Research and Practice – Adolescent Health

The ABC Study

Jenny Robinson, Maria Trent, Jean Anderson, Anne Burke
This study explores the contraceptive knowledge, attitudes, and choices of adolescent women living with HIV.

Addressing Transportation as a Social Determinant of Health: Improving Adolescent Access to Services Using the JH HUBLyft Services

Maria Trent
Baltimore, Maryland is a large city whose adolescents and emerging adults face significant health disparities, but engagement in routine health visits for receipt of preventive and health maintenance services declines during this period. Transportation is a major limitation for adolescent health-seeking behaviors and adherence for recommended follow-up visits. In Baltimore, these issues are compounded for low-income youth as Baltimore’s bus and rail system is limited making travel to routine health care visits time-consuming and cumbersome. Further, Baltimore is characterized as one of the most dangerous cities in America and the rates of violent crime in the few miles surrounding the Johns Hopkins Children’s Center is substantial. The Johns Hopkins University School of Medicine is currently offering the highly successful JH SafeRide program in collaboration with Lyft that ensures adult medical students can reach campus and move about the community safely. This proposal seeks to increase adolescent engagement in care by developing health transportation accounts for local teenagers receiving primary care at the Johns Hopkins Center for Adolescent and Young Adult Health (CAYAH) at Harriet Lane to afford them the same opportunities we give to our Hopkins students to reach campus safely for health visits.

Adolescent Reproductive Health Promotion Training Program

Maria Trent
The primary training objectives and goals for this training period are to assist trainees in developing skills in the diagnosis, management, and treatment of the unique medical and psychosocial problems of adolescence and young adulthood, development of significant and innovative research questions using interdisciplinary study designs, development of a primary research study, implementation of a primary research study, secondary data analysis, and development of a grant application.

Better Together

Terrinieka Powell
Better Together is a multiphase project that takes a community approach to reducing substance use among African American adolescents in Baltimore through partnerships with Black churches. There are three phases to this project. First, qualitative methods will be used to better understand interactions and experiences of youth with a drug-abusing parent. Second, we will develop an evidence-based intervention to be appropriate for youth with a drug-using parent. Finally, I will conduct a pilot test of the intervention in partnership with schools and churches in Baltimore City.

cART Adherence in YLHIV: TECH-N-2-CHECK IN

Maria Trent
Human immunodeficiency virus (HIV) infection has disproportionately persisted as a public health threat to adolescents and young adults (AYA) from minority communities in the United States. HIV has evolved into a chronic disease, which can be managed in the outpatient setting with antiretroviral therapy (ART) designed to achieve virologic suppression and life expectancy equivalent for uninfected individuals. However, for AYA, huge disparities exist compared to adults, with greater proportions unaware of their status, lower rates of care engagement, retention, and initiation and maintenance of ART, resulting in higher rates of virologic non- suppression, and development of sequelae including immunologic deterioration and transmission. Interventions designed to improve outcomes for youth living with HIV (YLHIV) are being sponsored by agencies including the Centers for Disease Control and Prevention and the National Institutes of Health, however, most target the early components of the continuum of care (identification, linkage, and ART initiation). Our research from the HIV Research Network shows that 30-40% of YLHIV are not virologically suppressed despite being in care, highlighting the need for novel interventions targeting the distal components of the care continuum. Community health nurse (CHN) interventions have been shown to increase access to appropriate resources, enhance health care utilization, and promote risk-reducing behavior among AYA. Use of short messaging service (SMS) messaging can further enhance clinical care by improving attendance at medical visits, medication adherence, and communication with the health care team. We have used these two modalities in randomized trials of youth with complex sexually transmitted infections (STIs) in low-income minority communities with high feasibility and acceptability amongst AYA and their families, remarkable improvements in visit completion, medication adherence, and reduction in recurrent STIs. The overarching goal of this project is to build on the evidence from this trial and to repurpose the intervention for YLHIV in the same community who are having challenges with care and medication non-adherence. We aim to compare the effectiveness of a technology-enhanced community health nursing intervention (TECH-N 2 CHECK-IN) to a standard of care control group using a randomized trial design. The central hypothesis is that the intervention will result in higher rates of adherence to ART and virologic suppression. We have demonstrated our interdisciplinary team's capacity to follow urban AYA in the community, utilizing the combination of CHNs and outreach workers to optimize care according to national standards. TECH-IN 2 CHECK-IN aims to enroll 120 YLHIV followed at clinics specializing in HIV care in the Baltimore-Washington Metropolitan area who are challenged with treatment adherence and randomizing them to receive TECH-IN 2 CHECK-IN vs. standard of care. Results of this trial will inform best practices for engaging YLHIV by addressing the distal component of the continuum, critical to achieving the elusive 90-90-90 HIV goals.

Developing a Dyadic Intervention for STI/HIV Prevention among STI-Affected Youth

Maria Trent
While public health programs have demonstrated modest success in reducing the adolescent and young adult (AYA) risk for STI/HIV, significant health disparities remain. The risk of STI/HIV is not uniform among AYA. AYA residing in segregated urban communities with high STI prevalence and complicated sexual networks face even greater risk for disease and associated complications. Additional supports designed to increase engagement in care and reduce STI acquisition and transmissions are urgently needed to meet the sexual health and reproductive health goals for the nation. Overwhelmingly, AYA STI prevention interventions have targeted individuals and individual-level factors. While effective, these interventions do not adequately address other important influences affecting AYA risk for STI/HIV, such as partner or relationship influences on sexual decision-making and behavior. Partner notification and treatment is a key strategy for disease control and has previously been tested among adults for STI/HIV prevention work but has yet to be evaluated for AYA. Our prior research demonstrates that AYAs with complicated STIs are likely to notify their partners to seek treatment (88-92%); however, AYAs receiving brief behavioral interventions, relative to those receiving standard of care were 3 times more likely to be successful in arranging for their partner's treatment. Thus, partner interventions may hold promise for harnessing the power of relationship dynamics to enhance sexual decision-making, communication, and subsequent health behaviors. We propose to pilot test an intervention designed to change sexual health outcomes by understanding partners and the learning environment related to sex [COUPLES] by simultaneously delivering two evidence-based STI/HIV prevention interventions Sister- to-Sister Teen and Focus on the Future. The simultaneous delivery of effective interventions will be augmented with a joint partner health education counseling session focused on enhancing communication and negotiation of safe sexual practices within the relationship. If successful, this pilot will support the development of a larger trial designed to evaluate the effectiveness of this approach in the busy primary care setting by providing evidence that AYA can and will safely engage their partners in a supportive primary care setting that integrates high quality treatment with evidence-based STI/HIV prevention interventions delivered by health educator teams.

Developing and Evaluating Life Skills Training Plus

Terrinieka Powell, Phil Leaf, Beth Marshall
This study was the core research project of the Center for Adolescent Health from 2014 - 2019. Through this project, we developed and evaluated the impact of additional Life Skills Training Modules focused on sexual risk taking on the risk behaviors and academic outcomes of Baltimore City middle school students. Additionally, neighborhood and other contextual data were examined the variability in program impact. (Complete)

Early Adolescent Sexual and Reproductive Needs in Refugee Settings

Courtland Robinson
The study explores sexual and reproductive health needs and risks of very young adolescents (10-14) in humanitarian contexts; unaccompanied and separated children in emergencies. The current research takes place in refugee camps and displaced persons settlements at the Thai-Burma and at the Ethopia-Somalia borders. It is a collaboration with the International Refugee Committee’s Womens Refugee Commission.

Effect of Injectable Contraceptives on Inflammation, Microbiota, and STI/HIV Risk Among Adolescents using Injectable Contraceptives

Maria Trent
Adolescent girls and young women who use injectable progestin contraceptives without barrier protection are at risk of acquiring an STI, including HIV. The proposed research is relevant to public health because it seeks to understand the interaction between hormonal contraception, vaginal microbiota, and inflammation that may increase STI/HIVsusceptibility. This knowledge is critical to help inform biomedical interventions to prevent STI/HIV acquisition among adolescent girls and young women.

Evaluation of Sexual Health Curriculum for Health Students in Tanzania

Maria Trent
As documented in the US Surgeon General's Call to Action to Promote Sexual Health and Responsible Sexual Behavior, training of health providers in sexual health care is critical to addressing a broad array of the nation's sexual and reproductive health concerns. Yet rigorous trials evaluating the effects of sexual health curricula on provider behavior are rare. In sub-Saharan Africa, an environment which has the highest rates of HIV, STI, teen pregnancy, unwanted pregnancy, unsafe abortion, child marriage of girls and sexual assault of boys in the world, and where female genital cutting, wife-beating, marital rape, criminalization of homosexuality, stigmatization of Lesbian, Gay, Bisexual and Transgender (LGBT) persons, myths about masturbation leading to dysfunction, and rates of sexual dysfunction in both men and women are common, we could find no formalized training of health providers in sexual health care. Sexual health education, even of health providers, is a sensitive issue in Africa. Consequently, a rigorous study of its effects is needed, if such education is to be widely adopted. Recently, at Muhimbili University of Health and Allied Sciences (MUHAS) in Dar es Salaam, we adapted a PAHO/WHO sexual health curriculum training for healthcare providers for implementation in Tanzania. Participants were 87 nursing, midwifery, and allied health science students. Pre-post evaluations show the curriculum to be highly acceptable, needed, and desired by students, feasible in implementation, and effective in improving student knowledge, attitudes, and skills in providing sexual health care to patients. The logical next step in this line of research is to conduct the first rigorous trial of a comprehensive sexual health training curriculum for health professionals in Tanzania. There are three specific aims. Aim 1 is to conduct a social ecological needs assessment of sexual health care delivery in Tanzania. To determine whether midwifery, nursing, medical, and allied health science students would benefit from one curriculum or separate curricula tailored by discipline, we will conduct focus groups (3 from each discipline). We will also conduct individual interviews with key informants to address structural and cultural issues. In Aim 2, we will further adapt our curriculum, ensure it is culturally tailored to the Tanzanian/sub-Saharan context, and pilot test it. Aim 3 is to evaluate the effectiveness of an African-based, culturally-appropriate, sexual health curriculum. We will conduct a randomized, controlled, single blinded trial of the curriculum against a waitlist control assessing effects on sexual health knowledge, attitudes, and counseling skills (n=206 students per arm; 412 in total). Hypotheses will test if the curriculum is effective, and whether it is more effective for one discipline than another. If effective, MUHAS has committed to implement the curriculum for all their health students. Given MUHAS is preeminent in health student education across Africa, the curriculum assessed in this study has high potential to be widely adopted as a new standard of training for health professionals across Africa.

Faith-based Adolescents Involved in Total Health

Terrinieka Powell, Sam Illangasekare
Focused on those areas of Baltimore where the adolescent pregnancy rates are the highest, this study aims to understand what is currently being done in the churches of those communities to address pregnancy prevention and to identify the potentials and barriers for effective interventions. (Complete)

The Global Early Adolescent Study

Robert Blum, Caroline Moreau, Kristin Mmari, Saifuddin Ahmed, Lori Heise, Leah Keonig, Mengmeng Li, Mark Emerson
The Global Early Adolescent Study (GEAS) seeks to understand how norms, attitudes and expectations about gender influence health outcomes and behaviors across the adolescent period. Building upon formative, mixed-methods research conducted in sixteen countries between 2014 and 2016, the GEAS has collected baseline data from over 13,000 adolescents on five continents since 2017. Additional survey topics include sexual and reproductive health, mental health, body comfort, school retention and empowerment. In four countries, the GEAS is used to evaluate the longitudinal impact of gender-transformative interventions carried out by Rutgers, Netherlands; Save the Children and the Institute of Women and Ethnic Studies. Participating GEAS sites include New Orleans, USA; Cuenca, Ecuador; Santiago, Chile; São Paolo, Brazil; Belgium; Indonesia; Shanghai, China; Kinshasa, DRC; Cape Town, South Africa; and Blantyre, Malawi. Results from the longitudinal GEAS will help to answer important questions about the formation and manifestations of gender inequality, its relationship to health and well-being and the interventions that are effective in promoting gender equality.

Current activities include efforts to improve awareness of and response to ethical issues in research and programming with adolescents living in vulnerable contexts the development of a special supplement using baseline GEAS focused on gender equality. At present, students are involved in manuscript development with partners in China, Ecuador, Bolivia and Malawi. For more information about the GEAS, including our global network of collaborators, recent reports and publications and open-access survey and training instruments, please visit the GEAS website.

Grads2Careers Process Evaluation

Kristin Mmari
In an effort to reduce the number of opportunity youth, Baltimore’s Promise Career Pathways Demonstration Model (Grads2Careers) is a new program that aims to connect recent high school graduates to careers by providing career readiness training, occupational training, and wraparound supports. To understand how Grads2Careers is implemented across various occupational training sites, we are conducting a process evaluation to measure feasibility, acceptability, fidelity, systems change and institutional alignment, as well as overall sustainability and scalability. Process data will provide a rich understanding of the extent to which Grads2Careers is able to develop a clear pathway from high school to employment among opportunity youth, including barriers and facilitators, and its overall contribution to reducing opportunity youth in Baltimore City.

Harriet Lane Clinic’s Title X Program

Arik V. Marcell
Funded by the Baltimore City Health Department to provide reproductive health services to adolescents & young adults who are uninsured, underinsured or seeking confidential services and conduct quality improvement strategies to ensure providers are delivering quality family planning and sexual and reproductive health care services.

Improving the Detection of STIs in the Pediatric Emergency Department: A Pragmatic Trial

Maria Trent
Sexually transmitted infections (STIs) are highly prevalent among adolescents. Despite established principles for STI control, clinical practices related to screening and diagnosis, treatment, and prevention of STIs among adolescents are suboptimal. There is an urgent need to expand our screening programs to nontraditional healthcare settings such as emergency departments (ED) to reach those adolescents who would otherwise not receive preventive healthcare, and to determine the most efficient and cost-effective method for providing this screening. The goal of this application is to leverage our recent insights obtained from single center ED-based adolescent gonorrhea and chlamydia screening research and apply them across a national pediatric ED research network to determine the most clinically effective and cost-effective screening approach for adolescents when implemented into a real-world clinical setting through a pragmatic trial. This will be accomplished through a network of children’s hospital EDs with a track record of robust research collaboration (Pediatric Emergency Care Applied Research Network or PECARN). This research will contribute to the evidence base for creating clinically effective, cost-effective, and sustainable GC/CT screening programs that can be successfully implemented into the clinical workflow of the ED. It will also improve diagnosis of asymptomatic STIs and decrease the time interval to treatment, consequently decreasing reinfection rates of transmission and the overall STI burden as well as decreasing healthcare costs. This intervention will rely on an innovative approach that electronically integrates patient-reported data to guide clinical decision support. This work is significant because it has the potential to shift current ED clinical practice paradigms from only acute health encounters to participation in the broader management of public health, and it will fill gaps in the literature needed to provide evidence for the best method of gonorrhea and chlamydia screening in an ED setting. First, we will apply human factors modeling methods to perform ED workflow evaluations at each participating pediatric ED to determine the most efficient way to integrate the screening process into everyday clinical care. Following these analyses, we will conduct a comparative effectiveness pragmatic trial of targeted STI screening (screening only those disclosing high risk sexual behavior) versus universally-offered STI screening (offered to all, regardless of risk) through electronic integration of patient reported data for provision of clinical decision support. We will then develop decision analytic models to evaluate the cost-effectiveness of targeted screening compared to universally offered screening. This research is novel in that it shifts the usual clinical practice paradigm in the ED from STI diagnosis in symptomatic adolescents to STI screening and prevention, an approach that is critical to addressing the STI epidemic among adolescents.

Medical Consultation for Baltimore City School Based Health Program

Maria Trent
This a service contract for medical oversight for clinical services provided to adolescents by physicians and advanced nurse practitioner staff in school health clinics.

Meaningful Use of Technology to Improve Health Care Delivery (DepoText Project)

Maria Trent
Randomized pilot trial designed to determine the feasibility and acceptability of an SMS program to assist adolescents and young adults who have selected Moderately-long Acting Reversible Contraceptives (MARCS) with clinic attendance at family planning appointments. To learn more, visit the Meaningful Use of Technology to Improve Health Care Delivery page.

Prevention in Churches

Terrinieka Powell
To better understand the influence, if any, of churches on HIV risk and protective behaviors among young adult (ages 18-25) Black men who have sex with men (BMSM) by 1) exploring the relationship between HIV risk and protective behaviors (e.g., HIV testing, condom and substance use) and experiences in churches among BMSM and 2) assessing the extent to which churches can increase HIV voluntary counseling and testing (VCT), risk reduction, and health promotion among BMSM. (Complete)

Project Connect Baltimore

Arik V. Marcell
CDC-funded program to evaluate school and community-based methods to engage males in HIV/STD testing and sexual and reproductive health care in Baltimore City by training youth-serving professionals on a web-based clinical services provider guide for male-specific clinical services (Y2CONNECT.org). Current work includes sustainability of Y2CONNECT.org that has been expanded into a comprehensive youth resource for Baltimore City.

Quality improvement to integrate HIV testing in the Harriet Lane Clinic’s Title X Program

Arik V. Marcell
Funded by the Office of Population Affairs, the goal of this program is to integrate rapid HIV testing as part of Title X services and increase the proportion of clients receiving HIV test results and evaluate increased use using rapid Plan-Do-Study-Act cycles.

Technology Enchanced Community Health Nursing to Reduce Recurrent STIs after PID

Maria Trent
This study examines the efficacy of a technology-enhanced community health nursing intervention on adherence to PID treatment recommendations and subsequent short-term sexually transmitted infection acquisition using a randomized controlled trial.

Text4Father

Arik V. Marcell
Funded by the NIHCD, this study evaluates the feasibility, acceptability, and preliminary efficacy of Text4Father among first-time lower income fathers. Text4Father is a text messaging educational program delivered from mid-pregnancy through 2 months of postnatal age.