Contraception Initiation in the Emergency Department: Adolescent Perspectives.

PURPOSE: The purpose of this study was to identify factors affecting contraceptive intention and behavior among adolescent females in the pediatric Emergency Department. METHODS: We conducted a qualitative interview study nested within a larger prospective cohort study examining adolescent contraceptive counseling for females ages 15-18 years at-risk of unintended pregnancy presenting to the pediatric Emergency Department. Interviews were conducted in a subset of participants. The ecologically expanded Theory of Planned Behavior, expert opinion, and literature review informed the interview guide. Interviews were recorded, transcribed, coded and monitored for thematic saturation. RESULTS: Twenty-eight interviews were analyzed. Mean age was 17.1 years. Themes were mapped to ecologically expanded Theory of Planned Behavior constructs. Within health system influences, prior contraceptive experiences and patient-clinician interactions were described. Within community influences, contraceptive education, knowledge and misinformation, teen pregnancy norms, and social media impacts were described. Within attitudes influences, side-effect and safety concerns, contraceptive motivations and teen pregnancy beliefs were described. Within subjective norm influences, peer and family impacts were described. Within perceived behavioral control, Emergency Department (ED) counseling intervention impacts were described. DISCUSSION: We identified factors affecting contraceptive initiation/behavior among an ED adolescent population that otherwise may not have received contraceptive education in similar detail as provided by study clinicians. Adolescents' prior contraceptive and clinician interactions, limited access to contraceptive education, knowledge and misinformation, and side-effect and safety concerns affected initiation. Peer/family sharing and social media were leading contraceptive information sources. Future studies should incorporate insights into adolescent ED intervention design to make optimal use of resources while maximizing potential benefit.

Expanding Contraceptive Access for Teens-Leveraging the Pediatric Emergency Department.

PURPOSE: Adolescents have limited access to sexual healthcare services, and the emergency department (ED) may be the only place some will seek care. We implemented an ED-based contraception counseling intervention to assess intervention feasibility, and adolescent intention to initiate contraception, contraception initiation, and follow-up visit completion. METHODS: This prospective cohort study trained advanced practice providers in the EDs of two pediatric urban academic medical centers to deliver brief contraception counseling. A convenience sample of patients enrolled from 2019 to 2021 included females aged 15-18 not pregnant/desiring pregnancy and/or using hormonal contraception/an intrauterine device. Participants completed surveys to assess demographics and intention to initiate contraception (yes/no). Sessions were audiotaped and reviewed for fidelity. We ascertained contraception initiation and follow-up visit completion via medical record review and participant survey at 8 weeks. RESULTS: Twenty-seven advanced practice providers were trained, and 96 adolescents were counseled/responded to surveys (mean age 16.7 years; 19% non-Hispanic White, 56% non-Hispanic Black; 18% Hispanic). Mean counseling duration was 12 minutes and >90% of reviewed sessions maintained fidelity to content/style. Most participants (61%) reported intention to initiate contraception, and these participants were older and more likely to report prior contraceptive use, compared to those without intention. One-third (33%) initiated contraception in the ED or after the follow-up visit. DISCUSSION: Contraceptive counseling was feasible to integrate in the ED visit. Intention to initiate contraception was common and many adolescents initiated contraception. Future work should increase the pool of trained providers and supports for same-day contraception initiation for those desiring in this novel setting.

Prenatal Care Utilization Challenges and Facilitators for a Growing Latino Community in the Midwest.

BACKGROUND: Latina women are less likely to start prenatal care in the first trimester and to attend the recommended amount of prenatal visits compared to their non-Latina white counterparts. OBJECTIVES: This study aimed to assess challenges and facilitators to first-trimester prenatal care (FTPNC) and prenatal care utilization (PNCU) in a Midwestern urban area with a growing immigrant Latino community. METHODS: This study used a mixed-method approach based on the Theoretical Domains Framework. Nine semi-structured interviews were conducted with healthcare professionals that worked in birth centers, clinics, or hospitals that provided prenatal care (PNC) services for Latina women. Eight focus groups and quantitative surveys were conducted with Latina women and their supporters in Kansas City metropolitan area. RESULTS: FTPNC was challenged by women's immigrant status, lack of healthcare coverage due to immigrant status, and complexity of Medicaid application. PNCU was challenged by the cost of PNC when diagnosed with gestational diabetes, lack of healthcare coverage, PNC literacy, late access to gynecologists/obstetricians, inadequate interpretation services, transportation, and mental health distress. Meanwhile, FTPNC was facilitated by social support and connectedness. PNCU was facilitated by Spanish-proficient providers and interpreters, effective nonverbal communication and education techniques, and pregnancy prevention access and education. CONCLUSIONS FOR PRACTICE: Results from this study highlight important targets to improve PNC for Latina women. Participants called for various types of support to address identified challenges, ranging from information on social media about PNC services to broader efforts such as building trust from the community toward PNC providers and making PNC services affordable for women with gestational diabetes.

Contraceptive counseling for adolescents in the emergency department: A novel curriculum for nurse practitioners and physician assistants.

ABSTRACT: Many adolescents use the emergency department (ED) as their primary source of health care. As a result, the ED serves as a unique opportunity to reach adolescents. Although many adolescent visits to the ED are related to reproductive health, ED providers report barriers to providing this care, including lack of training. Nurse practitioners (NPs) and physician assistants (PAs) serve a vital role in the provision of consistent care to adolescents in the ED. The purpose of this study was to create a curriculum to train NPs and PAs at two pediatric institutions to provide patient-centered contraceptive counseling to adolescents in the pediatric ED regardless of their chief complaint. To do this, we created a four-part webinar followed by an in-person training session. Participants completed training and then conducted counseling sessions with adolescents in the ED. Counseling sessions were recorded and reviewed for fidelity to delineated counseling principles, and data from post-counseling surveys were collected. 27 NPs and PAs completed the training and conducted 99 counseling sessions. Nearly all sessions incorporated essential content and communication principles such as shared decision making (90%) and teach-back methods (75%). All NPs and PAs who participated reported satisfaction and subjective improvement in knowledge and competence from the training. This curriculum offers a novel and feasible approach to train NPs and PAs to deliver patient-centered contraception counseling to adolescents in the ED setting, and it can serve as a model for how to educate different providers to incorporate reproductive health education into the busy ED visit.

The Perfect Storm: Perceptions of Influencing Adults Regarding Latino Teen Pregnancy in Rural Communities.

INTRODUCTION: Recognition of the importance of adolescents' environments in influencing their sexual and reproductive health (SRH) decision-making necessitates a deeper understanding of the role that community stakeholders play in shaping Adolescent and Young Adults (AYA) access to SRH education and care. We describe community stakeholders' knowledge, beliefs, and attitudes about AYA's SRH needs in three rural Latino communities in Kansas. METHODS: Key stakeholders completed a written survey incorporating the theory of Planned Behavior to assess attitudes, norms, and intentions to support AYA's SRH education and access to care. RESULTS: Across three rural immigrant community settings, respondents (N = 55) included 8 community health workers, 9 health care providers, 7 public health officials, 19 school health officials, and 12 community members. More than half self-identified as Latino (55%). Six (11%) participants, half of whom were in the health sector, thought SRH education would increase the likelihood that teens would engage in sexual activities. In contrast, other stakeholders thought that providing condoms (17, 30.9%), contraception other than condoms (14, 25.5%), and providing HPV immunization (5, 9.6%) would increase the likelihood of engaging in sexual activity. Ambivalence regarding support for SRH education and service provision prevailed across sectors, reflected even in the endorsement of the distribution of less effective contraceptive methods. Obstacles to care include immigration status, discrimination, lack of confidential services, and transportation. CONCLUSION: Key stakeholders living in rural communities revealed misconceptions, negative attitudes, and ambivalent beliefs related to the delivery of SRH education and services, potentially creating barriers to AYA's successful access to care.

Little is known about the knowledge, beliefs and attitudes held by key stakeholders in rural immigrant Latino communities regarding their level of support for AYA's SRH needs. Key stakeholders may harbor influential and ambivalent opinions regarding AYA's sexuality considering existing cultural norms, therefore, stigmatizing access to SRH education and care. We examined key community stakeholders' attitudes and norms as measures of intentions to support AYA's SRH education and care. We identify actionable steps needed to eliminate existing barriers to AYA's access to SRH education and care among at-risk immigrant Latino communities in the rural Midwest.

Sexual Health and Relationship Abuse Interventions in Pediatric Primary Care: A Systematic Review.

PURPOSE: Supporting adolescents in developing healthy relationships and promoting sexual and reproductive health (SRH) is an important responsibility of pediatric primary care providers. Less is known about evidence-based interventions in pediatric settings focused on healthy relationships and SRH. METHODS: We conducted a systematic review to describe SRH and healthy relationship/adolescent relationship abuse (ARA) interventions for pediatric primary care over the past 20 years. Eligible articles were original research on an SRH-focused or ARA-focused intervention, conducted in-person within pediatric primary care or school-based health centers specifically for middle or high school-aged adolescents. Data abstracted from included articles included intervention description, content, delivery, evaluation design, and effectiveness of primary outcomes. Heterogeneous outcomes and evidence levels made conducting a meta-analysis infeasible. RESULTS: Nineteen studies described 17 interventions targeting a variety of SRH and ARA topics (e.g., sexually transmitted infections, contraception, ARA). Interventions largely focused on screening/counseling adolescents (89%). Interventions generally were reported as being effective in changing adolescent health or practice-level outcomes. DISCUSSION: This review provides preliminary evidence that SRH and ARA interventions in pediatric primary care settings can be effective in promoting adolescent health. Future work should consider ARA-specific prevention interventions, including parents in interventions, and strategies for implementation, dissemination, and scaling.

Addressing Adolescent Relationship Abuse in the Context of Reproductive Health Care.

Adolescent relationship abuse (ARA) is a significant public health issue that includes physical, sexual, psychological and cyber abuse, reproductive coercion, and/or sexual exploitation within an intimate relationship in which one or both partners is a minor. ARA is associated with numerous negative outcomes that include all domains of health. Many negative outcomes of ARA are related to reproductive and sexual health (RSH); thus, reproductive health care providers must be equipped to recognize and address ARA. This article will review the epidemiology and outcomes of ARA, followed by a discussion of means to robustly address ARA in health care settings. We recommend a strengths-based approach that promotes healthy adolescent relationships, connects adolescents experiencing ARA to harm reduction resources, and equips adolescents to serve as a resource for their peers.

Knowledge, Beliefs, and Attitudes About Contraception Among Rural Latino Adolescents and Young Adults.

PURPOSE: Latino youth experience significant disparities in rates of teen pregnancy, and reproductive health needs of rural Latino youth are not well understood. The purpose of this study was to describe knowledge, beliefs, and attitudes about contraception among rural Latino adolescents and young adults (Latino youth). METHODS: Eighty-four Latino youth, aged 15-24 years from rural Kansas communities participated in 15 focus groups (FG) and completed an individual survey. The survey assessed demographics and acculturation. FG participants discussed attitudes, subjective norms, and perceived sexual behaviors regarding teen sexuality, pregnancy, and contraception. RESULTS: FGs revealed multiple obstacles to accessing reproductive health services: geographical/rural location, cultural barriers, religious influences, lack of sexual education, and personal attitudes toward pregnancy and contraception use. Participants described close-knit communities with limited access to confidential reproductive health care. They identified cultural and religious factors (sexual taboo, virginity, Familismo, and family dishonor) that influence family planning behaviors among Latino youth and obstruct access to sexual health and contraception knowledge and services. Ambivalence regarding pregnancy intentions was common, along with the belief that contraception equates with abortion. CONCLUSIONS: Latino youth in rural communities face multiple physical and sociocultural obstacles to accessing family planning information and services. Community-based pregnancy prevention interventions must target these obstacles to optimize reproductive health outcomes for Latino youth in rural settings.

GnRH Agonist Improves Hyperandrogenism in an Adolescent Girl With an Insulin Receptor Gene Mutation.

Type A insulin resistance (IR) is caused by heterozygous mutations in the insulin receptor gene. It presents with mild acanthosis nigricans, severe IR, and hyperandrogenism in the absence of obesity or lipodystrophy. Treatment aims to improve insulin sensitivity and decrease androgens. An adolescent girl was evaluated for secondary amenorrhea and prominent hirsutism. She had a normal body mass index, and laboratory testing revealed an elevated LH to FSH ratio (LH 11.6 mIU/mL, FSH 4.2 mIU/mL), testosterone 96 ng/dL (reference range <50 ng/dL), free testosterone 2.21 ng/dL (reference range <1.09 ng/dL), normal glucose, and HbA1c of 5.6%. She received a diagnosis of polycystic ovary syndrome (PCOS) and was referred to our Multi-Specialty Adolescent PCOS Program. There, oral glucose tolerance test showed fasting glucose and insulin of 80 mg/dL and 63.1 mIU/mL, respectively. The 2-hour glucose and insulin were 199 mg/dL and 1480 µIU/mL, respectively. Because of hyperandrogenism with severe IR, dysglycemia, and normal lipids, type A IR was considered. Genetic testing revealed a heterozygous mutation in the insulin receptor gene [c.3095G>A(pGly1032Asp)]. After standard treatment of hirsutism and hyperinsulinism failed, a trial of GnRH agonist therapy improved hyperandrogenism and reduced ovarian size while severe IR persisted. We describe an adolescent with type A IR who experienced resolution of clinical and biochemical hyperandrogenism during GnRH agonist treatment. Given the patient's marked reduction in testosterone and hirsutism despite persistent hyperinsulinism, this case challenges the idea that insulin increases steroidogenesis independently of gonadotropin effect. GnRH agonist therapy should be considered in the treatment of hyperandrogenism in severe cases of IR.

Concomitant HPV and MenACWY vaccination among sixth and seventh graders receiving Tdap.

OBJECTIVE: To describe use of human papilloma virus (HPV) and meningococcal (MenACWY) vaccines among sixth and seventh grade Kansas children receiving their school-required tetanus, diphtheria, and acellular pertussis (Tdap) booster. METHODS: We used Medicaid and commercial claims data in Kansas from 2013, 2014, and 2015 to identify HPV and MenACWY vaccinations among sixth and seventh graders receiving a Tdap booster. Rates of concomitant vaccinations were calculated at the state and county level, and logistic regression was used to identify predictors of concomitant vaccination. RESULTS: Of sixth and seventh graders in Kansas receiving their required Tdap booster, 53-82% failed to receive a concomitant HPV vaccine and 36-47% failed to receive a concomitant MenACWY vaccine from 2013 to 2015. Rates of concomitant vaccinations varied more than four-fold across counties. Female gender, younger age, and Medicaid (versus commercial insurance) were positively associated with concomitant vaccination; concomitant vaccination rates increased from 2013 to 2015 (p < 0.001). Of children continuously enrolled in Medicaid from 2013 to 2015, who did not receive concomitant vaccination in 2013, 72.3% and 68.6% remained unvaccinated against HPV and MenACWY, respectively by the end of 2015. CONCLUSIONS: Failure to get a concomitant vaccination at the time of their Tdap booster identifies children at high risk of not getting immunized in the ensuing 2-3 years. 'Back to school' programs focusing only on school-required vaccinations could have negative impacts on overall vaccination rates. Tracking rates of concomitant vaccination might be useful in supporting quality assessment and improvement efforts. CLINICAL TRIAL REGISTRATION: This study was not a clinical trial.