Utilization of online systems to promote youth participation in research: A methodological study.

BACKGROUND: Online surveys can align with youth's increased use of the internet and can be a mechanism for expanding youth participation in research. This is particularly important during the coronavirus disease 2019 (COVID-19) pandemic, when in-person interactions are limited. However, the advantages and drawbacks of online systems used for research need to be carefully considered before utilizing such methodologies. AIM: To describe and discuss the strengths and limitations of an online system developed to recruit adolescent girls for a sexual health research study and conduct a three-month follow up survey. METHODS: This methodology paper examines the use of an online system to recruit and follow participants three months after their medical visit to evaluate a mobile sexual and reproductive health application, Health-E You/Salud iTuTM, for adolescent girls attending school-based health centers (SBHCs) across the United States. SBHC staff gave adolescent girls a web link to an online eligibility and consent survey. Participants were then asked to complete two online surveys (baseline and 3-month follow-up). Surveys, reminders, and incentives to complete them were distributed through short message service (SMS) text messages. Upon completing each survey, participants were also sent an email with a link to an electronic gift card as a thank-you for their participation. Barriers to implementing this system were discussed with clinicians and staff at each participating SBHC. RESULTS: This online recruitment and retention system enabled participant recruitment at 26 different SBHCs in seven states across the United States. Between September 2021 and June 2022, 415 adolescent girls were screened using the Qualtrics online survey platform, and 182 were eligible to participate. Of those eligible, 78.0% (n = 142) completed the baseline survey. Participants were racially, geographically, and linguistically diverse. Most of the participants (89.4%) were non-White, and 40.8% spoke Spanish. A total of 62.0% (n = 88) completed the 3-month follow-up survey. Limitations of this system included reliance on internet access (via Wi-Fi or cell service), which was not universally available or reliable. In addition, an individual unrelated to the study obtained the survey link, filled out multiple surveys, and received multiple gift cards before the research team discovered and stopped this activity. As a result, additional security protocols were instituted. CONCLUSION: Online systems for health research can increase the reach and diversity of study participants, reduce costs for research personnel time and travel, allow for continued study operation when in-person visits are limited (such as during the COVID-19 pandemic), and connect youth with research using technology. However, there are challenges and limitations to online systems, which include limited internet access, intermittent internet connection, data security concerns, and the potential for fraudulent users. These challenges should be considered prior to using online systems for research.

Supporting Adolescent Engagement with Artificial Intelligence-Driven Digital Health Behavior Change Interventions.

Understanding and optimizing adolescent-specific engagement with behavior change interventions will open doors for providers to promote healthy changes in an age group that is simultaneously difficult to engage and especially important to affect. For digital interventions, there is untapped potential in combining the vastness of process-level data with the analytical power of artificial intelligence (AI) to understand not only how adolescents engage but also how to improve upon interventions with the goal of increasing engagement and, ultimately, efficacy. Rooted in the example of the INSPIRE narrative-centered digital health behavior change intervention (DHBCI) for adolescent risky behaviors around alcohol use, we propose a framework for harnessing AI to accomplish 4 goals that are pertinent to health care providers and software developers alike: measurement of adolescent engagement, modeling of adolescent engagement, optimization of current interventions, and generation of novel interventions. Operationalization of this framework with youths must be situated in the ethical use of this technology, and we have outlined the potential pitfalls of AI with particular attention to privacy concerns for adolescents. Given how recently AI advances have opened up these possibilities in this field, the opportunities for further investigation are plenty.

Understanding Barriers to Timely Diagnosis and Intervention Among Immigrant Children With Hearing Loss.

OBJECTIVE: Identify the age at diagnosis and intervention of immigrant and/or non-English-speaking children with hearing loss (HL) and risk factors associated with delays. Identify barriers for non-English-speaking caregivers of deaf/hard-of-hearing children. STUDY DESIGN: Sequential mixed methods. SETTING: Tertiary care center in an urban city. METHODS: The analysis includes descriptive statistics, and 1-way and 2-way analysis of variance of the retrospective chart review. The quantitative study demonstrated foreign-born experienced disparities, so we conducted semistructured interviews on a subset of non-English-speaking families in the cohort that was then thematically analyzed using a human-centered design strategy. RESULTS: We divided 532 children into 3 groups: US-born with English as the preferred language (N = 294), US-born and non-English language preferred (N = 173), and foreign-born (N = 67). The laterality of HL and pure-tone averages were similar among the groups (p = .972 and .071, respectively). Age at diagnosis and time to the intervention were significantly different (39.7, 31.5, 75.8 months, p < .001 and 24.6, 29.2, 48.9 months, p = .001, respectively). Ages at diagnosis and intervention were associated with birthplace (p = .005, p = .0005, respectively) but not preferred language (p = .667, p = .343, respectively). Included in the qualitative interviews were Mandarin- (n = 5), Arabic- (n = 4), and Spanish-speaking families (n = 3). Insights revealed participants' quest for anticipatory guidance and social support, the consequences of cultural stigma, and the complexity of caring for a child with HL in an immigrant family. CONCLUSION: Foreign-born children with HL have significant delays in diagnosis and intervention compared to US-born children. For non-English-speaking parents, the diagnosis of HL presents challenges beyond that of the immigrant experience.

Understanding the Psychological Impacts of Teenage Pregnancy through a Socio-ecological Framework and Life Course Approach.

The relationship between mental health and teenage pregnancy is complex. Mental health can be both an antecedent and contributing factor to teenage pregnancy and a concurrent factor wherein pregnancy itself can contribute to depression. Expectant and parenting teens (EPT) are faced with the simultaneous challenges of pregnancy and parenting while navigating the developmental tasks of adolescence which increases their risk for mental health problems. In addition, adolescents growing up in stressful community or home situations where their parents experienced depression, further places them and their children at greater risk of repeated patterns over time. However, adverse mental health outcomes are not inevitable. The socio-ecological model combined with a life course perspective provides a framework for understanding the complexity of risk and protective factors at multiple levels that influence knowledge, attitudes, behaviors, and other health outcomes later in life and across generations. This approach has important implications for reducing adolescents' risk of an unintended/mistimed pregnancy and improving mental health and other outcomes for EPT. This paper describes the prevalence of mental health problems in EPT and using a socio-ecological framework and life course perspective explains variations in mental health outcome among EPT. Implications for interventions and innovative approaches are also discussed.

Promoting teen-to-teen contraceptive communication with the SpeakOut intervention, a cluster randomized trial.

OBJECTIVES: To improve teen contraceptive use, the SpeakOut intervention combines structured counseling, online resources, and text reminders to encourage teens to share their experiences using intrauterine contraception (IUC) or an implant with peers. STUDY DESIGN: To evaluate the effectiveness of remote delivery of the SpeakOut intervention in increasing teen contraceptive use, we conducted a cluster randomized trial involving female adolescents who were recruited online. Primary participants (n = 520) were randomly assigned to receive SpeakOut or an attention control; each primary participant recruited a cluster of up to 5 female peers as secondary participants (n = 581). We assessed contraceptive communication, knowledge, and use, at baseline, 3 and 9 months after participants enrolled. We examined differences between study groups, controlling for clustering by primary participant and baseline characteristics. RESULTS: The trial's primary outcome, contraceptive use by secondary participants, was similar between groups at both 3 and 9 months postintervention. Compared to controls, primary participants receiving SpeakOut tended to be less likely to discontinue contraception within 9 months (4.8% vs 7.8%, p = 0.11 for IUC; 7.8% vs 9.8%, p = 0.45 for implants), but this did not reach statistical significance. SpeakOut failed to increase contraceptive communication; regardless of study group, most secondary participants reported peer communication about contraception (86% vs 88%, p = 0.57). Most secondary participants were aware of the hormonal IUC (91.4% vs 90.4%, p = 0.72), copper IUC (92.9% vs 88.6%, p = 0.13), and implant (96.5% vs 96.1%, p = 0.83) 3 months after enrolling, regardless of the intervention their primary participant received. However, contraceptive knowledge remained incomplete in all study groups. CONCLUSION: Remote delivery of the SpeakOutintervention did not improve contraceptive communication, knowledge or use among participating teens or their peers. IMPLICATIONS: Efforts to support teen-to-teen contraceptive communication and ensure that teens have accurate information about the full range of contraceptive methods, including highly effective reversible contraceptives, require refinement.

Improving contraceptive use among Latina adolescents: A cluster-randomized controlled trial evaluating an mHealth application, Health-E You/Salud iTu.

OBJECTIVE: To evaluate the effectiveness of Health-E You/Salud iTu, a mobile health application (app), on increasing knowledge, self-efficacy and contraception use among Latina adolescents, its impact on visit quality, and app satisfaction. STUDY DESIGN: This study used cluster-randomized controlled trial (CRCT) of 18 school-based health centers (SBHCs). Prior to the visit, intervention participants received the patient-centered contraceptive decision-making support app and controls answered sexual health questions on iPads. Participants completed a previsit questionnaire and 3 follow-up surveys (48 hours, 3-, and 6-months) after the recruitment visit (where intervention participants completed the app). Differences in adolescents' contraceptive knowledge, self-efficacy, and use over the 6-month follow-up were assessed by generalized mixed effects regression models. RESULTS: A total of 1,360 Latina adolescents participated; 57.2% responded to the 48-hour survey, 50.1% to the 3-month, 49.7% to the 6-month, and 42.3% to both the 3- and 6-month surveys. Health-E You users' demonstrated significant increases in pre-post knowledge (p < 0.001). Intervention participants who completed the follow-up survey reported greater increases in mean self-efficacy from baseline (23.2 intervention vs. 22.5 controls) to 6 months (26.1 vs. 23.4; b = 1.58, 95% CI 0.38-2.77, p = 0.01), and greater increases in non-barrier contraceptive use from baseline (29% intervention vs. 30% controls) to 3 months (63% vs. 45%; OR = 3.29, 95% CI 1.04-10.36, p = 0.04) and 6 months (63% vs. 44%; OR = 5.54, 95% CI 1.70-18.06, p = 0.005). Providers and adolescents reported high app satisfaction and stated it improved visit quality. CONCLUSIONS: While data suggest that Health-E You improved outcomes, findings must be interpreted cautiously. Intervention participants had higher baseline sexual activity rates, more recruitment visits for pregnancy testing, emergency contraception or birth control, and lower completion rates of follow-up surveys than controls. IMPLICATIONS: Despite declines in adolescent pregnancy in the United States, Latinas continue to have disproportionately high rates compared to white females. The Health-E You app may be an effective support tool for both adolescents and providers in SBHCs, and possibly other clinical settings, across the country to increase contraceptive use and thereby decrease unintended pregnancies. It could potentially reduce disparities in adolescent pregnancies and create more efficient visit time spent between clients and their providers.

Adapting to Changes in Teen Pregnancy Prevention Research: Social Media as an Expedited Recruitment Strategy.

PURPOSE: Teen pregnancy prevention projects funded by the U.S. Office of Adolescent Health were disrupted by the Trump administration in the July 2017 announcement that funding would be terminated. Although funding was later reinstated toward the end of 2018 after a class-action lawsuit, we needed to change our recruitment protocol to mitigate this disruption to the study timeline and staffing. This led to a natural experiment comparing in person and social media recruitment strategies. METHODS: The original approach was to recruit girls, aged 15-19 years, who were using intrauterine or subdermal contraception, in person in clinic settings. After the funding disruption, we transitioned to an online recruitment strategy. Costs associated with each approach (in-person and online recruitment) were tracked, and we compared cost of per-person enrollment with each approach. RESULTS: In-person, clinic-based recruitment enrolled 118 participants over 293 days from eight high-volume clinics. Online recruitment enrolled 518 participants over 146 days. Online recruitment resulted in cost savings and a diverse sample representing a larger geographic region. CONCLUSION: Online recruitment can cut costs and be more efficient than a clinic-based recruitment strategy, but special considerations are warranted when considering social media recruitment.

The Association Between Nonbarrier Contraceptive Use and Condom Use Among Sexually Active Latina Adolescents.

PURPOSE: This study aimed to determine the association between use of highly effective methods of nonbarrier contraception and condom use in a sample of Latina adolescents and whether the change to a more effective method of nonbarrier contraception is associated with a change in condom use. METHODS: As part of a larger study, 442 sexually active Latina adolescents aged 14-18 years were surveyed immediately before an appointment with a medical care provider at a school-based health center and 3 months later. Ordinal logistic and linear regression were used in the analysis of cross-sectional and longitudinal data to assess the relationship between patterns of nonbarrier contraception and condom use. RESULTS: The use of all types of nonbarrier methods of contraception was significantly associated with decreased condom use. Change over time from a less effective to a more effective nonbarrier method of contraception was also associated with a decrease in condom use. Greater number of sexual encounters was associated with lower the frequency of condom use. CONCLUSIONS: The use of highly effective methods of nonbarrier contraception was associated with reduced frequency of condom use. This highlights the need to promote condom use concurrently with nonbarrier methods of contraception to improve protection against both pregnancy and STIs.

Addressing Environmental Smoke Exposure During Pediatric Hospitalization: Attitudes and Practices of Pediatric Nurses Versus Respiratory Therapists.

BACKGROUND: Tobacco smoke exposure leads to numerous adverse health effects in children. Providing cessation interventions to caregivers who smoke during pediatric hospitalizations can help protect children from such exposure. Both pediatric registered nurses (RNs) and pediatric respiratory therapists (RTs) are well positioned to provide these interventions. Little is known about their rates of participation in cessation efforts. Our objective was to compare the attitudes and practice of pediatric RNs versus pediatric RTs to evaluate their relative cessation-intervention practices in the in-patient pediatric setting. METHODS: An online survey was sent to pediatric RNs and RTs at 4 tertiary pediatric hospitals in California. The survey assessed individual demographics, work environment, experience, beliefs, and practices related to smoking cessation activities. Questions used 3-point and 5-point Likert scales and were compared with the chi-square test. Institutions with a response rate < 20% were excluded. RESULTS: A total of 401 respondents were included in the final analysis (292 RNs, 109 RTs). RTs versus RNs were older (42.0 y vs 35.4 y, respectively, P < .001) and more likely to be former smokers (29.9% vs 13.3%, respectively, P < .001). RNs reported lower levels of confidence in discussing smoking cessation with parents, with 11.7% saying they felt "very confident" compared to 29.0% of RTs (P < .001). RNs also reported screening for smoke exposure less frequently than RTs, with 18.8% responding "often" or "always" compared to 28.9% of RTs (P = .033). RNs had lower rates of advising parents "to make a smoke-free home policy" compared to RTs (ie, 13.4% vs 26.9%, respectively, P = .002). CONCLUSIONS: Compared to in-patient pediatric RNs, RTs reported higher rates of confidence in providing cessation interventions, screening for smoke exposure, and counseling on reducing smoke exposure, suggesting that they may be better positioned for intervening. These results can inform the design of an in-patient cessation intervention for caregivers of hospitalized children.

Fostering Engagement in Health Behavior Change: Iterative Development of an Interactive Narrative Environment to Enhance Adolescent Preventive Health Services.

PURPOSE: Accidents and unintentional injuries account for the greatest number of adolescent deaths, often involving use of alcohol and other substances. This article describes the iterative design and development of Interactive Narrative System for Patient-Individualized Reflective Exploration (INSPIRE), a narrative-centered behavior change environment for adolescents focused on reducing alcohol use. INSPIRE is designed to serve as an extension to clinical preventive care, engaging adolescents in a theoretically grounded intervention for health behavior change by leveraging 3D game engine and interactive narrative technologies. METHODS: Adolescents were engaged in all aspects of the iterative, multiyear development process of INSPIRE through over 20 focus groups and iterative pilot testing involving more than 145 adolescents. Qualitative findings from focus groups are reported, as well as quantitative findings from small-scale pilot sessions investigating adolescent engagement with a prototype version of INSPIRE using a combination of questionnaire and interaction trace log data. RESULTS: Adolescents reported that they found INSPIRE to be engaging, believable, and relevant to their lives. The majority of participants indicated that the narrative's protagonist character was like them (84%) and that the narrative featured virtual characters that they could relate to (79%). In the interactive narrative, the goals most frequently chosen by adolescents were "stay in control" (60%) and "do not get in trouble" (55%). CONCLUSIONS: With a strong theoretical framework (social-cognitive behavior change theory) and technology advances (narrative-centered learning environments), the field is well positioned to design health behavior change systems that can realize significant impacts on behavior change for adolescent preventive health.

A Mobile Health Contraception Decision Support Intervention for Latina Adolescents: Implementation Evaluation for Use in School-Based Health Centers.

BACKGROUND: Health care providers are a trusted and accurate source of sexual health information for most adolescents, and clinical guidelines recommend that all youth receive comprehensive, confidential sexual health information and services. However, these guidelines are followed inconsistently. Providers often lack the time, comfort, and skills to provide patient-centered comprehensive contraceptive counseling and services. There are significant disparities in the provision of sexual health services for Latino adolescents, which contribute to disproportionately higher rates of teenage pregnancy. To address this, we developed Health-E You or Salud iTu in Spanish, an evidence-informed mobile health (mHealth) app, to provide interactive, individually tailored sexual health information and contraception decision support for English and Spanish speakers. It is designed to be used in conjunction with a clinical encounter to increase access to patient-centered contraceptive information and services for adolescents at risk of pregnancy. Based on user input, the app provides tailored contraceptive recommendations and asks the youth to indicate what methods they are most interested in. This information is shared with the provider before the in-person visit. The app is designed to prepare youth for the visit and acts as a clinician extender to support the delivery of health education and enhance the quality of patient-centered sexual health care. Despite the promise of this app, there is limited research on the integration of such interventions into clinical practice. OBJECTIVE: This study described efforts used to support the successful adoption and implementation of the Health-E You app in clinical settings and described facilitators and barriers encountered to inform future efforts aimed at integrating mHealth interventions into clinical settings. METHODS: This study was part of a larger, cluster randomized control trial to evaluate the effectiveness of Health-E You on its ability to reduce health disparities in contraceptive knowledge, access to contraceptive services, and unintended pregnancies among sexually active Latina adolescents at 18 school-based health centers (SBHCs) across Los Angeles County, California. App development and implementation were informed by the theory of diffusion of innovation, the Patient-Centered Outcomes Research Institute's principles of engagement, and iterative pilot testing with adolescents and clinicians. Implementation facilitators and barriers were identified through monthly conference calls, site visits, and quarterly in-person collaborative meetings. RESULTS: Implementation approaches enhanced the development, adoption, and integration of Health-E You into SBHCs. Implementation challenges were also identified to improve the integration of mHealth interventions into clinical settings. CONCLUSIONS: This study provides important insights that can inform and improve the implementation efforts for future mHealth interventions. In particular, an implementation approach founded in a strong theoretical framework and active engagement with patient and community partners can enhance the development, adoption, and integration of mHealth technologies into clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov NCT02847858; https://clinicaltrials.gov/ct2/show/NCT02847858 (Archived by WebCite at http://www.webcitation.org/761yVIRTp).

Innovative Approaches to Address Social Determinants of Health Among Adolescents and Young Adults.

Background: Social determinants are the leading causes of health disparities. Yet health care systems have not systemically addressed social determinants of health as it pertains to adolescents and young adults (AYAs), among other populations in need. This study identified promising innovative programs across the United States. Methods: Thirteen representatives from 10 programs completed a 45-min telephone interview. Transcripts were reviewed and analyzed to identify cross-cutting themes. Results: Strategies included increasing access to quality, comprehensive and confidential health services, addressing the holistic needs of AYAs, collaborations across the health care delivery systems and other community services, and leveraging technology. Conclusion: This study showcased innovative approaches to inform future efforts.

Assessing the effectiveness of a patient-centred computer-based clinic intervention, Health-E You/Salud iTu, to reduce health disparities in unintended pregnancies among Hispanic adolescents: study protocol for a cluster randomised control trial.

INTRODUCTION: Teen pregnancy rates in the USA remain higher than any other industrialised nation, and pregnancies among Hispanic adolescents are disproportionately high. Computer-based interventions represent a promising approach to address sexual health and contraceptive use disparities. Preliminary findings have demonstrated that the Health-E You/Salud iTu, computer application (app) is feasible to implement, acceptable to Latina adolescents and improves sexual health knowledge and interest in selecting an effective contraceptive method when used in conjunction with a healthcare visit. The app is now ready for efficacy testing. The purpose of this manuscript is to describe patient-centred approaches used both in developing and testing the Health-E You app and to present the research methods used to evaluate its effectiveness in improving intentions to use an effective method of contraception as well as actual contraceptive use. METHODS AND ANALYSIS: This study is designed to assess the effectiveness of a patient-centred computer-based clinic intervention, Health-E You/Salud iTu, on its ability to reduce health disparities in unintended pregnancies among Latina adolescent girls. This study uses a cluster randomised control trial design in which 18 school-based health centers from the Los Angeles Unified School District were randomly assigned, at equal chance, to either the intervention (Health-E You app) or control group. Analyses will examine differences between the control and intervention group's knowledge of and attitudes towards contraceptive use, receipt of contraception at the clinic visit and self-reported use of contraception at 3-month and 6-month follow-ups. The study began enrolling participants in August 2016, and a total of 1400 participants (700 per treatment group) are expected to be enrolled by March 2018. ETHICS AND DISSEMINATION: Ethics approval was obtained through the University of California, San Francisco Institutional Review Board. Results of this trial will be submitted for publication in peer-reviewed journals. This study is registered with the US National Institutes of Health. TRIAL REGISTRATION NUMBER: NCT02847858.

Effect of an iPad-Based Intervention to Improve Sexual Health Knowledge and Intentions for Contraceptive Use Among Adolescent Females at School-Based Health Centers.

OBJECTIVES: The use of effective contraception can decrease the incidence of unplanned pregnancy among adolescents. This study aims to examine the effectiveness of an iPad-based application (app) on improving adolescent girls' sexual health knowledge and on its ability to influence their intentions to use effective contraception. STUDY DESIGN: This was a prospective study of girls aged 12 to 18 years recruited from 3 school-based health centers in California. RESULTS: A total of 120 racially/ethnically diverse participants used the iPad app; 54% were sexually active, with only 26% using effective contraception at baseline. The average score on baseline sexual health knowledge assessment was 58%. After using the app, 68% of the sexually active participants reported intention to use effective contraception in the future, and sexual health knowledge improved significantly to 79% ( P < .001). CONCLUSIONS: This iPad-based app is a promising intervention to educate adolescents about sexual health and support them in selecting an effective contraception method.

Use of theory in computer-based interventions to reduce alcohol use among adolescents and young adults: a systematic review.

BACKGROUND: Alcohol use and binge drinking among adolescents and young adults remain frequent causes of preventable injuries, disease, and death, and there has been growing attention to computer-based modes of intervention delivery to prevent/reduce alcohol use. Research suggests that health interventions grounded in established theory are more effective than those with no theoretical basis. The goal of this study was to conduct a literature review of computer-based interventions (CBIs) designed to address alcohol use among adolescents and young adults (aged 12-21 years) and examine the extent to which CBIs use theories of behavior change in their development and evaluations. This study also provides an update on extant CBIs addressing alcohol use among youth and their effectiveness. METHODS: Between November and December of 2014, a literature review of CBIs aimed at preventing or reducing alcohol in PsychINFO, PubMed, and Google Scholar was conducted. The use of theory in each CBI was examined using a modified version of the classification system developed by Painter et al. (Ann Behav Med 35:358-362, 2008). RESULTS: The search yielded 600 unique articles, 500 were excluded because they did not meet the inclusion criteria. The 100 remaining articles were retained for analyses. Many articles were written about a single intervention; thus, the search revealed a total of 42 unique CBIs. In examining the use of theory, 22 CBIs (52 %) explicitly named one or more theoretical frameworks. Primary theories mentioned were social cognitive theory, transtheoretical model, theory of planned behavior and reasoned action, and health belief model. Less than half (48 %), did not use theory, but mentioned either use of a theoretical construct (such as self-efficacy) or an intervention technique (e.g., manipulating social norms). Only a few articles provided detailed information about how the theory was applied to the CBI; the vast majority included little to no information. CONCLUSIONS: Given the importance of theory in guiding interventions, greater emphasis on the selection and application of theory is needed. The classification system used in this review offers a guiding framework for reporting how theory based principles can be applied to computer based interventions.

Opportunities and Challenges for Adolescent Health Under the Affordable Care Act.

The purpose of this commentary is to highlight some of the key policy changes under the Patient Protection and Affordable Care Act (ACA) that have the potential to improve health care services for adolescents as well as to draw attention to challenges that have yet to be addressed. This commentary stems from our prior policy research, which examined the extent to which the health care needs of adolescents were being considered in the early implementation phases of the ACA. This study was informed by a literature review and interviews with health care administrators, health policy researchers, and adolescent medicine specialists. The ACA has significantly expanded health insurance access; however, inequities in coverage and access remain. Primarily, the structure and financing of adolescent health care needs to be improved to better support the delivery of patient-centered, comprehensive care for this special population. Additionally, improvements in youths' awareness of their benefits under the ACA as well as a greater appreciation of preventive visits are critical. Furthermore, an unanticipated consequence of the ACA is that it exacerbates the risk of confidentiality breaches through explanation of benefits and electronic health records, which can compromise adolescents' access and utilization of health care services. Greater attention to improving and sustaining health promoting behaviors within the context of the ACA is critical for it to truly have a positive impact on adolescent health.

Options for assuring access to confidential care for adolescents and young adults in an explanation of benefits environment.

The Affordable Care Act (ACA) has expanded the enrollment of young people in insurance plans and aims to increase access to preventive health services. For adolescents and young adults to fully utilize these services, access to confidential care is critical, especially for sensitive services, like sexual and reproductive health care. With this expansion, the ACA inadvertently exposes more individuals (especially those with private insurance) to confidentiality breaches through routine communications in the form of Explanation of Benefits (EOBs) sent to policyholders (typically the parent). This commentary is based on a qualitative study of individual, semi-structured telephone interviews with 31 health care administrators, policy experts, clinicians, and health plan representatives. The study identified and examined five main policy options aimed at reconciling confidentiality protections and EOBs. While no one solution emerged, approaches that incorporate automatic system changes that do not require action from the patient or provider for protections to take effect were considered most effective for protecting confidentiality. The review of these policy options are designed to inform states and health care advocates confronting this issue. In addition, since many of these approaches are new, a better understanding of how they are operationalized and enforced is necessary to truly evaluate their effectiveness.

Mothers' attitudes toward adolescent confidential services: development and validation of scales for use in English- and Spanish-speaking populations.

PURPOSE: To explore parental beliefs and attitudes about confidential services for their teenagers; and to develop an instrument to assess these beliefs and attitudes that could be used among English and Spanish speakers. The long-term goal is to use this research to better understand and evaluate interventions to improve parental knowledge and attitudes toward their adolescent's access and utilization of comprehensive confidential health services. METHODS: The instrument was developed using an extensive literature review and theoretical framework followed by qualitative data from focus groups and in-depth interviews. It was then pilot tested with a random sample of English- and Spanish-speaking parents and further revised. The final instrument was administered to a random sample of 1,000 mothers. The psychometric properties of the instrument were assessed for Spanish and English speakers. RESULTS: The instrument consisted of 12 scales. Most Cronbach alphas were >.70 for Spanish and English speakers. Fewer items for Spanish speakers "loaded" for the Responsibility and Communication scales. Parental Control of Health Information failed for Spanish speakers. CONCLUSIONS: The Parental Attitudes of Adolescent Confidential Health Services Questionnaire (PAACS-Q) contains 12 scales and is a valid and reliable instrument to assess parental knowledge and attitudes toward confidential health services for adolescents among English speakers and all but one scale was applicable for Spanish speakers. More research is needed to understand key constructs with Spanish speakers.

Parental acceptability of contraceptive methods offered to their teen during a confidential health care visit.

PURPOSE: To examine parental acceptability of contraceptive methods offered confidentially to their adolescent daughter. METHODS: A random sample of 261 parents/guardians with a daughter aged 12-17 years completed a telephone survey examining the relationship between parental acceptability of seven contraceptive methods and adolescents' likelihood to have sex, parenting beliefs, parents' sexual health as teens, sexually transmitted infection knowledge, and demographic factors. RESULTS: Acceptability was highest for oral contraceptive pills (59%) and lowest for intrauterine device (18%). Parental acceptance of teens' autonomy was significantly associated with increased acceptability of all methods. Parental knowledge of sexually transmitted infections was poor, and 51% found it acceptable for clinicians to provide their sexually active teen with condoms. CONCLUSIONS: Parents were more accepting of oral contraceptive pills and condoms compared with intrauterine devices and implants. Parental recognition of their teen's autonomy was associated with greater parental acceptability of clinicians providing their adolescent with contraceptives (regardless of the specific type of method being offered).