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Bryson AE, Milliren CE, Golub SA, Maslyanskaya S, Escovedo M, Borzutzky C, Pitts SAB, DiVasta AD. Telemedicine for adolescent and young adult long-acting reversible contraception post-insertion visits: outcomes over 1 year. J Pediatr Adolesc Gynecol 2024:S1083-3188(24)00223-7. [PMID: 38679156 DOI: 10.1016/j.jpag.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 04/12/2024] [Accepted: 04/22/2024] [Indexed: 05/01/2024]
Abstract
OBJECTIVES Telemedicine for long-acting reversible contraception (LARC) care is understudied given the rapid implementation of these services in response to the COVID-19 pandemic. We compared outcomes over 1 year of adolescents and young adults (AYAs) attending a LARC post-insertion visit via telemedicine versus in person. STUDY DESIGN We included AYAs (ages 13-26 years) who received LARC between 4/1/20-3/1/21 and attended a post-insertion visit within 12 weeks. Outcomes over 1 year were compared between AYAs who completed this visit via telemedicine versus in person. We analyzed the data using descriptive statistics, bivariate analyses, and regression models. RESULTS Of 194 AYAs (ages 13.9-25.7 years) attending a post-insertion visit, 40.2% utilized telemedicine. Menstrual management (OR = 1.02, CI: 0.40-2.60), acne management (p = .28), number of visits attended (RR = 1.08, CI: 0.99-1.19), and LARC removal (p = .95) were similar between groups. AYAs attending via telemedicine were less likely than those attending in person to have STI testing (p = .001). Intrauterine device expulsion or malposition and arm symptoms with implant in situ were rare outcomes in both groups. CONCLUSION Roughly 40% of AYAs attended a post-insertion visit via telemedicine during the first year of the COVID-19 pandemic and had similar 1-year outcomes as those attending in person. The decreased likelihood of STI testing for those using telemedicine highlights the need to provide alternative options, when indicated, such as asynchronous or home testing. IMPLICATIONS Our results support the use of telemedicine for AYA LARC post-insertion care given similar clinical outcomes and healthcare utilization for LARC-related concerns over 1 year as in-person visits. Furthermore, our results identify STI testing as a potential gap in telemedicine care which can help inform and improve clinic protocols.
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Affiliation(s)
- Amanda E Bryson
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA.
| | - Carly E Milliren
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA
| | - Sarah A Golub
- Division of Adolescent Medicine, Seattle Children's Hospital, Seattle, WA
| | - Sofya Maslyanskaya
- Division of Adolescent Medicine, Children's Hospital at Montefiore, New York, New York
| | - Michelle Escovedo
- Division of Adolescent/Young Adult Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Claudia Borzutzky
- Division of Adolescent/Young Adult Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Sarah A B Pitts
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA
| | - Amy D DiVasta
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA
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Bryson AE, Milliren CE, Borzutzky C, Golub SA, Pitts SAB, DiVasta AD. Adolescent and young adult long-acting reversible contraception post-insertion visit attendance before and after COVID-19. Int J Adolesc Med Health 2024; 36:55-60. [PMID: 37982676 DOI: 10.1515/ijamh-2023-0134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/07/2023] [Indexed: 11/21/2023]
Abstract
OBJECTIVES Widespread use of telemedicine for contraceptive care, including long-acting reversible contraception (LARC), was adopted in the United States in response to the COVID-19 pandemic. Given the rapid implementation of these services, little is known about the use of telemedicine for adolescent and young adult (AYA) contraceptive care. This study examined the routine use of telemedicine for LARC post-insertion care by comparing visit attendance between AYAs receiving LARC before and after the COVID-19 pandemic onset. METHODS This analysis included LARC insertions 3/1/19-11/30/19 (pre-pandemic onset cohort) and 4/1/20-12/31/20 (post-pandemic onset cohort) from three Adolescent Medicine subspecialty clinics in the United States. De-identified data were collected via review of the electronic health record. Descriptive statistics, χ2 tests, and t-tests described and compared groups. Adjusted logistic regression models examined factors associated with attending a post-insertion visit and attending this visit via telemedicine. RESULTS This analysis included 525 LARC insertions (279 pre- and 246 post-pandemic onset). The proportion of AYAs attending a post-insertion visit increased after the COVID-19 pandemic onset (pre 30 % vs. post 46 %; p≤0.001). Adjusted models revealed that the post-pandemic onset cohort was nearly twice as likely to attend a post-insertion visit as the pre-pandemic onset cohort (OR=1.90; 95 % CI=1.68-2.15). Of those attending this visit in the post-pandemic onset cohort (n=112), 42 % utilized telemedicine. CONCLUSIONS AYAs were more likely to attend post-insertion visits after the COVID-19 pandemic onset than before. Telemedicine may have influenced this change in visit attendance.
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Affiliation(s)
- Amanda E Bryson
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Carly E Milliren
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, USA
| | - Claudia Borzutzky
- Division of Adolescent/Young Adult Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Sarah A Golub
- Division of Adolescent Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Sarah A B Pitts
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Amy D DiVasta
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, USA
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Bryson AE, Milliren CE, Borzutzky C, Golub SA, Pitts SAB, DiVasta AD. Telemedicine for Adolescent and Young Adult Long-Acting Reversible Contraception Follow-Up Care amidst a Global Pandemic. J Pediatr Adolesc Gynecol 2023; 36:51-57. [PMID: 35948207 DOI: 10.1016/j.jpag.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/11/2022] [Accepted: 08/04/2022] [Indexed: 01/18/2023]
Abstract
STUDY OBJECTIVE To describe adolescent and young adult (AYA) long-acting reversible contraception (LARC) follow-up care via telemedicine in the year following the COVID-19 pandemic onset DESIGN: Longitudinal cohort study SETTING: Three academic adolescent medicine clinics in the United States PARTICIPANTS: AYAs using LARC INTERVENTIONS: None MAIN OUTCOME MEASURES: The main outcome measures were patient characteristics, visit information (frequency, timing, and modality), patient-reported symptoms, and outcomes for those presenting for LARC follow-up care between April 1, 2020, and March 31, 2021. Descriptive statistics were used to describe the sample. χ2 tests and t tests were used to compare groups. Adjusted logistic regression models using general estimating equations were applied to assess factors associated with telemedicine visits and to examine visit outcomes. RESULTS Of the 319 AYAs (ages 13.6-25.7 years), 40.1% attended at least one LARC telemedicine visit. Patients attending any telemedicine encounter vs only in-person visits had similar demographic and clinical characteristics. Of the 426 follow-up visits, 270 (63.4%) were conducted in person and 156 (36.6%) were performed via telemedicine. Most visits (62.7%) occurred within 12 months of device insertion. Reports of bothersome uterine bleeding beyond patient expectations (OR = 1.26; 95% CI, 0.80-1.96), any symptom (OR = 1.40; 95% CI, 0.94-2.10), or 2 or more symptoms (OR = 1.22; 95% CI, 0.67-2.22) at follow-up was not associated, positively or negatively, with mode of follow-up. Management of bleeding (OR = 1.27; 95% CI, 0.56-2.89), management of acne (P = .46), and need for rapid follow-up (P = .33) were similar between follow-up modalities. CONCLUSIONS Patient demographic/clinical characteristics and visit outcomes were similar between telemedicine and in-person LARC follow-up. Telemedicine could play an important role in AYA LARC care.
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Affiliation(s)
- Amanda E Bryson
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts.
| | - Carly E Milliren
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, Massachusetts
| | - Claudia Borzutzky
- Division of Adolescent/Young Adult Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Sarah A Golub
- Division of Adolescent Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Sarah A B Pitts
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Amy D DiVasta
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, Massachusetts
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Ahrens K, Udell W, Albertson K, Coatney A, Golub SA, Lowry SJ. Sexual Health and Communication Between Foster Youth and Their Caregivers. Acad Pediatr 2022; 23:731-736. [PMID: 36208693 DOI: 10.1016/j.acap.2022.09.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 09/22/2022] [Accepted: 09/25/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Foster youth are at increased risk for negative sexual health outcomes and rarely receive the information or social/familial support needed to reduce risks. Foster and kinship caregivers report lacking the information and skills needed to effectively talk to youth in their care about sexual health. In a sample of caregivers from 2 large urban jurisdictions, our goals were to: 1) describe caregiver sexual health variables including communication and monitoring characteristics; and 2) assess associations between self-reported emotion regulation and caregiver-youth conflict and these variables. METHODS We administered surveys to foster and kinship caregivers in New York, New York and Los Angeles, California. Surveys assessed caregiver emotion regulation, caregiver-youth conflict, sexual/reproductive health knowledge, communication expectations and behaviors, and caregiver monitoring/youth disclosure. We generated descriptive statistics for all variables (aim 1) then performed multivariate regression analyses for aim 2. RESULTS Our sample included 127 foster and kinship caregivers who were primarily female (92%) and African American (55%). Most reported having >4 years of caregiving experience with foster youth (66%). On average, caregivers answered sexual health knowledge questions correctly 68% of the time. Caregiver-youth conflict was the only variable significantly associated with assessed sexual health variables; it was inversely associated with percent correct on the knowledge scale, outcomes expectations, number of topics discussed, and monitoring/disclosure. CONCLUSION Our study suggests that caregiver-youth conflict behaviors are related to sexual health knowledge, communication, and monitoring variables. Further prospective and longitudinal investigation is warranted to better characterize the complex relationship between these variables.
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Affiliation(s)
- Kym Ahrens
- Seattle Children's Research Institute (K Ahrens, K Albertson, A Coatney, and SJ Lowry), Seattle, Wash; Department of Pediatrics, University of Washington School of Medicine (K Ahrens and SA Golub), Seattle, Wash; Division of Adolescent Medicine, Seattle Children's Hospital (K Ahrens and SA Golub), Seattle, Wash
| | - Wadiya Udell
- University of Washington, Bothell Campus (W Udell), Bothell, Wash
| | - Katie Albertson
- Seattle Children's Research Institute (K Ahrens, K Albertson, A Coatney, and SJ Lowry), Seattle, Wash
| | - Alexis Coatney
- Seattle Children's Research Institute (K Ahrens, K Albertson, A Coatney, and SJ Lowry), Seattle, Wash
| | - Sarah A Golub
- Department of Pediatrics, University of Washington School of Medicine (K Ahrens and SA Golub), Seattle, Wash; Division of Adolescent Medicine, Seattle Children's Hospital (K Ahrens and SA Golub), Seattle, Wash
| | - Sarah J Lowry
- Seattle Children's Research Institute (K Ahrens, K Albertson, A Coatney, and SJ Lowry), Seattle, Wash.
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Golub SA, Pham DQ, Bargeron EL, Breuner CC, Evans YN. Evaluating the Educational Impact of Telehealth on Adolescent Medicine Trainees: a Qualitative Approach. Curr Pediatr Rep 2021; 9:72-76. [PMID: 34277143 PMCID: PMC8277226 DOI: 10.1007/s40124-021-00244-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/25/2021] [Indexed: 11/24/2022]
Abstract
Purpose of Review Telehealth has been swiftly incorporated into clinical practice since the onset of the COVID-19 pandemic, with limited understanding of how it affects trainees’ educational experiences. Our study evaluates the impact of telehealth on clinical education in pediatric and Adolescent Medicine trainees during the pandemic. Recent Findings Previous literature on telehealth focused on provider and patient perceptions in addition to clinical education for students, though none has evaluated the experiences of medical residents and fellows in Adolescent Medicine. Summary Trainees reported enhanced opportunities for bidirectional observation with attending physicians, increased flexibility for the trainee and families, and the opportunity to engage with adolescents in their home environment. Drawbacks include decreased physical exam skill-building and technological difficulties that can interrupt the learning experience. Telehealth is a valuable tool in clinical education and innovative strategies are needed to refine and enhance these educational experiences for pediatric and Adolescent Medicine trainees.
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Affiliation(s)
- Sarah A Golub
- Division of Adolescent Medicine, Seattle Children's Hospital, 4540 Sand Point Way NE Suite 200, M/S CSB-200, PO Box 5371, Seattle, WA 98145-5005 USA.,Department of Pediatrics, University of Washington School of Medicine, Seattle, WA USA
| | - Do-Quyen Pham
- Division of Adolescent Medicine, Seattle Children's Hospital, 4540 Sand Point Way NE Suite 200, M/S CSB-200, PO Box 5371, Seattle, WA 98145-5005 USA.,Department of Pediatrics, University of Washington School of Medicine, Seattle, WA USA
| | | | - Cora Collette Breuner
- Division of Adolescent Medicine, Seattle Children's Hospital, 4540 Sand Point Way NE Suite 200, M/S CSB-200, PO Box 5371, Seattle, WA 98145-5005 USA.,Department of Pediatrics, University of Washington School of Medicine, Seattle, WA USA
| | - Yolanda N Evans
- Division of Adolescent Medicine, Seattle Children's Hospital, 4540 Sand Point Way NE Suite 200, M/S CSB-200, PO Box 5371, Seattle, WA 98145-5005 USA.,Department of Pediatrics, University of Washington School of Medicine, Seattle, WA USA
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Pham DQ, Golub SA, Breuner CC, Evans YN. The Impact of Telehealth on Clinical Education in Adolescent Medicine During the COVID-19 Pandemic: Positive Preliminary Findings. Front Pediatr 2021; 9:642279. [PMID: 33816404 PMCID: PMC8017179 DOI: 10.3389/fped.2021.642279] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/01/2021] [Indexed: 12/14/2022] Open
Abstract
Purpose: Following the start of the COVID-19 pandemic, much of clinical care rapidly transitioned to telehealth, shifting the clinical training milieu for most trainees. In the wake of this shift, educators have attempted to keep learners engaged in patient care and optimize medical education as much as possible. There is, however, limited understanding of the effect of telehealth on clinical education. The aim of our study was to better understand the educational experience of pediatric and Adolescent Medicine trainees participating in clinical encounters via telehealth in a specialty consultation Adolescent Medicine Clinic at a quaternary pediatric care hospital. Methods: Using a web-based anonymous questionnaire, we surveyed trainees rotating through the Adolescent Medicine Clinic between March and June 2020. We used descriptive statistics to evaluate their experiences with telehealth and identify techniques that were effective to facilitate learning during a telehealth visit. Results: Surveys from 12 pediatric and Adolescent Medicine trainees were received, a 75% response rate. Most trainees (83.3%) reported no prior experience with telehealth before the onset of the pandemic. By the end of their rotation, trainees identified techniques that helped facilitate learning during a telehealth visit. The majority of trainees (83.3%) rated their experience as effective or very effective, and all reported interest in incorporating telehealth into their future practice. Conclusions: Pediatric and Adolescent Medicine trainees reported overall positive experiences with telehealth in clinical education and an interest in incorporating this tool into future practice. Additional research is needed to refine techniques in engaging learners through telehealth.
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Affiliation(s)
- Do-Quyen Pham
- Division of Adolescent Medicine, Seattle Children's Hospital, Seattle, WA, United States.,Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Sarah A Golub
- Division of Adolescent Medicine, Seattle Children's Hospital, Seattle, WA, United States.,Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Cora Collette Breuner
- Division of Adolescent Medicine, Seattle Children's Hospital, Seattle, WA, United States.,Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
| | - Yolanda N Evans
- Division of Adolescent Medicine, Seattle Children's Hospital, Seattle, WA, United States.,Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, United States
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Golub SA, Maza Reyes JC, Stamoulis C, Leal Pensabene A, Tijerino Cordón PA, Calgua E, Hassan A. Guatemala City youth: an analysis of health indicators through the lens of a clinical registry. Int Health 2019; 11:265-271. [PMID: 30428054 DOI: 10.1093/inthealth/ihy081] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/29/2018] [Accepted: 09/13/2018] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Despite the inclusion of adolescent health in recent global frameworks, limited data exist on health indicators in low-income countries. Our objective was to identify socioeconomic measures, risk behaviors and health indicators of young people in Guatemala. METHODS We conducted a secondary data analysis of the Pan American Health Organization's Sistema Informático del Adolescente of 2831 participants ages 10-24 y from 2008 to 2014. We examined frequencies for a core set of items, and generalized regression models assessed correlations between age, sex and ethnicity with health outcomes of interest. RESULTS Fewer than 17% of participants reported a history of chronic illness (16.6%) and severe psychological problems (16.8%). While 66.1% of participants' mothers and 36.6% of fathers reported job instability, far fewer families had housing instability (1.9% with no electricity, 6.3% with no running water). Fewer than one-third (29.1%) were sexually active and the majority (76.0%) routinely used condoms. About one-quarter (22.6%) reported abnormal mood. Indigenous participants were significantly more likely to have experienced psychological problems (odds ratio [OR] 1.75 [confidence interval {CI} 1.65-1.86]) and violence (OR 1.34 [CI 1.27-1.42]) compared with whites. CONCLUSIONS The prevalence of risk behaviors and mental health concerns is low compared with other sources of national and regional data. Further work is needed to examine the benefits and limitations of this system in order to improve health surveillance.
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Affiliation(s)
- Sarah A Golub
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Juan Carlos Maza Reyes
- Departamento Pediatria Adolescentes, Hospital San Juan De Dios, Guatemala City, Guatemala.,School of Medicine, Universidad de San Carlos de Guatemala, Guatemala City, Guatemala
| | - Catherine Stamoulis
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | | | | | - Erwin Calgua
- School of Medicine, Universidad de San Carlos de Guatemala, Guatemala City, Guatemala
| | - Areej Hassan
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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Golub SA, Maza Reyes JC, Williams DN, Christensen S, Reyes Lopez A, Lopez C, Calgua E, Hassan A. Perspectives on the use of a health surveillance system for Guatemalan youth: a stakeholder analysis. Int J Adolesc Med Health 2019; 33:/j/ijamh.ahead-of-print/ijamh-2018-0262/ijamh-2018-0262.xml. [PMID: 31125313 DOI: 10.1515/ijamh-2018-0262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 02/19/2019] [Indexed: 11/15/2022]
Abstract
In Guatemala, adolescent health indicators are collected using the Sistema Informático del Adolescente (SIA), a clinical survey developed by the Pan-American Health Organization. Recent analysis revealed significant gaps in data, limiting the ability of clinicians and policy makers to effectively address health disparities. Our objective was to explore adolescent health stakeholders' perceptions of the SIA. We conducted semi-structured interviews with 22 clinic personnel recruited from six adolescent health clinics throughout Guatemala. Stakeholders included multi-disciplinary providers and key database personnel. Interviews were conducted in Spanish, recorded and transcribed; a coding scheme was developed using a phenomenological approach, and Dedoose was used for analysis. Four major themes emerged: (1) Collecting baseline adolescent health data was useful for prevention, diagnosis and treatment of adolescent health issues. (2) The SIA was instrumental in streamlining clinical care and informing the psychosocial needs of patients. (3) The questionnaire was time-intensive, repetitive and often problematic for data input/extraction. (4) Condensing the survey and using a web-based version may improve the system for future use. Our findings show that despite the use of a standardized system, multiple barriers contribute to gaps in comprehensive data collection in Guatemala. Refining the system may enhance adolescent health surveillance and improve quality of care in this vulnerable population.
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Affiliation(s)
- Sarah A Golub
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Adolescent Medicine, Seattle Children's Hospital, Seattle, WA, USA
| | - Juan Carlos Maza Reyes
- Departamento Pediatria Adolescentes, Hospital San Juan De Dios, Guatemala City, Guatemala
- School of Medicine, Universidad de San Carlos de Guatemala, Guatemala City, Guatemala
| | - David N Williams
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, USA
| | - Sinead Christensen
- Institutional Centers for Clinical and Translational Research, Boston Children's Hospital, Boston, MA, USA
| | - Andrea Reyes Lopez
- Departamento Pediatria Adolescentes, Hospital San Juan De Dios, Guatemala City, Guatemala
| | | | - Erwin Calgua
- School of Medicine, Universidad de San Carlos de Guatemala, Guatemala City, Guatemala
| | - Areej Hassan
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
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