Reviewer 1 Comments

Response

Abstract1.                   The introductory sentence, “Adolescents and young adults (AYAs), especially those from underserved communities, often face barriers to sexual and reproductive health (SRH)”shouId be revised for greater clarity and specificity. The authors should clarify whether they are referring to barriers in accessing SRH services, or to the fact that this population experiences poorer SRH outcomes. Being explicit about the nature of the barriers will help strengthen the opening and better contextualize the focus of the study.

We have clarified this 1^st sentence as suggested and have specifically mentioned disparities faced by Black and Hispanic women.

2.                   The methods section provides a helpful overview of the intervention and the data collection approach; however, several important elements need further clarification and elaboration to strengthen the rigor and transparency of the study:•              Study Design Clarification: While the section identifies this as a pilot study, it does not clearly specify the implementation study design (e.g., mixed methods, hybrid designs, step wedge, quasi experimental etc). Naming the specific design would help readers understand the methodological framework.•              Participant Information: There is no information on participant recruitment, sample size, inclusion and exclusion criteria, or consent procedures. Since both quantitative and qualitative data were collected, it's important to clarify how many participants contributed to each component and how they were selected.•              Setting and Context: The setting (e.g., clinic type, geographic location, or demographic context) is not mentioned. Providing this information is essential for understanding the context of implementation and assessing generalizability.•              Data Analysis: The section mentions that thematic analysis was conducted, but it lacks details about the process. Who conducted the analysis? Was coding conducted independently by multiple researchers? How was inter-raterreliability addressed (if at all)? Also, there is no mention of how quantitative data were analyzed, if at all.

We have clarified in the methods section that this is a pilot implementation study consisted of pre-post app use data and a  case-study  where we examined, how one clinical practice site implemented the intervention using interviews and clinical observations.

Because this is an implementation study, the participants are clinicians and clinic staff.  De-identified data from youth participants was extracted to identify the number of users during the trial period.

We have added a subsection, Setting/context and provided additional information about the clinical setting in the revised manuscript. Specifically, in addition to stating that this SBHC is in Los Angeles, we add that this clinic in an area of high need and serves primarily Latine/Hispanic youth.

We have also specified the data analytic steps that we used.

3.                   The sentence in lines 26-27 that “Between April 2024 and June 2024, a total of 14 students engaged with 26 the RAAPS screener and 10 completed the Health-E You app.” Should be moved to the methodology section. This is not a finding; it is just stating what was happened and when.

Thank you for this recommendation, we have moved it accordingly.

Introduction

1.                   In lines 49—51, the sentence stating, “Those from groups who have been excluded in care often come from underserved communities, and experience disproportionately higher rates of adverse sexual and reproductive health (SRH) outcomes,” lacks clarity. The authors should specify which groups they are referring to. Since reference [2] cited, identifies minority women and adolescent females of all races and ethnicities as being disproportionately affected, it would be more accurate and informative for the authors to explicitly mention these populations. Additionally, the sentence should be restructured for improved readability and precision.

We appreciate the opportunity to provide additional clarity on the disparities in SRH outcomes and report this so that it is consistent with reference #2 as recommended by the reviewer.

2.                   The authors should clarify the specific age group they are referring to, as definitions of age ranges can vary across studies and contexts.

We appreciate this comment and have added more information about the age group in the background and more details about the app participants in the results.

3.                   The authors need to clarify the time period or specific study from which the figures in lines 55-56 are drawn. As written, the sentence feels incomplete, as it references a specific timeframe that is not explicitly stated. Readers should not be expected to search through the cited references to determine the relevant period, this information should be clearly presented within the text.

The timeline of the study is now clearly defined in the methods section.

4.                   In lines 57—58, the term “regular screening” is broad. It would be helpful for the authors to specify what types of screening are being referred to. Providing examples of relevant screenings, such as STI testing, cervical cancer screening, or contraceptive use, and more importantly the screening targeted in the pilot study being reported would add clarity and strengthen the reader's understanding of what is considered critical at this stage.

Thank you for the opportunity to add more information on routine/regular health screenings. We have included this information in the revised manuscript.

Methodology

1.                   The study design is not clearly stated. The authors should specify whether the study employed a hybrid, quasi-experimental, pre-post, mixed methods, or another design. Clearly identifying the study design is essential for understanding the methodological approach and interpreting the findings.

As noted previously in the overall comment about the methods, we have clarified the study design.

2.                   Ethical Considerations: The section does not mention whether the study received ethical approval or how informed consent was obtained. Even for a pilot study, these are critical components that need to be reported.

In addition to providing this information to the editorial team and at the end of the manuscript in additional details section; we have added that “The study received human use approval from the California, San Francisco, Internal Review Board” in the methods section

3.                   The authors need to clarify that two distinct participant groups—students and healthcare workers, were involved in the study, and clearly explain how each group was recruited. Additionally, the inclusion and exclusion criteria for each group should be specified. The sampling method should also be described, along with information on whether and how informed consent was obtained from participants.

Because this is an implementation study, the participants are clinicians and clinic staff.  We have clarified that only de-identified data from youth participants was extracted for the sole purpose of identifying the number of app users during the trial period. Because this is an evidence-based practice tool that is being implemented in a real-world setting, apps users are not participating in a research study and their use of the app is part of regular clinic practice.

4.                                     The authors should specify how many participants were involved in the quantitative and qualitative components of the study, respectively. Additionally, the rationale for determining these sample sized should be provided, including any consideration or calculations used to justify their adequacy, or any previous sources cited that used similar approach.

We have clarified in the methods section that all clinic staff and clinicians were invited to participate. This was in order to capture the perspectives of everyone at this SBHC. To assess the reach of the app at this clinic site (as part of the Re-Aim framework), clinic staff were instructed to offer the app to all adolescent females (14-19 years of age).

5.                   How was the quantitative data collected? Which implementation science measures were used? It is important to describe the measures and their sources. By the way, each component of the framework is a construct and had a measure associated with it that the authors could use to measure the implementation of their intervention.

We have clarified that de-identified data was gathered from the back-end of the app which provided information on race/ethnicity, sexual activity status, method of current contraceptive use, app recommendations for contraceptive use, and the method the sexually active adolescents’ were most likely interested in using after completing the app (including the option, “I’m not ready to select a method.” This is provided in the results.

6.                   How was quantitative data analyzed? Was any software used?

As noted in the paper, descriptive analyses were used. Because of the small sample, no statistical software was used.

7.                   How was qualitative data analyzed? There is need to describe the steps followed in this thematic analysis. Also, identify the analytic approach used, and give references. The description of the qualitative data analysis appears to be insufficient. More information is needed about the research assistant involved, specifically, their qualifications and role in the analysis process. It is unclear why the authors did not participate in the data analysis themselves or how they ensured the rigor and trustworthiness of the findings. The authors should clarify whether the data were validated and whether any experts reviewed or verified the interpretations to strengthen the credibility of the analysis. Was member checking of the data analysis done?

The revised manuscript provides additional details on how the coding scheme was developed and how the qualitative data was analyzed.

8.                   The authors should consider including a visual representation of the RE-AIM framework to illustrate how it was applied in the study. A figure or diagram would help readers better understand the framework's integration into the research design and analysis.

Thank you for this suggestion. We have added in a figure of the Re-Aim framework and provided the reference for this figure.

Results

9.                   There is need to describe the sample. Authors can add a sociodemographic characteristics table.

The results section states that all adolescents were from Hispanic backgrounds and we have added in the mean age of the participants. 

10.                Some information, such as lines 207 to 207 needs to be put in the methodology section. Any information related to how and what kind of data was collected, any information regarding how the intervention was implemented, how the participants engaged with the apps and how often, needs to be put under methodology. The results section should include findings related to reach, effectiveness, adoption, implementation, and maintenance.

Thank you for this suggestion, as a result, we have reorganized the methods and the results. The results are significantly improved due to the suggestion reorganization related t0 the Re-Aim framework.

11.                The sentence in line 213 that “Clinic site visits and technical assistance calls corroborated these main themes” is not clear. Please clarify.

We have clarified this sentence to read: “Many of the themes that emerged during the interviews were also observed during the two site visits to the clinic and were documented and addressed during the T.a. calls.”

12.                Each quotation presented should be accompanied by a brief description of the individual who provided it. Since quotations reflect the perspectives of specific participants, it is important to include identifying details, such as role, age group, or other relevant characteristics in parentheses at the end of each quote to provide context and enhance the credibility of the findings.

We have gone back through the interviews and provide the staff role for each of the quotes.

13.                The methodology indicates that both qualitative and quantitative data were collected; however, the findings from the quantitative component are not presented. Additionally, there is no integration of the quantitative and qualitative results. If the authors intend to report only the qualitative findings, this should be clearly stated. Otherwise, in a mixed methods study, both sets of data need to be presented and meaningfully integrated to provide a comprehensive understanding of the research questions.

We have revised the manuscript to include more details on the quantitative analysis. See Table1 and expanded results section.

Discussion

We agree with the reviewer’s assessment and have provided a more critical discussion of the study findings.

Thank you for this recommendation, we have provided this in the limitation section of the discussion

We have made a distinction between implications of the research findings and future recommendations.

We appreciate this suggestion and have expanded the discussion accordingly.

References

Thank you for noticing the inconsistencies in reference formatting. We have reviewed the references and made formatting changes based on how other articles are published in this journal. We defer to the editorial staff to make any additional edits/recommendations to the format of the references.

We have revised the references accordingly.