Discussion of Potentially Sensitive Topics With Young People

Accelerating Innovation in Primary Care to Support Adolescent Health Discussions

BACKGROUND AND OBJECTIVES

Adolescent strengths and risks are not routinely captured in systematized and actionable ways in pediatric primary care. To address this problem, we developed a comprehensive adolescent health questionnaire (AHQ) integrated within the electronic health record and evaluated the AHQ's impact on collection of information on prioritized health-related domains.

METHODS

We developed and pilot tested the AHQ. We then scaled and assessed the AHQ's impact on data collection. AHQ development used innovation methods and measured feasibility and acceptability outcomes. Scaling and postscaling outcomes included Reach, Effectiveness, Adoption, Implementation, Maintenance and Sustainability measures: Reach (total questionnaires completed), Effectiveness (capture of key information across health domains pre- vs post-AHQ scaling), Adoption (proportion of practices that adopted the AHQ), Implementation (proportion of eligible adolescents who completed the AHQ), and Maintenance (monthly completion rates).

RESULTS

AHQ development led to a tool that was feasible and acceptable for use. During scaling (October 2020-December 2021), 22 147 questionnaires were completed by 20 749 unique adolescents aged 13 to 21 years at their preventive visit. Comparing pre- versus post-AHQ scaling data, use of the AHQ increased collection of information across domains, especially for strengths, gun safety, substance use, sexual activity, sexual orientation, and gender identity, from ranges of 0%-25% to 92%-95%. All 31 practices adopted the AHQ with completion at 88.7% of visits (n = 24 968). Two years postscaling, completion rates were >91% per month.

CONCLUSIONS

We successfully developed, scaled, and maintained an AHQ in a widely-used electronic health record system, a model for improving adolescent care and foundation for developing future interventions.

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.

Evaluating the Impact of an Adolescent Sexuality Education Workshop on Medical Student Communication in an Objective Structured Clinical Examination

PURPOSE

Gaps still exist in medical education about the sexual health needs of sexual diverse populations, and little is known about how translatable current learning modules are to patient encounters. Efforts at an academic medical institution have been made to address this need, including a two-hour adolescent sexuality workshop during the Core Clerkship in Pediatrics. This workshop's efficacy was evaluated in an objective structured clinical examination (OSCE) given to rising fourth-year medical students, where the standardized patient case focused on an adolescent cisgender male with dysuria and in a new, same-sex relationship.

METHODS

Performance of students who completed the workshop prior to the OSCE (n = 48) were compared to those of students who did not participate in the workshop prior to the OSCE (n = 17). The encounters were recorded and transcribed, and the deidentified transcripts were scored on a rubric focusing on five domains: sexual identity disclosure, behavioral assessment, psychosocial history, counseling and anticipatory guidance, and relationship building.

RESULTS

Student's t-test comparison of the scores found significantly higher scores for the psychosocial history domain (p = .04), particularly concerning disclosure of a new boyfriend and recent sexual activity (p = .008), for students who had the workshop before the OSCE.

DISCUSSION

Students who took the adolescent sexuality workshop performed better in gathering psychosocial information in an OSCE encounter a sexual minority adolescent. These results affirm prior work that active learning on sexual diverse health in medical school curricula may prepare students for effective engagement with adolescents exploring their sexuality.

Adolescent Healthcare Access: A Qualitative Study of Provider Perspectives

INTRODUCTION

Adolescent access to quality healthcare is key to prevention and early intervention for health risk behaviors. This paper provides a healthcare provider perspective on barriers and facilitators to youth accessing care.

METHODS

Five focus groups were conducted from November to December 2020 with providers from a variety of healthcare settings. Participants were asked to describe their respective adolescent patient populations, adolescent-specific health concerns, and organizational accommodations specific for youth services. Transcripts were analyzed using Inductive Thematic Analysis and themes were grouped using a social-ecological framework.

RESULTS

At an individual level, providers noted that an adolescent's knowledge and ability to navigate services varied greatly across settings. Providers identified provider trust and parent/guardian support as key interpersonal factors that support adolescents' access to services. Organizational factors included bureaucratic barriers and the clinic's reputation among youth. Community factors centered on mistrust within healthcare systems and stigmatization of seeking certain types of services. Participants also described how state-level policies influence parent/guardian consent requirements, which can limit adolescents' access to care.

CONCLUSION

Adolescent access to and utilization of healthcare in the United States is a complex problem requiring systems-level change. Healthcare organizations and providers have the opportunity and capacity to positively influence adolescents' healthcare access and experiences, however a lack of standardized, clinic-level priorities and guidelines can limit adolescent-centered care.

A qualitative assessment of adolescent perspectives on patient education in the outpatient setting

Objective

To explore adolescent perspectives on the content and delivery of anticipatory guidance (AG), both during and after outpatient visits, in order to develop targeted resources and educational material for adolescent patients.

Methods

Semi-structured phone interviews among patients ages 12 to 21 seen between May-July 2021 at four outpatient sites of NewYork Presbyterian Hospital were recorded, transcribed and analyzed using thematic analysis. Content domains included attitudes toward and preferences around AG, discharge instructions and patient education resources.

Results

Twenty-eight of 156 recruited patients completed interviews; 52% received an After Visit Summary (AVS); of the 48% who did not receive it, half of them expressed interest in receiving one. Themes included positive perceptions of the AVS, patient-physician communication, multimodal delivery of educational materials, and critical discussion topics such as mental health and nutrition.

Conclusion

Adolescents value the AVS and prefer multimodal materials and topics that are specifically geared towards them, rather than their caregivers.

Innovation

This study is the first to explore adolescent perspectives on AG and after-visit informational materials. These findings may help more effectively reach, educate and engage adolescent patients in the primary care setting by guiding the focused development of patient-centered instructions and resources.

Association of Adolescents' Body Mass Index Classification With Preventive Clinical Care Receipt

PURPOSE

To examine differences in screening and advising for modifiable risk behaviors during well-visits based on adolescents' body mass index categories.

METHODS

Retrospective analyses were conducted with the National Institute of Health's NEXT Generation Health Study data, a nationally representative cohort of 10th graders. In wave 1 (2010), adolescents were classified as being underweight (<4.99th percentile), normal-weight (5-84.99th percentile), overweight (85-94.99th percentile), or with obesity (≥95th percentile) based on the body mass index categories described by the Centers for Disease Control and Prevention. In wave 2 (2011), adolescents were asked by their provider about smoking, alcohol use, use of other drugs, sexual activity, nutrition, and exercise, and whether they were advised about risks associated with these behaviors.

RESULTS

The sample consisted of 1,639 eligible participants as follows: 57.8% females, 63.3% 16-year-olds, 47.8% non-Hispanic Whites, 41.5% living in the South, 75.4% with health insurance, and 29.8% with low family affluence. Screening rates for overweight compared to normal-weight males were 51% reduced for smoking, 46% for alcohol use, 47% for other drug use, 57% for nutrition, and 47% for exercise. Screening rates were 40% reduced for other drug use for males with obesity, and 89% reduced for alcohol use for underweight males compared to normal-weight males. Advice receipt for females with obesity compared to normal-weight females was 90% increased for nutrition and 78% increased for exercise.

DISCUSSION

Overweight male adolescents reported being less likely to be screened across almost all preventive service topics representing missed opportunities for care delivery.

Occurrence of sensitive topics during ward round: an ancillary analysis of the BEDSIDE-OUTSIDE trial

OBJECTIVE

Discussing sensitive topics (eg, medical uncertainty, social issues, non-adherence) during ward rounds is challenging and may negatively impact patient satisfaction with the healthcare they are receiving. In the previous multicentre randomised BEDSIDE-OUTSIDE trial focusing on communication during ward rounds, we investigated the interplay between sensitive topics and low reported satisfaction with care.

DESIGN

Pre-planned secondary analysis of a randomised controlled trial. For this analysis data of the original trial was pooled across intervention groups.

SETTING

Three Swiss teaching hospitals.

PARTICIPANTS

Adult patients hospitalised for medical care.

INTERVENTIONS

We analysed predefined sensitive health topics and specific elements of communication from audiotapes recorded during ward rounds, for both patients dealing with and without sensitive topics.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary endpoint was overall patient satisfaction with care; measured on a Visual Analogue Scale from 0 to 100. Secondary endpoints included duration of ward rounds and further satisfaction outcomes.

RESULTS

Of the 919 included patients, 474 had at least one sensitive topic including medical uncertainty (n=251), psychiatric comorbidities (n=161), tumour diagnosis (n=137) and social issues (n=125). Compared with patients without sensitive topics, patients with sensitive topics reported lower satisfaction with care (mean (SD), 87.7 (±14.6) vs 90.2 (±12.1), adjusted difference -2.5 (95% CI -4.28 to -0.72), p=0.006. Among patients with sensitive topics, risk factors for low satisfaction included several parameters concerning patient-physician interaction such as disagreements during ward rounds (mean (SD), 14/212 (6.6%) vs 41/254 (16.1%), adjusted OR 2.78 (95% CI 1.47 to 5.27), p=0.002).

CONCLUSIONS

A large proportion of medical inpatients must deal with sensitive health topics. This is associated with lower satisfaction with care, particularly if the patient perceives the interaction with doctors during ward rounds as unsatisfactory. Educating physicians on specific communication techniques may help improve care for these patients.

TRIAL REGISTRATION NUMBER

NCT03210987.

Achieving Health Equity for Sexual and Gender-Diverse Youth

Compared to their heterosexual and cisgender peers, sexual and gender diverse (SGD) youth, especially those from minoritized racial/ethnic groups, experience significant disparities in health, health care, and social conditions that can threaten their health and well-being. This article describes the disparities impacting SGD youth, their differential exposure to the stigma and discrimination that foster these disparities, and the protective factors that can mitigate or disrupt the impact of these exposures. On the final point, the article specifically focuses on pediatric providers and inclusive, affirming, medical homes as critical protective factors for SGD youth and their families.

Provider Facilitation of Parent-Adolescent Health Communication: Findings From a National Survey

INTRODUCTION

Primary care providers are well-positioned to facilitate parent-adolescent health communication. We examined provider-facilitated parent-adolescent health communication prevalence and associations with parent-adolescent health communication.

METHOD

Using data from a national survey of parent-adolescent dyads (n = 853), we calculated the prevalence of provider-facilitated parent-adolescent health communication about 11 topics as a result of adolescent's last preventive visit. We examined correlates of of provider-facilitatedparent-adolescent communication and associations with with parent-adolescent communication.

RESULTS

Eighteen percent of adolescents reported that a provider helped them talk with their parent about a health concern, with little variability by adolescent, parent, or provider characteristics. Prevalence of parent-adolescent communication because of an adolescent's last preventive visit ranged between 38.4% and 79.5%. Provider facilitation was positively associated with parent-adolescent communication for all topics.

DISCUSSION

Given the low prevalence of provider-facilitated-parent-adolescent health communication and positive associations between provider facilitation and parent-adolescent communication about multiple important health-related topics, efforts to improve this practice could be beneficial.

Parent Perspectives about Initiating Contraception Conversations with Adolescent Daughters

OBJECTIVES

Parent-youth Sexual and Reproductive Health (SRH) conversations are critical to reducing adolescent pregnancy, yet many parents do not discuss contraception before youth become sexually active. We aim to describe parental perspectives about when and how to initiate contraception discussions, characterize motivators to discuss contraception, and explore the role of healthcare providers in supporting contraception communication with youth.

METHODS

We conducted semi-structured interviews with 20 parents of female youth ages 9-20 recruited from areas of Dallas, TX, with high rates of racial and ethnic disparities in adolescent pregnancy. We analyzed interview transcripts with a combined deductive and inductive approach, with discrepancies resolved by consensus.

RESULTS

Parents were 60% Hispanic, 40% non-Hispanic Black, and 45% were interviewed in Spanish. Most identified as female (90%). Many initiated contraception discussions based on age, physical development, emotional maturity, or perceived likelihood of sexual activity. Some expected daughters to initiate SRH discussions. Cultural avoidance of SRH discussion often motivates parents to improve communication. Other motivators included reducing pregnancy risk and managing anticipated youth sexual autonomy. Some feared that discussing contraception could encourage sex. Parents trusted and wanted pediatricians to serve as a bridge to discuss contraception with youth before sexual debut through confidential, comfortable communication.

CONCLUSIONS

Tension between the desire to prevent adolescent pregnancy, cultural avoidance, and fear of encouraging sexual behaviors causes many parents to delay contraception discussions prior to sexual debut. Healthcare providers can serve as a bridge between sexually naïve adolescents and parents by proactively discussing contraception using confidential and individually-tailored communication.

Factors influencing the conduction of confidential conversations with adolescents in the emergency department: A multicenter, qualitative analysis

BACKGROUND

Health care providers (HCPs) in the emergency department (ED) frequently must decide whether to conduct or forego confidential conversations with adolescent patients about sensitive topics, such as those related to mental health, substance use, and sexual and reproductive health. The objective of this multicenter qualitative analysis was to identify factors that influence the conduct of confidential conversations with adolescent patients in the ED.

METHODS

In this qualitative study, we conducted semistructured interviews of ED HCPs from five academic, pediatric EDs in distinct geographic regions. We purposively sampled HCPs across gender, professional title, and professional experience. We used the Theoretical Domains Framework (TDF) to develop an interview guide to assess individual and system-level factors affecting HCP behavior regarding the conduct of confidential conversations with adolescents. Enrollment continued until we reached saturation. Interviews were recorded, transcribed, and coded by three investigators based on thematic analysis. We used the coded transcripts to collaboratively generate belief statements, which are first-person statements that reflect shared perspectives.

RESULTS

We conducted 38 interviews (18 physicians, 11 registered nurses, five nurse practitioners, and four physician assistants). We generated 17 belief statements across nine TDF domains. Predominant influences on having confidential conversations included self-efficacy in speaking with adolescents alone, wanting to address sexual health complaints, maintaining patient flow, experiencing parental resistance and limited space, and having inadequate resources to address patient concerns and personal preconceptions about patients. Perspectives divided between wanting to provide focused medical care related only to their chief complaint versus self-identifying as a holistic medical HCP.

CONCLUSIONS

The factors influencing the conduct of confidential conversations included multiple TDF domains, elucidating how numerous intersecting factors influence whether ED HCPs address sensitive adolescent health needs. These data suggest methods to enhance and facilitate confidential conversations when deemed appropriate in the care of adolescents in the ED.

Opportunities to Improve Adolescent Sexual and Reproductive Health Services in Primary Care Clinics

Primary care providers are well positioned to address the sexual and reproductive health (SRH) needs of adolescents; however, gaps often exist in the delivery of quality SRH services in primary care. Our objective was to identify specific opportunities to improve the delivery of adolescent SRH services in primary care. We conducted in-depth interviews with 25 primary care providers from various disciplines across rural and urban areas of Minnesota and conducted thematic analysis of transcribed data. Participants identified salient opportunities in three areas: (1) training and resources for providers (e.g., related to minor consent laws or addressing sensitive subjects), (2) practices and procedures (e.g., time-alone procedures and policies for confidential screening and sharing test results), and (3) education for adolescents (e.g., knowing their rights and accessing confidential SRH services). Study findings provide actionable opportunities to improve delivery of adolescent SRH services in primary care.

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.

Cross-sectional online survey of clinicians' knowledge, attitudes and challenges to screening and counselling adolescents and young adults for substance use

OBJECTIVE

To examine adolescent healthcare clinicians' self-reported screening practices as well as their knowledge, attitudes, comfort level and challenges with screening and counselling adolescents and young adults (AYA) for cigarette, e-cigarette, alcohol, marijuana, hookah and blunt use.

DESIGN

A 2016 cross-sectional survey.

SETTING

Academic departments and community-based internal medicine, family medicine and paediatrics practices.

PARTICIPANTS

Adolescent healthcare clinicians (N=771) from 12 US medical schools and respondents to national surveys. Of the participants, 36% indicated male, 64% female, mean age was 44 years (SD=12.3); 12.3% of participants identified as Asian, 73.7% as white, 4.8% as black, 4.2% as Hispanic and 3.8% as other.

PRIMARY AND SECONDARY OUTCOME MEASURES

Survey items queried clinicians about knowledge, attitudes, comfort level, self-efficacy and challenges with screening and counselling AYA patients about marijuana, blunts, cigarettes, e-cigarettes, hookah and alcohol.

RESULTS

Participants were asked what percentage of their 10-17 years old patients they screened for substance use. The median number of physicians reported screening 100% of their patients for cigarette (1st, 3rd quartiles; 80, 100) and alcohol use (75, 100) and 99.5% for marijuana use (50,100); for e-cigarettes, participants reported screening half of their patients and 0.0% (0, 50), (0, 75)) reported screening for hookah and blunts, respectively. On average (median), clinicians estimated that 15.0% of all 10-17 years old patients smoked cigarettes, 10.0% used e-cigarettes, 20.0% used marijuana, 25.0% drank alcohol and 5.0% used hookah or blunts, respectively; yet they estimated lower than national rates of use of each product for their own patients. Clinicians reported greater comfort discussing cigarettes and alcohol with patients and less comfort discussing e-cigarettes, hookah, marijuana and blunts.

CONCLUSIONS

This study identified low rates of screening and counselling AYA patients for use of e-cigarettes, hookahs and blunts by adolescent healthcare clinicians and points to potential missed opportunities to improve prevention efforts.

Obamacare: A bibliometric perspective

Obamacare is the colloquial name given to the Affordable Care Act (ACA) signed into law by President Obama in the USA, which ultimately aims to provide universal access to health care services for US citizens. The aim of this paper is to provide an overview of the political-legal, economic, social, management (or administrative), and medical (or health) repercussions of this law, using a bibliometric methodology as a basis. In addition, the main contributors to research on ACA issues have been identified in terms of authors, organizations, journals, and countries. The downward trend in scientific production on this law has been noted, and it has been concluded that a balance has not yet been reached between the coexistence of private and public health care that guarantees broad social coverage without economic or other types of barriers. The law requires political consensus to be implemented in a definitive and global manner for the whole of the United States.

An Intervention to Promote Healthcare Transition Planning Among Pediatric Residents

PURPOSE

Poorly planned healthcare transition (HCT) from pediatric to adult-based care for adolescents and young adults with special healthcare needs (AYASHCN) is associated with increased morbidity and mortality. Most pediatricians and pediatric residents are not trained to assist AYASHCN with HCT planning. An electronic medical record-based Transition Planning Tool (TPT) was developed at a large children's hospital to guide provider-patient interactions around HCT planning. The purpose of this study was to evaluate an educational intervention to promote residents' use of the TPT.

METHODS

A multimodal (TPT training, demonstrations, use prompts, and case discussions) curriculum promoting the use of the TPT was developed and implemented within a one-month Adolescent Medicine Rotation. A prospective, nonrandomized, quasi-experimental design with Intervention and Historical Control groups was used. Forty-two residents received the intervention. Twenty-three Historical Control residents received minimal formal training in the TPT. Intervention Group residents completed prerotation/postrotation assessments measuring perceived importance of/comfort with HCT planning and self-reported HCT planning activities. TPT use was compared between the two groups.

RESULTS

Compared to the Historical Control Group, Intervention Group residents were significantly more likely to use the TPT (98% vs. 37%, p < .001) and had a higher mean number of uses (5.5 ± 3.0 vs. 2.6 ± 1.2, p < .001). Residents reported greater perceived importance of (p < .001) and engagement in (p < .001) transition planning activities after completing the intervention. Nearly all (91%) reported that their training increased their comfort in HCT planning.

CONCLUSIONS

A targeted intervention improved pediatric residents' use of the TPT and HCT planning activities.

Screening Adolescents for Sensitive Health Topics in Primary Care: A Scoping Review

We sought to aggregate common barriers and facilitators to screening adolescents for sensitive health topics (e.g., depression, chlamydia) in primary care, as well as those that are unique to a given health topic. We conducted a literature search of three databases (PsycInfo, MEDLINE, and CINAHL) and reference lists of included articles. Studies focused on barriers and facilitators to screening adolescents (ages 12-17 years) for sensitive health topics in primary care that are recommended by national guidelines. Articles were peer-reviewed, presented empirical data, and were published in English in 2006-2021. We coded barriers and facilitators using the Consolidated Framework for Implementation Research, a well-established framework within implementation science. In total, 39 studies met inclusion criteria and spanned several health topics: depression, suicide, substance use, HIV, and chlamydia. We found common barriers and facilitators to screening across health topics, with most relating to characteristics of the primary care clinics (e.g., time constraints). Other factors relevant to screening implementation ranged from confidentiality concerns to clinician knowledge. Barriers and facilitators specific to certain health topics, such as the availability of on-site laboratories for HIV screening, were also noted. Findings can guide refinements to screening implementation.

Receipt of Private Time Among Adolescents and Young Adults With and Without Special Healthcare Needs

PURPOSE

Private time is an opportunity for the adolescent patient to speak directly to a healthcare provider and a marker of quality preventive health care. Little is known about whether adolescents and young adults (AYAs) with special healthcare needs (SHCNs) are afforded private discussions with their primary care clinicians.

METHODS

We surveyed a nationally representative sample of 1,209 adolescents (13-18 years) and 709 young adults (19-26 years) about whether they had SHCNs and whether they had ever had private, one-on-one time with their healthcare providers.

RESULTS

SHCNs were reported by 20.3% of adolescents and 15.6% of young adults. Among adolescents, older age was associated with more SHCNs. Among young adults, women and blacks were more likely to report SHCNs than men and those reporting other race categories. For both AYAs, those with SHCNs more often received private time than those without SHCNs: 54.2% of adolescents and 88.1% of young adults with SHCNs reported ever having received private time, compared with 29.6% of adolescents and 62.1% of young adults without SHCNs.

CONCLUSIONS

Lack of private time continues to impact quality primary care for AYAs; however, AYAs with SHCNs are more likely to have received private time than AYAs who do not have SHCNs. Further research is needed to understand whether increased number of clinical visits, clinician-related factors, or other factors lead to more opportunities for young people with SHCNs to receive private time from their clinicians.

Correlates of Sexual and Reproductive Health Discussions During Preventive Visits: Findings From a National Sample of U.S. Adolescents

PURPOSE

This study examines characteristics of healthcare delivery, providers, and adolescents associated with provider-adolescent discussions about sexual and reproductive health (SRH) during preventive visits.

METHODS

Data were from a 2019 national internet survey of U.S. adolescents ages 11-17 years and their parents. Adolescents who had a preventive visit in the past 2 years (n = 853) were asked whether their provider discussed each of eight SRH topics at that visit: puberty, safe dating, gender identity, sexual orientation, whether or not to have sex, sexually transmitted infections including human immunodeficiency virus, birth control methods, and where to get SRH services. Eight multivariable logistic regression models were examined (one for each SRH topic as the outcome), with each model including modifiable healthcare delivery and provider characteristics, adolescent beliefs, behaviors, and demographic characteristics as potential correlates.

RESULTS

Provider-adolescent discussions about SRH topics at the last preventive visit were positively associated with face-to-face screening about sexual activity for all eight topics (range of adjusted odds ratios [AORs] = 3.40-9.61), having time alone with the adolescent during that visit (seven topics; AORs = 1.87-3.87), and ever having communicated about confidentiality with adolescents (two topics; AORs = 1.88-2.19) and with parents (one topic; AOR = 2.73). Adolescents' perception that a topic was important to discuss with their provider was associated with provider-adolescent discussions about seven topics (AORs = 2.34-5.46).

CONCLUSIONS

Findings that provider-adolescent discussions about SRH during preventive visits were associated with modifiable practices including time alone between providers and adolescents and screening about sexual activity can inform efforts to improve the delivery of adolescent SRH services within primary care.

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.

Are healthcare providers and young people talking about sexuality? A scoping review to characterize conversations and identify barriers

BACKGROUND

Conversations about sexuality with healthcare providers (HCPs) are critical to youth's positive development, including youth with disabilities or chronic conditions. Yet, little is known about the characteristics of sexuality conversations with youth in healthcare settings. This scoping review examined the nature and extent of sexuality conversations between HCPs and youth (with and without a disability or chronic condition) and aimed to identify barriers to these conversations.

METHODS

Scoping review methodology using rapid review principles was employed.

INCLUSION CRITERIA

studies published between 2009 and 2019; examined conversations between HCPs and youth aged 21 and below; addressed sexuality; and took place in a healthcare setting. Study characteristics were described and clustered into thematic groups.

RESULTS

Of the 5543 identified, 32 articles were included. Articles addressed (i) the content of sexuality conversations, (ii) prevalence of sexuality conversations and (iii) barriers to discussing sexuality. The content of sexuality discussions was largely biologically focused. The prevalence of sexuality discussions varied, with some discrepancy between youth-reported and HCP-reported rates. Seven barriers (three personal and four systemic) were identified. Youth with disabilities or chronic conditions were vastly under-represented in the published literature.

CONCLUSIONS

This study highlighted that sexuality is an underexplored topic between HCPs and young people, especially young people with disabilities and/or chronic conditions. Given the importance of sexuality to young people's mental and physical health, research addressing barriers to these discussions and development of evidence-informed resources to support HCPs and youth to engage in conversations about sexuality should be a priority.

Exploring Adolescent Experiences with Disclosing Self-Injurious Thoughts and Behaviors Across Settings

Disclosure of self-injurious thoughts and behaviors (SITBs) is critical to current treatment and prevention programs. Limited research has examined patterns of and barriers to SITB disclosure in adolescents. This work is critical given the limits of confidentiality in this population. Over 1,000 adolescents aged 13-17 with a history of mental health treatment and SITBs were recruited online. Participants reported their history with disclosing SITBs across a range of relationships, honesty in and barriers to disclosure to health care providers, and their experiences with breaches of confidentiality to parents/guardians. We examined relationships among these experiences and a range of outcomes, including perceived likelihood of future disclosure. Participants reported most frequent disclosure of all SITBs to friends, and more frequent disclosure of nonsuicidal self-injury compared to suicide ideation or attempts. Adolescents were most likely to disclose SITBs when directly asked by health care providers, though many participants reported continued SITB concealment. The most commonly endorsed barrier to disclosure was fear that the provider would tell a parent/guardian. Experiences with confidentiality breaches involving a non-collaborative breach were negatively associated with future disclosure, mental health symptoms, and adolescent-parent relationships. SITB disclosure is a cornerstone to their treatment and prevention. Better understanding of to whom and when, barriers, and the impact of disclosure experiences is critical. Our research suggests that most adolescents do not want their parents to know about their SITBs, and that fear of parent involvement prevents disclosure. Results have several implications for SITB assessment across physical and mental healthcare settings.

Correlates of sexually transmitted infection knowledge among late adolescents

Background Accurate knowledge about sexually transmitted infections (STIs) is imperative for young people's development and sexual health outcomes, but STI knowledge has been found to be inadequate among youth. Little is known about the factors that are associated with STI knowledge. This study therefore comprehensively assessed correlates of STI knowledge among late adolescents.

METHODS

Undergraduate students (n = 419) at a large public Midwestern university completed an online survey that assessed general STI knowledge using an established modified scale, demographics, sexual health and behavioural factors, and sources of STI information. Exploratory bivariate analyses were first conducted followed by a multiple linear regression examining the correlates initially identified as significantly and strongly associated with STI knowledge.

RESULTS

Although many factors were significantly correlated with STI knowledge, gender, nationality, sexual identity, STI testing history, knowing someone diagnosed with an STI, prior school-based STI education, and receiving STI information from a healthcare provider were most strongly associated (P < 0.001 with medium or large effect sizes). All but prior school-based STI education were predictive of STI knowledge score (P = 0.103), with nationality (β = 0.172, P = 0.003) and gender (β = 0.147, P = 0.002) being the strongest predictors.

CONCLUSIONS

Late adolescents' STI knowledge was universally low, but disparities existed and were related to a variety of characteristics. These findings expand the current literature on young people's STI knowledge and provide needed information to prioritise populations and methods for educational interventions in order to enhance STI knowledge among youth.

Sexual and Reproductive Health Discussions During Preventive Visits

OBJECTIVES

To quantify adolescent- and parent-perceived importance of provider-adolescent discussions about sexual and reproductive health (SRH), describe prevalence of provider confidentiality practices and provider-adolescent discussions about SRH topics during preventive visits, and identify missed opportunities for such conversations.

METHODS

We used data from a national Internet survey of 11- to 17-year-old adolescents and their parents. Data were weighted to represent the noninstitutionalized US adolescent population. Adolescents who had a preventive visit in the past 2 years and their parents reported on perceived importance of provider-adolescent discussions about SRH topics: puberty, safe dating, gender identity, sexual orientation, sexual decision-making, sexually transmitted infections and HIV, methods of birth control, and where to get SRH services. Adolescents and parents reported whether they had ever discussed confidentiality with the adolescent's provider. Adolescents reported experiences at their most recent preventive visit, including whether a provider spoke about specific SRH topics and whether they had time alone with a provider.

RESULTS

A majority of adolescents and parents deemed provider-adolescent discussions about puberty, sexually transmitted infections and HIV, and birth control as important. However, fewer than one-third of adolescents reported discussions about SRH topics other than puberty at their most recent preventive visit. These discussions were particularly uncommon among younger adolescents. Within age groups, discussions about several topics varied by sex.

CONCLUSIONS

Although most parents and adolescents value provider-adolescent discussions of selected SRH topics, these discussions do not occur routinely during preventive visits. Preventive visits represent a missed opportunity for adolescents to receive screening, education, and guidance related to SRH.

Young people's advisory groups in health research: scoping review and mapping of practices

BACKGROUND

Young people's advisory groups (YPAGs) for research are comprised of children or adolescents who work with researchers to shape different stages of the research process. Their involvement is expected to ensure studies better reflect the preferences and needs of targeted youth populations. However, despite their increasing use in health research, there is little systematic evidence on the methods and impacts associated with YPAGs.

METHOD

To address this gap, we conducted a scoping review of YPAGs in youth-focused health studies. We systematically searched MEDLINE for empirical studies in populations between 12 years and 18 years of age published in 2019. If a potential YPAG was identified, authors were contacted for additional information about the activities and level of involvement of the YPAG.

FINDINGS

Of all studies that collected primary data from persons aged 12-18 years, only 21 studies reported using youth advice during their research. This represents less than 1% of all published empirical child and adolescent studies. There was variation in the type of research activity undertaken by YPAGs and their level of involvement. Most studies involved YPAGs in co-production of research design and/or in dissemination activities. The majority of authors that responded were positive about the impact of YPAGs.

INTERPRETATION

Recommendations for consistent reporting of YPAG involvement in empirical studies include reporting on the match between YPAG and study populations, frequency/format of meetings, and the nature and level of involvement.

Smoking Assessment and Current Smoking Status Among Adolescents in Primary Care Settings

INTRODUCTION

Initiating tobacco use in adolescence increases the risk of nicotine dependence and continued use into adulthood. Primary care visits provide opportunities for the assessment and treatment of tobacco use; however, little is known about prevalence and correlates of assessing smoking status and current use among adolescents in these settings.

AIMS AND METHODS

Using electronic health record data from the OCHIN network, we identified adolescents with greater than or equal to one primary care visit to a study clinic (n = 366 clinics from 15 US states) during January 1, 2016 to December 31, 2017. We estimated odds ratios of smoking assessment and current smoking status by patient covariates.

RESULTS

Of 140 887 patients, 87.4% were assessed for smoking. Being Latino or Black (adjusted odds ratio = 1.22, 95% confidence interval: 1.13-1.32; adjusted odds ratio = 1.17, 95% confidence interval: 1.07-1.29, respectively, vs. non-Hispanic White), publicly insured, having more visits, and having an asthma diagnosis or other respiratory symptoms were associated with higher odds of assessment. Odds were lower if the patient was male and uninsured. Of those assessed, 1.6% identified as current smokers. Being older, having more visits, an asthma diagnosis, other respiratory symptoms, and lower household income was associated with higher odds of being a current smoker. Latinos and Blacks had lower odds than non-Hispanic Whites.

CONCLUSIONS

Although some commonly reported tobacco-related disparities were not present, smoking assessment and current smoking status differed significantly by most patient demographics. Implementation of adolescent tobacco assessment protocols and the development of interventions to target subpopulations of adolescents with higher rates of smoking could mitigate disparate rates of assessment and smoking, respectively.

IMPLICATIONS

Clinical guidelines recommend screening adolescents for tobacco use in primary care settings. We found that most adolescents seen in US safety-net primary care clinics were assessed for smoking. We also found that smoking assessment and current smoking status differed significantly by most patient demographics. Implementing tobacco assessment protocols specific to adolescents could mitigate disparate rates of assessment and ensure accurate documentation of all forms of tobacco use, given the evolution of alternative tobacco products and poly use among adolescents. Interventions to target subpopulations of adolescents with higher smoking rates are needed to prevent the negative health effects of continued smoking.

Romantic Relationships in Transgender Adolescents: A Qualitative Study

BACKGROUND

Identity formation and exploration of interpersonal relationships are important tasks that occur during adolescence. Transgender, gender diverse, and gender-nonconforming (TGNC) individuals must face these developmental milestones in the context of their transgender identity. Our aim with this article is to describe adolescents' history and experiences with romantic partners.

METHODS

We conducted phenomenological, qualitative semistructured interviews with transgender adolescents. Questions were focused on romantic experiences, thoughts, and perceptions. All interviews were coded by 2 members of the research team, with disagreements resolved by discussion and, if needed, with a third member of the research team. Thematic analysis was used to analyze the data, as well as descriptive categorization.

RESULTS

In total, 30 adolescents (18 transmasculine and 12 transfeminine) between the ages of 15 and 20 years were interviewed. Themes included (1) engagement in romantic relationships, (2) disclosure of gender identity and romantic relationships, (3) experience with abusive relationships, and (4) perceived impact of gender-affirming hormone care on romantic experiences.

CONCLUSIONS

TGNC adolescents are engaged in romantic experiences before and during social and/or medical transitioning and are cultivating relationships through both proximal peers and online connections. There is perceived benefit of gender-affirming hormone care on romantic experiences. Risk of transphobia in romantic relationships impacts the approach that transgender adolescents take toward romance and influences decisions of identity disclosure. TGNC adolescents have experience with relationship abuse in different forms. Providers can incorporate these findings in their approach to counseling and screening when caring for TGNC youth.

Monitoring Adolescents' Receipt of Time Alone From Two National Surveys

PURPOSE

Despite professional endorsement and research supporting time alone with a clinician for adolescents, low rates and disparities persist. The purpose of the present analysis was to provide detailed monitoring of time alone estimates in two national surveys that assess time alone for adolescents aged 12-17 years: the National Survey of Children's Health (NSCH) and the Medical Expenditure Panel Survey (MEPS).

METHODS

Time alone assessments in the NSCH and the MEPS have different definitions. The NSCH assessed time alone within the most recent preventive visit, and the MEPS assessed it within the most recent health care visit. We analyzed these within the subsample of 12- to 17-year-olds who had any past-year preventive visit: MEPS 2016-2017, n = 2,689; and NSCH 2016-2017, n = 24,085. We developed time alone estimates for full and subgroup samples and conducted multivariable logistic regressions to determine differences by age, sex, race/ethnicity, income, insurance, and region.

RESULTS

Overall time alone receipt was 49% (NSCH) and 29% (MEPS). Overall rates are not comparable because their definitions differ. Some subgroup differences were similar across datasets: younger adolescents (p < .01) and females (p < .05) had lower rates.

CONCLUSIONS

Among adolescents with a past-year preventive visit, time alone rates are low. Lower rates for females versus males and younger versus older adolescents persist. Detailed monitoring results can help to shape promising strategies including clinic-based interventions, such as provider training and educating parents, in efforts to improve the provision of time alone in clinical practice.

The Unmet Need for Discussions Between Health Care Providers and Adolescents and Young Adults

PURPOSE

The aims of the study were to identify factors related to (1) adolescents and young adults (AYA) desire to discuss health topics; (2) whether discussions occurred at their last medical visit; and (3) the gap (unmet need) between desire and actual discussion.

METHODS

We used data from a nationally representative, cross-sectional online survey of AYA aged 13-26 years (n = 1,509) who had had a visit in the past 2 years. Bivariate analyses examined 11 topics. Multivariable regression identified health care factors and demographic factors related to unmet need across four salient topics (HIV/sexually transmitted infections, alcohol and drug use, tobacco, and contraception).

RESULTS

Across 11 topics, unmet need averaged 28% and ranged as high as 60%; unmet need generally increased with AYA age. In multivariable analyses, ever having discussed confidentiality with a health care provider was associated with greater desire to discuss three of four salient topics, increased discussions (four of four topics), and reduced unmet need (two topics). Patient use of a clinical checklist/questionnaire at the last medical visit was associated with an increase in discussions (four topics) and reduced unmet need (four topics). Longer office visits were associated with an increase in discussions (three topics) and reduced unmet need (two topics). Older and minority youth had greater desire for discussions and unmet need.

CONCLUSIONS

A considerable gap exists between young people's desire to discuss health topics with their health care providers and actual practice.

What's PrEP?: peer navigator acceptability among minority MSM in Washington

Background

Peer navigation is a promising strategy to link at-risk minority men who have sex with men (MSM) to HIV prevention services including pre-exposure prophylaxis (PrEP).

Methods

Thirty-two Black and 63 Latinx HIV-negative MSM living in western Washington completed a survey examining attitudes towards peer navigation and PrEP. Factor analysis derived a score for peer navigator acceptability, and linear regression identified associations with this outcome.

Results

Forty-eight percent were interested in peer navigation. Being insured, higher sexual stigma, and higher PHQ-9 score were associated with higher acceptability, while higher income and having a regular medical provider were associated with lower acceptability. In multivariable analysis, higher sexual stigma predicted higher acceptability, while higher income predicted lower acceptability. Men preferred that peers be matched on sexual orientation, race, age and culture.

Conclusion

Peer navigation interventions to reach minority men should address stigma, focus on lower-income men, and try to match peers to clients to the extent possible.

US Provider Perceptions of Differences in the Sexual and Reproductive Health Needs of Adolescents with Perinatally Acquired and Behaviorally Acquired HIV: A Mixed Methods Study

This study explores health care providers' perceptions of similarities and differences in the sexual and reproductive needs of adolescents with perinatally acquired HIV (PHIV) and behaviorally acquired HIV (BHIV). Interviews (n = 13) and online surveys (n = 46) were completed by medical and social service providers (n = 30, n = 29, respectively) who care for adolescents with HIV. Eligible providers were recruited using snowball sampling. Responses to open-ended questions were coded for emergent themes. Sixty-eight percent of participants perceived differences in the sexual and reproductive health needs of adolescents with PHIV and BHIV. Differences included factors related to psychosocial, sexual, and medical needs. Providers believed adolescents with PHIV had integrated their diagnosis into their identity, were more adept at communicating with providers, and were more sexually cautious than youth with BHIV. Providers perceived adolescents with BHIV as more comfortable discussing sex-related issues, and suggested youth with PHIV were more comfortable accessing health care. Adolescents with PHIV were thought to have complex medical histories/treatment and greater knowledge of illness/medications. Existing research on adolescent-reported sexual and reproductive health knowledge and experiences in care suggests that provider and adolescent perspectives do not always align. Mode of transmission may provide some information about psychosocial functioning and sexual behavior. However, assumptions about sexual and reproductive health needs based solely on mode of transmission may contribute to gaps in sexual and reproductive health care. Future research is needed to examine whether these differing perspectives indeed lead to discrepancies in the care provided to adolescents with HIV.

Confidentiality Discussions and Private Time With a Health-Care Provider for Youth, United States, 2016

PURPOSE

The objective of the study was to define factors associated with adolescent and young adult (AYA) experiences with private time and having discussed confidentiality and the impact of these experiences on improving delivery of clinical preventive services.

METHODS

In 2016, a nationally representative sample of 1,918 US AYAs (13- to 26-year-olds) was surveyed. Survey questionnaire domains were based on prior research and Fishers' information-motivation-behavior skills conceptual model. Data were weighted to represent US households with AYA and analyzed to identify factors independently associated with ever experiencing private time and discussions of confidentiality with a regular health-care provider (HCP). We examined the association of these experiences on AYA attitudes about health care.

RESULTS

Fifty-five percent of female and 49% of male AYA reported ever having had private time with an HCP and 55% of female and 44% of male AYA had spoken to an HCP about confidentiality. Independent predictors of having experienced private time and confidentiality included older age, race, higher household income, gender of the provider, amount of years with the provider, and involvement in risk behaviors. AYA who had experienced private time and confidentiality discussions had more positive attitudes about their providers, were more willing and comfortable discussing sensitive topics, and thought that these discussions should happen at younger ages.

CONCLUSIONS

Although confidentiality and private time are important to AYA, many are not experiencing these components of care. Providing private time and discussions of confidentiality can improve the delivery of health care for young people by enhancing positive youth attitudes about preventive care.