UMMS Affiliation

Department of Population and Quantitative Health Sciences, Division of Preventive and Behavioral Medicine; UMass Worcester Prevention Research Center

Publication Date


Document Type



Behavior and Behavior Mechanisms | Bioethics and Medical Ethics | Community Health and Preventive Medicine | Health Information Technology | Health Psychology | Health Services Administration | Pediatrics | Preventive Medicine | Primary Care | Quantitative, Qualitative, Comparative, and Historical Methodologies | Substance Abuse and Addiction


BACKGROUND: Electronic clinical support tools show promise for facilitating tobacco screening and counseling in adolescent well-care. However, the application of support tools in pediatric settings has not been thoroughly studied. Successfully implementing support tools in local settings requires an understanding of barriers and facilitators from the perspective of both patients and providers.

OBJECTIVE: This paper aimed to present the findings of a qualitative study conducted to inform the development and implementation of a support tool for adolescent tobacco screening and counseling in 3 pediatric clinics in North Florida. The primary objective of the study was to test and collect information needed to refine a tablet-based support tool with input from patients and providers in the study clinics.

METHODS: A tablet prototype was designed to collect information from adolescents on tobacco susceptibility and use before their well-care visit and to present tobacco prevention videos based on their responses. Information collected from adolescents by the support tool would be available to providers during the visit to facilitate and streamline tobacco use assessment and counseling components of well-care. Focus groups with providers and staff from 3 pediatric clinics (n=24) identified barriers and facilitators to implementation of the support tool. In-depth interviews with racially and ethnically diverse adolescent patients who screened as susceptible to tobacco use (n=16) focused on acceptability and usability of the tool. All focus groups and interviews were audio-recorded and transcribed for team-based coding using thematic analysis.

RESULTS: Privacy and confidentiality of information was a salient theme. Both groups expressed concerns that the tool's audio and visual components would impede privacy and that parents may read their child's responses or exert control over the process. Nearly all adolescents stated they would be comfortable with the option to complete the tool at home via a Web portal. Most adolescents stated they would feel comfortable discussing tobacco with their doctor. Adolescent interviews elicited 3 emergent themes that added context to perspectives on confidentiality and had practical implications for implementation: (1) purity: an expressed lack of concern for confidentiality among adolescents with no reported history of tobacco use; (2) steadfast honesty: a commitment to being honest with parents and providers about tobacco use, regardless of the situation; and (3) indifference: a perceived lack of relevance of confidentiality, based on the premise that others will "find out anyway" if adolescents are using tobacco.

CONCLUSIONS: This study informed several modifications to the intervention to address confidentiality and introduce efficiency to well-care visits. The support tool was integrated into the electronic health record system used by the study clinics and modified to offer videos to all adolescents regardless of their tobacco use or susceptibility. Future studies will further test the acceptability of the intervention in practice. Pbert, Ramzi G Salloum. Originally published in JMIR Formative Research (, 28.04.2019.


adolescent, clinical decision support, confidentiality, implementation science, primary care, qualitative research, tobacco use

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Copyright © Ryan P Theis, Ali M Malik, Lindsay A Thompson, Elizabeth A Shenkman, Lori Pbert, Ramzi G Salloum. Originally published in JMIR Formative Research (, 28.04.2019. This is an open-access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information, a link to the original publication on well as this copyright and license information must be included.

DOI of Published Version



JMIR Form Res. 2019 Apr 28;3(2):e12406. doi: 10.2196/12406. Link to article on publisher's site

Journal/Book/Conference Title

JMIR formative research

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Creative Commons License

Creative Commons Attribution 4.0 License
This work is licensed under a Creative Commons Attribution 4.0 License.