OBJECTIVES

To fill access gaps for adolescents, addressing sexual and reproductive health (SRH) is recommended in nontraditional settings. In previous improvement work, we increased documentation of sexual history to >80% of adolescents hospitalized on our pediatric hospital medicine (PHM) service. This study assessed adolescents’ perception of SRH conversations with hospital providers and the extent to which they were helpful.

METHODS

Postdischarge survey of patients 13 to 17 years discharged from the PHM service at an academic children’s hospital between August 2019 and March 2020. Survey items included demographics; whether confidential discussion of sexual health topics such as contraception, sexually transmitted infection (STI), and sexual orientation occurred; perceptions of these discussions, and sexual history.

RESULTS

Eighty-three patients enrolled and 44 (53%) completed the survey after discharge. A total of 68% of respondents were female and median age was 15 years (interquartile range 14–16). A total of 77% reported discussing SRH privately with a PHM provider. A total of 18% recalled discussing condoms, and 63% rated the discussion helpful. A total of 27% of females reported discussing birth control, and 40% rated it helpful. A total of 57% recalled discussing sexual orientation, and 40% rated it helpful. None reported discussions of STI testing with PHM. Of the 23% who were sexually active, none reported being given condoms.

CONCLUSIONS

Analysis of adolescent patient experiences identified opportunities for continued improvement in the content and quality of SRH discussions, specifically regarding offering STI testing, condom distribution, and sexual orientation conversations. Our work highlights the importance of incorporating patient-reported data into improvement work to ensure providers are addressing targeted gaps in adolescent care.

Adolescents have unique and evolving needs regarding education and access to sexual and reproductive health (SRH). Notably, national data estimate that about half of all new sexually transmitted infections (STIs) are in patients aged 15 to 24 years, and adolescents aged 15 to 19 years have the highest unintended pregnancy rate of any age group.13  With recent legal changes after the Supreme Court decision regarding the full spectrum of SRH available to patients, providing SRH education frequently, efficiently, and easily becomes even more important.4  Although adolescents learn about SRH from a variety of credible sources such as school-based education and their primary care providers, they also consult friends and the Internet, which could potentially be sources of misinformation.1  In the primary care setting, most parents and adolescents agree that confidential time with providers is important; however, providing that time can be difficult.5,6  In 1 study, only one-third of adolescents reported private time with their health care provider in the outpatient setting, and another study found adolescents received minimal information about SRH from a health care provider.6,7  Although primary care offices have been the mainstay of pediatric anticipatory guidance, including SRH education, adolescents present infrequently for preventative visits to their pediatrician.8 

Recent literature advises using nontraditional settings to provide SRH education and services.912  The hospital setting is an area where adolescents have expressed an interest in education and guidance regarding SRH.13  Ideally, a confidential social history is taken once an adolescent is hospitalized, and this discussion can provide an opportunity to educate and offer services to adolescents. However, SRH history, a crucial element of social history, is often not addressed in the hospital. In our previous work, retrospective review of our pediatric hospital medicine (PHM) service showed that about half (55%) of adolescent patients had SRH history documented during their hospitalization. Twelve percent of adolescent patients had STI testing, and 2% of females received contraception services before discharge.14  To improve this missed opportunity to provide care, we implemented a quality improvement initiative involving provider education and electronic health record (EHR) modifications to increase SRH history documentation and reproductive health service delivery. After these interventions, we noted that SRH history documentation for adolescent patients increased from 55% to above 80%. STI testing also increased modestly, but neither STI testing nor contraception provision reached special cause variation during the study.15 

Although improving SRH history documentation was an important first step in improving discussion of reproductive health, it did not address how this change translated to improvement in adolescents’ experiences or care. In this study, we sought to assess whether adolescents in our hospital recalled conversations they had about SRH with their hospital provider, and the extent to which they found these interactions beneficial.

This study included adolescent patients aged 13 to 17 years admitted or transferred to the PHM service at a Midwestern tertiary care, academic children’s hospital. Patients aged <18 years were targeted because they may have greater challenges in receiving SRH compared with patients aged 18 years and older. Patients who had a documented developmental delay in the EHR, did not speak English, or were previously enrolled were excluded during screening. Patients with current altered mental status, safety concerns, or who were actively receiving medical care or intervention at the time of potential enrollment were also excluded. At the end of the enrollment period, patients were excluded because of personal protective equipment restrictions and research restrictions at the start of the coronavirus disease 2019 pandemic. Age and sex were collected for all patients who were asked to participate.

A cross-sectional Qualtrics survey was conducted over a 7-month period (August 2019–March 2020). Our survey was adapted from the Young Adult Healthcare survey,16  with the addition of the sexual behavior section from the validated Youth Risk Behavior Surveillance System survey.17  Our survey inquired about patient demographics, receipt of patient-centered and confidential care, whether discussion of SRH topics (contraception, STI and HIV testing, sexual orientation) occurred during hospitalization with physicians or advanced practice providers, adolescent perceptions of these discussions, and their SRH and risk behaviors. Perceptions of each discussion topic were rated on a 4-point Likert-type scale from “Not at all helpful” to “Very helpful,” with a fifth option for “Not sure” (Appendix 1).

Patients were screened for enrollment using the EHR to identify eligible adolescents on the PHM service. A member of the research team approached adolescents directly in their rooms. Study introduction included statement of study goal, to obtain feedback about their health care experience, and opportunity to receive a gift card. If adolescent expressed interest, parents were asked to leave the room, if present, before verbal consent was obtained. If enrolled, they were given a business card-sized enrollment card, which had a link to the survey via both a Snapchat QR code18  and a short link URL. Adolescents were instructed to wait until after they left the hospital to take the survey so that their responses would be based on all provider interactions that occurred during hospitalization. Upon completion of the survey, a unique, $10 Amazon gift code appeared on the final page.

Data were summarized as median and interquartile range (interquartile range) or n (%). Fisher’s exact test was used to compare categorical variables and the Mann-Whitney-Wilcoxon test was used to compare continuous variables. P < .05 was considered significant. SAS 9.4 (SAS Institute, Cary, NC) and SPSS 28.0 (Armonk, NY: IBM Corp) were used for the analysis.

This study was reviewed and approved by our institution’s institutional review board.

Of the 185 patients screened, 69% (127 of 185) were eligible for enrollment in the study and 31% (58 of 185) were excluded on the basis of eligibility criteria (Fig 1). Thirty-five patients were eligible but were not asked to participate because an acute medical intervention was occurring, they were sleeping, or they were discharged before enrollment attempt. Overall, 92 patients were asked to participate, and 83 patients (90%) agreed to participate and received an enrollment card. There were no significant differences in age and sex of patients who agreed to enroll and those who did not. Fifty-three percent (44 of 83) of patients responded to the survey (Table 1). Sixty-eight percent (30 of 44) of respondents were female, with a median age of 15 years (interquartile range 14–16 years), corresponding well to the demographics of all who initially enrolled. Because the survey was anonymous, it is unknown which participants responded after enrollment. Therefore, we could not compare age and sex between respondents and nonrespondents. Fifty-nine percent (26 of 44) self-identified on the survey as white, and 20% (9 of 44) identified their ethnicity as Hispanic. Regarding sexual activity, 23% (10 of 44) of adolescents reported being sexually active, and 90% (9 of 10) of them endorsed using some method of pregnancy prevention during their last sexual encounter, with 1 of the 9 (10%) endorsing condom use (Table 2).

Seventy-seven percent (34 of 44) of adolescents reported that a doctor spoke with them privately during hospitalization, whereas 18% (8 of 33) reported a doctor did not speak with them privately, and 5% (2 of 44) could not remember. Eighty-four percent of those who spoke with a doctor privately reported that the doctor told them the conversation would be confidential (27 of 32 respondents; 2 skipped this question).

Table 3 presents adolescents’ recall and perceptions of SRH discussions with providers during their hospital stay. When responding to whether STI and HIV testing discussions occurred during the hospitalization, 25% (11 of 44) stated these discussions occurred only in the emergency department, 1 respondent said she could not remember, and all other respondents (73% or 32 of 44) said the discussion never happened while they were in the hospital. One survey question asked females only about discussion of birth control. Twenty-seven percent (8 of 30) of female respondents endorsed discussion of birth control and 38% (3 of 8) reported the discussion was helpful or very helpful. One patient was started on birth control while in the hospital. Regarding using condoms to prevent STIs, eighteen percent (8/44) of adolescents reported discussion of condoms occurred, and of those patients, 63% (5/8) found the discussed helpful or very helpful. Though free condoms were available to distribute as part of our ongoing improvement work, no patients endorsed receiving condoms at the hospital. Fifty-seven percent of respondents (25 of 44) reported discussion about sexual orientation, and 40% (10 of 25) endorsed it being helpful or somewhat helpful.

We found 77% of patients hospitalized on the PHM service reported speaking with a provider privately about SRH, which correlated well with our previous work on increasing sexual history documentation rate to >80%.15  A youth participatory study in Canada found that, although adolescents received SRH education from a variety of sources, health care providers were seen as positive sources, especially because of privacy and confidentiality inherent in the conversation.19  Another study interviewed adolescents about patient–provider communication during an SRH visit and found that comfort with discussing reproductive health was dependent on a variety of factors including age, maturity, sexual experience, and trust of the health care provider’s knowledge and ability to keep confidence of conversations.20  By including confidential SRH history as part of the hospitalization workflow, most adolescents were given the opportunity to have private time with a health care provider.

By asking adolescent patients about their experiences, we identified substantial opportunities for continued improvement, specifically in the content and quality of SRH discussions. This study acknowledges that, although physicians may have discussions with adolescents about what may be helpful to their health, adolescents’ perceptions of these conversations and whether they were beneficial may differ. Although many of the adolescents in our study reported private conversations with their health care provider, only a small proportion of adolescents in our study could report specific topics discussed during conversations. A few adolescents reported having discussions regarding birth control and condoms, and none reported having a discussion about STI testing while hospitalized. Of those who were sexually active, none reported being offered condoms, which are available for free as part of our improvement efforts. The helpfulness of discussions regarding specific sexual and reproductive health topics were varied, with some regarded as not being helpful. Future qualitative research should focus on elucidating why certain topics were beneficial compared with others. These topics are important, not only from a prevention standpoint, but also may drive testing, treatment, and resources offered while the patient is hospitalized, and as well as referrals to services upon discharge.

What we learned from this study will serve to refine and improve our delivery of SRH to adolescents. As previously mentioned, adolescents had difficulty reporting specific topics that were discussed. This finding may reflect that providers did not offer comprehensive SRH guidance during the confidential history or at other times during the hospitalization. It may also be that adolescents could not recall these discussions if they occurred, or it may be a mix of both. To address potential lack of recall, providers could focus on asking patients what they would like to discuss in a more open-mannered way during confidential history-taking, which may be more helpful to engaging adolescents in a patient-centered way.21  Given that discussion involving sexual orientation was recalled most frequently by adolescents, we could also include discussions about sex and identity, and more readily include information and resources as part of our materials. A 2010 American Academy of Pediatrics survey found that, although 86% of primary care pediatricians discussed sexual and reproductive health, only 18% discussed sexual orientation and sex identity.22  In our study, we learned that 40% of adolescents surveyed found the discussion of sexual orientation helpful. Thus, this could be a future area of focus for health care providers to address more readily in conversations.

Although SRH materials and free condoms are readily available for our institution’s providers to distribute, an assessment of why these resources are underutilized could guide our improvement work with providers. Further discussions with providers will be needed to address this lapse in offering and distributing condoms. Condoms are available for distribution in white bags and in team workrooms. However, this is an extra step for the provider and difficult to ensure discretion. We may need to move condoms closer to patient rooms or distribute them in a more discrete manner.

We also asked about helpfulness of private conversations with providers but did not broach the possibility of whether these conversations were experienced as distressing by the patients. As a next step, open-ended survey questions, focus groups, or interviews with adolescents would add qualitative feedback about SRH in the hospital setting and allow us to optimize patient-centered care.

Accessing the survey required a smartphone device or a computer, and although most adolescents were familiar with either Snapcode or short-link URL, some may not have been able to access the survey later, particularly if they were discharged to a mental health care facility or did not have access to the Internet. Our enrollment was discontinued with the onset of the coronavirus disease 2019 pandemic and restrictions on personal protective equipment use for nonclinical purposes, and a subsequent pause in many research operations at our institution. Additionally, there were missed enrollment opportunities if the patients did not speak English because our survey was only offered in English, had active medical treatment at the time of enrollment, if they were discharged before enrollment, or if they were sleeping. Although those who responded to the survey may have had different experiences from those who did not respond, it is encouraging that the age and sex of the patients who responded were similar to those who enrolled. Adolescents were asked to wait until after discharge to fill out the survey so that all conversations during hospitalization would be captured. However, some adolescents may have completed the survey before discharge when relevant conversations may not yet have occurred, or others may have been waiting longer after discharge and may not have been able to remember. Although it was advantageous to recruit and give adolescents the enrollment card during hospitalization rather than contacting them after discharge, adolescents may have forgotten about the survey, or misplaced the card. This likely accounts for the high enrollment rate but lower completion rate and resulted in small sample sizes, especially among subgroups. In terms of our survey itself, more inclusive language to capture range of sex identities and sexual behaviors should have been used.

We found that 77% of adolescents who completed this survey reported private and confidential conversations about SRH with their health care providers in the hospital setting, which complements our previous work on SRH documentation. However, fewer adolescents could report specific topics of SRH discussion, and there was variability in perceived helpfulness of the topics discussed. Our work highlights the importance of incorporating patient-reported data into improvement work on adolescent reproductive health care provision to ensure providers in nontraditional settings are addressing this opportunity in a meaningful way.

FUNDING: Supported by the Children’s Wisconsin Improving Health in Kids Fund awarded to Dr McFadden. The funder had no participation in the design or conduct of this study.

CONFLICT OF INTEREST DISCLAIMER: The authors have indicated they have no conflicts of interest relevant to this article to disclose.

Dr Mehta conceptualized and designed the study, designed the data collection instrument, recruited and enrolled subjects, interpreted data, drafted the initial manuscript, and revised the manuscript; Ms Porada designed the data collection instrument, recruited and enrolled subjects, interpreted data, and revised the manuscript for important intellectual content; Ms Liegl and Dr Pan designed the data collection instrument, performed statistical analysis, and revised the manuscript for important intellectual content; Dr McFadden conceptualized and designed the study, designed the data collection instrument, interpreted data, and revised the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

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Supplementary data