The purpose of this commentary is to highlight some of the key policy changes under the Patient Protection and Affordable Care Act (ACA) that have the potential to improve health care services for adolescents as well as to draw attention to challenges that have yet to be addressed. This commentary stems from our prior policy research, which examined the extent to which the health care needs of adolescents were being considered in the early implementation phases of the ACA. This study was informed by a literature review and interviews with health care administrators, health policy researchers, and adolescent medicine specialists. The ACA has significantly expanded health insurance access; however, inequities in coverage and access remain. Primarily, the structure and financing of adolescent health care needs to be improved to better support the delivery of patient-centered, comprehensive care for this special population. Additionally, improvements in youths' awareness of their benefits under the ACA as well as a greater appreciation of preventive visits are critical. Furthermore, an unanticipated consequence of the ACA is that it exacerbates the risk of confidentiality breaches through explanation of benefits and electronic health records, which can compromise adolescents' access and utilization of health care services. Greater attention to improving and sustaining health promoting behaviors within the context of the ACA is critical for it to truly have a positive impact on adolescent health.

The Affordable Care Act (ACA) has expanded the enrollment of young people in insurance plans and aims to increase access to preventive health services. For adolescents and young adults to fully utilize these services, access to confidential care is critical, especially for sensitive services, like sexual and reproductive health care. With this expansion, the ACA inadvertently exposes more individuals (especially those with private insurance) to confidentiality breaches through routine communications in the form of Explanation of Benefits (EOBs) sent to policyholders (typically the parent). This commentary is based on a qualitative study of individual, semi-structured telephone interviews with 31 health care administrators, policy experts, clinicians, and health plan representatives. The study identified and examined five main policy options aimed at reconciling confidentiality protections and EOBs. While no one solution emerged, approaches that incorporate automatic system changes that do not require action from the patient or provider for protections to take effect were considered most effective for protecting confidentiality. The review of these policy options are designed to inform states and health care advocates confronting this issue. In addition, since many of these approaches are new, a better understanding of how they are operationalized and enforced is necessary to truly evaluate their effectiveness.

BACKGROUND: Restrictive gender norms exacerbate health inequalities all over the world. More specifically, they prevent women from seeking preventive health services, constrain womens economic empowerment, and are associated with reproductive health decision making. Gender norms, a subset of social norms, are dynamic and change over time. However, we lack data on how they are changing and how these changes affect health outcomes because current measures do not adequately capture the complex concept of gender norms. METHODS: We originally developed and validated a gender norms scale, the G-NORM, in India. In this study, using cross-sectional data, we adapted the G-NORM from Southeast Asia (India and Nepal) to sub-Saharan Africa (Uganda) in four steps: 1. Formulation of new scale items (via qualitative analysis) 2. Cognitive Interviewing 3. Questionnaire Administration (n = 2422 women of reproductive age) and 4. Psychometric analysis (Confirmatory Factor Analysis). RESULTS: Like the original scale, descriptive norms and injunctive norms comprised two unique sub scales with high Cronbachs alphas (.80 & .92). Average scores differed depending on the type of norm suggesting that some gender norms are changing faster than others. Specifically, more equitable injunctive norms were associated with lower odds of partner-dominated contraceptive decision making but descriptive norms were not. CONCLUSIONS: Gender norms serve as a multi-faceted determinant of health and wellbeing and require measurement tools which account for their conceptual complexity. Validating the G-NORM in Uganda expands measurement options for researchers in the sub-Saharan African region working to change norms to reduce health inequalities or to understand the gender normative context before beginning a study.

Research calls for the sexual and reproductive rights field to prioritize gender norms to ensure that women can act on their reproductive rights. However, there is a gap in accepted measures. We addressed this by including important theoretical components of gender norms: differentiating between descriptive and injunctive norms and adding a referent group. Our team originally developed and validated the G-NORM, a gender norms scale, in India. In this paper, we describe how we subsequently adapted and validated it in Nepal. We administered items to women of reproductive age, conducted exploratory and confirmatory factor analysis, and examined associations between the subscales and reproductive health outcomes. Like the original G-NORM, our factor analyses showed that descriptive norms and injunctive norms comprise two distinct scales which fit the data well and had Cronbach alphas of 0.92 and 0.89. More equitable descriptive gender norms were associated with higher decision-making scores, increased odds of intending to use family planning, disagreeing that it is wrong to use family planning, and older ideal age at marriage. Injunctive gender norms were only associated with disagreeing that it is wrong to use family planning. Findings offer an improved measure of gender norms in Nepal and provide evidence that gender norms are critical for agency and reproductive health outcomes.

More than half of women of reproductive age in India are anemic. This study investigates the role of interpersonal communication in increasing the consumption of iron-folic acid supplements. Interventions that increase interpersonal communication may influence and empower individuals and the larger community in promoting behavior change. This investigation uses data from a cluster randomized intervention to understand the pathways by which interpersonal communication mediates the consumption of iron-folic acid supplements. Longitudinal data from control and intervention arms in rural Odisha, India, were collected at baseline (N = 3,691) and 20 months later at end-line (N = 3,394). Structural equation models highlighted the positive role of interpersonal communication in mediating iron-folic acid supplement use. This study illustrates that even during social distancing due to COVID-19, strategic interpersonal communication can improve iron-folic acid supplement use. Our results elucidate two key interpersonal communication pathways at play, namely the ritualistic and instrumental pathways in improving health behavior change in the community.

Background

Sexual and reproductive health organizations have been advocating for a human rights-based approach to contraceptive programming for many years, but progress has been slow. Peer social support shows promise to address structural and social barriers limiting women's agency to make and act on decisions related to contraception, but evidence-based models are lacking. Informed by Social Support Theory and the Contraceptive Agency Framework, we used human-centered design to develop "I-CAN", a community-based peer mentorship intervention in which experienced contraception users in Uganda provide tailored support to peers to promote agency and self-efficacy to use self-injectable contraception among women interested in this method. We conducted a six-month pilot of I-CAN and report here on qualitative findings from a longitudinal study exploring I-CAN's social support mechanisms.

Methods

We conducted serial in-depth interviews with n = 25 women who received mentorship at baseline, three months, and six months in 2023. We conducted parallel interviews with a comparison group (n = 15) without the intervention. Women were purposefully sampled for diversity in contraceptive use, district, and age. We analyzed interviews using a codebook informed by I-CAN's theory of action.

Results

We identified two primary ways in which I-CAN peer social support appeared to improve mentee agency more than existing social support in the control group: (1) improved contraceptive knowledge, particularly allaying side effect concerns, and (2) improved ability to act on contraceptive preferences via communication with unsupportive partners, covert use, or accessing contraceptive services or products. Less prominent changes compared to the control included improved self-efficacy to self-inject and perceived control over and consciousness of the right to contraceptive choice.

Conclusions

Underpinned by a human rights-based approach to contraception, the I-CAN intervention, shows promise that locally tailored peer social support models can effectively improve contraceptive agency, particularly related to knowledge and partner communication.

Much of the methodological literature on rapid qualitative analysis describes processes used by a relatively small number of researchers focusing on one study site and using rapid analysis to replace a traditional analytical approach. In this paper, we describe the experiences of a transnational research consortium integrating both rapid and traditional qualitative analysis approaches to develop social theory while also informing program design. Research was conducted by the Innovations for Choice and Autonomy (ICAN) consortium, which seeks to understand how self-injection of the contraceptive subcutaneous depot medroxyprogesterone acetate (DMPA-SC) can be implemented in a way that best meets women's needs, as defined by women themselves. Consortium members are based in Kenya, Uganda, Malawi, Nigeria, and the United States. Data for the ICAN study was collected in all four countries in sub-Saharan Africa. In order to both illuminate social phenomena across study sites and inform the program design component of the study, researchers developed tools meant to gather both in-depth information about women's contraceptive decision-making and data targeted specifically to program design during the formative qualitative phase of the study. Using these two bodies of data, researchers then simultaneously conducted both a traditional qualitative and rapid analysis to meet multiple study objectives. To complete the traditional analysis, researchers coded interview transcripts and kept analytical memos, while also drawing on data collected by tools developed for the rapid analysis. Rapid analysis consisted of simultaneously collecting data and reviewing notes developed specifically for this analysis. We conclude that integrating traditional and rapid qualitative analysis enabled us to meet the needs of a complex transnational study with the added benefit of grounding our program design work in more robust primary data than normally is available for studies using a human-centered design approach to intervention development. However, the realities of conducting a multi-faceted study across multiple countries and contexts made truly "rapid" analysis challenging.