Transition to adult care: experiences and expectations of adolescents with a chronic illness.

BACKGROUND: Effective means of transitioning adolescent patients with chronic illness from paediatric to adult medical care are poorly documented and supported by limited evidence. The purpose of this study is to describe expectations and concerns of adolescents with chronic illness regarding transition from subspecialty paediatric to adult-centred care during the transition process in order guide effective programme design and implementation. METHODS: Qualitative content and thematic analysis of semi-structured individual interviews with 22 adolescents with chronic illness, including cystic fibrosis, sickle cell disease, juvenile rheumatoid arthritis, and inflammatory bowel disease. Interviews took place at 1-3 time points over an 18-month study period. RESULTS: Transition topics included: timing of transfer to adult care, the transition process, attitudes about transition, and factors that might aid transition. During the study period, one-third of participants made the transition to adult-oriented health care. All participants who had transitioned to adult-oriented care reported participating in a structured transition programme. Concerns of those who had not initiated the transition process centred on re-establishing relationships and bringing a new team 'up to speed'. Most adolescents anticipating transfer to adult care identified only downsides and felt unprepared to transition at the time of the interview. Subjects who had transitioned noted benefits of the adult-oriented system, even if they had been ambivalent prior to transfer of care. Participants suggested that earlier discussions about transition, opportunities to meet new healthcare teams and visits to adult-oriented venues prior to transition might aid in the transition process. CONCLUSIONS: Subspecialty paediatric providers should anticipate common fears and concerns of adolescents and discuss the benefits of transfer to adult-oriented care. Further evaluation of existing transition programmes is an area for future study and is necessary for improvement of the continuum of care for adolescents with chronic medical conditions.

Acceptability of human papillomavirus self testing in female adolescents.

OBJECTIVES: To develop scales assessing acceptability of human papillomavirus (HPV) testing in adolescents, to compare acceptability of self to clinician testing, and to identify adolescent characteristics associated with acceptability. METHODS: Female adolescents 14-21 years of age attending a hospital based teen health centre self collected vaginal samples and a clinician, using a speculum, collected cervicovaginal samples for HPV DNA. Acceptability of and preferences for self and clinician testing were assessed at baseline and 2 week visits. RESULTS: The mean age of the 121 participants was 17.8 years and 82% were black. The acceptability scales demonstrated good internal consistency, reliability, test-retest reliability, and factorial validity. Scores were significantly lower for self testing than clinician testing on the acceptability scale and three subscales measuring trust of the test result, confidence in one's ability to collect a specimen, and perceived effects of testing (p < 0.01). Of those who reported a preference, 73% preferred clinician to self testing. Acceptability scores for both self and clinician testing increased significantly pre-examination to post-examination (p < 0.01). Multivariable analyses demonstrated that race was independently associated with pre-examination and post-examination acceptability of self testing, and that sexual behaviours and gynaecological experiences were associated with specific acceptability subscales. CONCLUSIONS: This sample of adolescents found clinician testing for HPV to be more acceptable than self testing and preferred clinician to self testing. If self testing for HPV is offered in the future, clinicians should not assume that adolescent patients will prefer self testing. Instead, they should educate adolescents about available testing options and discuss any concerns regarding self collection technique or accuracy of test results.

Cross-cultural surveys of adolescent health and behavior: progress and problems.

Adolescent health surveys administered in different countries or regions often are described as cross-cultural. Although most include youth of different ethnic and cultural groups, few attempt to define these constructs or to collect data that allow their characterization. This paper explores four challenges shared by large-scale surveys of adolescent health-related behaviors and beliefs. First, adolescent health investigators have used the terms culture and ethnicity loosely. The growing interest in contextual analysis demands standardization of the definitions as they apply to adolescents, followed by correct usage of the terms. Hypotheses regarding the associations between race, ethnicity, culture, health-related behaviors, and health outcomes should be clearly stated and incorporated into conceptual models. Second, cross-cultural analyses are interpretable only when the study designs and sampling methods provide adequate representation of cultural and ethnic minorities and when the survey items allow differentiation of factors related to race, ethnicity, culture, and socioeconomic factors. Third, cross-cultural research may expose traditions, beliefs, and behaviors that are supported by one population yet criticized by another. Investigators must recognize their own personal biases and must work collaboratively to analyze and interpret their data correctly. Fourth, generalizations about cultural/ethnic comparisons can evoke powerful emotional reactions. Interpretation and dissemination of research findings should be done sensitively and with the help of experts from the cultural/ethnic groups that have been studied.

Intention to return for papanicolaou smears in adolescent girls and young women.

OBJECTIVE: Sexually active adolescent girls have high rates of abnormal cervical cytology. However, little is known about factors that influence intention to return for Papanicolaou screening or follow-up. The aim of this study was to determine whether a theory-based model that assessed knowledge, attitudes, and behaviors predicted intention to return. METHODS: The study design consisted of a self-administered, cross-sectional survey that assessed knowledge, beliefs, perceived control over follow-up, perceived risk, cues for Papanicolaou smears, impulsivity, risk behaviors, and past compliance with Papanicolaou smear follow-up. Participants were recruited from a hospital-based adolescent clinic that provides primary and subspecialty care, and the study sample consisted of all sexually active girls and young women who were aged 12 to 24 years and had had previous Papanicolaou smears. The main outcome measure was intention to return for Papanicolaou smear screening or follow-up. RESULTS: The enrollment rate was 92% (N = 490), mean age was 18.2 years, 50% were black, and 22% were Hispanic. Eighty-two percent of participants intended to return. Variables that were independently associated with intention to return included positive beliefs about follow-up (odds ratio [OR]: 1.07; 95% confidence interval [CI]: 1.02-1.11), perception that important others believe that the participant should obtain a Papanicolaou smear (OR: 1.93; 95% CI: 1.38-2.74), perceived control over returning (OR: 1.24; 95% CI: 1.06-1.46), and having received cues to obtain a Papanicolaou smear (OR: 1.31; 95% CI: 1.08-1.60). CONCLUSIONS: Analysis of this novel theoretical framework demonstrated that knowledge and previous behaviors were not associated with intention to return for Papanicolaou smear screening and follow-up in this population of young women. However, modifiable attitudinal components, including personal beliefs, perception of others' beliefs, and cues to obtaining Papanicolaou smears, were associated with intention to return.

Adoption as a risk factor for attempted suicide during adolescence.

OBJECTIVE: Depression, impulsivity, and aggression during adolescence have been associated with both adoption and suicidal behavior. Studies of adopted adults suggest that impulsivity, even more than depression, may be an inherited factor that mediates suicidal behavior. However, the association between adoption and adolescent suicide attempts and the mechanisms that might explain it remain unknown. The objective of this study was to determine the following: 1) whether suicide attempts are more common among adolescents who live with adoptive parents rather than biological parents; 2) whether the association is mediated by impulsivity, and 3) whether family connectedness decreases the risk of suicide attempt regardless of adoptive or biological status. METHODS: A secondary analysis of Wave I data from the National Longitudinal Study of Adolescent Health was conducted, which used a school-based, clustered sampling design to identify a nationally representative sample of 7th- to 12th-grade students, with oversampling of underrepresented groups. Of the 90 118 adolescents who completed the National Longitudinal Study of Adolescent Health in-school survey, 17 125 completed the in-home interview and had parents of identified gender who completed separate in-home questionnaire. The subset of adolescents for this study was drawn from the in-home sampling according to the following criteria: 1) adolescent living with adoptive or biological mother at the time of the interview, 2) adolescent had never been separated from mother for more than 6 months, 3) mother was in first marriage at the time of the interview, and 4) the adoptive mother had never been married to the adolescent's biological father. Of the 6577 adolescents in the final study sample, 214 (3.3%) were living with adoptive mothers and 6363 (96.7%) were living with biological mothers. Variables. The primary outcome measured was adolescent report of suicide attempt(s) in the past year. Other variables included in the analyses were sociodemographics characteristics (gender, age, race/ethnicity, family income, parental education), general health (self-rated health, routine examination in the past year, need for medical care in the past year that was not obtained), mental health (depressive symptoms, self-image, trouble relaxing in the past year, bad temper, psychological or emotional counseling in the past year), risk behaviors (cigarettes, alcohol, marijuana, sexual intercourse ever, delinquency, physical fighting in the past year, impulsive decision making), school-related characteristics (grade point average, school connectedness), and family interaction (family connectedness, parental presence, maternal satisfaction with parent-adolescent relationship). Data Analysis. Univariate analyses were used to compare adoptees versus nonadoptees, suicide attempters versus nonsuicide attempters, and adopted suicide attempters versus nonadopted suicide attempters on all variables. Variables that were associated with attempted suicide were entered into a forward stepwise logistic regression procedure, and variables that were associated with the log odds of attempt were retained in the model. The area under the model's receiver operating characteristic curve was calculated as a measure of its overall performance. After the association of adoption with attempted suicide was demonstrated, the potential mediating effect of impulsivity was explored by adding it to the model. The same procedure was followed for any variable that was associated with adoption in the full sample or the subsample of suicide attempters. To determine whether any variable in the model moderated the association between adoption and suicide attempt, the interaction term for that variable x adoption was forced into the model. RESULTS: Adoptees differed significantly from nonadoptees on 4 of 26 variables. They were more likely to have attempted suicide (7.6% vs 3.1%) and to have received psychological or emotional counseling in the past year (16.9% vs 8.2%), and their mothers reported higher parental education and family income. Attempters differed significantly from nonattempters on all variables except for age, race/ethnicity, parental education, family income, and routine examination in the past year. On logistic regression, 9 variables were independently associated with attempted suicide: depression (adjusted odds ratio [AOR]: 3.41), counseling (AOR: 2.83), female gender (AOR: 2.31), cigarette use (AOR: 2.31), delinquency (AOR: 2.17), adoption (AOR: 1.98), low self-image (AOR: 1.78), aggression (AOR: 1.48), and high family connectedness (AOR: 0.60). The receiver operating characteristic curve for the model had an area of 0.834, indicating performance significantly better than chance. The AOR for adoption did not change when parental education, family income, and impulsivity were forced into the model. (ABSTRACT TRUNCATED)

School disconnectedness: identifying adolescents at risk.

OBJECTIVE: School connectedness, or the feeling of closeness to school personnel and the school environment, decreases the likelihood of health risk behaviors during adolescence. The objective of this study was to identify factors differentiating youth who do and do not feel connected to their schools in an effort to target school-based interventions to those at highest health risk. METHODS: The study population consisted of all students attending the 7th through 12th grades of 8 public schools. The students were asked to complete a modified version of the in-school survey designed for the National Longitudinal Study of Adolescent Health (Add Health). The school connectedness score (SCS) was the summation of 5 survey items. Bivariate analyses were used to evaluate the association between SCS and 13 self-reported variables. Stepwise linear regression was conducted to identify the set of factors best predicting connectedness, and logistic regression analysis was performed to identify students with SCS >1 standard deviation below the mean. RESULTS: Of the 3491 students receiving surveys, 1959 (56%) submitted usable surveys. The sample was 47% white and 38% black. Median age was 15. Median grade was 9th. The SCS was normally distributed with a mean of 15.7 and a possible range of 5 to 25. Of the 12 variables associated with connectedness, 7 (gender, race, extracurricular involvement, cigarette use, health status, school nurse visits, and school area) entered the linear regression model. All but gender were significant in the logistic model predicting students with SCS >1 standard deviation below the mean. CONCLUSIONS: In our sample, decreasing school connectedness was associated with 4 potentially modifiable factors: declining health status, increasing school nurse visits, cigarette use, and lack of extracurricular involvement. Black race, female gender, and urban schools were also associated with lower SCS. Further work is needed to better understand the link between these variables and school connectedness. If these associations are found in other populations, school health providers could use these markers to target youth in need of assistance.

Validity of adolescent and young adult self-report of Papanicolaou smear results.

OBJECTIVE: To assess the validity of adolescent and young adult report of Papanicolaou smear results and to determine sociodemographic, cognitive, and behavioral factors associated with incorrect reporting. METHODS: We conducted a cross-sectional study of 477 female subjects aged 12 to 24 years who attended an adolescent clinic and had a previous Papanicolaou smear. Subjects completed a self-administered survey assessing self-report of Papanicolaou smear results, knowledge about Papanicolaou smears and human papillomavirus (HPV), attitudes about Papanicolaou screening and follow-up, and risk behaviors. The sensitivity, specificity, positive predictive value, and negative predictive value of self-reported results were calculated using the cytology report as the standard. Variables significantly associated with incorrect reporting were entered into logistic regression models controlling for age and race to determine independent predictors for incorrect reporting. RESULTS: Of the 477 participants, 128 (27%) had abnormal cytology reports and 66 (14%) had incorrect self-reports. Sensitivity of self-report was 0.79, specificity 0.89, positive predictive value 0.72, negative predictive value 0.92, and kappa (kappa) 0.66. The adjusted odds ratios (OR) and 95% confidence intervals (CI) of the variables comprising a logistic regression model predicting incorrect reporting were an HPV knowledge source of zero (OR 2.4, CI 1.0, 5.8), low perceived communication with the provider (OR 2.1, CI 1.1, 4.0), and no contraception at last intercourse (OR 5.5, CI 2.7, 11.0). CONCLUSION: The validity of adolescent and young adult self-reported Papanicolaou smear result is high, except among those who lack knowledge of HPV, perceive poor communication with the provider, and use contraception inconsistently.

Adolescent menstrual disorders. Update.

Menarche is an important event during adolescence. For most girls, it marks successful progression through puberty and the onset of reproductive capability. Confidential and sensitive discussion of growth and development, body image, menstrual function, and sexual behavior is an important component of the annual health examination. Menstrual problems are common during adolescence and frequently require evaluation and intervention. Although most problems are explained by maturation of the hypothalamic-pituitary-ovarian axis, organic pathology must always be considered and excluded in a logical and cost-effective manner.

Preventing HIV transmission: the perspective of inner-city Puerto Rican adolescents.

PURPOSE: To examine the development of HIV prevention strategies that address the concerns and needs of urban Puerto Rican adolescents. METHODS: The study included 542 Puerto-Rican adolescents, divided into age sets of 12 to 14 years and 15 to 19 years. Participants were recruited from community work programs, recreation centers, schools, drug rehabilitation programs, and directly from neighborhood streets in North Philadelphia. A hierarchical series of peer-facilitated group techniques and interviews allowed adolescents to generate, prioritize and explain strategies. The study question was developed in focus groups. Ideas were generated and prioritized in Nominal Technique Groups. The ideas with the highest priority were used to develop a survey that allowed participants to rank those they believed would be most effective. Participants then clarified the top-ranked ideas in open focus groups. RESULTS: In both age sets, the strategy perceived as the most effective in preventing HIV-risk behaviors was "Have people who are HIV-infected talk to teens." Similar ideas addressing this theme varied in perceived effectiveness. The second and third rated ideas among participants aged 12 to 14 years were "Teach teens how HIV infects them, " and "Show teens how people die from AIDS." The second and third rated ideas among participants aged 15 to 19 years were "Show teens what AIDS does to people " and "Have parents be more supportive of teens, so if they are having sex, they can encourage them to use condoms." Other top-ranked ideas included the development of community programs, increased efficacy and availability of condoms, and assessing partners for the risk of HIV infection. Three items revealed significant gender differences. Males were more likely to rate "Give out more free condoms" and "Educate teens in schools about AIDS." Females aged 15 to 19 years were more likely to rate "Teens should know their partner's background before having sex." CONCLUSIONS: To develop effective prevention strategies for youth, their views of the problems and interpretations of proposed solutions must be understood.

Utilization of physician offices by adolescents in the United States.

UNLABELLED: Recent guidelines for adolescent primary care call for the specification of clinical services by three adolescent age subgroups. Yet analyses of office visits have either merged adolescence into one stage or divided it at age 15 years. OBJECTIVE: To explore the utilization of physician offices in the United States by early (11-14 years), middle (15-17 years), and late (18-21 years) adolescents. DESIGN: Secondary analysis of the 1994 National Ambulatory Medical Care Survey, focusing on visits made by the three adolescent age groups. SETTING: Nationally representative sample of 2426 physicians in nonfederal, nonhospital offices. SUBJECTS: A total of 33 598 visits by patients of all ages, representing 681.5 million visits in 1994. MAIN OUTCOME MEASURES: Number of visits, health insurance, providers seen, duration of visits, reasons for visits, resulting diagnoses, and counseling provided. RESULTS: Adolescents aged 11 to 21 years made 9.1% (61.8 million) of the total office visits and represented 15.4% of the total US population in 1994. This underrepresentation in visits held across all three adolescent age subgroups. Within the adolescent cohort, whites were overrepresented relative to their population proportion (78.5% of visits, 67.6% of population) and blacks and Hispanic adolescents were underrepresented (8.3% and 9.3% of visits, 15.5% and 13.1% of population). Middle adolescence signaled a life turning point from male to female predominance in office visits. Peak lifetime uninsurance rates occurred at middle adolescence for females (18.7%) and late adolescence for males (24.0%). Between childhood and early adolescence, public insurance decreased from 24.7% to 15.7% and uninsurance increased from 12.7% to 19.7%. Pediatricians accounted for the highest proportion of early adolescent visits (41.2%), family physicians for middle adolescent visits (35.3%), obstetrician-gynecologists for late adolescent female visits (37.3%), and family physicians for late adolescent male visits (34.8%). Mean visit duration during adolescence was 16 minutes, did not differ by age subgroup or sex, exceeded that of children (14.6 minutes), and was shorter than that of adults (19.3 minutes). Obstetrician-gynecologists spent more time with adolescents than did other physicians. Education or counseling was included in 50.4% of adolescent visits, ranging from 65.1% for obstetrician-gynecologists to 34.8% for internists. During early adolescence, the leading reasons for both male and female visits were respiratory (19.4%), dermatological (10.0%), and musculoskeletal (9.7%). A similar profile was found for middle and late adolescent males. For middle and late adolescent females, the leading reason for visits was special obstetrical-gynecological examination (12.8% and 21.1%), and the leading diagnosis resulting from visits was pregnancy (9.5% and 20.4%). CONCLUSIONS: Adolescents underutilize physician offices and are more likely to be uninsured than any other age group. Visits are short, and counseling is not a uniform component of care. As adolescents mature, their providers, presenting problems, and resulting diagnoses change. The data from the National Ambulatory Medical Care Survey support a staged approach to adolescent preventive services, targeted to the needs of three age subgroups.

Menstrual disorders. Amenorrhea.

Adolescent patients with amenorrhea often present to primary care providers. A basic understanding of menstrual and pubertal physiology enables clinicians to initiate the clinical evaluation. A thorough history and physical examination focusing on pubertal development indicate the appropriate diagnostic algorithm. Usually, an accurate diagnosis can be obtained quickly. Management includes restoring ovulatory cycles if possible, replacing estrogen when necessary, reassurance, and re-evaluation.

Sexual abuse of boys: definition, prevalence, correlates, sequelae, and management.

OBJECTIVE: To clarify the definition of sexual abuse of boys, update estimates of its prevalence, and explore critically its reported correlates, sequelae, and management. DATA SOURCES: Studies from 1985 to 1997 were identified using OVID-MEDLINE and OVID-CINAHL. The search terms used were sexual abuse, sexual victimization, and sexual assault. Constraints applied included English language, human male subjects, age younger than 19 years, and North American samples. STUDY SELECTION: Publications were included for review if they appeared in peer-reviewed journals; had clear research designs; reported results for at least 20 male subjects; and were not reviews, perspectives, theoretical treatises, editorials, or letters. DATA EXTRACTION: Study types and sampling methods were categorized using well-established definitions. Preference was given to studies with large samples, with case-control or cohort designs, and/or with adjustment for effect modifiers or confounders. DATA SYNTHESIS: We identified 166 studies representing 149 sexual abuse samples. Studies were methodologically limited and definitions of sexual abuse varied widely. Prevalence estimates varied widely (by definition used and population studied), ranging from 4% to 76%. Boys at highest risk were younger than 13 years, nonwhite, of low socioeconomic status, and not living with their fathers. Perpetrators tended to be known but unrelated males. Abuse frequently occurred outside the home, involved penetration, and occurred more than once. Sequelae included psychological distress, substance abuse, and sexually related problems. Evaluation of management strategies was limited. CONCLUSIONS: Sexual abuse of boys appears to be common, underreported, underrecognized, and undertreated. Future study requires clearer definitions of abuse, improved sampling, more rigorous data collection, more sophisticated data analyses, and better assessment of management and treatment strategies. Regardless, health care professionals should be more aware of and sensitive to the possibility of sexual abuse in their male patients.

Emergency department utilization by adolescents in the United States.

BACKGROUND: Adolescents in the United States have been shown to underutilize primary care services and therefore may rely heavily on emergency service. Although several small studies have explored local emergency services for youth, there are no published reports of adolescent utilization of emergency services on a national scale. Furthermore, emergency services data have not been aggregated according to the age subgroups used by the current guidelines for adolescent care. OBJECTIVE: To explore the utilization of emergency departments in the United States by early (11 to 14 years), middle (15 to 17 years), and late (18 to 21 years) adolescent subgroups. DESIGN: Secondary analysis of the emergency department component of the 1994 National Hospital Ambulatory Medical Care Survey. SETTING: Nationally representative sample of 418 emergency departments in the United States. PATIENTS: Approximately 26,547 visits by patients of all ages, representing 93.4 million total visits in 1994 and 14.8 million adolescent visits. OUTCOME MEASURES: Number of visits, health insurance, reasons for visits, urgency of visits, resulting diagnoses, and hospitalization rates. RESULTS: Adolescents accounted for 15.4% of the population and 15.8% of emergency department visits in 1994. Late adolescents were overrepresented in emergency department visits relative to their population proportion (6.8% of visits, 5.3% of population), whereas early adolescents were underrepresented (4.6% of visits, 5.9% of population). Lack of health insurance was more common among 11- to 21-year-olds (26.2%) than either children (13.6%) or adults (22.7%). By ages 18 to 21 years, 40.5% of male visits and 27.6% of female visits were uninsured. Injury-related visits were more common among adolescents (28.6%) than either children (23.1%) or adults (18.2%). Injury was the leading reason for visits among all adolescent age-sex subgroups (36.6% to 42.0% of male visits and 14.1% to 27.2% of female visits) except females aged 18 to 21 years for whom digestive reasons ranked first (18.8%). Injury was the leading diagnosis for all adolescent age-sex subgroups, with peaks at early adolescence of 61.6% for males and 45.8% for females. Across all adolescent age-sex subgroups, 3.1% to 5.3% of visits resulted in hospitalization, and 41.0% to 52.5% of visits were urgent. These rates did not differ from those of children but were lower than those of adults. CONCLUSIONS: Utilization of emergency departments increases and health insurance decreases during adolescence, suggesting that adolescents with inadequate health insurance may rely heavily on emergency departments for their health care needs. Most adolescent visits to emergency departments are not urgent and might be better treated through nonemergency, primary care sites.

Depot medroxyprogesterone acetate or oral contraception in postpartum adolescents.

OBJECTIVE: To compare rates of method continuation and repeat pregnancy among postpartum adolescents selecting depot medroxyprogesterone acetate or oral contraceptives (OCs). METHODS: A retrospective study of 161 adolescents aged 19 years and younger who gave birth at an urban teaching hospital between May 1, 1994, and April 30, 1995, returned to the hospital's family planning clinic within 14 weeks of delivery and chose depot medroxyprogesterone acetate (n=111, 69%), or OC (n=50, 31%) as their postpartum contraceptive method. Most subjects were black (99%), single (97%), and on medical assistance (85%). Data were gathered 12-18 months postpartum (mean+/-standard deviation [SD] 14.5+/-1.6 months) by telephone interview and medical record review. The main outcome measures were method continuation and repeat pregnancy. RESULTS: The mean (+/-SD) age at delivery was 17.8+/-1.4 years. Variables differentiating subjects selecting depot medroxyprogesterone acetate or OC included multiparity (34% versus 12%, P < .05), mean age at first pregnancy (15.9 versus 16.6 years, P < .05), and mean age at first delivery (16.1 versus 16.9 years, P < .05). The survival curves for depot medroxyprogesterone acetate and OC continuation differed significantly (median duration of use 8.1 versus 5.4 months, respectively), but the continuation rates at 12 months were similar (34% versus 32%). The survival curves for repeat pregnancy among subjects selecting depot medroxyprogesterone acetate differed significantly from curves of those choosing OC, with repeat pregnancy rates of 15% and 36% by 15 months. Postpartum selection of OC was the only variable entering a Cox regression model designed to predict repeat pregnancy (relative risk 3.0, 95% confidence interval 1.4, 6.7). CONCLUSION: Adolescent mothers choosing depot medroxyprogesterone acetate or OC immediately postpartum face similarly high rates of method discontinuation and repeat pregnancy within 1 year.

Factors affecting the decision to seek health care: the voice of adolescents.

OBJECTIVE: To learn from teenagers why they do, or do not, seek preventive health care. METHODS: A teen-centered methodology utilized focus groups, nominal group technique sessions, and surveys to allow adolescents to generate, prioritize, and explain their own responses. This article reports the qualitative explanations offered by youths in focus groups. In 21 groups, teenagers commented on the 15 factors that ninth graders in the School District of Philadelphia had determined most influenced their decision to seek care. Transcriptions were reviewed for consistent themes. Direct quotations are presented here to be representative of those themes. RESULTS: Two key points emerged. First, adolescents are more concerned about provider characteristics than site or system characteristics. Second, they worry deeply about disease transmission in the health care setting. Teenagers suggest some simple steps that may produce significant inroads toward developing an effective working relationship with them. A few examples include: to alleviate anxiety of disease transmission, providers should wash hands and remove instruments from sterile packaging in front of patients; to reassure teenagers of competence, providers should keep diplomas and certificates displayed; and to alleviate perceptions of racism, sites should post signs that clearly explain why patients are sometimes seen out of order. CONCLUSIONS: Adolescents know what draws them to services and what offends them. This study documents, in the words of youths, the factors contributing to their decisions to seek care. The results allow health professionals who care for adolescents to consider what they do well and where change may be needed.

Teen father participation in child rearing: family perspectives.

OBJECTIVES: To explore adolescent fatherhood from the perspectives of teen fathers, teen mothers, paternal grandmothers (PGMs), and maternal grandmothers (MGMs). To identify perceived barriers to and recommendations for the enhancement of teen father participation in child rearing. METHODS: A total of 61 teen parents participated in the design of a structured interview. A community-based sample of 173 teen fathers, 167 teen mothers, 76 PGMs, and 79 MGMs were interviewed by teenage assistants. Multiple logistic regression analysis using maximum likelihood estimation and the best subset algorithm identified barriers most predictive of paternal uninvolvement in child rearing. RESULTS: Fifty-four percent of teen fathers and 70% of partners of teen mothers' met the definition of involvement in child rearing. Disinterest in child rearing most consistently predicted uninvolvement. Fathers were less likely than mothers to report paternal disinterest as a barrier and more likely to attribute their lack of involvement to resistance from mothers and MGMs (p < 0.05). The best model predicting paternal involvement from the fathers' perspective included paternal disinterest [odds ration (OR) = 0.42, confidence interval (CI) = 0.19-0.92] and age (OR = 0.74, CI = 0.56-0.97). The best model from the mothers' perspective included paternal disinterest (OR = 0.16, CI = 0.07-0.36) and lack of time (OR = 0.31, CI = 0.15-0.91). Of those fathers who cited disinterest, there was an association with lack of money (p = 0.002) and lack of knowledge of child care (p = 0.069. While fathers and mothers disagreed on several interventions, they agreed (82% and 95%, respectively) that availability of jobs would promote paternal involvement. CONCLUSIONS: Most teen fathers in this study were involved and interested in child rearing. A young father's financial insecurity or confusion about child care was most likely to lead to a stated disinterest, and that disinterest predicted uninvolvement.

PIP: A community-based sample of 173 teen fathers, 167 teen mothers, 76 paternal grandmothers, and 79 maternal grandmothers was interviewed by teenage assistants to explore adolescent fatherhood from a range of differing perspectives. 54% of teen fathers and 70% of partners of teen mothers met the definition of involvement in child rearing. Disinterest in child rearing most consistently predicted uninvolvement. Fathers were less likely than mothers to report paternal disinterest as a barrier and more likely to attribute their lack of involvement to resistance from mothers and maternal grandmothers. The best model predicting paternal involvement from the fathers' perspective included paternal disinterest and age, while the best model from the mothers' perspective included paternal disinterest and lack of time. Of those fathers who cited disinterest, there was an association with lack of money and lack of knowledge of child care. While fathers and mothers disagreed upon several interventions, they agreed that an availability of jobs would promote paternal involvement.

Gestational age and infant size at birth are associated with dietary sugar intake among pregnant adolescents.

The objective of this study was explore the relationship between pregnancy outcomes and dietary sugar intake by pregnant adolescents. From two urban, prenatal clinics in the City of Camden, NJ, a cohort of 594 nondiabetic, pregnant adolescents, aged 13-19 y, who delivered live, singleton newborns between 1985 and 1990, was recruited and followed through pregnancy. Registered dietitians collected up to three 24-h recalls during pregnancy. The adolescents were categorized according to total sugar in their diets, with those in the top 10th percentile defined as high sugar consumers (> or = 206 g, n = 60) and the remainder as reference consumers (< 206 g). Primary outcome measures were birth of small-for-gestational-age infants and gestational age. The cohort was 61% black, 30% Hispanic (Puerto Rican) and 9% white. The adjusted odds ratio was 2.01 (95% confidence interval 1.05-7.53) for the delivery of a small-for-gestational-age infant for adolescents consuming high sugar diets, regardless of their ethnicity. In addition, gestational age at delivery was -1.69 +/- 0.62 wk (beta +/- SE) shorter among Puerto Rican adolescents consuming high sugar diets (P = 0.007) compared with all reference sugar consumers and white adolescents consuming high sugar diets. Black adolescents consuming high sugar diets did not exhibit a shortening of gestation. Thus, adolescents consuming high sugar diets are at increased risk for delivering small-for-gestational-age infants, and for delivering infants earlier if they are of Puerto Rican ethnicity.

Adolescent health in Russia: a view from Moscow and St. Petersburg.

PURPOSE: The purpose of this study was to report on the current state of adolescent health in Russia. METHODS: By means of site visits, literature review, discussions with Russian colleagues, and a scientific meeting in Moscow, data were collected on health status of youth, the organization of health services, and professional training. RESULTS: Youth over the age of 14 are served in the adult health care system. Youth clinics are just now emerging. Substance abuse is a major issue; AIDS is rare. Rates of sexual intercourse parallel many western European countries; however, contraception is expensive by Russian standards and often not used. Those with behavioral, physical, and intellectual impairments tend to be educated in special settings and managed by psychiatrists. CONCLUSION: The Russian health care system is undergoing radical transformation. The traditional Soviet system, with its heavy reliance on medical interventions and prolonged inpatient hospitalizations, is threatened by a lack of resources. Privatization of health care poses additional threats, as do the social transformations that are occurring. These changes create a very uncertain future for the health and well-being of youth in Russia.

PIP: This article describes some health issues among adolescents in Russia and the health care delivery system for treating reproductive health problems, AIDS, mental health problems, and drug and alcohol dependency. Russian professionals expect improvements in the Russian health care system to meet the needs of a generation of grandchildren. Physicians and patients must now contend with primitive conditions and almost no resources. Medicines are in short supply. The health care system relies heavily on in-patient care. Equipment is very out-of-date. Adolescents older than 15 years of age are treated in the adult system. There are 14 district hospitals in Moscow for treating children aged under 14 years. Medical care is provided free of charge to all children. The average pediatric length of stay is 11.2 days, due to poor home conditions. Community clinics are linked to hospitals and treat children under 14 years of age. Family planning services are not available for teenagers at district clinics. Special family planning clinics provide adolescent contraception and counseling for children aged under 15 years with parents' consent. Family planning and abortion are available to children aged over 15 years without parental consent. The Center for Adolescent Reproductive Health in St. Petersburg is one of the few adolescent-specific health clinics in the country. The center provides sex education classes, gynecologic services, cosmetology, dysmenorrhea treatment, acupuncture, and AIDS surveillance. Resources for drug treatment are limited. Drug treatment at the St. Petersburg Narcological Center includes detoxification, medical stabilization, psychological rehabilitation, and vocational rehabilitation. Outreach programs include a hotline and school education groups. The authors were impressed with the dedication, knowledge, and strong desire for up-to-date information of professionals.