Int J Adolesc Med Health 2016; 28(1): 61–68
Maria Veronica Svetaz*, Diego Garcia-Huidobro, Ghaffar Ali Hurtado, Laura Trebs, Stephanie Hernandez, Anna Bartels, Bibiana Garzon and Michele Allen
Can a healthy youth development clinic serving latino families be youth friendly and family oriented? A mixed-methods evaluation Abstract Background: Parenting adolescents poses challenges that are exacerbated by immigration. Aqui Para Ti [Here for You] (APT) is a clinic-based, healthy youth development program that provides family-centered care for Latino youth and their families who are mostly immigrants from Mexico and Latin America. Objectives: To present the APT model of care and report the experiences of youth and their parents. Subjects: APT patients between 11 and 24 years (n = 30) and parents (n = 15). Most youth patients were female, between 11 and 17 years, and from Mexico. Most parents were female, 40 years or younger, and from Mexico. Methods: Youth participants completed a survey and participated in an individual semi-structured interview, and parent participants attended focus groups. Descriptive statistics summarized survey data. Interviews and focus groups were transcribed and analyzed in Spanish using content analysis by two independent coders. Quantitative and qualitative findings were integrated using side-byside comparisons. Researchers not involved in the coding process contributed with the interpretation of the findings. Results: Youth and parents were satisfied with the services received at APT. Youth felt listened to by their providers (100%), felt they could trust them (100%) and valued *Corresponding author: Maria Veronica Svetaz, Aqui Para Ti/Here For You, Hennepin County Medical Center, 2700 E. Lake Street, Minneapolis, MN 55406, USA, Phone: +1-612-873-8145, Fax: +1-612873-1960, E-mail: [email protected] Diego Garcia-Huidobro: Aqui Para Ti/Here For You, Hennepin County Medical Center, Minneapolis, MN, USA; and Department of Family Medicine, School of Medicine, Pontificia Universidad Catolica de Chile Ghaffar Ali Hurtado: University of Minnesota Extension, University of Minnesota, MN, USA Laura Trebs, Anna Bartels and Bibiana Garzon: Aqui Para Ti/Here For You, Hennepin County Medical Center, Minneapolis, MN, USA Stephanie Hernandez: Aqui Para Ti/Here For You, Hennepin County Medical Center, Minneapolis, MN, USA; and Department of Spanish and Portuguese Studies, University of Minnesota, MN, USA Michele Allen: Department of Family Medicine and Community Health, University of Minnesota, MN, USA
comprehensive care. Eighty-seven percent reported that their experiences at APT were better than at other clinics. Parents valued the family parallel care, confidentiality, family-centeredness, and the cultural inclusivity of the APT services. Conclusion: Patients and parents were satisfied with the services offered at APT. Family parallel care could be a positive alternative to deliver confidential and family-centered services to immigrant families. Keywords: adolescents; family; Latinos; parents; primary care. DOI 10.1515/ijamh-2014-0073 Received October 20, 2014; accepted January 1, 2015; previously published online March 25, 2015
Introduction Immigration, while offering many benefits including contributing to the diversity of communities, creates multiple sources of stress that strain family functioning and may challenge family dynamics (1, 2). This is particularly true for families with adolescents since during this developmental stage youth increase personal awareness and independence, frequently questioning their parent’s authority, their values, and preferences (1–3). As youth generally adapt to the codes of the new culture faster than their parents (3), these cultural differences widen the already existing generational gap with the potential for creating more conflict among family members. Additionally, as parents learn to navigate their new culture, they are uncertain of the best way to raise their children and how involved they should be in their adolescent’s medical care (3, 5). Therefore, it is critical to provide medical services that foster a new paradigm of care (4, 5) that acknowledge the unique developmental needs of immigrant adolescents and their families, as well as their social challenges. About 1.2 million Latinos/Hispanics have migrated to the Unites States (US) between 2000 and 2010 (7), Brought to you by | University of Exeter Authenticated Download Date | 10/11/16 10:39 AM
62 Svetaz et al.: A mixed-methods evaluation of a youth development clinic representing the largest ethnic group migrating to this country (7, 8), i.e., about 16% of the US population. Traditional Latino culture has a strong family orientation with limited meaning of privacy (9), which could potentially create a tension for the confidentiality of adolescent health care delivery in US. Although there is a paucity of research on Latino parents, it is known that parents want to be involved in and supportive of their youth’s health (10, 11), and also that adolescents expect confidential care (12–14). This generates a discrepancy between the expectations of the parents and youth regarding the confidentiality of health services. Providers themselves frequently struggle to deliver confidential adolescent care that maintains a family orientation (5, 12). Consequently, Latino youth are potentially less likely to receive confidential time with their providers in an attempt to respect cultural values (15), or, by the physician attending only to the adolescent, parents are alienated, disengaged and possibly find it difficult to cultivate interest in their youth’s health care. To address the need of integrating adolescent-friendly confidential care with a family focus, Aqui Para Ti [Here For You] (APT) developed an innovative model of care for Latino adolescents (5). This manuscript presents the APT model of primary care services for immigrant Latino families with adolescents living in the US, and evaluates parent and youth satisfaction with the model of care received.
Description of Aqui Para Ti APT is a clinic-based program that has provided familycentered and confidential care for Latino families with
Community oversight
adolescents since 2002 (16). A team composed of a physician, a health educator and a program coordinator delivers comprehensive services to youth (10–24 years old), both girls and boys, and their parents using a “family parallel care” approach. When families arrive at the clinic, the APT team explains the approach, the need for confidential care, and how services will be delivered. Both youth and parents are screened in a simultaneous but separate way, and services are provided (Figure 1). For screening, the Guidelines for Adolescent Preventive Services (GAPS) parent and youth questionnaires (17) and the Beck Depression Inventory (18) are used. After reviewing the questionnaires, the APT team convenes to design a comprehensive parallel intervention so there is coherence on what the parent and youth receive. The intent for this approach is to deliver positive interventions to both sides of the family; youth are supported in order to conquer their developmental milestones, and also parents are introduced to a developmentally appropriate parenting style and are assessed in key factors that will directly affect the development of their children, such as their own mental health. The interventions are tailored to the individual family needs and are culturally inclusive, taking into consideration Latino values and preferences, cultural navigation, and specific immigration challenges. These appointments form the basis for future case management of short, mid and long-term services. This type of care respects and honors the needs and values of parents and their children and recognizes that families are the supporting base for healthy youth development (3, 5, 19). Key elements of this healthcare delivery model are: 1) cultural concordance between providers and patients, 2) family
Parent and teen advisory boards Physician Parallel family care
Clinic services
Youth boys/girls 10–24
Community health worker After clinic services
Parent/s (or significant adult)
School/ college connector
Parent educator
Case management phone care coordination
Figure 1: Representation of Aqui Para Ti’s model of care.
Brought to you by | University of Exeter Authenticated Download Date | 10/11/16 10:39 AM
Svetaz et al.: A mixed-methods evaluation of a youth development clinic 63
parallel care, 3) structured approach to screening, 4) team based care and case management, and 5) connecting with community organizations. APT services were crafted by considering key research findings (19) and from local community surveys (20). Although APT approach was developed by integrating the needs of the Latino community, it did not have direct input from community members. Therefore, since satisfaction is a critical dimension of high quality medical services (21), this study assessed how Latino parents and youth perceived APT services.
Methods Study design We conducted a convergent mixed methods study to assess parent and youth satisfaction with APT (Figure 2). In this study design, quantitative and qualitative methods have similar relevance, the data are collected in the same phase of the research project, the analysis of each data is independent, and the findings are combined and interpreted in common (22). Adolescents completed a questionnaire and individual interviews, and parents completed a survey and participated in focus groups. The University of Minnesota Institutional Review Board and the Hennepin County Medical Center Human Subjects Research Committee approved all study procedures.
Participants Fifty three patients between 10 and 24 years old who received care at APT anytime between 2006 and 2008 were randomly selected to participate in this study using multi-stage sampling (23). First, participants were contacted through mailed letters and then invited through a phone call. The response rate was 57% and the final sample was 30 youth. A random sample of parents was also invited to participate. However, because none of them responded to the invitation, parent participants (n = 15) were invited by a research assistant to attend
focus groups conducted at the APT clinic directly after their children finished their appointments. Table 1 summarizes the demographics of participants. Most youth were female (80%), between the ages of 11 and 17 (90%) and from Mexico (67%). Most parents were mothers (73%) and from Mexico (67%).
Procedures Minor patients and their parents gave consent for their participation. Youth 18 years or older gave their own consent for their participation. Afterwards, youth completed both a brief questionnaire either at the clinic or at home and an audio-recorded semi-structured interview (average duration 14.6±5.6 min). Most interviews were conducted in Spanish (n = 21) by a female graduate student with experience in qualitative research, either in person at the clinic (n = 15) or over the phone (n = 15). Upon completion of the interviews, youth received a $15 gift card or tickets to the Minnesota State Zoo. Parents participated in three, audio-recorded focus groups that were conducted in Spanish at APT by the same graduate student with the intent of learning the parent’s perceptions of APTservices. The focus groups lasted between 37.5 and 77.1 min (average of 60.3 min), and the parents received a $15 gift card. The questions that guided the youth interviews and parent focus groups are presented in Table 2. The questionnaire for adolescents and parents evaluated demographics and their satisfaction with services received at APT. Satisfaction items included perceptions about wait time for appointments, length of appointment, whether or not health concerns were properly addressed and overall satisfaction with the clinic.
Data analysis The qualitative analyses were conducted before the quantitative analysis, so that the survey findings would not influence the coding processes. Once quantitative and qualitative data were independently analyzed, the findings were integrated using side-by-side comparisons (Figure 1). This method for merged analysis presents Table 1: Description of youth and parent participants. Youth Gender, female Age 14 or younger Older than 14 Country of origin, Mexico Number of times attending APT, 3 or more
Figure 2: Convergent parallel study design.
Parents Gender, female Age 40 or younger Older than 40 Country of origin, Mexico Number of times child attends APT, 3 or more
n, % 24 (80) 11 (36.7) 19 (63.3) 20 (66.7) 28 (93.3) n, % 11 (73.3) 9 (60) 6 (40) 10 (66.7) 12 (80)
Brought to you by | University of Exeter Authenticated Download Date | 10/11/16 10:39 AM
64 Svetaz et al.: A mixed-methods evaluation of a youth development clinic Table 2: Questions guiding youth interviews and parent focus groups. Youth interviews 1. Think about the first time you came to APT/Youth Clinic and your other visits to the Clinic. Do you feel that your experience with the APT team has been different from other experiences you have had in other clinics and with other doctors? If yes, in what way? If not, why not? 2. Overall, how comfortable do you feel with the Youth Clinic and the Youth Clinic team during your visits to the Clinic? What things make you feel comfortable? 3. Do you feel as though you could trust the health care providers and staff of the Youth Clinic team? What do you experience that makes you feel that way? 4. Do you feel that the health care providers and staff of the Youth Clinic listen to you and your needs? How do you notice this? 5. When the Youth Clinic team works with you to develop a plan to address your health issues and needs, how much do you feel that the team takes into account what you think/feel? Can you tell me why this is? 6. Overall, do you think your health is better, worse or about the same as when you first came to APT? In what ways is it better or worse? 7. How did the APT/Youth Clinic team help you? 8. Finally, can you tell me one thing that you have not liked about going to APT/Youth Clinic? What has been hard or difficult? 9. What suggestions do you have for the Youth Clinic team regarding how they can better meet the needs of other Youth Clinic patients like you? Parent focus groups 1. Think about the first time that you came with your child to the Aquí Para Ti Youth Clinic at Hennepin Care East Clinic: 1a. What was your first impression upon entering the Clinic? 1b. How were you and your child treated? 1c. Do you feel that your first experience with the APT team was different to other experiences that you have had in other clinics and with other doctors? Please explain. 2. Think about the reason that you and your child came to the APT Youth Clinic. Do you feel that the APT team responded to your/your child’s needs? Could you give an example? 3. Do you think that your relationship with your adolescent has changed as a result of the work that you and your child have done with the Youth Clinic team? (If your answer is yes, follow with: could you explain how it has changed?) 4. After coming to the Youth Clinic, have you made any changes in the way that you educate your child(ren)? (If the answer is yes, follow with: what types of changes?) 5. Have you noticed any changes in the behavior of your adolescent since he/she began to come to the Aquí Para Ti Youth Clinic as a patient? (If the answer is yes, follow with: what types of changes have you noticed?) 6. Do you have any suggestions about how the APT Youth Clinic team can better serve you and your child? 7. Is there anything else that anyone would like to mention?
quantitative and qualitative results together so they can be easily integrated and compared (22).
Results
Qualitative data analysis: The same graduate student who collected the data transcribed the open-ended survey questions, interviews and focus groups. Two independent bilingual coders with experience in qualitative research individually analyzed the three datasets in Spanish or English following the procedures of Content Analysis (24). First, coders read the open-ended questions and developed a common codebook. Then, the coders independently coded the dataset. Once all responses were analyzed, coders discussed their findings until reaching total agreement. The same procedures were used to analyze the interviews and focus groups data and included the memos taken during the individual and group interviews. Once the three datasets were separately analyzed, they were merged and interpreted in common. Researchers not involved in the coding process also participated in the interpretation of the findings. Selected quotes were translated from Spanish to English.
General satisfaction
Quantitative data analysis: Questionnaire responses were tabulated, and descriptive statistics were calculated. All analyses were conducted using STATA v.10 (StataCorp, College Station, US).
Youth and parents reported high levels of satisfaction with the services received at APT (Table 3). A very high proportion reported that their experience at APT was better than in other clinics (87%), and that they would recommend this clinic to friends and family members (97%). Reflecting their general satisfaction, adolescents and parents commented: “Everything is complete…the APT program has been a big help to me…. it is the only place where they have helped me out of so many hospitals and places I went to…” (Female youth) “Here it is like we were their relatives. They give you your space, your respect… I have not seen that they feel superior to anyone. For that reason I like it… on the other hand, other clinics are somehow tyrant.” (Parent focus group 1)
Brought to you by | University of Exeter Authenticated Download Date | 10/11/16 10:39 AM
Svetaz et al.: A mixed-methods evaluation of a youth development clinic 65 “I am thankful that when I need something and look for help, the help is always there. That is why … [I] would recommend a hundred times, or a thousand, this place.” (Parent focus group 3)
that moment, I felt their empathy towards us; that they cared about us.” (Parent focus group 3)
Strong relationship with patients and families Cultural-inclusiveness Almost all youth reported high levels of comfort (93%) and trust (100%) in APT providers, and considered that they listened to their needs (100%). Parents also expressed that APT providers were very kind and warm. For example: “…with the team you can trust in everything. And you can have a lot of trust and no fear of talking about the things that you say, because they aren’t going to judge you.” (Female youth) “They sat down and they listened to me …, kind of emotional listening…, giving me, like, not advice, but just listening to me.” (Female youth) “… I didn’t know what I was going to find [at APT]. I knew I was going to bring my daughter, but I didn’t know how the people were going to be, or how it worked, or how I was going to be treated. And I liked it very much because they helped us form a bond with a lot of communication.” (Parent focus group 3) “The doctor makes our adolescents feel so comfortable that they open up about how they feel, and they talk about their problems. They feel a lot of trust with the doctor and with the people who work around her.” (Parent focus group 2)
In addition, adolescents and their parents perceived that APT providers had an authentic interest in them, and that they understood the family’s context. For example, youth mentioned that: “I have never been in this situation… to feel…that the doctor worries about you. Like, if something is hurting you, that doctor worries for you. I go to another doctor and ‘Oh, no no, you don’t have anything. Take your prescription.’ But when I go to her [APT doctor], ‘What’s wrong, how has it been going?’ and always, always, she is interested in me. That is what I like best … that feeling, like they worry about the patients.” (Female youth) “I just feel that they really care, and they really want the best for us.” (Female youth) “She [APT Doctor] gives attention to you, and it’s not important to her how many more patients she has, just that you feel like she gives you the time, and she concentrates on what you have,… she listens to you, she attends to you, and she is there with you.” (Female youth)
Parents also commented that: “I saw the attention they gave us, and the special treatment. It was like they put themselves in my shoes and understood. From
Patients and parents valued that providers spoke fluent Spanish and delivered culturally-appropriate care. For example, parents mentioned: “I had no idea that there were Spanish services available, and much less of the quality that I found here… I was impressed with the services that were available for the community. Also, something really important is that I didn’t have health insurance, and much less the money, and I didn’t know how to get insurance to cover my expenses. They made me an appointment with the financial counselor. It’s like they are really with us as if we were their children, as if my daughter was one of theirs.” (Parent focus group 3) “They have the ability of communicating with someone that comes from a small town from any Latin country and explaining how things are here – something that is needed.” (Parent focus group 3)
Comprehensive and continuous care Most youth reported that during the clinical visits they discussed a wide array of topics, including their sexual behaviors, emotional issues and family relationships with APT providers, and that they were highly satisfied with the treatment and/or solution proposed in each of these
Table 3: Youth and parent satisfaction with services received at APT. Youth satisfaction Time to schedule an appointment, Short Long Length of the visit, just the right amount of time Satisfied with clinic schedule Fully satisfied with outcomes Would recommend APT to a family member Perceive improvement in health
n, % 6 (20) 5 (16.7) 23 (76.7) 24 (80) 30 (100) 29 (96.7) 26 (86.7)
Parent satisfaction Time to schedule an appointment, usual Length of the visit, just the right amount of time Satisfied with clinic schedule Fully satisfied with outcomes Would recommend APT to a family member
n, % 13 (86.7) 12 (80) 13 (86.7) 14 (93.3) 15 (100)
Brought to you by | University of Exeter Authenticated Download Date | 10/11/16 10:39 AM
66 Svetaz et al.: A mixed-methods evaluation of a youth development clinic areas, feeling that their health improved (Table 4). Parents also valued the holistic approach that included the physical, emotional, educational, financial and social aspects of families. For example, parents mentioned: “They talked about sexuality with my daughter – topics that sometimes we don’t know how to approach – or, maybe if we talk about STIs or pregnancy prevention with our teens, they don’t listen to us as much.” (Parent focus group 3) “They pay attention to our health, not only to our physical health but also to our mental health since we have a lot of problems in real life” (Parent focus group 1). Participants also highlighted that care was not limited to the visits, but also through followup phone calls and care coordination. For example, a parent mentioned: “They are constantly reminding us to come back for follow-up appointments and also of our psychology appointments. Their approach is very complete.” (Parent focus group 2)
Confidentiality and team parallel care
“I liked it...It is an appointment where a person takes time to speak with the child, and another talks with the mother, and then they talk with us together… so they give us the opportunity to share our concerns. For example, if the child does not want to talk about something in front of me, he doesn’t have to… or if I want to tell the doctor or the therapist something that my child doesn’t like, I can do it in privacy so we can find a solution without the child noticing. Everything was fantastic!” (Parent focus group 1) In addition, parents praised that services were delivered by a team where the many providers knew the issues that were going on and were willing to help with the patient’s and family’s needs. For example, a parent expressed: “They never told me, ‘we are not available’ or ‘there is no time’. If one provider was busy, I spoke with another. If the doctor was not available, I talked to [provider], or if [provider] couldn’t, they communicated me with [another provider]; someone always helped me.” (Parent focus group 2)
Focus on skill-building for future success
Parents valued confidential care for adolescents because parents could privately share their needs and how they were feeling. This allowed parents to express their concerns, as some did not feel ready to have certain conversations with their adolescents. Parents commented: “They told my adolescent, ‘this private space is for you – what you say, we are not going to tell your mother, because it’s private.’ I think that she wanted to know that it was private. So she [adolescent] started to have a lot of trust. She initially didn’t want to talk to anyone, and I am surprised she ended up having a lot of trust with one of the doctors. After years, she still talks to her, which does not happen with the psychiatrist or with other professionals.” (Parent focus group 3) “What called my attention when I came here for the first time was the way in which they do their interviews; I like the privacy
Table 4: Number (%) of youth who discussed their sexual behaviors, emotional and family issues during the clinical visits at APT, their satisfaction and perceived health improvement.
Sexual behaviors
Emotional issues
Family issues
Discussed the issue Satisfied with the discussiona Perceived improvement of their health in this areaa
26 (87) 25 (96)
26 (87) 26 (100)
24 (80) 22 (92)
22 (85)
24 (92)
20 (83)
Denominator is the number of participants who discussed the issue. a
where the doctor talks to the kids and then independently with us.” (Parent focus group 2)
In their questionnaires, many participants reported having discussed their plans/goals for the future (67%), ways to achieve those goals (50%) and how staying in school is important (93%). Additionally, youth and parents perceived that APT providers helped them gain insight into themselves (specifically, how they were relating to others), praised education and self-care, instilled hope and self-esteem and taught coping and communication skills. During the interview participants discussed how these skills helped improve their family relations, physical and mental health, and school achievement, while avoiding risky behaviors and joining gangs. Concerning these issues, adolescents and parents commented: “The most important is education. It’s because of her [APT Doctor] that I finished school. When I met the doctor, I was 16 years old, and I told myself … ‘Why go to school? I want to work.’ But now, afterwards, I realize that, no, I wasn’t right. What was I going to do tomorrow? If I had the opportunity to go to school, to study, that is what I was going to do. They [APT staff] always… instilled in me a lot of value for education.” (Female youth) “They taught me how to not just keep inside how you feel, to talk with parents instead of only thinking and not saying things. It helped me a lot to communicate myself with my parents.” (Male youth) “I think that the most important thing the team helped us with was learning how to speak and listen – taking the perspective of how our children are seeing things.” (Parent focus group 2)
Brought to you by | University of Exeter Authenticated Download Date | 10/11/16 10:39 AM
Svetaz et al.: A mixed-methods evaluation of a youth development clinic 67
Figure 3: Aqui Para Ti’s model of care.
Discussion Findings from this program evaluation suggest that APT youth had identified that their care was delivered in a “youth friendly clinic” that included confidential care, respectful treatment, integrated services, culturally competent staff, easy access to free or low cost services and promotion of parent-child communication (25). Furthermore, the results of this evaluation suggest that parents and youth attending APT felt the concepts of confidentiality and family-centered care can be successfully integrated into a culturally-sensitive team approach for immigrant adolescents. When Latino parents feel respected and that they can trust the providers, they feel comfortable with their adolescent receiving confidential care (26). Parents report valuing warm, culturally-competent providers who respect their values and needs. They also value integrated care, reiterating the importance of addressing social and environmental factors affecting health when providing care to adolescents. These aspects are critical to reduce health disparities (6, 27, 28) and provide high quality services for immigrant communities (29, 30), which validates the incorporation of these aspects when designing services for immigrant families with adolescents. Based on the youth’s and their parent’s perspectives, we refined the APT model of care, integrating our clients’ perspective, highlighting principles and clinical strategies (Figure 3). These findings helped introduced the need to incorporate a school/college connector to our team and also adding a parent educator to reinforce the parallel care model (Figure 1). Finally, to structure the youth, parent and family skill building interventions the team is developing standard coaching modules. There are several strengths to this evaluation. First, the evaluation describes a model to deliver youth-friendly family-centered medical services. Second, it unveils the evaluation’s surveys, interviews and focus groups results to assess satisfaction. Finally, the evaluation included both parents and youth. The convergence of parent and adolescent reports, and the convergence between the
quantitative and qualitative methods, support the significant role of APT in delivering an intervention that fits the needs of the families that the program serves, and produces high satisfaction, which is extremely important when evaluating adolescent services (31). However, these findings need to be interpreted within the limitations of this study. First, because parent and youth participants were volunteers, they might have been more satisfied than the participants who did not participate in this study (32), especially the sample of parents. In addition, although the person who conducted the interviews and focus groups was culturally and linguistically competent, she was a Caucasian female graduate student who spoke Spanish as a second language. This could have affected the participation in the study, especially of male adolescents and the quality of their responses (33, 34). Future studies should include interviewers sharing similar gender, age and ethnicity as the participants. Finally, this evaluation represents the first step of the larger evaluation effort the APT program has already undertaken. This study focused on the assessment of parent and youth satisfaction, which is only one dimension of the quality of care (21). A complete evaluation of the model, which is in preparation, will include APT impact on health outcomes and cost reduction. By providing parallel care to immigrant adolescents and their families, APT honors the need for confidential health services while respecting the needs and preferences of their parents. The high satisfaction with the services received at APT confirms that this model of care fulfills the expectations of immigrant families with adolescents while providing high quality of care. This concrete model is an innovative alternative to achieving family-centered and confidential adolescent care that can help improve health equity for immigrant communities.
References 1. Bacallao ML, Smokowski PR. The costs of getting ahead: Mexican family system changes after immigration. Fam Relat 2007;56:52–66.
Brought to you by | University of Exeter Authenticated Download Date | 10/11/16 10:39 AM
68 Svetaz et al.: A mixed-methods evaluation of a youth development clinic 2. Qin DB. Doing well vs. feeling well: understanding family dynamics and the psychological adjustment of Chinese immigrant adolescents. J Youth Adolesc 2008;37:22–35. 3. Kwak K. Adolescents and their parents: a review of intergenerational family relations for immigrant and non-immigrant families. Hum Dev 2003;46:115–36. 4. Sawyer SM, Afifi RA, Bearinger LH, Blakemore SJ, Dick B, et al. Adolescence: a foundation for future health. Lancet 2012;379:1630–40. 5. Svetaz MV, Garcia-Huidobro D, Allen ML. Parents and family matter: strategies for developing family-centered adolescent care within primary care practices. Prim Care 2014;41:489–506. 6. Viner RM, Ozer EM, Denny S, Marmot M, Resnick M, et al. Adolescence and the social determinants of health. Lancet 2012;379:1641–52. 7. United States Census Bureau. Demographic Analysis 2010: Sensitivity Analysis of the Foreign-Born Migration Component. Available at: http://www.census.gov/population/www/documentation/twps0098/twps0098.pdf. 8. United States Census Bureau. The Hispanic Population: 2010. Available at: https://www.census.gov/prod/cen2010/briefs/ c2010br-04.pdf. 9. Miranda AO, Bilot JM, Peluso PR, Berman K, Van Meek LG. Latino families: The relevance of the connection among acculturation, family dynamics, and health for family counseling research and practice. Fam J 2006;14:268–73. 10. Dempsey AF, Singer DD, Clark SJ, Davis MM. Adolescent preventive health care: what do parents want? J Pediatr 2009;155:689– 94. 11. Duncan RE, Vandeleur M, Derks A, Sawyer S. Confidentiality with adolescents in the medical setting: what do parents think? J Adolesc Health 2011;49:428–30. 12. Berlan ED, Bravender T. Confidentiality, consent, and caring for the adolescent patient. Curr Opin Pediatr 2009;21:450–6. 13. Cheng TL, Savageau JA, Sattler AL, DeWitt TG. Confidentiality in health care: a survey of knowledge, perceptions, and attitudes among high school students. J Am Med Assoc 1993;269:1404–7. 14. Kapphahn CJ, Wilson KM, Klein JD. Adolescent girls’ and boys’ preferences for provider gender and confidentiality in their health care. J Adolesc Health 1999;25:131–42. 15. Edman JC, Adams SH, Park MJ, Irwin Jr CE. Who gets confidential care? Disparities in a national sample of adolescents. J Adolesc Health 2010;46:393–5. 16. Svetaz MV, Landrieu MJ, Allen ML, Shlafer RJ. Aqui Para TI [Here for You]: a decade supporting Latino families and bridging the science of health equity and positive youth development. J Adolesc Health 2013;52(Supplement 1):S98.
17. Elster AB, Kuznets NJ. Guidelines for adolescent preventive services. Baltimore, MD: American Medical Association, 1994. 18. Beck AT, Steer RA, Carbin MG. Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clin Psychol Rev 1988;8:77–100. 19. Resnick MD. Protective factors, resiliency, and healthy youth development. Adolesc Med State Art Rev 2000;11:157–64. 20. Chase R, Clement D. West Side community health assessment. Saint Paul, MN: Research Center, 2000:44. 21. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood) 2008;27:759–69. 22. Clark VLP, Creswell JW. Designing and conducting mixed methods research. Thousand Oakes, CA: Sage, 2011:488. 23. Rea LM, Parker RA. Designing and conducting survey research: a comprehensive guide, 3rd ed. San Francisco, CA: John Wiley & Sons, 2005:304. 24. Weber RP. Basic content analysis. Thousand Oakes, CA: Sage, 1990:96. 25. Alford S. Best Practices for youth-friendly clinical services. Available at: http://www.advocatesforyouth.org/index. php?option=com_content&task=view&id=1347&Itemid=177. 26. Tebb K, Hernandez LK, Shafer MA, Chang F, Eyre SL, et al. Understanding the Attitudes of Latino Parents Toward Confidential Health Services for Teens. J Adolesc Health 2012;50:572–7. 27. Silow-Carroll S, Alteras T, Stepnick L. Patient-centered Care for Underserved Populations: Definition and Best Practices (pp. 1–43). Washington, DC: Economic and Social Research Institute, 2006:43. 28. Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong 2nd O. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep 2003;118:293–302. 29. Derose KP, Bahney BW, Lurie N, Escarce JJ. Immigrants and health care access, quality, and cost. Med Care Res Rev 2009;66:355–408. 30. Leduc N, Proulx M. Patterns of health services utilization by recent immigrants. J Immigr Health 2004;6:15–27. 31. Byczkowski TL, Kollar LM, Britto MT. Family experiences with outpatient care: Do adolescents and parents have the same perceptions? J Adolesc Health 2010;47:92–8. 32. Finkelstein MA. Volunteer satisfaction and volunteer action: A functional approach. Soc Behav Pers 2008;36:9–18. 33. Kvale S. Doing interviews. Thousand Oakes, CA: Sage, 2008:160. 34. Huddy L, Billig J, Bracciodieta J, Hoeffler L, Moynihan PJ, et al. The effect of interviewer gender on the survey response. Political Behav 1997;19:197–220.
Brought to you by | University of Exeter Authenticated Download Date | 10/11/16 10:39 AM
Maria Veronica Svetaz*, Diego Garcia-Huidobro, Ghaffar Ali Hurtado, Laura Trebs, Stephanie Hernandez, Anna Bartels, Bibiana Garzon and Michele Allen
Can a healthy youth development clinic serving latino families be youth friendly and family oriented? A mixed-methods evaluation Abstract Background: Parenting adolescents poses challenges that are exacerbated by immigration. Aqui Para Ti [Here for You] (APT) is a clinic-based, healthy youth development program that provides family-centered care for Latino youth and their families who are mostly immigrants from Mexico and Latin America. Objectives: To present the APT model of care and report the experiences of youth and their parents. Subjects: APT patients between 11 and 24 years (n = 30) and parents (n = 15). Most youth patients were female, between 11 and 17 years, and from Mexico. Most parents were female, 40 years or younger, and from Mexico. Methods: Youth participants completed a survey and participated in an individual semi-structured interview, and parent participants attended focus groups. Descriptive statistics summarized survey data. Interviews and focus groups were transcribed and analyzed in Spanish using content analysis by two independent coders. Quantitative and qualitative findings were integrated using side-byside comparisons. Researchers not involved in the coding process contributed with the interpretation of the findings. Results: Youth and parents were satisfied with the services received at APT. Youth felt listened to by their providers (100%), felt they could trust them (100%) and valued *Corresponding author: Maria Veronica Svetaz, Aqui Para Ti/Here For You, Hennepin County Medical Center, 2700 E. Lake Street, Minneapolis, MN 55406, USA, Phone: +1-612-873-8145, Fax: +1-612873-1960, E-mail: [email protected] Diego Garcia-Huidobro: Aqui Para Ti/Here For You, Hennepin County Medical Center, Minneapolis, MN, USA; and Department of Family Medicine, School of Medicine, Pontificia Universidad Catolica de Chile Ghaffar Ali Hurtado: University of Minnesota Extension, University of Minnesota, MN, USA Laura Trebs, Anna Bartels and Bibiana Garzon: Aqui Para Ti/Here For You, Hennepin County Medical Center, Minneapolis, MN, USA Stephanie Hernandez: Aqui Para Ti/Here For You, Hennepin County Medical Center, Minneapolis, MN, USA; and Department of Spanish and Portuguese Studies, University of Minnesota, MN, USA Michele Allen: Department of Family Medicine and Community Health, University of Minnesota, MN, USA
comprehensive care. Eighty-seven percent reported that their experiences at APT were better than at other clinics. Parents valued the family parallel care, confidentiality, family-centeredness, and the cultural inclusivity of the APT services. Conclusion: Patients and parents were satisfied with the services offered at APT. Family parallel care could be a positive alternative to deliver confidential and family-centered services to immigrant families. Keywords: adolescents; family; Latinos; parents; primary care. DOI 10.1515/ijamh-2014-0073 Received October 20, 2014; accepted January 1, 2015; previously published online March 25, 2015
Introduction Immigration, while offering many benefits including contributing to the diversity of communities, creates multiple sources of stress that strain family functioning and may challenge family dynamics (1, 2). This is particularly true for families with adolescents since during this developmental stage youth increase personal awareness and independence, frequently questioning their parent’s authority, their values, and preferences (1–3). As youth generally adapt to the codes of the new culture faster than their parents (3), these cultural differences widen the already existing generational gap with the potential for creating more conflict among family members. Additionally, as parents learn to navigate their new culture, they are uncertain of the best way to raise their children and how involved they should be in their adolescent’s medical care (3, 5). Therefore, it is critical to provide medical services that foster a new paradigm of care (4, 5) that acknowledge the unique developmental needs of immigrant adolescents and their families, as well as their social challenges. About 1.2 million Latinos/Hispanics have migrated to the Unites States (US) between 2000 and 2010 (7), Brought to you by | University of Exeter Authenticated Download Date | 10/11/16 10:39 AM
62 Svetaz et al.: A mixed-methods evaluation of a youth development clinic representing the largest ethnic group migrating to this country (7, 8), i.e., about 16% of the US population. Traditional Latino culture has a strong family orientation with limited meaning of privacy (9), which could potentially create a tension for the confidentiality of adolescent health care delivery in US. Although there is a paucity of research on Latino parents, it is known that parents want to be involved in and supportive of their youth’s health (10, 11), and also that adolescents expect confidential care (12–14). This generates a discrepancy between the expectations of the parents and youth regarding the confidentiality of health services. Providers themselves frequently struggle to deliver confidential adolescent care that maintains a family orientation (5, 12). Consequently, Latino youth are potentially less likely to receive confidential time with their providers in an attempt to respect cultural values (15), or, by the physician attending only to the adolescent, parents are alienated, disengaged and possibly find it difficult to cultivate interest in their youth’s health care. To address the need of integrating adolescent-friendly confidential care with a family focus, Aqui Para Ti [Here For You] (APT) developed an innovative model of care for Latino adolescents (5). This manuscript presents the APT model of primary care services for immigrant Latino families with adolescents living in the US, and evaluates parent and youth satisfaction with the model of care received.
Description of Aqui Para Ti APT is a clinic-based program that has provided familycentered and confidential care for Latino families with
Community oversight
adolescents since 2002 (16). A team composed of a physician, a health educator and a program coordinator delivers comprehensive services to youth (10–24 years old), both girls and boys, and their parents using a “family parallel care” approach. When families arrive at the clinic, the APT team explains the approach, the need for confidential care, and how services will be delivered. Both youth and parents are screened in a simultaneous but separate way, and services are provided (Figure 1). For screening, the Guidelines for Adolescent Preventive Services (GAPS) parent and youth questionnaires (17) and the Beck Depression Inventory (18) are used. After reviewing the questionnaires, the APT team convenes to design a comprehensive parallel intervention so there is coherence on what the parent and youth receive. The intent for this approach is to deliver positive interventions to both sides of the family; youth are supported in order to conquer their developmental milestones, and also parents are introduced to a developmentally appropriate parenting style and are assessed in key factors that will directly affect the development of their children, such as their own mental health. The interventions are tailored to the individual family needs and are culturally inclusive, taking into consideration Latino values and preferences, cultural navigation, and specific immigration challenges. These appointments form the basis for future case management of short, mid and long-term services. This type of care respects and honors the needs and values of parents and their children and recognizes that families are the supporting base for healthy youth development (3, 5, 19). Key elements of this healthcare delivery model are: 1) cultural concordance between providers and patients, 2) family
Parent and teen advisory boards Physician Parallel family care
Clinic services
Youth boys/girls 10–24
Community health worker After clinic services
Parent/s (or significant adult)
School/ college connector
Parent educator
Case management phone care coordination
Figure 1: Representation of Aqui Para Ti’s model of care.
Brought to you by | University of Exeter Authenticated Download Date | 10/11/16 10:39 AM
Svetaz et al.: A mixed-methods evaluation of a youth development clinic 63
parallel care, 3) structured approach to screening, 4) team based care and case management, and 5) connecting with community organizations. APT services were crafted by considering key research findings (19) and from local community surveys (20). Although APT approach was developed by integrating the needs of the Latino community, it did not have direct input from community members. Therefore, since satisfaction is a critical dimension of high quality medical services (21), this study assessed how Latino parents and youth perceived APT services.
Methods Study design We conducted a convergent mixed methods study to assess parent and youth satisfaction with APT (Figure 2). In this study design, quantitative and qualitative methods have similar relevance, the data are collected in the same phase of the research project, the analysis of each data is independent, and the findings are combined and interpreted in common (22). Adolescents completed a questionnaire and individual interviews, and parents completed a survey and participated in focus groups. The University of Minnesota Institutional Review Board and the Hennepin County Medical Center Human Subjects Research Committee approved all study procedures.
Participants Fifty three patients between 10 and 24 years old who received care at APT anytime between 2006 and 2008 were randomly selected to participate in this study using multi-stage sampling (23). First, participants were contacted through mailed letters and then invited through a phone call. The response rate was 57% and the final sample was 30 youth. A random sample of parents was also invited to participate. However, because none of them responded to the invitation, parent participants (n = 15) were invited by a research assistant to attend
focus groups conducted at the APT clinic directly after their children finished their appointments. Table 1 summarizes the demographics of participants. Most youth were female (80%), between the ages of 11 and 17 (90%) and from Mexico (67%). Most parents were mothers (73%) and from Mexico (67%).
Procedures Minor patients and their parents gave consent for their participation. Youth 18 years or older gave their own consent for their participation. Afterwards, youth completed both a brief questionnaire either at the clinic or at home and an audio-recorded semi-structured interview (average duration 14.6±5.6 min). Most interviews were conducted in Spanish (n = 21) by a female graduate student with experience in qualitative research, either in person at the clinic (n = 15) or over the phone (n = 15). Upon completion of the interviews, youth received a $15 gift card or tickets to the Minnesota State Zoo. Parents participated in three, audio-recorded focus groups that were conducted in Spanish at APT by the same graduate student with the intent of learning the parent’s perceptions of APTservices. The focus groups lasted between 37.5 and 77.1 min (average of 60.3 min), and the parents received a $15 gift card. The questions that guided the youth interviews and parent focus groups are presented in Table 2. The questionnaire for adolescents and parents evaluated demographics and their satisfaction with services received at APT. Satisfaction items included perceptions about wait time for appointments, length of appointment, whether or not health concerns were properly addressed and overall satisfaction with the clinic.
Data analysis The qualitative analyses were conducted before the quantitative analysis, so that the survey findings would not influence the coding processes. Once quantitative and qualitative data were independently analyzed, the findings were integrated using side-by-side comparisons (Figure 1). This method for merged analysis presents Table 1: Description of youth and parent participants. Youth Gender, female Age 14 or younger Older than 14 Country of origin, Mexico Number of times attending APT, 3 or more
Figure 2: Convergent parallel study design.
Parents Gender, female Age 40 or younger Older than 40 Country of origin, Mexico Number of times child attends APT, 3 or more
n, % 24 (80) 11 (36.7) 19 (63.3) 20 (66.7) 28 (93.3) n, % 11 (73.3) 9 (60) 6 (40) 10 (66.7) 12 (80)
Brought to you by | University of Exeter Authenticated Download Date | 10/11/16 10:39 AM
64 Svetaz et al.: A mixed-methods evaluation of a youth development clinic Table 2: Questions guiding youth interviews and parent focus groups. Youth interviews 1. Think about the first time you came to APT/Youth Clinic and your other visits to the Clinic. Do you feel that your experience with the APT team has been different from other experiences you have had in other clinics and with other doctors? If yes, in what way? If not, why not? 2. Overall, how comfortable do you feel with the Youth Clinic and the Youth Clinic team during your visits to the Clinic? What things make you feel comfortable? 3. Do you feel as though you could trust the health care providers and staff of the Youth Clinic team? What do you experience that makes you feel that way? 4. Do you feel that the health care providers and staff of the Youth Clinic listen to you and your needs? How do you notice this? 5. When the Youth Clinic team works with you to develop a plan to address your health issues and needs, how much do you feel that the team takes into account what you think/feel? Can you tell me why this is? 6. Overall, do you think your health is better, worse or about the same as when you first came to APT? In what ways is it better or worse? 7. How did the APT/Youth Clinic team help you? 8. Finally, can you tell me one thing that you have not liked about going to APT/Youth Clinic? What has been hard or difficult? 9. What suggestions do you have for the Youth Clinic team regarding how they can better meet the needs of other Youth Clinic patients like you? Parent focus groups 1. Think about the first time that you came with your child to the Aquí Para Ti Youth Clinic at Hennepin Care East Clinic: 1a. What was your first impression upon entering the Clinic? 1b. How were you and your child treated? 1c. Do you feel that your first experience with the APT team was different to other experiences that you have had in other clinics and with other doctors? Please explain. 2. Think about the reason that you and your child came to the APT Youth Clinic. Do you feel that the APT team responded to your/your child’s needs? Could you give an example? 3. Do you think that your relationship with your adolescent has changed as a result of the work that you and your child have done with the Youth Clinic team? (If your answer is yes, follow with: could you explain how it has changed?) 4. After coming to the Youth Clinic, have you made any changes in the way that you educate your child(ren)? (If the answer is yes, follow with: what types of changes?) 5. Have you noticed any changes in the behavior of your adolescent since he/she began to come to the Aquí Para Ti Youth Clinic as a patient? (If the answer is yes, follow with: what types of changes have you noticed?) 6. Do you have any suggestions about how the APT Youth Clinic team can better serve you and your child? 7. Is there anything else that anyone would like to mention?
quantitative and qualitative results together so they can be easily integrated and compared (22).
Results
Qualitative data analysis: The same graduate student who collected the data transcribed the open-ended survey questions, interviews and focus groups. Two independent bilingual coders with experience in qualitative research individually analyzed the three datasets in Spanish or English following the procedures of Content Analysis (24). First, coders read the open-ended questions and developed a common codebook. Then, the coders independently coded the dataset. Once all responses were analyzed, coders discussed their findings until reaching total agreement. The same procedures were used to analyze the interviews and focus groups data and included the memos taken during the individual and group interviews. Once the three datasets were separately analyzed, they were merged and interpreted in common. Researchers not involved in the coding process also participated in the interpretation of the findings. Selected quotes were translated from Spanish to English.
General satisfaction
Quantitative data analysis: Questionnaire responses were tabulated, and descriptive statistics were calculated. All analyses were conducted using STATA v.10 (StataCorp, College Station, US).
Youth and parents reported high levels of satisfaction with the services received at APT (Table 3). A very high proportion reported that their experience at APT was better than in other clinics (87%), and that they would recommend this clinic to friends and family members (97%). Reflecting their general satisfaction, adolescents and parents commented: “Everything is complete…the APT program has been a big help to me…. it is the only place where they have helped me out of so many hospitals and places I went to…” (Female youth) “Here it is like we were their relatives. They give you your space, your respect… I have not seen that they feel superior to anyone. For that reason I like it… on the other hand, other clinics are somehow tyrant.” (Parent focus group 1)
Brought to you by | University of Exeter Authenticated Download Date | 10/11/16 10:39 AM
Svetaz et al.: A mixed-methods evaluation of a youth development clinic 65 “I am thankful that when I need something and look for help, the help is always there. That is why … [I] would recommend a hundred times, or a thousand, this place.” (Parent focus group 3)
that moment, I felt their empathy towards us; that they cared about us.” (Parent focus group 3)
Strong relationship with patients and families Cultural-inclusiveness Almost all youth reported high levels of comfort (93%) and trust (100%) in APT providers, and considered that they listened to their needs (100%). Parents also expressed that APT providers were very kind and warm. For example: “…with the team you can trust in everything. And you can have a lot of trust and no fear of talking about the things that you say, because they aren’t going to judge you.” (Female youth) “They sat down and they listened to me …, kind of emotional listening…, giving me, like, not advice, but just listening to me.” (Female youth) “… I didn’t know what I was going to find [at APT]. I knew I was going to bring my daughter, but I didn’t know how the people were going to be, or how it worked, or how I was going to be treated. And I liked it very much because they helped us form a bond with a lot of communication.” (Parent focus group 3) “The doctor makes our adolescents feel so comfortable that they open up about how they feel, and they talk about their problems. They feel a lot of trust with the doctor and with the people who work around her.” (Parent focus group 2)
In addition, adolescents and their parents perceived that APT providers had an authentic interest in them, and that they understood the family’s context. For example, youth mentioned that: “I have never been in this situation… to feel…that the doctor worries about you. Like, if something is hurting you, that doctor worries for you. I go to another doctor and ‘Oh, no no, you don’t have anything. Take your prescription.’ But when I go to her [APT doctor], ‘What’s wrong, how has it been going?’ and always, always, she is interested in me. That is what I like best … that feeling, like they worry about the patients.” (Female youth) “I just feel that they really care, and they really want the best for us.” (Female youth) “She [APT Doctor] gives attention to you, and it’s not important to her how many more patients she has, just that you feel like she gives you the time, and she concentrates on what you have,… she listens to you, she attends to you, and she is there with you.” (Female youth)
Parents also commented that: “I saw the attention they gave us, and the special treatment. It was like they put themselves in my shoes and understood. From
Patients and parents valued that providers spoke fluent Spanish and delivered culturally-appropriate care. For example, parents mentioned: “I had no idea that there were Spanish services available, and much less of the quality that I found here… I was impressed with the services that were available for the community. Also, something really important is that I didn’t have health insurance, and much less the money, and I didn’t know how to get insurance to cover my expenses. They made me an appointment with the financial counselor. It’s like they are really with us as if we were their children, as if my daughter was one of theirs.” (Parent focus group 3) “They have the ability of communicating with someone that comes from a small town from any Latin country and explaining how things are here – something that is needed.” (Parent focus group 3)
Comprehensive and continuous care Most youth reported that during the clinical visits they discussed a wide array of topics, including their sexual behaviors, emotional issues and family relationships with APT providers, and that they were highly satisfied with the treatment and/or solution proposed in each of these
Table 3: Youth and parent satisfaction with services received at APT. Youth satisfaction Time to schedule an appointment, Short Long Length of the visit, just the right amount of time Satisfied with clinic schedule Fully satisfied with outcomes Would recommend APT to a family member Perceive improvement in health
n, % 6 (20) 5 (16.7) 23 (76.7) 24 (80) 30 (100) 29 (96.7) 26 (86.7)
Parent satisfaction Time to schedule an appointment, usual Length of the visit, just the right amount of time Satisfied with clinic schedule Fully satisfied with outcomes Would recommend APT to a family member
n, % 13 (86.7) 12 (80) 13 (86.7) 14 (93.3) 15 (100)
Brought to you by | University of Exeter Authenticated Download Date | 10/11/16 10:39 AM
66 Svetaz et al.: A mixed-methods evaluation of a youth development clinic areas, feeling that their health improved (Table 4). Parents also valued the holistic approach that included the physical, emotional, educational, financial and social aspects of families. For example, parents mentioned: “They talked about sexuality with my daughter – topics that sometimes we don’t know how to approach – or, maybe if we talk about STIs or pregnancy prevention with our teens, they don’t listen to us as much.” (Parent focus group 3) “They pay attention to our health, not only to our physical health but also to our mental health since we have a lot of problems in real life” (Parent focus group 1). Participants also highlighted that care was not limited to the visits, but also through followup phone calls and care coordination. For example, a parent mentioned: “They are constantly reminding us to come back for follow-up appointments and also of our psychology appointments. Their approach is very complete.” (Parent focus group 2)
Confidentiality and team parallel care
“I liked it...It is an appointment where a person takes time to speak with the child, and another talks with the mother, and then they talk with us together… so they give us the opportunity to share our concerns. For example, if the child does not want to talk about something in front of me, he doesn’t have to… or if I want to tell the doctor or the therapist something that my child doesn’t like, I can do it in privacy so we can find a solution without the child noticing. Everything was fantastic!” (Parent focus group 1) In addition, parents praised that services were delivered by a team where the many providers knew the issues that were going on and were willing to help with the patient’s and family’s needs. For example, a parent expressed: “They never told me, ‘we are not available’ or ‘there is no time’. If one provider was busy, I spoke with another. If the doctor was not available, I talked to [provider], or if [provider] couldn’t, they communicated me with [another provider]; someone always helped me.” (Parent focus group 2)
Focus on skill-building for future success
Parents valued confidential care for adolescents because parents could privately share their needs and how they were feeling. This allowed parents to express their concerns, as some did not feel ready to have certain conversations with their adolescents. Parents commented: “They told my adolescent, ‘this private space is for you – what you say, we are not going to tell your mother, because it’s private.’ I think that she wanted to know that it was private. So she [adolescent] started to have a lot of trust. She initially didn’t want to talk to anyone, and I am surprised she ended up having a lot of trust with one of the doctors. After years, she still talks to her, which does not happen with the psychiatrist or with other professionals.” (Parent focus group 3) “What called my attention when I came here for the first time was the way in which they do their interviews; I like the privacy
Table 4: Number (%) of youth who discussed their sexual behaviors, emotional and family issues during the clinical visits at APT, their satisfaction and perceived health improvement.
Sexual behaviors
Emotional issues
Family issues
Discussed the issue Satisfied with the discussiona Perceived improvement of their health in this areaa
26 (87) 25 (96)
26 (87) 26 (100)
24 (80) 22 (92)
22 (85)
24 (92)
20 (83)
Denominator is the number of participants who discussed the issue. a
where the doctor talks to the kids and then independently with us.” (Parent focus group 2)
In their questionnaires, many participants reported having discussed their plans/goals for the future (67%), ways to achieve those goals (50%) and how staying in school is important (93%). Additionally, youth and parents perceived that APT providers helped them gain insight into themselves (specifically, how they were relating to others), praised education and self-care, instilled hope and self-esteem and taught coping and communication skills. During the interview participants discussed how these skills helped improve their family relations, physical and mental health, and school achievement, while avoiding risky behaviors and joining gangs. Concerning these issues, adolescents and parents commented: “The most important is education. It’s because of her [APT Doctor] that I finished school. When I met the doctor, I was 16 years old, and I told myself … ‘Why go to school? I want to work.’ But now, afterwards, I realize that, no, I wasn’t right. What was I going to do tomorrow? If I had the opportunity to go to school, to study, that is what I was going to do. They [APT staff] always… instilled in me a lot of value for education.” (Female youth) “They taught me how to not just keep inside how you feel, to talk with parents instead of only thinking and not saying things. It helped me a lot to communicate myself with my parents.” (Male youth) “I think that the most important thing the team helped us with was learning how to speak and listen – taking the perspective of how our children are seeing things.” (Parent focus group 2)
Brought to you by | University of Exeter Authenticated Download Date | 10/11/16 10:39 AM
Svetaz et al.: A mixed-methods evaluation of a youth development clinic 67
Figure 3: Aqui Para Ti’s model of care.
Discussion Findings from this program evaluation suggest that APT youth had identified that their care was delivered in a “youth friendly clinic” that included confidential care, respectful treatment, integrated services, culturally competent staff, easy access to free or low cost services and promotion of parent-child communication (25). Furthermore, the results of this evaluation suggest that parents and youth attending APT felt the concepts of confidentiality and family-centered care can be successfully integrated into a culturally-sensitive team approach for immigrant adolescents. When Latino parents feel respected and that they can trust the providers, they feel comfortable with their adolescent receiving confidential care (26). Parents report valuing warm, culturally-competent providers who respect their values and needs. They also value integrated care, reiterating the importance of addressing social and environmental factors affecting health when providing care to adolescents. These aspects are critical to reduce health disparities (6, 27, 28) and provide high quality services for immigrant communities (29, 30), which validates the incorporation of these aspects when designing services for immigrant families with adolescents. Based on the youth’s and their parent’s perspectives, we refined the APT model of care, integrating our clients’ perspective, highlighting principles and clinical strategies (Figure 3). These findings helped introduced the need to incorporate a school/college connector to our team and also adding a parent educator to reinforce the parallel care model (Figure 1). Finally, to structure the youth, parent and family skill building interventions the team is developing standard coaching modules. There are several strengths to this evaluation. First, the evaluation describes a model to deliver youth-friendly family-centered medical services. Second, it unveils the evaluation’s surveys, interviews and focus groups results to assess satisfaction. Finally, the evaluation included both parents and youth. The convergence of parent and adolescent reports, and the convergence between the
quantitative and qualitative methods, support the significant role of APT in delivering an intervention that fits the needs of the families that the program serves, and produces high satisfaction, which is extremely important when evaluating adolescent services (31). However, these findings need to be interpreted within the limitations of this study. First, because parent and youth participants were volunteers, they might have been more satisfied than the participants who did not participate in this study (32), especially the sample of parents. In addition, although the person who conducted the interviews and focus groups was culturally and linguistically competent, she was a Caucasian female graduate student who spoke Spanish as a second language. This could have affected the participation in the study, especially of male adolescents and the quality of their responses (33, 34). Future studies should include interviewers sharing similar gender, age and ethnicity as the participants. Finally, this evaluation represents the first step of the larger evaluation effort the APT program has already undertaken. This study focused on the assessment of parent and youth satisfaction, which is only one dimension of the quality of care (21). A complete evaluation of the model, which is in preparation, will include APT impact on health outcomes and cost reduction. By providing parallel care to immigrant adolescents and their families, APT honors the need for confidential health services while respecting the needs and preferences of their parents. The high satisfaction with the services received at APT confirms that this model of care fulfills the expectations of immigrant families with adolescents while providing high quality of care. This concrete model is an innovative alternative to achieving family-centered and confidential adolescent care that can help improve health equity for immigrant communities.
References 1. Bacallao ML, Smokowski PR. The costs of getting ahead: Mexican family system changes after immigration. Fam Relat 2007;56:52–66.
Brought to you by | University of Exeter Authenticated Download Date | 10/11/16 10:39 AM
68 Svetaz et al.: A mixed-methods evaluation of a youth development clinic 2. Qin DB. Doing well vs. feeling well: understanding family dynamics and the psychological adjustment of Chinese immigrant adolescents. J Youth Adolesc 2008;37:22–35. 3. Kwak K. Adolescents and their parents: a review of intergenerational family relations for immigrant and non-immigrant families. Hum Dev 2003;46:115–36. 4. Sawyer SM, Afifi RA, Bearinger LH, Blakemore SJ, Dick B, et al. Adolescence: a foundation for future health. Lancet 2012;379:1630–40. 5. Svetaz MV, Garcia-Huidobro D, Allen ML. Parents and family matter: strategies for developing family-centered adolescent care within primary care practices. Prim Care 2014;41:489–506. 6. Viner RM, Ozer EM, Denny S, Marmot M, Resnick M, et al. Adolescence and the social determinants of health. Lancet 2012;379:1641–52. 7. United States Census Bureau. Demographic Analysis 2010: Sensitivity Analysis of the Foreign-Born Migration Component. Available at: http://www.census.gov/population/www/documentation/twps0098/twps0098.pdf. 8. United States Census Bureau. The Hispanic Population: 2010. Available at: https://www.census.gov/prod/cen2010/briefs/ c2010br-04.pdf. 9. Miranda AO, Bilot JM, Peluso PR, Berman K, Van Meek LG. Latino families: The relevance of the connection among acculturation, family dynamics, and health for family counseling research and practice. Fam J 2006;14:268–73. 10. Dempsey AF, Singer DD, Clark SJ, Davis MM. Adolescent preventive health care: what do parents want? J Pediatr 2009;155:689– 94. 11. Duncan RE, Vandeleur M, Derks A, Sawyer S. Confidentiality with adolescents in the medical setting: what do parents think? J Adolesc Health 2011;49:428–30. 12. Berlan ED, Bravender T. Confidentiality, consent, and caring for the adolescent patient. Curr Opin Pediatr 2009;21:450–6. 13. Cheng TL, Savageau JA, Sattler AL, DeWitt TG. Confidentiality in health care: a survey of knowledge, perceptions, and attitudes among high school students. J Am Med Assoc 1993;269:1404–7. 14. Kapphahn CJ, Wilson KM, Klein JD. Adolescent girls’ and boys’ preferences for provider gender and confidentiality in their health care. J Adolesc Health 1999;25:131–42. 15. Edman JC, Adams SH, Park MJ, Irwin Jr CE. Who gets confidential care? Disparities in a national sample of adolescents. J Adolesc Health 2010;46:393–5. 16. Svetaz MV, Landrieu MJ, Allen ML, Shlafer RJ. Aqui Para TI [Here for You]: a decade supporting Latino families and bridging the science of health equity and positive youth development. J Adolesc Health 2013;52(Supplement 1):S98.
17. Elster AB, Kuznets NJ. Guidelines for adolescent preventive services. Baltimore, MD: American Medical Association, 1994. 18. Beck AT, Steer RA, Carbin MG. Psychometric properties of the Beck Depression Inventory: twenty-five years of evaluation. Clin Psychol Rev 1988;8:77–100. 19. Resnick MD. Protective factors, resiliency, and healthy youth development. Adolesc Med State Art Rev 2000;11:157–64. 20. Chase R, Clement D. West Side community health assessment. Saint Paul, MN: Research Center, 2000:44. 21. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood) 2008;27:759–69. 22. Clark VLP, Creswell JW. Designing and conducting mixed methods research. Thousand Oakes, CA: Sage, 2011:488. 23. Rea LM, Parker RA. Designing and conducting survey research: a comprehensive guide, 3rd ed. San Francisco, CA: John Wiley & Sons, 2005:304. 24. Weber RP. Basic content analysis. Thousand Oakes, CA: Sage, 1990:96. 25. Alford S. Best Practices for youth-friendly clinical services. Available at: http://www.advocatesforyouth.org/index. php?option=com_content&task=view&id=1347&Itemid=177. 26. Tebb K, Hernandez LK, Shafer MA, Chang F, Eyre SL, et al. Understanding the Attitudes of Latino Parents Toward Confidential Health Services for Teens. J Adolesc Health 2012;50:572–7. 27. Silow-Carroll S, Alteras T, Stepnick L. Patient-centered Care for Underserved Populations: Definition and Best Practices (pp. 1–43). Washington, DC: Economic and Social Research Institute, 2006:43. 28. Betancourt JR, Green AR, Carrillo JE, Ananeh-Firempong 2nd O. Defining cultural competence: a practical framework for addressing racial/ethnic disparities in health and health care. Public Health Rep 2003;118:293–302. 29. Derose KP, Bahney BW, Lurie N, Escarce JJ. Immigrants and health care access, quality, and cost. Med Care Res Rev 2009;66:355–408. 30. Leduc N, Proulx M. Patterns of health services utilization by recent immigrants. J Immigr Health 2004;6:15–27. 31. Byczkowski TL, Kollar LM, Britto MT. Family experiences with outpatient care: Do adolescents and parents have the same perceptions? J Adolesc Health 2010;47:92–8. 32. Finkelstein MA. Volunteer satisfaction and volunteer action: A functional approach. Soc Behav Pers 2008;36:9–18. 33. Kvale S. Doing interviews. Thousand Oakes, CA: Sage, 2008:160. 34. Huddy L, Billig J, Bracciodieta J, Hoeffler L, Moynihan PJ, et al. The effect of interviewer gender on the survey response. Political Behav 1997;19:197–220.
Brought to you by | University of Exeter Authenticated Download Date | 10/11/16 10:39 AM
