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Study Objective Botswana has a high pregnancy rate among adolescent girls and young women (AGYW). Long-acting reversible contraceptive (LARC) use among AGYW in Botswana is low, despite its high effectiveness for preventing pregnancy. Using an implementation science framework, we assessed barriers and facilitators to LARC implementation among AGYW in Botswana. Design Cross-sectional mixed methods. Setting Gaborone, Botswana. Participants Twenty sexually active AGYW ages 18-24 years; 20 health system stakeholders. Interventions Surveys and semistructured interviews grounded in the Consolidated Framework for Implementation Research. Main Outcome Measures Themes reflecting barriers and facilitators of LARC implementation. Results The median age for AGYW was 22 (interquartile range, 21-23) years. Twenty percent were using an implant and none had ever used an intrauterine device. Barriers and facilitators of LARC implementation spanned factors at each Consolidated Framework for Implementation Research domain: (1) LARC characteristics like side effects; (2) the clinics’ inner settings, including availability of youth-friendly services; (3) characteristics of health system stakeholders, such as LARC skills, and AGYW experiences, attitudes, and beliefs about LARCs; (4) the outer setting external to clinics and Botswana's health system including reproductive health law and policy for minor adolescents; and (5) the implementation process level such as the availability of free or low-cost LARCs. Conclusion We identified multilevel, context-specific factors that affect LARC implementation. Our findings can inform the development of interventions to increase LARC implementation in Botswana by addressing intersecting factors across patient, clinic, health system, and sociopolitical levels, such as providing confidential services to minors and improving LARC training and supply chain pipelines.

Background: Clinical decision support (CDS) is a promising implementation strategy for improving uptake of HIV testing and pre-exposure prophylaxis (PrEP). However, little is known regarding provider perspectives on acceptability, appropriateness, and feasibility of CDS for HIV prevention in pediatric primary care, a key implementation setting. Methods: Cross-sectional mixed methods study utilizing surveys and in-depth interviews with pediatricians to 1) assess acceptability, appropriateness, and feasibility of CDS for HIV prevention, 2) assess optimal timing and contextual barriers and facilitators to CDS implementation, and 3) develop an Implementation Research Logic Model to conceptualize implementation determinants, mechanisms, and outcomes of potential CDS use. Interview scripts were grounded in the Consolidated Framework of Implementation Research. Qualitative analysis utilized a mixed inductive and deductive approach, and quantitative and qualitative data were merged to develop the logic model. Results: Participants (n=26) were primarily white (92%), female (88%), and physicians (73%). Using CDS to improve HIV testing and PrEP delivery was perceived as highly acceptable (median score 5), IQR [4-5]), appropriate (5, IQR [4-5]), and feasible (4, IQR [3.75-4.75]) using a five-point Likert scale. Providers identified confidentiality and time constraints as two key barriers to HIV prevention care spanning every workflow step. With respect to desired CDS features, providers sought interventions that were integrated into the primary care workflow; standardized to promote universal testing yet adaptable to the level of patient’s HIV risk; and addressed providers knowledge gaps and bolstered self-efficacy in providing HIV prevention services. Conclusions: This mixed methods study indicates that clinical decision support in the pediatric primary care setting may be an acceptable, feasible, and appropriate strategy for improving the reach and equitable delivery of HIV screening and PrEP. Design considerations for CDS in this setting should include deploying interventions early in the visit workflow, and prioritizing standardized but flexible designs.

BACKGROUND Data regarding the acceptability, feasibility, and quality of telehealth among adolescents and young adults (AYA) and their parents and caregivers (caregivers) are lacking. OBJECTIVE The aim of this study was to assess the noninferiority of telehealth versus in-person visits by comparing acceptability with respect to efficiency, effectiveness, equity, patient-centeredness, and confidentiality. METHODS Cross-sectional web-based surveys were sent to caregivers and AYA following video visits within an Adolescent Medicine subspecialty clinic in May-July 2020. Proportions of AYA and caregivers who rated telehealth as noninferior were compared using chi-squared tests. Feasibility was assessed via items measuring technical difficulties. Deductive thematic analysis using the Institute of Medicine dimensions of health care quality was used to code open-ended question responses. RESULTS Survey response rates were 20.5% (55/268) for AYA and 21.8% (123/563) for caregivers. The majority of the respondents were White cisgender females. Most AYA and caregivers rated telehealth as noninferior to in-person visits with respect to confidentiality, communication, medication management, and mental health care. A higher proportion of AYA compared to caregivers found telehealth inferior with respect to confidentiality (11/51, 22% vs 3/118, 2.5%, P CONCLUSIONS Telehealth was highly acceptable among AYA and caregivers. Future optimization should include improving privacy, ameliorating technical difficulties, and standardizing at-home methods of obtaining patient data to assure patient safety.

Background Data regarding the acceptability, feasibility, and quality of telehealth among adolescents and young adults (AYA) and their parents and caregivers (caregivers) are lacking. Objective The aim of this study was to assess the noninferiority of telehealth versus in-person visits by comparing acceptability with respect to efficiency, effectiveness, equity, patient-centeredness, and confidentiality. Methods Cross-sectional web-based surveys were sent to caregivers and AYA following video visits within an Adolescent Medicine subspecialty clinic in May-July 2020. Proportions of AYA and caregivers who rated telehealth as noninferior were compared using chi-squared tests. Feasibility was assessed via items measuring technical difficulties. Deductive thematic analysis using the Institute of Medicine dimensions of health care quality was used to code open-ended question responses. Results Survey response rates were 20.5% (55/268) for AYA and 21.8% (123/563) for caregivers. The majority of the respondents were White cisgender females. Most AYA and caregivers rated telehealth as noninferior to in-person visits with respect to confidentiality, communication, medication management, and mental health care. A higher proportion of AYA compared to caregivers found telehealth inferior with respect to confidentiality (11/51, 22% vs 3/118, 2.5%, P Conclusions Telehealth was highly acceptable among AYA and caregivers. Future optimization should include improving privacy, ameliorating technical difficulties, and standardizing at-home methods of obtaining patient data to assure patient safety.