Development of the Person-Centered Contraceptive Counseling scale (PCCC), a short form of the Interpersonal Quality of Family Planning care scale

"So that I can trust them with my body:" How people with low incomes who may become pregnant define and prioritize quality reproductive health care

OBJECTIVES

As part of a larger mixed-methods study to better define equity in access to sexual and reproductive health (SRH) care in Georgia, this analysis sought to understand: (1) how individuals define quality care for their SRH services; and (2) how quality of care is salient in their SRH care-seeking.

STUDY DESIGN

From January 2019 to February 2020, we conducted life history interviews with individuals with the capacity to become pregnant in suburban areas in Georgia. We analyzed interviews using thematic analysis.

RESULTS

SRH care quality was shaped by experiences with health center environment, with providers, and with staff. Study participants emphasized elements associated with trusted SRH care such as showing compassion, respecting and non-judging, taking time, providing information, and assuring agency. Participants also voiced a desire for holistic care that addressed the lived experiences of the individual. Participants took quality of care into account when care-seeking but sometimes had to weigh out preferences for quality with issues of affordability.

CONCLUSIONS

Access to quality person-centered care is an essential component of realized access to SRH services. Measures of equitable access and quality should account for experiences of quality care that include both provider and staff interactions as well as the larger healthcare environment and ability to use quality care despite financial constraints.

IMPLICATIONS

Quality family planning care should involve both clinicians and staff to incorporate showing compassion, providing respectful and non-judgmental care, taking time with patients, providing information, assuring agency in decision-making, as well as addressing the lived experiences of individuals.

Evaluating virtual visits for contraceptive counseling: An exploratory study using the Person-Centered Contraceptive Counseling (PCCC) scale, a patient-reported outcome measure

OBJECTIVES

To describe patient-reported quality of care for virtual contraceptive counseling, using the four-item Person-Centered Contraception Counseling (PCCC) scale. Secondary analyses evaluated PCCC scores by patient subgroups.

STUDY DESIGN

From December 2021 to May 2022, we offered an anonymous web-based survey, to English and Spanish-speaking female patients 18 to 45 years old who had virtual visits through two Family Planning offices affiliated with Columbia University/New York Presbyterian Hospital in New York City.

RESULTS

Among 196 respondents, 133 (68%) respondents gave the top score. The proportion who gave the top PCCC score was higher for the faculty-based practice vs. community-based practice (62% vs. 38% respectively, p = 0.02), video vs. telephone (84% vs. 16% respectively, p = 0.01), and English vs. Spanish (86% vs. 14% respectively, p = 0.02); but did not differ for ethnicity (p = 0.34).

CONCLUSIONS

Patient-perceived quality of contraceptive counseling in virtual visits was high, with some disparities seen in the subgroups.

IMPLICATIONS

This exploratory study about contraceptive counseling during virtual visits showed that 68% of survey respondents gave the top box PCCC score. Our work also suggests disparities in patient experiences based on several factors. Future work may expand on nuances of disparities and how these influence care.

Person-centered abortion care scale: Validation for medication abortion in the United States

OBJECTIVE

Medication abortions now make up the majority of abortions in the US, with new service delivery models such as telehealth; however, it is unclear how this may impact patient experiences. The objective of the study is to adapt and validate a person-centered abortion care (PCAC) scale for medication abortions that was developed in a global South context (Kenya) for use in the United States.

STUDY DESIGN

This study includes medication abortion patients from a hospital-based clinic who had one of two modes of service delivery: (1) telemedicine with no physical exam or ultrasound; or (2) in-person with clinic-based exams and ultrasounds. We conducted a sequential approach to scale development including: (1) defining constructs and item generation; (2) expert reviews; (3) cognitive interviews (n = 12); (4) survey development and online survey data collection (N = 182, including 45 telemedicine patients and 137 in-person patients); and (5) psychometric analyses.

RESULTS

Exploratory factor analyses identified 29-items for the US-PCAC scale with three subscales: (1) Respect and Dignity (10 items), (2) Responsive and Supportive Care (nine items for the full scale, one additional mode-specific item each for in-person and telemedicine), and (3) Communication and Autonomy (10 items for the full scale, one additional item for telemedicine). The US-PCAC had high content, construct, and criterion validity. It also had high reliability, with a standardized alpha for the full 29-item US-PCAC scale of 0.95. The US-PCAC score was associated with overall satisfaction.

CONCLUSION

This study found high validity and reliability of a newly-developed person-centered abortion care scale for use in the US. As medication abortion provision expands, this scale can be used in quality improvement efforts.

IMPLICATIONS

This study found high validity and reliability of a newly-developed person-centered care scale for use in the United States for in-person and telemedicine medication abortion.

Strengthening contraceptive counselling services to empower clients and meet their needs: protocol for a two-stage, multiphase complex intervention in Pakistan and Nigeria

BACKGROUND

High-quality contraceptive counselling can accelerate global efforts to reduce the unmet need for and suboptimal use of modern contraceptives. This study aims to identify a package of interventions designed to strengthen in Pakistan and Nigeria and determine their effectiveness in increasing client-level decision-making, autonomy and meeting of contraceptive needs.

METHODS

A multisite, two-stage and five-phase intervention design will start with a pre-formative, formative, design, experimental and reflective phase. The pre-formative phase will map potential study sites and establish the sampling frame. The two-part formative phase will first use participatory approaches to identify clients' perspectives, including young couples and providers, to ensure research contextualisation and address each interest group's needs and priorities followed by clinical observations of client-provider encounters to document routine care. The design workshop in the third phase will result in the development of a package of contraceptive counselling interventions. In the fourth experimental phase, a multi-intervention, three-arm, single-blinded, parallel cluster randomised-controlled trial will compare routine care (arm 1) with the contraceptive counselling package (arm 2) and the same package combined with wider methods availability (arm 3). The study aims to enrol a total of 7920 participants. The reflective phase aims to identify implementation barriers and enablers. The outcomes are clients' level of decision-making autonomy and use of modern contraceptives.

ETHICS AND DISSEMINATION

Ethical approval for this study was obtained from the WHO Scientific and Ethics Review Committee (Protocol ID Pakistan: ERC 006232 and Nigeria ERC: 006523). Each study site is required and has obtained the necessary ethical and regulatory approvals that are required in each specific country. Findings will be presented at local, national and international conferences and disseminated by peer-review publications.

TRIAL REGISTRATION NUMBER

NCT06081842.

A 3-year Retrospective Review of Contraceptive Initiation, Continuation, Switching, and Pregnancy Among Adolescents and Young Adults

PURPOSE

To understand contraceptive use patterns (initiation, switching, discontinuation) as well as associations with pregnancy in adolescents and young adults attending a teen family planning clinic.

METHODS

We performed a chart review of adolescent and young adult patients (ages 12-20) attending a teen family planning clinic in Atlanta, GA between January 1, 2017, and December 31, 2019. Using a standardized abstraction form with quality controls, we collected available data on contraceptive methods used and pregnancy test results during the 3-year period. We analyzed contraceptive use patterns descriptively. We calculated and compared pregnancy incidence according to different contraceptive switch patterns.

RESULTS

Our sample included 2,798 individuals who initiated 2,358 prescribed methods. The most commonly prescribed methods of contraception were the contraceptive injection (28.3%), etonogestrel implant (23.5%) and combined hormonal pill (23.2%). There were 599 discontinuations of prescribed methods; side effects like bleeding and headache were the most cited reasons for discontinuation. Most (75.8%) initiated a moderately or highly effective method after discontinuing a moderately or highly effective method. The incidence rate of pregnancy was highest for those who had discontinued an intrauterine device or implant and started a shorter-acting contraceptive method.

DISCUSSION

Employing patient-centered contraceptive counseling that incorporates contraceptive experiences in addition to facts and allows for exploration and change may be valuable for young people. Successful navigation of contraceptive switches may require additional attention, education, and strategy, which could include hypothetical problem solving, close follow-up, and telehealth or virtual care.

Contraceptive counseling, method satisfaction, and planned method continuation among women in the U.S. southeast

OBJECTIVES

We used the validated Person-Centered Contraceptive Counseling (PCCC) scale to examine experiences with counseling and associations between counseling quality, method satisfaction, and planned method continuation at the population level in two southeastern states.

STUDY DESIGN

We used data from the Statewide Survey of Women, a probability-based sample of reproductive-aged women in Alabama and South Carolina in 2017/18. We included women using a contraceptive method and reporting a contraceptive visit in the past year (n = 1265). Respondents rated their most recent provider experience across four PCCC items. Regression analyses examined relationships between counseling quality and outcomes of interest, and path analysis examined the extent to which method satisfaction mediated the effects of counseling quality on planned continuation.

RESULTS

Over half of participants (54%) reported optimal contraceptive counseling. Optimal counseling was associated with method satisfaction (aPR = 1.16; 95% confidence interval (CI) = 1.04-1.29) in adjusted models. Optimal counseling was marginally associated with planned discontinuation in the bivariate analysis but was attenuated in the adjusted model (aPR = 1.07; 95% CI = 0.98-1.18). In the path analysis, counseling quality influenced method satisfaction (0.143 (0.045), p = 0.001) which influenced planned continuation, controlling for PCCC (0.74 (0.07), p < 0.001). The total indirect effect of counseling quality on planned continuation was significant (0.106 (0.03), p = 0.001), and a residual direct effect from counseling quality to planned continuation was noted (0.106 (0.03), p = 0.001).

CONCLUSIONS

Counseling quality is independently associated with method satisfaction at the population level. The effect of counseling on planned continuation is partially mediated by method satisfaction.

IMPLICATIONS

Interventions to support person-centered contraceptive counseling promise to improve quality of care, patient experience with care, and reproductive outcomes.

Development and evaluation of measures to assess self-determination in peripartum contraceptive decision-making

OBJECTIVES

We aimed to adapt and validate person-centered measures to evaluate various contributors to self-determination in perinatal contraceptive decision-making.

STUDY DESIGN

We developed and administered four scales adapted from existing measures in the context of Self-Determination Theory: the Treatment Self-Regulation Questionnaire (TSRQ), Perceived Competence Scale, modified Health Care Climate Questionnaire, and Important Other Climate Questionnaire. The TSRQ consists of three subscales: autonomous motivation, controlled motivation, and amotivation. We recruited a nonprobability convenience sample of 300 hospitalized postpartum patients in Baltimore, MD, between 2015 and 2016 and administered surveys in English and Spanish. We validated the scales with Cronbach's alpha coefficients, confirmatory factor analysis, and invariance analysis. We examined construct validity by testing correlations between the scales and other person-centered measures, such as satisfaction with counseling.

RESULTS

Cronbach's alpha was >0.8 except for the amotivation subscale. Confirmatory factor analysis was adequate for all scales. Autonomous motivation correlated positively and significantly with perceived competence, health care provider autonomy support, important other autonomy support, and other measures of patient satisfaction.

CONCLUSIONS

We found the four scales to be internally consistent and valid except for the amotivation subscale. We recommend using the autonomous motivation subscale in place of the full TSRQ. The autonomous motivation subscale, Perceived Competence Scale, modified Health Care Climate Questionnaire, and Important Other Climate Questionnaire showed adequate internal consistency, construct validity, and adherence to the expected conceptual structure of the scales.

IMPLICATIONS

Autonomous decision-making is central to ethics and quality of care, especially for contraceptive methods that require a provider for initiation or discontinuation and at more vulnerable times, such as postpartum and postabortion. These scales may help tailor person-centered and autonomy-supportive interventions and programs to improve contraceptive counseling and care delivery.

Tools for patient-centred family planning counselling: A scoping review

Background

The focus of family planning counselling is gradually shifting from the tiered-effectiveness model to patient-centred counselling. Although tools exist that aim to make family planning counselling more patient-oriented without increasing the provider's workload, they are not widely used. This scoping review aims to address this by identifying key tools to make family planning care more patient-centred, reviewing the domains of patient-centred care they address, and identifying gaps in the evidence base.

Methods

We systematically searched PubMed and SCOPUS for documents on 'patient-centred family planning counselling or support' published between 2013 and 2022. Eligibility criteria included discussion of: 1) strategies for providing patient-centred care; 2) interventions using a patient-centred approach; or 3) the impact of patient-centred approaches. We identified tools for patient-centred care, and mapped them against an existing framework of the main domains of patient-centred care. We reported the available evidence of the impact on those tools.

Results

Our scoping review is based on 33 documents. We identified six tools for increasing the patient-centeredness of family planning counselling. None of the tools addressed all domains of patient-centred care. Evidence about the impact of these tools remains scarce. Although there is some evidence about the acceptability of the tools, key evidence gaps include the effect of the tools on quality of care and family planning outcomes.

Conclusions

Family planning implementers should be aware that existing tools differ in the extent to which they address key domains of patient-centred family planning counselling. There is a need for further research on factors that may deter providers from adopting these tools. A larger evidence base is needed to permit a future systematic review to determine the effect of these tools on family planning outcomes, such as method adoption and continuation.

Strategies for obstetricians and gynecologists to advance reproductive autonomy in a post-Roe landscape

The monumental reversal of Roe vs Wade dramatically impacted the landscape of reproductive healthcare access in the United States. The decision most significantly affects communities that historically have been and continue to be marginalized by systemic racism, classism, and ableism within the medical system. To minimize the harm of restrictive policies that have proliferated since the Supreme Court overturned Roe, it is incumbent on obstetrician-gynecologists to modify practice patterns to meet the pressing reproductive health needs of their patients and communities. Change will require cross-discipline advocacy focused on advancing equity and supporting the framework of reproductive justice. Now, more than ever, obstetrician-gynecologists have a critical responsibility to implement new approaches to service delivery and education that will expand access to evidence-based, respectful, and person-centered family planning and early pregnancy care regardless of their practice location or subspecialty.

An Interactive Curriculum to Teach Person-Centered Contraceptive Counseling

Introduction

Following the Dobbs v. Jackson Women's Health Organization Supreme Court decision, it is increasingly important for all providers to be equipped to counsel on contraceptive options. Current curricula are insufficient for medical students to attain competency in contraceptive counseling. Quality contraceptive counseling requires patient-centered communication skills, which are also critical in many other clinical scenarios. Systematic teaching of patient-centered communication is lacking, both in contraceptive counseling and more broadly.

Methods

We developed a person-centered contraceptive counseling curriculum containing a reference guide, 5- to 10-minute interactive online module, and 30-minute formative standardized patient session for clerkship-year medical students. Performance during formative sessions was evaluated using a checklist, with standardized patients and preceptors providing real-time feedback. We used surveys of knowledge, self-perceived skills, and attitudes about patient-centered counseling to compare students who did and did not receive the curriculum.

Results

Twenty-seven students received the new curriculum. The reference guide and online module were easily integrated into a clinical rotation without requiring additional time spent by educators. The formative session required more resources to implement but was valuable for students to solidify the communication skills in the new curriculum. Checklist results showed that students demonstrated many of the counseling skills taught in the module. Survey results about the impact of the new curriculum were promising but limited by the small sample size.

Discussion

The curriculum successfully introduced patient-centered contraceptive counseling skills and provided a valuable practice opportunity. Other sites could adapt components of this curriculum to enhance education in person-centered contraceptive counseling.

Methods and Measures to Assess Health Care Provider Behavior and Behavioral Determinants in Reproductive, Maternal, Newborn, and Child Health: A Rapid Review

BACKGROUND

Health care provider behavior is the outcome of a complex set of factors that are both internal and external to the provider. Social and behavior change (SBC) programs are increasingly engaging providers and introducing strategies to improve their service delivery. However, there is limited understanding of methods and measures applied to assess provider behavioral outcomes and strengthen provider behavior change programming.

METHODS

Using PubMed, we conducted a rapid review of published research on behaviors of health workers providing reproductive, maternal, newborn, and child health services in low- and middle-income countries (2010-2021). Information on study identifiers (e.g., type of provider), select domains from Green and Kreuter's PRECEDE-PROCEED framework (e.g., predisposing factors such as attitudes), study characteristics (e.g., study type and design), and evidence of theory-driven research were extracted from a final sample of articles (N=89) and summarized.

RESULTS

More than 80% of articles were descriptive/formative and examined knowledge, attitudes, and practice, mostly related to family planning. Among the few evaluation studies, training-focused interventions to increase provider knowledge or improve competency in providing a health service were dominant. Research driven by behavioral theory was observed in only 3 studies. Most articles (75%) focused on the quality of client-provider interaction, though topics and modes of measurement varied widely. Very few studies incorporated a validated scale to measure underlying constructs, such as attitudes and beliefs, and how these may be associated with provider behaviors.

CONCLUSION

A need exists for (1) theory-driven approaches to designing and measuring provider behavior change interventions and (2) measurement that addresses important internal and structural factors related to a provider's behavior (beyond knowledge-enhancing training approaches). Additional investment in implementation research is also needed to better understand which SBC approaches are shifting provider behavior and improving client-provider interactions. Finally, theory-driven approaches could help develop empirically measurable and comparable outcomes.

Validation of a measure to assess decision-making autonomy in family planning services in three low- and middle-income countries: The Family Planning Autonomous Decision-Making scale (FP-ADM)

BACKGROUND

Integrating measures of respectful care is an important priority in family planning programs, aligned with maternal health efforts. Ensuring women can make autonomous reproductive health decisions is an important indicator of respectful care. While scales have been developed and validated in family planning for dimensions of person-centered care, none focus specifically on decision-making autonomy. The Mothers Autonomy in Decision-Making (MADM) scale measures autonomy in decision-making during maternity care. We adapted the MADM scale to measure autonomy surrounding a woman's decision to use a contraceptive method within the context of contraceptive counselling. This study presents a psychometric validation of the Family Planning Autonomous Decision-Making (FP-ADM) scale using data from Argentina, Ghana, and India.

METHODS AND FINDINGS

We used cross-sectional data from women in four subnational areas in Argentina (n = 890), Ghana (n = 1,114), and India (n = 1,130). In each area, 20 primary sampling units (PSUs) were randomly selected based on probability proportional to size. Households were randomly selected in Ghana and India. In Argentina, all facilities providing reproductive and maternal health services within selected PSUs were included and women were randomly selected upon exiting the facility. Interviews were conducted with a sample of 360 women per district. In total, 890 women completed the FP-ADM in Argentina, 1,114 in Ghana and 1,130 in India. To measure autonomous decision-making within FP service delivery, we adapted the items of the MADM scale to focus on family planning. To assess the scale's psychometric properties, we first examined the eigenvalues and conducted a parallel analysis to determine the number of factors. We then conducted exploratory factor analysis to determine which items to retain. The resulting factors were then identified based on the corresponding items. Internal consistency reliability was assessed with Cronbach's alpha. We assessed both convergent and divergent construct validity by examining associations with expected outcomes related to the underlying construct. The Eigenvalues and parallel analysis suggested a two-factor solution. The two underlying dimensions of the construct were identified as "Bidirectional Exchange of Information" (Factor 1) and "Empowered Choice" (Factor 2). Cronbach's alpha was calculated for the full scale and each subscale. Results suggested good internal consistency of the scale. There was a strong, significant positive association between whether a woman expressed satisfaction with quality of care received from the healthcare provider and her FP-ADM score in all three countries and a significant negative association between a woman's FP-ADM score and her stated desire to switch contraceptive methods in the future.

CONCLUSIONS

Our results suggest the FP-ADM is a valid instrument to assess decision-making autonomy in contraceptive counseling and service delivery in diverse low- and middle-income countries. The scale evidenced strong construct, convergent, and divergent validity and high internal consistency reliability. Use of the FP-ADM scale could contribute to improved measurement of person-centered family planning services.

Religious affiliation and women's receipt of person-centered contraceptive care: Findings from the National Survey of Family Growth, 2017-2019

OBJECTIVES

To assess patient ratings of person-centered contraceptive care among women of different religious affiliations in the United States.

STUDY DESIGN

Data from the 2017-2019 National Survey of Family Growth and a sample of female respondents ages 15-49 years who received contraceptive services in the past year and completed the Person-Centered Contraceptive Counseling scale (N = 2226).

RESULTS

Catholic and Protestant women had higher odds of reporting overall person-centered contraceptive care (odds ratio [OR] = 1.77, OR = 1.54) compared to respondents without a religious affiliation and net sociodemographic characteristics.

CONCLUSIONS

Women's experiences with person-centered contraceptive care differ based on their religious affiliation.

IMPLICATIONS

Advancing research on the barriers to person-centered contraceptive care is essential for providing quality health care and reproductive autonomy. This analysis suggests that researchers and clinicians should consider how patient religious affiliation shapes patient-provider encounters and patient experiences of person-centered care to promote quality, equitable family planning care.

Massachusetts' innovative policy approach to expanding contraceptive options in primary care

As health systems pivot toward value-based care and as the reversal of Roe vs Wade has significantly decreased access to abortion care in the United States, contraception is increasingly recognized as a high-value health service. However, the United States has a long and troubling history of using contraceptive policies and practices, including forced sterilization, to limit the reproductive rights of people of color and individuals with disabilities. We hope to highlight an innovative program developed by Massachusetts' Medicaid program, which seeks to expand access to long-acting reversible contraception (LARC) within primary care clinics in a way that promotes both value and reproductive justice. This program provides financial incentives for clinics that serve patients with Medicaid to offer LARC to all patients within the primary care space. Unlike LARC programs that exclusively target patients with Medicaid insurance and provide incentivizes based on number of LARC insertions, this policy has the potential to "lift all boats" and expand access to LARC for all patients regardless of payer. Careful evaluation of this program will be necessary to ensure that the intended outcomes-to increase access to LARC, promote reproductive justice, and deliver value to the health system-are achieved.

The status of person-centered contraceptive care in the United States: Results from a nationally representative sample

CONTEXT

The Person-Centered Contraceptive Care measure (PCCC) evaluates patient experience of contraceptive counseling, a construct not represented within United States surveillance metrics of contraceptive care. We explore use of PCCC in a national probability sample and examine predictors of person-centered contraceptive care.

METHODS

Among 2228 women from the 2017-2019 National Survey of Family Growth who reported receiving contraceptive care in the last year, we conducted univariate and multivariable linear regression to identify associations between individual characteristics and PCCC scores.

RESULTS

PCCC scores were high (x ¯ : 17.84, CI: 17.59-18.08 on a 4-20 scale), yet varied across characteristics. In adjusted analyses, Hispanic identity with Spanish language primacy and non-Hispanic other or multiple racial identities were significantly associated with lower average PCCC scores compared to those of non-Hispanic white identity (B = -1.232 [-1.970, -0.493]; B = -0.792 [-1.411, -0.173]). Gay, lesbian, or bisexual identity was associated with lower average PCCC scores compared to heterosexual (B = -0.673 [-1.243, -0.103]). PCCC scores had a positive association with incomes of 150%-299% and ≥300% of the federal poverty level compared to those of income <150% (150%-299%: B = 0.669 [0.198, 1.141]; ≥300%: B = 0.892 [0.412, 1.372]). Cannabis use in the past year was associated with lower PCCC scores (B = -0.542 [-0.971, -0.113]).

CONCLUSIONS

The PCCC can capture differential experiences of contraceptive care to monitor patient experience and to motivate and track care quality over time. Differences in reported quality of care have implications for informing national priorities for contraceptive care improvements.

Development of a clinical questionnaire to support contraception decisions in an adolescent reproductive health clinic in Colorado

CONTEXT

Adolescents need support to make informed decisions about contraception. Few clinical questionnaires exist to help adolescents and their healthcare providers align contraception decisions with patient needs and preferences.

METHODS

Our mixed-methods study involved a convenience sample of English-speaking, female patients aged 13-19 seeking contraception services at an adolescent reproductive health clinic in Colorado, USA. Qualitative interviews informed development of clinical questionnaire items. The questionnaire elicited demographic characteristics, pregnancy and contraception use history, preferred contraception attributes, peer and family involvement, healthcare information and support needs, motivations for contraceptive use, and barriers to contraceptive services. We identified key decision-making factors and reduced the number of questionnaire items through principal components analysis. Using multivariable analyses, we examined the correlation between questionnaire responses and current contraceptive method.

RESULTS

Twenty individuals participated in interviews and 373 individuals completed the preliminary questionnaire with 63 candidate items. We identified five contraceptive decision-making factors: side-effect avoidance (eight items, Cronbach's alpha = 0.84), preferred method attributes (six items, Cronbach's alpha = 0.67), parental involvement (three items, Cronbach's alpha = 0.67), life goals prior to parenting (four items, Cronbach's alpha = 0.88), and access to a contraceptive provider (two items, Cronbach's alpha = 0.92) and nine stand-alone items. In multivariable analyses, we found that questionnaire responses for decision-making factors varied among participants using different contraceptive methods.

CONCLUSIONS

Multiple priorities may influence adolescent contraceptive decisions. This clinical questionnaire can elicit these priorities before or during a healthcare encounter. Future studies should assess generalizability of the questionnaire and examine impact on method choice, continuation, satisfaction, and reproductive health outcomes.

Clinicians' Perspectives and Proposed Solutions to Improve Contraceptive Counseling in the United States: Qualitative Semistructured Interview Study With Clinicians From the Society of Family Planning

BACKGROUND

Contraceptive care is a key element of reproductive health, yet only 12%-30% of women report being able to access and receive the information they need to make these complex, personal health care decisions. Current guidelines recommend implementing shared decision-making approaches; and tools such as patient decision aid (PtDA) applications have been proposed to improve patients' access to information, contraceptive knowledge, decisional conflict, and engagement in decision-making and contraception use. To inform the design of meaningful, effective, elegant, and feasible PtDA applications, studies are needed of all users' current experiences, needs, and barriers. While multiple studies have explored patients' experiences, needs, and barriers, little is known about clinicians' experiences, perspectives, and barriers to delivering contraceptive counseling.

OBJECTIVE

This study focused on assessing clinicians' experiences, including their perspectives of patients' needs and barriers. It also explored clinicians' suggestions for improving contraceptive counseling and the feasibility of a contraceptive PtDA.

METHODS

Following the decisional needs assessment approach, we conducted semistructured interviews with clinicians recruited from the Society of Family Planning. The Ottawa Decision Support Framework informed the interview guide and initial codebook, with a specific focus on decision support and decisional needs as key elements that should be assessed from the clinicians' perspective. An inductive content approach was used to analyze data and identify primary themes and suggestions for improvement.

RESULTS

Fifteen clinicians (12 medical doctors and 3 nurse practitioners) participated, with an average of 19 years of experience in multiple regions of the United States. Analyses identified 3 primary barriers to the provision of quality contraceptive counseling: gaps in patients' underlying sexual health knowledge, biases that impede decision-making, and time constraints. All clinicians supported the development of contraceptive PtDAs as a feasible solution to these main barriers. Multiple suggestions for improvement were provided, including clinician- and system-level training, tools, and changes that could support successful implementation.

CONCLUSIONS

Clinicians and developers interested in improving contraceptive counseling and decision-making may wish to incorporate approaches that assess and address upstream factors, such as sexual health knowledge and existing heuristics and biases. Clinical leaders and administrators may also wish to prioritize solutions that improve equity and accessibility, including PtDAs designed to provide education and support in advance of the time-constrained consultations, and strategic training opportunities that support cultural awareness and shared decision-making skills. Future studies can then explore whether well-designed, user-centered shared decision-making programs lead to successful and sustainable uptake and improve patients' reproductive health contraceptive decision-making.

Person-centred sexual and reproductive health: A call for standardized measurement

Person-centred sexual and reproductive health (PCSRH) care refers to care that is respectful of and responsive to people's preferences, needs, and values, and which empowers them to take charge of their own sexual and reproductive health (SRH). It is an important indicator of SRH rights and quality of care. Despite the recognition of the importance of PCSRH, there is a gap in standardized measurement in some SRH services, as well as a lack of guidance on how similar person-centred care measures could be applied across the SRH continuum. Drawing on validated scales for measuring person-centred family planning, abortion, prenatal and intrapartum care, we propose a set of items that could be validated in future studies to measure PCSRH in a standardized way. A standardized approach to measurement will help highlight gaps across services and facilitate efforts to improve person-centred care across the SRH continuum. PATIENT OR PUBLIC CONTRIBUTION: This viewpoint is based on a review of validated scales that were developed through expert reviews and cognitive interviews with services users and providers across the different SRH services. They provided feedback on the relevance, clarity, and comprehensiveness of the items in each scale.

Prioritizing patient experience: Validation of the person-centered contraceptive counseling measure as a performance measure

OBJECTIVE

A performance measure assessing how often patients experience patient-centered contraceptive counseling can inform quality improvement in contraceptive care and enable efforts to enhance equity in the provision of this care. We sought to test the validity and reliability of the Person-Centered Contraceptive Counseling (PCCC) measure as a performance measure, in preparation for application for endorsement from the National Quality Forum.

STUDY DESIGN

We combined data from two research studies, a statewide quality improvement assessment, and a dedicated data collection effort at nine sites, all collected between 2009 and 2019 at 22 total sites in the United States, to evaluate the validity and reliability of the four-item PCCC measure aggregated at the provider and facility level. We scored the PCCC dichotomously as a "top-box" score of 20 versus less than 20. We assessed reliability using the Spearman-Brown coefficient, and validity by comparing scores on the PCCC to aggregated scores on single-item measures of patient satisfaction.

RESULTS

We included 22 facilities and 34 providers in the analyses. The average PCCC top-box score by provider and facility was 81% and 79%, respectively. We found adequate reliability with panel sizes of 20-50. PCCC scores were strongly associated with the single-item measures of satisfaction. There were notable disparities by race/ethnicity and language (Spanish vs English) in PCCC scores.

DISCUSSION

The PCCC is a valid and reliable performance measure for use at the provider and facility level. The development and use of the measures of patient experience, like the PCCC, is critical for prioritizing patient-centeredness in reproductive health care.

IMPLICATIONS

The PCCC measure can facilitate the identification of gaps and disparities in patient-centered contraceptive counseling and enable quality improvement to promote quality, equitable contraceptive care. Using this measure provides the opportunity to enhance patient experience of care and build trust between contraceptive providers and the communities they serve.

Testing the validity and reliability of the Person-Centered Contraceptive Counseling (PCCC) Performance Measure in a Real-World Contraceptive Access Program

OBJECTIVES

To validate the Person-Centered Contraceptive Counseling (PCCC) patient-reported outcome performance measure and assess for differences by sociodemographic attributes using survey data from a multistate contraceptive access program.

STUDY DESIGN

This analysis explored internal reliability and construct validity of the PCCC using survey data from 1413 patients who visited 15 health centers in Washington state and Massachusetts that had partnered with Upstream USA.

RESULTS

Multiple psychometric indicators provided evidence of reliability and validity. Significant associations between the highest PCCC rating and conceptually-related survey questions (i.e., experience with bias/coercion and shared decision-making) provided further evidence of construct validity.

CONCLUSIONS

Our findings demonstrate that the PCCC is valid and reliable. The results also highlight differences in experience of care by patient-reported race and ethnicity, income level, and language.

A Mixed Methods Study of Contraceptive Counseling and Care at a Federally Qualified Health Center in Maryland

This study examined the experience of contraceptive counseling and care in a Federally Qualified Health Center in Maryland. Patients attending medical visits in 2021 were surveyed using the Interpersonal Quality of Family Planning scale to assess the quality of contraceptive counseling. Medical chart reviews were performed to identify alignment between contraceptive care received, and preferences patients had expressed. Primary care providers, reproductive health providers, and a subgroup of patients were interviewed to further contextualize survey and chart review findings. The average item score for the 94 survey participants was 4.39 (SD: 0.9) out of 5. Factor analysis showed high internal consistency reliability (alpha  =  0.96). Eighty percent of patients received contraceptive care that aligned with their preferences, 4% did not, and 16% lacked clear contraceptive preferences. Qualitative analysis revealed that patients desired more guidance from providers in selecting a contraceptive method, while providers noted logistical and insurance-related barriers to care. While the quality of contraceptive counseling was high, patient experience of care may be improved by implementing team-based care.

"She should support me, she's my doctor:" Patient perceptions of agency in contraceptive decision-making in the clinical encounter in Northern California

INTRODUCTION

Agency in contraceptive decision-making is an essential aspect of reproductive autonomy. We conducted qualitative research to investigate what agency means to patients seeking contraceptive care to inform the development of a validated measure of this construct.

METHODOLOGY

We held four focus group discussions and seven interviews with sexually-active individuals assigned female at birth, ages 16-29 years, recruited from reproductive health clinics in Northern California. We explored experiences in contraceptive decision-making during the clinic visit. We coded data in ATLAS.ti and by hand, compared codes across three coders, and used thematic analysis to identify salient themes.

RESULTS

The sample mean age was 21 years, with 17% of participants identifying as Asian, 23% as Black, 27% as Latinx, 17% as Multiracial/other, and 27% as white. Overall, participants reported active and engaged decision-making in their recent contraceptive visit but noted experiences that had undermined their agency in the past. They described how non-judgmental care allowed them to communicate openly, affirming their ability to make their own decisions. However, several mentioned how unexpected contraceptive side effects after the visit had reduced their sense of agency over their decision in retrospect. Several participants, including those who identified as Black, Latinx, and/or Asian, described prior experiences where pressure to use a contraceptive method had undermined their agency and where they had switched providers to regain agency over their contraceptive decisions.

DISCUSSION

Most participants were aware of their agency during contraceptive visits and how it varied in different experiences with providers and the healthcare system. Patient perspectives can help to inform measurement development and ultimately the delivery of care that supports contraceptive agency.

Evaluating Counseling for Choice in Malawi: A Client-Centered Approach to Contraceptive Counseling

INTRODUCTION

High-quality contraceptive counseling is critical for supporting full, free, and informed contraceptive decision-making. However, the quality of family planning counseling remains poor globally and is too often not tailored to the individual client. The Counseling for Choice (C4C) approach comprises provider tools and training to structure counseling to center clients' self-identified priorities and to provide relevant information and anticipatory side effects counseling.

METHODS

Providers at 25 public and 20 private facilities in Malawi were trained in the C4C approach. Between October and December 2018, we enrolled women seeking contraceptive services in intervention facilities and in matched comparison clinics in a quasi-experimental study. We collected data immediately before and after contraceptive services were received. We used multilevel logistic regression to compare dimensions of women's counseling experience.

RESULTS

Of 1,179 participants, women counseled by C4C-trained providers rated their providers higher on several quality dimensions, including enabling informed decision-making (11.1% of the comparison group rated their provider as excellent versus 34.4% in intervention), respectful care (35.0% comparison versus 51.3% intervention), and information given about side effects (38.1% comparison versus 72.5% intervention).

CONCLUSION

In Malawi, C4C improved the quality of care that clients received and their client experience relative to standard counseling. Counseling approaches that center clients' priorities and provide enhanced anticipatory side effects counseling show promise in improving contraceptive counseling experiences and the quality of care that clients receive.

Where Do Reproductive-Aged Women Want to Get Contraception?

Background: People's preferences regarding how they want to obtain contraception should be considered when building and refining high-quality contraceptive care programs, especially in light of recent shifts to incorporate more telehealth options into contraceptive care due to the coronavirus disease 2019 (COVID-19) pandemic. Methods: Our study is a cross-sectional analysis of population-representative surveys conducted between November 2019 and August 2020 among women aged 18-44 years in Arizona (N = 885), New Jersey (N = 952), and Wisconsin (N = 967). We use multivariable logistic regression to identify characteristics associated with each of five contraception source preference groups (in-person via health care provider, offsite with a provider via telemedicine, offsite without a provider via telehealth, at a pharmacy, or via innovative strategies), and we examine associations between contraceptive care experiences and perceptions and each preference group. Results: Across states, most respondents (73%) expressed preferences for obtaining contraception via more than one source. One quarter indicated a narrow preference for obtaining contraception in-person from a provider, 19% expressed interest in doing so offsite with a provider via telemedicine, 64% for doing so offsite without a provider via telehealth, 71% reported interest in pharmacy-based contraception, and 25% indicated interest in getting contraception through innovative strategies. Those who had experienced nonperson-centered contraceptive counseling reported higher levels of interest in telehealth and innovative sources, and those who expressed mistrust in the contraceptive care system had higher levels of preferring to obtain contraception offsite, via telemedicine, telehealth, and other innovative avenues. Conclusions: Policies that ensure access to a diversity of contraceptive sources, which acknowledge and address people's past experiences of contraceptive care, have the greatest likelihood of closing the gap between people's contraceptive access preferences and realities.

Elevating the patient voice in contraceptive care quality improvement: A qualitative study of patient preferences for peripastum contraceptive care

OBJECTIVE

Patient-centeredness is an important indicator of peripartum contraceptive care quality. Prior work demonstrates how care fragmentation, provider biases, and other factors sometimes undermine the patient-centeredness and quality of this care. To guide the design of future quality improvement interventions, we explored patient preferences for peripartum contraceptive care.

STUDY DESIGN

For this qualitative study, we recruited a convenience sample of individuals receiving prenatal care at the study site and participating in an online survey about their experience of peripartum contraceptive care during February-July 2020. We conducted individual, in-depth, semistructured interviews to assess patients' preferences for peripartum contraceptive care. Using inductive and deductive qualitative content analysis, we evaluated interview data for patient preferences for peripartum contraceptive counseling and organized preferences into domains to inform future quality measurement.

RESULTS

Interviews (lasting 7-26 min) included 21 postpartum individuals, who were largely White with high levels of formal education. Many participants described suboptimal care experiences characterized by insufficient information, inadequate centering of patient values, and, occasionally, disrespectful care. We identified four key themes describing patients' desire for (1) comprehensive, anticipatory information from one's peripartum provider; (2) counseling and decision-making that (a) prioritize patient preferences and values and (b) avoid pressure; (3) care that respects patient feelings and wishes; and (4) provider responsiveness to individual patient preferences regarding timing and frequency of counseling.

CONCLUSIONS

We newly identify four key domains of patient preferences for peripartum contraceptive care. Additional research is needed to understand peripartum contraceptive care preferences among diverse patient populations. Future research should develop validated measures for evaluating the patient experience of peripartum contraceptive care at scale, as part of ongoing efforts to improve the quality and respectfulness of peripartum care.

IMPLICATIONS

Patients want peripartum contraceptive care to provide comprehensive, anticipatory information; elicit and respond to their counseling and decision-making preferences; and demonstrate respect for their wishes.

Understanding quality of contraceptive counseling in the CHARM2 gender-equity focused family planning intervention: Findings from a cluster randomized controlled trial among couples in rural India

OBJECTIVES

The CHARM2 (Counseling Husbands and wives to Achieve Reproductive Health and Marital Equity) intervention engages health care providers to deliver gender-equity and family planning sessions to couples using a person-centered shared decision-making approach for contraception counseling. We previously showed that the intervention improved contraceptive use at 9-month follow-up. We sought to assess whether the intervention was further associated with the quality of care reported by participants and whether the quality of care reported mediated the effect of the intervention on contraceptive use.

STUDY DESIGN

This is a planned secondary analysis of the effect of the CHARM2 intervention on 1201 married couples in rural Maharashtra, India in a cluster randomized controlled trial completed between 2018 and 2020. We assessed the effect of CHARM2 on perceived quality of care as measured by the Interpersonal Quality of Family Planning (IQFP) scale using a difference-in-differences linear regression approach including a mixed-effects model with nested random effects to account for clustering. We assessed whether the association between CHARM2 and modern contraceptive use was mediated by quality of family planning care.

RESULTS

Intervention participants had higher mean IQFP scores than control participants at 9-month follow-up (intervention 3.2, SD 0.6 vs. control 2.3 mean, SD 0.9, p < 0.001). The quality of care reported mediated the effect of the intervention on contraceptive use (indirect effect coefficient 0.29, 95% CI 0.07-0.50).

CONCLUSION

Family planning interventions such as CHARM2, which utilize person-centered shared decision-making contraceptive counseling approaches improve women's perceived quality of care. Effects on quality of care mediate observed effects of the intervention on contraceptive use.

IMPLICATIONS

Contraceptive interventions should focus on improving person-centered outcomes, such as quality of care, rather than contraceptive use targets. By focusing on improving person-centered care, interventions will improve contraceptive use among those who desire a method while meeting the holistic reproductive health needs of clients and couples.

Reduction of the Quality of Contraceptive Counseling (QCC) scale to a short version (QCC-10) in Ethiopia, India, and Mexico

OBJECTIVE

To reduce the Quality of Contraceptive Counseling (QCC) scale to a shortened version, coined the QCC-10, for use in measuring client-reported quality of counseling across varied settings.

STUDY DESIGN

Secondary psychometric analysis of data collected for validating full versions of the QCC scale (QCC-Mexico, QCC-Ethiopia, QCC-India) and expert voting to reduce the original 26 QCC items to a 10-item set.

RESULTS

Exploratory factor analysis revealed a clear one-factor solution for the QCC-10 in each country. Factor loadings were consistently >0.4 for all but two items; both were retained due to their importance to content validity. Internal consistency reliability of the QCC-10 was α=0.8 in Mexico and Ethiopia, and α=0.5 in India. QCC-10 scores were highly and positively correlated with a dichotomous overall measure of client experience and intention to initiate selected method, indicating convergent validity.

CONCLUSION

The QCC-10 offers an innovative, cross-cultural approach to measuring quality in contraceptive counseling. Future efforts should examine its validity and reliability for use globally, with additional exploration of how to best measure negative aspects of care, particularly in India where such items were problematic. Thoughtful, nuanced measurement of client perspectives on their counseling experiences, available via the QCC-10, is critical to monitoring and improving quality of person-centered care and the fulfilment of human rights in contraceptive services worldwide.

IMPLICATIONS

Cross-cultural, person-centered measures of quality in contraceptive counseling, such as the QCC-10, can help inform efforts to improve quality of family planning services and fulfillment of human rights. Future work will continue to explore the validity of this 10-item measure for use in various settings.

Agency in Contraceptive Decision-Making in Patient Care: a Psychometric Measure

BACKGROUND

Patient agency in contraceptive decision-making is an essential component of reproductive autonomy.

OBJECTIVE

We aimed to develop a psychometrically robust measure of patient contraceptive agency in the clinic visit, as a measure does not yet exist.

DESIGN

For scale development, we generated and field tested 54 questionnaire items, grounded in qualitative research. We used item response theory-based methods to select and evaluate scale items for psychometric performance. We iteratively examined model fit, dimensionality, internal consistency, internal structure validity, and differential item functioning to arrive at a final scale.

PARTICIPANTS

A racially/ethnically diverse sample of 338 individuals, aged 15-34 years, receiving contraceptive care across nine California clinics in 2019-2020.

MAIN MEASURES

Contraceptive Agency Scale (CAS) of patient agency in preventive care.

KEY RESULTS

Participants were 20.5 mean years, with 36% identifying as Latinx, 26% White, 20% Black, 10% Asian/Native Hawaiian/Pacific Islander. Scale items covered the domains of freedom from coercion, non-judgmental care, and active decision-making, and loaded on to a single factor, with a Cronbach's α of 0.80. Item responses fit a unidimensional partial credit item response model (weighted mean square statistic within 0.75-1.33 for each item), met criteria for internal structure validity, and showed no meaningful differential item functioning. Most participants expressed high agency in their contraceptive visit (mean score 9.6 out of 14). One-fifth, however, experienced low agency or coercion, with the provider wanting them to use a specific method or to make decisions for them. Agency scores were lowest among Asian/Native Hawaiian/Pacific Islander participants (adjusted coefficient: -1.5 [-2.9, -0.1] vs. White) and among those whose mothers had less than a high school education (adjusted coefficient; -2.1 [-3.3, -0.8] vs. college degree or more).

CONCLUSIONS

The Contraceptive Agency Scale can be used in research and clinical care to reinforce non-coercive service provision as a standard of care.

A Prospective Cohort Study of Changes in Access to Contraceptive Care and Use Two Years after Iowa Medicaid Coverage Restrictions at Abortion-Providing Facilities Went into Effect

Inequities in access to contraception based on ability to pay can interfere with individuals’ reproductive autonomy. This study examines the impact of a 2017 state-level policy in Iowa restricting Medicaid coverage at abortion-providing health care centers on patients’ access to contraceptive care and subsequent contraceptive use. We draw on a unique panel dataset of individuals who originally sought care at a publicly supported family planning site in Iowa in 2018–2019 and then participated in subsequent follow-up surveys every 6 months for 2 years to examine an effect of access to care on contraceptive use. Among our final analytic sample of 368 individuals, our findings indicate that receipt of recent contraceptive care decreased over the study period; this coincided with patients shifting away from getting contraceptive care at sites potentially impacted by the 2017 Iowa Medicaid policy restriction while those getting this care at non-impacted sites remained relatively steady over the study period. At the same time, nonuse of contraception increased while use of a contraceptive method that carries cost, use of a provider-involved method, and satisfaction with one’s method decreased. We find that, after controlling for patient characteristics, those who shifted toward receiving contraceptive care experienced increases in these three contraceptive outcomes. We interpret this as preliminary descriptive evidence demonstrating an impact of disruptions in access to contraceptive care on contraceptive outcomes. Supportive payment and funding strategies for contraception, rather than policies that impede or restrict access, are needed to enable people to realize full reproductive autonomy.

Perceived Contraceptive Counseling Quality Among Veterans Using VA Primary Care: Data from the ECUUN Study

BACKGROUND

High-quality contraceptive counseling is critical to support Veterans' reproductive autonomy and promote healthy outcomes.

OBJECTIVE

To describe perceived quality of contraceptive counseling in Veterans Health Administration (VA) primary care and assess factors associated with perceived high- and low-quality contraceptive counseling.

DESIGN

Cross-sectional study using data from the Examining Contraceptive Use and Unmet Need in women Veterans (ECUUN) national telephone survey.

PARTICIPANTS

Veterans aged 18-44 who received contraceptive services from a VA primary care clinic in the past year (N=506).

MAIN MEASURES

Perceived quality of contraceptive counseling was captured by assessing Veterans' agreement with 6 statements regarding provider counseling adapted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. High-quality counseling was defined as a top score of strongly agreeing on all 6 items; low-quality counseling was defined as not agreeing (neutral, disagreeing, or strongly disagreeing) with >3 items. We constructed two multivariable models to assess associations between patient-, provider-, and system-level factors and perceived high-quality (Model 1) and perceived low-quality counseling (Model 2).

KEY RESULTS

Most participants strongly agreed that their providers listened carefully (74%), explained things clearly (77%), and spent enough time discussing things (71%). Lower proportions strongly agreed that their provider discussed more than one option (54%), discussed pros/cons of various methods (44%), or asked which choice they thought was best for them (62%). In Model 1, Veterans who received care in a Women's Health Clinic (WHC) had twice the odds of perceiving high-quality counseling (aOR=1.99; 95%CI=1.24-3.22). In Model 2, Veterans who received care in a WHC (aOR=0.49; 95%CI=0.25-0.97) or from clinicians who provide cervical cancer screening (aOR=0.49; 95%CI=0.26-0.95) had half the odds of perceiving low-quality counseling.

CONCLUSIONS

Opportunities exist to improve the quality of contraceptive counseling within VA primary care settings, including more consistent efforts to seek patients' perspectives with respect to contraceptive decisions.

Association of Title X clinic status with receipt of person-centered contraceptive counseling: a population-based study

OBJECTIVE

To describe receipt of person-centered contraceptive counseling among reproductive-aged women in the United States who sought contraceptive care at Title X clinics, non-Title X public clinics, and private clinics.

STUDY DESIGN

We conducted a secondary analysis of the 2017-2019 wave of the National Survey of Family Growth (NSFG). The sample included female respondents ages 15-49 who received contraceptive services in the past year and completed the Person-Centered Contraceptive Counseling (PCCC) measure, a quality metric evaluating interpersonal quality of the care received. We used multivariable logistic regression to estimate the predicted probability of receiving person-centered contraceptive counseling by source of care, adjusted for individual-level characteristics.

RESULTS

Of 2,225 (weighted N=26,599,620) eligible respondents, 6.9% received care at a Title X clinic, 8.2% at a non-Title X public clinic, and 84.9% at a private clinic. The adjusted predicted probability of receiving person-centered contraceptive counseling among respondents attending private clinics was 50.6% (95% CI 46.3-54.8%) compared with 51.3% (95% CI 40.4-62.3%) at Title X clinics and 52.4% (95% CI 44.0-60.7%) at other public clinics. Respondents with incomes ≥300% above the federal poverty level (FPL) had higher odds of reporting receipt of person-centered counseling compared to those with incomes below 100% of the FPL (aOR = 2.12; 95% CI 1.47-3.06). Non-Latina Black respondents had lower odds of receiving person-centered contraceptive counseling (aOR = 0.69; 95% CI 0.51-0.94), compared to non-Latina white respondents.

CONCLUSION

Title X clinics perform as well as the private sector in delivering person-centered contraceptive counseling.

IMPLICATIONS

Title X clinics provide quality person-centered contraceptive counseling on par with the private sector, despite serving populations that are often less likely to report high quality care. Broad implementation of the PCCC measure will permit tracking person-centered contraceptive care across diverse practice settings and populations.

Contraceptive self-injection through routine service delivery: Experiences of Ugandan women in the public health system

Contraceptive self-injection (SI) is a new self-care practice with potential to transform women's family planning access by putting a popular method, injectable contraception, directly into the hands of users. Research shows that SI is feasible and acceptable; evidence regarding how to design and implement SI programs under real-world conditions is still needed. This evaluation examined women's experiences when self-injection of subcutaneous depot medroxyprogesterone acetate (DMPA-SC) was introduced in Uganda alongside other contraceptive options in the context of informed choice. We conducted structured survey interviews with 958 randomly selected SI clients trained in three districts in 2019. SI clients demonstrated their injection technique on a model to permit an assessment of injection proficiency. A randomly selected subset of 200 were re-interviewed 10-17 months post-training to understand resupply experiences, waste disposal practices and continuation. Finally, we conducted survey interviews with a random sample of 200 clients who participated in training but declined to self-inject. Data were analyzed using Stata IC/14.2. Differences between groups were measured using chi square and t-tests. Multivariate analyses predicting injection proficiency and SI adoption employed mixed effects logistic regression. Nearly three quarters of SI clients (73%) were able to demonstrate injection proficiency without additional instruction from a provider. Years of education, having received a complete training, practicing, and taking home a job aid were associated with higher odds of proficiency. Self-reported satisfaction and continuation were high, with 93% reinjecting independently 3 months post-training. However, a substantial share of those trained opted not to self-inject. Being single, having a partner supportive of family planning use, training with a job aid, practicing, witnessing a demonstration and exposure to a full training were associated with higher odds of becoming an SI client; conversely, those trained in a group had reduced odds of becoming an SI client. The self-care program was successful for the majority of women who became self-injectors, enabling most women to demonstrate SI proficiency. Nearly all those who opted to self-inject reinjected independently, and the majority continued self-injecting for at least 1 year. Additional research should identify strategies to facilitate adoption by women who wish to self-inject but face challenges.

Telehealth for Contraceptive Care During the COVID-19 Pandemic: Results of a 2021 National Survey

Objectives. To investigate trends in the use and quality of telehealth for contraceptive care during the COVID-19 pandemic in the United States. Methods. The 2021 Guttmacher Survey of Reproductive Health Experiences is a national online survey of 6211 people assigned female at birth, aged 18 to 49 years, and that ever had penile‒vaginal sex. We used weighted bivariable and multivariable logistic regressions to analyze the use of telehealth for contraceptive care and the quality of this care. Results. Of the respondents, 34% received a contraceptive service in the 6 months before the survey; of this group, 17% utilized telehealth. Respondents who were uninsured at some point in the 6 months before the survey had greater odds of using telehealth for this care. Respondents had lower odds of rating the person-centeredness of their care as "excellent" if they received services via telehealth compared with in person (25% vs 39%). Conclusions. Telehealth has helped bridge gaps in contraceptive care deepened by COVID-19. More work is needed to improve the quality of care and reduce access barriers to ensure telehealth can meet its full potential as part of a spectrum of care options. (Am J Public Health. 2022;112(S5):S545-S554. https://doi.org/10.2105/AJPH.2022.306886).

Associations between unfulfilled contraceptive preferences due to cost and low-income patients' access to and experiences of contraceptive care in the United States, 2015-2019

Objective

To identify prevalence of unfulfilled contraceptive preferences due to cost among low-income United States female contraceptive method users and nonusers, and associations between access to, and experience with, contraceptive care and this outcome.

Methods

We drew on data from the 2015-2019 National Surveys of Family Growth to conduct simple and multivariable logistic regression analyses on unfulfilled contraceptive preferences due to cost among nationally representative samples of low-income women ages 15 to 49 who were current contraceptive users (N = 3178) and nonusers (N = 1073).

Results

Overall, 23% of female contraceptive users reported they would use a different method, and 39% of nonusers reported they would start using a method, if cost were not an issue. Controlling for user characteristics, low-income contraceptive users who received recent publicly supported contraceptive care reported significantly higher levels of unfulfilled contraceptive preferences due to cost than those without any access to SRH care (aOR = 1.6, CI 1.0-2.5), while having private (aOR = 0.6, CI 0.4-0.9) or public (aOR = 0.7, CI 0.5-1.0) health insurance was associated with significantly lower levels of this outcome. Nonusers of contraception who had recently received publicly supported contraceptive care also reported marginally higher levels of this outcome (aOR = 2.2, CI 1.0-5.1). Contraceptive users who received recent person-centered contraceptive counseling had marginally lower odds of unfulfilled contraceptive preferences due to cost (aOR = 0.6, CI 0.4-1.0).

Conclusions

Cost is a barrier to using preferred contraception for both contraceptive users and nonusers; health insurance coverage and person-centered contraceptive counseling may help contraceptive users to overcome cost barriers and realize their contraceptive preferences.

Implications

Factors related to contraceptive access at the systems level-specifically the subsidization and experience of contraceptive care-impact whether cost serves as a barrier to individuals' contraceptive preferences. Delivery of patient-centered care and shoring up health insurance coverage for all can help to mitigate cost barriers and enable individuals to realize their contraceptive preferences.

Reimagining Preexposure Prophylaxis Provision for Women in the United States

Structural determinants of health drive inequities in the acquisition of human immunodeficiency virus (HIV) and the use of preexposure prophylaxis (PrEP) for HIV prevention among cisgender women in the United States. However, current PrEP clinical guidance and implementation paradigms largely focus on individual behaviors and characteristics, resulting in missed opportunities to improve PrEP access, and the implicit transferring of prevention work from health systems to individuals. In this viewpoint article, we outline ways to apply a structural lens to clinical guidance and PrEP implementation for women and propose areas for future work.

Feasibility and acceptability of a toolkit-based process to implement patient-centered, immediate postpartum long-acting reversible contraception services

BACKGROUND

National guidelines recommend that maternity systems provide patient-centered access to immediate postpartum long-acting reversible contraception (ie, insertion of an intrauterine device or implant during the delivery hospitalization). Hospitals face significant barriers to offering these services, and efforts to improve peripartum contraception care quality have met with mixed success. Implementation toolkits-packages of resources and strategies to facilitate the implementation of new services-are a promising approach for guiding clinical practice change.

OBJECTIVE

This study aimed to develop a theory-informed toolkit, evaluate the feasibility of toolkit-based implementation of immediate postpartum long-acting reversible contraception care in a single site, and refine the toolkit and implementation process for future effectiveness testing.

STUDY DESIGN

We conducted a single-site feasibility study of the toolkit-based implementation of immediate postpartum contraception services at a large academic medical center in 2017 to 2020. Based on previous qualitative work, we developed a theory-informed implementation toolkit. A stakeholder panel selected toolkit resources to use in a multicomponent implementation intervention at the study site. These resources included tools and strategies designed to optimize implementation conditions (ie, implementation leadership, planning, and evaluation; the financial environment; engagement of key stakeholders; patient needs; compatibility with workflow; and clinician and staff knowledge, skills, and attitudes). The implementation intervention was executed from January 2018 to April 2019. Study outcomes included implementation outcomes (ie, provider perceptions of the implementation process and implementation tools [assessed via online provider survey]) and healthcare quality outcomes (ie, trends in prenatal contraceptive counseling, trends in immediate postpartum long-acting reversible contraceptive utilization [both ascertained by institutional administrative data], and the patient experience of contraceptive care [assessed via serial, cross-sectional, online patient survey items adapted from the National Quality Forum-endorsed, validated Person-Centered Contraceptive Counseling measure]).

RESULTS

In the implementation process, among 172 of 401 eligible clinicians (43%) participating in surveys, 70% were "extremely" or "somewhat" satisfied with the implementation process overall. In the prenatal contraceptive counseling, among 4960 individuals undergoing childbirth at the study site in 2019, 1789 (36.1%) had documented prenatal counseling about postpartum contraception. Documented counseling rates increased overall throughout 2019 (Q1, 12.5%; Q4, 51.0%) but varied significantly by clinic site (Q4, range 30%-79%). Immediate postpartum long-acting reversible contraception utilization increased throughout the study period (before implementation, 5.46% of deliveries; during implementation, 8.95%; after implementation, 8.58%). In the patient experience of contraceptive care, patient survey respondents (response rate, 15%-29%) were largely White (344/425 [81%]) and highly educated (309/425 [73%] with at least a 4-year college degree), reflecting the study site population. Scores were poor across settings, with modest improvements in the hospital setting from 2018 to 2020 (prenatal visits, 67%-63%; hospitalization, 45%-58%; outpatient after delivery, 69%-65%). Based on these findings, toolkit refinements included additional resources designed to routinize prenatal contraceptive counseling and support a more patient-centered experience of contraceptive care.

CONCLUSION

A toolkit-based process to implement immediate postpartum long-acting reversible contraceptive services at a single academic center was associated with high acceptability but mixed healthcare quality outcomes. Toolkit resources were added to optimize counseling rates and the patient experience of contraceptive care. Future research should formally test the effectiveness of the refined toolkit in a multisite, prospective trial.

A prospective analysis of the relationship between sexual acceptability and contraceptive satisfaction over time

BACKGROUND

Contraceptives are used to prevent unwanted pregnancies and treat certain gynecologic conditions, but many women report non-use or inconsistent use because of method dissatisfaction. The sexual acceptability of contraception-how birth control methods affect users' sexual well-being-is likely an important component of contraceptive satisfaction but has yet to be systematically examined.

OBJECTIVE

This study aimed to assess contraceptive satisfaction among new-start contraceptive users and examine whether sexual acceptability measures predict contraceptive satisfaction at 3 months while controlling for more commonly measured contraceptive side effects.

STUDY DESIGN

This analysis used data derived from the baseline, 1-month, and 3-month surveys of the HER Salt Lake Contraceptive Initiative, a prospective cohort study of new contraceptive clients. From March 2016 to March 2017, enrolled participants received their desired contraceptive method at no cost and could switch or discontinue at any time (up to 3 years). This analysis included individuals who continued their new contraceptive method for at least 1 month and completed all relevant survey measures. We used ordered logistic regression modeling to predict contraceptive satisfaction at 3 months. Primary predictor variables included changes in sexual functioning (6-item Female Sexual Function Index), sexual satisfaction (New Sexual Satisfaction Scale), and perceived impact of the contraceptive method on sex life at 1 month. Covariates included vaginal bleeding changes, physical side effects, and mood-related side effects.

RESULTS

Our analytical sample included 1879 individuals. At 3 months, 52.1% of participants were "completely satisfied" with their contraceptive method, 30.7% were "somewhat satisfied," 4.2% were "neither satisfied nor dissatisfied," 6.9% were "somewhat dissatisfied," and 6.2% were "completely dissatisfied." Compared with patients who said their contraceptive method made their sex life "a lot" worse at 1 month, patients whose method improved their sex life "a lot" had a 7.7 times increased odds of greater satisfaction at 3 months (95% confidence interval, 4.02-14.60; P<.0001) and patients whose method improved their sex life a "little" had a 5.88 times increased odds of greater satisfaction (confidence interval, 3.12-11.11; P<.001). To a much lesser degree, experiencing less or no bleeding was significantly associated with increased satisfaction, whereas worsening of physical side effects was linked to decreased satisfaction. The only other factors significantly associated with satisfaction were changes in bleeding and physical side effects.

CONCLUSION

Our findings suggest that patients' sexual experiences of their contraceptive methods are important correlates of satisfaction. Clinicians may wish to underscore that sexual experiences of birth control methods matter and encourage patients to find a contraceptive method that works for them sexually.

Evaluation of the impact of humor used in contraception education on the attitudes of university students towards contraceptive methods

OBJECTIVE

This study has been performed as a parallel randomised controlled study to evaluate the impact of humour benefitted in contraception education of university students on the attitudes of students towards contraception methods.

METHODS

The study sample was composed of 88 students (44 experiments, 44 controls) studying at a public university in Turkey. The study data were collected using the Questionnaire Form and the Family Planning Attitude Scale. The students were divided into experimental and control groups as per the pre-test score of the Family Planning Attitude Scale and gender using stratified block randomisation. The students were divided into groups of 10 people, and each group received a one-time education of 45-60 min. The content of the education was the same for the experimental and control groups, but additionally, the humour method was used during the education of the experimental group. The Family Planning Attitude Scale was re-applied to the students one month after the education. Number, percentage, mean value, Student t-test Mann Whitney-U test, and Chi-square test were used to evaluate the data.

RESULTS

While there was no statistically significant difference between the pre-test mean scores of the students in the experimental and control groups (p > 0.05); the post-test showed a significantly higher mean score in the experimental group (p < 0.05) (1-β: 0.921, Cohen's d: 0.658). While there was no significant difference between the pre-test and post-test total mean scores of the students in the control group (p > 0.05); the post-test mean score of the students in the experimental group was significantly higher than the pre-test mean (p < 0.05) (1-β: 1.000, Cohen's d: 1.556).

CONCLUSIONS

The method of contraception education with humour given to university students is more effective than the education given ordinarily in developing attitudes towards contraceptives.

Effectiveness of Contraceptive Decision Aids in Adolescents and Young Adults: A Systematic Review

BACKGROUND

Contraceptive decision aids may support adolescents and young adults (AYA) in choosing contraceptive methods that fit their unique reproductive health needs.

OBJECTIVE

To provide a systematic review of studies examining the effectiveness of contraceptive decision aids in AYA.

MATERIALS AND METHODS

A systematic search was conducted of studies published between January 1, 2011, and March 31, 2021 using PubMed, Cochrane, and ClinicalTrials.gov. Studies were included if a contraceptive decision aid (ie, paper handout, mobile application, website, or video) was evaluated in AYA populations (age ≤30 years) in the United States. The primary outcome was decision aid effectiveness (ie, change in contraceptive knowledge, interest in contraception, contraceptive use, unintended pregnancies, and satisfaction with the decision aid).

RESULTS

Seven randomized controlled trials and 3 pre-post studies, reporting on 3725 AYA (range, 11-30 years), met inclusion criteria. No studies were excluded due to risk of bias. The methodologies and results were heterogeneous, but most consistently demonstrated increased contraceptive knowledge.

CONCLUSION

Ten studies evaluated a range of contraceptive decision aid formats for AYA. Decision aids appear to be effective at increasing contraceptive knowledge temporarily, but their effect on other contraceptive outcomes is unclear. Future research should evaluate decision aids specifically in adolescents.

Women's experiences with person-centered family planning care: Differences by sociodemographic characteristics

Objective

Person-centered contraceptive care is associated with positive reproductive health outcomes. Our objective was to analyze patients’ ratings on the newly developed Person-Centered Contraceptive Counseling scale (PCCC) to provide distributions for a nationally representative population and to assess differences by sociodemographic characteristics.

Study design

Using data from 2017 to 2019 National Survey of Family Growth (NSFG), we analyzed ratings across the four PCCC items among 2242 women who received contraceptive counseling in the past year. Items measured patients’ reports of how providers respected them, let them describe their contraceptive preferences, took their preferences seriously, and adequately informed them about their options. We studied each PCCC item individually as well as the combined scale, distinguishing between ratings of “excellent” versus lower ratings. Bivariate and multivariate logistic regression models assessed how patients’ characteristics (age, race/ethnicity and English proficiency, sexual orientation, income, and parity) and provider type were associated with the likelihood of experiencing person-centered care.

Results

The majority of women (59%–69%) reported that their family planning provider was “excellent” across the four PCCC items and just over half (51%) reported “excellent” on all items. In multivariate analyses, having a lower income, Black race, non-heterosexual identity, and Hispanic ethnicity combined with low English proficiency were associated with lower PCCC ratings.

Conclusions

In a nationally representative sample, the PCCC captured variation in women's experiences with person-centered family planning care by sociodemographic characteristics. Findings highlight the need for contraceptive counseling that centers on clients’ preferences and experiences, particularly for patients who belong to groups experiencing health inequities.

Implications

Person-centered care is a key component of high-quality family planning services. This analysis highlights sociodemographic disparities in person-centered care by analyzing PCCC ratings. Findings show the value of this new health care performance measure and affirm the need for family planning care that centers individuals' preferences and lived experiences.

Impact of contraceptive counseling on Texans who can and cannot receive no-cost post-abortion contraception

OBJECTIVE

To assess optimal timing, patient satisfaction, and 1-year contraceptive continuation associated with contraceptive counseling among Texans who could and could not receive no-cost long-acting reversible contraception (LARC) via a specialized funding program.

STUDY DESIGN

In this prospective study conducted between October 2014 and March 2016, we evaluated participants' desire for contraceptive counseling during abortion visits, impact of counseling on change in contraceptive preference, satisfaction with counseling, and 1-year postabortion contraceptive continuation. We stratified participants into 3 groups by income, insurance status, and eligibility for no-cost LARC: (1) low-income eligible, (2) low-income ineligible, and (3) higher-income and/or insured ineligible. We examined the association between contraceptive counseling rating and 1-year method continuation by program eligibility and post-abortion contraceptive type.

RESULTS

Among 428 abortion patients, 68% wanted to receive contraceptive counseling at their first abortion visit. Counseling led to a contraceptive preference change for 34%. Of these, 21% low-income eligible participants received a more effective method than initially desired, 10% received a less effective method, and 69% received the method they initially desired. No low-income ineligible participants received a more effective method than they initially desired, 55% received a less effective method, and 45% received the method they initially desired. Five percent of higher-income eligible participants received a more effective method than they initially desired, 48% received a less effective method, and 47% received the method they initially desired. Highest counseling rating was reported by 51%. Compared to those providing a lower rating in each group, highest counseling rating was significantly associated with lower 1-year contraceptive discontinuation for low-income eligible participants (aHR 0.34, 95% CI 0.14, 0.81), but not for low-income ineligible (aHR 1.56, 95% CI 0.83, 2.91) and higher-income (aHR 0.73, 95% CI 0.47,1.13) participants. Additionally, 1-year contraceptive continuation was associated with highest counseling rating (OR 1.72, 95% CI 1.09, 2.72) and post-abortion LARC use (OR 11.70, 95% CI 6.37, 21.48) in unadjusted models, but only postabortion LARC in adjusted models (aOR 1.55, 95% CI 0.90, 2.66 for highest counseling rating vs. aOR 11.83, 95% CI 6.29, 22.25 for postabortion LARC use).

CONCLUSIONS

In Texas, where access to affordable postabortion contraception is limited, high quality contraceptive counseling is associated with 1-year contraceptive continuation only among those eligible for no-cost methods.

IMPLICATIONS

State policies which restrict access to affordable post-abortion contraception limit the beneficial impact of patient-centered counseling and impede patients' ability to obtain their preferred method.