Attitudinal and contextual factors associated with discussion of sexual issues during adolescent health visits

Communication about Contraception with Adolescent Females with Asthma in Pediatric Visits

STUDY OBJECTIVE

The occurrence and characteristics of contraception discussions with adolescents are unexplored. Our study sought to address this gap using transcripts of audiotaped healthcare visits.

DESIGN, SETTING, AND PARTICIPANTS

This study was a secondary analysis of 153 transcripts of medical visits with female adolescents with asthma. Medical visits took place among 4 outpatient clinics in North Carolina.

MAIN OUTCOME MEASURES

Transcripts were reviewed for occurrence and characteristics of contraception discussions. Demographics were collected from adolescent interviews, caregiver questionnaires, and provider questionnaires.

RESULTS

Contraception was mentioned in 3% (n = 5) of office visits. Conversations about contraception included the topics of contraception efficacy (20%), contraception side effects (60%), contraception adherence (20%), and adolescent sexual health (20%). No conversations included the topics of contraception indication or alternative methods.

CONCLUSIONS

Conversations about contraception occurred infrequently in healthcare visits. When conversations did occur, the topics that they covered lacked alignment with guideline recommendations.

Preexposure Prophylaxis for Prevention of HIV Acquisition Among Adolescents: Clinical Considerations, 2020

Preexposure prophylaxis (PrEP) with antiretroviral medication has been proven effective in reducing the risk for acquiring human immunodeficiency virus (HIV). The fixed-dose combination tablet of tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) was approved by the U.S. Food and Drug Administration (FDA) for use as PrEP for adults in 2012. Since then, recognition has been increasing that adolescents at risk for acquiring HIV can benefit from PrEP. In 2018, FDA approved revised labeling for TDF/FTC that expanded the indication for PrEP to include adolescents weighing at least 77 lb (35 kg) who are at risk for acquiring HIV. In 2019, FDA approved the combination product tenofovir alafenamide (TAF)/FTC as PrEP for adolescents and adults weighing at least 77 lb (35 kg), excluding those at risk for acquiring HIV through receptive vaginal sex. This exclusion is due to the lack of clinical data regarding the efficacy of TAF/FTC in cisgender women.

Clinical providers who evaluate adolescents for PrEP use must consider certain topics that are unique to the adolescent population. Important considerations related to adolescents include PrEP safety data, legal issues about consent for clinical care and confidentiality, the therapeutic partnership with adolescents and their parents or guardians, the approach to the adolescent patient’s clinical visit, and medication initiation, adherence, and persistence during adolescence. Overall, data support the safety of PrEP for adolescents. PrEP providers should be familiar with the statutes and regulations about the provision of health care to minors in their states. Providers should partner with the adolescent patient for PrEP decisions, recognizing the adolescent’s autonomy to the extent allowable by law and including parents in the conversation about PrEP when it is safe and reasonable to do so. A comprehensive approach to adolescent health is recommended, including considering PrEP as one possible component of providing medical care to adolescents who inject drugs or engage in sexual behaviors that place them at risk for acquiring HIV. PrEP adherence declined over time in the studies evaluating PrEP among adolescents, a trend that also has been observed among adult patients. Clinicians should implement strategies to address medication adherence as a routine part of prescribing PrEP; more frequent clinical follow-up is one possible approach.

PrEP is an effective HIV prevention tool for protecting adolescents at risk for HIV acquisition. For providers, unique considerations that are part of providing PrEP to adolescents include the possible need for more frequent, supportive interactions to promote medication adherence. Recommendations for PrEP medical management and additional resources for providers are available in the U.S. Public Health Service clinical practice guideline Preexposure Prophylaxis for the Prevention of HIV Infection in the United States — 2017 Update and the clinical providers’ supplement Preexposure Prophylaxis for the Prevention of HIV Infection in the United States — 2017 Update: Clinical Providers’ Supplement (https://www.cdc.gov/hiv/clinicians/prevention/prep.html).

Efforts to Increase Implementation of Evidence-Based Clinical Practices to Improve Adolescent-Friendly Reproductive Health Services

PURPOSE

The purposes of this study were to describe changes in implementation of evidence-based clinical practices among health center partners as part of a multicomponent, community-wide teen pregnancy prevention initiative; to better understand the barriers to and facilitators of implementation of the evidence-based clinical practices; and to describe the technical assistance and training provided to the health center partners and key lessons learned.

METHODS

Health center data from the second and third years (2012 and 2013) of the teen pregnancy prevention community-wide initiative were analyzed from 10 communities (the first year was a planning year; program implementation began in the second year). Data were analyzed from 48 health center partners that contributed data in both years to identify evidence-based clinical practices that were being implemented and opportunities for improvement. In addition, data were analyzed from a purposive sample of 30 health center partners who were asked to describe their experiences in implementing evidence-based clinical practices in adolescent reproductive health care and barriers and facilitators to implementation.

RESULTS

Across 48 health centers in the 10 communities, 52% reported an increase in the implementation of evidence-based clinical practices from 2012 to 2013, mostly in providing contraceptive access (23%) and offering Quick Start (19%). Among health centers that reported no change (13%), the majority reported that practices were already being implemented before the initiative. Finally, among health centers that reported a decrease in implementation of evidence-based clinical practices (35%), most reported a decrease in having either hormonal contraception or intrauterine devices available at every visit (15%), having HIV rapid testing available (10%), or participating in the federal 340B Drug Discount Program (2%). In addition, health systems and community-level factors influence health center implementation of evidence-based clinical practices. In particular, support from health center leadership, communication between leadership and staff, and staff attitudes and beliefs were reported as factors that facilitated the implementation of new practices.

CONCLUSIONS

To increase adolescent's use of quality, client-centered, affordable and confidential reproductive health services, improvement in the implementation of evidence-based clinical practices is needed. Efforts to identify barriers to and facilitators for implementation of evidence-based clinical practices can inform for health centers of opportunities to build their capacity to ensure that evidence-based clinical practices are being implemented.

Adolescent views on comprehensive health risk assessment and counseling: assessing gender differences

PURPOSE

Adolescence is an important time for the detection of health risk behaviors and factors with subsequent counseling and intervention. Limited research has examined adolescent perceptions of comprehensive health risk assessments (HRAs) and counseling with an assessment of gender differences.

METHODS

Participants were identified using Florida's Medicaid and State Children's Health Insurance Program databases. A total of 35 low-income, racially/ethnically diverse adolescents (ages 14-18 years) participated in eight focus groups stratified by gender. Adolescents completed an internet-based, tablet-administered, comprehensive HRA and then participated in a semi-structured interview. Discussions were recorded, transcribed, and analyzed using a multi-step, team-based approach applying grounded theory to determine major themes.

RESULTS

Male adolescents desired less parental involvement, had less understanding of the protections of clinical confidentiality and the need for comprehensive HRA, and placed greater emphasis on the importance of professional appearance. In contrast, more females valued face-to-face interactions and stressed the importance of concern from the health risk assessor. Overall, adolescents placed importance on their relationship with the health risk assessor, and on valuing trust, confidentiality, and nonjudgmental care. Adolescents preferred to complete HRAs in clinical, private, and professional settings, and reported that tablet technology supported their confidentially in completing the HRA. Furthermore, they stressed the importance of autonomy and learning about the health risk outcomes for risk reduction.

CONCLUSIONS

Gender differences exist in adolescent perceptions of comprehensive HRAs. Adolescent perceptions of HRAs support their use in confidential primary care settings using modalities that emphasize nonjudgmental, private care, and the use of communication techniques that respect adolescents' autonomy to change health risks.

College students' preferences for health care providers when accessing sexual health resources

OBJECTIVE

Many emerging adults (18-25 year olds) report unmet health needs and disproportionately experience problems such as sexually transmitted infections. This study was conducted to examine college students' perceptions of health care providers, specifically in the context of accessing sexual health resources.

DESIGN AND SAMPLE

Students (N = 52) were recruited from five diverse colleges in one state to participate in a one-to-one interview that involved walking and virtually exploring resources on and near campus. Interviews were conducted from May to November 2010.

MEASURES

Open-ended one-to-one interview questions.

RESULTS

Inductive qualitative analysis yielded six themes summarizing students' perceptions of provider characteristics, health care resources, the role of their peers, and students' suggestions for strengthening health care services. Importantly, students consider a variety of staff-and their student peers-to be resources for sexual health information and services.

CONCLUSIONS

Findings emphasize the importance of collaboration between health service staff and broader campus staff because students often turn to campus staff initially. Postsecondary students welcome opportunities to know a provider through interactive websites that include details about providers on campus; their decisions to seek sexual health care services are influenced by their perceptions of providers' characteristics and interpersonal skills.

Sexually transmitted infection (STI) testing among young oil and gas workers: the need for innovative, place-based approaches to STI control

BACKGROUND

Northeastern British Columbia is undergoing rapid in-migration of young, primarily male workers in response to the "boom" in the oil/gas industries. Accompanying the boom is a rise in Chlamydia rates among youth, which exceed the provincial average by 22%. STI testing reduces the disease burden, contributing to STI prevention.

OBJECTIVES

1) To document youths' perceptions regarding the socio-cultural and structural forces that affect young oil/gas workers' access to STI testing; 2) to gather service providers' perspectives on sexual health service delivery for workers; and 3) to develop recommendations to improve the accessibility of STI testing.

METHODS

We conducted ethnographic fieldwork (8 weeks) in a remote oil/gas community, including in-depth interviews with 25 young people (ages 15-25) and 14 health and social service providers.

RESULTS

Participants identified limited opportunities to access testing, geographic isolation, and 'rigger' culture as three key categories inhibiting STI testing among oil/gas Workers.

DISCUSSION

These results suggest the need for place-based approaches to STI control. Innovative outreach strategies are suggested to address oil/gas workers' needs, including a locally tailored STI awareness campaign, condom distribution, expanded clinic hours, and onsite STI testing.

Providing contraceptive care to low-income, African American teens: the experience of urban community health centers

Recently, attention has been drawn to the quality of the patient-provider relationship as a mediator of health outcomes for racial and ethnic minorities. The purpose of this study was to examine the provider-patient relationship in reproductive health care for low income African American teens and to identify effective techniques they use in caring for teens. We conducted focus groups with providers at two clinics serving six low-income neighborhoods on the Southside of Chicago. Sessions were audio-taped then transcribed verbatim. ATLAS/ti 5.0 (a qualitative data analysis software program), was used for coding, text retrieval, data management and analysis of data. Providers in community clinics use a number of tactics when working with teens. First, they forge strong relationships through the use of language, shared background experiences, honesty and spending extra time with teens. Second, clinic employees work collectively to care for the patients with all staff members, both professional and clerical, contributing to the provider-patient relationship. Third, providers seek opportunities for contraceptive counseling even attempting to reach males outside of clinic. Techniques used by providers in neighborhood clinics may provide important insights for providing reproductive health care to low income, African American teens.

Transition of care from paediatric to adult rheumatology

The origin of paediatric rheumatology in the UK mainly lies in adult rheumatology and this has proved invaluable in terms of transition provision, education and training, and collaborative research. The last 5 years have seen adolescent rheumatology gather momentum with the creation of an objective evidence base, a sound foundation for future work addressing the many unanswered questions and hypotheses in the area of transitional care. The aim of this paper is to review the evidence supporting the recent developments in transitional care within rheumatology. Acknowledging the non-categorical nature of transition, the author will also refer to evidence from other chronic illnesses which has informed these developments.

Adolescent mothers' attitudes toward contraceptive use before and after pregnancy

STUDY OBJECTIVE

To understand attitudes and beliefs influencing use and nonuse of contraceptive methods pre- and postpartum among a group of adolescent mothers.

DESIGN AND SETTING

Qualitative descriptive study utilizing focus groups conducted between May, 2005 and January, 2006 in Central Massachusetts.

PARTICIPANTS

Adolescent mothers attending a federally funded multi-professional medical program. Inclusion criteria included being at least one year postpartum. Forty-six mothers were eligible; 34 were successfully contacted via telephone. Twenty-two agreed to attend; 15 adolescent mothers attended one of four groups.

MAIN OUTCOME MEASURE

Emergent themes were identified concerning adolescent mothers' attitudes and beliefs regarding contraception pre and postpartum.

RESULTS

Themes pertaining to nonuse of contraception prior to first pregnancy were: denial, not planning to have sex, not considering the consequences of unprotected sex, and wanting to become pregnant. Participants identified barriers to obtaining and utilizing contraception, including embarrassment discussing the topic, confidentiality, inability to obtain contraception without parental knowledge, and lack of knowledge regarding methods. Participants reported that convenience, perceived effectiveness, familiarity, and side effects were the primary reasons for selecting or changing a method of contraception postpartum and recommended several methods of promoting contraceptive use among adolescents. These included persuading health care providers to discuss the issue routinely with every adolescent patient, parental involvement, outreach by young mothers to at-risk teens, and media campaigns.

CONCLUSIONS

Given the adverse consequences of adolescent pregnancy, understanding the attitudes and beliefs of postpartum adolescents regarding contraceptives is important for developing effective interventions. Focus groups conducted with adolescent mothers, a difficult population to engage, provide a venue for exploring this complex issue.

Patterns of men's use of sexual and reproductive health services

CONTEXT

Men have been neglected as a target population for sexual and reproductive health services. As a result, little is known about the rates and antecedents of men's service utilization.

METHODS

Data from the 2002 National Survey of Family Growth were used to examine utilization of sexual and reproductive health services among 3,611 men aged 20-44 who had ever had sex with a woman. Associations between demographic and behavioral variables and measures of service utilization were assessed in univariate and logistic regression analyses.

RESULTS

Only 48% of men reported receiving sexual and reproductive health services in the past year. The testicular exam was the most commonly received service (35%), but half of men who had had a testicular exam had received no other sexual and reproductive health services. Levels of unmet need for services among men engaging in sexual risk behaviors were substantial (32-63%). The odds of having received nontesticular services were elevated among men who were nonwhite and older, engaged in sexual risk behaviors, had had a physical exam and had public health insurance. The odds of having received only a testicular exam were elevated among men who were white, had lower levels of sexual risk, had had a physical exam and had private or no insurance.

CONCLUSIONS

Men who have sex with women are not receiving adequate levels of sexual and reproductive health care, and the care they receive is neither comprehensive nor integrated. Standards of clinical care need to be defined and communicated to men and providers.

Contraceptive care for the adolescent

Despite recent improvements in rates of teen pregnancy, abortion, birth,and contraceptive use, effective contraceptive counseling for adolescents should be a high priority for the primary care provider in the office setting. Adolescent psychosocial risk screening and appropriate counseling about sexual decision-making is necessary. Contraceptive services visits include, relevant history, limited physical examination, provision of information, anticipatory guidance about sexual behaviors, and the provision of contraceptive methods. Teens should always be encouraged to use a male condom during sex to reduce STI risk. A variety of barrier and hormonal contraceptive methods are available for the adolescent population. Education about and provision of EC is effective in reducing the rate of unintended pregnancy and abortion in the United States. Contraceptive care for adolescents is a rewarding experience for primary care providers.

Review of Clinical Trials Testing the Effectiveness of Clinician Intervention Approaches to Prevent Sexually Transmitted Diseases in Adolescent Outpatients

OBJECTIVE

Identify approaches for improving clinician provision of sexually transmitted diseases (STDs) prevention services among outpatient adolescents.

METHODS

Reviewed all peer-reviewed, published clinical trials identified through computerized searches (MEDLINE, PsychINFO) evaluating STD prevention services to outpatient adolescents by clinicians.

RESULTS

Five trials were identified examining changes in clinician provision of STD prevention services. Two of these trials resulted in adolescent self-reported risk reduction but neither of these trials effectively demonstrated reductions in objectively measured STD incidence. Nine clinical trials were identified that compared clinician with non-clinician provision of STD prevention services. Four of these trials resulted in adolescent self-reported risk reduction, and one of these trials demonstrated a reduction in objectively measured STD incidence.

CONCLUSIONS

Trials indicate that improvement in outpatient adolescent STD incidence is possible with non-clinicians as interventionists, and perhaps clinicians as interventionists if clinicians are supported by other educational resources. Opportunities for personalized, interactive adolescent education appears key to intervention success. The clinician role that is tested in most trials is confined to a single brief encounter with little attention to: development of clinician skills, quality of psychosexual risk assessment and tailoring to meet individual adolescent need, systems-level resources and supports, the parental role, or the impact of incorporating prevention into an ongoing adolescent-clinician relationship.