Delivering confidential health service to teens is complicated by payment issues, transportation problems and differences in legislation from state to state. Teens who have health insurance are typically covered under their parents' health plans and bills reflecting services provided are sent to parents. Many teens do not have access to a car and must depend on parents to transport them for health services making it difficult for them to obtain services without parental involvement. In addition, legislation concerning teens right to privacy in health care vary from state to state.

Results of a recent survey (Klein, 1998) of 14-19 years old adolescents indicated that only 8.4% had used confidential services. More than half of the adolescents interviewed did not know where they could go to receive confidential health services.

Nurses know that "confidentiality refers to the privileged and private nature of information provided during the health care transaction" (AMA, 1993). There is strong national consensus endorsing confidential health services for adolescents. Most membership organizations have a policy that directly supports adolescents' need for confidential health services (Gans, 1993). Over the past ten years, these policies have been supported by important national reports including; "Adolescent Health" (1991) by the U.S. Congress, Office of Technology Assessment; "Code Blue: Uniting for Healthier Youth" (1989) by the National Commission on the Role of the School and the Comnmunity in promoting Adolescent Health; and "Turning Points" (1989) by the Carnegie Council on Adolescent Development, which also advocate for confidential health services for adolescents.

Likewise, adolescents report that confidentiality is important in the delivery of health care (Resnick, 1980). Their reasons included the need to prevent rumors, to avoid punishment from punitive parents, and to promote better problem-solving skills.

Confidentiality is considered crucial to adolescents' willingness to provide accurate information about sensitive health issues. Recent research documents that counseling of adolescents about risk-taking behaviors by nurses was enhanced by their use of a confidential computerized health assessment tool (Papenny, 1999). Adolescents participating in this study were told that the information they provided was confidential and, as a result, it is believed, answered questions about risk-taking behaviors more honestly. Subsequently, counseling messages could be tailored to specific risk-taking behaviors and were more likely to be relevant to the adolescents' needs. Not only did this tool provide essential information, it, or similar type tools, could also be used to alleviate provider time constraints. On average, each adolescent client reports participating in 10 risk behaviors, only 7 of which were discussed by providers during a preventive service visit (Epner, 1998). Similarly, if a teen reports 3 or more risk behaviors, or a relatively severe health problem, even fewer risk behaviors are discussed.

Since confidentiality laws vary from state to state, it is imperative that nurse providers explain their policies regarding confidentiality during an initial clinic interview. These policies need to be explained to both the adolescent patient and parent(s). Providing this explanation in the beginning will help to allay future misunderstandings. When working with a family over time, nurses have an opportunity to prepare parents for their child's growing need for privacy as part of normal adolescent development. By beginning early, parents may come to accept confidential visits by their teenagers as part of healthy maturation during adolescence.

Given the array of laws pertaining to informed consent and confidentiality that currently exist, it is no wonder that adolescents and perhaps even nurses are confused about how these laws pertain to them. Congress has the ability to intervene to reduce these uncertainties by moving federal and state laws in the direction of greater uniformity. Until this occurs, it may be easier for nurses to encourage their localities and schools to integrate information about legal aspects of adolescent access to health services into health education courses.