adolescence is characterized by evolving personality , impulsivity , rebellion , and deviation from established adult norms , often leading adolescents to take higher personal risks without realizing short- or long - term consequences [ 13 ] . this behavior is age appropriate to some extent , reflecting the neurodevelopmental chronology of the human brain . this risk taking translates into many arenas of preventable adverse health outcomes including motor vehicle accidents , tobacco use , alcohol and drug use , unsafe sexual activity , and interpersonal violence . the developmental changes that define the teenage years occur across all demographic and culture groups in the usa and globally . according to the usa census bureau ( 2005 ) , 33.9% of the latino population was under 21 years of age , making health care of latino youth an important and relevant issue . yet , latino youth , in particular , face systemic language and cultural barriers to accessing care and information , making it increasingly difficult to make healthy personal decisions . not only are minority adolescents at higher risk of health and behavioral problems during adolescence , but they also face several barriers in accessing care that are inadequately addressed within the health system , including no insurance , lack of knowledge about the medical system , and limited transportation . an estimated 9 million adolescents are uninsured ; those in low - income families , single - parent households , and latino are at the highest risk for being medically uninsured [ 79 ] . compared with their insured counterparts , uninsured adolescents were five times as likely to lack a usual source of care , four times as likely to have unmet health care needs , and twice as likely to go without physician contact during the course of a year . in addition , outside sources of health information and education for high - risk teens are inconsistent . health education depends on the quality of classroom teaching , the access to computers and the internet , and the health education levels of the surrounding community , all affecting health literacy . latino youth are particularly vulnerable to the lack of available and culturally appropriate health education . for minority teens who may not be able to depend on other means of information , the health care system has a critical role in delivering accurate and available adolescent health information . yet , gaps have been identified between the health information that teens want from the health care system and what is received . latino students have higher pregnancy and std ( gonorrhea , chlamydia , syphilis , and hiv / aids ) rates than white non - hispanic youth . physicians have been given guidance on adolescent screening and counseling by the american medical association ( ama ) general adolescent preventive services ( gaps ) . gaps addresses the developmental , physical , and psychosocial health and serves as a comprehensive framework for preadolescent and adolescent services for patients between 11 and 21 years of age . these guidelines outline which topics should be addressed at each developmental stage and coincide closely with the top risk behaviors assessed by the centers for disease control ( cdc ) from the youth risk behavior survey . gaps exists to increase health promotion and reduces teen morbidity and mortality by addressing teen risk factors . the purpose of our study was to examine the gaps between teen risk behaviors , identified in the course of baseline interviews for an nih funded research study , and subsequent disclosure at health care visits , in this case the initiation of care for latent tuberculosis . this juxtaposition allowed for the exploration of providers ' assessment and documentation of adolescent risk behavior and the extent of adolescent disclosure to providers against the revealed risk behaviors in the health - study setting . the providers included physicians , nurse practitioners ( np ) , and physician assistants ( pa ) . this was a cross - sectional study based on baseline data from a larger study ( national heart , lung , and blood institute , national institutes of health , grant no . the larger study was a tb medication adherence trial that examined the difference in adherence to isoniazid ( inh ) for the 9-month recommended regimen between two groups of san diego county high school students receiving peer counseling . the participants in this study were public high school students aged from 13 to 19 , in southern san diego county , who tested positive for ltbi during school screenings . participants agreed to inh therapy subsequently initiated with a san diego - based health care provider , agreed to participate in the inh compliance study , and signed a medical release form granting access to their medical charts . out of the 540 adolescents eligible for the study , 285 ( 52.8% ) were recruited , and 263 ( 92.3% ) were retained for analyses . other than the refusal to participate , other reasons for not enrolling or continuing in the trial included disclosure of pregnancy , leaving home , refusal by their physicians to prescribe inh treatment , or ltbi treatment already initiated in mexico . the parent study included participants with a positive tuberculin skin test who agreed to treatment and consent . for this analysis , we included only those participants attending at least one provider visit for the treatment for latent tuberculosis . for participants under 18 years of age , parental written consent and subject assent were obtained . all participants and parents / guardians of minor participants were asked to sign a medical records release form and received the participants ' bill of rights . following informed consent and assent and prior to seeing a physician to initiate inh , trained research assistants of the same gender as the participant administered baseline interviews . information was gathered on demographic characteristics , acculturation , health care barriers , risk behaviors , parenting practices , past healthcare use , medication - taking behavior , social support , self - esteem , tb knowledge and exposure , and use of adherence aids for medical regimens . not all participants had to answer every question as skip patterns were used when the screening question was negative . interviews took place in a location that was out of hearing range of anyone other than the participant and the interviewer and confidentiality was verbally emphasized . signed medical records release forms were collected ; medical records were requested 12 months after enrollment and obtained by mail or fax . due to variability in the number of visits provided by the providers and the practice of nurse - only visits for chemoprophylaxis refills , only the first visit was used in this analysis . the time period was generally short between the interviews and the first visit with the provider , less than 3 months . participants were asked several demographic ( age , country of birth , and education ) and social ( employment and school activities ) questions . behavioral risks were assessed by 260 questions addressing several health and risk behaviors , including diet , exercise , mental health , birth control , sexual activity , tobacco use , alcohol and other substance use , injury prevention , violence , and dental health . for the purpose of this report , only the 85 questions related to tobacco , alcohol , substance use , sexuality , exercise , and violence were included . while the survey as a whole was not validated , the questions were based on 20 years of study questions in assessing adolescent risk behavior . after the first visit to the provider , medical charts for each participant were examined for the following items : ( 1 ) documentation of provider screening for high - risk health behavior , ( 2 ) documentation of provider taking any action such as counseling or referrals to specialists , laboratory tests , or prescriptions written as a result of any identified risky behavior , and ( 3 ) characteristics of the clinic , type of insurance , and provider type ( e.g. , md , np , pa ) and specialty , if applicable . charts were reviewed by a ca - licensed physician investigator ; 10% of charts received a second review by a licensed rn / mph investigator for quality assurance . the baseline provider interview was reviewed for behavioral risk factors which the participant reported during the prior year . charts were reviewed for health and risk behavior assessments , responses , and actions taken , with frequency calculations . the majority of participants ( 96% ) were identified as hispanic , 45% were foreign - born , and 46% were male . participants were reasonably well distributed across all four grades of high school , with a mean age of 15.9 years ( range : 1319 years ) . a wide range of yearly household income was reported by the parents , with a mean of $ 20,000$29,999 dollars per year ( range : from 0 to $ 50,000 + a year ) . valid data were available on 221 ; the other 11 records were incomplete and did not include a record of the appropriate visit . during their first ltbi visit , participants were primarily seen ( 74% ) by physicians ( md / do ) , with the remainder by nurse practitioners ( np ) and physician assistants ( pa ) . the majority were seen in federally qualified community health centers ( 73% ) , private practices ( 17% ) , the county health clinic ( 6.3% ) , and large group practices ( 5% ) ; missing data and other settings accounted for 2% . the 221 teens had revealed to the project staff a total of 399 risk behaviors : tobacco : 41 ( 20 females ) ; alcohol : 162 ( 84 females ) ; street drugs : 32 ( 20 females ) ; sexual exposures : 41 ( 23 females ) ; lack of exercise : 39 ( 31 females ) ; and interpersonal violence 51 ( 18 females ) . the use of birth control was reported in 34 of participants ( 18 females ) ( table 1 ) . the only significant gender differences found were the risks of lack of exercise ( females at greater risk ) and violence ( males at greater risk ) . the risk behaviors were distributed as follows : 8 participants ( 3.6% ) reported zero risks , 66 reported one risk ( 30% ) , 72 ( 33% ) reported two risks , 36 ( 16% ) reported three risks , 23 ( 10% ) reported four risks , 13 ( 6% ) reported five risks , and 3 ( 1.4% ) reported six or more . the charting documented screening for these risk behaviors varied from 3% for violence to 52% for tobacco . there were 41 ( 19% ) ( 20 females ) teenagers who reported tobacco use in their baseline interview to the research staff . an assessment of tobacco use was documented in 114 ( 52% ) ( 59 females ) of medical encounters , more than for any other substance . this higher level of assessment reflects the inclusion of tobacco use and exposure in some previsit vitals assessment done by the medical assistant . of the 41 teenagers who reported tobacco use to the research staff , providers documented asking 21 . only one teen ( a female ) reported tobacco use to their providers , and this teen received counseling ; two additional teens had generic tobacco cessation counseling documented . almost three - fourths ( 162 ; 73% ) participants ( 84 females ) reported alcohol use in the baseline tb study interview . providers documented asking about alcohol use to 48 ( 22% ) ( 25 females ) participants and identified only five participants ( 3 females ) who reported alcohol use , four of whom received counseling from their provider ; two additional teens received nonspecific antialcohol advice . of the 162 teenagers reporting alcohol use to the research staff , providers documented asking 32 . interviews of teens by the project staff revealed a total of 32 ( 15% ) ( 20 females ) cases of current or past drug use , with the most commonly used substances being marijuana ( 20 ) , diet pills ( 10 ) , and inhalants ( 4 ) . drugs used by only one to two participants included methamphetamines , cocaine , speed , lsd , and ecstasy . more providers documented screening for drug use than alcohol use , occurring in 89 ( 40% ) ( 45 females ) of the 221 assessed office encounters ; however , only one teen ( a female ) admitted drug use . of the 34 who reported drug use to research staff , providers documented asking 10 . four teens ( 2 females ) received targeted and/or generic counseling by the provider . in interviews with project staff , teens were asked about their histories of sex , vaginal sex , anal sex , and oral sex . a total of 41 ( 19% ) ( 23 females ) teens reported a sexual history : 37 reported vaginal sex , 1 reported anal sex , and 17 reported oral sex . interestingly , participants appeared to be more forthcoming to providers about their sexual activity than their substance use . of the 38 participants ( 23 females ) who were asked about sex by their providers , eight ( 7 females ) reported sexual activity . providers took some type of action in all eight cases and did generic counseling in an additional participant . of the 41 teens reporting sexual behavior to the research staff , providers documented asking 12 . project staff collected data regarding birth control use for the teens that reported any type of sexual history . a total of 34 ( 15% ) ( 18 females ) participants reported a history of birth control use , with control methods including condoms ( 34 ) , pills ( 5 ) , and the long - acting progesterone shot ( 1 ) . no participants reported use of a patch , implantable device , diaphragm , sponge , or spermicide . of the 31 ( 19 females ) participants asked about birth control , seven participants ( 6 females ) reported birth control use to their providers , and providers documented an intervention in all of these cases . providers assessed physical activity in 21 of the 221 encounters . although 38 ( 17% ) ( 31 females ) teens admitted a grossly sedentary lifestyle to research staff ( < 20  min exercise / week ) , providers identified two sedentary youth ( 1 female ) ; three received targeted and/or generic counseling . the interview assessed violence , fights , or carrying weapons in the last 12 months . a surprisingly high number of teens , 51 ( 23% ) ( 18 females ) , screened positive for violence , including fights and weapons . one teen reported carrying a gun , 10 carrying a knife , and eight reported carrying a club . of the six participants ( 4 females ) screened for violence by their providers , none admitted to a positive history of violence . this study confirmed the gap between adolescent risk behaviors and the disclosure of these behaviors to health professionals . of the total of 399 risk behaviors reported to the research project staff by participating teens , only 24 risk behaviors were disclosed to the providers . all but six teens reported at least one risk factor to project staff at baseline . the only significant differences by gender in behaviors reported to project staff were the baseline exercise assessment , with females significantly more likely not to exercise , and violence , with males at greater risk . although the primary purpose of the office visit in this study was for initiating inh therapy , the presence of a teen in any clinic setting should prompt inquiry and appropriate counseling for risk behaviors . a recent study documented that only 38% of adolescents had received preventive care visits in the last two years , and hispanics and low - income adolescents were the least likely to receive such visits . in addition , these preventive services are often not covered during a routine well - child exam . thus , one can not rely on the well - child exam alone to identify youth with high - risk behavior or to provide anticipatory guidance to teens . recent efforts to provide more patient - centered care are supported by this study , suggesting that nonphysician staff may be appropriate to elicit sensitive medical information from adolescents . a unique component of this study is the prior confidential assessment of self - disclosed risk behaviors to ethnically similar research staff by the participants . this enabled the comparison of the risk behaviors reported to trained research assistants in confidential settings with those elicited and reported to their providers and documented in their medical records . several barriers were identified in this study that prevented providers and participants from discussing behavioral risk and risk avoidance strategies . first , providers either failed to inquire about behavior in the majority of cases in all risk areas or properly failed to document their inquiry . providers missed almost all of the teen alcohol use , missing an opportunity for counseling in a very young drinking group . second , when participants were asked about risk behaviors by providers , they did not disclose their risk behaviors to their providers to the same degree as they did with project staff . this difference was most evident with substance use , including tobacco ; however , teens were more forthcoming to providers about sexual activity and birth control . this may represent the teens ' perceived benefit of discussing sexual health in a medical setting , such as access to family planning resources . the paucity of questioning is concerning given a recent report that low - income and minority children receive more counseling during routine care than other groups . an additional factor , one that we were unable to assess by the chart review , was the opportunity for teens to speak privately and confidentially with their providers . several steps can be done to increase the likelihood of disclosure by teens , thus creating opportunities for prevention and counseling . provider education and awareness campaigns may be necessary to improve routine risk behavior screening in all encounters , as we have done for immunization . time issues may also play a role , with many competing priorities in the primary care visit . in order for teens to volunteer information about their own behavior , questions need to be asked in a nonjudgmental , confidential , and teen - friendly way . although this study did not look at methods for questioning and provider interactions with teens , the difference in reports to researcher versus providers in this study suggests a deficiency in provider - patient rapport . the limitations of this study include the accuracy of self - report and chart review . chart review included not only the progress notes but also lab notes , problem lists , immunization lists , and other sources of information in the chart . in the project interviews , every attempt was made to obtain accurate self - report in a both a neutral manner and confidential setting by trained , bilingual research assistants . the chart - review data were obtained on the first tb - related visit , and there is certainly a chance that on subsequent visits , that were not part of the chart audit , providers did appropriately query about health risk behaviors . in addition , this project was limited to the behavior and practice of providers located in southern san diego county located clinics and private practices and may not represent other providers ' practices locally , regionally , or nationally . this study was not a prevalence study , and the population has some unique features . nonetheless , this study highlights the gaps between teens high - risk behavior , their disclosure , and subsequent provision of counseling , which are likely generalizable . adolescents engage in high - risk behaviors , and providers have the opportunity to provide evidence - based and effective counseling if these behaviors are identified . all contacts with the medical system should be used to discuss common behavioral risks , as recommended by the ama and gaps guidelines . greater effort to employ sensitive and trusted providers ( e.g. , lvns ) to obtain more complete reports of risk practices should be considered as a routine process prior to physician , np , or pa appointments . this study revealed multiple barriers to the identification of risk factors by physicians of high - risk teens . physicians should be aware that their adolescent patients are often engaging in high - risk behaviors and that adolescents limit their disclosure of this information .
objective . 
 the purpose of this study was to determine the gaps between disclosed high - risk behaviors in low - income , mainly hispanic youth and the identification of these risks by health care providers . 
 methods . this cross - sectional study included youth 1319 years old who participated in a study on latent tuberculosis treatment . 
 youth were interviewed at baseline by bilingual research assistants ; the provider visit was assessed by the chart review . 
 results . of 221 youth , the majority ( 96% ) were identified as hispanic , 45% were foreign - born , and 46% were male . 
 a total of 399 risk behaviors were revealed to research staff by the participants ; only 24 risk behaviors were revealed to providers . 
 conclusions . 
 the majority of risk behaviors based on the chart review were neither queried nor disclosed to the physicians . 
 physicians providing care to adolescents should consider strategies to improve disclosure as a necessary precursor to interventions .