PURPOSE Clinician time alone with an adolescent has a major impact on disclosure of risk behavior. This study sought to describe primary care clinicians' patterns of delivering time alone, decision making about introducing time alone to adolescents and their parents, and experiences delivering confi dential services. METHODSWe undertook qualitative interviews with 18 primary care clinicians in urban health centers staffed by specialists in pediatrics, family medicine, and adolescent medicine. RESULTSThe annual preventive care visit is the primary context for provision of time alone with adolescents; clinicians consider the parent-child dynamic and the nature of the chief complaint for including time alone during visits for other than preventive care. Time constraints are a major barrier to offering time alone more frequently. Clinicians perceive that parental discomfort with time alone is rare. Many clinicians wrestle with internal confl ict about providing confi dential services to adolescents with serious health threats and regard their role as facilitating adolescent-parent communication. Health systems factors can interfere with delivery of confi dential services, such as inconsistent procedures for determining whether unaccompanied youth would be seen.CONCLUSION Despite competing time demands, clinicians report commitment to offering time alone during preventive care visits and infrequently offer it at other times. Experienced clinicians can gain skills in the art of managing complex relationships between adolescents and their parents. Offi ce systems should be developed that enhance the consistency of delivery of confi dential services.

IntroductionAdolescents residing in impoverished urban environments are at considerable risk for negative health consequences of sexual activity, such as exposure to STIs and unplanned pregnancy [1][2]. Confidential care (time alone with an adolescent) is essential for quality adolescent primary care, especially to counsel about sexual health risks. Professional guidelines recommend routine provision of confidential care [3], yet many adolescents never have time alone with a health care provider [4][5][6]. Only 60% of urban youth reported private time with physicians during their last visit [7]. Most research has relied on retrospective accounts from adolescent patients [4][5][6][7]. This study required providers document prospectively the provision of time alone and content of adolescent visits.The purpose of the study was to track primary care providers' (PCPs) time alone with adolescent patients, and to identify key factors associated with its provision. Patient age and gender, history of care, type of visit and complaint were assessed. We also examined key factors associated with provision of sexual health services. Methods SampleWe used purposeful stratified sampling to enroll providers (family physicians, pediatricians and adolescent specialists). A list of randomized names across five community health centers and one adolescent practice was generated. All practices were located in low-income, primarily minority communities in New York. Those who worked at least 50% time at the clinic were eligible. The first 25 providers were approached. Twenty-one provided informed consent and were enrolled into the study. Correspondence to: Lucia F. O'Sullivan. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. (1) whether the adolescent had attended the clinic alone; (2) the provider's history of care for the parent and adolescent; (3) whether time alone was offered; (4) how the accompanying parent responded when asked to leave the room (1-not at all well to 4-extremely well); (5) the amount of time (if any) spent alone with the adolescent patient during the visit (0%-100%); (6) whether a sexual history was obtained; (7) the type of sexual health services that resulted (if any) from a checklist; and (8) any needs identified that warranted confidential care follow-up. Piloting showed cards took less than one minute to complete. NIH Public Access ProceduresProviders were trained to complete index cards in 10-minute sessions by the third author and instructed to complete one immediately following each adolescent encounter. Adolescents were defined as any patient between the ages of 12...

In an urban population, overweight and obesity are very common as is food insecurity. We found an association between food insecurity and obesity only among women not receiving food assistance suggesting a possible protective role for food assistance. Providers should consider food insecurity in similar populations when trying to address obesity.

Purpose Although the intrauterine device (IUD) may be safely used in adolescents, few US adolescents use IUDs. Increasing IUD use in adolescents can decrease pregnancy rates. Primary care providers’ clinical practices many be one of the many barriers to increasing adolescents access to IUDs. We explored primary care physicians’ (PCPs) approaches to contraception counseling with adolescents, focusing on their views about who would be appropriate IUD candidates. Methods Phone interviews were conducted with 28 urban family physicians, pediatricians, and obstetrician-gynecologists. Using standard qualitative techniques, we developed coding template and applied codes. Results Most respondents have a patient-centered general contraceptive counseling approach. However, when considering IUDs many PCPs describe more paternalistic counseling. For example, although many respondents believe adolescents’ primary concern is pregnancy prevention, many PCPs prioritize sexually transmitted infection (STI) prevention and thus would not offer an IUD. Attributes PCPs associate with an appropriate IUD candidate include responsibility, reliability, maturity, and monogamy. Conclusion Our findings suggest that when considering IUDs for adolescents some PCPs’ subjective assessment of adolescent sexual behavior, attitudes about STI risk factors and use of overly restrictive IUD eligibility criteria impede adolescent’s IUD access. Education around best practices may be insufficient to counterbalance attitudes concerning adolescent sexuality and STI risk; there is also a need to identify and discuss PCPs potential biases or assumptions affecting contraception counseling.

Purpose Primary care providers’ (PCPs’) provision of time alone with an adolescent without the parents present (henceforth referred to as “confidential care”) has a significant impact on adolescents’ disclosure of risk behavior. To inform the development of interventions to improve PCPs’ delivery of confidential care, we obtained the perspectives of adolescent males and their mothers about the health care concerns of adolescent males and the provision of confidential care. Methods This focus-group study (5 groups: 2 with adolescent males and 2 with mothers) used standard qualitative methods for analysis. We recruited mother/son dyads who had been seen at urban primary care practices. Results Adolescents’ health concerns focused on pregnancy and sexually transmitted infections; mothers took a broader view. Many adolescents felt that PCPs often delivered safe sex counseling in a superficial, impersonal manner that did not add much value to what they already knew, and that their PCP’s principal role was limited to performing sexually transmitted infection testing. Though adolescents cited a number of advantages of confidential care and disclosure, they expressed some general mistrust in PCPs and concerns about limits of confidentiality. Rapport and relationship building with their PCP are key elements to adolescents’ comfort and increased disclosure. Overall, mothers viewed confidential care positively, especially in the context of continuity of care, but many felt excluded. Conclusions To increase adolescents’ perception of the relevance of primary care and to foster disclosure during health encounters, our participants described the critical nature of a strong doctor–patient relationship and positive physician demeanor and personalized messages, especially in the context of a continuity relationship. Regular, routine inclusion of confidential care time starting early in adolescence, as well as discussion of the purpose and limitations of confidentiality with parents and adolescents, could lead to greater parental comfort with confidential care and increased disclosure by the adolescent.

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Objective Sexually active urban adolescents experience a high burden of sexually transmitted infections (STI). Adolescents often access medical care through general primary care providers; their time alone with a provider increases the likelihood that youth will disclose risky behavior, which may result in STI testing. Our goals were to assess the association (if any) between the provision of time alone and STI testing, and describe the rates of STI testing among sexually active adolescents in urban primary care. Methods Youth (aged 12–19 years) presenting for care at 4 urban health centers were invited to complete post-visit surveys of their experience. Sexually transmitted infection screening rates were obtained from the clinical information systems (CIS); CIS data were linked to survey responses. Results We received 101 surveys. Surveyed youth experienced time alone in 69% of all visits. Time alone varied by age (older teens experienced more time alone), and it occurred more frequently in preventive visits (71%) versus nonpreventive visits (33%). It did not vary by gender. Forty-two of the 46 sexually active youth experienced time alone. Screening rates for sexually active females, either at the index visit or within 6 months prior to the index visit, were 17.9% for human immunodeficiency virus and 32.1% for gonorrhea/Chlamydia. No sexually active surveyed males were tested. Overall screening rates varied widely across practices (human immunodeficiency virus 0%–29%; gonorrhea/Chlamydia 7%–29%). There was no difference in screening rates among youth with and without time alone. Conclusion STI testing for adolescents is being conducted in this primary care urban population, especially for sexually active females. However, clinicians in this setting are not screening females consistently enough and rarely screen males. We were unable to test our hypothesis that provision of time alone was associated with a higher rate of STI testing. Site differences suggest substantial variation in clinician practices that should be addressed in quality improvement interventions.

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