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PURPOSE: After dramatic declines in teen births and pregnancies from 1991 to 2005, teen birth rates in the United States increased in 2006 and 2007. We examined behavioral determinants of these trends and the likely direction of future trends. METHODS: Pregnancy risk was estimated based on recent sexual activity, method of contraception used, and method-specific contraceptive efficacy, using data from young women on the national Youth Risk Behavior Survey (N approximately 125,000). Weighted logistic and linear regression were used to test for linear and quadratic (curved) trends over time. RESULTS: Between 1991 and 2007, behavioral risk for pregnancy declined, with all of the decline occurring between 1991 and 2003. Improvements in contraceptive use from 1991 to 2003 were found in condom use, nonuse, and use of withdrawal. Recent sexual activity (past 3 months) was unchanged over the entire period, except among black students. Quadratic changes were found in pregnancy risk for black teens and in condom use among all teens and black teens, suggesting that trends had reversed or flattened out. Although no change was found for any behavior between 2003 and 2007, pregnancy risk among sexually active teens demonstrated a borderline increase (p=.06) and small nonsignificant declines were seen for specific contraceptive methods. Pregnancy risk estimated from behavioral data correlated well with actual changes in teen pregnancy rates (1991-2004) and birth rates (1991-2006). DISCUSSION: After improvement in the 1990s and early 2000s, trends in behavioral risk for pregnancy appear to have stalled or even reversed among certain groups since 2003. These behavioral trends are consistent with the 2006 and 2007 increases in the teen birth rate. They may well portend further increases in 2008. [ABSTRACT FROM AUTHOR]

OBJECTIVES: We examined pregnancy decisionmaking among women seeking abortion or prenatal care. METHODS: Conventional measures of pregnancy intentions were compared with newer measures in 1017 women seeking abortion. A reduced sample of abortion patients (142 African American women from New Orleans) was compared with 464 similar women entering prenatal care. RESULTS: Virtually all abortion patients reported the pregnancy as unintended; two thirds of prenatal patients reported the pregnancy as unintended. Reasons for seeking abortion related to life circumstances, including cost, readiness, not wanting any more children, marital status, relationship stability, and being too young. Abortion patients were more likely to report trying hard to avoid a pregnancy and not being in a relationship. They were less likely to report that their partner wanted a baby (odds ratio=0.10) or that they wanted a baby with their partner (odds ratio=0.13) than prenatal patients. CONCLUSIONS: Traditional measures of pregnancy intentions did not readily predict a woman's choice to continue or abort the pregnancy. Relationship with male partners, desire for a baby with the partner, and life circumstances were critical dimensions in pregnancy decisionmaking. [ABSTRACT FROM AUTHOR]

PURPOSE: To estimate trends in use and nonuse of effective protection among adolescents 1991-2003, and to assess factors associated with poorly protected sex in 2003. METHODS: We analyzed seven Youth Risk Behavior Surveys (YRBSs) of 9th-12th graders conducted from 1991 through 2003. We estimated trends in use of condoms, effective contraception, withdrawal, and no method, using linear logistic regression models, and evaluated correlates of the use of no method or withdrawal in 2003. RESULTS: Throughout 1991-2003, about one third of students reported that they had been sexually active in the previous 3 months. Condom use increased significantly throughout 1991-2003, from 46.2% (+ or - 3.3%) in 1991 to 63.0% (+ or - 2.5%) in 2003, and the percentage reporting use of either withdrawal or no method steadily declined, from 32.6% (+ or - 2.7%) to 18.8% (+ or - 2.1%). In 2003, use of withdrawal or no method was greater among females, Hispanics, those who had been pregnant or had caused a pregnancy, and those who reported feeling sad or hopeless or had considered suicide. CONCLUSIONS: Reported unprotected sex decreased, while use of condoms increased. A high-risk group engaging in poorly protected sex was identified, accounting for 6.4% of students. [ABSTRACT FROM AUTHOR]

PURPOSE: To explore the utility of using national data from high school students to explain changes in national declines in pregnancy rates. Although declines in teen pregnancy and birthrates in the 1990s have been welcome news to those interested in adolescent health and welfare, the reasons for these declines are not readily apparent. Previous attempts to explain these declines focused on the period before 1995 and did not directly calculate the impact of improved contraceptive use. METHODS: The national Youth Risk Behavior Survey provided estimates for sexual activity and contraceptive use among teens aged 15-17 years between 1991 and 2001 (n = 31,058). These data were combined with method-specific contraceptive failure rates (CFRs) derived from the 1988 and 1995 National Survey of Family Growth and pregnancy rates from the National Vital Statistics System. We calculated weighted-average CFRs (WACFR) and used the annual rate of change in the WACFR and sexual activity to estimate their relative contributions to the annual change in risk of pregnancy. Weighted least-squares regression in SUDAAN was used to test change over time. RESULTS: Between 1991 and 2001, annual rates of change in sexual behaviors were -1.7% for sexual experience and -1.6% for the WACFR. Improvements in WACFR resulted primarily from a decline in use of withdrawal (from 20% to 13%) and use of no method (from 17% to 13%) and an increase in condom use (40% to 51%). Recent sexual intercourse (i.e., intercourse during the past 3 months among teens who had ever had intercourse) did not change over time. The change in the estimated risk of pregnancy closely approximated the annual decline in the pregnancy rates for blacks and Hispanics but underestimated the actual decline for whites. Overall, 53% of the decline in pregnancy rates can be attributed to decreased sexual experience (95%CI 26% to 79%) and 47% to improved contraceptive use (95%CI 21% to 74%). CONCLUSIONS: Use of school-based behavior data reflects well the pregnancy experience for school-age black and Hispanic adolescents, but does not track well with the pregnancy risk of white adolescents. Care should be taken in attributing changes in pregnancy rates to changes in behavior, given broad confidence intervals around these estimates. These data suggest that both delayed initiation of sexual intercourse and improved contraceptive practice contributed equally to declines in pregnancy rates among high school-aged teens during the 1990s; however, estimates varied among racial and ethnic groups. [ABSTRACT FROM AUTHOR]

PURPOSE: To explore potential psychosocial predictors for initiation of sexual intercourse among middle-school, inner-city youth, using longitudinal data from the Healthy and Alive! project. METHODS: We conducted hierarchical, logistic regression with adjustment for intraclass correlation over two sequential periods, including seventh and eighth grades (N = 3163), to assess the independent influence of psychosocial and demographic factors. Internally reliable scales to assess psychosocial influences were created, based on major theories of behavior. The sample was 52% female, 51% black, 30% Hispanic, 9% white, and 3% Asian. At baseline, 13% of girls and 39% of boys reported already having initiated sexual intercourse. RESULTS: Personal and perceived peer norms about refraining from sex were a strong and consistent protective factor. Alcohol and other drug use, poor academic performance, male gender, and black race were consistent risk factors. Self-efficacy showed a mixed effect: protective in the seventh grade but increasing risk in the eighth grade. Speaking a language other than English was a protective factor in seventh grade. Both psychosocial and demographic factors provided independent explanatory power. CONCLUSIONS: Psychosocial factors, particularly norms about having sex, influence initiation of sexual intercourse. These data suggest that programs to delay initiation of sexual intercourse should reinforce norms about refraining from sex. [ABSTRACT FROM AUTHOR]

PURPOSE: To describe the state of reproductive health services, including access to contraception and health center policies, among school-based health centers (SBHCs) serving adolescents in the United States METHODS: We examined questionnaire data on provision of reproductive health services from the 1998-99 Census of School-Based Health Centers (response rate 70%). We examined 551 SBHCs in schools with high or middle school grades. We used logistic regression to define factors independently associated with services and policies. RESULTS: Most SBHCs (76%) were open full-time; over one-half (51%) of centers had opened in the past 4 years. Services provided, either on-site or by referral, included gynecological examinations (95%), pregnancy testing (96%), sexually transmitted disease (STD) diagnosis and treatment (95%), Human Immunodeficiency Virus (HIV) counseling (94%), HIV testing (93%), oral contraceptive pills (89%), condoms (88%), Depo-Provera (88%), Norplant (78%), and emergency contraception (77%). Counseling, screening, pregnancy testing, and STD/HIV services were often provided on-site (range 55%-82%); contraception was often provided only by referral (on-site availability = 3%-28%). SBHCs with more provider staffing were more likely to provide services on-site; rural SBHCs and those serving younger grades were less likely to provide these services on-site. Over three-quarters (76%) of SBHCs reported prohibitions about providing contraceptive services on-site; the sources of these prohibitions included school district policy (74%), school policy (30%), state law (13%), and health center policy (12%). While SBHCs generally required parental permission for general health services, many allowed adolescents to access care independently for certain services including STD care (48%) and family planning (40%). Older SBHCs were more likely to allow independent access.CONCLUSIONS: SBHCs provide a broad range of reproductive health services directly or via referral; however, they often face institutional and logistical barriers to providing recommended reproductive health care. [ABSTRACT FROM AUTHOR]

OBJECTIVE: We examined social disparities in unintended pregnancy among postpartum women to better understand 1) the role of socioeconomic factors in racial/ethnic disparities and 2) factors that might explain both socioeconomic and racial/ethnic disparities in the risk for unintended pregnancy among women who give birth. METHODS: We used 1999 and 2000 data from a statewide-representative mail and telephone survey of postpartum women in California (N = 7044). We examined associations between unintended pregnancy and race/ethnicity (African American, Asian or Pacific Islander, U.S.-born Latina, foreign-born Latina, European or Middle Eastern), three socioeconomic factors (poverty status, maternal education, paternal education), and several potential explanatory factors. RESULTS: Overall, racial/ethnic disparities in unintended pregnancy were reduced by the three socioeconomic factors individually and collectively (e.g., reducing higher unadjusted odds for African Americans from 3.4 to 1.9); additional adjustment for marital status age, parity, insurance, language, abuse, sense of control, and interaction between marital status and race/ethnicity (each independently associated with unintended pregnancy) reduced the socioeconomic disparities (e.g., reducing odds for the poorest women from 4.1 to 2.3). Although reduced, significant racial/ethnic and socioeconomic disparities remained after adjustment, but generally only among married women. Results for Latinas appeared to vary by nativity, with foreign-born Latinas being at lower odds and U.S.-born Latinas being at higher odds of unintended pregnancy. CONCLUSIONS: Racial/ethnic disparities in unintended pregnancy are partly explained by the socioeconomic factors we measured. Several additional factors were identified that suggest possible directions for policies and programs to help reduce social disparities in unintended pregnancy among childbearing women. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study assessed the relation of socioeconomic status (SES), family structure, and race/ethnicity to adolescent sexual behaviors that are key determinants of pregnancy and sexually transmitted diseases (STDs). METHODS: The 1992 Youth Risk Behavior Survey/Supplement to the National Health Interview Survey provided family data from household adults and behavioral data from adolescents. RESULTS: Among male and female adolescents, greater parental education, living in a 2-parent family, and White race were independently associated with never having had sexual intercourse. Parental education did not show a linear association with other behaviors. Household income was not linearly related to any sexual behavior. Adjustment for SES and family structure had a limited effect on the association between race/ethnicity and sexual behaviors. CONCLUSIONS: Differences in adolescent sexual behavior by race and SES were not large enough to fully explain differences in rates of pregnancy and STD infection. This suggests that other factors, including access to health services and community prevalence of STDs, may be important mediating variables between SES and STD transmission and pregnancy among adolescents. [ABSTRACT FROM AUTHOR]

The AIDS Prevention for Pediatric Life Enrichment (APPLE) project is a community-based program to prevent perinatal HIV infection by preventing infection in women. One project component tested a primary prevention model developed from principles of cognitive social learning theory which used street outreach and community-targeted small media materials to increase the use of condoms. Formative research was used to explore community perceptions about HIV/AIDS and to design media materials. Program evaluation employed a two-community, time series, quasi-experimental design. Annual street surveys sampled individuals in areas where they were likely to encounter outreach workers. Baseline surveys found substantial pre-programmatic behavior change. After two years considerable APPLE name recognition (40%), contact with media materials (63%), and contact with outreach workers (36%) were found and norms reflecting social acceptability of condoms were more positive among women in the intervention community. Condom use at last sexual encounter rose in both communities but was significantly higher in the intervention community. Condom use also was higher among women who reported exposure to either small media or small media plus street outreach. Other self-reported HlV-prevention behaviors did not show change in the initial period. [ABSTRACT FROM AUTHOR]

Few studies have sought to untangle the influence of social determinants and pregnancy on adolescent marriage declines. Using longitudinal data from 15- to 17-year-old girls in the Rakai Community Cohort Survey, we assessed how education, socio-economic status, orphanhood and pregnancy contributed to trends in adolescent marriage. We examined descriptive trends and logistic regressions of the associations between social determinants and adolescent marriage, and conducted causal mediation analysis to assess the extent that pregnancy mediated the effect of education on marriage. Between 1999-2018, adolescent marriages and pregnancies dropped substantially (24%-6% and 28%-8%). Girls' secondary schooling was strongly associated with lower marriage risk (aOR marriage=0.09; 95%CI=0.07-0.12), accounting for time. Lower pregnancy rates partially explained the effect of secondary schooling on lower adolescent marriage (aOR indirect effect=0.55; 95%CI=0.421-0.721). Findings affirm the importance of education in preventing adolescent marriages but call attention to the role of pregnancies in influencing adolescent marriages.

Background: East and Southern Africa have the highest HIV incidence and prevalence in the world, with adolescents and young adults being at the greatest risk. Despite effective combination prevention tools, including the recently available pre-exposure prophylaxis (PrEP), HIV incidence among adolescents and young adults in Uganda remains high, and PrEP use remains low. Mental health and substance use (behavioral health) play a role in sexual behavior and decision-making, contributing to an increase in the risk for acquiring HIV. Interventions that target multiple HIV risk factors, including sexual and mental health and problematic substance use, are crucial to ending the HIV epidemic. Yet few interventions addressing HIV related health disparities and comorbidities among adolescents and young adults in East and Southern Africa currently exist., Objective: This study aims to evaluate the acceptability and feasibility of Kirabo, an SMS text message intervention informed by the information, motivation, and behavior model and to be disseminated through secondary schools. The study will gather preliminary estimates of Kirabo's effectiveness in increasing HIV testing and linking users to mental health counselors., Methods: We identified Mobile 4 Reproductive Health for adaptation using the assessment, decision, administration, production, topical experts, integration, training, testing (ADAPT-ITT) framework. Mobile 4 Reproductive Health is an evidence-based automated 2-way SMS text messaging and interactive voice response platform that offers sexual and reproductive health information and links users to HIV clinics in East Africa. Through ADAPT-ITT we refined our approach and created Kirabo, an SMS text message-based intervention for linking adolescents and young adults to health services, including HIV testing and mental health counseling. We will conduct a 2-arm randomized controlled trial in Masaka, Uganda. Adolescents (N=200) will be recruited from local schools. Baseline sociodemographic characteristics, HIV test history, and behavioral health symptoms will be assessed. We will evaluate acceptability and feasibility using surveys, interviews, and mobile phone data. The preliminary efficacy of Kirabo in increasing HIV testing and linking users to mental health counselors will be evaluated immediately after the intervention and at the 3-month follow-up. We will also assess the intervention's impact on self-efficacy in testing for HIV, adopting PrEP, and contacting a mental health counselor., Results: Intervention adaptation began in 2019. A pretest was conducted in 2021. The randomized controlled trial, including usability and feasibility assessments and effectiveness measurements, commenced in August 2023., Conclusions: Kirabo is a tool that assists in the efforts to end the HIV epidemic by targeting the health disparities and comorbidities among adolescents in Uganda. The intervention includes local HIV clinic information, PrEP information, and behavioral health screening, with referrals as needed. Increasing access to prevention strategies and mitigating factors that make adolescents and young adults susceptible to HIV acquisition can contribute to global efforts to end the HIV epidemic., Trial Registration: ClinicalTrials.gov NCT05130151; https://clinicaltrials.gov/study/NCT05130151., International Registered Report Identifier (irrid): DERR1-10.2196/49352., (©Philip Kreniske, Olive Imelda Namuyaba, Robert Kasumba, Phionah Namatovu, Fred Ssewamala, Gina Wingood, Ying Wei, Michele L Ybarra, Charlotte Oloya, Costella Tindyebwa, Christina Ntulo, Vincent Mujune, Larry W Chang, Claude A Mellins, John S Santelli. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 19.12.2023.)

Objective: Since rapid population growth challenges longitudinal population-based HIV cohorts in Africa to maintain coverage of their target populations, this study evaluated whether the exclusion of some residents due to growing population size biases key HIV metrics like prevalence and population-level viremia., Design, Setting and Participants: Data were obtained from the Rakai Community Cohort Study (RCCS) in south central Uganda, an open population-based cohort which began excluding some residents of newly constructed household structures within its surveillance boundaries in 2008. The study includes adults aged 15-49 years who were censused from 2019 to 2020., Measures: We fit ensemble machine learning models to RCCS census and survey data to predict HIV seroprevalence and viremia (prevalence of those with viral load >1000 copies/mL) in the excluded population and evaluated whether their inclusion would change overall estimates., Results: Of the 24 729 census-eligible residents, 2920 (12%) residents were excluded from the RCCS because they were living in new households. The predicted seroprevalence for these excluded residents was 10.8% (95% CI: 9.6% to 11.8%)-somewhat lower than 11.7% (95% CI: 11.2% to 12.3%) in the observed sample. Predicted seroprevalence for younger excluded residents aged 15-24 years was 4.9% (95% CI: 3.6% to 6.1%)-significantly higher than that in the observed sample for the same age group (2.6% (95% CI: 2.2% to 3.1%)), while predicted seroprevalence for older excluded residents aged 25-49 years was 15.0% (95% CI: 13.3% to 16.4%)-significantly lower than their counterparts in the observed sample (17.2% (95% CI: 16.4% to 18.1%)). Over all ages, the predicted prevalence of viremia in excluded residents (3.7% (95% CI: 3.0% to 4.5%)) was significantly higher than that in the observed sample (1.7% (95% CI: 1.5% to 1.9%)), resulting in a higher overall population-level viremia estimate of 2.1% (95% CI: 1.8% to 2.4%)., Conclusions: Exclusion of residents in new households may modestly bias HIV viremia estimates and some age-specific seroprevalence estimates in the RCCS. Overall, HIV seroprevalence estimates were not significantly affected., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Primary care providers are well positioned to address the sexual and reproductive health (SRH) needs of adolescents; however, gaps often exist in the delivery of quality SRH services in primary care. Our objective was to identify specific opportunities to improve the delivery of adolescent SRH services in primary care. We conducted in-depth interviews with 25 primary care providers from various disciplines across rural and urban areas of Minnesota and conducted thematic analysis of transcribed data. Participants identified salient opportunities in three areas: (1) training and resources for providers (e.g., related to minor consent laws or addressing sensitive subjects), (2) practices and procedures (e.g., time-alone procedures and policies for confidential screening and sharing test results), and (3) education for adolescents (e.g., knowing their rights and accessing confidential SRH services). Study findings provide actionable opportunities to improve delivery of adolescent SRH services in primary care.

Objectives: To assess the cognitive capacity of early, middle, and late adolescents and their parents or guardians to provide informed consent to a population-based cohort study., Study Design: Adolescent-parent/guardian dyads including 40 early (n = 80; 10-14 years), 20 middle (15-17 years), and 20 late (18-19 years) adolescents were recruited from the Rakai Community Cohort Study, an open demographic cohort in Uganda. Participants were administered the MacArthur Competence Assessment Tool for Clinical Research, a structured open-ended assessment; interviews were recorded and transcribed. Twenty transcripts were scored independently by two coders; the intraclass correlation coefficient was 0.89. The remaining interviews were scored individually. We compared mean scores for early and middle/late adolescents using a one-sided t test and score differences between parent/guardian and adolescent dyads using two-sided paired t tests., Results: Early adolescents (mean score, 28.8; 95% CI, 27.1-30.5) scored significantly lower (P < .01) than middle/late adolescents (32.4; 31.6-33.1). In paired dyad comparisons, we observed no statistically significant difference in scores between parents/guardians and middle/late adolescents (difference, -0.2; 95% CI, -1.0-0.6). We found a statistically significant difference in scores between parents/guardians and early adolescents (difference, 3.0; 95% CI, 1.2-4.8)., Conclusions: The capacity of adolescents-of different ages and in diverse settings-to comprehend risks, benefits, and other elements of informed consent is a critical but understudied area in research ethics. Our findings support the practice of having middle and late adolescents provide independent informed consent for sexual and reproductive health studies. Early adolescents may benefit from supported decision-making approaches., (Copyright © 2022. Published by Elsevier Inc.)

This article examines how gendered access to digital capital-in the form of the social and economic resources needed to own and use a mobile phone-is connected to key adult milestones, such as securing employment and engaging in romantic relationships. Descriptive statistical analysis of 11,030 young people aged 15-24 in Rakai, Uganda indicated that men were more likely to own mobile phones than women. Analysis of qualitative interviews with young people ( N  = 31) and ethnographic participant observations among young people ( N  = 24) add nuance and depth to the observed gender difference. We go beyond a 'categorical' approach to gender (i.e. comparing rates between men and women) to examine how access to digital capital is gendered both for men and for women. Mobile phone ownership both reproduces and destabilises gendered social organisation in ways that have implications for economic opportunities, social connections, HIV risk and overall health and well-being. Young men had greater access to the benefits of mobile phone ownership, whereas young women's access to those benefits was impeded by covert and overt gendered mechanisms of control that limited access to digital capital. Findings suggest that mhealth initiatives, increasingly deployed to reach under-resourced populations, must take into account gendered access to digital capital.

Objective: To examine racial and ethnic self-identification among adolescents and explore psychosocial outcomes and peer treatment for multiracial adolescents in the United States., Methods: Data are from the 2014 Child Development Supplement, a subsample of the Panel Study of Income Dynamics. Data were weighted to be nationally representative. Descriptive statistics were used to describe the population and to explore family and parent demographics. Multivariable regressions tested for differences in psychosocial outcomes and peer treatment and group behaviors for multiracial youth in comparison to their single race peers., Results: Black multiracial youth had significantly lower scores on the children's depression index compared to single race Black youth, and White multiracial youth reported significantly higher rates of peer mistreatment in comparison to White single race youth. Black multiracial and White multiracial adolescents reported similar positive and negative peer group behaviors., Conclusions: Complex patterns emerge when examining the psychosocial and peer treatment variables presented in this analysis for multiracial adolescents and their single-race peers. The findings regarding depressive symptoms and peer bullying point to signs of different relationships between multiracial groups. White multiracial adolescents report worse outcomes than their White single-race peers, but Black multiracial adolescents reporting better outcomes than their Black single-race peers., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Grilo, Santelli, Nathanson, Catallozzi, Abraido-Lanza, Adelman and Hernández.)

There is a growing group of adolescents and young adults in the USA who identify as multiracial. However, very little research, especially health research, focuses on understanding multiracial identification and health and behavioral outcomes for multiracial populations in comparison to their single-race counterparts. Understanding the intersectional influences on this identification process is critical to updating the literature on racial and ethnic identity and health with more accurate identifications and categories. It is especially critical that there is an explicit focus on understanding the impact of structural racism and discrimination when studying the process of racial identification and the impact on health. This review takes an interdisciplinary approach relying on a review of multiple research literatures: the historical literature on race, racism and categorization, psychological and adolescent medicine literatures on adolescent development, the sociological literature on racial and ethnic identification, and the limited public health research beginning to disentangle multiracial health outcomes. An empirically testable conceptual framework is offered to frame the organization of this review-demonstrating the multiple spheres of influence on racial and ethnic identification and the implication for health outcomes., (© 2022. W. Montague Cobb-NMA Health Institute.)

Background: Health care providers (HCPs) in the emergency department (ED) frequently must decide whether to conduct or forego confidential conversations with adolescent patients about sensitive topics, such as those related to mental health, substance use, and sexual and reproductive health. The objective of this multicenter qualitative analysis was to identify factors that influence the conduct of confidential conversations with adolescent patients in the ED., Methods: In this qualitative study, we conducted semistructured interviews of ED HCPs from five academic, pediatric EDs in distinct geographic regions. We purposively sampled HCPs across gender, professional title, and professional experience. We used the Theoretical Domains Framework (TDF) to develop an interview guide to assess individual and system-level factors affecting HCP behavior regarding the conduct of confidential conversations with adolescents. Enrollment continued until we reached saturation. Interviews were recorded, transcribed, and coded by three investigators based on thematic analysis. We used the coded transcripts to collaboratively generate belief statements, which are first-person statements that reflect shared perspectives., Results: We conducted 38 interviews (18 physicians, 11 registered nurses, five nurse practitioners, and four physician assistants). We generated 17 belief statements across nine TDF domains. Predominant influences on having confidential conversations included self-efficacy in speaking with adolescents alone, wanting to address sexual health complaints, maintaining patient flow, experiencing parental resistance and limited space, and having inadequate resources to address patient concerns and personal preconceptions about patients. Perspectives divided between wanting to provide focused medical care related only to their chief complaint versus self-identifying as a holistic medical HCP., Conclusions: The factors influencing the conduct of confidential conversations included multiple TDF domains, elucidating how numerous intersecting factors influence whether ED HCPs address sensitive adolescent health needs. These data suggest methods to enhance and facilitate confidential conversations when deemed appropriate in the care of adolescents in the ED., (© 2022 Society for Academic Emergency Medicine.)

Scholars of global health have embraced universal education as a structural intervention to prevent HIV. Yet the costs of school, including fees and other ancillary costs, create an economic burden for students and their families, indicating both the challenge of realising the potential of education for preventing HIV and the ways in which the desire for education may produce vulnerabilities to HIV for those struggling to afford it. To explore this paradox, this article draws from collaborative, team-based ethnographic research conducted from June to August 2019 in the Rakai district of Uganda. Respondents reported that education is the most significant cost burden faced by Ugandan families, sometimes amounting to as much as 66% of yearly household budgets per student. Respondents further understood paying for children's schooling as both a legal requirement and a valued social goal, and they pointed to men's labour migrations to high HIV-prevalence communities and women's participation in sex work as strategies to achieve that. Building from regional evidence showing young East African women participate in transactional, intergenerational sex to secure school fees for themselves, our findings point to the negative health spillover effects of Uganda's universal schooling policies for the whole family.

Competing Interests: We declare no competing interests.

Introduction: This article examines recent moral panics over sex education in Uganda from historical perspectives. Public outcry over comprehensive sexuality education erupted in 2016 over claims that children were being taught "homosexuality" by international NGOs. Subsequent debates over sex education revolved around defending what public figures claimed were national, religious, and cultural values from foreign infiltration., Methods: This paper is grounded in a survey of Uganda's two English-print national newspapers (2016-2018), archival research of newspapers held at Uganda's Vision Group media company (1985-2005), analyses of public rhetoric as reported in nationally circulating media, textual analysis of Uganda's National Sexuality Education Framework (2018), formal interviews with Ugandan NGO officers (3), and semi-structured interviews with Ugandan educators (3)., Results: Uganda's current panic over sex education reignited longstanding anxieties over foreign interventions into the sexual health and rights of Ugandans. We argue that in the wake of a 35-year battle with HIV/AIDS and more recent controversies over LGBT rights, both of which brought international donor resources and governance, the issue of where and how to teach young people about sex became a new battleground over the state's authority to govern the health and economic prosperity of its citizens., Conclusions: Ethno- and religio-nationalist rhetoric used to oppose the state's new sexuality education policy was also used to justify sex education as a tool for economic development., Policy Implications: Analyzing rhetoric mobilized by both supporters and detractors of sex education reveals the contested political terrain policy advocates must navigate in Uganda and other postcolonial contexts., Competing Interests: Conflicts of interest/Competing interests Not applicable. (include appropriate disclosures)

Background: Sexual partner characteristics are important determinants of HIV acquisition, but little is known about partner types of young men in sub-Saharan Africa., Methods: Sexually active men aged 15-24 years from 5 rounds (2005-2013) of the Rakai Community Cohort Study in Uganda reported characteristics of up to 4 past-year female partners. Partner types were identified using latent class analysis. HIV incidence rates (IRs) were calculated by partner-type combinations, and individual-level risk adjusted IR ratios (aIRRs) relative to the lowest incidence type were estimated using the Poisson regression with generalized estimating equations., Results: Young men (N = 1771) reported 4539 past-year female sexual partners. Three partner types were identified: type A: noncohabiting, student, medium duration partnerships; type B: cohabiting, nonstudent, longer duration partnerships; and type C: noncohabiting, nonstudent shorter duration partnerships. Type C partners engaged in the most HIV-related risk behaviors. Many men (29%) had more than 1 partner type/round. IR overall was 9.8/1000 person-years [95% confidence interval (CI): 4.7 to 20.6]. IR was 4.0 (95% CI: 1.2 to 12.7) for men with type A partners alone (41% of men). Relative to them, IR for those with type B partners alone (25%) was not significantly different. Men with type C partners alone (5%) had higher risk (aIRR = 3.2; 95% CI: 1.0 to 9.9), as did men with >1 partner type, including men with both type A and type B partners (12%; aIRR = 6.3; 95% CI: 2.5 to 15.9) and men with type C and other partner types (17%; aIRR = 4.3; 95% CI: 1.7 to 10.8)., Conclusions: Partner-type combination was strongly associated with HIV incidence; type C partners and having more than 1 partner type were the riskiest patterns., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: Private time is an opportunity for the adolescent patient to speak directly to a healthcare provider and a marker of quality preventive health care. Little is known about whether adolescents and young adults (AYAs) with special healthcare needs (SHCNs) are afforded private discussions with their primary care clinicians., Methods: We surveyed a nationally representative sample of 1,209 adolescents (13-18 years) and 709 young adults (19-26 years) about whether they had SHCNs and whether they had ever had private, one-on-one time with their healthcare providers., Results: SHCNs were reported by 20.3% of adolescents and 15.6% of young adults. Among adolescents, older age was associated with more SHCNs. Among young adults, women and blacks were more likely to report SHCNs than men and those reporting other race categories. For both AYAs, those with SHCNs more often received private time than those without SHCNs: 54.2% of adolescents and 88.1% of young adults with SHCNs reported ever having received private time, compared with 29.6% of adolescents and 62.1% of young adults without SHCNs., Conclusions: Lack of private time continues to impact quality primary care for AYAs; however, AYAs with SHCNs are more likely to have received private time than AYAs who do not have SHCNs. Further research is needed to understand whether increased number of clinical visits, clinician-related factors, or other factors lead to more opportunities for young people with SHCNs to receive private time from their clinicians., (Copyright © 2021 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Developmental assets foster positive health outcomes among adolescents, but have not been studied in adolescents with chronic illness or depression, two conditions that impact behaviors in school. We examined parent-reported assets in a national sample of adolescents and compared the number and types of assets by health statuses., Methods: Data were from the 2016 National Survey of Children's Health (N = 15,734 adolescents), which captured 15 of 40 assets in the Developmental Assets Framework. We categorized adolescents as healthy; chronic physical illness alone; depression alone; and chronic physical illness with co-morbid depression. Data were analyzed using analysis of variance and logistic regression., Results: Healthy adolescents and those with chronic physical illness alone were comparable in number and types of assets. Adolescents with chronic physical illness and co-morbid depression had fewer assets compared to healthy adolescents and those with chronic physical illness alone. Similar associations were found in comparing healthy adolescents to those with depression without chronic physical illness., Conclusions: The presence of depression, among adolescents with and without chronic physical illness, was associated with fewer internal and external assets. The absence of assets may serve as a unique indicator of underlying depressive symptoms among adolescents in the school setting., (© 2022 American School Health Association.)

Global health researchers often approach Traditional, Complementary, and Alternative Medicine (TCAM) from a health efficacy perspective, asking whether the presence of plural medical systems helps or hinders the uptake of biomedicine. Medical anthropologists, by contrast, typically emphasize how plural medical systems encourage us to rethink health ontologies-that is, who and what comes to constitute the experience of health and illness, and through which practices. Building on both approaches, we explore the role of "healers," a term we use to encompass several different kinds of TCAM providers, in the sexual and reproductive healthcare (SRH) of young people from southcentral Uganda, a region well known as an HIV/AIDS epicenter. Drawing from ethnographic data, we describe three reasons that young people seek SRH from healers. First, they associate stigma, scarcity, and high costs with biomedical SRH. Second, healers work across biomedical and non-biomedical therapeutic divides, prescribing herbs for sexually transmitted infections while simultaneously referring clients to biomedical HIV clinics. Third, healers provide counseling focused on pleasurable and economically-motivated sex. Because these therapies diverge from international and national HIV prevention messaging that frames non-marital and transactional sex in terms of danger and disease, healers' holistic approach to SRH may help to reconstitute the meaning, practice, and experience of "sexual health" in contemporary Uganda. This has important implications for improving global SRH programs and for understanding the continued appeal of TCAM more generally., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Orphanhood increased markedly in the 1980s and 1990s in sub-Saharan Africa because of HIV-related mortality. Little is known about the contribution of HIV interventions, such as antiretroviral therapy (ART) and male medical circumcision, to more recent trends in orphanhood. In this study, we examined trends over time in maternal-only, paternal-only, and double orphanhood among adolescents before and after ART and male medical circumcision became widely available in the Rakai region of south-central Uganda. We sought to understand the association between adolescent orphanhood and HIV combination prevention (community-level ART use and prevalence of male medical circumcision). We hypothesised that increasing combination prevention, including greater use of ART and higher prevalence of male medical circumcision, would be associated with a lower probability of orphanhood., Methods: We examined the prevalence of orphanhood among adolescents aged 15-19 years, before and after roll-out of ART in mid-2004 and male medical circumcision in 2007, using data from 28 continuously followed communities within the Rakai Community Cohort Study. We used multinomial logistic regression with clustered SEs to estimate adjusted relative risk ratios (RRs) for maternal-only, paternal-only, and double orphanhood compared with non-orphanhood over 11 survey rounds between 2001 and 2018. Controlling for community HIV prevalence, household socioeconomic status, and adolescent age, we examined the association between community prevalence of ART use among people living with HIV and prevalence of male circumcision, including traditional circumcision. The primary outcome was orphanhood among adolescents aged 15-19 years., Findings: Orphanhood declined from 52% (920 of 1768 participants) in 2001-02 to 23% (592 of 2609 participants) by 2016-18 (p<0·0001), while double orphanhood declined from 20% (346 of 1768 participants) to 3% (86 of 2609 participants) (p<0·0001). Community prevalence of ART use among people living with HIV increased from 11% (105 of 945 participants) in 2005-06 to 78% (1163 of 1485 participants) in 2016-18. Male circumcision rates rose from 19% (147 of 790 participants) in 2005-06 to 65% (3535 of 5433 participants) in 2016-18. In the multinomial logistic regression model, a 10% increase in community prevalence of ART use was associated with a decrease in maternal orphanhood (adjusted relative RR 0·90, 95% CI 0·85-0·95) and double orphanhood (0·80, 0·75-0·85). In the post-ART era, a 10% increase in the community prevalence of male circumcision was associated with a decrease in paternal orphanhood (2005-18, adjusted relative RR 0·92, 0·87-0·97) and double orphanhood (0·91, 0·85-0·98)., Interpretation: Widespread availability and uptake of HIV combination prevention was associated with marked reductions in orphanhood among adolescents. Reductions in orphanhood promise improved health and social outcomes for young people., Funding: Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute of Allergy and Infectious Diseases, the National Institute of Mental Health, and the Division of Intramural Research of the National Institute for Allergy and Infectious Diseases., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

In some Ugandan fishing communities, almost half the population lives with HIV. Researchers designate these communities "HIV hotspots" and attribute disproportionate disease burdens to "sex-for-fish" relationships endemic to the lakeshores. In this article, we trace the emergence of Uganda's HIV hotspots to structural adjustment. We show how global economic policies negotiated in the 1990s precipitated the collapse of Uganda's coffee sector, causing mass economic dislocation among women workers, who migrated to the lake. There, they entered overt forms of sex work or marriages they may have otherwise avoided, intimate economic arrangements that helped to "engineer the spread of HIV," as one respondent recounted.

Objective: To examine the relationship between household wealth and HIV incidence in rural Uganda over time from 1994 to 2018. In research conducted early in the epidemic, greater wealth (i.e. higher socioeconomic status, SES) was associated with higher HIV prevalence in sub-Saharan Africa (SSA); this relationship reversed in some settings in later years., Design: Analysis of associations over time in a population-based open cohort of persons 15-49 years from 17 survey-rounds in 28 continuously followed communities of the Rakai Community Cohort Study (RCCS)., Methods: The RCCS sample averaged 8622 individuals and 5387 households per round. Principal components analysis was used to create a nine-item asset-based measure of household wealth. Poisson regression with generalized estimating equation (GEE) and exchangeable correlation structure was used to estimate HIV incidence rate ratios (IRRs) by SES quartile, survey-round, sex, and age group., Results: From 1994 to 2018, SES rose considerably, and HIV incidence declined from 1.45 to 0.40 per 100 person-years (IRR = 0.39, 95% CI = 0.32--0.47, P < 0.001). HIV incidence was similar by SES category in the initial survey intervals (1994-1997); however, higher SES groups showed greater declines in HIV incidence over time. Multivariable analyses showed significant associations between HIV incidence and SES (IRR = 0.55 for highest compared with lowest quartile, 95% CI = 0.45--0.66, P < 0.001) controlling for time, sex, and age group., Conclusion: Beyond the early years of the RCCS, higher SES was associated with lower HIV incidence and SES gradients widened over time. The poor, like other key populations, should be targeted for HIV prevention, including treatment as prevention., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: In East Africa, where landlines are used by 1% of the population and access to the internet is limited, owning a cell phone is rapidly becoming essential for acquiring information and resources. Our analysis illuminates the perils and potential promise of mobile phones with implications for future interventions to promote the health of adolescents and young adults (AYAs) and to prevent HIV infection., Objective: The aim of this study is to describe the current state of AYAs' phone use in the region and trace out the implications for mobile health interventions., Methods: We identified 2 trading centers that were representative of southern Uganda in terms of key demographics, proportion of cell phone ownership, and community HIV prevalence. We stratified the sample of potential informants by age group (15-19 years and 20-24 years), gender, and phone ownership and randomly sampled 31 key informant interview participants within these categories. In addition, we conducted 24 ethnographic participant observations among AYAs in the communities of study., Results: AYA frequently reported barriers to using their phones, such as difficulty accessing electricity. Nearly all AYAs used mobile phones to participate in the local economy and communicate with sexual partners. Phone use was frequently a point of contention between sexual partners, with many AYAs reporting that their sexual partners associated phone use with infidelity. Few AYAs reported using their phones for health-related purposes, with most getting health information in person from health workers. However, most AYAs reported an instance when they used their phone in an emergency, with childbirth-related emergencies being the most common. Finally, most AYAs reported that they would like to use their phones for health purposes and specifically stated that they would like to use their mobile phones to access current HIV prevention information., Conclusions: This study demonstrates how mobile phones are related to income-generating practices in the region and communication with sexual partners but not access to health and HIV information. Our analysis offers some explanation for our previous study, which suggested an association between mobile phone ownership, having multiple sexual partners, and HIV risk. Mobile phones have untapped potential to serve as tools for health promotion and HIV prevention., (©Philip Kreniske, Alyssa Basmajian, Neema Nakyanjo, William Ddaaki, Dauda Isabirye, Charles Ssekyewa, Rosette Nakubulwa, Jennifer S. Hirsch, Andrea Deisher, Fred Nalugoda, Larry W Chang, John S Santelli. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 02.02.2021.)

Purpose: The aims of the study were to identify factors related to (1) adolescents and young adults (AYA) desire to discuss health topics; (2) whether discussions occurred at their last medical visit; and (3) the gap (unmet need) between desire and actual discussion., Methods: We used data from a nationally representative, cross-sectional online survey of AYA aged 13-26 years (n = 1,509) who had had a visit in the past 2 years. Bivariate analyses examined 11 topics. Multivariable regression identified health care factors and demographic factors related to unmet need across four salient topics (HIV/sexually transmitted infections, alcohol and drug use, tobacco, and contraception)., Results: Across 11 topics, unmet need averaged 28% and ranged as high as 60%; unmet need generally increased with AYA age. In multivariable analyses, ever having discussed confidentiality with a health care provider was associated with greater desire to discuss three of four salient topics, increased discussions (four of four topics), and reduced unmet need (two topics). Patient use of a clinical checklist/questionnaire at the last medical visit was associated with an increase in discussions (four topics) and reduced unmet need (four topics). Longer office visits were associated with an increase in discussions (three topics) and reduced unmet need (two topics). Older and minority youth had greater desire for discussions and unmet need., Conclusions: A considerable gap exists between young people's desire to discuss health topics with their health care providers and actual practice., (Copyright © 2020 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Cell phones have increased communication and connection across the globe and particularly in sub-Saharan Africa-with potential consequences for the HIV epidemic. We examined the association among ownership of cell phones, sexual behaviors (number of sexual partners, alcohol use before sex, inconsistent condom use), and HIV prevalence. Data were from four rounds (2010-2016) of the Rakai Community Cohort Study (N = 58,275). Sexual behaviors and HIV prevalence were compared between people who owned a cell phone to people who did not own a cell phone. We stratified analysis by younger (15-24 years) and older (25+ years) age groups and by gender. Using logistic regression and after adjusting for sociodemographic characteristics, we found cell phone ownership was independently associated with increased odds of having two or more sexual partners in the past 12 months across age and gender groups (young men AOR 1.67, 95% CI 1.47-1.90; young women AOR 1.28 95% CI 1.08-1.53; older men AOR 1.54 95% CI 1.41-1.69; older women AOR 1.44 95% CI 1.26-1.65). Interestingly, young men who owned cell phones had decreased odds of using condoms inconsistently (AOR 0.66, 95% CI 0.57-0.75). For young women, cell phone ownership was associated with increased odds of using alcohol before sex (AOR 1.38 95% CI 1.17-1.63) and increased odds of inconsistent condom use (AOR 1.40, 95% 1.17-1.67). After adjusting for sociodemographic characteristics, only young women who owned cell phones had increased odds of being HIV positive (AOR 1.27 95% CI 1.07-1.50). This association was not mediated by sexual behaviors (Adjusted for sociodemographic characteristics and sexual behaviors AOR 1.24, 95% CI 1.05-1.46). While cell phone ownership appears to be associated with increased HIV risk for young women, we also see a potential opportunity for future cell phone-based health interventions.

HIV prevalence varies markedly throughout Africa, and it is often presumed areas of higher HIV prevalence (i.e., hotspots) serve as sources of infection to neighboring areas of lower prevalence. However, the small-scale geography of migration networks and movement of HIV-positive individuals between communities is poorly understood. Here, we use population-based data from ~22,000 persons of known HIV status to characterize migratory patterns and their relationship to HIV among 38 communities in Rakai, Uganda with HIV prevalence ranging from 9 to 43%. We find that migrants moving into hotspots had significantly higher HIV prevalence than migrants moving elsewhere, but out-migration from hotspots was geographically dispersed, contributing minimally to HIV burden in destination locations. Our results challenge the assumption that high prevalence hotspots are drivers of transmission in regional epidemics, instead suggesting that migrants with high HIV prevalence, particularly women, selectively migrate to these areas.

Background: Targeting combination HIV interventions to locations and populations with high HIV burden is a global priority, but the impact of these strategies on HIV incidence is unclear. We assessed the impact of combination HIV interventions on HIV incidence in four HIV-hyperendemic communities in Uganda., Methods: We did an open population-based cohort study of people aged 15-49 years residing in four fishing communities on Lake Victoria. The communities were surveyed five times to collect self-reported demographic, behavioural, and service-uptake data. Free HIV testing was provided at each interview, with referral to combination HIV intervention services as appropriate. From November, 2011, combination HIV intervention services were rapidly expanded in these geographical areas. We evaluated trends in HIV testing coverage among all participants, circumcision coverage among male participants, antiretroviral therapy (ART) coverage and HIV viral load among HIV-positive participants, and sexual behaviours and HIV incidence among HIV-negative participants., Findings: From Nov 4, 2011, to Aug 16, 2017, data were collected from five surveys. Overall, 8942 participants contributed 20 721 person-visits; 4619 (52%) of 8942 participants were male. HIV prevalence was 41% (1598 of 3870) in the 2011-12 baseline survey and declined to 37% (1740 of 4738) at the final survey (p<0·0001). 3222 participants who were HIV-negative at baseline, and who had at least one repeat visit, contributed 9477 person-years of follow-up, and 230 incident HIV infections occurred. From the first survey in 2011-12 to the last survey in 2016-17, HIV testing coverage increased from 68% (2613 of 3870) to 96% (4526 of 4738; p<0·0001); male circumcision coverage increased from 35% (698 of 2011) to 65% (1630 of 2525; p<0·0001); ART coverage increased from 16% (254 of 1598) to 82% (1420 of 1740; p<0·0001); and population HIV viral load suppression in all HIV-positive participants increased from 34% (546 of 1596) to 80% (1383 of 1734; p<0·0001). Risky sexual behaviours did not decrease over this period. HIV incidence decreased from 3·43 per 100 person-years (95% CI 2·45-4·67) in 2011-12 to 1·59 per 100 person-years (95% CI 1·19-2·07) in 2016-17; adjusted incidence rate ratio (IRR) 0·52 (95% CI 0·34-0·79). Declines in HIV incidence were similar among men (adjusted IRR 0·53, 95% CI 0·30-0·93) and women (0·51, 0·27-0·96). The risk of incident HIV infection was lower in circumcised men than in uncircumcised men (0·46, 0·32-0·67)., Interpretation: Rapid expansion of combination HIV interventions in HIV-hyperendemic fishing communities is feasible and could have a substantial impact on HIV incidence. However, incidence remains higher than HIV epidemic control targets, and additional efforts will be needed to achieve this global health priority., Funding: The National Institute of Mental Health, the National Institute of Allergy and Infectious Diseases, the National Institute of Child Health and Development, the National Cancer Institute, the National Institute for Allergy and Infectious Diseases Division of Intramural Research, Centers for Disease Control and Prevention Uganda, Karolinska Institutet, and the Johns Hopkins University Center for AIDS Research., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

School enrollment, mobility, and occupation are each important factors to consider when examining HIV (human immunodeficiency virus) infection risk among youth in sub-Saharan Africa. Through an analysis of narrative life histories from 30 HIV-positive and 30 HIV-negative youth (aged 15-24 years), matched on gender, age, and village and purposively selected and interviewed from the Rakai Community Cohort Study, this article shows the complex connection between leaving school, mobility, and occupation with implications for HIV risk. We identified a pattern of risk factors that was present in many more HIV-positive than HIV-negative youth life stories. These HIV-positive youth shared a similar pathway during their transition to adulthood: After leaving school, they moved in search of occupations; they then engaged in risky occupations before eventually returning to their home village. Linking the lines of inquiry on school enrollment, mobility, and risky occupations, our findings have important implications for adolescent health research, practice, and policy in Uganda and across sub-Saharan Africa and the developing world.

Background: Rapid demographic, epidemiological, and nutritional transitons have brought a pressing need to track progress in adolescent health. Here, we present country-level estimates of 12 headline indicators from the Lancet Commission on adolescent health and wellbeing, from 1990 to 2016., Methods: Indicators included those of health outcomes (disability-adjusted life-years [DALYs] due to communicable, maternal, and nutritional diseases; injuries; and non-communicable diseases); health risks (tobacco smoking, binge drinking, overweight, and anaemia); and social determinants of health (adolescent fertility; completion of secondary education; not in education, employment, or training [NEET]; child marriage; and demand for contraception satisfied with modern methods). We drew data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2016, International Labour Organisation, household surveys, and the Barro-Lee education dataset., Findings: From 1990 to 2016, remarkable shifts in adolescent health occurred. A decrease in disease burden in many countries has been offset by population growth in countries with the poorest adolescent health profiles. Compared with 1990, an additional 250 million adolescents were living in multi-burden countries in 2016, where they face a heavy and complex burden of disease. The rapidity of nutritional transition is evident from the 324·1 million (18%) of 1·8 billion adolescents globally who were overweight or obese in 2016, an increase of 176·9 million compared with 1990, and the 430·7 million (24%) who had anaemia in 2016, an increase of 74·2 million compared with 1990. Child marriage remains common, with an estimated 66 million women aged 20-24 years married before age 18 years. Although gender-parity in secondary school completion exists globally, prevalence of NEET remains high for young women in multi-burden countries, suggesting few opportunities to enter the workforce in these settings., Interpretation: Although disease burden has fallen in many settings, demographic shifts have heightened global inequalities. Global disease burden has changed little since 1990 and the prevalence of many adolescent health risks have increased. Health, education, and legal systems have not kept pace with shifting adolescent needs and demographic changes. Gender inequity remains a powerful driver of poor adolescent health in many countries., Funding: Australian National Health and Medical Research Council, and the Bill & Melinda Gates Foundation., (Copyright © 2019 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Purpose: The objective of the study was to define factors associated with adolescent and young adult (AYA) experiences with private time and having discussed confidentiality and the impact of these experiences on improving delivery of clinical preventive services., Methods: In 2016, a nationally representative sample of 1,918 US AYAs (13- to 26-year-olds) was surveyed. Survey questionnaire domains were based on prior research and Fishers' information-motivation-behavior skills conceptual model. Data were weighted to represent US households with AYA and analyzed to identify factors independently associated with ever experiencing private time and discussions of confidentiality with a regular health-care provider (HCP). We examined the association of these experiences on AYA attitudes about health care., Results: Fifty-five percent of female and 49% of male AYA reported ever having had private time with an HCP and 55% of female and 44% of male AYA had spoken to an HCP about confidentiality. Independent predictors of having experienced private time and confidentiality included older age, race, higher household income, gender of the provider, amount of years with the provider, and involvement in risk behaviors. AYA who had experienced private time and confidentiality discussions had more positive attitudes about their providers, were more willing and comfortable discussing sensitive topics, and thought that these discussions should happen at younger ages., Conclusions: Although confidentiality and private time are important to AYA, many are not experiencing these components of care. Providing private time and discussions of confidentiality can improve the delivery of health care for young people by enhancing positive youth attitudes about preventive care., (Copyright © 2018 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)