Adolescent Relationship Abuse Education and Prevention in Pediatric Primary Care: Provider, Adolescent, and Parent Perspectives

Abstract

Purpose

Adolescent relationship abuse (ARA) is associated with myriad negative health outcomes. Pediatric primary care presents an opportunity to engage adolescents and parents (who can be protective against ARA) in ARA prevention; however, no family-focused, healthcare-based ARA interventions exist. The purpose of this study is to explore the perspectives of adolescents, parents, and healthcare providers (HCPs) on incorporating ARA prevention into primary care, including 1) current discussions around ARA; 2) how to best incorporate ARA prevention education; and 3) how to address implementation barriers.

Methods

We conducted individual, semi-structured interviews with HCPs, adolescents ages 11–15, and parents recruited through convenience sampling. Transcripts were individually coded by four study team members (with every third transcript co-coded to assess discrepancies) and analyzed via thematic analysis.

Results

Participants identified a need for pediatric HCPs to involve younger adolescents and parents in universal, inclusive ARA prevention and noted that HCPs require training, techniques, and resources around ARA. Participants acknowledged multi-level barriers to implementing primary care-based ARA prevention and suggested intentional integration into HCP and clinic workflows and strategies to garner adolescent and parent buy-in to facilitate ARA-focused conversations.

Conclusions

Pediatric primary care is a promising environment to involve parents and adolescents in universal ARA-prevention. Future research should contextualize these results with larger samples across multiple practice settings and integrate relevant partners in the development and evaluation of evidenced-based ARA prevention for pediatric primary care.

Introduction

Adolescent relationship abuse (ARA: physical, sexual, psychological, or cyber abuse in adolescent romantic relationships)¹ impacts 69% of youth ages 12–18 who have started intimate relationships.² ARA is longitudinally associated with myriad negative health outcomes, including depression, suicidality, sexually transmitted infections, unintended pregnancy, substance use, lower academic achievement, and violence victimization in adult relationships.^2–6

Primary care is a promising setting for ARA prevention. Conversations about intimate relationships are recommended by the American Academy of Pediatrics (AAP)⁷ and up to 80% of adolescents complete their annual well-visit.⁸ However, just 11% of adolescents ages 11–14 report discussing ARA with their provider.⁹ Further, a recent systematic review of sexual health and ARA-focused interventions for primary care found only one ARA-focused program, specifically for older adolescents at school-based health centers (S.K. Khetarpal et al., unpublished data, 2022). Pediatric primary care also offers a natural opportunity to involve parents and caregivers (who often accompany adolescents to well-visits) in ARA prevention. Though parental monitoring and parent-adolescent communication are associated with decreased ARA and long-term improvements in youth health,^10–15 to our knowledge, no family-focused, healthcare-based ARA interventions exist.¹⁶

Despite the benefits of addressing ARA in primary care, current practices and available resources are not sufficient and further tools, resources, and training are needed. However, little is known about how to incorporate ARA prevention, which content areas to prioritize, and best practices for delivery. Additionally, little work has examined potential implementation barriers and facilitators. Thus, this study examines the perspectives of adolescents, parents, and healthcare providers (HCPs) on ARA prevention in pediatric primary care including 1) current discussions around ARA; 2) how to best incorporate ARA prevention education; and 3) how to address implementation barriers.

Methods

We conducted individual, semi-structured qualitative interviews with HCPs, adolescents ages 11–15 (a developmental period when interest in romantic and sexual relationships often begins¹⁷), and parents of adolescents ages 11–15 to explore each group’s perspectives on ARA prevention in pediatric primary care. The University of Pittsburgh Institutional Review Board approved this study. The multidisciplinary team included qualitative and ARA content expertise and affiliations with pediatrics, social work, public health, and community health.

Interview Guides

Interview questions addressed research objectives: (1) how HCPs currently discuss intimate relationships and ARA; (2) potential content for ARA prevention; (3) best practices for delivery and follow up; and (4) barriers and facilitators for implementing ARA education in primary care. Separate interview guides were developed for HCPs, adolescents, and parents (Appendix includes the adolescent guide).

Participants and Recruitment

Eligibility criteria for adolescents and parents included: (1) being age 11–15 or the parent of an adolescent age 11–15; and (2) speaking English or Spanish. Eligible HCPs included pediatric or adolescent primary care advanced practice practitioners, physicians, or social workers. We used a convenience sampling approach. HCPs were recruited via email from a pediatric primary care or adolescent clinic housed within a tertiary care children’s hospital system. Parents and adolescents were recruited from Pitt+Me, an online recruitment repository, or the pediatric clinic. Interested individuals were contacted by a study team member to determine eligibility, review consent information, and schedule an interview. Participants provided verbal informed assent/consent. 68 potential participants were successfully contacted: 17 HCPs, 26 parents, and 25 adolescents. Of these, one parent and two adolescents declined participation.

Parent and adolescent recruitment prioritized inclusivity in terms of adolescent age, gender identity, and racial and ethnic identity. After initial recruitment yielded primarily female-identified parents and adolescents ages 11–12, further recruitment prioritized male-identified parents and adolescents ages 13–15, via demographic screening prior to contact. Recruitment targeted parent-adolescent dyads; however, enrollment was not limited to dyads.

Spanish language interview

Bilingual study team members translated interview guides into Spanish, recruited Spanish-speaking participants, conducted interviews in Spanish, transcribed audio-recordings in Spanish, and assisted with proofreading of translations and coding of transcripts in Spanish. Spanish-speaking families were recruited from a bilingual and bicultural pediatric medical home affiliated with the pediatric clinic.

Data Collection and Analysis

Interviews were conducted virtually via Zoom or in-person by four trained study team members and lasted 45–60 minutes. Interviews were audio-recorded with participant permission and transcribed verbatim. Participants received a $40 gift card upon interview completion. De-identified transcripts were coded within the Dedoose qualitative software program¹⁸ for thematic analysis.^19–20 Two team members co-coded the first 10 transcripts using deductive codes derived from interview guides, adding inductive codes as they emerged. The codebook was finalized after the first 10 transcripts. One of four coders independently coded subsequent transcripts; every third transcript was co-coded to assess discrepancies. Coders met weekly to discuss emerging codes, review co-coded transcripts, and resolve discrepancies through transcript review and discussion. To identify thematic saturation (the point at which no new codes emerge), data collection and analysis occurred simultaneously.²¹

The research team met twice during the coding process to discuss emerging themes. We conducted member checking by presenting emerging themes to a group of seven parents, three HCPs, and five violence prevention experts (recruited from study participants and our team’s network), as well as our institution’s Youth Research Advisory Board, comprised of high school and college age adolescents.²² Members affirmed emerging themes; violence prevention experts suggested additional focus on preventing ARA perpetration, which was incorporated into interview guides.

Results

60 participants completed interviews: 17 HCPs, 23 parents, and 20 adolescents. Three parents completed interviews in Spanish. Two adolescents identified as gender non-conforming; see Table 1 for additional demographics. Two domains with associated themes emerged: 1) The need for primary-care based ARA education as well as content and delivery recommendations; and 2) multi-level implementation barriers and facilitators. Representative quotations with participant ID numbers are below (translated quotations are noted with an asterisk); see Table 2 for additional quotations.

Table 1:

Demographics

	Adolescent	Parent	HCP
	n = 20	n = 23	n = 17
	n (%)	n (%)	n (%)
Age of adolescent
11	2 (10%)	3 (13%)	n/a
12	5 (25%)	5 (22%)
13	4 (20%)	5 (22%)
14	4 (20%)	6 (26%)
15	5 (25%)	4 (17%)
Not disclosed	0 (0%)	0 (0%)
Gender identity
Transgender/gender non-binary	2 (10%)	0 (0%)	0 (0%)
Cisgender man	10 (50%)	6 (26%)	4 (24%)
Cisgender woman	8 (40%)	17 (74%)	12 (71%)
Not disclosed	0 (0%)	0 (0%)	1 (6%)
Race and ethnicity*
American Indian/Alaska Native	0 (0%)	0 (0%)	0 (0%)
Asian or Pacific Islander	1 (5%)	0 (0%)	3 (18%)
Black or African American	6 (30%)	6 (26%)	0 (0%)
Hispanic, Latino/a/e	3 (15%)	4 (17%)	2 (12%)
Non-Hispanic white	9 (45%)	12 (52%)	10 (59%)
Multiracial or other	1 (5%)	2 (9%)	1 (6%)
Not disclosed	0 (0%)	0 (0%)	1 (6%)
Language
English	20 (100%)	20 (87%)	n/a
Spanish	0 (0%)	3 (13%)
Role
Primary care pediatrician	n/a	n/a	9 (53%)
Adolescent medicine physician			3 (18%)
Advanced practice practitioner			3 (18%)
Social worker			1 (6%)
Not disclosed			1 (6%)
Pediatric Healthcare Setting
Primary Care Clinic	n/a	n/a	11 (65%)
Adolescent Clinic			5 (29%)
Not disclosed			1 (6%)

Table 2:

Representative Quotations

Domain 1: Need, Content, and Delivery
There is need for pediatric healthcare providers to provide anticipatory guidance about ARA, as ARA is not currently discussed during well-child visits.	“With [my child’s] doctor we haven’t had the opportunity to talk [about relationships] and I say that would…be something just as important, to have that confidence in her pediatrician, to have that communication that we have as parents” (P21*) “Honestly, I feel like I don’t get a chance to go into those kind of details. I feel like I’m usually hitting…protection, and [consent]” (HCP03) “it’s very important for doctors to be able to have this conversation, especially if…the teenager can’t have this conversation with their parents” (A18)
Conversations about ARA should engage parents and adolescents while maintaining adolescent confidentiality	“[I]t would be helpful…hearing how the doctor would approach [ARA]…having that additional perspective, especially from someone who works with children on a regular basis, is very beneficial” (P10) “it is important to still have some of [the conversation] together to make sure [you and your parent are] both hearing the same things” (A22) “I’d definitely keep the confidentiality there, just because of the fact that might be what saves the child” (P02)
HCPs need evidenced-based ARA resources, training, and content	“Specifically for teenagers, the more resources, the more skills, the more techniques, the more knowledge that we have about it the better…What we learned about teenagers, for example, when we were in medical school and in our residency, might have changed over the last 10, 15 years” (HCP13) “[ARA is] something I could definitely benefit on getting some more resources for, I think. …[F]or general dating, I don’t have guidance” (HCP05) “[HCPs need] knowledge of the resources, good education on the resources, and knowledge of the social service networks” (P03)
Guidance and resources should be designed for universal use yet attentive to inclusivity and the needs of each family	“I don’t think it needs to be different for a straight couple or an LGBTQ couple…everything applies to everyone” (A23) “One doesn’t- doesn’t know…what gender [their children are] going to- to develop when it’s with their relationship, right?…So [the doctor] would have to talk about it…with them. To explain to them- everything, right? Genders, respect that they have to have” (P27*) “We are lucky that our pediatrician speaks Spanish, but not all of them do and that’s why parents don’t ask questions, or they think their questions are a burden” (P16*)
Domain 2: Multi-Level Implementation Barriers and Facilitators
Barriers and facilitators to parent involvement	“I would assume that some parents just don’t even wanna talk about it. Like, ‘My kid isn’t dating. They will not be dating’” (P01) “I think you have to deliver it in a way that iťs very clear that you’re not accusing their kids of anything or accusing their kids of being at risk of anything” (HCP02) “If a parent isn’t receptive…the pediatrician could…provide statistics as an entry point to [a parent] who seems hesitant to maybe have them buy in to the fact that it’s a real problem” (P09) “before the next appointment, maybe their doctor brings it up. ‘Hey, listen. This is what we’re doing’ …no one would want to be surprised with this. Iťs an extremely important topic” (P23)
Barriers and facilitators to adolescent involvement	“Kids not being honest….Because they don’t want their parents to know” (A09) “Maybe a child…wouldnť tell the doctor because…they’re afraid [of] whaťs gonna happen if it gets reported” (P22) “Try to let [the adolescent] know that they are safe talking about it to the [HCP] and that the information won’t spread out so they could feel less safe” (A03)
Barriers and facilitators to HCP and clinic involvement	“you have a normal flow that you get used to with your [well-checks]…If there was a way to get this into the flow, that would be really, really cool, especially because now SHADE/HEADS has become so easy” (HCP12) “I like the written questionnaire ahead of time ’cause it allows me to segue to that conversation more easily, and they’re a little bit more mentally prepared that it could come up” (HCP07) “I think iťs helpful to give the words to general pediatricians...Going from talking about feeding and ear infections to talking about sex and healthy relationships, that’s a shift. You need different language” (HCP09) “I think anytime you’re implementing an intervention it’s always good to have the support staff involved…who are really so integral to the flow of things getting done” (HCP04)

Domain One: Need, Content, and Delivery

Theme 1: There is need for pediatric healthcare providers to provide anticipatory guidance about ARA, as ARA is not regularly discussed during well-child visits.

Participants (parents, adolescents, and HCPs) shared that ARA is not regularly addressed during well-child visits, especially if a teen has yet to start seeking out intimate relationships or is not sexually active: “We haven’t really had a big conversation about [dating] with the doctor because she’s not sexually active” (P11). A teen shared: “I honestly cannot remember the last time I talked to my doctor about relationships. I don’t think I have ever” (A20). An HCP noted: “The conversations that I do have are more general....I don’t go into those types of specifics about things to look out for at every visit” (HCP07).

However, most participants view ARA as an important, relevant topic for primary care. Parents and adolescents reported limited conversation regarding ARA at home and felt HCPs could provide needed information or support: “Maybe the child doesn’t get that kind of information at school, and maybe the parent doesn’t want to talk about it” (P06). Participants also noted that HCPs are a trusted knowledge source and thus well-positioned to deliver ARA-prevention education: “it’s… a way for kids to learn from somebody besides a parent and hear different perspectives. I think [adolescents] take more weight from a doctor than they would a parent” (P19).

Theme 2: Conversations about ARA should engage parents while maintaining adolescent confidentiality

Participants recommended that discussions about ARA include parents: “it would be nice to have something to also involve [parents] because… [doctors] can’t screen all the time, the parents are right there…watching for unhealthy things that might be going on” (HCP14). Many participants noted that doing so could increase parent-adolescent communication about ARA at home: “it’d be good, ‘cause then [the parent] could pick up on what the doctor’s saying and apply it, when they talk to [their teen], too” (A09).

While participants identified the value of joint learning and engagement [“I would know what information [my child’s] getting, and [my child] would know information I’m getting, which would be helpful” (P01)], they also highlighted the importance of a private patient-HCP conversation: “I would like the doctor to talk to the child….You know, checking up on them” (A14). Participants endorsed leveraging this confidential time to engage parents in ARA prevention via a pamphlet, website, or video: “When I have [the] parent wait for us in the waiting room, I don’t have anything particular to keep them entertained. It sounds to me you have something for [the] parent to do while the teen is speaking with [the] provider” (HCP15).

Theme 3: HCPs need evidenced-based ARA resources, training, and content

Participants identified ARA as a subject requiring specialized knowledge and training: “If you knew someone...was trained specifically for this...you would feel better about hearing from them because you’d be more assured that they know what they’re talking about” (A22). Additionally, participants described a lack of evidence-based resources about ARA: “I hope I know [ARA] when I see it...It’s hard to put it into clear words. It would be nice to have something that’s... reproducible and more evidence-based to use” (HCP02). A parent agreed: “[it would be helpful] if [HCPs] had resources, because there’s so many resources out there that I don’t even know where to begin to look sometimes” (P04). Participants suggested an array of important content, including types of abuse, relationship “red flags” and “green flags”, ARA prevalence and impact, the role of social media, supporting a child in an unhealthy relationship, and ways to start conversations about ARA at home.

Theme 4: Guidance and resources should be designed for universal use yet attentive to inclusivity and the needs of each family

Most participants agreed that everyone should receive the same foundational guidance and resources: “everybody would need to know...what a proper dating situation looks like, how to treat people...it doesn’t matter what situation you’re in” (P20). Participants recommended using language inclusive of all genders and sexual orientations: “[The] moment that a patient who identifies as bisexual perceives an intervention as being targeted at heterosexual people, I can see that as an immediate turn off” (HCP10); as well as ensuring information is available in multiple languages: “I think that’s really important is being able to have it in different languages...My primary doctor speaks Spanish...so it’s easier for my family ‘cause we speak Spanish” (A18). Also recommended was content that addresses both victimization and perpetration: “[adolescents] need to hear it from both sides....A lot of younger people can’t control their anger. They think the best way to address it is physical, so...if we just hear it from both sides, it would be a big deal” (P17).

Participants also felt delivery could be adapted in certain circumstances, such as patient age or developmental stage: “Depending on the age of the person, [information] could be more complex if they’re older and a little bit simpler if they’re younger, just because of how much… they can comprehend” (A17). For example, HCPs could gradually incorporate information regarding sexual abuse. A family history of intimate partner violence may also indicate a tailored approach: “How can I communicate…with [the parent]…so that they can have a conversation with their child about [ARA] that doesn’t feel triggering or traumatic?” (HCP05).

Domain Two: Multi-Level Implementation Barriers and Facilitators

Barriers and facilitators to parent involvement

While most parents endorsed ARA-focused conversations in primary care, participants warned that some parents could perceive the topic as infringing on parental authority. For example, parents may “feel like [relationships are] a family situation and that they don’t need an outsider in the middle of the family business” (P06). Parents could also dismiss the conversation if their child is not allowed to date: “I feel like at 11 you might get a little bit of pushback from the parent like, ‘Why are we even bringing this up right now? This isn’t even something that we would even think of at this point’” (HCP08). Framing conversations to generate parental buy-in was highlighted as critical to navigating these barriers: “parents really want what’s best for their child…most parents want their child to know this information and want their children to be in safe, happy, and healthy relationships” (HCP06). Participants also felt a “heads-up” could help introduce the conversation: “maybe [the doctor] can send a message, they can bring it up every time we go to the doctor…let [parents] become familiar with it….it will grab their attention” (P16*).

Barriers and facilitators to adolescent involvement

Participants discussed adolescents’ potential discomfort in conversations around ARA, with or without their parent in the room: “Some kids could feel uncomfortable with their parents not being around…because they don’t wanna answer with an adult not being there with ‘em.” (A25). Fear of HCPs sharing details about intimate relationships with parents (including a partner’s gender) emerged as another barrier: “an adolescent maybe being scared...that their parent’s gonna find out” (P02). Participants highlighted the importance of building rapport and suggested easing into the conversation: an adolescent suggested “going into it slowly, not just, ‘Oh, do you think about doing this? Do you think about doing that?’” (A12). Participants also identified the critical role of confidentiality: “when we talk to them one-on-one and tell them that we won’t share this with their family… a lot of them are very open, more so than sometimes I’m ready for” (HCP12). To increase relevance regardless of whether the adolescent has started intimate relationships, participants endorsed framing information as something adolescents can use to help a friend: “I’ve never been in a relationship…I think it would be more helpful, not for me, but for other people that I’m friends with” (A23).

Barriers and facilitators to HCP and clinic involvement

Though participants described an urgent need for this intervention, they also noted several implementation barriers unique to primary care, particularly limited time. A parent shared: “I think it’d be very beneficial, but I don’t know how much time doctors have to spend on a non-medical situation. You’re in and out in 20 minutes” (P20). An HCP offered a similar opinion: “That’s a health system problem that we get 20 minutes to see patients…it’s a hard challenge to address without massive health system reimbursement changes” (HCP10). HCPs highlighted additional clinic-level barriers: one stressed “the durability of it, how you’re gonna continue to retrain as new…doctors join the practice …and then, also, the transportability, [that] it doesn’t rely on [supports]…that just exist in one practice” (HCP01). Some HCPs felt incorporating ARA into the confidential social history and providing conversation scripts may address these barriers. One suggested: “[ARA could be] something that’s built in like the SHADDESS [social history] assessment. We’re always doing that and consistently across all providers” (HCP14). Another noted: “I think it’s helpful to give the words to general pediatricians...Going from talking about feeding and ear infections to talking about sex and healthy relationships...that’s a shift. You need different language” (HCP09). Other clinic-level implementation facilitators included engaging support staff, adding ARA to a clinic’s screening process, and incorporating prompts into the electronic charting system: “if everything cued in Epic [electronic medical record], then it’s workable, and we’ll figure out a way to make it fit” (HCP06).

Discussion

To our knowledge, this study is among the first to examine the perspectives of parents, adolescents, and HCPs regarding family-focused ARA prevention in pediatric primary care. Similar to findings from a national study, our interviews revealed that ARA is not regularly addressed in pediatric settings.⁹ Other health topics (like substance use, sexual health, and mental health) are addressed more frequently during well-visits^23–24 and have been a focus for universal guidance, screening, and healthcare-based programs.^25–31 In contrast, a recent systematic review identified only two programs focused on healthy intimate relationships and one focused on ARA prevention (S.K. Khetarpal et al., unpublished data, 2022). Amplifying healthy relationships and ARA as a critical issue related to adolescent health is necessary and aligned with guidelines from the Society for Adolescent Health and Medicine and the AAP Bright Futures guidelines.^7,32

Participants identified evidence-based training, techniques, and resources as vital to effective ARA prevention and support for young people experiencing ARA. However, anticipatory guidance is not widely standardized, with significant variability in topics discussed with adolescents.^23,33 Though a few potential intervention models exist, they were developed for other healthcare settings. Miller et al. developed an HCP-delivered ARA prevention intervention for adolescents ages 14–19 in school-based health centers that utilizes universal education (providing resources to all patients regardless of ARA disclosure).³⁴ Rothman et al. designed an emergency department-based brief intervention using motivational interviewing to decrease ARA perpetration.³⁵ Similar programs developed for pediatric primary care, a setting that allows for the involvement of parents and adolescents together, are needed.

Parents emerged as essential to ARA-focused discussion in primary care settings. Parents and caregivers can be protective across a wide variety of health outcomes (including ARA) through increased parental monitoring and parent-adolescent communication.^10–15 Though prior studies demonstrated the feasibility and effectiveness of engaging parents in brief primary-care based interventions focused on sexual health,³¹ depression,³⁶ and substance use,³⁷ no ARA-focused, healthcare-based interventions involving parents exist.¹⁶ Participants highlighted the importance of including parents and identified the confidential social history (a time, beginning in early adolescence, when adolescents speak alone with their HCP) as an opportunity to provide parent-focused educational materials about ARA for parents to review in the waiting room and discuss with the HCP when they return to the exam room. Leveraging opportunities for parental involvement during adolescent visits while balancing adolescents’ confidential time with HCPs is critical to family-focused ARA prevention.

Participants emphasized the need for thoughtful integration of ARA prevention into HCP and clinic workflows given pediatric primary care is incredibly busy, with multiple age-dependent recommended topics. Although implementation efforts often focus on HCP/health system factors, our findings also included barriers and facilitators around garnering parent and adolescent buy-in to engage in ARA-related conversations (especially around the confidential social history that participants identified as crucial to ARA prevention). Use of healing-centered engagement, a framework that leverages strengths and supports relationship and community building, to help children and families thrive, can create a clinical space where parents and adolescents feel comfortable engaging in conversations around ARA.^38–39

Participants endorsed a universal approach to ARA-prevention (i.e., providing ARA prevention education and resources to all families, rather than only those who disclose) with attention to inclusivity. For example, it was recommended that ARA-focused conversations be inclusive of all genders and sexual orientations and available in different languages. This aligns with the idea of “centering the margins” (i.e., prioritizing the perspective of marginalized groups who are often excluded from mainstream discourse) to create a universally-resonant product.⁴⁰ Such a product is better-positioned to meet the needs of all families while avoiding singling out (or “othering”) individuals who identify as gender and sexual minorities and/or do not speak English. Because a universal intervention does not require adaptation to be effective for those outside the majority, it may also be easier to disseminate and scale.

This exploratory study has limitations. Providers were drawn from a single academic medical center and parents and adolescents from a single clinic and university-run recruitment repository; thus, their perspectives may not be generalizable to other regions and healthcare settings. Because most parents identified as female (74%), the perspectives of male-identified and gender non-conforming parents and caregivers are underrepresented. Such perspectives are critical to understanding how gender non-confirming and male-identifying caregivers discuss ARA with their adolescent children and perceive healthcare conversations about ARA. Finally, individuals who spoke languages other than English and Spanish were not eligible to participate.

Implications

Our study sets the stage for additional research and clinical innovation. Future research should include groups underrepresented in this sample, such as parents who identify as male or gender non-conforming and families who speak languages other than English and Spanish, to better understand their perspectives. Studies with larger samples using quantitative methodologies are also important to better contextualize this work and include a larger group of providers across practice settings. Future work should involve families, HCPs, and violence prevention experts to collaboratively develop and test ARA prevention for pediatric primary care. Prioritizing implementation strategies is needed from the beginning of program development, with particular focus on clinical workflows and consideration of payor reimbursement. Findings also set the stage for researchers to explore parental engagement in other health topics.

From a clinical perspective, results highlight the importance of evidenced-based, age-appropriate resources and provider training to address sensitive, complex topics like ARA and support providers’ prioritization of confidential time with adolescents while revealing opportunities for parental engagement during waiting room downtime. Finally, our study highlights pediatric primary care as a promising (and often underutilized) setting in which to intentionally involve parents and caregivers as partners in optimizing adolescent health.

Conclusion

We describe the perspectives of adolescents, parents, and HCPs on ARA prevention in primary care. We found ARA is rarely addressed in pediatric settings and identified pediatric primary care as a promising environment to involve parents and adolescents in ARA-prevention. We described several factors that must be considered to facilitate the implementation and sustainability of ARA-focused conversations that engage parents and adolescents. Future research should contextualize these results with larger samples across multiple practice settings and integrate relevant partners in the development and evaluation of evidenced-based ARA prevention for pediatric primary care.

Implications & Contribution.

Findings identify a need for universal primary care-based ARA prevention that involves parents while prioritizing adolescents’ confidential time with a provider and highlight the importance of supporting providers with resources, training, and content. Results set the stage for development of an evidenced-based ARA prevention program for pediatric primary care.

Abbreviations:

ARA

Adolescent Relationship Abuse

Appendix

INTERVIEW GUIDE: ADOLESCENTS

Thank you for participating in this interview! The goal of this interview is to learn more about how primary care doctors talk to you and your parents about healthy and unhealthy relationships during annual check-ups. When answering these questions, please think about your experiences during annual check-ups with your primary care doctor, not your experiences with any specialists you may have seen for a specific issue. Everything you say is confidential and you may skip any questions that you don’t want to answer. Whenever we ask about your parents’ thoughts, please think about the parent who is participating with you in this study. Do you have any questions before we get started?

Introduction/Ice beaker

• 1To start, please describe the last time you went to the doctor for an annual check-up. What was it like? What did you and your primary care doctor talk about?
• 2How would you describe an unhealthy adolescent dating relationship? How is it different from a healthy adolescent dating relationship?
• 3Next, I’m curious about any conversations you have had with your parents about dating or about dating violence. What did your parents say to you about these topics? Who started the conversation? What were you thinking about what they were saying?

Section I: HOW IS ARA DISCUSSED CURRENTLY DURING WELL-CHILD VISITS

• 4Can you please remember back to the times you have visited your doctor for an annual check-up. What has your doctor said to you about healthy and unhealthy dating relationships?

  Probe: What are the topics you have discussed with your doctor?

  What have you found to be helpful/unhelpful?

  How did the doctor talk about unhealthy dating relationships? Was it something you or the doctor brought up?

  How old were you when these conversations happened?

  If you have not discussed this, is it something you would like to talk about with your doctor? Why or why not?

• 5How were your conversations with your doctor about adolescent dating relationships inclusive of youth of all gender identities and orientations?

  Probe: If not, what aspects were not inclusive?

• 6What resources or referrals did your doctor give you about healthy and unhealthy adolescent relationships?
• 7Now please think about the same questions, but for your parent (repeat questions).

Section II: TOPICS WHICH SHOULD BE ADDRESSED DURING THE INTERVENTION

We are developing a program to educate parents and their children ages 11 to 14 about healthy and unhealthy dating relationships. We envision that this program will be delivered to both parents and children during the child’s annual check-up. Before we develop this program, we want to learn more from you about what doctors offices can do to help young people be in healthy dating relationships and avoid unhealthy dating relationships.

To start, please share some overall thoughts about this idea. What are your initial impressions?

• 8Please describe what you would like your parent(s) to hear from a doctor about healthy and unhealthy dating relationships during your annual check-up?

  Probe: Topics to discuss, resources, questions to ask

• 9Please describe what you would like answered about healthy and unhealthy dating relationships during your annual check-up?

  Probe: Topics to discuss, resources, questions to ask

• 10This program will be delivered to all young people and their parents, regardless of gender identity or sexual orientation. What do you think doctors can do to make sure this program is helpful to young people of all gender identities and orientations?

  Probe: Topics, language, resources

  Do you think it is important for conversations around healthy and unhealthy relationships to be inclusive in this way? Why or why not?

• 11As I mentioned, we are developing this intervention for all parents and young people. However, we recognize that every family is different. What about your family or family dynamics might make it easier or more difficult to discuss this topic? How might this intervention be adapted to be more helpful for you and your parent(s)?
• 12Please describe the topics that are most important for healthcare providers to talk about with parents of middle school students. How does that change as youth grow older?

Section III: HOW SHOULD THE INTERVENTION BE DELIVERED

• 13How would you like to learn about adolescent healthy and unhealthy relationships during your annual check-up?

  Probe: When, with your adolescent or separately, how frequently, how long?

  Who should deliver?

  What else can your doctor’s office do? (Posters, case managers, behavioral health, health educator)

• 14What resources would be helpful to you to help you learn more about healthy and unhealthy dating relationships?

  Probe: Brochure, video, website

• 15Would you like any follow-up from your doctors’ office to continue conversations about healthy and unhealthy dating relationships? What follow up would be most helpful to you?

  Probe: Provider checking in, health education coaches, other follow up

• 16Now please think about the same questions, but for your parent (repeat questions).

Section IV: BARRIERS AND FACILITATORS?

• 17Please describe some of the challenges that may happen in providing this program? How can we address these challenges?

  Probe: Adolescents-only, parents-only, adolescents and parents together?

• 18Please describe what you think is needed to make this program successful.

Section V: CONCLUSION

• 19Is there anything else we have not discussed which you would like to share?

Are there any questions I did not ask you that you think I should ask other ado