Brief Motivational Interviewing Delivered by Clinician or Computer to Reduce Sexual Risk Behaviors in Adolescents: Acceptability Study.

BACKGROUND: Clinicians are expected to screen their adolescent patients for an increasing number of health behaviors and intervene when they uncover risky behaviors, yet, the clinic time allotted to screen, intervene, and provide resources is insufficient. Brief motivational interviewing (MI) offers succinct behavior change counseling; however, for implementation, clinicians need training, skill, and time. Computerized screening and counseling adjuvants may help clinicians increase their scope of behavioral screening, especially with sensitive topics such as sexual health, and provide risk-reduction interventions without consuming provider time during visits. OBJECTIVE: The objectives of this study were to (1) understand the extent to which health care providers use brief MI for sexual health discussions with adolescent patients and (2) assess the acceptability of incorporating a brief MI-based intervention to reduce sexual risk behaviors into their clinical practice delivered by either themselves or a computer. METHODS: At a national medical conference, surveys were administered to clinicians who provide sexual health care to adolescents. They were asked about their current use of MI for sexual risk behavior discussions and their willingness to implement computerized sexual health screening and computerized sexual risk behavior interventions into their clinical practice. RESULTS: The large majority (87.6%, 170/194) of clinicians already used MI with their patients with less than half (72/148, 48.6%) reporting they had been formally trained in MI. Despite all (195/195, 100.0%) clinicians feeling very or completely comfortable discussing sexual risk behaviors with their patients, the large majority (160/195, 82.1%) reported it would be useful, very useful, or extremely useful for a computerized program to do it all: screen their patients, generate risk profiles, and provide the risk-reduction counseling rather than doing it themselves. CONCLUSIONS: In this study, most clinicians used some form of brief MI or client-centered counseling when discussing sexual risk behaviors with adolescents and are very comfortable doing so. However, the large majority would prefer to implement computerized sexual health screening, risk assessment, and sexual risk behavior interventions into their clinical care of adolescents.

Pediatric Primary Care Providers' Perspectives on Telehealth Platforms to Support Care for Transgender and Gender-Diverse Youths: Exploratory Qualitative Study.

BACKGROUND: Access to gender-affirming care services for transgender and gender-diverse youths is limited, in part because this care is currently provided primarily by specialists. Telehealth platforms that enable primary care providers (PCPs) to receive education from and consult specialists may help improve the access to such services. However, little is known about PCPs' preferences regarding receiving this support. OBJECTIVE: This study aimed to explore pediatric PCPs' perspectives regarding optimal ways to provide telehealth-based support to facilitate gender-affirming care provision in the primary care setting. METHODS: PCPs who had previously requested support from the Seattle Children's Gender Clinic were recruited to participate in semistructured, 1-hour web-based interviews. Overall, 3 specialist-to-PCP telehealth modalities (tele-education, electronic consultation, and telephonic consultation) were described, and the participants were invited to share their perspectives on the benefits and drawbacks of each modality, which modality would be the most effective, and the most important characteristics or outcomes of a successful platform. Interviews were transcribed and analyzed using a reflexive thematic analysis framework. RESULTS: The interviews were completed with 15 pediatric PCPs. The benefits of the tele-education platform were developing a network with other PCPs to facilitate shared learning, receiving comprehensive didactic and case-based education, having scheduled education sessions, and increasing provider confidence. The drawbacks were requiring a substantial time commitment and not allowing for real-time, patient-specific consultation. The benefits of the electronic consultation platform were convenient and efficient communication, documentation in the electronic health record, the ability to bill for provider time, and sufficient time to synthesize information. The drawbacks of this platform were electronic health record-related difficulties, text-based communication challenges, inability to receive an answer in real time, forced conversations with patients about billing, and limitations for providers who lack baseline knowledge. With respect to telephonic consultation, the benefits were having a dialogue with a specialist, receiving compensation for PCP's time, and helping with high acuity or complex cases. The drawbacks were challenges associated with using the phone for communication, the limited expertise of the responding providers, and the lack of utility for nonemergent issues. Regarding the most effective platform, the responses were mixed, with 27% (4/15) preferring the electronic consultation, 27% (4/15) preferring tele-education, 20% (3/15) preferring telephonic consultation, and the remaining 27% (4/15) suggesting a hybrid of the 3 models. CONCLUSIONS: A diverse suite of telehealth-based training and consultation services must be developed to meet the needs of PCPs with different levels of experience and training in gender-affirming care. Beyond the widely used telephonic consultation model, electronic consultation and tele-education may provide important alternative training and consultation opportunities to facilitate greater PCP independence and promote wider access to gender-affirming care.

Implementation of Standardized Care for the Medical Stabilization of Patients With Anorexia Nervosa.

Approaches to refeeding patients with anorexia nervosa for medical stabilization vary across institutions, and there is no established standard of care. This study assessed the impact of a refeeding pathway on hospital length of stay and transfer to the psychiatry unit. Methods: This quality improvement intervention sought to standardize care for adolescents with anorexia nervosa at a tertiary care, free-standing children's hospital from Spring 2017 to Fall 2018. The pathway specified admission criteria, nutritional advancement, activity restriction, laboratory monitoring, readiness to transfer to the psychiatry unit, and discharge criteria. Statistical process control analysis was utilized to identify system-level changes over time. We used linear regression to assess pre- and postpathway differences in length of stay and transfer to the psychiatry unit. Results: There were 161 patient encounters for anorexia nervosa admitted for medical stabilization. 84% of the sample were female with median age of 15.2 (IQR 14.0-17.0) years. There was no difference in hospital length of stay between the pre- and postpathway groups. There was a statistically significant increase in the proportion of patients transferred to the psychiatry unit over the study period. Conclusion: Clinical pathway use to deliver standardized care to achieve medical stability for patients with anorexia nervosa did not shorten hospital length of stay. Multiple potentially confounding medical and psychosocial factors may have contributed to this lack of improvement.

Provider Use of Time Alone With Adolescents: Differences by Health Concern.

PURPOSE: To examine associations between reports of sensitive health behaviors and the provision of time alone by a clinician during adolescent well visits. METHODS: Data were collected from 547 adolescents who completed a well visit at one of eight clinics. Adjusted mixed logistic regression was used to examine whether reports of sexual behavior, substance use, disordered eating, mental health concerns, and demographic characteristics were associated with time alone. RESULTS: Sexual behavior was found to be significantly associated with time alone, while substance use, disordered eating, a positive depression screen, and suicidal ideation were not. Older adolescents and males were more likely to report time alone, while race/ethnicity had no association with time alone. DISCUSSION: Clinicians may be prioritizing time alone for behavioral concerns differently than for other sensitive behaviors.

Electronic Screening for Adolescent Risk Behaviors in the Emergency Department: A Randomized Controlled Trial.

INTRODUCTION: In this study we aimed to assess the impact of an electronic health assessment with individualized feedback for risk behaviors in adolescents seeking care in a pediatric emergency department (ED). METHODS: We conducted a randomized control trial using a tablet-based screening program with a study population of adolescents in a busy pediatric ED. The intervention group received the screening program with individualized feedback. The control group received the screening program without feedback. All participants received one-day and three-month follow-up surveys to assess behaviors and attitudes toward health behaviors. RESULTS: A total of 296 subjects were enrolled and randomized. There was no difference in changes in risky behaviors between the control and experimental groups. A higher proportion of participants in the intervention groups reported that the screener changed the way they thought about their health at one-day follow-up (27.0%, 36/133) compared to the control group (15.5%, 20/129, P = .02). CONCLUSION: This study successfully tested a multivariable electronic health screener in a real-world setting of a busy pediatric ED. The tool did not significantly change risky health behaviors in the adolescent population screened. However, our finding that the intervention changed adolescents' perceptions of their health opens a door to the continued development of electronic interventions to screen for and target risk behaviors in adolescents in the ED setting.

Office-Based Screening for Sexually Transmitted Infections in Adolescents.

Almost 1 in 4 adolescents have a sexually transmitted infection (STI). These infections are preventable through safe sexual practices and routine screening. Pediatricians are the first line of clinical care for adolescents and are well positioned to offer sexual and reproductive health care counseling and services to their patients; yet, there is a paucity of sexual health screening provided at routine health supervision visits. This article addresses the epidemiology of STIs in adolescents, reviews the evidence of current clinical practice, presents recommended STI screening from government and medical agencies, and offers strategies to address barriers to providing care for adolescents and for sexual health screening in primary care.

Screening adolescent patients admitted to the trauma service for high-risk behaviors: who is responsible?

BACKGROUND: Trauma remains the leading cause of death for adolescents in the United States. Adolescents are a hard to access medical population, with few opportunities for providers to screen for high-risk behaviors. The trauma team has a unique opportunity to screen for concurrent risk behaviors. The objective of this study was to assess surgeon knowledge, attitudes, and current practice of screening for high-risk behaviors in injured adolescents. METHODS: From June 2007 to September 2007, a 16-item survey was mailed to 880 trauma surgeons assess their current screening practices of their adolescent patients (14-18 years); their perception of patients' risk taking; the perceived need for additional screening; and the surgeons' willingness to add routine screening to their workup. RESULTS: The majority of trauma surgeons believed screening for risk behaviors in their adolescent patients was an important part of the trauma admission, although most thought it was not their personal responsibility. The highest rate of screening was for substance abuse, whereas the lowest was for gun ownership and sexual behavior. The majority of surgeons (74.4%) were willing to routinely consult specialists in adolescent medicine/pediatrics to assess for and manage risk behaviors in their adolescent trauma patients. CONCLUSION: The majority of trauma surgeons agree that risk screening is an important part of the trauma treatment for adolescent patients and are interested in involving adolescent medicine and pediatric specialists to ensure adequate screening, management, and follow-up of risk behaviors in their patients.

Results from e-KISS: electronic-KIOSK Intervention for Safer Sex: A pilot randomized controlled trial of an interactive computer-based intervention for sexual health in adolescents and young adults.

INTRODUCTION: Interactive computer-based interventions (ICBI) are potentially scalable tools for use in real-world settings to promote sexual health and prevent sexually transmitted infections (STIs) and unintended pregnancies. We developed and assessed the feasibility and acceptability of an ICBI for promoting adolescent and young adult sexual health, and the effectiveness of the intervention in reducing unprotected sex, STIs, and unintended pregnancy. METHODS: This pilot randomized controlled trial enrolled STI Clinic patients, in Seattle, Washington, who were 14-24 years old and reported unprotected vaginal sex during the last 2 months. Both the control and intervention group used a computerized survey to enter their sexual health and only the intervention group received the ICBI. The ICBI included personalized sexual health feedback from a physician avatar; instructive video modules advocating sexual health; and identification of one behavior to change. At 3-month follow-up, participants reported on interim sexual and pregnancy histories and underwent repeat STI testing. We assessed intervention impact on unprotected vaginal sex, number of sexual partners, incident STIs, and unintended pregnancy. RESULTS: Of 272 participants, 242 (89%) completed the study, of whom 65% were female. While these findings did not reach statistical significance, at 3-month follow-up, the intervention group reported a 33% lower rate of unprotected vaginal sex (no condom use) [IRR = 0.67, 95% CI: 0.44-1.02]; 29% fewer sex partners [IRR = 0.71, 95% CI: 0.50-1.03]; and 48% fewer STIs [IRR = 0.52, 95% CI: 0.25-1.08] when compared to the control group. Similarly, as compared to the control group, intervention females reported a lower rate of unprotected vaginal sex (no birth control) [IRR = 0.80, 95% CI: 0.47-1.35] and half as many unintended pregnancies (n = 5) versus control females (n = 10) [IRR = 0.51, 95% CI: 0.17-1.58]. In exploratory analyses, intervention females reported fewer partners [IRR = 0.71, 95% CI: 0.50-1.00] and a significantly lower rate of vaginal sex without condoms [IRR = 0.50, 95% CI: 0.30-0.85]. CONCLUSION: The intervention was acceptable to both males and females, and at 3-month follow-up, there were non-significant reductions in risk behavior for all outcomes. Among females, exploratory analysis showed a significant reduction in vaginal sex without condoms.

Adolescent Reproductive Health Care: Views and Practices of Pediatric Hospitalists.

BACKGROUND AND OBJECTIVES: Many hospitalized adolescents are at increased risk for pregnancy complications due to an underlying medical condition, however sexual risk assessment is not consistently performed in this setting. While adolescents and their parents are supportive of sexual health discussion in the inpatient setting, a thorough understanding of factors that influence provision of this care among pediatric hospital physicians is lacking. This formative information is needed to facilitate efforts to improve and standardize clinical care provision. Our objective is to assess the frequency and factors that influence the provision of adolescent sexual and reproductive care by pediatric hospitalists. METHODS: We performed a cross-sectional computerized survey of hospitalists at 5 pediatric hospitals who cared for ≥1 adolescent (14-21 years old) in the past year. Sexual and reproductive care practices were assessed by using a 76-item novel survey informed by the theory of planned behavior. We used descriptive statistics to summarize the data. RESULTS: Sixty-eight pediatric hospitalists participated (49% response rate): 78% were women and 65% were aged <40 years. Most (69%) reported treating >46 adolescents annually, including many who are at an increased risk for pregnancy complications due to teratogenic medication use or a comorbid condition. A majority felt that sexual and reproductive services are appropriate, although many endorsed barriers, including concern about follow-up after emergency contraception (63%) and time constraints (53%). Most reported insufficient knowledge regarding contraception (59%), desired contraception education (57%), and were likely to increase contraceptive provision if provided education (63%). Hospitalists rarely provided condoms or referral for an intrauterine device. CONCLUSIONS: Pediatric hospitalists frequently care for adolescents who are at risk for pregnancy complications and generally agree that reproductive care is appropriate in the inpatient setting. With these findings, we highlight the critical need for effective comprehensive reproductive health service interventions that are tailored to address the numerous actionable barriers identified in this study.

Association between condom use at sexual debut and subsequent sexual trajectories: a longitudinal study using biomarkers.

OBJECTIVES: We compared subsequent sexual behaviors and risk of sexually transmitted infections among adolescents who did and did not use a condom at their sexual debut. METHODS: We derived data from the National Longitudinal Study of Adolescent Health, which followed a sample of 4018 sexually active adolescents between 1994 and 2002. During waves I, II, and III of the study, data on sexual behavior were gathered, and at wave III urine specimens were collected to test for sexually transmitted infections. RESULTS: Among interviewed adolescents, those who reported condom use at their debut were more likely than those who did not use condoms at their debut to report condom use at their most recent intercourse (on average 6.8 years after sexual debut), and they were only half as likely to test positive for chlamydia or gonorrhea (adjusted odds ratio=0.50; 95% confidence interval=0.26, 0.95). Reported lifetime numbers of sexual partners did not differ between the 2 groups. CONCLUSIONS: Adolescents who use condoms at their sexual debut do not report more sexual partners, are more likely to engage in subsequent protective behaviors, and experience fewer sexually transmitted infections than do adolescents who do not use condoms at their sexual debut.

Adolescent Perspectives on Patient-Provider Sexual Health Communication: A Qualitative Study.

BACKGROUND: Adolescents in the United States are disproportionately affected by sexually transmitted infections and unintended pregnancy. Adolescent-centered health services may reduce barriers to health care; yet, limited research has focused on adolescents' own perspectives on patient-provider communication during a sexual health visit. METHODS: Twenty-four adolescents (14-19 years old) seeking care in a public health clinic in Washington State participated in one-on-one qualitative interviews. Interviews explored participants' past experiences with medical providers and their preferences regarding provider characteristics and communication strategies. RESULTS: Interviews revealed that (1) individual patient dynamics and (2) patient-provider interaction dynamics shape the experience during a sexual health visit. Individual patient dynamics included evolving level of maturity, autonomy, and sexual experience. Patient-provider interaction dynamics were shaped by adolescents' perceptions of providers as sources of health information who distribute valued sexual health supplies like contraception and condoms. Participant concerns about provider judgment, power differential, and lack of confidentiality also emerged as important themes. CONCLUSIONS: Adolescents demonstrate diverse and evolving needs for sexual health care and interactions with clinicians as they navigate sexual and emotional development.

An overview of sexually transmitted infections among adolescents.

Half of all United States high school students are sexually experienced. Female adolescents bear the highest rates of many STIs. Many adolescents infected with STIs report no symptoms suggestive of their infections. Health care providers who see adolescents should be poised to implement effective STI control through risk assessment, disease screening, and CDC-recommended treatment and prevention counseling.

Diagnosis and treatment of chlamydia, gonorrhea, and trichomonas in adolescents.

CME EDUCATIONAL OBJECTIVES: 1.Determine and discuss issues surrounding consent, confidentiality, and billing for sexually transmitted infection (STI) care delivery in the adolescent population.2.Review currently available testing modalities for STIs and their applicability in the adolescent population.3.Provide treatment and prevention strategies for the most commonly encountered STIs in the adolescent demographic. Adolescents and young adults, 15 to 24 years of age, carry a disproportionate burden of sexually transmitted infections compared with other age groups in the United States (see Figure 1).1.

The adolescent sexual health visit.

Addressing sexual health, screening, and counseling to prevent sequelae of risky sexual behavior are essential components of the adolescent visit to the gynecologist. Discussing sexuality and taking a sexual history may cause feelings of discomfort for the provider and adolescent patient alike. Taking the time to build rapport and trust and the guarantee of confidentiality are key to engaging adolescent patients to discuss their personal health concerns with their provider. This article offers recommendations to facilitate dialog with the adolescent patient, addresses special considerations for the adolescent examination, discusses the use of some of the newly available tests for sexually transmitted infections (STIs), and suggests the recommended approach to management of STIs in adolescents.

Rising rates of syphilis in the era of syphilis elimination.

OBJECTIVE: The objective of this study was to assess the impact of syphilis control activities in King County, Washington. STUDY DESIGN: We calculated rates of early syphilis and trends in numbers of persons tested and diagnosed through screening and partner notification from 1998 to 2005. RESULTS: Early syphilis cases increased from 38 in 1998 to 188 in 2005 with 92% occurring among men who have sex with men (MSM). Our health department conducted public awareness campaigns, increased publicly financed syphilis screening among MSM by 179%, and intensified partner notification efforts. Despite these efforts, the prevalence of syphilis among screened populations was only 1.1%, and 71% syphilis cases were diagnosed after seeking care for symptoms. The proportion of cases diagnosed through screening and partner notification did not significantly change during the evaluation period. Early syphilis incidence among MSM more than doubled between 2003 and 2005. CONCLUSIONS: New, innovative approaches to syphilis control are needed.

Is condom use habit forming?: Condom use at sexual debut and subsequent condom use.

OBJECTIVE: The objective of this study was to assess whether using a condom at adolescent sexual debut is associated with an increased likelihood of subsequent condom use. STUDY DESIGN: A nationally representative sample was used, including 4024 sexually active adolescents (12-18 years) from the National Longitudinal Study of Adolescent Health. Logistic regression was used to model the association of condom use at sexual debut on condom use at most recent sex (mean interval, 23 months). RESULTS: Condom use at adolescent sexual debut was associated with a twofold increased likelihood of condom use during most recent sex (odds ratio, 2.28; 95% confidence interval, 1.91-2.73). CONCLUSIONS: Among adolescents, early condom use is associated with an increased likelihood of subsequent condom use.