Task shifting and community engagement as the keys to increasing access to modern contraception: Findings from mixed methods operational research in coastal Kenya.

RATIONALE: Kilifi County, Kenya, has a modern contraceptive prevalence of 44%, compared to the national prevalence of 61%. In 2018, the Government of Kenya and Population Services Kenya implemented a pilot project in Kilifi to improve contraceptive awareness and access. AIMS AND OBJECTIVES: The Riziki Demonstration Project task shifted contraceptive injectable and implant provision to community health extension workers (CHEWs) and supported community engagement led by community health volunteers (CHVs). This mixed methods evaluation examined the effect of Riziki on contraceptive service provision and identified drivers of the intervention's success in increasing public sector contraceptive uptake. METHOD: We obtained monthly contraceptive service provision data from DHIS2 for intervention and comparison facilities from June 2018 to July 2020. Controlled interrupted time series analyses were used to assess difference-in-differences effects on the levels and trends in service provision. Qualitative data included key informant interviews with health workers, community-based focus group discussions and contraceptive journey mapping. Topics included contraception-related shifts in the health system and social environment and changes to contraceptive accessibility and demand. RESULTS: We found positive difference-in-differences effects for levels of provision for implant (adj. ß = 7.4 per month, per facility, 95% confidence interval [CI]: 2.8-12.0) and all methods combined (adj. ß = 12.2, 95% CI: 3.0-21.3). The health system provided a legal framework and management support for the pilot. Community engagement by CHVs and CHEWs, including with men and religious leaders, bolstered supportive social norms by emphasizing birth spacing and family wellbeing. Awareness and supportive social norms were strengthened among women and their husbands through counselling that leveraged CHEW and CHV community embeddedness. CONCLUSION: Findings demonstrate the potential for task sharing combined with community engagement efforts to improve contraceptive awareness, knowledge and supply. Community engagement should include men, traditional leaders and other influencers to strengthen norms that position family planning in alignment with community values.

Understanding changes made to reproductive, maternal, newborn and child health services in Pakistan during the COVID-19 pandemic: a qualitative study.

COVID-19 mitigation measures have disrupted the provision of essential health services. The goal of this study was to understand changes in reproductive, maternal, neonatal, and child health (RMNCH) services during the pandemic in Pakistan. We conducted a qualitative study in November and December 2020 consisting of telephone in-depth interviews with women, healthcare providers, and community stakeholders. Interviews were analysed using a thematic, iterative approach. All health facilities had changed their routine procedures, including adjustments in service delivery time and staff hours to reduce crowding, and maintain standard operating procedures (SOPs) such as social distancing. Women highlighted stockouts and lack of supplies as key barriers to care-seeking. Stockouts and crowding led to shifts in care-seeking away from public to private facilities. RMNCH service utilisation declined first due to restrictions during the lockdown, then due to fear of contracting COVID-19 at healthcare facilities. This study provides important insights into RMNCH services during the COVID-19 pandemic from care-seekers' and care-providers' perspectives. The findings of this study were used to develop interventions to address access to RMNCH care during the COVID-19 pandemic.

Postabortion Medicaid Enrollment and the Affordable Care Act Medicaid Expansion in Oregon.

Background: The Affordable Care Act Medicaid expansion had the potential to increase continuity of insurance coverage and remove barriers to accessing health services following an abortion in states where Medicaid pays for abortion. We examined the association of Medicaid expansion with postabortion Medicaid enrollment and described postabortion preventive reproductive services among Medicaid-enrolled women in Oregon. Methods: We used Medicaid claims and enrollment data to identify abortions to women ages 20-44 in 2009-2017 (N = 30,786), classified into a treatment group-those likely to be affected by Medicaid expansion-and a comparison group. Outcomes included Medicaid enrollment (number of months enrolled and any lapse in enrollment) in the 6 and 12 months postabortion. Difference-in-differences analyses were used to compare outcomes preexpansion (2009-2012) and postexpansion (2014-2017) for treatment and comparison groups. Linear regression models were adjusted for age, race/ethnicity, rurality, and month. We described receipt of preventive reproductive services in 0-2 months and in 3-12 months postabortion. Results: Medicaid expansion was associated with enrollment increases of 2.0 and 4.7 months and with declines in any enrollment lapse of 54 and 48 percentage-points over 6 and 12 months postabortion, respectively (p < 0.001). Many who remained enrolled through postabortion received preventive care including contraceptive services (41%) and screening for sexually transmitted infections (23%). Conclusions: Medicaid expansion may increase continuity of insurance coverage for those receiving abortions, and in turn promote access to preventive services that can improve subsequent reproductive health outcomes.

Medicaid expansion and neonatal outcomes in Oregon.

RATIONALE, AIMS AND OBJECTIVES: Low-income women disproportionately experience preventable, adverse neonatal outcomes. Prior to the Affordable Care Act (ACA) Medicaid expansion, many low-income women became eligible for coverage only after becoming pregnant, reducing their access to healthcare before pregnancy and creating discontinuities in care that may delay Medicaid enrollment. The objective of this study was to examine the impact of the ACA Medicaid expansion on neonatal outcomes among low-income populations in Oregon. METHOD: We used linked Oregon birth certificate and Medicaid data from 2008-2016 to identify control and policy groups of women who gave birth both before and after implementation of the ACA Medicaid expansion (n = 21 204 births to N = 10 602 women). We conducted a difference-in-differences analysis of the effect of Medicaid expansion on preterm birth, low birthweight (LBW), neonatal intensive care unit (NICU) admissions, and neonatal mortality. RESULTS: We found policy effects on reducing LBW (interaction aOR = 0.71, 95% CI: 0.57-0.90) and preterm birth (interaction aOR 0.77, 95% CI: 0.62 = 0.96) but not on NICU admissions or neonatal mortality. CONCLUSIONS: This study provides evidence that expanding Medicaid coverage may have positive effects on LBW and preterm birth, which could lead to important long-term impacts on childhood and later-life health outcomes. States that have not expanded their Medicaid programs might improve neonatal outcomes among low-income populations by extending insurance coverage to low-income adults.

Linking family planning market census data with consumer experiences in three countries: the Consumer's Market for Family Planning study protocol and data.

Background: The Consumer's Market for Family Planning (CM4FP) project was designed to address limitations of existing family planning (FP) data sources that prevent a full understanding of the total FP market. CM4FP data provide a picture of the complete supply environment and how consumers experience it. Study objectives were to 1) test a ring-fenced census approach consisting of an outlet census in a defined geographical area and a household survey in a smaller inner ring, to comprehensively map the total FP market in a local geography; 2) explore FP supply market dynamism through longitudinal data collection from contraceptive outlets; and 3) test a methodology for directly linking household and outlet data to measure the relationship between contraceptive demand and supply. Methods: Data were collected from study sites in Nigeria, Kenya, and Uganda from 2019 to 2020. Longitudinal outlet census data and repeated cross-sectional household survey data from women ages 18-49 were collected at three quarterly time points. Outlets were located in an outer ring geography to encompass locations likely visited by women sampled from a smaller inner ring. Data from women who received a contraceptive method in the past 12 months were linked to data for the outlet from which they received the method. Results: Datasets include product audits for 22,380 individual FP products, collected from a total of 1,836 outlets across 12 study sites. The datasets also contain data from 11,536 female respondents, of whom 1,975 were successfully matched to the outlet where they most recently obtained their method. Conclusions: CM4FP data are available at www.cm4fp.org. This unique dataset enables in-depth exploration of the family planning supply market in addition to interactions between the market and consumer perspectives and behaviors within each study site. The data can also be used to explore novel methodologies to inform future study designs.

Contraceptive Services After Medicaid Expansion in a State with a Medicaid Family Planning Waiver Program.

Background: Medicaid family planning programs provide coverage for contraceptive services to low-income women who otherwise do not meet eligibility criteria for Medicaid. In some states that expanded Medicaid eligibility following the Affordable Care Act (ACA), women who were previously eligible only for family planning services became eligible for full-scope Medicaid. The objective of this study was to provide context for the impact of the ACA Medicaid expansion on contraceptive service provision to women in Oregon who were newly enrolled in Medicaid following the expansion. Materials and Methods: We used Medicaid eligibility data to identify women ages 15-44 years who were newly enrolled in Oregon's Medicaid program following the ACA expansion (n = 305,042). Using Medicaid claims data, we described contraceptive services and other preventive reproductive care received in 2014-2017. Results: Overall, 20% of women newly enrolled in Medicaid received contraceptive counseling and 31% received at least one method. The most frequently received methods were the pill (38% of women who received any method), intrauterine device (28%), implant (15%), and injectable (12%). Community health centers played a significant role in contraceptive service provision, particularly for the implant and injectable. Nine of 10 women (89%) who received contraceptive services also received other preventive reproductive services. Conclusions: This study provides insight regarding receipt of contraceptive services and preventive reproductive care following Medicaid expansion in a state with a Medicaid family planning program. These findings underscore the importance of Medicaid expansion for reproductive health even in states with preexisting Medicaid family planning.

Association of Medicaid Expansion With Access to Abortion Services for Women With Low Incomes in Oregon.

BACKGROUND: The Affordable Care Act allowed states to expand Medicaid eligibility for women with low incomes before pregnancy. Women who experience an unintended pregnancy may encounter fewer delays in accessing abortion services if they are already enrolled in Medicaid. In states where the Medicaid program includes coverage for abortion services, Medicaid expansion may increase timely access to abortion services. Oregon has expanded Medicaid and is 1 of 16 states in which the Medicaid program covers abortion services. We explored how Medicaid expansion in Oregon was associated with Medicaid-financed abortion rates and receipt of medication abortion relative to surgical abortion. METHODS: Using Medicaid claims and eligibility data we identified women ages 19 to 43 (n = 30,367) who had abortions before the expansion period (2008-2013) and after the expansion period (2014-2016). We used American Community Survey data to estimate the annual number of Oregon women aged 19 to 43 with incomes below 185% of the federal poverty level who would be eligible for a Medicaid-financed abortion. We conducted interrupted time series analyses using negative binomial and logistic regression models. RESULTS: Incidence of Medicaid-financed abortion increased from 13.4 in 1,000 women in 2008 to 16.3 in 2016. Medication abortion receipt increased from 11.5% of abortions in 2008 to 31.7% in 2016. For both outcomes, we identified an increasing time trend after Medicaid expansion, followed by a subsequent leveling off of the trend. By the end of 2016, incidence of Medicaid-financed abortion was 4.5 abortions per 1,000 women-years (95% confidence interval, 3.3-5.7) higher than it would have been without expansion and medication abortions comprised a 7.4 percentage point (95% confidence interval, 4.4-10.4) greater share of all abortions. CONCLUSIONS: Medicaid expansion was associated with increased receipt of Medicaid-financed abortions and may have reduced out-of-pocket payment among women with low incomes. Increased receipt of medication abortion may indicate that expansion enhanced earlier access to services, possibly as a result of increased prepregnancy Medicaid enrollment, and this earlier access may increase reproductive autonomy and safety.

Impact of Medicaid expansion in Oregon on access to prenatal care.

Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) has the potential to improve reproductive health by allowing low-income women access to healthcare before and early in pregnancy. The aim of this study was to examine the effects of Oregon's Medicaid expansion on timely and adequate prenatal care. We included live births in Oregon from 2012 to 2015 and used individually-linked birth certificate and Medicaid eligibility data. Outcomes were receipt of first trimester prenatal care and receipt of adequate prenatal care. We also assessed Medicaid enrollment one month prior to pregnancy. We estimated the overall effect of Medicaid expansion on prenatal care utilization using probit regression models. Additionally, we assessed the impact of Medicaid expansion on prenatal care utilization via pre-pregnancy Medicaid enrollment using bivariate probit models. Overall, receipt of first trimester prenatal care increased post-expansion by 1.5 percentage points (p < 0.01) after expansion. Receipt of adequate prenatal care also increased significantly post-expansion with an incremental increase of 2.8 percentage points (p < 0.001). Pre-pregnancy Medicaid enrollment increased following Medicaid expansion (ß = 0.55, p < 0.001) and was associated with both timely (ß = 0.48, p < 0.001) and adequate receipt of prenatal care (ß = 0.14, p < 0.001). Using two years of post-ACA data we found that Medicaid expansion had significant positive associations with Medicaid enrollment prior to pregnancy, which subsequently increased receipt of timely and adequate prenatal care. Our study provides evidence that expanding Medicaid has positive effects on women's use of healthcare.

Pharmacist prescription and access to hormonal contraception for Medicaid-insured women in Oregon.

OBJECTIVE: To assess the impact of Oregon's policy that allows pharmacist prescription of the pill and patch on contraceptive receipt for Medicaid-insured women. STUDY DESIGN: We conducted a difference-in-differences analysis using Oregon Medicaid claims data to compare changes in receipt of all contraceptive services and receipt of the pill or patch for Medicaid-enrolled women (n = 436,258) before and after policy implementation in areas with and without participating pharmacists. We then described filled prescriptions for the contraceptive pill and patch by type of prescribing provider before and after implementation of the policy. We also compared past contraceptive use for women receiving prescriptions from pharmacists and non-pharmacists. RESULTS: We found no significant policy effects on receipt of all contraceptive services or on receipt of the pill or patch. More than 98% of prescriptions filled for the pill and patch in the first two years of policy implementation were prescribed by a non-pharmacist provider. Women receiving contraceptive pill and patch prescriptions from pharmacists and non-pharmacists were equally likely to be continuing contraceptive users. CONCLUSION: We identified no increase in receipt of contraceptive services among Medicaid-insured women in the two years following the implementation of a pharmacy access policy. Additional research is needed to investigate other possible benefits of the policy, such as satisfaction, convenience, cost and equity. IMPLICATIONS: We identified no effect of allowing pharmacist prescription of the contraceptive pill and patch on increasing utilization of contraceptive services for Medicaid-insured women in Oregon. Impacts on access to contraceptive services and unintended pregnancy may emerge in subsequent years as availability of and demand for pharmacist-prescribed hormonal contraception increases.

Development and validation of a claims-based measure of abortion services.

RATIONALE: Data on abortion services are critical for monitoring trends in access and utilization, evaluating policies, and examining a wide range of research questions. Accurate and timely data, however, can be difficult to obtain for abortion services. Oregon is one of several states that use state funds to finance abortion services in their Medicaid programmes. Oregon's Medicaid programme contracts with managed care plans that receive global budgets to provide care. Abortion services, however, must be billed directly to the state through fee-for-service (FFS) billing to ensure that federal funds are not used. In this study, we identify possible abortions using Medicaid insurance claims data from Oregon and categorize identified abortions as high, medium, or low confidence according to convergent validity analysis of FFS billing. METHODS: We used individually linked Medicaid eligibility and claims data from women ages 15 to 44 enrolled in Oregon's Medicaid programme from 2008 to 2013. Abortion-related Medicaid claims were identified and categorized based on diagnosis, procedure, and drug codes. These categories were assessed for convergent validity by examining FFS billing for possible abortions to women enrolled in managed care plans. RESULTS: In total, 23 763 possible abortions obtained by 18 518 women were classified with high (n = 21 450), medium (n = 562), and low (n = 1751) confidence. Among managed care abortions, more than 99% of high confidence abortions were billed on an FFS basis compared with 72% of medium confidence and <1% of low confidence abortions. The majority of high confidence abortions were to urban-residing (89%) white (73%) women. CONCLUSIONS: Research on abortion services using insurance claims has important implications for women's health care and public health policy. A high-quality claims-based measure can facilitate monitoring the provision of abortion services within health systems and evaluation of initiatives to increase equitable abortion access.

Evaluating the effect of Medicaid expansion on access to preventive reproductive care for women in Oregon.

We evaluated the effect of the Affordable Care Act (ACA) Medicaid expansion on receipt of preventive reproductive services for women in Oregon. First, we compared service receipt among continuing Medicaid enrollees pre- and post-ACA. We then compared receipt among new post-ACA Medicaid enrollees to receipt by continuing enrollees after ACA implementation. Using Medicaid enrollment and claims data, we identified well-woman visits, contraceptive counseling, contraceptive services, sexually transmitted infection (STI) screening, and cervical cancer screening among women ages 15-44 in years when not pregnant. For pre-ACA enrollees, we assessed pre-ACA receipt in 2011-2013 (n = 83,719) and post-ACA receipt in 2014-2016 (n = 103,225). For post-ACA enrollees we similarly assessed post-ACA service receipt (n = 73,945) and compared this to service receipt by pre-ACA enrollees during 2014-2016. We estimated logistic regression models to compare service receipt over time and between enrollment groups. Among pre-ACA enrollees we found lower receipt of all services post-ACA. Adjusted declines ranged from 7.0 percentage points (95% CI: -7.5, -6.4) for cervical cancer screening to 0.4 percentage points [-0.6, -0.2] for STI screening. In 2014-2016, post-ACA enrollees differed significantly from pre-ACA enrollees in receipt of all services, but all differences were <2 percentage points. Despite small declines in receipt of several preventive reproductive services among prior enrollees, the ACA resulted in Medicaid financing of these services for a large number of newly enrolled low-income women in Oregon, which may eventually lead to population-level improvements in reproductive health. These findings among women in Oregon could inform Medicaid coverage efforts in other states.

Sexual activity and weekly contraceptive use among young adult women in Michigan.

Past studies on the influence of sexual activity on contraceptive behaviours are inconclusive, relying heavily on cross-sectional data. We used a population-based longitudinal sample of young women in Michigan to evaluate weekly associations between sexual activity and contraceptive use at three levels of measurement: comparing between women, among individual women's partnerships, and from week to week within partnerships. We used multinomial logistic regression accounting for correlations within partnerships and women. Relative to use of least effective methods, weekly sexual activity was significantly associated with increased use of condoms, pills, and highly effective methods. For pills and highly effective methods, partnership-, woman-, and week-level effects were similar. For condoms, there was no significant woman-level effect. Evidence of immediate effects of sexual activity on contraceptive use highlights the importance of longitudinal data. These dynamics may be diluted or missed altogether when relying on cross-sectional data approaches that compare groups of individuals.

Sexual Activity and Weekly Contraceptive Discontinuation and Selection Among Young Adult Women in Michigan.

Understanding young women's contraceptive and pregnancy prevention behaviors is important for helping women and their partners control if and when they have children. Prior research on associations between patterns of sexual activity and contraceptive behaviors is limited. We assessed the influence of recent sexual activity on discontinuation and selection of specific contraceptive methods. We used weekly data from the Relationship Dynamics and Social Life (RDSL) study, a longitudinal 2.5-year population-based project that sampled woman ages 18 and 19 (N = 1,003) in one Michigan county. We estimated logistic and multinomial regression models that accounted for clustering of weekly observations within partnerships and women. Weekly discontinuation of longer-acting methods declined with increasing sexual activity in the past month, as did discontinuation of shorter-acting hormonal methods. Sexual activity was associated with decreased selection of condoms relative to other methods. Future research into life events that lead to changes in the frequency of sexual activity may provide insight into times when women are at risk of contraceptive discontinuation. These findings underscore the importance of anticipatory guidance in contraceptive counseling so that when women change their contraceptive behavior they are equipped in advance with resources to make safe transitions between methods.

Does it take a village? Fostering gender equity among early adolescents in Nepal.

Background Gender inequity contributes to a range of poor health outcomes. Early adolescence presents a window of opportunity for gender transformative interventions to shift inequitable gender norms, attitudes and behaviors. Objective The objective of this study is to evaluate a set of individual, family and community interventions to increase gender equity among very young adolescents (VYAs) in rural Nepal. Methods Two communities received the individual-level Choices intervention as well the family and community Voices and Promises interventions (CVP). Two comparison communities received only Choices. Samples of 1200 VYAs and 600 parents were interviewed at baseline before implementation and at end line 1 year later. Results In both CVP and Choices only areas most measures of gender norms, attitudes, and behaviors improved, suggesting a positive effect of the individual-level intervention. Increases in norms, attitudes, and behaviors reported by VYAs were generally greater in CVP areas compared to Choices areas, suggesting an added benefit from the family and community interventions. Parent-reported measures did not demonstrate an intervention effect of the family and community interventions. Uneven evaluation results, particularly among parents, may reflect implementation challenges such as the compressed 3-month intervention period due to the 2015 earthquakes and subsequent political unrest. Conclusion Overall findings are encouraging and suggest that adding family and community interventions may improve gender equity.

Sexual and Reproductive Health Care Receipt Among Young Males Aged 15-24.

PURPOSE: This study aimed to describe young men's sexual and reproductive health care (SRHC) receipt by sexual behavior and factors associated with greater SRHC receipt. METHODS: There were 427 male patients aged 15-24 who were recruited from 3 primary care and 2 sexually transmitted disease (STD) clinics in 1 urban city. Immediately after the visit, the survey assessed receipt of 18 recommended SRHC services across four domains: screening history (sexual health, STD/HIV test, family planning); laboratories (STDs/HIV); condom products (condoms/lubrication); and counseling (STD/HIV risk reduction, family planning, condoms); in addition, demographic, sexual behavior, and visit characteristics were examined. Multivariable Poisson regressions examined factors associated with each SRHC subdomain adjusting for participant clustering within clinics. RESULTS: Of the participants, 90% were non-Hispanic black, 61% were aged 20-24, 90% were sexually active, 71% had female partners (FPs), and 20% had male or male and female partners (M/MFPs). Among sexually active males, 1 in 10 received all services. Half or more were asked about sexual health and STD/HIV tests, tested for STDs/HIV, and were counseled on STD/HIV risk reduction and correct condom use. Fewer were asked about family planning (23%), were provided condom products (32%), and were counseled about family planning (35%). Overall and for each subdomain, never sexually active males reported fewer services than sexually active males. Factors consistently associated with greater SRHC receipt across subdomains included having M/MFPs versus FPs, routine versus non-STD-acute visit, time alone with provider without parent, and seen at STD versus primary care clinic. Males having FPs versus M/MFPs reported greater family planning counseling. CONCLUSIONS: Findings have implications for improving young men's SRHC delivery beyond the narrow scope of STD/HIV care.

'Yeah, I've grown; I can't go out anymore': differences in perceived risks between girls and boys entering adolescence.

This analysis is based on data from the Global Early Adolescent Study, which aims to understand the factors that predispose young people aged 10-14 years to positive or negative health trajectories. Specifically, interview transcripts from 202 adolescents and 191 parents across six diverse urban sites (Baltimore, Ghent, Nairobi, Ile Ife, Assuit and Shanghai) were analysed to compare the perceived risks associated with entering adolescence and how these risks differed by gender. Findings reveal that in all sites except Ghent, both young people and their parents perceived that girls face greater risks related to their sexual and reproductive health, and because of their sexual development, were perceived to require more protection. In contrast, when boys grow up, they and their parents recognised that their independence broadened, and parents felt that boys were strong enough to protect themselves. This has negative consequences as well, as boys were perceived to be more prone to risks associated with street violence and peer pressure. These differences in perceptions of vulnerability and related mobility are markers of a gender system that separates young women and men's roles, responsibilities and behaviours in ways that widen gender power imbalance with lifelong social and health consequences for people of both sexes.

Perceived partner fertility desires and influence on contraceptive use.

BACKGROUND: Perceived discordance of fertility desires may be more common among couples with certain sociodemographic characteristics and may lead to lower contraceptive use. METHODS: Using nationally representative data from adults ages 15-49 in France in 2010, we analysed associations between sociodemographic characteristics, perceived discordance of fertility desires and contraceptive use with design-based logistic regression. RESULTS: Only 8% of participants perceived discordant fertility desires while 92% perceived concordance with partner fertility desire. Discordance varied by age and relationship duration and by the presence of children from previous relationships. Perceived discordance was not associated with use of a hormonal or highly effective method. Beyond own intentions, perception of a partner's fertility desires was associated with using a highly effective method among participants using any method. CONCLUSIONS: Engaging men and couples in family planning programmes may be important for achieving both partners' desired fertility goals.

Do Nonclinical Community-Based Youth-Serving Professionals Talk With Young Men About Sexual and Reproductive Health and Intend to Refer Them for Care?

Young men (ages 15-24) may benefit from community-based connections to care since many have sexual and reproductive health (SRH) needs and low care use. This study describes nonclinical community-based youth-serving professionals' (YSPs) SRH knowledge, confidence, past behaviors, and future intentions to talk with young men about SRH and refer them to care, and examines factors associated with care referral intentions. YSPs ( n = 158) from 22 settings in one mid-Atlantic city answered questions about the study's goal, their demographics and work environment from August 2014 to December 2015. Poisson regression assessed factors associated with YSPs' care referral intentions. On average, YSPs answered 58% of knowledge questions correctly, knew 5 of 8 SRH care dimensions of where to refer young men, and perceived being somewhat/very confident talking with young men about SRH (63%) and referring them to care (77%). During the past month, the majority (63%) talked with young men about SRH but only one-third made care referrals; the majority (66%) were somewhat/very likely to refer them to care in the next 3 months. Adjusted models indicated YSPs were more likely to refer young men if they had a very supportive work environment to talk about SRH (adjusted RR = 1.51, 95% CI [1.15, 1.98]), greater confidence in SRH care referral (1.28 [1.00, 1.62]), and greater SRH care referrals in the past month (1.16 [1.02, 1.33]). Nonclinical community-based YSPs have poor-to-moderate knowledge about young men's SRH care, and less than one-third reported referrals in the past month. Findings have implications for educating YSPs about young men's SRH care.

Long-Acting Reversible Contraception Counseling and Use for Older Adolescents and Nulliparous Women.

PURPOSE: The majority of pregnancies during adolescence are unintended, and few adolescents use long-acting reversible contraception (LARC) due in part to health care providers' misconceptions about nulliparous women's eligibility for the intrauterine device. We examined differences in LARC counseling, selection, and initiation by age and parity in a study with a provider's LARC training intervention. METHODS: Sexually active women aged 18-25 years receiving contraceptive counseling (n = 1,500) were enrolled at 20 interventions and 20 control clinics and followed for 12 months. We assessed LARC counseling and selection, by age and parity, with generalized estimated equations with robust standard errors. We assessed LARC use over 1 year with Cox proportional hazards models with shared frailty for clustering. RESULTS: Women in the intervention had increased LARC counseling, selection, and initiation, with similar effects among older adolescent and nulliparous women, and among young adult and parous women. Across study arms, older adolescents were as likely as young adults to receive LARC counseling (adjusted odds ratio [aOR] = .85; 95% confidence interval [CI]: .63-1.15), select LARC (aOR = .86; 95% CI: .64-1.17), and use LARC methods (adjusted hazard ratio [aHR] = .94; 95% CI: .69-1.27). Nulliparous women were less likely to receive counseling (aOR = .57; 95% CI: .42-.79) and to select LARC (aOR = .53; 95% CI: .37-.75) than parous women, and they initiated LARC methods at lower rates (aHR = .65; 95% CI: .48-.90). Nulliparous women had similar rates of implant initiation but lower rates of intrauterine device initiation (aHR = .59; 95% CI: .41-.85). CONCLUSIONS: Continued efforts should be made to improve counseling and access to LARC methods for nulliparous women of all ages.