PURPOSE: The COVID-19 pandemic disrupted pediatric health care in the United States, and this disruption layered on existing barriers to health care. We sought to characterize disparities in unmet pediatric health care needs during this period. METHODS: We analyzed data from Wave 1 (October through November 2020) and Wave 2 (March through May 2021) of the COVID Experiences Survey, a national longitudinal survey delivered online or via telephone to parents of children aged 5 through 12 years using a probability-based sample representative of the US household population. We examined 3 indicators of unmet pediatric health care needs as outcomes: forgone care and forgone well-child visits during fall 2020 through spring 2021, and no well-child visit in the past year as of spring 2021. Multivariate models examined relationships of child-, parent-, household-, and county-level characteristics with these indicators, adjusting for child's age, sex, and race/ethnicity. RESULTS: On the basis of parent report, 16.3% of children aged 5 through 12 years had forgone care, 10.9% had forgone well-child visits, and 30.1% had no well-child visit in the past year. Adjusted analyses identified disparities in indicators of pediatric health care access by characteristics at the level of the child (eg, race/ethnicity, existing health conditions, mode of school instruction), parent (eg, childcare challenges), household (eg, income), and county (eg, urban-rural classification, availability of primary care physicians). Both child and parent experiences of racism were also associated with specific indicators of unmet health care needs. CONCLUSIONS: Our findings highlight the need for continued research examining unmet health care needs and for continued efforts to optimize the clinical experience to be culturally inclusive.

OBJECTIVES: National guidelines call for annual testing for certain sexually transmitted infections (STIs) among specific adolescent populations, yet we have limited population-based data on STI testing prevalence among adolescents. With inclusion of a new item in the 2019 national Youth Risk Behavior Survey, we provide generalizable estimates of annual STI testing among sexually active high school students. METHODS: We report weighted prevalence estimates of STI testing (other than HIV) in the past 12 months among sexually active students (n = 2501) and bivariate associations between testing and demographic characteristics (sex, age, race and ethnicity, sexual identity, and sex of sexual contact). Multivariable models stratified by sex and adjusted for demographics examine the relationships between testing and sexual behaviors (age of initiation, number of sex partners, condom nonuse at last sexual intercourse, and substance use at last sexual intercourse). RESULTS: One-fifth (20.4%) of sexually active high school students reported testing for an STI in the previous year. A significantly higher proportion of female (26.1%) than male (13.7%) students reported testing. Among female students, prevalence differed by age (15 years = 12.6%, age 16 = 22.8%, age 17 = 28.5%, or 18 years = 36.9%). For male students, there were no differences by demographic characteristics, including sexual identity, but most sexual risk behaviors were associated with increased likelihood of STI testing (adjusted prevalence ratios ranging from 1.48 to 2.47). CONCLUSIONS: Low prevalence of STI testing suggests suboptimal adherence to national guidelines, particularly for sexually active adolescent females and young men who have sex with men who should be tested for Chlamydia and gonorrhea annually.

Adolescents health behaviors and experiences contribute to many outcomes, including risks for HIV, other sexually transmitted diseases, and unintended pregnancy. Public health interventions and approaches addressing risk behaviors or experiences in adolescence have the potential for wide-reaching impacts on sexual health and other related outcomes across the lifespan, and schools are a critical venue for such interventions. This paper describes a school-based program model developed by the Centers for Disease Control and Prevention's Division of Adolescent and School Health for preventing HIV/sexually transmitted diseases, unintended pregnancy, and related health risk behaviors and experiences among middle and high school students. This includes a summary of the theoretical and evidence base that inform the model, and a description of the model's activities, organized into three key strategies (sexual health education, sexual health services, and safe and supportive environments) and across three cross-cutting domains (strengthening staff capacity, increasing student access to programs and services, and engaging parent and community partners). The paper also outlines implications for adolescent health professionals and organizations working across schools, clinics, and communities, to address and promote adolescent sexual health and well-being. 2021

BACKGROUND: Because COVID-19 was declared a pandemic in March 2020, nearly 93% of U.S. students engaged in some distance learning. These school disruptions may negatively influence adolescent mental health. Protective factors, like feeling connected to family or school may demonstrate a buffering effect, potentially moderating negative mental health outcomes. The purpose of the study is to test our hypothesis that mode of school instruction influences mental health and determine if school and family connectedness attenuates these relationships. METHODS: The COVID Experiences Survey was administered online or via telephone from October to November 2020 in adolescents ages 1319 using National Opinion Research Centers AmeriSpeak Panel, a probability-based panel recruited using random addressbased sampling with mail and telephone nonresponse follow-up. The final sample included 567 adolescents in grades 712 who received virtual, in-person, or combined instruction. Unadjusted and adjusted associations among four mental health outcomes and instruction mode were measured, and associations with school and family connectedness were explored for protective effects. RESULTS: Students attending school virtually reported poorer mental health than students attending in-person. Adolescents receiving virtual instruction reported more mentally unhealthy days, more persistent symptoms of depression, and a greater likelihood of seriously considering attempting suicide than students in other modes of instruction. After demographic adjustments school and family connectedness each mitigated the association between virtual versus in-person instruction for all four mental health indicators. CONCLUSION: As hypothesized, mode of school instruction was associated with mental health outcomes, with adolescents receiving in-person instruction reporting the lowest prevalence of negative mental health indicators. School and family connectedness may play a critical role in buffering negative mental health outcomes.

INTRODUCTION: Given mixed findings regarding the relationship between long-acting reversible contraception and condom use, this systematic review and meta-analysis synthesizes studies comparing sexually transmitted infection‒related outcomes between users of long-acting reversible contraception (intrauterine devices, implants) and users of moderately effective contraceptive methods (oral contraceptives, injectables, patches, rings). METHODS: MEDLINE, Embase, PsycINFO, Global Health, CINAHL, Cochrane Library, and Scopus were searched for articles published between January 1990 and July 2018. Eligible studies included those that (1) were published in the English language, (2) were published in a peer-reviewed journal, (3) reported empirical, quantitative analyses, and (4) compared at least 1 outcome of interest (condom use, sexual behaviors other than condom use, sexually transmitted infection‒related service receipt, or sexually transmitted infections/HIV) between users of long-acting reversible contraception and users of moderately effective methods. In 2020, pooled ORs were calculated for condom use, chlamydia/gonorrhea infection, and trichomoniasis infection; findings for other outcomes were synthesized qualitatively. The protocol is registered on the International Prospective Register of Systematic Reviews (CRD42018109489). RESULTS: A total of 33 studies were included. Long-acting reversible contraception users had decreased odds of using condoms compared with oral contraceptive users (OR=0.43, 95% CI=0.30, 0.63) and injectable, patch, or ring users (OR=0.58, 95% CI=0.48, 0.71); this association remained when limited to adolescents and young adults only. Findings related to multiple sex partners were mixed, and only 2 studies examined sexually transmitted infection testing, reporting mainly null findings. Pooled estimates for chlamydia and/or gonorrhea were null, but long-acting reversible contraception users had increased odds of trichomoniasis infection compared with oral contraceptive users (OR=2.01, 95% CI=1.11, 3.62). DISCUSSION: Promoting condom use specifically for sexually transmitted infection prevention may be particularly important among long-acting reversible contraception users at risk for sexually transmitted infections, including adolescents and young adults.

In March 2020, efforts to slow transmission of SARS-CoV-2, the virus that causes COVID-19, resulted in widespread closures of school buildings, shifts to virtual educational models, modifications to school-based services, and disruptions in the educational experiences of school-aged children. Changes in modes of instruction have presented psychosocial stressors to children and parents that can increase risks to mental health and well-being and might exacerbate educational and health disparities (1,2). CDC examined differences in child and parent experiences and indicators of well-being according to children's mode of school instruction (i.e., in-person only [in-person], virtual-only [virtual], or combined virtual and in-person [combined]) using data from the COVID Experiences nationwide survey. During October 8-November 13, 2020, parents or legal guardians (parents) of children aged 5-12 years were surveyed using the NORC at the University of Chicago AmeriSpeak panel,* a probability-based panel designed to be representative of the U.S. household population. Among 1,290 respondents with a child enrolled in public or private school, 45.7% reported that their child received virtual instruction, 30.9% in-person instruction, and 23.4% combined instruction. For 11 of 17 stress and well-being indicators concerning child mental health and physical activity and parental emotional distress, findings were worse for parents of children receiving virtual or combined instruction than were those for parents of children receiving in-person instruction. Children not receiving in-person instruction and their parents might experience increased risk for negative mental, emotional, or physical health outcomes and might need additional support to mitigate pandemic effects. Community-wide actions to reduce COVID-19 incidence and support mitigation strategies in schools are critically important to support students' return to in-person learning.

PURPOSE: The purpose of this study was to describe whether adolescent and young adult patients truthfully disclose sexual activity to providers during a sexual history and explore associations between disclosure and receipt of recommended services. METHODS: Data from the 2018 National Survey of Sexual Health and Behavior were used to describe self-reported disclsoure of sexually active 14- to 24-year-olds who had a health care visit in the previous year where a sexual history was taken (n = 196). We examined bivariate associations between disclosure and age, race/ethnicity, sex, sexual identity, and receipt of sexual health services. RESULTS: Most (88%) respondents reported telling their provider the truth about sexual activity. A higher proportion of the younger adolescents (14- to 17-year-olds) did not disclose compared with the 18- to 24-year-old respondents (25.4% vs 3.9%; p < .001). A higher proportion of patients who disclosed reported having a sexually transmitted disease test (69.6% vs 26.7%; p < .001); being offered a sexually transmitted disease test (44.3% vs 4.5%; p < .001); and being asked by providers about number of partners (54.3% vs 15.4%; p < .01). CONCLUSIONS: Most young patients disclose their sexual history to their provider, but younger patients might be less likely to do so. Positive patient-provider relationships may encourage disclosure of sexual activity and support receipt of indicated sexual and reproductive health services.

Confidentiality protections are a key component of high-quality adolescent sexual and reproductive health (SRH) care. Research has shown that adolescents value confidentiality and are more likely to seek care and provide honest information when confidentiality protections are implemented. However, many adolescents do not receive confidential SRH care. We synthesize studies of adolescents, parents, and providers to identify confidentiality-related factors that may explain why adolescents do not seek care or receive confidential services when they do access care. We present themes relevant to each population that address individual-level knowledge, attitudes, and behaviors, as well as clinic-level characteristics such as protocols, billing mechanisms, and clinic type. These findings have the potential to inform intervention efforts to improve the delivery of confidential SRH care for young people.

PURPOSE: Many young people are not aware of their rights to confidential sexual and reproductive health (SRH) care. Given that online health information seeking is common among adolescents, we examined how health education Web content about SRH for young people addresses confidentiality. METHODS: In Spring 2017, we conducted Google keyword searches (e.g., "teens" and "sex education") to identify health promotion Web sites operated by public health/medical organizations in the United States and providing original content about SRH for adolescents/young adults. Thirty-two Web sites met inclusion criteria. We uploaded Web site PDFs to qualitative analysis software to identify confidentiality-related content and conduct thematic analysis of the 29 Web sites with confidentiality content. RESULTS: Sexually transmitted infection testing and contraception were the SRH services most commonly described as confidential. Clear and comprehensive definitions of confidentiality were lacking; Web sites typically described confidentiality in relation to legal rights to receive care without parental consent or notification. Few mentioned the importance of time alone with a medical provider. Only half of the Web sites described potential inadvertent breaches of confidentiality associated with billing and even fewer described other restrictions to confidentiality practices (e.g., mandatory reporting laws). Although many Web sites recommended that adolescents verify confidentiality, guidance for doing so was not routinely provided. Information about confidentiality often encouraged adolescents to communicate with parents. CONCLUSIONS: There is a need to provide comprehensive information, assurances, and resources about confidentiality practices while also addressing limitations to confidentiality in a way that does not create an undue burden on adolescents or reinforce and exacerbate confidentiality concerns.

BACKGROUND: In an attempt to increase high school students' STD testing ratesrates, the Centers for Disease Control and Prevention's Division of Adolescent and School Health partnered with ICF and Chicago Public Schools (CPS) to adapt and implement the "GYT: Get Yourself Tested" health marketing campaign for a high school. METHODS: Clinic record data and student retrospective self-report surveys (n=193) tested for differences between the GYT intervention school and a comparison school on a number of outcomes including HIV and STD testing. RESULTS: Clinic record data showed that testing increased significantly more for the intervention than the comparison school during the GYT implementation period (B = 2.9, SE = 1.1, p < 0.05). Furthermore, the odds of being tested at the referral clinic were more than four times (OR=4.4) as high for students in the campaign school than for those in the comparison school (95% CI = 2.3 - 8.2). Survey data did not show increased self-reported testing but, more students in the GYT school (92.7%) were aware of where to receive free, low-cost, or affordable HIV and STD testing than students in the comparison school (76.0%) (p<.01). Among sexually experienced students (n=142), significantly more from the campaign school reported that they intended to test for STDs in the next 3 months (48.4% strongly agree and 33.2% agree) compared to those at the comparison school (27.4% strongly agree and 32.9% agree) (p<.05). CONCLUSIONS: Our pilot suggests that a student-led GYT campaign in high schools may successfully increase STD testing of students. Although some of the findings from this pilot evaluation are promising, they are limited and broader implementation and evaluation is needed. Future evaluation efforts can include more rigorous study designs, multiple schools or districts, longer campaign and evaluation across an entire school or calendar year, or in combination with other school-based testing strategies like a mass school-based screening event.

OBJECTIVE: This review synthesizes findings from the peer-reviewed evaluation literature on condom availability programs (CAPs) in secondary schools. DATA SOURCE: Peer-reviewed evaluation literature indexed in MEDLINE, EMBASE, PsychINFO, ERIC, CINAHL, Sociological Abstracts, SCOPUS, and POPLINE. STUDY INCLUSION AND EXCLUSION CRITERIA: Manuscripts had to be, written in English, and report evaluation data from a US school-based CAP. DATA EXTRACTION: Articles were coded independently by 2 authors. Discrepancies were resolved through open discussion. DATA SYNTHESIS: We grouped findings into outcome evaluation and process evaluation findings. Outcome evaluation findings included sexually transmitted infections (STIs), pregnancy rates, condom use, contraception use, sexual risk, and substance use. Process evaluation findings included awareness of CAPs, attitudes toward CAPs, attitudes toward condoms, and receipt of education and instruction. RESULTS: Of the 138 citations reviewed, 12 articles published between 1995 and 2012 met the inclusion criteria, representing 8 programs. Evaluations indicate CAPs yield condom acquisition rates between 23% and 48%, have mixed results related to condom use, and are not associated with increases in sexual and other risk behaviors. One program found CAPs were associated with a decrease in a combined rate of chlamydia and gonorrhea. One program found no association between CAPs and unintended pregnancy. Students' attitudes toward CAPs were favorable and awareness was high. CONCLUSIONS: Condom availability programs are accepted by students and can be an appropriate and relevant school-based intervention for teens. Condom availability programs can increase condom use, but more evaluations are needed on CAP impact on rates of HIV, STIs, and unintended pregnancy.

Adolescents and young adults are disproportionately affected by sexually transmitted diseases (STDs). This study examined the association of GYT: Get Yourself Tested (GYT), a sexual health social marketing campaign, with several sexual health behaviors on a nationally representative sample of high school (HS) and college students ( n = 2,329) recruited through an online panel survey. Behaviors examined were STD testing, HIV testing, and whether students had communication with health care providers and their romantic partners about STDs and STD testing. Rao-Scott chi-square tests and multivariable logistic regression models were conducted. The results indicated college students were more aware of GYT than HS students. Awareness of GYT was significantly associated with STD testing ( p < .05), HIV testing ( p < .01), and talking with romantic partners ( p < .01) for college students but only with STD testing ( p < .05) and talking to a provider ( p < .05) for HS students. The differences between HS and college students provide insight for those developing and implementing interventions across such a broad age range of youth.

PURPOSE: Long-acting reversible contraceptive (LARC) methods do not require annual clinic visits for continuation, potentially impacting receipt of recommended sexually transmitted infection (STI)/human immunodeficiency virus (HIV) services for young women. We assess service receipt among new and continuing LARC users versus moderately and less effective method users and non-contraceptors. METHODS: Using 2011-2015 National Survey of Family Growth data from sexually active women aged 15-24 years (n = 2,018), we conducted logistic comparisons of chlamydia, any STI and HIV testing, and sexual risk assessment in the past year by current contraceptive type. RESULTS: Less than half of respondents were tested for chlamydia (40.9%), any STI (47.3%), or HIV (25.9%); 66.5% had their sexual risk assessed. Differences in service receipt between new and continuing LARC users as compared with moderately effective method users were not detected in multivariable models, except that continuing LARC users were less likely to be tested for HIV (adjusted prevalence ratio [aPR] = .52, 95% confidence interval [CI] = .32-.85). New, but not continuing, LARC users were more likely than less effective method users (aPR = 1.35, 95% CI = 1.03-1.76) and non-contraceptors (aPR = 1.43, 95% CI = 1.11-1.85) to have their sexual risk assessed, although both groups were more likely than non-contraceptors to be tested for chlamydia (new: aPR = 1.52, 95% CI = 1.08-2.15; continuing: aPR = 1.69, 95% CI = 1.24-2.29). CONCLUSIONS: We found little evidence that LARC use was associated with lower prevalence of STI testing. However, new, but not continuing, LARC users, as compared with those not using a method requiring a clinic visit, were more likely to have had their risk assessed, suggesting that initiating LARC may offer an opportunity to receive services that does not persist.

Preventing unintended pregnancy and sexually transmitted infections (STIs), including HIV, are public health priorities in the U.S.1 Recognizing that both outcomes are related to sexual behavior, experts have called for integration of these prevention efforts.2,3 Yet, integrating unintended pregnancy and STI/HIV prevention is challenging, partly because the most effective contraceptive options for preventing pregnancy provide no protection against STIs/HIV. Although condoms can be 98% effective at preventing pregnancy when used correctly and consistently,4 recent estimates indicate with typical use they are associated with a 13% pregnancy rate during the first year.5 Use of a condom for STI/HIV prevention along with a more effective method for pregnancy prevention (e.g., intrauterine devices [IUDs], implants, oral contraceptives) is thus typically recommended for heterosexual couples who are not in a mutually monogamous relationship.6 However, this behavior is uncommon.7 Moreover, recent evidence suggests that users of long-acting reversible contraception (LARC), namely implants and IUDs, are less likely to use condoms compared with users of oral contraceptives.7,8 Although the impact of LARC use on STI rates remains unclear, these findings have renewed attention on STI prevention within the context of pregnancy prevention,9 particularly because LARC use is increasing.10

We describe school-based screening events in four Detroit, Michigan public high schools. To examine trends, we analyzed Chlamydia trachomatis data from 2010 to 2015. Prevalence of C. trachomatis decreased significantly (P < .01): from 10.24% to 6.27%. Future school-based screening events may bring about similar results if the program is instituted in a high-prevalence area and can achieve high student participation. (Am J Public Health. Published online ahead of print December 21, 2017: e1-e3. doi:10.2105/AJPH.2017.304163).

Sexual minority youth (SMY) experience elevated rates of adverse sexual health outcomes. Although risk factors driving these outcomes are well studied, less attention has been paid to protective factors that potentially promote health and/or reduce negative effects of risk. Many factors within interpersonal relationships have been identified as protective for the sexual health of adolescents generally. We sought to systematically map the current evidence base of relationship-level protective factors specifically for the sexual health of SMY through a systematic mapping of peer-reviewed observational research. Articles examining at least one association between a relationship-level protective factor and a sexual health outcome in a sample or subsample of SMY were eligible for inclusion. A total of 36 articles reporting findings from 27 data sources met inclusion criteria. Included articles examined characteristics of relationships with peers, parents, romantic/sexual partners, and medical providers. Peer norms about safer sex and behaviorally specific communication with regular romantic/sexual partners were repeatedly protective in cross-sectional analyses, suggesting that these factors may be promising intervention targets. Generally, we found some limits to this literature: few types of relationship-level factors were tested, most articles focused on young sexual minority men, and the bulk of the data was cross-sectional. Future work should expand the types of relationship-level factors investigated, strengthen the measurement of relationship-level factors, include young sexual minority women in samples, and use longitudinal designs. Doing so will move the field toward development of empirically sound interventions for SMY that promote protective factors and improve sexual health.

RATIONALE: Studies of inequities in diffusion of medical innovations rarely consider the role of patient-centered care. OBJECTIVE: We used uptake of the human papillomavirus (HPV) vaccine shortly after its licensing to explore the role of patient-centered care. METHODS: Using a longitudinal multi-site survey of US parents and adolescents, we assessed whether patient-centered care ratings might shape racial/ethnic and socioeconomic gaps at two decision points in the HPV vaccination process: (1) Whether a medical provider recommends the vaccine and (2) whether a parent decides to vaccinate. RESULTS: We did not find evidence that the association of patient-centeredness with vaccination varies by parent education. In contrast, parent ratings of providers' patient-centeredness were significantly associated with racial/ethnic disparities in parents' reports of receiving a HPV vaccine recommendation from a provider: Among parents who rate patient-centered care as low, white parents' odds of receiving such a recommendation are 2.6 times higher than black parents' odds, but the racial/ethnic gap nearly disappears when parents report high patient-centeredness. Moderated mediation analyses suggest that patient-centeredness is a major contributor underlying vaccination uptake disparities: Among parents who report low patient-centeredness, white parents' odds of vaccinating their child are 8.1 times higher than black parents' odds, while both groups are equally likely to vaccinate when patient-centeredness is high. CONCLUSION: The results indicate that patient-centered care, which has been a relatively understudied factor in the unequal diffusion of medical innovations, deserves more attention. Efforts to raise HPV vaccination rates should explore why certain patient groups may be less likely to receive recommendations and should support providers to consistently inform all patient groups about vaccination.

OBJECTIVE: National guidelines advise providers to counsel patients about contraception and condom use during sexual and reproductive health care visits. This study assesses provider communication with adolescent and young women about birth control, emergency contraception, and condoms during such visits. STUDY DESIGN: Using data from sexually active 15-24year old women participating in the 2011-2015 National Survey of Family Growth, we examined prevalence of provider communication about birth control, emergency contraception and condoms when receiving other sexual and reproductive health services in the past year. We used chi-square statistics and logistic models to assess differences by demographics, sexual behavior, and source of care. RESULTS: Approximately two-thirds of women received provider communication about condoms during a visit for STD testing (65.0%) and birth control during a visit for pregnancy testing (64.0%) or a visit for a pelvic exam or Pap test (66.8%). Communication about condoms was lower among private providers (58.8%) vs. Title X (80.0%) or non-Title X (72.7%) public clinics (p=.<.001). Communication about birth control during pregnancy test visits was higher among Title X funded clinic (81.8%) vs. private providers (63.6%) and non-Title X public clinics (54.8%) (p=<.001). Differences by age, race/ethnicity, mother's education, number of partners, and condom use were also found. CONCLUSION: Although a majority of sexually active young women attending sexual and reproductive health visits received provider communication about condoms and birth control, communication about these topics is not universal and varies by source of care as well as demographic and sexual behavior factors. IMPLICATIONS: Considering the fundamental role of communication in provider counseling, instances when providers are not communicating at sexual and reproductive health visits may indicate missed opportunities for prevention.

This study examined predictors of having received HIV and sexually transmitted disease (STD) testing and having been referred by school staff for HIV/STD testing. In 2014, students in seven high schools completed paper-and-pencil questionnaires assessing demographic characteristics, sexual behavior, referrals for HIV/STD testing, and HIV/STD testing. The analytic sample (n = 11,303) was 50.7% female, 40.7% Hispanic/Latino, 34.7% Black/African American (non-Hispanic), and mean age was 15.86 (SD = 1.22). After controlling for demographic characteristics, significant predictors of reporting having been tested for HIV or STDs were reporting having received a referral for HIV/STD testing (odds ratio [OR] = 3.18; 95% CI = [2.14, 4.70]) and reporting staff following-up on the referral (OR = 3.29; 95% CI = [1.31, 8.23]). Students reporting referrals had significantly higher odds of being male (OR = 2.49; 95% CI = [1.70, 3.65]), "other" or multiracial (non-Hispanic; compared to White, non-Hispanic; OR = 2.72; 95% CI = [1.35, 5.46]), sexual minority (OR = 3.80; 95% CI = [2.57, 5.62]), and sexually experienced (OR = 2.58; 95% CI = [1.76, 3.795]). School staff referrals with follow-up may increase HIV/STD testing among students.

Access to school health clinics and nurses has been linked with improved student achievement and health. Unfortunately, no studies have examined how many students report using school clinics or nurses and for which services. This study addressed this gap with data from a nationally representative sample of 15- to 25-year-olds. Respondents who reported being in high school were provided a list of services and asked whether they had gone to a school nurse or clinic for any of the listed services. Nearly 90% reported having access to a school clinic or nurse. Among students with access, 65.6% reported using at least one service. Non-White students and younger students were more likely to report having access to a clinic or nurse. These results show many students have access to clinics or nurses and are using these services, although not uniformly for all services.

IMPORTANCE: Long-acting reversible contraception (LARC), specifically intrauterine devices and implants, offers an unprecedented opportunity to reduce unintended pregnancies among adolescents because it is highly effective even with typical use. However, adolescent LARC users may be less likely to use condoms for preventing sexually transmitted infections compared with users of moderately effective contraceptive methods (ie, oral, Depo-Provera injection, patch, and ring contraceptives). OBJECTIVE: To compare condom use between sexually active female LARC users and users of moderately effective contraceptive methods. Design, Setting, and Participants: Cross-sectional analysis using data from the 2013 national Youth Risk Behavior Survey, a nationally representative sample of US high school students in grades 9 through 12. Descriptive analyses were conducted among sexually active female students (n = 2288); logistic regression analyses were restricted to sexually active female users of LARC and moderately effective contraception (n = 619). The analyses were conducted in July and August 2015. MAIN OUTCOMES AND MEASURES: Contraceptive method at last sexual intercourse was assessed by 1 item-respondents could select birth control pills; condoms; an intrauterine device or implant; injection, patch, or ring; withdrawal or other method; or not sure. A separate item asked whether respondents used a condom at last sexual intercourse. We created an indicator variable to distinguish those reporting use of (1) LARC (intrauterine device or implant), (2) oral contraceptives, and (3) Depo-Provera, patch, or ring. RESULTS: Among the 2288 sexually active female participants (56.7% white; 33.6% in 12th grade), 1.8% used LARC; 5.7% used Depo-Provera, patch, or ring; 22.4% used oral contraceptives; 40.8% used condoms; 11.8% used withdrawal or other method; 15.7% used no contraceptive method; and 1.9% were not sure. In adjusted analyses, LARC users were about 60% less likely to use condoms compared with oral contraceptive users (adjusted prevalence ratio [aPR], 0.42; 95% CI, 0.21-0.84). No significant differences in condom use were observed between LARC users and Depo-Provera injection, patch, or ring users (aPR, 0.57; 95% CI, 0.26-1.25). The LARC users were more than twice as likely to have 2 or more recent sexual partners compared with oral contraceptive users (aPR, 2.61; 95% CI, 1.75-3.90) and Depo-Provera, patch, or ring users (aPR, 2.58; 95% CI, 1.17-5.67). CONCLUSIONS AND RELEVANCE: Observed differences in condom use may reflect motivations to use condoms for backup pregnancy prevention. Users of highly effective LARC methods may no longer perceive a need for condoms even if they have multiple sexual partners, which places them at risk for sexually transmitted infections. As uptake of LARC increases among adolescents, a clear need exists to incorporate messages about condom use specifically for sexually transmitted infection prevention.

PURPOSE: Withdrawal is less effective for preventing pregnancy than other contraceptive methods and offers no protection against sexually transmitted infections including HIV. Little is known from a national perspective about adolescents who primarily use withdrawal. This study describes the prevalence of withdrawalas their primary method of pregnancy prevention at last sexual intercourse among sexually active US high school students and associations with sexual risk and substance use. METHODS: Data from the 2011 national Youth Risk Behavior Survey were used to estimate sexually active students' most recent contraceptive method. Logistic regressions examined sexual behaviors and substance use, comparing students who used withdrawal to those who used no method, a condom, and a highly effective method. RESULTS: Among 4,793 currently sexually active students, 10.2% used withdrawalonly, 12.4% used no method, 53.6% used a condom, and 23.8% used a more effective method as their primary form of pregnancy prevention during last sexual intercourse. Students who used withdrawal were less likely than those who used no method to have had sexual intercourse before age 13 years (APR=.56) and currently use cocaine (APR=.36). Among females, students who used withdrawal were more likely to engage in risky behaviors than those who used a condom and those who used a highly effective method of pregnancy prevention in a number of ways (e.g. having multiple sex partners during the past three months, current alcohol use, binge drinking, current marijuana use, drank alcohol or used drugs before last sexual intercourse). CONCLUSIONS: Approximately 1 in 10 sexually active students used withdrawal only, about the same percentage as those who used no method. Health care providers and others who serve adolescents may want to discuss its pros and cons with their clients and help ensure they have information about and access to other contraceptive methods that are more effective at preventing pregnancy and sexually transmitted infections. Health care professionals should not consider young people who use withdrawal similar in risk to those that use no method.

IMPORTANCE: Since licensure of the human papillomavirus (HPV) vaccine in 2006, HPV vaccine coverage among US adolescents has increased but remains low compared with other recommended vaccines. OBJECTIVE: To systematically review the literature on barriers to HPV vaccination among US adolescents to inform future efforts to increase HPV vaccine coverage. EVIDENCE REVIEW: We searched PubMed and previous review articles to identify original research articles describing barriers to HPV vaccine initiation and completion among US adolescents. Only articles reporting data collected in 2009 or later were included. Findings from 55 relevant articles were summarized by target populations: health care professionals, parents, underserved and disadvantaged populations, and males. FINDINGS: Health care professionals cited financial concerns and parental attitudes and concerns as barriers to providing the HPV vaccine to patients. Parents often reported needing more information before vaccinating their children. Concerns about the vaccine's effect on sexual behavior, low perceived risk of HPV infection, social influences, irregular preventive care, and vaccine cost were also identified as potential barriers among parents. Some parents of sons reported not vaccinating their sons because of the perceived lack of direct benefit. Parents consistently cited health care professional recommendations as one of the most important factors in their decision to vaccinate their children. CONCLUSIONS AND RELEVANCE: Continued efforts are needed to ensure that health care professionals and parents understand the importance of vaccinating adolescents before they become sexually active. Health care professionals may benefit from guidance on communicating HPV recommendations to patients and parents. Further efforts are also needed to reduce missed opportunities for HPV vaccination when adolescents interface with the health care system. Efforts to increase uptake should take into account the specific needs of subgroups within the population. Efforts that address system-level barriers to vaccination may help to increase overall HPV vaccine uptake.

PURPOSE: Despite official recommendation for routine HPV vaccination of boys and girls at age 11-12 years, parents and providers are more likely to vaccinate their children/patients at older ages. Preferences for vaccinating older adolescents may be related to beliefs about an adolescent's sexual experience or perceived parental resistance to vaccinating children who are assumed to be sexually inexperienced. METHODS: Using data from the 1995 wave of the National Longitudinal Study of Adolescent Health (ADD Health), a subset of a nationally representative sample of adolescents in grades 7 through 12 and their parents (n = 13,461), we investigated maternal underestimation of adolescent sexual experience. RESULTS: About one third (34.8%) of adolescents reported being sexually experienced and of these, 46.8% of their mothers inaccurately reported that their child was not sexually experienced. Underestimation varied by adolescent age with 78.1% of mothers of sexually active 11-13-year-olds reporting their child was not sexually active, compared with 56.4% of mothers of sexually active 14-16-year-olds and only 34.4% of mothers of 17-18-year-olds. CONCLUSIONS: Although most adolescents are not sexually active at age 11 or 12 years, waiting until a parent thinks a child is sexually active could result in missed opportunities for prevention.

BACKGROUND: Maximizing HPV vaccine uptake among those at highest risk for cervical cancer is critical. We explored healthcare provider perspectives on factors influencing HPV vaccination among adolescent girls in a community with high cervical cancer rates. METHODS: From March to May 2009, we conducted in-depth interviews with 21 medical staff providing care to adolescent girls at two clinics in Los Angeles, CA, serving a predominantly Hispanic population with high cervical cancer rates. Interviews were recorded and transcribed data were reviewed for coding and thematic content related to potential barriers and facilitators of HPV vaccination. RESULTS: Providers and medical staff overwhelmingly focused on parental beliefs as barriers to HPV vaccination. Perceived parental misconceptions acting as barriers included the belief that adolescents do not need vaccinations and that no-cost vaccine programs like Vaccines for Children are only available for younger children. Perceived parental concerns that the vaccine will promote sexual activity were prevalent, which prompted providers to frame HPV vaccine as a "routine" vaccine. However, the medical staff felt mothers with a friend or relative supportive of HPV vaccination were more likely to request the vaccine. The staff also noted that for Hispanic parents the "preferred" source of information is peers; if the "right people" in the community were supportive of HPV vaccine, parents were more willing to vaccinate. Other barriers included lack of immunization records among immigrant parents and a difficult-to-reach, mobile clientele. CONCLUSIONS: Providers noted a number of barriers to HPV vaccination, including some perceived parental misconceptions that could be addressed with education about the need for adolescent vaccines and available free vaccine programs. Because community support appears particularly important to Hispanic parents, the use of promotoras - peer liaisons between health organizations and the community - may increase HPV vaccine uptake in this population.

The purpose of this study was to examine patterns and predictors of HIV/STI risk over time among Latino migrant men in a new receiving community. Latino men (N=125) were interviewed quarterly for 18 months and HIV/STI tested annually. Selected individual, environmental and cultural factors by partner type and condom use were explored longitudinally and in a cross-section. Sex with female sex workers (FSWs) and multiple partners decreased, sex with main partners and abstinence increased, while the number of casual partners remained stable. Consistent condom use was highest with FSWs, lowest with main partners and midrange with casual partners with no trends over time. STI morbidity was low; no HIV was detected. Drug use and high mobility were associated with inconsistent condom use with FSW, whereas having family in the household was protective. HIV/STI prevention efforts should focus on drug using Latino migrants who are highly mobile and should foster healthy social connections.

BACKGROUND AND PURPOSE: HPV vaccine coverage for females has increased in the U.S., although challenges to achieving high coverage remain. HPV vaccine coverage continues to lag behind that of other routinely recommended adolescent vaccines and these gaps in coverage are widening. To inform strategies to improve uptake, we explore correlates of vaccine intention and describe reasons for refusing HPV vaccination among unvaccinated females in a nationally representative sample of adolescents and young adults during early stages of HPV vaccine availability. METHODS: In 2007-2008, 1243 females aged 15-24 years were asked about HPV vaccination in the National Survey of Family Growth (NSFG). For unvaccinated women (n=955), we evaluated demographic and sexual behavior correlates of likelihood to receive the vaccine in the next 12 months in bivariate and multivariable analyses by age. Correlates to the main reasons for foregoing vaccination are described. RESULTS: A minority (42.5%) of unvaccinated respondents said they intended to receive HPV vaccine in the next 12 months: 37.6% of adolescents (15-19 years) and 42.0% of young adults (20-24 years). Sexually experienced women were more than twice as likely as non-sexually experienced women to intend to receive HPV vaccine (15-19 years: aOR=2.39, 95% CI=1.15, 4.94; 20-24 years: aOR=2.17, 95% CI=1.08, 4.33). Having health insurance was associated with being likely to receive HPV vaccine among adolescents. Hispanic young adults were more likely than non-Hispanic Whites to be likely to receive HPV vaccine. The belief of not being at risk for HPV and institutional barriers were the two most commonly cited reasons for foregoing vaccination.Among unvaccinated women who did not intend to get vaccinated, respondents who never had sex were more likely to report not being at risk as the main reason for not needing the vaccine compared to women with sexual experience (44.5 vs. 24.4%) but this finding was only marginally significant in our limited sample. CONCLUSION: In the first years immediately post-licensure of an HPV vaccine, the majority of unvaccinated women indicated that they were unlikely to seek vaccination. Intent to receive the HPV vaccine is tied to sexual experience and most women who do not intend to get vaccinated and have never had sex believe they are not at risk of HPV or do not need an HPV vaccine. These findings highlight the need to better communicate information regarding lifetime risk for HPV and the importance of receiving HPV vaccine prior to sexual initiation. These findings should inform strategies to increase vaccine uptake.

BACKGROUND: Vaccines to prevent certain types of human papillomavirus (HPV) and associated cancers are recommended for routine use among young women. Nationally representative reports of vaccine uptake have not explored the relationship between HPV vaccine initiation and various sexual behaviors. PURPOSE: Explore sexual behavior and demographic correlates of HPV vaccine initiation from a nationally representative survey of adolescent and young adult women. METHODS: In 2007-2008, a total of 1243 girls/women aged 15-24 years responded to questions about receiving HPV vaccine in the National Survey of Family Growth (NSFG). In 2010, demographic and sexual behavior correlates were evaluated in bivariate and multivariate analyses by age. RESULTS: HPV vaccine initiation was higher among those aged 15-19 years than those aged 20-24 years (30.3% vs 15.9%, p<0.001). No differences existed by race/ethnicity for those aged 15-19 years, but among women aged 20-24 years, non-Hispanic blacks were less likely than non-Hispanic whites to have received the HPV vaccine (AOR=0.15). HPV vaccine initiation was greater for those with insurance regardless of age. HPV vaccination was not associated with being sexually active or number of sex partners at either age. Among sexually active adolescents aged 15-19 years, those who received HPV vaccine were more likely to always wear a condom (AOR=3.0). CONCLUSIONS: This study highlights disparities in HPV vaccine initiation by insurance status among girls/women aged 15-24 years and by race/ethnicity among women aged >19 years. No association was found between HPV vaccination and risky sexual behavior.

We characterized parental attitudes regarding school HPV vaccination requirements for adolescent girls. Study participants were 889 parents of 10-18 year-old girls in areas of North Carolina with elevated cervical cancer incidence. We calculated odds ratios (ORs) and 95% confidence intervals (CIs) by logistic regression. Approximately half (47%) of parents agreed that laws requiring HPV immunization for school attendance "are a good idea" when opt-out provisions were not mentioned. Far more agreed that "these laws are okay only if parents can opt out if they want to" (84%). Predictors of supporting requirements included believing HPV vaccine is highly effective against cervical cancer (OR=2.5, 95%CI:1.7-5.0) or is more beneficial if provided at an earlier age (OR=16.1, 95%CI:8.4-30.9). Parents were less likely to agree with vaccine requirements being a good idea if they expressed concerns related to HPV vaccine safety (OR=0.3, 95%CI:0.1-0.5), its recent introduction (OR=0.3,95%CI:0.2-0.6), or its potential to increase their daughters' sexual activity (OR=0.4,95%CI:0.2-0.6). Parental acceptance of school requirements appears to depend on perceived HPV vaccine safety and efficacy, understanding of the optimal age for vaccine administration, and inclusion of opt-out provisions.

BACKGROUND: Human papillomavirus (HPV) immunization requirements for school entry could increase HPV vaccine uptake but are controversial. This study assessed parents' attitudes about HPV immunization requirements. METHODS: During October 2007-June 2008, we conducted telephone surveys with 484 parents of girls attending middle/high schools serving communities in Los Angeles County with elevated cervical cancer rates. RESULTS: Parents were mostly Hispanic (81%) or African-American (15%); 71% responded in Spanish. Many parents did not know if HPV vaccine works well (42%) or is unsafe (41%). Overall, 59% of parents agreed that laws requiring HPV vaccination for school attendance "are a good idea." In multivariable analysis, African-Americans and Hispanics responding in English were less likely than Hispanics responding in Spanish to agree (aOR 0.4, CI 0.2-0.8; aOR 0.1, CI 0.1-0.3, respectively). Parents were less likely to agree with these laws if they did not believe the vaccine works well (aOR 0.2, CI 0.1-0.5) but more likely to agree if they believed the vaccine is not "too new for laws like these" (aOR 4.5, CI 2.6-8.0). Agreement with laws increased to 92% when including agreement that "these laws are okay only if parents can opt out." CONCLUSIONS: In this at-risk community, over half of parents agreed with HPV immunization requirements generally, and the vast majority agreed when including opt-out provisions. Impact: Support for HPV vaccine requirements may depend on race/ethnicity and inclusion of opt-out provisions. Information about vaccine efficacy and safety may increase support and reduce uncertainty about HPV vaccine in high risk populations.