Improving Research, Policy and Practice to Address Unique Sexual and Reproductive Health Care Needs of an “Elusive” Population of Women

Abstract

Emerging adult-aged women (18–25 years old) have the highest rates of unintended pregnancy and sexually transmitted infections. Despite disproportionate risk, women’s sexual and reproductive health during emerging adulthood is poorly understood. As a result, few age-specific policies or patient-centered practice guidelines are available to reduce sexual risk. This commentary explores the unique characteristics of emerging adulthood contributing to higher sexual and reproductive health risks for women. Current evidence on sexual and reproductive health outcomes of emerging-adult aged women and limited practice guidelines are discussed. Recommendations for health care providers, especially nurses, guiding personalized care for emerging adult-aged women are discussed.

Précis:

Providers must incorporate age-specific sexual and reproductive care for emerging adult-aged women who have unique needs and are oftentimes absent from the healthcare system.

Personalized care targeting women’s sexual and reproductive health (SRH) is essential to improve health outcomes for women and their potential offspring. Compared to men, women suffer disparate poorer SRH outcomes and disproportionate SRH risk, especially women aged 18–25 years-old (Centers for Disease Control and Prevention [CDC], 2019). Current literature is inconsistent in defining and classifying those within the emerging adulthood life course stage (18–25 years) as emerging adults (Carvajal et al., 2017; Cohen et al., 2017; Downey et al., 2017; Gomez & Freihart, 2017; Hoopes et al., 2018)—referred to here as emerging adult-aged (EA) women. A paucity of literature exists targeting emerging adult-aged women’s SRH risk and care needs. Consequently, little is known about the personalized sexual and reproductive health care needs of EA women, limiting the ability of healthcare providers to appropriately care for this vulnerable and at-risk population. To be most effective, health care providers must strive to provide SRH care in a culturally responsive and personally acceptable manner that targets the unique challenges to access and utilization of services during this critical developmental time period.

This commentary explores the unique characteristics of emerging adulthood contributing to higher SRH risks for women. Current disparities and practice guidelines present in the scientific and practice literature are examined. Recommendations for health care providers delivering sexual and reproductive health care, especially nurses on the front lines of care management, are provided. The scientific community’s theoretical understanding of emerging adulthood guides health care practice driving the care of emerging adult-aged women suffering from missed opportunities for SRH care and poorer SRH outcomes.

Research on Emerging Adulthood and Emerging Adult-aged Women

Emerging adulthood has garnered increasing attention within the developmental science field over the last two decades (Arnett, 2000). Emerging adulthood (aged 18–25 years) is characterized as a time of volatility, changing dependence, and increased risky behaviors (Arnett, 2000). At the same time, emerging adults are also increasing independence from families and gaining personal responsibility for their own healthcare decisions (Blum et al., 1993; White et al., 2018). Consequently, at the time of greatest SRH risk and vulnerability (CDC, 2019), EA women may navigate the healthcare system without the assistance or support of family or other caregivers.

Arnett (2000) states emerging adulthood stands apart from both adolescence and adulthood as a unique period of developmental tasks and life experiences. In Western society, this lifecourse stage results from an increasingly delayed transition to marriage and financial independence often seen in industrialized countries (Arnett, 2000). Arnett describes the developmental period as a “distinct period of the life course, characterized by change and exploration of possible directions,” (Arnett, 2000, p. 469) and refers to the period as unpredictable and experimental. During emerging adulthood, one’s experience with the adolescent to adult role transition varies by personal life experiences and socio-demographic factors such as education, neighborhood, and income (Arnett & Tanner, 2011). For example, women with options to further their education by attending college are more likely to experience a longer transition from adolescence to adulthood than women who enter the workforce immediately after leaving the primary education system.

Historically, the transition to adulthood has been defined using proxy social measures such as marriage, career settlement, or birth of a child (Hogan & Astone, 1986) and legally using an arbitrary cutoff age of 18 years. In contrast, EA women themselves describe their own transition to adulthood as “accepting responsibility for one’s self, making independent decisions, and becoming financially independent” (Arnett, 2000, p. 473). Important differences between proxy measures, legal definitions, and emerging adult-aged women’s own definitions limit the scope and usefulness of current women’s health practice guidelines.

One’s own definition of the transition to adulthood contributes to large variations in defining and describing emerging adulthood across research populations and cultures. This variability presents unique challenges to provide personalized and responsive SRH care to EA women. EA women experience their own transition and progression from adolescence to adulthood variably because of their educational level, income, relationship status, and SRH care needs. For this reason, EA women are conceptualized as a unique sub-population during the emerging adulthood lifecourse period and are the focus of this commentary.

Further complicating the understanding of emerging adulthood, women complete the transition to adulthood at different “speeds” or variability. Consider a 20-year-old woman who meets the definition of emerging adulthood based on age, but she is financially independent from her parent(s) or guardian(s), works full-time, and is married with children. Although she is an EA woman by age, she has completed the developmental transition to adulthood. As health care providers, we must consider the typical developmental needs that one’s age suggest but not generalize our care based on age alone. Some EA women consider themselves “adults” and therefore the nomenclature most appropriate to describe this developmental period is “emerging adult-aged”.

Emerging Adult-aged Women’s Sexual and Reproductive Health

Developmental characteristics of the emerging adult life course period contribute to increased SRH risks. Specifically, volatility (discussed earlier) and the multitude of changes to important social contexts within a short period of time—such as living environments, romantic partnerships, peer and family social support, employment status, educational or skill trade pursuits, and geographic location of residence. EA women have disproportionately high rates of sexually transmitted infections and the highest rate of unintended pregnancy (CDC, 2019; Finer & Zolna, 2016). Despite higher risks, important limitations plague research focused on EA women, in turn preventing a deeper understanding of this sub-population’s unmet health care needs.

Contextual changes during emerging adulthood contribute to challenges or barriers for women to access and utilize SRH services. Contextual factors result in changes to health care providers to seek care, sources to access health care, and often a disruption in SRH care utilization. For example, women in college typically cycle through several SRH providers as they seek care from student health care services or urgent care settings. Multiple changes to health care services are disruptive to SRH preventive care and SRH acute care needs. EA women frequently enter this transitional period with a pediatrician or primary care provider chosen by a family caregiver with access to provider services “at their permanent residence” rather than their college residency. When entering college or secondary schooling, women may transition to an on-campus provider for urgent or preventive SRH health needs rather than continued reliance on their former pediatrician or health care provider from their home residence.

Emerging adult-aged women may also change health care providers due to changing employment status, health insurance coverage, or personally selecting health care providers healthcare providers or health care sources diminish a sense of trust in the health care systems and the providers that serve them. Trust in one’s health care provider is critical to establishing a positive patient-provider relationship, especially when providing care targeting sensitive needs such as SRH care (Carvajal et al., 2017).

For women, SRH care during emerging adulthood has short-term and long-term consequences on overall health throughout the lifecourse. The immediate or short-term health consequences are tied to higher rates of unintended pregnancy and increased risk of transmission of sexually transmitted infections [STIs] among women during emerging adulthood (CDC, 2019; Finer & Zolna, 2016). Longer-term health consequences may include increased risk of cervical cancer, pelvic inflammatory disease, infertility, ectopic pregnancy, and chronic pain from STI exposure (Cates et al., 1990; CDC, 2015). Other adverse pregnancy or fetal outcomes common to EA women include early-onset of labor, preterm birth, and transmission of disabling infections to newborns (Bowen et al., 2015; CDC, 2015). Figure 1 provides examples of the cascading effects of sexual and reproductive health behaviors and risks during emerging adulthood.

Figure 1.

Cascading Effects of Behaviors and Risks During Emerging Adulthood

Unintended Pregnancy

Nearly half of pregnancies in the United States are unintended and EA women have the highest rates of unintended pregnancies, compared to all other age groups (Finer & Zolna, 2016). Unintended pregnancies are associated with higher maternal and child health risks (Hall, Richards, et al., 2017) and cost U.S. taxpayers an estimated $21 billion in 2010 (Sonfield & Kost, 2015). Other health–related risk behaviors associated with unintended pregnancy are higher rates of illicit substance use, smoking, second-hand smoke exposure, and lower rates of folic acid intake during pregnancy (Dott et al., 2010). Historically, unintended pregnancy has been strongly linked to high risk behaviors, poorer health outcomes, and lack of prenatal care (Hillemeier et al., 2008; Institute of Medicine (US) Committee on Unintended Pregnancy, 1995; Naimi et al., 2003) and little has changed in 10–15 years (Toivonen et al., 2017).

Unintended pregnancy during emerging adulthood can alter academic and career progression, current and future financial stability, and family and peer relationships. Despite long-standing national efforts to reduce unintended pregnancy, it remains a critical health concern. Decades of federal and state policies targeting unintended pregnancy have failed to meaningfully reduce the rates with over half of all pregnancies among 20–24 year-old women being unintended (Finer & Zolna, 2016). Among women 20–24 years of age, over half of unintended pregnancies are a result of imperfect contraceptive adherence (Trussell et al., 2013). Trussel et al. have identified potential savings with increased use of long-acting reversible contraceptives (LARC), however in 2014 only 14.3% of women used LARC methods; EA women have the lowest utilization rates of all ages (Kavanaugh & Jerman, 2018). A better understanding of birth control decision-making and contraceptive choices among EA women is essential. Only after health care leaders have this deeper understanding can policy initiatives follow. Initiatives must expand beyond education of EA women about effective contraceptives. Increased access to LARCs and other contraceptives are the best tools to reduce the burden of unintended pregnancy on the health care system and generate net health care cost-savings.

Sexually Transmitted Infections

Unintended pregnancy is not the only SRH risk plaguing EA women. EA women have the highest national rates of chlamydia, regardless of age or gender, and the highest rates of gonorrhea and syphilis among all women. The rates of all three STIs among EA women have been increasing since 2014 (CDC, 2019). In the United States, the rate per 100,000 of Chlamydial infection among women is 697.2, compared to 380.6 for all men (CDC, 2019). Women between the ages of 20–24 years have a Chlamydial infection rate of 4,064.4 (CDC, 2019). The CDC (2019) also reports women ages 20–24 experience the highest rates of Gonorrhea infection (702.6 per 100,000), compared to all women (145.8) and all men (212.8). Twenty to twenty-four-year-old women also have the highest rate of primary syphilis (10.0 per 100,000) of all women (3.0; CDC, 2019). The disproportionate burden of STIs compounds overall health risk leading to poorer SRH health and poorer general outcomes among EA women when compared to other women of reproductive age (15–49 years).

The Intersection of Age, Gender, Race, and Sexual Identity and Orientation

Sub-populations of EA women demonstrate even greater SRH risks and risk behaviors related to the intersection of age, race, socioeconomic status, and sexual identity and orientation (Cheney et al., 2014). Minoritized emerging adult-aged women are particularly vulnerable to the synergistic effects of SRH risks. Black EA women have the highest rates of non-monogamous sexual partners (Aholou et al., 2017) and, along with Hispanic EA women, are less likely than White EA women to ask partners about their STI status (Cipres et al., 2017). In another study, by Yoauatt et al. (2017), comparing sexual minoritized [lesbian, gay, bisexual, transgender] and non-minoritized [heterosexual] EA women, only 35% of minoritized EA women reported “being out” to their health care provider. This means the majority of sexual minoritized EA women do not disclose their sexuality status to health care providers. Further, less than half of sexual minority EA women reported having a Pap screening or STI test in the previous year (Youatt et al., 2017).

Although minoritized emerging adult-aged women have consistently been found to have the highest SRH risks, assuming that non-minoritized (White) EA women have lower SRH risk is problematic. For example, despite being more likely to ask partners about their STI status, White EA women report the lowest prevalence of condom use (Aholou et al., 2017; Cipres et al., 2017). These trends further indicate the need for personalized and responsive SRH care for EA women. To have a sustainable effect, personalized care for EA women must assess and treat the unique health risks and unmet SRH needs that they experience as individuals. Through personalized care, including comprehensive SRH assessments, gains in the mitigation of SRH risks and poorer SRH outcomes can be achieved in this most vulnerable population.

Overlooking distinct sub-group differences as well as generalizing care need assumptions for EA women results in missed opportunities for health promotion and risk reduction through personalized screening, counseling, and the establishment of a usual source of care. These missed opportunities have life trajectory consequences. Although SRH risks and adverse SRH outcomes among EA women are documented through quantitative studies and public health surveillance, a deeper understanding of EA women’s own perceptions of SRH and SRH care needs is lacking. Only EA women can give us the active voice needed to more fully understand their SRH risks and SRH care needs. Beyond the reliance of age-specific research to guide “evidence-based practice”, health care providers must use current research-based evidence to tailor sensitive care while recognizing personal SRH risks among EA women. Health care providers are challenged to view each encounter with EA women uniquely because EA women experience the transition to adulthood and manage their own SRH and SRH needs individually and uniquely.

Current Policy and Practice Guidelines

Despite the long-recognized SRH risk and SRH care needs of EA women, only recently have federal guidelines on SRH started to report age-specific incidence and prevalence rates of sexual outcomes for women ages 20–24 years (CDC, 2019). Previous surveillance reports reported rates for “women of reproductive age” generally considered ages 15–45 years old (CDC, 2015). This overly broad age range that spans several developmental lifecourse stages distorts age-specific SRH care needs of EA women. To date, age-specific practice guidelines specifically target the adolescent developmental period or more generally “youth” (adolescents and young adults) to guide adolescent SRH care (CDC, 2015). While guidelines targeting youth may be somewhat useful when caring for younger adult women, the guidelines disregard unique characteristics and the disproportionate SRH risks prevalent during the EA period. Simply stated, current SRH guidelines and recommendations do not recognize the personalized care needs of EA women. See Table 1 for the current practice guidelines inclusive of EA women.

Table 1.

Current United States Practice Guidelines for Emerging Adult-Aged Women

SRH Topic	Agency	Age Group	Recommendation	USPSTF Grade
Cervical Cancer	AHRQ	Women ages 21–65	Screen with cytology (Pap smear) every 3 years	A
		Women younger than 21	Do not screen	D
Chlamydial Infection	AHRQ	Non-Pregnant; 24 years and younger	Screen if sexually active; at least annually	A
		Non-Pregnant; 25 years and older; not at increased risk	Do not automatically screen	C
		Non-Pregnant; 25 years and older; At increased risk	Screen; at least annually	A
Genital Herpes	AHRQ	Asymptomatic adolescents and adults	Do not screen for herpes simplex virus	D
Gonorrhea	AHRQ	Sexually active women	Screen for gonorrhea; optimal screening interval unknown in non-pregnant population	B
HIV Infection	AHRQ	Adolescents and adults aged 15 to 65 years	Screen for HIV infections	A
Intimate Partner Violence and Elderly Abuse	AHRQ	Asymptomatic women of childbearing age	Screen women for IPV, and provide or refer women who screen positive to intervention services	B
	ACOG	Non-pregnant women	Screening at routine OB/GYN visits, family planning visits, and preconception visits
Ovarian Cancer	AHRQ	Asymptomatic women without known genetic mutations that increase risk for ovarian cancer	Do not screen for ovarian cancer	D
STIs	AHRQ	All sexually active adolescents	Offer high-intensity counseling	B
		Adults at increased risk for STIs	Offer high-intensity counseling	B
		Non-sexually-active adolescents and adults not at increased risk for STIs	No recommendation	I (Insufficient)
Chlamydia and Gonorrhea: Screening	USPSTF	Sexually active women	The USPSTF recommends screening for chlamydia and gonorrhea in sexually active women age 24 years and younger and in older women who are at increased risk for infection	B
	CDC	Sexually active females aged 25 years or younger	Annual screening for chlamydia; screening for gonorrhea among females at increased risk of infection (<25)
	ACOG	“”	Recommends screening for chlamydia and gonorrhea
	AAP	“”	Recommends routine annual screening

Chart summarized from information provided in Agency for Health Care Research and Quality and U.S. Preventive Services Taskforce published clinical recommendations (Agency for Healthcare Research and Quality, 2014; United States Preventive Services Taskforce, n.d.)

AHRQ Agency for Healthcare Research and Quality, ACOG American Congress of Obstetricians and Gynecologists, USPSTF United States Preventive Services Task Force, CDC Centers for Disease Control and Prevention, AAP American Academy of Pediatrics

The recent shift in reporting age-specific STI rates among women support our overall argument that each age group is unique and must be provided SRH care with this understanding. This is especially important for EA women who suffer from poorer SRH health outcomes and higher SRH risk, compared to other women. Although a favorable start, more specificity in the reporting of SRH rates is needed. For example, although sexual outcomes are reported in an age-specific means, EA women are not classified as a distinct age group. Reported rates still include portions of EA women within other distinct age groups including adolescents aged 15–19 years and young adults aged 25–29 years. To provide more meaningful rates and better understand SRH risk, age ranges should be adjusted as follows: adolescents, 10–17 years; emerging adults, 18–25 years; young adults 26–33 years; adults 33–40 years; and mature adults 41–49 years.

Recent efforts have been made to expand access to women’s health services through the Affordable Care Act (2010) and the Department of Health and Human Services regulations or mandates (Department of Health and Human Services, 2012). Strategies including expanded insurance coverage for low-income childless adults through State Medicaid and insurance exchange programs and dependent coverage up to age 26 years through a parents’ health plan, increased insurance availability for childless EA women previously uninsured at high rates (Sommers et al., 2012). Since the expansion of insurance coverage, the United States has seen increased access to and utilization of well-woman care; increased utilization of contraceptives, and decreased rates of abortion (Jatlaoui et al., 2016; Ranji et al., 2015).

Although meaningful, these efforts fall short in addressing the needs of EA women. For example, the expansion of health insurance coverage to dependent children (age 18–26) is limited to only those individuals who have parents or guardians with private health insurance; this strategy introduces new concerns about confidentiality of care (Leichliter et al., 2017). While the state insurance exchanges provide opportunities for affordable coverage, high premiums and high variation of premium price between plans has limited the expected affordability of the program (Fehr et al., 2019; Semanskee et al., 2017). The addition of no-cost sharing guidelines for certain preventive services increased access and affordability of women’s health services, however no significant change in utilization rates for preventive reproductive services has been found (Arora & Desai, 2016). Moving forward, efforts to encourage use of preventive services and additional policies to assist EA women without parental or guardian assistance or with confidentiality concerns are needed.

Tailored Practice Recommendations

Arnett and Tanner (2006) describe the adolescent-adult transition as volatile and variable. Variability in this transition is a result of distinct personal context shaped by ever changing individual social factors (Arnett & Tanner, 2006). This high variability between women within emerging adulthood creates hurdles for health care providers tasked with delivering preventive and acute SRH care. Although care recommendations or guidelines are useful in describing standards of care generalized to EA women, SRH care needs and personalized care diverge from general recommendations because of the social context and individual SRH needs of each EA woman. Therefore, the use of recommendations or guidelines of care standards for EA women creates a complex health care practice challenge.

Acknowledging emerging adulthood as a unique lifecourse stage allows health care providers to offer age group with tailored counseling, interventions, and information. Although robust and widespread research on the SRH practices of EA women is limited, providers should not, as a result of limited findings, superimpose care guidelines and recommendations for other, distinct, age groups of women onto their care of EA women. What happens when a woman or her behaviors do not match a provider’s assumptions? How is care affected? If a provider assumes a 25-year-old woman is approaching her childbearing years and likely understands the basics of sexual and reproductive health, there may be a missed opportunity to educate in a meaningful and responsive way. That older EA woman may have never received education on basic sexual and reproductive health topics or pregnancy and will then enter her adult years with little preparation or knowledge on healthy childbearing. The theoretical foundation of wide variation in lived experience of EA women should support a method of patient-specific care for these women.

Until we have a better understanding of EA women’s SRH beliefs and behaviors, health care providers should approach their planned care to EA women with more questions than answers; asking women about their SRH priorities and individual beliefs directs SRH counseling and screening. Further, because EA women broadly have highly volatile contextual circumstances between the ages of 18 and 25, health care providers should make concerted effort to build a level of trust that encourages repeat and frequent visits for care. And, in the event that a healthcare provider first sees a woman in an emergency department or clinic, efforts should be made to remind her that insurance coverage supports a yearly visit with a women’s health specialist. Practitioners in emergency departments and clinics can work towards providing primary care resources to women who present for STI and pregnancy testing, as opposed to the simple test, treat, repeat model that is seen now.

Additionally, health care providers with limited time for prolonged counseling can utilize pregnancy intention tools to improve their ability to fit counseling into every visit. Pregnancy intention tools identify a woman’s desire to become pregnant and direct provider counseling based on identified desires. A randomized trial compared use of the One Key Question® and the Family Planning Quotient tools (Baldwin et al., 2018). Each tool was found similarly helpful by women; however, a greater percentage of providers found the One Key Question® (OKQ) tool helpful. The OKQ tool includes one question, “Do you plan to become pregnant in the next year?” and would be useful for providers outside the Women’s Health Specialty. Emergency providers and primary care providers can use the opportunity of every healthcare encounter to utilize this tool with a woman and provide quick and appropriate counseling.

To provide personalized care for a group of women with diverse experiences, providers should approach each EA woman with an inquisitive nature. These Tips for Providers provide basic suggestions for approaching visits with EA women in any setting. Time limitations in offices, clinics, and emergency departments often limit the opportunity for prolonged interactions between women and providers. To improve the ability to utilize these tips, all health professionals can use them, including medical technicians, medical assistants, patient care assistants, licensed practical nurses, registered nurses, physician’s assistants, physicians, or nurse practitioners. Alternatively, the questions presented in Tips for Providers could be provided as a brief survey for women to fill out at the time of her arrival to the office, clinic, or emergency room. Certain questions can be flagged for follow-up during the provider exam.

Using what is known about emerging adult-aged women and current practice guidelines, a list of proposed practice guidelines (see Table 2) is provided as a suggestion for basic screening needs in the EA population. These proposed guidelines should be instituted in tandem with a personalized approach to care delivery (as described above). The guidelines are meant to provide a minimum standard of care for emerging adult-aged women.

Table 2.

Proposed Sexual and Reproductive Health Practice Guidelines for Emerging Adult-aged Women

SRH Topic	Recommendation
Cervical Cancer	Maintain current guidelines
Intimate Partner Violence Screening	Maintain current guidelines
Ovarian Cancer	Maintain current guidelines
Pregnancy Screening and Counseling	Utilize the OKQ tool at every healthcare encounter, at least annually, and provide counseling or refer to a women’s health specialist as needed
STI Screening	Screen at every healthcare encounter, at least annually, by obtaining complete sexual history
STI Testing	Perform testing for multiple STIs with positive screen of any STI; Perform add-on testing for STIs with routine and non-routine serological tests when appropriate and feasible

The Role of Nursing

Emerging adulthood falls in the middle of one person’s lifespan and as the preamble for another. A birth during this period alters the life trajectory of a woman, especially if unintended; and sets the trajectory for the beginning of another life. Nurses have the potential to intervene, provide best recommendations, counsel, educate, and provide preventive care during this period. Nurses have all the qualifications to serve as a guide during this period. With high rates of preterm birth (Martin et al., 2018), infant mortality (Ely & Driscoll, 2019; Singh et al., 2017), and maternal mortality (Creanga et al., 2015) in the U.S. it is important for nursing to address this lifecourse stage as a crucial stage for intervention and health programs.

Nurses, more so than any other health discipline, have the expertise to reach women “where they are.” Nurses practice in every arena, hospitals, clinics, private offices, schools, workplaces, churches, and even grocery stores. Evidence confirms that EA women are least likely to have a usual source of care (Hall, Harris, et al., 2017). They enter and exit the health care system reactively and inconsistently. If nursing were to have a cohesive plan to address the health and well-being of women during this lifecourse stage, a patchwork of providers—nurses in various settings—could create a quilt of care, that could piece by piece improve the health of emerging EA women that supports successful transitions to adulthood, whether they choose to have children or not.

If EA women choose to have children, they will be better prepared to ask questions and investigate their needs further if they have a basic understanding of SRH and healthier decisions. That being said, Nursing must commit to an “inquire and teach” philosophy in practice. The teaching component of nursing provides a great backbone for this philosophy. First, identify a woman’s starting point by asking about basic sexual and reproductive health information and healthy practices. These basics could include basic hygiene, basic anatomy, the menstrual cycle, how to use a condom, how to negotiate safe sex, and how to negotiate condom use. Second, identify the most critical piece of knowledge that must be communicated at that point of care, for example she may report limited knowledge or inaccurate information about her menstrual cycle. Finally, kindly and respectfully provide education on that critical and personalized piece of information. This could be as simple as providing a quick informational session at the time of the visit, providing a pamphlet to take home and read, or providing a list of online resources with informational articles or videos.

Nursing cannot delegate or pass off SRH counseling and education to a scheduled visit with a primary care provider or an Obstetrician/Gynecologist. Nurses must take every interaction as an opportunity to engage. This engagement may not only help one women, but through the “network of women” wherein peers and kin share experience and knowledge, that information may be shared with friends, family, and down the road potential children who will enter the healthcare system with a better understanding of how to care for themselves and their own potential offspring. This patchwork of care, if built on positive encounters, may also encourage additional visits and relationship building with women and their communities, which is especially crucial for emerging adult-aged women who are at a critical period of development and healthcare interaction where relationships are just forming. EA women are leaving their pediatricians office and going on first dates with adult providers who may survive one visit or many years. But each interaction is an important opportunity to build trusting relationships and share accurate knowledge.

Implications for Practice

The United States healthcare system sharply delineates pediatric and adult health care provision. Up until age 18, interacting with the health care system and health care providers is largely the directive of an individual’s guardian(s). Emerging adulthood is the time-period when transitions to independent health care decision-making and care provider choices are made. EA women transition from a dependent role in families to an independent role in their own lives. This transition period also coincides with the initiation of adult health care, resulting in EA women experiencing new independence and self-responsibility for the management of their own health care (Patton et al., 2016). During this lifecourse stage unique SRH care needs also emerge due to riskier sexual practices and higher rates of unintended pregnancy. At the same time EA women face unique challenges in navigating the (often new) health care system. Consequently, SRH care needs of EA women go unmet at a time of greatest need.

A brief gap in health care access and utilization during emerging adulthood often occurs due to changes in the level of parental involvement and financial support (Caal et al., 2013). Although one could argue that a gap in health care is not cause for concern for healthy EA women, EA women bear a disproportionate burden of this gap in care because of their unique SRH needs, higher SRH risk, and poorer SRH outcomes. Consequently, more fully understanding SRH perceptions, health care preferences, and unmet needs of EA women are critically important to not only scientists but also health care providers and policymakers because EA women continue to suffer the most from poorer lifecourse trajectories and poorer long-term health outcomes related to sexual risk behaviors (CDC, 2015).

Sexual and reproductive care needs specific to EA women begins with education, information sharing, and counseling including birth control options, personalized counseling on STIs or unplanned sexual behavior. Preventive care measures also include STI and pregnancy screenings coupled with sexual health assessments to personalize reproductive health education (Bombard et al., 2013). Despite efforts to implement sexual and reproductive health core competencies (Cappiello et al., 2016; World Health Organization, 2011), Levi (2017) found women and health care providers report low uptake of and barriers to SRH counseling. Providers also report low educational opportunities specific to their SRH care (Levi, 2017).

Training and support for SRH education of health care providers to reduce barriers to provision of SRH care and counseling is needed. Further, age-specific education and interventions that are culturally appropriate and evidence-based warrants attention to the emerging adult-aged population. Care geared towards the needs of this sub-population of women is necessary however responsive care is dependent on the production of strong evidence and sufficient age-specific educational opportunities for SRH providers.

Conclusion

EA women suffer from persistent and pervasive disparate poor SRH outcomes. Scientists and health care providers must work in tandem to address EA women’s SRH risk. Together they should support new strategies to provide targeted care to this sub-population of women. Health care providers must start by acknowledging the unique nature of EA women’s SRH and behavioral risks inherent uniquely to this age group and gender. While limited guidelines for care exist, women’s health care providers must rely on comprehensive, sensitive sexual health assessment and counseling skills to provide individualized care that includes personal needs of EA women such as volatile romantic partnerships, sexual risk-taking behaviors, volatile financial status and subsequently health insurance status, and increasing independence. The volatile nature of this life stage contributes to high utilization of emergency and clinic services more often than primary care. Therefore, health care providers outside the women’s health specialty should regard each care encounter in any setting as an opportunity to address SRH risks and to refer women to women’s health specialists for their covered annual women’s health exam. Further, their enhanced capacity to assess and counsel and their widespread placement in every healthcare setting makes nurses uniquely capable of caring for emerging adult-aged women who sporadically access healthcare services. To best meet the needs of EA women, health care providers should approach each encounter without any preconceived assumptions about the SRH care needs of EA women. The opportunity to better understand SRH and to deliver the tailored and personal care for EA women is upon us now.

Tips for providers.

• Don’t make assumptions

• Ask questions

• Be non-judgmental

• Ask about previous care, what was her experience?

• Ask for a complete sexual history at each new encounter

• Ask about new sexual or romantic partners at subsequent encounters

• Ask if she has questions or concerns

• If performing an exam, ask if she has ever had that type of exam

Clinical Implications:

• Health care providers must understand the age-specific sexual and reproductive risks inherent to the emerging adulthood lifecourse stage but not hold strict assumptions. There is high variability among emerging adult-aged women.

• Use an inquisitive and non-judgmental approach when providing care for emerging adult-aged women.

• Emerging adult-aged women use healthcare services inconsistently and sporadically. Nurses work in diverse healthcare settings and may be best suited for reaching this elusive population of women. Providers can utilize every healthcare encounter as an opportunity for assessment and counseling.