Adolescent Healthcare Access: A Qualitative Study of Provider Perspectives.

INTRODUCTION: Adolescent access to quality healthcare is key to prevention and early intervention for health risk behaviors. This paper provides a healthcare provider perspective on barriers and facilitators to youth accessing care. METHODS: Five focus groups were conducted from November to December 2020 with providers from a variety of healthcare settings. Participants were asked to describe their respective adolescent patient populations, adolescent-specific health concerns, and organizational accommodations specific for youth services. Transcripts were analyzed using Inductive Thematic Analysis and themes were grouped using a social-ecological framework. RESULTS: At an individual level, providers noted that an adolescent's knowledge and ability to navigate services varied greatly across settings. Providers identified provider trust and parent/guardian support as key interpersonal factors that support adolescents' access to services. Organizational factors included bureaucratic barriers and the clinic's reputation among youth. Community factors centered on mistrust within healthcare systems and stigmatization of seeking certain types of services. Participants also described how state-level policies influence parent/guardian consent requirements, which can limit adolescents' access to care. CONCLUSION: Adolescent access to and utilization of healthcare in the United States is a complex problem requiring systems-level change. Healthcare organizations and providers have the opportunity and capacity to positively influence adolescents' healthcare access and experiences, however a lack of standardized, clinic-level priorities and guidelines can limit adolescent-centered care.

Development of Youth-Centered Health Messaging Posters for High School-Based Health Clinics in Hawaii.

BACKGROUND: Youth may be reluctant to seek health care from school health providers due to feeling embarrassed or stigmatized in the health office environment or worried about their confidentiality. The purpose of this project was to create a set of youth-centered health posters that promote youth engagement with nursing staff and to standardize health messaging across high schools in Hawaii school-based clinics. METHODS: Two community advisory boards, 1 composed of 10 youth stakeholders (mean age 17 years) and the other of 7 adult stakeholders, informed poster development utilizing web-based discussion groups. The discussions were transcribed, and additional data was collected using field notes and anonymous digital messages. Adult advisory board members also provided feedback on suggested poster text through an online survey. RESULTS: Youth and adult advisory board participants identified 4 key health concerns facing youth: confidentiality, sexual health, relationships, and mental health. Based on input from the 2 advisory boards, 4 posters were developed, each centered on 1 key health issue. IMPLICATIONS FOR SCHOOL HEALTH POLICY, PRACTICE, AND EQUITY: School-based posters can convey important messages to help youth understand their health care rights and responsibilities, as well as identify important issues open for discussion with nurses. CONCLUSION: Posters are an underutilized tool for school health providers to create welcoming, inclusive health care environments and facilitate health-related conversations with youth. This paper describes participant feedback about the characteristics of a memorable poster and briefly outlines current knowledge and recommendations for school health providers regarding each of the 4 health issues.

The Development of a Systems-Level Approach to Address Adolescent Access to Health Care: A Novel Confidentiality Policy Intervention.

Most evidence-based interventions in adolescent sexual and reproductive health and mental health remain largely aimed at individual-level outcomes and do not conceptualize adolescent health within a social-ecological model. Interventions to affect policy, systems, and environmental change offer potential for sustained population impact. The current initiative used an innovation framework to develop a novel systems-level approach to address adolescent access to health care. The Framework for Public Health Innovation provided an approach to develop a novel intervention. Confident Teen is a systems-level intervention that creates the opportunity, through organizational policy change, to increase adolescents' access to confidential sexual and reproductive health services through organizational policies. Gaps in adolescents' access to health care services allowed for a systems-level approach to be designed through an adolescent pregnancy prevention innovation initiative. Confidentiality is a right and critical component to their health care; therefore, a policy and conversation between provider and patient is a prioritized component of the novel intervention.

Addressing Evaluation Barriers with Early Innovation Development for Adolescent-Focused Sexual and Reproductive Health Interventions.

Most evidence-based teen pregnancy prevention programs focus on individual-level sexual health outcomes (e.g., STIs, pregnancy, teen births). To expand program and intervention approaches within teen pregnancy prevention (TPP), the Department of Health and Human Services funded two grantees, Innovative Teen Pregnancy Prevention Programs (iTP3) and Innovation Next (IN) to support and enable early innovation to advance adolescent health and prevent teen pregnancy. The pipeline to support and enable innovation in adolescent health is complex, resulting in barriers and challenges to research and evaluation of novel programs. This paper presents some of the barriers encountered by the grantees. Data for this paper was collected from key personnel and secondary data sources. Focus group participants included seven representatives (n = 7) across the two organizations. Focus group questions assessed barriers related to innovative intervention development and evaluation. Key findings include four barriers to evaluation when fostering innovative adolescent-focused pregnancy prevention interventions. These included (a) funding constraints on evaluation activities, (b) innovation readiness for rigorous testing, (c) evaluation knowledge and expertise on innovation-development teams, and (d) challenges with evaluation requirements. Novel and promising system- and technology-focused interventions with the potential to impact TPP require alternative tools and approaches for evaluation. This would allow research to focus on how systems-level change mechanisms (i.e., policy, access to care) impact sexual risk behaviors and better understand ecological and social determinants of health for the priority population. The advancement of approaches to impact adolescent health identifies the need to expand the focus of evidence-based interventions beyond the adolescent themselves and understand approaches that impact external contexts and environments related to reducing sexual and reproductive health (SRH) risk-taking.

Supporting and Enabling the Process of Innovation in Public Health: The Framework for Public Health Innovation.

This manuscript introduces a new framework for creating innovations in public health-the Framework for Public Health Innovation. The framework was developed through a longitudinal qualitative research study that investigated the process of creating innovative adolescent health programs. Interviews were conducted with a national sample of 26 organizations over two time points. Data collection focused on the process of innovative program development; organizational capacity; training; and technical assistance needs, successes, and barriers. The framework was developed and modified based on interview findings and expert advice; then, the final framework was validated with content experts. The framework illustrates a dynamic process of innovation that begins with dissatisfaction with the status quo, and then, illustrates three necessary components for innovation-space, process, and partnerships. Four categories of innovation, which range in complexity, are proposed: (1) creating a new component to an existing program, (2) adapting an existing program to meet new needs, (3) taking an alternative approach to addressing an existing program, and (4) reframing a health problem from a new perspective. As illustrated by a feedback loop, the resulting innovations disrupt the status quo. This model can be applied to any content area in public health and is useful for both research and practitioners.

A program evaluation of the Innovative Teen Pregnancy Prevention Programs (iTP3) Project.

BACKGROUND: Teen pregnancy prevention in the United States has traditionally focused on the development, testing, and subsequent implementation of a set of evidence-based programs (EBPs), recommended nationally. However, these existing EBPs often do not prioritize the most at-risk or vulnerable populations. METHODS: The Innovative Teen Pregnancy Prevention Programs (iTP3) project was funded to facilitate the development of new, innovative programs to reach disparate populations. Through a mixed methods design, iTP3 evaluated the process and resulting innovative programs from five iterative cohorts of funded organizations, referred to as Innovators. iTP3 utilized both a traditional funding model with more traditional methods of capacity building assistance, but transitioned over time to a design-focused funding model in which organizations and individuals developed innovative programs through an intensive human centered design process. RESULTS: Evaluation results showed that the resulting portfolio of programs had differences in the types of programs resulting from the differing funding models. Notable differences among programs from the two funding models include program length, along with personnel, time, and resources needed to develop and manage. CONCLUSION: Both traditional and design funding models led to innovative programs, with notable differences in the development process and resulting programs.

School-Level Efforts to Address Sexual Health and Risky Sexual Behavior Among Students in Texas Alternative High Schools.

We compared sexual/reproductive health services and sexuality education topics provided in Texas alternative high schools (AHSs) with the prevalence of sexual risk behaviors among students in AHS. Using cross-sectional data from convenience samples of 14 principals, 14 lead health educators, and 515 students, we calculated descriptive statistics for 20 services and 15 sexuality education topics provided by AHSs and seven sexual risk behaviors among students in AHS. AHSs provided few sexual/reproductive health services and limited educational content, despite high levels of sexual risk taking among students. For example, no AHSs taught students about proper condom use, yet 84% of students have had sex. Findings provide preliminary evidence of unmet needs for school-based sexual/reproductive health services and comprehensive sexuality education in AHS settings. Future investigation with larger, representative samples is needed to assess the provision of sexual/reproductive health services and sexuality education in AHSs and monitor sexual risk behaviors in the AHS population.

Self-Perceptions and Factors Associated With Being Put Down at School Among Middle and High School Students.

This study assessed the prevalence of verbally being put down by others and intrapersonal and normative factors associated with being put down by others among middle and high school students. Students (N = 1,027) completed the Adolescent Health Risk Behavior Survey. Over 16% of participants reported being put down at school. Students who identified with the negative words confused, unattractive, dull, and careless and identified less with the positive words popular, smart, considerate, cool, and self-confident reported being put down by others. High school students were less likely to be put down. As students scored higher on the Negative Self-Description Scale, their odds of being put down increased. As students scored higher on the Positive Self-Description Scale, their odds of being put down decreased. Students who perceived their friends drinking alcohol regularly were less likely to be put down. Strategies to enhance self-perceptions to raise self-awareness and form healthy/positive identities are needed.

Provision of contraceptive implants in school-based health centers: A cost-effectiveness analysis.

OBJECTIVE: To evaluate the cost-effectiveness of providing contraceptive implants in school-based health centers (SBHCs) compared to the practice of referring adolescents to non-SBHCs in New York City. STUDY DESIGN: We developed a microsimulation model of teen pregnancy to estimate the cost-effectiveness of immediate provision of contraceptive implants at SBHCs over a 3-year time horizon. Model parameters were derived from both a retrospective chart review of patient data and published literature. The model projected the number of pregnancies as well as the total costs for each intervention scenario. The incremental cost-effectiveness ratio was calculated using the public payer perspective, using direct costs only. RESULTS: The health care cost of immediate provision of contraceptive implants at SBHCs was projected to be $13,719 per person compared to $13,567 per person for delayed provision at the referral appointment over 3 years. However, immediate provision would prevent 78 more pregnancies per 1000 adolescents over 3 years. The incremental cost-effectiveness ratio for implementing in-school provision was $1940 per additional pregnancy prevented, which was less than the $4206.41 willingness-to-pay threshold. Sensitivity analyses showed that the cost-effectiveness conclusion was robust over a wide range of key model inputs. CONCLUSION: Provision of contraceptive implants in SBHCs compared to non-SBHCs is cost-effective for preventing unintended teen pregnancy. Health care providers and policymakers should consider expanding this model of patient-centered health care delivery to other locations.

Condom Use for Sexually Transmitted Infection Prevention Among Hispanic Teenage Mothers: A Community-Based Randomized Trial.

Background: Hispanics experience a higher prevalence of sexually transmitted infections (STIs) than non-Hispanics. Specifically, Hispanic teenagers are more at risk for HIV, have close to four times the rate of primary and secondary syphilis, and close to two times the rate of chlamydia and gonorrhea compared with non-Hispanic white teenagers. Hispanic youth engage in sexual activity at a younger age than non-Hispanic white youth and are less likely to use condoms in these encounters, thereby contributing to increased rates of teenage pregnancy and STIs. Prevention of STIs is needed for unmarried Hispanic teenage mothers. The purpose of this study was to examine whether Project Mothers and Schools (Project MAS), a support program for parenting teenagers, changed condom use to prevent STIs among Hispanic participants. Methods: A longitudinal study was conducted among 84 Hispanic teenage mothers. Generalized estimating equations were used to identify factors associated with participants' reported condom use to prevent STIs. Results: Overall, participants were 3.21 times more likely to report condom use to prevent STIs from baseline to 12-month follow-up (p = 0.030). Those using condoms to prevent pregnancy at 12-month follow-up were significantly more likely to report using a condom to prevent STIs (OR = 3.23, p = 0.017). Conclusions: Participation in Program MAS improved condom use patterns for STI prevention. These services and supports have potential to change unmarried Hispanic teenage mothers' condom use behaviors and decrease STI infection disparities among the teenage Hispanic population.

Identifying the Inclusion of National Sexuality Education Standards Utilizing a Systematic Analysis of Teen Dating Violence Prevention Curriculum.

BACKGROUND: Violent behaviors have devastating impacts on youth and adolescents. National standards offer a framework for age and developmentally appropriate health education expectations. This study provides findings from a systematic review and analysis of teen dating violence (TDV) prevention curricula using National Sexuality Education Standards (NSES) and National Health Education Standards (NHES). METHODS: Evidence-based and/or practice informed interventions for TDV prevention were compiled and analyzed. We used a standardized review instrument to analyze each curriculum (N = 11); each curriculum was reviewed independently and results met inter-rater agreement requirements. Data were analyzed to determine NSES and NHES inclusion. RESULTS: This study provides findings from the TDV prevention curriculum analysis using the NSES. Five NSES topic areas were addressed in the TDV prevention curriculum and included personal safety, healthy relationships, identity, sexually transmitted diseases and human immunodeficieny virus, and pregnancy and reproduction. Personal safety was the most included topic and ranged from 37% to 77%. Healthy relationships were the second most included NSES and ranged from 11% to 53%. Inclusions of NHES skills, as they are embedded within the NSES, are identified. CONCLUSIONS: Curricula decision-makers gain insight by conducting reviews before recommendations are made or the adoption process is complete. The NSES and NHES support expectations for TDV prevention and can guide curricula adoption for a school or district. School professionals should work together to ensure TDV prevention curricula complements sexuality education units. While TDV curricula may cover critical topics, a singular focus on one content area cannot replace comprehensive sexuality education.

Factors Associated with College Women's Personal and Parental Decisions to be Vaccinated Against HPV.

The human papillomavirus (HPV) is a public health concern because of its association with cancer. HPV vaccine rates among college students remains low. This is a critical catch-up age for individuals to receive the HPV vaccine and research shows parents still play a role in college students' medical decision-making. Therefore, the purpose of this study was to examine factors related to college women making a solo decision to initiate the HPV vaccination in comparison to making a joint parent-daughter decision. Data collected using an internet-delivered questionnaire were analyzed from 799 college women who had initiated or completed the HPV vaccination. Multinomial logistic regression was performed to compare study variables on who decided the participant should be vaccinated (self-decision, parent-only decision, joint parent-daughter decision). Participants who were older (OR 1.68, p < 0.001) and sexually active (OR 4.97, p < 0.001) were significantly more likely to have made a solo decision to be vaccinated. Participants who completed the HPV vaccination (OR 0.33, p < 0.001) and those who talked with a parent about the HPV vaccine (OR 0.12, p < 0.001) were significantly less likely to have made a solo decision to be vaccinated. Findings indicate joint parent-daughter decisions may improve HPV vaccination cycle completion.

Characteristics Associated with HPV Diagnosis and Perceived Risk for Cervical Cancer Among Unmarried, Sexually Active College Women.

Human papillomavirus (HPV) has been identified as the leading cause of cervical cancer. While HPV risk factors have been well studied, less is known about those with HPV and their perceptions about health ramifications. The purposes of this study were to examine unmarried college student women's (1) HPV diagnosis status and (2) perceived risk of getting cervical cancer in the next 5 years. Data were analyzed from 1106 unmarried, sexually active college women aged 18 to 26. Binary logistic regression compared HPV-related knowledge, vaccination-related perceptions, mandate support, healthcare utilization, sexual behaviors, and personal characteristics. Multinomial logistic regression was performed to assess the degree to which these factors were associated with perceived risk of cervical cancer diagnosis. Relative to those not diagnosed with HPV, participants who had more lifetime sex partners (P < 0.001), unprotected sex during last intercourse (P = 0.003), Pap test in the past year (P < 0.001), and perceived themselves to be at higher risk for cervical cancer (P < 0.001) were significantly more likely to be diagnosed with HPV. Those with HPV were more likely to support HPV vaccination mandates (P = 0.036) and have fewer friends vaccinated (P = 0.002). Participants who were uninsured (P = 0.011), diagnosed with HPV (P < 0.001), and had a family member (P < 0.001) or friend (P < 0.001) with cervical cancer were more likely to perceive themselves at risk for developing cervical cancer in the next 5 years. Findings indicate women with HPV, despite engaging in risky sexual behaviors, acknowledge their cervical cancer risk and may be strong advocates for HPV vaccination mandates to protect youth against this preventable virus.

Exploring sexual behaviors and health communication among older women.

Older women around the globe are generally depicted as asexual beings, which may impact patient-provider discussions about sex. We examined data on 703 aging women in the United States to compare factors associated with women perceiving sex as important and women discussing sex with their physicians since turning 50. While 65.1% of participants perceived sex to be important, only 23.8% discussed sex with their providers since turning 50. Factors related to discussing sex included age, education, having a chronic condition, and consuming alcohol. Provider training and tools about sexual health communication could help launch those discussions about sex and increase advocacy for older women's sexual health.

HPV Vaccination Status and Mandate Support for School-Aged Adolescents Among College Females.

The purpose of this study was to describe college-aged females' human papillomavirus (HPV) knowledge and beliefs, perceptions and perceived benefits of the HPV vaccine, and identify characteristics associated with vaccination status and support for HPV vaccine mandates. Data were collected from 1,105 females by an Internet-delivered questionnaire during February to March 2011. This descriptive study utilizes χ2 tests and t-tests to compare participant responses. HPV-related knowledge scores were 8.08 out of 11 points. Those who initiated HPV vaccination were significantly younger, single, engaged in sex, were sexually active, and had a Pap test. Participants who had more friends receiving the vaccine were significantly more likely to support mandates for 9-11 and 12-17 years and were more likely to complete the HPV vaccination cycle. Findings suggest the importance of educational programs adopted and delivered by school nurses, which aim to improve student knowledge and reduce misconceptions related to the HPV vaccine and vaccination mandates.

Factors associated with school nurses' HPV vaccine attitudes for school-aged youth.

School nurses are at the intersection of the healthcare and school communities, thus, they can be considered opinion leaders in providing health advice - including information about the human papillomavirus (HPV) vaccine - to parents and students. This study examined school nurses' attitudes toward the HPV vaccine based on age, years as a school nurse, geographic location, urban vs. rural work setting, HPV and vaccine knowledge, perception of role as opinion leaders, and school district support in providing health education. Participants (n = 413) were systematically sampled from the National Association of School Nurses' membership and completed a web-based survey. Multiple regression was used to predict positive HPV vaccine attitudes. The model was statistically significant accounting for 50.8% of the variance (F [9, 400] = 45.96, p < .001). Positive attitudes regarding the HPV vaccine were predicted by higher HPV and vaccine knowledge (ß = .096, p < .001) and stronger perceptions of role as opinion leaders for the vaccine (ß = .665, p < .001). No other variables were found to be statistically significant. These results suggest knowledge is essential in predicting positive attitudes, but not the strongest predictor as perceptions of role as opinion leaders was more crucial in terms of predicting school nurses' positive attitudes towards HPV vaccine. Despite school nurses being seen as champions for adolescent vaccines, they need additional professional development to increase their HPV vaccine knowledge and attitudes to encourage parents and adolescents to consider the uptake of HPV vaccination. To engage school nurses' in promoting HPV vaccine uptake, interventions need to focus on increasing school nurses' perception of their role as opinion leaders for HPV vaccine and knowledge to increase positive attitudes towards HPV vaccination for youth.

Factors Associated With Intentions to Engage in Vaginal Intercourse Among Sexually Abstinent Missouri High School Freshmen.

BACKGROUND: We examine personal characteristics, alcohol consumption, normative beliefs, household factors, and extracurricular engagement associated with intentions to have intercourse before marriage among abstinent students. METHODS: Data were analyzed from 245 freshmen enrolled in a school-based abstinence-only-until-marriage program. Two binary logistic regression analyses identified factors associated with intentions to engage in intercourse before marriage and within the next year. RESULTS: Approximately 21% and 14% of participants reported intentions to have intercourse. Respondents participated in 2.2 (standard deviation [SD] = 1.2) extracurricular activities. Freshmen who were male, perceived their friends to approve of premarital sex, and consumed alcohol were more likely to report intentions to have intercourse. For every additional extracurricular activity in which freshmen participated, they were less likely to report intentions to have intercourse within the next year (odds ratio [OR] = 0.56). CONCLUSIONS: Factors such as extracurricular activities provide youth with opportunities to build supportive relationships, connect with peers and role models, and positively engage in schools and communities. Extracurricular activities typically already exist, have funding, and are generally well-supported. School-based strategies can increase teenagers' autonomy by providing a variety of activities to participate in and reduce unsupervised time. This, in turn, has the potential to decrease sexual risk taking behaviors.

Failure to Report Effect Sizes: The Handling of Quantitative Results in Published Health Education and Behavior Research.

Given the American Psychological Association's strong recommendation to always report effect sizes in research, scholars have a responsibility to provide complete information regarding their findings. The purposes of this study were to (a) determine the frequencies with which different effect sizes were reported in published, peer-reviewed articles in health education, promotion, and behavior journals and (b) discuss implications for reporting effect size in social science research. Across a 4-year time period (2010-2013), 1,950 peer-reviewed published articles were examined from the following six health education and behavior journals: American Journal of Health Behavior, American Journal of Health Promotion, Health Education & Behavior, Health Education Research, Journal of American College Health, and Journal of School Health Quantitative features from eligible manuscripts were documented using Qualtrics online survey software. Of the 1,245 articles in the final sample that reported quantitative data analyses, approximately 47.9% (n = 597) of the articles reported an effect size. While 16 unique types of effect size were reported across all included journals, many of the effect sizes were reported with little frequency across most journals. Overall, odds ratio/adjusted odds ratio (n = 340, 50.1%), Pearson r/r(2) (n = 162, 23.8%), and eta squared/partial eta squared (n = 46, 7.2%) accounted for the most frequently used effect size. Quality research practice requires both testing statistical significance and reporting effect size. However, our study shows that a substantial portion of published literature in health education and behavior lacks consistent reporting of effect size.