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https://doi.org/10.1177/2150131917730210

Journal of Primary Care & Community Health 2017, Vol. 8(4) 332 –337 © The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/2150131917730210 journals.sagepub.com/home/jpc

Pilot Studies

Introduction

Adolescents have the highest rates of sexually transmitted infections (STIs) of any age group in the United States. Despite a downward trend, US adolescents continue to have higher rates of unintended pregnancies compared with other developed countries.1,2 Access to adolescent-friendly health care is integral to addressing sexual health behaviors and preventing poor outcomes, including STIs/human immuno- deficiency virus (HIV) and unintended pregnancies.3-5 However, little is known about how adolescents define “adolescent-friendly” services or about their experiences communicating with providers regarding sexual health.

There is a growing body of evidence that the quality of adults’ experience with health care providers impacts both patient satisfaction and health outcomes, including adher- ence to prescribed medication and utilization of preventive care services.6,7 Patients who perceive “good communica- tion” with their provider are more adherent to diabetes self- management and cancer screening.8-10

Although the impact of provider communication on health outcomes for adolescents is unknown, there is evi- dence that communication affects their health care experi- ence.11 A systematic review of studies examining adolescent perspectives on general adolescent health care identified feeling welcome, trust in clinicians, understanding health information, and involvement in health care decisions criti- cal to adolescents’ perception of health care quality.11 A minority of studies in this review specifically addressed sexual health services. Survey studies have demonstrated that when providers initiate sexual health discussions, adolescents have a more positive perception of providers

730210 JPCXXX10.1177/2150131917730210Journal of Primary Care & Community HealthHoopes et al research-article2017

1Kaiser Permanente Washington, Bellevue, WA, USA 2University of Washington School of Medicine, Seattle, WA, USA 3Fred Hutchinson Cancer Research Center, Seattle, WA, USA

Corresponding Author: Andrea J. Hoopes, MD, MPH, Kaiser Permanente Washington Adolescent Center, 13451 SE 36th Street, Bellevue, WA 98006, USA. Email: hoopes.a@ghc.org

Adolescent Perspectives on Patient-Provider Sexual Health Communication: A Qualitative Study

Andrea J. Hoopes1, Samantha K. Benson2, Heather B. Howard2, Diane M. Morrison2, Linda K. Ko3, and Taraneh Shafii2

Abstract Background: Adolescents in the United States are disproportionately affected by sexually transmitted infections and unintended pregnancy. Adolescent-centered health services may reduce barriers to health care; yet, limited research has focused on adolescents’ own perspectives on patient-provider communication during a sexual health visit. Methods: Twenty-four adolescents (14-19 years old) seeking care in a public health clinic in Washington State participated in one-on- one qualitative interviews. Interviews explored participants’ past experiences with medical providers and their preferences regarding provider characteristics and communication strategies. Results: Interviews revealed that (1) individual patient dynamics and (2) patient-provider interaction dynamics shape the experience during a sexual health visit. Individual patient dynamics included evolving level of maturity, autonomy, and sexual experience. Patient-provider interaction dynamics were shaped by adolescents’ perceptions of providers as sources of health information who distribute valued sexual health supplies like contraception and condoms. Participant concerns about provider judgment, power differential, and lack of confidentiality also emerged as important themes. Conclusions: Adolescents demonstrate diverse and evolving needs for sexual health care and interactions with clinicians as they navigate sexual and emotional development.

Keywords community health, patient-centeredness, pediatrics, risky sexual behavior, qualitative methods

Hoopes et al 333

and increased STI testing.12,13 Despite these benefits, many adolescent health care visits do not address sexual health, and those that do are very brief, lasting on average 36 sec- onds.14 Barriers to effective and realistic sexual health com- munication strategies for providers remain elusive.

Qualitative studies using focus groups have explored the adolescent patient experience when accessing confidential sexual health services.15-18 Concerns raised by adolescents include judgment by providers, lack of confidentiality, and impersonal patient-provider interactions. While focus groups provide insight into social norms, they are limited in the ability to elicit personal experiences from individuals on sensitive topics like sexual health. For this reason, this study used one-on-one, in-depth interviews to explore ado- lescents’ perspectives on patient-provider interactions dur- ing a sexual health visit and how these shape their preferences for patient-provider communication.

Methods

Eligibility and Recruitment

Adolescents seeking care in an urban public health STI clinic were recruited from September 2008 to January 2009. The clinic serves more than 6000 unique patients annually and provides services for STI management, pregnancy test- ing, and contraception, prevention counseling, and linkages to community support resources for adolescents and adults at sliding scale costs. Services are provided by advanced practice providers (nurse practitioners and physician’s assistants) with physician support when indicated. Among 10- to 19-year-old patients, approximately 45% identify as women and 55% as men. Among older patients, approxi- mately 30% identify as women and 70% as men. Race/eth- nicity distribution for 14- to 19-year-olds utilizing the clinic during the study period was 50% non-Hispanic White, 32% non-Hispanic Black, 8% Asian, and 10% other, as deter- mined by self-report at time of service. This is largely con- sistent with the race/ethnicity distribution of all-aged patients seeking care.

Patients were approached by a research assistant during regular clinic operation hours within the recruitment period and invited via a standard script to learn more about the study. The research assistant recruited 10 to 20 hours per week, primarily during afternoon hours to reach more young people. If participants were interested, they com- pleted a 6-item paper survey in the waiting room to deter- mine eligibility. Inclusion criteria were age 14 to 19 years, ability to speak and read English, vaginal sex in the past 12 months and at least one of the following: 1 episode of unprotected (no condom or no birth control) vaginal sex in the past 2 months, more than 1 vaginal sex partner in the past 2 months, or history of STI or unintended pregnancy in self or partner.

Eligible participants learned about the study in a private clinic room and completed standard written informed con- sent with the research assistant. The University of Washington Human Subjects Division approved this study and waived parental permission for participants aged 14 to 17 years, which aligns with the age of consent for sexual health care in Washington.

Study Procedures

A research team member (HBH) interviewed all partici- pants using in-depth, semi-structured interviews. The inter- views lasted 45 to 60 minutes and included questions about preferences in provider communication styles and experi- ences with providers when discussing sexual health. To ensure confidentiality, the only demographic information collected was gender and age. On completion of the inter- view, participants received $25 cash. Interviews were recorded with a digital audio recorder, transcribed by a research team member (HBH), and reviewed for accuracy by the interviewer.

Analysis

Transcribed interviews were managed using the ATLAS.ti version 7 (Berlin, Germany) qualitative data software pro- gram. The research team generated tentative labels to capture the essence of each idea and compared and contrasted their notes.19 Two members of the research team (TS and HBH) independently reviewed the first 3 transcripts to cluster simi- lar ideas and generate preliminary codes. Two different research team members (AJH and SKB), oriented to the pre- liminary codes, independently coded all interviews and com- pared and contrasted notes as new codes emerged. Any coding discrepancies were reconciled verbally between AJH and SKB until 100% agreement was reached. Atypical cases that did not fit patterns for the majority were evaluated and discussed by AJH, SB, and TS, and freehand domain charts were created to map the interrelationship between concepts.

Results

Of 43 patients approached, 10 did not meet eligibility crite- ria and 9 declined to participate. Twenty-four of 33 (72.7%) participated: 15 females and 9 males. Average age was 17.3 years. Emerging themes around patient-provider experience and communication revealed a distinction between individ- ual patient dynamics and patient-provider interaction dynamics.

Individual Patient Dynamics

Comfort in Discussing Sex. Participants described feeling uncomfortable talking about sexual health topics with their

334 Journal of Primary Care & Community Health 8(4)

provider. However, being older (more “mature”) and hav- ing more romantic relationship experience eased their discomfort.

The doctor asked me “am I sexually active” and I didn’t feel comfortable. It was probably two years ago. I was probably 17 years old. I did not feel comfortable, because I thought, “This is wrong.” . . . But, I’ve matured now and it’s okay. (Female, 18 years)

Interviews revealed a common sentiment of “embarrass- ment” when discussing sexual health with adults. This was in contrast with how participants described discussing sex with friends:

Most kids just get embarrassed to talk to an adult about sex, ’cause they can talk to their friends all day about it and it won’t be embarrassing, but once there is an adult . . ., it’s just like, I don’t know. (Gender, age unrecorded)

Lack of Trust and Confidentiality. Participants described feel- ings of being caught off guard or offended when an unfa- miliar health care provider asked questions about sexual health and clinical symptoms, suggesting a misunderstand- ing of why providers elicit such information. One partici- pant described feeling unprepared for sexual history questions in an interaction with a provider that felt impersonal:

Well, I guess it’s like I don’t really know her as a person, so it’s kinda like, “Hello stranger, tell me about your body,” you know, so . . . (Female, 19 years)

Participants voiced concerns that confidentiality might be violated by providers:

[. . .] I know it’s supposed to be confidential [. . .] But I think some doctors, like, be telling, like, the children’s parents what they talk about. (Female, 18 years)

Fear of Judgment From Providers. Many interviewed expressed fear of being judged by providers for their sexual behaviors:

Some doctors are like, “[sigh] You’re disgusting.” They don’t say that, but they’re basically, like, “Shame on you. How could you not expect this to happen?” (Female, 19 years)

Personal Responsibility Regarding Health Needs and Self-Effi- cacy. Some adolescents demonstrated a sense of personal responsibility for their sexual health:

I don’t really think I need anything from my doctor, I think it’s more myself. Like, I need to go there and get checked, I need to use condoms, I need to be on birth control. (Female, 16 years)

In fact, some participants believed safer sex practices are not dependent on health care services at all, but rather on personal choices:

[. . .] Yeah, but when it boils down to it, in the heat of the moment sometimes it doesn’t happen like that. So you just have to be smart and just know this is important to my body and I want to use a condom. (Female, 18 years)

Patient-Provider Interaction Dynamics

Sensitivity to Confidentiality and Patient Comfort. Participants raised concerns that providers ask them about sexual activ- ity in front of their parents, creating an environment that dissuades accurate responses and negatively affects patient- provider rapport:

[. . .] I went to get a check-up, and um, my dad was in the room with me, believe it or not. And the doctor asked me “am I sexually active” [. . .] So, um, I answered falsely so that I don’t have my dad look at me bad or the doctor look at me bad. (Female, 18 years)

Many interviewed commented on the impersonal and automated nature with which providers asked very sensitive sexual behavior questions:

[. . .] it’s just, like, okay you talk to your everyday doctor, and he’s on the computer asking you questions. Like, “Okay, well do you have Chlamydia? Do you have this?” and there’s no contact, he’s just asking you questions. That doesn’t seem like he cares, he’s just doing his job. (Gender, age unrecorded)

Adolescents alluded to a power differential between themselves and the provider where they were asked to divulge sensitive information while the provider remains closed and impersonal.

You know how they say that we’re not going to answer personal questions kind of makes you feel, you know, unequal. It’s like you’re a human giving information out, but the doctor’s not sharing their experience with you. (Male, 17 years)

Preferred Communication Styles. Several participants shared preferred communication styles of providers based on posi- tive experiences; however, these preferences were notably varied. Some expressed appreciation when providers had a straightforward style:

They don’t beat around the bush with it, which is a good thing. I don’t like when people, like, say something to try to start the conversation. I just like when they go, “How are you doing?” And then, “Have you been using condoms,” and “How is your sex life,” and stuff like that. (Female, 18 years)

Hoopes et al 335

Others particularly appreciated providers who acknowl- edged their concerns about being normal and contextual- ized sexuality as a part of routine health care.

Treating it like anything else . . . saying, “Yeah, like it can kind of be nerve-wracking, but don’t worry, I’m not attacking you, I ask all my patients this” [. . .] I think that’s good, ’cause teenagers are always afraid of “being the only one.” (Female, 15 years)

Provider Adaptation to Patient’s Maturity Level. Participants spoke apprehensively about sexual health discussions that did not feel appropriate for their knowledge and maturity level. One participant described going to a doctor at 10 years for birth control pills to treat heavy and painful menstrual periods:

And, like, they were like, “Well, you know if you do decide to have sex, blah, blah, blah.” … and I was like, why are you telling me all this? It was so uncomfortable. I was like, okay, I’m not going to have sex right now. And like, even if I was, or something like, it was like waaay too much information. (Female, 15 years)

Some referenced the frustration of providers’ failing to rec- ognize a patient’s capacity to make autonomous decisions.

Me and my partner took a long time before we had sex . . . Took a while for her to be ready, for me to be ready, to be able to trust each other. And sometimes I think the doctors forget that teenagers can think too. We have brains. (Male, 17 years)

Provider as Source of Sexual Health Expertise and Services

Participants referred to providers as sexual health experts and resources for accurate information.

Because I’m not really gonna talk to anybody else about it, so I’d rather talk to the person who knows about it the most, and is gonna keep everything . . . like not judge me, and is gonna actually help me with it (Gender, age unrecorded)

Adolescents recognize providers as the gateway for health care services and supplies such as condoms, contraception, and STI testing. These offerings were described as key aspects of the health care encounter and emphasized by some as more valuable than provider counseling:

Give me protection. Give me condoms and saying maybe if I don’t use condoms, try using birth control, or something of that sort. (Female, 19 years)

Discussion

Using the words and experiences of adolescent patients in a public health clinic, this study identified specific individual

dynamics and patient-provider interaction dynamics that shape communication during sexual health visits. Adolescents’ perspectives provided insights into how their level of maturity and sexual experience influence their pref- erences for providers broaching sexual health discussions. Level of emerging autonomy was a major factor in their comfort and willingness to discuss sexual health. Some identified providers as resources for health information and supplies, but others emphasized concerns about confidenti- ality, judgment, and the power imbalance. While prefer- ences about communication style varied, preferred attributes included nonjudgmental and straightforward providers able to normalize sexual health issues.

Participants in our study expressed themes consistent with prior studies; they were less comfortable discussing sexual health when concerned about confidentiality or with providers perceived as highly judgmental.15,20 Our study findings further reinforced the importance of patient-pro- vider communication.21,22 The literature suggests that ado- lescents with chronic illness,23 young men who have sex with men,13 and adolescents seeking preventive health care12,24 have a more favorable experience and are more engaged in their health care when there is higher quality patient-provider communication.

This study adds new insights into how level of maturity and sexual experience factor into patient preferences and needs within a patient-provider interaction. Our findings suggest differences between patient and perceived provider goals for the sexual health visit. Some adolescents perceive the provider as primarily a resource for sexual health sup- plies and services. They find the sexual health interview invasive, rather than recognizing its purpose to assess risk and determine sexual health needs. Therefore, providers should communicate why they ask questions about sexual behaviors to tailor their approach to the adolescent’s matu- rity level.

Despite the importance of risk screening, providers face challenges in discussing sexual health due to shortened clinic visits, increasing number of preventive health topics, and discomfort or lack of training in sexual health care. Prior studies have found that providers miss opportunities to screen and provide sexual health services and counseling to adolescents, even those with known high-risk behav- iors.25-27 It is clear that providers need adequate resources and innovative strategies to carry out recommended screen- ing and management guidelines.

This study was qualitative and exploratory and subject to limitations of participants living in one geographical region attending one clinic and is not generalizable to all adoles- cents. Interview responses may be influenced by social desir- ability and potentially reflective of their public health clinic experiences rather than experiences in other clinical settings. The demographic information collected was limited to age and gender, which excludes understanding responses in the

336 Journal of Primary Care & Community Health 8(4)

context of specific demographic characteristics. Of note, individual gender and age was unintentionally not recorded for 2 participants’ audio files, limiting our ability to attribute age and gender to quotations by those participants. The clinic serves a high-risk population and these findings may not reflect experiences of adolescents in the primary care setting. Furthermore, inclusion criteria were limited to participants who reported penile-vaginal intercourse and therefore the experiences and preferences of adolescents engaging in other sexual activities were not captured in this study. Although the interviews were conducted from 2008 to 2009, the model of clinic-based, adolescent sexual health services that existed during data collection has not substantially changed since that time, specifically that confidential services are provided at sliding-scale cost in an ambulatory setting requiring a clin- ical history, examination, laboratory tests, and provision of medications, counseling, and preventive supplies such as condoms. For this reason, findings are considered still rele- vant and applicable to providers seeing adolescents in outpa- tient clinical setting currently.

This study offers valuable insights into the adolescent experience during a sexual health visit. The data reflect the evolving and fluctuating health care needs of adolescents as they navigate sexual and emotional development and gain confidence in accessing and utilizing health care services. Our findings highlight the importance of providers’ ability to assess a patient’s developmental stage and prior experi- ences and to tailor their communication style and health messages accordingly. There is a clear need for innovative tools that support providers to rapidly assess and adjust to an adolescent’s stage of psychosocial development, level of sexual experience, and risk behaviors to facilitate more ado- lescent-friendly interactions. Next steps might involve development and study of tools and interventions that sup- port providers in these activities. Since these findings reflect only the perspectives of the patients, further research that includes provider interviews or patient-provider observa- tion might elucidate more comprehensive insights. Subsequent studies should also explore patient-provider communication in other health care settings serving adoles- cents, such as school-based health or acute care settings, and among adolescents who have special health care needs.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by Eunice Kennedy Shriver National Institute of Child Health and Human Development 5K23HD052621 (PI Taraneh Shafii, MD, MPH) NIH Mentored Patient-Oriented Research Career Development Award (K23).

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Author Biographies

Andrea J. Hoopes, MD, MPH, is an adolescent medicine physi- cian at Kaiser Permanente Washington in Seattle, Washington. Her research focuses on improving sexual and reproductive health services for adolescents in resource-limited communities.

Samantha K. Benson, MPH, received her MPH from the University of Washington in 2012 with a focus on Maternal and Child Health. She has since worked at the University of Washington and is currently an educator with a program works with US health departments to adapt to changes in the HIV pre- vention landscape.

Heather B. Howard has expertise in patient-centered program design, sexual and reproductive health, health systems strengthen- ing, and health innovation among vulnerable populations in domestic, development, and humanitarian settings. Ms. Howard earned her MPH from the University of Washington in 2010.

Diane M. Morrison, PhD, is Professor Emerita at the University of Washington School of Social Work. Her research interests focus on adolescent and young adult sexual behavior and decision making.

Linda K. Ko, PhD, is a behavioral scientist with expertise in the development, testing, and evaluation of health communication strategies. Dr. Ko is an Assistant Member in the Division of Public Health Sciences at the Fred Hutchinson Cancer Research Center and Associate Professor in the Department of Health Services at University of Washington.

Taraneh Shafii, MD, MPH is an Associate Professor of Pediatrics in the Department of Pediatrics, Division of Adolescent Medicine at the University of Washington School of Medicine. Dr. Shafii’s research focus is the development and testing of interactive, com- puter-based interventions to promote sexual health and prevent STI/HIV and unintended pregnancy in adolescents and young adults. She serves as Director of the Inpatient Service at Seattle Children’s Hospital and is Director of Quality Improvement in the Division of Adolescent Medicine.