'Our mind could be our biggest challenge': A qualitative analysis of urban adolescents' sleep experiences and opportunities for mind-body integrative health approaches to improve sleep

Objective

To inform the development of a combined sleep and mind-body integrative health (MBIH) intervention, we explored urban adolescents' sleep experiences and perceptions of MBIH techniques.

Methods

We conducted eight focus groups with school-based health center patients in New York City, exploring sleep experiences; mindfulness, body awareness, tapping, acupressure, and self-hypnosis; and intervention delivery preferences. We recorded, transcribed, and analyzed the discussions applying methods from grounded theory.

Results

Participants (n = 25) were ages 14-17, predominantly female (64%), Latino (60%), and Black (40%). Participants reported social, physical, and internal sleep barriers, but had limited success implementing sleep improvement strategies. Participants viewed MBIH techniques positively, noted audio-guided techniques' accessibility, and were intrigued by less-familiar techniques. Preferences varied around domains of intervention delivery.

Conclusion

Results underscore the need for adolescent-informed interventions offering sleep improvement strategies. Participants' interest and willingness to engage in MBIH techniques present an opportunity for practitioners to develop and deliver sleep interventions incorporating MBIH components to urban adolescents. Varied intervention preferences highlight the need to be adaptable to adolescents' lived experiences, comfort levels, and learning styles.

Innovation

This study elucidates the perspectives of underrepresented adolescents whose perspectives on MBIH have rarely been explored, an important first step in developing tailored interventions.

Mixed-methods Exploration of Telehealth-supported Long-acting Reversible Contraceptive Services in School-based Health Centers: How Much Added Value?

INTRODUCTION

This study explored adolescent and young adult preferences and experiences with telehealth-supported long-acting reversible contraceptive (LARC) services in New York City school-based health centers (SBHCs) during COVID-19.

METHOD

Sequential mixed methods included post-LARC insertion surveys and in-depth interviews.

RESULTS

Survey respondents (n = 45) were aged 14-21 years and predominantly Hispanic (53.3%). Only four respondents completed a postinsertion visit via telehealth. Most (82.2%) preferred in-person for future LARC visits; none preferred telehealth. Four themes emerged in interviews (n = 15): LARC self-efficacy and autonomy; SBHC convenience and accessibility; comfort with SBHC providers; and preference for in-person visits despite telehealth benefits.

DISCUSSION

Although telehealth theoretically adds value to LARC service delivery, uptake and preference for telehealth in the SBHC context were low. Despite the perceived acceptability of telehealth, adolescents and young adults prefer in-person SBHC visits, suggesting SBHC access may eliminate barriers to care that telehealth seeks to overcome.

FORWARD: Building a Model to Hold Schools of Public Health Accountable for Antiracism Work

Schools of public health have increasingly adopted programs, praxis, and competencies for antiracist work. Fighting Oppression, Racism and White Supremacy through Action, Research and Discourse (FORWARD) was founded to accelerate antiracist work at the Columbia University Mailman School of Public Health in New York City. Seven action corps reporting to an accountability cabinet were established with 183 participants. FORWARD achieved progress across five core pillars. We describe how an iterative, dynamic structure and explicit framework for accountability can guide future antiracism work. (Am J Public Health. 2023;113(10):1086-1088. https://doi.org/10.2105/AJPH.2023.307356).

Sleeping Healthy, Living Healthy: Using Iterative, Participatory Processes to Develop and Adapt an Integrated Sleep Hygiene/Mind-Body Integrative Health Intervention for Urban Adolescents

Racial and ethnic minority adolescents living in urban settings experience sleep disparities. Few interventions have been developed to address these disparities. Guided by principles of participatory design and inclusion, our team developed a novel intervention that combined sleep hygiene education with mind-body integrative health (MBIH) practices to improve sleep quality among adolescents in New York City. The goal of this article is to describe our iterative development and design process, the final product, and future directions. Our participatory approach incorporated information from formative work with adolescents having lived experience, practitioners, and syntheses of published literature. The final intervention-Sleeping Healthy, Living Healthy-consists of six, 40-minute group sessions and one 20-minute individual session designed for high school students. Each session has a set of learning objectives, combining instruction, group activities, and discussions on sleep hygiene and MBIH topics. Our manualized intervention includes handouts created by a graphic design team that served as a review and reminder for home practice. We describe intervention implementation to two unique cohorts and detail our methods used to fine-tune the intervention between cohorts. Our partnership with and insights from both adolescents and practitioners serve as a guide for researchers aiming to use participatory methods to develop interventions to decrease health disparities in specific populations.

Effects of a Mentoring Program for Black, Indigenous, and People of Color and First-Generation Public Health Students

OBJECTIVES

Among graduate public health students, Black, Indigenous, and other people of color (BIPOC; including Latinx, Asian, Middle Eastern and North African, Native Hawaiian and Pacific Islander, and multiracial) experience educational and personal challenges that require institutional support and reform. The objective of this study was to evaluate the effects of an antiracist mentorship program on the sense of belonging and overall experience among BIPOC and first-generation students at Columbia University Mailman School of Public Health in New York City.

METHODS

We used 2 data sources to retrospectively evaluate experiences of BIPOC and first-generation graduate students: the 2021 Mentoring of Students and Igniting Community (MOSAIC) Student Survey (n = 39), which collected data on experiences of students who participated in the MOSAIC program, and the 2016-2020 Graduate Exit Surveys (n = 1222), which collected data on graduating students' experiences, satisfaction, and perspectives on diversity, equity, and inclusion. A difference-in-difference analysis compared overall experience, public health career preparedness, quality of life, and department satisfaction among all students before (2016-2018) and after (2019-2020) implementation of the MOSAIC program.

RESULTS

Satisfaction among graduate students attributable to the MOSAIC program introduced in 2019 increased by about 25%. Compared with students who had not been exposed to MOSAIC, students exposed to MOSAIC had a 25% positive difference (P = .003) in overall graduate school experience, a 28% difference (P < .001) in quality of life, and a 10% difference (P = .001) in satisfaction with their departments.

CONCLUSION

Mentorship for BIPOC and first-generation public health graduate students offers an effective strategy to improve student experiences and satisfaction with graduate departments and, ultimately, may help students meet educational and professional goals.

Increasing student engagement with course content in graduate public health education: A pilot randomized trial of behavioral nudges

Digital advances in the learning space have changed the contours of student engagement as well as how it is measured. Learning management systems and other learning technologies now provide information about student behaviors with course materials in the form of learning analytics. In the context of a large, integrated and interdisciplinary Core curriculum course in a graduate school of public health, this study undertook a pilot randomized controlled trial testing the effect of providing a "behavioral nudge" in the form of digital images containing specific information derived from learning analytics about past student behaviors and performance. The study found that student engagement varied significantly from week to week, but nudges linking coursework completion to assessment grade performance did not significantly change student engagement. While the a priori hypotheses of this pilot trial were not upheld, this study yielded significant findings that can guide future efforts to increase student engagement. Future work should include a robust qualitative assessment of student motivations, testing of nudges that tap into these motivations and a richer examination of student learning behaviors over time using stochastic analyses of data from the learning management system.

Mind-Body Integrative Health (MBIH) Interventions for Sleep among Adolescents: A Scoping Review of Implementation, Participation and Outcomes

Adolescents get insufficient sleep, adversely affecting health. Mind-body integrative health interventions for adolescents have been shown to reduce stress, a barrier to good sleep. This scoping review aimed to synthesize mind-body integrative health interventions for adolescents, how interventions were implemented, who was reached. A systematic search of four online databases was conducted. Randomized, quasi-experimental, and single-group designs with participants ages 10-24 years were included. Twelve studies covering 10 interventions using mindfulness, qigong, aromatherapy, or yoga were identified. Participants were predominantly female; only one study reported participants' race or ethnicity (81% non-Hispanic white). Most (n=6) interventions were delivered in groups, and half reported significant improvements in subjective sleep quality. Mindfulness-based stress reduction and mindfulness-based cognitive therapy were the most commonly used modalities, with reported impact on sleep outcomes measured objectively. The two interventions that found statistically significant, moderate improvements in objectively-measured sleep onset latency and sleep efficiency were of higher intensity and used mindfulness. Four interventions were self-directed; participants in these struggled with adherence; significant impacts on sleep were not found. While findings were mixed, stemming in part from the quality of the underlying studies, this review identified several promising features of interventions, including using mindfulness, ensuring sufficient intervention dose, and targeting interventions towards adolescents with poor sleep at baseline (rather than a general population of adolescents). The findings suggests that sleep interventions for adolescents may improve psychological well-being as an intermediate effect, as sleep improvements were observed mostly among participants with poor sleep quality or anxiety symptoms at baseline. This review identified several gaps in the literature. Despite documented racial and ethnic disparities in sleep quality among adolescents, published evidence of mind-body integrative health-based sleep interventions among Black and Latinx adolescents is lacking. None of the studies in this review assessed developmental stage or age differences, despite documented differences in sleep across age groups of adolescents. These two gaps in the evidence should be addressed in future intervention research.

Comprehensive sexuality education for fraternity-affiliated undergraduates: a pilot program to improve sexual and reproductive health knowledge, attitudes, and communication

Objective: Comprehensive sexuality education (CSE) allows for informed and healthy decisions. College students often lack understanding of sexual and reproductive health (SRH). Conversations and Pizza (CAP), an interactive curriculum, was designed to address gaps in CSE and improve SRH outcomes. Participants: 66 fraternity affiliated undergraduate students. Methods: A six-session intervention discussed gender norms, biology, consent, harassment, and bystander intervention. Pre- and post-quantitative surveys assessed attitudes and behaviors; plus-delta format was used for qualitative feedback. Results: Qualitative data reflected engagement. Post-intervention, multiple measures improved (McNemar p < 0.05): perceived self-efficacy in consent and peer norms (4/8 measures), bystander intervention (5/6), and awareness of harassment (2/5). Participants reported more conversations with partners (pregnancy and STI prevention, 50% to 75%); human papillomavirus (HPV) vaccination receipt increased (60% to 93%, McNemar p < 0.001). Conclusion: Reproductive health outcomes improved in this pilot, laying the groundwork for continued testing. CAP is a successful pilot program that can be evaluated for a variety of groups and formats.

Needs Assessment of Integrative Health Services at School-Based Health Centers

OBJECTIVE

The purpose of this needs assessment was to hear about adolescents' experience with and interest in accessing integrative health services (IHS) at their school-based health centers (SBHCs) so that future education and service offerings could be better informed.

SUBJECTS

We surveyed 373 9th to 12th graders, of mostly low-income and minority status, who were enrolled as patients at 6 SBHCs in New York City, New York. Verbal consent was obtained prior to their completing a survey on provided mobile devices.

DESIGN

The 35-item anonymous survey asked about adolescents' health goals, familiarity and experience with 14 different integrative health modalities and interest in learning about and accessing these modalities.

RESULTS

Among all patients, the most common health goal was improving sleep (65%). Before completing the needs assessment survey, almost all patients (98%) had heard of at least 1 integrative health modality and 69% had ever used any modality. On average, patients were interested in learning more about 7.6 of the modalities and were significantly more interested in learning about each modality from trained professionals than from trained peers or by themselves.

CONCLUSIONS

Improving sleep was a central health goal for SBHC patients. The majority expressed interest in receiving information on massage, meditation and yoga from trained health professionals, and they wanted access to these modalities at their SBHCs. SBHCs are in a unique position of power in which they can bring desired, cost-effective integrative health modalities to marginalized students. Future efforts should expand provider training to support education on and delivery of these modalities and evaluation of their effectiveness at SBHCs.

Providing Contraceptive Health Services to Adolescents and Young Adults by Telemedicine: A Scoping Review of Patient and Provider Perspectives

OBJECTIVE

The objective of this scoping review is to synthesize and identify gaps in existing research on accessibility of telemedicine-delivered contraceptive health services to female adolescents and young adults (AYAs) and acceptability of these services to AYA patients and their medical providers.

METHODS

We searched the PubMed, Scopus, Embase, and CINAHL databases to extract relevant studies on telemedicine and provision of contraceptive services among non-institutionalized, non-chronically ill female AYAs, ages 10 through 24 years.

RESULTS

We screened 154 articles, and 6 articles representing 5 studies met the full inclusion criteria. Three studies assessed telemedicine acceptability and accessibility from the perspective of providers, and 3 described patients' perceived accessibility and acceptability of a theoretical telemedicine visit. No studies directly assessed AYA patients' satisfaction with actual telemedicine visits for contraceptive services. Providers viewed telemedicine-delivered sexual and reproductive health (SRH) services as acceptable to themselves and AYA patients. Most AYAs reported that they would use telemedicine for SRH services, although they would prefer in-person care. All articles identified concerns about privacy and confidentiality as a barrier to SRH telemedicine care.

CONCLUSIONS

Telemedicine-delivered contraceptive health services for AYAs were perceived as acceptable and accessible by providers and by most AYA patients, although patients reported a preference for in-person care. However, none of these findings are based on patients' actual experiences with SRH telemedicine. Further research is needed to directly assess the accessibility and acceptability of telemedicine-delivered contraceptive health services for female AYA patients.

Publicly-Funded Services Providing Sexual, Reproductive, and Maternal Healthcare to Immigrant Women in the United States: A Systematic Review

Sexual, reproductive, and maternal health (SRMH) care in the US is highly politicized, with restrictions that impede immigrant women's health. This review describes SRMH outcomes among immigrant women accessing publicly-funded services. We examined articles published from December 2007 to August 2020 in PubMed, PsycINFO, and Web of Science databases, following PRISMA guidelines. Included articles (n = 9) consisted of predominantly Latina immigrant samples. The majority included a subsample of women classified as vulnerable due to low income, low educational attainment, and/or documentation status. Our search strategy included a range of SRMH outcomes; however, the majority of articles focused on prenatal care (PNC). Over half of the articles revealed that underserved immigrant women with access to Medicaid/CHIP during expansion had higher rates of PNC adequacy compared to those without access. There is a need for more research on the impact of publicly-funded services other than Medicaid on outcomes beyond PNC.

Electrodermal Activity of Auricular Acupoints in Pediatric Patients With Functional Abdominal Pain Disorders

OBJECTIVES

Functional abdominal pain disorders (FAPD) affect approximately 13.5% of children. Pharmacotherapy is often ineffective, leaving providers, and families seeking adjunctive therapies. Auriculotherapy provides treatment for pain and other symptoms, without a defined protocol for FAPD. A handheld point-finder device measuring transdermal electrical current determines active acupoints, with a higher current indicating a more active acupoint. Our objectives were to determine auricular acupoint (AA) activity in FAPD and to assess participants' attitudes towards auriculotherapy.

METHODS

This is a prospective double-blind study evaluating the electrodermal activity of AAs in pediatric-aged female participants with FAPD compared to healthy controls (HC). Participants completed surveys regarding demographics and interest in auriculotherapy. The electrodermal assessment evaluated 20 AAs per ear using a point-finder device. Each AA current measurement was analyzed by average relative rank and median, with a median current measurement ≥50 μA considered active.

RESULTS

We enrolled 46 female participants, 22 FAPD (mean age 15.8 years) and 24 HC (mean age 15.4 years). In FAPD, 12 of 40 AAs were active, of which only six were also active in HC. Comparison of median current and average ranking between participants demonstrated consistency. In the post-assessment survey, 86.4% of FAPD expressed interest in receiving auricular acupressure and 68.2% would travel to the clinic solely for treatment.

CONCLUSIONS

Based on electrodermal measurements, we propose a treatment protocol using auriculotherapy for FAPD symptom-management. We demonstrated there is considerable patient interest in auriculotherapy. Further studies are needed to confirm the findings in a larger sample size and validate the efficacy of this treatment protocol.

Evaluation of sexual orientation and gender identity documentation at school-based health centers in New York City

RATIONALE

National organizations have called for routine collection of data on sexual orientation and gender identity (SOGI) in clinical settings to track access to and quality of care provided to sexual and gender minority patients to improve health outcomes. However, there are limited data on this implementation for among adolescent populations.

METHODS

A secondary data analysis from seven school-based health centers (SBHCs) in New York City explored SOGI documentation for 8888 adolescent patients in 2015 to 2018. Using Electronic Health Records, SBHC medical providers' implementation rate of patient SOGI documentation was assessed. Trends in SOGI documentation were reviewed.

RESULTS

At 18-month post-EHR modification and training, SOGI documentation increased and was sustained at 47%. Those documented as female were significantly more likely to have SOGI documentation compared to those documented as male (36% vs 26% for SO; 36% vs 25% for GI).

CONCLUSIONS

This study identified incomplete data collection in SOGI documentation among adolescents receiving medical and mental health services in SBHCs.

Columbia University Master of Public Health Core Curriculum: Implementation, Student Experience, and Learning Outcomes, 2013-2018

OBJECTIVES

Public health education must respond to 21st-century public health challenges in an ever-evolving landscape. We describe implementation and educational outcomes of the Columbia University Master of Public Health (MPH) Core (hereinafter, Core) curriculum since its inception.

METHODS

This retrospective evaluation combined 6 years (2013-2018) of student survey data collected from students (N = 1902) on the structure and delivery of the Core curriculum to quantify implementation, student experience, and learning outcomes, both during study (Core Evaluation Survey [CES]) and after graduation (Graduate Exit Survey [GES]). We used χ² tests and analysis of variance to compare outcomes across years, and we used McNemar tests to compare differences in outcomes from the same students at different time points.

RESULTS

Of 1902 respondents to the CES, 1795 (94.4%) completed the Core curriculum. During the study period, 81.7% of students were able to integrate concepts across Core curriculum modules with ease; postgraduation, a similar proportion of respondents were able to apply Core curriculum content to departmental and certificate coursework and applied field experiences. On-time graduation rates were high (range, 85%-93%).

CONCLUSIONS

The high percentage of students who reported their ability to integrate concepts and who completed the Core during the study period likely reflected changes to teaching team structures, training, attention to inclusion and equity, and collaboration to implement active learning strategies. The Core curriculum meets its intended goals by providing critical learning abilities to support ongoing interdisciplinary work.

Young Men's Communication With Partners and Contraception Use: A Systematic Review

PURPOSE

The rate of adolescent unintended pregnancy in the U.S. is high compared with that in other developed countries. While past research and interventions have focused on young women, the role of young men in pregnancy prevention has increasingly been recognized. Studies have assessed young men's knowledge and attitudes toward pregnancy prevention as well as their role in male-controlled methods of birth control such as condoms or withdrawal. However, less is known about how young men contribute to decision-making about contraceptive methods other than condoms with female partners. The purpose of this systematic review was to explore how young men communicate with their female partners and the effect of such communication on contraception use to prevent pregnancy.

METHODS

We conducted a systematic review of six databases to identify English language articles published from January 1, 2002, through March 24, 2019. The review specifically explored how young men aged 11-24 years communicate with and affect their female partner (noncondom) contraceptive use. The systematic review explored additional questions, including those pertaining to the timing of partner communication in a relationship, communication strategies used by young men, and which dynamics of partner communication were measured in studies.

RESULTS

Of the 12 articles identified as exploring male partner communication, five of the articles used quantitative analysis to measure any association between partner communication and contraception use, three of which produced statistically significant findings suggesting that communication increases the use of contraception other than condoms. Seven qualitative studies provided supporting narratives from young men describing communication with partners and how they influence contraception use by female partners. The articles also explored timing and strategies of communication, as well as topics, prompts, and communication cues used by young men. Measurements of both communication and contraception varied across studies.

CONCLUSIONS

With the small number of studies identified in this systematic review, we conclude that future research needs to corroborate the relationship between partner communication and contraception use with more robust and precise measurements of both communication and contraception.

Building Community Capacity for Qualitative Research to Improve Pregnancy Intention Screening

BACKGROUND

Community-based participatory research (CBPR), with an emphasis on co-learning and collaboration, holds promise for exploring the pregnancy intention (PI) screening needs of Latina patients and their health care providers. We describe a CBPR partnership exploring PI screening processes at a federally qualified health center in New York City, and lessons learned related to community participation, training, and collaboration between partners.

METHODS

Stakeholders convened a community advisory board (CAB) to carry out CBPR. The CAB administered a biannual process evaluation to assess members' experiences with the project.

RESULTS

Despite challenges, the CAB prioritized community participation, training, and collaboration. At three time points, members reported gaining research skills (93%, 100%, 100%), and believing in the project's potential to improve PI screening (100%, 100%, 100%).

CONCLUSIONS

Building capacity for CBPR requires providing iterative training, navigating discrepancies between CAB members' interests and training needs, facilitating the meaningful participation of members with limited time and/or technical skills, and ensuring an equitable division of labor.

School-Based Health Centers and School Connectedness

BACKGROUND

Improvements in health behaviors and academic outcomes have been associated with school-based health centers (SBHCs). However, underlying mechanisms for these associations have been largely unexamined, particularly among lower-income youth. The current study examines the relationship between SBHCs and school connectedness and whether this relationship differs by youths' socioeconomic status (SES).

METHODS

Student-level cross-sectional data from 503 traditional high schools in California were analyzed using multilevel regression models. California Healthy Kids Survey 2013-2014 data included information on 3 dimensions of school connectedness and demographic characteristics including SES as measured by parental education. School-level demographic data was gathered from publicly available sources.

RESULTS

Although no significant relationship between SBHCs and any of the school connectedness dimensions emerged, there were significant cross-level interactions between SBHCs and parent education. SBHCs were more positively associated with school connectedness (adult caring, adult expectations, and meaningful participation) among lower SES students compared to students with higher SES.

CONCLUSIONS

SBHCs may be particularly effective in affecting school connectedness among lower income youth populations. This has wide ranging implications with regards to planning (eg, careful selection of where SBHCs can be most effective), and future research (eg, examining the effectiveness of specific SBHC strategies that support connectedness).

MyLARC: A Theory-Based Interactive Smartphone App to Support Adolescents' Use of Long-Acting Reversible Contraception

STUDY OBJECTIVE

Develop and test the feasibility of a Health Belief Model theory-based interactive smartphone application (app) aimed at providing information and support to adolescents with long-acting reversible contraception (LARC).

DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS

Using a mixed-method design, we conducted 30 in-person interviews with adolescent LARC users who were enrolled in school-based health centers in New York City. Interviews were conducted in 2 phases: during phase 1, 12 participants viewed a pilot version of the app (MyLARC); during phase 2, 18 additional participants interacted with an expanded version of the app. Phase 2 participants downloaded MyLARC onto their smartphone and app usage was tracked.

MAIN OUTCOME MEASURES

Participants' responses to the in-person interviews and data usage of MyLARC from phase 2 determined the feasibility and acceptability of using MyLARC to support young women's satisfaction and continuation of LARC methods.

RESULTS

Noneducational games were recommended as an approach to provide information to adolescents in an engaging way, as well as educational graphics and visually appealing content. Data tracking of MyLARC usage among phase 2 participants revealed a total of 67 unique logins to the app with 18 average page visits per unique login. The total amount of times MyLARC was opened was 1197. The most frequented features were 'Info about LARC' (95 unique visits) and 'Games' (80 unique plays).

CONCLUSION

A theory-based interactive smartphone app with LARC-specific information and support is an appropriate and appealing medium to provide information and support to adolescents using LARC. Games represented a novel opportunity to engage adolescents with health information.

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.

Advance provision of emergency contraception to young men: An exploratory study in a clinic setting

PURPOSE

To explore the acceptability of advance provision of emergency contraceptive pills (ECPs) to young men seeking health care.

METHODS

For this exploratory study in a clinic setting, we approached young men aged 16-35 to participate in a survey eliciting socio-demographics, sexual and contraceptive history, and knowledge about ECPs. We offered young men advance provision of ECPs and compared characteristics of 126 young men who did and did not accept the ECPs.

RESULTS

Most (76%) of the participants accepted advance provision and left with an ECP pack, with even higher proportions among males whose sexual histories were suggestive of increased risk of involvement in an unintended pregnancy.

CONCLUSIONS

This study holds promise to inform scale up of advance provision of ECPs among young men.

"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 OBJECTIVE

Youth-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.

DESIGN, SETTING, AND PARTICIPANTS

We conducted semistructured, in-depth interviews with 30 female adolescent LARC users enrolled in urban school-based health centers.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Descriptive 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.

RESULTS

Participants (mean age, 16 years; range, 14-19 years) 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% (n = 3) 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).

CONCLUSION

These 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).

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

PURPOSE

Despite 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 15-24 years, 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.

METHODS

This randomized controlled trial will recruit 945 sexually active young men between the ages of 15 and 24 years 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 men's sexual and reproductive health behaviors and fitness at baseline, 12, 24, 36, and 64 weeks using a mobile device app created for the study.

RESULTS

Pending ongoing study.

CONCLUSIONS

Results from the study are expected to enhance our understanding of the efficacy of CAMI to enhance young men's reproductive health and fitness behaviors.

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.

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 SETTING

Adolescents 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.

PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES

We 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 Ambresin's 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.

RESULTS

Interviewees 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.

CONCLUSION

This 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.

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.

Global Trends in Adolescent Fertility, 1990-2012, in Relation to National Wealth, Income Inequalities, and Educational Expenditures

PURPOSE

National wealth, income inequalities, and expenditures on education can profoundly influence the health of a nation's women, children, and adolescents. We explored the association of trends in national socioeconomic status (SES) indicators with trends in adolescent birth rates (ABRs), by nation and region.

METHODS

An ecologic research design was employed using national-level data from the World Bank on birth rates per 1,000 women aged 15-19 years, national wealth (per capita gross domestic product or GDP), income inequality (Gini index), and expenditures on education as a percentage of GDP (EduExp). Data were available for 142 countries and seven regions for 1990-2012. Multiple linear regression for repeated measures with generalized estimating equations was used to examine independent associations.

RESULTS

ABRs in 2012 varied >200-fold-with the highest rates in Sub-Saharan Africa and lowest rates in the Western Europe/Central Asia region. The median national ABR fell 40% from 72.4/1,000 in 1990 to 43.6/1,000 in 2012. The largest regional declines in ABR occurred in South Asia (70%), Europe/Central Asia (63%), and the Middle East/North Africa (53%)-regions with lower income inequality. In multivariable analyses considering change over time, ABRs were negatively associated with GDP and EduExp and positively associated with greater income inequality.

CONCLUSIONS

ABRs have declined globally since 1990. Declines closely followed rising socioeconomic status and were greater where income inequalities were lower in 1990. Reducing poverty and income inequalities and increasing investments in education should be essential components of national policies to prevent adolescent childbearing.

Comparing women with and without disabilities in five-site "Healthy Weight" interventions for lesbian/bisexual women over 40

BACKGROUND

Lesbian/bisexual women with physical disabilities (LBPD) are an under-studied population.

OBJECTIVES

This study compared LBPD to LB women without physical disabilities as defined by the Americans with Disabilities Act on socio-demographic variables, health characteristics, and quality of life, physical activity, weight, and nutrition outcomes following a health intervention.

METHODS

Data came from the Healthy Weight in Lesbian and Bisexual Women Study (HWLB) where 376 LB women were recruited into five geographically dispersed interventions. Baseline data were examined to compare women with and without physical disabilities as defined by the ADA, and pre/post intervention data were analyzed for differences in treatment outcomes including quality of life, physical activity, nutrition, and body size.

RESULTS

Compared to women without disability, LBPD were more likely to be bisexual or another sexual identity than lesbian, single, report poor or fair health status, postmenopausal, and had a higher body mass index and waist circumference to height ratio. LBPD women were less likely to work and to drink heavily, and reported reduced physical and mental health quality of life. In spite of these differences, after the intervention, LBPD had similar outcomes to women without disabilities on most measures, and were more likely to show improvements in physical quality of life and consumption of fruits/vegetables.

CONCLUSIONS

Although different from women without disabilities on many socio-demographic and health variables at baseline, the study suggests that LBPD have similar outcomes to women without disabilities, or may even do better, in group health interventions.

Adapting the Get Yourself Tested Campaign to Reach Black and Latino Sexual-Minority Youth

BACKGROUND

Culturally appropriate efforts are needed to increase sexually transmitted disease (STD) testing and care among Black and Latino sexual-minority youth, who are at high risk for STDs. Get Yourself Tested, a national testing campaign, has demonstrated success among youth, but it has yet to be assessed for relevance or impact among this population.

METHOD

This effort included (1) formative and materials-testing research through focus groups; (2) adaptation of existing Get Yourself Tested campaign materials to be more inclusive of Black and Latino sexual-minority youth; (3) a 3-month campaign in four venues of New York City, promoting STD testing at events and through mobile testing and online and social media platforms; (4) process evaluation of outreach activities; and (5) an outcome evaluation of testing at select campaign venues, using a preexperimental design.

RESULTS

During the 3-month campaign period, the number of STD tests conducted at select campaign venues increased from a comparable 3-month baseline period. Although testing uptake through mobile vans remained low in absolute numbers, the van drew a high-prevalence sample, with positivity rates of 26.9% for chlamydia and 11.5% for gonorrhea. This article documents the process and lessons learned from adapting and implementing a local campaign for Black and Latino sexual-minority youth.

Assessing the Impact of School-Based Health Centers on Academic Achievement and College Preparation Efforts: Using Propensity Score Matching to Assess School-Level Data in California

This study examines the association between school-based health center (SBHC) presence and school-wide measures of academic achievement and college preparation efforts. Publicly available educational and demographic data from 810 California public high schools were linked to a list of schools with an SBHC. Propensity score matching, a method to reduce bias inherent in nonrandomized control studies, was used to select comparison schools. Regression analyses, controlling for proportion of English-language learners, were conducted for each outcome including proportion of students participating in three College Board exams, graduation rates, and meeting university graduation requirements. Findings suggest that SBHC presence is positively associated with college preparation outcomes but not with academic achievement outcomes (graduation rates or meeting state graduation requirements). Future research must examine underlying mechanisms supporting this association, such as school connectedness. Additional research should explore the role that SBHC staff could have in supporting college preparation efforts.

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.

Improving contraceptive choice: fidelity of implementation and the gap between effectiveness and efficacy

Interventions to reduce unintended pregnancy through improved contraceptive use are a public health priority. A comprehensive process evaluation of a contraceptive assessment module intervention with demonstrated efficacy was undertaken. The 12-month process evaluation goal was to describe the extent to which the intervention was implemented as intended over time, and to identify programmatic adjustments to improve implementation fidelity. Quantitative and qualitative methods included staff surveys, electronic health record data, usage monitoring, and observations. Fidelity of implementation was low overall (<10% of eligible patients completed the entire module [dose received]). Although a midcourse correction making the module available in clinical areas led to increased dose delivered (23% vs. 30%, chi-square test p = .006), dose received did not increase significantly after this adjustment. Contextual factors including competing organizational and staff priorities and staff buy-in limited the level of implementation and precluded adoption of some strategies such as adjusting patient flow. Using a process evaluation framework enabled the research team to identify and address complexities inherent in effectiveness studies and facilitated the alignment of program and context.

Agreement between patient-reported and provider-reported choice of contraceptive method among family planning patients in New York City: implications for public health

National data on choice of contraceptive method and subsequent use are critical for monitoring progress toward meeting public health goals in reducing unintended pregnancy in the US. Yet few studies have focused on the reliability of clinically-reported or patient-reported measures of choice of contraceptive method for the range of available contraceptive methods. Among 1,844 women receiving reproductive health care at two federally funded centers in New York City, choice of contraceptive method at the end of the visit from two data sources was compared, ie, patient self-report, and provider-report as recorded in the clinical-administrative database. Agreement between the two data sources was assessed for the sample. Sociodemographic predictors of agreement were assessed using logistic regression. Agreement between the data sources was also assessed on a method-by-method basis using positive specific agreement. Participants were predominantly Latina (69%), foreign-born (76%), and low-income (99% with incomes <200% federal poverty level). Agreement of patient-reported and provider-reported contraceptive choice was highest for hormonal methods (positive specific agreement 94.0%) and intrauterine devices (89.9%), and lowest for condoms (53.5%). In the logistic regression model, agreement was lower among teens aged 16–19 years compared with women aged 25+ years (odds ratio 0.74; 95% confidence interval 0.55–0.99). Because teens are more likely to rely on condoms, the logistic regression model was repeated, adjusting for provider report of condom choice; after adjustment, no sociodemographic differences in agreement were observed. National data sources or studies relying on provider-reported method choice to derive estimates of contraceptive prevalence may overestimate choice of condoms. Our findings raise the question of whether condom choice can be accurately assessed by a single open-ended measure of choice of contraceptive method.

Tailored health messaging improves contraceptive continuation and adherence: results from a randomized controlled trial

BACKGROUND

Discontinuation and incorrect use of contraceptive methods may contribute to as many as 1 million unintended pregnancies annually in the United States. Interventions to improve contraceptive method continuation and adherence are needed.

STUDY DESIGN

A three-arm randomized controlled trial was conducted at two family planning sites testing the efficacy of a computer-based contraceptive assessment module in increasing the proportion of patients who continued use of their chosen contraceptive method 4 months after the family planning visit (n=224).

RESULTS

In analyses adjusting for clinical site of recruitment, family planning patients who used the module and received individually tailored health materials (n=78), compared to those in the control group (n=70), were significantly more likely to continue use of their chosen contraceptive method [95% compared to 77%; odds ratio (OR)=5.48; 95% confidence interval (CI): 1.72-17.42] and to adhere to their method (86% compared to 69%; OR=2.74; 95% CI: 1.21-6.21). No significant differences in these outcomes were found for participants who used the module but did not receive tailored materials (n=76), compared to the control group.

CONCLUSIONS

Tailored health materials significantly improved contraceptive method continuation and adherence. Additional research on the impact of the intervention on continuation and adherence in a larger sample and over a longer follow-up period is merited.

Functional health literacy in Spanish-speaking Latinas seeking breast cancer screening through the National Breast and Cervical Cancer Screening Program

Background:

This analysis examines the association between functional health literacy and follow-up after mammography among women receiving breast cancer screening at a National Breast and Cervical Cancer Early Detection Program site in New York City that provides universal bilingual case management.

Methods:

A total of 707 Latinas who spoke Spanish as their primary language completed a survey of health and demographic characteristics and the Test of Functional Health Literacy in Spanish (TOFHLA-S). Survey results were matched with clinical outcome data.

Results:

Among the survey participants, 98% were foreign-born and 99% had no health insurance. While the study found significant differences in access to health information and past screening behavior, women without adequate health literacy in Spanish were no less likely to receive clinical resolution of abnormal mammograms within 60 days (81.8% overall; n = 110) or to return for a repeat mammogram within 18 months (57.2% overall; n = 697). In fact, among those referred for a Pap test (n = 310), women without adequate health literacy were more likely to receive a Pap test within 60 days of their mammogram than those with adequate health literacy (82% compared to 71%, OR: 1.83, 95% CI: 1.04–3.22).

Discussion:

The lack of significantly lower follow-up outcomes among women with inadequate and marginal functional health literacy in this population of primary Spanish-speaking Latinas suggests that, once women have accessed screening services, programmatic approaches may exist to mitigate barriers to follow-up and to ensure optimal cancer screening outcomes for women of all literacy levels.

Association between symptoms of depression and contraceptive method choices among low-income women at urban reproductive health centers

Among adult women of reproductive age, research has focused on depression symptoms after unintended pregnancy, or associated with hormonal contraceptive method use, with little focus on depression as a predictor of unintended pregnancy. This study was conducted to identify mental and behavioral health characteristics associated with use of less effective contraceptive methods. Choosing a less effective method of contraception places sexually active women who are not seeking pregnancy at increased risk of unintended pregnancy. Analysis was conducted using administrative data from family planning visits of 2,476 predominantly Latina and black women who received standardized behavioral and mental health screening as part of clinical care at eight reproductive health centers in New York City serving low-income women. Sociodemographic characteristics, method choice, and behavioral and mental health characteristics were compared between patients who screened positive for depression (using the PHQ-9) and those who did not. The primary outcome measure, contraceptive method choice, was dichotomized into two groups: more effective method or less effective method. In a multivariate logistic regression model adjusting for all behavioral health characteristics (binge drinking, illicit drug use, smoking, anxiety, and childhood or adult physical or sexual abuse) and birthplace, women screening positive for depression had significantly lower odds of choosing a more effective method of contraception (adjusted OR = 0.56, 95% CI: 0.36-0.87). These findings suggest that screening positive for depression may have an effect on contraceptive choice. Contraceptive counseling strategies should be individually tailored to promote decision-making and appropriate contraceptive choice, particularly among women with depression.

Breast cancer screening and health behaviors among African American and Caribbean Women in New York City

A telephone-based survey regarding breast cancer screening practices among 300 African American and Caribbean women age 40 and over in New York City revealed that while U.S.-born women had significantly different sociodemographic profiles (in terms of insurance status, marital status, educational attainment), they were no more likely to have had a mammogram than the foreign-born women. Adjusting for insurance status and source of care, women with a provider recommendation were 8 times more likely ever to have had a mammogram (AOR 8.01, 95%CI: 3.74-17.14). Among foreign-born Caribbean women in the U.S. for less than half their lives, only 52% ever had a provider recommend a mammogram, compared with 77% of U.S.-born women. The findings confirm previous reports of the importance of physician recommendation in increasing mammography screening among urban Black women, and suggest that efforts to reach Caribbean-born women with breast cancer screening messages should emphasize the important role of providers.