Loretta E. Gavin

Worldwide application of prevention science in adolescent health

The burden of morbidity and mortality from non-communicable disease has risen worldwide and is accelerating in low-income and middle-income countries, whereas the burden from infectious diseases has declined. Since this transition, the prevention of non-communicable disease as well as communicable disease causes of adolescent mortality has risen in importance. Problem behaviours that increase the short-term or long-term likelihood of morbidity and mortality, including alcohol, tobacco, and other drug misuse, mental health problems, unsafe sex, risky and unsafe driving, and violence are largely preventable. In the past 30 years new discoveries have led to prevention science being established as a discipline designed to mitigate these problem behaviours. Longitudinal studies have provided an understanding of risk and protective factors across the life course for many of these problem behaviours. Risks cluster across development to produce early accumulation of risk in childhood and more pervasive risk in adolescence. This understanding has led to the construction of developmentally appropriate prevention policies and programmes that have shown short-term and long-term reductions in these adolescent problem behaviours. We describe the principles of prevention science, provide examples of efficacious preventive interventions, describe challenges and potential solutions to take efficacious prevention policies and programmes to scale, and conclude with recommendations to reduce the burden of adolescent mortality and morbidity worldwide through preventive intervention.

Health Care for Youth in the Juvenile Justice System

Youth in the juvenile correctional system are a high-risk population who, in many cases, have unmet physical, developmental, and mental health needs. Multiple studies have found that some of these health issues occur at higher rates than in the general adolescent population. Although some youth in the juvenile justice system have interfaced with health care providers in their community on a regular basis, others have had inconsistent or nonexistent care. The health needs of these youth are commonly identified when they are admitted to a juvenile custodial facility. Pediatricians and other health care providers play an important role in the care of these youth, and continuity between the community and the correctional facility is crucial. This policy statement provides an overview of the health needs of youth in the juvenile correctional system, including existing resources and standards for care, financing of health care within correctional facilities, and evidence-based interventions. Recommendations are provided for the provision of health care services to youth in the juvenile correctional system as well as specific areas for advocacy efforts.

Impact of Contraceptive Education on Contraceptive Knowledge and Decision Making: A Systematic Review.

CONTEXT Educational interventions can help increase knowledge of available contraceptive methods, enabling individuals to make informed decisions and use contraception more effectively. This systematic review evaluated contraceptive education interventions to guide national recommendations on quality family planning services. EVIDENCE ACQUISITION Three databases (CINAHL, PubMed, and PsycINFO) were searched from 1985 through 2012 for peer-reviewed articles on educational interventions, with supplemental searches conducted through 2015. Primary outcomes were knowledge, participation in and comfort with decision making, and attitudes toward contraception. Secondary outcomes included contraceptive use behaviors and unintended pregnancy. EVIDENCE SYNTHESIS Database searches in 2011 identified 5,830 articles; 17 met inclusion criteria and were abstracted into evidence tables. Searches in 2012 and 2015 identified four additional studies. Studies used a wide range of tools (decision aids, written materials, audio/videotapes, and interactive games), with and without input from a healthcare provider or educator. Of 15 studies that examined the impact of educational interventions on knowledge, 14 found significant improvement using a range of tools, with and without input from a healthcare provider or educator. Fewer studies evaluated outcomes related to decision making, attitudes toward contraception, contraceptive use behaviors, or unintended pregnancy. CONCLUSIONS Results from this systematic review are consistent with evidence from the broader healthcare field suggesting that a range of educational interventions can increase knowledge. Future studies should assess what aspects of educational interventions are most effective, the extent to which it is necessary to include a healthcare provider or educator, and the extent to which educational interventions can impact behaviors.

Screening for Nonviral Sexually Transmitted Infections in Adolescents and Young Adults

Prevalence rates of many sexually transmitted infections (STIs) are highest among adolescents. If nonviral STIs are detected early, they can be treated, transmission to others can be eliminated, and sequelae can be averted. The US Preventive Services Task Force and the Centers for Disease Control and Prevention have published chlamydia, gonorrhea, and syphilis screening guidelines that recommend screening those at risk on the basis of epidemiologic and clinical outcomes data. This policy statement specifically focuses on these curable, nonviral STIs and reviews the evidence for nonviral STI screening in adolescents, communicates the value of screening, and outlines recommendations for routine nonviral STI screening of adolescents.

Impact of Contraceptive Counseling in Clinical Settings: A Systematic Review.

CONTEXT This systematic review evaluated the evidence on the impact of contraceptive counseling provided in clinical settings on reproductive health outcomes to provide information to guide national recommendations on quality family planning services. EVIDENCE ACQUISITION Multiple databases were searched during 2010-2011 for peer-reviewed articles published in English from January 1985 through February 2011 describing studies that evaluated contraceptive counseling interventions in clinical settings. Studies were excluded if they focused primarily on prevention of HIV or sexually transmitted infections, focused solely on men, or were conducted outside the U.S., Canada, Europe, Australia, or New Zealand. EVIDENCE SYNTHESIS The initial search identified 12,327 articles, of which 22 studies (from 23 articles) met the inclusion criteria. Six studies examined the impact of contraceptive counseling among adolescents, with four finding a significant positive impact on at least one outcome of interest. Sixteen studies examined the impact of counseling among adults or mixed populations (adults and adolescents), with 11 finding a significant positive impact on at least one outcome of interest. CONCLUSIONS Promising components of contraceptive counseling were identified despite the diversity of interventions and inability to compare the relative effectiveness of one approach versus another. The evidence base would be strengthened by improved documentation of counseling procedures; assessment of intervention implementation and fidelity to put study findings into context; and development and inclusion of more RCTs, studies conducted among general samples of women, and studies with sample sizes sufficient to detect important behavioral outcomes at least 12 months post-intervention.

Programs to Strengthen Parent-Adolescent Communication about Reproductive Health: A Systematic Review

CONTEXT When caring for an adolescent client, providers of contraceptive services must consider whether and how to encourage parent/guardian-child communication about the adolescents reproductive health. The objective of this systematic review was to summarize the evidence on the effectiveness of programs designed to increase parent-child communication about reproductive health. The review was used to inform national recommendations on quality family planning services. Data analysis occurred from mid-2011 through 2012. EVIDENCE ACQUISITION Several electronic bibliographic databases were used to identify relevant articles, including PubMed, CINAHL, PsycINFO, and Popline, published from January 1985 through February 2011. EVIDENCE SYNTHESIS Sixteen articles met the inclusion criteria: all studies examined the impact on at least one medium- or short-term outcome, and two studies assessed the impact on teen pregnancy. One study examined the impact of a program conducted in a clinic setting; the remainder examined the impact of programs in community settings. All studies showed a positive impact on at least one short-term outcome, and 12 of 16 studies showed an increase in parent-child communication about reproductive health. Four of seven studies found an impact on sexual risk behavior. CONCLUSIONS Most programs increased parent-child communication, and several resulted in reduced sexual risk behavior of adolescents. This suggests that delivering a clinic-based program that effectively helps parents/guardians talk to their adolescent child(ren) about reproductive health, or referring parents/guardians to an evidence-based program in the community, may be beneficial. However, further rigorous research on delivery of these programs in clinical settings is needed.

Developing Federal Clinical Care Recommendations for Men.

U.S. men experience substantial sexual and reproductive health needs across the life span. A significant barrier for providers in serving men in family planning, primary care, and sexually transmitted disease clinics has been the lack of standards for mens sexual and reproductive health care. The goal of this synthesis paper is to describe the development of clinical recommendations for the delivery of family planning services for men that were developed and published by CDC and the U.S. Office of Population Affairs. This paper is intended to describe the process used from 2011 to 2014 to develop the recommendations for the delivery of comprehensive reproductive healthcare services to men, and the rationale underpinning them.

Impact of Reminder Systems in Clinical Settings to Improve Family Planning Outcomes: A Systematic Review

CONTEXT This systematic review evaluated the evidence on the impact of family planning reminder systems-interventions intended to remind patients of behaviors to achieve reproductive health goals (e.g., daily text messages reminding oral contraceptive [OC] users to take a pill)-to provide information to guide national recommendations on quality family planning services. EVIDENCE ACQUISITION Multiple databases including PubMed were searched during 2010-2011 for peer-reviewed articles published in English from January 1985 through February 2011 describing studies evaluating reminder systems to improve family planning outcomes. Studies were excluded if they focused primarily on HIV or sexually transmitted infection prevention, focused solely on men, or were conducted outside the U.S., Europe, Australia, or New Zealand. EVIDENCE SYNTHESIS The initial search identified 16,129 articles, five of which met the inclusion criteria. Three studies examined the impact of OC reminder systems; two found a statistically significant positive impact on correct use. Two studies examined the impact of reminder systems among depot medroxyprogesterone acetate (DMPA) users; one found a statistically significant positive impact on correct use. CONCLUSIONS Although mixed support was found for the effectiveness of reminder system interventions on correct use of OCs and DMPA, the highest-quality evidence yielded null findings. The evidence base would be strengthened by the development of additional studies, especially RCTs, which objectively measure outcomes, examine additional contraceptive methods, and have sufficient sample sizes to detect behavioral outcomes at least 12 months post-intervention.

Four aspects of the scope and quality of family planning services in US publicly funded health centers: Results from a survey of health center administrators

OBJECTIVES This study aims to describe aspects of the scope and quality of family planning services provided by US publicly funded health centers before the release of relevant federal recommendations. STUDY DESIGN Using nationally representative survey data (N=1615), we describe four aspects of service delivery: family planning services provided, contraceptive methods provided onsite, written contraceptive counseling protocols and youth-friendly services. We created a count index for each issue and used multivariable ordered logistic regression to identify health center characteristics associated with scoring higher on each. RESULTS Half of the sample received Title X funding and about a third each were a community health center or health department clinic. The vast majority reported frequently providing contraceptive services (89%) and STD services (87%) for women in the past 3 months. Service provision to males was substantially lower except for STD screening. A total of 63% and 48% of health centers provided hormonal IUDs and implants onsite in the past 3 months, respectively. Forty percent of health centers included all five recommended contraceptive counseling practices in written protocols. Of youth-friendly services, active promotion of confidential services was among the most commonly reported (83%); offering weekend/evening hours was among the least (42%). In multivariable analyses, receiving Title X funding, having larger volumes of family planning clients and being a Planned Parenthood clinic were associated with higher scores on most indices. CONCLUSION Many services were consistent with the recommendations for providing quality family planning services, but there was room for improvement across domains and health centers types. IMPLICATIONS STATEMENT As assessed in this paper, the scope and quality of these family planning services was relatively high, particularly among Planned Parenthood clinics and Title X-funded centers. However, results point to important areas for improvement. Future studies should assess change as implementation of recent family planning service recommendations continues.

Client and Provider Perspectives on Quality of Care A Systematic Review

CONTEXT A central premise of the literature on healthcare quality is that improving the quality of care will lead to improvements in health outcomes. A systematic review was conducted to better inform quality improvement efforts in the area of family planning. The objective of this systematic review is to update a previous review focused on the quality of family planning services, namely, the impact of quality improvement efforts and client perspectives about what constitutes quality family planning services. In addition, this review includes new literature examining provider perspectives. EVIDENCE ACQUISITION Multiple databases from January 1985 through January 2015 were searched within the peer-reviewed literature that described the quality of family planning services. The retrieval and inclusion criteria included full-length articles published in English, which described studies occurring in a clinic-based setting to include family planning services. EVIDENCE SYNTHESIS Search strategies identified 16,145 articles, 16 of which met the inclusion criteria. No new intervention studies addressing the impact of quality improvement efforts on family planning outcomes were identified. Sixteen articles provided information relevant to client or provider perspectives about what constitutes quality family planning services. Clients and providers mostly identified the need for services that were accessible, client-centered, and equitable. Themes related to effectiveness, efficiency, and safety were mentioned less frequently. CONCLUSIONS Family planning services that account for both patient and provider perspectives may be more effective. Further research is needed to examine the impact of improved quality on provider practices, client behavior, and health outcomes.