Forgone health care among U.S. adolescents: associations between risk characteristics and confidentiality concern

Youth and Guardian Expectations of Privacy in Adolescent Health Care

PURPOSE

Adolescent access to confidential care is codified by most states with age-specific laws; however, adolescent and guardian awareness of these laws are poorly understood. In this study, we assessed adolescent and guardian perceptions of conditional confidentiality in health care.

METHODS

We surveyed youth aged 11-18 years, and guardians accompanying youth seeking care at an urban adolescent outpatient clinic that provides adolescent primary and subspecialty care. Participants completed brief True/False surveys which queried whether a parent would be notified for common, hypothetical scenarios. We analyzed adolescent responses by age group and compared responses of adolescents and guardians.

RESULTS

Two hundred seventy nine adolescents and 178 guardians completed the survey. Among participants, 86% of adolescents and 67% of guardians believed they understood which health topics were confidential. Adolescent and guardian answers aligned with mandatory reporting laws for scenarios concerning safety and suicidality. Younger adolescents consistently underestimated their legal right to privacy for all hypothetical scenarios. Many adolescents anticipated disclosure to parents for confidential services, including contraception, pregnancy, and sexually transmitted infection testing. Guardians expected disclosure about sexual health services at higher rates than they did about substance use.

DISCUSSION

We identified age-associated knowledge gaps among participants pertaining to adolescent privacy in the clinical setting. These deficits were found in a setting where adolescent privacy is routinely discussed, and our findings may underestimate the knowledge gap in the general pediatric population where confidentiality may not be discussed as often. Providers caring for adolescents share the responsibility of educating both youth and families about the importance of adolescent confidentiality.

Confidentiality in the Care of Adolescents: Technical Report

Confidentiality is a foundational element of high-quality, accessible, and equitable health care. Despite strong grounding in federal and state laws, professional guidelines, and ethical standards, health care professionals and adolescent patients face a range of complexities and barriers to seeking and providing confidential care to adolescents across different settings and circumstances. The dynamic needs of adolescents, the oftentimes competing interests of key stakeholders, the rapidly evolving technological context of care, and variable health care billing and claims requirements are all important considerations in understanding how to optimize care to focus on and meet the needs of the adolescent patient. The following assessment of the evolving evidence base offers a view of the current state and best practices while pointing to numerous unmet needs and opportunities for improvement in the care experiences of youth as well as their health outcomes.

"It's about how you take in things with your brain" - young people's perspectives on mental health and help seeking: an interview study

INTRODUCTION

Poor mental health in young people has become a growing problem globally over the past decades. However, young people have also been shown to underutilize available healthcare resources. The World Health Organisation (WHO) has formulated guidelines for youth-friendly health services (YFHSs) to increase youth participation in healthcare. Still, little is known about how young people using these services perceive mental health, indicating a knowledge gap concerning the subjective evaluation of their mental health.

AIM

To investigate how young people visiting youth health clinics (YHC) perceive the concept of mental health and factors they view as central to maintaining mental health.

METHODS

In total 21 interviews were carried out, 16 in 2018, and 5 in 2023 to assure no changes in findings after the COVID-19 pandemic. Subjects were recruited during visits to youth health clinics (YHCs) in mid-Sweden and were aged 15-23 years. Recruitment strived to achieve heterogeneity in the sample concerning gender, sexual orientation, gender identity and age. Interviews were transcribed and analysed using qualitative content analysis.

FINDINGS

Findings of the analysis revealed two themes, "Mental health is helped and hindered by the surroundings" and "Mental health is difficult to understand and difficult to achieve". The participants described their health as highly dependent on their social surroundings, and that these are important to maintaining health but may also affect health negatively. They described mixed experiences of the health care services and mentioned prerequisites for seeking care for mental health problems such as accessibility and respect for their integrity, including the right to turn down offered treatment. The informants also viewed mental health as an ongoing undertaking that one must work for, and that it is sometimes difficult to know what constitutes mental health. They also expressed a need from healthcare services to enquire about their health, and to show an active interest in how they are doing.

CONCLUSIONS

Findings underline the need of young people's individual needs to be met in the healthcare system and their vulnerability to their social surroundings. Health status assessments in young people should consider social and individual factors to fully capture mental health.

Development of Youth-Centered Health Messaging Posters for High School-Based Health Clinics in Hawaii

BACKGROUND

Youth may be reluctant to seek health care from school health providers due to feeling embarrassed or stigmatized in the health office environment or worried about their confidentiality. The purpose of this project was to create a set of youth-centered health posters that promote youth engagement with nursing staff and to standardize health messaging across high schools in Hawaii school-based clinics.

METHODS

Two community advisory boards, 1 composed of 10 youth stakeholders (mean age 17 years) and the other of 7 adult stakeholders, informed poster development utilizing web-based discussion groups. The discussions were transcribed, and additional data was collected using field notes and anonymous digital messages. Adult advisory board members also provided feedback on suggested poster text through an online survey.

RESULTS

Youth and adult advisory board participants identified 4 key health concerns facing youth: confidentiality, sexual health, relationships, and mental health. Based on input from the 2 advisory boards, 4 posters were developed, each centered on 1 key health issue.

IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY

School-based posters can convey important messages to help youth understand their health care rights and responsibilities, as well as identify important issues open for discussion with nurses.

CONCLUSION

Posters are an underutilized tool for school health providers to create welcoming, inclusive health care environments and facilitate health-related conversations with youth. This paper describes participant feedback about the characteristics of a memorable poster and briefly outlines current knowledge and recommendations for school health providers regarding each of the 4 health issues.

Empowering the next generation: integrating adolescents into the Reproductive Justice movement

This article explores the ethical implications of mandatory parental consent requirements for adolescents seeking sexual and reproductive health services (SRHS). Using a Reproductive Justice framework, which identifies systemic barriers to accessing healthcare services, we examine ageism as a potential factor restricting adolescents' access to SRHS. While the Reproductive Justice framework has addressed systemic issues like racism and ableism in healthcare, ageism involving adolescents has been less explored. The article challenges the pertinence of mandatory parental consent requirements-as a potential barrier-for adolescents' access to SRHS. We argue that in the specific context of SRHS (contraceptives, abortion, testing and treatment of sexually transmitted infections), adolescents' autonomy (self-determination) should be respected if they request to access those services independently. From a global health perspective, adolescents have a low prevalence and uneven access to SRHS. To address the issue, we propose the integration of adolescence into the Reproductive Justice movement to empower them through education on how to access the SRHS they need.

Confidentiality in Primary Care Pediatrics

Confidentiality is a core component of adolescent health. Confidentiality is shown to be a basic human right that is in the best interest of the adolescent, addresses health inequities, and supports adolescents' developing capacity. Practical aspects of confidentiality are discussed, resources provided to navigate a changing legal landscape, and threats to confidentiality addressed. Although confidentiality can be a source of conflict with parents and caregivers, pediatric providers can use confidentiality to assist parents and caregivers in shifting from making decisions for the adolescent to supporting the adolescent in making their own health decisions, thus facilitating a healthy transition to adulthood.

Confidentiality and privacy considerations for adolescents receiving contraceptive health services via telemedicine: A narrative review

Confidential medical care for adolescent patients is essential as they are likely to forgo needed care if privacy cannot be maintained. The use of telemedicine for adolescent health has rapidly expanded due to the COVID-19 pandemic and can increase access to important services like reproductive care; however, it has raised challenges for providers, patients, and their parents/guardians related to confidentiality and privacy. Health care providers are often uncertain about the laws and regulations that govern confidential services including the 21st Century Cures Act. Through a narrative review of studies on confidentiality and telemedicine, this article seeks to summarize the available evidence and provide recommendations on maintaining privacy during virtual encounters and identify current best practices for prescribing contraception via telemedicine.

Confidentiality and Contraception: Protecting Adolescent Care in Response to One State's "Parents' Bill of Rights"

PURPOSE

This study aims to analyze parent responses to current strict Oklahoma confidentiality and consent laws in an outpatient subspecialty setting.

METHODS

A consent for treatment form including an explanation of the benefits of qualified confidential care for adolescents was given to parents of patients under 18 years of age. The form asked parents to waive the right to access confidential portions of the medical record, be present for the physical exam, be present for risk behavior discussions, and consent for hormonal contraception including a subdermal implant. Demographic information was collected using patient medical records. Data were analyzed using frequencies, chi-square, and t tests.

RESULTS

Of the 507 parent forms, 95% of total parents gave permission for providers to have confidential conversations with the patients, 86% allowed providers to examine the patient alone, 84% of parents allowed providers to prescribe contraception, and 66% gave permission for subdermal implant. New patient status, race, ethnicity, assigned sex at birth, and insurance type did not correlate with parents' willingness to provide permissions. There was a statistically significant difference between patient gender identity and percentage of parents who granted permission for a confidential physical exam. Groups more likely to discuss questions about confidential care with the health care provider included parents of new patients, Native American and Black patients, and cisgender female patients.

DISCUSSION

Despite laws that limit adolescent ability to access confidential care in Oklahoma, the majority of parents who were provided an explanatory document allowed their children the right to access this care.

Adolescent Perspectives on the Use of Telemedicine for Confidential Health Care: An Exploratory Mixed-Methods Study

PURPOSE

Telemedicine can improve access to adolescent health care, but adolescents may experience barriers to accessing this care confidentially. Gender-diverse youth (GDY) may especially benefit from telemedicine through increased access to geographically limited adolescent medicine subspecialty care but may have unique confidentiality needs. In an exploratory analysis, we examined adolescents' perceived acceptability, preferences, and self-efficacy related to using telemedicine for confidential care.

METHODS

We surveyed 12- to 17-year-olds following a telemedicine visit with an adolescent medicine subspecialist. Open-ended questions assessing acceptability of telemedicine for confidential care and opportunities to enhance confidentiality were qualitatively analyzed. Likert-type questions assessing preference for future use of telemedicine for confidential care and self-efficacy to complete components of telemedicine visits confidentially were summarized and compared across cisgender versus GDY.

RESULTS

Participants (n = 88) included 57 GDY and 28 cisgender females. Factors affecting the acceptability of telemedicine for confidential care related to patient location, telehealth technology, adolescent-clinician relationships, and quality or experience of care. Perceived opportunities to protect confidentiality included using headphones, secure messaging, and prompting from clinicians. Most participants (53/88) were likely or very likely to use telemedicine for future confidential care, but self-efficacy for completing components of telemedicine visits confidentially varied by component.

DISCUSSION

Adolescents in our sample were interested in using telemedicine for confidential care, but cisgender and GDY recognized threats to confidentiality that may reduce acceptability of telemedicine for these services. Clinicians and health systems should carefully consider youth's preferences and unique confidentiality needs to ensure equitable access, uptake, and outcomes of telemedicine.

Adolescent patient portals and concerns about confidentiality

PURPOSE OF REVIEW

To better understand confidentiality issues that arise from adolescent access to patient portals.

RECENT FINDINGS

Studies have evaluated the views of teens, parents, providers, and institutional leadership on adolescent patient portals and the risks they pose to adolescent privacy. Additional investigations have shown that teen portal accounts are often inappropriately accessed by parents. Guidelines are needed to better inform the creation of secure teen patient portals. Adolescent providers and other medical staff should be aware of the information available on portals, how to ensure portals are being accessed appropriately, and the potential for confidentiality breaches that come with portal use. Medical organizations that offer portal access need to provide resources to adolescents and their families to improve understanding around the importance of confidential care and how to maintain confidentiality while still engaging meaningfully with the healthcare system through patient portals.

SUMMARY

Adolescents realize the benefits portals may offer regarding improved understanding of their health conditions, communication with their providers, and autonomy in their healthcare decisions. However, confidentiality of patient portals is a major concern and a potential barrier to adolescent portal utilization. Adolescent providers should be aware of the limitations of portal systems and advocate for improved confidentiality functionality to ensure teens can access the benefits of patient portals without any harm.

Sharing Clinical Notes while Protecting Adolescent Confidentiality and Maintaining Parental Insight

BACKGROUND

The 21st Century Cures Act mandates sharing electronic health records (EHRs) with patients. Health care providers must ensure confidential sharing of medical information with adolescents while maintaining parental insight into adolescent health. Given variability in state laws, provider opinions, EHR systems, and technological limitations, consensus on best practices to achieve adolescent clinical note sharing at scale is needed.

OBJECTIVES

This study aimed to identify an effective intervention process to implement adolescent clinical note sharing, including ensuring adolescent portal account registration accuracy, across a large multihospital health care system comprising inpatient, emergency, and ambulatory settings.

METHODS

A query was built to assess portal account registration accuracy. At a large multihospital health care system, 80.0% of 12- to 17-year-old patient portal accounts were classified as inaccurately registered (IR) under a parent or registration accuracy unknown (RAU). To increase accurately registered (AR) accounts, the following interventions were pursued: (1) distribution of standardized portal enrollment training; (2) patient outreach email campaign to reregister 29,599 portal accounts; (3) restriction of access to remaining IR and RAU accounts. Proxy portal configurations were also optimized. Subsequently, adolescent clinical note sharing was implemented.

RESULTS

Distribution of standardized training materials decreased IR and increased AR accounts (p = 0.0492 and 0.0058, respectively). Our email campaign (response rate: 26.8%) was most effective in decreasing IR and RAU accounts and increasing AR accounts (p < 0.002 for all categories). Remaining IR and RAU accounts, 54.6% of adolescent portal accounts, were subsequently restricted. Postrestriction, IR accounts continued declining significantly (p = 0.0056). Proxy portal enhancements with interventions deployed increased proxy portal account adoption.

CONCLUSION

A multistep intervention process can be utilized to effectively implement adolescent clinical note sharing at a large scale across care settings. Improvements to EHR technology, portal enrollment training, adolescent/proxy portal settings, detection, and automation in reenrollment of inaccurate portal accounts are needed to maintain integrity of adolescent portal access.

Perceived barriers to the provision of adolescent confidential care in a tertiary care setting

Objective

Adolescents are more likely to seek care and disclose sensitive health information if confidentiality is assured. Little is known regarding the provision of confidential care to adolescents in the hospital setting. We sought to understand confidentiality practices and barriers for adolescents cared for in a tertiary hospital setting.

Methods

This was a cross-sectional survey of all Emergency Department (ED), hospitalist, and resident physicians at a tertiary paediatric hospital from May/2019 to July/2019. Participants were asked multiple choice questions regarding practices, comfort, and barriers to confidential care.

Results

Response rate was 91% (n = 72/79; 26 ED, 14 hospitalists, 32 residents). Overall, 47% of respondents doubted that confidential care was being consistently provided to adolescents. Fifty-eight per cent of attendings and 31% of residents reported usually/always offering confidential care. Factors most reported to influence the provision of confidential care were chief complaint (75%), time of visit (45%), and patient age (25%). Barriers to the quantity or quality of confidential care were identified by 89%, most commonly including time constraints (21%), perceived parental resistance (26%), lack of private space (26%), and the belief that confidentiality is not necessary for all adolescent encounters (34%). Forty per cent of respondents reported breaching confidentially and discussing sensitive topics with adolescents in front of family members. Overall, only 45% felt they had received adequate training on how best to deliver confidential care, and 75% reported a desire for additional training.

Conclusion

Results suggest inadequate provision of confidential care in a tertiary teaching hospital, with several potentially modifiable barriers.

The role of social capital in resilience among adolescents with adverse family environments

The Life Course Health Development (LCHD) framework underscores the profound impact of stressors during critical developmental phases on an individual's lifelong health, including their mental well-being. Among these developmental transitions, adolescence emerges as a pivotal life stage where an adolescent's mental health trajectory is significantly influenced by the various risk and promotive factors embedded within their social ecosystem. Adolescents from adverse family environments (AFEs) face heightened susceptibility to mental health challenges. Nevertheless, there are opportunities within the adolescent's environment to foster resilience. In this paper, we employ an interdisciplinary approach grounded in the LCHD framework to assess existing research pertaining to resilience, social capital, and health development. Furthermore, we aim to provide actionable recommendations tailored to healthcare providers, with a specific emphasis on strategies to augment mental health outcomes among adolescent populations, particularly those experiencing AFEs.

Potential Effects of Age-Based Changes in Screening Guidelines on the Identification of Women at Risk for Developing Cervical Cancer

Current American Cancer Society guidelines estimated that screening starting at the age of 25 years with Pap and/or human papillomavirus (HPV) testing is sufficient to prevent cervical cancer. The effect of having HPV infections without Pap-based care until age 25 on the prevalence of higher grades of cervical intraepithelial neoplasia (≥CIN 2) and their determinants are largely unknown. The objectives of the study were to document the potential effects of age-based changes in screening guidelines on the identification of ≥CIN 2 and their determinants. The study included 1,584 women diagnosed with abnormal Pap and tested for HPVs and histologic diagnoses of cervical lesions. The association between demographic/lifestyle factors and HPV status and risk of being diagnosed with ≥CIN 2 among younger (21-<25 years) or older (≥25 year) women was tested using unconditional multiple logistic regression models. We observed that younger women who are not screened have a similar or higher risk of developing specific high-risk HPV genotype-associated ≥CIN 2 lesions compared with older women who are screened according to the current guidelines. In addition, younger women who reported live births, smoking, contraceptive use, and a higher number of sexual partners were significantly at higher risk of being diagnosed with ≥CIN 2. Targeted screening of younger women at risk for developing ≥CIN 2 will address the concern of overtreatment while providing the recommended care to those who require such care to prevent the development of cervical cancer.

PREVENTION RELEVANCE

This study documents the concerns of the age-based changes in screening guidelines on the identification of higher grades of cervical intraepithelial neoplasia and their determinants in women diagnosed with abnormal Pap smear and emphasize the need for targeted screening of younger women to prevent cervical cancer.

Ask me, listen to me, treat me well and I shall tell: a qualitative study of Swedish youths' experiences of systematic assessment of sexual health and risk-taking (SEXIT)

Sexual ill health among young people, in terms of sexually transmitted infections (STIs), unintended pregnancy, transactional sex and sexual violence, is a global public health concern. To that end, the SEXual health Identification Tool (SEXIT) was developed. The purpose of this study was to explore the visitors' experiences of a youth clinic visit when SEXIT was used. A purposively selected sample of 20 participants (16-24 years of age) was recruited from three Swedish youth clinics using SEXIT. Participants were interviewed individually in March and April 2016, and data were analysed using inductive qualitative content analysis. The analysis resulted in four main categories describing the participants' experiences of using SEXIT: "Issues of concern" includes descriptions of the items in SEXIT as important; "Enabling disclosure" describes how SEXIT serves as an invitation to talk and facilitates disclosure of negative experiences; "Road to change" captures experiences of the conversation with the healthcare professional; and "Managing power imbalance" describes experiences regarding the response and attitudes of the healthcare professional as well as the participants' fears of being judged. The categories are connected by the overarching theme "Ask me, listen to me, treat me well and I shall tell". This study contributes knowledge on young people's experiences of a tool-supported dialogue on sexual health and risk-taking initiated by the healthcare professional. Structured questions in a written format, as a basis for dialogue, are appreciated and experienced as a functioning way of addressing sexual ill health and risk-taking at Swedish youth clinics.

Confidentiality matters! Adolescent males' views of primary care in relation to psychosocial health: a structural equation modelling approach

OBJECTIVE

To investigate to what degree adolescent males (1) value confidentiality, (2) experience confidentiality and are comfortable asking sensitive questions when visiting a general practitioner (GP), and (3) whether self-reported symptoms of poor mental health and health-compromising behaviours (HCB) affect these states of matters.

DESIGN

Cross-sectional.

SETTING

School-based census on life, health and primary care in Region Sörmland, Sweden.

SUBJECTS

2,358 males aged 15-17 years (response rate 84%).

MAIN OUTCOME MEASURES

The impact of poor mental health and HCBs on adolescent males' valuing and experiencing private time with the GP, having professional secrecy explained, and being comfortable asking about the body, love and sex, analysed with structural equation modelling.

RESULTS

Almost all respondents valued confidentiality regardless of their mental health or whether they engaged in HCBs: 86% valued spending private time with the GP, and 83% valued receiving a secrecy explanation. Among those who had visited a GP in the past year (n = 1,200), 74% had experienced private time and 42% a secrecy explanation. Three-quarters were at least partly comfortable asking sensitive questions. Adolescent males with HCBs were more likely to experience a secrecy explanation (approximative odds ratio [appOR] 1.26; p = 0.005) and to be comfortable asking about sex than their peers (appOR 1.22; p = 0.007). Respondents reporting experienced confidentiality were more comfortable asking sensitive questions (appOR 1.25-1.54; p ≤ 0.010).

CONCLUSION

Confidentiality matters regardless of poor mental health or HCBs and makes adolescent males more comfortable asking sensitive questions. We suggest that GPs consistently offer private time and explain professional secrecy.Key PointsConfidentiality for adolescent males has been scantily studied in relation to mental health and health-compromising behaviours.In this study, most adolescent males valued confidentiality, regardless of their mental health and health-compromising behaviours.Health-compromising behaviours impacted only slightly, and mental health not at all, on experiences of confidentiality in primary care.When provided private time and an explanation of professional secrecy, adolescent males were more comfortable asking the GP sensitive questions.

State-by-State Variability in Adolescent Privacy Laws

OBJECTIVES

Health care providers managing the complex health needs of adolescents must comply with state laws governing adolescent consent and right to privacy. However, these laws vary. Our objectives were to summarize consent and privacy laws state-by-state and assess the implications of variation for compliance with the 21st Century Cures Act and with evidence-based guidance on adolescent care.

METHODS

We summarized state laws and regulations on minor consent for the following: health services, substance abuse treatment, prenatal care, mental health care, contraceptive management, immunizations, sexually transmitted infection management, human immunodeficiency viruses testing and treatment, dental care, and sexual assault evaluation. We compared state laws and regulations with American Academy of Pediatrics' evidence-based guidelines to assess consistencies in guidance.

RESULTS

We observed notable state-by-state variability in laws governing consent for adolescent patients. No states had identical policies for all services studied. For example, although all states had provisions for consent to management of sexually transmitted infections, there were variable specifications in the age and type of minor, whether this includes human immunodeficiency viruses, and whether confidentiality is protected. Providing confidential care to the adolescent patient has been set as a priority by medical societies; however, guidelines are limited by the need to comply with state laws and regulations.

CONCLUSIONS

State laws on consent and privacy for adolescents are highly variable, and many do not reflect pediatric professional standards of care. This inconsistency is a barrier to operationalizing a consistent and equitable experience providing evidence-based medical care and ensuring adolescent privacy protection.

Are State-Level HIV Testing Policies for Minors Associated With HIV Testing Behavior and Awareness of Home-Based HIV Testing in Young Men Who Have Sex With Men?

PURPOSE

The objective of this study was to determine whether state-level policies that restrict minors' access to confidential HIV testing without parental consent may suppress HIV testing in young men who have sex with men (YMSM) in the United States.

METHODS

Secondary data from a national HIV prevention trial among YMSM aged 13-17 years (N= 612) were analyzed to evaluate the association between living in a state with restrictive HIV testing policies for minors and HIV testing behavior, awareness of home-based HIV testing, and confidential interactions with a physician. Multilevel logistic regression models were adjusted for age, parents' education level, race, ethnicity, sexual orientation, being sexually experienced, and health literacy of medical forms and controlled for clustering by state. Age-stratified models by state-level age of consent for HIV testing and a subanalysis (including only sexually experienced participants) were also conducted.

RESULTS

Residing in a state with restrictive HIV testing policies was associated with the lack of awareness of home-based HIV testing (adjusted odds ratio [aOR]: 3.06; 95% confidence intervals [CI]: 1.49, 6.28). No significant associations were found for HIV testing behavior (aOR: 1.81; 95% CI: 0.85, 3.84), speaking privately with a physician (aOR: 1.00; 95% CI: 0.56, 1.79), or discussing confidentiality with a physician (aOR: 0.95; 95% CI: 0.52, 1.71) and HIV testing policies for minors. These results were consistent in both the age-stratified models and subanalysis.

DISCUSSION

HIV testing proportions among YMSM did not differ by state-level minor consent laws. However, YMSM living in states with restrictive policies on HIV testing for minors were less likely to be aware of home-based HIV testing.

Non-disclosing youth: a cross sectional study to understand why young people do not disclose suicidal thoughts to their mental health professional

BACKGROUND

Prevalence of suicidal ideation increases rapidly in adolescence, and many choose not to seek help and disclose their ideation. Young people who do disclose suicidal ideation, prefer to do so with peers and family compared to mental health professionals, who are best placed to provide evidence-based treatment. This study aimed to identify key factors associated with young people's decision to, or not to disclose suicidal thoughts to their mental health practitioner.

METHODS

A community-based sample of young Australians (16 - 25 years), who had experienced suicidal ideation and engaged with a mental health professional, completed an online questionnaire (N=513) which assessed demographic characteristics, severity of depression, anxiety, psychological distress, and suicidal ideation, lifetime suicide attempts, exposure to suicide loss, personal suicide stigma, prioritisation of mental health issues, and therapeutic alliance. Logistic regression analyses were used to identify factors associated with disclosure.

RESULTS

Though the full sample had engaged in therapy, 39% had never disclosed suicidal ideation to their clinician. Those who had disclosed were more likely to report greater therapeutic alliance (OR=1.04, 95% CI=1.02-1.06), personal suicide stigma (OR=1.04, 95% CI=1.01-1.06), prioritisation of suicidal ideation (OR=.24, 95% CI=0.14-0.42), and lifetime history of suicide attempt (OR=.32, 95% CI=0.18-0.57). The most common reason for not disclosing was concern that it would not remain confidential.

CONCLUSION

These findings provide new insights into why young people may not seek help by disclosing suicidal ideation, despite having access to a mental health professional, and establish evidence to inform practice decisions and the development of prevention strategies to support young people for suicide.

Adolescents and Young Adults: The Pediatrician's Role in HIV Testing and Pre- and Postexposure HIV Prophylaxis

Most sexually active youth in the United States do not believe that they are at risk for contracting HIV and have never been tested. Creating safe environments that promote confidentiality and respect, obtaining an accurate sexual and reproductive health assessment, and providing nonstigmatizing risk counseling are key components of any youth encounters. Pediatricians can play a key role in preventing and controlling HIV infection by promoting risk-reduction counseling and offering routine HIV testing and prophylaxis to adolescent and young adult (youth) patients. In light of persistently high numbers of people living with HIV in the United States and documented missed opportunities for HIV testing, the Centers for Disease Control and Prevention and the US Preventive Services Task Force recommend universal and routine HIV screening among US populations, including youth. Recent advances in HIV diagnostics, treatment, and prevention help support this recommendation. This clinical report reviews epidemiological data and recommends that routine HIV screening be offered to all youth 15 years or older, at least once, in health care settings. After initial screening, youth at increased risk, including those who are sexually active, should be rescreened at least annually, and potentially as frequently as every 3 to 6 months if at high risk (male youth reporting male sexual contact, active injection drug users, transgender youth; youth having sexual partners who are HIV-infected, of both genders, or injection drug users; youth exchanging sex for drugs or money; or youth who have had a diagnosis of or have requested testing for other sexually transmitted infections). Youth at substantial risk for HIV acquisition should be routinely offered HIV preexposure prophylaxis, and HIV postexposure prophylaxis is also indicated after high-risk exposures. This clinical report also addresses consent, confidentiality, and coverage issues that pediatricians face in promoting routine HIV testing and HIV prophylaxis for their patients.

Optimizing e-Consultations to Adolescent Medicine Specialists: Qualitative Synthesis of Feedback From User-Centered Design

BACKGROUND

e-Consultations between primary care physicians and specialists are a valuable means of improving access to specialty care. Adolescents and young adults (AYAs) face unique challenges in accessing limited adolescent medicine specialty care resources, which contributes to delayed or forgone care. e-Consultations between general pediatricians and adolescent medicine specialists may alleviate these barriers to care. However, the optimal application of this model in adolescent medicine requires careful attention to the nuances of AYA care.

OBJECTIVE

This study aims to qualitatively analyze feedback obtained during the iterative development of an e-consultation system for communication between general pediatricians and adolescent medicine specialists tailored to the specific health care needs of AYAs.

METHODS

We conducted an iterative user-centered design and evaluation process in two phases. In the first phase, we created a static e-consultation prototype and storyboards and evaluated them with target users (general pediatricians and adolescent medicine specialists). In the second phase, we incorporated feedback to develop a functional prototype within the electronic health record and again evaluated this with general pediatricians and adolescent medicine specialists. In each phase, general pediatricians and adolescent medicine specialists provided think-aloud feedback during the use of the prototypes and semistructured exit interviews, which was qualitatively analyzed to identify perspectives related to the usefulness and usability of the e-consultation system.

RESULTS

Both general pediatricians (n=12) and adolescent medicine specialists (n=12) perceived the usefulness of e-consultations for AYA patients, with more varied perceptions of potential usefulness for generalist and adolescent medicine clinicians. General pediatricians and adolescent medicine specialists discussed ways to maximize the usability of e-consultations for AYAs, primarily by improving efficiency (eg, reducing documentation, emphasizing critical information, using autopopulated data fields, and balancing specificity and efficiency through text prompts) and reducing the potential for errors (eg, prompting a review of autopopulated data fields, requiring physician contact information, and prompting explicit discussion of patient communication and confidentiality expectations). Through iterative design, patient history documentation was streamlined, whereas documentation of communication and confidentiality expectations were enhanced.

CONCLUSIONS

Through an iterative user-centered design process, we identified user perspectives to guide the refinement of an e-consultation system based on general pediatrician and adolescent medicine specialist feedback on usefulness and usability related to the care of AYAs. Qualitative analysis of this feedback revealed both opportunities and risks related to confidentiality, communication, and the use of tailored documentation prompts that should be considered in the development and use of e-consultations with AYAs.

"Improving the quality of care for adolescents and young adults on an adult medical ward"

BACKGROUND

Adolescents and young adults have health needs which are distinctly different from children and adults. A lack of education and training is reported by clinicians to be one of the main barriers to providing comprehensive developmentally appropriate care to young people, including the provision of confidential healthcare and taking a holistic approach.

AIM

This study documents the current provision of care to young people on an adult inpatient medical ward at a large tertiary teaching hospital in Auckland.

METHODS

Forty-three staff and 40 patients aged 16-24 years on an adult medical ward completed surveys, which were based on the Northern Regional Alliance, Northern Regional Youth Health Network Standards for Quality Care for Adolescents and Young Adults in Secondary or Tertiary Care.

RESULTS

Few staff (12%) had completed any specific training in looking after adolescent and young adult (AYA) patients. Confidentiality was not routinely discussed with young people by 50% of clinicians, and only 23% of staff reported that they see a young person alone as part of their consultation or admission. Less than half of young people reported receiving a comprehensive psychosocial assessment that included sexual health, mental health and suicide, and safety.

CONCLUSIONS

Key components of comprehensive developmentally appropriate healthcare were not regularly carried out by staff on an adult medical ward. These findings suggest that further education and training, and service improvements are needed in tertiary adult hospital settings. This article is protected by copyright. All rights reserved.

Improving contraceptive use among Latina adolescents: A cluster-randomized controlled trial evaluating an mHealth application, Health-E You/Salud iTu

OBJECTIVE

To evaluate the effectiveness of Health-E You/Salud iTu, a mobile health application (app), on increasing knowledge, self-efficacy and contraception use among Latina adolescents, its impact on visit quality, and app satisfaction.

STUDY DESIGN

This study used cluster-randomized controlled trial (CRCT) of 18 school-based health centers (SBHCs). Prior to the visit, intervention participants received the patient-centered contraceptive decision-making support app and controls answered sexual health questions on iPads. Participants completed a previsit questionnaire and 3 follow-up surveys (48 hours, 3-, and 6-months) after the recruitment visit (where intervention participants completed the app). Differences in adolescents' contraceptive knowledge, self-efficacy, and use over the 6-month follow-up were assessed by generalized mixed effects regression models.

RESULTS

A total of 1,360 Latina adolescents participated; 57.2% responded to the 48-hour survey, 50.1% to the 3-month, 49.7% to the 6-month, and 42.3% to both the 3- and 6-month surveys. Health-E You users' demonstrated significant increases in pre-post knowledge (p < 0.001). Intervention participants who completed the follow-up survey reported greater increases in mean self-efficacy from baseline (23.2 intervention vs. 22.5 controls) to 6 months (26.1 vs. 23.4; b = 1.58, 95% CI 0.38-2.77, p = 0.01), and greater increases in non-barrier contraceptive use from baseline (29% intervention vs. 30% controls) to 3 months (63% vs. 45%; OR = 3.29, 95% CI 1.04-10.36, p = 0.04) and 6 months (63% vs. 44%; OR = 5.54, 95% CI 1.70-18.06, p = 0.005). Providers and adolescents reported high app satisfaction and stated it improved visit quality.

CONCLUSIONS

While data suggest that Health-E You improved outcomes, findings must be interpreted cautiously. Intervention participants had higher baseline sexual activity rates, more recruitment visits for pregnancy testing, emergency contraception or birth control, and lower completion rates of follow-up surveys than controls.

IMPLICATIONS

Despite declines in adolescent pregnancy in the United States, Latinas continue to have disproportionately high rates compared to white females. The Health-E You app may be an effective support tool for both adolescents and providers in SBHCs, and possibly other clinical settings, across the country to increase contraceptive use and thereby decrease unintended pregnancies. It could potentially reduce disparities in adolescent pregnancies and create more efficient visit time spent between clients and their providers.

Physicians' Knowledge, Perceptions, and Attitudes Related to Patient Confidentiality and Data Sharing

BACKGROUND

The protection of patient confidentiality is an essential practice for the successful provision of healthcare. This study examines physicians' knowledge and attitudes related to data sharing and patient confidentiality.

METHODS

This is a descriptive, questionnaire-based study. Physicians were invited via e-mail to complete the study survey. The survey comprised three sections related to knowledge, attitudes, and demographic characteristics.

RESULTS

A total of 221 physicians, with varying levels of experience and from a range of specialty areas, completed the study survey. Ethical dilemmas were encountered annually by physicians specialized in family medicine and daily by physicians in internal medicine wards more often than those in other departments. The mean score for knowledge was 7.34 (out of 14; SD=2.92) and had a positive correlation with attitudes towards the protection of data confidentiality (r2=0.282, p<0.001). Undergraduate courses were the main source of knowledge related to ethical issues (167; 74.9%). Sex (B=-1.47, p=0.001), marriage (B=-1.198, p=0.021), and source of consultation (B=-.248, p=0.02) were all found to predict knowledge scores. Likewise, attitudes were predicted by experience (B= 0.279, p<0.001), sex (B= -2.797, p=0.002), marriage (B=1.91, p=0.02), and number of ethical dilemmas faced (B=1.695, p <0.001).

CONCLUSION

Physicians from different departments were found to lack sufficient knowledge about many aspects of patient confidentiality. While some of the physicians' practices complied with the law, other practices were identified as patient confidentiality breaches.

Results of a National Text Message Poll of Youth: Perspectives on Primary Care

PURPOSE

There is a significant interest in improving adolescent access to primary care, yet limited attempts to incorporate youth feedback within these efforts. The purpose of this study was to describe the experiences related to primary care among a large national sample of adolescents to improve patient-centered care.

METHODS

Youth were sent open-ended text message prompts via an ongoing study of 14- to 24-year-olds in the U.S. Text responses were analyzed using qualitative thematic analysis, including descriptive coding, consensus building, and theme development. Secondary quantitative analyses were conducted to determine differences by demographics.

RESULTS

Of 1,123 eligible participants, 789 (70.2%) responded to at least one prompt. Four themes were developed: (1) youth recognized the importance of primary care, but barriers exist that limited their utilization; (2) youth felt that improving convenience would increase the use of primary care; (3) youth were unsure how to transition between primary care settings; and (4) feeling respected was essential to youth having positive experiences in a primary care health care setting. Older youth and those identifying as female, nonbinary, or transgender were more likely to report previous bad experiences with primary care.

CONCLUSIONS

Our findings describe barriers and possible solutions to primary care among youth. Because attitudes toward health and health care are established during adolescence, a transformation is needed to create more patient-centered care that aligns with young people's values and experiences. Thus, primary care providers have the opportunity to positively impact the health of young people today and the adults of the future.

Considerations for working with youth with socially complex needs

TOPIC

The presence of adverse childhood experiences offers a glimpse into the social complexity in the lives of youth. Thus far, youth have been categorized as "at-risk" or "vulnerable,"-identifiers which highlight a deficits-based framework and continue to stigmatize youth. To combat this systemic marginalization, we propose using the term youth with socially complex needs. These youth, often minority ethnic/racial and/or sexual/gender minorities, experience repeated adversity and discrimination.

PURPOSE

The purpose of this paper is to conceptualize the unique considerations of working with youth with socially complex needs-who have an increased vulnerability for social marginalization.

SOURCES USED

Given the adversity experienced and challenges inherent in working with youth with socially complex needs, ethical principles, and relevant care delivery models were explored.

CONCLUSIONS

Delivering mental health care and/or conducting research in collaboration with youth with socially complex needs requires thoughtful consideration of ethical principles and models of care. In conclusion, we propose a strengths-based, individualized approach to working with youth with socially complex needs that requires a dynamic, fluid, multisystemic approach to care and research.

Pediatric Nurse Practitioners' Perspectives on Engaging Adolescents to Shift from Pediatric to Adolescent-Focused Health Care Services

INTRODUCTION

This study examined the perspectives of pediatric nurse practitioners (PNPs) on the shift from pediatric to adolescent-focused health care services (HCS). This movement coincides with the early stages of the health care transition process.

METHOD

Conference attendees (N = 170) participated in a discussion on the shift from pediatric to adolescent-focused HCS. A secondary analysis was conducted. Data were analyzed for themes using content analysis.

RESULTS

Confidentiality was found to be a foundational aspect of adolescent-focused HCS. Two additional themes described adolescent-focused HCS characteristics and the role of the PNP in providing education and empowerment for adolescents and parents throughout this process.

DISCUSSION

PNPs provide critical leadership in facilitating the shift to adolescent-focused care by providing HCS designed to support confidentiality, respond to the needs of adolescents, and offer education to empower adolescents and parents on the importance of adolescent-focused care and engagement in the overall health care transition process.

Barriers and facilitators for the sexual and reproductive health and rights of young people in refugee contexts globally: A scoping review

BACKGROUND

The need to address sexual and reproductive health and rights (SRHR) in humanitarian settings is more urgent than ever, especially among young refugees. We conducted a scoping review to identify and synthesise the literature on perceived barriers and facilitators to SRHR among young refugees and interventions created to address their needs.

METHODS

We searched three databases (PubMed, Global Health and POPLINE) for peer-reviewed and grey literature published in English between January 2008 and June 2018 that reported on SRHR barriers, facilitators and interventions for young refugees aged 10 to 24 years. We extracted data using standardised templates and assessed the quality of studies according to study design. Data were charted using qualitative content analysis and organised in line with a socio-ecological framework (individual, social and community, institutional and health system, and structural).

FINDINGS

We screened 1,169 records and included 30 publications (qualitative, quantitative, and mixed methods) across 22 countries; 15 were peer-reviewed articles and 15 were from the grey literature. Twenty-two publications reported on young people in refugee camps or alternatives to camps (e.g. sustainable settlements), and eight referred to young refugees who had been resettled to a third country. We identified 19 sub-categories for barriers and 14 for facilitators at the individual, social and community, institutional and health system, and structural levels. No publications discussed the SRHR challenges faced by young homosexual, bisexual, transgender or queer refugees, or those living with HIV. Nine publications described interventions, which tended to focus on the provision of SRHR services and information, and the training of peers, parents, religious leaders and/or service providers.

CONCLUSIONS

Findings highlight that while young refugees experience similar barriers to SRHR as other young people, many of these barriers are exacerbated by the refugee context. The limited number of publications and evidence on interventions underlines the immediate need to invest in and evaluate SRHR interventions in refugee contexts.

Le counseling auprès des adolescents et des parents au sujet du cannabis : une introduction pour les professionnels de la santé

L’usage de cannabis est fréquent chez les adolescents du Canada, mais les jeunes en reconnaissent les dangers potentiels et s’attendent de plus en plus à ce que des dispensateurs de soins bien informés leur parlent d’usage de substances psychoactives dans leur pratique quotidienne. Le présent point de pratique propose de solides outils fondés sur des données probantes pour aider les professionnels de la santé à parler d’usage de cannabis à des fins non médicales (récréatives) et des risques qui s’y associent. Les auteurs expliquent comment rendre le milieu clinique sécuritaire pour parler de substances psychoactives avec les jeunes et suggèrent des stratégies précises pour leur parler d’usage de cannabis de manière efficace et adaptée à leur développement. Conformément aux publications scientifiques récentes, ils recommandent des questionnaires de dépistage pour contribuer à structurer les échanges et déterminer quels adolescents pourraient profiter d’interventions plus spécialisées. Puisqu’un adolescent sur six qui expérimente le cannabis finit par en faire un usage abusif, l’évaluation de la volonté des adolescents à modifier leurs comportements à risque représente un aspect essentiel des soins, conjointement avec l’établissement d’objectifs complémentaires et l’aide aux familles. Enfin, des ressources pour les praticiens et les parents sont recommandées.

Tant les parents que les adolescents se préoccupent des effets et des dommages potentiels du cannabis et des autres substances psychoactives (1,2). De nombreux adolescents considèrent les professionnels de la santé comme des sources d’information fiables sur les substances psychoactives et s’attendent à ce qu’ils abordent l’usage ou les risques qui s’y associent lors des rendez-vous de santé (3). Dans le rôle de facilitateurs et de courtiers du savoir, les dispensateurs de soins (DdS) peuvent entretenir un dialogue efficace avec les jeunes et leur famille.

Counselling adolescents and parents about cannabis: A primer for health professionals

While cannabis use among adolescents is frequent in Canada, youth do recognize the potential harms, and increasingly expect knowledgeable health care providers to discuss substance use in everyday practice. This practice point provides sound, evidence-based tools to help health professionals address nonmedical (recreational) cannabis use and its related risks. After highlighting how to make the clinical setting a safe space for youth to talk about psychoactive substances, specific strategies for approaching cannabis use in effective, developmentally appropriate ways are described. Consistent with current literature, screening questionnaires to help structure discussion and identify adolescents who may benefit from more specialized interventions are recommended. Because one in six adolescents who experiments with cannabis goes on to misuse it, appraising their willingness to change risky behaviours is a key aspect of care, along with supportive goal-setting and helping families. Recommended resources for practitioners and parents are included.

Availability of Confidential Services for Teens Declined After the 2011-2013 Changes to Publicly Funded Family Planning Programs in Texas

PURPOSE

Texas is one of 24 states that does not explicitly allow minors to consent to contraception. We explore changes in the provision of confidential reproductive health services after the implementation of state policies that cut and reorganized public family planning funding, including Title X.

METHODS

We use data from 3 waves of in-depth interviews, conducted between February 2012 and February 2015, with program administrators at publicly funded family planning organizations in Texas about changes in service delivery. We conducted a thematic analysis of transcripts from 47 organizations with segments related to the provision of services to minor teens.

RESULTS

Overall, 34 of the 47 organizations received Title X funding before 2013, and 79% lost this funding during the study period. Respondents at these organizations frequently reported a decrease in teen clients, which they attributed to loss of confidential services previously guaranteed under Title X. As the number of Title X-funded sites decreased, availability of confidential services became inconsistent. Most organizations offered confidential testing for pregnancy and sexually transmitted infections, but availability of confidential contraceptive services varied across and within organizations and often depended on insurance coverage. Respondents also reported challenges clarifying parental consent requirements after the changes in Title X and state funding.

CONCLUSIONS

Loss of Title X funding decreased availability of quality family planning services for teens and burdened organizations. As the new Title X regulations are implemented, family planning organizations' experiences in Texas foreshadow what might occur nationally, particularly in states that do not allow minors to consent for contraception.

Physicians' Attitudes Toward Adolescent Confidentiality Services: Scale Development and Validation

Introduction

Confidentiality is one of the oldest ethical principles in healthcare. However, confidentiality in adolescent healthcare is not a universally-accepted doctrine among scholars. The ethical acceptability of confidential services in adolescents’ healthcare is based on perceptions of adolescent maturity and an appreciation of its importance to adolescents’ access and utilization of healthcare services. Despite legal policies that promote adolescents’ rights, physicians’ attitudes toward adolescent confidentiality can be a determining factor in their ultimate decision to protect adolescents’ confidentiality.

Method

A new Attitude towards Adolescent Confidentiality Scale was developed based on the results of a qualitative interview study. This new instrument was administered to a sample of 152 physicians working at school pediatric and gynecology departments in 13 primary healthcare institutions in Belgrade. Principal component analysis was applied to determine the main components of the scale. Reliability was assessed by calculating Cronbach alpha and mean inter-item correlations.

Results

Psychometric analysis of the final 19-item version of the scale showed a high level of reliability (Cronbach alpha of 0.83). Principal component analysis showed four components, which present subscales of the instrument: Confidentiality in clinical situation, Iimportance of confidentiality, Adolescent maturity, and Communication with parents.

Conclusions

The instrument showed satisfactory levels of reliability and validity. The results of the scale dissemination may be a valuable tool for needs assessment for future educational interventions and training programs that will raise physicians’ awareness of the importance of adolescent confidentiality.

Transition Cliffs for Young Adults with Anxiety and Depression: Is Integrated Mental Health Care a Solution?

Young adulthood is a major transition period, particularly challenging for those with mental disorders. Though the prevalence of depressive and anxiety disorders is especially high, young adults are less likely to receive mental health treatment than younger and older individuals. Reasons for this mental health treatment gap are multifold and range from individual- to system-level factors that must be taken into consideration when addressing young adult mental health needs. Studies in adults and adolescents have shown that integrated care in primary care settings is an effective model of treatment of mental disorders. After providing an overview of the mental health treatment gap in this developmental period, the argument is made for research focused on integrated care models specifically tailored for young adults that takes into consideration the various needs and challenges that they face and addresses the mental health treatment gap in young adulthood.

Pharmacists' perspectives on prescribing hormonal contraception in Washington, DC, with a focus on young people

OBJECTIVE

To assess pharmacists' interest, comfort level, training needs, and barriers to prescribing hormonal contraceptives, particularly in the context of serving young people in Washington, DC.

DESIGN

In this mixed-methods study, we conducted a focus group discussion with pharmacists in February 2017, which was analyzed thematically using inductive and deductive coding. In January 2018 to June 2018, we conducted a survey with pharmacists, which was analyzed using descriptive statistics.

SETTING AND PARTICIPANTS

Community and outpatient pharmacists in Washington, DC.

OUTCOMES MEASURES

Pharmacists' interest and comfort level to begin prescribing hormonal contraception, particularly in the context of serving young people.

RESULTS

A total of 6 pharmacists participated in the focus group discussion, and 82 pharmacists participated in the online survey. In the survey, 59% of pharmacists were interested in prescribing hormonal contraception as independent practitioners and 63% through collaborative practice agreements; focus group participants believed that other pharmacists might be less likely to participate. In addition, focus group and survey respondents reported high levels of comfort with activities related to prescribing hormonal contraception, including 96% of survey participants reporting comfort taking blood pressure and 93% reporting comfort counseling young women on hormonal contraceptive methods. Only 25% of pharmacists reported having a private consultation space that provided both visual and auditory privacy. To ensure that pharmacies were ready to implement this service, pharmacists identified multiple concerns that needed to be addressed, including workload, liability issues, compensation, and a need for additional training on hormonal contraceptive methods, and how to counsel young people on them.

CONCLUSION

Pharmacists in Washington, DC, are interested in and comfortable with activities related to prescribing hormonal contraception, including to young people. However, to become ready to offer these services, pharmacists desire additional training, and pharmacies need to ensure confidentiality for young people and address pharmacists' concerns about workload, liability, and compensation.

Unique Needs of the Adolescent

Adolescence is the transitional bridge between childhood and adulthood; it encompasses developmental milestones that are unique to this age group. Healthy cognitive, physical, sexual, and psychosocial development is both a right and a responsibility that must be guaranteed for all adolescents to successfully enter adulthood. There is consensus among national and international organizations that the unique needs of adolescents must be addressed and promoted to ensure the health of all adolescents. This policy statement outlines the special health challenges that adolescents face on their journey and transition to adulthood and provides recommendations for those who care for adolescents, their families, and the communities in which they live.

Variability in adolescent portal privacy features: how the unique privacy needs of the adolescent patient create a complex decision-making process

Objective

Medical privacy policies, which are clear-cut for adults and young children, become ambiguous during adolescence. Yet medical organizations must establish unambiguous rules about patient and parental access to electronic patient portals. We conducted a national interview study to characterize the diversity in adolescent portal policies across a range of institutions and determine the factors influencing decisions about these policies.

Methods

Within a sampling framework that ensured diversity of geography and medical organization type, we used purposive and snowball sampling to identify key informants. Semi-structured interviews were conducted and analyzed with inductive thematic analysis, followed by a member check.

Results

We interviewed informants from 25 medical organizations. Policies established different degrees of adolescent access (from none to partial to complete), access ages (from 10 to 18 years), degrees of parental access, and types of information considered sensitive. Federal and state law did not dominate policy decisions. Other factors in the decision process were: technology capabilities; differing patient population needs; resources; community expectations; balance between information access and privacy; balance between promoting autonomy and promoting family shared decision-making; and tension between teen privacy and parental preferences. Some informants believed that clearer standards would simplify policy-making; others worried that standards could restrict high-quality polices.

Conclusions

In the absence of universally accepted standards, medical organizations typically undergo an arduous decision-making process to develop teen portal policies, weighing legal, economic, social, clinical, and technological factors. As a result, portal access policies are highly inconsistent across the United States and within individual states.

Acne and the Lesbian, Gay, Bisexual, or Transgender Teenager

Although most teenagers experience acne, for sexual and gender minority teenagers, acne could be more challenging and require specific psychosocial considerations. Acne may be more strongly associated with mental health issues in sexual and gender minority adolescents. Acne development during puberty may trigger gender dysphoria in transgender patients. Transgender and gender nonbinary patients receiving testosterone therapy may experience new or worsening acne. Comprehensive care for moderate to severe acne in sexual and gender minority adolescents should include culturally competent discussions about sexual behaviors, contraception, and/or gender-affirmation treatment plans.

Public Schools' Identification and Management of Underage Alcohol Use: A Qualitative Study

Objectives

The objective of this qualitative study was to investigate how public schools in the Miami-Dade County School District identify and manage students' underage alcohol use and to explore the benefits and challenges of systematic screening for underage alcohol use in district schools.

Methods

Face-to-face interviews were conducted with 16 school officials directly responsible for addressing underage alcohol use incidents at district middle and high schools. These individuals included assistant principals, guidance counselors, social workers and school-based health care professionals. A grounded-theory approach was used to code and synthesize informants' responses.

Results

No informants reported systematic screening for underage alcohol use at their schools, although their middle and high schools employed a range of intervention strategies. Emergent themes reflected common ways by which students using alcohol were identified, factors influencing underage alcohol use, and barriers to screening intervention implementation. Lack of access to acute intoxication events, differing policies across schools, inadequate resources, and reliance on administrator discretion rather than explicit policy mandates appear to undermine the development of consistent strategies for addressing suspected or reported underage alcohol use.

Conclusion

Public schools may serve as key implementation contexts for future universal or selected screening initiatives to identify and manage cases of underage alcohol use. The benefits and challenges perceived by school staff and administrators - especially for implementing consistent policies across schools - are critical to the development of acceptable, feasible, and sustainable alcohol screening initiatives.

Youth Perspectives on Pharmacists' Provision of Birth Control: Findings From a Focus Group Study

PURPOSE

Young women face numerous obstacles to accessing contraception, including lack of money, time, or transportation to visit a doctor. In addition, concerns about confidentiality deter many adolescents from seeking contraceptive care. Pharmacists in Washington, D.C. will soon be able to prescribe hormonal birth control, which can potentially increase contraceptive access for adolescents. This study explores the needs and concerns of teens and young women residing in Washington, D.C. to inform implementation of this service.

METHODS

In this community-based participatory research study, four focus group discussions were conducted in February 2017, two with teen females aged 14-17 years and two with young women aged 18-24 years. A youth advisory council, comprising 13 women aged 16-22 years living in Washington, D.C., helped develop the discussion guide and interpret findings. Data were analyzed thematically by age group using inductive and deductive codes.

RESULTS

Young people viewed pharmacies as convenient locations to access contraceptives but expressed concerns about privacy, affordability, and pharmacist approachability. Younger participants viewed these concerns as significant barriers for their peers. Participants suggested pharmacies protect privacy and confidentiality by offering private consultation spaces and clear information about what insurance plans can disclose to parents. Participants also recommended pharmacies create a youth-friendly, nonjudgmental environment and offer pharmacists training on contraceptive counseling for young women.

CONCLUSIONS

Addressing concerns about privacy, costs, and pharmacist approachability can help ensure that youth seeking contraceptives can easily access their preferred method. Pharmacies should continuously incorporate young people's feedback to ensure this service remains accessible and acceptable to adolescents.

University efforts to address confidentiality issues for STI services

Objective: This study assessed university policies for addressing confidentiality issues for students seeking STI services. Participants: Universities with sponsored health insurance plans (SHIP) and/or wellness centers were selected from a university health services survey in 2017. Methods: STI service coverage and polices for addressing confidentiality issues related to explanation of benefit (EOB) forms were stratified by institution type (4-year versus 2-year) and minority serving institution (MSI) status. Rao-Scott chi-square tests were used to assess for differences in STI service coverage and polices. Results: More non-MSIs (61.6%) had SHIPs compared to MSIs (40.0%, p < .001). Only 40.8% of health centers had a policy for addressing EOB-related confidently issues. Of those, the most reported policy was that students could pay out-of-pocket to avoid generating an EOB (36.2%). Conclusions: Reducing confidentiality barriers are important for STI prevention in students. Universities may consider establishing policies for addressing EOB-related confidentiality concerns.

The Role of Parents and Family Networks in Adolescent Health-Seeking in Ethiopia

OBJECTIVE

This study examines the roles of parents, extended kin, and exchange networks in adolescent health-seeking behavior in Ethiopia.

BACKGROUND

Prior studies highlight the role of mothers in children's health, whereas fathers, extended kin and other network partners remain largely unexamined. The gender intensification hypothesis suggests that adolescents gravitate toward same gender parents for advice and assistance with health-related issues. A more expansive view of the hypothesis suggests that other same gender adults may also be important sources of support.

METHOD

Survey data were used from a random sample of 2,084 youth ages 13-17 collected in urban and rural communities in southwestern Ethiopia. Sources of advice, treatment, and accompaniment to get treatment were examined. Random intercept logistic regression models were used to identify factors associated with receipt of formal health care.

RESULTS

Fathers and mothers played an important role in all phases of adolescent health-seeking behavior. Fathers' involvement was especially common in rural areas and more so with boys than girls. Extended kin and exchange networks also played a role and were even more important for boys in female-headed households, suggesting they may have substituted for absent fathers.

CONCLUSION

Adolescents rely heavily on parents and other adults for health advice and treatment. Who children go to for assistance is highly gendered, especially in rural areas.

IMPLICATIONS

Studies of adolescent health-seeking and interventions designed to improve health services utilization need to recognize the important involvement of parents and other closely related adults in advising youth and accompanying them to get treatment.

Adolescent perspectives about their participation in alcohol intervention research in emergency care: A qualitative exploration using ethical principles as an analytical framework

AIMS

To explore adolescents' experiences of consenting to, and participating in, alcohol intervention trials when attending for emergency care.

METHODS

In-depth semi-structured interviews with 27 adolescents (16 males; aged 14-17 years (Mage = 15.7)) who had taken part in one of two linked brief alcohol intervention trials based in 10 accident and emergency departments in England. Interviews were transcribed verbatim and subject to thematic analysis.

RESULTS

Research and intervention methods were generally found to be acceptable though confidentiality was important and parental presence could hinder truthful disclosures regarding alcohol use. Participants discussed the importance of being involved in research that was relevant to them and recognised alcohol consumption as a normative part of adolescence, highlighting the importance of having access to appropriate health information. Beyond this, they recognised the benefits and risks of trial participation for themselves and others with the majority showing a degree of altruism in considering longer term implications for others as well as themselves.

CONCLUSIONS

Alcohol screening and intervention in emergency care is both acceptable and relevant to adolescents but acceptability is reliant on confidentiality being assured and may be inhibited by parental presence.

TRIAL REGISTRATION

ISRCTN Number: 45300218.

Blood-borne viral infections in pediatric hemodialysis

Hemodialysis patients are at increased risk for development of blood-borne viral infections. Human immunodeficiency virus (HIV), a once fatal infection, has become treatable, but continues to be associated with increased mortality. Hepatitis B and C viral infections can lead to acute and chronic hepatitis, cirrhosis, or hepatocellular carcinoma. Young children and immunocompromised patients are more likely to develop chronic disease leading to increased morbidity and mortality, as compared to the healthy population. The hemodialysis population is at increased risk of blood-borne viral infections as compared to the general population due to multiple factors. Here we review risk factors of blood-borne viral infections, strategies for prevention, and approach to therapy in the pediatric hemodialysis population.

Serbian primary care physicians' perspectives on adolescents' right to confidentiality in sexual and reproductive healthcare-a qualitative interview study

BACKGROUND

In prominent international documents and professional position papers, confidentiality was recognized as a necessary condition for effective reproductive healthcare of adolescents. Although legally guaranteed, it is questionable if the right to confidentiality of adolescents is respected in healthcare practice in Serbia.

OBJECTIVES

To assess primary care physicians' perspectives on the legal right of minors to confidentiality in sexual and reproductive healthcare, as well as their experiences in practice.

METHODS

Qualitative, semi-structured face-to-face interviews with 12 primary care pediatricians and gynecologists at several municipalities of the city of Belgrade were performed. Interview transcripts were analyzed using qualitative content analysis method.

RESULTS

Most interviewees were aware of their legal obligations and support the general idea of granting adolescents the right to confidentiality. They recognized that the lack of confidentiality assurances prevents adolescents' access to sensitive care. However, physicians expressed concerns regarding medical situations when parents should be notified, which was reflected in their inconsistent respect of said right in actual practice. Several organizational obstacles were emphasized by interviewees, including insufficient number of physicians, time constraints, poor access to gynecological services and vague definitions of legal provisions.

CONCLUSION

If the aim is for adolescents' right to confidentiality to be consistently respected in practice, primary care physicians need to be systematically educated about legal provisions and given comprehensive clinical guidelines. The general positive attitude towards confidentiality expressed by the primary care physicians implies that a possibility exists to engage them as main advocates for improvements in access to the necessary health care.

Primary Care Physician Attitudes and Intentions Toward the Use of HIV Pre-exposure Prophylaxis in Adolescents in One Metropolitan Region

PURPOSE

Understanding the attitudes of physicians toward the use of pre-exposure prophylaxis (PrEP) for HIV prevention among youth is critical to improving access to PrEP. We examined PrEP-related attitudes among physicians who provide primary care to 13- to 21-year-old adolescents.

METHODS

Individual, in-depth, semistructured interviews were conducted with 38 physicians from adolescent medicine, family practice, internal medicine/medicine-pediatrics, obstetrics/gynecology, and pediatrics who care for any adolescents younger than 18 years. Interviews assessed familiarity with PrEP, perceived benefits and barriers to providing PrEP to adolescents, facilitating factors for prescribing PrEP, and likelihood of recommending and prescribing PrEP to adolescents.

RESULTS

Mean age was 44.6 years (standard deviation 10.9). Fourteen physicians (37%) reported being somewhat or very familiar with PrEP. Perceived benefits of prescribing PrEP included decreased acquisition/rates of HIV, improved provision of sexual health services, and improved patient awareness of HIV risk. Barriers to PrEP were reported at the patient (e.g., lack of acceptability to patients), provider (e.g., concerns about patient adherence, safety/side effects, parents as a barrier to PrEP use), and system (e.g., high cost) levels. Facilitating factors for prescribing PrEP included low cost/coverage by insurance, physician education about PrEP, patient educational materials, and clinical guidelines for PrEP use in youth. A higher proportion of physicians reported being highly or somewhat likely to recommend (N = 16, 42%) than prescribe PrEP (N = 13, 34%).

CONCLUSIONS

In this study of primary care physician attitudes toward PrEP prescribing for adolescents, physicians identified numerous barriers to providing PrEP. Addressing these barriers may increase adolescents' access to PrEP.