Missed opportunities for sexually transmitted diseases, human immunodeficiency virus, and pregnancy prevention services during adolescent health supervision visits

A method to advance adolescent sexual health research: Automated algorithm finds sexual history documentation

Background:

We aimed to develop and validate a rule-based Natural Language Processing (NLP) algorithm to detect sexual history documentation and its five key components [partners, practices, past history of sexually transmitted infections (STIs), protection from STIs, and prevention of pregnancy] among adolescent encounters in the pediatric emergency and inpatient settings.

Methods

We iteratively designed a NLP algorithm using pediatric emergency department (ED) provider notes from adolescent ED visits with specific abdominal or genitourinary (GU) chief complaints. The algorithm is composed of regular expressions identifying commonly used phrases in sexual history documentation. We validated this algorithm with inpatient admission notes for adolescents. We calculated the sensitivity, specificity, negative predictive value, positive predictive value, and F1 score of the tool in each environment using manual chart review as the gold standard.

Results

In the ED test cohort with abdominal or GU complaints, 97/179 (54%) provider notes had a sexual history documented, and the NLP algorithm correctly classified each note. In the inpatient validation cohort, 97/321 (30%) admission notes included a sexual history, and the NLP algorithm had 100% sensitivity and 98.2% specificity. The algorithm demonstrated >97% sensitivity and specificity in both settings for detection of elements of a high quality sexual history including protection used and contraception. Type of sexual practice and STI testing offered were also detected with >97% sensitivity and specificity in the ED test cohort with slightly lower performance in the inpatient validation cohort.

Conclusion

This NLP algorithm automatically detects the presence of sexual history documentation and its key components in ED and inpatient settings.

Effectiveness of Contraceptive Decision Aids in Adolescents and Young Adults: A Systematic Review

BACKGROUND

Contraceptive decision aids may support adolescents and young adults (AYA) in choosing contraceptive methods that fit their unique reproductive health needs.

OBJECTIVE

To provide a systematic review of studies examining the effectiveness of contraceptive decision aids in AYA.

MATERIALS AND METHODS

A systematic search was conducted of studies published between January 1, 2011, and March 31, 2021 using PubMed, Cochrane, and ClinicalTrials.gov. Studies were included if a contraceptive decision aid (ie, paper handout, mobile application, website, or video) was evaluated in AYA populations (age ≤30 years) in the United States. The primary outcome was decision aid effectiveness (ie, change in contraceptive knowledge, interest in contraception, contraceptive use, unintended pregnancies, and satisfaction with the decision aid).

RESULTS

Seven randomized controlled trials and 3 pre-post studies, reporting on 3725 AYA (range, 11-30 years), met inclusion criteria. No studies were excluded due to risk of bias. The methodologies and results were heterogeneous, but most consistently demonstrated increased contraceptive knowledge.

CONCLUSION

Ten studies evaluated a range of contraceptive decision aid formats for AYA. Decision aids appear to be effective at increasing contraceptive knowledge temporarily, but their effect on other contraceptive outcomes is unclear. Future research should evaluate decision aids specifically in adolescents.

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.

Using Reproductive Health as a Strategy to Engage Youth in Preventive Care

PURPOSE

This research examined differences in receipt of recommended preventive services by contraceptive use in adolescent and young adult (AYA) women.

METHODS

Data are from a retrospective chart review of 408 AYA women who received sexual health risk reduction counseling in an urban academic AYA clinic. Descriptive, bivariate, and logistic regression analyses were used to examine relationships between contraception use and receipt of care.

RESULTS

AYA women aged 12-24 years using hormonal contraception were more likely to receive recommended preventive care, including an annual preventive visit and sexually transmitted infection screening, compared with those using condoms or no contraception. Women using medium-acting reversible contraception were more likely to have an annual visit compared with those not using hormonal contraception.

CONCLUSIONS

AYA women using contraception are more likely to receive recommended preventive health services, suggesting reproductive health visits may be used to promote engagement around preventive care.

Staff's experiences of a pilot implementation of the SEXual health Identification Tool for assessing sexual ill health among visitors to Swedish youth clinics: A focus group study

BACKGROUND

Young people are disproportionally burdened by sexual ill health. The SEXual health Identification Tool (SEXIT) was developed for use at youth clinics, to facilitate identification of visitors exposed to or at risk of sexual ill health. The aim of this study was to explore experiences of using SEXIT among youth clinic staff who participated in a pilot implementation, with a focus on usefulness, implementation determinants, and feasibility of implementing SEXIT at Swedish youth clinics.

METHODS

Four focus group discussions were conducted with youth clinic staff from three clinics. The clinics had used SEXIT systematically in consultations with all visitors for one month. Data were analysed using qualitative analysis designed for focus groups.

RESULTS

Most participants experienced that the SEXIT routines were well functioning and that using SEXIT gave a comprehensive picture of the visitor and resulted in more concrete answers, which facilitated the risk assessment. The medical staff experienced that they identified more youth at risk with SEXIT, while the psychosocial staff were less convinced. Existing challenges related to the routines at the clinics and heavy workload during drop-in hours.

CONCLUSIONS

Staff experience SEXIT as useful for identifying young people exposed to or at risk of sexual ill health. Systematic use ensures consistency and quality in assessing the visitors, which may facilitate implementation. The use of SEXIT is challenged by heavy workload, conflicting routines, and the experience that some visitors identified through SEXIT decline further care. Implementation of SEXIT in Swedish youth clinics is considered feasible.

"Starting that Conversation Is Even Harder than Having It": Female Patients' Perceptions of Physicians' Communication Competence in Communication about Sexual Behavior

Female college students demonstrate a persistent lack of knowledge about safe sexual practices and engage in sexual behavior that puts them at risk for sexually transmitted infections and unplanned pregnancy. Physicians have an opportunity to provide accurate and timely information about safe sexual behavior to individuals in their care. However, many young people, and in particular young women, are reticent to talk to their physicians about sexual behavior because they typically consider the information to be private. Exacerbating this issue is the fact that many physicians are also uncomfortable discussing sexual topics with their patients. In this study, Communication Privacy Management (CPM) theory is used to investigate the criteria that female college students employ to negotiate the disclosure and concealment of information about sexual behavior in communication with physicians. Qualitative analysis of semi-structured interviews with female college students was used to explain their perceptions of disclosure of sexual behaviors to their physician. Specifically, the participants' perceptions of physicians' communication competence informed privacy management rules. These findings have the potential to improve communication interventions for both female college students and healthcare professionals.

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.

Improving Male Genital Examinations in Adolescent Patients: Creation and Preliminary Validation of an Assessment Tool

PURPOSE

Providers cite lack of training and knowledge as reasons for omitting male genitourinary (GU) examinations. Also, no standard tools exist for assessment of male GU exams despite instruments for female pelvic exams. The objective of this project was to create and validate a male GU assessment instrument to evaluate trainee skill level.

METHODS

A first-author created 18-item assessment instrument (addressing preparation, exam, communication) was reviewed by a seven-member expert panel of adolescent medicine providers who reviewed items using a 4-point Likert scale. Adolescent medicine faculty completed the instrument (n = 48) for trainees, and differences in assessments were analyzed utilizing chi-square (SPSS, v. 24.0 p < .05). Exempt status was granted by the Institutional Review Board.

RESULTS

Nineteen trainees (13 female, 6 male) completed the instrument; no significant differences existed in assessments by gender. Trainees who completed the assessment > 2 times inspected the glans/meatus (p = .045), palpated the inguinal canals (p = .02), and informed of exam steps (p = .04) well compared to their first assessment. There were differences between provider assessments washing hands (p = .001); inspecting pubic hair (p = .000), glans (p = .001), and penis shaft (p = .002); palpating inguinal canals (p = .000); explaining exam steps (p = .000); being professional (p = .000); and explaining exam findings (p = .000). Excluding the creator, only professionalism was rated differently among providers (p = .023).

CONCLUSIONS

The male genital exam assessment tool was preliminarily validated as highly relevant to the male GU exam, was not affected by learner gender, and showed learner improvement over time. There are differences between faculty, indicating individual perception of exam items and need for increased discussion before implementing the assessment instrument into practice.

Understanding Quality of Care and Satisfaction With Sexual and Reproductive Healthcare Among Young Men

OBJECTIVE

Sexual and reproductive healthcare (SRHC) guidelines recommend the delivery of quality preventive SRHC to males beginning in adolescence. A quality of care (QOC) framework was used to examine factors associated with young male's perceptions of QOC and satisfaction with care, which can influence their engagement and use of SRHC.

METHODS

Cross-sectional surveys were conducted from August 2014 to September 2016 with 385 male patients aged 15-24 years, recruited from primary care and sexually transmitted disease (STD) clinics. Surveys measured QOC received, satisfaction with care, and domains of a QOC framework. Poisson regression analyses examined associations between domains of quality and perceived QOC as well as satisfaction with care.

RESULTS

Over half of males reported QOC as excellent (59%) and were very satisfied with the services (56.7%). Excellent QOC and high satisfaction with services was associated with timely care, higher Clinician-Client Centeredness, and being a bisexual male. Excellent QOC was also associated with greater comfort in the clinic, being tested for human immunodeficiency virus/STDs, attending primary care settings, and receipt of higher number of SRHC services.

CONCLUSIONS

Using a QOC framework as part of providing SRHC to young males can be important in improving their perceptions of QOC and satisfaction with services.

Addressing Reproductive Health in Hospitalized Adolescents-A Missed Opportunity

PURPOSE

Adolescents are at high risk for sexually transmitted infections (STIs) and pregnancy. Since many adolescents have poor access to preventive care, hospitalizations present a critical opportunity to address adolescents' reproductive health. The purpose of this study was to assess provision of reproductive health services within a hospital setting.

METHODS

Retrospective study of a consecutive sample of adolescent patients aged 13 years and older hospitalized on the hospitalist service at a large academic pediatric tertiary care center. Measures included sexual history documentation, pregnancy and STI testing, Human papillomavirus immunization status and administration, and provision of contraception.

RESULTS

Only 55% of 150 patients had sexual history documentation, and of those, 47% endorsed sexual activity. Associations with increased likelihood of sexual history documentation included female patients (67% vs. 36%, p < .01), hospitalizations for ingestion (71% vs. 48%, p < .01), hospitalizations to hospital medicine compared with critical care (59% vs. 14%, p < .01), and admission note written by an intern compared with a senior resident, advanced practice provider, or fellow (67% vs. 44%, 29%, 13%, p < .01). Eighteen patients (12%) were tested for STIs. Only 19% of patients due for human papillomavirus immunization received it. Sixty percent of females received a pregnancy test. Contraception was provided in two encounters (2% of females).

CONCLUSIONS

Results demonstrate a substantial missed opportunity to provide reproductive health services to hospitalized adolescents. Providers in hospital settings should optimize the opportunity to screen for sexual activity and reproductive health needs, provide indicated services, and offer education regarding reproductive health to hospitalized adolescents.

Provider Adherence to Preventative Health Care Guidelines in Adolescent Girls Presenting for Well Visit

A dearth of research exists examining provider adherence to preventative health care guidelines at adolescent well-care visits. We examined adherence in 3 domains: documentation of sexual activity, documentation of menstrual characteristics, and administration of the human papillomavirus vaccine. We identified electronic health records of a random sample of 124 adolescent girls seen within the hospital-affiliated pediatric primary care clinics from July 1, 2014, to June 30, 2015. Approximately one quarter of the records examined had no documentation of sexual activity. Documentation occurred more frequently in English speakers (P = .003). Asian girls had the least documentation of sexual activity (P = .003). Clinicians documented menses characteristics in only 27% of adolescent girls with no documentation noted for Asian adolescents. Over 40% of eligible adolescents did not receive the human papillomavirus vaccine. Only 19.4% of adolescents received all the 3 recommended services. This study demonstrates that adolescent girls are not receiving recommended assessments or care to protect their reproductive health.

Implementing Adolescent Sexual and Reproductive Health Clinical Best Practice in the Bronx, New York

PURPOSE

Inequitable access to quality adolescent sexual and reproductive health (ASRH) care may contribute to the high rate of teen pregnancy in the Bronx, New York. Bronx Teens Connection (BxTC), a community-wide intervention, sought to increase the number of ASRH best practices implemented and the number of females 12-19 years old receiving services by health centers in the Bronx.

METHODS

To promote best practices, BxTC provided training and technical assistance to partnering health centers from 2011 to 2014. Health center staff completed a 26-item survey annually to document clinic practices and service utilization. Significance of changes was assessed with paired t tests.

RESULTS

BxTC provided 285 hours of training and technical assistance to 12 partnering health centers. Eight health centers consistently completed the survey. Of the possible 31 ASRH best practices, the average number implemented increased from 23 in 2011 to 28 in 2014. Increases in unduplicated female adolescent patients were observed among Hispanics/Latinas (p = .026) and all females aged 15-17 (p = .035). Contraceptive coverage reported by six of the eight health centers increased among Hispanic/Latinas (32%-55%, p = .006), patients ages 15-17 (33%-53%, p = .005), and patients 18-19 (38%-56%, p = .036). The total number of hormonal implants provided to teens increased from two in 2011 to 173 in 2014.

CONCLUSIONS

Other jurisdictions may consider prioritizing clinical linkages in order to improve ASRH outcomes by supporting best practices and expanding access to services in the most disinvested neighborhoods.

A Learning Collaborative Approach to Improve Primary Care STI Screening

The Bronx Ongoing Pediatric Screening (BOPS) project sought to improve screening for sexual activity and sexually transmitted infections (gonorrhea and chlamydia [GCC] and HIV) in a primary care network, employing a modified learning collaborative, real-time clinical data feedback to practices, improvement coaching, and a pay-for-quality monetary incentive. Outcomes are compared for 11 BOPS-participating sites and 10 non-participating sites. The quarterly median rate for documenting sexual activity status increased from 55% to 88% (BOPS sites) and from 13% to 74% (non-BOPS sites). GCC screening of sexually active youth increased at BOPS and non-BOPS sites. Screening at non-health care maintenance visits improved more at BOPS than non-BOPS sites. Data from nonparticipating sites suggests that introduction of an adolescent EMR template or other factors improved screening rates regardless of BOPS participation; BOPS activities appear to promote additional improvement of screening during non-health maintenance visits.

Optimizing Community-Based HIV Testing and Linkage to Care for Young Persons in Metropolitan Atlanta

HIV continuum of care analyses in Georgia during 2013 revealed that 82% of adolescents and adults living with HIV knew their diagnosis and that 75% were linked to care. However, of all persons in Georgia living with HIV in 2014, only 60% had at least one HIV care visit, and just 48% were retained in care. Understanding barriers for HIV testing, linkage, and retention in youth may strengthen HIV-related encounters and improve patient outcomes. We conducted 17 qualitative focus groups with HIV-positive and -negative youth, ages 18-24 years, from the Atlanta Metropolitan Statistical Area. Using computer-assisted thematic analyses, we examined focus group responses on ways to approach youth for community-based HIV testing and how service providers should discuss a new positive HIV diagnosis with youth. Of 68 participants, 85% were male, 90% were African American, 68% were HIV positive, and 50% had high school education or less. Mean age was 21.5 years (standard deviation: 1.8 years). Thematic analyses identified the following three key themes for approaching someone for HIV testing: (1) discretion, (2) being candid about testing, and (3) incentivizing testing. When service providers discuss an HIV positive test, participants recommended enhanced emotional support and reassurance of a potential healthy life span despite an HIV diagnosis. Community-based testing may be a viable option for increasing HIV screening of at-risk youth. Structuring an empathetic new diagnosis disclosure that addresses potential misconceptions and describes successful HIV treatment is essential to improving linkage to care among youth.

Sexual and Reproductive Health Care Receipt Among Young Males Aged 15-24

PURPOSE

This study aimed to describe young men's sexual and reproductive health care (SRHC) receipt by sexual behavior and factors associated with greater SRHC receipt.

METHODS

There were 427 male patients aged 15-24 who were recruited from 3 primary care and 2 sexually transmitted disease (STD) clinics in 1 urban city. Immediately after the visit, the survey assessed receipt of 18 recommended SRHC services across four domains: screening history (sexual health, STD/HIV test, family planning); laboratories (STDs/HIV); condom products (condoms/lubrication); and counseling (STD/HIV risk reduction, family planning, condoms); in addition, demographic, sexual behavior, and visit characteristics were examined. Multivariable Poisson regressions examined factors associated with each SRHC subdomain adjusting for participant clustering within clinics.

RESULTS

Of the participants, 90% were non-Hispanic black, 61% were aged 20-24, 90% were sexually active, 71% had female partners (FPs), and 20% had male or male and female partners (M/MFPs). Among sexually active males, 1 in 10 received all services. Half or more were asked about sexual health and STD/HIV tests, tested for STDs/HIV, and were counseled on STD/HIV risk reduction and correct condom use. Fewer were asked about family planning (23%), were provided condom products (32%), and were counseled about family planning (35%). Overall and for each subdomain, never sexually active males reported fewer services than sexually active males. Factors consistently associated with greater SRHC receipt across subdomains included having M/MFPs versus FPs, routine versus non-STD-acute visit, time alone with provider without parent, and seen at STD versus primary care clinic. Males having FPs versus M/MFPs reported greater family planning counseling.

CONCLUSIONS

Findings have implications for improving young men's SRHC delivery beyond the narrow scope of STD/HIV care.

Contraception for Adolescents and Young Adults in the Inpatient Setting: The Providers' Perspective

OBJECTIVES

To assess pediatric providers' attitudes and barriers to initiating a contraceptive method in the inpatient setting.

METHODS

Pediatric attending physicians and trainees from 5 academic institutions were surveyed about contraceptive prescribing practices, attitudes, and potential barriers to initiating contraception in the inpatient setting.

RESULTS

In 2016, 271 pediatric providers (34.0% were attending physicians, 18.1% fellows, and 47.9% residents) completed the survey; the response rate was 19.2%. Most participants practiced in both inpatient and outpatient settings (95.7% and 85.0%, respectively). More providers felt confident screening for sexual activity among young adults as compared with adolescents (71.9% vs 65.6%). The same was true for discussing contraceptive options (44.0% vs 38.8%, respectively). Inpatient providers reported seeing adolescents and young adults privately, discussing confidentiality, and asking about sex less than half of the time. More than 80% of providers agreed that it would be appropriate to initiate a contraceptive method for inpatients; 35.8% had done so, and 85.2% indicated that having additional consultation would increase initiation of a contraceptive method in the hospital (88.1% felt similarly for long-active reversible contraception methods). General barriers to initiating contraception included insufficient training, insufficient exposure to adolescents and young adults to maintain skills, and lack of time. Barriers specific to the inpatient setting included concerns about follow-up, confidentiality, and interference with the treatment plan.

CONCLUSIONS

Initiation of a contraceptive method in the inpatient setting is acceptable to providers. In our findings, it is suggested that strategies are needed to enhance provision of these services by addressing confidentiality concerns and educating providers.

The impact of an innovative web-based school nutrition intervention to increase fruits and vegetables and milk and alternatives in adolescents: a clustered randomized trial

Background

The increase in overweight and obesity in adolescents and its health-related consequences highlight the need to develop strategies, which could help them adopt healthy eating habits. The objective of this study was to evaluate the impact of an innovative web-based school nutrition intervention (Team Nutriathlon) aimed at promoting the consumption of vegetables and fruit (V/F) and milk and alternatives (M/A) in high school students and to identify facilitators and/or barriers influencing its success.

Methods

Ten classes of first and second year secondary students (grades 7 and 8) from the Québec City region were randomized into two groups (control n = 89 and intervention n = 193). Participants in the intervention (Team Nutriathlon) were to increase their consumption of V/F and M/A using an innovative web-based platform, developed for this study, over 6 weeks. The control group followed the regular school curriculum. The number of servings of V/F and M/A consumed by students per day was compared between the two groups before, during, immediately after and 10 weeks after the intervention using a web-based platform. Main outcome measures included V/F and M/A servings and facilitators and/or barriers of program success. Repeated measures linear fixed effects models were used to assess the impact of Team Nutriathlon on V/F and M/A consumption. A P-value of <0.05 was considered significant.

Results

Students in the intervention reported a significant increase of 3 servings and 1.8 servings per day of V/F and M/A, respectively, compared to the control group (P < 0.05); however, this was only observed in the short-term. Some factors contributing to the success of Team Nutriathlon included the team aspect of the program, use of the technology and recording results outside of classroom hours.

Conclusion

Team Nutriathlon represents an innovative web-based nutrition program which positively impacts V/F and M/A consumption among high school students. Using web-based or technological platforms may help youth adopt healthy eating habits that will have implications later in adulthood; however, further studies are needed to determine their long-term effects.

Trial registration

NCT03117374 (retrospectively registered).

Adolescent Perspectives on Patient-Provider Sexual Health Communication: A Qualitative Study

BACKGROUND

Adolescents in the United States are disproportionately affected by sexually transmitted infections and unintended pregnancy. Adolescent-centered health services may reduce barriers to health care; yet, limited research has focused on adolescents' own perspectives on patient-provider communication during a sexual health visit.

METHODS

Twenty-four adolescents (14-19 years old) seeking care in a public health clinic in Washington State participated in one-on-one qualitative interviews. Interviews explored participants' past experiences with medical providers and their preferences regarding provider characteristics and communication strategies.

RESULTS

Interviews revealed that (1) individual patient dynamics and (2) patient-provider interaction dynamics shape the experience during a sexual health visit. Individual patient dynamics included evolving level of maturity, autonomy, and sexual experience. Patient-provider interaction dynamics were shaped by adolescents' perceptions of providers as sources of health information who distribute valued sexual health supplies like contraception and condoms. Participant concerns about provider judgment, power differential, and lack of confidentiality also emerged as important themes.

CONCLUSIONS

Adolescents demonstrate diverse and evolving needs for sexual health care and interactions with clinicians as they navigate sexual and emotional development.

Knowledge and beliefs about HPV among college students in Vietnam and the United States

Any sexually active person has the possibility of contracting the human papillomavirus (HPV) sometime in their lifetime. HPV vaccines are effective in preventing HPV if obtained prior to viral exposure. Research on knowledge and beliefs of HPV and HPV vaccination among college students in Vietnam is significantly scarce. The purpose of this study is to examine the knowledge and beliefs about HPV among college students in Vietnam compared to college students in the US. This cross-cultural comparison will fill a void in current research on this subject. Over 900 college students (N=932: n=495 in Vietnam and n=437 in the US) participated in a self-administered survey on the knowledge and beliefs about HPV in September and October 2016. Vietnamese participants reported lower levels of knowledge and experiences with the HPV virus and vaccines (p<0.01). Additionally, Vietnamese participants also exhibited more barriers in obtaining the vaccination, as well as, HPV risk denial (p<0.01). The level of knowledge is an important predictor of barriers (p<0.01; η_p²=0.022) and risk denial (p<0.01; η_p²=0.116). On average, both Vietnamese and US participants could correctly answer less than half of the survey questions regarding HPV knowledge. Additionally, provider recommendations are potentially more important than informal connections (e.g. friends, family) to reduce barriers to HPV vaccination (p<0.01; η_p²=0.035) and denial of HPV risks (p<0.05; η_p²=0.008). The increase of knowledge about HPV prevention, including and vaccination, has the potential to be improved through provider interventions. Vietnam could take action toward promoting HPV vaccinations not only at an individual level but also at a national or local level. Further research may examine the effects of a lack of knowledge on HPV-related health outcomes.

Improving adolescent access and services in a large primary care network: report of a 10 year project

This report describes a decade long initiative to bring a unified approach and improved quality to the process and content of adolescent health care in a large and complex urban primary care network within an academic health system. The moving force was a voluntary multidisciplinary group who comprised the Montefiore Adolescent Primary Care Initiative, known as MAPCI, led by a physician subspecialist in Adolescent Medicine. A series of needs assessments formed the basis for a multipronged effort to create policies and procedures, educational activities and materials, changes in record-keeping and billing practices, and modification of staff attitudes and behavior that would enhance access and ensure confidentiality of services for the adolescent age group. The commitment of medical center leadership contributed to overall progress which was accelerated in the second half of the decade by the addition of a full-time staff member, with the title Adolescent Program Manager. Progress in various arenas was assessed with a series of planned studies, whose positive results provided encouragement for continuing efforts. The example of this initiative and its accomplishments should provide useful and replicable methods that could be adapted for improvement of adolescent health services in some of the other large primary care networks that are an ever-expanding presence in the current health care environment.

Missed Opportunities for Condom Counseling Among Adolescent Males

The purpose of this study was to quantify the rate of condom counseling (CC) among adolescent males at preventive (PV) and non-PV (NPV) clinic visits in order to identify missed opportunities for contraception counseling. Adolescent males attending an outpatient clinic at a tertiary children’s hospital from 2009 to 2013 were included. Patient demographics and provider responses to a postvisit electronic medical record questionnaire regarding CC were collected. Over 4 years, 2,439 males attended 6,123 visits; 33% were PVs. CC occurred at 92% PVs versus 43% NPVs ( p < .001). Those receiving CC were more likely to be older (16.1 vs. 15.9 years; p < .001) and minority (odds ratio = 1.43; 95% confidence interval = 1.28-1.61). In conclusion, in this single-center study among adolescent males, CC occurred routinely at PVs but infrequently at NPVs. CC was more likely among older, minority males. Providing CC at NPVs and ensuring younger, White males receive CC are two strategies to increase rates of CC among adolescent males.

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.

Research on Clinical Preventive Services for Adolescents and Young Adults: Where Are We and Where Do We Need to Go?

We reviewed research regarding system- and visit-level strategies to enhance clinical preventive service delivery and quality for adolescents and young adults. Despite professional consensus on recommended services for adolescents, a strong evidence base for services for young adults, and improved financial access to services with the Affordable Care Act's provisions, receipt of preventive services remains suboptimal. Further research that builds off successful models of linking traditional and community clinics is needed to improve access to care for all youth. To optimize the clinical encounter, promising clinician-focused strategies to improve delivery of preventive services include screening and decision support tools, particularly when integrated into electronic medical record systems and supported by training and feedback. Although results have been mixed, interventions have moved beyond increasing service delivery to demonstrating behavior change. Research on emerging technology-such as gaming platforms, mobile phone applications, and wearable devices-suggests opportunities to expand clinicians' reach; however, existing research is based on limited clinical settings and populations. Improved monitoring systems and further research are needed to examine preventive services facilitators and ensure that interventions are effective across the range of clinical settings where youth receive preventive care, across multiple populations, including young adults, and for more vulnerable populations with less access to quality care.

Men Aged 15-44 in Need of Preconception Care

OBJECTIVES

Preconception care for men focuses on prevention strategies implemented prior to conception of a first or subsequent pregnancy to improve pregnancy and infant outcomes. Little is known about U.S. men in need of preconception care. This analysis describes the proportion of men in need of preconception care and associations of these needs by background characteristics, related health conditions, access to care and receipt of services.

METHODS

Data from men aged 15-44 in the National Survey of Family Growth 2006-2010 were analyzed to describe men in need of preconception care, based on future childbearing intentions and self and partner fecundity status (among sexually experienced only), and associated factors with these needs using weighted bivariate analyses.

RESULTS

About 60 % of men are in need of preconception care. Higher prevalence of being in need was observed among men aged 15-29 than older; living in urban than non-urban settings; in school than not in school regardless of working status; not in a coresidential union than married or cohabiting; who were recent immigrants than U.S. born; and reporting never having had a child than ≥1 child(ren). Men in need were overweight/obese (56 %), ever binge drank in the last year (58 %), and have high STI risk (21 %). The majority of men in need reported access to care in the last year (>70 %), but few reported receipt of services including STD/HIV testing (<20 %) or counseling (<11 %).

CONCLUSIONS FOR PRACTICE

Findings from this analysis have implications for promoting preconception care among U.S. men.

Barriers and Facilitators to Health Center Implementation of Evidence-Based Clinical Practices in Adolescent Reproductive Health Services

PURPOSE

Despite the substantial evidence supporting the guidelines for the provision of reproductive health services for adolescents, research points to a persistent gap in their translation into health care practice. This study examines barriers and facilitators that health centers experience when implementing evidence-based clinical practices for adolescent reproductive health services and discusses strategies to address identified barriers.

METHODS

Semistructured interviews were conducted with 85 leaders and staff of 30 health centers in Alabama, Georgia, Massachusetts, North Carolina, South Carolina, Pennsylvania, and Texas. Interview data were analyzed for emergent themes following a grounded theory approach.

RESULTS

Data analysis revealed that certain factors at health system and community levels influenced health centers' efforts to implement evidence-based clinical practices for adolescent reproductive health care. 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

Health center efforts to implement new practice guidelines should include efforts to build the capacity of health center leadership to mobilize staff and resources to ensure that new practices are implemented consistently and with quality.

Teaching Trainees to Deliver Adolescent Reproductive Health Services

STUDY OBJECTIVE

Delivery of reproductive services to adolescents varies according to specialty and has been linked to differences in clinical training. Few studies have explored how different specialties' graduate medical education (GME) programs prepare providers to deliver adolescent reproductive services. We explored the perceptions of resident physicians regarding their training in delivering adolescent reproductive health services.

DESIGN

Between November 2008 and February 2009, 9 focus groups were conducted with graduate medical trainees in 3 specialties that routinely care for adolescents. The semistructured discussions were audio-recorded, transcribed, and analyzed using an inductive approach to content analysis.

SETTING

Large, urban academic medical center in Pittsburgh, Pennsylvania.

PARTICIPANTS

Fifty-four resident trainees in pediatrics, family medicine, and obstetrics/gynecology.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Trainees' perspectives regarding the didactic teaching and clinical training in providing adolescent reproductive services.

RESULTS

Five themes emerged, reflecting trainees' beliefs regarding the best practices in which GME programs can engage to ensure that trainees graduate with the belief that they are competent and will be comfortable delivering adolescent reproductive services. Trainees believed programs need to: (1) provide didactic lectures and diverse inpatient and outpatient clinical experiences; (2) have faculty preceptors skilled in providing and supervising adolescent reproductive services; (3) teach skills for engaging adolescents in clinical assessments and decision-making; (4) train providers to navigate confidentiality issues with adolescents and caregivers; and (5) provide infrastructure and resources for delivering adolescent reproductive services.

CONCLUSION

The 3 specialties differed in how well each of the 5 best practices were reportedly addressed during GME training. Policy recommendations are provided.

HIV Testing Among US High School Students and Young Adults

BACKGROUND

We assessed HIV testing trends among high school students and young adults.

METHODS

We analyzed National Youth Risk Behavior Survey (YRBS) and Behavioral Risk Factor Surveillance System (BRFSS) data to assess HIV testing prevalence among high school students and young adults aged 18 to 24, respectively. Logistic regression models for each sample stratified by gender and race/ethnicity were estimated to assess trends in the percentages ever tested, with year as a continuous linear variable. We report absolute differences in HIV testing prevalence and model results for 2005-2013 (YRBS) and 2011-2013 (BRFSS).

RESULTS

During the study periods, an average of 22% of high school students (17% of male and 27% of female students) who ever had sexual intercourse and 33% of young adults reported ever being tested for HIV. Among high school students, no change was detected in HIV testing prevalence during 2005-2013, regardless of gender or race/ethnicity. Among young adult males, an average of 27% had ever been tested, and no significant changes were detected overall or by race/ethnicity during 2011-2013. Significant decreases in testing prevalence were detected during 2011-2013 among young adult females overall (from 42.4% to 39.5%), young adult white females (from 37.2% to 33.9%), and young adult black females (from 68.9% to 59.9%).

CONCLUSIONS

HIV testing prevalence was low among high school students and young adults. No increase in testing among young adult males and decreased testing among young adult black females is concerning given their higher risk of HIV infection.

Sexually Transmitted Infection History among Adolescents Presenting to the Emergency Department

BACKGROUND

Adolescents and young adults account for about half of the annual diagnoses of sexually transmitted infections (STI) in the United States. Screening and treatment for STIs, as well as prevention, are needed in health-care settings to help offset the costs of untreated STIs.

OBJECTIVE

Our aim was to evaluate the prevalence and correlates of self-reported STI history among adolescents presenting to an emergency department (ED).

METHODS

Over two and a half years, 4389 youth (aged 14-20 years) presenting to the ED completed screening measures for a randomized controlled trial. About half (56%) reported lifetime sexual intercourse and were included in analyses examining sexual risk behaviors (e.g., inconsistent condom use), and relationships of STI history with demographics (sex, age, race, school enrollment), reason for ED presentation (i.e., medical or injury), and substance use.

RESULTS

Among sexually active youth, 10% reported that a medical professional had ever told them they had an STI (212 females, 35 males). Using logistic regression, female sex, older age, non-Caucasian race, not being enrolled in school, medically related ED chief complaint, and inconsistent condom use were associated with increased odds of self-reported STI history.

CONCLUSIONS

One in 10 sexually active youth in the ED reported a prior diagnosed STI. Previous STI was significantly higher among females than males. ED providers inquiring about inconsistent condom use and previous STI among male and female adolescents may be one strategy to focus biological testing resources and improve screening for current STI.

Brief condom interventions targeting males in clinical settings: a meta-analysis

OBJECTIVE

The objective of this study is to assess the effectiveness of brief clinic-based condom skills interventions that target males.

STUDY DESIGN

We searched PubMed, Cumulative Index of Nursing and Allied Health Literature and PsychInfo for studies published from January 1980 through September 2014, using relevant search terms. We included studies if interventions taught about condoms lasting 60 min or shorter, used randomized or quasi-experimental design, were conducted in a clinical setting and targeted males. Two investigators sequentially reviewed abstracts. We abstracted and reviewed data from 16 studies that met the selection criteria. Where outcomes were poolable, we conducted meta-analyses using a random-effects model and I(2) index to assess heterogeneity. Outcome measures included condom knowledge, attitudes, behaviors, sexually transmitted infections (STIs)/human immunodeficiency virus and unintended pregnancy.

RESULTS

Across studies, teaching about condoms was nested within sexual risk reduction curricula. Most interventions were one on one and conducted in STI clinics. Pooled analyses indicated that intervention receipt was associated with increases in percent of sex acts with condoms (standardized mean difference=0.29 [0.18, 0.41]; 0.19 [0.06, 0.33]) and reductions in STIs at 12-month follow-up or longer {odds ratio (OR)=0.82 [95% confidence interval: 0.67, 0.99]}. One study assessed unintended pregnancy and did not find an intervention effect.

CONCLUSIONS

Study findings hold promise for considering brief condom skills interventions in clinical settings that can result in improvements in males' condom behaviors and possibly biological outcomes.

Comparative Effectiveness of Web-Based vs. Educator-Delivered HIV Prevention for Adolescent Substance Users: A Randomized, Controlled Trial

BACKGROUND

Young people who engage in substance use are at risk for becoming infected with HIV and diseases with similar transmission dynamics. Effective disease prevention programs delivered by prevention specialists exist but are rarely provided in systems of care due to staffing/resource constraints and operational barriers-and are thus of limited reach. Web-based prevention interventions could possibly offer an effective alternative to prevention specialist-delivered interventions and may enable widespread, cost-effective access to evidence-based prevention programming. Previous research has shown the HIV/disease prevention program within the Web-based therapeutic education system (TES) to be an effective adjunct to a prevention specialist-delivered intervention. The present study was the first randomized, clinical trial to evaluate the comparative effectiveness of this Web-based intervention as a standalone intervention relative to a traditional, prevention specialist-delivered intervention.

METHODS

Adolescents entering outpatient treatment for substance use participated in this multi-site trial. Participants were randomly assigned to either a traditional intervention delivered by a prevention specialist (n=72) or the Web-delivered TES intervention (n=69). Intervention effectiveness was assessed by evaluating changes in participants' knowledge about HIV, hepatitis, and sexually transmitted infections, intentions to engage in safer sex, sex-related risk behavior, self-efficacy to use condoms, and condom use skills.

FINDINGS

Participants in the TES intervention achieved significant and comparable increases in HIV/disease-related knowledge, condom use self-efficacy, and condom use skills and comparable decreases in HIV risk behavior relative to participants who received the intervention delivered by a prevention specialist. Participants rated TES as easier to understand.

CONCLUSION

This study indicates that TES is as effective as HIV/disease prevention delivered by a prevention specialist. Because technology-based interventions such as TES have high fidelity, are inexpensive and scalable, and can be implemented in a wide variety of settings, they have the potential to greatly increase access to effective prevention programming.

Opportunities for earlier HIV diagnosis in a pediatric ED

OBJECTIVES

Emergency department (ED) HIV screening is recommended but challenging to implement and of uncertain effectiveness in pediatric EDs (PEDs). We sought to determine whether there were opportunities for earlier HIV diagnosis in the PED for a cohort of young adults diagnosed with HIV.

METHODS

This retrospective cohort study reviewed PED records of a group of young adults receiving HIV care in an urban hospital setting. Pediatric ED visits were selected for review if they took place after the patient's estimated time of HIV acquisition and before their eventual diagnosis. Charts were reviewed to determine whether HIV infection was suspected and whether testing was offered.

RESULTS

Among a cohort of HIV-positive young adults, only 3 (3.6%; 95% confidence interval, 0.9-10.8) of 84 were seen in the PED during the time they were undiagnosed but likely to be infected with HIV. Among these subjects, there was no documentation that HIV testing was offered or refused nor was there documented suspicion of HIV.

CONCLUSIONS

There are opportunities for earlier diagnosis of HIV in PEDs, affirming the importance of HIV screening implementation in these settings. However, PEDs are unlikely to have the same frequency of contact with undiagnosed individuals as do adult EDs. Alternative methods of accessing at-risk adolescent populations must be identified.

Factors Associated With Being Pleased With a Female Partner Pregnancy Among Sexually Active U.S. Adolescent Males

Adolescent pregnancy remains a major U.S. public health problem. Little is known about pregnancy attitudes in U.S. adolescent males. The study objective was to identify factors from different domains that are associated with sexually active U.S. adolescent males who would be pleased with a female partner pregnancy (hereafter known as pleased with a pregnancy). The National Survey of Family Growth is a nationally representative survey of those 15 to 44 years old. Bivariate and multivariable analyses were performed of the 2002 and 2006-2010 cycles to examine factors associated with being pleased with a pregnancy among sexually active U.S. males. Among the 1,445 sexually active U.S. adolescent males surveyed, 25% would be pleased with a pregnancy. In bivariate analyses, ever being suspended from school, having sporadic health insurance, age, and ever HIV tested were significantly associated with being pleased with a pregnancy. In final multivariable analyses, sporadic insurance was associated with almost triple the odds, and being older and ever HIV tested with double the odds of being pleased with a pregnancy. Higher educational attainment for both adolescent males and adolescent males' fathers was associated with reduced odds of a being pleased with a pregnancy. One quarter of sexually active U.S. adolescent males would be pleased with a pregnancy. Adolescent males who have been sporadically insured, are older, and ever HIV tested have higher odds of being pleased with a pregnancy. Targeting these adolescent males for more focused pregnancy-prevention counseling may prove useful in reducing adolescent pregnancy rates.

Sexuality talk during adolescent health maintenance visits

IMPORTANCE

Physicians may be important sources of sexuality information and preventive services, and one-on-one confidential time during health maintenance visits is recommended to allow discussions of sexual development, behavior, and risk reduction. However, little is known about the occurrence and characteristics of physician-adolescent discussions about sexuality.

OBJECTIVE

To examine predictors of time spent discussing sexuality, level of adolescent participation, and physician and patient characteristics associated with sexuality discussions during health maintenance visits by early and middle adolescents.

DESIGN, SETTING, AND PARTICIPANTS

Observational study of audio-recorded conversations between 253 adolescents (mean age, 14.3 years; 53% female; 40% white; 47% African American) and 49 physicians (82% pediatricians; 84% white; 65% female; mean age, 40.9 years; mean [SD] duration in practice, 11.8 [8.7] years) coded for sexuality content at 11 clinics (3 academic and 8 community-based practices) located throughout the Raleigh/Durham, North Carolina, area.

MAIN OUTCOMES AND MEASURES

Total time per visit during which sexuality issues were discussed. RESULTS One hundred sixty-five (65%) of all visits had some sexual content within it. The average time of sexuality talk was 36 seconds (35% 0 seconds; 30% 1-35 seconds; and 35% ≥ 36 seconds). Ordinal logistic regression (outcome of duration: 0, 1-35, or ≥ 36 seconds), adjusted for clustering of patients within physicians, found that female patients (odds ratio [OR] = 2.58; 95% CI, 1.53-4.36), older patients (OR = 1.37; 95% CI, 1.13-1.65), conversations with explicit confidentiality discussions (OR = 4.33; 95% CI, 2.58-7.28), African American adolescents (OR = 1.58; 95% CI, 1.01-2.48), and longer overall visit (OR = 1.07; 95% CI, 1.03-1.11) were associated with more sexuality talk, and Asian physicians were associated with less sexuality talk (OR = 0.13; 95% CI, 0.08-0.20). In addition, the same significant associations between adolescent, physician, and visit characteristics were significantly associated with greater adolescent participation.

CONCLUSIONS AND RELEVANCE

Our study may be the first to directly observe sexuality talk between physicians and adolescents. We found that one-third of all adolescents had annual visits without any mention of sexuality issues; when sexuality talk occurred, it was brief. Research is needed to identify successful strategies physicians can use to engage adolescents in discussions about sexuality to help promote healthy sexual development and decision making.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01040975.

The influence of individual, partner, and relationship factors on HIV testing in adolescents

Early identification of HIV by increasing testing is a national priority; however, little is known about HIV testing behaviors in high school age adolescents. We examined the association of individual, partner, and relationship factors with HIV testing using a computer-assisted survey administered from 2003 to 2006 in a community sample of 980 sexually active 14- to 17-year-olds (56% female, 55% Latino, 25% African American) living in a jurisdiction with a high AIDS burden. Twenty percent reported their first sexual encounter as having occurred when they were <13 years of age, 33% had had four or more lifetime sexual partners, 21% reported high partner HIV-risk behavior, and 428 (44%) had been tested for HIV. In our final regression model, independent associations with HIV testing included being female (OR=1.68 [1.23-2.30]), older (OR=1.41 [1.21-1.65]), and having had four or more lifetime sexual partners (OR=2.24 [1.64-3.05]). The strongest independent predictor of HIV testing was having high HIV-related partner communication (OR=3.70 [2.77-4.94]). Being in a serious committed relationship (OR=1.39 [1.02-1.87]) was also independently associated with HIV testing, whereas reporting high worry about HIV/AIDS (OR=0.53 [0.40-0.71]) was independently negatively associated with HIV testing. High HIV/AIDS knowledge, high partner HIV risk behavior, and young age at first sexual encounter were not associated with testing. These findings suggest that, for high school aged adolescents, optimal strategies to promote HIV testing should look beyond increasing HIV/AIDS knowledge and identifying individual risk behaviors to also considering the role of partners and relationships and their influence on testing behavior.

Using HPV vaccination for promotion of an adolescent package of care: opportunity and perspectives

Background

Adolescents are a difficult population to access for preventive health care, particularly in less resourced countries. Evidence from developed countries indicates that the HPV vaccine schedule may be a useful platform from which to deliver other adolescent health care services. We conducted a qualitative cross sectional study to assess the potential for using the HPV vaccine in the South African public health care system as an opportunity for integrated health care services for adolescents.

Methods

Parents, young adolescents, community members and key informants participated in interviews and focus group discussions about feasibility and acceptability, particularly the use of the HPV vaccination as the basis for an integrated adolescent package of care. Health care providers in both provinces participated in focus group discussions and completed a pairwise ranking exercise to compare and prioritise interventions for inclusion in an adolescent package of care.

Results

Participants were in favour of integration and showed preference for detailed information about the HPV vaccine, general health information and specific sexual and reproductive health information. Among health care workers, results differed markedly by location. In North West, prioritisation was given to information, screening and referral for tobacco and alcohol abuse, and screening for hearing and vision. In Gauteng integration with referral for male circumcision, and information, screening and referral for child abuse were ranked most highly.

Conclusions

There is generally support for the delivery of adolescent preventive health services. Despite national priorities to address adolescent health needs, our data suggest that national policies might not always be appropriate for vastly different local situations. While decisions about interventions to include have traditionally been made at country level, our results suggest that local context needs to be taken account of. We suggest low resource strategies for ensuring that national policies are introduced at local level in a manner that addresses local priorities, context and resource availability.

Access to private and confidential health care among secondary school students in New Zealand

PURPOSE

Private and confidential health care is an important indicator of the quality of health care for adolescents. The objective of this study was to determine the prevalence of health care utilization and private and confidential health care among a nationally representative population of high school students.

METHODS

A two-stage cluster sample of 9,107 students (grades 8-12, response rate 73%) from 96 New Zealand high schools (response rate 84%) participated in a 2007 health survey using Internet tablets. Questions included when and where they had accessed health care, if their health care provider had explained that their health care was confidential, and if they had been seen in private by their health care provider.

RESULTS

Although 83% of students had accessed health care in the previous 12 months, only 27% of students reported receiving private and confidential health care. Students who had accessed health care from a school-based health center (adjusted relative risk [95% confidence interval] 1.54 [1.42-1.66]) or family planning/sexual health clinics (adjusted relative risk = 2.1 [1.9-2.26]) were more likely to report receiving private and confidential health care compared with students who had not accessed health care from these settings.

CONCLUSIONS

While most young people access health care from their family doctor or general practitioner's clinic, rates of private and confidential health care were low suggesting that opportunities to adequately explore and respond to important yet sensitive topics are compromised in primary care settings.

Human papillomavirus vaccine discussions: an opportunity for mothers to talk with their daughters about sexual health

PURPOSE

Mother-daughter communication about sex is associated with healthier behavior during adolescence. We sought to characterize mothers' communication with their daughters about human papillomavirus (HPV) vaccine and the potential for these discussions to provide an opportunity for talking about sexual health.

METHODS

During December 2009, we conducted an online survey with a nationally representative sample of US mothers of girls aged 11 to 14 years (n = 900; response rate = 66%). We used 3 complimentary approaches to assess HPV vaccine as an opportunity for mother-daughter communication about sex. Estimates are weighted.

RESULTS

Sixty-five percent of mothers reported talking with their daughters about HPV vaccine, of whom 41% said that doing so led to a conversation about sex. Mothers who had talked with their daughters about HPV vaccine were more likely than those who had not to have also talked with their daughters about sex (92% vs. 74%, OR = 3.25, CI = 1.57-6.68, P < 0.05), in multivariate analyses. Among mothers who talked about sex when they talked about HPV vaccine, many felt that HPV vaccine provided a good reason to do so (64%) or that it made it easier to start a conversation (33%).

CONCLUSIONS

HPV vaccine discussions provide a cue to mother-daughter communication about sex that is as important as some more widely recognized cues. Discussions about HPV vaccine are an acceptable opportunity for mothers to talk with their daughters at an age when communication about sex is most influential. It may be possible for parents to capitalize on HPV vaccine discussions already happening in many families to promote sexual health.

Core sexual/reproductive health care to deliver to male adolescents: perceptions of clinicians focused on male health

PURPOSE

Male adolescents experience adverse sexual/reproductive health (SRH) outcomes, yet few providers deliver male SRH care. Given the lack of evidence base for male SRH care, the purpose of this study was to examine perceived importance in delivering SRH care to male adolescents among clinicians focused on male health.

METHODS

Seventeen primary care clinicians focused on male health, representing pediatricians, family physicians, internists, and nurse practitioners, were individually queried about male adolescents' SRH needs and perceived importance to screen/assess for 13 male SRH services using a case scenario approach varying by visit type and allotted time.

RESULTS

Participants were highly consistent in identifying a scope of 10 SRH services to deliver to male adolescents during a longer annual visit and a core set of six SRH services during a shorter annual visit, including (1) counseling on sexually transmitted infection/HIV risk reduction, including testing/treatment; and assessing for (2) pubertal growth/development; (3) substance abuse/mental health; (4) nonsexually transmitted infection/HIV genital abnormalities; (5) physical/sexual abuse; and (6) male pregnancy prevention methods. Participants did not agree whether SRH care should be delivered during nonannual acute visits.

CONCLUSIONS

Despite lack of data for male SRH care, clinicians focused on male health strongly agreed on male SRH care to deliver during annual visits that varied by visit type and allotted time. Study findings provide a foundation for much needed clinical guidelines for male adolescents' SRH care and have implications for education and training health professionals at all levels and the organization and delivery of male SRH services.

Sexual Health Information Networks: What are Urban African American Youth Learning?

This qualitative study examined sexual health information networks among urban African American youth living in low-income communities. The authors identified sources, message content, and utility of messages about sex and sexual health in a sample of 15-17-year olds (N = 81). Youth received sexual health information from a variety of sources. Messages from parents and sex education had high utility, whereas messages from the Internet and religion had low utility. Four information network patterns were identified, suggesting considerable variation in how youth are socialized regarding sex. Findings suggest that sexual information networks have the potential to affect sexual health and development.

Adolescents and HIV infection: the pediatrician's role in promoting routine testing

Pediatricians can play a key role in preventing and controlling HIV infection by promoting risk-reduction counseling and offering routine HIV testing to adolescent and young adult patients. Most sexually active youth do not feel that they are at risk of contracting HIV and have never been tested. Obtaining a sexual history and creating an atmosphere that promotes nonjudgmental risk counseling is a key component of the adolescent visit. In light of increasing numbers of people with HIV/AIDS and missed opportunities for HIV testing, the Centers for Disease Control and Prevention recommends universal and routine HIV testing for all patients seen in health care settings who are 13 to 64 years of age. There are advances in diagnostics and treatment that help support this recommendation. This policy statement reviews the epidemiologic data and recommends that routine screening be offered to all adolescents at least once by 16 to 18 years of age in health care settings when the prevalence of HIV in the patient population is more than 0.1%. In areas of lower community HIV prevalence, routine HIV testing is encouraged for all sexually active adolescents and those with other risk factors for HIV. This statement addresses many of the real and perceived barriers that pediatricians face in promoting routine HIV testing for their patients.

HIV Testing among Adolescents and Youth in the United States: Update from the 2009 Behavioral Risk Factor Surveillance System

OBJECTIVES

We examined the prevalence of HIV testing in a representative sample of US adolescents and youth, assessed the location and method of testing used during their last HIV testing, and compare the characteristics of those who had and had not been tested for HIV.

METHODS AND PRINCIPAL FINDINGS

Data on adolescents and youth who participated in the 2009 Behavioral Risk Factor Surveillance System (BRFSS) survey were analyzed. Of the 6,628 adolescents and youth who participated in the 2009 BRFSS, 54.4% were male, 59.1% were white, 37.4% graduated from high school, 29.6% live in the western states in the United States. Their mean age was 20.9 years (± 2.07 SD). Of these participants, 31.8% had been tested for HIV. The majority of adolescents had been tested for HIV either at private physician offices (38%) or public clinics (31.7%) compared to HIV counseling and testing sites (3.1%). Only 30.5% of adolescents were tested using a rapid HIV antibody test. Being female, African-American, Asian or multiracial, divorced/widowed, and living in the Western and NorthEastern states in the United States were associated with a high probability of testing for HIV.

CONCLUSIONS

The low prevalence of adolescents who tested for HIV and the low proportion of those offered rapid HIV testing after the 2006 CDC's new guidelines about HIV testing raise serious concerns about the effectiveness of HIV prevention efforts particularly among adolescents. More innovative strategies are needed to increase the number of adolescents and youth who become aware of their HIV serostatus.

The role of human papillomavirus vaccination in promoting delivery of other preventive and medical services

OBJECTIVE

Adolescents infrequently present for preventive health visits. The 3-dose human papillomavirus (HPV) vaccine may result in increased health care visits and thus indirectly improve health services for teens. We examined whether other health services were delivered in conjunction with the second (HPV2) or third (HPV3) dose of the HPV vaccine.

METHODS

We conducted a chart review for girls 9 to 20 years of age (n = 571) who received HPV2 or HPV3 within 4 months of its due date at any of 9 clinical sites. Analyses were limited to the 422 visits (72%) where HPV vaccine was specified as a reason for the visit. A generalized linear model was used to evaluate the impact of site of care on delivery of other health services.

RESULTS

Nearly half (43%) of adolescents received another medical or preventive health service at the time of HPV2 or HPV3 vaccine administration. Most common services were 1 or more other vaccines (30%) or medical services (35%). Older teens were more likely than younger teens to receive reproductive health services and sexually transmitted infection screening. After controlling for age and adjusting for clustering within sites, receiving care at an academic health center versus a private practice was strongly associated with increased odds of receiving other medical or preventive health services at follow-up (odds ratio 2.07; 95% confidence interval 1.44-2.97).

CONCLUSIONS

Adolescents, especially those receiving care at an academic health center, often received other health services at the time of HPV2 or HPV3 vaccination. Because visits occurred within 6 to 8 months of the prior vaccine dose, our findings suggest vaccine visits may lead to improved delivery of adolescent health services.

Testing adolescents for sexually transmitted infections in urban primary care practices: results from a baseline study

OBJECTIVE

Sexually active urban adolescents experience a high burden of sexually transmitted infections (STI). Adolescents often access medical care through general primary care providers; their time alone with a provider increases the likelihood that youth will disclose risky behavior, which may result in STI testing. Our goals were to assess the association (if any) between the provision of time alone and STI testing, and describe the rates of STI testing among sexually active adolescents in urban primary care.

METHODS

Youth (aged 12-19 years) presenting for care at 4 urban health centers were invited to complete post-visit surveys of their experience. Sexually transmitted infection screening rates were obtained from the clinical information systems (CIS); CIS data were linked to survey responses.

RESULTS

We received 101 surveys. Surveyed youth experienced time alone in 69% of all visits. Time alone varied by age (older teens experienced more time alone), and it occurred more frequently in preventive visits (71%) versus nonpreventive visits (33%). It did not vary by gender. Forty-two of the 46 sexually active youth experienced time alone. Screening rates for sexually active females, either at the index visit or within 6 months prior to the index visit, were 17.9% for human immunodeficiency virus and 32.1% for gonorrhea/Chlamydia. No sexually active surveyed males were tested. Overall screening rates varied widely across practices (human immunodeficiency virus 0%-29%; gonorrhea/Chlamydia 7%-29%). There was no difference in screening rates among youth with and without time alone.

CONCLUSION

STI testing for adolescents is being conducted in this primary care urban population, especially for sexually active females. However, clinicians in this setting are not screening females consistently enough and rarely screen males. We were unable to test our hypothesis that provision of time alone was associated with a higher rate of STI testing. Site differences suggest substantial variation in clinician practices that should be addressed in quality improvement interventions.