Better Communication for Better Public Health: Perspectives From an Interdisciplinary Training Program.

Myriad factors determine the health of young people-biological, psychological, familial, contextual, environmental, and political, to name a few. Improving the health of adolescents means that leaders in health care and public health must have the requisite skills for translating research into priorities, practices, and policies that influence a wide array of health determinants. While adolescent health training programs may give emphasis to effective communication with adolescents as patients or as priority populations in health education/promotion efforts, are we adequately preparing our future leaders with the skill sets necessary for moving scientific evidence into practice, programs, and policies? Internship and fellowship programs may invest heavily in teaching skills for conducting research and health education/promotion, but they may not focus enough on how to translate scientific evidence into practice, programs, and policy. In this commentary, we share our experiences equipping professionals working with adolescents in health care and public health settings with skills for scientific writing, public speaking, and advocacy on behalf of young people, and discuss the need for more collaboration across disciplines.

Adolescence: a foundation for future health.

Adolescence is a life phase in which the opportunities for health are great and future patterns of adult health are established. Health in adolescence is the result of interactions between prenatal and early childhood development and the specific biological and social-role changes that accompany puberty, shaped by social determinants and risk and protective factors that affect the uptake of health-related behaviours. The shape of adolescence is rapidly changing-the age of onset of puberty is decreasing and the age at which mature social roles are achieved is rising. New understandings of the diverse and dynamic effects on adolescent health include insights into the effects of puberty and brain development, together with social media. A focus on adolescence is central to the success of many public health agendas, including the Millennium Development Goals aiming to reduce child and maternal mortality and HIV/AIDS, and the more recent emphases on mental health, injuries, and non-communicable diseases. Greater attention to adolescence is needed within each of these public health domains if global health targets are to be met. Strategies that place the adolescent years centre stage-rather than focusing only on specific health agendas-provide important opportunities to improve health, both in adolescence and later in life.

Adolescent condom use consistency over time: global versus partner-specific measures.

BACKGROUND: The conundrum of measuring condom use consistency, particularly with adolescents, has left researchers with a cacophony of strategies, thereby limiting comparability and interpretation. OBJECTIVE: The aim of this analysis was to compare and contrast two measures of condom use consistency, global versus partner specific, and their relationships with key covariates, using trajectory groups differentiated by stability of condom use consistency over three time points. METHOD: Using self-report data from sexually active girls (aged 13-17 years) in a clinic-based intervention study aimed at lowering risk for early pregnancy, this analysis compared two measures of self-reported condom use consistency: (a) a global measure: overall condom use consistency in the past 6 months and (b) a partner-specific measure: condom use consistency with the most recent sex partner in the last 6 months. Using a subjective rule-based approach, the adolescent girls in the study (n = 151) were classified into trajectory groups representing their condom use consistency at three time points (baseline and 6 and 12 months). Then, using bivariate methods, trajectory groups were compared on four baseline covariates (age, treatment condition, hormonal use in the last 6 months, and number of sex partners in the last 6 months) and three time-varying covariates measured at baseline and at 6 and 12 months (hormonal use stability, stability of primary sex partner, and stability of number of sex partners). RESULTS: For the trajectory groups formed using the global measure of condom use consistency, stability of the primary sex partner differed significantly between trajectory groups. For the partner-specific trajectory groups, two baseline and one time-varying covariate relationships were significant: hormonal use in the 6 months prior to baseline, number of sex partners in the past 6 months (baseline), and stability of the primary sex partner (time varying), with hormonal use stability (time varying) trending toward significance. DISCUSSION: The larger number of significant covariate relationships with the partner-specific trajectory groups suggests greater utility in assessing partner-linked behavior rather than a global measure. Despite limitations of the analytic strategy, this study sheds light on a measurement conundrum that has been an obstacle to comparing and contrasting indicators of condom use consistency during adolescence.

Protective factors in the lives of bisexual adolescents in North America.

OBJECTIVES: We compared protective factors among bisexual adolescents with those of heterosexual, mostly heterosexual, and gay or lesbian adolescents. METHODS: We analyzed 6 school-based surveys in Minnesota and British Columbia. Sexual orientation was measured by gender of sexual partners, attraction, or self-labeling. Protective factors included family connectedness, school connectedness, and religious involvement. General linear models, conducted separately by gender and adjusted for age, tested differences between orientation groups. RESULTS: Bisexual adolescents reported significantly less family and school connectedness than did heterosexual and mostly heterosexual adolescents and higher or similar levels of religious involvement. In surveys that measured orientation by self-labeling or attraction, levels of protective factors were generally higher among bisexual than among gay and lesbian respondents. Adolescents with sexual partners of both genders reported levels of protective factors lower than or similar to those of adolescents with same-gender partners. CONCLUSIONS: Bisexual adolescents had lower levels of most protective factors than did heterosexual adolescents, which may help explain their higher prevalence of risky behavior. Social connectedness should be monitored by including questions about protective factors in youth health surveys.

Global perspectives on the sexual and reproductive health of adolescents: patterns, prevention, and potential.

Worldwide, societal shifts and behavioural patterns exacerbated by unique developmental vulnerabilities create a confluence of factors that place today's adolescents at heightened risks for poor health outcomes. Country-level data show that continued investment in effective prevention and treatment strategies is essential to protect adolescents' sexual and reproductive health. Whereas strategies must be tailored to the developmental needs of this age group and their social contexts, effective approaches are multifaceted. All adolescents need access to quality youth-friendly services provided by clinicians trained to work with this population. Sex education programmes should offer accurate, comprehensive information while building skills for negotiating sexual behaviours. Girls and boys also need equal access to youth development programmes that connect them with supportive adults and with educational and economic opportunities. Although progress has been made since the 1994 International Conference on Population and Development, adolescents continue to be disproportionately burdened by threats to their sexual and reproductive health.

Protecting urban American Indian young people from suicide.

OBJECTIVE: To examine the likelihood of a past suicide attempt for urban American Indian boys and girls, given salient risk and protective factors. METHODS: Survey data from 569 urban American Indian, ages 9-15, in-school youths. Logistic regression determined probabilities of past suicide attempts. RESULTS: For girls, suicidal histories were associated with substance use (risk) and positive mood (protective); probabilities ranged from 6.0% to 57.0%. For boys, probabilities for models with violence perpetration (risk), parent prosocial behavior norms (protective), and positive mood (protective) ranged from 1.0% to 38.0%. CONCLUSIONS: Highlights the value of assessing both risk and protective factors for suicidal vulnerability and prioritizing prevention strategies.

Perceptions of health among immigrant Latino adolescents from Mexico.

PURPOSE: This ethnographic study describes the health-related perceptions of immigrant Latino adolescents from Mexico. METHOD: Fourteen adolescents, purposively recruited from two non-health-based community settings, participated. Each was interviewed twice and completed a visual narrative project using disposable cameras. Audiotaped transcripts and photographs were inductively analyzed. FINDINGS: Being healthy is holistically perceived by these adolescents and includes physical, mental, spiritual, social, and environmental factors. Pictures portrayed healthy and unhealthy influences and behaviors, including eating habits, exercise, self-care, relationships, garbage, and pollution. Personal responsibility was important in being healthy and in promoting one's health. Family was identified as an important source of health-related information. IMPLICATIONS: Nurses recognizing the holistic, comprehensive health-related perceptions of immigrant Latino adolescents can promote their health and design culturally and developmentally appropriate educational strategies and health interventions aimed at eliminating health disparities.

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.

Protective Factors, Risk Indicators, and Contraceptive Consistency Among College Women.

OBJECTIVE: To explore risk and protective factors associated with consistent contraceptive use among emerging adult female college students and whether effects of risk indicators were moderated by protective factors. DESIGN: Secondary analysis of National Longitudinal Study of Adolescent to Adult Health Wave III data. SETTING: Data collected through in-home interviews in 2001 and 2002. PARTICIPANTS: National sample of 18- to 25-year-old women (N = 842) attending 4-year colleges. METHODS: We examined relationships between protective factors, risk indicators, and consistent contraceptive use. Consistent contraceptive use was defined as use all of the time during intercourse in the past 12 months. Protective factors included external supports of parental closeness and relationship with caring nonparental adult and internal assets of self-esteem, confidence, independence, and life satisfaction. Risk indicators included heavy episodic drinking, marijuana use, and depression symptoms. Multivariable logistic regression models were used to evaluate relationships between protective factors and consistent contraceptive use and between risk indicators and contraceptive use. RESULTS: Self-esteem, confidence, independence, and life satisfaction were significantly associated with more consistent contraceptive use. In a final model including all internal assets, life satisfaction was significantly related to consistent contraceptive use. Marijuana use and depression symptoms were significantly associated with less consistent use. With one exception, protective factors did not moderate relationships between risk indicators and consistent use. CONCLUSION: Based on our findings, we suggest that risk and protective factors may have largely independent influences on consistent contraceptive use among college women. A focus on risk and protective factors may improve contraceptive use rates and thereby reduce unintended pregnancy among college students.

Violence perpetration among urban american Indian youth: can protection offset risk?

OBJECTIVE: To predict the likelihood of violence perpetration given various combinations of the most statistically salient risk and protective factors related to violence perpetration. DESIGN: Urban Indian Youth Health Survey, conducted from October 9, 1995, to March 30, 1998, consisting of 200 forced-choice items exploring values, cultural identity, relationships, decision-making skills, and health and well-being. SETTING: Urban schools and an after-school youth development program at an urban American Indian center. PARTICIPANTS: Five hundred sixty-nine urban American Indian youth enrolled in grades 3 through 12. MAIN OUTCOME MEASURES: Violence perpetration dichotomized in 2 ways: (1) level of violence perpetration (ie, hitting someone 1-2 times in the past year vs picking fights, hitting repeatedly, participating in group fights, or shooting or stabbing someone in the past year) and (2) having shot and/or stabbed someone during the past year. RESULTS: In the final multivariate models with age as a covariate, most protective against violence perpetration were connections to school (odds ratio [OR], 0.17), positive affect (OR, 0.29), and peer prosocial behavior norms against violence (OR, 0.35). School connectedness (OR, 0.01) and positive affect (OR, 0.46) were also protective against shooting and/or stabbing someone, as was parental prosocial behavior norms against violence (OR, 0.23). The strongest risk factors for violence perpetration were substance use (OR, 2.60) and suicidal thoughts/behaviors (OR, 2.71); for shooting and/or stabbing, it was substance use (OR, 5.26). The likelihood of violence perpetration increased markedly (from 10% to 85%) as the exposure to risk factors increased and protective factors decreased. For shooting or stabbing someone, the probabilities ranged from 3% (0 risks and 3 protective factors) to 64% (1 risk and 0 protective factors). CONCLUSION: The dramatic reduction in the likelihood of violence involvement when risk was offset with protective factors in the probability profiles suggests the utility of a dual strategy of reducing risk while boosting protection.

Parental notification laws for minors' access to contraception: what do parents say?

BACKGROUND: Recent years have seen new challenges to laws protecting minors' confidential access to reproductive health services. Little research has explored parental views on the issue. OBJECTIVE: To examine parents' views about laws requiring parental notification (PNLs) when minor children seek to obtain prescription contraceptives, the exceptions parents would endorse, and the consequences they would expect. DESIGN: Fifteen-minute telephone surveys conducted in 2002. SETTING: Minnesota and Wisconsin. PARTICIPANTS: Population-based sample of 1069 parents of adolescents aged 13 to 17 years with a working telephone number. An additional 1095 eligible parents declined and 360 were not available to participate. MAIN OUTCOME MEASURES: Views about PNLs ("Do you think a law requiring notification of parents when a teen requests birth control from a clinic is a good idea, a bad idea, or neither a good nor a bad idea?"). RESULTS: Of the eligible parents, 42.4% completed the survey. More than half (55.1%) of participants thought PNLs were a good idea. However, 96.1% of parents expected at least 1 negative consequence and 47.6% expected 5 or more negative consequences to result with the enactment of PNLs. For exceptions to PNLs, 85.5% of parents endorsed at least 1, and 29.7% endorsed 5 to 6. Each additional anticipated positive consequence of enacting PNLs was significantly associated with more than twice the odds of favoring PNLs (odds ratio [OR], 2.28), and each additional negative consequence was associated with lower odds of supporting PNLs (OR, 0.87). Likewise, each additional exception endorsed was associated with lower odds of supporting PNLs (OR, 0.71). CONCLUSIONS: Many parents hold complex views on the need for confidentiality and the appropriate involvement of parents in adolescent health care services. Educating parents about the potential negative consequences of parental notification could change their support of PNLs.

Predicting adolescents' longitudinal risk for sexually transmitted infection: results from the National Longitudinal Study of Adolescent Health.

BACKGROUND: Influencing adolescents' sexual behaviors has the potential to influence trajectories of risk for sexually transmitted infections (STIs) among young adults. OBJECTIVE: To determine whether family, school, and individual factors associated with increased duration of virginity also protect against STIs in young adulthood. DESIGN: Prospective cohort study. Wave I of the National Longitudinal Study of Adolescent Health occurred in 1995 when participants were in grades 7 through 12. Six years later, all wave I participants who could be located were invited to participate in wave III and provide a urine specimen for STI testing. SETTING: In-home interviews in the continental United States, Alaska, and Hawaii. PARTICIPANTS: Population-based sample. Of 18,924 participants in the nationally representative weighted wave I sample, 14,322 (75.7%) were located and participated in wave III. Test results for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis were available for 11,594 (81.0%) of wave III participants. MAIN OUTCOME MEASURE: Positive test result for C. trachomatis, N. gonorrhoeae, or T. vaginalis. RESULTS: Controlling for biological sex, age, race/ethnicity, family structure, and maternal education, adolescents who perceived that their parents more strongly disapproved of their having sex during adolescence were less likely to have STIs 6 years later (adjusted odds ratio, 0.89; 95% confidence interval, 0.81-0.99). Those with a higher grade point average during adolescence were also less likely to acquire STIs (adjusted odds ratio, 0.84; 95% confidence interval, 0.71-0.99). Stratified analyses confirmed these findings among female, but not male, adolescents. Feelings of connection to family or school, reported importance of religion, attending a parochial school, and pledges of virginity during adolescence did not predict STI status 6 years later. CONCLUSIONS: Perceived parental disapproval of sexual intercourse and higher grades in school during adolescence have protective influences on the trajectory of risk for acquiring STIs, primarily among female adolescents. Most factors associated with increased duration of virginity in adolescence do not influence the trajectory of STI risk.

Correlations between family meals and psychosocial well-being among adolescents.

OBJECTIVE: To determine the association between frequency of family meals and multiple indicators of adolescent health and well-being (tobacco, alcohol, and marijuana use; academic performance; self-esteem; depressive symptoms; and suicide involvement) after controlling for family connectedness. METHODS: Data come from a 1998-1999 school-based survey of 4746 adolescents from ethnically and socioeconomically diverse communities in the Minneapolis/St Paul, Minn, metropolitan area. Logistic regression, controlling for family connectedness and sociodemographic variables, was used to identify relationships between family meals and adolescent health behaviors. RESULTS: Approximately one quarter (26.8%) of respondents ate 7 or more family meals in the past week, and approximately one quarter (23.1%) ate family meals 2 times or less. Frequency of family meals was inversely associated with tobacco, alcohol, and marijuana use; low grade point average; depressive symptoms; and suicide involvement after controlling for family connectedness (odds ratios, 0.76-0.93). CONCLUSIONS: Findings suggest that eating family meals may enhance the health and well-being of adolescents. Public education on the benefits of family mealtime is recommended.

Parents' beliefs about condoms and oral contraceptives: are they medically accurate?

CONTEXT: Parents are encouraged to be the primary sex educators for their children; however, little is known about the accuracy of parents' views about condoms and oral contraceptives. METHODS: Telephone surveys using validated measures provided data on beliefs about the effectiveness, safety and usability of condoms and the pill among 1,069 parents of 13-17-year-olds in Minnesota and Wisconsin in 2002. Pearson chi-square tests and multivariate logistic regression models were used to compare beliefs according to sex, age, race, religion, education, income and political orientation. RESULTS: Substantial proportions of parents underestimated the effectiveness of condoms for preventing pregnancy and sexually transmitted diseases (STDs). Only 47% believed that condoms are very effective for STD prevention, and 40% for pregnancy prevention. Fifty-two percent thought that pill use prevents pregnancy almost all the time; 39% thought that the pill is very safe. Approximately one-quarter of parents thought that most teenagers are capable of using condoms correctly; almost four in 10 thought that most teenagers can use the pill correctly. Fathers tended to have more accurate views about condoms than mothers did; mothers' views of the pill were generally more accurate than fathers'. Whites were more likely than nonwhites to hold accurate beliefs about the pill's safety and effectiveness; conservatives were less likely than liberals to hold accurate views about the effectiveness of condoms. CONCLUSION: Campaigns encouraging parents to talk with their teenagers about sexuality should provide parents with medically accurate information on the effectiveness, safety and usability of condoms and the pill.

Prime Time: long-term sexual health outcomes of a clinic-linked intervention.

CONTEXT: Evidence about long-term effects of preventive health services for youth with complex needs is lacking. Prime Time, a youth development intervention, aims to reduce pregnancy risk among vulnerable adolescent females seeking clinic services. METHODS: In a randomized trial, 253 sexually active females aged 13-17 who were at high risk for pregnancy were assigned to the Prime Time intervention or usual clinic services. The 18-month intervention, initiated in 2007-2008, comprised regular meetings with case managers and participation in youth leadership groups. Trial participants completed surveys at baseline and 30 months. Regression analyses were used to evaluate differences between groups in sexual and psychosocial outcomes at follow-up. RESULTS: At 30 months, the intervention group reported more months of consistent condom use (adjusted means, 1.8 vs. 1.1) and dual contraceptive use (0.9 vs. 0.3) in the past seven months than did controls. The intervention was most effective in promoting consistent use among participants with relatively high levels of connectedness to family or school. Fifteen percent of intervention participants, but only 6% of controls, reported having abstained from sex in the past six months (adjusted odds ratio, 2.9). Moreover, among high school graduates, those in the intervention group were more likely than those in the control group to have enrolled in college or technical school (72% vs. 37%; odds ratio, 4.5). CONCLUSION: Health services grounded in a youth development framework can lead to reductions in sexual risk among vulnerable youth that are evident one year following conclusion of services.

Life experiences of instability and sexual risk behaviors among high-risk adolescent females.

CONTEXT: Understanding the interplay of multiple contexts of adolescents' sexual risk behaviors is essential to helping them avoid pregnancy and STDs. Although a body of research has identified multiple individual- and family-level variables associated with adolescents' sexual risk behaviors, relatively few studies have examined relationships between these behaviors and latent indicators of unstable, chaotic environments. METHODS: In 2007-2008, a sample of 241 sexually active adolescent females who were at high risk for pregnancy and STDs were recruited through two school-based clinics and two community clinics in Minneapolis and St. Paul. Confirmatory factor analysis was used with baseline data to specify latent constructs of individual risk and family disengagement. Structural equation models examined longitudinal relationships between baseline measures of these constructs and sexual risk behaviors assessed six months later. RESULTS: The latent construct of individual risk encompassed substance use, violence perpetration, violence victimization and having witnessed violence; that of family disengagement included family disconnection, poor family communication and perceived lack of safety at home. Baseline level of individual risk was positively associated with number of male sex partners six months later (path coefficient, 0.2); it was not associated with consistent condom use at follow-up. Level of family disengagement was negatively associated with condom use consistency six months later (-0.3), but was not associated with number of male sex partners. CONCLUSIONS: To meet the health needs of vulnerable adolescents, health systems should incorporate coordinated and interdisciplinary services that acknowledge adolescents' relevant familial and social contexts.

Correlates of emotional distress in out-of-home youth.

PROBLEM: Adolescents in out-of-home placement have a high prevalence of mental health distress, and their vulnerability to poor mental health outcomes continues during placement. Risk and protective factors may influence mental health outcomes; however, little is known about their relationship to mental health distress in this population. METHODS: Using data from a population-based survey conducted in schools, mental health distress, along with other risk and protective factors, was evaluated in young people who reported living in out-of-home placements (n = 5,516) and a comparison group (n = 5,500). Multivariate analysis was used to determine the strength of association between risk and protective factors and mental health distress in the youth reporting out-of-home placement. FINDINGS: Comparisons of risk and protective factors indicated that out-of-home youth had greater risks (suicidal risk, mental health distress) and fewer protective factors (feeling parents care about them, other adults care, and school connectedness) than those in the comparison group. Multivariate analyses showed significant associations (38% explained variance) between mental health distress and the risk and protective factors, with the exception of other adult connectedness. CONCLUSIONS: Findings from this population-based school survey of young people reiterate that youth in out-of-home placements have higher levels of mental health distress and lower levels of protective factors compared to other youth. These results offer insights for those working with out-of-home or precariously housed young people.

Prime time: sexual health outcomes at 24 months for a clinic-linked intervention to prevent pregnancy risk behaviors.

IMPORTANCE: Preventing early pregnancy among vulnerable adolescents requires innovative and sustained approaches. Prime Time, a youth development intervention, aims to reduce pregnancy risk among adolescent girls seeking clinic services who are at high risk for pregnancy. OBJECTIVE: To evaluate sexual risk behaviors and related outcomes with a 24-month postbaseline survey, 6 months after the conclusion of the Prime Time intervention. DESIGN: Randomized controlled trial. SETTING: Community and school-based primary care clinics. PARTICIPANTS: Of 253 sexually active 13- to 17-year-old girls meeting specified risk criteria, 236 (93.3%) completed the 24-month follow-up survey. INTERVENTION: Offered during an 18-month period, Prime Time includes case management and youth leadership programs. MAIN OUTCOME MEASURES: Self-reported consistency of condom, hormonal, and dual-method contraceptive use with most recent male sex partner and number of male sex partners in the past 6 months. RESULTS: At 24-month follow-up, the intervention group reported significantly more consistent use of condoms, hormonal contraception, and dual-method contraception than the control group. Intervention participants also reported improvements in family connectedness and self-efficacy to refuse unwanted sex, and reductions in the perceived importance of having sex. No between-group differences were found in the number of recent male sex partners. CONCLUSIONS AND RELEVANCE: This study contributes to what has been a dearth of evidence regarding youth development interventions offered through clinic settings, where access to high-risk adolescents is plentiful but few efforts have emphasized a dual approach of strengthening sexual and nonsexual protective factors while addressing risk. Findings suggest that health services grounded in a youth development framework can lead to long-term reductions in sexual risk among vulnerable youth.