38. Understanding Variations In Primary Care Providers’ Perceptions And Practices In Implementing Confidential Sexual Health Services For Adolescents

Confidentiality and private time between adolescents and their healthcare providers are key elements in the delivery of quality sexual and reproductive health services (SRHS) and other clinical preventive services. There are substantial gaps between professional guidelines and clinical practice around confidential services for adolescents. Efforts to improve quality SRHS require exploration of barriers and facilitators to their delivery from the perspectives of primary care providers, adolescents, and parents. In this analysis, we examine providers’ perceptions and practices related to quality SRHS for adolescents. Guided by a conceptual framework that recognizes roles of adolescents, parents, and providers in adolescent healthcare, we conducted structured qualitative interviews with a purposive sample of pediatricians, family physicians, and nurse practitioners (n=24) from urban and rural communities, selected from areas with higher and lower rates of adolescent pregnancy in a Midwestern state. We sampled providers in primary care as the vast majority of adolescent preventive visits in the U.S. take place in these settings. Provider interviews included discussion of: perceived importance of private time with adolescent patients; confidentiality in providing SRHS to adolescents; sexual health screening and counseling practices; provision of clinical preventive services (e.g., vaccines, condoms, hormonal contraception); and SRHS referral practices. Thematic analysis of interviews using our conceptual framework surfaced key themes regarding provision of quality SRHS for adolescents. Two key themes emerged regarding providers’ perceptions and practices related to quality SRHS: 1) provider discretion/decision-making about introducing private time; and 2) variations in routine SRHS screening and counseling. Provider decision-making was influenced by many factors including the use of a patient’s age to guide introduction of private time and confidentiality, provider views regarding the purpose of private time, and provider judgements of risk (based on their relationship with the adolescent and/or their interactions with the adolescent’s parents). Most providers endorsed the importance of private time and confidentiality in adolescent visits but acknowledged that this did not always translate to including these elements in individual visits. Providers voiced a clear understanding of the need for and guidelines around routine SRHS screening. Variations in routine SRHS screening and counseling practices were influenced by factors including a provider’s comfort with specific topics, availability of resources, policies and protocols of the practice setting, and the presence and role of adolescents’ parents in the visit. This study is among the first to explore providers’ perceptions and practices related to quality SRHS for adolescents. Understanding practices for 11-17 year olds in communities with higher and lower access to SRHS and variable rates of adverse adolescent sexual health outcomes helps identify opportunities for providers and primary care settings to prepare adolescents and parents for the confidential visits required to deliver quality SRHS. Our findings indicate that providers would benefit from guidelines that include standardized language, protocols, and practices that can be readily integrated into their clinical practice settings and communicated to other clinical staff, adolescent patients, and their families.