Confidentiality and adolescents' use of providers for health information and for pelvic examinations

Primary care providers' reports of time alone and the provision of sexual health services to urban adolescent patients: results of a prospective card study

Confidential care is an essential element of quality adolescent primary care. Twenty-one primary care providers tracked provision of confidential care (time alone with adolescent) and sexual health services in clinics serving low-income, primarily minority communities. Over 144 visits attended by a parent, 68% involved time alone with the adolescent. Time alone was 18 times higher for physicals than same day or walk-in visits, and 3 times higher if teen presented a sex complaint. Provision of sexual health services was 3 times higher for those who had time alone with the provider, especially among girls. The results indicate some missed opportunities to deliver needed services to at-risk populations, especially among boys.

Adolescents' preferences for primary care provider interactions

PURPOSE

Adolescents receive less primary care than other age groups. One reason may be the negative ways that providers sometimes interact with adolescents. The purpose was to develop knowledge regarding adolescents' preferences for provider interactions.

DESIGN AND METHODS

Design was descriptive and mixed method. Donabedian's healthcare quality model guided the study. Data were collected via focus groups and a survey.

RESULTS

Twenty-four adolescents participated. Four themes described their preferences: forming a relationship, supporting independence, assuring confidentiality, and conveying caring.

PRACTICE IMPLICATIONS

Care that is congruent with adolescents' preferences may improve quality of, and access to, care and, ultimately, health outcomes.

Current pediatrician practices in identifying high-risk behaviors of adolescents

OBJECTIVE

In the United States, 15- to 24-year-olds represent approximately 14% of HIV cases diagnosed in 2006 and almost 50% of the 19 million sexually transmitted infections (STIs) reported annually. This survey assessed pediatricians' practices regarding preventive health care screening, provision of reproductive health services including HIV and STI screening and counseling, and barriers to providing these services.

METHODS

A random-sample mailed survey of 1626 US members of the American Academy of Pediatrics in 2005.A total of 752 completed questionnaires were returned (46% response rate). Analysis was limited to the 468 pediatricians who provided health supervision visits to patients who were older than 11 years.

RESULTS

Most pediatricians discussed sexual activity at preventive care visits; similar numbers discuss abstinence (62%), condoms (61%), and STIs (61%) with slightly fewer discussing HIV (54%). Pediatricians occasionally or rarely/never discussed homosexuality/sexual identity (82%). Most (71%) identified adolescents with high-risk behaviors by clinical interviews. Approximately 30% prescribed condoms, 22% distributed condoms, and 19% provided condom demonstrations. Whereas 46% of pediatricians recommended STI tests for all sexually active teens, only 28% recommended HIV testing for this population. Hospital/clinic-based and inner-city practitioners were more likely to prescribe, provide, and demonstrate condoms and recommend HIV/STI tests for sexually active teens. The most frequently identified barrier to HIV and STI prevention counseling was lack of time.

CONCLUSIONS

Pediatricians believed it is important to deliver reproductive health services, and most addressed adolescent sexual activity at preventive care visits but did not routinely address homosexuality/sexual identity. Counseling and testing practices varied by physician characteristics.

It is more than just a reproductive healthcare visit: experiences from an adolescent medicine clinic

The gynecologist may be the only physician that an adolescent depends on for primary and reproductive healthcare services. Because adolescent females often make personal healthcare decisions without the benefit of supportive parents/caregivers, it is imperative that the gynecologist understands the developmental issues encountered during this phase of life. The objective of this study is to identify cited complaints of adolescent females seeking reproductive care and, thus, provide gynecologists with needed information about the medical/mental health issues that may be encountered during routine reproductive care exams. The study group was adolescent females between the ages of 12 and 20 years old. The medical records of 479 adolescent females seeking reproductive care from an adolescent medicine clinic at a southeastern teaching medical center were reviewed to determine the most frequently cited medical/mental health complaints of adolescent females initiating a "routine" gynecological exam. Results indicated that adolescent females present for "routine" reproductive care exams with a myriad of concerns without formally requesting medical/mental health intervention upon initial presentation. The identified primary healthcare needs of adolescent females seeking reproductive healthcare include: 1) issues related to reproductive dysfunction (60%); 2) gastroenterological pain/issues (15%) 3) mental health issues (15%) and 4) general medical physical complaints (10%). Gynecologists are often asked to serve as a primary care provider as well as a reproductive healthcare specialist. Identification of the specific healthcare needs (reproductive and otherwise) of adolescent females will assist gynecologists in being uniquely prepared to practice in the setting of their choice.

Primary care follow-up plans for adolescents with substance use problems

OBJECTIVE

Primary care visits provide an opportunity to screen adolescents for substance use and offer early intervention, but little is known about follow-up plans. The objective of this study was to determine recommendations by PCPs and assess the relationship between their diagnostic impressions of substance use severity and plans for intervention.

METHODS

Data were collected through a prospective observational study conducted at 7 primary care practices in New England. Patients aged 12 to 18 years completed an interview, which included sociodemographic characteristics and the CRAFFT substance abuse screen. PCPs received screen results, noted their diagnostic impression of participants' substance use severity, and recorded follow-up plans. Follow-up plans other than "periodic screening" alone were defined as "active intervention." We examined the relationship of provider impressions with follow-up recommendations by using the chi(2) test.

RESULTS

For 2034 adolescents, PCPs recommended no plan for 369 patients, periodic screening for 1557 patients, a return visit for 98 patients, and referral to counseling for 44 patients. PCPs' diagnostic impressions identified 97 (4.8%) patients with problem use and 19 (0.01%) patients with abuse or dependence. Recommendations for active intervention were more likely with patients' higher severity of use. However, 1 in 5 patients thought to have problem use did not receive a recommendation for an active intervention. Parent notification was planned for only 13 patients.

CONCLUSIONS

When concerned about substance use, PCPs recommend a return visit to their office more than twice as often as referral to counseling, and rarely planned to engage parents. PCPs need enhanced training and strategies for delivery of office-based interventions.

[Youth-friendly outpatient care]

Ambulatory pediatric and family medicine takes care of adolescent patients, most of whom regularly consult a physician. Consultations with young people involve issues specifically related to their age. Regarding health care systems and physicians, adolescents' expectations vary from those of adults, not so much in terms of the issues discussed but in terms of the priorities that they give to them. Confidential interviews are not always proposed but are highly appreciated, as are certain personal qualities on the part of the caregivers such as honesty, respect, and friendliness. Finally, easy access to care together with the continuity of care are essential. Prevention of risk behaviors by screening and health education is clearly insufficient. This issue could be approached during the consultation through a psychosocial history. This is a good opportunity to discuss sensitive issues that adolescents seldom bring up themselves. More systematic prevention would probably decrease youth morbidity and mortality, which are both closely related to risk behaviors. To meet these expectations and special health care needs, the World Health Organization has developed the concept of youth-friendly health services. This concept can be applied in both a specialized adolescence center and a pediatric or family practice. Youth-friendly services are still rarely evaluated but seem to bring a clear benefit in terms of patient satisfaction and access to care.

Sub-Saharan African university students' beliefs about condoms, condom-use intention, and subsequent condom use: a prospective study

Whether certain behavioral beliefs, normative beliefs, and control beliefs predict the intention to use condoms and subsequent condom use was examined among 320 undergraduates at a university in South Africa who completed confidential questionnaires on two occasions separated by 3 months. Participants' mean age was 23.4 years, 47.8% were women, 48.9% were South Africans, and 51.1% were from other sub-Saharan African countries. Multiple regression revealed that condom-use intention was predicted by hedonistic behavioral beliefs, normative beliefs regarding sexual partners and peers, and control beliefs regarding condom-use technical skill and impulse control. Logistic regression revealed that baseline condom-use intention predicted consistent condom use and condom use during most recent intercourse at 3-month follow-up. HIV/STI risk-reduction interventions for undergraduates in South Africa should target their condom-use hedonistic beliefs, normative beliefs regarding partners and peers, and control beliefs regarding technical skill and impulse control.

Current issues in adolescent immunization

Based on the December 2006 Fondation Mérieux International Scientific Symposium, the current state of adolescent immunization is reviewed with a focus on the policy and programmatic issues that impact the acceptability, initiation, and successful implementation. Key questions are identified with proposed strategies to help achieve successful adolescent immunization programs. The role of current vaccines targeted to adolescents, such as those directed against invasive meningitis, pertussis, and the human papillomavirus, is reviewed as well as their role in rejuvenating interest in adolescent immunization, and more importantly, adolescent health as a whole.

Enhancing the relationship and improving communication between adolescents and their health care providers: a school based intervention by medical students

OBJECTIVE

To develop, implement and evaluate a workshop to help adolescents develop independent and active relationships with their physicians.

METHODS

A needs-assessment survey informed the development of a workshop delivered by medical student volunteers and incorporated into the career and personal planning curriculum of high schools in Vancouver, Canada.

RESULTS

Over a 6-year period, 64 workshops were delivered by 181 medical students to 1651 high school students in six schools.

CONCLUSION

The workshop is acceptable, do-able, effective and sustainable, characteristics that arise from the mutual benefits to all the groups involved: the medical school, the school board, the medical students, the high school teachers and students. The workshop provides a model for providing health care education to adolescents in the community.

PRACTICE IMPLICATIONS

Teaching adolescents the importance of good doctor-patient communication encourages them to take ongoing responsibility for their health care and is an alternative route to direct health care education.

Predictors of timely initiation of gynecologic care among urban adolescent girls

PURPOSE

To determine whether or not critical sexual health services are delivered to low-income girls, and to identify predictors of timely initiation of gynecologic care for sexually active adolescent girls. Few studies have addressed the interval between sexual debut and risk-appropriate primary care services.

METHODS

We conducted an anonymous, cross-sectional, laptop-based, self-administered branching survey of 9th-12th grade girls in three Bronx public high schools (n = 819).

RESULTS

Over half (60.0%) had an opportunity for confidential care at last clinical visit. Only 27% of sexually active girls had informed any clinician that they had been sexually active; 45% had ever had a pelvic exam. The mean interval between sexual debut and initial pelvic exam (our proxy for gynecologic care) was 13.3 months (range = 0-70 months, SD = 11.8 months). Cox proportional hazard modeling identified four predictors of time to first pelvic exam: experience of sexually transmitted infection (STI) or pregnancy (hazard ratio [HR] = 1.9), having disclosed sexual activity to any clinician (HR = 1.7), access to confidential care (HR = 3.1), and high self-efficacy for accessing confidential care (HR = 2.1).

CONCLUSIONS

Most sexually active girls have not told a clinician that they are sexually active and many have not had counseling related to sexual health. Delay between sexual debut and initial pelvic exam is substantial for low-income urban girls, and often occurs in reaction to pregnancy or STI. Setting of usual care does not predict timely gynecologic care, but access to confidential care does.

Adolescents' knowledge of and attitudes toward Minnesota laws concerning adolescent medical care

BACKGROUND

Healthcare delivery to adolescents involves consent to care, confidentiality, and reimbursement in attendance to patients' medical problems. State laws address the medical care of minors with respect to privacy and autonomy. This study was conducted to determine adolescents' knowledge and attitudes toward the laws in their state, Minnesota, that influence their medical care. This information may guide health care providers in their education of adolescent patients, as well as advise future legislation on the healthcare of minors.

METHODS

Written questionnaires were administered to 636 9(th) through 12(th) grade students in required classes at the three public high schools in Rochester, MN, providing a representative sample of approximately fifty participants from each of the four grades. Results from the sixteen-question, anonymous survey were compiled to calculate an overall median knowledge score. Median scores were also reported by individual question, policy category, gender, grade, and socioeconomic status. Adolescent opinion was scored on a system in which +1 signified a "good law," 0 "neither a good nor bad law," and -1 a "bad law." These opinion scores were used to determine adolescents' attitudes by category as well as an overall positive, negative, or neutral opinion toward the laws.

RESULTS

594(93.4%) students returned surveys. Adolescents obtained a median score of 31.3% (range, 0-100%) correct on a knowledge test. Opinion score was positive, with a median of + 0.38. 81.1% of adolescents reported that the laws in the survey had no effect on their lives.

CONCLUSIONS

These results indicate that adolescents are not knowledgeable of Minnesota laws regarding their medical care. Overall opinion of the existing laws is positive, particularly of those laws that protect minor consent. Most adolescents feel that these laws have not affected their lives. Low knowledge and a lack of a sense of impact from these laws indicate a need for clinicians to educate patients and their families about the legal aspects of adolescent medical care. These results are particularly relevant at a time when changes to current minor health care legislation are under consideration.

Growing up and moving on. A multicentre UK audit of the transfer of adolescents with juvenile idiopathic arthritis from paediatric to adult centred care

OBJECTIVE

To assess the provisions made for the transfer of adolescents with juvenile idiopathic arthritis to adult rheumatology clinics in the UK and the impact of a transitional care programme.

METHODS

An audit of the documentation of the provisions made for transfer in 10 centres participating in a controlled trial of transitional care. Each centre conducted a retrospective case note audit of the recent patients transferred to adult care before and 12-24 months after the start of the trial. Demographic details, age when transition was first discussed, age at transfer, transitional issues, multidisciplinary team involvement, adolescent self advocacy, and readiness were documented.

RESULTS

There were improvements at follow up in documentation of transitional issues, disease specific educational needs, adolescent readiness, and parental needs with the exception of dental care, dietary calcium, and home exercise programmes. The age at which the concept of an independent clinic visit was introduced was lower (mean (SD): 16.8 (1.06) v 15.8 (1.46) years, p = 0.01) but there were no other changes in age related transitional milestones. Significantly more participants had preparatory visits to the adult clinic, had a transition plan, and had joint injections while awake at follow up.

CONCLUSIONS

The improvement in documentation suggests that involvement in the research project increased awareness of transitional issues. The difficulty of changing policy into practice was highlighted, with room for improvement, particularly at the paediatric/adult interface. The reasons for this are likely to be multiple, including resources and lack of specific training.

Factors that influence adolescent reports of counseling by physicians on risky behavior

PURPOSE

To determine factors that affect whether low-income adolescents report that their doctor talked with them about risky behavior.

METHODS

Random digit-dial survey of low-income adolescents in New York City asking about depression, smoking, alcohol use, and sexual activity and the screening and counseling they received on these risk factors and risks during health visits.

RESULTS

Prevalence of counseling by physicians was low, according to adolescent reports, ranging from 17% of adolescents counseled about depression to 52% about sexually transmitted diseases. Older adolescents were more likely than younger to receive counseling about all topics. In bivariate and multivariate models, having the risk factor was strongly associated with physicians counseling for depression (adjusted [adj.] OR = 4.42; p < 0.001); for sexual activity and counseling about condom use (adj. OR = 4.06; p < 0.01), and birth control (adj. OR = 2.76; p < 0.03). Still, many adolescents at risk had not received counseling. Many adolescents have not had a private and confidential visit with their provider. Having a private and confidential visit was also associated with receipt of counseling.

CONCLUSIONS

Adolescents are not receiving sufficient counseling about risks and risky behavior, according to their own reports. There is need to improve delivery of counseling and ensure that private and confidential visits are provided to youth.

Confidential health care for adolescents: reconciling clinical evidence with family values

Community debate about confidential health care for adolescents was triggered recently by the federal government's proposal to allow parents of teenagers aged 16 years and under access to their children's Health Insurance Commission data without their consent. Extensive research evidence highlights the importance of confidentiality in promoting young people's access to health care, particularly for sensitive issues such as mental and sexual health, and substance use. Involving parents is important, but evidence for any benefit from mandatory parental involvement is lacking. The law recognises the rights of mature minors to make decisions about their medical treatment and to receive confidential health care; however, the doctor must weigh up certain factors to assess maturity and ensure that confidentiality around such treatment will be in the young person's best interests. Evaluation of maturity must take into account characteristics of the young person, gravity of the proposed treatment, family factors, and statutory restrictions.

Primary care providers' willingness to see unaccompanied adolescents

PURPOSE

To describe primary care practitioners' office policies and willingness to provide medical care for unaccompanied adolescents aged 11-17 years.

METHODS

A unique 32-item survey was mailed in June and July, 2001 to 1979 office-based pediatricians and family practitioners randomly selected from the American Medical Association's physician database. The survey included questions regarding demographic information, number of adolescents seen in the practice, office policies regarding adolescents alone in the clinic, and 5-point Likert scales regarding their willingness to see patients in various situations, as well as to see patients in 12 brief clinical scenarios. Predictors of the willingness to see adolescents alone were identified and entered into binomial logistic regression models. Specific policies included on the surveys were coded into groups.

RESULTS

Survey responses (n = 710) represented a 36% response rate. This sample included 288 family practitioners and 368 pediatricians; 43.3% of physicians reported having a specific policy regarding seeing adolescents without their parents present. Family practitioners were more likely than pediatricians to report having such a policy (51.3% vs. 38.2%, p =.001,), yet pediatricians reported a higher percentage of adolescents in their practices than family practitioners (22.6% vs. 12.4%, p <.0005). Not having a policy was an independent predictor of "often" or "always" seeing an adolescent alone for routine health maintenance (OR = 2.84, 95% CI 1.91-4.24) and urgent care visits (OR = 3.01, 95% CI 1.90-4.77). Specific policies varied, and many physicians assessed each case on an individual basis.

CONCLUSIONS

Specific policies are associated with a decreased willingness of physicians to see adolescents who are unaccompanied by a parent. Carefully developed clinic policies that are consistent with legal guidelines should be implemented in order to maximize adolescents' abilities to access care.

Perspectives of patients with cystic fibrosis on preventive counseling and transition to adult care

The purpose of this study was to investigate how adolescents and adults with cystic fibrosis (CF) view preventive counseling and their transition to adult-centered care within a children's hospital. Thirty-two patients >/=16 years old diagnosed with CF were recruited from a pediatric tertiary care setting. During face-to-face interviews, patients were asked 27 structured questions and completed a 30-item self-administered questionnaire on preventive counseling by healthcare providers and on transition issues. The median age of patients was 25.5 years (range, 16-43 years); 69% of patients identified a pulmonologist as their "main doctor," even though 78% had a primary care provider. Participants felt that 13-16 years of age was the best time for them to begin spending time alone with their main doctor. Less than half of the participants recalled receiving preventive counseling during the previous 12 months, and more patients wanted to discuss issues than actually did. Qualitative data emphasized the importance of independence in making decisions in healthcare and establishing relationships with providers, and many patients did not desire to transfer care to an adult hospital. Participants identified adult-focused services such as inpatient rooms, discussion groups, work options, and social service support that would enhance care. In conclusion, the majority of adolescent/young adult patients with CF receiving care in a pediatric institution reported satisfaction with their healthcare. However, patients identified preventive issues that they desired to be more regularly addressed, starting in early adolescence, and changes in the delivery of services to enhance transition to adult-oriented care. This study underscored the understanding of the integration of transition planning into the facilitation of healthcare decision-making by the adolescent in issues of self-care, sexuality, education, and finances. Future initiatives to enhance the care of patients with CF should provide training of pulmonologists in preventive care and increased attention to helping patients utilize appropriate primary-care services during the adult years. In addition, prospective studies are needed to compare outcomes of CF patients who have transitioned and transferred to adult hospitals and those transitioning to adult-oriented services in a pediatric institution.

Patient perspectives of medical confidentiality: a review of the literature

OBJECTIVE

To lay the groundwork for a better understanding of patient views on medical confidentiality.

DESIGN

Studies were found by searching medline, bioethicsline, and selected bibliographies. Articles concerning physician perspectives or implications of legal and administrative regulations were excluded. Only peer-reviewed journal articles reporting original research on patients' confidentiality views and conduct were included.

MAIN RESULTS

Many patients are unaware of or misunderstand their legal or ethical right to medical confidentiality protections, which leads them to both over- and underestimate confidentiality protections. The possibility that medical information might be revealed, intentionally or not, to acquaintances in a clinic or other social community troubles patients as much as information release to insurers or employers. A significant minority of patients distrust confidentiality protections, leading some to report that they delay or forgo medical care. If doubtful that confidentiality will be upheld, patients will act independently to protect information.

CONCLUSIONS

Our review found a wider variety of understandings and beliefs about medical confidentiality among patients than are often indicated in the writings of practitioners or legal experts. As medical confidentiality regulations evolve, these differences need to be recognized and accounted for in interactions between practitioners and patients.

Availability of adolescent health services and confidentiality in primary care practices

BACKGROUND

Little is known about availability of services and confidential care for adolescents in primary care practices or how availability among pediatric practices compares to that among other primary care practices. The objective of this study was to assess self-reported availability of services for medically emancipated conditions and confidential care in primary care practices, to compare physician responses to those from office staff who answer appointment lines, and to compare availability in pediatric practices to other primary care practice types.

METHODS

We conducted a telephone survey of randomly selected practices from the Washington, DC, metropolitan area in pediatrics (Peds), internal medicine (IM), and family medicine (FM). We asked staff who answer appointment lines about availability of services for medically emancipated conditions and confidential appointments for adolescents. Physicians received the same questions via a mail survey. Responses from office staff and physicians in the same practice were linked for comparison.

RESULTS

Of 434 practices contacted by telephone, 372 (86%) responded. Of the 615 physicians surveyed from these 372 practices, 264 (43%) from 170 practices responded to the mail survey. Peds practices were less likely than FM and IM practices to offer services for medically emancipated conditions and were less likely than FM practices to offer confidential services to adolescents. Office staff and physicians from FM and IM had higher agreement compared with Peds about availability of services for medically emancipated conditions. Agreement between office staff and physicians about provision of confidential appointments to adolescents was low among all practice types. However, having a written office policy on adolescent confidentiality was significantly associated with agreement between office staff and physicians about availability of confidential services.

CONCLUSIONS

Care for medically emancipated conditions and confidential services for adolescents are limited among primary care practices, especially among pediatric practices. All primary care practice types had significant disagreement between office staff and physicians about availability of confidential services to adolescents. Adolescents who call appointment lines are likely to receive inaccurate information about confidentiality policies. Establishing written office policies on adolescent confidentiality may help to improve access to confidential care for adolescents.

Association of adolescent risk behaviors with mental health symptoms in high school students

PURPOSE

To examine the hypothesis that self-reported symptoms of depression and stress may be associated with other risk behaviors.

METHODS

A secondary data analysis of the 1992 Massachusetts Adolescent Health Survey involving a representative sample of 2,224 ninth and twelfth grade students was performed. The dichotomous dependent variable was positive if the adolescent reported feeling depressed or stressed for 10 or more days in the past month. Potential independent variables examined were age, gender, race/ethnicity, and 14 risk or protective behaviors: each scored on a seven point scale representing increasing frequency of a behavior in the past month. A four-level sexual risk variable was constructed as well. Associations were assessed using Chi-square, and phi/contingency coefficients, and logistic regression analyses to predict the odds of reporting depression/stress.

RESULTS

The mean age of the sample was 16.2 +/- 1.6 years; 52% males; 78% were white, 9% black, 6% Latino, 2% Asian, and 4% other racial/ethnic heritage; 35% reported feeling depressed/stressed > or = 10 days in the past month. A logistic regression model found that feelings of depression/stress were associated with increasing age (OR = 1.09 with each additional year [95% CI, 1.02-1.18]), female gender (3.28 [2.62-4.12]); increasing levels of tobacco use (1.07 [1.01-1.12]), physical fights (1.19 [1.11-1.28]); and non-use of birth control compared with never having been sexually active (1.81 [1.31-2.49]). Independent variables of reporting depression/stress for males included increasing age (1.15 [1.03-1.28]), and physical fights (1.20 [1.10-1.30]), and non-use of birth control compared with never sexually active (1.91 [1.28-2.92]). Independent risk and protective factors for females included tobacco use (1.10 [1.02-1.19]), healthy diet (0.89 [0.83- 0.96]), and always (1.49 [1.03-2.28]) or sometimes used birth control (1.56 [1.03-1.28]) compared with never sexually active.

CONCLUSIONS

Female gender had greater than threefold increased odds of reporting depression/stress. Other associations, with some gender differences, include older age, physical fights, non-use of birth control, lack of a healthy diet, and use of tobacco.

Prevalence and correlates of pelvic examinations in sexually active female adolescents

OBJECTIVES

The pelvic examination is an important component of reproductive health services for adolescent girls and is recommended for those who become sexually active. The aims of this study were to describe self-reported rates of pelvic examinations in sexually active adolescent girls and to determine factors associated with having obtained an examination.

METHODS

Cross-sectional data from a national self-administered survey of nurses' adolescent daughters were used. Subjects were those girls (N = 635) who reported ever having had sexual intercourse. Bivariate and multivariate analyses were used to identify demographic and psychological variables, preventive health behaviors, and risk behaviors associated with having ever obtained a pelvic examination.

RESULTS

Median subject age was 16.0 years (range 12-19 years), and 46% of subjects reported having had a pelvic examination. Variables associated with having obtained an examination were older age (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.09-1.53), cigarette smoking (OR 1.51, 95% CI 1.02-2.24), higher number of sexual partners (OR 1.29, 95% CI 1.14-1.47), and no condom use during last sexual intercourse (OR 1.80, 95% CI 1.19-2.70).

CONCLUSIONS

Fewer than half of these sexually active adolescents had ever obtained a pelvic examination. Younger subjects who did not smoke regularly, had fewer partners, and used condoms were less likely to have obtained an examination; these adolescents may not be seeking reproductive health care services or be recognized by parents or providers as being in need of services.

Adolescent substance abuse. Confidentiality and consent

Although all states have laws that allow minors to consent to substance abuse treatment, there is variability from state to state. Health care providers need to be aware of laws within their states. When providing health care to adolescents, many situations arise in which the provider must make a determination of the patient's competence to consent and whether parental notification would be in the patient's best interest. Confidentiality should be honored when possible, with limitations of the extent of confidentiality explained. Adolescents are able to consent for alcohol and drug treatment in most states, but involvement of the family is optimal in most cases. Physicians and other medical care providers also need to manage confidentiality issues in drug testing, billing of services, and medical records and need to work with clinical administrative staff to clarify and implement policies to maintain confidentiality. Proposed changes to medical privacy regulations may compromise confidentiality for medical care of adolescents. Medical providers should continue to work with their professional societies and legislators to ensure that appropriate consent and confidentiality statues exist to provide optimal health care to adolescents.

Pregnant minors: confidentiality issues and nurses' duties

Abortions in those under 16 years of age raise the issue of what to do in the face of a request that the young person's parents not be involved. The first question in such cases is whether or not the young person is competent to request confidentiality. A younger person who is competent is owned the same duty of confidentiality as an adult. In practice this means that some such requests can be granted straightforwardly. However, in many cases the teenager's pregnancy raises concern about child abuse. In the face of a serious crime the obligation to respect confidentiality is overridden. This creates a dilemma. We cannot respect confidentiality fully in such cases, but a policy of failing to do so may lead young people to seek (illegitimate) help elsewhere. Therefore, reform of the current system may be needed.