Promoting Adolescent Health Through Triadic Interventions

Adolescents have a range of health care needs including receipt of recommended vaccinations and clinical preventive services and counseling to prevent or reduce risk behaviors and negative health outcomes, both during adolescence and later in life [1]. However, less than half of adolescents get preventive health care visits [2], less than three quarters of those have a sexual history taken (with internal medicine specialists being the least likely to take a sexual history), and even fewer receive recommended sexual and reproductive health services such as HPV vaccination, sexually transmitted disease testing, and effective contraception [3]. This may be due, in part, to inadequate time spent alone between adolescent patients and their physicians [4], as adolescents and their physicians are less likely to discuss any sex-related topics when a parent is present at the visit. Physician and patient discomfort in discussing sensitive topics such as sexual health, and inadequate time for the clinical encounter to allow for risk assessment and prevention counseling, have also been associated with fewer discussions about sexual topics and lower receipt of services [5,6].

For many adolescents, particularly those at higher risk, assurances of confidentiality will continue to be important when seeking sensitive services [7]. However, there is some evidence to suggest that directly involving parents in adolescents’ health care can lead to positive outcomes, particularly for children with special health needs [8], and some have advocated for parental involvement in adolescents’ reproductive health decisions [9]. In addition, adolescents want to receive information about sexual and reproductive health from their parents. In a national survey, young people aged 15−17 years listed parents as a main source of information about a variety of topics related to sexual health, including decisions about sex, pregnancy, and preventing sexual violence, and named parents and doctors and other health care providers as their most trusted and accurate sources of information [10]. Thus, triadic interventions, or provider-initiated efforts targeting adolescents and their families, may represent an effective means of addressing a variety of health topics important for adolescents.

Ford et al. [11−13] have explored parent−health care professional partnerships as a strategy for improving adolescent health. In a study published in this issue, parents and adolescents expressed moderate to high levels of interest in receiving information on a wide range of topics, including sexual health, and in a variety of formats, including direct communication from a doctor or nurse and printed handouts. Similarly, Miller et al. [14] assessed pediatricians’ practices and preferences regarding the provision of guidance to parents on sexual risk reduction among adolescent patients. Although the majority reported that providing such guidance was important, only 28% provided guidance to most of their adolescent patients’ parents. High-quality brochures, resource lists, and communication tools for parents were suggested most often by pediatricians to support parental efforts to address sexual risk with their adolescents.

There remain significant gaps in what is currently known about the effectiveness of a triadic approach. We have few examples of their success with adolescent populations [15], and more research is needed. For example, how do we know which content areas are most critical for a provider to focus on for a given adolescent? Brief screening tools could help, as it may not always be best to ask adolescents and parents about what they are most interested in as they may avoid more sensitive topics that may, in fact, be the most important given an adolescent’s current behavior or developmental stage. A primary care intervention by Ozer et al. [16], which included training and tools for primary care providers, increased screening and counseling of adolescents for risky health behaviors (e.g., drug and alcohol use, sexual behavior, seatbelt use) relative to standard-of-care controls. Thus, if providers are able to screen their adolescent patients for key risk behaviors, triadic interventions could then be tailored to adolescents’ needs. Similar screening tools could be developed for use with parents of adolescents to gain their perspective on their adolescent’s needs and level of risk.

Triadic interventions may be one way to address a key challenge of inadequate provider time spent with adolescent patients. Related to this is the need to expand the role of nurses, nurse practitioners, physician’s assistants, health educators, and social workers in triadic intervention approaches. Provider-endorsed interventions for parents of adolescents can be delivered by clinic staff in the waiting room or other space available at the clinic. Providers would then have greater opportunity for time alone with their adolescent patients in which to discuss private or sensitive health issues. For example, in the clinic implementation of the Families Talking Together intervention [15], physician endorsement was coupled with a social work intern delivering the intervention to parents in the waiting room. This brief intervention with parents led to delayed initiation of adolescent sexual intercourse and less frequent sex among sexually active adolescents.

Should triadic interventions be developed specifically for clinic settings, or can efficacious parenting interventions from other settings be adapted, and how can that best be accomplished? Evidence is mounting in favor of interventions targeted to parents leading to improvements in adolescent health across a variety of topic areas [17], although with less conclusive evidence for sexual health [18]. Program length and intensity present challenges for clinic adaptation, although creative solutions may be found through the use of technology, including Web sites, DVDs, tablets, mobile phone applications, and text messages, which may be used to complement direct communication between providers, clinic staff, adolescents, and their families. The right mix of approaches may vary by topic and by adolescent and family characteristics. Feasibility, acceptability, and effectiveness of triadic interventions may all be affected by the mode of intervention delivery.

The development and evaluation of triadic interventions to promote adolescent health is a promising new direction for public health researchers, practitioners, and clinicians. The benefits of such programs will likely extend to all three groups−providers, parents, and adolescents.