Don't ask, they won't tell: the quality of adolescent health screening in five practice settings

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.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Documentation of Sexual History in Hospitalized Adolescents on the General Pediatrics Service

OBJECTIVES

To determine the frequency of sexual history taking and the associated characteristics of hospitalized adolescents in the pediatric hospitalist service.

METHODS

A retrospective chart review of adolescents 14 to 18 years old who were admitted to the pediatric hospitalist service at an urban, academic children's hospital in the Northeast from 2013 to 2015 was conducted. Repeat admissions, admissions to specialty services, and charts that noted impairment because of psychosis, cognitive delay, or illness severity were excluded. For charts that met the criteria, the admission history and physical was carefully reviewed for a notation of sexual history. For those with documentation, sexual activity status and a risk level assessment were recorded. Patient demographics and admission characteristics were extracted. χ² tests and logistic regression were used to examine differences between those with sexual history and those without.

RESULTS

A total of 752 charts met the criteria for inclusion. The majority of adolescents were girls (n = 506; 67.3%); the mean age was 15.7 years (SD = 1.2). Girls had 2.99 (95% confidence interval [CI] 2.18-4.11) higher odds of documentation than boys, and older adolescents had 1.41 (95% CI 1.03-1.91) higher odds than younger adolescents. Documentation did not differ significantly on the basis of admission type (medical or psychiatric), admission time, patient race and/or ethnicity, or provider gender. Among those with a documented sexual history, risk-level details were often omitted.

CONCLUSIONS

Sexual history taking does not occur universally for hospitalized adolescents. Girls were screened more often than boys despite similar rates of sexual activity. The inpatient admission may be a missed opportunity for harm-reduction counseling and adherence to sexually transmitted infection testing guidelines.

Brief Motivational Interviewing Delivered by Clinician or Computer to Reduce Sexual Risk Behaviors in Adolescents: Acceptability Study

BACKGROUND

Clinicians are expected to screen their adolescent patients for an increasing number of health behaviors and intervene when they uncover risky behaviors, yet, the clinic time allotted to screen, intervene, and provide resources is insufficient. Brief motivational interviewing (MI) offers succinct behavior change counseling; however, for implementation, clinicians need training, skill, and time. Computerized screening and counseling adjuvants may help clinicians increase their scope of behavioral screening, especially with sensitive topics such as sexual health, and provide risk-reduction interventions without consuming provider time during visits.

OBJECTIVE

The objectives of this study were to (1) understand the extent to which health care providers use brief MI for sexual health discussions with adolescent patients and (2) assess the acceptability of incorporating a brief MI-based intervention to reduce sexual risk behaviors into their clinical practice delivered by either themselves or a computer.

METHODS

At a national medical conference, surveys were administered to clinicians who provide sexual health care to adolescents. They were asked about their current use of MI for sexual risk behavior discussions and their willingness to implement computerized sexual health screening and computerized sexual risk behavior interventions into their clinical practice.

RESULTS

The large majority (87.6%, 170/194) of clinicians already used MI with their patients with less than half (72/148, 48.6%) reporting they had been formally trained in MI. Despite all (195/195, 100.0%) clinicians feeling very or completely comfortable discussing sexual risk behaviors with their patients, the large majority (160/195, 82.1%) reported it would be useful, very useful, or extremely useful for a computerized program to do it all: screen their patients, generate risk profiles, and provide the risk-reduction counseling rather than doing it themselves.

CONCLUSIONS

In this study, most clinicians used some form of brief MI or client-centered counseling when discussing sexual risk behaviors with adolescents and are very comfortable doing so. However, the large majority would prefer to implement computerized sexual health screening, risk assessment, and sexual risk behavior interventions into their clinical care of adolescents.

A Learning Collaborative Approach to Improve Primary Care STI Screening

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

The Adolescent Champion Model: Primary Care Becomes Adolescent-Centered via Targeted Quality Improvement

OBJECTIVE

To evaluate the effects of implementing the Adolescent Champion model, a novel quality improvement program targeted at helping primary care sites become more adolescent-centered.

STUDY DESIGN

Nine primary care sites from pediatrics, family medicine, and medicine-pediatrics implemented the Adolescent Champion model. Each site identified a multidisciplinary champion team to undergo training on adolescent-centered care, deliver prepackaged trainings to other staff and providers, make youth-friendly site changes, implement a standardized flow to confidentially screen for risky behaviors, and complete a quality improvement project regarding confidentiality practices. Adolescent patients, staff, and providers were surveyed at baseline, year-end, and 1-year follow-up to assess changes.

RESULTS

Adolescent patients' experiences with both their provider and the site overall significantly improved (P values from <.0001 to .004, N = 474 baseline, 386 year-end). Staff perceived an improvement in clinic practices relating to adolescents and in their ability to make institutional and personal change (P < .0001, N = 121 baseline, 109 year-end). The majority of changes were sustained 1-year postintervention. Frequently noted site improvements included: (1) initiating a method to gather feedback from adolescent patients; (2) adding trainings on confidentiality, cultural humility, and using a nonjudgmental approach; (3) updating immunizations at every visit; and (4) training providers in long acting reversible contraception via implant training.

CONCLUSIONS

Implementing the Adolescent Champion model successfully helped primary care sites become more adolescent-centered. Further studies are needed to evaluate the effects of this model on patient outcomes.

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

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

Implementation and Evaluation of Two Educational Strategies to Improve Screening for Eating Disorders in Pediatric Primary Care

PURPOSE

Routine screening for disordered eating or body image concerns is recommended by the American Academy of Pediatrics. We evaluated the ability of two educational interventions to increase screening for eating disorders in pediatric primary care practice, predicting that the "active-learning" group would have an increase in documented screening after intervention.

METHODS

We studied 303 practitioners in a large independent practice association located in the northeastern United States. We used a quasi-experimental design to test the effect of printed educational materials ("print-learning" group, n = 280 participants) compared with in-person shared learning followed by on-line spaced education ("active-learning" group, n = 23 participants) on documented screening of adolescents for eating disorder symptoms during preventive care visits. A subset of 88 participants completed additional surveys regarding knowledge of eating disorders, comfort screening for, diagnosing, and treating eating disorders, and satisfaction with their training regarding eating disorders.

RESULTS

During the preintervention period, 4.5% of patients seen by practitioners in both the print-learning and active-learning groups had chart documentation of screening for eating disorder symptoms or body image concerns. This increased to 22% in the active-learning group and 5.7% in the print-learning group in the postintervention period, a statistically significant result. Compared with print-learning participants, active-learning group participants had greater eating disorder knowledge scores, increases in comfort diagnosing eating disorders, and satisfaction with their training in this area.

CONCLUSIONS

In-person shared learning followed by on-line spaced education is more effective than print educational materials for increasing provider documentation of screening for eating disorders in primary care.

Using Maintenance of Certification as a Tool to Improve the Delivery of Confidential Care for Adolescent Patients

STUDY OBJECTIVE

Providing adolescents with confidential health care results in better social and health outcomes. We sought to assess if a medical board Maintenance of Certification Part IV project could improve the delivery of confidential care to minor adolescent patients seen in outpatient primary care practices.

DESIGN

Participating physicians reviewed 3 months of charts for patients ages 12-17 years seen for well visits during a baseline time period, and after 2 Plan, Do, Study, Act intervention cycles to assess if they had met confidentiality standards. Participating physicians additionally completed an assessment tool on personal and clinic practices related to confidentiality.

SETTING

Nine academic and 3 private practice family medicine, pediatrics, and medicine-pediatrics sites.

PARTICIPANTS

Forty-four physicians.

INTERVENTIONS

Provider and staff deficits in knowledge of minor consent laws, resistance toward the idea of confidential care, and work flow issues around confidential screening were identified as primary barriers. Staff and provider trainings, scripts, and staff involvement in planning work flows were identified as key interventions.

MAIN OUTCOME MEASURES

Improvement in confidentiality standards met during minor adolescent well visits.

RESULTS

Participating physicians significantly increased the proportion of well visits in which they spent time alone with the patient (P = .001), explained minor consent laws (P < .001), and had the adolescent complete a confidential risk screening tool (P < .001), in addition to improving scores on their confidentiality assessment overall (P < .001).

CONCLUSIONS

A medical board Maintenance of Certification Part IV project is an effective way to change physician practice and improve the delivery of confidential care to minor adolescents seen for well visits.

Relationship Between Adolescent Report of Patient-Centered Care and of Quality of Primary Care

OBJECTIVE

Few studies have examined adolescent self-report of patient-centered care (PCC). We investigated whether adolescent self-report of PCC varied by patient characteristics and whether receipt of PCC is associated with measures of adolescent primary care quality.

METHODS

We analyzed cross-sectional data from Healthy Passages, a population-based survey of 4105 10th graders and their parents. Adolescent report of PCC was derived from 4 items. Adolescent primary care quality was assessed by measuring access to confidential care, screening for important adolescent health topics, unmet need, and overall rating of health care. We conducted weighted bivariate analyses and multivariate logistic regression models of the association of PCC with adolescent characteristics and primary care quality.

RESULTS

Forty-seven percent of adolescents reported that they received PCC. Report of receiving PCC was associated with high quality for other measures, such as having a private conversation with a clinician (adjusted odds ratio [aOR] 2.2; 95% confidence interval [CI] [1.9, 2.6]) and having talked about health behaviors (aOR 1.6; 95% CI 1.4, 1.8); it was also associated with lower likelihood for self-reported unmet need for care (aOR 0.8; 95% CI 0.7, 0.9) and having a serious untreated health problem (aOR 0.4; 95% CI 0.3, 0.5).

CONCLUSIONS

Many adolescents do not report receiving PCC. Adolescent-reported PCC positively correlates with measures of high-quality adolescent primary care. Our study provides support for using adolescent-report of PCC as a measure of adolescent primary care quality.

Physician Knowledge and Attitudes around Confidential Care for Minor Patients

STUDY OBJECTIVE

Minor adolescent patients have a legal right to access certain medical services confidentially without parental consent or notification. We sought to assess physicians' knowledge of these laws, attitudes around the provision of confidential care to minors, and barriers to providing confidential care.

DESIGN

An anonymous online survey was sent to physicians in the Departments of Family Medicine, Internal Medicine-Pediatrics, Obstetrics/Gynecology, and Pediatrics at the University of Michigan.

RESULTS

Response rate was 40% (259/650). The majority of physicians felt comfortable addressing sexual health, mental health, and substance use with adolescent patients. On average, physicians answered just over half of the legal knowledge questions correctly (mean 56.6% ± 16.7%). The majority of physicians approved of laws allowing minors to consent for confidential care (90.8% ± 1.7% approval), while substantially fewer (45.1% ± 4.5%) approved of laws allowing parental notification of this care at the physician's discretion. Most physicians agreed that assured access to confidential care should be a right for adolescents. After taking the survey most physicians (76.6%) felt they needed additional training on confidentiality laws. The provision of confidential care to minors was perceived to be most inhibited by insurance issues, parental concerns/relationships with the family, and issues with the electronic medical record.

CONCLUSIONS

Physicians are comfortable discussing sensitive issues with adolescents and generally approve of minor consent laws, but lack knowledge about what services a minor can access confidentially. Further research is needed to assess best methods to educate physicians about minors' legal rights to confidential healthcare services.

Disability and Discussions of Health-Related Behaviors Between Youth and Health Care Providers

PURPOSE

The purpose of this study was to examine the likelihood of discussing health-related behaviors with health care providers (HCPs), comparing youth with and without mobility limitations (MLs).

METHODS

Analyses were conducted using baseline data from the MyPath study. Adolescents and young adults between the ages of 16 and 24 years completed a survey about their health care and health-related experiences. Analyses assessed the relationship between mobility status and discussing health-related behaviors with an HCP. Secondary analyses examined the extent to which adolescents and young adults' engagement in these behaviors was associated with these discussions.

RESULTS

Overall, we found low rates of discussions about the following topics: substance use, sexual and reproductive health, healthy eating, weight, and physical activity. Adolescents and young adults with MLs were less likely to report discussing substance use and sexual and reproductive health, but were more likely to discuss healthy eating, weight, and physical activity than peers without MLs. Those adolescents and young adults who reported substance use had higher odds of discussing this topic and those who reported having sexual intercourse had higher odds of discussing sexual and reproductive health.

CONCLUSIONS

Results suggest mobility status and a young person's engagement in health risk and promoting behaviors are associated with the likelihood of discussing these behaviors with an HCP. It is important that HCPs view adolescents and young adults with MLs as needing the same counseling and guidance about health-related behaviors as any young person presenting him/herself for treatment.

A systematic review of the prevalence and risk factors of depression among iranian adolescents

Depression is the most common mood and psychiatric disorder. The aim of this comprehensive study was to provide a complete picture of the prevalence and risk factors of depression. The study employed a systematic review methodology, searching Iranian and international databases. After screening and evaluating the articles, a synthesis of 53 articles was accumulated. A meta-analysis of the studies showed that the prevalence of children and adolescent depression was 43.55% using the BDI, 15.87 % using SCL-90, and 13.05% using CDI. Also, the prevalence of depression was higher among girls than boys based on the BDI and CDI results. The most important factors contributing to depression were: the female sex, poor inter-parental relationship, poor adolescent-parent relationship, low socio-economic status (SES), state of parenting styles, low level of parental education, and poor academic performance. The comparatively high prevalence of depression among Iranian adolescents call for further investigation and measures.

Adolescents' use of the emergency department: does source of primary care make a difference?

BACKGROUND

Many of the 18 million emergency department visits by adolescents annually in the United States are for nonurgent problems that might be addressed in a primary care setting.

METHODS

As part of a larger randomized controlled intervention, 1023 adolescents aged 12 to 21 years registering in an urban pediatric emergency department (PED) were tracked over the subsequent 365 days to record all visits to the PED. Adolescents identifying an adolescent medicine service (AMS) as the primary care source were compared with adolescents receiving primary care elsewhere in an integrated urban medical system (non-AMS) to determine how often after the index PED visit they revisited the PED, returned to primary care (PC), visited a subspecialist (SS), or were hospitalized. Mean values and odds ratios of each type of visit were compared between AMS and non-AMS patients using multivariate logistic and ordinary least squares regressions to control for covariates.

RESULTS

AMS patients (n = 124, 12%), compared to non-AMS patients (n = 899, 88%), were more likely female (75% vs 48%, P < .001) and used public insurance (52% vs 40%, P = .017). In unadjusted comparisons, AMS and non-AMS patients did not differ in the probability of any return PED visit (46% vs 37%, P = .052) in the 365 days following the index PED visit but differed in the mean number of return PED visits (1.35 vs 0.93, P = .026). AMS patients were more likely to be hospitalized (15% vs 7%, P = .006) after the index PED visit and also had a greater mean number of hospitalizations (0.41 vs 0.19, P = .048). Multivariate analyses controlling for demographic variables, triage level of initial PED visit, and hospitalizations showed AMS patients returned to primary care after an index PED visit 24.6 days earlier than non-AMS patients (P = .026).

CONCLUSIONS

This study demonstrates attending an AMS for primary care predicted earlier return to the primary care provider after an index PED visit. Elements of adolescent specialty care producing such outcomes are worthy of further study.

The relationship of sex and risk behaviours to students' use of school-based health centres in Cape Breton, Nova Scotia

OBJECTIVE

Among other benefits, school-based health centres (SBHCs) are thought to provide opportunities to identify and help adolescents with risk-taking behaviours. The present study examined the use of SBHCs at three high schools in Cape Breton, Nova Scotia, to determine the extent to which SBHCs reach students at risk, and whether there are sex differences with respect to this reach.

METHODS

Self-administered surveys of students in grades 10 to 12 at the three high schools were carried out in May 2006.

RESULTS

The response rate was 70% of registered students. Boys were more often at risk than girls due to substance use, while girls were more often at risk due to sexual activity and suicidal thoughts. More girls visited SBHC nurses than boys (49% versus 10%; P<0.001). After adjusting for age, boys who saw a SBHC nurse were significantly more likely to engage in all risk-taking behaviours than boys who did not see a nurse; girls who saw a nurse engaged in most risk-taking behaviours significantly more often than girls who did not. However, no more than 22% of students with each specific risk behaviour used SBHCs to address those risks, with the exception of girls consulting for sexual health reasons, who made up 59% of all girls in the schools who reported being sexually active.

CONCLUSIONS

Boys infrequently use SBHCs, and many at-risk students of both sexes do not use SBHCs. If the full potential for these SBHCs to help students with risk behaviours is to be realized, the need to increase reach to students is clear.

Does delivering preventive services in primary care reduce adolescent risky behavior?

PURPOSE

To determine whether the delivery of preventive services changes adolescent behavior. This exploratory study examined the trajectory of risk behavior among adolescents receiving care in three pediatric clinics, in which a preventive services intervention was delivered during well visits.

METHODS

The intervention consisted of screening and brief counseling from a provider, followed by a health educator visit. At age 14 (year 1), 904 adolescents had a risk assessment and intervention, followed by a risk assessment 1 year later at age 15 (year 2). Outcomes were changes in adolescent behavior related to seat belt and helmet use; tobacco, alcohol, and drug use; and sexual behavior. Analysis involved age-related comparisons between the intervention and several cross-sectional comparison samples from the age of 14-15 years.

RESULTS

The change in helmet use in the intervention sample was 100% higher (p < .05), and the change in seat belt use among males was 50% higher (p = .14); the change in smoking among males was 54% lower (p < .10), in alcohol use was no different, and in drug use was 10% higher (not significant [NS]); and the change in rate of sexual intercourse was 18% and 22% lower than cohort comparison samples (NS).

CONCLUSIONS

The intervention had the strongest effect in the area of helmet use, shows promise for increasing seat belt use and reducing smoking among male adolescents, and indicates a nonsignificant trend toward delaying the onset of sexual activity. Participation in the intervention seemed to have no effect on the rates of experimentation with alcohol and drugs between the ages of 14 and 15 years.

Use of the program explication method to explore the benefits of a service for homeless and marginalized young people

Maintaining the alignment between the dynamic development of health and social services and the rapidly advancing scientific evaluation literature is a central challenge facing service administrators. We describe "program explication," a consulting method designed to assist services to identify and review implicit program logic assumptions against the evaluation literature. Program explication initially facilitates agency staff to identify and document service components and activities considered critical for improving client outcomes. Program assumptions regarding the relationship between service activities and client outcomes are then examined against available scientific evidence. We demonstrate the application of this method using an example of its use in reviewing a service for homeless young people operating in Melbourne, Australia, known as the Young People's Health Service (YPHS). The YPHS involved 21 activities organized within 4 components. The intended benefits of each of the activities were coherently articulated and logically consistent. Our literature search revealed moderate to strong evidence for around 1 quarter of the activities. The program explication method proved feasible for describing and appraising the YPHS service assumptions, thereby enhancing service evaluability.

Challenges of providing confidential care to adolescents in urban primary care: clinician perspectives

PURPOSE

Clinician time alone with an adolescent has a major impact on disclosure of risk behavior. This study sought to describe primary care clinicians' patterns of delivering time alone, decision making about introducing time alone to adolescents and their parents, and experiences delivering confidential services.

METHODS

We undertook qualitative interviews with 18 primary care clinicians in urban health centers staffed by specialists in pediatrics, family medicine, and adolescent medicine.

RESULTS

The annual preventive care visit is the primary context for provision of time alone with adolescents; clinicians consider the parent-child dynamic and the nature of the chief complaint for including time alone during visits for other than preventive care. Time constraints are a major barrier to offering time alone more frequently. Clinicians perceive that parental discomfort with time alone is rare. Many clinicians wrestle with internal conflict about providing confidential services to adolescents with serious health threats and regard their role as facilitating adolescent-parent communication. Health systems factors can interfere with delivery of confidential services, such as inconsistent procedures for determining whether unaccompanied youth would be seen.

CONCLUSION

Despite competing time demands, clinicians report commitment to offering time alone during preventive care visits and infrequently offer it at other times. Experienced clinicians can gain skills in the art of managing complex relationships between adolescents and their parents. Office systems should be developed that enhance the consistency of delivery of confidential services.

Development, validation, and utility of internet-based, behavioral health screen for adolescents

OBJECTIVES

The goals were to develop and to validate the Internet-based, Behavioral Health Screen (BHS) for adolescents and young adults in primary care.

METHODS

Items assessing risk behaviors and psychiatric symptoms were built into a Internet-based platform with broad functionality. Practicality and acceptability were examined with 24 patients. For psychometric validation, 415 adolescents completed the BHS and well-established rating scales. Participants recruited from primary care waiting rooms were 12 to 21 years of age (mean: 15.8 years); 66.5% were female and 77.5% black.

RESULTS

The BHS screens in 13 domains by using 54 required items and 39 follow-up items. The administration time was 8 to 15 minutes (mean: 12.4 minutes). The scales are unidimensional, are internally consistent (Cronbach's alpha = 0.75-0.87), and discriminate among adolescents with a range of diagnostic syndromes. Sensitivity and specificity were high, with overall accuracy ranging from 78% to 85%. Patients with scores above scale cutoff values for depression, suicide risk, anxiety, and posttraumatic stress disorder symptoms were > or =4 times more likely to endorse other risk behaviors or stressors.

CONCLUSIONS

The BHS addresses practical and clinical barriers to behavioral health screening in primary care. It is a brief but comprehensive, self-report, biopsychosocial assessment. The psychiatric scales are valid and predictive of risk behaviors, which facilitates exclusion of false-positive results, as well as assessment and triage.

Detecting emotional disorder in young people in primary care

PURPOSE OF REVIEW

Screening young people for emotional disorder in primary care has seemed sensible given most attend annually and most mental disorder is undetected. Yet evidence supporting screening has been scant. This review considers recent progress around conceptual frameworks, epidemiological findings, accuracy of available instruments and evidence for effectiveness of screening in reducing the burden of emotional disorders.

RECENT FINDINGS

Despite better evidence about the accuracy of screens in identifying adolescent depression and possible benefits of early intervention with current treatments, demonstration of improved health outcomes and cost-effectiveness is still lacking. Even when screening detects mental disorder other factors such as readiness for care and availability of effective treatments may affect responses. Best results are obtained when screening is linked to collaborative models of care. Evidence around harms from screening is scant but debate exists over potential harms of false-positives such as stigma and increased strain on healthcare resources.

SUMMARY

There is growing consensus that, if screening for emotional disorder is to be effective in primary care, facilitated access of identified young people to effective treatment options is necessary. Further research is required to demonstrate that routine screening will improve mental health outcomes and be cost-effective.

Time from first intercourse to first sexually transmitted infection diagnosis among adolescent women

OBJECTIVE

To determine the time between first intercourse and first sexually transmitted infection (STI) with Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis and time between repeated infections.

DESIGN

Observational study.

SETTING

Three adolescent medicine clinics.

PARTICIPANTS

A cohort of 386 urban young women aged 14 to 17 years at enrollment.

MAIN OUTCOME MEASURES

Age at first intercourse; organism-specific interval between first intercourse and first STI diagnosis; interval between repeated infections; and age at first STI test prior to study participation.

RESULTS

Participants had first intercourse at a young age (first, second, and third quartiles were 13, 14, and 15 years of age, respectively). By age 15 years, 25% of the women acquired their first STI, most often C trachomatis. Median interval between first intercourse and first STI diagnosis was 2 years. Within 1 year of first intercourse, 25% had their first C trachomatis infection. Repeated infections were common; within 3.6, 6, and 4.8 months, 25% of the women with prior C trachomatis, N gonorrhoeae, and T vaginalis infection were reinfected with the respective organisms. Considerable delay in STI testing was found for those who began sex at a younger age. The median interval between first sex and first test were 4.9, 3.5, 2.1, 1.8, and 1.2 years for those who had first sex at ages 10, 11, 12, 13, and 14 years, respectively.

CONCLUSIONS

Timely screening and treatment are important for prevention of STI sequelae. For urban adolescent women, STI screening (especially for C trachomatis) should begin within a year after first intercourse and infected individuals should be retested every 3 to 4 months.

Adolescent preventive health care: what do parents want?

OBJECTIVE

To understand parental opinions about which topics should be discussed during adolescent preventive health visits and how best to incorporate adolescent confidentiality into these visits.

STUDY DESIGN

Cross-sectional, web-based survey of a national sample of 1025 parents of adolescents.

RESULTS

Response rate was 71%. From a list of 18 possible topics, the 3 most frequently selected as being "very important for the doctor to discuss during adolescent well child examinations" were "diet/nutrition" (75%), "exercise/sports" (67%), and "physical changes of puberty" (60%). There was variability in topic popularity by parents' race/ethnicity and gender and by adolescents' age, health status, and gender. Most parents (66%) believed it was "very/somewhat" important for adolescents to have private time with the doctor during these visits, yet a substantial proportion of parents (46%) preferred that the doctor disclose to them the confidential information obtained during these private encounters.

CONCLUSIONS

Parents find numerous topics important for discussion during well adolescent health care visits suggesting that parents might value a broad range of preventive care services for adolescents. However, some parents appear conflicted about incorporating adolescent confidentiality into prevention-focused visits.

Confidentiality, consent, and caring for the adolescent patient

PURPOSE OF REVIEW

This study reviews the healthcare-related rationale for providing confidential care to adolescents, as well as the legal framework for the provision of such care.

RECENT FINDINGS

Physician assurances of confidentiality increase adolescents' willingness to disclose sensitive health information, but these assurances are rarely given. Physicians may not be aware of legal minor consent guidelines or may be concerned about parental reaction to such confidential discussions. Fortunately, many parents and teens understand the importance of confidential healthcare. Adolescent consent and confidentiality laws vary from state to state, but there are federal guidelines and common law concepts that are applicable throughout the United States. The Health Insurance Portability and Accountability Act Privacy Rule also provides guidelines for confidential care to minors. Future challenges for adolescent confidentiality include ease of access to electronic medical records as well as patient (and/or parent)-controlled health records.

SUMMARY

Confidentiality for adolescents has important implications for the quality provision of healthcare for this vulnerable population. Physicians and other healthcare providers must be aware of these health implications, as well as federal policies, common law, and their individual state's laws pertaining to this important topic.

'Is it normal to feel these questions ...?': a content analysis of the health concerns of adolescent girls writing to a magazine

BACKGROUND

There is a mismatch between presenting concerns of adolescents to GPs and behaviours that lead to adolescent morbidity and mortality. Better understanding of health concerns of this target group would enhance communication between health professionals and adolescent patients.

OBJECTIVE

To explore and categorize the health concerns of adolescent girls sending unsolicited emails to a teenage girls' magazine.

METHOD

We conducted a content analysis of 1000 systematic randomly selected unsolicited emails submitted to the health column of an Australian adolescent girls' magazine over a 6-month period.

RESULTS

Three main foci of concern were identified: Context of Concern, Health Issue of Concern and Advice Sought for Concern. Within Health Issue of Concern, there were five categories: body (47.5%), sex (31.9%), relationship (14.7%), mind (4.7%) and violence and/or safety (1.2%). Concerns within the body and sex categories ranged enormously, but frequently expressed intimate descriptions of anatomy, feelings, sexual practices and relationships. Many concerns occurred in the context of adolescents' relationships with others. The proportion of concerns about physical or psychological symptoms or health issues commonly associated with the adolescent age group (such as health risk behaviours, mental health, pregnancy and sexually transmitted infections) was relatively small.

CONCLUSIONS

GPs and other health professionals might engage more readily with adolescent patients with a deeper understanding of the concerns that adolescents have about their bodies, relationships and overall health. Seemingly 'trivial' issues, such as normal puberty, could be used as discussion triggers in health consultations to help alleviate anxiety and build rapport.

Effect of a pediatric practice-based smoking prevention and cessation intervention for adolescents: a randomized, controlled trial

OBJECTIVE

The purpose of this work was to determine whether a pediatric practice-based smoking prevention and cessation intervention increases abstinence rates among adolescents.

METHODS

Eight pediatric primary care clinics were randomly assigned to either intervention or usual care control condition. The provider- and peer-delivered intervention tested was based on the 5A model recommended by the US Public Health Service clinical practice guidelines and the American Academy of Pediatrics and consisted of brief counseling by the pediatric provider followed by 1 visit and 4 telephone calls by older peer counselors aged 21 to 25 years. A consecutive sample of patients aged 13 to 17 years scheduled for an office visit was eligible regardless of smoking status. Of 2711 patients who agreed to participate, 2709 completed baseline assessments, and 2700 (99.6%) and 2690 (99.2%) completed 6- and 12-month assessments, respectively.

RESULTS

Compared with the usual care condition, nonsmokers who received the provider- and peer-delivered intervention were significantly more likely to self-report having remained abstinent at 6-month and 12-month follow-up; smokers who received the provider- and peer-delivered intervention were more likely to report having quit at the 6-month but not the 12-month follow-up. A number of adolescent characteristics (eg, age, peer smoking, tobacco dependence, and susceptibility) were found to be predictive of abstinence at follow-up.

CONCLUSIONS

A pediatric practice-based intervention delivered by pediatric providers and older peer counselors proved feasible and effective in discouraging the initiation of smoking among nonsmoking adolescents for 1 year and in increasing abstinence rates among smokers for 6 months.

Providers' perceived barriers to sexually transmitted disease care in 2 large health maintenance organizations

GOAL

To identify providers' perceived barriers to sexually transmitted disease (STD) care in 2 health plans and plan-, clinician-, and patient-level factors that were associated with these barriers in order to inform quality improvement interventions.

STUDY DESIGN

Surveys were mailed to a stratified sample of 1000 physicians, physician assistants, and nurse practitioners at 2 large health plans in 1999-2000. Of the 743 (82%) providers who received questionnaires and responded, data were analyzed from 699 with complete specialty information.

RESULTS

Ninety-five percent of providers identified at least 1 barrier to STD care. The most commonly cited barriers in both plans related to insufficient time and staff to address STDs, to counsel patients or manage sex partners, to keep current with managing high-risk patients, and to monitor patient adherence to recommendations to abstain from sex or use condoms during treatment. Nurse practitioners and specialists in obstetrics and gynecology were more likely to cite these barriers. Providers in staff models were more likely to cite the most common patient-level barriers. Few cited barriers related to diagnostic and treatment services.

CONCLUSIONS

Interventions in health plans are necessary to address constraints related to time and staff performing STD related care, keeping current with managing high-risk patients, and supporting patient adherence to provider recommendations.

Providing contraceptive care to low-income, African American teens: the experience of urban community health centers

Recently, attention has been drawn to the quality of the patient-provider relationship as a mediator of health outcomes for racial and ethnic minorities. The purpose of this study was to examine the provider-patient relationship in reproductive health care for low income African American teens and to identify effective techniques they use in caring for teens. We conducted focus groups with providers at two clinics serving six low-income neighborhoods on the Southside of Chicago. Sessions were audio-taped then transcribed verbatim. ATLAS/ti 5.0 (a qualitative data analysis software program), was used for coding, text retrieval, data management and analysis of data. Providers in community clinics use a number of tactics when working with teens. First, they forge strong relationships through the use of language, shared background experiences, honesty and spending extra time with teens. Second, clinic employees work collectively to care for the patients with all staff members, both professional and clerical, contributing to the provider-patient relationship. Third, providers seek opportunities for contraceptive counseling even attempting to reach males outside of clinic. Techniques used by providers in neighborhood clinics may provide important insights for providing reproductive health care to low income, African American teens.

Access to primary health care for Australian adolescents: How congruent are the perspectives of health service providers and young people, and does it matter?

OBJECTIVE

To explore the extent of congruence between the views of service providers and young people (on adolescents' health concerns, barriers to accessing health services and ideal service model) in order to improve and increase the appropriateness, quality and usage of primary health care services.

METHODS

A qualitative data collection technique was used. During 2001/02, focus groups were conducted in urban and rural locations with adolescents (in and out of mainstream education), general practitioners, community health staff and youth health workers.

RESULTS

Service providers and young people identified a similar range of health concerns for young people, with young people adding additional issues of great importance to them that service providers felt were not in their 'domain of treatment'. There was reasonable congruence in regard to 'ideal service model' with some differences relating to methods of information delivery. However, for 'barriers to accessing services' there were major discrepancies.

CONCLUSIONS

While there is some common understanding between young people and service providers on certain aspects of health services, there are clearly areas where perceptions differ. This discrepancy matters because it may adversely affect the quality of provider-adolescent interaction and the willingness of adolescents to access services.

IMPLICATIONS

To deliver optimal health services to young people, the differences in understanding regarding services need to be addressed. Strategies could include promotion to, and encouragement of, young people to seek help, continuing professional education of providers and changes in remuneration policies.

Qualitative review of serotonin syndrome, ecstasy (MDMA) and the use of other serotonergic substances: hierarchy of risk

Growth of the antidepressant market and widespread use of the illicit drug ecstasy (methylenedioxymethamphetamine; MDMA) creates a need to delineate the potential harms associated with the concomitant use of ecstasy and serotonergic pharmaceutical drugs. One such harm is serotonin syndrome. The study aimed to synthesize the risk of serotonin syndrome associated with the concomitant use of ecstasy and other serotonergic substances in a clinically relevant hierarchy for psychiatrists and other medical practitioners. An extensive online database search was carried out of the literature on serotonin syndrome, in relation to illicit drugs and simultaneous use of other substances. Numerous licit and illicit substances implicated in serotonin syndrome, when used with ecstasy, have potential for increased toxicity and are presented in a resulting hierarchy of risk. Substances that inhibit serotonin re-uptake are less likely to lead to life-threatening elevations in serotonin when used with ecstasy. High doses or repeated use of stimulants such as methamphetamine and cocaine with ecstasy increase the risk of serotonin syndrome; as does the use of pharmaceutical amphetamine and ecstasy. Serotonin precursors also influence the course of serotonin syndrome when used with ecstasy. Substances that inhibit monoamine oxidase are most likely to lead to serious increases in serotonin when used with ecstasy. Findings highlight the importance of screening for the use of ecstasy and other serotonergic substances when prescribing antidepressant drugs.

Toward youth friendly services: a survey of young people in primary care

BACKGROUND

The World Health Organization encourages the development of youth friendly services, yet little is known on how youth currently present in general practice.

OBJECTIVE

To describe the perspectives, expectations, and service receipt of young people presenting to family doctors to inform the development of youth friendly services.

DESIGN

Cross-sectional survey.

PARTICIPANTS AND MEASUREMENTS

Consecutive young people attending 26 randomly selected practices were recruited in the waiting rooms. Standardized instruments were used to interview them before their consultation.

RESULTS

Of 501 young people who were approached, 450 participated (91% participation rate). Most had respiratory (26%) or dermatological complaints (18%). When asked to assess their health status, 59% perceived they had neither a physical nor a mental illness. However, 43% stated they had fears about their health problem and 1 in 5 feared it could be life-threatening. Although only 10% presented with psychological complaints, 24% perceived they currently had a mental illness. The most common expectations were treatment (50%) and good communication (42%). Most youth were prescribed medication (60%), but 40% of those who received a prescription had not expected to receive a treatment. A follow-up appointment was offered to 57% of participants.

CONCLUSIONS

This study identifies a gap between young people's perception of illness and their presentations to family doctors. It also highlights unexpected fears, and a mismatch between expectations and service receipt. These findings have implications for family medicine training and for clinical practice. They should inform the development of youth friendly services.

Far from ideal: weight perception, weight control, and associated risky behaviour of adolescent girls in Nova Scotia

OBJECTIVE

To examine the prevalence of weight-related concerns, unhealthy weight-control behaviour, and associated risky behaviour among adolescent girls, and to ascertain whether these girls had discussed a healthy weight with their physicians.

DESIGN

Anonymous, self-report, cross-sectional survey.

SETTING

Four high schools in rural Nova Scotia.

PARTICIPANTS

Adolescent girls in grades 10 to 12.

MAIN OUTCOME MEASURES

Weight perception, prevalence of weight-control behaviour, associations between weight perception and risky behaviour, associations between disordered eating behaviour and other risky behaviour.

RESULTS

Overall response rate was 76%. Half the 1133 participants saw themselves as not being the "right" weight; 60% were trying to lose weight. During the past 30 days, 16% of the girls were attempting to control or lose weight and had engaged in disordered eating behaviour. In univariate analysis, perception of being either overweight or underweight was significantly associated with suicidal thoughts, suicide planning, and risk of depression. In multivariate analysis, positive associations were found between disordered eating behaviour and suicidal thoughts (odds ratio [OR] 4.2, 95% confidence interval [CI] 2.6 to 6.7), suicide planning (OR 2.9, 95% CI 1.7 to 4.7), suicide attempts (OR 3.4, 95% CI 1.8 to 6.6), and ever having had vaginal intercourse (OR 1.6, 95% CI 1.1 to 2.5). Only 22% of respondents had spoken with a doctor about a healthy weight.

CONCLUSION

Weight concerns are prevalent among adolescent girls in Nova Scotia. Many of them, especially those who see themselves as overweight or underweight, engage in unhealthy weight-control methods. Perceived underweight and overweight and disordered eating behaviour have strong associations with depression and self-harming behaviour. Few participants had discussed a healthy weight with a physician. Health professionals should be aware of the associations between weight perception and disordered eating behaviour and other risky behaviour.

Assessment of health issues and concerns of Israeli seventh graders during school physician examinations: a pilot study

BACKGROUND

The AMA Guidelines for Adolescent Preventive Services (GAPS) recommends annual medical evaluations during adolescence, emphasizing screening and counseling regarding psychosocial issues. In Israel, seventh graders undergo medical examinations within the school health services, focusing on the detection of physical conditions. We addressed the psychosocial issues of these students by introducing an expanded school physician evaluation.

METHODS

Twelve school physicians performed structured expanded health evaluations for seventh graders in 11 schools. Each student completed a questionnaire (checklist) with 22 health topics "about which s/he may want to receive information." The physician then carried out a biomedical and psychosocial evaluation, physical examination, and offered counseling to the student.

RESULTS

Two hundred and seventy-eight students were examined. The questionnaire required 1-2 minutes, and the physician's evaluation 20-25 minutes. Health behaviors revealed included: currently dieting (28%), no physical activity after school (35%), ever smoked cigarettes (3%), ever smoked a water pipe (9%), used alcoholic beverages (6%), and does not always use front (22%) or rear (55%) seat belt. Nine percent rated their mood as being less than 7 (on a scale from 1 to 10). The leading topics about which the students requested information were height (50%), acne (42%), weight (38%), nutrition/diet (37%), physical activity (35%), and menstrual period (29% of the girls). The physicians counseled the students on an average of 3.6 topics per visit.

CONCLUSIONS

An expanded school physician examination identifies students with psychosocial problems otherwise undetected during standard physical examinations, and provides the opportunity to address their personal concerns.

A national needs assessment of nurses providing health care to adolescents

Nurses, as the largest group of health providers in the United States, and by virtue of their scope of practice, are in an important position to promote the health of adolescents. A national survey of nurse members of the American Public Health Association, the National Association of Pediatric Nurse Associates and Practitioners, and the National Association of School Nurses was conducted in 1997 (n = 520) and was compared with findings from a parallel survey conducted in 1985 that assessed perceived competence in addressing common adolescent health issues, relevance of those issues to nurses' practice, and leadership skills. Findings provided a hopeful yet cautious picture of nurses' competencies. Strong increases in the proportion of nurses who felt equipped to address common health problems of youth suggest improved adolescent health education among nurses. Yet, at least 25% of nurses indicated a low level of knowledge in half of the adolescent health areas, and, like 1985's nurses, most nurses in 1997 did not feel competent to address the needs of gay, lesbian, and bisexual youth. Several priority areas in Healthy People 2010 were considered by 25% or more of the nurses to be irrelevant to their practice, including smoking cessation, suicide, violence, and pregnancy. The task remains to assure that all nurses who work with adolescents are equipped to respond to their diverse and unique health needs.

Smoking prevention and cessation intervention delivery by pediatric providers, as assessed with patient exit interviews

OBJECTIVE

The goal was to evaluate the degree to which a smoking prevention and cessation intervention was delivered by providers to adolescents in the pediatric office setting.

METHODS

Eight pediatric clinics in central Massachusetts were assigned randomly to either a special intervention (brief pediatric provider-delivered intervention plus peer counseling) or the usual care condition. Subjects (n = 2710) were adolescents 13 to 17 years of age, both smokers (smoked in the past 30 days) and nonsmokers/former smokers. The degree to which smoking prevention and treatment interventions were delivered by providers was assessed through patient exit interviews with adolescents after their clinic visits; interviews assessed the occurrence of 10 possible intervention steps.

RESULTS

The percentage of providers engaging in the smoking interventions differed significantly between the special intervention and usual care conditions, according to adolescent reports in the patient exit interviews. For nonsmokers/former smokers, overall patient exit interview scores were 7.24 for the special intervention condition and 4.95 for the usual care condition. For current smokers, overall patient exit interview scores were 8.40 and 6.24 for the special intervention and usual care conditions, respectively. Intervention fidelity of special intervention providers was 72.2% and 84.0% for nonsmokers/former smokers and current smokers, respectively.

CONCLUSIONS

Pediatric providers who receive training and reminders to deliver a brief smoking prevention and cessation intervention to adolescents in the context of routine pediatric primary care practice can do so feasibly and with a high degree of fidelity to the intervention protocol.

Predictors of timely initiation of gynecologic care among urban adolescent girls

PURPOSE

To determine whether or not critical sexual health services are delivered to low-income girls, and to identify predictors of timely initiation of gynecologic care for sexually active adolescent girls. Few studies have addressed the interval between sexual debut and risk-appropriate primary care services.

METHODS

We conducted an anonymous, cross-sectional, laptop-based, self-administered branching survey of 9th-12th grade girls in three Bronx public high schools (n = 819).

RESULTS

Over half (60.0%) had an opportunity for confidential care at last clinical visit. Only 27% of sexually active girls had informed any clinician that they had been sexually active; 45% had ever had a pelvic exam. The mean interval between sexual debut and initial pelvic exam (our proxy for gynecologic care) was 13.3 months (range = 0-70 months, SD = 11.8 months). Cox proportional hazard modeling identified four predictors of time to first pelvic exam: experience of sexually transmitted infection (STI) or pregnancy (hazard ratio [HR] = 1.9), having disclosed sexual activity to any clinician (HR = 1.7), access to confidential care (HR = 3.1), and high self-efficacy for accessing confidential care (HR = 2.1).

CONCLUSIONS

Most sexually active girls have not told a clinician that they are sexually active and many have not had counseling related to sexual health. Delay between sexual debut and initial pelvic exam is substantial for low-income urban girls, and often occurs in reaction to pregnancy or STI. Setting of usual care does not predict timely gynecologic care, but access to confidential care does.

"What's really going on down there?" A practical approach to the adolescent who has gynecologic complaints

The purpose of this article is to review the common complaints related to the vaginal area in pubertal girls and offer an approach to those presenting with nonurologic perineal problems or issues related to emerging sexuality. Included is a discussion of the symptoms, diagnosis, and treatment of physiologic discharge, vulvovaginal candidiasis, bacterial vaginosis, trichomoniasis, gonorrhea, and chlamydia. Other vulvovaginal complaints are considered, and screening tests that can help differentiate the origin of the problem as urologic or gynecologic are briefly addressed.

Socio-economic factors and adolescent sexual activity and behaviour in Nova Scotia

PURPOSE

Little is known about associations of adolescents' socio-economic status (SES) and their sexual activity and risk behaviours. This study examined these associations in Nova Scotia adolescents aged 15-19.

METHODS

Students at four high schools in northern Nova Scotia completed surveys examining relationships of family SES factors and: 1) sexual activity (having had vaginal or anal intercourse, intercourse before age 15 (early intercourse)); and 2) risk behaviours (use of contraception/condoms, number of partners and unplanned intercourse after substance use).

RESULTS

Of students present when the survey was administered, 2,135 (91%) responded. Almost half (49%) had had vaginal intercourse, and 7% anal intercourse. In univariate analysis for young women, non-intact family structure and lower parental education were associated with having vaginal, anal and early intercourse. Female risk behaviours showed no significant univariate associations with SES. Young men had univariate associations of family structure, lower maternal education and paternal unemployment with early intercourse, and lower paternal education with anal intercourse. Condom use was higher for young men with employed fathers; those living with both parents less often had >1 sexual partner. In multivariate analysis, most SES associations with females' sexual activities held, while most for males did not, and few associations of SES and risk behaviours were seen for females.

CONCLUSIONS

Indicators of lower SES are associated with sexual activity in young women. Sexual risk behaviours are not often associated with SES in females, though they are more so in males. These findings have implications for sexual health promotion and health services.

Training emergency medicine nurses and physicians in youth violence prevention

Adolescents seen in an urban Emergency Department (ED) are more likely to die from violence than from any other illness or condition for which they seek care in the ED. Most injured patients presenting to our nation's EDs are treated and released, even after a firearm-related injury. These youth who are discharged from the ED will not interface with resources on the inpatient trauma unit. The current standard of care in the ED involves no referral for violence-related prevention services. Despite the fact that ED physicians and nurses frequently medically manage victims of violent assault, there are few courses on youth violence prevention (YVP) framed from the viewpoint of emergency healthcare providers, and ED staff remain relatively uneducated as a specialty on the identification, assessment, and referral resources available for early intervention and prevention. This article focuses on the development and in-depth description of a case-based, 1-hour continuing medical education presentation for ED physicians, residents, and nursing staff on YVP. This presentation is aimed to increase awareness of the role of ED personnel in YVP and to provide basic knowledge and skills needed to begin to incorporate YVP into routine clinical practice in an Emergency Department setting.

History and Overview of School-Based Health Centers in the US

SBHCs are filling a gap in health care needs for many of our nation's children. They provide services to an underserved population of children and adolescents, focusing on provision of health services and the promotion of health through population-based education programs. Schools with SBHCs are finding that significant physical, mental, and dental health issues are being addressed during the school day, allowing children to remain in school. The mission of SBHCs to contribute to the health of children by providing access to primary health care and preventive health care services is being actualized.

Service integration and teen friendliness in practice: a program assessment of sexual and reproductive health services for adolescents

PURPOSE

To aid front-line program administrators and providers in adopting national reproductive health recommendations, this exploratory case study examines the implementation of service integration and teen friendliness as strategies to improve adolescent sexual and reproductive health.

METHODS

The project team conducted semi-structured interviews with administrators, providers, and adolescent clients from 10 clinical adolescent sexual and reproductive health service agencies in Alameda County, California. Programs were placed into a topology of integrated service delivery models. The teen friendliness of each program was assessed. Spearman rank correlations were calculated to evaluate the relationship between integration and teen friendliness.

RESULTS

Clinical programs exhibited a great range of service delivery models within the integration topology. Human immunodeficiency virus (HIV) counseling and testing services were poorly integrated into clinic services. Teen friendliness and integration showed a negative, but not statistically significant, correlation (R = -.45, p = .19).

CONCLUSION

Programs have made different levels of commitment to service integration or teen friendliness policies. Lessons learned through the integration of sexually transmitted disease (STD) and family planning services may assist efforts to better integrate HIV services for adolescents. Further work to elucidate the relationship between integration and teen friendliness is needed. Periodic reviews can ensure that recommended clinical guidelines, specifically annual risk assessment, are being met, as well as identifying achievable next steps to improve adolescent sexual and reproductive health service delivery.

Socio-economic factors and adolescent sexual activity and behaviour in Nova Scotia

PURPOSE

Little is known about associations of adolescents' socio-economic status (SES) and their sexual activity and risk behaviours. This study examined these associations in Nova Scotia adolescents aged 15-19.

METHODS

Students at four high schools in northern Nova Scotia completed surveys examining relationships of family SES factors and: 1) sexual activity (having had vaginal or anal intercourse, intercourse before age 15 (early intercourse)); and 2) risk behaviours (use of contraception/condoms, number of partners and unplanned intercourse after substance use).

RESULTS

Of students present when the survey was administered, 2,135 (91%) responded. Almost half (49%) had had vaginal intercourse, and 7% anal intercourse. In univariate analysis for young women, non-intact family structure and lower parental education were associated with having vaginal, anal and early intercourse. Female risk behaviours showed no significant univariate associations with SES. Young men had univariate associations of family structure, lower maternal education and paternal unemployment with early intercourse, and lower paternal education with anal intercourse. Condom use was higher for young men with employed fathers; those living with both parents less often had >1 sexual partner. In multivariate analysis, most SES associations with females' sexual activities held, while most for males did not, and few associations of SES and risk behaviours were seen for females.

CONCLUSIONS

Indicators of lower SES are associated with sexual activity in young women. Sexual risk behaviours are not often associated with SES in females, though they are more so in males. These findings have implications for sexual health promotion and health services.

Behaviour evaluation for risk-taking adolescents (BERTA): an easy to use and assess instrument to detect adolescent risky behaviours in a clinical setting

To create an instrument to be used in an outpatient clinic to detect adolescents prone to risk-taking behaviours. Based on previous research, five identified variables (relationship with parents and teachers, liking going to school, average grades, and level of religiosity) were used to create a screening tool to detect at least one of ten risky behaviours (tobacco, alcohol, cannabis and other illegal drugs use; sexual intercourse and sexual risky behaviour; driving while intoxicated, riding with an intoxicated driver, not always using a seat belt, and not always using a helmet). The instrument was tested using the Barcelona Adolescent Health Survey 1993. A Receiver Operating Characteristics curve was used to find the best cut-off point between high and low risk score. Odds ratios and 95% confidence intervals were calculated to detect at least one risky behaviour and for each individual behaviour. In order to assess its predictive value, the analysis was repeated using the Barcelona Adolescent Health Survey 1999. In both cases, analyses were conducted for the whole sample and for younger and older adolescents. Adolescents with a high-risk score were more likely to take at least one risky behaviour both when the whole sample was analysed and by age groups. With very few exceptions, the Behaviour Evaluation for Risk-Taking Adolescents showed significant odds ratios for each individual variable.

CONCLUSION

The Behaviour Evaluation for Risk-Taking Adolescents has shown its potential as an easy to use instrument to screen for risk-taking behaviours. Future research must aim towards assessing this instrument's predictive value in the clinical setting and it's application to other populations.

The Effectiveness of Intervention Studies to Decrease Alcohol Use in College Undergraduate Students: An Integrative Analysis

AIMS

This analysis was performed to critique intervention studies targeted at decreasing alcohol use in college students for the purpose of (1) synthesizing the various types of interventions and outcomes used, (2) evaluating the effectiveness of the interventions, and (3) identifying the strengths and limitations of prior studies to make recommendations for evidence-based clinical practice and future research.

METHODS

An exhaustive literature search was performed for experimental studies conducted in the past 10 years.

FINDINGS

Analysis using 15 identified studies indicated the following strengths: (1) use of random assignment in many of the studies, (2) use of theoretical frameworks to guide the interventions, (3) replication of previous studies, and (4) inclusion of outcome measures of alcohol use, quantity, and frequency. Limitations included: (1) small convenience samples; (2) use of multiple tools to elicit outcomes, making it difficult to compare results across studies; (3) lack of long-term follow-up to assess sustainability of the interventions; (4) use of only self-report outcome measures, which rely on subject's recall memory; (5) lack of manipulation checks to assure that subjects actually processed the interventions; and (6) a paucity of stress and coping interventions.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Extensive research to address the problem of college alcohol use indicates that while education is an integral part of the approach for this problem, it is ineffective when used alone as an intervention strategy. However, some empirical support exists for the use of brief motivational interventions to reduce alcohol use and harm. A personalized approach addressing expectancies and normative use employing a motivational interviewing style may produce desired outcomes. In addition, theory-based manualized approaches using stress and coping intervention strategies need to be developed and tested. In the design of future studies, careful attention also should be given to methodological issues such as sampling, measurement issues, and inclusion of more long-term follow-up measures.

Assessing age-related risk for gonococcal and chlamydial infections among females in Hawaii, 2001: a comparison of morbidity rates with screening test positivity

OBJECTIVE

National and state public health officials generally present sexually transmitted disease (STD) surveillance information in terms of overall cases and population-based rates. Because many adolescents (especially in the younger ages) are not sexually active, the use of population-based denominators leads to the calculation of low age-specific STD rates. This study compared morbidity rates with screening test positivity for gonorrhea and chlamydia to better define age-related STD risk among females in Hawaii.

METHODS

All female gonorrhea and chlamydia cases reported to the Hawaii State Department of Health (HDOH) during 2001 were grouped by age. Population estimates were used to calculate age-specific morbidity rates. Age-specific screening test positivity was calculated by dividing the number of positive tests identified through the HDOH STD screening programs by the number of screening tests performed in each age category (x100).

RESULTS

Although morbidity rates for both chlamydia and gonorrhea were low among 10-14 year olds, this group had the highest screening test positivity. Screening test positivity decreased incrementally with increasing age.

CONCLUSIONS

Screening test positivity may provide a more accurate estimate of STD risk for sexually active adolescents than population-based rates. Physicians should obtain sexual histories from their adolescent patients and provide STD prevention counseling and screening to those found to be sexually active. In addition, expanded STD screening and treatment services should be made available and accessible to young, sexually active adolescents because they appear to be at greatest risk.

Reproductive health in school-based health centers: findings from the 1998-99 census of school-based health centers

PURPOSE

To describe the state of reproductive health services, including access to contraception and health center policies, among school-based health centers (SBHCs) serving adolescents in the United States

METHODS

We examined questionnaire data on provision of reproductive health services from the 1998-99 Census of School-Based Health Centers (response rate 70%). We examined 551 SBHCs in schools with high or middle school grades. We used logistic regression to define factors independently associated with services and policies.

RESULTS

Most SBHCs (76%) were open full-time; over one-half (51%) of centers had opened in the past 4 years. Services provided, either on-site or by referral, included gynecological examinations (95%), pregnancy testing (96%), sexually transmitted disease (STD) diagnosis and treatment (95%), Human Immunodeficiency Virus (HIV) counseling (94%), HIV testing (93%), oral contraceptive pills (89%), condoms (88%), Depo-Provera (88%), Norplant (78%), and emergency contraception (77%). Counseling, screening, pregnancy testing, and STD/HIV services were often provided on-site (range 55%-82%); contraception was often provided only by referral (on-site availability = 3%-28%). SBHCs with more provider staffing were more likely to provide services on-site; rural SBHCs and those serving younger grades were less likely to provide these services on-site. Over three-quarters (76%) of SBHCs reported prohibitions about providing contraceptive services on-site; the sources of these prohibitions included school district policy (74%), school policy (30%), state law (13%), and health center policy (12%). While SBHCs generally required parental permission for general health services, many allowed adolescents to access care independently for certain services including STD care (48%) and family planning (40%). Older SBHCs were more likely to allow independent access.

CONCLUSIONS

SBHCs provide a broad range of reproductive health services directly or via referral; however, they often face institutional and logistical barriers to providing recommended reproductive health care.

The state of office-based interventions for youth tobacco use

Tobacco use is a serious pediatric health issue as dependence begins during childhood or adolescence in the majority of tobacco users. Primary care settings provide tremendous opportunities for delivering tobacco treatment to young tobacco users. Although evidence-based practice guidelines for treating nicotine dependence in youths are not yet available, professional organizations and the current clinical practice guideline for adults provide recommendations based on expert opinion. This article reports on the current tobacco treatment practices of pediatric and family practice clinicians, discusses similarities and differences between adolescent and adult tobacco use, summarizes research efforts to date and current cutting-edge research that may ultimately help to inform and guide clinicians, and presents existing recommendations regarding treating tobacco use in youths. Finally, recommendations are made for the primary care clinician, professional organizations, and health care systems and policies. Pediatricians and other clinicians can and should play an important role in treating tobacco dependence in youths.