Confidence in adolescent contraceptive counseling among residents and fellows training at the University of Texas Southwestern in Dallas, Texas.

OBJECTIVES: Evaluate trainees' perceptions of past training and confidence in counseling about five contraceptive methods. STUDY DESIGN: Trainees completed an online survey in 2020. Logistic regressions evaluated the relationship between participant characteristics and confidence. RESULTS: Among 227 respondents (63% response rate), pediatric trainees reported the least confidence in counseling across each contraceptive method. Past training and confidence were associated. CONCLUSIONS: Gaps in training should be addressed to improve confidence in contraceptive counseling among pediatricians in reproductively restricted states. IMPLICATIONS: This study highlights gaps in physician trainee confidence regarding adolescent contraception counseling that should be addressed to improve adolescent sexual and reproductive healthcare.

Attitudes about the Provision of Sexual Health Services in an Inpatient Setting.

OBJECTIVE: To examine the relationship between clinicians' attitudes about the appropriateness of providing sexual health services in the inpatient setting and confidence in providing services METHODS: An online survey was emailed to pediatric hospitalists, adolescent medicine, and pediatric and adolescent gynecology societies and directors. Confidence in managing 8 sexual health situations was measured on a 4-point Likert scale, summed, averaged, and dichotomized into confident and not so confident. Participants were asked to rate on a 5-point Likert scale their belief that providing sexual health services in the inpatient setting would be appropriate. An adjusted, multivariate logistic regression identified associations between participant demographic characteristics, professional characteristics, and confidence and attitudes about the appropriateness of providing inpatient sexual health services. RESULTS: Among the 610 participants, the mean age was 40 years. Most were females (79%), non-Hispanic White (71%), and practiced pediatric hospital/general medicine (73%). Most (73%) were not so confident across all 8 confidence items. Overall, 61% "strongly agreed" that providing sexual health services in the inpatient setting was appropriate. Participants who reported younger age, being female, and confidence in providing services were significantly associated with strong agreement that it was appropriate to provide sexual health services in the inpatient setting. Those who identified as Christian non-Catholic were significantly less likely to report strong agreement. CONCLUSION: Most providers strongly agreed that providing sexual health services in the inpatient setting was appropriate, yet most were not so confident in managing sexual health situations. Future studies should focus on addressing concerns and barriers to providing sexual health services.

Characteristics of parents who think intrauterine devices or contraceptive implants are "best" for their daughter: An exploratory analysis in Dallas, Texas.

OBJECTIVE: To explore characteristics of parents who prefer an intrauterine device (IUD) or implant compared to all other contraceptive methods. STUDY DESIGN: Parents with an adolescent daughter completed a cross-sectional survey. The outcome evaluated the parent's perceived "best" contraceptive method for their daughter using bivariate statistics and multivariable modeling. RESULTS: Of 115 parents, parental willingness to use IUD or implant themselves (p = 0.014) and thinking IUD or implant is best at preventing pregnancy (p = 0.001) remained positively associated with parents thinking IUD or implant is the "best" contraceptive method for their daughter. CONCLUSIONS: Clinicians can consider integrating parents' personal experiences with IUD or implant during adolescent contraception counseling. IMPLICATIONS: Caregivers' personal contraceptive knowledge and personal willingness to use LARC influences their preferences for their daughter's contraception. Clinicians can assess and integrate caregivers' perspectives during adolescent contraception counseling.

Long-Acting Reversible Contraception for Adolescents: A Review of Practices to Support Better Communication, Counseling, and Adherence.

Long-acting reversible contraception (LARC) methods, including levonorgestrel and copper intrauterine devices (IUDs) and the subdermal contraceptive implant, are the most effective reversible forms of contraception and thus are an important aspect of adolescent pregnancy prevention. While LARC efficacy, safety, and appropriateness are supported by major medical organizations and usage rates are increasing, overall LARC uptake among United States (US) adolescents remains lower than uptake of short-acting contraceptive methods. A better understanding of the barriers affecting adolescent LARC uptake and reasons for discontinuation could help facilitate effective communication. For example, learning how to improve adolescent-centered communication, shared decision-making, and motivational counseling strategies may be the first step to improving utilization rates. This narrative review includes three sections. First, this review will describe the history, mechanisms of action, and epidemiology of adolescent LARC use in the US and globally. Next, this review will describe key factors influencing adolescent LARC uptake, reasons for discontinuation, and multilevel barriers specific to adolescent LARC use. Finally, this review will characterize communication techniques and LARC counseling strategies for adolescents in the context of a reproductive justice approach set in the health belief model framework. The distinction between moving away from a presumptive counseling approach towards an adolescent-centered, shared decision-making approach to encourage parent-adolescent sexual health communication to lay the foundation of empowering adolescent reproductive autonomy should be the underpinning of all effective reproductive communication strategies.

Parent Perspectives about Initiating Contraception Conversations with Adolescent Daughters.

OBJECTIVES: Parent-youth sexual and reproductive health (SRH) conversations are critical to reducing adolescent pregnancy, yet many parents do not discuss contraception before youth become sexually active. We aimed to describe parental perspectives about when and how to initiate contraception discussions, characterize motivators to discuss contraception, and explore the role of health care providers in supporting contraception communication with youth. METHODS: We conducted semi-structured interviews with 20 parents of female youth ages 9-20 recruited from areas of Dallas, Texas, with high rates of racial and ethnic disparities in adolescent pregnancy. We analyzed interview transcripts with a combined deductive and inductive approach, with discrepancies resolved by consensus. RESULTS: Parents were 60% Hispanic and 40% non-Hispanic Black, and 45% were interviewed in Spanish. Most identified as female (90%). Many initiated contraception discussions on the basis of age, physical development, emotional maturity, or perceived likelihood of sexual activity. Some expected their daughters to initiate SRH discussions. Cultural avoidance of SRH discussions often motivated parents to improve communication. Other motivators included reducing pregnancy risk and managing anticipated youth sexual autonomy. Some feared that discussing contraception could encourage sex. Parents trusted and wanted pediatricians to serve as a bridge to discuss contraception with youth before sexual debut through confidential, comfortable communication. CONCLUSION: Tension between the desire to prevent adolescent pregnancy, cultural avoidance, and fear of encouraging sexual behaviors causes many parents to delay contraception discussions before sexual debut. Health care providers can serve as a bridge between sexually naïve adolescents and parents by proactively discussing contraception using confidential and individually tailored communication.

Caregivers of youth in foster care in Texas and their role in contraception decision-making for adolescents in care.

OBJECTIVES: This study describes the perspectives of caregivers of youth in foster care in Texas about the caregiver's role in adolescent contraception decision-making for adolescents in their care, particularly for long-acting reversible contraception. The study also explores how providers and foster care agencies can better support pregnancy prevention for youth in care. STUDY DESIGN: Researchers recruited 18 caregivers of youth in care from an academic center in Texas to complete in-person, one-on-one, semistructured interviews from August to December 2019. Two independent coders identified the main concepts with thematic analysis; discrepancies were resolved by consensus. RESULTS: Most caregivers identified as female (88%), Black (59%), and ranged in age from 30 to 69 years old. Half (47%) reported previously caring for an adolescent who was pregnant or parenting. Themes from the interviews included the importance of building relationships before contraception conversations, the balance between adolescent autonomy and strict caregiver oversight in contraceptive decision-making, variation in beliefs about contraception for youth in care, and extreme reactions to long-acting reversible contraception in both directions. Providers and foster care agencies played an important role managing confidential expectations and providing resources or trainings about contraception. CONCLUSIONS: In a region of the country with high rates of adolescent pregnancy, strategies that empower adolescent autonomy allow delicate caregiver oversight, provide comprehensive information about all contraceptive options, and respond to extreme long-acting reversible contraception reactions and trainings that focus on the context of contraception that should inform communication-based interventions to address teen pregnancy prevention among youth in care. IMPLICATIONS: Few studies address the experiences of caregivers of adolescents in foster care. This study highlights a range of caregiver attitudes about contraception for adolescents in care. Provider training regarding contraception should include strategies to manage caregiver beliefs and extreme reactions to contraception use among youth in care.

Effects of the electronic health record on job satisfaction of academic pediatric faculty.

OBJECTIVE(S): To evaluate the association of Electronic Health Record (EHR) skills and available support with job satisfaction for pediatric faculty at an academic institution. To identify key opportunities for improvement. STUDY DESIGN: Cross-sectional study of pediatric academic faculty physicians using a REDCap survey to inquire about faculty EHR skills, support services, and associations between EHR workflow and job satisfaction. Results were analyzed using bivariate testing. RESULTS: The majority of respondents (n = 127, response rate 37%), rated the effect of EHR workflow on job satisfaction as neutral (36%) or negative (44%). Users with more EHR skills were more likely to indicate a positive effect of the EHR on overall job satisfaction (p = 0.019). 7% of respondents had none of the EHR skills queried and few felt that initial training (35%) or the Information Technology department (26%) were useful in acquiring skills. Two similar divisions, one with three and one without Physician Builders (providers with specialized training in EHR personalization), had statistically significant different EHR satisfaction ratings (p = 0.0012). CONCLUSIONS: Most faculty indicated a negative/neutral effect of the EHR on their overall job satisfaction. Users who indicated more EHR skills had a higher satisfaction rating. Existing training and support were not helpful to users. The division with the most Physician Builders ranked highest in satisfaction. We speculate that 1) adding EHR skills could increase overall job satisfaction and 2) adding Physician Builder resources could increase skills and satisfaction.

Social Media Perceptions and Internet Verification Skills Associated With Human Papillomavirus Vaccine Decision-Making Among Parents of Children and Adolescents: Cross-sectional Survey.

BACKGROUND: Human Papillomavirus (HPV) vaccination is recommended for children aged 11-12 years in the United States. One factor that may contribute to low national HPV vaccine uptake is parental exposure to misinformation on social media. OBJECTIVE: This study aimed to examine the association between parents' perceptions of the HPV vaccine information on social media and internet verification strategies used with the HPV vaccine decision-making stage for their child. METHODS: Parents of children and adolescents aged 9-17 years were recruited for a cross-sectional survey in North Texas (n=1192) and classified into 3 groups: children and adolescents who (1) were vaccinated, (2) unvaccinated and did not want the vaccine, and (3) unvaccinated and wanted the vaccine. Multinomial logistic regression models were estimated to identify factors associated with the HPV vaccine decision-making stage with children and adolescents who were vaccinated as the referent group. RESULTS: Of the 1192 respondents, 44.7% (n=533) had an HPV-vaccinated child, 38.8% (n=463) had an unvaccinated child and did not want the vaccine, and 16.4% (n=196) had an unvaccinated child and wanted the vaccine. Respondents were less likely to be "undecided/not wanting the vaccine" if they agreed that HPV information on social media is credible (adjusted odds ratio [aOR] 0.40, 95% CI 0.26-0.60; P=.001), disagreed that social media makes them question the HPV vaccine (aOR 0.22, 95% CI 0.15-0.33; P<.001), or had a higher internet verification score (aOR 0.74, 95% CI 0.62-0.88; P<.001). CONCLUSIONS: Interventions that promote web-based health literacy skills are needed so parents can protect their families from misinformation and make informed health care decisions.

Research Participation of Minor Adolescents in Foster Care.

STUDY OBJECTIVE: In this study we evaluated published studies about foster care to: (1) determine the types of data used; (2) describe the degree to which a sexual/reproductive health topic was addressed; and (3) describe the consent process. DESIGN: Analysis of published literature. SETTING: PubMed was searched using "foster care" for English articles published between January 1, 2017 and September 4, 2019. PARTICIPANTS: None. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Articles were coded into 4 data source categories: primary, secondary, peripheral, or perspective data. Articles with a primary data source were coded for participant ages: only 9 years old and younger, 10- to 17-year-olds (minor adolescents), and only 18 years old and older. Articles using a secondary data source were coded for the source of the data registry. All articles were coded for presence of a sexual/reproductive health outcome. The primary data articles that included minor adolescents were coded for the study topic and consent process. RESULTS: Of the 176 articles about foster care, 72/176 (41%) used primary data, 53/176 (30%) used secondary data, and 51/176 (29%) used peripheral/perspective data. Forty-eight of the primary data articles included minor adolescents. Secondary data sources included few national research surveys. Sexual/reproductive health outcomes were measured in 17 articles, 4 of which used primary data. The consent process for minor adolescents varied and had no consistent pattern across studies. CONCLUSION: Research on best practices for consent processes and use of registries could be developed to increase research on sexual/reproductive health outcomes among adolescents in foster care.

Provider perspectives on communication and dismissal policies with HPV vaccine hesitant parents.

Parental vaccine hesitancy is a growing concern. Less is known about provider or practice characteristics that encounter HPV-specific vaccine-hesitant parents, the providers' confidence in responding to HPV vaccine concerns, and the attitudes and use of vaccine dismissal policies (i.e., removing patients from the practice). North Texas providers completed an online survey. Dependent variables assessed: (1) percentage of HPV vaccine-hesitant parents encountered in practice defined as substantive, or high (≥11%, or among more than one out of ten adolescent patient encounters) versus low (≤10%) levels; (2) confidence in responding to 11 HPV vaccine concerns; (3) attitudes and use of vaccine dismissal policies. Chi-square and Fisher's exact tests were conducted. Among 156 providers, 29% reported high HPV vaccine hesitancy (≥11% of patient population). Overall, providers reported being "very confident" in addressing vaccine concerns (mean: 3.37 out of 4, SD: 0.57). Mean confidence scores were significantly higher for white (vs. non-white) providers and for pediatricians (vs. family practitioners). Providers were least confident in responding to parents' religious/personal beliefs (69%). Some providers (25%) agreed with policies that dismissed vaccine-hesitant parents after repeated counseling attempts. More providers used dismissal policies for childhood (19%) than adolescent (10%) immunizations. Provider communication training should include parental religious/personal beliefs to effectively address HPV vaccine hesitancy. Other regions should examine their HPV-specific vaccine hesitancy levels to understand how the use of dismissal policies might vary between adolescent and childhood immunizations.

Clinical Features of E-cigarette, or Vaping, Product Use-Associated Lung Injury in Teenagers.

BACKGROUND: In the United States in 2019, there was an outbreak of electronic cigarette, or vaping, product use-associated lung injury (EVALI). The manifestations of EVALI in adolescents are not well characterized. We describe the diagnosis, evaluation, and management of EVALI in adolescents hospitalized at a tertiary care, university-affiliated children's hospital. METHODS: A multidisciplinary committee developed an EVALI algorithm on the basis of guidelines from the Centers for Disease Control and Prevention. A retrospective chart review was conducted on patients diagnosed with EVALI. Descriptive analyses included sociodemographic characteristics, clinical presentation, laboratory and imaging results, pulmonary function testing, oxygen requirements, and clinic follow-up. RESULTS: Thirteen hospitalized adolescents were diagnosed with confirmed or probable EVALI. The majority were female (54%) with a mean age of 15.9 years. Sixty-nine percent of patients presented with respiratory symptoms, whereas gastrointestinal symptoms were prominent in 85% of patients. Vaping Δ-9-tetrahydrocannabinol was reported in 92% of patients, and vaping nicotine was reported in 62% of patients. All had bilateral ground-glass opacities on the chest computed tomography (CT) scan. Treatment with glucocorticoids led to clinical improvement in 11 of 12 patients. Treatment with glucocorticoids led to improvement in both forced expiratory volume in 1 second and forced vital capacity (P < .05). Four patients required home oxygen on the basis of 6-minute walk test results. CONCLUSIONS: Diagnosis of EVALI should be suspected on the basis of vaping history and clinical presentation. Glucocorticoid treatment led to an improvement in symptoms and lung function. The 6-minute walk test may help determine oxygen needs at discharge.

Adolescent and Parent Perceptions about Participation in Biomedical Sexual Health Trials.

Given the burden of HIV and other sexually transmitted infections among adolescents who are legal minors, it is critical that they be included in biomedical sexual health trials to ensure that new prevention and treatment interventions are safe, effective, and acceptable for their use. However, adolescents are often not well represented in clinical trials. We provide an overview of the available evidence regarding adolescent and parent willingness for adolescents to participate in biomedical sexual health trials, parental involvement in the permission-consent process, management of differences and discord among adolescents and parents, and parental involvement throughout the study period. We also outline recommendations for current practice and areas for future research.

Research participation provides adolescents and parents a launching pad for conversations.

Little is known about whether adolescent participation in sexual health research prompts adolescents and parents to have conversations about sensitive topics. One year after being presented with a hypothetical microbicide safety study, 248 adolescent-parent dyads were asked about conversations they may have had after their initial study visit. Sixty-three per cent of adolescents and 82% of parents reported having a conversation about the study. A launching conversation about broader topics (e.g. risk behaviours) was reported by 8% of adolescents and 17% of parents. Because there is evidence that conversations are occurring, researchers could provide guidance to help facilitate potentially sensitive discussions.

Adolescent-Parent Dyadic Retention in an Interview Study and Changes in Willingness to Participate in a Hypothetical Microbicide Safety Study.

STUDY OBJECTIVE: In this study we describe adolescent and parent retention and changes in willingness to participate (WTP) in research among adolescents, parents, and adolescent-parent dyads. DESIGN AND SETTING: Adolescent-parent dyads were recruited to participate in a longitudinal study to assess research participation attitudes using simultaneous individual interviews of the adolescent and parent with a return visit 1 year later using the same interview. PARTICIPANTS: Adolescents (14-17 years old) and their parents. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The relationship between participant characteristics and dyad retention was assessed. WTP was measured on a Likert scale and dichotomized (willing/unwilling) to assess changes in WTP attitudes over time for adolescents, parents, and dyads. RESULTS: Eighty-three percent of the 300 dyads were retained. Dyads in which there was successful contact with the parent before follow-up were more likely to be retained (odds ratio, 4.88; 95% confidence interval, 2.57-9.26). For adolescents at baseline, 59% were willing to participate and 55% were willing to participate at follow-up (McNemar S = 0.91; P = .34). For parents at baseline, 51% were willing to participate and 57% were willing to participate at follow-up (McNemar S = 5.12; P = .02). For dyads at baseline, 57% were concordant (in either direction) and 70% of dyads were concordant at follow-up (McNemar S = 10.56; P = .001). CONCLUSION: Over 1 year, parent contact might positively influence successful adolescent retention. Parents become more willing to let their adolescents participate over time, with dyads becoming more concordant about research participation.

Management of Adolescent-Parent Dyads' Discordance for Willingness to Participate in a Reproductive Health Clinical Trial.

The objective of this study is to understand the resolution of discordance between adolescent-parent dyads about participation in research. Adolescent (14-17 years) and parent dyads were recruited from NYC pediatric clinics to assess attitudes toward research participation. A subset of dyads participated in videotaped discussions about participation in a hypothetical study. Videos from dyads that held strongly discordant opinions about participation ( n = 30) were content-coded and analyzed using a thematic framework approach. Strategies used to resolve discordance included asserting authority, granting autonomy, or recognizing inaccurate assumptions using a variety of communication behaviors. Missed opportunities to enroll initially discordant dyads may be avoided by allowing time for adolescents and parents to elicit information, clarify a situation, or convince the other.

Pregnant young women's attitudes about microbicides: the anticipated influence of the grandmother and father of the baby on microbicide use.

Grandmothers and fathers of the baby may influence pregnant women's microbicide use. Pregnant young women's attitudes about grandmothers' and fathers' role in decision-making and their involvement in microbicide use were assessed. Participants (n=108) had a mean age of 20.2 years. The majority anticipated that the grandmother, father or both would have a decision-making role. Greater grandmother involvement in microbicide use was significantly associated with being younger, having no reproductive tract infection or contraceptive-ring-use history. Greater father involvement in use was associated with being in a relationship with him. Strategies for engaging grandmothers and fathers in microbicide use should be developed.

Long-Acting Reversible Contraception for Adolescents: A Review.

Importance: Adolescents have higher rates of unintended pregnancies than any other age group. Contraceptive implants and intrauterine devices (IUDs) are long-acting reversible contraceptives (LARCs) that are known to be highly effective in preventing pregnancy. New devices have recently been approved for use in adolescents, yet pediatricians may be less familiar with how to counsel adolescents about implants and IUDs. Observations: LARC methods should be described in basic terms to adolescents, including hormone dose, method of insertion, and method of pregnancy prevention. Clinicians should appreciate the developmental stages of adolescents, discuss the most effective methods of contraception, and ensure confidentiality from their parents. Short-acting contraception methods (eg, oral contraceptives) can be used as a temporary bridge to provide coverage until a LARC method can be placed. The most common adverse effect of LARC is nuisance bleeding, which can be managed with short courses of oral contraceptives or nonsteroidal anti-inflammatory drugs. Conclusions and Relevance: LARC devices constitute first-line contraceptive methods for adolescents. All clinicians, including pediatricians, can counsel about LARC even before suggesting an oral contraceptive or another less effective contraceptive method. Effective, confidential communication with sensitive language to inform adolescents of the different types of LARC is necessary to normalize offering LARC as a contraceptive option and improve its uptake among adolescents. Special clinical populations can also be offered appropriate contraceptive options inclusive of LARC.

Adolescent and Parent Willingness to Participate in Microbicide Safety Studies.

STUDY OBJECTIVE: To understand adolescents' and parents' willingness to participate (WTP) in a hypothetical phase I prevention study of sexually transmitted infections, discordance within adolescent-parent dyads, and expectations of each other during decision-making. DESIGN AND SETTING: Adolescent-parent dyads were recruited to participate in a longitudinal study about research participation attitudes. PARTICIPANTS: Adolescents (14-17 years old) and their parents (n = 301 dyads) participated. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Individual interviews at baseline assessed WTP on a 6-level Likert scale. WTP was dichotomized (willing/unwilling) to assess discordance. RESULTS: WTP was reported by 60% (182 of 301) of adolescents and 52% (156 of 300) of parents. In bivariate analyses, older adolescent age, sexual experience, and less involvement of parents in research processes were associated with higher level of WTP for adolescents; only sexual experience remained in the multivariable analysis. For parents, older adolescent age, perceived adolescent sexual experience, and conversations about sexual health were significant; only conversations remained. Dyadic discordance (44%, 132 of 300) was more likely in dyads in which the parent reported previous research experience, and less likely when parents reported higher family expressiveness. Adolescents (83%, 248 of 299) and parents (88%, 263 of 300) thought that the other would have similar views, influence their decision (adolescents 66%, 199 of 300; parents 75%, 224 of 300), and listen (adolescents 90%, 270 of 300; parents 96%, 287 of 300). There were no relationships between these perceptions and discordance. CONCLUSION: Inclusion of adolescents in phase I clinical trials is necessary to ensure that new methods are safe, effective, and acceptable for them. Because these trials currently require parental consent, strategies that manage adolescent-parent discordance and support adolescent independence and parental guidance are critically needed.

Qualitative Analysis of Sexually Experienced Female Adolescents: Attitudes about Vaginal Health.

STUDY OBJECTIVE: To explore adolescent's perceptions of vaginal health, practices, and vaginally-placed products. DESIGN: Semistructured interviews were audio-recorded and transcribed until theoretical saturation was achieved. SETTING: Adolescent medicine clinics in New York City. PARTICIPANTS: Female adolescents (N = 22) who were sexually experienced, predominately Hispanic (73%, n = 16) with a mean age of 17.7 years (range, 15-20 years). INTERVENTIONS: None. MAIN OUTCOME MEASURES: Interviews were used to assess perspectives on vaginal health, specific vaginal hygiene practices, and attitudes about vaginally-placed products (contraceptive rings, intrauterine devices), and proposed multipurpose technologies administered as ring or gel). The interviews were transcribed and coded for relevant themes. RESULTS: Overlapping themes included young women's view of their vagina as a space that needed to be healthy for sexual partners and future fertility. The vagina could not be presumed to be healthy and conversations about vaginal health were limited to include only specific individuals. All reported a variety of practices to maintain their vaginal health, including showering 1-5 times a day and using soaps specifically for the vagina. Attitudes about vaginally-placed products revealed concerns about the sensory experience of having a product in the vagina, safety concerns and interest in the product's objective (prevention of pregnancy or infection). CONCLUSION: Adolescents have very specific views and practices about their vaginas. Clinicians should initiate conversations about vaginal health and hygiene with adolescents and focus on the normalcy of the vagina. Development of vaginally-placed products should focus on the sensory experience, safety, and purpose of the product.