Promoting Adolescent Health Through Triadic Interventions

The Role of Family Support in Moderating Mental Health Outcomes for LGBTQ+ Youth in Primary Care

Importance

Lesbian, gay, bisexual, transgender, queer, and/or questioning (LGBTQ+) youth face worse mental health outcomes than non-LGBTQ+ peers. Family support may mitigate this, but sparse evidence demonstrates this in clinical settings.

Objectives

To compare depression and suicide risk between LGBTQ+ and non-LGBTQ+ youth in primary care settings and to investigate whether family support mitigates these negative mental health outcomes.

Design, Setting, and Participants

This cross-sectional study uses data from well care visits completed by adolescents aged 13 to 19 years from February 2022 through May 2023, including the Patient Health Questionnaire-9 Modified for Teens (PHQ-9-M) and the Adolescent Health Questionnaire (AHQ; an electronic screener assessing identity, behaviors, and guardian support), at 32 urban or suburban care clinics in Pennsylvania and New Jersey.

Exposures

The primary exposure was self-reported LGBTQ+ status. Family support moderators included parental discussion of adolescent strengths and listening to feelings. Race and ethnicity (determined via parent or guardian report at visit check-in), sex, payer, language, age, and geography were covariates.

Main Outcomes and Measures

PHQ-9-M-derived mental health outcomes, including total score, recent suicidal ideation, and past suicide attempt.

Results

The sample included 60 626 adolescents; among them, 9936 (16.4%) were LGBTQ+, 15 387 (25.5%) were Black, and 30 296 (50.0%) were assigned female sex at birth. LGBTQ+ youth, compared with non-LGBTQ+ youth, had significantly higher median (IQR) PHQ-9-M scores (5 [2-9] vs 1 [0-3]; P < .001) and prevalence of suicidal ideation (1568 [15.8%] vs 1723 [3.4%]; P < .001). Fewer LGBTQ+ youth endorsed parental support than non-LGBTQ+ youth (discussion of strengths, 8535 [85.9%] vs 47 003 [92.7%]; P < .001; and listening to feelings, 7930 [79.8%] vs 47 177 [93.1%]; P < .001). In linear regression adjusted for demographic characteristics and parental discussion of strengths, LGBTQ+ status was associated with a higher PHQ-9-M score (mean difference, 3.3 points; 95% CI, 3.2-3.3 points). In logistic regression, LGBTQ+ youth had increased adjusted odds of suicidal ideation (adjusted odds ratio, 4.3; 95% CI, 4.0-4.7) and prior suicide attempt (adjusted odds ratio, 4.4; 95% CI, 4.0-4.7). Parental support significantly moderated the association of LGBTQ+ status with PHQ-9-M score and suicidal ideation, with greater protection against these outcomes for LGBTQ+ vs non-LGBTQ+ youth.

Conclusions and Relevance

Compared with non-LGBTQ+ youth, LGBTQ+ youth at primary care visits had more depressive symptoms and higher odds of suicidal ideation and prior suicide attempt. Youth-reported parental support was protective against these outcomes, suggesting potential benefits of family support-focused interventions to mitigate mental health inequities for LGBTQ+ youth.

Efficacy of behavioral interventions to increase engagement in sexual health services among LatinX youth in the United States: A meta-analysis for post-pandemic implications

INTRODUCTION

LatinX youth in the U.S. are disproportionately affected by HIV and STIs, commonly attributed to a lack of diagnostic testing and regular physician consultations to address sexual health. These disparities have been exacerbated by the COVID-19 pandemic. This meta-analysis seeks to assess the efficacy of behavioral interventions among LatinX youth in the U.S. that aim to increase engagement in sexual health services (i.e., STI/HIV testing, physician consultations).

CONTENT

Following PRISMA guidelines, seven electronic databases were searched. We systematically extracted data with a coding form, and effect sizes were obtained from each study on HIV/STI testing outcomes and physician consultation. Moderator analyses were run for demographic and intervention characteristics.

SUMMARY AND OUTLOOK

Of nine included studies, the interventions created a small-to-moderate effect on increased engagement of sexual health services (d +=0.204, 95 % CI=0.079, 0.329). Moderator analyses showed that interventions including the following characteristics were most efficacious at facilitating care services: community-based or online setting, access to diagnostic testing, social media/remote components, parental involvement, and longer session duration. This meta-analysis provides informative results regarding behavioral interventions that have proven efficacious in facilitating engagement in sexual health services among LatinX youth. Most prominently, interventions that are remote or through social media, community-based, and incorporated parents had large positive effects. These findings prove useful for the ongoing COVID-19 pandemic situation and provide guidance for targeting LatinX youth to engage them in sexual health services as primary and secondary STI and HIV prevention.

Adolescent Perceptions of Adult-Mediated Healthcare Communication

Adolescence is a time of rapid growth and development and may be accompanied by increased risk-taking behaviors and independence. Youth are particularly at risk for high levels of stress, decreased physical activity, unsafe sexual activity, abuse, depression, and suicide. Considering the unique health risks adolescents face, healthcare service access and utilization can play a pivotal role in promoting positive long term health outcomes throughout adulthood. At the same time, adolescents must often rely on parents/caregivers to mediate their healthcare access. Understanding how adolescents perceive adult interactions within healthcare is important for developing interventions that increase youth access to healthcare. We found that adolescents perceived adult-mediated healthcare experiences as either supportive (Subthemes: Recognition Builds Trust and Validation) or unsupportive (Subthemes: Adult-Focused Communication and Lack of Privacy). Based on our findings, we argue that prevention-focused interventions should include communication-based strategies. We discuss social work and healthcare practice and policy implications of these findings.

An Exploratory Study of the PrEP Modality Preferences Among a Convenience Sample of Parents of Sexual and Gender Minority Adolescents

PURPOSE

Parents' attitudes toward contraceptive delivery methods have been shown to impact their adolescents' use of contraceptive methods. However, little is known about the HIV pre-exposure prophylaxis (PrEP) delivery method attitudes of parents of sexual and gender minority (SGM) adolescents assigned male at birth (AMAB). This exploratory, mixed-method formative study examined the PrEP delivery method preferences among a convenience sample of 33 parents of SGM adolescents AMAB who live in Texas.

METHODS

Participants completed an online survey, where they selected their preferred PrEP method for their SGM adolescent AMAB to use: PrEP as a daily oral pill, a bimonthly injectable, or a yearly implant. Parents answered an open-ended question about their reasons for choosing their preferred method. We analyzed data through descriptive statistics and inductive content analysis.

RESULTS

Findings from this convenience sample suggest that there is not one PrEP delivery method that parents of SGM adolescents AMAB prefer: one third of parents (33.3%) selected PrEP as a daily oral pill, 45.5% selected PrEP as a bimonthly injectable, and 21.2% selected PrEP as an annual implant. Parents cited multiple reasons for selecting a delivery method over another, with the most prevalent reasons being adherence (57.6%), access or cost (21.2%), and generic convenience or ease (21.2%).

DISCUSSION

Findings from this formative exploratory study sets the stage for future research and intervention development in increasing parental knowledge, preferences, and preference motivations for PrEP delivery methods.

Implementation Facilitators and Barriers for Primary Care Providers Prescribing Daily Oral PrEP to Adolescents in the United States

Primary care providers (PCPs) are critical in prescribing human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) to adolescents at risk of HIV. More research is needed to identify facilitators and barriers PCPs encounter in prescribing PrEP to eligible adolescents post-Food and Drug Administration (FDA) approval. This online cross-sectional survey examined the PrEP implementation facilitators and barriers among a national sample of PCPs in the United States. PCPs (n = 502) specializing in family medicine or pediatrics were recruited from a Qualtrics panel from July 15 to August 9, 2022. We analyzed the collected data using content analysis and applied the Expert Recommendations for Implementing Change (ERIC) to codebook creation and data analysis. We conducted a Fisher's exact chi-square test of independence to compare facilitator and barrier prevalence differences between participants who had and had not prescribed PrEP to an adolescent patient. Results demonstrate that (1) distributing prescriber-focused educational materials, (2) involving parents, (3) changing liability laws, (4) enhancing adolescent PrEP uptake and adherence, (5) changing clinical resources, and (6) using mass/social media to change community norms might be strategies that influence PCPs prescribing PrEP to eligible adolescent patients. Results from this study could facilitate the planning of hybrid implementation-effectiveness trials designed to determine the acceptability, feasibility, and effectiveness of implementation strategies in improving the practices of PCPs prescribing PrEP to at-risk adolescents.

Implementation Factors Associated With Primary Care Providers' Intention to Prescribe HIV PrEP to Adolescents in the United States

PURPOSE

In the United States, adolescents (those 13-18 years old) are a key age group of those at risk for and affected by HIV. Although HIV pre-exposure prophylaxis (PrEP), one promising HIV prevention tool, is approved for eligible adolescents to use, adolescent access to PrEP is limited by primary care providers' (PCPs) willingness to prescribe it. This study examined which Theoretical Domains Framework factors are associated with PCPs' intention to prescribe PrEP to sexually active adolescents.

METHODS

A total of 770 licensed PCPs practicing family medicine, internal medicine, or pediatrics in the United States completed an online cross-sectional questionnaire. Participants were recruited through a Qualtrics panel. We used a hierarchical regression to assess the association of demographic characteristics, sexual health care practices, and the 10 Theoretical Domains Framework factors with intention to prescribe PrEP to sexually active adolescents aged 13-18 years old.

RESULTS

Although nearly all PCPs had heard about PrEP (90.9%), 30.6% ever prescribed PrEP to an adolescent. Intention to prescribe PrEP to sexually active adolescents was associated with seven out of the 10 Theoretical Domains Framework factors: knowledge, skills, professional role, belief capacity, belief consequence, environmental resource, social influence, and emotion.

DISCUSSION

Our findings demonstrate that the Theoretical Domains Framework can be employed to understand the intrapersonal, interpersonal, and environmental factors associated with PCPs' intention to prescribe sexually active adolescents PrEP. Implementation strategies are needed to implement interventions that improve provider knowledge, attitudes, and skills related to prescribing PrEP to eligible adolescents.

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.

Addressing HIV/Sexually Transmitted Diseases and Pregnancy Prevention Through Schools: An Approach for Strengthening Education, Health Services, and School Environments That Promote Adolescent Sexual Health and Well-Being

Adolescents' health behaviors and experiences contribute to many outcomes, including risks for HIV, other sexually transmitted diseases, and unintended pregnancy. Public health interventions and approaches addressing risk behaviors or experiences in adolescence have the potential for wide-reaching impacts on sexual health and other related outcomes across the lifespan, and schools are a critical venue for such interventions. This paper describes a school-based program model developed by the Centers for Disease Control and Prevention's Division of Adolescent and School Health for preventing HIV/sexually transmitted diseases, unintended pregnancy, and related health risk behaviors and experiences among middle and high school students. This includes a summary of the theoretical and evidence base that inform the model, and a description of the model's activities, organized into three key strategies (sexual health education, sexual health services, and safe and supportive environments) and across three cross-cutting domains (strengthening staff capacity, increasing student access to programs and services, and engaging parent and community partners). The paper also outlines implications for adolescent health professionals and organizations working across schools, clinics, and communities, to address and promote adolescent sexual health and well-being.

How can healthcare professionals provide guidance and support to parents of adolescents? Results from a primary care-based study

BACKGROUND

This study explored the rewards and difficulties of raising an adolescent and investigated parents' level of interest in receiving guidance from healthcare providers on parenting and adolescent health topics. Additionally, this study investigated whether parents were interested in parenting programs in primary care and explored methods in which parents want to receive guidance.

METHODS

Parents of adolescents (ages 12-18) who attended an outpatient pediatric clinic with their adolescent were contacted by telephone and completed a short telephone survey. Parents were asked open-ended questions regarding the rewards and difficulties of parenting and rated how important it was to receive guidance from a healthcare provider on certain parenting and health topics. Additionally, parents reported their level of interest in a parenting program in primary care and rated how they would like to receive guidance.

RESULTS

Our final sample included 104 parents, 87% of whom were interested in a parenting program within primary care. A variety of parenting rewards and difficulties were associated with raising an adolescent. From the list of parenting topics, communication was rated very important to receive guidance on (65%), followed by conflict management (50%). Of health topics, parents were primarily interested in receiving guidance on sex (77%), mental health (75%), and alcohol and drugs (74%). Parents in the study wanted to receive guidance from a pediatrician or through written literature.

CONCLUSIONS

The current study finds that parents identify several rewarding and difficult aspects associated with raising an adolescent and are open to receiving guidance on a range of parenting topics in a variety of formats through primary care settings. Incorporating such education into healthcare visits could improve parents' knowledge. Healthcare providers are encouraged to consider how best to provide parenting support during this important developmental time period.

A Triadic Intervention for Adolescent Sexual Health: A Randomized Clinical Trial

OBJECTIVES

In this study, we evaluate the efficacy of Families Talking Together (FTT), a triadic intervention to reduce adolescent sexual risk behavior.

METHODS

Adolescents aged 11 to 14 and their female caregivers were recruited from a pediatric clinic; 900 families were enrolled; 84 declined. Families were randomly assigned to FTT or 1 of 2 control conditions. The FTT triadic intervention consisted of a 45-minute face-to-face session for mothers, health care provider endorsement of intervention content, printed materials for families, and a booster call for mothers. The primary outcomes were ever having had vaginal intercourse, sexual debut within the past 12 months, and condom use at last sexual intercourse. Assessments occurred at baseline, 3 months post baseline, and 12 months post baseline.

RESULTS

Of enrolled families, 73.4% identified as Hispanic, 20.4% as African American, and 6.2% as mixed race. Mean maternal age was 38.8 years, and mean adolescent grade was seventh grade. At the 12-month follow-up, 5.2% of adolescents in the experimental group reported having had sexual intercourse, compared with 18% of adolescents in the control groups (P < .05). In the experimental group, 4.7% of adolescents reported sexual debut within the past 12 months, compared with 14.7% of adolescents in the control group (P < .05). In the experimental group, 74.2% of sexually active adolescents indicated using a condom at last sexual intercourse, compared with 49.1% of adolescents in the control group (P < .05).

CONCLUSIONS

This research suggests that the FTT triadic intervention is efficacious in delaying sexual debut and reducing sexual risk behavior among adolescents.

Confidentiality Matters but How Do We Improve Implementation in Adolescent Sexual and Reproductive Health Care?

Confidentiality protections are a key component of high-quality adolescent sexual and reproductive health (SRH) care. Research has shown that adolescents value confidentiality and are more likely to seek care and provide honest information when confidentiality protections are implemented. However, many adolescents do not receive confidential SRH care. We synthesize studies of adolescents, parents, and providers to identify confidentiality-related factors that may explain why adolescents do not seek care or receive confidential services when they do access care. We present themes relevant to each population that address individual-level knowledge, attitudes, and behaviors, as well as clinic-level characteristics such as protocols, billing mechanisms, and clinic type. These findings have the potential to inform intervention efforts to improve the delivery of confidential SRH care for young people.

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

OBJECTIVE

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS

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

"Is It Really Confidential?" A Content Analysis of Online Information About Sexual and Reproductive Health Services for Adolescents

PURPOSE

Many young people are not aware of their rights to confidential sexual and reproductive health (SRH) care. Given that online health information seeking is common among adolescents, we examined how health education Web content about SRH for young people addresses confidentiality.

METHODS

In Spring 2017, we conducted Google keyword searches (e.g., "teens" and "sex education") to identify health promotion Web sites operated by public health/medical organizations in the United States and providing original content about SRH for adolescents/young adults. Thirty-two Web sites met inclusion criteria. We uploaded Web site PDFs to qualitative analysis software to identify confidentiality-related content and conduct thematic analysis of the 29 Web sites with confidentiality content.

RESULTS

Sexually transmitted infection testing and contraception were the SRH services most commonly described as confidential. Clear and comprehensive definitions of confidentiality were lacking; Web sites typically described confidentiality in relation to legal rights to receive care without parental consent or notification. Few mentioned the importance of time alone with a medical provider. Only half of the Web sites described potential inadvertent breaches of confidentiality associated with billing and even fewer described other restrictions to confidentiality practices (e.g., mandatory reporting laws). Although many Web sites recommended that adolescents verify confidentiality, guidance for doing so was not routinely provided. Information about confidentiality often encouraged adolescents to communicate with parents.

CONCLUSIONS

There is a need to provide comprehensive information, assurances, and resources about confidentiality practices while also addressing limitations to confidentiality in a way that does not create an undue burden on adolescents or reinforce and exacerbate confidentiality concerns.

Adolescent Health Risk Behaviors: Parental Concern and Concordance Between Parent and Adolescent Reports

OBJECTIVE

We investigated which adolescent health risk behaviors are of concern to parents generally, according to adolescent age, gender, and in the context of perceived risk. We compared adolescent and parent reports of the presence of health-risk behaviors and factors predicting agreement.

METHODS

Three hundred adolescents aged 13 to 18 years (mean, 14.5 years; 52% female) who presenting for well care completed an electronic screening tool used to assess health-risk behaviors. Parents completed parallel measures of their child's behavior and parental concern. Adolescent and parent reports were compared using McNemar test. Hierarchical linear regression was used to examine predictors of agreement.

RESULTS

High parental concern was most commonly reported for screen time and diet. When parents identified their adolescent as at-risk, high parental concern was near universal for mental health but less commonly reported for substance use. There were no differences in parental concern according to adolescent gender. Parents of older adolescents expressed more concern regarding physical activity and alcohol. Compared with adolescents, parents were more likely to report risk regarding anxiety, fruit and vegetable consumption, and physical activity, and less likely to report risk regarding screen time, sleep, and marijuana use. Younger adolescent age and higher family relationship quality were predictive of stronger parent-adolescent agreement.

CONCLUSIONS

Parents in well-care visits commonly have concerns about adolescent lifestyle behaviors. Although parents are more likely to report concern when they know about a behavior, parental concern is not always aligned with parental awareness of risk, particularly for substance use. Parent report of higher prevalence of some risk behaviors suggests their input might assist in risk identification.