Dual-Method Contraception Use Among Young Women Pre- and Post-ACA Implementation.

The 2012 implementation of the Patient Protection and Affordable Care Act (ACA) contraceptive coverage mandate removed financial barriers to contraception access for many insured women. Since that time, increases in sexually transmitted disease (STD) rates have been noted, particularly among Black adolescent and young adult women aged 15 to 24 years. It is unclear whether changes in dual-method contraception use (simultaneous use of nonbarrier contraceptive methods and condoms) are associated with the increase in STD rates. A repeated cross-sectional analysis was conducted among adolescent and young adult women to compare pre-ACA data from the 2006-2010 cohort and post-ACA data from the 2013-2015 cohort of the National Survey for Family Growth. A significant decrease in short-acting reversible contraception use (SARC; 78.2% vs. 67.5%; p < .01) and a significant increase in long-acting reversible contraception use (LARC; 8.9% vs. 21.8%; p < .01) were found, but no significant change in dual-method contraception use was found among pre- versus post-ACA SARC users and SARC nonusers (odds ratio [OR]: 1.88, 95% confidence interval [CI]: 0.64-5.46, p = .25), LARC users and LARC nonusers (adjusted odds ratio [AOR]: 1.62, 95% CI: 0.42-6.18, p = .48), or White and Black women (AOR: 1.45, 95% CI: 0.66-3.18, p = .35). There was no direct association between changes in contraception use and decreased condom use and therefore no indirect association between changes in contraception use and increased STD rates. Health care providers should continue promoting consistent condom use. Additional research is needed to understand recent increases in STD rates among Black women in the post-ACA era.

Adolescents and parental caregivers as lay health advisers in a community-based risk reduction intervention for youth: baseline data from Teach One, Reach One.

The purpose of the current study is to describe the demographic, behavioral, and psychosocial characteristics of adolescent and caregiver lay health advisers (LHAs) participating in an intervention designed to reduce risk behaviors among rural African-American adolescents. Teach One, Reach One integrates constructs from the Theory of Planned Behavior and Social Cognitive Theory. It acknowledges that changing the sexual behaviors of African-American adolescents requires changing one's knowledge, attitudes, normative beliefs about the behavior of peers, and self-efficacy regarding adolescent sexual behavior, parent-teen communication about sex, and healthy dating relations among adolescents. Study participants completed baseline questionnaires assessing demographics and psychosocial determinants (knowledge, attitudes, perceived social norms, and self-efficacy) of sexual behaviors. Sixty-two adolescent and caregiver dyads participated. Caregivers included biological parents, legal guardians, or other parental figures. Strengths and areas in need of improvement were determined using median splits. Few adolescents had initiated sex. Their strengths included high levels of open parent-teen communication; positive attitudes and normative beliefs regarding both sex communication and healthy dating relationships; and high knowledge and self-efficacy for healthy dating behaviors. Areas needing improvement included low knowledge, unfavorable attitudes, poor normative beliefs, and low self-efficacy regarding condom use. Caregiver strengths included positive attitudes, normative beliefs, and self-efficacy for sex communication; positive attitudes and self-efficacy for condom use; and low acceptance of couple violence. Areas needing improvement included low levels of actual communication about sex and low knowledge about effective communication strategies and condom use. The current study highlights the value of assessing baseline characteristics of LHAs prior to intervention implementation, as it enables a better understanding of the key characteristics necessary for planning and implementing interventions, as well as engaging in targeted training activities.

A qualitative exploration of the role of social networks in educating urban African American adolescents about sex.

OBJECTIVE: To explore social network members' role in educating African American adolescents about sexual health issues. DESIGN: We conducted 21 focus groups with urban African American mothers (n=51), fathers (n=18), sons (n=20), and daughters (n=36) from Allegheny County, Pennsylvania, USA, between December 2007 and March 2008. At least one biological parent (or legal guardian) and one adolescent aged 15-17 years from each family participated. Group conversations were audio-recorded, transcribed, and analyzed using directive content analysis and the constant comparison method. Two coders independently read each transcript to identify emergent themes. RESULTS: A broad range of people were reportedly involved in the education process. Older siblings, extended family, and peers were most commonly cited. However, unrelated adults were also described as playing important roles. Unrelated adults included the friends of an adolescent's parents and the parents of an adolescent's friends or romantic partners. Social network members were said to address three main issues: the facts about sex and sexuality, the social aspects of sexuality (e.g., appropriate dating behaviors, choosing dating partners), and promotion of family values. When educating adolescents about sex, social network members were described as playing eight functional roles, including that of a teacher, guide, challenger, confidant, shelterer, supervisor-chaperone, role model, and provider of access to reproductive health services. These roles were not mutually exclusive, meaning that social network members often assumed different roles depending on the situation. The influence of individuals who were not an adolescent's parent was highly dependent on adolescents' relationship with their parents or on their parents' comfort dealing with sexual issues. CONCLUSIONS: African American adolescents' social networks were described by parents and adolescents as dense, complex, and routinely involved in educating adolescents about sex.

Addressing Administrative and System-Level Challenges to Implementation of Long-Acting Reversible Contraceptives in Adolescent Medicine and Pediatric and Adolescent Gynecology Practices: A Qualitative Study.

STUDY OBJECTIVE: Adolescents use long-acting reversible contraceptive (LARC) methods less than adults. Practices that specialize in adolescent medicine, including Adolescent Medicine (AM) and Pediatric and Adolescent Gynecology (PAG), may be well positioned to help improve adolescent access to these methods. We describe administrative and system-level barriers encountered when implementing LARCs for adolescents and strategies that practices have successfully used to address these barriers. DESIGN/SETTING/PARTICIPANTS: We conducted a qualitative study with physicians and staff at AM and PAG practices that provide LARCs to adolescents. INTERVENTIONS: Semi-structured telephone interviews MAIN OUTCOME MEASURES: Interview guides were based on the Consolidated Framework for Implementation Research (CFIR), an implementation science methodology designed to understand the following aspects of settings adopting new practices: innovation characteristics, external environment, institutional and practice settings, the stakeholders involved, and the implementation process. RESULTS: Seventeen interviews were performed. When examining administrative and system-level challenges encountered by interviewees, the four CFIR constructs identified most frequently were cost, readiness for implementation-available resources, planning, and engaging. Interviewees shared strategies used to overcome these common barriers, including for billing and working with insurance companies, space and equipment needed to introduce LARCs, scheduling and use of telemedicine, and staff training and engagement. CONCLUSION: Sites used many strategies to address these common challenges to implementation. Examples could help with implementation of LARC provision in practices serving adolescent populations.

Development of a clinical questionnaire to support contraception decisions in an adolescent reproductive health clinic in Colorado.

CONTEXT: Adolescents need support to make informed decisions about contraception. Few clinical questionnaires exist to help adolescents and their healthcare providers align contraception decisions with patient needs and preferences. METHODS: Our mixed-methods study involved a convenience sample of English-speaking, female patients aged 13-19 seeking contraception services at an adolescent reproductive health clinic in Colorado, USA. Qualitative interviews informed development of clinical questionnaire items. The questionnaire elicited demographic characteristics, pregnancy and contraception use history, preferred contraception attributes, peer and family involvement, healthcare information and support needs, motivations for contraceptive use, and barriers to contraceptive services. We identified key decision-making factors and reduced the number of questionnaire items through principal components analysis. Using multivariable analyses, we examined the correlation between questionnaire responses and current contraceptive method. RESULTS: Twenty individuals participated in interviews and 373 individuals completed the preliminary questionnaire with 63 candidate items. We identified five contraceptive decision-making factors: side-effect avoidance (eight items, Cronbach's alpha = 0.84), preferred method attributes (six items, Cronbach's alpha = 0.67), parental involvement (three items, Cronbach's alpha = 0.67), life goals prior to parenting (four items, Cronbach's alpha = 0.88), and access to a contraceptive provider (two items, Cronbach's alpha = 0.92) and nine stand-alone items. In multivariable analyses, we found that questionnaire responses for decision-making factors varied among participants using different contraceptive methods. CONCLUSIONS: Multiple priorities may influence adolescent contraceptive decisions. This clinical questionnaire can elicit these priorities before or during a healthcare encounter. Future studies should assess generalizability of the questionnaire and examine impact on method choice, continuation, satisfaction, and reproductive health outcomes.

Pediatric Resident Perspectives on Long-Acting Reversible Contraception Training: A Cross-Sectional Survey of Accreditation Council for Graduate Medical Education Trainees.

PURPOSE: Although pediatricians are primary care providers for most adolescents, pediatric residents receive limited training on long-acting reversible contraceptive (LARC) methods. This study aimed to characterize pediatric resident comfort with placing contraceptive implants and intrauterine devices (IUDs) and assess pediatric resident interest in obtaining this training. METHODS: Pediatric residents in the United States were invited to participate in a survey assessing comfort with LARC methods and interest in LARC training during pediatric residency. Bivariate comparisons used Chi-square and Wilcoxon rank sum testing. Multivariate logistic regression was used to assess associations between primary outcomes and covariates including geographic region, training level, and career plans. RESULTS: Six hundred twenty seven pediatric residents across the United States completed the survey. Participants were predominantly female (68.4%, n = 429), self-identified their race as White (66.1%, n = 412), and anticipated a career in a subspecialty other than Adolescent Medicine (53.0%, n = 326). Most residents were confident counseling patients on the risks and benefits, side effects, and effective use of contraceptive implants (55.6%, n = 344) and both hormonal and nonhormonal IUDs (53.0%, n = 324). Few residents reported comfort with inserting contraceptive implants (13.6%, n = 84) or IUDs (6.3%, n = 39), with most of these respondents having learned these skills as a medical student. Most participants believed that residents should receive training on insertion of contraceptive implants (72.3%, n = 447) and IUDs (62.5%, n = 374). DISCUSSION: Although most pediatric residents believe LARC training should be a component of pediatric residency training, few pediatric residents are comfortable with provision of this care.

The impact of contraceptive counseling in primary care on contraceptive use.

BACKGROUND: Whether contraceptive counseling improves contraceptive use is unknown. OBJECTIVE: To evaluate the association between contraceptive counseling provided by primary care physicians and patients' contraceptive use. DESIGN/PARTICIPANTS: All women aged 18-50 who visited one of four primary care clinics between October 2008 and April 2010 were invited to complete surveys about their visit. Seven to 30 days post visit, participants completed a survey assessing pregnancy intentions, receipt of contraceptive counseling, and use of contraception at last sexual intercourse. Survey data were linked to medical record data regarding contraceptive prescriptions prior to and during the clinic visit. Women were classified as in need of contraceptive counseling if they were sexually active, were not pregnant or trying to get pregnant, and had no evidence of contraceptive use prior to their index clinic visit. KEY RESULTS: Fifty percent (n = 386) of women were in need of contraceptive counseling at the time of their visit. Those who received contraceptive counseling from a primary care provider were more likely to report use of hormonal contraception when they last had sex (unadjusted OR: 3.83, CI: 2.25-6.52), even after adjusting for age, race, education, income, marital status, pregnancy intentions, and prior pregnancy (adjusted OR: 2.68, CI: 1.48-4.87). Counseling regarding specific types of contraception was associated with an increased use of those methods. For example, counseling regarding hormonal contraceptives was associated with a greater likelihood of use of hormonal methods (adjusted OR: 4.78, CI: 2.51-9.12) and counseling regarding highly effective reversible methods was highly associated with use of those methods (adjusted OR: 18.45, CI: 4.88-69.84). These same relationships were observed for women with prior evidence of contraceptive use. CONCLUSIONS: Contraceptive counseling in primary care settings is associated with increased hormonal contraceptive use at last intercourse. Increasing provision of contraceptive counseling in primary care may reduce unintended pregnancy.

Understanding social capital and HIV risk in rural African American communities.

BACKGROUND: African Americans (AA) and rural communities often suffer disproportionately from poorer health. Theory-guided research examining how individual- and community-level factors influence health behaviors and contribute to disparities is needed. OBJECTIVE: To understand how a social network model that captures the interplay between individual and community factors might inform community-based interventions to reduce HIV risk in rural AA communities. DESIGN: Qualitative study. SETTING AND PARTICIPANTS: Eleven focus groups with 38 AA 16-24 year olds, 42 adults over age 25, and 13 formerly incarcerated individuals held in community settings in two rural, predominantly AA counties in North Carolina. Thirty-seven semi-structured interviews with multiethnic key informants. APPROACH: Semi-structured interviews and focus groups with open-ended questions assessed a) perceptions of multi-level HIV risk determinants from a social network model (individual, interpersonal, social, economic, political and structural) identified through literature review and b) community needs and assets affecting local HIV rates. Qualitative data was analyzed using directive content analysis guided by a social network model. RESULTS: We identified four themes regarding the interaction between individuals and their communities that mediate HIV risk: interpersonal processes, community structural environment, social disorder, and civic engagement. Communities were characterized as having a high degree of cohesiveness, tension, and HIV-related stigma. The community structural environment-characterized by neighborhood poverty, lack of skilled jobs, segregation, political disenfranchisement and institutional racism-was felt to reduce the availability and accessibility of resources to combat HIV. Adults noted an inability to combat social problems due to social disorder, which fuels HIV risk behaviors. Civic engagement as a means of identifying community concerns and developing solutions is limited by churches' reluctance to address HIV-related issues. CONCLUSION: To combat HIV-related stigma, physicians should follow recommendations for universal HIV testing. Besides asking about individual health behaviors, physicians should ask about the availability of support and local community resources. Physicians might consider tailoring their treatment recommendations based on available community resources. This strategy may potentially improve patient adherence and clinical outcomes.

Perceptions of prominent neighborhood individuals regarding neighborhood factors and intimate partner violence.

Research addressing the impact of neighborhood factors on intimate partner violence (IPV) often lacks discussion of how and why such factors impact IPV. In order to address this gap, 16 prominent neighborhood individuals (PNI) from 4 low-income urban neighborhoods were asked to share through in-depth interviews their insights and perceptions of IPV as an issue in their neighborhoods, and the relationship between social and structural neighborhood-level factors and IPV. PNIs most often associated IPV with only physical violence. Several did not feel IPV was a significant issue in their neighborhood, confirming a lack of awareness and underreporting of IPV. However, other PNIs were able to speak of the relationship between IPV and neighborhood factors, including lack of opportunities for employment, vacant housing, trash management, lack of community awareness, and social capacity to act to address IPV. Results provide unique insights regarding the mechanisms linking neighborhood factors to IPV outcomes. These results contribute to a deeper understanding of contextual influences upon IPV, the development of tailored quantitative research and to the design of local multi-level public health IPV intervention and prevention efforts.

The Timing of Obesity Matters: Associations Between Current Versus Chronic Obesity since Adolescence and Romantic Relationship Satisfaction Among Young Adult Women.

BACKGROUND: Although the social consequences of obesity for women are well-documented, its stigmatizing effect on romantic relationships across the life course has seldom been explored. We examined whether having current or chronic obesity since adolescence is associated with romantic relationship satisfaction among women in early adulthood. METHODS: This is a secondary analysis of data from the National Longitudinal Study of Adolescent Health. Female participants completing waves I and IV who self-reported their height and weight and were in a marital or cohabitating relationship at wave IV were included. Relationship satisfaction was assessed using a seven-item measure. Body mass index BMI at wave IV was categorized as normal weight, overweight, obesity, or chronic obesity (at waves I and IV). The odds of reporting low relationship satisfaction were estimated across body mass index categories using multivariate regression that controlled for key covariates (age, race, ethnicity, education, income, lifetime partners, relationship duration, and depression) and accounted for the complex sampling design. RESULTS: Among the 3,582 respondents, 74.8% were White, 65.5% had less than a college degree, and 61.8% were in their relationship for more than 3 years. At wave IV, 38.2% had a normal body mass index, 27.7% had overweight, 26.7% had obesity, and 7.5% had chronic obesity. Only having chronic obesity was associated with relationship satisfaction in early adulthood. Women with chronic obesity had 1.44 (95% confidence interval, 1.03-2.02) times the odds of reporting low relationship satisfaction compared with those categorized as normal weight. CONCLUSIONS: Chronic obesity since adolescence is associated with poor romantic relationship satisfaction in early adulthood.

Preconception and Interconception Pediatric Primary Care Utilization of Pregnant and Parenting Teens.

PURPOSE: Gaps in preventive care may contribute to adverse outcomes among pregnant teens. This study quantified teen preventive care utilization before and after pregnancy. METHODS: A continuous retrospective cohort identified 150 teens with a positive pregnancy test (July 2015 to May 2017) at two pediatric primary care sites. Chart review assessed office visits for 18 months before and after the pregnancy test. We also assessed contraceptive counseling, pregnancy outcomes (live birth, miscarriage, termination), and continuity with a single clinician. Demographic factors included age, race, ethnicity, primary insurance, and residential zip code. Logistic regression identified factors associated with visits after pregnancy. Separately, for a cohort of 47 parenting teens who received primary care at the same site as their infants, we assessed teen-infant care after birth. RESULTS: Teens were predominantly non-Latina black (91%) and Medicaid insured (71%). Before pregnancy, most teens had preventive visits (66%) and reported contraceptive use (65%). After pregnancy, 52% discussed pregnancy decisions within a month, 55% reported contraceptive use, and 64% had any primary care visit. Postpregnancy visits were associated with teen age (<18 vs. ≥18 years odds ratio 2.84, 95% confidence interval 1.17-6.90) and pregnancy outcome (termination vs. live birth odds ratio 4.02, 95% confidence interval 1.47-11.01). Among parenting teens, there were more infant visits than teen visits, and continuity was higher for infants. CONCLUSION: In a primary care cohort of pregnant teens, gaps persisted in pediatric clinical follow-up after pregnancy. Particularly in situations where pregnancy led to a birth, pregnancy frequently prompted a transition away from pediatric care.

What's Known and What's Next: Contraceptive Counseling and Support for Adolescents and Young Adult Women.

The low rates of actual contraceptive failure and high rates of contraceptive use among young women highlight that choice of contraceptive method and patterns of contraceptive use greatly influence unintended pregnancy risk. Promoting contraceptive use among adolescent and young adult women requires supportive health systems and health providers who understand this population's evolving developmental needs. It also requires an awareness of effective tools for counseling patients, while being mindful of the power dynamics operational during clinical encounters to avoid inadvertently coercive interpersonal dynamics. Missed opportunities to provide such patient-centered care can lead to unplanned pregnancies and suboptimal health and social consequences for young women. Unfortunately, health providers often lack the tools and resources to appropriately identify and meet individual young women's contraceptive needs. This article summarizes the evidence supporting contraceptive counseling strategies linked with contraceptive initiation among young women, and evidence-based approaches for supporting contraceptive adherence and continuation after method initiation. It also orients readers to the unique neurodevelopmental factors that influence the shared decision-making process during contraception counseling sessions with young women. New and emerging approaches for supporting contraceptive initiation, adherence, and continuation are reviewed.

Racial/Ethnic Disparities in Female Sexual Health from Adolescence to Young Adulthood: How Adolescent Characteristics Matter?

STUDY OBJECTIVE: To describe sexual initiation patterns in female adolescents and examine their association with adolescent characteristics and racial disparities in adverse sexual health across adolescence into early adulthood. DESIGN: A prospective, longitudinal, observational study from adolescence to adulthood. SETTING: Nationally representative, the National Longitudinal Study of Adolescent to Adult Health data, in the range of 24-32 years old at final assessment. PARTICIPANTS: Data from 43,577 US women from 1994 to 2008. INTERVENTIONS AND MAIN OUTCOME MEASURES: Adolescent sex-related characteristics at the individual-, family-, and school peer-level were assessed, and multiple sex partners, sexually transmitted infections (STIs)/HIV, and intimate partner violence (IPV) were longitudinally tracked. The sexual initiation pattern and its longitudinal association with sexual health were analyzed using latent class analysis and mixed effects Poisson regression models. RESULTS: Of the 43,577 subjects, the sexual initiation patterns were determined as normative (n = 28,712, 65.9%), late (n = 10,799, 24.8%), and early but unempowered (n = 4,066, 9.3%). The highest rate of the early-unempowered group was shown in Hispanic individuals (1,054/7,307 = 14.4%); they were more likely to be depressed, unsatisfied with their bodies, receiving welfare, and have less educated/permissive parents to their sexual initiation than others. The late group had a higher body mass index and greater satisfaction with their bodies. The highest number of STIs/HIV and IPV victimization was shown in non-Hispanic Black (NHB) and Hispanic individuals, respectively. However, NHB females' higher number of STIs/HIV was shown in the late/normative groups, not in the early-unempowered group. Among Hispanic females, adolescent sexual initiation patterns were not directly associated with their frequent IPV victimization. CONCLUSION: NHB females' higher STI/HIV in late/normative groups and Hispanic females' frequent IPV victimization regardless of their sexual initiation patterns might indicate that racial/ethnic disparities in female sexual health was not directly determined by adolescent risk behaviors.

Effect of Previous Adverse Reproductive Health Outcomes on Young Women's Engagement in a Health Coaching Intervention to Improve Contraceptive Continuation.

STUDY OBJECTIVE: Nonadherence in sexual risk reduction interventions might be common among adolescents. We compared intervention completion rates among adolescent and young adult women with and without a previous pregnancy or sexually transmitted infection (STI) participating in a program to improve contraceptive continuation. DESIGN: Secondary data analysis from a feasibility study of a health-coaching intervention to improve contraceptive continuation. SETTING: Three urban pediatric clinics in Philadelphia. PARTICIPANTS: Women ages 14-22 years who were English-speaking, sexually active in the past year, not desiring pregnancy in the next year, and starting a new contraceptive method. INTERVENTIONS: At baseline, participants completed a sociodemographic questionnaire and semistructured interview, followed by 5 monthly coaching sessions. Interviews and coaching sessions were audio-recorded, transcribed, and coded for thematic content. MAIN OUTCOME MEASURES: Intervention completion was defined as the number of completed coaching sessions. Secondary outcomes were qualitatively explored group differences in reproductive knowledge, attitudes, and risk perception. RESULTS: Participants with a previous adverse outcome (a previous STI and/or a previous pregnancy) completed fewer coaching sessions than those without such history (median: 2 vs 4; P = .03). Both groups had low HIV/STI knowledge, negative attitudes toward pregnancy, and low HIV/STI risk perception. Those with a previous adverse reproductive outcome held more negative attitudes toward condoms. CONCLUSION: Despite similar reproductive knowledge, attitudes, and risk perception, young women who have experienced an adverse reproductive outcome might be less likely to fully engage in sexual risk reduction interventions. Future studies should confirm these findings and consider strategies to optimize the intervention's reach for vulnerable youth.

Identifying Opportunities to Discuss Pre-Exposure Prophylaxis During Contraceptive Coaching Discussions With Urban Adolescent Women.

PURPOSE: HIV pre-exposure prophylaxis (PrEP) reduces HIV transmission and is approved for adolescents aged 12-17 years. Adolescent girls and young women (AGYW) have modest PrEP uptake rates, while many receive reproductive health counseling. We sought to identify opportunities for incorporating PrEP education in contraceptive counseling delivered to AGYW. METHODS: We performed a secondary analysis of data from the Health Coaching for Contraceptive Continuation pilot study, which supported contraceptive use among AGYW. Participants were 14-22 years old, sexually active with males, and not desiring pregnancy within 12 months. Coaches were sexual health educators with ≥5 years' experience providing contraceptive and PrEP counseling to youth. Participants completed a baseline visit within 30 days of contraceptive initiation and completed up to five monthly coaching sessions. Of 33 enrollees, this analysis includes the 21 who completed ≥4 sessions. Two coders deductively coded session transcripts for five themes: opportunities to discuss PrEP; HIV knowledge, risk perception, and testing attitudes; changes in HIV risk status; condom use knowledge and skills; and sexually transmitted infection knowledge and risk perception. RESULTS: Of the 111 transcripts coded, 24 contained opportunities to discuss PrEP and were inductively analyzed. Thematic analysis demonstrated three types of opportunities for PrEP discussions: failure to introduce information, and provision of incomplete information or misinformation. Analysis also revealed four opportunity contexts: sexually transmitted infection prevention strategies, HIV risk reduction, avoidance of adverse sexual health outcomes, and disclosures of condom nonprotected sexual behaviors. Only one transcript mentioned PrEP. CONCLUSIONS: Multiple opportunities to introduce PrEP counseling exist within contraceptive counseling provided to AGYW.

Feasibility study of a health coaching intervention to improve contraceptive continuation in adolescent and young adult women in Philadelphia, Pennsylvania.

INTRODUCTION: Few interventions to improve contraceptive continuation are tailored to meet the developmental needs of young women under age 25 years. The Health Coaching for Contraceptive Continuation (HC3) intervention was designed to address this gap. In this special report, we describe the rationale for using health coaching, conceptual framework, intervention processes, and findings from a single-arm feasibility study of the intervention protocol. METHODOLOGY: Health coaching is a person-centered behavioral change approach organized around five main strategies: providing education relevant to health goals, building health self-management skills, offering patient-centered counseling, identifying barriers to adherence, and fostering personal accountability for achieving health goals. We used these strategies to affect theory-driven mediators delineated in the Integrative Model of Behavioral Prediction (intentions, knowledge, attitudes, perceived social norms, and self-efficacy) and clinical mediators posited to change through program participation (shared contraceptive decision-making, method satisfaction, quality of life, distress tolerance, experiential avoidance, patient-coach alliance, and expectations of treatment effect). Experienced sexual health educators completed a manualized, 4-week health training program adapted from the National Society of Health Coaches. Between March and December 2017, we recruited a convenience sample of sexually-active women ages 14-21 years who initiated a new contraceptive in the prior 14 days from three urban pediatric clinics in Philadelphia, Pennsylvania. At baseline, participants completed a socio-demographic questionnaire, contraceptive needs assessment interview, and prioritized reproductive topics to learn more about. We synthesized these data into a coaching plan that guided the monthly coaching sessions which occurred for 6 months following contraceptive initiation. We assessed method adherence and continuation with monthly follow-up questionnaires and corroborated the findings through electronic medical record and pharmacy refill data review. Exit interviews assessed program acceptability. Feasibility outcomes measured throughout the protocol administration included recruitment and retention success. We used descriptive statistics to assess baseline and follow up questionnaire measures and audio-recorded and transcribed exit interviews verbatim. Two independent coders used deductive and inductive content analysis coding approaches to identify themes related to program acceptability. RESULTS: Of 92 women approached for the longitudinal intervention, 33 enrolled. Participants' mean age was 17.4 ± 2.1 years. Most were Black (n = 24), in high school (n = 23), and single/never-married (n = 31). Twenty-one completed ≥4 coaching sessions. Among the 23 for whom 6-month contraceptive continuation could be determined, 20 continued their baseline method, 2 switched methods without a gap in use, and 1 discontinued contraceptive use. Five were lost to follow up after enrollment; continuation status was indeterminant for the remaining five. Among the 22 who completed exit interviews, all expressed high program acceptability citing that it provided knowledge-based benefits, nonknowledge-based benefits, and an opportunity to develop a positive, supportive relationship with a reproductive health expert. Participants provided feedback on logistical aspects of the program they enjoyed and made suggestions for improvements prior to embarking on a larger efficacy trial. DISCUSSION: Health coaching is a new approach for promoting contraceptive continuation in young women. The conceptual framework, program structure, and feasibility findings demonstrate strong support for the program among participants. Subsequent research must explore program effects on contraceptive continuation and prevention of unintended pregnancy.

Facilitators and Barriers to Implementation of Long-Acting Reversible Contraceptive Services for Adolescent Girls and Young Women in Gaborone, Botswana.

STUDY OBJECTIVE: Botswana has a high pregnancy rate among adolescent girls and young women (AGYW). Long-acting reversible contraceptive (LARC) use among AGYW in Botswana is low, despite its high effectiveness for preventing pregnancy. Using an implementation science framework, we assessed barriers and facilitators to LARC implementation among AGYW in Botswana. DESIGN: Cross-sectional mixed methods. SETTING: Gaborone, Botswana. PARTICIPANTS: Twenty sexually active AGYW ages 18-24 years; 20 health system stakeholders. INTERVENTIONS: Surveys and semistructured interviews grounded in the Consolidated Framework for Implementation Research. MAIN OUTCOME MEASURES: Themes reflecting barriers and facilitators of LARC implementation. RESULTS: The median age for AGYW was 22 (interquartile range, 21-23) years. Twenty percent were using an implant and none had ever used an intrauterine device. Barriers and facilitators of LARC implementation spanned factors at each Consolidated Framework for Implementation Research domain: (1) LARC characteristics like side effects; (2) the clinics' inner settings, including availability of youth-friendly services; (3) characteristics of health system stakeholders, such as LARC skills, and AGYW experiences, attitudes, and beliefs about LARCs; (4) the outer setting external to clinics and Botswana's health system including reproductive health law and policy for minor adolescents; and (5) the implementation process level such as the availability of free or low-cost LARCs. CONCLUSION: We identified multilevel, context-specific factors that affect LARC implementation. Our findings can inform the development of interventions to increase LARC implementation in Botswana by addressing intersecting factors across patient, clinic, health system, and sociopolitical levels, such as providing confidential services to minors and improving LARC training and supply chain pipelines.

Evolving the Preconception Health Framework: A Call for Reproductive and Sexual Health Equity.

Over the past decade, increasing attention has been paid to intervening in individuals' health in the "preconception" period as an approach to optimizing pregnancy outcomes. Increasing attention to the structural and social determinants of health and to the need to prioritize reproductive autonomy has underscored the need to evolve the preconception health framework to center race equity and to engage with the historical and social context in which reproduction and reproductive health care occur. In this commentary, we describe the results of a meeting with a multidisciplinary group of maternal and child health experts, reproductive health researchers and practitioners, and Reproductive Justice leaders to define a new approach for clinical and public health systems to engage with the health of nonpregnant people. We describe a novel "Reproductive and Sexual Health Equity" framework, defined as an approach to comprehensively meet people's reproductive and sexual health needs, with explicit attention to structural influences on health and health care and grounded in a desire to achieve the highest level of health for all people and address inequities in health outcomes. Principles of the framework include centering the needs of and redistributing power to communities, having clinical and public health systems acknowledge historical and ongoing harms related to reproductive and sexual health, and addressing root causes of inequities. We conclude with a call to action for a multisectoral effort centered in equity to advance reproductive and sexual health across the reproductive life course.

Women's perspectives on counseling about risks for medication-induced birth defects.

PURPOSE: This qualitative study explored women's experiences with counseling about medication-induced birth defects, as well as how and when they would like to receive information on medication-induced birth defects from their health care providers (HCPs). METHODS: We conducted four focus groups with 36 women of reproductive age (18-45 years old) in Pittsburgh, Pennsylvania. Twenty-one women were using medications to treat a chronic health condition, and two were pregnant. Content analysis was performed by three independent coders using a grounded theory approach. Discrepancies were resolved by consensus. RESULTS: Women reported depending on their HCPs for information about the risks of teratogenic effects of medications on a pregnancy, but felt the information they had been provided was not always comprehensive. Women want HCPs to initiate discussions about potentially teratogenic medications at the time the medications are prescribed, regardless of whether the woman is sexually active or planning a pregnancy. Women want clear information about all potential outcomes for a fetus. Factors women reported as being critical to effective teratogenic risk counseling included privacy, sufficient time to discuss the topic, and a trusting relationship with their HCP. CONCLUSIONS: Women of reproductive age think that providing information about the possible teratogenic effects of medications could be improved by routine discussions of teratogenic risks at the time medications are prescribed.

HIV Testing Among Adolescents With Acute Sexually Transmitted Infections.

BACKGROUND AND OBJECTIVES: Rates of sexually transmitted infections (STIs) have increased over the decade. Guidelines recommend HIV testing with incident STIs. Prevalence and factors associated with HIV testing in acute STIs are unknown in adolescents. Our objective was to determine the prevalence of completed HIV testing among adolescents with incident STIs and identify patient and health care factors associated with HIV testing. METHODS: Retrospective study of STI episodes (gonorrhea, Chlamydia, trichomoniasis, or syphilis) of adolescents between 13 and 24 years old from July 2014 to December 2017 in 2 urban primary care clinics. We performed mixed effects logistic regression modeling to identify patient and health care factors associated with HIV testing within 90 days of STI diagnosis. RESULTS: The 1313 participants contributed 1816 acute STI episodes. Mean age at STI diagnosis was 17.2 years (SD = 1.7), 75% of episodes occurred in females, and 97% occurred in African Americans. Only half (55%) of acute STI episodes had a completed HIV test. In the adjusted model, female sex, previous STIs, uninsured status, and confidential sexual health encounters were associated with decreased odds of HIV testing. Patients enrolled in primary care at the clinics, compared with those receiving sexual health care alone, and those with multipathogen STI diagnoses were more likely to have HIV testing. CONCLUSIONS: HIV testing rates among adolescents with acute STIs are suboptimal. Patient and health care factors were found to be associated with receipt of testing and should be considered in clinical practice.