Att 2c_Response to public cmet from SisterLove, Inc.

Attachment 2c: Point by point response to public comment from SisterLove, Inc.

1. Issue (a): SLI recommends that social determinants of health must be taken into account when grouping girls ages 14-18 across the United States as one category in order for the proposed information to have practical utility to the agency.

We agree with SLI in that the social determinants provide an important lens through which we can better understand all the factors that affect health outcomes in a population. Healthy Teen Network, the subcontractor leading the research efforts, embraces a Youth 360^o frame in all of their work. Youth 360^o promotes moving beyond focusing only on individual behaviors to address the social determinants of health, to achieve better outcomes for all young people. In alignment with our frame, we plan to use descriptive statistics to understand the diversity in our sample frame. More specifically, we will disaggregate results based on age, race and ethnicity, geographic location, mother’s education, and sexual experience prior to enrollment. We are collecting information on sexual orientation, but we may have a sample too small for a proper analysis using this variable. Moreover, advanced statistical analyses, such as regression models, using the social determinants we are collecting are dependent on adequate sample size.

2. Issue (c): SLI recommends the agency ensure that the information the girls will be responding to is scientifically accurate and sex-positive information about

contraception, sex, and sexuality – including information on LGBTQ identity and

expression, in order to enhance the quality, utility and clarity of the information collected.

We agree with SLI’s position that youth must receive sexual health information that is scientifically accurate and sex-positive. All the content developed for Crush has been written and developed by Healthy Teen Network. Healthy Teen Network is a leader in the field of adolescent sexual health and is recognized for their high-quality trainings on evidence-based teen pregnancy prevention programs in multiple settings. They have used their knowledge of current evidence-based programs to design and write the content in Crush. They have used a variety of information sources including, but to limited to, government sources (e.g. Centers for Disease Control and Prevention) and national medical organizations (e.g. American Academy of Pediatrics and the American College of Obstetrics and Gynecology) to ensure that the information is aligned with current medical guidelines. In addition, the content has been vetted by Healthy Teen Network staff with clinical training (for medical accuracy) and sexual health education (for a sex-positive approach), and has been further reviewed by subject matter experts at the Centers for Disease Control and Prevention (CDC).

Crush includes most of the information requested by SLI, such as factual information about all effective birth control options, sexual autonomy, sexual consent, and parental notification laws by state.

3. Issue (c) SLI recommends that the Crush app provide scientifically supported information about HIV/AIDS, in order to enhance the quality, utility and clarity of the information received.

We agree with SLI’s suggestions that any HIV/AIDS information included in the application must be scientifically accurate and should not contribute to stigma. Crush includes a comprehensive section on sexually transmitted infections (STIs) which includes brief yet complete information about the infection, transmission, screening tests, treatment and prevention. This information is scientifically accurate and has been reviewed by Healthy Teen Network clinical staff, an adolescent health physician external to the project, and by CDC experts. Although we provide factual and basic information about HIV/AIDS and other STIs, we do not include in-depth information about HIV/AIDS treatment and care, coping, rights, HIV vulnerability, and supporting HIV positive people, as SLI suggests. We do, however, address issues of sexual orientation and gender identity. Crush is a tool mainly for pregnancy prevention. As such, we focused the content on supporting users in birth control access and clinic utilization.

SisterLove, Inc. also requested us to address the following four issues that were not fully discussed in the Federal Registry document.

1. The source of sexual education information provided by Crush.

As previously explained, Crush contains only medically accurate information based on evidence and best practices regarding contraception, clinical care, anatomy and physiology, relationships and infections. We have used only authoritative sources of information to develop each section, including government sources (CDC) and publications from national medical associations. All content has been vetted by clinicians, health educators and CDC experts to ensure the content is accurate, complete, and age appropriate.

2. Whether CDC will differentiate between types of clinics or reasons for a clinic visit in its analysis of the girls’ clinic utilization and, if so, how CDC will factor in these distinctions.

Our analyses will not address the types of clinics participants visit or the reasons they visit a clinic. First, clinic visitation data will be collected by asking them whether they visited a clinic for sexual and reproductive health services in the past three (3) months. We do not ask the reason or type of service they received since it is beyond the scope of this study. The second type of data we collect are participants’ utilization of the Clinic Finder tool programmed in Crush. We will be able to identify the number of times the tool was used, but not if they contacted that specific clinic.

3. What the recruitment process is for girls to participate in the study and whether it ensures that girls from a wide range of backgrounds are included in the study.

We will recruit study participants through diverse channels to attain a representative sample. First, we will use paid ads in popular social media outlets (e.g. Facebook, Instagram and SnapChat) to reach our target population. Second, we will reach out to adults who work with youth (e.g. educators, program managers and social workers) to recruit young women with whom they work. All potential participants will be directed to a website that explains the study and has a link to the study enrollment page. Recruitment, enrollment and data collection will all take place online, can be completed on a smartphone, and can be completed at any time. This will ensure that potential participants are able to enroll privately at times convenient to them.

4. Whether parental consent or notification on the nature and layout of the study is needed in order for the girls to participate in the study.

The IRB approved a waiver of parental consent for minors enrolled in the study. First, the study poses less than minimal risk to participants. In most states women under 18 years old are able to access sexual and reproductive health services without parental consent, and sexual health information, similar to the content contained in Crush, is easily available to all youth on the internet or nurses’ office.