Prioritizing Gender-Affirming Care for Youth: The Role of Pediatric-Focused Clinicians.

Gender-affirming care (GAC) acknowledges the right of each individual to live in the gender that is most authentic to them and to receive nonjudgmental, developmentally appropriate care. For transgender and gender-diverse (TGD) individuals, this care may include transition-related care, such as puberty blockers, gender-affirming hormones, and therapies, including surgery. All youth, including TGD youth, deserve confidential, adolescent-friendly care. However, recent legislation in many states seeks to limit access and/or ban GAC for TGD youth. This article reviews the evidence supporting GAC for adolescents, the risk of denying this care, and recommendations for advocacy from all pediatric-focused clinicians.

Something Has to Give: An Urban Community-Engaged Focus Group Study of Teen Sleep.

Sleep is critical to teen physical and mental health, daily function, and school performance. Yet, sleep deficiency is prevalent among ethnoracially diverse teens. The purpose of this community-engaged focus group study was to explore multilevel influences on teen sleep from teen and community stakeholder perspectives and to use this information to develop a tailored sleep health intervention. We conducted seven focus groups (N = 46) and analyzed data via content analysis. Five themes, each with subthemes, described sleep knowledge/attitudes, sleep habits, the multilevel causes and consequences of decreased nighttime sleep and suggestions for improving teen sleep. Teen health, mood, and school engagement were all impacted by inadequate nighttime sleep. Exhaustion emerged as an overarching theme and coincided with the transition to high school. The data from this study provide insight into important areas of focus for a sleep intervention tailored to the needs of ethnoracially diverse teens living in an urban community.

Pediatric Nurse Practitioners' Perspectives on Engaging Adolescents to Shift from Pediatric to Adolescent-Focused Health Care Services.

INTRODUCTION: This study examined the perspectives of pediatric nurse practitioners (PNPs) on the shift from pediatric to adolescent-focused health care services (HCS). This movement coincides with the early stages of the health care transition process. METHOD: Conference attendees (N = 170) participated in a discussion on the shift from pediatric to adolescent-focused HCS. A secondary analysis was conducted. Data were analyzed for themes using content analysis. RESULTS: Confidentiality was found to be a foundational aspect of adolescent-focused HCS. Two additional themes described adolescent-focused HCS characteristics and the role of the PNP in providing education and empowerment for adolescents and parents throughout this process. DISCUSSION: PNPs provide critical leadership in facilitating the shift to adolescent-focused care by providing HCS designed to support confidentiality, respond to the needs of adolescents, and offer education to empower adolescents and parents on the importance of adolescent-focused care and engagement in the overall health care transition process.

The Essential Elements of Adolescent-friendly Care in School-based Health Centers: A Mixed Methods Study of the Perspectives of Nurse Practitioners and Adolescents.

PURPOSE: In this study we identified the essential elements of adolescent-friendly care in school-based health centers (SBHCs) from the perspectives of the nurse practitioners (NPs) providing care to adolescents and the adolescents, as the consumers of these services. DESIGN AND METHODS: Complex adaptive systems provided the philosophical and theoretical foundation for this study. An explanatory sequential mixed methods study was conducted. A Delphi technique (strand one) was conducted with an expert panel of NPs (N = 21) to identify the essential elements of adolescent-friendly care in SBHCs. The second strand, a focus group study with adolescents (N = 30), elaborated on the Delphi results. Data from the two strands were then mixed. RESULTS: This study generated expert opinion regarding the essential elements of adolescent-friendly health care in SBHCs. After four Delphi rounds, consensus was reached on 98-items (49% of the original 200; consensus level of 0.75). The results clustered into 6 essential elements: Confidentiality/Privacy (n = 8; 8.2%), Accessibility, (n = 15; 15.3%), Clinician/Staff (n = 51; 52%), SBHC Clinical Services (n = 12; 12.2%), SBHC Environment (n = 4; 4.1%), and Relationship between the School and SBHC (n = 8; 8.2%). The adolescent focus groups confirmed the essential elements identified in the Delphi and added two overarching themes: Comfortable and Trusted Relationship. CONCLUSIONS: These findings contribute to a greater understanding of essential characteristics needed in adolescent friendly care. PRACTICE IMPLICATIONS: SBHCs, as an important community resource for addressing the health care needs of adolescents, should incorporate these characteristics.

Pediatric Nurse Practitioners' Perspectives on Health Care Transition From Pediatric to Adult Care.

INTRODUCTION: This study examined the perspectives of pediatric nurse practitioners (PNPs) regarding the needs of adolescents, parents/caregivers, clinicians, and institutions in the health care transition (HCT) process for adolescents/young adults. METHODS: PNPs (N = 170) participated in a luncheon for those interested in transition at an annual conference. Small groups discussed and recorded their perspectives related to health care transition from adolescent to adult services. Content analysis was used to analyze responses (Krippendorff, 2013). RESULTS: Four themes, Education, Health care system, Support, and Communication, emerged from the data analysis. PNPs identified health care informatics and adolescents' use of technology as additional critical aspects to be considered in health care transition. DISCUSSION: Opportunities and challenges identified by the PNPs are discussed to improve the quality and process of transitioning adolescents to adult services. This report will help National Association of Pediatric Nurse Practitioners formulate a new Health Care Transition Policy Statement for the organization.

"Treat Me Like a Normal Person!" A Meta-Ethnography of Adolescents' Expectations of Their Health Care Providers.

PURPOSE: Preventive health care services provide an important opportunity to assist adolescents to establish and maintain a healthy lifestyle and assume an increasing independent role in their health care. National guidelines emphasize the importance of an annual wellness visit to identify and address risk-behaviors that contribute significantly to the morbidity and mortality in this population. Despite these recommendations, adolescents utilize preventive health care at declining rates throughout adolescence. The purpose of this study was to capture a more holistic view of what adolescents, as consumers of health care services, expect from their primary health care providers (HCPs). METHOD: A metasynthesis of 12 qualitative research studies was conducted using Noblit and Hare's (1988) meta-ethnographic approach. RESULTS: Five overarching metaphors, Talk with Me- Not at Me, Accept Me, Respect My Privacy and Confidentiality, Show Me You Are a Professional, and A Trusted Relationship described adolescents' expectations of their HCPs. CONCLUSIONS: This study provides a more holistic view of adolescents' expectations of their HCPs. Clinical strategies are suggested to assist HCPs to meet adolescents' expectations.

What influences adolescents' contraceptive decision-making? A meta-ethnography.

Increased access to and use of contraception has contributed significantly to the decline in teen birth rates since 1991, yet many teens use contraception inconsistently or not at all. This meta-ethnography was conducted to identify the factors that influence adolescents' contraceptive decision-making. Fourteen qualitative studies were examined using G. W. Noblit and R. D. Hare's (1988) meta-ethnographic approach. Three themes of self, partner and family were found to influence contraceptive decision-making in both positive and negative ways. Assisting adolescents to maximize positive and reduce negative influences regarding contraceptive decision-making has the potential to assist teens to more effectively avoid unintended pregnancy and sexually transmitted infections.

The prevalence of HPV associated cervical intraepithelial neoplasia in women under age 21: who will be missed under the new cervical cancer screening guidelines?

STUDY OBJECTIVE: To quantify the number of adolescent females < age 21 years with pre-cancerous cervical lesions (cervical intraepithelial neoplasia grade 2 or higher (CIN 2+) or adenocarcinoma in situ (AIS)) in Connecticut in the time period before new cervical screening recommendations went into effect and identify any demographic associations with a diagnosis of CIN 3. DESIGN: Descriptive analysis, surveillance. SETTING: CIN 2+/AIS precancerous cervical lesions have been reportable conditions in Connecticut since 2008 for the purpose of public health surveillance. PARTICIPANTS: All women < 21 years old with pre-cancerous cervical lesions diagnosed between 2008 and 2010 (N = 681). RESULTS: Of the 681 reports, 478 (70.2%) women had CIN 2, 92 had CIN 2/3 (13.5%), and 110 (16.2%) had CIN 3. CIN 3 occurred at an average rate statewide of 19/100,000 per year for women ages 13-20. The majority of adolescents with pre-cancerous cervical lesions CIN 2+/AIS (70%) were 19 and 20 years of age. CIN 3 vs CIN 2 is not found to be associated with age, insurance status, specimen collection year, or living in a non-urban vs urban county. CONCLUSION: The majority of cases of pre-cancerous cervical lesions in adolescents diagnosed before new screening recommendations were in effect are CIN 2 and therefore, likely to regress. CIN 3 has been infrequently found in adolescent females under age 19 years; however, under the new screening guidelines, 110 cases of CIN 3 including 77 in women 19-20 years could have been missed in the adolescent female in Connecticut from 2008-2010 (54.4 per 100,000 per year for 19-20 year olds). Based upon these findings, it is necessary that clinicians educate adolescents and parents about the new screening guidelines and the importance of establishing regular cervical cancer screening beginning at age 21.

Adolescent-friendly remedies for the challenges of focus group research.

Focus groups are an increasingly popular method of qualitative research; however, as with any research method, limitations emerge that were not anticipated. This article reviewed the limitations reported in 21 research studies, published between 2002 and 2012, to identify the common concerns of researchers in focus group studies with adolescents. Limitations focused on methodological concerns, recruitment challenges, and the potential influences of peers and the moderator on research results. Remedies are suggested for modifying the focus group method to address these potential challenges within the context of adolescent development and adolescent-friendly care.

A clinical guideline for intrauterine device use in adolescents.

PURPOSE: To present an evidence-based review of the data for and against the use of the intrauterine device (IUD) in adolescent females and to provide guidelines for selection of appropriate candidates. DATA SOURCES: Clinical research, expert opinions, and systematic reviews of IUD use in adolescents. CONCLUSIONS: The use of the IUD in adolescents has been questioned in the past as a result of concerns surrounding increased risks for pelvic inflammatory disease and infertility in adolescents. Current research reveals no contraindications to IUD use based solely on age or parity and illuminates many benefits to use, including a decrease in menorrhagia and dysmenorrhea. IMPLICATIONS FOR PRACTICE: The U.S. adolescent pregnancy rates rose from 2005 to 2007, reversing a decade-long downward trend. Adolescents need safe, effective, user-friendly contraceptive methods. IUDs are a safe and effective option for adolescents and provide an additional contraceptive option for nurse practitioners to offer their patients to prevent unintended pregnancy and enhance adolescent sexual health and well-being. Proper selection of candidates for IUD use can mitigate clinical and legal risks associated with IUD use.

Rethinking school-based health centers as complex adaptive systems: maximizing opportunities for the prevention of teen pregnancy and sexually transmitted infections.

This article examines school-based health centers (SBHCs) as complex adaptive systems, the current gaps that exist in contraceptive access, and the potential to maximize this community resource in teen pregnancy and sexually transmitted infection (STI) prevention efforts. Adolescent pregnancy is a major public health challenge for the United States. Existing community resources need to be considered for their potential to impact teen pregnancy and STI prevention efforts. SBHCs are one such community resource to be leveraged in these efforts. They offer adolescent-friendly primary care services and are responsive to the diverse needs of the adolescents utilizing them. However, current restrictions on contraceptive availability limit the ability of SBHCs to maximize opportunities for comprehensive reproductive care and create missed opportunities for pregnancy and STI prevention. A clinical case explores the current models of health care services related to contraceptive care provided in SBHCs and the ability to meet or miss the needs of an adolescent seeking reproductive care in a SBHC.

Rationale for reducing the spread of human papillomavirus in adolescents: strategies to improve outcomes (CME multimedia activity).

As detailed in this online CME activity (http://cmeaccess.com/cme/JAH_HPV_program/index.asp?link_id=2), human papillomavirus (HPV) infection is the cause of cervical cancer and neoplasias in women, and genital warts in men and women. In addition, 35%-85% of vaginal, vulvar, anal, penile, and oropharyngeal cancers are attributable to HPV. An estimated 80% of females and 50% of males in the United States will become infected at some point in their lives; however, the incidence of this highly prevalent infection peaks in adolescents and young adults. Owing to the importance of vaccination before this elevated risk of exposure, the Centers for Disease Control and Prevention recommends HPV vaccination for girls aged 11-12 years with either the bivalent or quadrivalent vaccine. Recently, the quadrivalent vaccine, which also protects against genital warts and anal neoplasias and cancer, was approved for use in boys as well. Although the coverage rate has increased steadily in the 5 years since the vaccine's introduction, it remains below 50%. To overcome barriers to vaccination, including lack of awareness about adolescents' HPV risk and challenges associated with preventive care in this age group in general, healthcare providers must be able to educate parents/patients about HPV and the vaccine, as well as maximize opportunities to vaccinate adolescents at every office visit.

Providing adolescent-friendly HPV education.

Human papillomavirus (HPV) is the most common sexually transmitted infection, affecting more than 6.2 million individuals every year. Most new infections occur in adolescents and young adults shortly after the onset of sexual activity. Nurse practitioners play a key role in preventing HPV infection in teens through adolescent-friendly HPV education, prevention, and vaccination.

Contraceptive services in SBHCs: A community experience in creating change.

School Based Health Centers (SBHCs) are teen-friendly community resources currently underutilized in efforts to prevent teen pregnancy. Much of the decline in the teen birth rate has been attributed to increased access and use of contraception by adolescents. Yet 60% of SBHCs nationwide, which provide health care services to adolescents, are prohibited from prescribing and/or dispensing contraception. Pregnancy prevention efforts targeting increased contraceptive availability and accessibility are likely to be enhanced by changing existing policies that restrict contraceptive services to adolescents through SBHCs nationwide. This article describes a successful community-based effort to change school district policy to provide contraceptive access through the SBHCs. The Transtheoretical model (TM) is applied retrospectively to describe this change process and provides a useful framework for nurses to consider in guiding community health policy initiatives.

Emergency contraception: a primer for pediatric providers.

Emergency contraception (EC) is a contraceptive method used safely and successfully by women for more than 30 years to prevent pregnancy. Nurses at all levels are often the first point of contact for a woman who is requesting EC, thus it is particularly important for them to stay abreast of both the facts regarding the use of this product and the current political controversies. It is particularly important for Nurse Practitioners (NPs) working in primary care with adolescents to remain cognizant of the significant barriers that remain for many women of all ages trying to access this important contraceptive tool.

Reproductive care and rates of pregnancy in teenagers with negative pregnancy test results.

PURPOSE: The purpose of this study was to follow-up adolescent girls with negative pregnancy tests (NPTs) through an 18-month follow-up analysis of health services received, patterns of contraception use, and pregnancy outcomes. METHOD: This study involved a retrospective review of medical records of 129 adolescent patients who had a NPT result from clinical sites in an urban medical center during a 3-month period in 1997. A stratified random sample of participants was selected from adolescents who received care at 2 school-based health centers, a women's health center, and an adolescent health clinic associated with a large academic medical center. FINDINGS: Analysis of the 129 cases indicated that the cohort of adolescents with NPTs appears to be a higher risk group of girls than suggested by previous studies. Of the multi-ethnic sample with a mean age of 16.2 +/- 1.4 years at the time of the NPT, 47% had already had 1 or more pregnancies and 25% had 1 child. Thirty percent of the subjects were offered condoms, and 50% were offered hormonal contraception at the time of the NPT; only 46% were given a return appointment. By 18 months after the index pregnancy test, 36% of the subjects had 1 or more pregnancies, and the majority of the subjects had used no form of contraception or had used contraception inconsistently. CONCLUSIONS: Comprehensive reproductive health services often are not offered to adolescents who receive NPT results. Sexually active teenagers need thorough reproductive care and consistent follow-up evaluation to avoid sexually transmitted infections (STIs) and unintended pregnancies.

Adolescent girls with negative pregnancy tests.

UNLABELLED: STUDY OBJECTIVES AND DESIGN: This descriptive study assessed background characteristics and attitudes about pregnancy held by adolescent girls presenting for pregnancy tests and receiving negative results. An additional aim was to determine types of health care services that would be of perceived benefit to them to reduce their risk of subsequent pregnancy. SETTING: Two health care sites in an urban community included a hospital-based adolescent clinic and a hospital-based women's health care clinic. PARTICIPANTS: Sixty-five adolescent, low-income, single women with negative pregnancy test results in a consecutive sample were included in the study. Participants had a mean age of 16.9 (+/-1.3) years and described themselves as 64.1% African American, 26.6% Latina and 9.4% white, with 81.5% enrolled or recently graduated from high school. MAIN OUTCOME MEASURES: The following variables were included: demographic characteristics, reproductive health history, personal and perceived partner attitude about the negative pregnancy test result, perceived parental influences, and teens' suggestions for health care services to prevent unintended pregnancy. RESULTS: Health history data revealed high risk status for unintended pregnancy and sexually transmitted infections (STI); 28.5% of participants were ambivalent or disappointed with their negative result, 71.4% were pleased and the majority felt that their partners would be more disappointed with the negative result than they were. Health care services that teens felt would be most helpful were one-on-one contraceptive education and discussion sessions with their own health care provider. CONCLUSIONS: Sexually active teen women with negative pregnancy test results are at high risk of subsequent pregnancy and STIs, and present important opportunities for preventive reproductive health care during visits with health care providers.

Negative pregnancy tests in urban adolescents: an important and often missed opportunity for clinicians.

This study describes a project to determine the incidence of negative pregnancy tests performed in an urban community for teens 18-years old and younger. Pregnancy test logs were kept at a variety of clinical agencies for a three-month period. Five hundred and fifty urine pregnancy tests were performed; 77% were negative. In our community a large number of teens are accessing health care services for pregnancy tests, the vast majority of which are negative and represent an important opportunity to prevent unintended pregnancies in a population of adolescent girls.