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Reaching adolescents and young adults with accessible health services: Applications to HIV, contraception, and COVID-19


Adolescence and emerging adulthood are critical life stages that shape the trajectory of future health. However, adolescents and young adults are underserved by existing health services, which often fail to overcome the unique barriers to care they face. Achieving universal access to healthcare requires moving beyond service availability to understand and address the myriad interconnected structural, sociocultural, and demographic factors that determine individuals’ level of engagement with health services. Each chapter of this dissertation shares the unifying objective of informing real-world implementation strategies to improve access to essential health services among adolescents and young adults.

In Chapter 1, I present the preliminary impacts of a multifaceted loyalty program intervention on the provision of sexual and reproductive health products and health facility referrals to adolescent girls and young women (AGYW, ages 15-24 years) at drug shops in Tanzania. The intervention was evaluated through a 4-month randomized trial at 20 drug shops in 2019. By the end of the study, the rate of patronage by AGYW customers was four times higher at shops that implemented the intervention than comparison shops. Intervention shops also distributed more HIV self-test kits, contraceptives, and health facility referrals to AGYW than comparison shops over the study period. These results suggest that enhancing private sector drug shops with specialized programs designed around the needs and preferences of AGYW may be an effective strategy to reach them with sexual and reproductive health services.

In Chapter 2, I describe the findings of an integrated COVID-19 symptom and exposure monitoring and testing system piloted in a longitudinal cohort of 2,918 university students and employees in California in 2020. At baseline and endline, participants were tested for active SARS-CoV-2 infection via quantitative polymerase chain reaction (qPCR) test and provided blood samples for antibody testing. Throughout the study, participants who self-reported certain symptoms or exposures in daily surveys were automatically notified to return for additional qPCR testing. Analyses reveal that undergraduate students who were 18-19 years old were more likely than other participants to be diagnosed with SARS-CoV-2 infection via qPCR test, in part due to a superspreader event identified among those living in congregate housing. Test positivity was also higher among participants who recently reported symptoms or household exposures that triggered notifications to test than those without recent symptoms or exposures. Among participants with newly developed antibodies for SARS-CoV-2 at endline, 91% had been diagnosed with incident infection via qPCR test over the study period. These results demonstrate that integrated monitoring systems can successfully identify and link at-risk students to COVID-19 testing when combined with low-barrier entry points to services.

In Chapter 3, I assess HIV knowledge and condom-related beliefs and their associations with HIV testing and condom use in a cross-sectional sample of 6,079 Rwandan secondary school students (ages 12-19 years) surveyed in 2021. Participants’ level of HIV knowledge was high overall, with 74% answering at least 6 of 7 HIV knowledge questions correctly. In contrast, beliefs about condoms were mixed, with participants responding favorably to 4 of 8 condom-related statements on average. Most participants endorsed misconceptions about condoms or did not believe that condom use was appropriate in casual or serious relationships. In multivariable models, having high HIV knowledge was associated with recent HIV testing but not condom use. However, participants with supportive or middling condom beliefs were more likely to report condom use than those with prohibitive beliefs. These results motivate renewed attention to educational gaps about condoms’ value in prevention and school-based interventions to create supportive social norms around condom use among youth.

In summary, this dissertation provides rigorous evidence demonstrating the benefits of tailored, multipronged approaches to reduce barriers to health services experienced by adolescents and young adults. This research also underscores the importance of epidemiologic data analysis as a tool to identify disparities, evaluate impact, and enable evidence-based decision-making to reduce inequities experienced by youth and support health and well-being across the life span.

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