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.

"Time and money and support": Adolescents and young adults' perceived social and logistical support needs for safe abortion care.

OBJECTIVE: To understand what support adolescents and young adults need to access abortion amidst the changing legal landscape. STUDY DESIGN: A diverse nationwide sample (N = 638, response rate 78%) of individuals aged 14-24 responded to a text message survey in July 2022 about the social and logistical support they would need for safe abortion access. Responses were coded and analyzed thematically. RESULTS: Respondents described parents and friends as primary sources of social support for potential abortion decisions. They frequently cited money and transportation as logistical support needs for out-of-state abortion care. CONCLUSIONS: Adolescents and young adults report needing social support and specific resources to ensure access to abortion. IMPLICATIONS: This study highlights the perspectives and experiences of a diverse, nationwide sample of adolescents and young adults on their perceived abortion-related social and logistical support needs. These findings can support centering adolescents and young adults in practice and policy change to minimize barriers, improve social support, tailor resources and information about abortion, and streamline access to essential reproductive health services in a post-Dobbs landscape.

Characteristics of Adolescents Who Use Secure Messaging on a Health System's Patient Portal.

OBJECTIVES: To determine adolescent characteristics associated with patient portal secure messaging use within a health system. METHODS: This study analyzed monthly data from individuals aged 13 to 17 who met study eligibility criteria from 2019 to 2021. The primary outcome was any secure messages sent from an adolescent's account during each observed month. Unadjusted and adjusted associations between adolescent characteristics and secure messaging use were assessed using generalized estimating equations with log link and binomial variance. RESULTS: Of 667 678 observed months, 50.8% occurred among males who were not transgender, 51.5% among those identifying as non-Hispanic white, and 83.3% among the privately insured. The adjusted relative risks of secure messaging use were significantly higher for individuals with female sex and transgender identities (female sex, not transgender: adjusted relative risk [aRR] 1.41, 95% confidence interval [CI] 1.31-1.52; male sex, transgender: aRR 2.39, CI 1.98-2.90, female sex, transgender: aRR 3.01, 95% CI 2.63-3.46; referent male sex, not transgender), those with prior portal use (aRR 22.06, 95% CI 20.48-23.77; referent no use) and those with a recent preventive care visit (aRR 1.09, 95% CI 1.02-1.16; referent no recent visits). The adjusted relative risks of portal secure messaging use were significantly lower among those with public insurance (aRR 0.58, 95% CI 0.50-0.67; referent private). CONCLUSIONS: Adolescents who sent patient portal secure messages differed from those who did not. Interventions to encourage secure messaging use may require tailoring based on patient characteristics.

Adolescent Awareness of the Changing Legal Landscape of Abortion in the United States and Its Implications.

PURPOSE: Restrictions on abortion in the United States will have disproportionate and negative impacts on adolescents. Prior to the Supreme Court ruling to overturn federal protection of abortion, we sought to examine adolescents' awareness and knowledge about the legal landscape of abortion and how changes might affect them. METHODS: We fielded a 5-question open-ended survey via text message to a nationwide sample of adolescents aged 14-24 years on May 20, 2022. We coded the responses using inductive consensus coding. Summary statistics were calculated for code frequencies and demographic data, and analyzed qualitatively using visual inspection of results overall and by subgroups (e.g., age, race and ethnicity, gender, and restrictiveness of state of residence). RESULTS: A total of 654 responded (79% response rate), of which 11% were under 18 years. Most adolescents were aware of potential changes to abortion access. Most adolescents reported using the internet and social media for information about abortions. Overall, negative emotions about the changing legal landscape predominated, including anger, fear, and sadness. When considering factors for abortion decisions, adolescents most often discussed finances and life circumstances including their future, age, education, maturity, and emotional stability. Themes were relatively, uniformly distributed across subgroups. DISCUSSION: Our study suggests that many adolescents are aware of and concerned about potential impacts of abortion restrictions, across a diversity of ages, gender, racial/ethnic, and geographic perspectives. Understanding and amplifying the voices of adolescents during this critical time is necessary to inform novel access solutions and policy initiatives that center the needs of youth.

A Nationwide Sample of Adolescents and Young Adults Share Where They Would Go Online for Abortion Information After Dobbs v. Jackson.

PURPOSE: Given the changing landscape of abortion access, we sought to understand where adolescents and young adults retrieve information about abortion online. METHODS: A nationwide sample (n = 638) of 14- to 24-year-olds responded to a qualitative text message survey in July 2022 regarding websites or social media they would use for abortion-related information. Open-ended responses were coded and analyzed for themes. RESULTS: Forty-six percent of respondents (n = 234) named specific websites or accounts of known organizations or individuals; 14% named general clinical or governmental resources; and 13% named social media platforms. Eight percent expressed skeptical sentiments about online abortion information. 17% (n = 99) said they were not sure or did not have an opinion. DISCUSSION: Many adolescents and young adults could name an online resource for abortion information, but some are not aware of specific resources, underscoring a need to elevate reputable sources and provide guidance on how and where to look for accurate online abortion-related information.

A call to integrate health equity into learning health system research training.

In 2016, the Agency for Healthcare Research and Quality (AHRQ) recommended seven domains for training and mentoring researchers in learning health systems (LHS) science. Health equity was not included as a competency domain. This commentary from scholars in the Consortium for Applied Training to Advance the Learning health system with Scholars/Trainees (CATALyST) K12 program recommends that competency domains be extended to reflect growing demands for evidence on health inequities and interventions to alleviate them. We present real-life case studies from scholars in an LHS research training program that illustrate facilitators, challenges, and potential solutions at the program, funder, and research community-level to receiving training and mentorship in health equity-focused LHS science. We recommend actions in four areas for LHS research training programs: (a) integrate health equity throughout the current LHS domains; (b) develop training and mentoring in health equity; (c) establish program evaluation standards for consideration of health equity; and (d) bring forth relevant, extant expertise from the areas of health disparities research, community-based participatory research, and community-engaged health services research. We emphasize that LHS research must acknowledge and build on the substantial existing contributions, mainly by scholars of color, in the health equity field.

What Do Adolescents and Their Parents Need From Mental Health Integration in Primary Care? A Qualitative Exploration of Design Insights.

INTRODUCTION: The design of integrated adolescent mental health care should address needs and preferences of patients and parents/guardians. METHOD: We conducted interviews and focus groups with adolescents aged 13-17 years who received care at Kaiser Permanente Washington in 2020 and interviews with parents of such adolescents. We sought to (1) understand the challenges of primary care-based mental health and substance use screening and care for adolescents and (2) identify program design solutions. Sessions were audio-recorded, transcribed, and coded. Thematic analysis was applied to identify key challenges and design solutions. RESULTS: Emerging themes from interviews (n = 41) and focus groups (n = 10) were summarized in five overarching design principles: Engagement, Privacy, Communication, Choice, and Ease. Each design principle was expanded for operationalization within a new health system program. DISCUSSION: Health systems serving adolescents in primary care may consider application of these design principles to the development of mental health integration programs.

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.

Assessment of country policies affecting reproductive health for adolescents in the Philippines.

BACKGROUND: Adolescents in the Philippines face many legal, social and political barriers to access sexual and reproductive health (SRH) services, putting them at higher risk of unplanned pregnancy, abortion, sexually transmitted infections and HIV, and other health and development problems. OBJECTIVE: This study aims to evaluate whether current normative documents on SRH in the Philippines are in concurrence with adolescents' human rights principles using the World Health Organization (WHO) Guidance and Recommendations on ensuring human rights in the provision of contraceptive information and services. METHODS: The review focused on policies and normative guidance documents which included the national reproductive health law, its implementing rules and regulations, and the Supreme Court decisions on the law, and documents cited in the government's Adolescent and Youth Health Programme. Also included were documents identified through keyword searches in an online database of the health department. We assessed these documents on their agreement or non-agreement with WHO recommendations, and the presence or absence of adolescent-specific content. RESULTS: Of nine WHO summary recommendations, Philippine normative documents are in agreement with four, namely on acceptability, participation, accountability, and quality, and have adolescent-specific provisions in three. Philippine normative documents are partly in agreement with the remaining five WHO summary recommendations-nondiscrimination, availability, accessibility, informed decision-making, and privacy. Of twenty-four WHO sub-recommendations, Philippine normative documents are in agreement with fifteen, not in agreement with five, and partly in agreement with four. Two possible factors may explain the many documents with conflicting contents: devolution of the Philippine health system, and the deep social and policy divide on sexual and reproductive health. CONCLUSION: Many Philippine-governmental norms and standards are in agreement with adolescents' human rights to contraceptive information and services as recommended by the WHO. However, a significant number are restrictive, reflecting the strong influence of conservative religious beliefs. RECOMMENDATIONS: We recommend: 1) further elaboration of the laws and policies that are fully in agreement with WHO recommendations; 2) a more liberal interpretation of the law to ensure the provision, delivery and access to reproductive health care services, and to promote, protect and fulfill women's reproductive health and rights; and 3) popularization of ethical and human rights norms.

Applying the results based management framework to the CERCA multi-component project in adolescent sexual and reproductive health: a retrospective analysis.

BACKGROUND: Adolescent sexual and reproductive health (SRH), problems such as unplanned pregnancies are complex and multifactorial, thus requiring multifaceted prevention interventions. Evaluating the impact of such interventions is important to ensure efficiency, effectiveness and accountability for project funders and community members. In this study, we propose Results Based Management (RBM) as a framework for project management, using the Community Embedded Reproductive Health Care for Adolescents (CERCA) as a case study for RBM. The CERCA Project (2010-2014) tested interventions to reduce adolescent pregnancy in three Latin American countries, Bolivia, Ecuador and Nicaragua. Activities were designed to increase adolescent SRH behaviors in four domains: communication with parents, partners and peers; access to SRH information; access to SRH services; and use of contraception. When the project ended, the outcome evaluation showed limited impact with concerns about accuracy of monitoring and attrition of participants. METHODS: We reviewed and analyzed a series of CERCA documents and related data sources. Key findings from these documents were organized within an RBM framework (planning, monitoring, and impact evaluation) to understand how CERCA methodology and performance might have reaped improved results. RESULTS: Strengths and weaknesses were identified in all three elements of the RBM framework. In Planning, the proposed Theory of Change (ToC) differed from that which was carried out in the intervention package. Each country implemented a different intervention package without articulated assumptions on how the activities of intervention would bring about change. In Monitoring, the project oversight was mainly based on administrative and financial requirements rather than monitoring fidelity and quality of intervention activities. In Impact Evaluation, the original CERCA evaluation assessed intervention effects among adolescents, without identifying success and failure factors related to the outcomes, the nature of the outcomes, or cost-effectiveness of interventions. CONCLUSIONS: This analysis showed that multi-country projects are complex, entail risks in execution and require robust project management. RBM can be a useful tool to ensure a systematic approach at different phases within a multi-country setting.

Low Acceptability of Certain Contraceptive Methods among Young Women.

STUDY OBJECTIVE: To examine what predicts low personal acceptability of 4 different contraceptive methods among young women. DESIGN: Cross-sectional survey. SETTING: Urban adolescent contraception clinic in Colorado. PARTICIPANTS: Female clinic patients ages 13-24 initiating contraception from August 2011 to April 2012. INTERVENTIONS AND MAIN OUTCOME MEASURES: Survey participants reported their personal acceptability for oral contraceptive pills, depot medroxyprogesterone, contraceptive implants, and intrauterine devices on a scale from 0 (low) to 10 (high). Responses of 0-4 were categorized as low personal acceptability. Demographic characteristics, reproductive history, and perceived contraceptive satisfaction of friends and family members were incorporated into multivariable and hierarchical logistic regression models to determine distinct predictors of low personal acceptability for each method. RESULTS: Surveys were completed by 1067 women. Participants' mean age was 20 (±2.6) years. Half (552/1067) were white, 26% (277/1067) Hispanic, and 8.5% (91/1067) black. Of participants who were aware of oral contraceptive pills 52% (535/1037) reported low acceptability of this method compared with 74% (645/876) of those aware of depot medroxyprogesterone. Fewer reported low acceptability of intrauterine devices (37% or 303/825) or implant (43% or 356/839), although fewer overall participants had heard of these methods. Each method had unique predictors of low personal acceptability, however, for all method models, significant predictors included knowing someone who had become pregnant while using that method or having a friend who dislikes that method. CONCLUSION: Young women in this study with low personal acceptability of the 4 most common contraceptive methods had distinct demographic and reproductive health characteristics. Perceived negative experiences of friends and family members using contraception appeared most influential.

Adolescent Perspectives on Patient-Provider Sexual Health Communication: A Qualitative Study.

BACKGROUND: Adolescents in the United States are disproportionately affected by sexually transmitted infections and unintended pregnancy. Adolescent-centered health services may reduce barriers to health care; yet, limited research has focused on adolescents' own perspectives on patient-provider communication during a sexual health visit. METHODS: Twenty-four adolescents (14-19 years old) seeking care in a public health clinic in Washington State participated in one-on-one qualitative interviews. Interviews explored participants' past experiences with medical providers and their preferences regarding provider characteristics and communication strategies. RESULTS: Interviews revealed that (1) individual patient dynamics and (2) patient-provider interaction dynamics shape the experience during a sexual health visit. Individual patient dynamics included evolving level of maturity, autonomy, and sexual experience. Patient-provider interaction dynamics were shaped by adolescents' perceptions of providers as sources of health information who distribute valued sexual health supplies like contraception and condoms. Participant concerns about provider judgment, power differential, and lack of confidentiality also emerged as important themes. CONCLUSIONS: Adolescents demonstrate diverse and evolving needs for sexual health care and interactions with clinicians as they navigate sexual and emotional development.

How do national contraception laws and policies address the contraceptive needs of adolescents in Paraguay?

BACKGROUND: The main objective is to examine how the Paraguayan laws, policies and regulations (hereafter referred to as normative guidance) specifically address adolescents and their contraceptive information and service needs using a human rights analytic framework. It must be noted that this paper examines the adolescent content of national laws, policies and regulations on contraception, not how they were applied. METHODS: The recommendations on "Ensuring human rights in the provision of contraceptive information and services" from the World Health Organization (WHO) were used as an analytic framework to assess current Paraguayan laws, policies and regulations. Three questions were explored: 1) whether the Paraguayan normative guidance relating to each WHO recommendation was present and specifically addressed adolescents 2) whether the normative guidance for each WHO recommendation was present but did not specifically address adolescents, or 3) whether Paraguayan normative guidance relating to each WHO recommendation was absent. This assessment led to the development of an analytic table which was used by the co-authors to generate conclusions and recommendations. RESULTS: The analysis found specific normative guidance for adolescents relating to six out of nine WHO summary recommendations and nine out of the 24 sub-recommendations. The guidance included strategies to overcome contraceptive service barriers and to improve access for displaced populations. Further, it supported gender-sensitive counselling, quality assurance processes, competency-based training, and monitoring and evaluation of programmes. CONCLUSIONS: Paraguay's contraception laws and policies are grounded in human rights principles. However, there are a number of aspects that need to be addressed in order to improve the quality of contraceptive provision and access for adolescents. Our recommendations include improving accessibility of contraceptive information and services, ensuring acceptability, quality, and accountability of contraceptive information and services, and promoting community and adolescent participation in contraceptive programmes and service delivery.

2016 Updates to US Medical Eligibility Criteria for Contraceptive Use and Selected Practice Recommendations for Contraceptive Use: Highlights for Adolescent Patients.

The US Medical Eligibility Criteria for Contraceptive Use (MEC) and US Selected Practice Recommendations for Contraceptive Use (SPR) provide evidence-based guidance to safely provide contraception counseling and services. Both documents were updated in 2016 and are endorsed by the North American Society for Pediatric and Adolescent Gynecology. The purpose of this mini-review is to highlight updates to the US MEC and US SPR that are most relevant to health care providers of adolescents to support dissemination and implementation of these evidence-based best practices. This document is intended to highlight these changes and to complement, not replace, the detailed practice guidance within the US MEC and US SPR.

Measuring adolescent friendly health services in India: A scoping review of evaluations.

BACKGROUND: Initiatives to promote adolescent friendly health services (AFHS) have been taking place in India and many low- and middle-income countries for nearly two decades. Evaluations of these initiatives have been placed in the public arena from time to time, but little is known about what they say about the overall situation on AFHS in India. This study aimed to describe how efforts to provide AFHS in India have been evaluated, how well they have been evaluated, and what their findings and implications are. METHODS: We conducted a scoping review of evaluations of AFHS initiatives in India from 2000 to 2014. An electronic search was carried out in Medline and EMBASE. A manual search of grey literature was also performed, and experts were contacted in order to obtain additional manuscripts and reports. RESULTS: Thirty evaluation reports were identified representing a broad geographic distribution. Evaluations have focused on government-sponsored AFHS programmes or independent non-governmental organization (NGO) initiatives to strengthen government services. The evaluations primarily measured programme outputs (e.g. quality and service utilization) and health behavioural outcomes (e.g. condom use). Study designs were commonly descriptive or quasi-experimental. Most evaluations found improvement in quality and utilization of services, and some demonstrated an increase in adolescent knowledge or health behaviours. Few measured positive project/programme results such as older age at first pregnancy. Strengths of evaluations were clear objectives, frequent use of multiple data sources, and assessment of programmatic outputs as well as health outcomes. Weaknesses were lack of consistency and quality. CONCLUSIONS: Our findings confirm that a number of evaluations of AFHS initiatives in India have been carried out. They point to service quality and in behavioural improvements in adolescents. However, their lack of consistency hinders comparison across sites, and their uneven quality means that their findings need to be interpreted with caution.

Knowledge and Acceptability of Long-Acting Reversible Contraception Among Adolescent Women Receiving School-Based Primary Care Services.

BACKGROUND: A key strategy to reduce unintended adolescent pregnancies is to expand access to long-acting reversible contraceptive (LARC) methods, including intrauterine devices and subdermal contraceptive implants. LARC services can be provided to adolescents in school-based health and other primary care settings, yet limited knowledge and negative attitudes about LARC methods may influence adolescents' utilization of these methods. This study aimed to evaluate correlates of knowledge and acceptability of LARC methods among adolescent women at a school-based health center (SBHC). METHODS: In this cross-sectional study, female patients receiving care at 2 SBHCs in Seattle, Washington completed an electronic survey about sexual and reproductive health. Primary outcomes were (1) LARC knowledge as measured by percentage correct of 10 true-false questions and (2) LARC acceptability as measured by participants reporting either liking the idea of having an intrauterine device (IUD)/subdermal implant or currently using one. RESULTS: A total of 102 students diverse in race/ethnicity and socioeconomic backgrounds completed the survey (mean age 16.2 years, range 14.4-19.1 years). Approximately half reported a lifetime history of vaginal sex. Greater LARC knowledge was associated with white race (regression coefficient [coef] = 26.8; 95% CI 13.3-40.4; P < .001), history of vaginal intercourse (coef = 29.9; 95% CI 17.1-42.7; P < .001), and current/prior LARC use (coef = 22.8; 95% CI 6.5-40.0; P = .007). Older age was associated with lower IUD acceptability (odds ratio = 0.53, 95% CI 0.30-0.94; P = .029) while history of intercourse was associated with greater implant acceptability (odds ratio 5.66, 95% CI 1.46-22.0; P = .012). DISCUSSION: Adolescent women in this SBHC setting had variable knowledge and acceptability of LARC. A history of vaginal intercourse was the strongest predictor of LARC acceptability. Our findings suggest a need for LARC counseling and education strategies, particularly for young women from diverse cultural backgrounds and those with less sexual experience.