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INTRODUCTION: Children who are deaf or hard-of-hearing (DHH) are at risk for speech and language delay. Language outcomes are worse in DHH children from lower socioeconomic backgrounds, due in part to disparities in access to specialised speech-language therapy. Teletherapy may help improve access to this specialised care and close this language gap. Inclusion of diverse DHH children in prospective randomised clinical trials has been challenging but is necessary to address disparities and pursue hearing health equity. Stakeholder input regarding decisions on study design elements, including comparator groups, masking, assessments and compensation, is necessary to design inclusive studies. We have designed an inclusive, equitable comparativeness effectiveness trial to address disparities in paediatric hearing health. The specific aims of the study are to determine the effect of access to and utilisation of speech-language teletherapy in addressing language disparities in low-income children who are DHH. METHODS AND ANALYSIS: After stakeholder input and pilot data collection, we designed a randomised clinical trial and concurrent longitudinal cohort trial to be conducted at four tertiary childrens hospitals in the USA. Participants will include 210 DHH children aged 0-27 months. 140 of these children will be from lower income households, who will be randomised 1:1 to receive usual care versus usual care plus access to supplemental speech-language teletherapy. 70 children from higher income households will be simultaneously recruited as a comparison cohort. Primary outcome measure will be the Preschool Language Scales Auditory Comprehension subscale standard score, with additional speech, language, hearing and quality of life validated measures as secondary outcomes. ETHICS AND DISSEMINATION: This study was approved by the Institutional Review Boards of the participating sites: the University of California, San Francisco (19-28356), Rady Childrens Hospital (804651) and Seattle Childrens Hospital (STUDY00003750). Parents of enrolled children will provide written informed consent for their childs participation. Professional and parent stakeholder groups that have been involved throughout the study design will facilitate dissemination and implementation of study findings via publication and through national and regional organisations. TRIAL REGISTRATION NUMBER: NCT04928209.

BACKGROUND: Online surveys can align with youths increased use of the internet and can be a mechanism for expanding youth participation in research. This is particularly important during the coronavirus disease 2019 (COVID-19) pandemic, when in-person interactions are limited. However, the advantages and drawbacks of online systems used for research need to be carefully considered before utilizing such methodologies. AIM: To describe and discuss the strengths and limitations of an online system developed to recruit adolescent girls for a sexual health research study and conduct a three-month follow up survey. METHODS: This methodology paper examines the use of an online system to recruit and follow participants three months after their medical visit to evaluate a mobile sexual and reproductive health application, Health-E You/Salud iTuTM, for adolescent girls attending school-based health centers (SBHCs) across the United States. SBHC staff gave adolescent girls a web link to an online eligibility and consent survey. Participants were then asked to complete two online surveys (baseline and 3-month follow-up). Surveys, reminders, and incentives to complete them were distributed through short message service (SMS) text messages. Upon completing each survey, participants were also sent an email with a link to an electronic gift card as a thank-you for their participation. Barriers to implementing this system were discussed with clinicians and staff at each participating SBHC. RESULTS: This online recruitment and retention system enabled participant recruitment at 26 different SBHCs in seven states across the United States. Between September 2021 and June 2022, 415 adolescent girls were screened using the Qualtrics online survey platform, and 182 were eligible to participate. Of those eligible, 78.0% (n = 142) completed the baseline survey. Participants were racially, geographically, and linguistically diverse. Most of the participants (89.4%) were non-White, and 40.8% spoke Spanish. A total of 62.0% (n = 88) completed the 3-month follow-up survey. Limitations of this system included reliance on internet access (via Wi-Fi or cell service), which was not universally available or reliable. In addition, an individual unrelated to the study obtained the survey link, filled out multiple surveys, and received multiple gift cards before the research team discovered and stopped this activity. As a result, additional security protocols were instituted. CONCLUSION: Online systems for health research can increase the reach and diversity of study participants, reduce costs for research personnel time and travel, allow for continued study operation when in-person visits are limited (such as during the COVID-19 pandemic), and connect youth with research using technology. However, there are challenges and limitations to online systems, which include limited internet access, intermittent internet connection, data security concerns, and the potential for fraudulent users. These challenges should be considered prior to using online systems for research.

ObjectiveIdentify the age at diagnosis and intervention of immigrant and/or non-English-speaking children with hearing loss (HL) and risk factors associated with delays. Identify barriers for non-English-speaking caregivers of deaf/hard-of-hearing children.Study designSequential mixed methods.SettingTertiary care center in an urban city.MethodsThe analysis includes descriptive statistics, and 1-way and 2-way analysis of variance of the retrospective chart review. The quantitative study demonstrated foreign-born experienced disparities, so we conducted semistructured interviews on a subset of non-English-speaking families in the cohort that was then thematically analyzed using a human-centered design strategy.ResultsWe divided 532 children into 3 groups: US-born with English as the preferred language (N = 294), US-born and non-English language preferred (N = 173), and foreign-born (N = 67). The laterality of HL and pure-tone averages were similar among the groups (p = .972 and .071, respectively). Age at diagnosis and time to the intervention were significantly different (39.7, 31.5, 75.8 months, p

The Clinical Effort Against Secondhand Smoke Exposure (CEASE) is an evidence-based framework that increases pediatric providers' ability to address secondhand smoke exposure of minors. Physician champions at 4 University of California sites conducted regular 1-hour didactic trainings on CEASE principles to pediatric residents as part of a longitudinal curriculum. At the conclusion of the academic year, 111 of 284 residents (39%) completed an anonymous survey. CEASE-trained residents reported significantly higher rates than untrained residents of counseling on smoking cessation (adjusted odds ratio [OR] = 4.50, P = .009), and referring to the smokers' quitline (adjusted OR 3.6, P = .007) to 50% or more of their patients' caregivers who smoked. In addition, among CEASE-trained residents, there were significant increases in multiple post-training knowledge and self-efficacy items. Our results show that a brief educational curriculum can be helpful in changing pediatric residents' attitudes and behavior toward assisting adult caregivers to pediatric patients in smoking cessation.

IntroductionChildren's exposure to secondhand smoke is an underaddressed public health threat. The Clinical Effort Against Secondhand Smoke Exposure (CEASE) is a validated framework that trains pediatric providers to screen, counsel, refer to quitlines, and prescribe tobacco cessation medications to adult caregivers of children.MethodsA physician champion at a major urban academic center delivered a longitudinal didactic curriculum of CEASE principles to medical and nurse practitioner students and pediatrics and family medicine residents. At the end of each session, participants completed an anonymous survey measuring changes in self-perceived knowledge, comfort, and familiarity with smoking cessation skills and concepts. Using a separate end-of-year questionnaire, we also surveyed a group of pediatric residents to compare the impact of CEASE training on clinical practice. Finally, we tracked the number of referrals to the state's quitline for the duration of the training.ResultsFifty-two trainees (55% students, 45% residents) responded to the evaluation survey administered immediately following training. There were statistically significant improvements in median scores after CEASE training for comfort in screening, counseling, motivational interviewing, referring to smokers' helplines, and providing caregivers with nicotine replacement therapy (NRT) prescriptions. Fifty-one percent of pediatric residents (41 of 80) responded to the end-of-year survey, which showed statistically significant differences in the number of patients/caregivers offered a referral to California's quitline and prescription of NRT according to completion of CEASE training.DiscussionCEASE training successfully improved the self-efficacy of health professions students and residents in smoking cessation techniques for adult caregivers of children.

Introduction Children who are deaf or hard-of-hearing (DHH) are at risk for speech and language delay. Language outcomes are worse in DHH children from lower socioeconomic backgrounds, due in part to disparities in access to specialised speech-language therapy. Teletherapy may help improve access to this specialised care and close this language gap. Inclusion of diverse DHH children in prospective randomised clinical trials has been challenging but is necessary to address disparities and pursue hearing health equity. Stakeholder input regarding decisions on study design elements, including comparator groups, masking, assessments and compensation, is necessary to design inclusive studies. We have designed an inclusive, equitable comparativeness effectiveness trial to address disparities in paediatric hearing health. The specific aims of the study are to determine the effect of access to and utilisation of speech-language teletherapy in addressing language disparities in low-income children who are DHH.Methods and analysis After stakeholder input and pilot data collection, we designed a randomised clinical trial and concurrent longitudinal cohort trial to be conducted at four tertiary children’s hospitals in the USA. Participants will include 210 DHH children aged 0–27 months. 140 of these children will be from lower income households, who will be randomised 1:1 to receive usual care versus usual care plus access to supplemental speech-language teletherapy. 70 children from higher income households will be simultaneously recruited as a comparison cohort. Primary outcome measure will be the Preschool Language Scales Auditory Comprehension subscale standard score, with additional speech, language, hearing and quality of life validated measures as secondary outcomes.Ethics and dissemination This study was approved by the Institutional Review Boards of the participating sites: the University of California, San Francisco (19-28356), Rady Children’s Hospital (804651) and Seattle Children’s Hospital (STUDY00003750). Parents of enrolled children will provide written informed consent for their child’s participation. Professional and parent stakeholder groups that have been involved throughout the study design will facilitate dissemination and implementation of study findings via publication and through national and regional organisations.Trial registration number NCT04928209.

Background: Alcohol and binge drinking pose significant health risks, especially for underage women; nonetheless, binge drinking is common. Materials and Methods: To evaluate the effectiveness of the PartyWise intervention in increasing awareness of sex differences in the risks of binge drinking, we used social media to enroll 520 female adolescents aged 15-19 years in a randomized controlled trial. Intervention participants received telephone screening, a brief counseling intervention with web-based resources (http://www.partywise.org), and up to 8 weekly text messages. Results: At baseline, most (71%) participants reported alcohol consumption in the prior month and 44% reported binge drinking (four or more drinks on one occasion), without differences between study groups; 79% of participants were aware of sex-based differences in alcohol risks. At follow-up, intervention recipients were more knowledgeable about sex-based differences in alcohol risks (adjusted odds ratio [adj OR] 8.87, 95% confidence interval [CI] 3.35-23.49 at 3 months; adj OR 2.44, 95% CI 1.21-4.90 at 9 months) and more likely to accurately define binge drinking (adj OR 1.63, 95% CI 1.02-2.60 at 3 months; OR 1.37, 95% CI 0.89-2.06 at 9 months). Although rates of any binge drinking in the past month remained similar between groups, intervention recipients were less likely to report binge drinking more than once in the past 30 days (22% vs. 32%, adj OR 0.58, 95% CI 0.35-0.99 at 3 months; 27% vs. 30%, adj OR 0.97, 95% CI 0.60-1.55 at 9 months). Conclusions: The PartyWise intervention is a promising approach to increasing awareness of the risks of binge drinking for underage women in a remotely delivered platform. Clinical Trials Registration: The Share Health Study: Teen Social Connections and Health (Phase 2), NCT03842540, https://clinicaltrials.gov/ct2/show/NCT03842540?id=NCT03842540&draw=2&rank=1.

The relationship between mental health and teenage pregnancy is complex. Mental health can be both an antecedent and contributing factor to teenage pregnancy and a concurrent factor wherein pregnancy itself can contribute to depression. Expectant and parenting teens (EPT) are faced with the simultaneous challenges of pregnancy and parenting while navigating the developmental tasks of adolescence which increases their risk for mental health problems. In addition, adolescents growing up in stressful community or home situations where their parents experienced depression, further places them and their children at greater risk of repeated patterns over time. However, adverse mental health outcomes are not inevitable. The socio-ecological model combined with a life course perspective provides a framework for understanding the complexity of risk and protective factors at multiple levels that influence knowledge, attitudes, behaviors, and other health outcomes later in life and across generations. This approach has important implications for reducing adolescents' risk of an unintended/mistimed pregnancy and improving mental health and other outcomes for EPT. This paper describes the prevalence of mental health problems in EPT and using a socio-ecological framework and life course perspective explains variations in mental health outcome among EPT. Implications for interventions and innovative approaches are also discussed.

ObjectivesTo improve teen contraceptive use, the SpeakOut intervention combines structured counseling, online resources, and text reminders to encourage teens to share their experiences using intrauterine contraception (IUC) or an implant with peers.Study designTo evaluate the effectiveness of remote delivery of the SpeakOut intervention in increasing teen contraceptive use, we conducted a cluster randomized trial involving female adolescents who were recruited online. Primary participants (n = 520) were randomly assigned to receive SpeakOut or an attention control; each primary participant recruited a cluster of up to 5 female peers as secondary participants (n = 581). We assessed contraceptive communication, knowledge, and use, at baseline, 3 and 9 months after participants enrolled. We examined differences between study groups, controlling for clustering by primary participant and baseline characteristics.ResultsThe trial's primary outcome, contraceptive use by secondary participants, was similar between groups at both 3 and 9 months postintervention. Compared to controls, primary participants receiving SpeakOut tended to be less likely to discontinue contraception within 9 months (4.8% vs 7.8%, p = 0.11 for IUC; 7.8% vs 9.8%, p = 0.45 for implants), but this did not reach statistical significance. SpeakOut failed to increase contraceptive communication; regardless of study group, most secondary participants reported peer communication about contraception (86% vs 88%, p = 0.57). Most secondary participants were aware of the hormonal IUC (91.4% vs 90.4%, p = 0.72), copper IUC (92.9% vs 88.6%, p = 0.13), and implant (96.5% vs 96.1%, p = 0.83) 3 months after enrolling, regardless of the intervention their primary participant received. However, contraceptive knowledge remained incomplete in all study groups.ConclusionRemote delivery of the SpeakOutintervention did not improve contraceptive communication, knowledge or use among participating teens or their peers.ImplicationsEfforts to support teen-to-teen contraceptive communication and ensure that teens have accurate information about the full range of contraceptive methods, including highly effective reversible contraceptives, require refinement.

Purpose: Young adults with autism spectrum disorder (YAASD) often lack the skills needed for successful adult living and subsequently develop lower quality of life and health in adulthood. Therefore, we developed a framework to support resilience and improve quality of life in YAASD, which will be used to develop a life-skills curriculum for YAASD. Methods: We conducted a qualitative study of YAASD, parents of YAASD and service providers recruited from agencies that serve YAASD using Grounded Theory. We focused our interviews on supports and skills needed to enhance quality of life in adulthood. Results: A total of 23 individuals were interviewed. We developed the major theoretical code; “Self-actualization skills in young adults with autism to improve quality of life”. This code recognized the neurodiversity of YAASD as well as comorbid intellectual disability and mental health needs, which often were additional barriers to achieving life goals. We identified the need for developing skills to facilitate both independence and greater insight, including self-care, self-advocacy, and social integration. YAASD struggled in developing skills to adapt to the constantly changing environment that neurotypical adults deal with daily. Factors that would facilitate development of self-actualizing skills include resources that promote creating structure in an adult world that can appear unstructured to YAASD. Conclusions: Self-actualization for adults requires skills for self-care, decision making, and effective communication. Unfortunately, most programs for YAASD emphasize vocational and simple task performance. Our framework facilitates self-actualization skills to enhance health and wellness, potentially reducing barriers to living meaningfully within the community.

BackgroundAttention deficit hyperactivity disorder (ADHD) affects about 13% of adolescents and is associated with substance use-related morbidity and mortality. While evidence on effective interventions to reduce alcohol use among adolescents with ADHD is limited, parent-teen communication about alcohol use has been found to be protective. Other approaches, such as educational interventions, hold promise to reduce alcohol-related harms in adolescents with ADHD. Digital technology offers an innovative approach to health behavior change, expanding access to services and may promote learning for neurodiverse youth, including teens with ADHD. INSPIRE, a narrative-centered game-based behavior change environment designed to promote self-regulation and self-efficacy to prevent risky alcohol use has been found to engage a general adolescent population. The goals of this pilot study are (1) to examine the engagement of youth with ADHD in INSPIRE; and (2) to examine if INSPIRE fosters parent-teen communication.MethodAdolescents diagnosed with ADHD aged 14–16 were recruited from developmental medicine clinics and invited to a focus group offered via Zoom. Participants completed a pre-survey, interacted with the INSPIRE game, and answered a post-survey as well as open-ended questions about their gaming experience during the focus group. Engagement was measured through both self-report using subscales from the User Engagement Scale and computer data; survey and qualitative data collected information on parent-teen communication. Univariate statistics described adolescent characteristics, Rank-sum and Fisher’s exact tests examined relationships among variables, and qualitative analysis identified themes in open-ended questions.ResultsOf adolescent participants (N = 40), 45% identified as female, 17.5% Black, 7.5%, Hispanic, and 62.5% White. Post-survey mean engagement subscales of Usability (on a 5-point scale) was 3.67 (SD = 0.74), and Satisfaction was 3.63 (SD = 0.75). Computer data indicated that participants played the game for a median of 24 min. Adolescents shared that playing the game strengthened refusal skills and their ability to navigate social gatherings with alcohol. Post-survey, 63% planned to share information from INSPIRE with a parent.ConclusionFindings suggest that INSPIRE may support facilitating youth with ADHD to learn the developmental competencies needed to mitigate risk and thrive. INSPIRE warrants further testing to explore its impact on alcohol use in youth with ADHD.

ObjectiveTo evaluate the effectiveness of Health-E You/Salud iTu, a mobile health application (app), on increasing knowledge, self-efficacy and contraception use among Latina adolescents, its impact on visit quality, and app satisfaction.Study designThis study used cluster-randomized controlled trial (CRCT) of 18 school-based health centers (SBHCs). Prior to the visit, intervention participants received the patient-centered contraceptive decision-making support app and controls answered sexual health questions on iPads. Participants completed a previsit questionnaire and 3 follow-up surveys (48 hours, 3-, and 6-months) after the recruitment visit (where intervention participants completed the app). Differences in adolescents' contraceptive knowledge, self-efficacy, and use over the 6-month follow-up were assessed by generalized mixed effects regression models.ResultsA total of 1,360 Latina adolescents participated; 57.2% responded to the 48-hour survey, 50.1% to the 3-month, 49.7% to the 6-month, and 42.3% to both the 3- and 6-month surveys. Health-E You users' demonstrated significant increases in pre-post knowledge (p < 0.001). Intervention participants who completed the follow-up survey reported greater increases in mean self-efficacy from baseline (23.2 intervention vs. 22.5 controls) to 6 months (26.1 vs. 23.4; b = 1.58, 95% CI 0.38-2.77, p = 0.01), and greater increases in non-barrier contraceptive use from baseline (29% intervention vs. 30% controls) to 3 months (63% vs. 45%; OR = 3.29, 95% CI 1.04-10.36, p = 0.04) and 6 months (63% vs. 44%; OR = 5.54, 95% CI 1.70-18.06, p = 0.005). Providers and adolescents reported high app satisfaction and stated it improved visit quality.ConclusionsWhile data suggest that Health-E You improved outcomes, findings must be interpreted cautiously. Intervention participants had higher baseline sexual activity rates, more recruitment visits for pregnancy testing, emergency contraception or birth control, and lower completion rates of follow-up surveys than controls.ImplicationsDespite declines in adolescent pregnancy in the United States, Latinas continue to have disproportionately high rates compared to white females. The Health-E You app may be an effective support tool for both adolescents and providers in SBHCs, and possibly other clinical settings, across the country to increase contraceptive use and thereby decrease unintended pregnancies. It could potentially reduce disparities in adolescent pregnancies and create more efficient visit time spent between clients and their providers.

PurposeTeen pregnancy prevention projects funded by the U.S. Office of Adolescent Health were disrupted by the Trump administration in the July 2017 announcement that funding would be terminated. Although funding was later reinstated toward the end of 2018 after a class-action lawsuit, we needed to change our recruitment protocol to mitigate this disruption to the study timeline and staffing. This led to a natural experiment comparing in person and social media recruitment strategies.MethodsThe original approach was to recruit girls, aged 15-19 years, who were using intrauterine or subdermal contraception, in person in clinic settings. After the funding disruption, we transitioned to an online recruitment strategy. Costs associated with each approach (in-person and online recruitment) were tracked, and we compared cost of per-person enrollment with each approach.ResultsIn-person, clinic-based recruitment enrolled 118 participants over 293 days from eight high-volume clinics. Online recruitment enrolled 518 participants over 146 days. Online recruitment resulted in cost savings and a diverse sample representing a larger geographic region.ConclusionOnline recruitment can cut costs and be more efficient than a clinic-based recruitment strategy, but special considerations are warranted when considering social media recruitment.

PurposeThis study aimed to determine the association between use of highly effective methods of nonbarrier contraception and condom use in a sample of Latina adolescents and whether the change to a more effective method of nonbarrier contraception is associated with a change in condom use.MethodsAs part of a larger study, 442 sexually active Latina adolescents aged 14-18 years were surveyed immediately before an appointment with a medical care provider at a school-based health center and 3 months later. Ordinal logistic and linear regression were used in the analysis of cross-sectional and longitudinal data to assess the relationship between patterns of nonbarrier contraception and condom use.ResultsThe use of all types of nonbarrier methods of contraception was significantly associated with decreased condom use. Change over time from a less effective to a more effective nonbarrier method of contraception was also associated with a decrease in condom use. Greater number of sexual encounters was associated with lower the frequency of condom use.ConclusionsThe use of highly effective methods of nonbarrier contraception was associated with reduced frequency of condom use. This highlights the need to promote condom use concurrently with nonbarrier methods of contraception to improve protection against both pregnancy and STIs.

BackgroundTobacco smoke exposure leads to numerous adverse health effects in children. Providing cessation interventions to caregivers who smoke during pediatric hospitalizations can help protect children from such exposure. Both pediatric registered nurses (RNs) and pediatric respiratory therapists (RTs) are well positioned to provide these interventions. Little is known about their rates of participation in cessation efforts. Our objective was to compare the attitudes and practice of pediatric RNs versus pediatric RTs to evaluate their relative cessation-intervention practices in the in-patient pediatric setting.MethodsAn online survey was sent to pediatric RNs and RTs at 4 tertiary pediatric hospitals in California. The survey assessed individual demographics, work environment, experience, beliefs, and practices related to smoking cessation activities. Questions used 3-point and 5-point Likert scales and were compared with the chi-square test. Institutions with a response rate < 20% were excluded.ResultsA total of 401 respondents were included in the final analysis (292 RNs, 109 RTs). RTs versus RNs were older (42.0 y vs 35.4 y, respectively, P < .001) and more likely to be former smokers (29.9% vs 13.3%, respectively, P < .001). RNs reported lower levels of confidence in discussing smoking cessation with parents, with 11.7% saying they felt "very confident" compared to 29.0% of RTs (P < .001). RNs also reported screening for smoke exposure less frequently than RTs, with 18.8% responding "often" or "always" compared to 28.9% of RTs (P = .033). RNs had lower rates of advising parents "to make a smoke-free home policy" compared to RTs (ie, 13.4% vs 26.9%, respectively, P = .002).ConclusionsCompared to in-patient pediatric RNs, RTs reported higher rates of confidence in providing cessation interventions, screening for smoke exposure, and counseling on reducing smoke exposure, suggesting that they may be better positioned for intervening. These results can inform the design of an in-patient cessation intervention for caregivers of hospitalized children.

PurposeAccidents and unintentional injuries account for the greatest number of adolescent deaths, often involving use of alcohol and other substances. This article describes the iterative design and development of Interactive Narrative System for Patient-Individualized Reflective Exploration (INSPIRE), a narrative-centered behavior change environment for adolescents focused on reducing alcohol use. INSPIRE is designed to serve as an extension to clinical preventive care, engaging adolescents in a theoretically grounded intervention for health behavior change by leveraging 3D game engine and interactive narrative technologies.MethodsAdolescents were engaged in all aspects of the iterative, multiyear development process of INSPIRE through over 20 focus groups and iterative pilot testing involving more than 145 adolescents. Qualitative findings from focus groups are reported, as well as quantitative findings from small-scale pilot sessions investigating adolescent engagement with a prototype version of INSPIRE using a combination of questionnaire and interaction trace log data.ResultsAdolescents reported that they found INSPIRE to be engaging, believable, and relevant to their lives. The majority of participants indicated that the narrative's protagonist character was like them (84%) and that the narrative featured virtual characters that they could relate to (79%). In the interactive narrative, the goals most frequently chosen by adolescents were "stay in control" (60%) and "do not get in trouble" (55%).ConclusionsWith a strong theoretical framework (social-cognitive behavior change theory) and technology advances (narrative-centered learning environments), the field is well positioned to design health behavior change systems that can realize significant impacts on behavior change for adolescent preventive health.

Introduction: Adolescents who seek care in the emergency department (ED) are a cohort at increased risk of unintended pregnancy. Although adolescents are interested in learning about pregnancy prevention in the ED, there is a lack of effective educational interventions in this setting. Long-acting reversible contraceptives (LARC) are highly effective and safe in teens, yet are underutilized. This study assessed contraception use among adolescents in the ED and evaluated the impact of an educational video on their interest in and uptake of LARCs.Methods: We conducted a two-arm randomized controlled trial on a convenience sample of sexually active females 14 to 21 years old in an urban pediatric ED. Participants were randomized to an educational video or standard care. All participants completed a survey and were given an informational card about affiliated teen clinics with the option to schedule an appointment. We assessed pre-post mean differences between control and intervention participants and pre-post differences among intervention participants. Participants were followed three months after their ED visit to examine use of contraception.Results: A total of 79 females were enrolled (42 control and 37 intervention). The mean age was 17 years, and most were youth of color. The proportion of participants with a prior pregnancy was 18%. Almost all participants reported wanting to avoid pregnancy, yet 18% reported not using contraception at last intercourse. At baseline, 17.7% of participants were somewhat or very interested in the intrauterine device (IUD) or implant. After watching the video, 42.3% were somewhat or very interested in the IUD and 35.7% in the implant. Among those who watched the video, there were significant increases in interest in using an IUD or implant (p

Understanding and optimizing adolescent-specific engagement with behavior change interventions will open doors for providers to promote healthy changes in an age group that is simultaneously difficult to engage and especially important to affect. For digital interventions, there is untapped potential in combining the vastness of process-level data with the analytical power of artificial intelligence (AI) to understand not only how adolescents engage but also how to improve upon interventions with the goal of increasing engagement and, ultimately, efficacy. Rooted in the example of the INSPIRE narrative-centered digital health behavior change intervention (DHBCI) for adolescent risky behaviors around alcohol use, we propose a framework for harnessing AI to accomplish 4 goals that are pertinent to health care providers and software developers alike: measurement of adolescent engagement, modeling of adolescent engagement, optimization of current interventions, and generation of novel interventions. Operationalization of this framework with youths must be situated in the ethical use of this technology, and we have outlined the potential pitfalls of AI with particular attention to privacy concerns for adolescents. Given how recently AI advances have opened up these possibilities in this field, the opportunities for further investigation are plenty.

Introduction Children's exposure to secondhand smoke is an underaddressed public health threat. The Clinical Effort Against Secondhand Smoke Exposure (CEASE) is a validated framework that trains pediatric providers to screen, counsel, refer to quitlines, and prescribe tobacco cessation medications to adult caregivers of children. Methods A physician champion at a major urban academic center delivered a longitudinal didactic curriculum of CEASE principles to medical and nurse practitioner students and pediatrics and family medicine residents. At the end of each session, participants completed an anonymous survey measuring changes in self-perceived knowledge, comfort, and familiarity with smoking cessation skills and concepts. Using a separate end-of-year questionnaire, we also surveyed a group of pediatric residents to compare the impact of CEASE training on clinical practice. Finally, we tracked the number of referrals to the state's quitline for the duration of the training. Results Fifty-two trainees (55% students, 45% residents) responded to the evaluation survey administered immediately following training. There were statistically significant improvements in median scores after CEASE training for comfort in screening, counseling, motivational interviewing, referring to smokers’ helplines, and providing caregivers with nicotine replacement therapy (NRT) prescriptions. Fifty-one percent of pediatric residents (41 of 80) responded to the end-of-year survey, which showed statistically significant differences in the number of patients/caregivers offered a referral to California's quitline and prescription of NRT according to completion of CEASE training. Discussion CEASE training successfully improved the self-efficacy of health professions students and residents in smoking cessation techniques for adult caregivers of children.

Introduction: The use of alcohol, tobacco, and other drugs (ATOD) is a leading cause of preventable morbidity and mortality among adolescents. While traditional interventions have targeted specific health-risk behaviors (e.g., substance use, initiation of sexual intercourse, truancy, etc.), the evidence suggests that using a positive youth development (PYD) framework may have positive impacts across a number of domains. Friday Night Live Mentoring (FNLM) is a PYD-based, cross-age peer mentoring program that engages teams of older high school-aged youth to mentor teams of middle school-aged youth in a structured, ongoing, one-on-one relationship. While studies have demonstrated significant but small effect sizes of intergenerational youth mentoring programs in which an adult mentor is paired with the youth mentee, research on cross-age mentoring programs is limited. The purpose of the current study is to evaluate FNLM on its ability to improve participants' knowledge, attitudes, skills, opportunities to develop caring relationships, school engagement, and academic performance. Methods: A retrospective, pre–post survey was administered online to FNLM participants across 13 California counties. Participants rated their knowledge and attitudes about ATOD, skills, relationships with peers and adults, and academic indicators. Open-ended questions gathered information about participants' experiences in FNLM. Non-parametric related-samples Wilcoxon signed rank tests (an alternative to paired t-test) were used to compare pre–post differences. Participants were also asked two open-ended questions: "What are the best parts of FNLM?" and "What, if anything, would you change?". The responses to each question were reviewed, coded, and analyzed according to key themes. Results: A total of 512 participants completed the survey (287 mentors and 225 protégés). There were small but statistically significant improvements across all items for both mentors and protégés. Qualitative analyses showed that most mentors and protégés especially enjoyed getting to know and spend time with one another. Several mentors added that it was rewarding to be a positive influence on or to make a positive difference in the protégé's life. Many youth stated that the relationships formed, especially with their partner, and the activities were the best part of FNLM. The overwhelming majority would not change anything about the program. Those who provided recommendations for program improvement suggested more activities or more hands-on and engaging activities and more or longer meetings. Conclusion: FNLM actively engages youth and provides them with support and opportunities that promote knowledge, skill development, positive relationships, academic engagement, and success and raise awareness of the harms that the use of alcohol, tobacco, and other drugs (ATOD) can cause. While ATOD use was low prior to program participation, it was significantly lower after participating in the program. [ABSTRACT FROM AUTHOR]

Fish spawning aggregations are vulnerable to overexploitation, which can have severe ecological, social, and economic consequences. Knowledge on the spatial ecology of aggregating species is often lacking, but is crucial for their effective conservation. This study explores the spawning site residency, interannual fidelity, and migration of black seabream Spondyliosoma cantharus using acoustic (n =  55) and conventional (n =  2397) tagging within and outside Marine Conservation Zones in the southern UK. Detections and recaptures of tagged fish indicated that black seabream display significant interannual fidelity to nesting areas, but that residency of individuals at nesting areas was short relative to current temporal management of these areas. Locations of detection and recapture during autumn/winter indicated migration by black seabream into deeper waters of the English Channel and coastal waters of France and the Channel Islands. The results indicate spatial structuring of black seabream populations maintained by homing of adults to previously occupied sites. However, short residency periods within protected reproductive sites, and evidence of transboundary migrations emphasize the importance of effective fisheries management, i.e. collaborative between European nations. These findings highlight the importance of international-scale telemetry studies and networks for informing ecosystem-based fisheries management of sensitive migratory species. [ABSTRACT FROM AUTHOR]

Abstract Background Disseminated aspergillosis (DA) in dogs has a guarded prognosis and there is a lack of a gold standard treatment protocol. Objective To retrospectively assess survival times and factors influencing survival times. Animals Dogs diagnosed with DA from January 2007 to June 2017. Methods Disseminated aspergillosis case data were retrieved from 13 Australian veterinary referral centers, with a diagnosis confirmed with culture or PCR. Factors influencing survival time after diagnosis were quantified using a Cox proportional hazards regression model. Results Thirty‐four dogs met the study inclusion criteria. Twenty‐two dogs were treated with antifungal treatment and 12 dogs received no antifungal treatment. Accounting for censoring of dogs that were either still alive on the date of data collection or were loss to follow‐up, dogs treated with itraconazole alone (n = 8) had a median survival time (MST) of 63 (95% CI: 20−272) days compared to 830 (95% CI: 267‐1259) days for the n = 14 dogs that received multimodal antifungal therapy (χ2 test statistic 8.6; df = 1; P

Background: Social determinants are the leading causes of health disparities. Yet health care systems have not systemically addressed social determinants of health as it pertains to adolescents and young adults (AYAs), among other populations in need. This study identified promising innovative programs across the United States. Methods: Thirteen representatives from 10 programs completed a 45-min telephone interview. Transcripts were reviewed and analyzed to identify cross-cutting themes. Results: Strategies included increasing access to quality, comprehensive and confidential health services, addressing the holistic needs of AYAs, collaborations across the health care delivery systems and other community services, and leveraging technology. Conclusion: This study showcased innovative approaches to inform future efforts.

INTRODUCTION:Teen pregnancy rates in the USA remain higher than any other industrialised nation, and pregnancies among Hispanic adolescents are disproportionately high. Computer-based interventions represent a promising approach to address sexual health and contraceptive use disparities. Preliminary findings have demonstrated that the Health-E You/Salud iTu, computer application (app) is feasible to implement, acceptable to Latina adolescents and improves sexual health knowledge and interest in selecting an effective contraceptive method when used in conjunction with a healthcare visit. The app is now ready for efficacy testing. The purpose of this manuscript is to describe patient-centred approaches used both in developing and testing the Health-E You app and to present the research methods used to evaluate its effectiveness in improving intentions to use an effective method of contraception as well as actual contraceptive use. METHODS AND ANALYSIS:This study is designed to assess the effectiveness of a patient-centred computer-based clinic intervention, Health-E You/Salud iTu, on its ability to reduce health disparities in unintended pregnancies among Latina adolescent girls. This study uses a cluster randomised control trial design in which 18 school-based health centers from the Los Angeles Unified School District were randomly assigned, at equal chance, to either the intervention (Health-E You app) or control group. Analyses will examine differences between the control and intervention group's knowledge of and attitudes towards contraceptive use, receipt of contraception at the clinic visit and self-reported use of contraception at 3-month and 6-month follow-ups. The study began enrolling participants in August 2016, and a total of 1400 participants (700 per treatment group) are expected to be enrolled by March 2018. ETHICS AND DISSEMINATION:Ethics approval was obtained through the University of California, San Francisco Institutional Review Board. Results of this trial will be submitted for publication in peer-reviewed journals. This study is registered with the US National Institutes of Health. TRIAL REGISTRATION NUMBER:NCT02847858.

Background: Chemotherapy is associated with decreased quality of life (QOL), fatigue, depression, and weight gain in patients with breast cancer. Weight gain is associated with poorer prognosis. Yoga improves QOL, fatigue, and mood in women with breast cancer but its effect on treatment-related weight gain has not been studied. The aim of this trial was to determine the feasibility of personalized yoga therapy in women receiving treatment for early-stage or locally advanced breast cancer and assess its impact on weight gain. Methods: Thirty women were randomized 1:1 to receive yoga therapy by a certified yoga therapist during treatment or a control group. Participants in the yoga arm were asked to complete three 30 minute yoga sessions weekly (which included movement, breath work, mindfulness, and relaxation) throughout adjuvant or neoadjuvant chemotherapy (N = 29) or endocrine (N = 1); the control arm received breast cancer treatment without yoga. For comparability between participants randomized to yoga therapy, the single patient treated with endocrine therapy was excluded from the analysis. Primary outcomes were feasibility and weight change. Additional outcomes were mood, fatigue, QOL, serum tumor necrosis factor-alpha (TNF-alpha), and C-reactive protein (CRP) as immune mediator biomarkers. Results: Mean age was 51.6 years, 75.9% were white and 24.1% were people of color, reflecting the cancer center population. 80% had stage II-III disease. Enrollment was completed in 9 months. Compliance was lower than predicted; however, participants participated in on average 1.7 yoga sessions/week for a mean 15.6 weeks duration. There were no adverse events. Control arm participants gained on average 2.63% body weight during treatment while yoga participants lost 0.14% body weight (weight change = −0.36 in yoga arm vs. 2.89 in standard of care arm, Wilcoxon rank sum test P = .024). Control participants reported increased fatigue and decreased QOL, while yoga participants reported no change in QOL. No significant change in TNF-alpha or CRP was noted in either arm. Conclusion: This feasibility study suggests that personalized yoga therapy is beneficial for QOL and weight maintenance among women undergoing chemotherapy for early-stage or locally advanced breast cancer. Weight maintenance associated with yoga therapy may be of clinical significance in this population given the poorer prognosis associated with weight gain in breast cancer survivors. Trial Registration: NIH Clinicaltrials.gov #NCT03262831; August 25, 2017. https://clinicaltrials.gov/ct2/show/NCT03262831

OBJECTIVES: The use of effective contraception can decrease the incidence of unplanned pregnancy among adolescents. This study aims to examine the effectiveness of an iPad-based application (app) on improving adolescent girls sexual health knowledge and on its ability to influence their intentions to use effective contraception. STUDY DESIGN: This was a prospective study of girls aged 12 to 18 years recruited from 3 school-based health centers in California. RESULTS: A total of 120 racially/ethnically diverse participants used the iPad app; 54% were sexually active, with only 26% using effective contraception at baseline. The average score on baseline sexual health knowledge assessment was 58%. After using the app, 68% of the sexually active participants reported intention to use effective contraception in the future, and sexual health knowledge improved significantly to 79% ( P < .001). CONCLUSIONS: This iPad-based app is a promising intervention to educate adolescents about sexual health and support them in selecting an effective contraception method.

BackgroundAlcohol use and binge drinking among adolescents and young adults remain frequent causes of preventable injuries, disease, and death, and there has been growing attention to computer-based modes of intervention delivery to prevent/reduce alcohol use. Research suggests that health interventions grounded in established theory are more effective than those with no theoretical basis. The goal of this study was to conduct a literature review of computer-based interventions (CBIs) designed to address alcohol use among adolescents and young adults (aged 12-21 years) and examine the extent to which CBIs use theories of behavior change in their development and evaluations. This study also provides an update on extant CBIs addressing alcohol use among youth and their effectiveness.MethodsBetween November and December of 2014, a literature review of CBIs aimed at preventing or reducing alcohol in PsychINFO, PubMed, and Google Scholar was conducted. The use of theory in each CBI was examined using a modified version of the classification system developed by Painter et al. (Ann Behav Med 35:358-362, 2008).ResultsThe search yielded 600 unique articles, 500 were excluded because they did not meet the inclusion criteria. The 100 remaining articles were retained for analyses. Many articles were written about a single intervention; thus, the search revealed a total of 42 unique CBIs. In examining the use of theory, 22 CBIs (52 %) explicitly named one or more theoretical frameworks. Primary theories mentioned were social cognitive theory, transtheoretical model, theory of planned behavior and reasoned action, and health belief model. Less than half (48 %), did not use theory, but mentioned either use of a theoretical construct (such as self-efficacy) or an intervention technique (e.g., manipulating social norms). Only a few articles provided detailed information about how the theory was applied to the CBI; the vast majority included little to no information.ConclusionsGiven the importance of theory in guiding interventions, greater emphasis on the selection and application of theory is needed. The classification system used in this review offers a guiding framework for reporting how theory based principles can be applied to computer based interventions.

The purpose of this commentary is to highlight some of the key policy changes under the Patient Protection and Affordable Care Act (ACA) that have the potential to improve health care services for adolescents as well as to draw attention to challenges that have yet to be addressed. This commentary stems from our prior policy research, which examined the extent to which the health care needs of adolescents were being considered in the early implementation phases of the ACA. This study was informed by a literature review and interviews with health care administrators, health policy researchers, and adolescent medicine specialists. The ACA has significantly expanded health insurance access; however, inequities in coverage and access remain. Primarily, the structure and financing of adolescent health care needs to be improved to better support the delivery of patient-centered, comprehensive care for this special population. Additionally, improvements in youths’ awareness of their benefits under the ACA as well as a greater appreciation of preventive visits are critical. Furthermore, an unanticipated consequence of the ACA is that it exacerbates the risk of confidentiality breaches through explanation of benefits and electronic health records, which can compromise adolescents’ access and utilization of health care services. Greater attention to improving and sustaining health promoting behaviors within the context of the ACA is critical for it to truly have a positive impact on adolescent health.

The Affordable Care Act (ACA) has expanded the enrollment of young people in insurance plans and aims to increase access to preventive health services. For adolescents and young adults to fully utilize these services, access to confidential care is critical, especially for sensitive services, like sexual and reproductive health care. With this expansion, the ACA inadvertently exposes more individuals (especially those with private insurance) to confidentiality breaches through routine communications in the form of Explanation of Benefits (EOBs) sent to policyholders (typically the parent). This commentary is based on a qualitative study of individual, semi-structured telephone interviews with 31 health care administrators, policy experts, clinicians, and health plan representatives. The study identified and examined five main policy options aimed at reconciling confidentiality protections and EOBs. While no one solution emerged, approaches that incorporate automatic system changes that do not require action from the patient or provider for protections to take effect were considered most effective for protecting confidentiality. The review of these policy options are designed to inform states and health care advocates confronting this issue. In addition, since many of these approaches are new, a better understanding of how they are operationalized and enforced is necessary to truly evaluate their effectiveness.

Objective: To describe a population of dogs with acute spontaneous hemoperitoneum (ASH) that were treated with either surgical or medical management in the first 12 h after presentation, and to perform a preliminary investigation into whether there were differences in achieving cardiovascular stabilization or patterns of red blood cell (RBC) transfusion between patients treated with early (