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Abstract

Objective

Adolescents frequently encounter contraceptive information online. Our objective was to evaluate the feasibility and pilot outcomes of a clinician training module designed to support counseling about online contraceptive information.

Methods

We co-developed a contraceptive counseling training with community advisory boards. We recruited adolescent-serving clinicians across North Carolina to participate in the virtual 3-hour training. One of the five modules was Supporting Teens with Online Information. To assess feasibility, acceptability, appropriateness, and pilot outcomes of this module, participants completed pre-, immediate post-, and 4-month-post-intervention measures about counseling about online contraceptive information and participated in a 4-month post-intervention interview. Analysis used a convergent mixed methods approach.

Results

35 clinicians participated, with 27 (77%) completing the 4-month interview. Immediately post-intervention, the module was perceived as acceptable (mean=4.6, SD 0.5), appropriate (4.7, 0.5), and feasible (4.6, 0.5) on a 5-point scale. Participants showed immediate and 4-month increases in knowledge, beliefs, self-efficacy, and self-reported counseling behaviors (p<0.05). Qualitative results indicated that participants liked the module and many reported adapting their counseling approach and/or providing new patient-facing resources. However, they faced barriers like time constraints and difficulty remaining abreast of social media information. They recommended inclusion of specific social media posts (versus overarching themes) and a more accessible resource toolkit.

Conclusions

This module demonstrated feasibility, with clinician-reported pilot outcomes showing increases at both immediate post-intervention and 4-month follow-up. This intervention is among the first developed to support person-centered counseling about online contraceptive information and warrants further investigation in a rigorous trial.

Keywords

contraception adolescent online health information clinician communication misinformation continuing medical education digital health literacy

1. Introduction

Adolescents need accurate contraceptive information to make values-congruent reproductive health decisions.¹ Young patients today navigate a complex health information environment shaped by the internet, particularly social media.^2,3 A recent national survey found that nearly half of women aged 18-25 encountered contraception content on social media in the last year,⁴ and a separate study found nearly 1 in 5 adolescents aged 15-17 reported similar exposure.⁵

The content and quality of contraceptive information on social media varies widely. While social media has amplified patient voices (e.g., those reporting negative experiences of intrauterine device (IUD) insertion pain),⁶ it has also fueled contraception misinformation.^7–10 This is especially troubling given today’s increasingly restricted reproductive policy environment, which disproportionately affects minors.¹¹

Importantly, adolescents identify clinicians as their most preferred source of contraceptive information,⁵ underscoring the importance of clinician engagement. While other areas of medicine have prioritized discussing online information on topics such as vaccination,¹² less is known about how to support clinicians in discussing digital sexual and reproductive health information with adolescent patients. Guidance in this area is emerging,¹³ but few, if any, evidence-based interventions exist to improve these skills in the context of contraception.

1.1. Purpose

Our objective was to evaluate the feasibility and pilot outcomes of a clinician training module designed to support counseling about online contraceptive information.

2. Methods

2.1. Study design

We conducted a single-arm pilot feasibility study with secondary outcomes assessing preliminary signals, using a convergent mixed methods approach. A mixed methods approach was selected to account for respective strengths and limitations of quantitative and qualitative data, and thus to enhance the rigor and usefulness of our findings.¹⁴

2.2. Curriculum co-development with community advisors

The co-development of our training has been described in detail elsewhere.¹⁵ Briefly, we recruited three advisory boards of teens, caregivers, and clinicians (N=20). Over 5 months, we used human-centered design techniques¹⁶ to co-develop a synchronous, virtual, interactive training for clinicians designed to support adolescent-centered contraceptive counseling, called Contraceptive Adolescent-Centered Counseling and Empowerment Skills for Success (ACCESS). The training consisted of 5 modules; the fourth, Supporting Teens with Online Information (“Online Information” module), is the focus of this manuscript. From study inception, this module was designed to be evaluated separately from the overarching program due to its unique topical focus. It was developed within the framework of the Theory of Planned Behavior, which posits that behavioral intentions—the proximal determinant of behavior—are shaped by attitudes, subjective norms, and perceived behavioral control.^17,18

2.3. Participants and recruitment

Eligible participants were adolescent-serving clinicians (MD/DOs, NPs, or PAs) across North Carolina who were not involved in training development. Physicians who had not completed residency were excluded. Clinics across North Carolina in a variety of practice settings were asked to distribute recruitment materials to clinicians through email. Interested clinicians completed an eligibility and scheduling form. Those eligible who consented were grouped into four training sessions (7-11 participants each).

2.4. Intervention

In Fall 2024, participants attended the 3-hour virtual Contraceptive ACCESS training (Appendix A). For the 25-minute Online Information module, participants were in a main Zoom room for most of the session, with 9 minutes allotted in breakout rooms for an interactive case study. A physician and non-physician co-facilitated. During the session, participants received a digital resource toolkit with content aligned with each module, and after the session, we sent monthly post-session emails with refreshers and new resources, including those addressing online contraceptive information.

2.5. Ethics and IRB

The IRB determined the study to be minimal risk (#24-1207). All participants provided informed consent electronically.

2.6. Data collection

Surveys were administered via Qualtrics at three time points: baseline, immediate post-intervention, and 4-month follow-up. Participants were invited for 4-month follow-up interviews conducted and transcribed using Zoom. Two interviewers (CS, LB) completed a standardized memo template after each interview. Transcripts were cleaned and de-identified before analysis.

2.7. Survey development

The pre-survey included demographic questions and de novo measures on pilot outcomes of the Online Information module (i.e., knowledge, beliefs, self-efficacy, and behaviors) (Appendix B). Post-surveys immediately after the training contained the same pilot outcome measures as well as validated feasibility measures about the module,¹⁹ and at 4 months, only the pilot outcome measures were collected.

2.8. Measures

For feasibility testing, we used the Acceptability of Implementation (AIM), Intervention Appropriateness Measure (IAM), and Feasibility of Implementation Measure (FIM).¹⁹ The definitions of these constructs are: Acceptability (that a given innovation is “agreeable, palatable, or satisfactory”), Appropriateness (“perceived fit, relevance, or compatibility of the innovation…for a given practice setting; and/or perceived fit of the innovation to address a particular issue or problem”), and Feasibility (“the extent to which a new… innovation can be successfully used or carried out within a given… setting”).²⁰ Of note, each of these measures is designed to test the acceptability, appropriateness, and feasibility of the intervention itself, not necessarily the real-world implementation of its recommendations in practice.

Corresponding with the Theory of Planned Behavior,^17,18 pilot outcomes assessed beliefs and self-efficacy (reflecting attitudes toward the behavior and perceived behavioral control, respectively), and behavioral intentions and self-reported behaviors. Knowledge was also assessed as an antecedent to attitude formation and informed decision-making, consistent with prior applications of the Theory of Planned Behavior in health research.^21–23 We were unable to find preexisting pilot outcome measures related to clinicians supporting teens with online health information, and thus, we developed novel measures. The primary knowledge item assessed whether participants could correctly identify clinicians as adolescents’ most preferred source of contraceptive information (Appendix B).⁵ Beliefs assessed whether participants believed they should ask patients about online contraceptive content; self-efficacy assessed confidence discussing online contraceptive information; and behavior items asked whether clinicians inquire about patients’ sources of contraceptive knowledge, including the internet and social media. Immediate post-intervention, clinicians were asked about behavioral intentions as they did not have time to enact changes yet. Four clinicians not involved with the study underwent cognitive interviews using a “think-aloud” technique²⁴ to give feedback to refine the measures’ understandability (IRB Exempt #24-2225).

2.9. Semi-structured interview guide

A semi-structured interview guide (Appendix C) adapted from implementation science constructs,²⁵ explored perceived training impact and barriers to clinical application. Questions aligned with the feasibility and pilot outcome domains assessed in the survey but were also open-ended so that participants could share additional perspectives beyond these domains. We refined the guide with expert feedback and mock interviews.

2.10. Analysis

2.10.1. Quantitative

Survey data were analyzed using R (v4.2.2).²⁶ Frequencies and means summarized demographics from the baseline survey. Acceptability, appropriateness, and feasibility scores¹⁹ were summarized with means and standard deviations from the immediate post-intervention survey. For pilot outcome measures, we compared baseline data to immediate-post and baseline to 4-month follow-up data. For knowledge testing we evaluated changes in percentage correct using McNemar’s Chi-squared test to assess paired dichotomous data.²⁷ To examine differences in Likert scale means, we used paired Wilcoxon signed-rank test with a continuity correction.²⁸ To quantify the magnitude of change in Likert-scale outcomes, we calculated Cohen’s d_z as the effect size for within-subjects comparisons, computed as the mean difference divided by the standard deviation of the difference scores.²⁹ Effect sizes were interpreted using Cohen’s conventions: small (d_z=0.2), medium (d_z=0.5), and large (d_z =0.8).²⁹ Effect sizes are reported descriptively given the pilot nature of this study and use of single-item measures, which may restrict variance and should be interpreted with caution. Missing data were handled using complete case analysis. To assess potential attrition bias, we compared completers to non-completers on baseline demographic characteristics and outcome measures using Fisher’s exact test for categorical variables and t-tests for continuous variables.

2.10.2. Qualitative

Three research team members (CS, LB, BAA) reviewed recordings and memos to identify emerging themes. Using deductive categories from the interview guide and inductive emerging themes, a matrix was created, consistent with rapid qualitative thematic analysis.^30,31 A primarily descriptive approach was used given the highly applied nature of the research question.³² Transcript data were iteratively sorted by CS with review by BAA. Quotes were lightly edited for clarity.

2.10.3. Mixed methods

Quantitative and qualitative data were collected in parallel, then compared for convergence and divergence.¹⁴ Joint displays of quantitative and qualitative findings were reviewed and interpreted by the research team to identify areas where findings mutually confirmed, expanded upon, or contradicted one another.

2.10.4. Reflexivity

The research team consisted of physicians, researchers, and trainees who believe that online health information presents both opportunities and challenges for adolescent reproductive health decision-making.

2.10.5. Reporting guidelines

We adhered to Standards for Reporting Qualitative Research (SRQR)³³ and Good Reporting of a Mixed Methods Study (GRAMMS)³⁴ available in Appendices D and E.

3. Results

3.1. Demographics

A total of 35 clinicians participated in the intervention and completed the pre- and immediate post-surveys (Table 1). At 4-month follow-up, 29 (83%) completed the survey and 27 (77%) participated in the interview. Attrition analyses comparing completers (n=29) to non-completers (n=6) revealed that non-completers had completed fewer years of clinical practice (mean 5.7 vs. 10.6 years, p=0.015). No other meaningful differences were found between groups. Most participants were women (n=33, 94%), white (n=23, 66%), had MD/DO training (n=28, 80%), and used social media at least daily (n=23, 66%). Mean age was 39.1 (SD 7.9) with a mean 9.7 (SD 8.0) years of practice, and most were general pediatricians (n=30, 86%). Baseline contraceptive counseling behaviors (e.g. methods prescribed) are detailed in Appendix F.

Table 1.

Participant and clinic characteristics of participating North Carolina clinicians, 2024.

Characteristic	n/%N=35
Gender
Cisgender man	1 (3%)
Cisgender woman	33 (94%)
Missing	1 (3%)
Age
Mean (SD)	39.1 (7.9)
Race
Asian	3 (9%)
Black/African American	2 (6%)
White	23 (66%)
Other	6 (17%)
Missing	1 (3%)
Ethnicity
Hispanic/Latinx	2 (6%)
Not Hispanic/Latinx	32 (91%)
Missing	1 (3%)
Sexual orientation
LGBQ+	2 (6%)
Heterosexual or Straight	32 (91%)
Missing	1 (3%)
Religion
Christian – Any denomination	22 (63%)
Hindu	2 (6%)
Unaffiliated	10 (29%)
Missing	1 (3%)
Degree
MD/DO	28 (80%)
Nurse Practitioner	5 (14%)
Physician Assistant	2 (6%)
Specialty
Family Medicine	2 (6%)
Medicine-Pediatrics, general	1 (3%)
Pediatrics sub-specialty	2 (6%)
Pediatrics, general	30 (86%)
Years of practice
Mean (SD)	9.7 (8.0)
Median [Min, Max]	7.0 [1.0, 29.0]
Missing	2 (6%)
Practice setting
Rural	3 (9%)
Urban	32 (91%)
Practice type
Academic medical center	14 (40%)
Private practice	17 (49%)
Public/community health clinic	1 (3%)
Other	3 (9%)
Hours/week of clinical care
10-20 hours	1 (3%)
21-30 hours	13 (37%)
More than 30 hours	21 (60%)
Accept Medicaid
No	1 (3%)
Yes	34 (97%)
Social media use
Multiple times a day	9 (26%)
Daily	14 (40%)
Multiple times a week	4 (11%)
Weekly	4 (11%)
Never	3 (9%)
Missing	1 (3%)

3.2. Pilot implementation outcomes

3.2.1. Acceptability

Acceptability was rated at a mean of 4.6/5 (SD 0.5). Qualitatively, nearly all participants liked the module, [e.g. “I really enjoyed it” [Participant 1 (P1)] and “I thought it was a great module” (P3)]. One participant described the emphasis on social media throughout the overall training as “a bit heavy” (P10) but also felt that it was an important topic to discuss. All respondents said that they would recommend the module to other clinicians [e.g. “Definitely. If you’re seeing adolescents in your clinic, I feel like you should be required to take this” (P5)].

3.2.2. Appropriateness

The module mean appropriateness score was 4.7/5 (SD 0.5). Many clinicians described the training as relevant to their patient population: “Oh, I feel like it hit it head on… I think the training was spot on for the needs of my patients” (P1). Several clinicians mentioned that the module was one of their main takeaways from the overall training, explaining “I thought that [module] was one of the more valuable parts… of the course. Because it applies not just to contraception, but to a myriad of other teen-based issues” (P20).

On the other hand, a few described it as less applicable than some of the other material in the overall training: “I think that [module] was out of everything one of the areas where… I was less likely to take that information and change the way that I do anything in the clinic. Good information, but maybe a little bit less applicable” (P25).

Some mentioned that it may be particularly helpful for clinicians who have been out of training for many years and/or don’t use social media, although several mentioned that it was also helpful for younger clinicians too.

3.2.3. Feasibility

Feasibility was rated at a mean of 4.6/5 (SD 0.5). Participants qualitatively described that participating in the module was feasible, but noted challenges implementing the recommendations in actual practice: “I think it was helpful, having the conversation about… social media, where they’re getting their information from, and that was very useful. Have I been able to incorporate [sharing] the good websites? Not as much as I would like” (P22).

3.2.4. Suggestions for future training

Participants suggested several improvements to the module. The first was incorporating specific existing social media content, as opposed to broad themes that cut across platforms: “[I’d like] examples of what they’re actually seeing...so maybe more… specific media examples of myths. Or even with the list of social media physicians…. like [an actual] clip of them” (P5).

About a third of participants asked for vetted social media accounts and other resources that they could share with adolescents, [e.g. “I apologize if I’ve missed any of this, but I think that would be super useful as a pediatrician who doesn’t do this all the time, having good… patient-accessible resources” (P11)]. These requested resources were included as part of the digital toolkit but participants appeared not to recall receiving them.

Participants who did utilize the training’s resource toolkit requested resources in formats that clinicians could more easily share with teens: “Maybe incorporating [trusted sources] into their visit packet, or having it posted somewhere in the clinic... Maybe like QR Codes [which] are really easy for kids to use if they’re already on their phones” (P7).

3.3. Intermediate outcomes

Across all outcome categories of knowledge, beliefs, self-efficacy, and behaviors, there were immediate and 4-month increases (Table 3; Appendix G).

3.3.1. Awareness, knowledge, and stated skills

The percentage of participants correctly identifying clinicians as adolescents’ most preferred contraceptive information source increased from 29% to 68% (p=0.003) immediate post-intervention with increases also observed at 4 months (48%, p=0.035).

Qualitatively, participants described greater awareness about what teens may be seeing online, as well as knowledge of new resources to share with patients. A few mentioned being surprised at clinicians being teens’ preferred knowledge source.

I learned about how teenagers use social media to build their knowledge, but that they still rely on clinicians’ recommendations… I always felt like they would rely on social media more than us… but that was nice to know that they actually would listen to us. (P24)

Several described learning new counseling skills [e.g. “learning how to say the right words” to connect with teens about online information (P14)], but others described not being able to recall the details of the training beyond general encouragement to bring this up with teens, such as P5: “Oh, goodness! I don’t know if I remember specifically what strategies were included in that module.”

3.3.2. Beliefs

While baseline belief in the importance of discussing online contraceptive information with patients was high, participants still demonstrated increases in their ratings at both time points (4.1 to 4.8 post-intervention, p<0.001; d_z=0.84, 4.5 at follow-up, p=0.012; dz=0.52), reflecting large and medium effect sizes, respectively.

Qualitatively, participants described believing that educating patients about online health information is increasingly important for pediatric clinical care broadly.

I definitely think social media education in general is incredibly important… There are these really cool QR code signs that you can scan and it gives parents and physicians information about each type of social media and what type of information… it gets, is it videos, is it posts, is it tweets... We’ve made handouts that go into our after-visit summaries. Again... social media and healthcare education is very important. (P6)

Additionally, many clinicians described discussing online health information as a mechanism to connect with teens and as increasingly essential to adolescent-friendly care.

I think this is a fact, if you’re going to take care of adolescents that they’re going to get information from online, so the better we are informed in knowing that that’s where they’re going to get information the better we can do it… making sure that they are well informed. (P18)

Participants differed regarding whether they believed it mattered clinically if patients obtained information online or elsewhere, with a few describing the source (e.g. social media) as less important than the content, [e.g. “I usually try to just ask them… what they know about something, because I find that that’s more effective than asking them where they get their information” (P13)]. This contrasted with other clinicians:

It is interesting to ask where their information came from. If it’s from personal experience that’s going to lead you in one direction, if it’s from a family member…, that’s going lead you in another direction. If it’s from an online source… that’s going lead you in another direction. (P20)

Finally, a few clinicians said that this was not yet a priority for their clinic but anticipated it might be in the future: “I don’t think it’s top priority right now, but I do think it will be because we’re starting to see… different viewpoints emerging right now. So it probably will be” (P15).

3.3.3. Self-efficacy

At baseline, confidence discussing contraceptive information seen on social media was 2.9 and increased to 4.2 post intervention (p<0.001, d_z=1.51, very large effect), with a large effect observed at 4-month follow-up (4.0, p<0.001, d_z=0.89).

While a few participants qualitatively described themselves as having high or low confidence, most described themselves as moderately confident when discussing online information about contraception. Participants described low confidence as stemming from the wide array of online information available to patients, including content that clinicians may not feel prepared to counsel about.

I still think it can be pretty intimidating, because there’s a million different resources, and even they mostly go to TikTok, what you're seeing on TikTok could be anywhere from another physician to a Kardashian giving their input on things so I still get a little bit intimidated, because there is just such a wide variety of things that you can find on there. (P16)

Participants described a mixed relationship between personal social media use and confidence (i.e. some thought it might help with confidence, others did not). Those who were on social media, however, described feeling empathy for patients and families who may be confused and overwhelmed by online information: “I can see how overwhelming it is for parents to see this, or read that, or see this TikTok on how this is bad for your kid… I get it on my feeds too. If I had no medical background, I’m sure I’d be overwhelmed” (P23).

3.3.4. Intentions and behaviors

In immediate post-testing, participants’ intention to ask about adolescent contraceptive information sources and the role of social media in patients’ contraceptive decision-making increased from baseline (3.1 to 4.8, p<0.001, d_z=1.27, and 2.7 to 4.6, p<0.001, d_z=1.68, respectively), both with very large effects. Compared to baseline, at 4-month follow-up, participants reported higher levels of enacting these counseling behaviors (3.1 to 3.9, p<0.001, d_z=0.77, and 2.7 to 3.6, p=0.001, d_z=0.75, respectively), both reflecting medium-large effects.

Qualitatively, participants described two main areas of reported behavior change following the training. The first was more consistently asking patients about their information sources, including specific probes about social media: “[The training] definitely has contributed. I definitely talk more about social media in general… A few years ago it was more like, oh what are your friends saying, now it’s like, okay what’s TikTok saying” (P6).

The second was provision of new patient-facing resources, which most often were based off the online resource toolkit provided as part of the intervention: “[Now] I bring in that binder [that my colleagues and I made from the toolkit] and say, ‘Hey, you mentioned that… some of your information comes from social media. These are really good accounts that have information that is accurate’” (P3).

Several clinicians stated that they already routinely discussed online information with patients so did not change behaviors in response to the module. Others who did not report changing behaviors following the module shared that they had thought about and were open to discussing it more but would only prioritize discussing online health information if the conversation were patient-initiated.

3.4. Barriers and facilitators to implementation of training recommendations

Clinicians described several barriers and facilitators to applying the training’s suggestions (Table 4). Time constraints were the main barrier: “The nature is there’s always so much to talk about, and not enough time” (P15). Staying up-to-date on online information was also a challenge: “It’s hard for us to do all our own research, not only on what’s medically relevant, but also now socially, medically relevant” (P19).

Facilitators included receiving specific resources [“Oh, [it was helpful] that they gave us specific Instagram handles, like they weren’t like, oh, there’s some really good doctors out there” (P2)], as well as integration into routine counseling topics (e.g. screentime, asking about peer behaviors).

I think [this conversation] fits in perfectly [in my workflow], because we always talk about social media usage… we might talk about how much they are on social media and then I can follow up and be like, what sites are you on, we might talk about inappropriate texts or sexting and things like that, so it segues pretty easily. (P8)

3.5. Mixed methods integration

Across most domains, quantitative and qualitative findings converged (Table 2; Table 3). High acceptability and appropriateness scores were corroborated by highly positive qualitative responses, with only two participants (P10 and P25) describing negative aspects of acceptability and appropriateness. The participant who found the emphasis “a little heavy” later described concrete positive takeaways of the module that resulted in increased confidence discussing social media content with patients (Table 3), whereas P25 explained that beliefs surrounding the “less applicable” nature of the module—and associated lack of behavior change—stemmed from the perception that the content was not a current priority for her patient population (Table 3). Quantitative gains in self-efficacy and behavioral intentions aligned with qualitative reports of increased confidence and modified counseling approaches.

Table 2.

Mixed methods synthesis of pilot implementation findings among North Carolina clinicians, 2024-2025.

Domain	Mean score (SD)^a	Sub-themes and quotations^b
Acceptability	4.6 (0.5) (AIM)^c	Participants liked the training: Yeah, I loved it. I thought it was really cool. (Participant 16)One thought the emphasis was a little heavy overall: Maybe the social media emphasis was kind of a bit heavy [when considering the overall training], but it was important to discuss, so I can’t say that anything was too much. (Participant 10)All respondents said they would recommend to other clinicians: “Yeah, absolutely [I would recommend it]. I think anyone who sees teens and provides contraceptive counseling would benefit from this.” (Participant 3)
Appropriateness	4.7 (0.5) (IAM)^d	Participants generally described the training as relevant to their patient population: I think it was really useful, because that’s the reality of where a lot of them will get information so it was good to have that highlighted. (Participant 26) and “Thought it was great. It’s really relevant. Super relevant.” (Participant 7)There were mixed opinions about whether the training would be more helpful and appropriate for older clinicians and/or those without social media: Yeah, I think in this digital age… I think it’s probably important to have a module like this, especially for pediatricians who are my generation and older, who did not grow up with social media... Yeah, even younger clinicians who may be familiar with social media, but not sure about what teens are seeing online. (Participant 4)I mean, we see a ton of adolescents, and I trained like 20 years ago… I’m never on TikTok. I don’t know anything about social media, but just awareness of this is what our teenagers are seeing now and getting their information on now. So how can I relate to them more and give them more up-to-date, real-life information? So I think that was important for me. (Participant 5)
Feasibility	4.6 (0.5) (FIM)^e	Participating in the module was seen as feasible: It’s not super time consuming and it’s very, very helpful. (Participant 5)Implementing the module’s recommendations had mixed feasibility: I think it’s hard. I mean, I think it’s a great idea but, practically speaking, like there’s just so much other stuff to talk about. (Participant 24)We always talk about how there’s not enough time in all of our visits, I think it’s something that will have to be fit into our workflow, because I don’t think it’s going anywhere… I think that people are getting more of their information online and from influencers and social media and so I think that it is something that we’re going to have to incorporate more often. (Participant 6)
Suggestions for future training	N/A	Include specific social media content embedded in the training: I would like somebody to go through and go, this is TikTok, here’s what TikTok looks like and here’s why kids are so excited about TikTok. And here’s XYZ, and here’s Instagram, and here’s YouTube shorts, and… and if there’s somebody who stands out about giving health information, whether it’s correct or not correct online. (Participant 4)Include a list of social media accounts to follow:^f It might be interesting to have some reliable resources for where to point teens. I do have a couple Instagram, like a nutrition, like some behavior specialists and nutritionists that I feel like give really good information on a parent level, or like just an everyday level, and not necessarily like just for medical professionals. And I feel comfortable giving those to parents. If I had some really good resources for like this doctor on Instagram talks a lot about birth control, this maybe like, check this person out. A list of maybe some of those options I would be interested in saying, oh, you like to do this on Instagram. Why don’t you look at this? Since you have questions about birth control. (Participant 17)Make patient-facing resources more accessible: I really liked the options for the support for the teens… having something for them to go home and read that’s not just TikTok or their friends, or whatever it may be. It’s definitely something on my back burner that I really do want to do… if there was some kind of dot phrase, or some way to make this into Epic, that is definitely something I’d be interested in. (Participant 16)

^aEvaluated immediately post-intervention with N=35 clinicians.

^bCollected 4-months post-intervention in interviews with 27 clinicians. Initial data collection before and immediately after the intervention took place in Fall 2024 and follow-up data collection was completed in Spring 2025.

^cAcceptability of Implementation Measure (Weiner et al. 2017).

^dIntervention Appropriateness Measure (Weiner et al. 2017).

^eFeasibility of Implementation Measure (Weiner et al. 2017).

^fA list of social media accounts similar to what the participant described here was included as part of the online resource toolkit.

Table 3.

Mixed methods synthesis of preliminary efficacy outcomes among North Carolina clinicians, 2024-2025.

Domain and item	Quantitative findings^a	Qualitative findings^b
KnowledgeCorrectly identifies clinicians as adolescents’ most preferred contraceptive information sourceResponse options:CliniciansSocial media (e.g. TikTok)ParentsOther internet sources (e.g. educational websites)Peers or siblings		Increased awareness of what teens may be seeing online: I’m not on TikTok so it’s good to see… the kids always come in and, even parents, come in saying like, oh I heard this on TikTok, but not knowing personally what’s out there on TikTok, it’s good to know. (Participant 23)Recognition of clinicians as preferred knowledge source: I was actually really surprised to know that clinicians are the preferred source of contraceptive information. I did not expect that. And that’s really good to know. (Participant 3)Identification of new resources: I had no clue about those online resources that could be given to the adolescents and it’s one of those, you don’t know it exists if you don’t know it exists and so I thought it was a good just outline of you know what I could share. (Participant 12)Learned new counseling skills: I really liked… learning how to say the right words cause like just avoiding the term misinformation… when we say the wrong things and the teens get put off and they don’t listen to us anymore. I think that really helped, knowing how to talk to them about it. (Participant 14)Mixed, unclear, or no changes in knowledge or awareness: Honestly, I’d have to go back and review the module. I don’t really remember too much about what specific tips they recommended for talking about online information, other than just bringing it up. (Participant 4)
BeliefsI believe clinicians should ask patients what they have seen about contraception on the internet, including on social mediaStrongly disagree (1) to strongly agree (5)		Relevance for pediatric clinical care broadly: Oh, gosh! I feel like [I talk about this] all the time. Teens, I feel like I discuss it with them [directly] more often. But I have discussions with my parents all the time, especially the younger patients because I feel like there’s always a ton of videos about babies in social media… I discuss social media information with them constantly. (Participant 13)Important when caring for teens: I think it’s very pertinent to the teens, it’s very much how they’re getting a lot of their information, and how they feel most comfortable. Approaching this information and so being able to relate to that, or at least acknowledging that, I think makes us much more relatable to the teens. And hopefully helps them interact with us a little bit better, too. (Participant 16)Here to stay as an important information source: I also realize that social media isn’t going anywhere. I am of the age that social media was burgeoning on as an older teen myself, and I realize the impact that social media has played in my own life, so I don’t discount it as being a fad or like you’re just going to not be on it. And I feel like sometimes in the medical community it’s kind of like, oh, social media like, whatever. But I’m like this is legit, it’s going to be here, whether it’s not this platform, it’s another one that’s going to pop up… it’s not going anywhere. (Participant 13)Online information is not unique: I kind of feel like doesn’t really matter where they hear it from, if they’ve heard it, I need to either validate it or dispel the myth so yeah. (Participant 4)Not yet a priority: I don’t think [it’s currently a priority for our practice]… I’m not sure if I’ve noticed like much of an effect on my interactions with patients because of that. Other than again it would be it would be easier for me to counsel I feel like they did put a higher priority on it. (Participant 25)
Self-efficacyI feel confident counseling adolescent patients about contraceptive topics commonly discussed on social mediaStrongly disagree (1) to strongly agree (5)		A few had high confidence: In a general context, [I’m] very comfortable. Obviously, I am not like scrolling through TikTok all day every day, so I couldn’t really attest to like, oh yeah, this is going viral right now, but I feel very comfortable like talking about like, hey I know we’re seeing things on social media. (Participant 6)Most were fairly or moderately comfortable: [I’m] pretty comfortable. And if I don’t know it, I tell them, “I don’t know, that’s something I’m going to have to go back and like look up, but mostly comfortable. (Participant 1)A third described the training as increasing their confidence:There is so much out there on social media. I feel like there’s a big bombardment of negative stuff about birth control…I feel like [after the training] I’m more empowered to address some of the concerns that patients have. (Participant 10)A small number still had low confidence: I would say I still don’t feel super confident about it… I think what’s really hard is that they hear something on social media, and it elicits, you know, an emotional response that they’re invested in. And I don’t always feel like I know how to diffuse that, if they already don’t have some questions or some doubt about the validity of what they’re of what they’re hearing or seeing. (Participant 15)Personal social media use has complex relationship with self-efficacy:Some of the [provider accounts] that they’ve gotten information from I actually follow on social media, too. And so that makes it a little bit easier, because 9 times out of 10. I’ve already seen it myself. (Participant 1) [Does using social media impact your confidence at all?] I don’t know, maybe, but I don’t know. I feel I feel this way, too, even when people say that, oh, I read this article. New York Times said XYZ. (Participant 15)
Behaviors and intentionsa) I [will]^b ask my patients about their source(s) of contraceptive knowledgeb) When applicable, I [will]^c ask my patients to share how online health information impacts their decisions about contraceptionStrongly disagree (1) to strongly agree (5)		Changed counseling approaches: Oh yeah, that has changed [since the training], because that’s an area that that I probably didn’t touch on before. Now, it’s every day… I literally ask, what is your most typical source of getting information about health? That takes 30 seconds to go through that. If there’s something specific that they’ve already asked about, then I’ll ask them, what do you already know and where did you get this information? (Participant 20)Provided new patient-facing resources: I have used the packet of information to talk about social media with them, because a lot of teens do say, oh, I use social media, or I’ve heard this on social media. And so I’m like, here are actual, reliable places to follow. (Participant 19)Some already routinely covered this: I went on TikTok in 2017, just so I could like relate to my patients and find out what they were seeing on there. I mean I have teenagers, too so like I’m like a little bit more aware of it. [Did not make any changes in response to the training] (Participant 8)No proactive changes but thinking about topic more: If they bring it up, I will discuss it. But I don’t initiate the conversation about social media health information… I’ve thought about it more. I used to think about it not at all and now I think about it, I wonder if I should ask about that. (Participant 4)

*P-value <0.05.

^aStandard deviations included in main text and in Appendix G.

^bCollected 4-months post-intervention in interviews with 27 clinicians. The intervention took place in Fall 2024 and follow-up data were collected in Spring 2025.

^cParticipants were asked about intended behaviors immediate post-training, as they did not have time to enact relevant behavioral changes.

However, two areas of divergence warrant attention. First, while knowledge scores improved significantly post-intervention (29% to 68%), qualitative data revealed that several participants could not recall specific recommended strategies from the module at the follow-up interview, despite quantitative gains observed at 4-month follow-up (48%). This suggests that knowledge gains related to a specific fact (i.e., a multiple-choice question about preferred contraceptive information sources) may differ from broader multi-step skill-based knowledge which requires more challenging recall and integration of multiple concepts.

Second, while feasibility was rated highly, it is important to distinguish between the feasibility of participating in the module and the feasibility of enacting the module’s recommendations. Participants’ qualitative reflections on the module’s impact on their beliefs, self-efficacy, behavioral intentions, and self-reported behavior changes—as well as their shared barriers and facilitators and suggestions for improving the module (Table 4)— all highlight the tension between participation in a brief training and behavior change in practice.

Table 4.

Barriers and facilitators of incorporating discussion of online contraceptive information into counseling among North Carolina clinicians, 2025.

Category	Sub-themes and representative quotes^a
Barriers	Time constraints: I like the concept. Time is always the biggest issue, so if the main focus is just kind of debunking some of these crazy things, they’re on this birth control, but now they’re worried about it because of this thing they heard on TikTok then I think that’s very reasonable, and that’s something you can kind of fit into your appointment. But if it’s just your well-child check, and you’re already talking about contraception, and then they’re like, “This is what I’ve heard,” spending an extra five minutes to go over social media and healthcare, it’s just not super feasible. (Participant 16)Staying abreast of social media trends: I have a little bit of a black box… I don’t use social media, so I just don’t see what’s out there. But I feel like it would be hard for the training to kind of keep abreast. There’s just so much information, it’s not like you guys can summarize, this is the misinformation that’s trending out there or anything like that. (Participant 3)
Facilitators	Connect to other routine discussion topics: I think [this conversation] fits in perfectly [with my workflow], because we always talk about like social media usage and then I think even when I kick the parents out, I mean, it may come up even while the parents in the room, because we might talk about how much they are on social media and then I can follow up and be like, what sites are you on, we might talk about inappropriate text or sexting and things like that so it kind of segues pretty easily. (Participant 8)Provide specific resources: Getting those reliable sources, knowing that people have vetted them, and that they are reliable, is really nice to know that when we’re giving them out to patients. (Participant 19)

4. Discussion

4.1. Summary

This mixed methods pilot tested the Supporting Teens with Online Information module designed to support clinician counseling about online contraceptive information. The training demonstrated acceptability, appropriateness, and feasibility, with pilot outcomes showing increases at both immediate post-intervention and 4-month follow-up. To our knowledge, this is one of the first interventions aimed at supporting clinical dialogue on this topic. Participants also suggested areas for improvement (e.g., more specificity in the curriculum, more accessible patient-facing resources) in follow-up interviews. At 4-month follow-up, many participants did not recall receiving the patient-facing resources during the training, underscoring a need for more explicit integration of these resources into the training.

4.2. Integration with literature

Clinician trainings with practical components (i.e. opportunities to practice skills) yield better outcomes than didactic-only approaches.³⁵ Our training’s use of a case study during breakout rooms offered participants an opportunity to apply the suggested communication skills in real time and is recommended as a standard component in future trainings. Although this pilot did not assess direct patient-level outcomes, previous research shows that trainings that change clinician knowledge and skills can result in small but significant improvements in patient health behaviors,³⁵ suggesting this module may have downstream potential to positively influence patient health behaviors, though this remains to be tested. More robust simulation-based clinician trainings can be another high-impact way of improving counseling skills; however, these can be resource-intensive.³⁶ Emerging uses of artificial intelligence as simulated patients may offer scalable, cost-effective practice opportunities.³⁶ The divergence between quantitative knowledge gains and qualitative reports of difficulty recalling specific strategies at follow-up further underscores the importance of reinforcement mechanisms, such as the monthly follow-up emails provided in the study, and suggests that future iterations should incorporate repeated practice opportunities to support skill development and retention.³⁷ Multi-item measurement of knowledge will also provide better insight as to the degree to which information is being retained.^38,39

Although the module demonstrated high feasibility as assessed by the FIM—which is designed to evaluate the ease of direct participate in an intervention¹⁹—it is important to distinguish between the feasibility of participating in a brief training and the feasibility of implementing recommendations in busy clinical practice. While most participants found discussions of online health information to be an increasingly important aspect of their clinical counseling, some emphasized the challenge of keeping pace with a rapidly changing online landscape. Given adolescents’ complex relationship with online health information—including sexual health information⁴⁰—they need better guidance to successfully navigate online information and make values-aligned decisions about their health.^2,41 Our participants noted that sharing specific vetted resources or social media accounts was valuable (e.g. Bedsider, Planned Parenthood).^42,43 Professional organizations could support clinicians by curating a list of credible, accurate social media accounts or producing their own social media content to engage patients directly.

4.3. Limitations and strengths

This pilot study is limited by being a single-arm design that was not designed to assess changes in clinical behavior or patient-reported outcomes. This study was further limited by the use of novel single-item self-reported measures of knowledge, beliefs, self-efficacy, and behaviors; as single-item measures preclude calculation of internal consistency (e.g., Cronbach’s alpha), psychometric evaluation was not possible and findings should be interpreted with caution. Attrition analyses revealed that non-completers had significantly fewer years of practice (mean 5.7 vs. 10.6 years), suggesting findings may be more generalizable to more experienced clinicians who are further removed from formal training. Clinicians who agreed to participate in this training may systematically differ from those who did not participate regarding beliefs, motivation, or self-efficacy. Additionally, our sample was homogenous and not demographically representative of national pediatrician trends; for example, women clinicians were over-represented,⁴⁴ which may influence our results. Finally, social desirability bias may affect our findings.⁴⁵

Strengths of our statewide study include community-engaged co-development of the training, collection of longitudinal outcomes, and a mixed methods approach. This is a novel intervention focused on clinician-patient conversations about online contraceptive information, and it was feasible, acceptable, and appropriate.

4.4. Future research

These pilot data set the groundwork for a future randomized controlled trial. An appropriate comparator would be either a waitlist control or an active comparator, such as a contraceptive counseling training without the Online Information module, which would allow isolation of the module’s specific contribution to clinician outcomes. A future trial should incorporate multi-item validated outcome measures, a larger and more representative clinician sample, and patient-reported outcomes such as adolescent perceptions of clinician communication and contraceptive decision-making autonomy. The observed changes in beliefs, self-efficacy, and behavioral intentions align with the Theory of Planned Behavior’s posited pathway toward behavior change,^17,18 providing a theoretically grounded mechanism for further investigation in future trials.

4.5. Future adaptations

While the Online Information module is currently embedded in a 3-hour, synchronous training, it could be adapted into a standalone training that could be delivered asynchronously to a larger number of clinicians, thus expanding the reach of this intervention. Future adaptations might also target broader populations (e.g. adult contraceptive users) or different clinical topics, such as discussing social media content related to disordered eating.^4,46 Finally, helping patients navigate online content—especially amidst vast amounts of misinformation—requires not just clinician action, but coordinated efforts from professional societies and public health agencies.^47,48

5. Conclusion

This training module pilot test demonstrated feasibility, with clinician-reported outcomes of knowledge, beliefs, self-efficacy, and self-reported behaviors showing increases at both immediate post-intervention and 4-month follow up. Supporting patients in navigating complex online health information environments is an emerging clinical and public health priority, and this intervention offers a feasible model worthy of further investigation.

Supplemental material

Supplemental material - Feasibility and pilot outcomes of a novel training to help clinicians counsel adolescents about online contraceptive information

Supplemental material for Feasibility and pilot outcomes of a novel training to help clinicians counsel adolescents about online contraceptive information by Cambray Smith, PhD, Leah Frerichs, PhD, Hailey Leiva, MSW, Lucy Burwell, Melissa Gilkey, PhD, Christopher M. Shea, PhD, Betsy Sleath, PhD, Carol Golin, MD, Samantha Schilling, MD, MSHP, Bianca Allison, MD, MPH in DIGITAL HEALTH

Footnotes

Acknowledgements

The authors thank their teen, caregiver, and clinician advisory boards for co-developing this training. They also thank the Odum Institute, Yumei Yang, and Feng-Chang Lin, PhD for support with statistical analyses, Marcella Boynton, PhD for supporting development of the de novo preliminary efficacy measures and Anahita Gupta and Emma Brockman for assistance with transcript cleaning.

ORCID iDs

Cambray Smith

Christopher M. Shea

Ethical considerations

The IRB determined the study to be minimal risk (#24-1207). All participants provided informed consent electronically.

Author contributions

All authors meet criteria for authorship. Contributions are described below.

Conceptualization: CS, LF, BAA.

Methodology: CS, LF, MBG, CMS, BS, CG, SS, BAA.

Validation: all authors.

Formal analysis: CS, LF, BAA.

Investigation: CS, HL, LB, BAA.

Resources: CS, BAA.

Data curation: CS, HL, LB.

Writing – original draft: CS.

Writing – review & editing: all authors.

Visualization: CS, LF, BAA.

Supervision: LF, BAA.

Project administration: CS, HL, LB, BAA.

Funding acquisition: CS, LF, BAA.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Cambray Smith is supported by 1F30HD116454 from the National Institutes of Child Health and Human Development and is a recipient of the Gertrude B. Elion Mentored Medical Student Research Award of Triangle Community Foundation. Bianca A. Allison was partially supported by the Doris Duke Charitable Foundation [grant number 2020143], and the National Center for Advancing Translational Science (NCATS), National Institutes of Health [1K12TR004416-01]. Carol Golin was partially supported by the University of North Carolina at Chapel Hill Center for AIDS Research [P30 AI50410]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funders had no role in data collection, interpretation, or reporting.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Anonymized transcripts and analytical memos are available upon request to the corresponding author.*

Prior presentations

This project has been presented as works-in-progress at the 2025 Society of Adolescent Health and Medicine meeting and the 2025 Psychosocial Workshop prior to the Population Association of America meeting.

Preprints

This manuscript has not been posted on any preprint server.

Prior publication

An earlier version of this manuscript is available on University of North Carolina at Chapel Hill’s repository as part of a doctoral dissertation (CS):

Supplemental material

Supplemental material for this article is available online.

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