The game consists of 8 tasks with various educational tools (magnetic board and
magnetic cards, samples of contraception methods, models of penis for training of condom
handling), supplemented with a discussion, by means of which the students learn about
this topic. In the beginning, the lecturer gives students information about the course of the
game; it is important to put emphasis on the fact that the students should bear in mind
that the game is teamwork-oriented, not single-player with a competitive character.

Students are then divided into equally sized groups, ideally with mixed sexes. After
each accomplished game, the winning group is rewarded with so-called bouncing balls.
The primary aim of using the bouncing balls is to increase the motivation of students to be
active during the game; it is also possible to take the bouncing balls back away from the

Int. J. Environ. Res. Public Health 2021, 18, 6148 11 of 12

students for disruptions during the game, and to award bonus bouncing balls; nevertheless,
the lecturer informs the students that the reward is purely symbolic, and winning the game
is not the most important thing. In cases of extreme disruption of the programme and
non-cooperation (especially in students with behavioural disorders), such students may be
expelled from further participation in the programme.

The students then receive the output questionnaire, which serves to determine the
effectiveness of the programme. It contains questions identical to those in the input
questionnaire, supplemented with the possibility to evaluate the programme on a scale
from 1 to 5 and to add an open comment. After completion of the programme, each student
takes home educational materials and a condom.

References
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(accessed on 18 January 2021).
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(accessed on 12 January 2021).
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(accessed on 10 January 2021).

8. Strniskova, D. Introduction to HIV/AIDS; Palacký University Olomouc: Olomouc, Czech Republic, 2014.
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of HIV-positive pregnant women in the period 1996–2014. Ceska Gynekol. 2016, 81, 177–181. [PubMed]
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16. Ma, Z.Q.; Fisher, M.A.; Kuller, L.H. School-based HIV/AIDS education is associated with reduced risky sexual behaviors and

better grades with gender and race/ethnicity differences. Health Educ. Res. 2014, 29, 330–339. [CrossRef] [PubMed]
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Regional Public Health Authority of Plzeň Region: Prague, Czech Republic, 2015.
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21. Kirby, D.B.; Laris, B.A.; Rolleri, L.A. Sex and HIV education programs: Their impact on sexual behaviors of young people
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22. Oringanje, C.; Meremikwu, M.M.; Eko, H.; Esu, E.; Meremikwu, A.; Ehiri, J.E. Interventions for preventing unintended
pregnancies among adolescents. Cochrane Database Syst. Rev. 2009, 7, CD005215. [CrossRef]

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24. Johnson, B.T.; Scott-Sheldon, L.A.J.; Huedo-Medina, T.B.; Carey, M.P. Interventions to Reduce Sexual Risk for Human Immunod-
eficiency Virus in Adolescents: A Meta-analysis of Trials, 1985–2008. Arch. Pediatr. Adolesc. Med. 2011, 165, 77–84. [CrossRef]
[PubMed]

25. Haruna, H.; Hu, X.; Chu, S.K.W.; Mellecker, R.R.; Gabriel, G.; Ndekao, P.S. Improving Sexual Health Education Programs for
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26. The National Institute of Public Health, Results of a Questionnaire Survey on Teaching HIV/AIDS in Primary Schools and
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11 January 2021).

  • Introduction
  • Materials and Methods
    • Design
    • Measures
    • Data and Variables
    • Data Analysis
    • Ethical Considerations
  • Results
    • Questionnaire Results
    • What Factors Affect Knowledge?
    • Which of These Factors Are Significant?
  • Discussion
  • Conclusions
  • References

JMIR Res Protoc. 2019 Mar; 8(3): e10795.
Published online 2019 Mar 22. doi: 10.2196/10795

PMCID: PMC6450482
PMID: 30900994

Community-Based, Point-of-Care Sexually Transmitted Infection Screening Among High-Risk Adolescents in Los
Angeles and New Orleans: Protocol for a Mixed-Methods Study

Monitoring Editor: Rebecca Schnall, Susannah Allison, Ian Holloway, Brian Mustanski, and Audrey Pettifor

Reviewed by Patricia Dittus and Yamin Jahangir

Chelsea Lee Shannon, Maryann Koussa, MPH, Sung-Jae Lee, PhD, Jasmine Fournier, MS, Sue Ellen Abdalian, MD, Mary Jane Rotheram, PhD,
Jeffrey D Klausner, MD, MPH, and Adolescent Medicine Trials Network CARES Team

Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, United States
Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, CA, United States

Section of Adolescent Medicine, Department of Pediatrics, Tulane University, New Orleans, LA, United States
Jeffrey D Klausner, Division of Infectious Diseases, David Geffen School of Medicine, University of California Los Angeles, 10920 Wilshire Blvd, Suite 350, Los
Angeles, CA,, United States, Phone: 1 310 557 2273, Fax: 1 310 557 3450, Email: [email protected]

Abstract

Background

Sexually transmitted infection (STI) rates are increasing in the United States, with approximately half of new infections occurring
among adolescents aged 15-24 years. Gay, bisexual, and transgender youth (GBTY), homeless youth, and youth with histories of drug
use, mental health disorders, and incarceration are all at uniquely high risk for STIs. However, these adolescents often lack access to
sexual health services.

Objective

This study aims to use point-of-care STI tests in community-based settings to screen for and treat STIs in adolescents.

Methods

We are recruiting 1500 HIV-uninfected youth and 220 HIV-infected youth from homeless shelters, GBTY organizations, and commu-
nity health centers in Los Angeles, California and New Orleans, Louisiana. Study participants will receive STI screening every 4
months for 24 months. STI screening includes rapid HIV, syphilis, Chlamydia trachomatis, Neisseria gonorrhoeae, and Hepatitis C virus
testing. Trained paraprofessionals will conduct all STI testing. When a participant screens positive for an STI, they are either linked to
a partner medical clinic or provided with same-day antibiotic therapy and expedited partner therapy. We will monitor STI prevalence
among study participants as well as point-of-care test performance, linkage to care, and treatment outcomes.

Results

The project was funded in 2016, and enrollment will be completed in 2019. Preliminary data analysis is currently underway.

Conclusions

As STI rates continue to rise, it is important to improve access to screening and treatment services, particularly for high-risk adoles-
cents. In this study, we aim to evaluate the use of point-of-care STI diagnostic tests in community-based organizations. We hope to de-
termine the prevalence of STIs among these adolescents and evaluate the acceptability and feasibility of community-based STI
screening and treatment.

Trial Registration

ClinicalTrials.gov NCT03134833; https://clinicaltrials.gov/ct2/show/NCT03134833

International Registered Report Identifier (IRRID)

DERR1-10.2196/10795

Keywords: sexually transmitted infections, adolescents, point-of-care testing

Introduction

1 2 2 3 3 2

1 #

1

2

3

There are approximately 20 million new sexually transmitted infections (STIs) every year in the United States. Half of these infections
occur among adolescents aged 15-24 years [1]. STI rates have been steadily increasing over the past few years, with adolescent rates
of Chlamydia trachomatis (CT) infection, Neisseria gonorrhoeae (NG) infection, and syphilis infection on the rise (Figure 1) [2,3].

Figure 1

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) infection rates among adolescents from 2007 to 2016.

Adolescents are at particularly high risk for STIs due to a combination of behavioral, biological, and social factors. Behaviorally, ado-
lescents are more likely to engage in higher-risk sexual behaviors such as concurrent partners or sex without a condom. Biologically,
adolescent females are often more susceptible than adult women to contracting an infection if exposed [2,4]. Socially, adolescents of-
ten lack access to sexual health services or do not pursue STI testing due to con�identiality concerns [5].

STI prevalence is highest in the southern and western United States, with black and Latino adolescents at particularly high risk [2].
Social and geographic differences in STI prevalence are likely due to systemic inequalities leading to limited access to sexual health
services and reduced rates of STI screening [6]. The stigma surrounding sexual health may also contribute to reduced screening up-
take. Gay, bisexual male, and transgender female youth are at an increased risk for STIs due to a combination of risk factors, such as
condomless sex, concurrent partners, and sex with older partners [2]. Receptive anal intercourse also has a higher STI transmissibil-
ity than other forms of intercourse. Among gay, bisexual, and transgender youth (GBTY), parental rejection, stigma, discrimination by
peers, and increased stress associated with being a member of a minority, whether that minority status comes from race, ethnicity,
socioeconomic status, or sexual orientation, may increase sexual risk-taking behaviors and STI rates. Finally, several studies have
shown that homelessness, a history of incarceration, and illicit drug use are also associated with increased STI risk in adolescents [7-
9]. Reduced access to sexual health services, high levels of stigma, and increased rates of risk-taking behaviors may all contribute to
lower rates of screening and higher prevalence of STIs in these populations.

It is critical to diagnose and treat adolescent STIs for a number of reasons. Left untreated, many STIs can lead to long-term health
consequences. Bacterial STIs such as CT and NG may lead to reproductive system damage, while syphilis can cause serious neurologi-
cal damage [10-12]. Viral STIs such as human papillomavirus, herpes simplex virus, and hepatitis C virus (HCV) can cause cancer,
genital blisters, and liver failure, respectively [13-15]. Furthermore, STIs increase the risk of acquiring HIV infection 3-fold to 5-fold
[16].

Fortunately, diagnostic tests are available for many STIs. Speci�ically, rapid diagnostic tests create a new opportunity to screen for and
treat STIs in community-based settings previously unequipped to offer testing services [17-19]. As these tests become more readily
available, it is important to understand their effectiveness in diagnosing and treating STIs in high-risk adolescent populations. By un-
derstanding this, we can better evaluate if rapid STI testing in community-based settings may help improve access to sexual health
services, reduce stigma, and prevent con�identiality concerns among key high-risk populations.

In this component of the Comprehensive Adolescent Research and Engagement Studies (CARES), part of the Adolescent Medicine
Trials Network (ATN) for the HIV/AIDS Interventions Research Program Grant (National Institutes of Health grant U19HD089886),
we aim to evaluate the use of rapid STI testing among adolescents at community-based organizations in Los Angeles, California and
New Orleans, Louisiana. Rapid STI testing will be administered to 1500 high-risk HIV-uninfected youth and 220 HIV-infected youth
every 4 months over the course of 2 years. We will monitor STI prevalence, acceptability and feasibility of rapid diagnostic STI test-
ing, and STI treatment outcomes.

Methods

Objectives

We are conducting rapid HIV, CT, NG, syphilis, and HCV testing among adolescents aged 15-24 years at community-based organiza-
tions in Los Angeles and New Orleans. Our partner community-based organizations cater to GBTY, homeless youth, youth with a his-
tory of mental health disorders, and youth with a history of incarceration. Study participants receive STI testing at 4-month intervals
for 24 months, totaling 1 baseline visit and 6 follow-up visits. When a participant receives a positive STI test result, they are linked to
care at a nearby medical clinic or provided with antibiotic treatment by the interviewing staff. We hypothesize that by providing rapid
STI testing among high-risk adolescent populations, we will �ind STI prevalences higher than the national averages for adolescents.

We intend to evaluate the acceptability of testing as the uptake of screening among eligible participants, and we intend to evaluate the
feasibility of treatment as the proportion of participants who test positive for an STI and receive treatment. We expect that by provid-
ing same-day testing results and treatment, we will be able to provide quicker time to treatment and higher treatment rates than with
traditional lab-based testing. We will compare our time to treatment and treatment rates with historical data from AIDS Healthcare
Foundation, Los Angeles. We also intend to evaluate other treatment outcomes such as cure rates, reinfection rates, and partner
treatment rates. For objectives of other components of the ATN CARES study, refer to other ATN CARES protocol papers [20-24]. For
speci�ic power analyses, refer to the ATN CARES paper by Swendeman et al [22].

Research Ethics and Approval

The Institutional Review Board of the University of California, Los Angeles has approved the study protocol (16-001674-AM-00006).
We will report any protocol deviations or indications of adverse events to the Institutional Review Board. The study was registered
on ClinicalTrials.gov (NCT03134833) on April 28, 2017.

Sexually Transmitted Infection Tests

We selected rapid STI tests according to performance, availability, and cost. Table 1 shows the sensitivity and speci�icity values of
each test.

Table 1

Sensitivities and speci�icities of sexually transmitted infection rapid diagnostic tests.

Test name Sensitivity (%) Speci�icity (%

Determine HIV-1/2 Ag/Ab Combo [25] 99.9 99.8

Xpert HIV-1 Qual [26] 98.7 99.9

Syphilis Health Check [27] 71.4 91.5

Hepatitis C Virus Rapid Antibody Test [28] 99.9 99.9

Xpert CT /NG Assay [29]

Vaginal swabs

CT 99.5 99.1

NG 99.9 99.9

Urine

CT 98.5 99.8

NG 98.3 99.9

CT: Chlamydia trachomatis.
NG: Neisseria gonorrhoeae.

HIV antigen and antibody screening are done using the Determine HIV-1/2 Ag/Ab Combo test (Alere Inc) (Figure 2) [30]. This test is
a point-of-care lateral �low strip that detects both HIV-1 and HIV-2 antibodies and the HIV-1 p24 antigen using 50 µL of �ingerstick
whole blood. The window period is 12-26 days, and results are ready in 20-40 minutes. The test is Clinical Laboratory Improvement
Amendments (CLIA) waived and Food and Drug Administration (FDA) approved [25,31].

Figure 2

Determine HIV-1/2 Ag/Ab Combo test.

We will perform HIV RNA and DNA screening with the Xpert HIV-1 Qual test (Cepheid) (Figure 3) [32]. The test is a point-of-care
qualitative in vitro HIV test, detecting HIV-1 RNA and DNA. The HIV-1 Qual test requires 100 µL of whole blood, and results are avail-
able in 90 minutes [26]. The test is approved for use in the European Union and undergoing the approval process with the FDA. Our
study is the �irst in the United States to use the test, and results are available as research use only.

a b

a

b

Figure 3

GeneXpert machine used for HIV-1 Qual and CT/NG tests.

The HIV-1 Qual test can detect HIV infection an average of 5 days earlier than a p24 antigen test. Therefore, this test is done to detect
acute HIV infections that we may not be able to detect with the Alere HIV test.

Syphilis screening is done using the Syphilis Health Check, a rapid point-of-care treponemal antibody test (Diagnostics Direct) (
Figure 4) [33]. The test uses 50 µL of whole blood, and results are available in 10 minutes. The Syphilis Health Check is the only FDA-
approved rapid syphilis test [27].

Figure 4

Syphilis Health Check test.

We will perform HCV screening with the HCV Rapid Antibody Test (OraSure Technologies), a rapid point-of-care assay used for the
detection of HCV antibodies (Figure 5) [34]. The test uses whole blood and gives results in 20-40 minutes. The test has a waiver from
the CLIA and is approved by the FDA [28].

Figure 5

HCV Rapid Antibody Test.

Finally, we will perform CT and NG screening using the Xpert CT/NG Assay (Cepheid) (Figure 3). The test is a qualitative in vitro real-
time polymerase chain reaction test for the detection of CT and NG. Results are available in 90 minutes [29]. The test is FDA ap-
proved for urine samples and vaginal swabs. However, it is also veri�ied in accordance with CLIA for pharyngeal and rectal swabs

[35]. Male participants self-collect pharyngeal and rectal swabs as well as a urine sample, while female participants self-collect pha-
ryngeal, rectal, and vaginal swabs.

Training

Interviewing staff conducts all STI and HIV rapid testing at community-based recruitment sites. Interviewers are typically Bachelor of
Arts-level paraprofessionals with little prior experience related to rapid diagnostic testing. Some have previously received phle-
botomy training, but most receive phlebotomy training upon hiring. Interviewers receive training and certi�ication in state-speci�ic
HIV counselor training. HIV counselor training includes training on �ingerpricking, conducting different types of rapid HIV tests, in-
terpreting results, and providing counseling regarding safe sex practices. We also coordinate speci�ic training in Los Angeles and
New Orleans for each diagnostic test. The respective diagnostic test companies (Alere, Cepheid, Diagnostics Direct, and OraSure) con-
duct the training. We evaluate interviewers on their ability to properly collect �ingerprick blood and on their ability to correctly inter-
pret test results. We conduct repeat diagnostic test training every 6 months to ensure interviewers continue to correctly perform
tests. A binder with step-by-step test instructions is at every site in case any questions arise.

We also train interviewers on how to instruct participants to self-collect rectal swabs, pharyngeal swabs, vaginal swabs, and urine
samples. For rectal swabs, we provide an image to show the acceptable level of fecal contamination on the swab (Figure 6).

Figure 6

Instructions for self-collected rectal swabs. CT: Chlamydia trachomatis; NG: Neisseria gonorrhoeae.

Interviewers use Fleshlite (Austin) models to demonstrate how to self-collect vaginal and rectal swabs (Figures 7 and 8) [36], while
they use a mirror to locate the tonsils and demonstrate how to self-collect a pharyngeal swab.

Figure 7

Vaginal Fleshlite used to demonstrate how to self-collect vaginal swabs.

Figure 8

Anal Fleshlite used to demonstrate how to self-collect rectal swabs.

Finally, we train interviewers on how to administer treatment for CT and NG infections. A physician prescribes the antibiotics, and in-
terviewers are trained by the physician on how to properly deliver antibiotic therapy. Training includes information about antibiotic
mechanisms, pharmacokinetics, potential adverse effects, partner therapy, retesting, and STI counseling. Interviewers practice provid-
ing treatment using sample scenarios to demonstrate competence.

Testing Flow

While we perform HIV, CT, NG, and syphilis testing at every recruitment site, we only perform HCV testing at sites with populations at
higher risk of HCV (history of incarceration or drug use). Every study participant receives every STI test unless they speci�ically
choose to opt out. Opting out does not affect eligibility or reimbursement.

At baseline, the rapid HIV test is done as part of the eligibility screening to determine if the participant is HIV-infected or -uninfected.
We determine eligibility based on a risk assessment, with a minimum risk score necessary for enrollment. Inclusion criteria and risk
scoring are explained in detail in the ATN CARES protocol papers by Rotheram-Borus et al and Comulada et al [21,24]. If a partici-
pant is eligible for the study, they are enrolled and receive the additional STI testing. An interviewer with phlebotomy certi�ication
draws blood for use in the HIV RNA/DNA test, the syphilis test, and the HCV test at certain sites. The participant self-collects their
urine sample or pharyngeal, rectal, and vaginal swabs. Clients are encouraged to stay until their test results are available.

Routine follow-up appointments occur at 4-month intervals for 2 years. However, if a patient reports potential STI exposure or STI
symptoms to the interviewer, they will be invited for testing at any point during the study.

Linkage to Care, Treatment, and Partner Management

Participants receive their test results on the same day as the testing. Whenever possible, they are told the results in person. If the
participant needs to leave their appointment before results are available, the interviewer asks the participant how they would like to
receive the results and then communicates the results with them through a phone call, text, or email. When a patient receives a posi-
tive test result, they are either referred to a partner medical clinic or to their primary care provider to receive treatment, or they are
provided with treatment by the interviewing staff. All partner medical clinics agreed to and signed an STI treatment protocol that is in
accordance with Centers for Disease Control and Prevention recommendations.

If the participant elects to seek treatment at a clinic, the interviewer works with the participant to �ind a clinic that is geographically
convenient, and the study organizes free transport to the clinic via the Uber app. Interviewers counsel participants on the impor-
tance of partner treatment and safe sex practices. They also follow up with study participants to ensure they were able to receive
treatment, and study staff obtains records of the treatment from the clinic.

For syphilis infections, we will always refer the participant to a clinical provider since follow-up blood work and a penicillin injection
may be required. For CT and NG infections, it is up to the participant if they prefer to be referred to a clinic or receive same-day an-
tibiotic treatment from the interviewing staff. The interviewers treat vaginal, urethral, and pharyngeal CT infections with 1 g oral
azithromycin [1]. They treat rectal CT infections with 100 mg oral doxycycline twice daily for 7 days, as evidence shows doxycycline is
more effective than azithromycin in treating rectal CT [37-40]. NG infection, while often clinically treated with 1 g oral azithromycin
and an injection of 250 mg ceftriaxone, is instead treated with 1 g oral azithromycin and 400 mg oral ce�ixime [1]. The treatment of
concurrent CT and NG infections are according to the type of CT infection. If there is a vaginal, urethral, or pharyngeal CT infection in
addition to an NG infection, treatment is 1 g oral azithromycin and 400 mg oral ce�ixime. If there is a rectal CT infection in addition to
an NG infection, treatment is 100 mg oral doxycycline twice daily for 7 days and 400 mg oral ce�ixime. All treatment regimens follow
Centers for Disease Control and Prevention guidelines and are effective treatment methods.

We prepackage treatment packs that include antibiotic instructions, antibiotics, physician contact information, water, and a snack.
Every recruitment site has these treatment packs available. We also offer participants with a positive CT or NG result up to 10 expe-
dited partner therapy packets according to the number of partners reported in the past 90 days [41]. We provide the expedited part-
ner therapy packs according to the type of infection participants test positive for as well as the type of sex they report having with
their partner. For example, if a participant tests positive for urethral CT and reports insertive anal sex, we will provide doxycycline in
the expedited partner therapy pack.

Quality Control

The study team monitors STI prevalence to ensure that it falls within the expected range. A research assistant performs monthly
quality control testing at every testing site to con�irm that all tests are functioning properly. Monthly quality control testing involves
running a positive and negative control sample for each rapid STI test at each site. This ensures that the tests correctly identify both
positive and negative results. In addition to every month, we perform quality control testing whenever a new interviewer is conduct-
ing the tests, a new test lot number is received, or if the storage temperature falls outside the recommended range.

Data Collection and Analysis

Interviewing staff record STI lab results on a paper lab form as well as through CommCare, a mobile data collection platform created
by Dimagi (Cambridge). We then obtain the documentation of STI treatment from the medical clinics.

Using these data, we will evaluate STI prevalence, risk factors, and HIV seroconversion rates throughout the study period. We will
also evaluate successful linkage to care and treatment of positive STI cases.

Moving Forward

At the time of manuscript submission, we are in the process of making one change to our study protocol. Due to the high prevalence
of a history of syphilis in our study population and the low speci�icity of the Syphilis Health Check, a participant with a positive
Syphilis Health Check result requires additional laboratory testing. Therefore, we will obtain rapid plasma reagin titers and
Treponema pallidum particle agglutination testing when a participant has a reactive Syphilis Health Check result. Quest Diagnostics
will perform the rapid plasma reagin and Treponema pallidum particle agglutination tests. We anticipate that this change will signi�i-
cantly improve our ability to properly diagnose syphilis infections.

Results

The project was funded in 2016, and enrollment will be completed in 2019. Preliminary data analysis is currently under way.

Discussion

As STI prevalence in the United States continues to rise, it is critical to improve access to STI screening and treatment. This means im-
proving the availability of acceptable and feasible screening methods, particularly for our country’s highest risk populations. In this
study, we use point-of-care rapid diagnostic STI tests to screen adolescents for HIV, CT/NG, syphilis, and HCV. We are recruiting and
enrolling participants at local community-based organizations in Los Angeles and New Orleans that cater to homeless youth and
GBTY as well as youth with histories of drug use, mental health disorders, and incarceration. By targeting that traditionally tough-to-
reach, high-risk group, we hope to determine the prevalence of STIs in the population and demonstrate the acceptability and feasibil-
ity of rapid STI testing and treatment programs in community-based settings.

A limitation of our study is that we are not evaluating cost-effectiveness. The GeneXpert machines used in our study were provided
by the manufacturer as part of the Xpert CT/NG and Xpert HIV-1 Qual cartridge purchase agreement. While the machines themselves
are expensive, they are cheaper than commercial laboratories. Moving forward, it would be advantageous to evaluate the cost-effec-
tiveness of rapid STI testing in community-based settings.

Acknowledgments

CARES is a program project grant funded by the ATN for the HIV/AIDS Interventions Research Program Grant at the National
Institutes of Health (U19HD089886). The Eunice Kennedy National Institute of Child Health and Human Development is the primary
funder of this network, with the support of the National Institute of Mental Health, National Institute on Drug Abuse, and National
Institute on Minority Health and Health Disparities.

The members of Adolescent Medicine Trials Network CARES are M Isabel Fernandez, Leslie Kozina, Manuel Ocasio, W Scott
Comulada, Robert E Weiss, Ronald Brookmeyer, Wenze Tang, Karin Nielsen, Yvonne Bryson, Tara Kerin, Ruth Cortado, Kate Mitchell,
Elizabeth May�ield Arnold, Norweeta Milburn, Dallas Swendeman, Cathy Reback, Marguerita Lightfoot, and Danielle Harris.

Abbreviations

ATN Adolescent Medicine Trials Network

CARES Comprehensive Adolescent Research and Engagement Studies

CLIA Clinical Laboratory Improvement Amendments

CT Chlamydia trachomatis

FDA Food and Drug Administration

GBTY gay, bisexual, and transgender youth

HCV Hepatitis C virus

NG Neisseria gonorrhoeae

STI sexually transmitted infection

Footnotes

Conflicts of Interest: None declared.

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1Sentís A, et al. BMJ Open 2019;9:e027245. doi:10.1136/bmjopen-2018-027245

Open access

Sexually transmitted infections in
young people and factors associated
with HIV coinfection: an observational
study in a large city

Alexis Sentís,  1 Mario Martin-Sanchez,  1,2 Maider Arando,3 Martí Vall,3
María Jesus Barbera,3 Inma Ocaña,3 Ana González Cordón,4 Mercè Alsina,4
Gemma Martin-Ezquerra,5 Hernando Knobel,5 Mercè Gurguí,6 Alvaro Vives,7
Josep Coll,8 Joan Artur Caylà,1,9,10 Patricia Garcia de Olalla,1,9 and STI-HIV group
of Barcelona

To cite: Sentís A, Martin-
Sanchez M, Arando M,
et al. Sexually transmitted
infections in young people and
factors associated with HIV
coinfection: an observational
study in a large city. BMJ Open
2019;9:e027245. doi:10.1136/
bmjopen-2018-027245

► Prepublication history for
this paper is available online.
To view these files, please visit
the journal online (http:// dx. doi.
org/ 10. 1136/ bmjopen- 2018-
027245).

Received 19 October 2018
Revised 9 January 2019
Accepted 27 February 2019

For numbered affiliations see
end of article.

Correspondence to
Dr Patricia Garcia de Olalla;
[email protected] aspb. cat

Research

© Author(s) (or their
employer(s)) 2019. Re-use
permitted under CC BY-NC. No
commercial re-use. See rights
and permissions. Published by
BMJ.

AbstrACt
Objectives Young people are a critical target group
for sexually transmitted infections (STI) surveillance
due to their particular behavioural and social related
vulnerability. The aim of this study was to describe
the epidemiological characteristics and trends in the
incidence of gonorrhoea, syphilis, HIV and venereal
lymphogranuloma (LGV) among 15–24-year-olds in
Barcelona, and to determine factors associated with HIV
coinfection.
Design We performed a population-based incidence study
covering the 2007–2015 period.
Participants All new cases of STI—HIV, gonorrhoea,
infectious syphilis and LGV—notified to the
epidemiological surveillance system in Barcelona between
2007 and 2015. 1218 cases were studied: 84.6% were
men, 19.3% were 15–19 years old and 50.6% were born
in Spain. Among men, 73.7% were men who have sex with
men (MSM); among women, 85.6% were women that have
sex with men.
Primary and secondary outcomes Incidence of HIV,
gonorrhoea, infectious syphilis and LGV. HIV coinfection.
results There was an increase in the incidence of
gonorrhoea, from 1.9 cases per 10 000 people in 2007
to 7.6/10 000 in 2015 (p<0.01), in MSM from 27.1
to 228.8/10 000 (p<0.01). The incidence of syphilis
increased from 0.4/10 000 in 2007 to 3.1/10 000 in
2015 (significant in men only, p<0.01), in MSM from
18.1 to 116.9/10 000 (p<0.01). The incidence of HIV
showed a non-significant increase in men (p=0.27), and
that of LGV remained stable (p=0.59). Factors associated
with increased risk of HIV coinfection included being
MSM (adjusted OR[ORa]=14.14, 95% CI 3.34 to 59.91)
and having >10 sexual partners (ORa=4.11, 95% CI 1.53
to 11.01) or STI diagnosis during the previous 12 months
(ORa=2.06; 95% CI 1.13 to 3.77).
Conclusions The incidence of gonorrhoea and syphilis
among 15–24-year-olds increased, while HIV infection
remained stable but with a high incidence among MSM.
Being MSM, having sex with multiple partners and
having a diagnosis of an STI in the previous 12 months
were factors associated with HIV coinfection.

IntrODuCtIOn
With more than one million acquired infec-
tions per day worldwide, sexually transmitted
infections (STI) remain one of the most
common acute illnesses globally.1 Although
trend data can be influenced by heteroge-
neous reporting and differences between
healthcare systems, during the last decade,
there has been a clear overall increase in the
incidence of Chlamydia trachomatis, gonor-
rhoea, syphilis and venereal lymphogranu-
loma (LGV) in Europe, including Spain.2 3
In contrast, there has been a steady decline
in HIV incidence in recent years.4 5 A recent
study based in Barcelona reported an increase
in the number of STI cases, mainly in men
who had sex with men (MSM) with universi-
ty-level education.6

In 2013 in Europe, young people and
MSM were the most vulnerable groups for

strengths and limitations of this study

► A population-based sexually transmitted infection
(STI) incidence study in young people from a large
city with a robust STI surveillance system. The use
of logistic regression models allowed us to disentan-
gle factors associated with HIV coinfection.

► The inclusion of sociodemographic, clinical and be-
havioural variables permitted a strong description
and analysis of the results.

► For some variables, the proportion of missing values
was high. Nonetheless, we have included a missing
category in all variables, such that all cases are con-
sidered in the models.

► The lack of data about other STI, since they were not
mandatory notification diseases, may mean a loss
of valuable information regarding the analysis of STI
impact in a large city.

2 Sentís A, et al. BMJ Open 2019;9:e027245. doi:10.1136/bmjopen-2018-027245

Open access

STI acquisition. People aged 15–24 years accounted for
two-thirds of all cases of C. trachomatis and 39% of all
cases of gonorrhoea.2 Adolescents and young people
are a critical target group for STI surveillance because
they are vulnerable for various reasons, mostly related
to behaviour and social factors,7 8 and also because many
young people at risk of STI are not properly screened.9 10
Special emphasis must be placed on HIV because STI
carriers have an increased risk of HIV infection11 and
adolescents infected with HIV are more likely to acquire
other STI infections.7 12

The main aim of this study was to describe the epide-
miological characteristics and trends in the incidence
of HIV infection, gonorrhoea, syphilis and LGV among
young people in a large city. In addition, we assessed
whether HIV status was associated with prevalent risk
factors among young people with gonorrhoea, syphilis or
LGV.

MethODs
study design and participants
This is a population-based incidence study of all new
cases of sexually transmitted HIV, gonorrhoea, syph-
ilis and LGV infection notified to the epidemiological
surveillance system in Barcelona city using case defini-
tions established following the European standards.13
The target population was young people aged 15–24 years
who were residents in Barcelona and diagnosed between
January 2007 and December 2015 (total population of
the city on 30 June 2015 was 1 604 550, of which 141.363
(8.8%) were aged 15–24 years14). Cases of congenital, late
latent and tertiary syphilis were excluded from the study,
as were cases of AIDS or cases of HIV infection in intrave-
nous drug user or due to vertical transmission.

Variables
We analysed sociodemographic variables: sex, country
of birth, educational level and age (in two categories,
15–19 and 20–24 years, in line with the most common
uses by Centers for Disease Control and Prevention15 and
WHO1). Clinical variables: STI diagnosis in the previous 12
months and coinfection with HIV. Behavioural variables:
number of sexual partners in the previous 12 months,
use of condom in most recent sexual contact and sexual
behaviour, categorised separately for men and women as
follows. Men (three groups): MSM, including transgender
women and bisexual men; men who have sex with women
only (MSW); and unknown sexual behaviour. Women
(three groups): women who have sex with men (WSM),
including bisexual and heterosexual, women who have
sex with women (WSW) and unknown sexual behaviour.
In the regression models, due to the small numbers of
WSW, we only used one category, ‘women’.

statistical analyses
A descriptive analysis of the epidemiological characteris-
tics of all new cases of STI—HIV, gonorrhoea, syphilis and

LGV infections—was carried out. We calculated annual
incidence rates per 10 000 inhabitants, stratified by sex
and sexual behaviour category. Sex-specific rates were
estimated based on population data from the Barcelona
municipal census for each year of study14; rates for the
various categories of sexual behaviour were estimated
based on data from the 2011 Barcelona Health Interview
Survey.16 Incidence trends were analysed using the χ2 test
for linear trend.

We examined risk factors associated with HIV coinfec-
tion, prevalent HIV cases during the study period, among
persons diagnosed with gonorrhoea, syphilis or LGV. In
persons with more than one STI, only the last diagnosed
event was included. First, we fit bivariate logistic regres-
sion models to assess the association between positive HIV
diagnosis as a dependent variable and each of the poten-
tial risk factors mentioned above. Second, potential risk
factors that showed a statistically significant association
with HIV diagnosis were included in multivariable logistic
regression models, along with variables for education
and country of birth, which are thought to be important
regardless of whether or not they showed a statistically
significant association in the bivariate analysis.6

Odds ratios (OR) and its 95% confidence intervals (CI)
were estimated. All analyses were performed using STATA
(V.13; Stata Corporation, College Station, Texas, USA).

ethical considerations
In Barcelona city, surveillance of obligatory notifiable
diseases is provided by the Barcelona Public Health Agency
(ASPB). In compliance with article 13 of law 67/2010 (25
May 2010) of the Health Department of Generalitat de
Catalunya, nominal notification of cases of gonorrhoea,
syphilis and LGV has been obligatory since 2007. Notifi-
cation of HIV cases was voluntary between 2001 and July
2010, and obligatory and nominal thereafter.17

Data confidentiality and other ethical considerations
were handled according the international recommen-
dations,18 the Helsinki Declaration revised by the World
Medical Organization in Fortaleza in 2013 and Spanish
Law 15/1999 on Data Protection. Patient information was
anonymised and deidentified prior to analysis and there-
fore no informed consent was required.

Patient and public involvement statement
Patients were not directly involved in this study; only data
coming from notifiable disease surveillance systems were
used.

results
sociodemographic, clinical and behavioural characteristics of
the population
This study included 1218 cases of STI, affecting 1139
persons, 187 (15.4%) of the cases were women, 235
(19.3%) were aged 15–19 years and 574 (47.1%) were
born in Spain. Of the 1031 men, 62.1% were MSM and
22.2% were MSW. Of the 187 women, 160 (85.6%) were

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WSM, of whom 15 were bisexual women; two of them
were diagnosed with syphilis, three with gonorrhoea and
ten with HIV.

The most common infection was gonorrhoea (51.9%,
n=632), followed by HIV (25.4%, n=309) and syphilis
(21.8%, n=266), while LGV was the least common infec-
tion with just 11 cases among MSM. Women accounted
for 19.6% of cases of gonorrhoea, 11.7% of syphilis and
10.4% of HIV. The proportion of MSM among HIV cases
was 84.8% (n=235), 71.5% for syphilis and 44.5% gonor-
rhoea (table 1).

Among cases of gonorrhoea and syphilis, men and
women differed in terms of the number of sexual part-
ners (p<0.01), with woman having significantly fewer
partners than men (table 1). Also, for cases of gonor-
rhoea, the younger group (15–19 years) had a higher
proportion of women (36.3%, vs 21.5% for men); women
had lower proportion of university education and had a
higher proportion of condom use (p<0.05) (table 1).

Sixty-two persons presented reinfections during the
study period, resulting in 141 cases (11.6% of the total
number of cases). Of those persons, 50 had two infections,
eight had three, three had four and one person had five
infections. The most common pattern was two consecutive
gonorrhoea infections (affecting 18 persons), followed
by a diagnosis of syphilis and subsequently gonorrhoea
(affecting 10 persons).

Incidence and trends in incidence
The incidence of HIV decreased from 1.6/10 000 in 2007
to 0.5/10 000 in 2015. A non-significant statistical increase
was observed in men (p=0.27). However, in more recent
years, there has been a slightly decreasing tendency in
MSM (141.5 cases per 10 000 people in 2013, and 131.5
in 2015) (figure 1).

The incidence of gonorrhoea increased from
1.9/10 000 in 2007 to 7.6/10 000 in 2015 (p<0.01). This
increase was observed in both men and women (figure 2).
Regarding sexual behaviour, the increase in incidence
of gonorrhoea was statically significant in all three cate-
gories analysed (p<0.01), with higher incidence rates in
MSM (27.1/10 000 in 2007 and 228.8/10 000 in 2015)
(figure 2). The incidence of syphilis increased from
0.4/10 000 in 2007 to 3.1/10 000 in 2015, though this was
only statistically significant in men (p<0.01) (figure 2).
Regarding sexual behaviour, the increase of syphilis was
statistically significant in MSM and MSW (p<0.01), with
higher incidence for MSM (18.1/10 000 in 2007 and
116.9/10 000 in 2015) (figure 2). Finally, the incidence
of LGV remained stable throughout the study period
(p=0.59).

hIV COInfeCtIOn
In the descriptive analysis of the HIV coinfection for
each STI, we observed statistically significant differences
between men and women. Among cases of gonorrhoea
and syphilis, the proportion of HIV coinfection was 7.7%

in men and 1.6% in women (p=0.01) and 16.6% of men
and 0% of women, respectively. Among men, the highest
rate of HIV coinfection was observed among LGV cases
(63.6%).

We also observed statistically significant differences in
the proportion of HIV coinfection in gonorrhoea and
syphilis when stratifying by (1) sexual behaviour (75.6%
and 89.7% of cases of gonorrhoea and syphilis with HIV
coinfection, respectively, were MSM; p<0.01 in both
cases), (2) number of sexual partners the previous 12
months (36.6% and 35.9% of cases of gonorrhoea and
syphilis with HIV coinfection, respectively, had ≥10 sexual
partners; p<0.01 in both cases), (3) STI diagnoses during
the previous 12 months (41.5% and 28.2% of cases of
gonorrhoea and syphilis, respectively, were previously
diagnosed with HIV coinfection, compared with 14.04%
and 12.3% with a non-HIV coinfection; p<0.01 in both
cases). Among cases of gonorrhoea, but not syphilis,
the proportion of HIV coinfection varied significantly
between age categories (90.2% of cases of HIV coinfec-
tion were aged 20–24 years, compared with 74.6% among
cases of non-HIV coinfection). Among cases of syphilis,
the proportion of HIV coinfection varied significantly
according to country of birth (46.1% of cases of HIV coin-
fection were people born in Latin America, compared
with 22% of cases of non-HIV coinfection).

To identify risk factors associated with HIV coinfection,
we analysed only one STI per person as it is mentioned
in methods. 830 patients with gonorrhoea, syphilis or
LGV were included and we found that the following vari-
able categories were associated with increased risk of HIV
coinfection: being MSM (ORa: 14.14, 95% CI 3.34 to
59.91), having ≥10 sexual partners during the previous 12
months (ORa=4.11, 95% CI 1.53 to 11.01) and having a
previous diagnosis of STI during the previous 12 months
(ORa=2.06; 95% CI 1.13 to 3.77) (table 2).

DIsCussIOn
In this study of people aged 15–24 years residing in
Barcelona city, we observed a significant increase in
the incidence of gonorrhoea and syphilis in men, espe-
cially in MSM, and of gonorrhoea in women. In young
people, being MSM, having 10 or more sexual partners
or a previous diagnosis of STIs during the previous year
showed an increased risk of HIV coinfection.

Previous studies have found that new STI diagnoses in
15–24-year-olds account for half of all new cases of STI
in the USA,7 and more than a half of those worldwide,19
even though this age group represents only ~25% of the
sexually active population.7 15 In Europe, this group of
people account for 5%, 13% and 35% of all reported
cases of LGV, syphilis and gonorrhoea, respectively.20–22 In
Barcelona, this proportion was 3%, 8% and 18%, respec-
tively.23 Usually, higher STI rates have been described in
large cities or urban areas where vulnerable populations
are found more concentrated.24 25

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Table 1 Distribution of sociodemographic, clinical and behavioural characteristics in cases of HIV, gonorrhoea, syphilis or
venereal lymphogranuloma (LGV) in 15–24-year-olds in Barcelona, 2007–2015

HIV Gonorrhoea Syphilis LGV

Men Women Men Women Men Women Men

N (%) N (%) N (%) N (%) N (%) N (%) N (%)

Total cases 277 (100) 32 (100) 508 (100) 124 (100) 235 (100) 31 (100) 11 (100)

Age group

15–19 36 (13.0) 7 (21.9) 109 (21.5) 45 (36.3) 31 (13.2) 6 (19.4) 1 (9.1)

20–24 241 (87.0) 25 (78.1) 399 (78.5) 79 (63.7) 204 (86.8) 25 (80.6) 10 (90.9)

Education level

University 35 (12.6) 1 (3.1) 83 (16.3) 13 (10.5) 35 (14.9) 7 (22.6) 3 (9.1)

Secondary 118 (42.6) 11 (34.4) 131 (25.8) 44 (35.5) 63 (26.8) 10 (32.3) 7 (63.6)

Primary or less 25 (9.0) 7 (21.9) 64 (12.6) 25 (20.2) 57 (24.3) 7 (22.6) 1 (9.1)

Missing 99 (35.7) 13 (40.6) 230 (45.3) 42 (33.9) 80 (34.0) 7 (22.69 0

Country of birth

Spain 129 (46.6) 8 (25.0) 249 (49.0) 59 (47.6) 113 (48.1) 10 (32.3) 6 (54.5)

Western countries* 15 (5.4) 0 46 (9.1) 7 (5.7) 18 (7.7) 0 1 (9.1)

Latin America 104 (37.6) 15 (46.9) 129 (25.4) 34 (27.4) 58 (24.7) 10 (32.3) 4 (36.4)

Eastern Europe 10 (3.6) 2 (6.3) 15 (2.9) 7 (5.7) 7 (3.0) 5 (16.1) 0

Other 18 (6.5) 7 (21.9) 24 (4.7) 2 (1.6) 19 (8.1) 4 (12.9) 0

Missing 1 (0.4) 0 45 (8.9) 15 (12.1) 20 (8.5) 2 (6.5) 0

Sexual behaviour

MSW 32 (11.6) na 160 (31.5) na 37 (15.7) na 0

MSM 235 (84.8) na 226 (44.5) na 168 (71.5) na 11 (100)

WSM na 32 (100)† na 105 (84.7)‡ na 23 (74.2)§ na

Missing 10 (3.6) 0 122 (24.0) 19 (15.3) 30 (12.8) 8 (25.8) 0

STI diagnoses in the previous 12 months

No 251 (90.6) 31 (96.9) 427 (84.0) 105 (84.7) 199 (84.7) 28 (90.3) 6 (54.5)

Yes 26 (9.4) 1 (3.1) 81 (15.9) 19 (15.3) 36 (15.3) 3 (9.7) 5 (45.5)

Number of sexual partners in the previous 12 months

1 to 3 na na 107 (21.1) 60 (48.4) 36 (15.3) 12 (38.7) 1 (9.1)

4 to 6 na na 39 (7.7) 11 (8.9) 14 (6.0) 0 0

7 to 10 na na 29 (5.7) 6 (4.8) 25 (10.6) 2 (6.5) 1 (9.1)

>10 na na 69 (13.6) 3 (2.4) 44 (18.7) 0 (0.0) 6 (54.6)

Missing na na 264 (52.0) 44 (35.5) 116 (49.4) 17 (54,8) 3 (27.3)

HIV coinfection

No na na 469 (92.3) 122 (98.4) 196 (83.4) 31 (100) 4 (36.4)

Yes na na 39 (7.7) 2 (1.6) 39 (16.6) 0 7 (63.6)

Condom use

Yes na na 73 (14.4) 29 (23.4) 47 (20.0) 4 (12.9) 3 (27.3)

No na na 253 (49.8) 67 (54,0) 103 (43.8) 13 (41.9) 7 (63.6)

Missing na na 182 (35.8) 28 (22.6) 85 (36.2) 14 (45.2) 1 (9.1)

*Western countries: Western Europe, USA, Canada and Australia.
†10 women were bisexual.
‡Three women were bisexual.
§Two women were bisexual.
na, not applicable; MSM, men that have sex with men; MSW, men that have sex only with women; STI, sexually transmitted infection; WSM,
women who have sex with men.

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To our knowledge, few studies have analysed trends in
the incidence of STIs in 15–24-year-olds. For instance,
in recent years, it has been observed an increase in the
incidence of cases of STI among people under 20 years
old in Ireland26 and in 15–24-years old in the UK.24 27
In this study, we observed an increase in the incidence
in 15–24-year-olds in Barcelona. We want to remark that,
although there was not any massive campaign or specific
community project to increase STI detection or notifi-
cation in Barcelona, the recent introduction of PCR for
gonorrhea diagnosis may have improved the surveillance
system sensitivity. Besides, STI surveillance has been a
priority for ASPB even before 2007 when gonorrhoea,

syphilis and LGV were declared mandatory notifiable
diseases in Catalonia.17 In spite of this, we believe that last
year’s observed increase specifically in Spain but also in
all the European region,2 26 mostly in large cities, is likely
to be a real increase on the incidence and not only due
because of an improvement on the surveillance system
sensitivity or other related issues.

Moreover, the incidence of STI was higher among
women,9 28 MSM19 29 and younger people, highlighting
them as especially vulnerable populations. Our results
show that MSM are a risk group for the STIs analysed,
mainly for HIV, syphilis and LGV. In fact, we found
that young MSM sometimes show up to 20-fold higher

Figure 1 Incidence in people between 15 and 24 years of: HIV in MSM (men who had sex with men) (a), MSW (men who have
sex with women only) (b) and in women (b) per 10 000 MSM/MSW/women. The dashed line indicates that HIV cases were
subject to voluntary notification from 2007 to 2009, and obligatory and nominal notification thereafter.

Figure 2 Incidence  in people between 15 and 24 years of:  gonorrhoea and syphilis in men who had sex with men (MSM)
(a,c), men who have sex with women only (MSW) (b,d) and in women (b,d) per 10 000 MSM/MSW/women.

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increase in incidence and magnitude than MSW or
women. Several studies indicate a low incidence of gonor-
rhoea observed among women due to the difficulties to
reach them.9 28 30 Despite this, we also found that, among
women diagnosed with gonorrhoea, the proportion of
15–19-year-olds was approximately 50% higher than
that among men. In fact, we found that the incidence of
gonorrhoea differed between men and women according
to educational level, which may be due to the younger
age of the female cases. These observations underline the
need to put special emphasis and efforts in the youngest
women. The increasing trends may also be partly due
to improved coverage of epidemiological surveillance
programmes, and the broader availability of more sensi-
tive diagnostic tests.20–22

We stress the importance of improving programmes
and interventions targeting STIs in young people. In
some countries, STIs are mainly detected by general
practitioners; however, specialised STI centres31 have
been shown to be more effective in diagnosing STI such
as chlamydia, gonorrhoea and syphilis, especially among
young men. In Barcelona in recent years, specialised STI
centres have diagnosed approximately 40% of all cases of
gonorrhoea (unpublished data).

Given the higher risk of HIV coinfection among young
MSM also observed in the multivariate analysis and the
reported increase in incidence of syphilis and gonor-
rhoea also in young MSM, we must remain alert to a
possible increase in the incidence of HIV in this group;
but as in other studies and reports,4 our HIV results
cannot corroborate this possibility at present. In fact, our
results show a statistically non-significant decrease in inci-
dence of HIV in MSM in the last few years. Moreover, HIV
carriers are vulnerable to new STIs, especially MSM,32
young people7 12 and those who had a previous history
of STI.32 Also, the greater risk associated with a higher
number of sexual partners found in the multivariate anal-
ysis is consistent with previous reports.7 26 In light of our
results, young MSM as well as young people with a high
number of sexual partners or a previous diagnosis of STIs
have a higher risk of acquiring HIV, which could make
them potential candidates for HIV Pre-Exposure Prophy-
laxis (PrEP). The use of PrEP along with promotion of
condom use and adherence support could be considered
in young people in specific situations as some guidelines
are already recommending.33

A limitation of our study is that, for some variables,
the proportion of missing values was high. Nonetheless,
we have included a missing category in all variables, such
that all cases are considered in the models, allowing us to
disentangle the direction and magnitude of association
with HIV coinfection for the missing category. Also, we
have to mention that we could not study chlamydial infec-
tion since, in Barcelona, this infection, probably the most
frequent in young people, has been nominal notifiable
since 2016.

We also stress the importance of continued efforts to
develop effective interventions for STI prevention and
control among young people. Screening programmes,
brief behavioural counselling and partner notification
often work well, depending on the setting where they
are implemented, which is an important factor when
designing such interventions.34

In conclusion, the incidence of gonorrhoea and syph-
ilis among 15–24-year-olds has increased in Barcelona
in recent years, especially in MSM, while HIV infection
remains stable but with a high incidence among MSM.
Factors related to specific behaviours that are more
common among younger people, such as having sex with
multiple partners and incorrect condom use,7 15 19 and
added to a deficient screening for some STIs9 10 may lead
eventually to an increase in HIV incidence. Our results
show that previous diagnosis of a STI, sexual behaviour

Table 2 Associated factors to HIV coinfection in
15–24-year-old patients diagnosed of gonorrhoea, syphilis
or venereal lymphogranuloma in Barcelona (N=830)

Variables ORa* 95% CI

Age

Each more 1 year 1.13 0.96 to 1.28

Education

Secondary or university 1.00

Primary or less 1.03 0.47 to 2.26

Missing 0.95 0.49 to 1.84

Country of birth

Spain 1.00

Not Spain 1.37 0.79 to 2.38

Missing 1.01 0.35 to 2.90

Sexual behaviour

MSW 1.00

MSM 14.14 3.34 to 59.91

Missing (men) 4.91 0.96 to 25.13

Women 1.40 0.19 to 10.12

STI diagnoses in the previous 12 months

No 1.00

Yes 2.06 1.13 to 3.77

Number of sexual partners in the previous 12 months

One to three 1.00

Four to six 1.33 0.34 to 5.16

Seven to ten 0.89 0.21 to 3.84

>10 4.11 1.53 to 11.01

Missing 2.33 0.89 to 6.10

*This model was adjusted for all the listed variables in the table:
Age, education, country of birth, sexual behaviour, previous 12
months STI diagnoses and number of sexual partners (last 12
months).
MSM, men who have sex with men; MSW, men who have sex with
women only; ORa, adjusted odds ratio ; STI, sexually transmitted
infection.

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and number of sexual partners are good predictors of
HIV coinfection among young people diagnosed of
gonorrhoea, syphilis or LGV that allow identifying them
to refer for intervention. Implementing and improving
STI/HIV prevention and control programmes that
reduce STI in young people are needed to avert future
STI and HIV acquisition, especially targeting the most
vulnerable persons.

Author affiliations
1Epidemiology Service, Public Health Agency of Barcelona (ASPB), Barcelona, Spain
2Preventive Medicine and Public Health Training Unit PSMar-UPF-ASPB (Parc de
Salut Mar – Pompeu Fabra University – Agència de Salut Pública de Barcelona),
Barcelona, Spain
3Hospital de la Vall d’Hebron, Universitat Autònoma de Barcelona, Spain
4Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, Spain
5Hospital del Mar, Universitat Autonòma de Barcelona, Barcelona, Spain
6Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona,
Barcelona, Spain
7Hospital Puigvert, Universitat Autònoma de Barcelona, Spain
8Hospital Tries i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona,
Spain
9CIBER Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
10Foundation of Tuberculosis Research Unit of Barcelona, Spain

Acknowledgements We thank all the reporting physicians who have contributed
to the collection and quality of the information in the surveys. The Spanish Society
of Epidemiology (SEE) for rewarding with ‘VII Premio Emilio Perea’ the work that
gave rise to this article as the second best oral senior communication in the SEE
Congress held in Barcelona in September 2017.

Collaborators STI-HIV group of Barcelona: ASPB (Cristina Rius, Sonia Gil, Pilar
Gorrindo, Roser Clos, Raquel Sánchez, Miriam Ros, Eva Masdeu, Pere Simon, Maria
Jose Santomà), Hospital de la Vall d’Hebron (Pere Armengol, Adrià Curran, Esteve
Ribera, Vicenç Falcó), Hospital de la Santa Creu i Sant Pau (Maria Gracia Mateo, M
Mar Gutierrez, Pere Domingo, Joaquin López-Contreras), Hospital del Mar (Judit
Villar, Ana Guelar,), Hospital Germans Tries i Pujol (Beatriz Mothe), Hospital Clínic de
Barcelona (Irene Fuertes, Ana Gonzalez Cordon, José L Blanco, Felipe García, Josep
Mallolas, Josep M Miró).

Contributors PGdO and JC developed the surveillance system for STI. PGdO
designed the study, AS and MM carried out the bibliographic search and the
statistical analysis. AS, MM, JC, PGdO, MAr, MV, MJB, IO, AG-C, MAl, GM-E, HK, MG,
AV and JC interpreted the results. AS and MM prepared the manuscript. STI-HIV
group of Barcelona participated in the acquisition and interpretation of the data.
AS, MM, JAC, PGdO, MAr, MV, MJB, IO, AG-C, MAl, GM-E, HK, MG, AV, JC and STI-
HIV group of Barcelona collaborated in the critical review and approved the final
manuscript.

funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional data are available.

Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non-commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.

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  • Sexually transmitted infections in young people and factors associated with HIV coinfection: an observational study in a large city
    • Abstract
    • Introduction
    • Methods
      • Study design and participants
      • Variables
      • Statistical analyses
      • Ethical considerations
      • Patient and public involvement statement
    • Results
      • Sociodemographic, clinical and behavioural characteristics of the population
      • Incidence and trends in incidence
    • HIV coinfection
    • Discussion
    • References

RESEARCH Open Access

The future of STI screening and treatment
for youth: a National Survey of youth
perspectives and intentions
Vinaya Gogineni1, Marika E. Waselewski2, Cornelius D. Jamison2,3, Jasmine A. Bell4, Nicole Hadler5,
Kiren A. Chaudhry6, Tammy Chang2,3,7 and Okeoma O. Mmeje3,4,6*

Abstract

Background: Sexually transmitted infection (STI) rates continue to rise in the U.S., with disproportionately high rates
among those aged 15–24 years. Effective programs and policies are necessary to address this growing public health
problem. The purpose of this study is to assess the perspectives of a national sample of youth on access to STI care
and behaviors regarding STIs.

Methods: MyVoice, a national text message survey of youth, was used to pose four open-ended questions on STI
screening and treatment to 1115 youth aged 14–24 in August 2018. A mixed-methods strategy was employed for
the study. Qualitative data was analyzed using a modified grounded theory approach. Summary statistics were
calculated for demographic data and prevalence of themes.

Results: Of the 800 participants who responded to at least one question (72% response rate), mean age was 19
years (SD = 3.1), 55% identified as female, 61% identified as non-Hispanic white, and 33% qualified for free/reduced
lunch. A majority felt it would be easy to get screened (69%) or treated (68%) for an STI. Nearly all respondents
(95%) stated they would share an STI diagnosis with their sexual partners.

Conclusions: Despite high rates of STIs among youth, most respondents reported that STI screening and treatment
is accessible, and they would share an STI diagnosis with their partner.

Keywords: Sexual and reproductive health, Text message, School-based health centers, Adolescent health

Background
The continuous rise in sexually transmitted infections
(STIs), specifically among youth, raises concerns for the
U.S. population’s reproductive health outcomes. The
Centers for Disease Control and Prevention’s (CDC) an-
nual STI surveillance report in 2018 revealed more than
1.7 million cases of Chlamydia trachomatis (CT) and
more than 583,000 cases of Neisseria gonorrhoeae (NG)

in the United States [1]. Youth aged 15–24 years account
for nearly half of the new cases of STIs due to riskier
sexual behavior such as multiple concurrent partners or
unprotected intercourse and lower access to sexual
healthcare [2]. Recurrent or untreated CT and NG infec-
tions increase the risk of pelvic inflammatory disease in
women and infertility and HIV infection in men and
women. Additionally, there are increasing rates of anti-
biotic resistance in NG infections, which affect both
men and women [1]. Therefore, it is critical that effect-
ive preventive measures be utilized to prevent STI trans-
mission and STI-related morbidity.

© The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article’s Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.

* Correspondence: [email protected]
3University of Michigan Institute for Healthcare Policy and Innovation, 2800
Plymouth Rd. Bldg. 16, Ann Arbor, MI 48109, USA
4University of Michigan Department of Obstetrics and Gynecology, 1500 E.
Medical Center Dr., L4100 Women’s Hospital, Ann Arbor, MI 48109, USA
Full list of author information is available at the end of the article

Gogineni et al. BMC Public Health (2021) 21:2006
https://doi.org/10.1186/s12889-021-12091-y

Understanding youth perceptions and behaviors re-
garding STIs is a crucial first step in the development
and implementation of effective STI treatment and pre-
vention methods for this population [2]. Despite the
high incidence of CT and NG, a 2016 national survey of
youth aged 15–25 years reported only 16.6% of female
respondents and 6.6% of male respondents had received
STI screening within the past year [2]. Previous work
has suggested potential barriers to youth STI screening
and according to a 2013–2015 national survey, youth
aged 15–25 years had concerns about privacy and confi-
dentiality that hindered many individuals from obtaining
STI screening [3]. In some cases, youth do not believe
they are at risk for contracting an STI and therefore do
not seek these sexual health services [4]. However, there
is currently a lack of research that addresses youth-
specific STI interventions [2]. This gap in literature in-
troduces an opportunity for our study to provide new
insight on youth perceptions of STI testing and treat-
ment, access to care, and notification of partners.
We sought to understand youth perceptions of their

access to STI screening and treatment to better shape
the delivery of reproductive healthcare services to youth
populations. We posed open-ended questions to a na-
tional sample of diverse youth regarding their perspec-
tives on their access and willingness to pursue CT and
NG screening and treatment.

Methods
We used a longitudinal text message survey, MyVoice,
of 1115 youth aged 14–24 years, to characterize youth
perspectives on STI screening and treatment [5].
MyVoice participants are recruited to the survey cohort
via targeted Facebook® and Instagram® advertisements
based on demographic benchmarks (age, gender, race
and ethnicity, and region of the country) from weighted
samples of the American Community Survey [6]. Eligi-
bility criteria include age 14–24 years, ability to under-
stand and respond in English text, and access to a device
with text messaging capabilities. MyVoice participants
meet the minimum age requirement where parental con-
sent is not required for STI services [7]. Once recruited,
participants in the MyVoice cohort are asked open-
ended questions via text message each week on a variety
of health and health policy topics. Questions posed are
iteratively developed by a team of physicians, methodol-
ogists, statisticians, and students to ensure clarity and
ease of response for participants.
In August 2018, the MyVoice participants were

prompted to respond to a set of four questions related
to STI screening, treatment, and disclosure of their STI
infections: 1) We want to talk about chlamydia and gon-
orrhea, two of the most common sexually transmitted in-
fections (STIs). Would it be hard for you to get TESTED

for chlamydia or gonorrhea if you wanted? 2) If you
tested positive, would it be hard for you to get TREATED
for chlamydia or gonorrhea? 3) If you thought you had
chlamydia or gonorrhea, where would you go to get treat-
ment? 4) If you got chlamydia or gonorrhea, would you
tell your sexual partner(s)? Why or why not?
Grounded theory methodology was used to review the

responses by identifying themes and iteratively develop-
ing a codebook that consisted of categories representing
the most common responses. Two reviewers independ-
ently coded each question, with discrepancies resolved
by a third reviewer. Summary statistics were calculated
for demographic data collected at enrollment and in-
cluded gender, race, U.S. geographic region [8], educa-
tion level, and receipt of free or reduced school lunch (a
proxy for socioeconomic status). The frequency of coded
themes was also analyzed using summary statistics
(Microsoft Corporation. 2016. Microsoft Excel). The
mean age of individuals in each response category for
question 1 and 2 were compared using t-test with p <
0.05 representing statistical significance (SAS Institute
Inc. 2013. SAS® 9.4).

Results
Among the 800 participants who responded to at least
one question (72% response rate), the mean age was 19
years (SD = 3.1), 55% identified as female, 61% identified
as non-Hispanic white, and 33% qualified for free or re-
duced lunch (Table 1). Quotes from respondents are in-
cluded below as representative examples of specific
themes.

Most respondents felt it would be easy to get screened
and treated for an STI
When prompted about ease of access to STI services,
the majority of youth felt that it would not be difficult to
both get screened (69%) and treated (68%) for an STI
(Table 2). STI screening was reported to be easily ac-
cessible by the majority of respondents primarily because
“there are a lot of ways that you are able to get tested
whether it be at the doctor or at a clinic” and “the doctor
[is] close by and I believe testing is very cheap.” A few re-
spondents (n = 10) who believed they were not at risk or
did not have STIs stated that “It wouldn’t be hard for me
to get tested because I know I do not have chlamydia or
gonorrhea.” For those who expressed difficulty in obtain-
ing testing (21%), the most common reason was due to
their minor status (37%) because they had “been told by
doctors in the past that they don’t know how STI tests
show up on bills and my parents would be very upset to
learn I was having sex.” Respondents who reported that
it was hard to get tested or treated for STIs (6.5%) were
on average younger than those who reported no (i.e., no,
unsure, and other) difficulty (17.4 years vs 19.0 years; p <

Gogineni et al. BMC Public Health (2021) 21:2006 Page 2 of 8

0.001 and 17.4 years vs. 18.9 years; p < 0.001, respect-
ively). They commonly cited that “I have no idea where I
would go to get tested, so I’m not really sure if it would
be difficult or not. I guess the first thing I would need to
do is find out where or who would even have that kind of
service” (31%). See Additional file 1 for detailed response
patterns.
Many participants (41%) noted that STI treatment

would be easy to get because they “have insurance and
are financially stable enough to treat it.” Respondents
who thought treatment would be difficult to get (16%)
had concerns about how “my health insurance doesn’t
cover STDs” (42%) and “I won’t feel so comfortable talk-
ing to my parents which I would probably have to I guess.
But I wouldn’t know how to handle it myself” (25%).

Those who remained uncertain (16%) primarily indi-
cated they “don’t actually know what [their] options
would be for treatment” (24%).

Primary care offices were the most common place youth
would go for STI treatment
Youth indicated preference for STI treatment via pri-
mary care providers by stating that “my doctor” (49%),
free clinics (14%), or hospitals (14%) were the main loca-
tions they would seek health services. Less common lo-
cations included a gynecologist (11%) and “If it was
during the school year, I would start with on-campus
health services” (9%). An additional 11% of respondents
were unsure about where they would go for their STI
treatment.

Table 1 Demographic characteristics of survey respondents and non-respondents from the MyVoice cohort

Characteristic Respondents (n = 800)
n (%) or Mean (SD)

Non-Respondents (n = 315)
n (%) or Mean (SD)

Age 18.6 (3.1) 18.6 (3.1)

Gender

Male 305 (38.1) 143 (45.8)

Female 443 (55.4) 144 (46.2)

Other gender 52 (6.5) 25 (8.0)

Race

Asian 82 (10.3) 37 (11.9)

Black or African American 69 (8.6) 32 (10.3)

White or Caucasian 546 (68.3) 201 (64.4)

Mixed race 69 (8.6) 24 (7.7)

Other race 34 (4.3) 18 (5.8)

Ethnicity

Hispanic or Latino 98 (12.3) 50 (16.0)

Non-Hispanic or Latino 702 (87.8) 262 (84.0)

Education Level

Less than high school 434 (54.3) 158 (50.6)

High school graduate 70 (8.8) 35 (11.2)

Some college or tech school 185 (23.1) 70 (22.4)

Associate’s degree or tech graduate 21 (2.6) 9 (2.9)

Bachelor’s degree or higher 90 (11.3) 40 (12.8)

Region

Midwest 389 (48.9) 172 (55.3)

Northeast 84 (10.5) 32 (10.3)

South 186 (23.3) 48 (15.4)

West 138 (17.3) 59 (19.0)

Free and reduced lunch eligibility

Yes 263 (33.2) 91 (30.0)

No 530 (66.8) 212 (70.0)

Gogineni et al. BMC Public Health (2021) 21:2006 Page 3 of 8

Almost all respondents would share an STI diagnosis with
their sexual partners
Nearly all respondents to this question (95%) also stated
they would communicate their STI diagnosis with their

sexual partners because “they could have it too,” “it
would be important for them to know and get tested and
contact any other sexual partners to also be checked,”
and “it’s the right thing to do.” Those who would not

Table 2 Questions, themes, and representative respondent quotes

Question, Theme n (%)a Representative Quote

Would it be hard for you to get TESTED for chlamydia or gonorrhea if you wanted? (n = 782)b

No 539 (68.9)

Easy access to care 385 (71.4) “there are clinics everywhere”

Access to insurance/funds 81 (15.0) “I have insurance so I could get tested free”

Importance of health 33 (6.1) “No I want to see if I’m STD free”

Yes 162 (20.7)

Notification of parents 60 (37.0) “Yes, I am not going to tell my parents I’m sexually active”

Embarrassment/stigma 38 (23.5) “There is some stigma”

Unsure of process or location 39 (24.1) “Yes, as I am not sure how and where to get tested”

Cost/insurance 29 (17.9) “I don’t have health insurance”

Unsure 51 (6.5)

Unsure of process or location 16 (31.4) “Probably not, but I don’t know where or how to”

If you tested positive, would it be hard for you to get TREATED for chlamydia or gonorrhea? (n = 771)b

No 523 (67.8)

Access to insurance/funds 216 (41.3) “I have health insurance and am financially stable enough … “

Easy access 202 (38.6) “I have access to many good medical facilities”

Importance of health 41 (7.8) “that is the only option for me to get better and healthy”

Yes 122 (15.8)

Cost/insurance 51 (41.8) “My health insurance doesn’t cover STDs”

Notification of parents 30 (24.6) “difficult to explain to parents”

Embarrassment/stigma 21 (17.2) “The social stigma surrounding STIs would prevent me from asking for help about any treatment”

Unsure 122 (15.8)

Unsure of process 29 (23.8) “I don’t know enough about treatment.”

Depends on cost/insurance 23 (18.9) “If my healthcare covers it, then no. If it doesn’t, that’s a different story.”

If you thought you had chlamydia or gonorrhea, where would you go to get treatment? (n = 745)b

Doctor’s office 368 (49.4) “… my PCP for a consultation and to get treated/tested”

Free clinic/Planned Parenthood 106 (14.2) “Planned Parenthood or a walk-in-clinic if … at school”

Hospital 105 (14.1) “university system or other local hospital”

Gynecology/STI doctor 85 (11.4) “My gynecologist, preferably. If I couldn’t schedule an appointment for a while, I’d go to a clinic.”

Unsure 83 (11.1) “I’m not sure, the doctor?”

School clinic 65 (8.7) “If it was during the school year, I would start with on campus health services.”

If you got chlamydia or gonorrhea would you tell your sexual partner(s)? Why or why not? (n = 774)b

Yes 736 (95.1)

Effects partner 185 (23.9) “it’s not something that only affects you, but anyone else you may have been with”

Morality 180 (23.3) “Yes, that is the right thing to do”

Importance of testing/treatment 146 (18.9) “Absolutely. He would need to get treated/tested too.”

No 16 (2.1)

Social stigma 10 (62.5) “I would be too ashamed”
aNumbers may not add to 100%, as codes are not mutually exclusive; not all codes are displayed
bN = the number of coded responses to each question; not all respondents answered each question
STI = sexually transmitted infection

Gogineni et al. BMC Public Health (2021) 21:2006 Page 4 of 8

disclose their status to their partner (2%) cited “I would
be too ashamed” and “it would be embarrassing” as rea-
sons for not informing their partner of their infection.

Discussion
Our study found that most youth consider both STI
screening and treatment to be accessible because of easy
access to healthcare or access to insurance and funding.
Additionally, youth in our sample noted a preference for
going to their established doctors or primary care pro-
viders for treatment services. Most notably, we found
that nearly all MyVoice youth respondents indicated
they would confide in their partners about an STI diag-
nosis, with more than half of these respondents report-
ing reasons such as how the diagnosis impacts their
partners and that it is morally right.
While other studies report that many youth have ac-

cess to general healthcare, there is limited literature on
youth knowledge of included health services [9, 10]. Our
study provides insight here by noting that our cohort be-
lieves STI screening and treatment services to be access-
ible via established or local health providers. This
highlights the importance of youth having a healthcare
home at sites that they routinely encounter, such as
school-based health centers and federally qualified
health centers. During the COVID-19 pandemic, the use
of telehealth services has increased to support wider ac-
cess to health services, but virtual healthcare services
may not replace necessary clinical services when inequi-
ties in technology access remain [11]. Harnessing the
interest and willingness of youth to seek sexual health-
care services at locations they are comfortable with is
critical given that access to reproductive health services
continues to decline [12], despite the growing incidence
of STIs among youth [13]. Similar to our findings, access
to care and insurance has previously been noted to make
screening and treatment easy for youth [14]. However,
our data does not support limited knowledge of health
services as the primary barrier to care. Youth in our
sample noted other barriers in accessing these services
like cost or insurance coverage, embarrassment, and
concerns about notifying their parents.
Youth concerns about confidentiality regarding an STI

diagnosis note difficulty “… because it would be some-
thing that I would have to tell my parents and that
would be very uncomfortable,” or “… because treatment
would require health care, which would require me tell-
ing my parents.” This is consistent with existing litera-
ture that reports how perceptions of confidentiality may
pose a barrier to healthcare for youth [3, 4]. Addressing
youth concerns about cost and confidentiality must be
considered when developing and implementing STI
treatment and prevention services. Providers and health
departments can encourage positive communication

about sexual health between parents and their children,
thus promoting safer sex practices and better health out-
comes [15, 16]. In addition, providers can educate youth
on the rules of confidentiality between minor patients
and providers.
Despite their perceived ease of access to STI screening

and treatment, actual use of these services remains low
among U.S. youth. A possible explanation for this dis-
crepancy, as noted in previous work, may be due to
youth assuming that they are STI-free or generally not
at risk [4]. Our study supports this conclusion, with
some respondents reporting “It wouldn’t be hard for me
to get tested because I know I do not have chlamydia or
gonorrhea” and “No I go to the doctors often and they ask
if I want to get tested but I’ve been with the same person
since the last test I have no reason to get tested.” Youth
must also want to, or perceive a need to, get STI screen-
ing. This barrier to use of STI screening services illus-
trates the need for local and federal health officials to
support initiatives that emphasize—to youth and pro-
viders—the importance of regular STI screening, even in
asymptomatic individuals.
Findings from our work also suggest primary care of-

fices as the preferred location for STI screening and
treatment in youth. This is congruent with previous
work on STI screening amongst youth in the U.S. that
indicated the majority of those who sought STI screen-
ing were evaluated at primary care physicians’ offices [4].
Youth preferences for STI screening and treatment at
primary care clinics and concern for costs may require
additional support and education for primary care health
professionals. Furthermore, STI screening and preven-
tion counseling for youth during their routine clinic
visits will serve to increase awareness of STI screening
methods and treatment options.
Our study also reports the important finding that

nearly all respondents (95%) stated they would share
their STI results with their partners. Common responses
included “Yes because they need to know, in case they
have it too. Also, they can help prevent the spread.” and
“Yes it’s the most responsible thing to do. They would de-
serve to know.” A previous study on sexual health behav-
iors of U.S. college-age men similarly reported that the
majority of participants were willing to disclose their
STI status to their partners [17]. Our results contrast
with previous data on youth concerns of STI stigma and
the general misperception of youth being less willing to
notify their partners [3, 4, 18, 19]. Youth willingness to
confide in their sexual partners and concern about
health effects on their sexual partners supports potential
use of expedited partner therapy (EPT) to increase treat-
ment of STIs. EPT—a treatment option where individ-
uals can obtain STI medications or prescriptions for
their sexual partners—may provide a useful opportunity

Gogineni et al. BMC Public Health (2021) 21:2006 Page 5 of 8

to support youth treatment as it is quick, convenient,
and respects patient privacy [20]. Clinician education on
youth willingness to share STI results and use of EPT
may also be beneficial to their efforts to increase screen-
ing and treatment in their patient populations. Addition-
ally, it may address the hesitancy and uncertainty that
some clinicians may face regarding the permissibility of
this therapeutic measure [21]. It is important to note
that youth willingness to participate in partner notifica-
tion does not necessarily reflect youth behaviors. Cur-
rently, there is a gap in literature on the rates of partner
notification specifically in the youth population [22]. In
an Australian evaluation of individuals > 16 years diag-
nosed with chlamydia (median age of 27 and 24 years in
males and females, respectively), 31 and 46% of hetero-
sexual males and females notified their partners [23].
However, partner notification is increased in youth (ages
13–20 years) with higher levels of self-efficacy and in re-
lationships with stronger emotional ties [24]. This mir-
rors the findings noted in adult populations, where
partner notification is highest for spousal partners than
for causal or commercial partners [22]. Thus, further
evaluations of partner notification in youth ages 15–24
years are needed to quantify the efficacy of interventions
like EPT among youth.
Though the MyVoice cohort sample recruits nationally

from youth aged 14–24 years, there are some limitations.
While MyVoice recruits based on benchmarks for na-
tional data on age, gender, race and ethnicity, and region
of the country, respondents are not nationally represen-
tative because there is no assurance that the recruitment
advertisements will reach all eligible participants. Add-
itionally, recruitment via social media may bias the

sample by including only those who use social media,
limiting generalizability. Specifically, MyVoice respon-
dents are oversampled in the Midwest region (Fig. 1) of
the U.S., thereby providing data that may not necessarily
reflect the perceptions and practices of youth in other
parts of the country. Another limitation stems from the
lack of concurrence between the time at which the sur-
vey was administered and analyzed and the onset of the
COVID-19 pandemic. The majority of the cohort re-
ported access to healthcare services at the time the sur-
vey was administered, yet youth have experienced
decreased access to reproductive healthcare services dur-
ing the COVID-19 pandemic [25]. To protect our re-
spondents from having to self-report their past STI
history, the open-ended questions posed to youth also
asked about their theoretical behaviors. This may lead to
desirability bias, as individuals may over- or under-
report to conform to societal norms [26]. The other
limitation of assessing theoretical behaviors is that inten-
tions may not always lead to actions. Finally, the an-
onymous nature of this protocol prevented us from
clarifying any unclear or missing responses. This is illus-
trated by our inability to discern if sexual partners were
primary or casual in nature.

Conclusions
Understanding youth insights on their sexual health per-
spectives is instrumental in mitigating the disproportion-
ately high rates of STIs that affect this population. Our
findings suggest that youth are committed to both their
and their partners’ sexual health, presenting an invalu-
able opportunity for eventual large-scale intervention
through partner-based referral and treatment options

Fig. 1 MyVoice survey participant heat map, by state

Gogineni et al. BMC Public Health (2021) 21:2006 Page 6 of 8

such as EPT. However, before such solutions can be ex-
plored, the discrepancy between youth intentions and
actions must be addressed to provide insight on how to
encourage positive behavioral change that could poten-
tially reduce STI rates in this population. Longer-term
societal efforts toward educating parents and youth on
appropriate sexual health education, STI screening and
treatment costs, and resources may support reduction in
STI transmission [16, 27, 28]. Health and education de-
partments can also partner to implement policies and
programs that support and normalize regular STI
screening. Ultimately, promotion of STI prevention ser-
vices and reduction of the perceived barriers are needed
to help combat the increasing STI incidence rates
among youth.

Abbreviations
STI: sexually transmitted infection; CDC: Centers for Disease Control and
Prevention; CT: Chlamydia trachomatis; NG: Neisseria gonorrhoeae

Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12889-021-12091-y.

Additional file 1. Details of Q2 responses based on Q1 responses.
Description: Details showing the relationship between the responses for
those who completed question 2 in relation to their response to
question 1.

Acknowledgements
Data from this study was accepted for virtual presentation at the Centers for
Disease Control and Prevention STD Prevention Conference, September 14-
24, 2020.

Authors’ contributions
OM conceived of and managed the conduct of the project and led the
writing and review process. TC led the iterative development and review of
the survey items. MW completed the quantitative analysis and led the
qualitative evaluation. CJ, MW, and VG organized and drafted the
manuscript. VG led the manuscript writing. Two reviewers independently
applied the codebook to each question (CJ, VG, JB, NH) with a third
reviewer, MW, reviewing all discrepancies. All authors have read and
approved the final manuscript.

Funding
Dr. Mmeje was supported by the University of Michigan’s Office of the
Provost and the University of Michigan Medical School Department of
Obstetrics and Gynecology. This research was funded by the Michigan
Institute for Clinical & Health Research, the University of Michigan MCubed
program, and the University of Michigan Department of Family Medicine.
These funders had no role in the study design; the collection, analysis, and
interpretation of data; the writing of the report; or the decision to submit
the manuscript for publication.

Availability of data and materials
The datasets used and/or analyzed during the current study are available
from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate
The MyVoice study is approved by the University of Michigan Institutional
Review Board (HUM00119982) and participants provided consent via the
study website, which including a waiver of parental consent for minor

participants. All study methods were carried out in accordance with relevant
guidelines and regulations.

Consent for publication
Not applicable.

Competing interests
The authors declare that they have no competing interests.

Author details
1The University of Toledo College of Medicine and Life Sciences, 3000
Arlington Ave, Toledo, OH 43614, USA. 2University of Michigan Department
of Family Medicine, 1500 E. Medical Center Dr, Ann Arbor, MI 48109, USA.
3University of Michigan Institute for Healthcare Policy and Innovation, 2800
Plymouth Rd. Bldg. 16, Ann Arbor, MI 48109, USA. 4University of Michigan
Department of Obstetrics and Gynecology, 1500 E. Medical Center Dr., L4100
Women’s Hospital, Ann Arbor, MI 48109, USA. 5University of Michigan
Medical School, 1301 Catherine St, Ann Arbor, MI 48109, USA. 6Department
of Health Behavior and Health Education, University of Michigan School of
Public Health, 415 Washington Heights, Ann Arbor, MI 48109, USA. 7National
Clinician Scholars Program, University of Michigan, 2800 Plymouth Rd. Bldg.
16, Ann Arbor, MI 48109, USA.

Received: 11 May 2021 Accepted: 18 October 2021

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25. Mmeje OO, Coleman JS, Chang T. Unintended consequences of the COVID-
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26. Schroder KE, Carey MP, Vanable PA. Methodological challenges in research
on sexual risk behavior: II. Accuracy of self-reports Ann Behav Med. 2003;
26(2):104–23. https://doi.org/10.1207/S15324796ABM2602_03.

27. Lederman RP, Chan W, Roberts-Gray C. Parent-adolescent relationship
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BMED.33.4.137-144.

28. Coyle K, Basen-Engquist K, Kirby D, Parcel G, Banspach S, Harrist R, et al.
Short-term impact of safer choices: a multicomponent, school-based HIV,
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Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.

Gogineni et al. BMC Public Health (2021) 21:2006 Page 8 of 8

  • Abstract
    • Background
    • Methods
    • Results
    • Conclusions
  • Background
  • Methods
  • Results
    • Most respondents felt it would be easy to get screened and treated for an STI
    • Primary care offices were the most common place youth would go for STI treatment
    • Almost all respondents would share an STI diagnosis with their sexual partners
  • Discussion
  • Conclusions
  • Abbreviations
  • Supplementary Information
  • Acknowledgements
  • Authors’ contributions
  • Funding
  • Availability of data and materials
  • Declarations
  • Ethics approval and consent to participate
  • Consent for publication
  • Competing interests
  • Author details
  • References
  • Publisher’s Note

fpsyg-11-00285 February 22, 2020 Time: 15:45 # 1

ORIGINAL RESEARCH
published: 25 February 2020

doi: 10.3389/fpsyg.2020.00285

Edited by:
María del Mar Molero,

University of Almería, Spain

Reviewed by:
Luigi Isaia Lecca,

University of Cagliari, Italy
Dragan Mijakoski,

Institute of Occupational Health,
North Macedonia

*Correspondence:
Krystyna Kowalczuk

[email protected]

Specialty section:
This article was submitted to

Organizational Psychology,
a section of the journal
Frontiers in Psychology

Received: 23 October 2019
Accepted: 06 February 2020
Published: 25 February 2020

Citation:
Kowalczuk K, Krajewska-Kułak E

and Sobolewski M (2020) Working
Excessively and Burnout Among

Nurses in the Context of Sick Leaves.
Front. Psychol. 11:285.

doi: 10.3389/fpsyg.2020.00285

Working Excessively and Burnout
Among Nurses in the Context of Sick
Leaves
Krystyna Kowalczuk1* , Elżbieta Krajewska-Kułak1 and Marek Sobolewski2

1 Department of Integrated Medical Care, Medical University of Białystok, Białystok, Poland, 2 Faculty of Management,
Rzeszow University of Technology, Rzeszow, Poland

Introduction: Nurses are particularly at risk of being affected by professional
burnout because of the unique patient – caregiver relationship, which requires strong
emotional involvement.

Aim: In this study, we decided to examine the mutual correlations of working excessively
and burnout – two basic occurrences affecting the mental well-being of employees – and
their relationship with sick leave.

Materials and Methods: The study was conducted among 460 nurses working in 3
hospitals in Poland. The polish version of Maslach Burnout Inventory and the Working
Excessively Questionnaire developed by Paluchowski were used to conduct the survey.
All the demographic data and data on sick leaves were obtained from surveys in the
form of respondents’ self-reports.

Results: The constructed regression model shows that the tendency to work
excessively, as assessed by loss of control over work (LCW), perfectionist work style
(PWS), and perceived oppressiveness of the organization (OOP) measures, explains
12.4% of the variation in burnout levels. This confirms that overburden with work can
be a factor contributing to the increase in burnout measures. The constructed logistic
regression model showed that increase in the level of occupational burnout by 1 point,
the chance of nurse having at least three sick leaves per year increases 1.029 times
(i.e., by about 2.9%). None of working excessively measures affected the frequency of
sick leaves.

Conclusion: (1) Excessive workload increases burnout symptoms, which in turn
encourages nurses to take sick leave more frequently. (2) The tendency for nurses to
overburden themselves with work may be seen by hospital managers as a positive
phenomenon, but, based on this study, it is clear that this can only be done in the
short term, whereas in the long term it will be clearly detrimental to the organization of
hospitals and the quality of care.

Keywords: burnout, nurse, working excessively, sick leave, mental health, hospital management

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Kowalczuk et al. Working Excessively and Burnout Among Nurses

INTRODUCTION

A shortage of nursing personnel severely affects the quality
of medical services. This problem has been trending in most
countries around the world (Buerhaus et al., 2007; Haddad and
Toney-Butler, 2019; Haegdorens et al., 2019). Poland, however,
has one of the lowest indicators of practicing nurses per 1000
residents among the OECD countries. This, in 2015, was only 5.2.
For comparison, the highest indicator was in Switzerland at 18.0;
and in neighboring countries it was: Denmark – 16.7, Germany –
13.3, Sweden – 11.1, Czechia – 8.0, and Lithuania – 7.7. Moreover,
the average for 35 OECD countries was 9.0 (OECD, 2017).
According to the data from the Polish Supreme Council of Nurses
and Midwives report, the same indicator of practicing nurses in
2015 was only 3.9 in the Podlaskie Voivodeship. This was the
lowest in the country. This report also points out a decrease
in the number of practicing nurses in Poland in recent years
and predicts a continuation of this trend in the following years
(Supreme Chamber of Nurses and Midwives, 2017).

The successive decrease in the number of professionally active
nurses is affected by such issues as: lack of employment in the
profession despite obtained qualifications, financially-motivated
emigration, and leaving the profession. The scientific literature
has identified a number of factors that are the most frequent
reasons for nurses leaving the profession. Among them, low
wages, too many responsibilities, health problems, psychosocial
burden in the workplace, and burnout are usually indicated (Li
et al., 2011; Dall’Ora et al., 2015; de Oliveira et al., 2017).

As a professional group, nurses are highly subject to burnout
due to the specific patient and caregiver relationship. This
relationship requires emotional involvement, where the caregiver
must deal with various possible situations, including the patients’
suffering, fear, aggression, or lack of respect for their work
(Leiter and Maslach, 2009; Lewandowska and Litwin, 2009;
Nayeri et al., 2009).

Burnout was first defined in Freudenberger (1974) as a state
characterized by a sense of physical and mental exhaustion,
excessive irritability, impatience combined with cynicism, a
tendency to isolate oneself, suppressing the emotions, and
feelings of chronic boredom. Burnout is the body’s response to
long-term overload with obligations, too many responsibilities
and difficult tasks, as well as exhausting, monotonous and
boring work, and most of all, to chronic work-related stress.
Maslach, the author of the Maslach Burnout Inventory (MBI)
that we used in our research, defines burnout as “a syndrome
of emotional exhaustion, depersonalization, and a reduced sense
of personal achievement that can occur in people working with
others in a certain way.” Emotional exhaustion is a feeling
of emptiness and depletion of strength caused by excessive
psychological and emotional requirements made by the job, or
the employee himself/herself by having unrealistic requirements
toward his/her own abilities. Depersonalization is a sense of
heartlessness, detachment and cynicism toward others, and
a lowered sensitivity toward other employees. In contrast, a
lowered evaluation of personal achievement is a feeling of wasting
time and effort at the workplace (Maslach and Leiter, 2005;
Maslach et al., 2009, 2012).

Working excessively is defined as an imbalance between
work and home, leisure time, and social relationships (Schaufeli
et al., 2009a; Molino et al., 2012). The authors of the Working
Excessively Questionnaire (WEQ), which we used in our study,
define working excessively as a dysfunctionality that affects the
entire life. Accordingly, working excessively is not defined by the
intensity of work, but that the work is unnecessary. Working
excessively occurs in four aspects: a perfectionist work style,
loss of control over work, general views about work, and the
perceived oppressiveness of the organization. The perfectionist
work style is characterized by an excessive passion for order and
an exaggerated pursuit of excellence in performing the entrusted
responsibilities. General views about work show to what extent
the employee agrees with the normative reasons justifying hard
work. The perceived oppressiveness of the organization shows
to what extent working excessively results from an economic
necessity and fear of losing one’s job or acting in accordance with
the organization’s culture. Loss of control over work shows the
degree of dependence on work (Paluchowski et al., 2014).

Working excessively is often indicated as one of the symptoms
of workaholism (Taris et al., 2005; Schaufeli et al., 2008; Van
Beek et al., 2012). However, the scientific literature cites many
other reasons that could lead to workaholism. Wrzesniewski
described three different ways of relating to work: orientation
toward activity, where the main expectation of work is money;
orientation toward career, where achieving prestige is the main
expectation; and vocation, meaning work in the name of aims
beyond the individual (Wrzesniewski and Dutton, 2001). Nursing
is not perceived as a prestigious profession in Poland, therefore,
in the case of nurses, the first and third occur the most often.

Research by the Supreme Council of Nurses and Midwives
indicates that nurses in Poland are overworked. This is primarily
due to the fact that the minimum employment standards are set
based on the registered health services, the number of beds and
the type of ward, rather than the actual needs of the hospital. This
results in, among others, one nurse only working a night shift and
less personnel on the floor on Sundays and holidays, leading to a
greater workload due to an increased number of responsibilities
per person. Still, nurses often take on extra shifts to work for
absent colleagues because they have a sense of mission about their
profession that does not allow them to leave patients unattended,
while at the same time they take on additional employment
because they are underpaid (Wyderka and Niedzielska, 2016;
Supreme Chamber of Nurses and Midwives, 2017).

In this study, we decided to examine the mutual correlations of
working excessively and burnout – two fundamental occurrences
affecting the mental well-being of employees – and their
relationship with sick leave. The aim of such a study was
to compare the level of measures of excessive work and
burnout among nurses grouped by frequency of using sick
leave, and, consequently, the effect of burnout and excessive
work on nurses’ sick leave. The results of such an examination
should be useful to hospital managers and enable them to take
measures to reduce overburdening the nursing personnel with
professional responsibilities and to prevent the intensification of
burnout. Nurses’ burnout and working excessively are known
in the scientific literature, but the interplay of these events

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Kowalczuk et al. Working Excessively and Burnout Among Nurses

from the perspective of sick leave had, until now, not been
studied in Poland.

MATERIALS AND METHODS

The cross-sectional study was conducted from September 28,
2017 to April 30, 2018, in Poland, in the Podlaskie Voivodeship.
It included registered nurses working in three inpatient hospitals
and in nine departments. Participation in the study was
voluntary, and all procedures were approved by the Institutional
Review Board of the Medical University of Białystok, ref. no.
R-I-002/296/2017.

Study Group Selection
The selection of respondents to the study group was based
on the register of associated nurses in the District Chamber
of Nurses and Midwives in Białystok. The total number of
registered nurses was 6085 persons (5990 women and 95 men).
The selection criterion was employment based on employment
contract in a hospital, in the psychiatric, internal medicine,
surgical and emergency departments. Nurses working part-
time, elsewhere than hospital and on other than employment
contract were excluded. The three largest hospitals in the
voivodeship employing 10% of the total workforce were selected
to conduct the study.

Study Procedure
The study used was conducted using paper-based questionnaires.
The questionnaires were distributed by researchers to the
nurses during their work time. All invited hospitals agreed
to the participation of their employees in the study, and to
it being conducted during working hours. Participation was
voluntary. Before the study, each nurse was informed about the
anonymity of the conducted research, and about the possibility of
withdrawing from the study without stating a reason. They were
asked to complete the surveys in their free time within 2 weeks
and send the completed questionnaires in a sealed envelope to
the investigators’ address. There were 600 questionnaire surveys
distributed, out of which 460 correctly completed questionnaires
were obtained. Acceptance rate was 77%. There are no known
reasons why 140 respondents did not participate in the study. All
the demographic data and data on sick leaves were obtained from
surveys in the form of respondents’ self-reports. No incentives
were used to encourage participation in the study.

Study Group
The research group consisted of 460 nurses. The vast majority
of the respondents were women (92.4%). The mean age for
the studied group was 37.4 ± 12.3 years, with a slightly lower
median equal to 34 years. The youngest employee was 22 years
old and the oldest was 65. Every fourth person surveyed was not
more than 26 years old and every fourth person was not less
than 48 years old. Over 65% of the respondents had completed
higher nursing education, 20% had secondary education with a
specialization and 12.2% had secondary education. The majority
of the respondents (80% of all respondents) worked as unit
nurses, and 10% as surgical nurses.

Description of the Questionnaire and the
Applied Measures
The research tool was the Polish adaptation of the MBI developed
by Pasikowski and Sȩk (Maslach and Leiter, 2005; Pasikowski,
2009), and the Working Excessively Questionnaire (WEQ)
developed by Paluchowski et al. (2014).

The Maslach Burnout Inventory measures three dimensions of
occupational burnout: emotional exhaustion, depersonalization,
personal accomplishment and overall score, which is the average
of the detailed measures. These measures are standardized by the
authors of the questionnaire for a range of 0–100 points (thus,
the results can be compared between measures). The higher the
values of these measures, the higher the level of occupational
burnout. The MBI original and Polish version both have been
extensively validated and both have clear scoring guidelines
(Pasikowski, 2009).

The Working Excessively Questionnaire (WEQ) used in the
study is the latest version of the questionnaire developed by
the Paluchowski team between 2004 and 2013. The WEQ has
been extensively validated and has clear scoring guidelines
(Paluchowski et al., 2014). The questionnaire consists of 65
questions grouped into 4 numerical scores, measuring the signs
of excessive workload: Loss of Control over Work (LCW),
Perfectionist Work Style (PWS), General Views about Work
(GVW), Oppressiveness of the Organization as Perceived (OOP).
These measures have not been standardized by the authors of the
questionnaire, therefore, their results cannot be compared.

The internal compatibility of the questionnaires was assessed
in the examined group of 460 people, with the following
Cronbach’s alpha coefficients obtained. For MBI: emotional
exhaustion – 0.94, depersonalization – 0.87, lack of work
satisfaction – 0.82, general measure – 0.92. For WEQ: loss of
control over work – 0.77, perfectionist work style – 0.84, general
views about work – 0.87, oppressiveness of the organization –
0.58. The psychometric properties of the questionnaires used are
satisfactory – the only exception is the low Cronbach’s alpha value
for the last WEQ measure.

Statistical Methods
Correlations between the measures of working excessively and
occupational burnout were analyzed at the level of the entire
population using Spearman’s rank correlation coefficient. To
examine the occurrence of statistically significant differences
in burnout and working excessively measures between groups
of nurses with different numbers of sick leaves, the Kruskal–
Wallis test was used. The selection of non-parametric methods
in these analyzes resulted from the lack of normality in
the distribution of MBI and WEQ measures, which was
verified using the Shapiro–Wilk test. These correlations were
analyzed in pairs (e.g., WEQ with MBI, WEQ with sick
leaves, MBI with sick leaves) to receive results that can
be compared with other research conducted separately with
MBI or WEQ measures. Linear regression analysis was
applied to present the combined effect of WEQ components
on the overall burnout index. Logistic regression model
was constructed to show the impact of MBI and WEQ
measures on frequency of sick leaves. Based on the nurse’s

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Kowalczuk et al. Working Excessively and Burnout Among Nurses

responses, they were placed within three groups as shown
in Table 1.

RESULTS

First, the occurrence of occupational burnout and excessive
workload in the studied population was analyzed. The average
levels of occupational burnout measures range from 32.7 to 38.6%
of the maximum value. Herein, it is important to note that 25%
of the most burned-out people have a result above 50.7% of the
maximum value in the case of the general measure, and even
above 66.7% in the case of dissatisfaction with work. The results
of job satisfaction loss are the least favorable among the three
components of occupational burnout (Table 2).

Next, the levels of measures for excessive workload were
analyzed. As in the case of occupational burnout, the results
confirm the existence of the excessive workload phenomenon in
the study group (Table 3). The biggest burden is the perfectionist
work style, where the mean value was 72.3% of the maximum
result, and 25% of the most burdened people had a result
exceeding 81.1% of the maximum value. The lowest burden
turned out to be general views on work, where the average was
48.9% of the maximum result, and 25% of the most burdened
people had a result above 57.9% of the maximum value.

Confirmation of occupational burnout and excessive workload
presence in the studied population allowed an examination
of the correlation between these syndromes. The analysis was
performed using the Spearman rank correlation coefficient.

TABLE 1 | Distribution of number of sick leaves.

Sick leaves during the year Number Percentage Mean age (years)

None 218 47.4 35.1

1–2 times 175 38.0 37.5

3 times or more 67 14.6 44.7

TABLE 2 | Occupational burnout measures.

Burnout measures x̄ Me S c25 c75 Minimum Maximum

Emotional exhaustion 34,8 33,3 30,5 11,1 55,6 0 100

Depersonalization 32,7 20,0 32,0 0,0 60,0 0 100

Lack of work satisfaction 38,6 33,3 30,1 16,7 66,7 0 100

General measure 35,4 32,6 23,6 16,7 50,7 0 100

TABLE 3 | Working excessively measures.

WEQ measures x̄ Me S c25 c75 Minimum Maximum

Loss of control over
work LCW

41,3 42 10,1 34 48 16 77

Perfectionist work style
PWS

65,1 65 11,0 57 73 28 90

General views about
work GVW

46,5 47 12,8 37 55 19 95

Oppressiveness of the
organization OOP

33,4 34 6,7 29 38 15 56

As can be seen from the summary presented in Table 4,
the three measures of excessive workload (LCW, GVW, and
OOP) are statistically significantly positively correlated with
two components of occupational burnout: emotional exhaustion
and depersonalization, and with the general measure. Lack of
occupational satisfaction shows a statistically significant negative
correlation only with the perfectionist work style.

Summing up this part of the analysis, it should be mentioned
that the correlations between the measures calculated from the
MBI and WEQ questionnaires have low statistical strength.

Burnout has an impact on the health of nurses. An analysis
of the correlations between measures of MBI and WEQ and the
frequency of sick leave use was conducted.

Table 5 summarizes the values of descriptive statistics for
MBI measures in terms of being on sick leave. MBI measures
(except the lack of work satisfaction) show statistically significant
differences between groups of nurses with different levels of
absenteeism. The average level of these measures in the first two
groups differs from the MBI values in the group of nurses with at
least three redundancies per year.

Table 6 summarizes the values of descriptive statistics for
WEQ measures in terms of being on sick leave. WEQ measures
(except PWS) show statistically significant differences between
groups of nurses with different levels of absenteeism. The average
level of these measures is very similar in the first two groups,
which differs from the WEQ values in the group of nurses with
at least three redundancies per year.

Using regression analysis tools, we constructed a model
that would enable to describe the combined impact of WEQ
components on the overall burnout measure. Herein, the overall
burnout rate as a dependent variable and four WEQ components
as independent factors were entered into the initial model. Since
GVW, as an independent factor, did not have a significant impact
on burnout level (p = 0.7224), the model parameters underwent
re-estimation after the exclusion of this factor. The final version
of the model, shown in Table 7, was thus obtained.

The constructed regression model shows that the tendency to
work excessively, as assessed by LCW, PWS, and OOP measures,
explains 12.4% of the variation in burnout levels. This is not
an extremely strong result, yet it does confirm that overburden
with work can be a factor contributing to the increase in burnout
rates. Accordingly, higher LCW and OOP values correspond to
an increase in burnout – 1 LCW point is on average an increase
in burnout by 0.595 points, and 1 OOP point is an increase in
burnout by 0.466 points. Furthermore, the more a perfectionist
work style is followed, the lower the occupational burnout level –
an increase in PWS by 1 point translates into a drop in the
burnout level by 0.427 points.

The last stage of statistical analysis was to investigate the
simultaneous impact of MBI and WEQ measures on the
frequency of nurses taking sick leave. The logistic regression
model was used. In the constructed model, the number of sick
leaves greater than or equal to three times a year relative to the
number of sick leaves at the maximum level of 2 was assumed as
a dependent variable of dichotomous nature. The independent
variables were MBI and WEQ measures and age as a factor
affecting the frequency of absenteeism (Table 1). A model with
only statistically significant factors was constructed using the

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TABLE 4 | MBI measures vs. WEQ measures.

WEQ measures MBI measures

Emotional exhaustion Depersonalization Lack of work satisfaction General measure

Loss of control over work LCW 0.28 (p < 0.001***) 0.23 (p < 0.001***) 0.08 (p = 0.0988) 0.26 (p = 0.0000***)

Perfectionist work style PWS −0.02 (p = 0.5989) −0.03 (p = 0.4993) −0.27 (p < 0.001***) −0.14 (p = 0.0031**)

General views about work GVW 0.19 (p < 0.001***) 0.15 (p = 0.0009***) −0.04 (p = 0.3525) 0.14 (p = 0.0025**)

Oppressiveness of the organization OOP 0.27 (p < 0.001***) 0.19 (p = 0.0001***) 0.09 (p = 0.0670) 0.24 (p < 0.001***)

** statistically highly significant correlation, *** statistically very highly significant correlation.

TABLE 5 | MBI burnout measures and sick leaves.

MBI burout measures Number of sick leaves during the year p

None (N = 218) 1–2 times (N = 175) 3 or more (N = 67)

x̄ Me s x̄ Me s x̄ Me s

Emotional exhaustion 27.4 22.2 27.0 36.4 33.3 30.0 54.6 66.7 33.8 <0.001***

Depersonalization 26.8 20.0 29.7 33.5 20.0 30.6 49.9 60.0 36.6 <0.001***

Lack of work satisfaction 36.6 33.3 29.6 37.5 33.3 28.1 48.0 50.0 35.2 0.0584

General measure 30.3 27.0 20.9 35.8 32.2 22.2 50.8 49.6 28.4 <0.001***

*** statistically very highly significant correlation.

TABLE 6 | WEQ working excessively measures and sick leaves.

WEQ Number of sick leaves during the year p

None (N = 218) 1–2 times (N = 175) 3 or more (N = 67)

x̄ Me s x̄ Me S x̄ Me s

Loss of control over work (LCW) 40.4 40 9.7 41.4 42 10.5 44.1 45 9.7 0.0116*

Perfectionist work style (PWS) 65.2 66 10.5 65.5 66 11.0 63.2 62 12.2 0.1660

General views about work (GVW) 45.4 45 12.8 46.4 47 12.2 50.5 51 13.5 0.0153*

Oppressiveness of the organization (SOO) 33.0 33 6.7 33.1 34 6.5 35.4 36 6.7 0.0268*

* statistically significant correlation.

progressive step regression procedure. Factors that statistically
significantly affect the probability of frequent absenteeism at
work are age and the overall measure of occupational burnout.
WEQ measures were statistically insignificant and were not used
in the final model. The final model is presented in Table 8.

The chance that a nurse will have at least three sick leaves
increases with age (by 5.1% each year). An increase in the level

TABLE 7 | Working excessively measures and overall burnout measure.

Working excessively
measures (WEQ)

Overall burnout measure

R2 = 12.4% F = 21.4 p = 0.0000***

B p β

Loss of control over
work (LCW)

0.595 0.0000*** 0.254

Perfectionist work style
(PWS)

−0.427 0.0000*** −0.198

Oppressiveness of the
organization (OOP)

0.466 0.0054** 0.132

** statistically highly significant correlation, *** statistically very highly significant
correlation.

of occupational burnout according to the overall MBI measure
by 1 point translates into an increase in the chance of frequent
absences by 2.9%.

DISCUSSION

The phenomena of excessive workload and burnout are the
subject of many studies, and nurses stand out as one of the
most vulnerable occupational groups at risk of burnout. This

TABLE 8 | Impact of MBI and WEQ on frequent sick leaves – logistic regression
model.

Independent variables Number of sick leaves during
the year (≥3 vs. <3)

OR (95% c.i.) p

Overall burnout measure [pts] 1.029 (1.017–1.041) 0.0000***

Age [years] 1.051 (1.028–1.075) 0.0000***

OR, odds ratio (with 95% confidence interval). *** statistically very highly significant
correlation.

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was found, among others, in studies conducted in Poland where
nurses and civil servants were compared (Jaracz et al., 2017)
and in Taiwan (Chou et al., 2014), where different groups of
healthcare workers were examined.

According to a study conducted on the Polish nursing
profession (Znañska-Kozłowska, 2013), age and duration of
service do not significantly affect the incidence of occupational
burnout. This confirms the need to search for the causes of
this phenomenon in other areas. A hypothesis has been made
that excessive workload is a factor in the increase of burnout
among nurses, because it is recognized that nurses in Poland are
overloaded with work. This is evidenced not only by the results of
our research, but also by that of the study of Kunecka (2015). This
shows that only 6.5% of the examined nurses spend their time in
accordance with the accepted standards on breaks at work.

There are many studies available among the various
occupational groups showing association between signs of
workaholism (Schaufeli et al., 2009b; Jenaabadi et al., 2016, 2017)
(a phenomenon in which one of the two pillars is excessive
workload) and burnout, usually presented as a general measure.
The results of studies conducted among other occupational
groups particularly exposed to occupational burnout, such as
doctors and teachers, confirm the positive correlation between
the components of workaholism and occupational burnout
(Taris et al., 2005; Schaufeli et al., 2008). In particular, research
conducted among university lecturers in Iran has shown that
excessive workload, as part of workaholism, can be a factor
predicting the occurrence of each of the three dimensions of
burnout defined by Maslach (Hamidizadeh et al., 2014). These
results indicate that correlations of these phenomena may also
occur in other occupational groups identified as particularly
vulnerable to burnout syndrome, including nurses.

The influence of individual manifestations of excessive
workload on occupational burnout among nurses has not been
comprehensively analyzed so far (Manzano-García and Ayala,
2017). The regression model we developed allowed us to describe
the effects of individual components of excessive workload
(WEQ) on the overall occupational burnout rate. Based on this, it
was concluded that the tendency to overburden oneself with work
as indicated by LCW, PWS, OOP measures allows to explain
12.4% of all variability in the level of professional burnout. This
is not an extremely “strong” result, but enables a conclusion
to be made that being overburdened with work is a predictor
of professional burnout. For comparison, the regression model
constructed by Spanish researchers explains the variability of the
burnout rate only in 4% (Gil-Monte, 2008).

According to our results, higher values of LCW and OOP
measures translate into an increase in occupational burnout.
In contrast, the more perfectionistic the work style, the
lower the professional burnout level. Most studies carried
out in this area confirm the existence of certain correlations
between these phenomena. A study conducted on a group of
Italian nurses by Nonnis has shown that excessive workload
affects emotional exhaustion, which is one of the occupational
burnout manifestations (Nonnis et al., 2018). Furthermore,
the study conducted by Włodarczyk confirmed the negative
influence of perfectionism on the formation of occupational
burnout (Włodarczyk and Obacz, 2013). Nurses in Iran

have also been surveyed, confirming a positive correlation
between the overall workload rate and emotional exhaustion,
depersonalization, and professional dissatisfaction (Bemana et al.,
2013; Asgari et al., 2016). What is more, studies carried
out in Italian hospitals have shown the direct effect of
workload on burnout, particularly on emotional exhaustion
(Portoghese et al., 2014). In addition, researches in Portugal
indicate that work overload is one of the predisposing
factors of burnout (Queiros et al., 2013). Finally, research
conducted in Iran has shown that nurses from departments
more exposed to workloads, such as emergency services,
are more likely to become victims of occupational burnout
(Ahmadi et al., 2014).

Health problems of nurses often originate in psychosocial
burdens in the workplace. This is confirmed in numerous
scientific studies on the general impact of stress on the physical
and mental health of employees as well as in detailed research,
e.g., confirming the unequivocally negative impact of bullying on
psycho-emotional aspects of nurse health, and indirectly as one
of the factors causing burnout on the general condition health
of nurses (Arcangeli et al., 2014; Giorgi et al., 2016; Cullati et al.,
2017; Nielsen et al., 2019).

The results of our research have shown that occupational
burnout among nurses measured by the overall rate is
strongly positively correlated with the frequency of taking sick
leaves. A similar result was obtained for two components:
depersonalization and emotional exhaustion. The lack of
correlation with the job satisfaction loss is an exception.
Similar results were obtained by researchers in a group of
nurses in Greece, where a direct correlation between the
physical health of workers and symptoms of burnout was found
(Bellali et al., 2007).

Another hypothesis was that occupational burnout and
excessive workload increase the probability of the sickness
absenteeism of nurses. The subjects of particular interest were
nurses, who had to take advantage of the dismissal at least three
times a year, because such frequent absences can disrupt the
functioning of hospitals. This group constitutes about 15% of
the entire population and is about 8–9 years older than nurses
with less sickness absence. The logistic regression model we have
developed has confirmed the strong effect of general measure
of burnout on the frequency of sick leaves taken by nurses. An
increase in the overall burnout rate of the MBI questionnaire by 1
point increases the probability that an employee will take at least
three sick leaves per year by 2.9%. Similar correlation between
burnout and absenteeism was found in the United States (Dyrbye
et al., 2019) and Brazil (Da Silva and Diaz Merino, 2017), but
no regression model presenting detailed correlation parameters
was developed. A Danish team of researchers, however, identified
occupational burnout as a predictor of sickness absence among
human service workers (Borritz et al., 2010).

The hypotheses made to achieve the aim presented in the
introduction have been confirmed by the study results. The
negative effect of excessive workload on the burnout syndrome
has been confirmed. Thus, increase in professional burnout is
conducive to the sickness absenteeism of nurses.

We would like to draw attention to one more obvious
correlation. The absence of nurses due to health reasons results

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Kowalczuk et al. Working Excessively and Burnout Among Nurses

in an additional workload for their colleagues remaining in
the workplace. Staff shortages mean that nurses replace absent
workers, with excessive workloads or additional on-call time.
Sometimes they stay in the hospital and fill the shortage of staff
in the next shift, immediately after working for one duty shift.
They do so either out of inner sense of responsibility that does
not allow them to leave patients unattended or they use it as
an opportunity to earn extra remuneration. Additional duties
naturally contribute to an increase in the workload, which, in
turn, has effect on burnout and thus creates a cyclical self-
perpetuating mechanism.

METHODOLICAL LIMITATIONS

The sample used, study design (cross-sectional study), lack of
adjustment for possible confounders and low Cronbach’s alpha
value for “oppressiveness of the organization” measure in WEQ
questionaire are significant limitations of the study. The research
was conducted only in three hospitals located in a single region
of Poland. The financial situation of a country influences the
health and workability of workers (Giorgi et al., 2015). Mucci
et al. (2016) found that the economic crisis was an important
stressor that had a negative impact on workers’ mental health and
sickness absence rates. As the economic crisis bypassed Poland,
direct comparisons with findings from other studies should be
done with caution.

Number of sick leaves were self-reported by the respondents
and are influenced by problems that are common to self-report
methodology. The reasons for not taking part in the study by
23% of invited persons are unknown due to the manner the study
was conducted. It is also unknown whether the nurses who did
not participate in the study were more burdened with work than
those who participated in the study, and similarly with regard to
occupational burnout syndrome.

CONCLUSION

(1) Excessive workload and burnout symptoms among nurses
interact in such a way that excessive workload increases

burnout symptoms, which in turn encourages nurses to
take sick leave more frequently. In this way, the resulting
sickness absenteeism is a factor that increases the workload
for nurses who are obliged to work as replacements
for their absent colleagues. Additional duties naturally
contribute to an increase in the workload, which in turn
has effect on burnout and thus creates a cyclical self-
perpetuating mechanism.

(2) The tendency for nurses to overburden themselves with
work may be seen by hospital managers as a positive
phenomenon, but, based on this study, it is clear that this
can only be done in the short term, whereas in the long
term it will be clearly detrimental to the organization of
hospitals and the quality of care. All the necessary measures
must be taken to prevent nurses from becoming excessively
overloaded with work.

DATA AVAILABILITY STATEMENT

The datasets generated for this study are available on request to
the corresponding author.

ETHICS STATEMENT

The studies involving human participants were reviewed and
approved by the Institutional Review Board of the Medical
University of Białystok, ref. no. R-I-002/296/2017. Written
informed consent for participation was not required for this
study in accordance with the national legislation and the
institutional requirements.

AUTHOR CONTRIBUTIONS

KK: concept of the research, design of article structure,
conducting of the research, review of the literature, results
analysis, and writing the article. EK-K: review of the literature and
review of article drafts. MS: statistical analysis.

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Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.

Copyright © 2020 Kowalczuk, Krajewska-Kułak and Sobolewski. This is an open-
access article distributed under the terms of the Creative Commons Attribution
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provided the original author(s) and the copyright owner(s) are credited and that the
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Frontiers in Psychology | www.frontiersin.org 8 February 2020 | Volume 11 | Article 285

  • Working Excessively and Burnout Among Nurses in the Context of Sick Leaves
    • Introduction
    • Materials and Methods
      • Study Group Selection
      • Study Procedure
      • Study Group
      • Description of the Questionnaire and the Applied Measures
      • Statistical Methods
    • Results
    • Discussion
    • Methodolical Limitations
    • Conclusion
    • Data Availability Statement
    • Ethics Statement
    • Author Contributions
    • References

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Available online at www.sciencedirect.com

Nur s Out l oo k 6 9 ( 2 0 2 1 ) 9 6 �1 0 2
www.nursingoutlook.org

Impact of nurse burnout on organizational

De
*Co
E-m
1 D
2 D

Health
0029-6
https:

and position turnover

Lesly A. Kelly, PhD, RN, FAANa,b,1*, Perry M. Gee, PhD, RNa,b,c,d,2,

Richard J. Butler, PhDe,f

aCommonSpirit Health, Phoenix, AZ
bEdson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ

cIntermountain Healthcare, Salt Lake City, UT
dCollege of Nursing, University of Utah, Salt Lake City, UT

eDepartment of Economics, Brigham Young University, Provo, UT
fSouthwestern University of Finance and Economics, Chengdu, China

clarations of Interest: None.
rresponding author. Lesly A.Kelly, PhD
ail address: [email protected]
r. Kelly conducted the research in both
r. Gee conducted the research in his po
care.
554/$ -see front matter � 2020 Elsevier
//doi.org/10.1016/j.outlook.2020.06.008

A B S T R A C T

Background: The National Academies of Medicine describes clinician burnout as a
serious threat to organizational health, including employee turnover.
Purpose: To determine the relationship between resilience, burnout, and organiza-
tional and position turnover.
Methods: We surveyed direct care nurses in three hospitals 1 year apart between
2018 and 2019; 1,688 nurses completed 3,135 surveys included in analysis.
Findings: Fifty-four percent of nurses in our sample suffer frommoderate burnout,
with emotional exhaustion scores increasing by 10% and cynicism scores
increasing 19% after 1 year. The impact of burnout on organizational turnover
was significant, with a 12% increase in a nurse leaving for each unit increase on
the emotional exhaustion scale, though it was not a factor in position turnover.
Discussion: These findings contribute to the growing body of evidence of nurse
burnout and support policies and programs for annual measurement of burnout,
increased employee wellbeing support, and improved work environments.
Cite this article: Kelly, L.A., Gee, P.M., & Butler, R.J. (2021, January/February). Impact of nurse burnout on

organizational and position turnover. Nurs Outlook, 69(1), 96�102. https://doi.org/10.1016/j.

outlook.2020.06.008.

A R T I C L E I N F O

Article history:
Received 12 February 2020
Received in revised form
9 June 2020
Accepted 16 June 2020
Available online October 4, 2020.

Keywords:
Nursing
Burnout
Turnover
Resilience
Wellbeing

, RN, FAAN, CommonSpirit Health, 3033 North 3rd Avenue, Phoenix, AZ 85013.
.org (L.A. Kelly).
her positions at ASU and CommonSpirit Health.
sition at CommonSpirit Health and has since moved into his new position at Intermountain

Inc. All rights reserved.

Introduction and Background

Nursing burnout is a deleterious and consequential
syndrome that affects not only the individuals, but
also the organization and patients in which those
nurses labor. As many as half of the nursing workforce

are experiencing burnout, with likelihood of personal
consequence, job dysfunction, and potential risk to
patients (Dyerbye et al., 2017). An increase in aware-
ness, including the National Academy of Medicine’s
establishment of the Action Collaborative on Clinician
Wellbeing and Resilience (National Academy of Medicine

Nur s Out l o ok 6 9 ( 2 0 2 1 ) 9 6�1 0 2 97

[NAM], 2020) has contributed to efforts to produce out-
come data; however, there is a paucity of quality
research with the nursing workforce and organiza-
tional outcomes. In this analysis, we examine the
influence of nurses’ resilience on burnout, and how
nurse burnout affects subsequent organizational and
position turnover.
Because burnout is characterized through three

classic symptoms of exhaustion, depersonalization
(cynicism), and reduced personal accomplishment
(Maslach & Leiter, 2016), it stands that burnout contrib-
utes to employees leaving their positions. Burned out
individuals may become exhausted doing their best to
care for patients, where the chances of recovery are
minimal. The burned out clinician may express cyni-
cism in uncharacteristic negative behaviors, poor com-
munication with others, and even incivility toward co-
workers. When clinicians are burned out they feel they
are not performing their job responsibilities at the
highest levels, lack motivation, and have poor per-
sonal job related self-esteem. The emotional toll on
health care workers, especially nurses who care for
patients through death, may impact nurses’ own emo-
tions (Wilson & Kirshbaum, 2011). Nurses may feel
reduced personal accomplishment and a lack of satis-
faction in response to job-related stressors and even-
tually leave their position. In addition to the
disruption to patient care, the loss of a nurse leaving
their position is also associated with significant finan-
cial costs, estimated from $11,000 to $90,000 per nurse
with up to $8.5 million in associated wider costs (e.g.,
unfilled vacancies, patient deferment, training and ori-
entations) (Halter et al., 2017).
Despite the hypothesized link, few studies have eval-

uated burnout and actual job turnover in the nursing
workforce, instead using an individual’s intention to
leave their position as a proxy for turnover. A recent
physician study described the relationship between
clinician’s actual turnover and burnout, finding physi-
cians and advanced practice providers to be 1.5 times
more likely to turnover when they had high burnout
(Willard-Grace et al., 2019). Moreover, virtually no
attention has been given to position turnover or the
associated contributing factors (Kovner et al., 2016;
Taylor & Covaleski, 1985). Since studies confirm that
up to one third of nurses leave their position in the first
one to two years of employment (Unruh & Zhang, 2014)
and nationally turnover for nurses is approximately
18% (Nursing Solutions, Inc., 2020), it is critical to eval-
uate the role of burnout in turnover.
To fully understand clinician wellbeing, the role of

resilience, or one’s ability to overcome adversity, must
be evaluated related to burnout and outcomes (NAM,
2018). A growing trend has emerged to generally view
resilience as a method to prevent burnout; while evi-
dence generally describes personal resilience building
activities as support for decreasing stress, improving
coping, and adapting (Kamath et al., 2017; Rees, Breen,
Cusack, & Hegney, 2015; Rushton, Batcheller,
Schroeder, & Donohue, 2015). In the nursing

profession, resilience is required to mitigate burnout,
with many interventions aiming to increase personal
resilience in order to affect organizational culture and
work environment (Rushton et al., 2015). Thus, the
examination of personal resilience must be included
in evaluating the relationship of nurse burnout and its
effect on turnover. The purpose of this study is to eval-
uate the relationship between resilience, burnout, and
both organizational and position turnover.

Methods

A quantitative nonexperimental study was conducted
using a survey of direct care nurses at two points in
time. Institutional review board approval was received
from the health system and the partner university.

Sample

The study was conducted in three hospitals in a single
health system in the United States in March 2018 and
March 2019. The nonprofit health system hospitals
included two community hospitals and one academic
medical center with two facilities under one campus.
We surveyed employed nurses from 78 units who pro-
vided direct patient care. Non-nurses and nurses
whose primary role was not patient care (e.g., leaders,
case management, educators) and advanced practice
nurses were excluded. An estimated 3,574 eligible
nurses were surveyed in 2018 and 3,528 eligible nurses
in 2019.

Measures

Common validated instruments were used to measure
burnout and resilience: the Maslach Burnout Inventory
(MBI) (Maslach, Schaufeli, & Leiter, 2001) and the Con-
nor Davidson Resilience Scale -10 item version
(CDRISC-10) (Davidson & Connor, 2018), respectively.
The MBI measures emotional exhaustion, cynicism,
and personal accomplishment, with higher scores on
the exhaustion and cynicism subscales indicating a
higher burnout, whereas a lower score on personal
accomplishment indicates burnout through decreased
motivation (Maslach, Schaufeli, & Leiter, 2001). As
with previous research, we classified moderate burn-
out as a score of 16�26, and high burnout 27 or higher
on the emotional exhaustion scale (Lee, 2017;
McHugh, Kutney-Lee, Cimiotti, Sloane, & Aiken, 2011).
The CDRISC-10 measures resilience with a total score
of the 10 items, with a higher total indicating increased
resilience (Davidson & Connor, 2018).
The survey included questions asking the nurse’s

age, tenure as a registered nurse, and average hours
worked in a typical week. Additionally, nurses were
asked their race, most common shift work (day/night),
whether they held a national certification in nursing,
and whether they were a member of a professional

98 Nur s Ou t l o ok 6 9 ( 2 0 2 1 ) 9 6�1 0 2

organization. To assess workplace conditions related
to burnout, we asked nurses to recall the number of
patients assigned to their care on their last shift, as a
proxy for staffing/workload, and the number of patient
deaths they were involved with in the last 30 days, to
assess the number of patient deaths nurses were
involved with on average. Finally, we asked nurses
whether they intend to be in their position in 1 year.
Organizational turnover was defined as the nurse

leaving this health care system and position turnover
was defined as an individual leaving their position and
accepting another position within the organization
(Kovner, Brewer, Fatehi, & Jun, 2014). We collected
turnover data from April 2018 to June 2019.

Data Collection

We utilized a third-party honest broker to identify eli-
gible nurses, administer the survey and collect
responses, which allowed us to link year over year
data via the employed nurse’s unique identification
code. Nurses were invited to participate in the surveys
each year through their email. After accessing the sur-
vey through the emailed link, the first page of the sur-
vey included informed consent the nurse must agree
to in order to participate. The same survey was
repeated in both years. The survey was open for 3
weeks each year the study was conducted. Throughout
the 3 weeks of data collection, response rates were
provided by unit and the research team utilized round-
ing and multiple forms of communication to encour-
age participation.
Turnover data was extracted from the health systems

workforce department and matched through the same
employee number used for the survey. Once matched,
data were deidentified by removing employee numbers
and utilizing unique codes for each nurse for analysis.

Data Analysis

All survey data was transferred to the research team
from the third party honest broker. All participants
who completed surveys in both 2018 and 2019 were
included in analysis, with standard errors clustered
for each nurse to account for if the nurse took the sur-
vey in both years. We utilized a recursive regression
modeling structure (Thiel, 1971) to evaluate the path-
ways from resiliency, to nurse burnout, and then sub-
sequently organizational and position turnover. This
recursive modeling structure follows an intuitive
development of resiliency to burnout through the
examination of how independent variables lead to
dependent variables without a feedback loop. Fixed
effects (for each unit) linear regressions were used to
predict nurse burnout (partially determined by resil-
iency) and separate regressions were used to predict
organizational and position turnover (partially deter-
mined by resiliency and burnout, as measured by emo-
tional exhaustion). We estimated organizational and
position turnover using all survey data with

nonmissing values, with 15 months of turnover expo-
sure risk for 2018 survey respondents (3 months for
2019 respondents) and controlling for the exposure in
measuring turnover with year fixed effects, as well as
all other controls including departmental fixed effects.

Limitations

Our study is limited to one system in a single state,
however, we report on a large sample of three hospi-
tals across 78 departments. The demographics, work
conditions, technology, and regional practices of the
area may affect generalizability. Our response rate is
average to surveys with the nursing workforce; how-
ever, response bias may be present and influence the
validity of the results. Although we collected data at
two points in time, continued longitudinal data may
provide more information about the workforce trends
over time. A limitation of all prospective analyses of
turnover, including ours, is that the time frames in
which a turnover is observed are right censored. In our
models, we control for the differential censoring
between 2018 and 2019 with year fixed effects.

Findings

In 2018, a total of 1,834 surveys (51% response rate)
were returned and in 2019,1,632 surveys (46% response
rate) were returned. The final analytic sample on com-
plete outcome data was conducted on 3,135 surveys.
This sample comes from 1,688 nurses in 78 units.
We find that 54% of nurses in our sample to be

experiencing burnout (emotional exhaustion score
above 16), with 28% of nurses experiencing high levels
of burnout (score above 27). On average, nurses in all
units report exposure to patient death at a rate of one
death every other month (0.477 deaths per month), but
variance within the sample demonstrates two high
acuity areas, intensive care units and emergency<