Characteristics of U.S. Abortion Patients Who Obtained Care Out of State Prior to the Overturning of Roe v. Wade.

CONTEXT: In light of the Dobbs v. Jackson Women's Health Organization decision overturning Roe v. Wade, the number of people who need to travel out of state for abortion is increasing as several states impose abortion bans. Better understanding the characteristics of patients who obtained out-of-state abortions before the decision can provide a reference point for future research and inform efforts to improve abortion access. METHODS: We used data from the 2014 Abortion Patient Survey, administered by the Guttmacher Institute, to examine the prevalence and characteristics of patients obtaining nonhospital abortions outside of their state of residence. We examined bivariate and multivariable associations between selected characteristics and obtaining an abortion out of state. RESULTS: Six percent of abortion patients traveled out of state for care. Among patients who obtained their abortion out of state, more than half (56.9%) were non-Hispanic (NH) white, 26.6% were non-Hispanic Black, and 10.2% were Hispanic. Two-fifths (43.9%) resided in the South, one-third (34.3%) resided in the Midwest, 15% resided in the Northeast, and 7% resided in the West. More than one-third (38.2%) had family incomes below 100% of the federal poverty level (FPL), and two-thirds (67.7%) paid out of pocket; only 3% used Medicaid. Profiles of out-of-state abortion patients differed from in-state abortion patients by all characteristics except age. In adjusted analyses, NH Black (adjusted odds ratio [AOR]: 0.76; 95% confidence interval [CI]: 0.61-0.96), NH Asian, South Asian, and Asian Pacific Islander (AOR: 0.37; 95% CI: 0.20-0.67), and Hispanic (AOR: 0.46; 95% CI: 0.33-0.64) patients had lower odds of traveling out of state compared with their NH white counterparts. Compared with those paying for their abortion with private insurance, those who paid out of pocket had higher odds of traveling out of state (AOR: 1.75; 95% CI: 1.29-2.37) and those paying with Medicaid had lower odds (AOR: 0.27; 95% CI: 0.15-0.47). CONCLUSION: Given the observed differences by race/ethnicity and method of payment for abortion, people of color and those without resources to pay out of pocket may especially benefit from efforts to support access to abortion care via interstate travel as an increasing number of states ban abortion.

Catalyzing Technology-Based Innovation in Teen Pregnancy Prevention: an Implementation Model and Findings from a Human-Centered Design Initiative.

From 2015 to 2021, the US Department of Health and Human Services' Teen Pregnancy Prevention (TPP) program funded Power to Decide, a national reproductive health nonprofit organization, to catalyze innovation in adolescent sexual and reproductive health through the development of technology-based interventions. Power to Decide's initiative, Innovation Next, supported twenty innovation teams in using human-centered design (HCD) to develop new products, services, and programs. We describe the Innovation Next implementation model, which can inform future efforts to develop innovative, technology-based TPP programs using HCD. To that end, we draw on quantitative and qualitative data collected for program improvement to summarize key implementation findings.

Is the COVID-19 Pandemic Continuing to Impact Sexual and Reproductive Health Services for Adolescents? Findings From a 2021 Survey of US Physicians.

PURPOSE: We examined the impact of the COVID-19 pandemic in Fall 2021 on sexual and reproductive health (SRH) services among physicians whose practice provided these services to adolescents just before the pandemic. METHODS: Data were from the DocStyles online panel survey administered September-November 2021 to US physicians who reported their practice provided SRH services to adolescent patients before the pandemic (n = 948). We calculated prevalence of service delivery challenges (e.g., limited long-acting reversible contraception services) and use of strategies to support access (e.g., telehealth) in the month prior to survey completion, compared these estimates with prevalence "at any point during the COVID-19 pandemic", and examined differences by physician specialty and adolescent patient volume. RESULTS: Fewer physicians reported their practice experienced service delivery challenges in the month prior to survey completion than at any point during the pandemic. About 10% indicated limited long-acting reversible contraception and sexually transmitted infection testing services in the prior month overall; prevalence varied by physician specialty (e.g., 26% and 17%, respectively by service, among internists). Overall, about 25% of physicians reported reductions in walk-in hours, weekend/evening hours, and adolescents seeking care in the prior month. While most practices that initiated strategies supporting access to services during the pandemic used such strategies in the prior month, some practices (22%-37% depending on the strategy) did not. DISCUSSION: Findings suggest some physicians who serve adolescents continued to experience challenges providing SRH services in the Fall 2021, and some discontinued strategies to support access that had been initiated during the pandemic.

Provider Facilitation of Parent-Adolescent Health Communication: Findings From a National Survey.

INTRODUCTION: Primary care providers are well-positioned to facilitate parent-adolescent health communication. We examined provider-facilitated parent-adolescent health communication prevalence and associations with parent-adolescent health communication. METHOD: Using data from a national survey of parent-adolescent dyads (n = 853), we calculated the prevalence of provider-facilitated parent-adolescent health communication about 11 topics as a result of adolescent's last preventive visit. We examined correlates of of provider-facilitatedparent-adolescent communication and associations with with parent-adolescent communication. RESULTS: Eighteen percent of adolescents reported that a provider helped them talk with their parent about a health concern, with little variability by adolescent, parent, or provider characteristics. Prevalence of parent-adolescent communication because of an adolescent's last preventive visit ranged between 38.4% and 79.5%. Provider facilitation was positively associated with parent-adolescent communication for all topics. DISCUSSION: Given the low prevalence of provider-facilitated-parent-adolescent health communication and positive associations between provider facilitation and parent-adolescent communication about multiple important health-related topics, efforts to improve this practice could be beneficial.

Trends in the teaching of sexual and reproductive health topics and skills in required courses in secondary schools, in 38 US states between 2008 and 2018.

Information about state and local education policies regarding sexually transmitted infections, including human immunodeficiency virus, and unintended pregnancy prevention is available, yet less is known about school-level implementation of such policies. We examine trends in the percentage of US secondary schools teaching sexual and reproductive health (SRH) topics in a required course in Grades 6-8 and 9-12, including healthy relationships, sexual abstinence, condoms and condoms with other contraceptive methods. We analyze representative data from 38 states across six cycles of School Health Profiles (2008-18) assessed through self-administered questionnaires completed by lead health teachers. Logistic regression models examined linear trends in the percentages of schools teaching topics for Grades 6-8 and 9-12, separately. Trends were calculated for states having representative data for at least three cycles, including 2018. During 2008-18, it was more common to have increases in teaching how to obtain condoms, correct condom use and use condoms with other contraceptive methods in Grades 6-12 than decreases. More states showed decreases in teaching abstinence in Grades 6-12 than increases. Most states had no change in teaching SRH topics across grades. Findings suggest some improvement in school-based SRH education, yet efforts are needed to improve comprehensive, developmentally appropriate content.

Annual STI Testing Among Sexually Active Adolescents.

OBJECTIVES: National guidelines call for annual testing for certain sexually transmitted infections (STIs) among specific adolescent populations, yet we have limited population-based data on STI testing prevalence among adolescents. With inclusion of a new item in the 2019 national Youth Risk Behavior Survey, we provide generalizable estimates of annual STI testing among sexually active high school students. METHODS: We report weighted prevalence estimates of STI testing (other than HIV) in the past 12 months among sexually active students (n = 2501) and bivariate associations between testing and demographic characteristics (sex, age, race and ethnicity, sexual identity, and sex of sexual contact). Multivariable models stratified by sex and adjusted for demographics examine the relationships between testing and sexual behaviors (age of initiation, number of sex partners, condom nonuse at last sexual intercourse, and substance use at last sexual intercourse). RESULTS: One-fifth (20.4%) of sexually active high school students reported testing for an STI in the previous year. A significantly higher proportion of female (26.1%) than male (13.7%) students reported testing. Among female students, prevalence differed by age (≤15 years = 12.6%, age 16 = 22.8%, age 17 = 28.5%, or ≥18 years = 36.9%). For male students, there were no differences by demographic characteristics, including sexual identity, but most sexual risk behaviors were associated with increased likelihood of STI testing (adjusted prevalence ratios ranging from 1.48 to 2.47). CONCLUSIONS: Low prevalence of STI testing suggests suboptimal adherence to national guidelines, particularly for sexually active adolescent females and young men who have sex with men who should be tested for Chlamydia and gonorrhea annually.

Improving Access to and Quality of Sexual and Reproductive Health Services for Adolescents in the United States.

Equitable access to high quality adolescent sexual and reproductive health (ASRH) services can help reduce unintended pregnancies, sexually transmitted diseases, and disparities in these outcomes. The Centers for Disease Control and Prevention (CDC), Division of Reproductive Health, has a long history of working to improve access to and quality of ASRH services through applied research and public health practice. This report from CDC summarizes the evolution of these efforts from more than a decade of work-from community-based demonstration projects to an initiative to support wide-scale implementation. We describe a community-wide teen pregnancy prevention program model that includes a component addressing ASRH services (2010-2015), focused efforts related to quality improvement (QI) of and community-clinic linkages to ASRH services (2015-2020), and the development of a QI package that collates implementation strategies and tools to improve ASRH services (2020-2022). We conclude by discussing future directions. In disseminating key strategies and resources from this work, we aim to support broader public health and clinical efforts to strengthen ASRH care in the United States in ways that promote health equity.

Parents' Sources of Adolescent Sexual Health Information and Their Interest in Resources From Primary Care.

OBJECTIVE: To examine sources of information used by parents to facilitate parent-adolescent communication about sexual and reproductive health (SRH), parents' preferences for receiving SRH information through primary care, and factors associated with parents' interest in primary-care-based SRH information (ie, resources recommended or offered in the primary care setting). METHODS: In this cross-sectional study, a nationally representative sample of 11-17-year-old adolescents and their parents (n = 1005 dyads) were surveyed online; 993 were retained for these analyses. Parents were asked about their use of 11 resources to help them talk with their adolescents about SRH and rated the likelihood of using specific primary-care-based resources. We used multivariable logistic regression to examine characteristics associated with parent interest in primary-care-based SRH resources. RESULTS: Only 25.8% of parents reported receiving at least a moderate amount of SRH information from primary care; half (53.3%) reported receiving no SRH information from their adolescent's provider. Parents received the most information from personal connections (eg, spouse/partner, friends). Most parents (59.1%) reported being likely to utilize a primary-care-based resource for SRH information. Parents who previously received SRH information from primary care sources had greater odds of reporting they would be likely to utilize a primary-care-based resources (AOR = 4.06, 95% CI: 2.55-6.46). CONCLUSIONS: This study provides insights into parents' sources of information for communicating with their adolescents about SRH and ways primary care practices might increase support for parents in having SRH conversations with their adolescents. Future studies are needed to establish clinical best practices for promoting parent-adolescent communication about SRH.

Correlates of Sexual and Reproductive Health Discussions During Preventive Visits: Findings From a National Sample of U.S. Adolescents.

PURPOSE: This study examines characteristics of healthcare delivery, providers, and adolescents associated with provider-adolescent discussions about sexual and reproductive health (SRH) during preventive visits. METHODS: Data were from a 2019 national internet survey of U.S. adolescents ages 11-17 years and their parents. Adolescents who had a preventive visit in the past 2 years (n = 853) were asked whether their provider discussed each of eight SRH topics at that visit: puberty, safe dating, gender identity, sexual orientation, whether or not to have sex, sexually transmitted infections including human immunodeficiency virus, birth control methods, and where to get SRH services. Eight multivariable logistic regression models were examined (one for each SRH topic as the outcome), with each model including modifiable healthcare delivery and provider characteristics, adolescent beliefs, behaviors, and demographic characteristics as potential correlates. RESULTS: Provider-adolescent discussions about SRH topics at the last preventive visit were positively associated with face-to-face screening about sexual activity for all eight topics (range of adjusted odds ratios [AORs] = 3.40-9.61), having time alone with the adolescent during that visit (seven topics; AORs = 1.87-3.87), and ever having communicated about confidentiality with adolescents (two topics; AORs = 1.88-2.19) and with parents (one topic; AOR = 2.73). Adolescents' perception that a topic was important to discuss with their provider was associated with provider-adolescent discussions about seven topics (AORs = 2.34-5.46). CONCLUSIONS: Findings that provider-adolescent discussions about SRH during preventive visits were associated with modifiable practices including time alone between providers and adolescents and screening about sexual activity can inform efforts to improve the delivery of adolescent SRH services within primary care.

Long-Acting Reversible Contraception, Condom Use, and Sexually Transmitted Infections: A Systematic Review and Meta-analysis.

INTRODUCTION: Given mixed findings regarding the relationship between long-acting reversible contraception and condom use, this systematic review and meta-analysis synthesizes studies comparing sexually transmitted infection‒related outcomes between users of long-acting reversible contraception (intrauterine devices, implants) and users of moderately effective contraceptive methods (oral contraceptives, injectables, patches, rings). METHODS: MEDLINE, Embase, PsycINFO, Global Health, CINAHL, Cochrane Library, and Scopus were searched for articles published between January 1990 and July 2018. Eligible studies included those that (1) were published in the English language, (2) were published in a peer-reviewed journal, (3) reported empirical, quantitative analyses, and (4) compared at least 1 outcome of interest (condom use, sexual behaviors other than condom use, sexually transmitted infection‒related service receipt, or sexually transmitted infections/HIV) between users of long-acting reversible contraception and users of moderately effective methods. In 2020, pooled ORs were calculated for condom use, chlamydia/gonorrhea infection, and trichomoniasis infection; findings for other outcomes were synthesized qualitatively. The protocol is registered on the International Prospective Register of Systematic Reviews (CRD42018109489). RESULTS: A total of 33 studies were included. Long-acting reversible contraception users had decreased odds of using condoms compared with oral contraceptive users (OR=0.43, 95% CI=0.30, 0.63) and injectable, patch, or ring users (OR=0.58, 95% CI=0.48, 0.71); this association remained when limited to adolescents and young adults only. Findings related to multiple sex partners were mixed, and only 2 studies examined sexually transmitted infection testing, reporting mainly null findings. Pooled estimates for chlamydia and/or gonorrhea were null, but long-acting reversible contraception users had increased odds of trichomoniasis infection compared with oral contraceptive users (OR=2.01, 95% CI=1.11, 3.62). DISCUSSION: Promoting condom use specifically for sexually transmitted infection prevention may be particularly important among long-acting reversible contraception users at risk for sexually transmitted infections, including adolescents and young adults.

Sexual and Reproductive Health Discussions During Preventive Visits.

OBJECTIVES: To quantify adolescent- and parent-perceived importance of provider-adolescent discussions about sexual and reproductive health (SRH), describe prevalence of provider confidentiality practices and provider-adolescent discussions about SRH topics during preventive visits, and identify missed opportunities for such conversations. METHODS: We used data from a national Internet survey of 11- to 17-year-old adolescents and their parents. Data were weighted to represent the noninstitutionalized US adolescent population. Adolescents who had a preventive visit in the past 2 years and their parents reported on perceived importance of provider-adolescent discussions about SRH topics: puberty, safe dating, gender identity, sexual orientation, sexual decision-making, sexually transmitted infections and HIV, methods of birth control, and where to get SRH services. Adolescents and parents reported whether they had ever discussed confidentiality with the adolescent's provider. Adolescents reported experiences at their most recent preventive visit, including whether a provider spoke about specific SRH topics and whether they had time alone with a provider. RESULTS: A majority of adolescents and parents deemed provider-adolescent discussions about puberty, sexually transmitted infections and HIV, and birth control as important. However, fewer than one-third of adolescents reported discussions about SRH topics other than puberty at their most recent preventive visit. These discussions were particularly uncommon among younger adolescents. Within age groups, discussions about several topics varied by sex. CONCLUSIONS: Although most parents and adolescents value provider-adolescent discussions of selected SRH topics, these discussions do not occur routinely during preventive visits. Preventive visits represent a missed opportunity for adolescents to receive screening, education, and guidance related to SRH.

COVID-19 and Sexual and Reproductive Health Care: Findings From Primary Care Providers Who Serve Adolescents.

PURPOSE: Among U.S. primary care physicians who delivered sexual and reproductive health (SRH) services to adolescents before the COVID-19 pandemic, we examine (1) changes in availability of in-person SRH services; (2) changes in accessibility and utilization of SRH services; and (3) use of strategies to support provision of SRH services during the pandemic. METHODS: Data were from the DocStyles provider survey administered September-October 2020. Descriptive analyses were restricted to family practitioners, internists, and pediatricians whose main work setting was outpatient and whose practice provided family planning or sexually transmitted infection services to ≥ one patient aged 15-19 years per week just before the COVID-19 pandemic (n = 791). RESULTS: Among physicians whose practices provided intrauterine device/implant placement/removal or clinic-based sexually transmitted infection testing before the COVID-19 pandemic, 51% and 36% indicated disruption of these services during the pandemic, respectively. Some physicians also reported reductions in walk-in hours (38%), evening/weekend hours (31%), and adolescents seeking care (43%) in the past month. At any point during the pandemic, 61% provided contraception initiation/continuation and 44% provided sexually transmitted infection services via telehealth. Among these physicians, about one-quarter reported confidentiality concerns with telehealth in the past month. There were small increases or no changes in other strategies to support contraceptive care. CONCLUSIONS: Findings suggest disruption of certain SRH services and issues with access because of the pandemic among primary care providers who serve adolescents. There are opportunities to enhance implementation of confidential telehealth services and other service delivery strategies that could help promote adolescent SRH in the United States.

COVID-19 and family planning service delivery: Findings from a survey of U.S. physicians.

Equitable access to contraception is critical for reproductive autonomy. Using cross-sectional data from the DocStyles survey administered September-October 2020 (68% response rate), we compared changes in family planning-related clinical services and healthcare delivery strategies before and during the COVID-19 pandemic and assessed service provision issues among 1063 U.S. physicians whose practice provided family planning services just before the pandemic. About one-fifth of those whose practices provided the following services or strategies just before the pandemic discontinued these services during the pandemic: long-acting reversible contraception (LARC) placement (16%); LARC removal (17%); providing or prescribing emergency contraceptive pills (ECPs) in advance (18%); and reminding patients about contraception injections or LARC removal or replacement (20%). Many practices not providing the following services or strategies just before the pandemic initiated these services during the pandemic: telehealth for contraception initiation (43%); telehealth for contraception continuation (48%); and renewing contraception prescriptions without requiring an office visit (36%). While a smaller proportion of physicians reported service provision issues in the month before survey completion than at any point during the pandemic, about one-third still reported fewer adult females seeking care (37%) and technical challenges with telehealth (32%). Discontinuation of key family planning services during the COVID-19 pandemic may limit contraception access and impede reproductive autonomy. Implementing healthcare service delivery strategies that reduce the need for in-person visits (e.g., telehealth for contraception, providing or prescribing ECPs in advance) may decrease disruptions in care. Resources exist for public health and clinical efforts to ensure contraception access during the pandemic.

Perspectives of Transgender Youth on Parental Support: Qualitative Findings From the Resilience and Transgender Youth Study.

Transgender youth are more likely than cisgender youth to report health risks related to violence victimization, substance use, mental health, and sexual health. Parental support may help foster resilience and better health outcomes among this population. However, limited research has characterized parental support among transgender youth. To address this gap, we conducted a thematic analysis of 33 in-depth interviews with transgender youth. We coded interviews using the dimensions of the social support framework (i.e., emotional, instrumental, appraisal, and informational) as well as inductive codes to identify emergent themes. Almost all participants described some form of general parental support (e.g., expressions of love, housing, advice, and affirmation). Parental support specific to gender identity was also noted (e.g., emotional support for coming out as transgender and chosen name and pronoun use) but was more limited. Parents may benefit from resources and programming to promote acceptance and gender-affirming behaviors.

Truth Be Told: Adolescents' Disclosure of Sexual Activity to Healthcare Providers.

PURPOSE: The purpose of this study was to describe whether adolescent and young adult patients truthfully disclose sexual activity to providers during a sexual history and explore associations between disclosure and receipt of recommended services. METHODS: Data from the 2018 National Survey of Sexual Health and Behavior were used to describe self-reported disclsoure of sexually active 14- to 24-year-olds who had a health care visit in the previous year where a sexual history was taken (n = 196). We examined bivariate associations between disclosure and age, race/ethnicity, sex, sexual identity, and receipt of sexual health services. RESULTS: Most (88%) respondents reported telling their provider the truth about sexual activity. A higher proportion of the younger adolescents (14- to 17-year-olds) did not disclose compared with the 18- to 24-year-old respondents (25.4% vs 3.9%; p < .001). A higher proportion of patients who disclosed reported having a sexually transmitted disease test (69.6% vs 26.7%; p < .001); being offered a sexually transmitted disease test (44.3% vs 4.5%; p < .001); and being asked by providers about number of partners (54.3% vs 15.4%; p < .01). CONCLUSIONS: Most young patients disclose their sexual history to their provider, but younger patients might be less likely to do so. Positive patient-provider relationships may encourage disclosure of sexual activity and support receipt of indicated sexual and reproductive health services.

"We Deserve Care and we Deserve Competent Care": Qualitative Perspectives on Health Care from Transgender Youth in the Southeast United States.

PURPOSE: Transgender populations experience health inequities that underscore the importance of ensuring access to high quality care. We thematically summarize the health care experiences of transgender youth living in the southeast United States to identify potential barriers and facilitators to health care. DESIGN AND METHODS: Transgender youth recruited from community settings in an urban area of the southeast United States participated in individual interviews (n = 33) and focus groups (n = 9) about protective factors. We conducted a thematic analysis of data from 42 participants who described their experiences seeking and receiving health care. RESULTS: Participants reported a wide range of gender identities. The individual interview sample was majority Black (54.5%) and the mean age was 21.7 years and focus group participants were all white and the mean age was 16.8 years. Participants described numerous barriers to health care, including limited availability of gender affirming care, logistical challenges, such as gatekeeping and cost, concerns about confidentiality in relation to sexual behavior and gender identity, and inadequate cultural competency among providers regarding gender-affirming care. Facilitators included intake procedures collecting chosen pronouns and names and consistent use of them by providers, and open communication, including active listening. CONCLUSIONS: Findings underscore the need for a multi-component approach to ensure both transgender- and youth-friendly care. PRACTICE IMPLICATIONS: Providers and office staff may benefit from transgender cultural competency trainings. In addition, clinic protocols relating to confidentiality and chosen name and pronoun use may help facilitate access to and receipt of quality care.

Condom and Contraceptive Use Among Sexually Active High School Students - Youth Risk Behavior Survey, United States, 2019.

Preventing unintended pregnancy and sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV) infection, among adolescents is a public health priority. This report presents prevalence estimates for condom and contraceptive use among sexually active U.S. high school students from the 2019 Youth Risk Behavior Survey. Behaviors examined included any condom use, primary contraceptive method use, and condom use with a more effective contraceptive method, all reported at last sexual intercourse. Analyses were limited to sexually active students (i.e., those who had sexual intercourse with one or more persons during the 3 months before the survey). Except for any condom use, students reporting only same-sex sexual contact were excluded from analyses. Weighted prevalence estimates were calculated, and bivariate differences in prevalence were examined by demographic characteristics (sex, race/ethnicity, and grade) and other sexual risk behaviors (age of sexual initiation, previous 3-month and lifetime number of sex partners, and substance use before last sexual intercourse). Nationwide, 27.4% of high school students reported being sexually active (n = 3,226). Among sexually active students who reported having had sexual contact with someone of the opposite sex (n = 2,698), most students (89.7%) had used a condom or a primary contraceptive method at last sexual intercourse. Prevalence of any condom use at last sexual intercourse was 54.3%, and condoms were the most prevalent primary contraceptive method (43.9% versus 23.3% for birth control pills; 4.8% for intrauterine device [IUD] or implant; and 3.3% for shot, patch, or ring). Approximately 9% had used condoms with an IUD, implant, shot, patch, ring, or birth control pills. Using no pregnancy prevention method was more common among non-Hispanic black (23.2%) and Hispanic (12.8%) students compared with non-Hispanic white students (6.8%); compared with Hispanic students, using no pregnancy prevention method was more common among non-Hispanic black students. Prevalence of condom use was consistently lower among students with other sexual risk behaviors. Results underscore the need for public health professionals to provide quality sexual and reproductive health education and clinical services for preventing unintended pregnancy and STDs/HIV and decreasing disparities among sexually active youths.

Understanding Primary Care Providers' Perceptions and Practices in Implementing Confidential Adolescent Sexual and Reproductive Health Services.

PURPOSE: Substantial gaps exist between professional guidelines and practice around confidential adolescent services, including private time between health-care providers and adolescents. Efforts to provide quality sexual and reproductive health services (SRHS) require an understanding of barriers and facilitators to care from the perspectives of primary care providers working with adolescents and their parents. METHODS: We conducted structured qualitative interviews with a purposive sample of pediatricians, family physicians, and nurse practitioners (n = 25) from urban and rural Minnesota communities with higher and lower rates of adolescent pregnancy. Provider interviews included confidentiality beliefs and practices; SRHS screening and counseling; and referral practices. RESULTS: The analysis identified two key themes: (1) individual and structural factors were related to variations in SRH screening and counseling and (2) a wide range of factors influenced provider decision-making in initiating private time. A nuanced set of factors informed SRHS provided, including provider comfort with specific topics; provider engagement and relationship with parents; use of adolescent screening tools; practices, policies, and resources within the clinic setting; and community norms including openness with communication about sex and religious considerations regarding adolescent sexuality. Factors that shaped providers' decisions in initiating private time included adolescent age, developmental stage, health behaviors and other characteristics; observed adolescent-parent interactions; parent support for private time; reason for clinic visit; laws and professional guidelines; and cultural considerations. CONCLUSIONS: Findings suggest opportunities for interventions related to provider and clinic staff training, routine communication with adolescents and their parents, and clinic policies and protocols that can improve the quality of adolescent SRHS.