Social determinants of health and their relationships to reproductive outcomes.

The medical community has begun to focus on factors that impact not only health but also wellness for both mainstream and disadvantaged communities. Public health initiatives have evaluated nonmedical factors to determine whether they have a broader influence on physical health than traditional medicine, especially in reproductive care. These factors, referred to as social determinants of health (SDOH), affect a variety of medical conditions, have an impact on medical strategies, and suggest that traditional medicine may be more limited than commonly thought. The purpose of this article, therefore, is threefold: First, it will offer a general review of selected components of current SDOH that act as nonmedical factors in health and behavioral wellness. Second, it will present specific SODH and their impact on contraceptive and prenatal care. Finally, it will highlight SODH policies that either enhance or impede the ability of health systems to deliver innovative reproductive services to underserved populations.

Development of a Peer-Based Intervention Educating Teenagers about Long-Acting Reversible Contraception.

OBJECTIVE: Despite a decrease in teenage pregnancy rates in the United States in the past decades, teen pregnancy continues to be a considerable health issue. In this paper, we outline the development of our novel peer-based intervention, Get It?, that aims to increase awareness of and self-efficacy to use long-active reversible contraceptives (LARCs) among teenagers. METHODS: Peer narrative videos were created from audio recording semi-structured, one-on-one interviews with teenage LARC users. Focus groups of young women 19 years old and younger were conducted to choose the most audience-appropriate videos to be included in the final intervention. Using a thematic content analysis approach, transcripts of the audio recorded focus groups were reviewed and manually coded. RESULTS: The final layout of Get It? included 4 videos that were chosen by participants of the focus groups, as well as supplemental activities that included a basic description of the LARC devices, the ability to anonymously post personal stories about LARCs that can be shared with others, and the opportunity to email the primary investigator questions about LARCs. Thematic analysis of the focus group discussions revealed that when it came to narrative videos, participants desired (1) an authentic narrator, (2) more information on the narrator, and (3) narrators displaying ample emotions. CONCLUSION: Peer narratives play a vital role in influencing a teenager's perspective on their health status; therefore, understanding what constitutes reliable narration from an online format was critical in the development of a peer-based electronic intervention that informs teenagers of the most effective contraceptive available to them.

Psychological factors that may influence use of long-acting reversible contraceptives (LARC): A qualitative study.

Although long-acting reversible contraceptives (LARC) remain the most effective method of contraception for teenagers, most adolescents continue to use less reliable methods. The purpose of this study was to investigate possible psychological factors that may lead to this low uptake rate by studying the LARC decisionmaking process among teenagers. In-depth, semistructured, open-ended interviews of sexually active teenagers who had LARC devices placed prior to 18 years of age were conducted. Four key themes emerged from the interviews: (a) the influences of peers (friends and family members) on LARC decision-making; (b) the lack of awareness about obtaining LARC devices; (c) the fear of weight gain as a driving force during contraceptive and LARC decision-making; and (d) the disproportional anxiety about pain from LARC insertion. The results suggest that a paradigm shift in contraceptive counseling is necessary in order to tackle these psychological barriers to teenage LARC use.

Adolescents Accessing School-Based versus Family Planning Clinics: Chlamydia and Gonorrhea Testing and Treatment Outcomes.

The prevalence and treatment of chlamydia (CT) and gonorrhea (GC) at school-based clinics (SBCs) requires revisiting. To assess whether clinic type influences CT/GC testing and treatment for minors (individuals 13-17 years of age), our study compared four SBCs with five family planning clinics (FPCs) in the Houston, Harris County metropolitan area of Texas, USA for: (1) the prevalence of CT/GC infection (pre-COVID-19 and during COVID-19); (2) treatment rates at the last positive diagnosis; and (3) the time, in days, from testing-to-diagnosis and testing-to-treatment. Between January 2019 and December 2020, 2439 unique patients (1579 at SBCs, 860 at FPCs) were seen. Of the 1924 tests obtained, 39.2% and 15.9% were positive for CT and GC, respectively. The prevalence of CT and GC at SBCs was similar prior to COVID-19 vs. during the COVID-19 pandemic. SBCs were able to provide treatment significantly faster after diagnosis (mean, 6.07 days; 95% CI, 3.22-8.90; 94.7% were within 30 days) than FPCs (mean, 17.60 days; 95% CI, 10.15-25.12; 84.7% were within 30 days) (p = 0.0257). This comparison within our large clinic system, with consistent clinical management protocols, suggests that SBC care may be critical to ensuring optimal sexually transmitted infection management in minors.

Commentary: Making the case for linking behavioral health strategies to enhance work as a social determinant for youth.

This commentary addresses the importance of work as a social determinant of health and the role that behavioral health interventions play in its successful execution. Data on the influence of nonmedical factors on wellness of vulnerable populations is reviewed as well as the need to facilitate acquisition of meaningful employment for post-high school graduates, referred to as opportunity youth. It also discusses the role of behavioral health professionals to proactively manage mental health concerns that negatively influence the employment process. Moreover, it suggests that behavioral health professionals can potentially predict work acquisition success based on participant risks and barriers to employment. Such analyses can affect decisions regarding program participant selection and the assessment of program/staff resources required for a successful pathway to job acquisition. Such insights can provide useful guideposts on how to apply this social determinant theory to effectively integrate this unutilized workforce into productive jobs.

Pregnant Adolescents As Perpetrators and Victims of Intimate Partner Violence.

The role of pregnant adolescents as perpetrators of intimate partner violence (IPV) is not well understood. Socioecological factors associated with IPV (physical assault and injury, and psychological aggression) perpetrated by pregnant adolescents and the association between IPV and attitudes toward the use of physical punishment to discipline children were examined among 246 pregnant adolescents. Pregnant adolescents were more likely to report perpetrating both physical assault (24%) and psychological aggression (52.7%) than being the recipient (12.2% and 38.6%, respectively) and having been physically injured (7%) than inflicting injury (4.1%). Risk factors for perpetrating physical assault included prior assault by partner, being African American, exposure to community violence, being in trouble with the police, and multiple lifetime drug use. IPV perpetrators had more favorable attitudes toward the use of physical punishment. Interventions should address IPV and parenting attitudes in young couples to maximize the health and safety of both mother and unborn child.

Trends of Contraceptive Choices Among Young Women in Inner City Houston.

STUDY OBJECTIVE: Although long-acting reversible contraceptives (LARC) such as intrauterine devices and subdermal implants remain the most effective methods of contraception for teenagers, most adolescents continue to use less reliable methods. The purpose of this study was to determine: (1) the distribution of contraceptive type according to age of the patients in our clinic system (Baylor Teen Health Clinic); and (2) the differences in this distribution over the past decade. DESIGN: This study was a comprehensive chart review of at least 15,500 charts for the years 2005 to 2014. SETTING: Baylor Teen Health Clinic. PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Charts of patients less than 25 years of age who attended one of the 9 Baylor Teen Health Clinics were reviewed. Contraceptive uptake by age and year was the main outcome measured. RESULTS: The percentage of women younger than age 25 years who used LARC increased for all age groups from 2005 to 2014, with the greatest increase for women 20-24 years old (<1% to 9%). The percentage of women using no method decreased for all age groups from 2005 to 2014 with the greatest decrease for women 15-19 years old (9% to 5%). The percentage of women using less effective methods decreased for teenagers younger than 18 years old, but increased for women 20-24 years old and remained the same for women 18-19 years old. Use of pills/patches/rings decreased for all age groups and use of hormonal injections increased for all age groups, with the greatest increase for teenagers younger than 15 years of age (35% to 68%). Our clinic population has a greater proportion of teenagers and young women using LARC than the national average, possibly because of the increased access to LARC when these women enter our clinic system. Nevertheless, less than 10% of all age groups studied used LARC, with the proportion being lowest in teenagers younger than 18 years. CONCLUSION: More efforts need to be placed on determining the reasons for low LARC uptake despite greatest efficacy in this young, vulnerable population.

Enhancing Parent Consent for School-Based Primary and Reproductive Health Care Among Vulnerable Youth.

This quality-improvement initiative evaluated procedures to increase parental consent for students, 13 to 18+ years old, to access a school-based health clinic that provides primary and reproductive health care in a Hispanic immigrant neighborhood in the U.S. Southwest. Six consent-retrieval procedures were sequentially implemented. Procedures included school registration, competition, hand delivery, PTO meetings, self-consent, and mail. Age, grade, and number of completed consents were calculated and compared. The percentage of students with completed consents increased from 35% to 72%. Lessons learned include increasing the number of completed consents is difficult; however, it is important to increase students' access to health-care services.

Comprehensive Assessment of Health Needs of Young Minority Males Attending a Family Planning Clinic.

The objective of this study was to assess the overall health, including sexual and reproductive health (SRH) knowledge and needs, sexual behaviors, and testicular health practices among young minority males. Anonymous questionnaires were administered to 18- to 25-year-old males receiving services at health clinics in a large southwestern U.S. city. The survey was completed by 258 males with a mean age of 20.8 years. Most young males (67.1%) identified as African American, and 32.9% as Hispanic. Results suggest study participants lack SRH knowledge related to pregnancy and condom effectiveness, and engage in risky sexual behavior including not using birth control at their last sexual encounter. Although 21.6% of participants had a sexually transmitted infection (STI) in the past year, approximately 80% perceived their STI/HIV risk as very low or low. Respondents had low engagement and lack of knowledge of testicular health practices. The majority of respondents (71.1%) reported having been in a physical fight one or more times and 18.1% reported being victims of intimate partner violence. These data support a need for comprehensive health services for minority young males.

Changes in the Use of Contraception at First Intercourse: A Comparison of the National Survey of Family Growth 1995 and 2006-2010 Databases.

STUDY OBJECTIVE: To determine trends in characteristics associated with contraceptive use at coitarche from 1995 to 2006-2010. METHODS: The National Survey of Family Growth (NSFG) 1995 and 2006-2010 databases were used to abstract variables of interest. Generalized linear models (GLM) were applied to examine the association between the use of contraceptive methods at coitarche and variables abstracted for each database. RESULTS: Of the 9599 women from the 1995 database included in this study, 3885 (40%) used contraception at coitarche in comparison to 4860 (82%) out of 5931 women assessed in 2006-2010. For both time periods, Hispanic women were significantly less likely to use contraception at coitarche when compared to White women. In the 1995 database, only women from families with incomes >$50,000 were more likely to use contraception at coitarche, while women from families with income > $20,000 were more likely to use contraception at coitarche in 2006-2010. There were some differences noted in the association between age at coitarche and contraception use at coitarche, but in general, women who had a higher age at coitarche were more likely to use contraception. For both time periods, women were more likely to use contraception at coitarche if they used barrier methods as their first form of contraception or if they obtained their first contraceptive method from a spouse, partner, or friend. CONCLUSIONS: Our results suggest that access to contraception may be associated with use of a contraceptive method at coitarche. Innovative measures need to be investigated so that this young population has increased access to more reliable methods before their first sexual experience.

Integrating Routine HIV Testing into Family Planning Clinics That Treat Adolescents and Young Adults.

OBJECTIVE: Adolescents and young adults remain at high risk for new HIV infections and for unknowingly transmitting the virus to others. Yet, they have demonstrated low rates of testing due to barriers such as stigma and difficulty accessing testing services. Few existing programs have successfully integrated family planning and HIV care services to improve testing and diagnosis rates among young adults and adolescents, particularly those of minority groups. This study describes the process of implementing HIV services into family planning clinics and how to train staff in routine, opt-out testing. METHODS: This study used HIV screening data from 10 family planning clinics serving adolescents and young adults in Houston, Texas. A total of 34,299 patients were tested for HIV during a 48-month study period, from January 2010 through December 2014. RESULTS: Patients tested included minors <18 years of age (25.5%), males (22.8%), and individuals who had missed opportunities for HIV testing at other health-care settings. From the opt-in period (2006-2007) to the routine, opt-out period (2008-2010), the yearly average number of tests administered more than doubled; the yearly average increased again by 50% from the routine, opt-out period to the routine, rapid period (2011-2014). Eighty-eight (0.3%) patients were diagnosed with HIV, a higher seropositivity rate than CDC's recommended threshold of 0.1% for settings where routine screening is warranted. CONCLUSION: Routine, opt-out HIV testing integrated into family planning clinics increased rates of testing acceptance, receipt of test results, and HIV-positive diagnoses among adolescents and young adults.

Choice of Postpartum Contraception: Factors Predisposing Pregnant Adolescents to Choose Less Effective Methods Over Long-Acting Reversible Contraception.

PURPOSE: The purposes were to determine contraceptive methods pregnant adolescents intend to use postpartum and to understand factors that predispose intention to use less effective birth control than long-acting reversible contraception (LARC). METHODS: Participants were 247 pregnant minority adolescents in a prenatal program. Intention was assessed by asking "Which of the following methods of preventing pregnancy do you intend to use after you deliver?" Multinomial logistic regression analysis was used to determine factors associated with intent to use nonhormonal (NH) contraception (male/female condoms, abstinence, withdrawal and no method) or short-/medium-acting hormonal (SMH) contraception (birth control pill, patch, vaginal ring, injectable medroxyprogesterone acetate) compared with LARC (implant and intrauterine device) postpartum. RESULTS: Twenty-three percent intended to use LARC, 53% an SMH method, and 24% an NH method. Participants who intended to use NH or SMH contraceptive methods over LARC were significantly more likely to believe that LARC is not effective at preventing pregnancy, to report that they do not make decisions to help reach their goals and that partners are not important when making contraceptive decisions. Other important factors were having a mother who was aged >19 years at first birth and had not graduated from high school, not having experienced a prior pregnancy or talked with parents about birth control options, and the perception of having limited financial resources. CONCLUSIONS: Distinct profiles of factors associated with intending to use NH or SMH contraceptive methods over LARC postpartum were identified and may inform future interventions to promote the use of LARC to prevent repeat pregnancy.

A Socioecological Framework to Assessing Depression Among Pregnant Teens.

To examine individual, interpersonal, family, and community correlates associated with moderate-to-severe depressive symptoms among pregnant adolescents. A total of 249 primarily African American and Hispanic pregnant adolescents ages 15-18 years were recruited into either an intervention group utilizing Centering Pregnancy prenatal care and case management, or to a comparison group receiving case management only. Moderate-to-severe depressive symptoms were defined as a score ≥16 on the Center for Epidemiologic Studies Depression Scale (CES-D). Intervention and comparison groups did not significantly differ on demographic characteristics or depression scores at baseline. A total of 115 (46.1 %) participants met criteria for moderate-to-severe depressive symptoms at entry into the program. Pregnant adolescents who were moderately-to-severely depressed were more likely to be African American, to have reported limited contact with the father of the baby, and to have experienced prior verbal, physical or sexual abuse. Depressed adolescents also experienced high levels of family criticism, low levels of general support, and exposure to community violence. A significant number of pregnant adolescents were affected by depression and other challenges that could affect their health. Comprehensive interventions addressing these challenges and incorporating partners and families are needed.

Talk with Tiff: teen's inquiries to a sexual health website.

Because of its availability, anonymity, and low cost of access, the Internet is an increasingly common way for adolescents to find information about sensitive issues. Sexual health website question portals are an important way for adolescents to seek personalized information tailored to their individualized needs. Few studies have examined the content within anonymous e-mails sent to these question portals. The purpose of this qualitative evaluation was to analyze thematic content of anonymous e-mails sent through a question portal on a comprehensive sexual health clinic website for an adolescent family planning clinic in a large city in the southwest United States. Between August 2009 and June 2012, the e-mail server received questions from 484 individuals who were seeking sexual health-related information. The authors used a content analysis to identify recurrent themes in the questions submitted. The most common questions regarded the cost of the clinic's services and testing for sexually transmitted diseases. The questions revealed that adolescents lack basic sexual health knowledge and hold many misconceptions. The findings support the usefulness of online question portals as effective venues for teenagers to quickly and anonymously obtain accurate information on sensitive issues.

Reproductive health professionals' adoption of emerging technologies for health promotion.

The purpose of this study was to assess reproductive health professionals' familiarity with and use of various electronic technologies to support health promotion. The study also examined the relationship between demographic characteristics and attitudes and beliefs of the effectiveness of new technologies and perceived barriers for usage. A total of 165 reproductive health professionals at two conferences related to reproductive health in the United States completed the study survey. Personal and organizational factors affected the adoption of electronic technologies for health promotion. This included lack of knowledge, skills, and confidence as well as privacy concerns. The results of the study also suggested that being from an older generation was associated with having lower levels of knowledge, skills, and confidence in using new media. These findings highlight the importance of creating learning opportunities on the use of new technology for health promotion as well as addressing specific perceived barriers among reproductive health professionals in order to promote the adoption of these technologies.

Access to sexual and reproductive health care services: young men's perspectives.

This study aimed to identify health issues that affect young men and the barriers they experience in accessing care. Participants were 48 minority men 18-28 years old, distributed among 9 focus groups. Four main themes emerged in the study. First, the authors identified sexually transmitted infections, mental health problems, and drug use as major health issues. Second, participants identified attitudinal and institutional barriers to accessing care. This included denial; fear; embarrassment; perception that it is not considered manly to seek help; cost; and accessibility. Third, focus group participants felt that services have to be augmented in order to address the specific needs of men. Last, participants suggested strategies to attract men to family planning clinics that are consistent with a youth culture. Focus groups are effective in obtaining input in order to augment services for men.

HIV risk perceptions among adolescents attending family planning clinics: an integrated perspective.

Abstract The current study assessed the impact of individual, interpersonal, and contextual factors on HIV risk perception. A total of 426 female adolescents attending family planning clinics took part in this study. The majority, 60.1% were African-American and 39.9% were Hispanic. The results indicated that the majority of participants perceived themselves to be at no or low risk for contracting HIV. Individual, interpersonal as well as contextual factors correlated with HIV risk perception in the study. Adolescents who perceived themselves to be at no or low risk were more likely to be Hispanic, be married and had children. They also felt that they can control situations where they have to refuse sex or insist on condom use, had more frequent communication with sexual partners about condom use and held perceptions that peer norms support condom use. The findings in this study have important implications for risk reduction education for female adolescents. Risk reduction education should strengthen adolescents' personal skills to help them avoid HIV risk despite the various pressures they experience in their life.

Students' experiences and perceived benefits of a sex education curriculum: a qualitative analysis.

A qualitative evaluation explored the experiences and perceived benefits of students who participated in an abstinence-plus sex education program at enrollment and conclusion. The sample included 1130 inner-city high school students, 73.7% of whom were Hispanic. Thematic analysis was used to identify main themes in responses made by students to 3 open-ended questions. The most common preparticipation request was for information about sexually transmitted infections. At program conclusion, the most common response theme involved the quality of course delivery. Students indicated that they appreciated the facilitators who allowed open conversations. The implications of these findings to sex education programs are discussed.

Ethnicity as a factor in reproductive health care utilization among males attending family planning clinics.

Health care utilization of reproductive health care services among males is an emerging issue. This study examined ethnicity as a factor in reproductive health care utilization among 1,606 African American and Hispanic young males attending family planning clinics. Seventy percent were African American and 30% were Hispanic. Across groups, the most received service was treatment for a sexually transmitted infection (STI). African American males were more likely than Hispanic males to have health insurance, report a prior visit to a family planning/STI clinic, and have a history of an STI. Hispanic males had higher rates of employment. The most common source of referral for family planning services for both groups was either a current girlfriend or female friend. Hispanic males were more likely to use family as a referral source than African American males. Differences were also noted in regard to interest in health topics with African American males most interested in STI prevention and getting a job and Hispanic males in services related to working-out/eating well, controlling anger, feeling depressed, and getting along with family. Young males' perceptions of what they consider to be important health care needs should be assessed carefully in order to maintain their interest in returning to the clinics.