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Purpose HIV pre-exposure prophylaxis (PrEP) reduces HIV transmission and is approved for adolescents aged 12–17 years. Adolescent girls and young women (AGYW) have modest PrEP uptake rates, while many receive reproductive health counseling. We sought to identify opportunities for incorporating PrEP education in contraceptive counseling delivered to AGYW. Methods We performed a secondary analysis of data from the Health Coaching for Contraceptive Continuation pilot study, which supported contraceptive use among AGYW. Participants were 14–22 years old, sexually active with males, and not desiring pregnancy within 12 months. Coaches were sexual health educators with ≥5 years’ experience providing contraceptive and PrEP counseling to youth. Participants completed a baseline visit within 30 days of contraceptive initiation and completed up to five monthly coaching sessions. Of 33 enrollees, this analysis includes the 21 who completed ≥4 sessions. Two coders deductively coded session transcripts for five themes: opportunities to discuss PrEP; HIV knowledge, risk perception, and testing attitudes; changes in HIV risk status; condom use knowledge and skills; and sexually transmitted infection knowledge and risk perception. Results Of the 111 transcripts coded, 24 contained opportunities to discuss PrEP and were inductively analyzed. Thematic analysis demonstrated three types of opportunities for PrEP discussions: failure to introduce information, and provision of incomplete information or misinformation. Analysis also revealed four opportunity contexts: sexually transmitted infection prevention strategies, HIV risk reduction, avoidance of adverse sexual health outcomes, and disclosures of condom nonprotected sexual behaviors. Only one transcript mentioned PrEP. Conclusions Multiple opportunities to introduce PrEP counseling exist within contraceptive counseling provided to AGYW.

Study Objective Botswana has a high pregnancy rate among adolescent girls and young women (AGYW). Long-acting reversible contraceptive (LARC) use among AGYW in Botswana is low, despite its high effectiveness for preventing pregnancy. Using an implementation science framework, we assessed barriers and facilitators to LARC implementation among AGYW in Botswana. Design Cross-sectional mixed methods. Setting Gaborone, Botswana. Participants Twenty sexually active AGYW ages 18-24 years; 20 health system stakeholders. Interventions Surveys and semistructured interviews grounded in the Consolidated Framework for Implementation Research. Main Outcome Measures Themes reflecting barriers and facilitators of LARC implementation. Results The median age for AGYW was 22 (interquartile range, 21-23) years. Twenty percent were using an implant and none had ever used an intrauterine device. Barriers and facilitators of LARC implementation spanned factors at each Consolidated Framework for Implementation Research domain: (1) LARC characteristics like side effects; (2) the clinics’ inner settings, including availability of youth-friendly services; (3) characteristics of health system stakeholders, such as LARC skills, and AGYW experiences, attitudes, and beliefs about LARCs; (4) the outer setting external to clinics and Botswana's health system including reproductive health law and policy for minor adolescents; and (5) the implementation process level such as the availability of free or low-cost LARCs. Conclusion We identified multilevel, context-specific factors that affect LARC implementation. Our findings can inform the development of interventions to increase LARC implementation in Botswana by addressing intersecting factors across patient, clinic, health system, and sociopolitical levels, such as providing confidential services to minors and improving LARC training and supply chain pipelines.

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.

The 2012 implementation of the Patient Protection and Affordable Care Act (ACA) contraceptive coverage mandate removed financial barriers to contraception access for many insured women. Since that time, increases in sexually transmitted disease (STD) rates have been noted, particularly among Black adolescent and young adult women aged 15 to 24 years. It is unclear whether changes in dual-method contraception use (simultaneous use of nonbarrier contraceptive methods and condoms) are associated with the increase in STD rates. A repeated cross-sectional analysis was conducted among adolescent and young adult women to compare pre-ACA data from the 2006–2010 cohort and post-ACA data from the 2013–2015 cohort of the National Survey for Family Growth. A significant decrease in short-acting reversible contraception use (SARC; 78.2% vs. 67.5%; p < .01) and a significant increase in long-acting reversible contraception use (LARC; 8.9% vs. 21.8%; p < .01) were found, but no significant change in dual-method contraception use was found among pre- versus post-ACA SARC users and SARC nonusers (odds ratio [OR]: 1.88, 95% confidence interval [CI]: 0.64–5.46, p = .25), LARC users and LARC nonusers (adjusted odds ratio [AOR]: 1.62, 95% CI: 0.42–6.18, p = .48), or White and Black women (AOR: 1.45, 95% CI: 0.66–3.18, p = .35). There was no direct association between changes in contraception use and decreased condom use and therefore no indirect association between changes in contraception use and increased STD rates. Health care providers should continue promoting consistent condom use. Additional research is needed to understand recent increases in STD rates among Black women in the post-ACA era.

Over the past decade, increasing attention has been paid to intervening in individuals' health in the "preconception" period as an approach to optimizing pregnancy outcomes. Increasing attention to the structural and social determinants of health and to the need to prioritize reproductive autonomy has underscored the need to evolve the preconception health framework to center race equity and to engage with the historical and social context in which reproduction and reproductive health care occur. In this commentary, we describe the results of a meeting with a multidisciplinary group of maternal and child health experts, reproductive health researchers and practitioners, and Reproductive Justice leaders to define a new approach for clinical and public health systems to engage with the health of nonpregnant people. We describe a novel "Reproductive and Sexual Health Equity" framework, defined as an approach to comprehensively meet people's reproductive and sexual health needs, with explicit attention to structural influences on health and health care and grounded in a desire to achieve the highest level of health for all people and address inequities in health outcomes. Principles of the framework include centering the needs of and redistributing power to communities, having clinical and public health systems acknowledge historical and ongoing harms related to reproductive and sexual health, and addressing root causes of inequities. We conclude with a call to action for a multisectoral effort centered in equity to advance reproductive and sexual health across the reproductive life course.

Background Although the social consequences of obesity for women are well-documented, its stigmatizing effect on romantic relationships across the life course has seldom been explored. We examined whether having current or chronic obesity since adolescence is associated with romantic relationship satisfaction among women in early adulthood. Methods This is a secondary analysis of data from the National Longitudinal Study of Adolescent Health. Female participants completing waves I and IV who self-reported their height and weight and were in a marital or cohabitating relationship at wave IV were included. Relationship satisfaction was assessed using a seven-item measure. Body mass index BMI at wave IV was categorized as normal weight, overweight, obesity, or chronic obesity (at waves I and IV). The odds of reporting low relationship satisfaction were estimated across body mass index categories using multivariate regression that controlled for key covariates (age, race, ethnicity, education, income, lifetime partners, relationship duration, and depression) and accounted for the complex sampling design. Results Among the 3,582 respondents, 74.8% were White, 65.5% had less than a college degree, and 61.8% were in their relationship for more than 3 years. At wave IV, 38.2% had a normal body mass index, 27.7% had overweight, 26.7% had obesity, and 7.5% had chronic obesity. Only having chronic obesity was associated with relationship satisfaction in early adulthood. Women with chronic obesity had 1.44 (95% confidence interval, 1.03–2.02) times the odds of reporting low relationship satisfaction compared with those categorized as normal weight. Conclusions Chronic obesity since adolescence is associated with poor romantic relationship satisfaction in early adulthood.

Study Objective Nonadherence in sexual risk reduction interventions might be common among adolescents. We compared intervention completion rates among adolescent and young adult women with and without a previous pregnancy or sexually transmitted infection (STI) participating in a program to improve contraceptive continuation. Design Secondary data analysis from a feasibility study of a health-coaching intervention to improve contraceptive continuation. Setting Three urban pediatric clinics in Philadelphia. Participants Women ages 14-22 years who were English-speaking, sexually active in the past year, not desiring pregnancy in the next year, and starting a new contraceptive method. Interventions At baseline, participants completed a sociodemographic questionnaire and semistructured interview, followed by 5 monthly coaching sessions. Interviews and coaching sessions were audio-recorded, transcribed, and coded for thematic content. Main Outcome Measures Intervention completion was defined as the number of completed coaching sessions. Secondary outcomes were qualitatively explored group differences in reproductive knowledge, attitudes, and risk perception. Results Participants with a previous adverse outcome (a previous STI and/or a previous pregnancy) completed fewer coaching sessions than those without such history (median: 2 vs 4; P = .03). Both groups had low HIV/STI knowledge, negative attitudes toward pregnancy, and low HIV/STI risk perception. Those with a previous adverse reproductive outcome held more negative attitudes toward condoms. Conclusion Despite similar reproductive knowledge, attitudes, and risk perception, young women who have experienced an adverse reproductive outcome might be less likely to fully engage in sexual risk reduction interventions. Future studies should confirm these findings and consider strategies to optimize the intervention's reach for vulnerable youth.

Gaps in preventive care may contribute to adverse outcomes among pregnant teens. This study quantified teen preventive care utilization before and after pregnancy.A continuous retrospective cohort identified 150 teens with a positive pregnancy test (July 2015 to May 2017) at two pediatric primary care sites. Chart review assessed office visits for 18 months before and after the pregnancy test. We also assessed contraceptive counseling, pregnancy outcomes (live birth, miscarriage, termination), and continuity with a single clinician. Demographic factors included age, race, ethnicity, primary insurance, and residential zip code. Logistic regression identified factors associated with visits after pregnancy. Separately, for a cohort of 47 parenting teens who received primary care at the same site as their infants, we assessed teen-infant care after birth.Teens were predominantly non-Latina black (91%) and Medicaid insured (71%). Before pregnancy, most teens had preventive visits (66%) and reported contraceptive use (65%). After pregnancy, 52% discussed pregnancy decisions within a month, 55% reported contraceptive use, and 64% had any primary care visit. Postpregnancy visits were associated with teen age (18 vs. ≥18 years odds ratio 2.84, 95% confidence interval 1.17-6.90) and pregnancy outcome (termination vs. live birth odds ratio 4.02, 95% confidence interval 1.47-11.01). Among parenting teens, there were more infant visits than teen visits, and continuity was higher for infants.In a primary care cohort of pregnant teens, gaps persisted in pediatric clinical follow-up after pregnancy. Particularly in situations where pregnancy led to a birth, pregnancy frequently prompted a transition away from pediatric care.

Few interventions to improve contraceptive continuation are tailored to meet the developmental needs of young women under age 25 years. The Health Coaching for Contraceptive Continuation (HC3) intervention was designed to address this gap. In this special report, we describe the rationale for using health coaching, conceptual framework, intervention processes, and findings from a single-arm feasibility study of the intervention protocol.Health coaching is a person-centered behavioral change approach organized around five main strategies: providing education relevant to health goals, building health self-management skills, offering patient-centered counseling, identifying barriers to adherence, and fostering personal accountability for achieving health goals. We used these strategies to affect theory-driven mediators delineated in the Integrative Model of Behavioral Prediction (intentions, knowledge, attitudes, perceived social norms, and self-efficacy) and clinical mediators posited to change through program participation (shared contraceptive decision-making, method satisfaction, quality of life, distress tolerance, experiential avoidance, patient-coach alliance, and expectations of treatment effect). Experienced sexual health educators completed a manualized, 4-week health training program adapted from the National Society of Health Coaches. Between March and December 2017, we recruited a convenience sample of sexually-active women ages 14-21 years who initiated a new contraceptive in the prior 14 days from three urban pediatric clinics in Philadelphia, Pennsylvania. At baseline, participants completed a socio-demographic questionnaire, contraceptive needs assessment interview, and prioritized reproductive topics to learn more about. We synthesized these data into a coaching plan that guided the monthly coaching sessions which occurred for 6 months following contraceptive initiation. We assessed method adherence and continuation with monthly follow-up questionnaires and corroborated the findings through electronic medical record and pharmacy refill data review. Exit interviews assessed program acceptability. Feasibility outcomes measured throughout the protocol administration included recruitment and retention success. We used descriptive statistics to assess baseline and follow up questionnaire measures and audio-recorded and transcribed exit interviews verbatim. Two independent coders used deductive and inductive content analysis coding approaches to identify themes related to program acceptability.Of 92 women approached for the longitudinal intervention, 33 enrolled. Participants' mean age was 17.4 ± 2.1 years. Most were Black (n = 24), in high school (n = 23), and single/never-married (n = 31). Twenty-one completed ≥4 coaching sessions. Among the 23 for whom 6-month contraceptive continuation could be determined, 20 continued their baseline method, 2 switched methods without a gap in use, and 1 discontinued contraceptive use. Five were lost to follow up after enrollment; continuation status was indeterminant for the remaining five. Among the 22 who completed exit interviews, all expressed high program acceptability citing that it provided knowledge-based benefits, nonknowledge-based benefits, and an opportunity to develop a positive, supportive relationship with a reproductive health expert. Participants provided feedback on logistical aspects of the program they enjoyed and made suggestions for improvements prior to embarking on a larger efficacy trial.Health coaching is a new approach for promoting contraceptive continuation in young women. The conceptual framework, program structure, and feasibility findings demonstrate strong support for the program among participants. Subsequent research must explore program effects on contraceptive continuation and prevention of unintended pregnancy.

Study Objective To describe sexual initiation patterns in female adolescents and examine their association with adolescent characteristics and racial disparities in adverse sexual health across adolescence into early adulthood. Design A prospective, longitudinal, observational study from adolescence to adulthood. Setting Nationally representative, the National Longitudinal Study of Adolescent to Adult Health data, in the range of 24-32 years old at final assessment. Participants Data from 43,577 US women from 1994 to 2008. Interventions and Main Outcome Measures Adolescent sex-related characteristics at the individual-, family-, and school peer-level were assessed, and multiple sex partners, sexually transmitted infections (STIs)/HIV, and intimate partner violence (IPV) were longitudinally tracked. The sexual initiation pattern and its longitudinal association with sexual health were analyzed using latent class analysis and mixed effects Poisson regression models. Results Of the 43,577 subjects, the sexual initiation patterns were determined as normative (n = 28,712, 65.9%), late (n = 10,799, 24.8%), and early but unempowered (n = 4,066, 9.3%). The highest rate of the early-unempowered group was shown in Hispanic individuals (1,054/7,307 = 14.4%); they were more likely to be depressed, unsatisfied with their bodies, receiving welfare, and have less educated/permissive parents to their sexual initiation than others. The late group had a higher body mass index and greater satisfaction with their bodies. The highest number of STIs/HIV and IPV victimization was shown in non-Hispanic Black (NHB) and Hispanic individuals, respectively. However, NHB females’ higher number of STIs/HIV was shown in the late/normative groups, not in the early-unempowered group. Among Hispanic females, adolescent sexual initiation patterns were not directly associated with their frequent IPV victimization. Conclusion NHB females' higher STI/HIV in late/normative groups and Hispanic females’ frequent IPV victimization regardless of their sexual initiation patterns might indicate that racial/ethnic disparities in female sexual health was not directly determined by adolescent risk behaviors.

BACKGROUND AND OBJECTIVES: Rates of sexually transmitted infections (STIs) have increased over the decade. Guidelines recommend HIV testing with incident STIs. Prevalence and factors associated with HIV testing in acute STIs are unknown in adolescents. Our objective was to determine the prevalence of completed HIV testing among adolescents with incident STIs and identify patient and health care factors associated with HIV testing. METHODS: Retrospective study of STI episodes (gonorrhea, Chlamydia, trichomoniasis, or syphilis) of adolescents between 13 and 24 years old from July 2014 to December 2017 in 2 urban primary care clinics. We performed mixed effects logistic regression modeling to identify patient and health care factors associated with HIV testing within 90 days of STI diagnosis. RESULTS: The 1313 participants contributed 1816 acute STI episodes. Mean age at STI diagnosis was 17.2 years (SD = 1.7), 75% of episodes occurred in females, and 97% occurred in African Americans. Only half (55%) of acute STI episodes had a completed HIV test. In the adjusted model, female sex, previous STIs, uninsured status, and confidential sexual health encounters were associated with decreased odds of HIV testing. Patients enrolled in primary care at the clinics, compared with those receiving sexual health care alone, and those with multipathogen STI diagnoses were more likely to have HIV testing. CONCLUSIONS: HIV testing rates among adolescents with acute STIs are suboptimal. Patient and health care factors were found to be associated with receipt of testing and should be considered in clinical practice.

This study examined the relationship between pubertal development and type of caregiver-adolescent communication about sex (CACS) among 441 African American caregivers participating in an intervention trial in rural North Carolina. We assessed CACS about general sexual health topics and positive aspects of sexuality. Caregivers’ attitudes and self-efficacy for CACS, and open communication style were examined as potential mediators. Caregivers engaged in low levels of communication about sex regardless of type. Among caregivers of males, pubertal development was associated with greater communication about general sexual health, which was mediated by self-efficacy for CACS. Among caregivers of females, pubertal development was associated with less communication about general and positive sexual health topics; however, there were no mediating factors. These findings highlight the predictors of CACS among young men and women after pubertal onset. Age appropriate, practical guidance for initiating CACS may be critical for ensuring caregiver talk about sex.

Reproductive health is a key component of cancer care and survivorship, encompassing gynecologic issues ranging from contraception and fertility to treatment of sexual dysfunction and menopause. Yet, oncology providers are often unfamiliar with the management of gynecologic issues. In order to address the unmet needs of female cancer patients, reproductive health should be addressed at the time of cancer diagnosis and continue through survivorship. Universal screening for pregnancy intention can guide counseling on contraception and fertility preservation. Safe and efficacious contraceptive options for both patients undergoing active treatment and cancer survivors are available and can often offer non-contraceptive benefits such as regulation of menses. Prompt referral to reproductive endocrinology specialists allows patients to explore options for fertility preservation prior to the receipt of cancer-directed therapies. Due to a rapid drop in hormone levels, treatment-induced menopause often results in severe symptoms. In patients with induced menopause, balancing the risks of hormone therapy compared to the decreased quality of life and health concerns associated with early menopause may help patients with difficult decisions regarding symptom control. Cancer treatment impacts sexual function with both physical changes to the vulvovaginal tissues and altered relationship dynamics. Open discussions on the impact to sexual health are paramount to quality of life after cancer. While more data is needed in many areas, proactive management of reproductive health issues is crucial to quality of life in cancer survivorship. In this article, we review contemporary management of the reproductive health of the female cancer patient.

To evaluate satisfaction with intrauterine device (IUD) insertion procedures among adolescent and young adult women.This secondary analysis of data from a multisite, single-blind, sham-controlled randomized trial of women having a levonorgestrel 13.5-mg IUD inserted enrolled participants from March 2015 through July 2016 at three family planning clinics in Philadelphia, Pennsylvania. Eligible participants were 14-22 years of age, nulliparous, not pregnant, and English-speaking. Randomization was computer-generated allocation in block sizes of four to a 1% lidocaine paracervical or sham block. Only patients were blinded. Satisfaction was measured with three items that assessed overall satisfaction with the procedure, whether participants would recommend the IUD to a friend, and the perception that the IUD was worth the discomfort. Predictors included demographics, sexual and reproductive history, pain after IUD insertion, and treatment group.Ninety-five women enrolled; 93 (97.9%) were included in the analysis. Forty-five (47.4%) were white, 34 (36.0%) were black, 62 (66.0%) were privately insured, and 75 (79.0%) had used contraception previously. Most (n=73 [76.8%]) reported high overall satisfaction with the procedure, 64 (67.4%) would recommend an IUD to a friend, and 79 (83.2%) perceived the IUD was worth the discomfort. The odds of reporting high overall satisfaction were lower among adolescents compared with young adults (odds ratio [OR] 0.07, 95% CI 0.008-0.68); those who never had a gynecologic examination compared with those who had (OR 0.26, 95% CI 0.07-0.99); and decreased as pain score increased (OR 0.96, 95% CI 0.94-0.99). Higher pain scores were negatively correlated with the odds of recommending an IUD to a friend and perceiving the IUD was worth the discomfort.Adolescent and young adult women report high levels of satisfaction after the IUD insertion procedure. Young age, lack of experience with gynecologic examinations, and high pain were inversely related to satisfaction.ClinicalTrials.gov, NCT02352714.

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.

Numerous studies examining parent–teen communication about sex (PTCS) have focused on reproductive and sexual health information (i.e., pregnancy, physical development, contraception), with significantly fewer addressing communication about sensitive sex topics (i.e., sexual pleasure, masturbation). This study compares predictors of communication about reproductive and sexual health to those of sensitive sex topics with early adolescents. Participants were 465 rural caregivers and their African American youth. Positive attitudes and self-efficacy for PTCS, open communication style, and older youth age predicted caregiver reports of communication about reproductive and sexual health topics. Open communication style and self-efficacy for PTCS predicted caregiver reports of communication about sensitive sex topics. For youth, only older age and being female predicted communication about reproductive and sexual health, while only being female predicted communication about sensitive sex topics. This study may inform interventions that seek to increase PTCS by highlighting strategies for improving communication about both reproductive and sensitive sex topics.

To estimate the effect of a 1% lidocaine paracervical nerve block on pain during intrauterine device (IUD) insertion compared with a sham block in adolescents and young women.We conducted a multisite, single-blind, sham-controlled randomized trial in adolescents and young women having a 13.5-mg levonorgestrel IUD inserted. Enrollment occurred at three family planning clinics in Philadelphia, Pennsylvania. Eligible adolescents and young women were aged 14-22 years, nulliparous, not currently or recently pregnant, and English-speaking. Participants were randomized using computer-generated allocation in block sizes of four to receive a 10-mL 1% lidocaine paracervical block or a sham block (1 cm depression of the vaginal epithelium at paracervical block sites with a wooden cotton-tipped applicator). Only patients were blinded. The primary outcome was pain after IUD insertion measured with a 100-mm visual analog scale. Using a two-sided t test and assuming a 20-mm difference in visual analog scale scores, a SD of 28 mm, an α of 0.05, and 90% power, a sample of 43 participants per group was estimated.Between March 2015 and July 2016, 95 participants enrolled (47 lidocaine block group; 48 sham block group). All were included in the analysis. Forty-four percent were white, 36% black, 65% privately insured, and 79% previously used contraception. The median visual analog scale score after IUD insertion was 30.0 (95% CI 20.0-58.0) in the lidocaine block group and 71.5 (95% CI 66.0-82.0) in the sham block (P.001).A 10-mL 1% lidocaine paracervical nerve block reduces pain during IUD insertion in adolescents and young women compared with a sham block with pressure on the vaginal epithelium.ClinicalTrials.gov, NCT02352714.

Caregiver-adolescent communication about sex plays a critical role in the sexual socialization of youth. Many caregivers, however, do not engage their youth in such conversations, potentially placing them at risk for negative sexual health outcomes. Lack of caregiver-adolescent communication about sex may be particularly harmful for rural African American youth, as they often report early sex initiation and are disproportionately impacted by STIs. Moreover, sexual communication may be particularly challenging for families with strong religious backgrounds, potentially affecting the occurrence and breadth of topics covered during communication. Study aims were to: determine whether there was a relationship between caregiver religiosity and type of topics covered during communication about sex (e.g., general sexual health vs. positive aspects of sexuality) among 435 caregivers of early adolescent, African American youth; and if so, identify factors that might explain how religiosity affects communication about sex. Results indicated that caregiver religiosity was positively associated with communication about general, but not positive aspects of sexuality for caregivers of males. Attitudes towards communication about sex and open communication style mediated the relationship. There was no association between religiosity and communication about sex for caregivers of females. The findings from this study could provide a base to better understand and support the sexual socialization process within religious, African American families.

Study Objective To identify predictors of anticipated pain with intrauterine device (IUD) insertion in adolescents and young women. Design We performed linear regression to identify demographic, sexual/gynecologic history, and mood covariates associated with anticipated pain using visual analog pain scores (VAS) collected as part of a single-blind randomized trial of women receiving a 13.5 mg levonorgestrel IUD. Setting Three academic family planning clinics in Philadelphia PA. Participants Ninety-three adolescents and young adult women age 14-22. Intervention: Participants received either a 1% lidocaine or sham paracervical block. Main Outcome Measures Anticipated pain measured using a Visual Analog Scores (VAS) before and perceived pain at 6 time points during the IUD insertion procedure. Results Black or African-American participants had a median anticipated pain score of 68 (IQR 52, 83), White participants had a median anticipated pain of 51 (IQR 35, 68), while participants of other races had a median anticipated pain score of 64 (IQR 36, 73); p=0.012. In multivariate analysis, race was the only covariate that significantly predicted anticipated pain at IUD insertion. Women with anticipated pain scores above the median had significantly higher perceived pain during all timepoints of the IUD insertion procedure. Conclusions Increased anticipated pain is associated with increased perceived pain with IUD insertion. Black adolescent women experience greater anticipated pain with IUD insertion. This population may benefit from counseling and clinical measures to reduce this barrier to IUD use.

Study Objective Long-acting reversible contraceptives (LARCs) are the most effective form of pregnancy prevention for sexually active adolescents, yet usage rates are low. The Affordable Care Act (ACA) mandated insurers cover LARCs without cost-sharing. Compliance with this policy is not well documented. This study assessed LARC coverage by insurers in a large pediatric health system. Design, Setting, Participants, and Interventions Between June and August 2016, LARC coverage was assessed through content reviews of insurance Web sites, formularies, and summaries of benefits for all Pennsylvania Medicaid plans and the top 20 commercial insurers for a large pediatric health system. Main Outcome Measures The primary outcome was adherence to the ACA mandate for LARC coverage without cost-sharing. Results Among the 37 plans (17 public, 20 private), 21 (56.8%) were adherent and 16 (43.2%) were nonadherent. Among nonadherent plans, 3 plans covered LARC services but required cost-sharing, whereas 13 did not cover LARC services at all. There was not a statistically significant difference in LARC coverage between public and private plans. Conclusion Despite the landmark ACA mandate, insurance coverage of LARCs in pediatric hospitals is low for young women among private and public insurers. Insurer failure to adhere to the ACA among pediatric patients represents a barrier to LARC access for those at high risk of unintended pregnancy.

Study Objective Describe follow-up care patterns and continuation rates during the first 6 months after initiating a long-acting reversible contraceptive (LARC) device among adolescent and young adult women. Design Retrospective chart review among patients who had an intrauterine device (IUD) or subdermal implant placed between January 2015 and December 2016. Setting Urban adolescent specialty care clinic. Participants Women ages 13-23 years. Main Outcome Measures Follow-up encounters were defined as scheduled and unscheduled phone calls, outpatient clinic visits, or emergency department visits during the 6 months after device placement. Continuation was defined as not having the device removed or expelled during the 6 months after initiation. Frequencies were calculated, and logistic regression was used to determine predictors of follow-up encounters and continuation. Results Among the 177 patients, 180 LARC devices were placed. Most were 13-17 years of age (56%), non-Hispanic black (64%), publicly insured (57%), and had an IUD placed (57%). Most (86%) had 1 or more clinical encounters during the 6 months: 70% attended a scheduled encounter and 53% had an unscheduled encounter. Approximately half (45%) attended the scheduled 2-week office visit; only 6% attended the 6-month office visit. The 6-month LARC continuation rate was 92% (n = 166), with most discontinuations among IUD users (n = 12; 7%). Conclusion LARC continuation rates were high in our study population. Most adolescent and young adult women have at least 1 follow-up encounter in the 6 months after LARC placement. Clinical practices should be prepared to address issues that arise during follow-up encounters, whether in person or by phone.

CONTEXT: Studies have shown that obesity is associated with increased sexual risk-taking, particularly among adolescent females, but the relationships between obesity, perceived weight and sexual risk behaviors are poorly understood. METHODS: Integrative data analysis was performed that combined baseline data from the 1994-1995 National Longitudinal Study of Adolescent Health (from 17,606 respondents in grades 7-12) and the 1997 National Longitudinal Survey of Youth (from 7,752 respondents aged 12-16). Using six sexual behaviors measured in both data sets (age at first intercourse, various measures of contraceptive use and number of partners), cluster analysis was conducted that identified five distinct behavior clusters. Multivariate ordinal logistic regression analysis examined associations between adolescents' weight status (categorized as underweight, normal-weight, overweight or obese) and weight perception and their cluster membership. RESULTS: Among males, being underweight, rather than normal-weight, was negatively associated with membership in increasingly risky clusters (odds ratio, 0.5), as was the perception of being overweight, as opposed to about the right weight (0.8). However, being overweight was positively associated with males' membership in increasingly risky clusters (1.3). Among females, being obese, rather than normal-weight, was negatively correlated with membership in increasingly risky clusters (0.8), while the perception of being overweight was positively correlated with such membership (1.1). CONCLUSIONS: Both objective and subjective assessments of weight are associated with the clustering of risky sexual behaviors among adolescents, and these behavioral patterns differ by gender.Copyright © 2016 by the Guttmacher Institute. Language: en

This article is a comment on Prior's (2016) article “Adolescents’ Use of Combined Hormonal Contraceptives for Menstrual Cycle–Related Problem Treatment and Contraception: Evidence of Potential Lifelong Negative Reproductive and Bone Effects.” In this article, we differ with Prior's conclusions about whether to prescribe combined oral contraceptives to adolescents in general and for off-label reasons in particular. We discuss guidelines on the practice from various medical societies, and we place any decision about treatment in the context of patient autonomy, shared decision-making, the clinician's role as an information agent, and consideration of both treatment and contraceptive needs. Adolescents’ likelihood of adherence to a treatment plan is also an important consideration.

Study Objective Delivery of reproductive services to adolescents varies according to specialty and has been linked to differences in clinical training. Few studies have explored how different specialties' graduate medical education (GME) programs prepare providers to deliver adolescent reproductive services. We explored the perceptions of resident physicians regarding their training in delivering adolescent reproductive health services. Design Between November 2008 and February 2009, 9 focus groups were conducted with graduate medical trainees in 3 specialties that routinely care for adolescents. The semistructured discussions were audio-recorded, transcribed, and analyzed using an inductive approach to content analysis. Setting Large, urban academic medical center in Pittsburgh, Pennsylvania. Participants Fifty-four resident trainees in pediatrics, family medicine, and obstetrics/gynecology. Interventions None. Main Outcome Measures Trainees' perspectives regarding the didactic teaching and clinical training in providing adolescent reproductive services. Results Five themes emerged, reflecting trainees' beliefs regarding the best practices in which GME programs can engage to ensure that trainees graduate with the belief that they are competent and will be comfortable delivering adolescent reproductive services. Trainees believed programs need to: (1) provide didactic lectures and diverse inpatient and outpatient clinical experiences; (2) have faculty preceptors skilled in providing and supervising adolescent reproductive services; (3) teach skills for engaging adolescents in clinical assessments and decision-making; (4) train providers to navigate confidentiality issues with adolescents and caregivers; and (5) provide infrastructure and resources for delivering adolescent reproductive services. Conclusion The 3 specialties differed in how well each of the 5 best practices were reportedly addressed during GME training. Policy recommendations are provided.

Concerns about pain during IUD insertion are a major barrier to use of IUDs among adolescent and young adult patients who may otherwise be interested in this method. Although few studies of pain control options have been conducted in this population, available data suggest that several pharmacologic interventions discussed in this chapter may be beneficial. Pre-procedure naproxen, ketorolac, or tramadol can help to reduce post-procedure discomfort. Paracervical nerve blockage with lidocaine-based anesthetics, topical lidocaine spray, or EMLA cream also appears to reduce pain with IUD insertion. Intravaginal 2% lidocaine gel may reduce pain with tenaculum and speculum placement. This chapter will discuss the complex nature of pain in gynecological procedures, including IUD placement, and the impact of anxiety and fear on pain perception. It will also review clinical guidelines to assist with pain control during procedures and describe evidence-based pharmacological pain control modalities that can be used during IUD procedures.

Study Objective Little is known about the content of parental discussions with young adolescents about reproductive health topics. We sought to characterize the messages mothers share about contraception and condoms. Design Recruitment occurred between January 2012 and May 2013. Mothers and their 12- to 14-year-old adolescent son or daughter were invited to participate in a semistructured conversation about everyday issues and health topics, including reproductive health topics. Discussions were audio-recorded, transcribed, and a grounded theory approach to content analysis was performed. Content analysis was performed to characterize maternal messages regarding contraception and condoms. Setting Urban city in western Pennsylvania. Participants Twenty-five dyads; 14 mother–daughter dyads and 11 mother–son dyads. Interventions None. Main Outcome Measures Maternal reproductive health messages during conversations with early adolescent children. Results Four key themes emerged. Theme 1 focused on general facts about condoms and contraceptive methods, how each works, and how to obtain them. Theme 2 emphasized the consequences of sexual behaviors and the advantages of safe sex. Theme 3 conveyed the effectiveness of condoms and contraceptive methods for preventing pregnancy and sexually transmitted infections. Theme 4 described where adolescents could get more information about condoms and contraception. Conclusion Mothers convey a broad range of information about contraceptives and condoms to young adolescents.

STUDY OBJECTIVE: Intrauterine device (IUD) utilization in the United States is low among adolescent and young adult women. Longer procedure duration has been proposed as one potential barrier to IUD insertion in this population. We hypothesized that procedure duration would be longer in adolescents compared to young adult women. DESIGN, SETTING, AND PARTICIPANTS: This study was a secondary analysis of a randomized clinical trial comparing the effectiveness of a lidocaine versus sham paracervical nerve block for pain control during levonorgestrel 13.5 mg IUD insertion. Adolescent and young adult women ages 14 to 22 years were recruited from three outpatient academic sites in Philadelphia, PA. INTERVENTIONS AND MAIN OUTCOME MEASURES: Pain scores were recorded at seven steps during the procedure from speculum insertion through removal. Time stamps associated with each step were used to calculate the overall procedure duration. Cumulative IUD insertion procedure duration was estimated using the Kaplan-Meier method. RESULTS: Ninety-five women enrolled. Nineteen (20%) were ages 14 to 17 and 76 (80%) were ages 18 to 22 years. The median procedure duration (seconds ± IQR) was longer for adolescents than young adults (555 ± 428 seconds versus 383 ± 196 seconds, p = 0.008). After adjusting for study site, the difference in expected median procedure duration between age groups was not significant (p=0.3832). CONCLUSION: The duration of IUD insertion procedures in adolescent and young adult women is not clinically or statistically significant. Providers should not withhold IUDs from appropriate adolescent and young adult women based on age alone. CLINICAL TRIAL REGISTRATION: Clinicaltrials.gov (NCT# NCT02352714)

Background Obesity is recognized as a barrier to receiving women's preventive health services, including cervical and breast cancer screening. Little is known about whether obesity is associated with a lower incidence of human papillomavirus (HPV) vaccination, another important preventive care service for adolescent girls and young women. The objective of this study was to determine if adolescent girls and young women with obesity are less likely to receive HPV vaccination compared with individuals with normal weight. Methods We examined whether HPV vaccination was associated with obesity status in women aged 9–30 years surveyed from 2009 to 2016 by the U.S. National Health and Nutrition Examination Survey. Results from logistic and linear regression models were adjusted for age, race, income, insurance status, self-reported health, and health care use, accounting for the weighted survey design. Results The final cohort included 5,517 women. Overall, 32.9% of participants reported vaccination, with a mean age at vaccination of 15.8 years. Adolescent girls and young women with obesity were less likely to report vaccination; the adjusted odds ratio of vaccination was 0.79 (p = .01) compared with normal weight women. Among those vaccinated, the age at vaccination was significantly older for women with obesity, 16.3 years compared with 15.2 years (p = .002), but there was no difference in the completion of the vaccination series rate by obesity. Conclusions Adolescent girls and young women with obesity were less likely to report HPV vaccination and, if they were vaccinated, received the vaccination at a later age.

Background Unintended pregnancy is common and disproportionately occurs among low-income and African-American (AA) women. Male partners may influence women's risk of unintended pregnancy through reproductive coercion, although studies have not assessed whether racial differences in reproductive coercion impact AA women's disparate risk for unintended pregnancy. We sought to describe women's experiences with pregnancy-promoting behaviors by male partners and explore differences in such experiences by race. Methods Semistructured interviews were conducted with low-income, AA and White women aged 18 to 45 years recruited from reproductive health clinics in Western Pennsylvania to explore contextual factors that shape women's contraceptive behaviors. Narratives were analyzed using content analysis and the constant comparison method. Findings Among the 66 participants (36 AA and 30 White), 25 (38%) described experiences with male partner reproductive coercion. Narratives provided accounts of contraceptive sabotage, verbal pressure to promote pregnancy and specific pregnancy outcomes, and potential motives behind these behaviors. AA women in the sample reported experiences of reproductive coercion more often than White women (53% and 20%, respectively). AA women were also more likely than White women to attribute a current or prior pregnancy to reproductive coercion. AA women identified relationship transiency and impending incarceration as potential motivations for men to secure a connection with a female partner via pregnancy. Conclusions Our findings suggest that reproductive coercion may be a factor contributing to disparities in unintended pregnancy. More research, including population-level studies, is needed to determine the impact of reproductive coercion on unintended pregnancy and to understand the social and structural factors associated with pregnancy-promoting behaviors.

Study Objective Little is known about the information shared during family discussions about sexuality. From a public health perspective, abstinence is one of the most important sexuality topics parents can talk about with adolescents. We sought to characterize the messages mothers communicate to young adolescents regarding abstinence. Design Content analysis of dyadic discussions that occurred between June 2011-December 2012 between mothers and their 10- to 14-year-old adolescent sons and daughters. Discussions were audio-recorded, transcribed, and a grounded theory approach to content analysis performed. Setting Urban city in Western Pennsylvania. Participants Twenty-one dyads; 15 mother-daughter dyads and 6 mother-son dyads. Interventions None. Main Outcome Measures None. Results Four key themes emerged reflecting the high priority mothers placed on abstinence, delaying their adolescent's sexual debut, and nurturing sexual decision-making skills. Theme 1 focused on ensuring that adolescents understand what abstinence means. In defining abstinence, only 1 mother explained what sex is. The 3 remaining themes emphasized sexual decision-making and emphasized when it is acceptable to stop being abstinent (theme 2), why abstinence is important (theme 3), and mothers' desire to engage in ongoing discussions, particularly when an adolescent was considering becoming sexually active (theme 4). Messages did not vary according to mothers' age or according to adolescent age, gender, or race. Conclusion Mothers convey complex information about abstinence and sexual decision-making to young, non-sexually active adolescents. Message tailoring on the basis of the adolescents’ age or sex was not observed.

Children whose mothers are victims of intimate partner violence (IPV) are at increased risk of adverse health and psychosocial consequences, including becoming victims or perpetrators of violence in their own relationships. This study aimed to understand the role mothers may play in preventing the perpetuation of violence in their children’s lives. We performed semistructured interviews with 18 IPV victims who are mothers and were living at the Women’s Center & Shelter of Greater Pittsburgh from July through November 2011. We sought to understand how they communicate with their children about IPV and relationships. These mothers described a desire to explain their IPV experience and offer advice about avoiding violence in relationships. As foundations for these discussions, they emphasized the importance of close relationships and open communication with their children. Although mothers are interested in talking about IPV and relationships and identify communication strategies for doing so, many have never discussed these topics with their children. These mothers need and want an intervention to help them learn how to communicate with their children to promote healthy relationships. Development of a program to facilitate communication between IPV victims and their children could create an important tool to empower mothers to break the cross-generational cycle of domestic violence.

Objective Little is known about prevention-focused counseling health providers deliver to parents of adolescents. This study compared parental report of discussions with their adolescents’ providers about a range of adolescent prevention topics. Methods Between June and November 2009, a questionnaire was provided to parents accompanying adolescents aged 11–18 on outpatient clinic visits. Parents indicated, anonymously, which of 22 prevention topics they remembered discussing with their adolescent's provider. Hierarchical logistic regression models were used to identify correlates of parental recall. Results Among the 358 participants, 83% reported discussing at least one prevention topic. More parents reported discussing general prevention topics than mental health or high-risk topics (e.g. sex). Adolescent gender, visit type, having a usual source of care, and parental beliefs about their adolescents’ risk behaviors correlated with parental report of discussions about high-risk and mental health topics. Conclusion Most parents recalled discussing one or more topics with their adolescent's health provider. However, parental report of discussions about topics linked to significant adolescent morbidity was low. Practice implications Strategies to improve the frequency, timeliness and appropriateness of counseling services delivered to parents about adolescent preventive health are needed. Strategies that utilize decision support tools or patient education tools may be warranted.