Exploring the Connectivity Paradox: How the Sociophysical Environment of Telehealth Shapes Adolescent Patients' and Parents' Perceptions of the Patient-Clinician Relationship.

Even before the widespread transition to telehealth as a result of COVID-19, there was a considerable amount of research exploring its value and impact. However, telehealth research with adolescent patients is somewhat limited, with most work focusing on access, feasibility, and acceptability but reporting far less frequently on relationship building and rapport. This study examines qualitative interviews with adolescent patients (n = 14) and parents (n = 20) from a larger convergent parallel mixed methods study to explore how they understand telehealth to have altered the sociophysical environment of primary care clinic encounters and whether they perceive these changes to influence adolescents' relationships with clinicians. We show that participants perceived the sociophysical environment of telehealth to be both less institutional (e.g. more relaxed and less rushed) and more instrumental (e.g. more focused on the chief complaint), which shaped interactions with clinicians in ways that were experienced as paradoxically less personal (e.g. lacking social connection) and more person-centered (e.g. more attentive to the individual patient). We discuss theoretical and practical implications of these findings and what they mean for defining person-centered communication for adolescent care.

Exploring the Complexity of Telehealth Privacy Through a Lens of Adolescent Development.

Many challenges exist related to ensuring adolescent privacy with health care providers (HCPs), and the rapid integration of telehealth visits has created additional complexities in organizing privacy for adolescents. Through interviews with adolescent patients and their parents (n = 34), this qualitative analysis aimed to explore the complicated relationship and balance of adolescent alone time with HCPs, parental presence and support, and organization of privacy in order to consider how privacy during telehealth visits may contribute to adolescents' healthy development. A framework by Blum et al. (2014) proposed four central goals of adolescent development: emotional security, engagement with learning, self-efficacy, and decision-making skills. This conceptual framework was used to outline the ways in which adolescent privacy during telehealth impacts adolescent development. Some adolescents reported that having their parents present during their telehealth visit afforded reassurance and comfort, and many parents explained that they served as a role-model during their adolescent's telehealth visit. However, other adolescents felt higher emotional security when they could establish an independent relationship with their HCP, with many describing how privacy during their telehealth visit enabled them to have more sensitive discussions with their HCP. Adolescents and parents also reported that telehealth allowed increased experiential learning for adolescents, given their proficiency with technology and ability to access their health care visits autonomously. Furthermore, the organization of privacy was complicated by a lack of understanding whose responsibility it was to facilitate alone time between the adolescent and HCP, as well as external factors such as location and quality of technology and the proximity of family members in the home. By ensuring opportunities for private healthcare encounters, both in telehealth and in-person visits, HCPs and parents can help support adolescents in achieving successful and healthy development.

Increased Detection of Gonorrhea and Chlamydia After Implementation of a Universal Screening Protocol in a Pediatric Primary Care Clinic.

BACKGROUND: Literature suggests that adolescents may not accurately report sexual activity to their providers, impeding risk-based screening efforts for gonorrhea and chlamydia (GC/CT). We assessed the effect of a clinic-based universal GC/CT screening initiative on GC/CT screening frequency and detection of GC/CT infections among adolescents (boys and girls ≥13 years) and the association between positive GC/CT and documented sexual activity. METHODS: We conducted a pre-post analysis of a primary care clinic affiliated with an academic institution. The electronic medical record was queried to extract all adolescent well and acute encounters for the 12 months preimplementation and postimplementation of universal GC/CT screening in January 2015. RESULTS: Eight hundred fifty-six encounters from 752 unique adolescents were included. Screening increased postimplementation (23.3% vs 61.4%, P < 0.001) of universal screening. Although there were similar rates of documented sexual activity preimplementation and postimplementation (14.6% vs 16.0%), a larger proportion of unknown sexual activity was documented (10.5% vs 23.7%, P < 0.001). Provider-level factors were the most frequent reasons for not screening. The absolute number of GC/CT cases increased, although the proportion of cases out of all eligible adolescents remained similar as more testing was completed (chlamydia, 5 of 752 vs 12 of 752; P = 0.09; gonorrhea, 0 of 752 vs 1 of 752; P = 0.32). Nearly half of positive chlamydia infections postimplementation appeared in adolescents who reported no sexual activity. CONCLUSIONS: Universal screening in a primary care clinic increased screening and detection of cases of gonorrhea and chlamydia, including in adolescents who did not report sexual activity.

Community-based interventions for improving maternal health and for reducing maternal health inequalities in high-income countries: a systematic map of research.

BACKGROUND: This review is part of a European Commission project, MASCOT, aimed at reducing maternal and child health inequalities. The purpose was to identify and describe the literature on community-based interventions on maternal health in high-income countries (HIC) and conceptually map the literature according to country focus, topics addressed, nature of the intervention and the intervention provider, and interventions designed to address inequalities in maternal health. METHODS: The research protocol for this review was based on a low-income country (LMIC) systematic review protocol within the MASCOT Project. We searched PubMED and CINAHL databases for literature published between January 2000 and April 2013. OECD countries were used to determine the HIC and different terms were used to refer to community based interventions, defined as those "delivered in community settings or any activities occurring outside of health facilities". RESULTS: 119 publications were selected for inclusion in this mapping study. 95 (80%) were Randomised Control Trials (RCTs) and 24 (20%) were systematic reviews (SRs). We categorised the study topics according to the main interventions covered: breastfeeding assistance and promotion, preventing and treating post-natal depression, interventions to support and build capacity around parenting and child care, antenatal interventions preparing women for birth, postnatal planning of future births and control trials around changing maternal behaviours. The home was used as the most common setting to implement these interventions and health professionals accounted for the largest group of intervention providers. CONCLUSIONS: This review maps and brings knowledge on the type of studies and topics being addressed in community based interventions around maternal health in HICs. It opens the opportunity for further studies on interventions' effectiveness and knowledge transfer to LMICs settings.

Increasing access to LARC removal in pediatrics to support adolescent reproductive justice in the United States.

BACKGROUND: In the United States (U.S.), adolescents and young adults are increasingly using contraception, including long-acting reversible contraception (LARC) [e.g., subdermal implants (e.g., Nexplanon®) and intrauterine devices (IUDs)]; however, access to LARC device removal may be difficult for adolescents and young adults. Reproductive justice is the right to bodily autonomy, have children, not have children, and safely parent the children we have. METHODS: In this commentary, we discuss that while the specialties of family medicine and obstetrics and gynecology have incorporated the principles of reproductive justice into their contraceptive care, further work is needed to ingrain this philosophy into pediatrics training. Since LARC devices are historically only removable by health care providers, pediatricians may act as gatekeepers to removing LARC, obstructing the reproductive justice of adolescents and young adults. RESULTS: We describe that adolescents and young adults in the U.S. face unique barriers to LARC removal including limited access to the health care system, potential breaches in confidentiality, and provider bias. These barriers may lead adolescents and young adults to remove their own LARC device when experiencing unwanted side effects or desiring pregnancy. While IUD self-removal is a safe and accessible option, safety and efficacy data on subdermal implant self-removal is currently limited. CONCLUSION: In order to promote reproductive justice in adolescents and young adults, we recommend that (1) pediatricians should address potential barriers to LARC removal prior to insertion, (2) pediatricians must offer unbiased LARC removal, (3) pediatricians who place LARC must be knowledgeable about complicated LARC removal, and (4) pediatricians should discuss LARC self-removal options with adolescents and young adults.

Trends in Continuation of Long-Acting Reversible Contraception Among Adolescents Receiving Medicaid.

PURPOSE: Despite increasing use of long-acting reversible contraception (LARC) among U.S. adolescents, there is limited literature on factors affecting intrauterine device (IUD) or subdermal implant use. This study aimed to describe statewide rates, and associated patient and provider factors of adolescent IUD or implant initiation and continuation. METHODS: This retrospective cohort study used N.C. Medicaid claims data. 10,408 adolescents were eligible (i.e., 13-19 years, female sex, continuous Medicaid enrollment, had an IUD or implant insertion or removal code from January 1, 2013, to October 1, 2015). Bivariate analyses assessed differences in adolescents using IUD versus implant. Kaplan-Meier curves were created to assess IUD or implant discontinuation through December 31, 2018. RESULTS: Adolescents initiated 8,592 implants and 3,369 IUDs (N = 11,961). There were significant differences in nearly all provider and patient factors for those who initiated implants versus IUDs. 16% of implants and 53% of IUDs were removed in the first year. Younger (i.e., age <18 years old), Hispanic, and Black adolescents had higher adjusted continuation of implants compared with older and White adolescents, respectively (both p < .001). Those whose IUD was inserted by an obstetrician/gynecologist provider had lower continuation of IUDs compared with non-obstetrician/gynecologist providers (p < .001). DISCUSSION: We found that age-related, racial, and ethnic disparities exist in both implant and IUD continuation. Practice changes to support positive adolescent experiences with implant and IUD insertion and removals are needed, including patient-centered health care provider training in contraception counseling, LARC initiation and removal training for adolescent-facing providers, and broader clinic capacity for LARC services.

Cultural Connection and Well-being for American Indian Adolescents.

American Indian and Alaska Native (AI/AN) adolescents face health disparities resulting from historical traumas. There is a paucity of research focusing on mental health in AI/AN adolescents or the relationship between cultural connection and health. This project assesses the relationship between cultural identity and markers of mental health and well-being for AI/AN adolescents. Adolescents 12 to 18 years old from the Lumbee Tribe of North Carolina participated in this mixed-methods study. Phase 1, discussed in this manuscript, involved surveys using validated instruments to assess cultural connection and markers of mental health and well-being. Characteristics of the 122 AI/AN youth who completed the survey included: mean age 14.9 years (SD = 2.0); 61% (n = 75) assigned female at birth; 56% (n = 70) identified as female; and 4.1% (n = 5) identified as non-binary. Mean tribal affiliation (TA) and ethnic identity (EI) scores suggest strong cultural connection (TA: M = 3.1/5, SD = 0.6; EI: M = 3.4/5, SD = 0.9). Sleep quality (M = 2.63/5) and positive stress management (M = 2.06/5) were low. Bivariate and logistic regression demonstrated moderate positive correlations between EI and friendship, EI and emotional support, TA and friendship, and TA and emotional support. AI/AN adolescents in this sample have a moderate-strong connection with Native culture, marked by ethnic identity and tribal affiliation, and positive markers of mental health and well-being. Data from this study may be used for policy formulation to promote increased funding and programming addressing mental health for AI/AN youth.

Integrating education for clinical practice change.

BACKGROUND: Children with chronic medical conditions and their families have significant emotional health concerns, yet paediatricians are often ill-equipped to address these needs. The American Board of Pediatrics launched the Roadmap Project to better support emotional health as part of routine care. We present pilot work in paediatric training programmes to test educational approaches and explore lessons learned. APPROACH: Four institutions implemented Roadmap tools into their paediatric training programmes, either incorporating them into existing educational structures or embedding them into the clinical workplace. One programme utilised an existing longitudinal curriculum, and another incorporated into a block rotation. Two programmes embedded training for residents into a larger programme for the healthcare team within the clinical space, one in outpatient clinics and one in an inpatient service. EVALUATION: Evaluation strategies at each site matched the intended outcomes. Sites working within education programmes evaluated learners, demonstrating increases in resident skills and confidence on pre-/post-self-assessments. Sites embedding tools into the practice context measured changes in the clinical practice of the healthcare team. Despite variability in implementation, all approaches improved trainee skills; sites embedding education into a clinical setting saw greater changes in clinical practice. IMPLICATIONS: Our pilot provided structure yet allowed for flexibility, and all sites improved trainee skills. Engaging the entire healthcare team within practice settings appears advantageous, thus embedding education into clinical practice may be preferable to a separate education programme. Similar to outcomes found in interprofessional education (IPE), educating clinical teams together may be more impactful for cultural shifts needed for changing clinical practice.

Confidential Telehealth Care for Adolescents: Challenges and Solutions Identified During the COVID-19 Pandemic.

Purpose of review: To identify lessons learned about maintaining confidentiality for adolescent telehealth care during the COVID-19 pandemic. Recent findings: Adolescents, parents, and providers recognize benefits of telehealth for confidential care while also identifying potential risks for confidentiality breach unique to the telehealth care setting. Summary: Rapid implementation of telehealth care during COVID-19 presented an opportunity to test strategies that protect confidentiality for adolescents accessing care through telehealth. Policy, practice, and provider-level interventions are needed to ensure that adolescents can access confidential care through telehealth.

"I feel like it gives me what I need to know": A qualitative study on adolescent perceptions of two contraceptive decision aids.

OBJECTIVES: We sought to understand how adolescents perceive two commonly used contraceptive decision aids and which elements adolescents identified as most important to them. STUDY DESIGN: We conducted a cross-sectional qualitative study of adolescents' perceptions of two decision aids, Your Birth Control Choices designed by the Reproductive Health Access Project and Birth Control: What's Important to You? designed by Power to Decide for Bedsider.org. We conducted semistructured interviews with 20 adolescents (aged 15-19 years) who were assigned female sex at birth and attended a single clinic in North Carolina. Interview questions addressed the decision aids' aesthetic design, informational content, inclusivity, and comprehensibility. We transcribed and analyzed interviews using Dedoose software. We developed a codebook using a combination of a priori and inductive codes followed by content analysis to identify themes. RESULTS: All participants agreed that both decision aids could be helpful with contraceptive decision-making and with patient-provider discussions. However, some phrasing and descriptions of contraceptive methods were confusing. Participants preferred realistic imagery, clear explanations of side effects, and details on method use. Participants expressed a preference for the information contained in the detailed Reproductive Health Access Project decision aid, while most favored the aesthetic design and layout of the Bedsider decision aid. CONCLUSIONS: Although adolescents expressed sentiments of increased knowledge and empowerment after reviewing the decision aids, this study suggests neither decision aid completely meets adolescent needs and preferences. Additional adaptations are necessary to create adolescent-centered contraceptive decision aids. IMPLICATIONS: Adolescents in this study found two contraceptive decision aids as useful adjuncts to conversations with providers. The decision aids improved contraceptive knowledge and may facilitate decision-making. However, neither of the studied decision aids fully met the perceived needs of adolescents. Future adaptations or designs should include additional adolescent-centered content.

Effectiveness of Contraceptive Decision Aids in Adolescents and Young Adults: A Systematic Review.

BACKGROUND: Contraceptive decision aids may support adolescents and young adults (AYA) in choosing contraceptive methods that fit their unique reproductive health needs. OBJECTIVE: To provide a systematic review of studies examining the effectiveness of contraceptive decision aids in AYA. MATERIALS AND METHODS: A systematic search was conducted of studies published between January 1, 2011, and March 31, 2021 using PubMed, Cochrane, and ClinicalTrials.gov. Studies were included if a contraceptive decision aid (ie, paper handout, mobile application, website, or video) was evaluated in AYA populations (age ≤30 years) in the United States. The primary outcome was decision aid effectiveness (ie, change in contraceptive knowledge, interest in contraception, contraceptive use, unintended pregnancies, and satisfaction with the decision aid). RESULTS: Seven randomized controlled trials and 3 pre-post studies, reporting on 3725 AYA (range, 11-30 years), met inclusion criteria. No studies were excluded due to risk of bias. The methodologies and results were heterogeneous, but most consistently demonstrated increased contraceptive knowledge. CONCLUSION: Ten studies evaluated a range of contraceptive decision aid formats for AYA. Decision aids appear to be effective at increasing contraceptive knowledge temporarily, but their effect on other contraceptive outcomes is unclear. Future research should evaluate decision aids specifically in adolescents.

Adolescent and Parent Perceptions of Telehealth Visits: A Mixed-Methods Study.

PURPOSE: Telehealth presents unique benefits and challenges for adolescents and their parents. This study aimed to explore adolescent and parent perceptions of privacy, confidentiality, and therapeutic alliance during telehealth video visits. METHODS: This was a cross-sectional convergent parallel mixed-methods study. English-speaking parents and 13- to 17-year-old adolescents who completed a video visit at eight academic-affiliated pediatric primary care practices in the Southeastern U.S. were recruited between September 2020 and January 2021. Online surveys were administered and analyzed using descriptive and bivariable analysis. Subsequent semi-structured qualitative interviews were conducted and analyzed using thematic analysis. RESULTS: Forty-eight adolescents and 104 parents completed surveys. Fourteen adolescents and 20 parents were interviewed. Mean ages of adolescents and parents were 15 and 46 years, respectively, and most participants identified as female, non-Hispanic, and white. Seventy-seven percent of adolescents reported very private telehealth visits. Most privacy concerns were related to the location of the visit in the patient's home or family members overhearing. Adolescents reported that alone time with their provider increased comfort in discussing sensitive issues, although only 31% of adolescents reported having time alone with their provider during their telehealth visit. Neither adolescents nor parents reported concerns about confidentiality. Interviews suggested that adolescent autonomy and independence in accessing health care may explain the positive relationship observed between therapeutic alliance and privacy. CONCLUSIONS: Adolescents and parents describe telehealth as convenient, useful, private, and confidential. Providers should strive to maximize privacy and the therapeutic alliance during video visits, including encouraging alone time and supporting adolescent autonomy and independence.

A Quality Improvement Approach to Enhance LGBTQ+ Inclusivity in Pediatric Primary Care.

BACKGROUND: Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) teens are at higher risk of illness as a result of bias but are less likely than peers to attend well visits. Medical organizations recommend improving care through staff education, visual cues, and routine inquiry of sexual orientation and gender identity (SO/GI) and pronouns. It is unknown how to do this confidentially in pediatrics. This quality improvement (QI) project aimed to confidentially collect and document SO/GI and pronouns early in at least 90% of teen acute care visits. METHODS: A diverse, representative QI team in a resident primary care clinic conducted a series of staff and clinician trainings to improve knowledge, then displayed welcoming signage and offered staff pronoun and rainbow pins. Multiple Plan-Do-Study-Act cycles developed methods of routine and private collection of SO/GI and pronouns. Outcome measures included proportion of teen acute visits with such documentation collected via weekly chart reviews. Process measures included staff/clinician preparedness, assessed by surveys. RESULTS: SO/GI and pronouns were documented in 0% of teen acute visits at baseline, 70% after 6 months, and 90% during the 20-week sustainment measurement phase. The proportion of staff and clinicians who felt prepared to provide care for LGB and transgender patients increased (53% to 68% for LGB, P = .07; and 30% to 57% for transgender, P = .002). CONCLUSIONS: QI methods can create protocols for confidential, sustainable SO/GI and pronoun collection from teens early in acute visits. This allows clinicians and staff to address patients appropriately and for clinicians to better meet their needs.

Adherence to Pre-Exposure Prophylaxis in Adolescents and Young Adults: A Systematic Review and Meta-Analysis.

This meta-analysis synthesized the proportion of adolescents and young adults (AYAs) who are adherent to pre-exposure prophylaxis (PrEP) and factors moderating adherence. A systematic search was conducted of studies published through May 2020 using PubMed, PsycInfo, Cochrane, EMBASE, and CINAHL. Included studies reported the proportion of AYAs (mean age ≤ 29 years) who were PrEP adherent. PrEP adherence was meta-analyzed using random-effects models. Secondary analyses evaluated potential moderating variables. A total of 41 individual samples, from 29 studies, of 8,679 AYA (weighted average age = 23.8 years) were synthesized. The proportion of AYA who met study-defined thresholds for PrEP adherence was .64 (95% confidence interval .57-.71) across studies. Subgroup analyses revealed that adherence was lower in young cisgender women (.46) than young men who have sex with men (.65) and serodiscordant heterosexual couples (.98). Adherence was higher in studies initiated after 2012 (.70) than earlier studies (.47). No differences based on participant age, country, or strategies to promote adherence were found. Across published studies to date, 64% of AYA demonstrate adequate PrEP adherence. Findings can be used to guide PrEP adherence interventions and also provide directions for future research on PrEP among AYA.

Initiation of Long-Acting Reversible Contraception in Hospitalized Adolescents in the United States.

OBJECTIVES: To analyze factors associated with the initiation of long-acting reversible contraception (LARC) among adolescent patients in inpatient settings in the United States. METHODS: This study is a secondary data analysis of the national Kids' Inpatient Database 2016 data (N = 4200 hospitals). Eligible patients were hospitalized girls 10 to 20 years old. The primary outcome was initiation of LARC (ie, subdermal implant and/or intrauterine device [IUD]) while hospitalized. Covariables included age, race or ethnicity, insurance type, postpregnancy status, geographic region, hospital type (rural or urban), hospital size, and children's hospital status. Bivariable statistics were calculated by using survey-weighted analysis, and a design-based logistic regression model was used to determine the adjusted odds of LARC initiation and of implant versus IUD initiation. RESULTS: LARC initiation occurred in 0.4% (n = 3706) of eligible hospital admissions (n = 874 193). There were differences in LARC initiation by patient age, insurance type, race or ethnicity, postpregnancy status, hospital type, and hospital status (all P < .01). In the adjusted model, older age, public insurance, nonwhite race or ethnicity, postpregnancy status, and urban, teaching or larger hospitals were independently associated with LARC initiation (all P < .01). Smaller hospital size and postpregnancy status increased the odds of implant versus IUD initiation after stratifying by hospital region. CONCLUSIONS: LARC initiation occurred in <1% of adolescent hospitalizations, with 90% of those occurring in postpregnancy adolescents. Addressing LARC capacity in rural, nonteaching, and smaller hospitals is important in increasing access. Future research is needed to identify and close gaps in the number of adolescents desiring and initiating LARC in hospital settings.

A Clinic-Based Quality Improvement Initiative to Increase Screening for Gonorrhea and Chlamydia in Adolescents.

BACKGROUND: Universal screening is a strategy for addressing the limitations of risk-based screening for gonorrhea and chlamydia (GC/CT). This quality improvement (QI) initiative aimed to improve GC/CT screening by implementing universal annual screening for all adolescents ≥ 13 years old. METHODS: At an academic pediatric resident continuity clinic, an interdisciplinary team designed and conducted multiple Plan-Do-Study-Act (PDSA) cycles over one year. The primary aim, and process measure, was to increase the percentage of encounters with screening for GC/CT in the 12 months prior to the encounter to 80%. The secondary outcome measure was rate of detection of GC or CT infection. Further, pulse checks of provider/staff knowledge and adherence were conducted. The balancing measure was denied insurance claims. RESULTS: The mean screening rate of 29.2% increased during the project implementation to 65.1% with several bundles of PDSA cycles. There were no cases of gonorrhea detected in the baseline period or implementation period. The case rate of chlamydia was similar during both periods (from 9.7 per 1,000 adolescent encounters to 10.8 per 1,000 adolescent encounters, p = 0.74). There was similarly high provider/staff knowledge about (p = 0.35) and adherence to (p = 0.06) the screening protocol at 6 and 12 months of implementation. There was no increase in percentage of denied insurance claims. CONCLUSION: This QI initiative doubled rates of GC/CT screening with no statistically significant increase in number of cases.

Long-Acting Reversible Contraception Initiation Among Adolescents After an American Academy of Pediatrics Policy Statement.

This cross-sectional study compares monthly rates of long-acting reversible contraception (LARC) insertions among adolescents before and after an American Academy of Pediatrics (AAP) policy statement recommending LARC for this age group.

Commentary: improving the quality and effectiveness of IUHPE communications: work plan 2007--2010.

The article presents the work plan of the IUHPE Communications portfolio during the present term of the Vice-President for communications in the IUHPE Board of Trustees (2007-10). The plan has been put together after a comprehensive review of the existing IUHPE communications areas. The result is a plan that aims to provide overarching support for the development of the organisation. In the plan, existing IUHPE communication tools are strengthened to respond better to today's communications' aims and objectives; while new tools are designed to make an impact through all communications' channels. The quality and effectiveness of these tools will contribute to shape a sustainable communications strategy and priorities.

Enhancing the effectiveness of the International Union for Health Promotion and Education to move health promotion forward.

The success in recent years of many IUHPE initiatives provides cause for celebration, but also reminds us of the challenges that lie ahead. The Global Programme for Health Promotion Effectiveness provides a blueprint for how the IUHPE can effectively participate in, and lead, global networks for health. Health promotion research is well organized and productive in most of the Northern hemisphere, but important wells of health promotion knowledge in the Southern hemisphere are not widely-enough disseminated. The IUHPE needs to help liberate knowledge producers everywhere from unnecessary structures, and find innovative ways to illuminate knowledge for all to see. We have developed and proven the effectiveness of a range of technologies such as settings-based health promotion. However, the vast majority of communities are untouched, and the IUHPE needs to be a leader in finding ways to better disseminate effective health promotion practice. The IUHPE is a vigorous and effective advocate for health promotion training, practice and research. Now we need to expand our advocacy for equity in health, building on our effective work on social clauses in trade agreements and on tobacco control.