Detecting, Preventing, and Treating Sexually Transmitted Diseases Among Adolescent Arrestees: An Unmet Public Health Need

Studies of detained and incarcerated adolescent offenders in the United States indicate that these juveniles have an elevated risk of sexually transmitted diseases (STDs). However, many more arrestees enter the “front end” of the juvenile justice system than are detained or incarcerated, and research into the STD risk profiles and service needs of this larger group is lacking. An expansion of STD testing (including of asymptomatic youths), prevention, and treatment is needed, as is improved knowledge about gender- and race-specific services. A pilot program in Florida has shown that juvenile justice and public health systems can collaborate to implement STD testing among new arrestees. With integrated linkages to treatment and prevention after release, this model could greatly reduce the STD burden in this underserved, high-risk population.Adolescents in the US juvenile justice system have relatively high rates of health problems,^1–3 including elevated risks of the sexually transmitted diseases (STDs) chlamydia (Chlamydia trachomatis) and gonorrhea (Neisseria gonorrhoeae). Detained and incarcerated adolescent offenders, in particular, have high rates of STDs that make them a potentially important core subgroup of STD transmitters.^4–8 However, the STD risks and service needs of adolescent offenders before detention or incarceration (the largest adolescent offender population) or the organizational factors that limit access and service linkages for this population have been little discussed. Although most arrested youths quickly return to the community, we are unaware of any STD screening protocols at the initial stage of arrest. Models of STD transmission dynamics^9,10 suggest that reducing or preventing infections in core risk groups, such as in juvenile arrestees, can further reduce transmission in the community.¹¹A critical need exists to expand STD surveillance among young arrestees before detention or incarceration. Studies of the prevalence of STDs and their drug- and sex-related risk behaviors indicate a high risk of STDs among detained or incarcerated youths. However, numerous organizational and structural barriers and policy and implementation issues limit the expansion of STD testing and treatment at the initial stages of the juvenile justice process. Nevertheless, a promising voluntary STD testing and treatment program for newly arrested juveniles illustrates a collaborative partnership between the public health and juvenile justice systems that overcomes these barriers. This model provides immediate access to STD services for this high-risk and underserved population. (For ease of expression, we use the term nonincarcerated throughout to refer to youths who are in the community and are not in secure custody, whether detained pending adjudication or incarcerated after a finding of guilt).     

Telepsychiatry with incarcerated youth

PurposeIncarcerated adolescents have a high prevalence of psychiatric disorders but lack psychiatrists to provide ongoing care. Telepsychiatry may provide one solution to treating this underserved population.MethodsInteractive video conferencing was used to connect a minimum security correctional facility with a regional telemedicine program. Clinical records were reviewed to examine utilization, demographics, diagnoses, pharmacotherapy, and patient satisfaction.ResultsDuring the 29-month study period, 115 youth were treated using 275 telepsychiatry visits. Substance-use, behavioral, and emotional disorders were highly prevalent. Eighty percent (80%) of the youth were successfully prescribed medications. Youth expressed confidence with the psychiatrist’s recommendations but expressed concerns about privacy.ConclusionsTelepsychiatry can successfully deliver services to incarcerated adolescents with a wide range of psychiatric needs. A patient-centered approach that directly assesses adolescents’ satisfaction is recommended to ensure youths’ optimal involvement in needed services.     

Vaccination in juvenile correctional facilities: state practices, hepatitis B, and the impact on anticipated sexually transmitted infection vaccines

OBJECTIVES: Juvenile correctional facilities are an ideal setting to provide preventive vaccines to adolescents who are at risk. In many instances of incarceration, facilities overcome the need for parental consent by making young people wards of the state and the state providing consent. The authors investigated current state practices for administering hepatitis B vaccine to incarcerated adolescents. These may impact the delivery of anticipated sexually transmitted infection (STI) vaccines to incarcerated adolescents. METHODS: From June to August 2004, interviews were conducted with state Immunization Program Managers by telephone about hepatitis B vaccination and consent policies in juvenile correctional facilities. RESULTS: Forty-five states were able to provide information about hepatitis B immunization in publicly funded juvenile correctional facilities. Forty-one of the 45 states offered hepatitis B vaccine to adolescents who were sentenced and thereby considered to be wards of the state. Of those 41 states, 20 also made hepatitis B vaccine easily accessible to detained adolescents (no parental consent required). Those 20 states considered detained adolescents as wards of the state (n=13), or allowed them to self-consent for the vaccine (n=7). CONCLUSIONS: Most states offer hepatitis B vaccination to sentenced adolescents in correctional facilities. Just over half of these states also vaccinate detained adolescents. Juvenile correctional facilities have experience administering vaccines, and this might allow for expansion of vaccination services when new STI vaccines become available. Still, there are major barriers to universal vaccination of incarcerated adolescents, including the issue of consent.     

Behavioral Health Care Needs,Detention-Based Care,and Criminal Recidivism at Community Reentry From Juvenile Detention: A Multisite Survival Curve Analysis

Objectives. We examined the provision of behavioral health services to youths detained in Indiana between 2008 and 2012 and the impact of services on recidivism.Method. We obtained information about behavioral health needs, behavioral health treatment received, and recidivism within 12 months after release for 8363 adolescents (aged 12–18 years; 79.4% male). We conducted survival analyses to determine whether behavioral health services significantly affected time to recidivating.Results. Approximately 19.1% of youths had positive mental health screens, and 25.3% of all youths recidivated within 12 months after release. Of youths with positive screens, 29.2% saw a mental health clinician, 16.1% received behavioral health services during detention, and 30.0% received referrals for postdetention services. Survival analyses showed that being male, Black, and younger, and having higher scores on the substance use or irritability subscales of the screen predicted shorter time to recidivism. Receiving a behavior precaution, behavioral health services in detention, or an assessment in the community also predicted shorter time to recidivating.Conclusions. Findings support previous research showing that behavioral health problems are related to recidivism and that Black males are disproportionately rearrested after detention.Detained youths have significant mental health needs, with the majority meeting the diagnostic criteria for a mental health disorder. Specifically, about 60% to 80% of detained youths have at least 1 mental disorder, compared with only 15% to 20% of the general adolescent population.1–4 Practice guidelines highlighting the need for mental health screening, assessment, and treatment have been developed, and juvenile justice mental health screening programs have become increasingly common in the United States.5 However, the role of detention-based mental health care on future outcomes has largely been unexplored.Recidivism is the repetition of criminal behavior and is usually measured as the occurrence or frequency of a rearrest or reincarceration in a specific period. Depending on the base rate of arrest and how recidivism is defined, as many as 40% to 70% of adolescents recidivate within 1 year of release from detention.6,7 Within the detained adolescent population, recidivism rates tend to be higher among boys, racial/ethnic minority youths, youths who are younger at first referral, and youths with a history of early childhood misbehavior or conduct problems.8 Other factors that significantly predict recidivism within 12 to 30 months include prior criminal history, poor academic achievement or attendance, relations with deviant peers, low socioeconomic status, large families, older siblings involved in criminal activity, out-of-home placements, and family instability.7,9Behavioral health problems (i.e., mental health and substance abuse problems) are also associated with recidivism. According to 1 meta-analysis of 23 studies and 15 265 adolescents, mental health disorders (e.g., anxiety, depression) are one of the strongest predictors of juvenile recidivism.10 Substance abuse, trauma and neglect, conduct problems, attention-deficit/hyperactivity disorder, and untreated mental health symptoms have also been shown to increase the risk of recidivism.6,8,11 A recent longitudinal study found that substance use disorders and comorbidity of substance use with mental health disorders were directly associated with an increased likelihood of recidivism.12 However, one study found that behavioral health needs, as measured by a behavioral health screen, failed to significantly predict recidivism among a group of juvenile defendants.8 In a longitudinal study of serious adolescent offenders, when several criminogenic and mental health risk factors were included as predictors, only substance use disorders, and not mental health problems, were consistently associated with negative outcomes.13 Hence, the results of research on the role of behavioral health problems in recidivism is mixed and further research is needed.Behavioral health treatment services are a promising avenue for reducing recidivism.14,15 Multisystemic therapy, functional family therapy, and multidimensional treatment foster care are 3 interventions that target mental illness, maladaptive family dynamics, and behavioral problems. Each has strong empirical support for treating detained youths.16 Specifically, these interventions have produced many positive outcomes, including better self-esteem, reduced psychiatric symptoms, reduced substance use, improved family functioning, decreased association with deviant peers, reduced number of rearrests and severity of charges, and delayed time of rearrest.16,17 It should be noted, however, that reduced recidivism stemming from behavioral health intervention is not a universal finding, and poorly implemented interventions have failed to demonstrate significant drops in recidivism.18Because of the benefits of behavioral health services, providing behavioral health care during and following detention may substantially lower recidivism. Currently, the National Commission on Correctional Health Care guidelines recommend that facilities administer behavioral health screens within 14 days of intake, provide 24-hour emergency behavioral health services, and grant detained youths the right to request behavioral health treatment services daily.19 However, facilities are not required to maintain accreditation with the National Commission on Correctional Health Care, so there is no consistent mechanism for monitoring services, keeping facilities accountable, or providing funding to facilities.20,21 As a result, many juvenile justice facilities with limited resources are unable to meet the established standards for behavioral health care.22,23 In fact, fewer than half of facilities comply with National Commission on Correctional Health Care accreditation standards19 and more than one third of facilities use correctional staff to administer behavioral health assessments and services, despite having little or no background or training in mental health.22Evidence indicates that detained youths have significant behavioral health needs, and interventions that target behavioral health issues have the potential to reduce recidivism. However, few studies have adequately examined the relationship between behavioral health needs, detention-based behavioral health services, and recidivism.24 Accordingly, we examined whether the provision of behavioral health services to youths during detention and referrals for behavioral health services after detention affect recidivism. In particular, we expected that, after controlling for behavioral health needs, the provision of behavioral health services would be related to lower rates of recidivism.     

Victimización sexual autorreportada en adolescentes españoles comunitarios y en colectivos de riesgo

ObjectiveTo determine the extent of sexual victimization in four groups of Spanish adolescents based on their own reports.MethodAn observational, cross-sectional, multicenter study was conducted. Sexual victimization was assessed by seven questions included in the Juvenile Victimization Questionnaire. The samples were composed of 1,105 adolescents (mean age [M] = 14.52, standard deviation [SD] = 1.76) from seven secondary schools; 149 adolescents (M = 14.28; SD = 1.45) from 14 child and adolescent mental health centers; 129 adolescents (M = 14.59, SD = 1.62) institutionalized in 18 long-term (78.3%) and short-term (21.7%) residential centers belonging to the child protection system; and 101 adolescents (M = 16.08, SD = 0.99) recruited from three detention centers (77.2%) and five open regime teams or follow-up services for court orders for minors not requiring loss of freedom (22.8%).ResultsThe extent of lifetime sexual victimization ranged from 14.7% of the adolescents in the community sample to 23.5% of youths attended in mental health services, 35.6% of youths involved in the juvenile justice system, and 36.4% of children protected by the child welfare system. Most of the victims were female, the only exception being the group of male victims from the juvenile justice system.ConclusionsSexual victimization of children is widespread in Spain and its distribution differs depending on the group of children under study.     

Traumatic Brain Injury Among Newly Admitted Adolescents in the New York City Jail System

PurposeRelatively little is known about the prevalence of traumatic brain injury (TBI) among adolescents who come into contact with the criminal justice system.MethodsWe undertook screening for TBI among newly admitted adolescents in the New York City jail system using a validated TBI screening tool. A convenience sample of 300 male and 84 female screenings was examined.ResultsScreening revealed that 50% of male and 49% of female adolescents enter jail with a history of TBI. Incidence of TBI was assessed using patient health records, and revealed an incidence of 3,107 TBI per 100,000 person-years.ConclusionsElevated prevalence and incidence of TBI among incarcerated adolescents may relate to criminal justice involvement as well as friction in jail. Given the large representation of violence as a cause of TBI among our patients, we have begun focus groups with them to elicit meaningful strategies for living with and avoiding TBI.     

Racial differences in the mental health needs and service utilization of youth in the juvenile justice system

Mental health placement rates by the juvenile justice system differ by race. However, it is unknown whether mental health needs differ by race. This study attempted to investigate potential differences in mental health needs and service utilization among Caucasian, African American, and Hispanic juvenile justice involved youth. A stratified random sample of 473 youth petitioned, adjudicated, and incarcerated from 1995–1996 was examined using a standard chart review protocol and the Childhood Severity of Psychiatric Illness measure for mental health needs. Significant and unique mental health needs were demonstrated for all racial groups. African American youth demonstrated the greatest level of needs. Minority status indicated significantly lower rates of mental health service utilization. Minority youth in the juvenile justice system are most at risk for underserved mental health needs. Based on the current data, it can be inferred that the first contact with the state's child and adolescent serving system, which includes the juvenile justice and mental health sectors, appears to be through the juvenile justice sector for many minority youth with delinquency problems.     

Association Between Disability Trajectory and Health Care Service Utilization Among Older Adults in China

ObjectivesThis study aimed to identify the heterogeneous disability trajectories among older Chinese adults and examine the association between disability trajectories and health care service utilization.DesignProspective cohort study.Setting and ParticipantsA community-based study including older adults aged ≥65 years from the Chinese Longitudinal Healthy Longevity Survey.MethodsDisability was assessed by the difficulties in activities of daily living and instrumental activities of daily living between 2002 and 2018. Health care utilization was measured by the expenditures on outpatient and inpatient services in 2018. Growth mixture modeling was conducted to estimate heterogeneous disability trajectories. A 2-part model was used to analyze the association of disability trajectories and health care utilization. Covariates were included based on Andersen's behavioral model.ResultsThree classes of disability trajectories were identified: the progressive (7.9%), late-onset (13.7%), and normal classes (78.4%). Older adults who followed the late-onset trajectory of disability were more likely to use inpatient services compared with the normal class (odds ratio = 1.47, P < .010), after controlling potential confounders. Compared with the normal class, the progressive class on average spent US$145.94 more annually (45.2% higher) on outpatient services (P < .010) and $738.99 more annually (72.6% higher) on inpatient services (P < .001); the late-onset class reported higher annual expenditures on outpatient and inpatient services of $215.94 (66.9% higher) and $1405.00 (138.0% higher), respectively (all P < .001).Conclusions and ImplicationsHeterogeneous disability trajectories exhibited distinct health care service utilization patterns among older Chinese adults. Older adults affected by late-onset disability incurred the highest health care needs. These findings provide valuable policy-relevant evidence for reducing health care burden among older adults.     

The relationship between sleeping problems and aggression, anger, and impulsivity in a population of juvenile and young offenders

PurposeThe current study examines both the quantity and quality of sleep reported by male adolescents detained in prison, with a focus on exploring the association between the quantity and quality of sleep with aggression, impulsivity, or anger. This represents a novel area of study not yet explored among incarcerated male adolescents.MethodOne hundred eighty-four offenders took part; 104 young (average age 19 years) and 80 juvenile (average age 16 years). All completed a questionnaire exploring sleeping problems, and measures assessing aggression, anger, and impulsivity.ResultsAggression was found to relate both to the quantity and quality of sleep reported, with reduced quantity and quality predicted by increased overall aggression. Across aggression subscales, only increased hostility was predictive of reduced current hours of sleep and increased problems in sleep quality. Apnea risk scores were not predicted by aggression, anger, or impulsivity. Differences in sleep behavior before and during prison were demonstrated, with evidence for increased poor sleeping habits within detention. No differences were observed between young and juvenile offenders.ConclusionsThis study suggests a potential relationship between aggression and sleep among an incarcerated adolescent male sample, highlighting in particular a role for hostility. The findings are discussed in relationship to implications for treatment and directions for future research.     

Health needs of incarcerated youth.

From a health care point-of-view, the most needy adolescents in the United States are those who become incarcerated in the juvenile justice system. These youngsters have poor health care before incarceration is not much better. Their health problems range from the results of trauma to the consequences of sexual activity to severe psychological problems. Their health needs include: (1) prevention of health problems which contribute to behaviors for which youths are incarcerated; (2) comprehensive assessment and care; (3) continuity of care after discharge from the institutions; (4) comprehensive health education and health promotion; (5) professional, competent health care providers; (6) educated, sympathetic administrators and supervisory personnel; and (7) adequate financing of health services. Concerned health providers must become advocates for these adolescents and for their health care in correctional and political settings.     

Factors associated with assault-related firearm injuries in male adolescents.

PURPOSE: To identify factors associated with an increased prevalence of assault-related firearm injuries in male adolescents. METHODS: This study is a retrospective comparison of two samples of adolescent males from the same geographic localities regarding their involvement in the juvenile justice system (court involvement) and injury status (current or prior firearm injury at the time of the study). The subjects included adolescent male patients admitted to an urban, Level I trauma center for assault-related firearm injuries (court-involved and noncourt- involved, n = 65); and incarcerated juvenile offenders (prior firearm injury and no known firearm injury, n = 267). RESULTS: Two-thirds of the male assault-related pediatric firearm injury victims treated over a two-year period were involved in the juvenile justice system (court involved). Court-involved adolescents were almost 22 times more likely to have sustained an assault-related firearm injury, when compared to noncourt-involved patients with firearm injuries. Additional analysis documented recent substance use and/or involvement in criminal offenses in 82% of the victims. For most of the juvenile offenders (88%), court involvement preceded their injuries. Analysis of the injury patterns revealed an increased prevalence of truncal injuries (injuries to thorax or abdomen) in the court-involved victims, when compared to their noncourt-involved peers (40% and 14% for the court-involved and noncourt-involved samples, respectively; p <.05). Incarceration was associated with a 17-fold increase in the firearm injury prevalence over the court-involved, but not incarcerated, sample. CONCLUSIONS: These results suggest that involvement in substance use and/or the criminal justice system is associated with an increased risk of firearm injuries in male adolescents, and that an increased level of involvement in the juvenile justice system is associated with a concomitant increase in firearm injuries.     

The consequences of juvenile detention reform for mental health and sexually transmitted infection screening among detained youth

PurposeTo understand how diversion of low-risk youth from juvenile detention affected screening practices for detained youth.MethodsIn a 22-month cross-sectional study of 2,532 detainees (age, 13–18 years), mental health and sexually transmitted infection (STI) screening data were compared before and after the beginning of diversion efforts through implementation of a Risk Assessment Instrument (RAI).ResultsDetention diversion resulted in a 30% census reduction. In a logistic regression, younger age (odds ratio [OR] = 1.10 for a 1-year increase; confidence interval [CI]: 1.03, 1.17), Hispanic versus white race/ethnicity (OR = .53; CI: .35, .82), and less severe crime (OR = .90 per 1 point; CI: .89, .91) predicted reduced likelihood of detention. Mental health and STI screening increased significantly after implementation of the RAI. Additionally, the rate of positive STI tests increased among detained males (9% pre-RAI to 14% after implementation of the RAI, p = .01). However, implementation of the RAI did not result in a significant increase in the number of positive mental health screens.ConclusionsUniversal mental health and STI screening are increasingly common public health practices in detention centers. The results of this study indicate that juvenile justice diversion programming affects public health screening rates among detained youth in our population. Future study of the possible unintended consequences of criminal justice initiatives on public health outcomes is recommended.     

Incarcerated Youths’ Perspectives on Protective Factors and Risk Factors for Juvenile Offending: A Qualitative Analysis

Objectives. We sought to understand incarcerated youths’ perspectives on the role of protective factors and risk factors for juvenile offending.Methods. We performed an in-depth qualitative analysis of interviews (conducted October–December 2013) with 20 incarcerated youths detained in the largest juvenile hall in Los Angeles.Results. The adolescent participants described their homes, schools, and neighborhoods as chaotic and unsafe. They expressed a need for love and attention, discipline and control, and role models and perspective. Youths perceived that when home or school failed to meet these needs, they spent more time on the streets, leading to incarceration. They contrasted the path through school with the path to jail, reporting that the path to jail felt easier. All of them expressed the insight that they had made bad decisions and that the more difficult path was not only better but also still potentially achievable.Conclusions. Breaking cycles of juvenile incarceration will require that the public health community partner with legislators, educators, community leaders, and youths to determine how to make success, rather than incarceration, the easier path for disadvantaged adolescents.With 2 million juveniles arrested and over 60 000 detained annually, the United States incarcerates a larger proportion of youths than any other developed country.1–3 Incarcerated adolescents represent a high-risk, vulnerable population with disproportionately high rates of unmet physical, developmental, social, and mental health needs, and higher mortality.4–7 Juvenile offending predicts a higher likelihood of chronic adult offending, as well as adverse adult outcomes such as poor health, substance use, and increased mortality.8 Further, significant disparities exist. African American youths are approximately 5 times more likely, and Latino and American Indian adolescents are 3 times more likely, to be detained than their White counterparts.3 Additionally, adolescents from socially disadvantaged neighborhoods are at higher risk for incarceration.9 These inequities perpetuate future incarcerations. Prior incarceration places youths at greater risk for repeat offending throughout adolescence and adulthood.10 Within 3 years of release, approximately 75% of adolescents are rearrested.2Identification of protective and risk factors for juvenile offending can inform programs and policies to disrupt youths’ pathways to jail. Quantitative studies identify low school achievement, poor mental health, substance use, parental incarceration, large family size, single-parent families, poor parental supervision, delinquent peer groups, and residing in high-crime neighborhoods as risk factors for juvenile offending.11,12 The modest literature on protective factors for juvenile incarceration highlights the importance of supportive family relationships, prosocial peers, academic achievement, reading ability, and psychological factors such as self-esteem and empathy.13–15Qualitative research to identify underlying mechanisms for these associations is needed. For effective implementation, predictive factors need to be understood in the context of youths’ situations, goals, and ideas about pathways to jail within their communities. Yet adolescent voices on pathways to jail are notably lacking in this literature. To date, only 1 published study has examined incarcerated youths’ perspectives on protective and risk factors for incarceration. The study, which focused on barriers and protective factors during community reentry after juvenile incarceration, identified social connectedness and having a future-oriented perspective as the main predictors of success.16 Adolescents’ views of the pathways to jail across the entire trajectory of juvenile offending—from initiation of delinquency and entry into the juvenile justice system, to repeat arrests and, ultimately, their expected endpoints for these trajectories—remain unknown.To address these gaps, we interviewed incarcerated youths to elucidate their perspectives on pathways to jail across the trajectory of juvenile offending. We explored their perceptions of protective and risk factors in their communities, with the ultimate goal of strengthening programs that prevent juvenile offending and disrupt cycles of incarceration.     

A Statewide Collaboration to Initiate Mental Health Screening and Assess Services for Detained Youths in Indiana

Objectives. We describe a statewide effort to implement detention-based mental health screening and assess follow-up services offered to detained youths in Indiana.Methods. A total of 25 265 detention stays (15 461 unique youths) occurred between January 1, 2008, and December 31, 2011, across 16 detention centers participating in the Indiana Juvenile Mental Health Screening Project. We collected screening results and reports of detention-based follow-up mental health services and referrals from justice system records.Results. Approximately 21% of youths screened positive for mental health issues requiring follow-up. A positive screen significantly predicted that youths would receive a follow-up mental health service or referral while detained or upon detention center discharge, compared with youths who did not screen positive (61% vs 39%). Logistic regression models indicated that a positive screen was associated with (1) contact with a mental health clinician within 24 hours of detention center intake and (2) a mental health referral upon discharge. White youths were more likely than minorities to receive both follow-up services.Conclusions. Future statewide efforts to improve the mental health of detained youths should incorporate standards for providing appropriate follow-up services in detention centers.On any given day, nearly 100 000 youths are held in detention centers across the United States.1 Although reported estimates vary, researchers find that detained adolescents exhibit mental health problems at significantly higher rates than the general adolescent population.1–4 Prevalence studies indicate that a majority of detained youths (60%–70%) meet the criteria for a diagnosable mental health disorder.5,6 Over the past decade, researchers and practitioners have called for systematic ways to reliably identify and treat detained youths in need of mental health services.7–10 We describe statewide efforts to improve the mental health of Indiana’s detained youths—adopting a standard mental health screening process and tracking the detention-based follow-up mental health services and referrals offered to screened youths.     

Health, mental health, substance use, and service utilization among rural and urban incarcerated women.

Incarcerated women commonly report health, mental health, and substance use problems, yet there is limited research on service utilization before incarceration, particularly among women from urban and rural areas. This study includes a stratified random sample of 100 rural and urban incarcerated women to profile the health, mental health, substance use, and service utilization; examine the relationship between the number of self-reported problems and service utilization; and examine self-reported health and mental health problems in prison as associated with preincarceration health-related problems and community service utilization. Study findings suggest that health and mental health problems and substance use do not differ significantly among rural and urban women prisoners. However, there are differences in service utilization -- particularly behavioral health services including mental health and substance abuse services; urban women report more service utilization. In addition, rural women who reported using needed community services before prison also reported fewer health problems in prison. Implications for correctional and community treatment opportunities in rural and urban areas are discussed.     

Crush: A Randomized Trial to Evaluate the Impact of a Mobile Health App on Adolescent Sexual Health

PurposeMobile technology allows delivery of sexual and reproductive health (SRH) information directly to youth. We tested the efficacy of Crush, a mobile application aimed at improving sexual health by promoting the use of SRH services and contraception among female adolescents.MethodsWe recruited 1,210 women aged 14–18 years through social media advertising and randomized them into a Crush intervention group and a control group that received a wellness app. At 3 and 6 months post randomization, we compared changes from baseline in behaviors, attitudes, self-efficacy, perceived social norms, birth control knowledge, perceived control and use intentions, and SRH service utilization. Odds ratios were estimated with multivariable logistic regression and adjusted for baseline outcome, age, race/ethnicity, mother's education, and sexual experience.ResultsThere was no difference in accessing SRH services according to study group. Three months post baseline, Crush users had higher odds (p < .05) than control participants of reporting confidence in accessing SRH services (adjusted odds ratio [aOR] = 1.6, 95% confidence interval [CI]: 1.1–2.3) and of believing that it is a good thing to use birth control consistently (aOR = 2.3, 95% CI: 1.4–3.8). Six months after baseline, Crush users had higher odds than control participants of reporting they can control whether birth control is used every time they have sex (aOR = 1.8, 95% CI: 1.2–2.6) and perceiving they would get pregnant if they did not use birth control (aOR: 1.5, 95% CI: 1.1–2.2). Impacts on other behavioral constructs were also found.DiscussionCrush was associated with improvements in knowledge, attitudes, and self-efficacy related to key SRH behaviors and may be a strategy to deliver SRH education to adolescent women. Studies including larger numbers of sexually active adolescents are needed to demonstrate behavioral impacts.     

Health beliefs and reported symptoms among a sample of incarcerated adolescent females

Purpose: To understand the health care needs (or perceived needs) of incarcerated female adolescents by comparing their rates of physical complaints, health attitudes, and treatment seeking to a normative sample.Methods: A sample (n = 138) of incarcerated girls was administered the Somatic Symptom Checklist, the Illness Attitudes Scales, and the Reynolds Adolescent Depression Scale to assess lifetime prevalence of physical symptoms, attitudes toward health, treatment-seeking experience, and emotional distress, and allow for comparison with a normative sample. Information regarding length of incarceration, race, and school achievement was obtained from institutional records.Results: A median lifetime prevalence of 12 symptoms for the incarcerated sample differed significantly from the median of six symptoms reported by a normative sample. The symptoms most commonly expressed by the detainees were dizziness, heart pounding, chest pains, and nausea. In both their attitudes toward illness and actual physical complaints, these subjects were more concerned about illness and perceived themselves to be more physically impaired. Self-reported symptoms of depression and illness were positively correlated. Physical complaints were independent of age, race, length of incarceration, or achievement scores.Conclusions: The frequency and variety of somatic complaints, as well as their relationship to emotional distress, among these incarcerated girls highlight the need for integration of physical and mental health services within juvenile facilities.     

Acceptability as a key determinant of client satisfaction: lessons from an evaluation of adolescent friendly health services in Mongolia

PurposeThe primary focus of this study is to investigate which characteristics of health service quality are most likely to determine client satisfaction with health services among adolescents in Mongolia.MethodsData were gathered from 1301 male and female clients. Exit interviews were used to measure client satisfaction; 82 clinics were visited. All clients between the ages of 10 and 19 years were asked to participate in the client exit interview; those who agreed to participate completed the questionnaire. Bivariate and multivariate analyses were conducted to determine significant associations between service satisfaction and the independent variables. All variables showing a significant bivariate association with service satisfaction (p ≤ .05) were retained for logistic regression analyses.ResultsThe strongest determinant to client satisfaction related to acceptability: adequate facility physical environment, receiving adequate information about the facility, and if the facility was private (i.e., other people didn’t know the services the client received). Additionally, clients who said they received some interruptions, either by other health workers or clients, were significantly less likely to be satisfied with the services.ConclusionsThis study demonstrates the importance of understanding and measuring different aspects of health service quality in defining client satisfaction. Although both accessibility and acceptability of services have been shown to be important in other studies, characteristics relating to acceptability emerged as critical in determining client satisfaction among adolescents in Mongolia. Efforts to improve health service delivery to adolescents need to understand and address the “adolescent friendly” characteristics that are most salient, and least fulfilled, in each particular context.