The emerging adulthood gap in diabetes prevention research.

Emerging adulthood, the period between ages 18 and 25, is distinct from older and younger populations in terms of both physiology and social circumstances. As a critical developmental window with long-lasting repercussions, emerging adulthood presents a key opportunity for prevention of cardiovascular disease. Despite significant advances in diabetes and cardiovascular disease prevention for other age groups, 18-25 year-olds remain underrepresented in research. Using diabetes prevention as an example, we analyzed the cited evidence behind four major guidelines that influence US clinical practice on screening and management of prediabetes in children and adults, revealing that the majority of these studies in both the pediatric and adult literature do not include emerging adults in their study populations. This gap between the pediatric and adult diabetes prevention literature creates a missing link connecting childhood risks to adult chronic disease. In this article, we draw attention to this often overlooked age group, and provide tangible recommendations as a path forward for both pediatric and adult researchers to increase the representation of emerging adults in diabetes prevention and other cardiovascular disease prevention studies.

A Quality Improvement Initiative to Improve Health Care Transition Planning at Adolescent Well Visits.

OBJECTIVE: Health care transition (HCT) planning supports adolescents as they move from pediatric to adult health care and is recommended for all youth. HCT planning uptake remains low, with little known about HCT in the adolescent well child check (WCC) setting. We sought to increase rates of HCT planning at WCCs by adapting best practices for HCT from specialty and chronic care. METHODS: This quality improvement initiative at 12 to 17-year-old WCCs at four Internal Medicine-Pediatrics primary care clinics, was based on the first three of the "Six Core Elements" of HCT framework and integrated into the electronic health record. Two uptake measures were assessed via chart review after three plan-do-study-act (PDSA) cycles, with two provider surveys and an implementation science analysis further informing interpretation. RESULTS: By the final PDSA cycle, the percentage of 14 to 17-year-old WCCs at which HCT planning was discussed and a screening tool completed increased from 5% to 31%, and the percentage of 12 to 13-year-old WCCs at which the HCT policy was discussed increased from 6% to 47%. Provider survey results revealed endorsement of HCT goals, but time and technological barriers, which were further elucidated in the implementation science analysis. CONCLUSIONS: This quality improvement initiative increased rates of HCT planning during adolescent WCCs. While limited to three Core Elements and Internal Medicine-Pediatrics clinics, strengths include measures capturing all WCCs, contextualized by provider surveys and an implementation science framework. Lessons from this effort can inform future tailored HCT initiatives at adolescent WCCs.

A guaranteed income intervention to improve the health and financial well-being of low-income black emerging adults: study protocol for the Black Economic Equity Movement randomized controlled crossover trial.

Background: Economic inequity systematically affects Black emerging adults (BEA), aged 18-24, and their healthy trajectory into adulthood. Guaranteed income (GI)-temporary, unconditional cash payments-is gaining traction as a policy solution to address the inequitable distribution of resources sewn by decades of structural racism and disinvestment. GI provides recipients with security, time, and support to enable their transition into adulthood and shows promise for improving mental and physical health outcomes. To date, few GI pilots have targeted emerging adults. The BEEM trial seeks to determine whether providing GI to BEA improves financial wellbeing, mental and physical health as a means to address health disparities. Methods/design: Using a randomized controlled crossover trial design, 300 low-income BEA from San Francisco and Oakland, California, are randomized to receive a $500/month GI either during the first 12-months of follow-up (Phase I) or during the second 12-months of a total of 24-months follow-up (Phase II). All participants are offered enrollment in optional peer discussion groups and financial mentoring to bolster financial capability. Primary intention-to-treat analyzes will evaluate the impact of GI at 12 months among Phase I GI recipients compared to waitlist arm participants using Generalized Estimating Equations (GEE). Primary outcomes include: (a) financial well-being (investing in education/training); (b) mental health status (depressive symptoms); and (c) unmet need for mental health and sexual and reproductive health services. Secondary analyzes will examine effects of optional financial capability components using GEE with causal inference methods to adjust for differences across sub-strata. We will also explore the degree to which GI impacts dissipate after payments end. Study outcomes will be collected via surveys every 3 months throughout the study. A nested longitudinal qualitative cohort of 36 participants will further clarify how GI impacts these outcomes. We also discuss how anti-racism praxis guided the intervention design, evaluation design, and implementation. Discussion: Findings will provide the first experimental evidence of whether targeted GI paired with complementary financial programming improves the financial well-being, mental health, and unmet health service needs of urban BEA. Results will contribute timely evidence for utilizing GI as a policy tool to reduce health disparities. Clinical trial registration: https://clinicaltrials.gov, identifier NCT05609188.

Advocacy Curricula in Graduate Medical Education: an Updated Systematic Review from 2017 to 2022.

BACKGROUND: Advocacy is an integral component of a physician's professional responsibilities, yet efforts to teach advocacy skills in a systematic and comprehensive manner have been inconsistent and challenging. There is currently no consensus on the tools and content that should be included in advocacy curricula for graduate medical trainees. OBJECTIVE: To conduct a systematic review of recently published GME advocacy curricula and delineate foundational concepts and topics in advocacy education that are pertinent to trainees across specialties and career paths. METHODS: We conducted an updated systematic review based off Howell et al. (J Gen Intern Med 34(11):2592-2601, 2019) to identify articles published between September 2017 and March 2022 that described GME advocacy curricula developed in the USA and Canada. Searches of grey literature were used to find citations potentially missed by the search strategy. Articles were independently reviewed by two authors to identify those meeting our inclusion and exclusion criteria; a third author resolved discrepancies. Three reviewers used a web-based interface to extract curricular details from the final selection of articles. Two reviewers conducted a detailed analysis of recurring themes in curricular design and implementation. RESULTS: Of 867 articles reviewed, 26 articles, describing 31 unique curricula, met inclusion and exclusion criteria. The majority (84%) represented Internal Medicine, Family Medicine, Pediatrics, and Psychiatry programs. The most common learning methods included experiential learning, didactics, and project-based work. Most covered community partnerships (58%) and legislative advocacy (58%) as advocacy tools and social determinants of health (58%) as an educational topic. Evaluation results were inconsistently reported. Analysis of recurring themes showed that advocacy curricula benefit from an overarching culture supportive of advocacy education and should ideally be learner-centric, educator-friendly, and action-oriented. DISCUSSION: Combining core features of advocacy curricula identified in prior publications with our findings, we propose an integrative framework to guide design and implementation of advocacy curricula for GME trainees. Additional research is needed to build expert consensus and ultimately develop model curricula for disseminated use.

Construct validity and responsiveness of a health-related symptom index for persons either treated or monitored for anal high-grade squamous intraepithelial lesions (HSIL): AMC-A01/-A03.

PURPOSE: To determine whether treatment of anal high-grade squamous intraepithelial lesions (HSIL), vs active monitoring, is effective in reducing incidence of anal cancer in persons living with HIV, the US National Cancer Institute funded the Phase III ANal Cancer/HSIL Outcomes Research (ANCHOR) clinical trial. As no established patient-reported outcomes (PRO) tool exists for persons with anal HSIL, we sought to estimate the construct validity and responsiveness of the ANCHOR Health-Related Symptom Index (A-HRSI). METHODS: The construct validity phase enrolled ANCHOR participants who were within two weeks of randomization to complete A-HRSI and legacy PRO questionnaires at a single time point. The responsiveness phase enrolled a separate cohort of ANCHOR participants who were not yet randomized to complete A-HRSI at three time points: prior to randomization (T1), 14-70 (T2), and 71-112 (T3) days following randomization. RESULTS: Confirmatory factor analysis techniques established a three-factor model (i.e., physical symptoms, impact on physical functioning, impact on psychological functioning), with moderate evidence of convergent validity and strong evidence of discriminant validity in the construct validity phase (n = 303). We observed a significant moderate effect for changes in A-HRSI impact on physical functioning (standardized response mean = 0.52) and psychological symptoms (standardized response mean = 0.60) from T2 (n = 86) to T3 (n = 92), providing evidence of responsiveness. CONCLUSION: A-HRSI is a brief PRO index that captures health-related symptoms and impacts related to anal HSIL. This instrument may have broad applicability in other contexts assessing individuals with anal HSIL, which may ultimately help improve clinical care and assist providers and patients with medical decision-making.

Treatment of Anal High-Grade Squamous Intraepithelial Lesions to Prevent Anal Cancer.

BACKGROUND: The incidence of anal cancer is substantially higher among persons living with the human immunodeficiency virus (HIV) than in the general population. Similar to cervical cancer, anal cancer is preceded by high-grade squamous intraepithelial lesions (HSILs). Treatment for cervical HSIL reduces progression to cervical cancer; however, data from prospective studies of treatment for anal HSIL to prevent anal cancer are lacking. METHODS: We conducted a phase 3 trial at 25 U.S. sites. Persons living with HIV who were 35 years of age or older and who had biopsy-proven anal HSIL were randomly assigned, in a 1:1 ratio, to receive either HSIL treatment or active monitoring without treatment. Treatment included office-based ablative procedures, ablation or excision under anesthesia, or the administration of topical fluorouracil or imiquimod. The primary outcome was progression to anal cancer in a time-to-event analysis. Participants in the treatment group were treated until HSIL was completely resolved. All the participants underwent high-resolution anoscopy at least every 6 months; biopsy was also performed for suspected ongoing HSIL in the treatment group, annually in the active-monitoring group, or any time there was concern for cancer. RESULTS: Of 4459 participants who underwent randomization, 4446 (99.7%) were included in the analysis of the time to progression to cancer. With a median follow-up of 25.8 months, 9 cases were diagnosed in the treatment group (173 per 100,000 person-years; 95% confidence interval [CI], 90 to 332) and 21 cases in the active-monitoring group (402 per 100,000 person-years; 95% CI, 262 to 616). The rate of progression to anal cancer was lower in the treatment group than in the active-monitoring group by 57% (95% CI, 6 to 80; P = 0.03 by log-rank test). CONCLUSIONS: Among participants with biopsy-proven anal HSIL, the risk of anal cancer was significantly lower with treatment for anal HSIL than with active monitoring. (Funded by the National Cancer Institute; ClinicalTrials.gov number, NCT02135419.).

Using a Life Course Health Development Framework to Redesign Medicaid.

Since the Affordable Care Act, Medicaid programs serve millions more enrollees across the life course, yet beneficiaries continue to experience high rates of preventable morbidity and mortality rooted in earlier life experiences. By incorporating evidence from life course science into Medicaid, using the Life Course Health Development (LCHD) framework, states can more effectively achieve lifelong health improvement. We describe 5 elements of an LCHD-informed strategy states can use to align Medicaid redesign initiatives toward a common goal of improving life course health outcomes: targeting prevention to sensitive periods; prioritizing intervention on social exposures; maximizing longitudinal continuity in coverage and service delivery; building technological systems with capability to measure performance and outcomes over time; and selecting financial models that support LCHD-informed care. With this framework, states can strategically direct investment to improve health for vulnerable Americans, and assure their investment will pay off over time.

Identifying Novel Predictors of State Legislative Action to Address Obesity.

OBJECTIVE: There is wide variation in the number and types of obesity policies enacted across states, and prior studies suggest that partisan factors may not fully explain this variation. In this exploratory analysis, we examined the association of a broad array of state-level factors with the number and types of obesity policies across states. DESIGN: We analyzed 32 predictor variables across 7 categories of state-level characteristics. We abstracted data from 1652 state obesity policies introduced during 2009-2014. We used multilevel regression models and principal component analysis to examine the association between state-level characteristics and policy outcomes. MAIN OUTCOME MEASURES: Our outcome measures included whether bills involved topics that were public health-oriented or business interest-oriented, whether bills were enacted into law, and the number of introduced bills and enacted laws per state. RESULTS: Numerous state-level characteristics were associated with obesity-related bill introduction and law enactment, and different state characteristics were associated with public health-oriented versus business interest-oriented policies. For example, state-level demographics, economic factors, policy environment, public programs, and the prevalence of obesity's downstream consequences were associated with the number of public health laws whereas obesity prevalence and policy environment were associated with the number of business interest laws. CONCLUSIONS: Our results support the hypothesis that a variety of factors contribute to a complex state obesity policymaking environment, highlighting the need for future research to disentangle these key predictors.

Geographic and Longitudinal Trends in Media Framing of Obesity in the United States.

OBJECTIVE: The media's framing of public health issues is closely linked to public opinion on these issues and support for interventions to address them. This study characterized geographic and temporal variation in the US media's framing of obesity across states from 2006 to 2015. METHODS: Newspaper articles that mentioned the term obesity were drawn from Access World News (NewsBank, Inc., Naples, Florida), a comprehensive online database (N = 364,288). This study employed automated content analysis, a machine learning technique, to categorize articles as (1) attributing obesity to individual-level causes (e.g., lifestyle behaviors), (2) attributing obesity to environmental/systemic causes (e.g., neighborhood walkability), (3) attributing obesity to both individual-level causes and environmental/systemic causes, or (4) articles without any such attribution framework. RESULTS: Nationwide across all years, a higher proportion of articles focused on individual-level attribution of obesity than environmental-level attribution or both. Missouri and Idaho had the highest proportions of articles with an individual framework, and Nevada, Arkansas, and Wisconsin had the highest proportions of articles with an environmental framework. CONCLUSIONS: This analysis demonstrates that US media sources heavily focus on an individual framing of obesity, which may be informing public perceptions of obesity. By highlighting differences in obesity media portrayal, this study could inform research to understand why particular states represent outliers and how this may affect obesity policy making.

Documenting social determinants of health-related clinical activities using standardized medical vocabularies.

OBJECTIVES: Growing recognition that health is shaped by social and economic circumstances has resulted in a rapidly expanding set of clinical activities related to identifying, diagnosing, and intervening around patients' social risks in the context of health care delivery. The objective of this exploratory analysis was to identify existing documentation tools in common US medical coding systems reflecting these emerging clinical practices to improve patients' social health. MATERIALS AND METHODS: We identified 20 social determinants of health (SDH)-related domains used in 6 published social health assessment tools. We then used medical vocabulary search engines to conduct three independent searches for codes related to these 20 domains included in common medical coding systems (LOINC, SNOMED CT, ICD-10-CM, and CPT). Each of the 3 searches focused on one of three clinical activities: Screening, Assessment/Diagnosis, and Treatment/Intervention. RESULTS: We found at least 1 social Screening code for 18 of the 20 SDH domains, 686 social risk Assessment/Diagnosis codes, and 243 Treatment/Intervention codes. Fourteen SDH domains (70%) had codes across all 3 clinical activity areas. DISCUSSION: Our exploratory analysis revealed 1095 existing codes in common medical coding vocabularies that can facilitate documentation of social health-related clinical activities. Despite a large absolute number of codes, there are addressable gaps in the capacity of current medical vocabularies to document specific social risk factor screening, diagnosis, and interventions activities. CONCLUSIONS: Findings from this analysis should help inform efforts both to develop a comprehensive set of SDH codes and ultimately to improve documentation of SDH-related activities in clinical settings.

Participation in the special supplemental nutrition program for women, infants, and children is not associated with early childhood socioemotional development: Results from a longitudinal cohort study.

Socioemotional development in early childhood has long-term impacts on health status and social outcomes, and racial and socioeconomic disparities in socioemotional skills emerge early in life. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is an early childhood nutrition intervention with the potential to ameliorate these disparities. Our objective was to assess the impact of WIC on early socioemotional development in a longitudinal study. We examined the association between WIC participation and scores on the Brief Infant Toddler Social Emotional Assessment (BITSEA) in 327 predominantly African American mother-child dyads who were participants in the longitudinal Conditions Affecting Neurocognitive Development in Early Life (CANDLE) Study (Memphis, TN). To account for selection bias, we used within-child fixed effects to model the variability in each child's BITSEA scores over two measurement occasions (ages 12 and 24 months). Final models were adjusted for time-varying characteristics including child age, maternal stress, mental health, child abuse potential, marital status, and food stamp participation. In fully adjusted models, we found no statistically significant effect of WIC on change in socioemotional development (ß = 0.22 [SD = 0.39] and ß = - 0.58 [SD = 0.79] for BITSEA Competence and Problem subdomains, respectively). Using rigorous methods and a longitudinal study design, we found no significant association between WIC and socioemotional development in a high needs population. This finding suggests that early childhood interventions that more specifically target socioemotional development are necessary if we are to reduce racial disparities in socioemotional skills and prevent poor social and health outcomes across the life course.

Implementation in Practice: Adaptations to Sexuality Education Curricula in California.

BACKGROUND: Local implementation of evidence-based curricula, including sex education, has received increasing attention. Although there are expectations that practitioners will implement evidence-based programs with fidelity, little is known regarding the experiences of instructors in meeting such standards. During 2005 to 2009, the California Department of Public Health funded local agencies through its Teen Pregnancy Prevention Programs (TPP) to provide comprehensive sex education. METHODS: To improve understanding of how agencies implemented curricula, in-depth telephone interviews with 128 coordinators were conducted in 2008 to 2009. Qualitative data were analyzed for content and themes. Selected data were quantified and analyzed to examine differences in curriculum adaptations across settings and curricula type. RESULTS: Whereas over half of the TPP agencies (59%) implemented evidence-based curricula, most agencies (95%) reported adapting the curriculum, with the majority (83%) adding content. Reasons for adaptations included ensuring that the material was accurate and appropriate; responding to logistical or time constraints; and other factors, such as parental and institutional support. CONCLUSION: These adaptations reflected agencies' efforts to balance state and local requirements, maintain curriculum fidelity, and provide more up-to-date and accessible information. These experiences highlight the need for guidelines that enable appropriate adaptations, while maintaining fidelity to the core components of the original curriculum.

Impact of years of clinical experience on perceived contraindications and barriers to the use of LARC: a survey of family planning providers.

BACKGROUND: Despite their efficacy in preventing unintended pregnancies, intrauterine devices (IUDs) are still relatively underutilized by American women. Although cost of these methods is clearly a barrier to use, IUDs have had a long and sometimes controversial history, and earlier versions were removed from the market. METHODS: This study explores the degree to which the length of licensure for providers is related to their attitudes toward or fears about these methods. Data come from a 2012 survey of 114 clinicians in Colorado and Iowa, collected as part of two, statewide initiatives to reduce unintended pregnancy. Providers were asked about service barriers to prescribing these methods and for which patients they perceived them to be suitable and safe. RESULTS: The most experienced clinicians were the least concerned about uterine perforation and history of the Dalkon Shield, but were more likely to fear a lawsuit over complications. More experienced clinicians were also less approving of Copper T IUDs for all 11 subgroups of women, including nulliparous women and those with histories of sexually transmitted infections. They were also less approving of hormonal IUDs for 10 groups of women, including those with histories of ectopic pregnancies. However, clinicians with the most recent licensure were more conservative in their approval of single rod implants than were the providers with the most years since licensure. CONCLUSIONS: This paper explores potential reasons for these findings and suggests trainings to recognize and overcome these barriers so as to promote consistent and accurate practice across clinicians, regardless of years of experience.

Same-day LARC insertion attitudes and practices.

BACKGROUND: Little is known regarding clinicians' attitudes about or the extent to which the recommendation to offer same-day insertions for long-acting reversible contraception (LARC) is applied in practice. STUDY DESIGN: Since 2006, 47 family planning agencies in Colorado and Iowa participated in two initiatives to reduce unintended pregnancy by increasing LARC provision. Clinic directors (n = 45) and clinicians (n = 114) participating in these initiatives were interviewed and surveyed regarding their LARC provision practices and attitudes. RESULTS: Agencies required fewer visits for the contraceptive implant than for the intrauterine device (IUD). Only 18% of agencies typically offered an IUD, and 36% typically offered an implant in one visit. Years of experience and professional title significantly predicted attitudes about the number of visits required to get LARC. DISCUSSION: Barriers must be overcome for full implementation of professional LARC guidelines and for more women to receive chosen methods without the extra burden of multiple visits.

Limited socioeconomic opportunities and Latina teen childbearing: a qualitative study of family and structural factors affecting future expectations.

The decrease in adolescent birth rates in the United States has been slower among Latinas than among other ethnic/racial groups. Limited research has explored how socioeconomic opportunities influence childbearing among Latina adolescents. We conducted in-depth interviews with 65 pregnant foreign- and US-born Latina women (31 adolescents; 34 adults) in two California counties. We assessed perceived socioeconomic opportunities and examined how family, immigration and acculturation affected the relationships between socioeconomic opportunities and adolescent childbearing. Compared with women who delayed childbearing into adulthood, pregnant adolescents described having few resources for educational and career development and experiencing numerous socioeconomic and social barriers to achieving their goals. Socioeconomic instability and policies limiting access to education influenced childbearing for immigrant adolescents. In contrast, family disintegration tied to poverty figured prominently in US-born adolescents' childbearing. Limited socioeconomic opportunities may play a large role in persistently high pregnancy rates among Latina adolescents.

Educational barriers, social isolation, and stable romantic relationships among pregnant immigrant Latina teens.

Latina teen birth rates, particularly those of immigrant Latinas, surpass those of any major racial/ ethnic group. Little is known about how immigration experiences influence early childbearing. Fourteen pregnant Latina immigrant teens were interviewed regarding their feelings about pregnancy and birth control, educational and vocational expectations, and their partners' influences. Common themes included feelings of isolation, barriers to education and future opportunities, and a heavy reliance on partners as a stable source of emotional and financial support, all of which appeared to influence teens' desire for pregnancy. Findings suggest the need to help immigrant youth overcome barriers to education and work and to offer them culturally and linguistically appropriate clinical care including birth control information and services, preconception and prenatal care, and assistance navigating the system.

Creating an environmental justice framework for policy change in childhood asthma: a grassroots to treetops approach.

OBJECTIVES: The Community Action to Fight Asthma Initiative, a network of coalitions and technical assistance providers in California, employed an environmental justice approach to reduce risk factors for asthma in school-aged children. Policy advocacy focused on housing, schools, and outdoor air quality. Technical assistance partners from environmental science, policy advocacy, asthma prevention, and media assisted in advocacy. An evaluation team assessed progress and outcomes. METHODS: A theory of change and corresponding logic model were used to document coalition development and successes. Site visits, surveys, policymaker interviews, and participation in meetings documented the processes and outcomes. Quantitative and qualitative data were analyzed to assess strategies, successes, and challenges. RESULTS: Coalitions, working with community residents and technical assistance experts, successfully advocated for policies to reduce children's exposures to environmental triggers, particularly in low-income communities and communities of color. Policies were implemented at various levels. CONCLUSIONS: Environmental justice approaches to policy advocacy could be an effective strategy to address inequities across communities. Strong technical assistance, close community involvement, and multilevel strategies were all essential to effective policies to reduce environmental inequities.

Family planning and life planning reproductive intentions among individuals seeking reproductive health care.

BACKGROUND: Little research has focused on men and women's reproductive intentions before pregnancy and their perceived personal and social motivations to prevent an unintended pregnancy. METHODS: To assess the reproductive intentions of low-income men and women in California, we asked individuals seeking reproductive health services about their plans for childbearing, including an ideal timeframe and perceived advantages of delay. We also asked about their health care visit to examine how contraceptive use and services relate to reproductive intentions. RESULTS: The majority (77%) of the 1,409 reproductive health clients surveyed wanted to have a/another child, but hoped to delay childbearing by an average of 5.4 years. The most common reasons for wanting to delay pregnancy were related to finances (24%) or education (19%), with differences by race/ethnicity and gender. We did not observe a clear relationship between the length of time the client wanted to delay pregnancy and the type of contraceptive method dispensed during the clinic visit. CONCLUSIONS: Individuals seeking reproductive health care perceive many personal benefits to planning and timing their pregnancies, and most will need many years of contraceptive protection to achieve their reproductive goals. Providers should work with their patients to ensure that they receive a contraceptive method that is consistent with the length of pregnancy prevention they desire.

Trends in knowledge of emergency contraception among women in California, 1999-2004.

OBJECTIVE: To examine trends in knowledge of emergency contraception (EC) and determine whether disparities in knowledge have persisted over time. STUDY DESIGN: This study is based on 6 years of the California Women's Health Survey, a population-based telephone survey. We examine predictors of EC knowledge among 11,998 women age 18-44. RESULTS: Between 1999 and 2004, the percentage of women aware of EC increased from 40-57%. Despite this increase, disparities in EC knowledge based on women's age, race/ethnicity, and socioeconomic status persist. Foreign-born Hispanic women, women whose income falls below the poverty level, and women who did not complete high school reported the lowest levels of EC knowledge in 2004. CONCLUSIONS: Education efforts may increase overall knowledge of the method. However, efforts must tailor these messages to women who may be outside the reach of traditional media and remain unaware of EC.

Contraceptive use and risk of unintended pregnancy in California.

California is home to more than one out of eight American women of reproductive age. Because California has a large, diverse and growing population, national statistics do not necessarily describe the reproductive health of California women. This article presents risk for pregnancy and sexually transmitted infections among women in California based on the California Women's Health Survey. Over 8900 women of reproductive age who participated in this survey between 1998 and 2001 provide estimates of access to care and use of family-planning methods in the state. We find that 49% of the female population aged 18-44 in California is at risk of unintended pregnancy. Nine percent (9%) of women at risk of an unintended pregnancy are not using any method of contraception, primarily for method-related reasons, such as a concern about side effects or a dislike of available contraceptive methods. Among women at risk for unintended pregnancy, we find disparities by race/ethnicity and education in use of contraceptive methods.