Enhancing Parent Consent for School-Based Primary and Reproductive Health Care Among Vulnerable Youth.

This quality-improvement initiative evaluated procedures to increase parental consent for students, 13 to 18+ years old, to access a school-based health clinic that provides primary and reproductive health care in a Hispanic immigrant neighborhood in the U.S. Southwest. Six consent-retrieval procedures were sequentially implemented. Procedures included school registration, competition, hand delivery, PTO meetings, self-consent, and mail. Age, grade, and number of completed consents were calculated and compared. The percentage of students with completed consents increased from 35% to 72%. Lessons learned include increasing the number of completed consents is difficult; however, it is important to increase students' access to health-care services.

Evaluation of the professional process portfolio: an innovative tool to help develop and demonstrate leadership competency.

The professional process portfolio (PPP) was adopted by the Maternal Child and Health Bureau (MCHB) as an 'innovation' in best practice for all Leadership in Education and Adolescent Health (LEAH) Training Programs; however it had not been formally evaluated. Thus the objective was to evaluate the utility of the PPP for graduates of the LEAH training program in terms of (1) how alumni have used, adapted, and applied it since completing fellowship, (2) what fellows learned or gained through completing it, and (3) how it can be improved for continued use in training programs. Graduates from six disciplines were asked via telephone or email to participate in a survey regarding their experience with the PPP. Descriptive statistics were generated for demographic characteristics and closed-choice questions. Responses to open-ended questions were analyzed by a team of faculty using framework analysis. Sixty-one graduates completed surveys. The majority (85%) found the PPP useful and utilized it post-graduation for multiple purposes in professional development: interviewing, training, and referencing previous work. Graduates recommended that the PPP be improved by making it electronic, discipline-specific, and providing earlier and more frequent instruction from faculty on expectations of creating it. Four themes emerged from the qualitative data analysis: accomplishment, experiential learning, skills and accountability, and a best practice of learning. The PPP was an effective personal learning tool for the majority of graduates and enhanced graduates' experiences. We highlight the ways that the PPP may facilitate the development of learning experiences associated with MCH leadership competence.

Adolescents Accessing School-Based versus Family Planning Clinics: Chlamydia and Gonorrhea Testing and Treatment Outcomes.

The prevalence and treatment of chlamydia (CT) and gonorrhea (GC) at school-based clinics (SBCs) requires revisiting. To assess whether clinic type influences CT/GC testing and treatment for minors (individuals 13-17 years of age), our study compared four SBCs with five family planning clinics (FPCs) in the Houston, Harris County metropolitan area of Texas, USA for: (1) the prevalence of CT/GC infection (pre-COVID-19 and during COVID-19); (2) treatment rates at the last positive diagnosis; and (3) the time, in days, from testing-to-diagnosis and testing-to-treatment. Between January 2019 and December 2020, 2439 unique patients (1579 at SBCs, 860 at FPCs) were seen. Of the 1924 tests obtained, 39.2% and 15.9% were positive for CT and GC, respectively. The prevalence of CT and GC at SBCs was similar prior to COVID-19 vs. during the COVID-19 pandemic. SBCs were able to provide treatment significantly faster after diagnosis (mean, 6.07 days; 95% CI, 3.22-8.90; 94.7% were within 30 days) than FPCs (mean, 17.60 days; 95% CI, 10.15-25.12; 84.7% were within 30 days) (p = 0.0257). This comparison within our large clinic system, with consistent clinical management protocols, suggests that SBC care may be critical to ensuring optimal sexually transmitted infection management in minors.

Choice of Postpartum Contraception: Factors Predisposing Pregnant Adolescents to Choose Less Effective Methods Over Long-Acting Reversible Contraception.

PURPOSE: The purposes were to determine contraceptive methods pregnant adolescents intend to use postpartum and to understand factors that predispose intention to use less effective birth control than long-acting reversible contraception (LARC). METHODS: Participants were 247 pregnant minority adolescents in a prenatal program. Intention was assessed by asking "Which of the following methods of preventing pregnancy do you intend to use after you deliver?" Multinomial logistic regression analysis was used to determine factors associated with intent to use nonhormonal (NH) contraception (male/female condoms, abstinence, withdrawal and no method) or short-/medium-acting hormonal (SMH) contraception (birth control pill, patch, vaginal ring, injectable medroxyprogesterone acetate) compared with LARC (implant and intrauterine device) postpartum. RESULTS: Twenty-three percent intended to use LARC, 53% an SMH method, and 24% an NH method. Participants who intended to use NH or SMH contraceptive methods over LARC were significantly more likely to believe that LARC is not effective at preventing pregnancy, to report that they do not make decisions to help reach their goals and that partners are not important when making contraceptive decisions. Other important factors were having a mother who was aged >19 years at first birth and had not graduated from high school, not having experienced a prior pregnancy or talked with parents about birth control options, and the perception of having limited financial resources. CONCLUSIONS: Distinct profiles of factors associated with intending to use NH or SMH contraceptive methods over LARC postpartum were identified and may inform future interventions to promote the use of LARC to prevent repeat pregnancy.

Pelvic inflammatory disease in adolescents.

Pelvic inflammatory disease (PID) is a polymicrobial infection typically occurring in sexually active females. It occurs when microorganisms ascend from the lower genital tract into the upper genital tract. The clinical presentation varies in severity, with most patients presenting with mild disease. Complications include tubo-ovarian abscess, ectopic pregnancy, infertility, and chronic pain. The newly revised criteria issued by the Centers for Disease Control and Prevention now include either cervical motion tenderness or adnexal tenderness with unchanged additional criteria.

Enhancing recruitment and retention of minority young women in community-based clinical research.

Women are disproportionately affected by the sexually transmitted infections (STI) epidemic, with African-Americans and Latinos at significantly higher risk for STIs than Caucasians. Successful recruitment and retention strategies used with young minority women in community-based STI prevention or intervention research have not been previously reported. This communication presents eight key strategies learned in the recruitment and retention of 16- to 21-year-old urban women participating in a 12-month randomized clinical trial designed to promote STI screening to decrease the duration of untreated chlamydia and gonorrhea infection. Strategies learned include: (1) Educate clinic staff on the rigors of study design; (2) Facilitate a team effort between clinical and research staff; modify recruitment procedures, as needed; (3) Provide prospective participants the option of enrolling by return appointment; (4) Anticipate a diminishing recruitment pool over time; (5) Set positive recruitment tone at the beginning of each clinic session; (6) Consider participants' mothers as important points of contact; (7) Match communication styles to participant contacts; and (8) Consider a variety of retention techniques. Together, these strategies helped to reinforce participant's commitment to the project, facilitated their attendance at interviews, and encouraged them to adhere to the treatment protocol.

Gonorrhea and chlamydia screening among young women: stage of change, decisional balance, and self-efficacy.

PURPOSE: To assess perceived sexually transmitted disease (STD) (gonorrhea and chlamdydia) screening behaviors among young women at risk for STDs by evaluating readiness, pros and cons, and self-efficacy to seek STD screening in the absence of symptoms. METHODS: Two hundred forty young urban women (mean 18.8 years +/-1.59) consecutively attending an urban reproductive clinic voluntarily completed a 67-item questionnaire on STD screening behaviors that included the stages of change (SOCs), decisional balance, and self-efficacy as well as sexual practices and partner relationships. The data were analyzed using descriptive statistics, multivariate analyses of variance, Chi-square tests, and Wilcoxon signed rank test. RESULTS: Ninety-five percent of the participants would be willing to obtain STD screening for early disease detection. Participants were further along the SOCs for STD screening following unprotected sex with a change in partner than main partner, (p <.001). Pros and cons of STD screening varied according to the SOCs for STD screening with a change in partner and main partner. Self-efficacy increased linearly along the SOCs for STD screening (p <.001). CONCLUSIONS: Most young women recognize the importance of STD screening but are not currently being tested when at risk for STDs. STD screening behaviors varied according to the partner relationship, which highlights the importance of stage- and partner-matched counseling to promote STD screening particularly when at risk for STDs.

Gonorrhea and chlamydia screening in sexually active young women: the processes of change.

A pilot study conducted with young women in an urban clinic examined a Transtheoretical Model processes of change measure to better understand strategies and behavioral mechanics that facilitate seeking gonorrhea and chlamydia screening. This information may be useful in developing interventions to improve sexually transmitted infection (STI) screening. Consistent with other studies, greater use of experiential and behavioral processes was associated with the action/maintenance stages for seeking gonorrhea and chlamydia screening.

Pelvic inflammatory disease in adolescents.

Pelvic inflammatory disease (PID) is an infection of the upper female genital tract. It encompasses an array of inflammatory disorders, including endometritis, parametritis, salpingitis, oophoritis, tubo-ovarian abscess, peritonitis, and perihepatitis. In most adolescents with acute severe infections it is difficult to differentiate some of these entities; thus the term PID is used commonly. Perihepatitis (Fitz-Hugh-Curtis syndrome) and tubo-ovarian abscess are acute complications, whereas chronic complications include infertility, ectopic pregnancy, and chronic pain.

Chlamydia and gonorrhea screening in asymptomatic young women.

BACKGROUND: Adolescent and young adult minority women are at high risk for chlamydia (CT) and gonorrhea (NGC) cervical infections, which are significant causes of pelvic inflammatory disease, impaired fertility, ectopic pregnancy and chronic pain. The purpose of this article is to review among young women in the United States: (1) the epidemiology of CT and NGC cervical infection and their medical complications; (2) current public health recommendations to promote asymptomatic CT and NGC screening; (3) current screening practices and challenges of implementing public health recommendations; (4) testing and cost issues; and (5) future directions in promoting asymptomatic CT and NGC screening. METHODS: We conducted a MEDLINE search for articles published over the last two decades relating to CT and NGC screening in young women and then systematically reviewed all relevant articles. RESULTS: The data indicate that CT and NGC infection are geographically widespread in the U.S. and asymptomatic infection is highly prevalent among economically disadvantaged young females. Public health recommendations promoting CT and NGC screening in asymptomatic young women are directed to both health care providers and clients. However, strategies to promote screening efforts have been primarily directed toward health care providers; there are no published studies on client-initiated screening strategies. Challenges of implementing public health recommendations and future directions for CT and NGC screening are discussed. CONCLUSIONS: Young sexually active women continue to be at high risk for CT and NGC infection. The data indicate that implementation of health provider-based and client-initiated screening in private and public health care settings is a challenge. However, there is a great need to develop strategies to understand and promote client-initiated screening.

Learning about pap smears: an educational skit for Hispanic adolescents.

PURPOSE: To assess the efficacy of an educational skit on improving knowledge and decision making/behavior toward obtaining a Pap smear. METHODS: Ninety-two Hispanic high school female volunteers participated in an intervention, single-sample, preintervention/postintervention survey. Data were collected prior to (T(0)), immediately after (T(1)), and seven weeks after (T(2)) the intervention. The intervention was a live, 15-minute, English-language skit. RESULTS: Fifty percent reported sexual intercourse. Viewing the skit was associated with 29% of those who needed a Pap smear done, actually scheduling or having a Pap smear done between T(0) and T(2). However, a causal relationship was not proven (P = 0.09). Knowledge was greater at T(1) and T(2) compared to T(0) (P < 0.00001). However, there was a decrease in knowledge at T(2) compared to T(1). More subjects agreed that females their age were at risk for cancer at T(2) compared to T(0) (P = 0.0001). CONCLUSIONS: There was an improvement in and retention of knowledge about Pap smears after viewing this educational skit. This study sets the stage for evaluating this educational skit on a larger sample with a comparison group.

Feasibility of providing sexually transmitted infection testing and treatment in off-campus, nonclinic settings for adolescents enrolled in a school-based research project.

BACKGROUND: This study examined the acceptability and feasibility of using a biological outcome measure to evaluate a school-based sexuality education program. Confidential field-delivered sexually transmitted infection (STI) testing by nonmedical field staff and STI treatment by medically trained field staff was assessed in off-campus and off-clinic settings for adolescents enrolled in the trial. METHODS: After parental and adolescent consent were obtained, a convenient time and location was identified to collect urine to test for chlamydia (Chlamydia trachomatis, CT), gonorrhea (Neisseria gonorrheae, NG), and trichomonas (Trichomonas vaginalis, TV) infection and to treat students with positive results. RESULTS: A total of 391 of 1742 students had permission to participate (22%); 353 (90%) provided urine samples; 28 (8%) had positive test results: CT(18), NG(5), and TV(8). Testing and treatment occurred at home for 92% and 59% of students, respectively; on weekdays (for 69% and 96%, respectively) and between noon and 8 pm (for 76% and 88%, respectively). All students who tested positive were treated. Several lessons and strategies that may improve the likelihood that students will participate in field-delivered STI testing and treatment emerged. CONCLUSION: STI testing and treatment are feasible for students enrolled in a school-based sexuality education program. However, obtaining parental consent may be challenging.

Relationship between health literacy, reading comprehension, and risk for sexually transmitted infections in young women.

We investigated the relationship between health literacy, comprehension of sexually transmitted infection information, and sexual behavior in 127 women aged 16-21 years attending a reproductive health clinic. Women with lower health literacy scores demonstrated lower comprehension of written information related to sexually transmitted infections but did not have greater high-risk sexual behaviors.

Efficacy of a motivational behavioral intervention to promote chlamydia and gonorrhea screening in young women: a randomized controlled trial.

BACKGROUND: Seeking screening and treatment for chlamydia (CT) and gonorrhea (GC) by young women is critical to reduction of asymptomatic cervicitis and its complications. OBJECTIVES: To evaluate the efficacy of a client-centered motivational behavioral intervention (MBI), to promote seeking of sexually tranmitted infection (STI) checkups by young women. METHODS: Three hundred seventy-six of 770 eligible sexually active, nonpregnant, English-speaking women (mean age 18.5 years) were recruited from an urban reproductive health clinic and randomized to two groups: intervention plus standard care (MBI) or standard care alone (SC). MBI (two sessions plus booster) was based on the Transtheoretical Model of Change and employed motivational interviewing. Outcome measures monitored for 12 months included: client-initiated clinic visits for STI checkups in response to seven high-risk sexual behaviors by self-report (primary), consistent condom use, number of CT and GC episodes, and movement along the stages of change obtained at baseline and 6- and 12-month follow-up assessments (secondary). Analyses included chi-square, logistic regression, and generalized estimating equations. RESULTS: At baseline, more than 70% endorsed the action stage of change for seeking STI checkups for three of seven high-risk sexual behaviors. No significant differences were noted between the two groups for the primary or secondary outcomes. Across groups, having multiple partners and being pregnant or thinking one might be pregnant were associated with STI checkups. CONCLUSIONS: This is the first known client-centered clinical trial to promote STI screening. Risk-taking and health-seeking behaviors are complex and interrelated with STI and pregnancy concerns. The intervention may have an effect if it is targeted to women in a less medically connected community-based sample.

Correlates of consistent condom use with main-new and main-old sexual partners.

An exploratory study identified correlates of consistent condom use for young women reporting Main-new or Main-old partners in the past 3 months: frequency of vaginal sex (across partner types); perceived likelihood of getting a STI (Main-new); age and STI history (Main-old). To enhance programmatic efficacy in community clinics, these key correlates of condom use for main partner types should be incorporated in STI risk reduction counseling.

Young women's perspective of the pros and cons to seeking screening for chlamydia and gonorrhea: an exploratory study.

STUDY OBJECTIVE: To identify young women's pros and cons (decisional balance) to seeking chlamydia (CT) and gonorrhea (NGC) screening. DESIGN: Prospective, cross sectional study SETTING: Community-based reproductive health clinic PARTICIPANTS: 192 young women (66% African American; mean age 18.9 years). MAIN OUTCOME MEASURES: Content analysis of responses obtained during a decisional balance exercise (pros and cons) promoting CT and NGC screening was conducted. Thematic categories were developed through a coding process, and each response was assigned to one thematic category. The frequency of pros and cons responses for each category and the frequency of participants endorsing each category were calculated. RESULTS: Ten thematic categories in relation to pros and cons of seeking CT and NGC screening were: being healthy; awareness of the body; systemic factors around the clinic visit and testing procedures; benefits and aversions around treatment; partner trust issues; confidentiality; prevention of long term adverse effects, protection of the body; concern for others; fear of results/aversion to testing; and logistical barriers. The three most often cited pros were awareness of the body, being healthy and treatment issues; and the three most often cited cons were logistical barriers (time/transportation), fear/aversion to testing, and systemic factors. CONCLUSIONS: A variety of pros and cons to seeking CT and NGC screening were identified at a community-based clinic. Providers in clinical settings can utilize this information when encouraging patients to seek regular STI screening by elucidating and emphasizing those pros and cons that have the most influence on a young woman's decision-making to seek screening.

Neural tube defects: knowledge and preconceptional prevention practices in minority young women.

OBJECTIVE: To assess 1) knowledge of neural tube defect (NTD) prevention by folic acid, 2) frequency of intake of multivitamins and folate- and folic acid-fortified food, and 3) factors associated with knowledge and prevention practices among sexually active minority adolescent and young adult women. METHODS: Young minority women were enrolled in a folic acid program at 3 urban Houston, Texas, reproductive health clinics and assessed for NTD knowledge and preventive practices. A 3-month supply of multivitamins was also dispensed at enrollment. A 3-month program follow-up survey of a randomly selected sample at 2 sites was conducted. RESULTS: Of 387 women (mean age: 18 +/- 1.9 years), 72% were black and 28% were Hispanic. At enrollment, clinics were a major source of information of NTD prevention (44%); 52% had heard of folic acid, 45% had heard of NTDs, and 50% had heard of birth defects prevention by multivitamins. Significantly more Hispanic than black young women had heard of NTDs (59% vs 39%). Pregnancy history, regular birth control use, and education level for age were independently associated with knowledge. In young women with low education level for age, regular birth control use was significantly associated with knowledge. At enrollment, daily multivitamin intake was very low (9%) and folate-rich foods were consumed in inadequate amounts. Adequate folate diet was not associated with knowledge. The program follow-up survey indicated that 88% to 92% had knowledge of NTDs and folic acid, and 67% reported taking a daily multivitamin. CONCLUSIONS: Publicly funded clinics may be the only source of information on NTD prevention for many minority young women. Preliminary evidence suggests that a promotion program improves knowledge, and dispensing of multivitamins increases multivitamin use. However, clinicians in such programs need to reinforce daily adherence to multivitamins in young women.

Use of hymenal measurements in the diagnosis of previous penetration.

OBJECTIVE: To determine the usefulness of measurements of the vaginal opening and amount of hymenal tissue present inferiorly and laterally in the diagnosis of vaginal penetration. METHODS: The transhymenal diameters and the amount of tissue present between the hymenal edge and vestibule inferiorly at 6 o'clock and laterally at 3 o'clock and 9 o'clock were measured from photographs of 189 prepubertal children with a validated history of digital or penile penetration and 197 children who denied previous sexual abuse. Statistical analyses were conducted to compare the mean values and hymenal symmetry between groups as well as to determine the sensitivity and specificity of various cutoff points. RESULTS: Comparison of the mean diameters demonstrated that children with a penetration history had a significantly larger transverse opening than nonabused children when examined in the knee-chest position (5.6 vs 4.6 mm). However, there was extensive overlap in measurements between the 2 groups. No significant differences were noted between groups in the size of the vertical diameter, the amount of tissue present inferiorly or laterally, or the symmetry of the hymen in either position. Children with previous penetration were more likely than nonabused children to have a horizontal opening measuring >6.5 mm in the knee-chest position, but the sensitivity and specificity of this test were low (29% and 86%, respectively). Higher values had better specificity but very low sensitivity. Less than 1.0 mm of hymenal tissue was detected at 6 o'clock only in those with a history of penetration (100% specificity), but the sensitivity was low (1%-2%). CONCLUSION: Most hymenal measurements lack adequate sensitivity or specificity to be used to confirm previous penetration. Less than 1.0 mm of hymenal tissue at 6 o'clock was detected only in victims of abuse, but the usefulness of this test is limited by the rarity of this finding.