In the Know: A Cluster Randomized Trial of an In-person Sexual Health Education Program Integrating Digital Technologies for Adolescents.

PURPOSE: Integrating digital technologies into sexual health education can offer advantages for connecting with adolescents, particularly populations who may be underserved through common school-based approaches. This study assessed the effectiveness of In the Know, an in-person, group-based sexual health education program integrating digital technologies, codesigned with adolescents. METHODS: The study design was a cluster randomized trial with 1,263 adolescents aged 13-19 in 95 cohorts, implemented in community-based organizations and schools throughout Fresno County, California. Participants completed a baseline survey and a follow-up survey 3 months later. Two-level mixed-effects regression models with random intercepts for cohort were used to estimate the intervention's impact on unprotected sex, use of clinical health services, knowledge of local sexual health services, technology use to find or schedule services, and sexual health knowledge at the 3-month follow-up. RESULTS: The average age of participants was 15.7 years, and the majority identified as Hispanic (71%). In adjusted analyses, intervention group participants were more likely to use clinical services (42.7% vs. 33.2%, p = .009) and reported greater sexual health knowledge at 3 months (57.6% of items answered correctly vs. 50.7%, p = .001). No significant differences were observed in the other outcomes by study group. DISCUSSION: In the Know participants demonstrated greater use of clinical health services and sexual health knowledge at 3 months. The study findings show the potential for incorporating user-centered design and technology into sexual health education to better support adolescents who may have limited access to this important information.

Contraceptive access experiences and perspectives of Mexican-origin youth: a binational qualitative study.

Access to comprehensive contraceptive services for youth is essential to improving sexual and reproductive health. However, youth in many countries still face substantial obstacles to contraceptive access and use. The purpose of this study is to compare the contraceptive access experiences and perspectives of pregnant and parenting Mexican-origin youth in Guanajuato, Mexico, and Fresno County, California. Focus groups and in-depth interviews were conducted in Spanish and English among female youth in Mexico (n = 49) and California (n = 25). Participants also completed a brief sociodemographic survey. Using a modified grounded theory approach, qualitative data were coded and thematically analysed based on Penchansky and Thomas's Theory of Access, and results were compared by location. Although knowledge of a service provider was high among youth in both locations, access was affected by social, cultural, and institutional dynamics and contraceptive use was mixed. Across locations, participants described obstacles to accessing their preferred method. Participants worried about parental and peer opinions about their use of contraception (acceptability), and about perceived side effects including infertility and pain (adequacy). Contextual differences included lack of contraceptive choice in Guanajuato (availability) and incomplete knowledge about options in Fresno County (awareness). The power to request and receive their method of choice (agency) emerged as an important dimension that was not part of the original theory. Latina youth living in Mexico and the United States face multiple challenges accessing needed contraceptive options and services. Recognising and reducing these barriers can strengthen the contraceptive care landscape and promote the reproductive health and agency of young people. DOI: 10.1080/26410397.2023.2216527Plain language summary: Although sexually active youth need access to comprehensive sexual and reproductive health services, youth in many countries face substantial barriers to care. This study compares the experiences of pregnant and parenting youth in accessing contraceptive services in Mexico and the United States. We conducted interviews and focus groups with 74 Mexican-origin young women and found that contraceptive use and access was affected by their concerns about parental and peer opinions as well as by provider attitudes. In Mexico, several participants reported being denied their preferred method by their provider. Identifying and addressing barriers to services can improve the quality of care and the reproductive health of young people.

Integrated Theory-Based Health and Development Interventions for Young People: A Global Scoping Review.

BACKGROUND: Most health and developmental issues affecting young people are interrelated. However, few interventions address multiple behavioral domains simultaneously or are based on theories that encompass a holistic perspective of youth development. AIM: The purpose of this scoping review was to identify and describe the range of theory-based, multibehavioral health interventions aimed at improving two or more of the following behavioral youth outcomes: (1) sexual and reproductive health; (2) education and employment; (3) violence; and (4) substance use. METHODS: Interventions conducted worldwide and published in English or Spanish between January 2000 and July 2020 were identified using four databases: PubMed, PsycINFO, LILACS, and SciELO. RESULTS: A total of 11,084 articles were identified, of which 477 were retrieved and assessed for eligibility. Twenty-three articles (evaluating 21 interventions) ultimately met the inclusion criteria. Most interventions were conducted in the United States and addressed two behavioral domains of interest, although seven interventions incorporated three domains, and one incorporated all four. Substance use was the most common domain (16 interventions) but only in the United States/Canada, followed by sexual and reproductive health (14 interventions). All produced significant improvement in at least one outcome or for at least one subgroup of youth. The most common theoretical foundations were positive youth development and social learning theory. CONCLUSION: Integrated interventions that are theory based and evidence informed can support positive development and empower youth to make healthy decisions. Further efforts are needed to address structural and policy issues that affect young people's developmental opportunities and health outcomes.

Youth perceptions and concerns about sexually transmissible infections versus pregnancy: a qualitative comparative study in California.

BACKGROUND: Although rates of adolescent pregnancy have been declining for decades, rates of sexually transmissible infections (STIs) continue to increase among youth. Little is known about youth's comparative concern regarding pregnancy and STIs, particularly among marginalised populations. Therefore, this study compares concerns toward unplanned pregnancy and STIs and identifies underlying reasons for these differing concerns in youth populations with elevated rates of STIs. METHODS: Fourteen focus groups were held with 92 youth in two counties in California, USA. Youth were purposefully selected from community-based organisations and schools to represent a variety of backgrounds and populations with elevated rates of pregnancy and STIs. Qualitative coding and analysis were conducted using ATLAS.ti. 7.0. RESULTS: Almost all participants were youth of colour (86%), 27% identified as gay, lesbian or bisexual, and 21% had ever experienced homelessness. Although most youth were generally concerned about the consequences of contracting an STI, including the possible stigma associated with it, both males and females were more worried about an unplanned pregnancy. Emergent themes included varying concerns about the lasting consequences of unplanned pregnancies and STIs; greater visibility of pregnancy compared to infection; stigma; and limited STI prevention efforts compared to teen pregnancy prevention. CONCLUSIONS: By addressing the underlying concerns and varying perceptions that different groups of youth have toward STIs and pregnancy, prevention approaches and messages can be tailored, including by age, gender, sexual orientation, and for those exposed to vulnerable living situations. Additional efforts are needed to address increasing rates of STIs among young people.

Educators' Perspectives on Integrating Technology Into Sexual Health Education: Implementation Study.

BACKGROUND: In the last decade, the use of technology-based sexual health education has increased. Multiple studies have shown the feasibility of technology-based interventions, while a subset has also shown efficacy in improving youths' sexual health outcomes such as increased condom use and knowledge. However, little is known about health educators' experiences in integrating technology to augment sexual health curricula. OBJECTIVE: The purpose of this study was to assess the perceptions and experiences of health educators regarding the incorporation of technology into a sexual health education program designed for underserved youth in Fresno County, California, and to identify facilitators and challenges to incorporating technology into the in-person curriculum. METHODS: This implementation study used data collected as part of a cluster randomized controlled trial to evaluate In the Know (ITK), an in-person sexual health education curriculum that includes technology-based content, such as a resource locator, videos, and games, which can be accessed through a mobile app or website. Data from implementation logs from each cohort (n=51) and annual interviews (n=8) with health educators were analyzed to assess the health educators' experiences using the technology and adaptations made during the implementation. RESULTS: The health educators reported that technological issues affected implementation to some degree: 87% of the time in the first year, which decreased to 47% in the third year as health educators' familiarity with the app increased and functionality improved. Technology issues were also more common in non-school settings. Successes and challenges in 3 domains emerged: managing technology, usability of the ITK app, and youth engagement. The health educators generally had positive comments about the app and youth engagement with the technology-based content and activities; however, they also noted certain barriers to adolescents' use of the mobile app including limited data storage and battery life on mobile phones. CONCLUSIONS: Health educators require training and support to optimize technology as a resource for engaging with youth and providing sensitive information. Although technology is often presented as a solution to reach underserved populations, educational programs should consider the technological needs and limitations of the participants, educators, and settings. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/18060.

Young people's romantic relationships and sexual activity before and during the COVID-19 pandemic.

BACKGROUND: Social distancing measures to reduce the spread of COVID-19 may profoundly impact young people's relationships. This study compared adolescent and young adults' romantic relationships and sexual activity before and after social distancing policies were enacted. METHODS: In June 2020, 351 youth participating in an ongoing intervention study in Fresno County, California completed an online survey about their experiences related to COVID-19. The survey included open and closed-ended questions about their romantic relationships, sexual activity, and online romantic or sexual interactions before and during social distancing restrictions. We used the chi-square test of independence to compare adolescent (ages 13-17) and young adults' (ages 18-21) responses. Results were also compared to responses in the intervention study's baseline survey. RESULTS: One-third (37%) of youth were dating or in a romantic relationship and 28% spent time in person with a partner early in the COVID-19 pandemic. Among those dating or in a relationship, 34% physically distanced from their partner due to parental restrictions related to COVID-19. Youth also spent less time in person with their partners during the pandemic than before. Although most youth (69%) were not sexually active before or during the pandemic, 22% had sex during the social distancing period. Young adults were more likely to spend time with their partners and have sex during the restrictions than adolescents. Most youth were not involved in sexting or online dating, before or during the pandemic. CONCLUSIONS: Adolescents and young adults have continued to engage in sexual and romantic relationships during the COVID-19 pandemic, although many reported physical distancing from their partners. Results suggest that youth continue to need access to sexual health education and services during emergencies such as the COVID-19 pandemic.

Bridging the Gap between Sexual Health Education and Clinical Services: Adolescent Perspectives and Recommendations.

BACKGROUND: Adolescents often lack access to accurate and appropriate sexual health information and services. Providing information about local clinical services during sexual health education classes is one strategy to increase awareness, yet many programs miss this opportunity. This study aims to learn about adolescents' experiences with sexual health education and their perceptions of barriers and facilitators to clinical care. METHODS: Nine focus groups were conducted between April to July 2018 with 69 adolescents who had recently attended a comprehensive sexual health education program in California. Topics included information received about local clinics during class and barriers and facilitators to access care. Qualitative data were coded and analyzed for key themes and compared by sex and geographic location. RESULTS: The majority of participants (89%) were Latino and most reported receiving relevant information about clinical services and had positive impressions of local services. Several mentioned that this information increased the likelihood that they would access services if needed. Common barriers to clinic services included parental disapproval, stigma, embarrassment, and confidentiality concerns. Facilitators included peer and family support, confidentiality of services, awareness and education, and accessibility. CONCLUSIONS: Sexual health education programs can provide an important bridge to local clinic services and address adolescents' concerns.

Youth-centered maternity care: a binational qualitative comparison of the experiences and perspectives of Latina adolescents and healthcare providers.

BACKGROUND: Although there is growing recognition of the importance of person-centered maternity care, the needs and perspectives of pregnant adolescents are rarely considered. The purpose of this study was to compare the maternity care experiences of Mexican-origin adolescents in Guanajuato, Mexico and Fresno, California from both youth and healthcare provider perspectives. METHODS: Qualitative interviews and focus groups were conducted with a total of 89 respondents, including 74 pregnant and parenting adolescents as well as 15 providers between December 2016 and July 2017. Adolescents also completed a short demographic survey prior to participation. Transcripts in English and Spanish were coded and thematically analyzed using Dedoose software. Results were compared by location and between youth and providers. RESULTS: Four themes emerged regarding patient-provider interactions: the need for communication and clear explanations, respectful versus judgmental providers, engaging youth in decision-making, and a focus on the age of the youth and their partners. While youth had similar perspectives and priorities in both locations, youth in Mexico reported more negative healthcare experiences than youth in California. Perspectives varied between the youth and providers, with providers in both California and Mexico identifying several structural challenges in providing quality care to adolescents. In California, challenges to supporting immigrant Latina adolescents and their families included language and translation issues as well as barriers to care due to immigration status and documentation. In both locations, providers also mentioned high patient caseloads and their own concerns about the youth's life choices. CONCLUSION: Youth-centered care requires more effective and respectful patient-provider communication, where adolescents are engaged in their healthcare decision-making and delivery options. Changes in patient-provider interactions can help improve the maternity care experiences and outcomes of Latina adolescents. Healthcare systems and providers need to reconfigure their approaches to focus on the needs and priorities of adolescents.

Perspectives on Adolescent Pregnancy Prevention Strategies in the United States: Looking Back, Looking Forward.

Attempts to solve the "problem of adolescent pregnancy" have long been a  focus of national, state, and local efforts in the United States. This review article summarizes trends and strategies around adolescent pregnancy prevention, provides lessons learned and best practices, and presents ideas for future directions. Over the past decades, a wide variety of policy and programmatic interventions have been implemented - including educational efforts, clinical health services, and community-wide coalitions - accompanied by a growing consensus regarding viable solutions. While notable reductions in adolescent pregnancy and childbearing have occurred across all sociodemographic groups, racial/ethnic, geographic, and socioeconomic disparities persist. Many adolescents who most need sexual health information and services are underserved by current programs and policies. A growing understanding of the role of social determinants of health, the impacts of structural racism, and the need for equity and inclusion must inform the next set of interventions and societal commitments to not only ameliorate the occurrence of unintended adolescent pregnancy but also foster healthy adolescent development. Recommendations for future efforts include improving the content, quality, and sustainability of education programs; actively engaging youth in the design of policies, programs, and clinical services; using technology thoughtfully to improve health literacy; expanding access to services through telehealth and other delivery options; and designing programs and policies that recognize and address structural racism, health equity, and inclusion.

Evaluating the Effectiveness of an Intervention Integrating Technology and In-Person Sexual Health Education for Adolescents (In the Know): Protocol for a Cluster Randomized Controlled Trial.

BACKGROUND: Access to a smartphone is nearly universal among American adolescents, and most of them have used the internet to seek health information. Integrating digital technologies into health program delivery may expand opportunities for youth to receive important health information, yet there are few rigorous studies assessing the effectiveness of this type of intervention. OBJECTIVE: The purpose of this study is to assess the effectiveness of In the Know (ITK), a program integrating in-person and technology-based sexual health education for underserved adolescents. METHODS: Youth were engaged in the development of the intervention, including the design of the digital technology and the curriculum content. The intervention focuses on 3 main areas: sexual health and contraceptive use, healthy relationships, and educational and career success. It includes an in-person, classroom component, along with a web-based component to complement and reinforce key content. A cluster randomized controlled trial is in progress among adolescents aged 13-19 years living in Fresno County, California. It is designed to examine the differences in self-reported health and behavioral outcomes among youth in the intervention and control groups at 3 and 9 months. Primary outcomes are condom and contraceptive use or no sex in the past 3 months and use of any clinical health services in the past 3 months. Secondary outcomes include the number of sexual partners in the past 3 months and knowledge of local clinical sexual health services. We will use mixed-effects linear and logistic regression models to assess differences between the intervention and control groups. RESULTS: Trial enrollment began in October 2017 and ended in March 2020 with a total of 1260 participants. The mean age of the participants is 15.73 (SD 1.83) years, and 69.98% (867/1239) of the participants report being Hispanic or Latino. Study results will be available in 2021. CONCLUSIONS: ITK has the potential to improve contraceptive and clinic use among underserved youth. This trial will inform future youth-focused health interventions that are considering incorporating technology. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/18060.