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.

Acceptance- and mindfulness-based techniques for physical activity promotion in breast cancer survivors: a qualitative study.

PURPOSE: The purpose of this study was to develop and characterize the relevance and potential utility of an electronically delivered acceptance- and mindfulness-based approaches to physical activity promotion for insufficiently active breast cancer survivors. METHODS: The acceptance- and mindfulness-based physical activity intervention was delivered to participants electronically over the course of 4-8 weeks. It consisted of didactic videos, experiential exercises, and workbook-type activities that targeted principles from acceptance and commitment therapy (ACT). We conducted semi-structured, in-depth interviews with participants after they completed the intervention. Three coders conducted qualitative data analysis on interview transcripts to identify overarching themes and subthemes. RESULTS: We recruited 30 participants. Of those, 16 engaged in an individual interview. The mean age of the sample was 58.4 years (SD = 13.8). The sample was relatively well educated (50.0% college graduates) and mostly overweight or obese (58.8%). We identified two overarching themes from interviews. They were centered on (1) internal and external barriers to physical activity adherence and (2) the utility of targeting core ACT processes (acceptance and defusion, mindfulness, and values clarification) for physical activity promotion. CONCLUSION: Intervention content was perceived to be acceptable, relevant, and to fulfill important needs related to healthy living. Findings suggest that this approach to physical activity promotion can be delivered effectively online. Electronically delivered acceptance- and mindfulness-based approaches hold promise for helping insufficiently active breast cancer survivors increase physical activity.

A Randomized Controlled Trial to Prevent Depression and Ameliorate Insulin Resistance in Adolescent Girls at Risk for Type 2 Diabetes.

BACKGROUND: Prospective data suggest depressive symptoms worsen insulin resistance and accelerate type 2 diabetes (T2D) onset. PURPOSE: We sought to determine whether reducing depressive symptoms in overweight/obese adolescents at risk for T2D would increase insulin sensitivity and mitigate T2D risk. METHOD: We conducted a parallel-group, randomized controlled trial comparing a 6-week cognitive-behavioral (CB) depression prevention group with a 6-week health education (HE) control group in 119 overweight/obese adolescent girls with mild-to-moderate depressive symptoms (Center for Epidemiological Studies-Depression Scale [CES-D] ≥16) and T2D family history. Primary outcomes were baseline to post-intervention changes in CES-D and whole body insulin sensitivity index (WBISI), derived from 2-h oral glucose tolerance tests. Outcome changes were compared between groups using ANCOVA, adjusting for respective baseline outcome, puberty, race, facilitator, T2D family history degree, baseline age, adiposity, and adiposity change. Multiple imputation was used for missing data. RESULTS: Depressive symptoms decreased (p < 0.001) in CB and HE from baseline to posttreatment, but did not differ between groups (ΔCESD = -12 vs. -11, 95 % CI difference = -4 to +1, p = 0.31). Insulin sensitivity was stable (p > 0.29) in CB and HE (ΔWBISI = 0.1 vs. 0.2, 95 % CI difference = -0.6 to +0.4, p = 0.63). Among all participants, reductions in depressive symptoms were associated with improvements in insulin sensitivity (p = 0.02). CONCLUSIONS: Girls at risk for T2D displayed reduced depressive symptoms following 6 weeks of CB or HE. Decreases in depressive symptoms related to improvements in insulin sensitivity. Longer-term follow-up is needed to determine whether either program causes sustained decreases in depressive symptoms and improvements in insulin sensitivity. TRIAL REGISTRATION NUMBER: The trial was registered with clinicaltrials.gov (NCT01425905).

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.

The Acceptability of an Electronically Delivered Acceptance- and Mindfulness-Based Physical Activity Intervention for Survivors of Breast Cancer: One-Group Pretest-Posttest Design.

BACKGROUND: Survivors of breast cancer can face internal barriers to physical activity, such as uncertainty and frustration stemming from physical limitations, decreased physical functioning, fatigue, and pain. Interventions that draw from the principles of Acceptance and Commitment Therapy (ACT) may help survivors of breast cancer overcome some of the internal barriers associated with physical activity. OBJECTIVE: The primary aim of this study was to investigate the acceptability of an electronically delivered physical activity intervention for survivors of breast cancer, centered on ACT processes. METHODS: This study used a 1-group pretest-posttest design. We recruited 80 insufficiently active female survivors of breast cancer using a web-based recruitment strategy. The 8-week intervention consisted of weekly modules that featured didactic lessons and experiential exercises targeting key ACT processes in the context of physical activity promotion (namely, values, committed action, acceptance, defusion, and contacting the present moment). We determined intervention acceptability according to study retention (≥70%), adherence rates (≥75% of the participants completing ≥50% of the modules), and posttest survey scores reflecting the perceived ease of use, perceived usefulness, and interest and enjoyment of the intervention (≥5 on a 7-point Likert-type scale). We also evaluated changes in self-reported aerobic and muscle strengthening-physical activity, physical activity acceptance, physical activity regulation, and health-related outcomes. RESULTS: The retention rate (61/80, 76%), adherence rate (60/80, 75%), average perceived ease of use (6.17, SD 1.17), perceived usefulness (5.59, SD 1.40), and interest and enjoyment scores (5.43, SD 1.40) met the acceptability criteria. Participants increased their self-reported aerobic physical activity (Cohen d=1.04), muscle strengthening-physical activity (Cohen d=1.02), physical activity acceptance (cognitive acceptance: Cohen d=0.35; behavioral commitment: Cohen d=0.51), physical activity regulation (identified regulation: Cohen d=0.37; integrated regulation: Cohen d=0.66), increased their ability to participate in social roles and activities (Cohen d=0.18), and reported less fatigue (Cohen d=0.33) and sleep disturbance (Cohen d=0.53). CONCLUSIONS: Electronically delivered acceptance- and mindfulness-based interventions may be useful for promoting physical activity in survivors of breast cancer. Further research is needed to refine these approaches and evaluate their effectiveness.

Evaluating Weight Status and Sex as Moderators of the Association of Serum Leptin with Bone Mineral Density in Children and Adolescents
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BACKGROUND/AIMS: Animal studies suggest that leptin may adversely affect bone mineral density (BMD). Clinical studies have yielded conflicting results. We therefore investigated associations between leptin and bone parameters in children. METHODS: 830 healthy children (age = 11.4 ± 3.1 years; 75% female; BMI standard deviation score [BMIz] = 1.5 ± 1.1) had fasting serum leptin measured with ELISA and body composition by dual-energy X-ray absorptiometry. The main effects for leptin and BMIz plus leptin's interactions with sex and BMIz were examined using hierarchical linear regressions for appendicular, pelvis, and lumbar spine BMD as well as bone mineral content (BMC), and bone area (BA). RESULTS: Accounting for demographic, pubertal development, and anthropometric variables, leptin was negatively and independently associated with lumbar spine BMC and BA, pelvis BA, and leg BA (p < 0.05 for all). Sex, but not BMIz, moderated the associations of leptin with bone parameters. In boys, leptin was negatively correlated with leg and arm BMD, BMC at all bone sites, and BA at the subtotal and lumbar spine (p < 0.01 for all). In girls, leptin was positively correlated with leg and arm BMD (p < 0.05 for both). CONCLUSION: Independent of body size, leptin is negatively associated with bone measures; however, these associations are moderated by sex: boys, but not girls, have a negative independent association between leptin and BMD.
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