Development of a clinical questionnaire to support contraception decisions in an adolescent reproductive health clinic in Colorado.

CONTEXT: Adolescents need support to make informed decisions about contraception. Few clinical questionnaires exist to help adolescents and their healthcare providers align contraception decisions with patient needs and preferences. METHODS: Our mixed-methods study involved a convenience sample of English-speaking, female patients aged 13-19 seeking contraception services at an adolescent reproductive health clinic in Colorado, USA. Qualitative interviews informed development of clinical questionnaire items. The questionnaire elicited demographic characteristics, pregnancy and contraception use history, preferred contraception attributes, peer and family involvement, healthcare information and support needs, motivations for contraceptive use, and barriers to contraceptive services. We identified key decision-making factors and reduced the number of questionnaire items through principal components analysis. Using multivariable analyses, we examined the correlation between questionnaire responses and current contraceptive method. RESULTS: Twenty individuals participated in interviews and 373 individuals completed the preliminary questionnaire with 63 candidate items. We identified five contraceptive decision-making factors: side-effect avoidance (eight items, Cronbach's alpha = 0.84), preferred method attributes (six items, Cronbach's alpha = 0.67), parental involvement (three items, Cronbach's alpha = 0.67), life goals prior to parenting (four items, Cronbach's alpha = 0.88), and access to a contraceptive provider (two items, Cronbach's alpha = 0.92) and nine stand-alone items. In multivariable analyses, we found that questionnaire responses for decision-making factors varied among participants using different contraceptive methods. CONCLUSIONS: Multiple priorities may influence adolescent contraceptive decisions. This clinical questionnaire can elicit these priorities before or during a healthcare encounter. Future studies should assess generalizability of the questionnaire and examine impact on method choice, continuation, satisfaction, and reproductive health outcomes.

Pediatric Resident Perspectives on Long-Acting Reversible Contraception Training: A Cross-Sectional Survey of Accreditation Council for Graduate Medical Education Trainees.

PURPOSE: Although pediatricians are primary care providers for most adolescents, pediatric residents receive limited training on long-acting reversible contraceptive (LARC) methods. This study aimed to characterize pediatric resident comfort with placing contraceptive implants and intrauterine devices (IUDs) and assess pediatric resident interest in obtaining this training. METHODS: Pediatric residents in the United States were invited to participate in a survey assessing comfort with LARC methods and interest in LARC training during pediatric residency. Bivariate comparisons used Chi-square and Wilcoxon rank sum testing. Multivariate logistic regression was used to assess associations between primary outcomes and covariates including geographic region, training level, and career plans. RESULTS: Six hundred twenty seven pediatric residents across the United States completed the survey. Participants were predominantly female (68.4%, n = 429), self-identified their race as White (66.1%, n = 412), and anticipated a career in a subspecialty other than Adolescent Medicine (53.0%, n = 326). Most residents were confident counseling patients on the risks and benefits, side effects, and effective use of contraceptive implants (55.6%, n = 344) and both hormonal and nonhormonal IUDs (53.0%, n = 324). Few residents reported comfort with inserting contraceptive implants (13.6%, n = 84) or IUDs (6.3%, n = 39), with most of these respondents having learned these skills as a medical student. Most participants believed that residents should receive training on insertion of contraceptive implants (72.3%, n = 447) and IUDs (62.5%, n = 374). DISCUSSION: Although most pediatric residents believe LARC training should be a component of pediatric residency training, few pediatric residents are comfortable with provision of this care.

Addressing Administrative and System-Level Challenges to Implementation of Long-Acting Reversible Contraceptives in Adolescent Medicine and Pediatric and Adolescent Gynecology Practices: A Qualitative Study.

STUDY OBJECTIVE: Adolescents use long-acting reversible contraceptive (LARC) methods less than adults. Practices that specialize in adolescent medicine, including Adolescent Medicine (AM) and Pediatric and Adolescent Gynecology (PAG), may be well positioned to help improve adolescent access to these methods. We describe administrative and system-level barriers encountered when implementing LARCs for adolescents and strategies that practices have successfully used to address these barriers. DESIGN/SETTING/PARTICIPANTS: We conducted a qualitative study with physicians and staff at AM and PAG practices that provide LARCs to adolescents. INTERVENTIONS: Semi-structured telephone interviews MAIN OUTCOME MEASURES: Interview guides were based on the Consolidated Framework for Implementation Research (CFIR), an implementation science methodology designed to understand the following aspects of settings adopting new practices: innovation characteristics, external environment, institutional and practice settings, the stakeholders involved, and the implementation process. RESULTS: Seventeen interviews were performed. When examining administrative and system-level challenges encountered by interviewees, the four CFIR constructs identified most frequently were cost, readiness for implementation-available resources, planning, and engaging. Interviewees shared strategies used to overcome these common barriers, including for billing and working with insurance companies, space and equipment needed to introduce LARCs, scheduling and use of telemedicine, and staff training and engagement. CONCLUSION: Sites used many strategies to address these common challenges to implementation. Examples could help with implementation of LARC provision in practices serving adolescent populations.

The Timing of Obesity Matters: Associations Between Current Versus Chronic Obesity since Adolescence and Romantic Relationship Satisfaction Among Young Adult Women.

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

Identifying Opportunities to Discuss Pre-Exposure Prophylaxis During Contraceptive Coaching Discussions With Urban Adolescent Women.

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

Facilitators and Barriers to Implementation of Long-Acting Reversible Contraceptive Services for Adolescent Girls and Young Women in Gaborone, Botswana.

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

Effect of Previous Adverse Reproductive Health Outcomes on Young Women's Engagement in a Health Coaching Intervention to Improve Contraceptive Continuation.

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

Preconception and Interconception Pediatric Primary Care Utilization of Pregnant and Parenting Teens.

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

Evolving the Preconception Health Framework: A Call for Reproductive and Sexual Health Equity.

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

What's Known and What's Next: Contraceptive Counseling and Support for Adolescents and Young Adult Women.

The low rates of actual contraceptive failure and high rates of contraceptive use among young women highlight that choice of contraceptive method and patterns of contraceptive use greatly influence unintended pregnancy risk. Promoting contraceptive use among adolescent and young adult women requires supportive health systems and health providers who understand this population's evolving developmental needs. It also requires an awareness of effective tools for counseling patients, while being mindful of the power dynamics operational during clinical encounters to avoid inadvertently coercive interpersonal dynamics. Missed opportunities to provide such patient-centered care can lead to unplanned pregnancies and suboptimal health and social consequences for young women. Unfortunately, health providers often lack the tools and resources to appropriately identify and meet individual young women's contraceptive needs. This article summarizes the evidence supporting contraceptive counseling strategies linked with contraceptive initiation among young women, and evidence-based approaches for supporting contraceptive adherence and continuation after method initiation. It also orients readers to the unique neurodevelopmental factors that influence the shared decision-making process during contraception counseling sessions with young women. New and emerging approaches for supporting contraceptive initiation, adherence, and continuation are reviewed.

Feasibility study of a health coaching intervention to improve contraceptive continuation in adolescent and young adult women in Philadelphia, Pennsylvania.

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

Racial/Ethnic Disparities in Female Sexual Health from Adolescence to Young Adulthood: How Adolescent Characteristics Matter?

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

Dual-Method Contraception Use Among Young Women Pre- and Post-ACA Implementation.

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

HIV Testing Among Adolescents With Acute Sexually Transmitted Infections.

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

Follow-Up Care and 6-Month Continuation Rates for Long-Acting Reversible Contraceptives in Adolescents and Young Adults: A Retrospective Chart Review.

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

Anticipated Pain During Intrauterine Device Insertion.

STUDY OBJECTIVE: To identify predictors of anticipated pain with intrauterine device (IUD) insertion in adolescents and young women. DESIGN: We performed linear regression to identify demographic, sexual/gynecologic history, and mood covariates associated with anticipated pain using a visual analogue scale pain score collected as part of a single-blind randomized trial of women who received a 13.5-mg levonorgestrel IUD. SETTING: Three academic family planning clinics in Philadelphia Pennsylvania. PARTICIPANTS: Ninety-three adolescents and young adult women aged 14-22 years. INTERVENTION: Participants received either a 1% lidocaine or sham paracervical block. MAIN OUTCOME MEASURES: Anticipated pain measured using a visual analogue scale before and perceived pain at 6 time points during the IUD insertion procedure. RESULTS: Black or African American participants had a median anticipated pain score of 68 (interquartile range [IQR], 52-83), White participants had a median anticipated pain of 51 (IQR, 35-68), whereas participants of other races had a median anticipated pain score of 64 (IQR, 36-73); P = .012. In multivariate analysis, race was the only covariate that significantly predicted anticipated pain at IUD insertion. Women with anticipated pain scores above the median had significantly higher perceived pain during all timepoints of the IUD insertion procedure. CONCLUSION: Increased anticipated pain is associated with increased perceived pain with IUD insertion. Black adolescent women experience greater anticipated pain with IUD insertion. This population might benefit from counseling and clinical measures to reduce this barrier to IUD use.

Messages About Contraception and Condoms in Mother-Adolescent Dyadic Conversations: Knowledge, Risks, and Effectiveness.

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

Intrauterine Device Insertion Procedure Duration in Adolescent and Young Adult Women.

STUDY OBJECTIVE: Intrauterine device (IUD) utilization in the United States is low among adolescent and young adult women. Longer procedure duration has been proposed as one potential barrier to IUD insertion in this population. We hypothesized that procedure duration would be longer in adolescents compared to young adult women. DESIGN, SETTING, AND PARTICIPANTS: This study was a secondary analysis of a randomized clinical trial comparing the effectiveness of a lidocaine vs sham paracervical nerve block for pain control during levonorgestrel 13.5 mg IUD insertion. Adolescent and young adult women ages 14-22 years were recruited from 3 outpatient academic sites in Philadelphia, Pennsylvania. INTERVENTIONS AND MAIN OUTCOME MEASURES: Pain scores were recorded at 7 steps during the procedure from speculum insertion through removal. Time stamps associated with each step were used to calculate the overall procedure duration. Cumulative IUD insertion procedure duration was estimated using the Kaplan-Meier method. RESULTS: Ninety-five women enrolled. Nineteen (19/95, 20%) were ages 14-17 and 76 (76/95, 80%) were ages 18-22 years. The median procedure duration (seconds ± interquartile range) was longer for adolescents than for young adults (555 ± 428 seconds vs 383 ± 196 seconds; P = .008). After adjusting for study site, the difference in expected median procedure duration between age groups was not significant (P = .3832). CONCLUSION: The difference in duration of IUD insertion procedures in adolescent and young adult women is not clinically or statistically significant. Providers should not withhold IUDs from appropriate adolescent and young adult women on the basis of age alone.

Obesity and Disparities in Human Papillomavirus Vaccination for U.S. Adolescent Girls and Young Women.

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

Satisfaction With the Intrauterine Device Insertion Procedure Among Adolescent and Young Adult Women.

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