PEDIATRICS Vol. 116 No. 4 October 2005, pp. 966-971 (doi:10.1542/peds.2005-0318)
Changing Parental Opinions About Teen Privacy Through Education
Department of Adolescent Medicine, Brooke Army Medical Center, Ft Sam, Houston, Texas
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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Objective. Confidentiality for adolescent patients is the standard of care. However, some parents object to this practice. We determined the prevalence of parents who have negative opinions regarding adolescent privacy policies and education's effect on that prevalence.
Methods. All parents who sought care for their teen at 2 adolescent medicine clinics were asked to complete a computer survey about teen privacy and risk-taking behavior. Parents who did not know the clinic's privacy policy or had never been to the clinic were asked to participate in an educational study. Study participants were randomly selected to receive education by a handout or a scripted face-to-face encounter. They were surveyed again the same day. For evaluating long-term retention, a follow-up survey was conducted at least 30 days after the education.
Results. A total of 563 parents were surveyed. Of 281 eligible parents, 130 (46%) completed the postintervention survey and 52 (19%) completed the follow-up survey. Repeated measures analysis of variance showed that both education types were equally effective in teaching parents chosen privacy facts. The average number of correct test questions increased from 58.6% to 89.1%. More than 30 days later, the parents' score was 86.9%. Before education, 35% disagreed or strongly disagreed with teens' having private information, compared with 13.8% immediately after education and 15.4% at follow-up. The percentage of parents who disagreed or strongly disagreed with providers' seeing the patient alone was 30.5%, which decreased to 14.5% after education and 17.3% with the follow-up survey. 
2 tests showed no statistically significant differences between face-to-face and written education in changing parental opinions regarding privacy. When an adolescent wanted to speak with a provider alone, 93% of the parents agreed with that choice, regardless of intervention.
Conclusions. This study identifies that almost one third of the parents who presented to these adolescent medicine clinics had negative opinions about some privacy practices. The 2 main issues were teens' seeing a provider alone and providers' keeping information confidential. Education was effective in teaching parents about privacy issues and produced a significant improvement in parental opinion about confidentiality. Simultaneously, an overwhelming majority of parents support the idea that teens should speak with a provider alone if the teen so desires, suggesting that parents acknowledge a need for independence. Providing confidential services is an essential part of adolescent health care that works best with the alliance of parents. This study supports the continued need to assess parental attitudes about privacy issues and to provide parents with education.
Key Words: adolescent • education • privacy • parents • confidentiality • attitudes
Abbreviations: FTF, face-to-face
Consistently screening for risk-taking behaviors among youths during clinical encounters has been incorporated into the American Academy of Pediatrics, Society of Adolescent Medicine, and the American Medical Association guidelines for optimal adolescent health care provision.1–4 To practice these guidelines, providers should strive to integrate questions about potential risk-taking behaviors into each encounter. This can be accomplished briefly with either questionnaires or interview techniques such as the Home Education Activities Drugs Sex Suicide mnemonic.5, 6
A crucial step to obtaining meaningful information when screening for sensitive issues such as drug use and sexual activity is to ensure that adolescents have some private time with the provider during the clinical encounter.7, 8 This is essential because many teens desire to speak with the provider about sensitive health issues such as how to avoid sexually transmitted infections. They may also be engaged in risk-taking behaviors that they do not want to reveal to their parents.9 It is also clear that when parents' permission is required for sensitive health services such as oral contraception and sexually transmitted disease evaluations, adolescents are more likely to forego or delay such services.10 Limiting access to privacy during clinical encounters and missing opportunities to deliver relevant confidential information undermine health promotion and prevention for adolescents.4
One reason that providers do not interview adolescent patients alone may be related to the anxiety of a possible confrontation with the parent.4, 11 Unfortunately, many health care providers for teens have struggled with parents' being offended by the idea that their child is provided certain services, such as contraception and drug testing, without the parent's knowledge or permission.12, 13 Parents may also minimize the adolescent's need for such services or information. Providing the necessary confidential services should not produce trepidation or be a source of conflict between a provider and a parent. We should be able to provide these services as easily as we provide well-child guidance.
Even as attitudes toward children's rights have changed, many parents continue to wrestle with issues of teen independence and parental responsibility. In our history, when children were once considered property, there was no thought of privacy as long as the child lived with the parent.14 Although American society recognizes that rights are not solely dependent on age, there is a concern that we have given teens too many rights.13, 15 It is part of the daily art of adolescent medicine to balance patients' needs with the parents' needs and desires and to work with families who require these services the most.
Several articles and opinions have addressed privacy desires of the adolescent,7, 9, 15, 16 yet little is known regarding parental concerns about privacy. Our study was conducted to explore the prevalence of parents who have negative attitudes about teen privacy and whether education can influence a parent's attitude. It addresses the question, "Can we make the policy of teen privacy more acceptable to parents through education?" The assumption of this research is that the prevalence of parents who feel negatively about adolescent confidentiality is a vocal minority that can be reached through education.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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After approval by the Institutional Review Board, this study was conducted during the months of May and June 2004. All parents of patients who were between the ages of 13 and 23 and presented with their adolescent to either of 2 adolescent medicine clinics in military teaching hospitals were invited to participate in a survey. The parents were asked to complete a survey to help identify parental attitudes regarding adolescents' privacy and their knowledge of common adolescent risk-taking behaviors. Surveys were available in either English or Spanish. There were no exclusion criteria for taking the survey, and only clinic space and available personnel limited 100% capture. For enrolling parents who were naive to adolescent privacy issues into the education portion of the study, only parents who had never been to the clinic or who did not know the clinic's privacy policy were eligible for the education segment. Parents who took the survey in Spanish were excluded from the educational study because the education would be given in English. However, parental responses from the Spanish surveys were used to characterize more fully the range of attitudes and knowledge of all parents. Demographics of the surveyed parents and those who completed the study are shown in Table 1, showing no significant difference between the study group and all parents.
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Questionnaire and Measures
At a computer, parents were given the options of declining to take the survey, taking it in English or Spanish, or reporting that they had taken it before. The survey was a 38-question branching survey that inquired about demographics, attitude about adolescent privacy, and knowledge of privacy issues. Questions about adolescent privacy issues and attitudes were created by combined efforts of the adolescent medicine service that covers the 2 hospitals. Knowledge questions were used to compare baseline understanding of privacy topics before and after education. Ten questions were asked about confidentiality, local and federal law, and risk-taking behavior. The points of information were chosen by our clinic and were derived from local practice, state laws, and 2003 Youth Risk Behavior Survey statistics.17 Sample information included details such as suicide plans are not kept confidential, there is a higher-than-average local teen birth rate, and that more than half of high school students have tried cigarettes.15, 17, 18
Education Method
Parents in the study were randomly divided into a written or face-to-face (FTF) education group. The written group was given a 1-page handout about the clinic policy and national statistics of high school risk-taking behaviors. The FTF group was taught by 1 of 3 regular clinic providers: an LPN, RN, or MD The verbal education was scripted with the opportunity to ask questions at the end of the monologue. (See Fig 5.)
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Response Rate
A total of 634 parents were invited to take the survey, 21 of whom declined; 50 reported having taken the survey previously, and 12 took the survey in Spanish. Of the 551 parents who completed the survey in English, 281 (49.9%) were eligible for the educational intervention. Eighty-eight were first-time users, and 193 replied that they did not know the clinic's privacy policy. A total of 188 completed the education; 130 completed the posteducation survey, and 52 completed the survey at least 30 days after visiting the clinic.
Characteristics of Parent Population
The parents who participated represented a racially and educationally diverse group. All parents had some affiliation with the military: retired, active-duty, or family member of a retired or active-duty service member. Similar to other studies, mothers accompanied the patient more often than fathers,19 with the majority being parents of a high school student.
Characteristics of the Study Population
Participants represented the parent population with a slightly greater level of education. The parents in the education study had a higher percentage with at least some college education (92.3%) compared with all of the parents surveyed (85.5%) and significantly greater than the national percentage of Americans over 25 years of age with some college education (51.8%).20 In another study with parents of adolescents who were followed in an adolescent clinic for a chronic disease, the percentage with at least some college education was 63%.19 The study group was otherwise similar to the entire surveyed population in all other areas, including age, race, relationship with the patient, religious service attendance, and responses to opinion questions.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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We found that most parents believe that doctors should speak with teens alone during clinical encounters, that parents believe that there are good reasons to have confidential information between teen patients and their doctor, and that their son or daughter should be able to speak with a doctor alone if he or she wants to. Both a written fact sheet and FTF educational interventions were equally effective in teaching parents about adolescent privacy. Using SPSS (v.1.5.0) for Windows, the education types were compared using repeated measures analysis of variance and showed no statistical difference between the 2 educational interventions types with test scores or opinion questions before and after intervention. The average number of knowledge-based questions answered correctly for all parents and the study group was 58.6%. After parental education, the average number of correct responses increased to 89.1%. The 30-day follow-up remained at 86.9% correct (P < .001). Figure 1 represents the distribution of test scores before and after education in the study group.
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Regarding opinion-oriented questions, 35% of the parents disagreed or strongly disagreed that there are good reasons for teens to have confidential information. This percentage dropped to 13.8% after education and 15.7% when asked again at least 30 days later. Before any education, 30.5% believed that teens should not speak with doctors alone. After education, this number dropped to 14.5% the same day and 17.6% at the follow-up. Very few (3.7%) parents in the parent population believed that teens should not speak with providers alone if the teen wanted to. After education, the number of parents with a negative opinion about teens who want to speak with doctors alone unexpectedly increased to 6.1%. All parents had the option to enter comments after the survey; however, no recurring themes were noted. The 30-day follow-up results of whether teens should speak with the doctor dropped to 1.9%. Of the parents who strongly disagreed after education, 4 of 6 were given FTF education from different providers. The 2 parents who felt strongly and did not change opinions were given written education and answered all 10 knowledge questions correctly, demonstrating that they read and understood the handout. The questions used to measure parental attitudes are shown in Figs 2 to 4.
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Educating parents can change their opinion about teen privacy. This straightforward study validates the daily pediatric practice of educating parents during clinical visits. We often ruminate over which method is more effective: sitting down and talking to a parent or giving them a written handout. We demonstrated that, in the area of privacy, parents can be educated effectively through verbal or written methods, and this education can change parental opinions about adolescent privacy. The verbal education was also as effective whether from an MD, RN, or LPN. The equal efficacy of education delivered by various personnel is reassuring for clinics that have limited support and would rely primarily on handouts for education. Both methods were also effective in changing parental attitudes about one of the most anxiety-producing aspects of adolescent health care: the need to speak with the patient alone (Fig 5).
The 3 opinion questions described in this study best represent some of the negative statements often dealt with by experienced providers. One of the most significant results is that the overwhelming majority of parents support teens' talking to providers alone if the patient expresses the desire. This may represent parents' understanding and acceptance of the adolescent's need for independence or the acknowledgment that teens may need other adults to whom to talk. As providers, it is encouraging that parents are not inflexible. The obvious hurdle, however, is giving a 14-year-old the courage to ask his or her parent to leave so that he or she can talk. Situations of abuse or exploitation would make it almost impossible for a teen to admit that he or she wanted the parent to leave the room. It remains within our purview as providers to create an environment where a teen feels safe to talk.
This study may not be generalizable to all parents of teens, as there was a fairly high level of education attained by the parents in our population. There is the possibility that a less educated cohort would have a different opinion about confidential services or not respond as well to educational interventions. Despite the education level, we believe that the parents in this population are a fair representation of parents in our setting who would accompany their teenager to a health visit. Our population was racially diverse, with more than half of the participants between the age 36 and 45. A spectrum of religious affiliations was also represented, and military families are more likely to have lived in many geographic locations across the nation.
Another limitation is using a nonvalidated computer-based tool to assess opinions and knowledge. Available research revealed no tool that could be used to evaluate parental opinions about privacy. The level of education was likely a strong influence on the population's ability to easily use the computer and their ability to learn the information that we provided. Using our population as the control improves the reliability of the change in opinion. The points chosen to teach the parents are not critical because each clinic may want to emphasize different areas. In our handout and teaching, we emphasized that adolescents can engage in risk-taking behavior and that we want to work with the family and allow the patient the opportunity to address any issue of concern. Additional research is needed to identify reasons that a minority of parents feel strongly against confidentiality. This study was the first step in quantifying the magnitude of the problem of parents who are resistant to the practice of confidentiality.
Providing confidentiality may be limited by a provider's reluctance to oppose a parent's wishes or expectations. It is important to establish and maintain the relationships with parents and patients while providing the standard of care established by organizations that are dedicated to the best practices in health care of adolescents. With the capability of education to cut in half the number of parents with negative opinions about privacy, we should be encouraged to offer privacy proactively and consistently. We should also be secure in educating parents about teens' rights and needs for confidential services. Educating the parents will encourage dialogue in families and hopefully facilitate acceptance and support for optimized adolescent health care. As providers, we must make every effort to provide the opportunity for teens to take personal ownership for their health and express their needs and independence. We must not forget that most parents are not characteristically resisting their children's psychosocial maturation but rather are expressing their fear of the unknown and their anxiety about the changes that come with adolescence.
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ACKNOWLEDGMENTS |
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We gratefully acknowledge the critical assistance from our head clinic nurses Diane Elrod and Paula White. We also thank especially Dr Anneke Bush for technical and design support, which helped make this study possible, and the entire adolescent medicine staff.
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FOOTNOTES |
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Accepted May 23, 2005.
Address correspondence to Jeffrey W. Hutchinson, MD, Department of Adolescent Medicine, National Naval Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889. E-mail: hutch.w.hutchinson{at}us.army.mil
All comments and conclusions are those of the authors and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the United States of America
No conflict of interest declared.
PEDIATRICS (ISSN 0031 4005). Published in the public domain by the American Academy of Pediatrics.
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