1
|
Roe AH, Wu J, McAllister A, Aragoncillo S, Nunyi E, Voltaire S, Pishko A, Sayani F, Cebert M. Contraceptive Attitudes and Beliefs of Women With Sickle Cell Disease: A Qualitative Study. Womens Health Issues 2024:S1049-3867(24)00027-6. [PMID: 38704343 DOI: 10.1016/j.whi.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 03/14/2024] [Accepted: 03/27/2024] [Indexed: 05/06/2024]
Abstract
OBJECTIVES We aimed to qualitatively explore factors influencing contraceptive use in women living with sickle cell disease (SCD). STUDY DESIGN We conducted a semi-structured qualitative study using data from interviews with reproductive-aged women with SCD. The Theory of Planned Behavior, which describes an individual's attitudes, subjective norms, and perceived behavioral control as drivers of a health behavior, served as a framework for data collection and thematic analysis. RESULTS We analyzed interviews from 20 participants. Attitudes toward contraception showed skepticism regarding hormonal contraception and concern about adverse effects of contraception related to SCD. The role of subjective norms in contraceptive choice depended on whether participants possessed trusted sources of information, such as health care providers, family, and friends, or whether they relied on themselves alone in their contraceptive decision-making. The influence of health care providers was complicated by inconsistent and sometimes conflicting counseling. Finally, with regard to participants' perceived control in their contraceptive choices, some were motivated to alleviate menstrual pain or prevent SCD-related pregnancy risks, but many reported feeling disempowered in contraceptive decision-making settings because of their demographic characteristics or pressure from health care providers. CONCLUSIONS Women living with SCD are influenced by many factors similar to those documented for other populations when making decisions about contraception. However, SCD amplifies both the importance and risks of contraception and may also complicate individuals' autonomy and contraceptive access. Hematology and reproductive health providers should recognize the risk of coercion, maximize patients' reproductive agency, and coordinate reproductive health counseling for patients with SCD.
Collapse
Affiliation(s)
- Andrea H Roe
- Department of Obstetrics and Gynecology, Penn Medicine, Philadelphia, Pennsylvania.
| | - Jessica Wu
- Department of Obstetrics and Gynecology, Penn Medicine, Philadelphia, Pennsylvania
| | - Arden McAllister
- Department of Obstetrics and Gynecology, Penn Medicine, Philadelphia, Pennsylvania
| | - Shelley Aragoncillo
- Department of Obstetrics and Gynecology, Penn Medicine, Philadelphia, Pennsylvania
| | - Esofi Nunyi
- Department of Obstetrics and Gynecology, Penn Medicine, Philadelphia, Pennsylvania
| | - Samuelle Voltaire
- Department of Obstetrics and Gynecology, Penn Medicine, Philadelphia, Pennsylvania
| | - Allyson Pishko
- Department of Hematology, Penn Medicine, Philadelphia, Pennsylvania
| | - Farzana Sayani
- Department of Hematology, Penn Medicine, Philadelphia, Pennsylvania
| | | |
Collapse
|
2
|
Boehnlein C, Boniface ER, Packham AJ, Baldwin MK. A Social Media Survey of US Adolescent Preferences for Menstrual Bleeding Patterns. J Pediatr Adolesc Gynecol 2024; 37:25-32. [PMID: 37935280 DOI: 10.1016/j.jpag.2023.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 10/26/2023] [Accepted: 10/30/2023] [Indexed: 11/09/2023]
Abstract
STUDY OBJECTIVE To assess preferences for menstrual pattern and acceptability and knowledge about the safety of induced amenorrhea among adolescents and young adults METHODS: We conducted a cross-sectional online survey of US residents aged 14-24 years at least 1 year post-menarche. Online recruitment was conducted via the social media platform TikTok on a teen reproductive health channel. Survey questions focused on menstrual history, menstrual pattern preferences, and demographic characteristics. The primary outcome was the proportion of postmenstrual individuals who would prefer amenorrhea vs scheduled bleeding. RESULTS From 5113 potential respondents who accessed the eligibility screening, 3001 completed surveys and met the inclusion criteria. Most were aged 14-18 (63.7%), distributed proportionally among all US Census regions. When asked if they could pick their period-bleeding style without any permanent impacts, almost three-quarters chose no bleeding at all (amenorrhea; 71.5%) compared with scheduled periods (28.5%). However, 63.7% agreed or were uncertain when faced with the statement "It might be unsafe if hormone medications stop your period bleeding." After adjusting for age, gender expression, race, religion, heavy bleeding, and frequent bleeding, factors associated with preference for amenorrhea vs regular bleeding were younger age, masculine gender expression, White race, and non-Christian religious background. Baseline bleeding amount and frequency were not associated with preference for amenorrhea. CONCLUSION More than two-thirds of US adolescents and young adults indicated a preference for medication-induced amenorrhea if the method was assured to not have any permanent effects on the body, despite highly prevalent misconceptions about health and safety.
Collapse
|
3
|
Ahmed S, McLoughlin Dymond A, Correa M, Willcox ML. Views and experiences of long-acting reversible contraception among ethnic minorities in high-income countries: a systematic review of qualitative studies. BMJ Sex Reprod Health 2024; 50:53-66. [PMID: 37949640 DOI: 10.1136/bmjsrh-2023-201864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 09/30/2023] [Indexed: 11/12/2023]
Abstract
BackgroundEthnic minorities in high-income countries have higher rates of unintended pregnancies but are less likely to use highly efficacious long-acting reversible contraception (LARC). The reasons for this are unclear. AIM To understand the views and experiences of ethnic minorities within high-income countries about LARC. METHODOLOGY Medline, CINAHL, EMBASE and Sociological Abstracts were searched systematically to find qualitative articles about views on LARC. Titles and abstracts were screened to select qualitative studies about LARC whose participants were mainly from ethnic minorities in high-income countries. Quality assessment was conducted using the Critical Appraisal Skills Programme (CASP) tool. Thematic synthesis was conducted. RESULTS Seventeen studies (19 articles) met the inclusion criteria, 14 of which were from the USA (227 participants identified as Latina, 222 Black, 15 multiracial, 4 Asian). Two studies included 32 Chinese women in the UK and Australia and one included 20 Aboriginal women in Australia. Factors influencing uptake of LARC included side effects, convenience, and perceived efficacy of LARC compared with other methods; women's ideas, concerns and expectations; and external influences (partner, family/friends, health professionals and society). Convenience of LARC, control over reproductive decisions, and desire to prevent pregnancy were the main facilitators. Barriers included specific cultural concerns about irregular bleeding, concerns about racial discrimination, and family/friends having negative views on LARC. CONCLUSIONS Ethnic minority women often have additional needs and concerns about LARC compared with the White majority. Further research is needed to develop and evaluate customised respectful counselling on contraception options for ethnic minority women and their partners.
Collapse
Affiliation(s)
- Sumayyah Ahmed
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, University of Southampton Faculty of Medicine, Southampton, UK
| | - Abigail McLoughlin Dymond
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, University of Southampton Faculty of Medicine, Southampton, UK
| | - Michele Correa
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, University of Southampton Faculty of Medicine, Southampton, UK
| | - Merlin L Willcox
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, University of Southampton Faculty of Medicine, Southampton, UK
| |
Collapse
|
4
|
Kalata M, Richards M, Sheeder J. Negative Perceptions and Long-Acting Reversible Contraceptive Choice in Adolescents and Young Adults: A Cross-Sectional Study. J Pediatr Adolesc Gynecol 2023; 36:465-471. [PMID: 36934799 DOI: 10.1016/j.jpag.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 02/23/2023] [Accepted: 03/10/2023] [Indexed: 03/21/2023]
Abstract
OBJECTIVE Long-acting reversible contraceptives (LARCs) have high rates of safety, satisfaction, and continuation in adolescents and young adults (AYAs). Despite this, utilization of these methods by AYAs is low. The purpose of this study was to evaluate the negative personal perceptions or beliefs about birth control and LARCs and their association with contraceptive use in AYAs. METHODS We surveyed young people (14-24 years old) seeking care at a Title X-supported adolescent reproductive and sexual health clinic to assess negative perceptions of birth control methods, with an emphasis on LARCs. We used appropriate bivariate statistics to compare those endorsing 3 or fewer negative perceptions with those who had more than 3 and logistic regression to identify predictors of contraceptive choice. RESULTS We recruited 345 participants; 337 (97.7%) completed the survey. Among respondents, the median age was 20 (range 14-24) years, and 7.04% of participants had ever been pregnant. The most commonly held negative perceptions were fear of device migration or breakage causing adverse health effects and concern about effect on future fertility. The number of negative perceptions endorsed did not differ significantly by age. However, a greater number of negative perceptions and younger age were clinical predictors of LARC nonuse. CONCLUSION AYAs have negative perceptions about LARCs that are often inaccurate and may limit contraceptive acceptability and perceived options. Engaged and respectful dialogue with AYAs about their concerns and fears is essential to provide accurate and patient-centered contraceptive counseling and to ensure that young people can make informed contraceptive choices.
Collapse
Affiliation(s)
- Megan Kalata
- University of Colorado School of Medicine, Aurora, Colorado.
| | - Molly Richards
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado
| | - Jeanelle Sheeder
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado; Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, Colorado
| |
Collapse
|
5
|
Hoopes AJ, Akers AY, Jimenez-Zambrano A, Cain S, Maslowsky J, Sheeder J. Development of a clinical questionnaire to support contraception decisions in an adolescent reproductive health clinic in Colorado. Perspect Sex Reprod Health 2023; 55:140-152. [PMID: 37554114 PMCID: PMC10773971 DOI: 10.1363/psrh.12242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
CONTEXT Adolescents need support to make informed decisions about contraception. Few clinical questionnaires exist to help adolescents and their healthcare providers align contraception decisions with patient needs and preferences. METHODS Our mixed-methods study involved a convenience sample of English-speaking, female patients aged 13-19 seeking contraception services at an adolescent reproductive health clinic in Colorado, USA. Qualitative interviews informed development of clinical questionnaire items. The questionnaire elicited demographic characteristics, pregnancy and contraception use history, preferred contraception attributes, peer and family involvement, healthcare information and support needs, motivations for contraceptive use, and barriers to contraceptive services. We identified key decision-making factors and reduced the number of questionnaire items through principal components analysis. Using multivariable analyses, we examined the correlation between questionnaire responses and current contraceptive method. RESULTS Twenty individuals participated in interviews and 373 individuals completed the preliminary questionnaire with 63 candidate items. We identified five contraceptive decision-making factors: side-effect avoidance (eight items, Cronbach's alpha = 0.84), preferred method attributes (six items, Cronbach's alpha = 0.67), parental involvement (three items, Cronbach's alpha = 0.67), life goals prior to parenting (four items, Cronbach's alpha = 0.88), and access to a contraceptive provider (two items, Cronbach's alpha = 0.92) and nine stand-alone items. In multivariable analyses, we found that questionnaire responses for decision-making factors varied among participants using different contraceptive methods. CONCLUSIONS Multiple priorities may influence adolescent contraceptive decisions. This clinical questionnaire can elicit these priorities before or during a healthcare encounter. Future studies should assess generalizability of the questionnaire and examine impact on method choice, continuation, satisfaction, and reproductive health outcomes.
Collapse
Affiliation(s)
- Andrea J Hoopes
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, USA
| | - Aletha Y Akers
- Department of Pediatrics, Guttmacher Institute, New York, New York, USA
| | - Andrea Jimenez-Zambrano
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Sarah Cain
- Department of Emergency Medicine, Los Angeles County-University of Southern California Emergency Medicine Residency, Los Angeles, California, USA
| | - Julie Maslowsky
- Department of Community Health Sciences, Center of Excellence in Maternal and Child Health, University of Illinois-Chicago, School of Public Health, Chicago, Illinois, USA
| | - Jeanelle Sheeder
- Department of Obstetrics and Gynecology and Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| |
Collapse
|
6
|
Krass P, Sieke EH, Joshi P, Akers AY, Wood SM. Pediatric Resident Perspectives on Long-Acting Reversible Contraception Training: A Cross-Sectional Survey of Accreditation Council for Graduate Medical Education Trainees. J Adolesc Health 2023; 72:964-971. [PMID: 36907801 PMCID: PMC10198905 DOI: 10.1016/j.jadohealth.2023.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 03/14/2023]
Abstract
PURPOSE Although pediatricians are primary care providers for most adolescents, pediatric residents receive limited training on long-acting reversible contraceptive (LARC) methods. This study aimed to characterize pediatric resident comfort with placing contraceptive implants and intrauterine devices (IUDs) and assess pediatric resident interest in obtaining this training. METHODS Pediatric residents in the United States were invited to participate in a survey assessing comfort with LARC methods and interest in LARC training during pediatric residency. Bivariate comparisons used Chi-square and Wilcoxon rank sum testing. Multivariate logistic regression was used to assess associations between primary outcomes and covariates including geographic region, training level, and career plans. RESULTS Six hundred twenty seven pediatric residents across the United States completed the survey. Participants were predominantly female (68.4%, n = 429), self-identified their race as White (66.1%, n = 412), and anticipated a career in a subspecialty other than Adolescent Medicine (53.0%, n = 326). Most residents were confident counseling patients on the risks and benefits, side effects, and effective use of contraceptive implants (55.6%, n = 344) and both hormonal and nonhormonal IUDs (53.0%, n = 324). Few residents reported comfort with inserting contraceptive implants (13.6%, n = 84) or IUDs (6.3%, n = 39), with most of these respondents having learned these skills as a medical student. Most participants believed that residents should receive training on insertion of contraceptive implants (72.3%, n = 447) and IUDs (62.5%, n = 374). DISCUSSION Although most pediatric residents believe LARC training should be a component of pediatric residency training, few pediatric residents are comfortable with provision of this care.
Collapse
Affiliation(s)
- Polina Krass
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Erin H Sieke
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Priyanka Joshi
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Sarah M Wood
- PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadephia, Pennsylvania
| |
Collapse
|
7
|
Laksono AD, Rohmah N, Megatsari H. Barriers for multiparous women to using long-term contraceptive methods in Southeast Asia: case study in Philippines and Indonesia. BMC Public Health 2022; 22:1425. [PMID: 35883076 PMCID: PMC9327156 DOI: 10.1186/s12889-022-13844-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 07/14/2022] [Indexed: 11/25/2022] Open
Abstract
Background Multiparous women are supposed to be able to end their reproductive cycle to decrease population growth. This study aimed to analyze barriers for multiparous women to use long-term contraceptive methods (LTCM) in the Philippines and Indonesia. Methods The study population was women aged 15–49 years old who have given birth to a live baby > 1 in the Philippines and Indonesia. The weighted sample size was 12,085 Philippines women and 25,543 Indonesian women. To identify variables associated with the use of LTCM, we analyzed place of residence, age group, education level, marital status, employment status, and wealth status. The final step employed multinomial logistic regression. Results In both countries, the results showed that variables associated with non-user LTCM were younger women, living in rural areas with poor education. Women without partner and unemployed had higher probability to not use LTCM. Finally, low wealth status had a higher probability than the richest multiparous to not use LTCM. Conclusion The study concluded that there were six barriers for multiparous women to use LTCM in the Philippines and Indonesia. The six obstacles were living in rural areas, being younger, poor education, single, unemployed, and low wealth.
Collapse
Affiliation(s)
- Agung Dwi Laksono
- National Research and Innovation Agency, The Republic of Indonesia, Jakarta, Indonesia
| | - Nikmatur Rohmah
- Faculty of Health Science, Muhammadiyah University of Jember, East Java, Indonesia
| | - Hario Megatsari
- Faculty of Public Health, University of Airlangga, Surabaya, Indonesia.
| |
Collapse
|
8
|
Kirubarajan A, Li X, Yau M, Yu C, Got T, Li Q, Huszti E, Leung S, Thangavelu N, Sobel M. Awareness, knowledge, and misconceptions of adolescents and young people regarding long-acting reversible contraceptives: a systematic review and meta-analysis. Fertil Steril 2022; 118:168-179. [DOI: 10.1016/j.fertnstert.2022.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 11/04/2022]
|
9
|
Green S, Sheeder J, Richards M. The Etonogestrel Implant in Adolescents: Factors Associated With Removal for Bothersome Bleeding in the First Year After Insertion. J Pediatr Adolesc Gynecol 2021; 34:825-831. [PMID: 34089858 DOI: 10.1016/j.jpag.2021.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 05/21/2021] [Accepted: 05/26/2021] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE Temporizing measures such as hormonal pills can temporarily improve the side effect of breakthrough bleeding in individuals using the etonogestrel implant. The aims of this study were to determine demographic factors that are associated with bothersome bleeding and to evaluate the impact of prescribing temporizing measures on implant continuation. DESIGN Retrospective chart review. SETTING The research was conducted in an adolescent medicine primary and specialty care clinic, an adolescent family planning clinic, and a clinic that cares for parenting adolescents. PARTICIPANTS A chart review was conducted on 1200 patients aged 12-24 years who received the implant in 2016. INTERVENTIONS AND MAIN OUTCOME MEASURES The primary outcome measure was removal of the implant within the first year of use. We followed each patient for 1 year to determine rates of removal, reasons for removal, and temporizing measures prescribed for bleeding. RESULTS Younger age and lower body mass index were associated with reporting bothersome vaginal bleeding. Patients who were nulliparous or had bothersome bleeding were more likely to have the implant removed in the first year. Patients who received a temporizing measure for bleeding were more likely to retain the implant for 1 year than were those who did not receive one (67.1% vs 40%, P < .001). CONCLUSIONS Some patients are more likely to report concerns with bleeding or to have the implant removed in the first year after insertion. Prescribing temporizing measures to control bothersome vaginal bleeding may decrease rates of removal in the first year.
Collapse
Affiliation(s)
- Sarah Green
- Department of Pediatrics, Section of Adolescent Medicine, Children's Hospital Colorado, Aurora, Colorado; University of Colorado School of Medicine, Aurora, Colorado.
| | | | - Molly Richards
- Department of Pediatrics, Section of Adolescent Medicine, Children's Hospital Colorado, Aurora, Colorado; University of Colorado School of Medicine, Aurora, Colorado
| |
Collapse
|
10
|
Bryson A, Koyama A, Hassan A. Addressing long-acting reversible contraception access, bias, and coercion: supporting adolescent and young adult reproductive autonomy. Curr Opin Pediatr 2021; 33:345-353. [PMID: 33797464 DOI: 10.1097/mop.0000000000001008] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Long-acting reversible contraception (LARC) is comprised of highly effective methods (the subdermal implant and intrauterine devices) available to adolescents and young adults (AYAs). Professional medical societies endorse LARC use in AYAs and, more recently, have emphasized the importance of using a reproductive justice framework when providing LARC. This article reviews reproductive justice, discusses contraceptive coercion, examines bias, and highlights interventions that promote equitable reproductive healthcare. RECENT FINDINGS Research indicates that both bias and patient characteristics influence provider LARC practices. AYA access to comprehensive LARC services is limited, as counseling, provision, management, and removal are not offered at all sites providing reproductive healthcare to AYAs. Interventions aimed at addressing provider bias and knowledge, clinic policies, confidentiality concerns, insurance reimbursement, and systems of oppression can improve AYA access to equitable, comprehensive contraceptive care. Additionally, the COVID-19 pandemic has exacerbated inequities in reproductive healthcare, as well as provided unique innovations to decrease barriers, including telemedicine LARC services. SUMMARY Clinicians who care for AYAs should honor reproductive autonomy by approaching contraceptive services with a reproductive justice lens. This includes implementing patient-centered contraceptive counseling, increasing access to LARC, eliminating barriers to LARC removal, and committing to systemic changes to address healthcare inequities.
Collapse
Affiliation(s)
- Amanda Bryson
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Atsuko Koyama
- Department of Child Health, Division of Emergency Medicine, University of Arizona, College of Medicine-Phoenix, Phoenix, Arizona, USA
| | - Areej Hassan
- Division of Adolescent/Young Adult Medicine, Boston Children's Hospital
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|