Narrative Play-Promoting Adolescent Health With Interactive Games.

This Arts and Medicine feature discusses INSPIRE, a digital health game designed to foster adolescent health behavior change.

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

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

Albert Bandura (1925-2021).

Memorializes Albert Bandura (1925-2021). Bandura is internationally recognized as one of the world's most influential psychologists. Often compared in significance to Skinner, Freud, and Piaget, he is one of the most frequently cited psychologists of all time. His social cognitive theory of human functioning, emphasizing an agentic perspective toward self-development, adaptation, and change has had a profound effect across psychology, revolutionizing theories of behavior change and shaping education, public health, parenting, clinical health practice, and public policy. He served as President of the American Psychological Association (APA) in 1974 at a time when psychologists were facing negative publicity about the dangers of behavior modification and Nixon administration cuts in funding. He presided over the founding of the Association for the Advancement of Psychology, seeing it as a vehicle to utilize psychological knowledge in developing public policy. Bandura died on July 26, 2021, at his family home. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Adolescent Technology-use Rules and Sleep in a Large Representative Sample.

PURPOSE: This study investigated the prevalence of technology-use rules, typical sleep habits, and associations between rules and sleep using the representative 2017-2018 California Health Interview Survey adolescent sample. METHODS: Adolescents aged 12-17 years completed the California Health Interview Survey, including queries of (1) rules at home regarding times to turn off or put away electronics and (2) school-night bedtime and rise time. Rates of rules and associations between rules and sleep were investigated using descriptive statistics and bivariate and multivariable analyses. RESULTS: Seventy-two percent reported technology-use rules. Rates were comparable across subgroups. Rules and sleep were not significantly associated after adjusting for covariates. Reported time in bed fell below National Sleep Foundation guidelines for 38% of participants. CONCLUSIONS: Most adolescents reported technology-use rules at home. Associations between rules and bedtime were mixed, suggesting that further exploration of contextual and developmental factors is needed. Many reported inadequate sleep duration, supporting sleep as a key topic in adolescent health.

Delivering Anticipatory Guidance About Technology Use to Adolescents in Primary Care: Rates in a Representative California Sample.

PURPOSE: This study aimed to investigate rates of anticipatory guidance about technology use in primary care, as recommended by the American Academy of Pediatrics Bright Futures Guidelines, in a representative sample of California adolescents. METHODS: Adolescents 12-17 years of age were interviewed as part of the California Health Interview Survey, the largest state health surveillance survey in the U.S. Participants who reported seeing a doctor for a physical examination or checkup in the prior year were asked if their doctor had talked to them about technology use. RESULTS: Overall, 29.7% of the 742 participants reported that their doctor talked to them about technology use. There were no statistically significant differences in rates by age, sex, race/ethnicity, household income, or family type. CONCLUSIONS: While the American Academy of Pediatrics recommends that providers deliver anticipatory guidance about technology use to adolescents in primary care, less than one-third of adolescents surveyed reported having conversations about this topic with their doctor. Given concerns about potential impacts of technology use on adolescent health, medical education should facilitate provider screening and counseling of adolescents about technology use in primary care settings.

Evaluating the sustainability of a cancer screening intervention through a PRISM: The PreView experience.

Although many trials of cancer screening interventions evaluate efficacy and effectiveness, less research focuses on how to sustain interventions in non-research settings, which limit the potential reach of these interventions. Identifying the factors that influence the potential for sustainability is critical. We evaluate the factors influencing sustainability of PreView, a Cancer Screening Intervention, within the context of the Practical, Robust Implementation and Sustainability Model (PRISM). PRISM includes organizational and patient perspectives of the intervention as well as characteristics of the organizational and patient recipients. It considers how the program or intervention design, external environment, implementation, and sustainability infrastructure and the recipients influence program adoption, implementation, and maintenance. We evaluate the attempts at sustainability of PreView within the constructs of PRISM. Encouraging patients to use PreView was more difficult outside of a clinical trial. Organizational perspectives on how the intervention fit in with other goals, patient perspectives on how the intervention is individualized (i.e. being able to choose which cancer screening to address) and focused on barriers, patient characteristics (i.e. having multiple comorbidities making cancer screening less of a priority), organizational characteristics (i.e. middle managers having competing responsibilities), external environment influences (i.e. reimbursement for achieving certain cancer screening goals), and sustainability infrastructure all affect the likelihood of PreView being sustained in clinical practice. Despite advance planning for sustainability, adapting interventions to achieve sustainability is difficult. Lessons learned from evaluating PreView within the PRISM model can inform future sustainability efforts.

Using Standardized Patients to Augment Communication Skills and Self-Efficacy in Caring for Transgender Youth.

OBJECTIVE: To examine the impact of standardized patient encounters (SPEs) on gender-affirming communication skills and self-efficacy of pediatrics learners. METHODS: Fourth-year medical students, pediatrics interns, psychiatry interns, and nurse practitioner trainees on 1-month adolescent medicine blocks completed a curriculum with e-learning activities that was expanded to include SPEs. Following e-learning, learners completed 2 SPEs featuring transgender adolescent cases. Faculty observers and standardized patients completed checklists focused on history-taking, counseling, and interpersonal communication, and provided learner feedback after each case. The curriculum was evaluated by comparing skills checklists scores from case 1 to case 2 via Wilcoxon signed-rank tests. Self-efficacy was assessed precurriculum (Assessment 1), post-e-learning (Assessment 2), and post-SPE (Assessment 3) using a previously developed instrument. Changes in self-efficacy scores were assessed via linear regression models with generalized estimating equations. RESULTS: Forty-three eligible learners participated in the study. The majority were pediatrics interns, and 5 learners had worked in a transgender clinic prior to the curriculum participation. Learners increased median total checklist scores between cases from 22 to 28 (P < .001) (maximum score of 34). Learners' overall self-efficacy scores improved by 3.4 (confidence interval [CI]: 2.9-3.9; P < .001) between Assessments 1 and 2 and by 1.5 (CI: 1.2-1.7; P < .001) from Assessment 2 to 3. Similar improvements in checklist scores and self-efficacy occurred within stratified learner types. CONCLUSIONS: The combination of SPEs with e-learning is effective at improving self-efficacy and gender-affirming communication skills for a multidisciplinary pediatrics learners. The comprehensive curriculum allowed learners inexperienced with transgender youth to apply knowledge and practice skills.

Electronic Health Risk Behavior Screening With Integrated Feedback Among Adolescents in Primary Care: Randomized Controlled Trial.

BACKGROUND: Health risk behaviors are the most common sources of morbidity among adolescents. Adolescent health guidelines (Guidelines for Preventive Services by the AMA and Bright Futures by the Maternal Child Health Bureau) recommend screening and counseling, but the implementation is inconsistent. OBJECTIVE: This study aims to test the efficacy of electronic risk behavior screening with integrated patient-facing feedback on the delivery of adolescent-reported clinician counseling and risk behaviors over time. METHODS: This was a randomized controlled trial comparing an electronic tool to usual care in five pediatric clinics in the Pacific Northwest. A total of 300 participants aged 13-18 years who attended a well-care visit between September 30, 2016, and January 12, 2018, were included. Adolescents were randomized after consent by employing a 1:1 balanced age, sex, and clinic stratified schema with 150 adolescents in the intervention group and 150 in the control group. Intervention adolescents received electronic screening with integrated feedback, and the clinicians received a summary report of the results. Control adolescents received usual care. Outcomes, assessed via online survey methods, included adolescent-reported receipt of counseling during the visit (measured a day after the visit) and health risk behavior change (measured at 3 and 6 months after the visit). RESULTS: Of the original 300 participants, 94% (n=282), 94.3% (n=283), and 94.6% (n=284) completed follow-up surveys at 1 day, 3 months, and 6 months, respectively, with similar levels of attrition across study arms. The mean risk behavior score at baseline was 2.86 (SD 2.33) for intervention adolescents and 3.10 (SD 2.52) for control adolescents (score potential range 0-21). After adjusting for age, gender, and random effect of the clinic, intervention adolescents were 36% more likely to report having received counseling for endorsed risk behaviors than control adolescents (adjusted rate ratio 1.36, 95% CI 1.04 to 1.78) 1 day after the well-care visit. Both the intervention and control groups reported decreased risk behaviors at the 3- and 6-month follow-up assessments, with no significant group differences in risk behavior scores at either time point (3-month group difference: ß=-.15, 95% CI -0.57 to -0.01, P=.05; 6-month group difference: ß=-.12, 95% CI -0.29 to 0.52, P=.57). CONCLUSIONS: Although electronic health screening with integrated feedback improves the delivery of counseling by clinicians, the impact on risk behaviors is modest and, in this study, not significantly different from usual care. More research is needed to identify effective strategies to reduce risk in the context of well-care. TRIAL REGISTRATION: ClinicalTrials.gov NCT02882919; https://clinicaltrials.gov/ct2/show/NCT02882919.

Adolescent Risk Behavior Screening and Interventions in Hospital Settings: A Scoping Review.

CONTEXT: Risky behaviors are the main threats to adolescents' health; consequently, evidence-based guidelines recommend annual comprehensive risk behavior screening. OBJECTIVE: To review studies of adolescent risk behavior screening and interventions in urgent care, emergency department (ED), and hospital settings. DATA SOURCES: Our data sources included PubMed (1965-2019) and Embase (1947-2019). STUDY SELECTION: Studies were included on the basis of population (adolescents aged 10-25 years), topic (risk behavior screening or intervention), and setting (urgent care, ED, or hospital). Studies were excluded if they involved younger children or adults or only included previously identified high-risk adolescents. DATA EXTRACTION: Data extracted were risk behavior screening rates, screening and intervention tools, and attitudes toward screening and intervention. RESULTS: Forty-six studies were included; most (38 of 46) took place in the ED, and a single risk behavior domain was examined (sexual health [19 of 46], mood and suicidal ideation [12 of 46], substance use [7 of 46], and violence [2 of 46]). In 6 studies, authors examined comprehensive risk behavior screening, demonstrating low rates at baseline (∼10%) but significant increases with clinician reminder implementation. Adolescents and clinicians were highly accepting of risk behavior screening in all settings and preferred electronic screening over a face-to-face interview. Reported barriers were time constraints and limited resources. LIMITATIONS: Only 1 included study was a randomized controlled trial, and there was large heterogeneity of included studies, potentially limiting generalizability. CONCLUSIONS: Rates of adolescent risk behavior screening are low in urgent care, ED, and hospital settings. Our findings outline promising tools for improving screening and intervention, highlighting the critical need for continued development and testing of interventions in these settings to improve adolescent care.

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

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

"What's Important to You, Max?": The Influence of Goals on Engagement in an Interactive Narrative for Adolescent Health Behavior Change.

Interactive narrative technologies for preventive health care offer significant potential for promoting health behavior change in adolescents. By improving adolescents' knowledge, personal efficacy, and self-regulatory skills these technologies hold great promise for realizing positive impacts on adolescent health. These potential benefits are enabled through story-centric learning experiences that provide opportunities for adolescents to practice strategies to reduce risky health behaviors in engaging game-based environments. A distinctive feature of interactive narrative that promotes engagement is players' ability to influence the story through the choices they make. In this paper, we present initial work investigating engagement in an interactive narrative that focuses on reducing adolescents' risky behaviors around alcohol use. Specifically, we consider how the short-term and long-term goals adolescents choose as being important to the protagonist character relates to their engagement with the interactive narrative. Leveraging interaction log data from a pilot study with 20 adolescents, we conduct a cluster-based analysis of the goals players selected. We then examine how engagement differs between the identified clusters. Results indicate that adolescents' choices for the protagonist's short-term and long-term goals can significantly impact their engagement with the interactive narrative.

Digital Health Technology to Enhance Adolescent and Young Adult Clinical Preventive Services: Affordances and Challenges.

The lives of adolescents and young adults (AYAs) have become increasingly intertwined with technology. In this scoping review, studies about digital health tools are summarized in relation to five key affordances-social, cognitive, identity, emotional, and functional. Consideration of how a platform or tool exemplifies these affordances may help clinicians and researchers achieve the goal of using digital health technology to enhance clinical preventive services for AYAs. Across these five affordances, considerable research and development activity exists accompanied by signs of high promise, although the literature primarily reflects demonstration studies of acceptability or small sample experiments to discern impact. Digital health technology may afford an array of functions, yet its potential to enhance AYA clinical preventive services is met with three key challenges. The challenges discussed in this review are the disconnectedness between digital health tools and clinical care, threats to AYA privacy and security, and difficulty identifying high-value digital health products for AYA. The data presented are synthesized in calls to action for the use of digital health technology to enhance clinical preventive services and to ensure that the digital health ecosystem is relevant, effective, safe, and purposed for meeting the health needs of AYA.

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

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

Leveraging Technology to Improve Health in Adolescence: A Developmental Science Perspective.

As technologies continue to evolve at exponential rates, online platforms are becoming an increasingly salient social context for adolescents. Adolescents are often early adopters, savvy users, and innovators of technology use. This not only creates new vulnerabilities but also presents new opportunities for positive impact-particularly, the use of technology to promote healthy learning and adaptation during developmental windows of opportunity. For example, early adolescence appears to represent a developmental inflection point in health trajectories and in technology use in ways that may be strategically targeted for prevention and intervention. The field of adolescent health can capitalize on technology use during developmental windows of opportunity to promote well-being and behavior change in the following ways: (1) through a deeper understanding of the specific ways that developmental changes create new opportunities for motivation and engagement with technologies; (2) by leveraging these insights for more effective use of technology in intervention and prevention efforts; and (3) by combining developmental science-informed targeting with broader-reach technologic approaches to health behavior change at the population level (e.g., leveraging and changing social norms). Collaboration across disciplines-including developmental science, medicine, psychology, public health, and computer science-can create compelling innovations to use digital technology to promote health in adolescents.

A Pediatric Transgender Medicine Curriculum for Multidisciplinary Trainees.

Introduction: While pediatricians should receive training in the care of transgender youth, a paucity of formal educational curricula have been developed to train learners to care for this vulnerable population. Methods: We developed a curriculum including six online modules and an in-person afternoon session observing clinic visits in a pediatric gender clinic. Learners-fourth-year medical students, interns, and nurse practitioner trainees-received protected time during an adolescent medicine rotation to complete the online modules (total duration: 77 minutes). For 20 learners, we assessed the impact of the entire curriculum-online modules and in-person observation-on self-perceived knowledge of considerations for transgender youth. For 31 learners, we assessed the effect of the online modules alone on knowledge and self-efficacy. Descriptive analyses illustrated changes in educational domains by learner group. Results: On evaluations of the entire curriculum (modules and observation), median self-perceived knowledge scores (1 = not at all knowledgeable/aware, 5 = extremely knowledgeable/aware) increased within learner groups: pediatric interns (from 2.3 to 4.0), nurse practitioner trainees (from 2.9 to 4.7), fourth-year medical students (from 3.3 to 4.9), and psychiatry interns (from 2.8 to 4.4). Assessment of learners completing only the online modules demonstrated increases in median knowledge and self-efficacy scores within learner groups. All learner groups highly valued the curriculum. Discussion: Our curriculum for multidisciplinary learners in the care of transgender youth was successful and well received. Increasing learner knowledge and self-efficacy is an important step towards skill development in patient care for the transgender youth population.

PreView: a Randomized Trial of a Multi-site Intervention in Diverse Primary Care to Increase Rates of Age-Appropriate Cancer Screening.

BACKGROUND: Women aged 50-70 should receive breast, cervical (until age 65), and colorectal cancer (CRC) screening; men aged 50-70 should receive CRC screening and should discuss prostate cancer screening (PSA). PreView, an interactive, individually tailored Video Doctor Plus Provider Alert Intervention, adresses all cancers for which average risk 50-70-year-old individuals are due for screening or screening discussion. METHODS: We conducted a randomized controlled trial in 6 clinical sites. Participants were randomized to PreView or a video about healthy lifestyle. Intervention group participants completed PreView before their appointment and their clinicians received a "Provider Alert." Primary outcomes were receipt of mammography, Pap tests (with or without HPV testing), CRC screening (FIT in last year or colonoscopy in last 10 years), and PSA screening discussion. Additional outcomes included breast, cervical, and CRC screening discussion. RESULTS: A total of 508 individuals participated, 257 in the control group and 251 in the intervention group. Screening rates were relatively high at baseline. Compared with baseline screening rates, there was no significant increase in mammography or Pap smear screening, and a nonsignificant increase (18% vs 12%) in CRC screening. Intervention participants reported a higher rate of PSA discussion than did control participants (58% vs 36%: P < 0.01). Similar increases were seen in discussions about mammography, cervical cancer, and CRC screening. CONCLUSION: In clinics with relatively high overall screening rates at baseline, PreView did not result in significant increases in breast, cervical, or CRC screening. PreView led to an increase in PSA screening discussion. Clinician-patient discussion of all cancer screenings significantly increased, suggesting that interventions like PreView may be most useful when discussion of the pros and cons of screening is recommended and/or with patients reluctant to undergo screening. Future research should investigate PreView's impact on those who are hesitant or reluctant to undergo screening. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02264782.

Experiences With Querying Gender Identity Across Seven Adolescent Medicine Sites.

PURPOSE: To determine how the seven Maternal and Child Health Bureau funded Leadership and Education in Adolescent Health (LEAH) programs currently obtain information on gender identity from their patients. METHODS: A computerized survey was sent to all LEAH site directors with questions to identify if and how programs documented youth's gender identity and barriers to implementation. RESULTS: With response rate of 100%, seven LEAH programs reported a total of 43 primary care and specialty clinics. For clinics with Electronic Health Records, 67% of clinics had a standardized gender identity question. Barriers to implementing a standardized question included concerns about confidentiality, lack of trained providers, low numbers of transgender patients, and no validated gender identity question. CONCLUSIONS: Incorporation of inquiry of gender identity is possible in numerous clinical settings that serve adolescents. Future research is needed to determine how this information affects conversations with providers and necessary referrals to treatment.

Teaching paediatric transgender care.

BACKGROUND: We aimed to evaluate the effect of online modules - as stand-alone training - on paediatric transgender-related self-perceived knowledge, objective knowledge, and clinical self-efficacy of learners. We previously evaluated the online modules as part of a larger curriculum that included observation in a paediatric transgender clinic, and assessed change in self-perceived knowledge. METHODS: Paediatric interns, psychiatry interns, fourth-year medical students and nurse practitioner students were administered assessments before and after the completion of six online modules focused on medical and psychosocial considerations for transgender youth. The assessments queried learner demographics and transgender clinical exposure. Nine items tested transgender-related objective knowledge. Twenty-four items asked learners to rate self-perceived transgender-specific knowledge (1, not at all knowledgeable; 5, completely knowledgeable). Thirteen self-efficacy items asked learners to rate confidence in their ability to evaluate and counsel these youth (0, not at all confident; 10, completely confident). Overall and subscores were calculated for each domain. Wilcoxon signed-rank tests were used to compare the pre- and post-module scores. RESULTS: Thirty-six learners were eligible to join the study and 86% (n = 31) participated. Among the participants, 90% (n = 28) completed both assessments. The median number of transgender patients seen before the curriculum was one, and 10% had past experience in a transgender clinic. Comparing pre- and post-module scores, the overall objective knowledge scores increased from 22 to 56% (p < 0.001), self-perceived knowledge scores increased from 1.8 to 3.8 (p < 0.001) and self-efficacy scores increased from 3.5 to 7.0 (p < 0.001). [What is] the effect of online modules on paediatric transgender-related self-perceived knowledge [?] DISCUSSION: This study suggests that e-learning was an effective stand-alone intervention to enhance transgender-related knowledge and self-efficacy in interdisciplinary learners.

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

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