A qualitative exploration of psychosocial challenges of perinatally HIV-infected adolescents and families in Bangkok,Thailand

Thailand has the highest HIV prevalence in Asia, with 9600 HIV+ adolescents and thousands of additional younger HIV+ children. Studies from other settings suggest perinatally HIV-infected (PHIV+) adolescents are at high risk for mental health problems and engagement in risk behaviors that threaten individual and public health. Yet, few studies exist in Thailand, and few evidence-based psychosocial interventions have been developed for and studied in this population, despite great need. The current study qualitatively explored psychosocial issues among Thai PHIV+ adolescents to inform development or adaptation of interventions. Thai and US-based researchers and clinicians conducted two focus group discussions with PHIV+ adolescents aged 12–16 and their adult caregivers, and six in-depth key informant interviews with health/social work providers at a large clinic for PHIV+ youth in Bangkok, Thailand. Data were analyzed thematically using framework analysis. Multiple challenges for PHIV+ youth and caregivers were identified. Adherence to antiretroviral treatment was a significant challenge attributed to lack of adult support, side effects, feeling too well to take medicines and avoiding acknowledging sickness. Poor child–caregiver communication and conflict was a key concern, explained in part by cultural expectation of obedience and generation gaps. Concerns about societal stigma and discrimination emerged strongly and influenced delay or avoidance of disclosing HIV status to children and others. Respondents identified positive approaches to addressing these issues and highlighted the need for interventions to improve child–caregiver communication and generate peer and community support for PHIV+ youth. Thai PHIV+ adolescents and families experience significant psychosocial challenges, similar to those seen in other contexts. Cultural adaptation of an existing evidence-based clinic-based family group intervention is recommended to rapidly address these needs.     

Adolescent Experiences of Clinician–Patient HIV/STI Communication in Primary Care

Effective clinician–patient communication is linked to positive patient health outcomes in adults, yet the research on adolescent populations remains limited. We describe adolescent experiences of clinician–patient HIV/STI communication through qualitative interviews with predominantly African-American adolescent women from a youth-centered primary care clinic. Participants described acknowledging clinicians are professionals, the importance of confidentiality to foster clinician–adolescent communication, and calling for clinician-initiated HIV/STI communication. Adolescents expressed the necessity for clinicians to engage youth in these challenging conversations through an open and understanding approach. Additionally, adolescents described experiences of perceived judgment and uncomfortableness from clinicians, and non-disclosure of HIV/STI risk behaviors to their clinician. Findings underscore the adolescents’ desire to engage in HIV/STI communication with healthcare providers, while highlighting important strategies for clinicians. Results can inform health communication research and practice, and the development of interventions aimed at increasing clinician–adolescent HIV/STI communication.     

HIV / AIDS and STDs control: new policy perspectives

The prevention and control of HIV/AIDS is a social as well as a public health issue. This approach is reflected in new policy initiatives developed by the Government of India's National AIDS Control Organization in 1997. Future strategies will be based on a multisectoral, partnership-oriented approach. Bilateral agencies are encouraged to establish interventions in areas such as sexually transmitted disease (STD) control, condom distribution, counseling, health care, and hospice care. Special campaigns focused on youth and adolescents, including the inclusion of HIV/AIDS in the school curriculum, are planned. New strategies will be developed to address the HIV risk associated with drug abuse. The home- and community-based care of HIV/AIDS patients will be promoted, with emphasis on emotional and social support needs. Other areas to be addressed include the integration of STD control with primary health care, a blood transfusion policy, education for commercial sex workers, an end to discrimination against people with AIDS, and expansion of the national sentinel surveillance system.     

Towards an integrated adolescent health policy in Israel

The principle health issues of Israeli adolescents are largely related to health risk behaviors, and are therefore preventable. Deciding which public health interventions are of highest priority ought to be determined according to the relative importance of these issues among Israeli youth. Violence in the schools and dieting to lose weight are highly prevalent in this population, with unintentional accidents, smoking and other substance abuse, and reproductive health being other important issues. Special health planning considerations that take into account Israel's unique population mix are necessary. Israel does not yet have a comprehensive, integrated health policy for youth. Nevertheless, legislation has been enacted that provides universal national health insurance, as well as preventive school health services to all school children from the 1st to 9th grade under the Ministry of Health's responsibility, setting the foundations for such a comprehensive youth health policy. In addition, policy makers and health care providers have recently recognized the need for a pro-active approach regarding health service development for adolescents. In this article, we give an overview of current Israeli health policies that impact upon the adolescent population, and propose seven priority areas that should be addressed in order to advance the health of youth in this country.     

Coordinating the delivery of vaccinations and other preventive health care recommendations for adolescents

Although recommendations for annual preventive care for adolescents have been in place for decades, the need to bring adolescents to the medical setting for newly recommended vaccines has placed this issue in the public health spotlight. Aggressive efforts have been ongoing to increase adolescent adherence to new vaccine recommendations--a measured outcome variable, and the hope has been that enhanced adherence to comprehensive health care visits will follow. Evidence indicates that the implementation of more comprehensive preventive health care elements among adolescents may be improving; however, a passive approach to bringing more adolescents to preventive health visits using vaccine as an incentive may not be effective for all youth. This paper reviews the history of recommendations for new vaccines as well as comprehensive health care visit recommendations for adolescents, how these recommendations may synergistically improve preventive care for adolescents, and how we may need to continue to think creatively to further access all youth for preventive health care using vaccination implementation as a model for reaching out beyond the providers' office walls.     

Prevention of HIV Among Adolescents

Adolescents are at risk for HIV primarily through their sexual behavior. A comprehensive prevention strategy includes a national HIV campaign based on social marketing principles; targeted social marketing, intensive skill building, and sexually transmitted disease control programs for youth at high risk; programs targeting institutions (e.g., school health clinics), providers, and parents; and interventions to identify and reduce risk acts among seropositive youth. The U.S. focus for HIV prevention has been single-session educational classes (an ineffective strategy) or intensive multi-session, small-group interventions for youth at high risk (demonstrated to increase condom use by about 30%). There is a need to expand the range, modalities, and dissemination of HIV prevention programs nationally, to recognize (especially by policymakers) limitations of abstinence programs, and to increase early detection of HIV among youth.     

Health care information sources for adolescents: age and gender differences on use, concerns, and needs.

OBJECTIVES: To assess adolescents' sources of health care information, explore beliefs about topics which health care providers should address and about those which have been addressed, and identify topics that are embarrassing for adolescents to discuss with providers. METHODS: Participants included a nationally representative sample of 3153 boys and 3575 girls in 5th through 12th grades who completed the Commonwealth Fund survey. Data were analysed by inspection of percentages and bivariate associations. RESULTS: Boys (41.7%) and girls (58.4%) identified their mother as the primary resource for health care information. Younger boys and girls (grades five and six) were more likely than older boys and girls (grades 10 to 12) to ask their mother first about health issues (boys 54.4% vs. 35.2%; girls 71.7% vs. 46.4%). Doctors, nurses, or school nurses were also frequently identified as the first person asked about health issues (boys 23.9%, girls 18.2%). Most adolescents indicated that providers should address the following topics: drugs (65.0%); smoking (58.5%); sexually transmitted diseases (61.4%); alcohol use (56.2%); and good eating behaviors (56.8%). However, fewer adolescents reported that providers have actually discussed these issues with them; only 23.1% to 34.2% of adolescents reported having discussed the first four topics with them. Many youth noted that it would be embarrassing for them to discuss these issues with their providers. CONCLUSIONS: Adolescents report that parents and health care providers are key sources of health-related information. Although adolescents may be embarrass having discussions with their health care providers, adolescents do believe that these topics should be addressed. Adolescents' embarrassment about discussing sensitive health topics highlights the importance of providers initiating and facilitating these discussions.     

Adolescent tobacco use and dependence: assessment and treatment strategies

Tobacco use is common among children and adolescents, and about 50% who try smoking will progress to regular use and dependence. Tobacco dependence is best conceptualized as a pediatric disease that should be addressed in adolescence. This article focuses on tobacco dependence, assessment and treatment, including goals of abstinence and exposure reduction. Although more research is needed, treatment success is more likely to occur with multicomponent interventions that are tailored to the individual needs and the unique issues for this age group, including issues of parental involvement and consent for treatment, developmental issues, and patient preferences. Several school-based interventions appear promising, and many resources are available to provide education for parents, youth, and health care providers.     

Race, ethnicity, and access to ambulatory care among US adolescents.

OBJECTIVES. Improving the health of minority adolescents will require a better understanding of factors that influence their access to and use of health care. This study describes the differences in health care access and use among White, Black and Hispanic adolescents and evaluates how such differences are influenced by insurance. METHODS. We used data on 7465 10- to 17-year-olds included in the child health supplement to the 1988 National Health Interview Survey. RESULTS. Much higher proportions of Blacks (16%) and Hispanics (28%) than of Whites (11%) were uninsured. Despite having worse reported health status, Black and Hispanic adolescents made notably fewer doctor visits in the past year than their White peers, and were more apt to lack usual sources of routine and acute care as well as continuity between sources of care. Having health insurance was associated with greater increase in access and usage measures for minority youth than for White youth. However, racial differences persisted even after adjusting for health insurance, family income, need, and other factors. CONCLUSIONS. Minority adolescents are particularly vulnerable to the problems of health care access that affect all youth. While health insurance is especially important for increasing appropriate health care use among minority youth, nonfinancial methods of enabling more equitable use also deserve further study.     

The Law of Communicable Diseases Act and disclosure to sexual partners among HIV-positive youth

In Sweden, human immunodeficiency virus (HIV) is included among the venereal diseases covered by the Law of Communicable Diseases Act. HIV-positive (HIV(+)) people are required to inform their sexual partners about their infection and adopt safe sex behaviours. However, it is unclear how the law is perceived. This study explores how HIV(+) youth in Sweden perceive the law, handle their sexuality and disclose their HIV diagnosis to sexual partners. Ten HIV(+) women and men between 17 and 24 years of age were recruited from three different HIV infection clinics. These participants were interviewed in depth. The interviews were tape-recorded, transcribed verbatim and analysed according to a grounded theory approach. The core category-cultured to take responsibility-illuminates the informants' double-edged experiences regarding the law and how they handle disclosure to sexual partners. The legislation implies both support and burden for these HIV(+) youth; they feel that they have a great deal of responsibility, sometimes more than they can handle. 'Switch off lust', 'balancing lust, fear and obedience' and 'switch off the disease' are strategies that describe how the informants manage sexuality and disclosure. Young HIV(+) people have a difficult time informing partners of their HIV diagnosis and discussing safe sex strategies. These are challenges that health care providers need to take seriously. HIV(+) youth need better communication strategies to negotiate safer sex. Staff with extended education on sexuality should be a part of HIV health care.     

Adolescents and access to health care.

The developmental characteristics and health behaviors of adolescents make the availability of certain services--including reproductive health services, diagnosis and treatment of sexually transmitted disease, mental health and substance abuse counseling and treatment--critically important. Furthermore, to serve adolescents appropriately, services must be available in a wide range of health care settings, including community-based adolescent health, family planning and public health clinics, school-based and school-linked health clinics, physicians'' offices, HMOs, and hospitals. National, authoritative content standards (for example, the American Medical Association''s Guidelines for Adolescent Preventive Services (GAPS), a multispecialty, interdisciplinary guideline for a package of clinical preventive services for adolescents may increase the possibility that insurers will cover adolescent preventive services, and that these services will become part of health professionals'' curricula and thus part of routine practice. However, additional and specific guidelines mandating specific services that must be available to adolescents in clinical settings (whether in schools or in communities) are also needed. Although local government, parents, providers, and schools must assume responsibility for ensuring that health services are available and accessible to adolescents, federal and state financing mandates are also needed to assist communities and providers in achieving these goals. The limitations in what even comprehensive programs currently are able to provide, and the dismally low rates of preventive service delivery to adolescents, suggests that adolescents require multiple points of access to comprehensive, coordinated services, and that preventive health interventions must be actively and increasingly integrated across health care, school, and community settings. Unless access issues are dealt with in a rational, coordinated fashion, America''s adolescents will not have access to appropriate health services. Current efforts to minimize current health care expenditures through managed care programs inevitably conflict with efforts to deliver comprehensive preventive services to all adolescents. Use of multiple sites may not represent inadequate access to care. However, as managed care reimbursement continues to expand, school-based clinics and free-standing adolescent health programs increasingly report decreases in reimbursement without a change in demand for services. The Office of Technology Assessment study called for explicit funding and expansion of services for America''s youth; since then, a federal Office of Adolescent Health has been authorized, and, by the time this reaches print, should have received appropriations and been staffed. Dryfoos has called for expansion to nearly 5000 comprehensive programs in the coming years.(ABSTRACT TRUNCATED AT 400 WORDS)     

“It’s kind of hard to go to the doctor’s office if you’re hated there.” A call for gender‐affirming care from transgender and gender diverse adolescents in the United States

Research has identified discrimination and a lack of knowledgeable providers as major barriers for transgender and gender diverse (TGD) individuals seeking care, which contributes to greater stress and significant health disparities affecting this population. However, research involving TGD youth is limited. The aim of this study, therefore, was to describe TGD adolescents’ experiences, concerns and needs in healthcare settings, including their feedback on themes previously identified by healthcare providers (i.e. discomfort with gender‐related topics, reasons for not asking patients about gender and previous training regarding gender diversity). The authors conducted semi‐structured interviews with 12 TGD‐identified adolescents aged 14–17, living in Minnesota, USA in 2017–2018. Inductive thematic analysis was used to summarise participant comments into themes and subthemes. Two main themes were directly relevant to concerns and needs of TGD youth in healthcare settings and their views on healthcare providers’ concerns: (a) asking about gender and pronouns and (b) training for healthcare providers. Findings suggest the need for revisions to clinic materials, infrastructure and protocols. Adding training to all general medical and nursing education to increase knowledge, comfort and competence around gender identity would further improve care and ultimately reduce healthcare disparities affecting TGD youth.     

Recommendations for Promoting the Health and Well-Being of Lesbian,Gay, Bisexual,and Transgender Adolescents: A Position Paper of the Society for Adolescent Health and Medicine

Adolescent health care providers frequently care for patients who identify as lesbian, gay, bisexual, or transgendered (LGBT), or who may be struggling with or questioning their sexual orientation or gender identity. Whereas these youth have the same health concerns as their non-LGBT peers, LGBT teens may face additional challenges because of the complexity of the coming-out process, as well as societal discrimination and bias against sexual and gender minorities. The Society for Adolescent Health and Medicine encourages adolescent providers and researchers to incorporate the impact of these developmental processes (and understand the impacts of concurrent potential discrimination) when caring for LGBT adolescents. The Society for Adolescent Health and Medicine also encourages providers to help positively influence policy related to LGBT adolescents in schools, the foster care system, and the juvenile justice system, and within the family structure. Consistent with other medical organizations, the Society for Adolescent Health and Medicine rejects the mistaken notion that LGBT orientations are mental disorders, and opposes the use of any type of reparative therapy for LGBT adolescents.     

Minding the gap: health and social care provider perceptions of parental communication and Black-Canadian youths’ sexual health

Abstract

Health and social care providers’ perceptions of Black-Canadian parent-youth sexual health communication has important implications for addressing knowledge gaps in the provision of services to young people and their parents. Providers’ perceptions are crucial as they often act as advisers in tailoring programmes or services to the perceived needs of parents and youth. To understand these perceptions, 17 semi-structured in-depth interviews were conducted with providers who worked with African, Caribbean or Black (ACB) parents and youth in Toronto, Ontario, Canada. Critical Race Theory was used to help guide the interpretation of findings. The findings revealed providers believed that many parents were unlikely to explicitly discuss sexual health or HIV prevention with young people. Additionally, providers perceived that the content of and approach to parent-youth sexual health communication differed between African and Caribbean clients. Moreover, providers believed that both parents’ and young people’s sex and gender impacted the quality, content and style of sexual health communication and had important implications for programme development. Overall, findings suggest a need for understanding the development of providers’ perceptions of this communication, ways to address these perceptions and further parent-provider collaboration to promote Black youths’ sexual health.     

HIV prevention in street youth.

Homeless adolescents have remained an underserved population throughout the human immunodeficiency/acquired immune deficiency syndrome epidemic. This article reviews the recent literature investigating human immunodeficiency virus (HIV) risk behavior among street youth. Prevalence rates of both adolescent homelessness and HIV seropositivity are unknown. However, data from a number of samples document a high prevalence of HIV risk behavior, sexually transmitted diseases, and alcohol/drug use among homeless adolescents. A number of individual and social factors, often associated with street survival, propel adolescents toward high-risk behavior. For some adolescents, testing HIV positive is perceived as advantageous in the procurement of basic needs such as food and shelter. HIV risk-reduction interventions must take into consideration the cause of homelessness, access to and participation in shelter services, and individual factors (such as the effects of sexual orientation and ethnicity) that frequently have not been systematically included in previous research. HIV risk for many homeless adolescents stems directly from their state of homelessness. National policies and funding are needed to address the health needs of these youth.     

Runaway and street youth at risk for HIV infection: legal and ethical issues in access to care.

Significant numbers of runaway and street youth are at risk for human immunodeficiency virus (HIV) infection. These youth are physically, socially, and psychologically vulnerable and need access to health care and related services. Legal and ethical concerns of consent and confidentiality may limit their access, although in many states the law allows some minors to consent to HIV testing and treatment and protects confidentiality of HIV-related information. Appropriate pretest and posttest counseling and follow-up for youth at risk of infection are essential. Limited access to HIV treatment for youth testing positive raises serious ethical concerns. Access to comprehensive treatment is currently limited by lack of adequate financing, despite a patchwork of numerous public funding sources providing some coverage for treatment of HIV and acquired immunodeficiency syndrome (AIDS). Research studies and clinical trials are critical elements in the planning and delivery of HIV-related services to adolescents, but require consideration of special ethical and legal concerns.     

The changing ethnic makeup of America's adolescents: implications for health

As the percentage of minority adolescents in society increases, behaviors that affect the health of these adolescents will become increasingly important. Both mental and physical health as well as substance abuse and violence need to be addressed, and the ethnicity and culture of the adolescent patient may guide specific approaches and considerations. Many of the health problems affecting adolescents are preventable, and health care providers should aim significant resources at these issues. Gaps in adolescent health care, and especially barriers to entry for some ethnic groups, deserve greater attention to ensure that all groups can enjoy access to quality health care. Options available to health care practitioners for reducing these barriers are offered in the final portion of the article.     

秦岭山区洛南县生殖健康/计划生育服务需求调查

为了解我国贫困地区妇女生殖健康 /计划生育服务现状 ,找出影响妇女健康的不良因素 ,为开展干预工作提供决策依据 ,应用定性调查方法随机抽取陕西省洛南县县、乡卫生管理干部及服务提供者分别作为选题组 ;随机抽取 3个乡的已婚避孕妇女、未婚女青年分别为专题组。结果领导选题组认为“改变对生殖健康 /计划生育的认识 ,克服重行政干预 ,轻技术服务的作风”是最先要解决的问题 ;服务提供者认为“更新知识 ,提高技能”是最先要解决的问题 ;已婚避孕妇女组和未婚女青年组认为“提高保健服务质量 ,普及健康教育”是核心问题。据此作者认为 ,影响贫困地区妇女生殖健康的主要因素是妇女生殖保健知识缺乏和服务质量问题。     

Community-based adolescent health services in Israel: from theory to practice

Despite their engagement in health-risk behaviors and their health-related concerns, adolescents have the lowest rate of health service utilization of any age group. Time constraints during routine medical encounters generally leave little opportunity for professional screening for health-risk behaviors or for discussing psychosocial problems. In addition, providers express low levels of perceived competency in areas such as sexuality, eating disorders or drug abuse. To address these needs, a walk-in Adolescent Health Service was established by the Sheba Medical Center to provide diagnosis and short-term treatment for individual adolescents, as well as counseling and support for local care providers. A three-way model of cooperation and partnership was developed and implemented. A professional and financial partnership with local authorities were established to help define the particular needs of the community's youth and to improve the ability to reach youth with special health needs. The partnership along with the main medical provider (Kupat Holim Clalit) helped define local health needs, served as a referral source of patients with unmet health needs, and improved the continuity of care. The regional medical center (Sheba Medical Center) provided supervision and consultation for the medical staff of the service, as well as a referral center for patients. It was emphasized that the service staff was intended as a professional source for the primary physician and should not be considered a rival. The core staff included a specialist in adolescent medicine, gynecologist, mental health specialist and social worker. A structured intake procedure was developed for assessing health concerns and problems of adolescents in the context of a community clinic. Findings from the first years of services showed that the first 547 female adolescents demonstrated that a majority of adolescents presented with primary complaints of a somatic nature, while one third were diagnosed with psychosocial problems and one-fifth with a sexuality-related problem. A considerable percentage of those diagnosed with psychosocial or sexuality-related problems had not stated these issues as their "reason for encounter". This additional increment probably represents the contribution of the Health Concern Checklist (HCC), in which the adolescent was asked to mark each item for which she had concerns or would like to receive further information. The HCC can help primary care physicians as well as adolescent medical specialists approach the teenage patient and initiate productive communication. A practical approach to confidential health care for adolescents: The issue of confidentiality has not been sufficiently clarified by Israeli law or by the medical community. The need for confidentiality was strongly felt in the adolescent health service. A policy which provides all adolescents with the opportunity to meet with a physician and receive health guidance or advice at least once, even without parental knowledge or consent, was formulated and implemented. If parental consent was not feasible, the minor was allowed to give informed consent for medical and psychosocial care for himself/herself, with certain limitations.