Assessing youth-friendly sexual and reproductive health services: a systematic review

BACKGROUND

Over the last quarter century, there has been an emergence of evidence-based research directed toward the development, implementation, and assessment of youth-friendly health services (YFHS) to improve the delivery of sexual and reproductive health services for young people. Despite these research efforts, evidence supporting the effectiveness of YFHS is limited, which may be attributed to a lack of consensus on how to define and measure youth-friendliness to track progress and evaluate outcomes. The purpose of this systematic review is to assess how youth-friendly sexual and reproductive health services are measured worldwide.

METHODS

We conducted a systematic review of studies measuring youth-friendly sexual and reproductive health services at health facilities published between January 2000 and June 2015 using PubMed, Web of Science, and POPLINE databases. Additional studies were identified by reviewing references of selected articles. Studies were screened to identify measurements and indicators that have been used to measure YFHS.

RESULTS

Our review identified 20 studies from an initial search of more than 11,000 records, including six from high-income countries and 14 from low-and middle-income countries. The review identified 115 indicators used for measuring youth-friendly sexual and reproductive health services. Our review found a lack of consistency in the tools and indicators used to measure YFHS. The three most frequently assessed domains were accessibility, staff characteristics and competency, and confidentiality and privacy. The majority of the indicators were not specific to young people's needs and often reflected basic standards of care.

CONCLUSIONS

This review shows the need for standardization and prioritization of indicators for the evaluation of YFHS. The results can be used to identify a core set of indicators that can be incorporated into a framework for assessing youth-friendly sexual and reproductive health services. There is a need to further distinguish between those variables that may have greatest impact on the use of services by young people, such as respect and privacy, those that impact the quality of services offered, and those that have limited relevance. Conducting more rigorous studies using a refined set of indicators is critical to measure and compare the impact and effectiveness of YFHS efforts.

The Impact of a Parental Notification Requirement on Illinois Minors' Access to and Decision-Making Around Abortion

PURPOSE

This study aims to examine the impact of a parental notification (PN) requirement on the frequency, timing, and out-of-state travel of minors seeking abortion, as well as changes in who minors involve in their decision, support received, and decision certainty.

METHODS

We analyzed administrative and medical records of 1,577 women obtaining an abortion before and after implementation of a PN requirement at one Illinois facility. Using multivariate regression within a difference-in-differences framework, we quantified changes in the number and timing of women seeking care, frequency of parental awareness and support, travel from out-of-state, decision certainty, and anticipated coping among minors 17 years and below compared with young adults (YAs) aged 18-20 years.

RESULTS

A smaller proportion of abortions to women ages 20 years and under post-law were among minors (39%-33%, p = .017). Compared with YAs, minors experienced a larger increase in parental awareness (71%-93% [minors] vs. 53%-58% [YAs], p < .000]; however, parents' support for the decision was unchanged. The proportion of minors certain of their decision went from 77% pre-law to 71% post-law (p = .099) compared with 82% pre- and post-law among YAs (p = .798). Compared with YAs, a larger proportion of minors obtained second trimester care post-law if coming from another state (21%-31% [minors] vs. 23%-16% [YAs], p = .022).

CONCLUSIONS

Illinois' PN requirement was associated with a decrease in the number of abortions among minors, delayed care for those from out-of-state, increased parental awareness of the pregnancy, and no change in parents' support.

The ramifications of recent health policy actions for cardiovascular care of women: Progress, threats, and opportunities

Women's health and well-being are shaped by a combination of healthcare policies that impact the type of health insurance coverage they benefit from, as well as access to preventive, screening, and treatment services. Furthermore, more distal policies, such as those that pertain to housing, education, and employment, as well as social determinants of health, such as issues of socioeconomic status and women's status in society, also impact their cardiac health. Before the passage of the Affordable Care Act in 2010, women were at greater risk of facing barriers to coverage, reflecting gender rating and the higher likelihood of the existence of preexisting health conditions such as a previous pregnancy. The ACA made substantial progress in responding to women's health needs by expanding the numbers of low-income groups eligible for Medicaid (for the 32 states and Washington, DC that expanded the program) and other subsidized healthcare, as well as access to preventive health services. Although health reform efforts to eliminate the ACA failed in 2016, the administration and Congress are using a variety of channels, including the new Tax Cuts and Job Act, to implement policies such as the elimination of the individual insurance mandate, as well as the elimination of premium subsidies, that will likely impact women differentially, potentially undoing the progress that has been achieved over the past decade.

Coming of Age on the Margins: Mental Health and Wellbeing Among Latino Immigrant Young Adults Eligible for Deferred Action for Childhood Arrivals (DACA)

Undocumented immigrant young adults growing up in the United States face significant challenges. For those qualified, the Deferred Action for Childhood Arrivals (DACA) program's protections may alleviate stressors, with implications for their mental health and wellbeing (MHWB). We conducted nine focus groups with 61 DACA-eligible Latinos (ages 18-31) in California to investigate their health needs. Participants reported MHWB as their greatest health concern and viewed DACA as beneficial through increasing access to opportunities and promoting belonging and peer support. Participants found that DACA also introduced unanticipated challenges, including greater adult responsibilities and a new precarious identity. Thus, immigration policies such as DACA may influence undocumented young adults' MHWB in expected and unexpected ways. Research into the impacts of policy changes on young immigrants' MHWB can guide stakeholders to better address this population's health needs. MHWB implications include the need to reduce fear of deportation and increase access to services.

Improving Receipt and Preventive Care Delivery for Adolescents and Young Adults: Initial Lessons from Top-Performing States

Purpose Provisions of the Patient Protection and Affordable Care Act (ACA) of 2010 hold promise for improving access to and receipt of preventive services for adolescents and young adults (AYAs). The Title V Block Grant transformation also includes a focus on improving adolescent preventive care. This brief report describes and discusses an inquiry of promising strategies for improving access and preventive care delivery identified in selected high-performing states. Methods Two data sources were used to identify top-performing states in insurance enrollment and preventive care delivery: National Survey of Children's Health for adolescents (ages 12-17 years) and Behavioral Risk Factors Surveillance System for young adults (ages 18-25 years). Interviews were conducted with key stakeholders to identify promising strategies related to increasing AYAs' insurance enrollment and receipt of preventive services. Results Seven top-performing states were selected: California, Colorado, Illinois, Iowa, Oregon, Vermont, and Texas; 27 stakeholders completed interviews. Four strategies were identified regarding insurance enrollment: use of partnerships; special populations outreach; leveraging laws and resources; and youth engagement. Four strategies were identified regarding quality preventive care: expand provider capacity to serve AYAs; adopt medical home policies; establish quality improvement projects; and enhance consumer awareness of well-visit. States focused more on adolescents than young adults and on increasing health insurance enrollment than the provision of preventive services. Conclusions This commentary identifies strategies and recommends areas for future action, as Title V programs and their partners focus on improving healthcare for AYAs as ACA implementation and the Title V transformation continues.

Rates of Exposure to Victimizing Events and Use of Substances Among California’s Middle and High School Students

Nearly half of 5- to 17-year-olds have experienced trauma in the form of at-school victimization. Exposure to trauma increases students’ risk for mental health disorders and school failure. This study reviews at-school victimization in middle and high school students and associated health outcomes that may negatively impact academic outcomes. Analyzing the California Healthy Kids Survey 2010, we examine rates of victimization on school grounds, substance use, and symptoms of depression and eating disorders among a sample of 6th to 12th graders ( N = 639,925). Between 20% and 50% of students had experienced at least one type of victimizing event on school grounds, with the highest incidence in middle schools. A significantly higher share of victimized students reported using substances, symptoms of depression and eating disorders when compared to nonvictimized students. School district investment in school nurses, social workers, and school-based health centers could increase preventive interventions to improve school climate, student well-being, and academic success.

Assessing the effectiveness of a patient-centred computer-based clinic intervention, Health-E You/Salud iTu, to reduce health disparities in unintended pregnancies among Hispanic adolescents: study protocol for a cluster randomised control trial

INTRODUCTION

Teen pregnancy rates in the USA remain higher than any other industrialised nation, and pregnancies among Hispanic adolescents are disproportionately high. Computer-based interventions represent a promising approach to address sexual health and contraceptive use disparities. Preliminary findings have demonstrated that the Health-E You/Salud iTu, computer application (app) is feasible to implement, acceptable to Latina adolescents and improves sexual health knowledge and interest in selecting an effective contraceptive method when used in conjunction with a healthcare visit. The app is now ready for efficacy testing. The purpose of this manuscript is to describe patient-centred approaches used both in developing and testing the Health-E You app and to present the research methods used to evaluate its effectiveness in improving intentions to use an effective method of contraception as well as actual contraceptive use.

METHODS AND ANALYSIS

This study is designed to assess the effectiveness of a patient-centred computer-based clinic intervention, Health-E You/Salud iTu, on its ability to reduce health disparities in unintended pregnancies among Latina adolescent girls. This study uses a cluster randomised control trial design in which 18 school-based health centers from the Los Angeles Unified School District were randomly assigned, at equal chance, to either the intervention (Health-E You app) or control group. Analyses will examine differences between the control and intervention group's knowledge of and attitudes towards contraceptive use, receipt of contraception at the clinic visit and self-reported use of contraception at 3-month and 6-month follow-ups. The study began enrolling participants in August 2016, and a total of 1400 participants (700 per treatment group) are expected to be enrolled by March 2018.

ETHICS AND DISSEMINATION

Ethics approval was obtained through the University of California, San Francisco Institutional Review Board. Results of this trial will be submitted for publication in peer-reviewed journals. This study is registered with the US National Institutes of Health.

TRIAL REGISTRATION NUMBER

NCT02847858.

Association Between Adolescent Preventive Care and the Role of the Affordable Care Act

Importance

Despite decades of adolescent preventive well visit and services promotion (Guidelines for Adolescent Preventive Services and Bright Futures), rates are below recommended levels and little is known of the effect of the Patient Protection and Affordable Care Act (ACA) implementation on these care rates.

Objectives

To use Medical Expenditure Panel Survey data to determine (1) whether adolescent well visit rates increased from the pre-ACA period to post-ACA period, and (2) whether caregivers' reports of past-year preventive services delivery increased from the pre- to post-ACA period among adolescents with any past-year health care visit.

Design, Setting, and Participants

Secondary data analysis of 2007-2009 (before ACA implementation) and 2012-2014 (after ACA implementation) Medical Expenditure Panel Survey data on the differences in well visits and preventive services. Data were collected through computer-assisted personal interviews of caregivers of a nationally representative sample of a noninstitutionalized US population (n = 25 695 10- to 17-year-old adolescents).

Main Outcomes and Measures

For objective 1, pre- to post-ACA period differences in past-year well visits: (1) stratified bivariable logistic regressions identifying subgroup rate differences and (2) multivariable analyses controlling for demographic factors. For objective 2, pre- to post-ACA period differences in caregiver reports of preventive services receipt, including time alone with clinician: (1) bivariable (year differences) and (2) multivariable logistic regressions controlling for demographic variables.

Results

A total of 6279 (50.9%) and 6730 (50.8%) participating adolescents in the pre- and post-ACA period data were male, respectively. Under objective 1, we found that well-visit rates increased from 41% to 48% post-ACA implementation (odds ratio, 1.3; 95% CI, 1.2-1.5); minority and low-income groups had the greatest increases. Under objective 2, we found that among those with any past-year visit, most preventive services rates (8 of 9) increased post-ACA implementation (range, 2%-9%, absolute), with little or no change when controlling for demographic variables. Time alone with clinicians increased 1%, significant only when covariates were controlled (adjusted odds ratio, 1.2; 95% CI, 1.0-1.3).

Conclusions and Relevance

Despite modest to moderate increases, with greatest gains for underserved youth, adolescent preventive care rates remain low, highlighting the need for increased efforts to bring adolescents into well care and improve clinician delivery of preventive care within their practices.

Validation of a Brief Questionnaire Against Direct Observation to Assess Adolescents' School Lunchtime Beverage Consumption

OBJECTIVE

Beverage consumption is an important determinant of youth health outcomes. Beverage interventions often occur in schools, yet no brief validated questionnaires exist to assess whether these efforts improve in-school beverage consumption. This study validated a brief questionnaire to assess beverage consumption during school lunch.

METHODS

Researchers observed middle school students' (n = 25) beverage consumption during school lunchtime using a standardized tool. After lunch, students completed questionnaires regarding their lunchtime beverage consumption. Kappa statistics compared self-reported with observed beverage consumption across 15 beverage categories.

RESULTS

Eight beverages showed at least fair agreement (kappa [κ] > 0.20) for both type and amount consumed, with most showing substantial agreement (κ > 0.60). One beverage had high raw agreement but κ < 0.20. Six beverages had too few ratings to compute κ's.

CONCLUSIONS AND IMPLICATIONS

This brief questionnaire was useful for assessing school lunchtime consumption of many beverages and provides a low-cost tool for evaluating school-based beverage interventions.

Preterm birth: the role of knowledge transfer and exchange

BACKGROUND

Preterm birth (PTB) is the leading cause of death in children under age five. Healthcare policy and other decision-making relevant to PTB may rely on obsolete, incomplete or inapplicable research evidence, leading to worsened outcomes. Appropriate knowledge transfer and exchange (KTE) strategies are an important component of efforts to reduce the global PTB burden. We sought to develop a 'landscape' analysis of KTE strategies currently used in PTB and related contexts, and to make recommendations for optimising programmatic implementation and for future research.

METHODS

In the University of California, San Francisco's Preterm Birth Initiative, we convened a multidisciplinary working group and examined KTE frameworks. After selecting a widely-used, adaptable, theoretically-strong framework we reviewed the literature to identify evidence-based KTE strategies. We analysed KTE approaches focusing on key PTB stakeholders (individuals, families and communities, healthcare providers and policymakers). Guided by the framework, we articulated KTE approaches that would likely improve PTB outcomes. We further applied the KTE framework in developing recommendations.

RESULTS

We selected the Linking Research to Action framework. Searches identified 19 systematic reviews, including two 'reviews of reviews'. Twelve reviews provided evidence for KTE strategies in the context of maternal, neonatal and child health, though not PTB specifically; seven reviews provided 'cross-cutting' evidence that could likely be generalised to PTB contexts. For individuals, families and communities, potentially effective KTE strategies include community-based approaches, 'decision aids', regular discussions with providers and other strategies. For providers, KTE outcomes may be improved through local opinion leaders, electronic reminders, multifaceted strategies and other approaches. Policy decisions relevant to PTB may best be informed through the use of evidence briefs, deliberative dialogues, the SUPPORT tools for evidence-informed policymaking and other strategies. Our recommendations for research addressed knowledge gaps in regard to partner engagement, applicability and context, implementation strategy research, monitoring and evaluation, and infrastructure for sustainable KTE efforts.

CONCLUSIONS

Evidence-based KTE, using strategies appropriate to each stakeholder group, is essential to any effort to improve health at the population level. PTB stakeholders should be fully engaged in KTE and programme planning from its earliest stages, and ideally before planning begins.

Chronic Childhood Trauma, Mental Health, Academic Achievement, and School-Based Health Center Mental Health Services

BACKGROUND

Children and adolescents exposed to chronic trauma have a greater risk for mental health disorders and school failure. Children and adolescents of minority racial/ethnic groups and those living in poverty are at greater risk of exposure to trauma and less likely to have access to mental health services. School-based health centers (SBHCs) may be one strategy to decrease health disparities.

METHODS

Empirical studies between 2003 and 2013 of US pediatric populations and of US SBHCs were included if research was related to childhood trauma's effects, mental health care disparities, SBHC mental health services, or SBHC impact on academic achievement.

RESULTS

Eight studies show a significant risk of mental health disorders and poor academic achievement when exposed to childhood trauma. Seven studies found significant disparities in pediatric mental health care in the US. Nine studies reviewed SBHC mental health service access, utilization, quality, funding, and impact on school achievement.

CONCLUSION

Exposure to chronic childhood trauma negatively impacts school achievement when mediated by mental health disorders. Disparities are common in pediatric mental health care in the United States. SBHC mental health services have some showed evidence of their ability to reduce, though not eradicate, mental health care disparities.

Cancer Prevention During Early Adulthood: Highlights From a Meeting of Experts

Using a life course approach, the Centers for Disease Control and Prevention's Division of Cancer Prevention and Control and the National Association of Chronic Disease Directors co-hosted a 2-day meeting with 15 multidisciplinary experts to consider evidence linking factors in early adulthood to subsequent cancer risk and strategies for putting that evidence into practice to reduce cancer incidence. This paper provides an overview of key themes from those meeting discussions, drawing attention to the influence that early adulthood can have on lifetime cancer risk and potential strategies for intervention during this phase of life. A number of social, behavioral, and environmental factors during early adulthood influence cancer risk, including dietary patterns, physical inactivity, medical conditions (e.g., obesity, diabetes, viral infections), circadian rhythm disruption, chronic stress, and targeted marketing of cancer-causing products (e.g., tobacco, alcohol). Suggestions for translating research into practice are framed in the context of the four strategic directions of the National Prevention Strategy: building healthy and safe community environments; expanding quality preventive services in clinical and community settings; empowering people to make healthy choices; and eliminating health disparities. Promising strategies for prevention among young adults include collaborating with a variety of community sectors as well as mobilizing young adults to serve as advocates for change. Young adults are a heterogeneous demographic group, and targeted efforts are needed to address the unique needs of population subgroups that are often underserved and under-represented in research studies.

Teens, Tweets, and Tanning Beds: Rethinking the Use of Social Media for Skin Cancer Prevention

The incidence of skin cancer is rising in the U.S., and melanoma, the deadliest form, is increasing disproportionately among young white women. Indoor tanning is a modifiable risk factor for all skin cancers and continues to be used at the highest rates in young white women. Adolescents and young adults report personal appearance-based reasons for using indoor tanning. Previous research has explored the influences on tanning bed use, including individual factors as well as relationships with peers, family, schools, media influences, legislation, and societal beauty norms. Adolescents and young adults also have high rates of social media usage, and research is emerging on how best to utilize these platforms for prevention. Social media has the potential to be a cost-effective way to reach large numbers of young people and target messages at characteristics of specific audiences. Recent prevention efforts have shown that comprehensive prevention campaigns that include technology and social media are promising in reducing rates of indoor tanning among young adults. This review examines the literature on psychosocial influences on indoor tanning among adolescents and young adults, and highlights ways in which technology and social media can be used for prevention efforts.

Research and Engagement Strategies for Young Adult Immigrants Without Documentation: Lessons Learned Through Community Partnership

BACKGROUND

Limited research has focused on undocumented immigrants' health and access to care.

OBJECTIVES

This paper describes participant engagement strategies used to investigate the health needs of immigrants eligible for Deferred Action for Childhood Arrivals (DACA).

METHODS

Community-based strategies engaged advocates and undocumented Californians in study design and recruitment. Outreach in diverse settings, social media, and participant-driven sampling recruited 61 DACA-eligible focus group participants.

LESSONS LEARNED

Social media, community-based organizations (CBOs), family members, advocacy groups, and participant-driven sampling were the most successful recruitment strategies. Participants felt engaging in research was instrumental for sharing their concerns with health care providers and policymakers, noteworthy in light of their previously identified fears and mistrust of government officials.

CONCLUSIONS

Using multiple culturally responsive strategies including participant-driven sampling, engagement with CBOs, and use of social media, those eligible for DACA eagerly engage as research participants. Educating researchers and institutional review boards (IRBs) about legal and safety concerns can improve research engagement.

The Role of Publicly Funded Family Planning Sites In Health Insurance Enrollment

CONTEXT

Publicly funded family planning providers are well positioned to help uninsured individuals learn about health insurance coverage options and effectively navigate the enrollment process. Understanding how these providers are engaged in enrollment assistance and the challenges they face in providing assistance is important for maximizing their role in health insurance outreach and enrollment.

METHODS

In 2014, some 684 sites participating in California's family planning program were surveyed about their involvement in helping clients enroll in health insurance. Weighted univariate and bivariate analyses were conducted to examine enrollment activities and perceived barriers to facilitating enrollment by site characteristics.

RESULTS

Most family planning program sites provided eligibility screening (68%), enrollment education (77%), on-site enrollment assistance (55%) and referrals for off-site enrollment support (91%). The proportion of sites offering each type of assistance was highest among community clinics (83-96%), primary care and multispecialty sites (65-95%), Title X-funded sites (72-98%), sites with contracts to provide primary care services (64-93%) and sites using only electronic health records (66-94%). Commonly identified barriers to providing assistance were lack of staff time (reported by 52% of sites), lack of funding (47%), lack of physical space (34%) and lack of staff knowledge (33%); only 20% of sites received funding to support enrollment activities.

CONCLUSIONS

Although there were significant variations among them, publicly funded family planning providers in California are actively engaged in health insurance enrollment. Supporting their vital role in enrollment could help in the achievement of universal health insurance coverage.

Rural-Urban Differences in Awareness and Use of Family Planning Services Among Adolescent Women in California

PURPOSE

The purpose of this study was to compare awareness and use of family planning services by rural and urban program site among a sample of adolescent women before participation in the federal Personal Responsibility Education Program in California.

METHODS

We conducted a secondary analysis of survey data collected from youth before participation in California's Personal Responsibility Education Program. Bivariate and multivariate analyses were conducted for a sample of 4,614 females ages 14-18 years to compare awareness and use of family planning services between participants at rural and urban program sites, controlling for the program setting and participant demographic, sexual, and reproductive characteristics.

RESULTS

Overall, 61% of participants had heard of a family planning provider in their community, and 24% had visited a family planning provider. Awareness and use of family planning services were lower among rural participants than urban participants. After adjusting for the program setting and participant characteristics, rural participants were less likely to know about a family planning provider in their community (odds ratio, .64; 95% confidence interval, .50-.81) or receive family planning services (odds ratio, .76; 95% confidence interval, .58-.99) than urban participants.

CONCLUSIONS

Findings suggest that adolescents in rural areas face greater barriers to accessing family planning services than adolescents in urban areas. Targeted efforts to increase awareness and use of family planning services among adolescents in rural areas and among other underserved populations are needed.

Building Responsive Health Systems to Help Communities Affected by Migration: An International Delphi Consensus

Persons affected by migration require health systems that are responsive and adaptable to the needs of both disadvantaged migrants and non-migrant populations. The objective of this study is to support health systems for populations affected by migration.

MATERIALS AND METHODS

An international Delphi consensus process was used to identify policy approaches to improve health systems for populations affected by migration. Participants were leading migrant health experts from Americas, Europe, Middle East, Asia, and Australasia. We calculated average ranking scores and qualitatively analyzed open-ended questions.

RESULTS

Participants identified the following key areas as priorities for policy development: health inequities, system discrimination, migrant related health data, disadvantaged migrant sub-groups, and considerations for disadvantaged non-migrant populations. Highly ranked items to improve health systems were: Health Equity Impact Assessment, evidence based guidelines, and the International Organization for Migration annual reports.

DISCUSSION

Policy makers need tools, data and resources to address health systems challenges. Policies need to avoid preventable deaths of migrants and barriers to basic health services.

Implementation in Practice: Adaptations to Sexuality Education Curricula in California

BACKGROUND

Local implementation of evidence-based curricula, including sex education, has received increasing attention. Although there are expectations that practitioners will implement evidence-based programs with fidelity, little is known regarding the experiences of instructors in meeting such standards. During 2005 to 2009, the California Department of Public Health funded local agencies through its Teen Pregnancy Prevention Programs (TPP) to provide comprehensive sex education.

METHODS

To improve understanding of how agencies implemented curricula, in-depth telephone interviews with 128 coordinators were conducted in 2008 to 2009. Qualitative data were analyzed for content and themes. Selected data were quantified and analyzed to examine differences in curriculum adaptations across settings and curricula type.

RESULTS

Whereas over half of the TPP agencies (59%) implemented evidence-based curricula, most agencies (95%) reported adapting the curriculum, with the majority (83%) adding content. Reasons for adaptations included ensuring that the material was accurate and appropriate; responding to logistical or time constraints; and other factors, such as parental and institutional support.

CONCLUSION

These adaptations reflected agencies' efforts to balance state and local requirements, maintain curriculum fidelity, and provide more up-to-date and accessible information. These experiences highlight the need for guidelines that enable appropriate adaptations, while maintaining fidelity to the core components of the original curriculum.

Exploring how residential mobility and migration influences teenage pregnancy in five rural communities in California: youth and adult perceptions

Teenage birth rates among young people aged 15-19 years in California, USA, have declined from 47 births per 1000 in 2000 to 24 per 1000 in 2013. Nevertheless, the US counties with the highest teenage birth rates are predominantly rural and have a high proportion of Latinos/as. We conducted 42 interviews with key stakeholders and 12 focus groups with 107 young people in five rural communities to better understand local migration patterns and their influence on intermediate and proximate variables of pregnancy, such as interaction with role models and barriers to access contraception. The migration patterns identified were: residential mobility due to seasonal jobs, residential mobility due to economic and housing changes and migration from other countries to California. These patterns affect young people and families' interactions with school and health systems and other community members, creating both opportunities and barriers to prevent risky sexual behaviours. In rural areas, residential mobility and migration to the USA interconnect. As a result, young people dually navigate the challenges of residential mobility, while also adapting to the dominant US culture. It is important to promote programmes that support the integration of immigrant youth to reduce their sense of isolation, as well as to assure access to sexual health education and reproductive health services.

CDC Grand Rounds: Adolescence - Preparing for Lifelong Health and Wellness

Approximately 42 million adolescents aged 10-19 years, representing 13% of the population, resided in the United States in 2014 (1). Adolescence is characterized by rapid and profound physical, intellectual, emotional, and psychological changes (2), as well as development of healthy or risky behaviors that can last a lifetime. Parents have strong influence on their adolescent children's lives, and family-based programs can help parents support healthy adolescent development. Because schools are natural learning environments, implementing and improving school-based policies and programs are strategic ways to reinforce healthy behaviors and educate adolescents about reducing risky behaviors. Health care during adolescence should be tailored to meet the changing developmental needs of the adolescent while providing welcoming, safe, and confidential care. Parents, educators, care providers, public health officials, and communities should collaborate in fostering healthy environments for all adolescents, now and into the future.