Melanie A. Gold

Long-Acting Reversible Contraception for Adolescents: A Review

Importance Adolescents have higher rates of unintended pregnancies than any other age group. Contraceptive implants and intrauterine devices (IUDs) are long-acting reversible contraceptives (LARCs) that are known to be highly effective in preventing pregnancy. New devices have recently been approved for use in adolescents, yet pediatricians may be less familiar with how to counsel adolescents about implants and IUDs. Observations LARC methods should be described in basic terms to adolescents, including hormone dose, method of insertion, and method of pregnancy prevention. Clinicians should appreciate the developmental stages of adolescents, discuss the most effective methods of contraception, and ensure confidentiality from their parents. Short-acting contraception methods (eg, oral contraceptives) can be used as a temporary bridge to provide coverage until a LARC method can be placed. The most common adverse effect of LARC is nuisance bleeding, which can be managed with short courses of oral contraceptives or nonsteroidal anti-inflammatory drugs. Conclusions and Relevance LARC devices constitute first-line contraceptive methods for adolescents. All clinicians, including pediatricians, can counsel about LARC even before suggesting an oral contraceptive or another less effective contraceptive method. Effective, confidential communication with sensitive language to inform adolescents of the different types of LARC is necessary to normalize offering LARC as a contraceptive option and improve its uptake among adolescents. Special clinical populations can also be offered appropriate contraceptive options inclusive of LARC.

A Randomized Controlled Trial to Compare Computer-assisted Motivational Intervention with Didactic Educational Counseling to Reduce Unprotected Sex in Female Adolescents

STUDY OBJECTIVEnTo examine a computer-assisted, counselor-guided motivational intervention (CAMI) aimed at reducing the risk of unprotected sexual intercourse. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We conducted a 9-month, longitudinal randomized controlled trial with a multisite recruitment strategy including clinic, university, and social referrals, and compared the CAMI with didactic educational counseling in 572 female adolescents with a mean age of 17 years (SD = 2.2 years; range = 13-21 years; 59% African American) who were at risk for pregnancy and sexually transmitted diseases. The primary outcome was the acceptability of the CAMI according to self-reported rating scales. The secondary outcome was the reduction of pregnancy and sexually transmitted disease risk using a 9-month, self-report timeline follow-back calendar of unprotected sex.nnnRESULTSnThe CAMI was rated easy to use. Compared with the didactic educational counseling, there was a significant effect of the intervention which suggested that the CAMI helped reduce unprotected sex among participants who completed the study. However, because of the high attrition rate, the intent to treat analysis did not demonstrate a significant effect of the CAMI on reducing the rate of unprotected sex.nnnCONCLUSIONnAmong those who completed the intervention, the CAMI reduced unprotected sex among an at-risk, predominantly minority sample of female adolescents. Modification of the CAMI to address methodological issues that contributed to a high drop-out rate are needed to make the intervention more acceptable and feasible for use among sexually active predominantly minority, at-risk, female adolescents.

Measuring Success: Evaluation Designs and Approaches to Assessing the Impact of School-Based Health Centers

Since the founding of the first school-based health centers (SBHCs) >45 years ago, researchers have attempted to measure their impact on child and adolescent physical and mental health and academic outcomes. A review of the literature finds that SBHC evaluation studies have been diverse, encompassing different outcomes and varying target populations, study periods, methodological designs, and scales. A complex picture emerges of the impact of SBHCs on health outcomes, which may be a function of the specific health outcomes examined, the health needs of specific communities and schools, the characteristics of the individuals assessed, and/or the specific constellation of SBHC services. SBHC evaluations face numerous challenges that affect the interpretation of evaluation findings, including maturation, self-selection, low statistical power, and displacement effects. Using novel approaches such as implementing a multipronged approach to maximize participation, entering-class proxy-baseline design, propensity score methods, data set linkage, and multisite collaboration may mitigate documented challenges in SBHC evaluation.

“It's Pretty Hard to Tell Your Mom and Dad That You're on a Method”: Exploring How an App Could Promote Adolescents' Communication with Partners and Parent(s) to Increase Self-Efficacy in Long-Acting Reversible Contraception Use

STUDY OBJECTIVEnYouth-friendly information and support are integral components to promote adolescents successful use of long-acting reversible contraception (LARC), and smartphone apps offer a promising medium. To inform content development for an app guided by the Health Belief Model, we conducted interviews with adolescent LARC users to assess self-efficacy and experiences with LARC, their communication with partners and parent(s) about LARC, and how apps could support this communication.nnnDESIGN, SETTING, AND PARTICIPANTSnWe conducted semistructured, in-depth interviews with 30 female adolescent LARC users enrolled in urban school-based health centers.nnnINTERVENTIONS AND MAIN OUTCOME MEASURESnDescriptive analyses were used to assess demographic characteristics, experience and comfort communicating with current and future partners and parent(s) about LARC, self-efficacy around LARC, and how app elements could support LARC use.nnnRESULTSnParticipants (mean age, 16xa0years; range, 14-19xa0years) were predominately Hispanic (77%; n = 23) and black (20%; n = 6). Almost all (97%; n = 29) had told their current partner about their LARC, but of these, only 15 (50%) would feel comfortable talking with a new sexual partner. Most participants (73%; n = 22) had not told their parent(s) about getting a LARC, but many reported they were likely to share app information with their parent(s). Of the few participants who did tell their parent(s), 38% (nxa0=xa03) reported that it was difficult to do so. Adolescents described ways in which app use could help initiate conversations with new partners and parent(s).nnnCONCLUSIONnThese findings suggest the potential of a theory-based smartphone app to meet adolescent LARC users information and support needs. The app should include information on strategies for communicating with future partners and parent(s).

Males' Ability to Report Their Partner's Contraceptive Use at Last Sex in a Nationally Representative Sample: Implications for Unintended Pregnancy Prevention Evaluations.

Addressing and enabling the role of males in contraceptive choices may facilitate efforts to reduce unintended pregnancy rates and disparities in the United States, but little is known about males’ ability to report their partners’ contraceptive use. Data from the 2011-2013 National Survey of Family Growth from 2,238 males aged 15 to 44 years who had vaginal sex with a noncohabiting or nonmarital partner and were not seeking pregnancy were examined to tabulate the proportion of males able to report whether their partner used a specific contraceptive method use at last sex (PCM) by sociodemographic and sexual history characteristics. Logistic regression was used to assess odds of being unable to report PCM, adjusting for age and sexual history factors. Most (95.0%) were able to report PCM, with no difference by age group (chi-square = 7.27, p = .281) in unadjusted analyses. Males with a new sex partner (14.8% of the sample), compared with those with an established sex partner, had significantly higher odds of being unable to report PCM in bivariate (11.7% vs. 3.7%, chi-square = 39.39, p < .001) and multivariable (adjusted odds ratio [AOR]: 3.17, 95% confidence interval [CI: 1.74, 5.65]) analyses. Those whose last sexual encounter was more than 3 months ago also had higher odds of being unable to report in bivariate (OR: 1.74, 95% CI [1.05, 2.87]) and multivariable analyses (AOR: 2.04, 95% CI [1.04, 4.03]). Most men were able report PCM, but reporting was significantly lower among men with new sex partners. To inform future research and evaluation relying on male report, validation studies comparing male report with partner report, specifically among new couples, are needed.

Integrating Long-Acting Reversible Contraception Services into New York City School-Based Health Centers: Quality Improvement to Ensure Provision of Youth-Friendly Services

STUDY OBJECTIVE, DESIGN, AND SETTINGnAdolescents face barriers to accessing youth-friendly family planning services, specifically long-acting reversible contraception (LARC). School-based health centers (SBHCs) can provide youth-friendly care. A quality improvement project was undertaken to assess quality of care before, during, and after LARC services at 3 SBHCs, and to identify specific strategies for improving these LARC services.nnnPARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURESnWe interviewed 18 female adolescents who received LARC services. Two independent reviewers coded deidentified verbatim transcripts; discrepancies were resolved by consensus with a third reviewer. A guide of themes was structured corresponding to Ambresins domains of youth-friendly services. From these domains, we identified emerging themes using grounded theory, with a focus on practical suggestions for improving LARC services in SBHCs.nnnRESULTSnInterviewees ranged in age from 15 to 19 (average: 17) years. Most had insertions (12 levonorgestrel intrauterine system (LNG-IUS); Mirena®), 1 copper intrauterine device (Paragard®), 5 contraceptive implant (Nexplanon®). Overall, participants were highly satisfied with SBHC LARC services. Within the domain of communication, 2 key themes emerged: balancing need for information with concerns about being overwhelmed by information; and interest in information that directly addresses misconceptions about LARCs. Suggested strategies included providing postprocedure care packages with information and supplies, and supporting a peer-based network of adolescent LARC users and previous patients to serve as a resource for new patients.nnnCONCLUSIONnThis quality improvement project, conducted in a unique setting, gave adolescents a voice. The identified strategies for improving health education, social support, and outreach might be generalizable to other SBHCs. Future research could explore the effect of implementing these suggested strategies on reproductive health care use and outcomes at SBHCs.

Messages About Abstinence, Delaying Sexual Debut and Sexual Decision-Making in Conversations Between Mothers and Young Adolescents

STUDY OBJECTIVEnLittle 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.nnnDESIGNnContent 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.nnnSETTINGnUrban city in Western Pennsylvania.nnnPARTICIPANTSnTwenty-one dyads; 15 mother-daughter dyads and 6 mother-son dyads.nnnINTERVENTIONSnNone.nnnMAIN OUTCOME MEASURESnNone.nnnRESULTSnFour key themes emerged reflecting the high priority mothers placed on abstinence, delaying their adolescents 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.nnnCONCLUSIONnMothers 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.

Computer-Assisted Motivational Interviewing Intervention to Facilitate Teen Pregnancy Prevention and Fitness Behavior Changes: A Randomized Trial for Young Men

PURPOSEnDespite recent declines, teen unintended pregnancy and sexually transmitted infections in the United States remain at levels higher than comparable nations. Initiatives to prevent teen pregnancy have focused primarily on female adolescents; how to effectively engage young men to reduce their risk of fathering a teen pregnancy has not been well studied. We proposed to adapt an innovative computer-assisted motivational interviewing (CAMI) intervention, originally designed and tested with young women, for use with young men, aged 15-24xa0years, to reduce their risk of fathering a teen pregnancy. This manuscript describes the design of a CAMI intervention for young men aimed at preventing teen pregnancy and improving fitness.nnnMETHODSnThis randomized controlled trial will recruit 945 sexually active young men between the ages of 15 and 24xa0years from three health centers in New York City. Participants will be assigned by permuted block randomization to two study arms: one aimed at reducing involvement in unintended teen pregnancy (CAMI-teen pregnancy prevention) and the other at improving overall fitness (CAMI-Fitness). Except for topic, both intervention arms will provide four sessions of Motivational Interviewing coaching and use a mobile app to track behavior and set goals. We will assess young mens sexual and reproductive health behaviors and fitness at baseline, 12, 24, 36, and 64xa0weeks using a mobile device app created for the study.nnnRESULTSnPending ongoing study.nnnCONCLUSIONSnResults from the study are expected to enhance our understanding of the efficacy of CAMI to enhance young mens reproductive health and fitness behaviors.

Healthy Weight and Cardiovascular Health Promotion Interventions for Adolescent and Young Adult Males of Color: A Systematic Review

Cardiovascular disease is the leading cause of mortality in the United States, accounting for one fourth of deaths. Higher rates of obesity put Hispanic and Black men at increased risk. The American Heart Association cites diet quality, physical activity, and body weight as alterations responsive to health promotion intervention. Prevention strategies need to begin in adolescence and the emerging adulthood years to impact cumulative risk factors. A scoping review identified search terms and this was followed by a systematic review of Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PubMed databases for articles published in English from January 1, 2002, through May 11, 2017. This review explores community-based content, delivery, recruitment, or retention strategies used with young men of color aged 15 to 24 years. Of 17 articles describing 16 individual interventions and 1 describing multiple interventions (with samples ranging from 37 to 4,800), 13 reported significant results in one or more domains. No studies specifically targeted the needs of young men and only three had more than 50% male participants. There was a gap in studies that addressed young men in the ages of interest with most interventions reaching participants aged 11 to 19 years. Cultural tailoring was addressed through recruitment setting, interventionist characteristics, community involvement, and theoretical frameworks such as motivational interviewing that allow individual goal setting. Because young men seek access to preventive health services less than young women, it is suggested that interventions that are community based or use push technology (send information directly to the user) be increased.

Providing Culturally Competent Care for LGBTQ Youth in School-Based Health Centers: A Needs Assessment to Guide Quality of Care Improvements

School-based health centers (SBHCs) can take specific steps to provide culturally competent care for lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth, potentially impacting well-being. A needs assessment survey was conducted among a convenience sample of SBHC administrators and medical directors to assess climates and actions supportive of LGBTQ quality medical care. Half (53%) of the SBHCs surveyed (N = 66) reviewed print materials for negative LGBTQ stereotypes, and 27.3% conducted exhaustive materials review. Regional differences were detected: 46.2% of Southern SBHCs conducted any materials review compared to 91.3% in the West and all in the East and Midwest (χ2, p < .001). In the last academic year, 45.5% conducted no medical provider trainings, and 54.5% conducted no general staff trainings on providing care for LGBTQ youth. On intake forms, 85.4% included preferred names, but only 23.5% included preferred pronoun. There are significant gaps in the extent to which SBHCs provide culturally competent care. These findings can guide future training and advocacy.