Publications by authors named "Claire D Brindis"

135 Publications

Adapting to Changes in Teen Pregnancy Prevention Research: Social Media as an Expedited Recruitment Strategy.

J Adolesc Health 2021 Feb 22. Epub 2021 Feb 22.

Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of California San Francisco, San Francisco, California.

Purpose: Teen pregnancy prevention projects funded by the U.S. Office of Adolescent Health were disrupted by the Trump administration in the July 2017 announcement that funding would be terminated. Although funding was later reinstated toward the end of 2018 after a class-action lawsuit, we needed to change our recruitment protocol to mitigate this disruption to the study timeline and staffing. This led to a natural experiment comparing in person and social media recruitment strategies.

Methods: The original approach was to recruit girls, aged 15-19 years, who were using intrauterine or subdermal contraception, in person in clinic settings. After the funding disruption, we transitioned to an online recruitment strategy. Costs associated with each approach (in-person and online recruitment) were tracked, and we compared cost of per-person enrollment with each approach.

Results: In-person, clinic-based recruitment enrolled 118 participants over 293 days from eight high-volume clinics. Online recruitment enrolled 518 participants over 146 days. Online recruitment resulted in cost savings and a diverse sample representing a larger geographic region.

Conclusion: Online recruitment can cut costs and be more efficient than a clinic-based recruitment strategy, but special considerations are warranted when considering social media recruitment.
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http://dx.doi.org/10.1016/j.jadohealth.2020.12.140DOI Listing
February 2021

A cluster-randomized controlled trial of an elementary school drinking water access and promotion intervention: Rationale, study design, and protocol.

Contemp Clin Trials 2020 Dec 25;101:106255. Epub 2020 Dec 25.

Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, USA; Department of Pediatrics, School of Medicine, Stanford University, USA. Electronic address:

Introduction: Promoting water consumption among children in schools is a promising intervention to reduce sugar-sweetened beverage (SSB) intake and achieve healthful weight. To date, no studies in the United States have examined how a school-based water access and promotion intervention affects students' beverage and food intake both in and out of school and weight gain over time. The Water First trial is intended to evaluate these interventions.

Methods: Informed by the PRECEDE-PROCEED model and Social Cognitive Theory, the Water First intervention includes: 1) installation of lead-free water stations in cafeterias, physical activity spaces, and high-traffic common areas in lower-income public elementary schools, 2) provision of cups/reusable water bottles for students, and 3) a 6-month healthy beverage education campaign. A five year-long cluster randomized controlled trial of 26 low-income public elementary schools in the San Francisco Bay Area is examining how Water First impacts students' consumption of water, caloric intake from foods and beverages, and BMI z-score and overweight/obesity prevalence, from baseline to 7 months and 15 months after the start of the study. Intervention impact on outcomes will be examined using a difference-in-differences approach with mixed-effects regression accounting for the clustering of students in schools and classrooms.

Discussion: This paper describes the rationale, study design, and protocol for the Water First study. If the intervention is effective, findings will inform best practices for implementing school water policies, as well as the development of more expansive policies and programs to promote and improve access to drinking water in schools.
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http://dx.doi.org/10.1016/j.cct.2020.106255DOI Listing
December 2020

A Preliminary Study Examining the Validity of Brief Trauma Screening Tools for Young Adolescents in School-Based Health Centers.

J Nurs Meas 2020 Dec 17. Epub 2020 Dec 17.

University of California, San Francisco, CA.

Background And Purpose: There are very limited brief, validated, open access screening tools for trauma symptoms in adolescent populations. This study aimed to test two brief tools used with adults in primary care settings for use with adolescents.

Methods: Youth ( = 77) completed the Posttraumatic Stress Disorder (PTSD) Checklist (PCLC-2), the Primary Care PTSD Screen for , Fourth Edition (; PC-PTSD), and the PTSD Reaction Index for (reference tool). Sensitivities and specificities were analyzed.

Results: The PCLC-2 and PC-PTSD demonstrated high sensitivity and specificity with adolescents when using lower cutoff scores than those recommended for adults.

Conclusions: The PC-PTSD and PCLC-2 have the potential to be used as brief screens with adolescents. Additional research is needed to further examine their validity with larger, diverse youth samples in primary care and school-based settings.
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http://dx.doi.org/10.1891/JNM-D-19-00043DOI Listing
December 2020

Building a global policy agenda to prioritize preterm birth: A qualitative analysis on factors shaping global health policymaking.

Gates Open Res 2020 22;4:65. Epub 2020 Jun 22.

Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA, USA.

Preterm birth, defined as infants born before 37 weeks of gestation, is the largest contributor to child mortality. Despite new evidence highlighting the global burden of prematurity, policymakers have failed to adequately prioritize preterm birth despite the magnitude of its health impacts. Given current levels of political attention and investment, it is unlikely that the global community will be adequately mobilized to meet the 2012 report goal of reducing the preterm birth rate by 50% by 2025. : This study adapts the Shiffman and Smith framework for political priority to examine four components contributing to policy action in global health: actor power, ideas, political context, and issue characteristics. We conducted key informant interviews with 18 experts in prematurity and reproductive, maternal, newborn, and child health (RMNCH) and reviewed key literature on preterm birth. We aimed to identify the factors that shape the global political priority of preterm birth and to describe policy opportunities to increase its priority moving forward. : The global preterm birth community (academic researchers, multilateral organizations, government agencies, and civil society organizations) lacks evidence about the causes of and solutions to preterm birth; and country-level data quality is poor with gaps in the understanding required for implementing effective interventions. Limited funding compounds these challenges, creating divisions among experts on what policy actions to recommend. These factors contribute to the lack of priority and underrepresentation of preterm birth within the larger RMNCH agenda. : Increasing the political priority of prematurity is essential to reduce preventable newborn and child mortality, a key target of the 2030 Sustainable Development Goal for health (target 3.2). This study identifies three policy recommendations for the preterm birth community: address data and evidence gaps, clarify and invest in viable solutions, and bring visibility to prematurity within the larger RMNCH agendas.
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http://dx.doi.org/10.12688/gatesopenres.13098.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7578407PMC
June 2020

Perspectives on Adolescent Pregnancy Prevention Strategies in the United States: Looking Back, Looking Forward.

Adolesc Health Med Ther 2020 12;11:135-145. Epub 2020 Oct 12.

Philip R. Lee Institute for Health Policy Studies, Adolescent and Young Adult Health National Resource Center, Bixby Center for Global Reproductive Health, University of California, San Francisco, San Francisco, CA 94118, USA.

Attempts to solve the "problem of adolescent pregnancy" have long been a  focus of national, state, and local efforts in the United States. This review article summarizes trends and strategies around adolescent pregnancy prevention, provides lessons learned and best practices, and presents ideas for future directions. Over the past decades, a wide variety of policy and programmatic interventions have been implemented - including educational efforts, clinical health services, and community-wide coalitions - accompanied by a growing consensus regarding viable solutions. While notable reductions in adolescent pregnancy and childbearing have occurred across all sociodemographic groups, racial/ethnic, geographic, and socioeconomic disparities persist. Many adolescents who most need sexual health information and services are underserved by current programs and policies. A growing understanding of the role of social determinants of health, the impacts of structural racism, and the need for equity and inclusion must inform the next set of interventions and societal commitments to not only ameliorate the occurrence of unintended adolescent pregnancy but also foster healthy adolescent development. Recommendations for future efforts include improving the content, quality, and sustainability of education programs; actively engaging youth in the design of policies, programs, and clinical services; using technology thoughtfully to improve health literacy; expanding access to services through telehealth and other delivery options; and designing programs and policies that recognize and address structural racism, health equity, and inclusion.
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http://dx.doi.org/10.2147/AHMT.S219949DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7567553PMC
October 2020

Reasons for and Logistical Burdens of Judicial Bypass for Abortion in Illinois.

J Adolesc Health 2021 Jan 8;68(1):71-78. Epub 2020 Oct 8.

Advancing New Standards in Reproductive Health, Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, Oakland, California.

Purpose: Minors seeking abortion in states with parental involvement requirements can obtain judicial bypass (JB) as an alternative. Research on minors' reasons for choosing bypass and the logistical obstacles associated with bypass is limited, yet needed to assess potential burdens introduced by mandated parental involvement.

Methods: Using data from all minors represented in JB proceedings by the Illinois Judicial Bypass Coordination Project in 2017 and 2018, we present descriptive statistics summarizing minors' demographic characteristics, reasons for seeking bypass, individuals involved in decision-making, and distances traveled and time elapsed to attend the court hearing.

Results: Most minors obtaining bypass (n = 150) agreed to participate (n = 128). Just more than half (55%) were aged 17 years and lived with one parent (54%). A minority were already parenting (5%) and/or lived with someone besides a parent or on their own (16%). The reasons for bypass included concern about being forced to continue the pregnancy (50%), fear of being kicked out of their home and/or cut off financially (41%), having no/minimal relationship with parents (15%), and fear of physical/emotional abuse (13%). Minors traveled an average of 24 miles one-way (range 1-270 miles) to a courthouse for their hearing. On average, 6.4 days elapsed between contacting the Judicial Bypass Coordination Project and the hearing.

Conclusions: Judicial bypass can offer young people an opportunity to retain autonomy in decision-making, potentially avoiding abuse and other negative outcomes. However, even in a state with a well-organized network of attorneys, JB contributes 1 week to minors' abortion-seeking timeline and necessitates traveling long distances.
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http://dx.doi.org/10.1016/j.jadohealth.2020.08.025DOI Listing
January 2021

Political prioritization and the competing definitions of adolescent pregnancy in Kenya: An application of the Public Arenas Model.

PLoS One 2020 14;15(9):e0238136. Epub 2020 Sep 14.

Institute of Global Health Sciences, University of California, San Francisco, San Francisco, California, United States of America.

Background: Approximately one in every five adolescent girls in Kenya has either had a live birth or is pregnant with her first child. There is an urgent need to understand the language and symbols used to represent adolescent pregnancy, if the current trend in adolescent pregnancy is to be reversed. Agreement on the definition of a societal problem is an important precursor to a social issue's political prioritization and priority setting.

Methods: We apply the Public Arenas Model to appraise the environments, definitions, competition dynamics, principles of selection and current actors involved in problem-solving and prioritizing adolescent pregnancy as a policy issue. Using a focused ethnographic approach, we undertook semi-structured interviews with 14 members of adolescent sexual reproductive health networks at the national level and conducted thematic analysis of the interviews.

Findings: We found that existing definitions center around adolescent pregnancy as a "disease" that needs prevention and treatment, socially deviant behaviour that requires individual agency, and a national social concern that drains public resources and therefore needs to be regulated. These competing definitions contribute to the rarity of the topic achieving traction within the political agenda and contribute to conflicting solutions, such as lowering the legal age of consenting to sex, while limiting access to contraceptive information and services to minors.

Conclusion: This paper provides a timely theoretical approach to draw attention to the different competing definitions and subsequent divergent interpretations of the problem of adolescent pregnancy in Kenya. Adolescent reproductive health stakeholders need to be familiar with the existing definitions and deliberately reframe this important social problem for better political prioritization and resource allocation. We recommend a definition of adolescent pregnancy that cuts across different arenas, and leverages already existing dominant and concurrent social and economic issues that are already on the agenda table.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0238136PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489501PMC
October 2020

Development and Validation of the Sexual and Reproductive Empowerment Scale for Adolescents and Young Adults.

J Adolesc Health 2021 Jan 17;68(1):86-94. Epub 2020 Jul 17.

School of Nursing and Health Studies, University of Washington Bothell, Bothell, Washington.

Purpose: We developed and validated a measure that assesses the latent construct of sexual and reproductive empowerment among adolescents and young adults. A specific measure for this group is critical because of their unique life stage and circumstances, which often includes frequent changes in sexual partners and involvement from parents in decision-making.

Methods: After formative qualitative research, a review of the literature, and cognitive interviews, we developed 95 items representing nine dimensions of sexual and reproductive empowerment. Items were then fielded among a national sample of young people aged 15-24 years, and those who identified as sexually active completed a 3-month follow-up survey. We conducted psychometric analysis and scale validation.

Results: Exploratory factor analysis on responses from 1,117 participants resulted in the Sexual and Reproductive Empowerment Scale for Adolescents and Young Adults, containing 23 items captured by seven subscales: comfort talking with partner; choice of partners, marriage, and children; parental support; sexual safety; self-love; sense of future; and sexual pleasure. Validation using logistic regression demonstrated that the subscales were consistently associated with sexual and reproductive health information and access to sexual and reproductive health services measured at baseline and moderately associated with the use of desired contraceptive methods at 3-month follow-up.

Conclusions: The Sexual and Reproductive Empowerment Scale for Adolescents and Young Adults is a new measure that assesses young people's empowerment regarding sexual and reproductive health. It can be used by researchers, public health practitioners, and clinicians to measure sexual and reproductive empowerment among young people.
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http://dx.doi.org/10.1016/j.jadohealth.2020.05.031DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7755733PMC
January 2021

Medical Vulnerability of Young Adults to Severe COVID-19 Illness-Data From the National Health Interview Survey.

J Adolesc Health 2020 09 13;67(3):362-368. Epub 2020 Jul 13.

Division of Adolescent and Young Adult Medicine, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California.

Purpose: COVID-19 morbidity and mortality reports in the U.S. have not included findings specific to young adults. The Centers for Disease Control and Prevention provides a list of conditions and associated behaviors, including smoking, conferring vulnerability to severe COVID-19 illness regardless of age. This study examines young adults' medical vulnerability to severe COVID-19 illness, focusing on smoking-related behavior.

Methods: A young adult subsample (aged 18-25 years) was developed from the National Health Interview Survey, a nationally representative data set, pooling years 2016-2018. The medical vulnerability measure (yes vs. no) was developed, guided by the Centers for Disease Control and Prevention medical indicators. The estimates of medical vulnerability were developed for the full sample, the nonsmoking sample, and the individual risk indicators. Logistic regressions were conducted to examine differences by sex, race/ethnicity, income, and insurance.

Results: Medical vulnerability was 32% for the full sample and half that (16%) for the nonsmoking sample. Patterns and significance of some subgroup differences differed between the full and the nonsmoking sample. Male vulnerability was (33%) higher than female (30%; 95% CI: .7-.9) in the full sample, but lower in nonsmokers: male (14%) versus female (19%; 95% CI: 1.2-1.7). The white subgroup had higher vulnerability than Hispanic and Asian subgroups in both samples-full sample: white (31%) versus Hispanic (24%; 95% CI: .6-.9) and Asian (18%; 95% CI: .4-.5); nonsmokers: white (17%) versus Hispanic (13%; 95% CI: .06-.9) and Asian (10%; 95% CI: .3-.8).

Conclusions: Notably, lower young adult medical vulnerability within nonsmokers versus the full sample underscores the importance of smoking prevention and mitigation.
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http://dx.doi.org/10.1016/j.jadohealth.2020.06.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7355323PMC
September 2020

Early Affordable Care Act Medicaid: Coverage Effects for Low- and Moderate-Income Young Adults.

J Adolesc Health 2020 Sep 3;67(3):425-431. Epub 2020 Jul 3.

Philip R. Lee Institute for Health Policy Studies and Adolescent and Young Adult Health National Resource Center, University of California, San Francisco, San Francisco, California.

Purpose: The purpose of the study was to evaluate the effects of early Medicaid expansions on young adults, who also benefitted from a private dependent coverage expansion.

Methods: We used the American Community Survey 2008-2013 to study three early expansion states-California, Connecticut, and Minnesota-using difference-in-differences. Control states are weighted combinations of other states and are similar to expansion states in the prepolicy periods. We analyze young adults and subgroups of women and men.

Results: Early Medicaid reduced uninsurance and improved public coverage among low- and moderate-income young adults beyond the private dependent coverage expansion, but results differed across states. California, which targeted up to 200 percent of the federal poverty level (FPL), reduced uninsurance 1.3 percentage points (4.2% relative to mean) and increased public insurance by 1.4 percentage points (14.0%). Connecticut, which targeted up to 56 percent of FPL, had no change to uninsurance but a 5.4 percentage point (42.5%) increase in public coverage. Minnesota's programs (up to 75 and 250 percent of FPL) produced a 4.2 percentage point (21.9%) decline in uninsurance for their lowest income group, but no measurable changes for their moderate-income group. Young men benefitted more than women. Their uninsurance declined as much as 6.0 percentage points (25.0%, in Minnesota) and their public coverage increased up to 9.1 percentage points (61.5%, in Connecticut).

Conclusions: Medicaid expansion benefits young adults, even those with moderate incomes, and even following a private dependent expansion. Results were larger and concentrated among young men, who historically had little engagement with the program.
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http://dx.doi.org/10.1016/j.jadohealth.2020.05.029DOI Listing
September 2020

An Underpinning of School Inequities: Asthma Absences and Lost Revenue in California Schools.

J Sch Health 2020 03 19;90(3):200-211. Epub 2020 Jan 19.

Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, 3333 California Street, San Francisco, CA, 94118.

Background: Asthma is epidemic in many locations in the United States. Asthma exacerbations pose serious health and education risks for students through school absences, school dropout, and introduction to the juvenile justice system. Accurate school district-level asthma data, currently in short supply, would enable early interventions that focus on specific geographic areas and racial and ethnic subgroups that have higher asthma prevalence.

Methods: To support the development of better local level data systems, we used two California student databases, as well as state education and financial databases, to develop two models to estimate school absences and to extrapolate their economic impact in lost school revenue.

Results: Analysis demonstrated subpopulations that are appropriate for early intervention: African American elementary school boys have 9.4 average absences per year, higher than other primary racial and ethnic groups. Students who miss ≥3 school days due to asthma account for $26 million of lost revenue.

Conclusions: Accurate local level asthma data can identify subpopulations of students for whom environmental and treatment programs can be employed to reduce asthma absences and other related outcomes, and to reduce currently lost school revenues. Such programs also may diminish other asthma-related school inequities.
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http://dx.doi.org/10.1111/josh.12869DOI Listing
March 2020

Challenges to generating political prioritization for adolescent sexual and reproductive health in Kenya: A qualitative study.

PLoS One 2019 19;14(12):e0226426. Epub 2019 Dec 19.

Institute of Global Health Sciences, University of California, San Francisco, California, United States of America.

Background: Despite the high burden of adverse adolescent sexual and reproductive health (SRH) outcomes, it has remained a low political priority in Kenya. We examined factors that have shaped the lack of current political prioritization of adolescent SRH service provision.

Methods: We used the Shiffman and Smith policy framework consisting of four categories-actor power, ideas, political contexts, and issue characteristics-to analyse factors that have shaped political prioritization of adolescent SRH. We undertook semi-structured interviews with 14 members of adolescent SRH networks between February and April 2019 at the national level and conducted thematic analysis of the interviews.

Findings: Several factors hinder the attainment of political priority for adolescent SRH in Kenya. On actor power, the adolescent SRH community was diverse and united in adoption of international norms and policies, but lacked policy entrepreneurs to provide strong leadership, and policy windows were often missed. Regarding ideas, community members lacked consensus on a cohesive public positioning of the problem. On issue characteristics, the perception of adolescents as lacking political power made politicians reluctant to act on the existing data on the severity of adolescent SRH. There was also a lack of consensus on the nature of interventions to be implemented. Pertaining to political contexts, sectoral funding by donors and government treasury brought about tension within the different government ministries resulting in siloed approaches, lack of coordination and overall inefficiency. However, the SRH community has several strengths that augur well for future political support. These include the diverse multi-sectoral background of its members, commitment to improving adolescent SRH, and the potential to link with other health priorities such as maternal health and HIV/AIDS.

Conclusion: In order to increase political attention to adolescent SRH in Kenya, there is an urgent need for policy actors to: 1) create a more cohesive community of advocates across sectors, 2) develop a clearer public positioning of adolescent SRH, 3) agree on a set of precise approaches that will resonate with the political system, and 4) identify and nurture policy entrepreneurs to facilitate the coupling of adolescent SRH with potential solutions when windows of opportunity arise.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0226426PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6922405PMC
March 2020

Isolated Voices: Perspectives of Teachers, School Nurses, and Administrators Regarding Implementation of Sexual Health Education Policy.

J Sch Health 2020 02 8;90(2):88-98. Epub 2019 Dec 8.

Department of Pediatrics, Division of Adolescent Medicine, University of California San Francisco, Philip R. Lee Institute for Health Policy Studies, Adolescent and Young Adult Health National Resource Center, 3333 California Street, San Francisco, CA, 94118.

Background: Comprehensive sexual health education (SHE) reduces risky sexual behavior and increases protective behavior in adolescents. It is important to understand how professionals responsible for implementing SHE policy interpret state and local policy and what influences their commitment to formal SHE policy implementation.

Methods: This descriptive study explored content and delivery of SHE policy in a rural, southwestern state with high levels of poverty, unintended adolescent pregnancy, and sexually transmitted infections. The social ecological model (SEM) was used to better understand levels of influence on the implementation of SHE policy.

Results: We conducted telephone surveys with 38 teachers, 63 nurses, and 21 administrators in public secondary schools. There was substantial local variability in the scope and content of SHE curricula. Respondents identified significant barriers to the delivery of SHE content and minimal evaluation of whether educational objectives were met. Based on participant responses, community and organizational SEM levels had the greatest influence on SHE policy implementation, although examples of all SEM levels were identified.

Conclusions: Given perceived challenges regarding subject matter, successful SHE implementation at the local level requires committed stakeholders working in concert at the school and community levels, backed by strong policy commitment at the state level.
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http://dx.doi.org/10.1111/josh.12853DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7004136PMC
February 2020

Fulfilling the Promise of Adolescence: Realizing Opportunity for All Youth.

J Adolesc Health 2019 10 19;65(4):440-442. Epub 2019 Aug 19.

Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California. Electronic address:

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http://dx.doi.org/10.1016/j.jadohealth.2019.07.018DOI Listing
October 2019

The Double Bind of School Nurses and Policy Implementation: Intersecting the Framework and Teaching Sexual Health Education.

J Sch Nurs 2019 Aug 22:1059840519868764. Epub 2019 Aug 22.

2 Division of Adolescent Medicine, Department of Pediatrics, Adolescent and Young Adult Health National Resource Center, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, USA.

As described in the Framework for 21st Century School Nursing Practice, school nurses bridge the realities of health and education policy within the school community every day. This role is inclusive of helping teach sexual health education (SHE) to students. We were interested in characterizing how school nurses navigate requirements of health education policy to provide their students with the SHE content that they need. Using data from a larger study, we organized a subset of school nurse data within the street-level bureaucracy framework to better understand the many challenges school nurses face in implementing SHE policy. School nurses' involvement in SHE policy implementation was congruent with characteristics of the framework. This included using their professional discretion to manage dilemmas, working with inadequate resources, unclear policy expectations, lack of support, and ambiguous policy goals. Trusted relationships with teachers and students helped school nurses with their SHE policy implementation responsibilities.
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http://dx.doi.org/10.1177/1059840519868764DOI Listing
August 2019

Teachers as Healthy Beverage Role Models: Relationship of Student and Teacher Beverage Choices in Elementary Schools.

J Community Health 2020 02 12;45(1):121-127. Epub 2019 Aug 12.

Division of General Pediatrics, Stanford University, Stanford, USA.

Schools are a key setting for curbing student intake of sugar-sweetened beverages (SSBs). While studies suggest that restrictions on SSBs, increased access to healthier beverages, and education about the importance of drinking water instead of SSBs can promote healthier beverage patterns among students, there is little known about the impact that teachers' own beverage choices can have on those of their students. Data were drawn from cross-sectional surveys administered as part of a larger evaluation of a drinking water access and promotion intervention in public elementary schools in the San Francisco Bay Area region of California. Descriptive statistics were used to examine teacher (n = 56) and student (n = 1176) self-reported beverage consumption at school. Mixed-effects logistic regression was used to examine associations between teacher and student beverage intake adjusting for clustering of students by teacher. Teachers were also surveyed via open-ended questions about strategies to increase student water consumption at school. Nearly all teachers reported drinking water during the school day (95%), often in front of students. Teacher SSB intake was rare (9%). Students whose teachers drank water in front of their classes were significantly more likely to report drinking water during the school day. Teachers tend to select healthy beverages at work and may serve as role models to encourage student consumption of water instead of SSBs.
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http://dx.doi.org/10.1007/s10900-019-00717-7DOI Listing
February 2020

Effects of a multipronged beverage intervention on young children's beverage intake and weight: a cluster-randomized pilot study.

Public Health Nutr 2019 10 15;22(15):2856-2867. Epub 2019 Jul 15.

Department of Pediatrics, Stanford University, 1265 Welch Road MSOB X240, Mailcode 5459, Stanford, CA 94305, USA.

Objective: To evaluate whether a multipronged pilot intervention promoting healthier beverage consumption improved at-home beverage consumption and weight status among young children.

Design: In this exploratory pilot study, we randomly assigned four childcare centres to a control (delayed-intervention) condition or a 12-week intervention that promoted consumption of healthier beverages (water, unsweetened low- or non-fat milk) and discouraged consumption of less-healthy beverages (juice, sugar-sweetened beverages, high-fat or sweetened milk). The multipronged intervention was delivered via childcare centres; simultaneously targeted children, parents and childcare staff; and included environmental changes, policies and education. Outcomes were measured at baseline and immediately post-intervention and included children's (n 154) at-home beverage consumption (assessed via parental report) and overweight/obese status (assessed via objectively measured height and weight). We estimated intervention impact using difference-in-differences models controlling for children's demographics and classroom.

Setting: Two northern California cities, USA, 2013-2014.

Participants: Children aged 2-5 years and their parents.

Results: Relative to control group children, intervention group children reduced their consumption of less-healthy beverages from baseline to follow-up by 5·9 ounces/d (95 % CI -11·2, -0·6) (-174·5 ml/d; 95 % CI -331·2, -17·7) and increased their consumption of healthier beverages by 3·5 ounces/d (95 % CI -2·6, 9·5) (103·5 ml/d; 95 % CI -76·9, 280·9). Children's likelihood of being overweight decreased by 3 percentage points (pp) in the intervention group and increased by 3 pp in the control group (difference-in-differences: -6 pp; 95 % CI -15, 3).

Conclusions: Our exploratory pilot study suggests that interventions focused comprehensively on encouraging healthier beverage consumption could improve children's beverage intake and weight. Findings should be confirmed in longer, larger studies.
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http://dx.doi.org/10.1017/S1368980019001629DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6750979PMC
October 2019

Impact on Healthy Behaviors of Group Obesity Management Visits in Middle School Health Centers.

J Sch Nurs 2019 Apr 15:1059840519842226. Epub 2019 Apr 15.

1 School of Nursing, University of California, San Francisco, CA, USA.

This mixed-methods community-based participatory pilot study examined the feasibility and preliminary efficacy of group obesity management visits offered through school-based health centers. The study was implemented through an academic-community partnership in three school health centers serving primarily Latinx and African American youth. Participants ( n = 71) completed pre- and post-surveys about intention to change diet and exercise habits, knowledge and self-efficacy related to healthy eating, and social support. Focus groups were conducted after the intervention and 18 months later. Group visits were feasible and highly valued by study participants. Quantitative results showed a significant decrease in soda consumption, increased support from classmates, and an increased number of exercise days. In focus groups, youth endorsed cooking, tasting, and shopping activities, noted the importance of family involvement in behavior change, and stated that stress reduction mindfulness exercises helped to change eating habits. Implications for school-based health care and school nursing are discussed.
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http://dx.doi.org/10.1177/1059840519842226DOI Listing
April 2019

Young Adult Preventive Healthcare: Changes in Receipt of Care Pre- to Post-Affordable Care Act.

J Adolesc Health 2019 06 6;64(6):763-769. Epub 2019 Mar 6.

Division of Adolescent and Young Adult Medicine, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California, San Francisco, San Francisco, California.

Purpose: Young adults have unique health and health care needs. Although morbidity and mortality stem largely from preventable factors, they lack a structured set of preventive care guidelines. The Affordable Care Act (ACA), enacted in 2010, increased young adult insurance coverage, prohibited copayments for preventive visits among privately insured and for many preventive services. The objectives were to evaluate pre- to post-ACA changes in young adults' past-year well visits and, among those using a past-year health care visit, the receipt of preventive services.

Methods: We used pooled Medical Expenditure Panel Survey data, comparing pre-ACA (2007-2009, N = 10,294) to post-ACA (2014-2016, N = 10,567) young adults aged 18-25 years. Bivariable and multivariable stratified logistic regression, adjusting for sociodemographic covariates, were conducted to determine differences in well visits and in preventive services among past-year health care utilizers: blood pressure and cholesterol checks, influenza immunization, and all three received.

Results: Past-year well visits increased from pre-ACA (28%) to post-ACA (32%), p < .001. Increases were noted for most demographic subgroups with greatest increases among males, Asian, and highest income subgroups. Larger pre- to post-ACA increases were found for most of the preventive services, p < .05, including the receipt of all three services (7% vs. 16%), p < .001, among past-year health care utilizers.

Conclusion: Following ACA implementation, young adults experienced modest increases in well visit rates and larger increases in most preventive services received. Overall rates of both remain low. Building on these improvements requires concerted efforts that account for young adults' unique combination of health care issues and challenges in navigating an adult health care system.
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http://dx.doi.org/10.1016/j.jadohealth.2018.12.004DOI Listing
June 2019

Improving Medicaid Access in Times of Health Policy Change: Solutions from Focus Groups with Frontline Enrollment Workers.

J Health Care Poor Underserved 2019 ;30(1):280-296

Enrollment navigators and government-employed Medicaid workers were an important element in the Affordable Care Act's (ACA) initial enrollment success. The Centers for Medicare and Medicaid Services eliminated 41% of funding for 2017 navigator programs and 90% of funding for outreach, arguing less investment was needed. Given that many remain uninsured, it is critical to identify effective enrollment practices. This study characterizes barriers and enrollment strategies from the perspective of California's Medicaid government and community-based enrollment workers (n=101 in eight focus groups). Participants identified a need for communication with policymakers, the state exchange, and each other regarding changing enrollment processes. Solutions include increased contact between enrollment workers to share strategies and policy updates regarding application processing, uniform policy interpretation, and details of ACA-related immigration law. Given efforts to weaken the ACA, it is critical to engage frontline workers in problem solving to streamline enrollment strategies, particularly for vulnerable populations.
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http://dx.doi.org/10.1353/hpu.2019.0021DOI Listing
November 2019

A social determinants framework identifying state-level immigrant policies and their influence on health.

SSM Popul Health 2019 Apr 2;7:016-16. Epub 2018 Nov 2.

Adolescent and Young Adult Health National Resource Center, University of California, San Francisco, 3333 California St., Suite 265, San Francisco, CA 94143-0936, USA.

Background: Many conceptual frameworks that touch on immigration and health have been published over the past several years. Most discuss broad social trends or specific immigrant policies, but few address how the policy environment affects the context of settlement and incorporation. Research on the social determinants of health shows how policies across multiple sectors have an impact on health status and health services, but has not yet identified the policies most important for immigrants. Understanding the range and content of state-level policies that impact immigrant populations can focus health in all policies initiatives as well as contextualize future research on immigrant health.

Methods: Our framework identifies state-level policies across five different domains that impact the health of immigrants and that vary across states, especially for those without legal status. Our scan shows that immigrants are exposed to different contexts, ranging from relatively inclusive to highly exclusive; a number of states have mixed trends that are more inclusive in some areas, but exclusive in others. Finally, we examine how the relative inclusiveness of state policies are associated with state-level demographic and political characteristics.

Results: Contrary to the image that exclusive policies are a reaction to large immigrant populations that may compete for jobs and cultural space, we find that the higher the proportion of foreign born and Hispanics in the state, the more inclusive the set of policies; while the higher the proportion of Republican voters, the less inclusive.

Conclusions: Variation across immigrant policies is much larger than the variation in state demographic and political characteristics, suggesting that state-level policies need to be included as a possible independent, contextual effect, when assessing immigrant health outcomes. This policy framework can be particularly useful in bridging our understanding of how large macro processes are connected to the daily lives and health of immigrants.
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http://dx.doi.org/10.1016/j.ssmph.2018.10.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6293030PMC
April 2019

Innovative Approaches to Address Social Determinants of Health Among Adolescents and Young Adults.

Health Equity 2018 14;2(1):321-328. Epub 2018 Nov 14.

Division of Adolescent and Young Adult Medicine, Department of Pediatrics, Benioff Children's Hospital and the Adolescent and Young Adult Health National Resource Center, University of California, San Francisco, California.

Social determinants are the leading causes of health disparities. Yet health care systems have not systemically addressed social determinants of health as it pertains to adolescents and young adults (AYAs), among other populations in need. This study identified promising innovative programs across the United States. Thirteen representatives from 10 programs completed a 45-min telephone interview. Transcripts were reviewed and analyzed to identify cross-cutting themes. Strategies included increasing access to quality, comprehensive and confidential health services, addressing the holistic needs of AYAs, collaborations across the health care delivery systems and other community services, and leveraging technology. This study showcased innovative approaches to inform future efforts.
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http://dx.doi.org/10.1089/heq.2018.0011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6238651PMC
November 2018

Opportunity Youth: Insights and Opportunities for a Public Health Approach to Reengage Disconnected Teenagers and Young Adults.

Public Health Rep 2018 Nov/Dec;133(1_suppl):54S-64S

4 Adolescent and Young Adult Health National Research Center, University of California, San Francisco, School of Medicine, San Francisco, CA, USA.

Approximately 1 in 9 teenagers and young adults aged 16-24 in the United States is currently disconnected from school and employment. These disconnected young people (ie, opportunity youth) are not only at high risk for long-term emotional, behavioral, and health problems, but they also represent a loss of human capital, with high social and economic costs. In this article, we offer a public health perspective on opportunity youth by describing their distribution in the population and consequences of their disconnection; proposing a conceptual model of the issue based on epidemiological principles, life course development concepts, and ecological theory; and recommending multisector strategies for preventing disconnection of young people and reengaging opportunity youth. A public health approach to the problem of opportunity youth would involve developing and investing in youth monitoring data systems that can be coordinated across multiple sectors, consolidating both the delivery and funding of services for opportunity youth, developing policies and programs that encourage engagement of young people, and fostering systematic approaches to the testing and scaling up of preventive and reengagement interventions.
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http://dx.doi.org/10.1177/0033354918799344DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6243446PMC
March 2019

Opportunities for Improving Programs and Services for Children With Disabilities.

J Adolesc Health 2018 11;63(5):529-530

University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.

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http://dx.doi.org/10.1016/j.jadohealth.2018.08.004DOI Listing
November 2018

Neighborhoods matter. A systematic review of neighborhood characteristics and adolescent reproductive health outcomes.

Health Place 2018 11 10;54:178-190. Epub 2018 Oct 10.

Philip R. Lee Institute for Health Policy Studies University of California, San Francisco 3333 California Street, Suite 265, San Francisco, CA 94118, USA.

This systematic review examines the relationship between neighborhood characteristics and adolescent pregnancy, contraceptive use, sexual initiation, and birthrate. Several studies found a significant association between higher poverty and increased adolescent birthrate, pregnancy, and earlier age at sexual initiation. Unsafe neighborhoods were associated with earlier sexual initiation and increased adolescent pregnancy. Mixed results were found for neighborhood racial or ethnic composition. Lower collective efficacy and social support were associated with increased rates of adolescent pregnancy and earlier age at sexual initiation. Improved definitions of neighborhoods, as well as research on interactions between structural factors and social processes during adolescence is needed.
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http://dx.doi.org/10.1016/j.healthplace.2018.09.001DOI Listing
November 2018

The discordance between evidence and health policy in the United States: the science of translational research and the critical role of diverse stakeholders.

Health Res Policy Syst 2018 Aug 16;16(1):81. Epub 2018 Aug 16.

Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, 3333 California Street, Suite 265, San Francisco, CA, 94118, United States of America.

Background: There is often a discordance between health research evidence and public health policies implemented by the United States federal government. In the process of developing health policy, discordance can arise through subjective and objective factors that are unrelated to the value of the evidence itself, and can inhibit the use of research evidence. We explore two common types of discordance through four illustrative examples and then propose a potential means of addressing discordance.

Discussion: In Discordance 1, public health authorities make recommendations for policy action, yet these are not based on high quality, rigorously synthesised research evidence. In Discordance 2, evidence-based public health recommendations are ignored or discounted in developing United States federal government policy. Both types could lead to serious risks of public health and clinical patient harms. We suggest that, to mitigate risks associated with these discordances, public health practitioners, health policy-makers, health advocates and other key stakeholders should take the opportunity to learn or expand their knowledge regarding current research methods, as well as improve their skills for appropriately considering the strengths and limitations of research evidence. This could help stakeholders to adopt a more nuanced approach to developing health policy. Stakeholders should also have a more insightful contextual awareness of these discordances and understand their potential harms. In Discordance 1, public health organisations and authorities need to acknowledge their own historical roles in making public health recommendations with insufficient evidence for improving health outcomes. In Discordance 2, policy-makers should recognise the larger impact of their decision-making based on minimal or flawed evidence, including the potential for poor health outcomes at population level and the waste of huge sums. In both types of discordance, stakeholders need to consider the impact of their own unconscious biases in championing evidence that may not be valid or conclusive.

Conclusion: Public health policy needs to provide evidence-based solutions to public health problems, but this is not always done. We discuss some of the factors inhibiting evidence-based decision-making in United States federal government public health policy and suggest ways these could be addressed.
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http://dx.doi.org/10.1186/s12961-018-0336-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6097290PMC
August 2018

Increasing Delivery of Preventive Services to Adolescents and Young Adults: Does the Preventive Visit Help?

J Adolesc Health 2018 08 19;63(2):166-171. Epub 2018 Jun 19.

Division of Adolescent and Young Adult Medicine, Department of Pediatrics, UCSF Benioff Children's Hospital, University of California San Francisco, San Francisco, California.

Purpose: Despite decades of emphasizing the delivery of adolescent preventive care visits and evidence that many preventive services reduce risk, little evidence links preventive visits to increased preventive service delivery. This study examined whether a preventive healthcare visit versus any nonpreventive healthcare visit was associated with higher rates of adolescent and young adult preventive services.

Methods: Analyzed Medical Expenditure Panel Survey data (2013-2015) to determine whether those with a preventive versus nonpreventive healthcare visit had higher rates of past-year preventive services receipt; adolescents (N = 8,474, ages 10-17) and young adults (N = 5,732, ages 18-25). Bivariable and multivariable analyses adjusting for personal/sociodemographic covariates tested for differences in preventive services rates between preventive versus nonpreventive care groups. Adolescent services were blood pressure, height and weight measured, and all three measured; and guidance given regarding healthy eating, physical activity, seatbelts and helmets, secondhand smoke, dental care, all six topics received, and time alone with provider. Young adult services were blood pressure and cholesterol checked, received influenza immunization, and all three services received.

Results: All preventive services rates were significantly higher in those attending preventive visits versus those with nonpreventive visits. Adolescent services increase ranged from 7% to 19% and young adults increase from 9% to 14% (all bivariable and multivariable analyses, p < .001). However, most rates were low overall.

Conclusions: Higher rates of preventive services associated with preventive visits support its clinical care value. However, low preventive services rates overall highlight necessary increased efforts to promote preventive care and improve the provider delivery of prevention for both age groups.
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http://dx.doi.org/10.1016/j.jadohealth.2018.03.013DOI Listing
August 2018

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

BMC Health Serv Res 2018 03 27;18(1):216. Epub 2018 Mar 27.

Philip R. Lee Institute for Health Policy Studies and Bixby Center for Global Reproductive Health, University of California, San Francisco, 3333 California Street, Suite 265, San Francisco, CA, 94143-0936, USA.

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

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

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

Conclusions: This review shows the need for standardization and prioritization of indicators for the evaluation of YFHS. The results can be used to identify a core set of indicators that can be incorporated into a framework for assessing youth-friendly sexual and reproductive health services. There is a need to further distinguish between those variables that may have greatest impact on the use of services by young people, such as respect and privacy, those that impact the quality of services offered, and those that have limited relevance. Conducting more rigorous studies using a refined set of indicators is critical to measure and compare the impact and effectiveness of YFHS efforts.
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http://dx.doi.org/10.1186/s12913-018-2982-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5870922PMC
March 2018

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

Clin Cardiol 2018 Feb 27;41(2):173-178. Epub 2018 Feb 27.

Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts.

Women's health and well-being are shaped by a combination of healthcare policies that impact the type of health insurance coverage they benefit from, as well as access to preventive, screening, and treatment services. Furthermore, more distal policies, such as those that pertain to housing, education, and employment, as well as social determinants of health, such as issues of socioeconomic status and women's status in society, also impact their cardiac health. Before the passage of the Affordable Care Act in 2010, women were at greater risk of facing barriers to coverage, reflecting gender rating and the higher likelihood of the existence of preexisting health conditions such as a previous pregnancy. The ACA made substantial progress in responding to women's health needs by expanding the numbers of low-income groups eligible for Medicaid (for the 32 states and Washington, DC that expanded the program) and other subsidized healthcare, as well as access to preventive health services. Although health reform efforts to eliminate the ACA failed in 2016, the administration and Congress are using a variety of channels, including the new Tax Cuts and Job Act, to implement policies such as the elimination of the individual insurance mandate, as well as the elimination of premium subsidies, that will likely impact women differentially, potentially undoing the progress that has been achieved over the past decade.
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http://dx.doi.org/10.1002/clc.22896DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6490116PMC
February 2018