1
|
Taylor AL, Kogan J, Meyers J, Lupe S, Click B, Cohen B, Szigethy E, Keefer L, Nikolajski C. Perceptions of and Experiences with the COVID-19 Pandemic Among Individuals with Inflammatory Bowel Disease. J Clin Psychol Med Settings 2023:10.1007/s10880-023-09979-9. [PMID: 37932518 DOI: 10.1007/s10880-023-09979-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 11/08/2023]
Abstract
The COVID-19 pandemic resulted in increased feelings of emotional distress and disruptions in care across diverse patients subgroups, including those with chronic medical conditions such as inflammatory bowel diseases (IBD). We sought to understand the impact of the pandemic on the physical and emotional well-being of individuals with IBD and concurrent depression and/or anxiety symptoms. We conducted qualitative interviews after the beginning of the pandemic with 46 adults with IBD. Participants reported increased levels of emotional distress, feelings of social isolation, and uncertainty over whether IBD medications put them at increased risk. Young adults discussed feeling as if their lives had been disrupted. In addition, several individuals demonstrated resiliency and emphasized positives about the pandemic, including increased connectivity with family and friends, the convenience of being able to work from home despite their IBD symptoms, and lessened feelings of "missing out." Our findings highlight several opportunities to improve the health and well-being of individuals with IBD and beyond including increased support for combatting social isolation, enhanced counseling about medication risks and benefits, and the incorporation of resiliency skills building.
Collapse
Affiliation(s)
- Ashley L Taylor
- UPMC Center for High-Value Health Care, UPMC Insurance Services Division, U.S. Steel Tower, 600 Grant St., 40th Floor, Pittsburgh, PA, USA.
| | - Jane Kogan
- UPMC Center for High-Value Health Care, UPMC Insurance Services Division, U.S. Steel Tower, 600 Grant St., 40th Floor, Pittsburgh, PA, USA
| | - Jessica Meyers
- UPMC Center for High-Value Health Care, UPMC Insurance Services Division, U.S. Steel Tower, 600 Grant St., 40th Floor, Pittsburgh, PA, USA
| | - Stephen Lupe
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin Click
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
- Gastroenterology and Hepatology, University of Colorado, Aurora, CO, USA
| | - Benjamin Cohen
- Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Eva Szigethy
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Laurie Keefer
- Icahn School of Medicine, Mount Sinai, New York City, NY, USA
| | - Cara Nikolajski
- UPMC Center for High-Value Health Care, UPMC Insurance Services Division, U.S. Steel Tower, 600 Grant St., 40th Floor, Pittsburgh, PA, USA
| |
Collapse
|
2
|
Kang C, Zhang D, Schuster J, Kogan J, Nikolajski C, Reynolds CF. Bias-corrected and doubly robust inference for the three-level longitudinal cluster-randomized trials with missing continuous outcomes and small number of clusters: Simulation study and application to a study for adults with serious mental illnesses. Contemp Clin Trials Commun 2023; 35:101194. [PMID: 37588771 PMCID: PMC10425901 DOI: 10.1016/j.conctc.2023.101194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 04/21/2023] [Accepted: 07/19/2023] [Indexed: 08/18/2023] Open
Abstract
Longitudinal cluster-randomized designs have been popular tools for comparative effective research in clinical trials. The methodologies for the three-level hierarchical design with longitudinal outcomes need to be better understood under more pragmatic settings; that is, with a small number of clusters, heterogeneous cluster sizes, and missing outcomes. Generalized estimating equations (GEEs) have been frequently used when the distribution of data and the correlation model are unknown. Standard GEEs lead to bias and an inflated type I error rate due to the small number of available clinics and non-completely random missing data in longitudinal outcomes. We evaluate the performance of inverse probability weighted (IPW) estimating equations, with and without augmentation, for two types of missing data in continuous outcomes and individual-level treatment allocation mechanisms combined with two bias-corrected variance estimators. Our intensive simulation results suggest that the proposed augmented IPW method with bias-corrected variance estimation successfully prevents the inflation of false positive findings and improves efficiency when the number of clinics is small, with moderate to severe missing outcomes. Our findings are expected to aid researchers in choosing appropriate analysis methods for three-level longitudinal cluster-randomized designs. The proposed approaches were applied to analyze data from a longitudinal cluster-randomized clinical trial involving adults with serious mental illnesses.
Collapse
Affiliation(s)
- Chaeryon Kang
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Di Zhang
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | | | - Jane Kogan
- UPMC Center for High-Value Health Care, Pittsburgh, PA 15219, USA
| | - Cara Nikolajski
- UPMC Center for High-Value Health Care, Pittsburgh, PA 15219, USA
| | - Charles F. Reynolds
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
| |
Collapse
|
3
|
Nikolajski C, O'Brien J, Nardo E, Szigethy E, Jonassaint C. Tailoring a Digital Mental Health Program for Patients With Sickle Cell Disease: Qualitative Study. JMIR Ment Health 2023; 10:e44216. [PMID: 37023443 PMCID: PMC10131651 DOI: 10.2196/44216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/11/2023] [Accepted: 02/13/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Depression and other mental health disorders are prevalent among people living with chronic health conditions. Although digital cognitive behavioral therapy (CBT) is considered an effective treatment, African American individuals are less likely to engage in and adhere to digital therapies for mental health disorders compared with White individuals. OBJECTIVE The aim of this study was to understand digital CBT mental health treatment perceptions and preferences of African American individuals with sickle cell disease (SCD). METHODS African American individuals with SCD from various US locations were invited to participate in a series of focus groups. Participants were introduced to a health coach-supported mental health app and then asked a series of questions about the usability and appeal of the program as well as, more generally, what would make a digital mental health program effective for them. The authors reviewed the focus group transcripts and conducted a qualitative analysis of the results. RESULTS A total of 25 people participated in 5 focus groups. Overall, 5 primary themes emerged regarding how app content and related coaching could be modified to enhance digital CBT engagement. These themes included connection with others living with SCD, the personalization of app content and coaching, characteristics of coaches, journaling and pain tracking, and considerations for optimal engagement. CONCLUSIONS Enhancing the user experience by making digital CBT tools relevant to patient populations is critical for optimizing program engagement and its uptake. Our findings highlight potential strategies to modify and design digital CBT tools for users with SCD and may also be applicable to patients with other chronic conditions. TRIAL REGISTRATION ClinicalTrials.gov NCT04587661; https://clinicaltrials.gov/ct2/show/NCT04587661.
Collapse
Affiliation(s)
- Cara Nikolajski
- Center for High-Value Health Care, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Julia O'Brien
- Department of Health and Community Systems, School of Nursing, University of Pittsburgh, Pittsburgh, PA, United States
| | - Emily Nardo
- Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, United States
- Center for Behavioral Health and Smart Technology, University of Pittsburgh, Pittsburgh, PA, United States
| | - Eva Szigethy
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Charles Jonassaint
- Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, United States
- Center for Behavioral Health and Smart Technology, University of Pittsburgh, Pittsburgh, PA, United States
| |
Collapse
|
4
|
Nikolajski C, Williams K, Schake P, Carney T, Hamm M, Schuster J. Staff Perceptions of Barriers and Facilitators to Implementation of Behavioral Health Homes at Community Mental Health Provider Settings. Community Ment Health J 2022; 58:1093-1100. [PMID: 34799772 DOI: 10.1007/s10597-021-00918-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 11/11/2021] [Indexed: 11/26/2022]
Abstract
Individuals living with a serious mental illness are disproportionately affected by preventable and/or manageable chronic conditions. Integrated care and support for behavioral and physical health within community mental health provider (CMHP) settings, also known as behavioral health homes (BHH), can lead to improvements in care and cost outcomes. This study explored staff perceptions of barriers and facilitators to BHH implementation. We conducted semi-structured interviews with CMHP staff at baseline, 1, and 2 years after the start of implementation. We analyzed interviews to identify major themes. We conducted 65 total interviews with 30 unique staff members. Common barriers included staff turnover, hesitation to change care processes, and acute service user needs. Facilitators included agency-wide culture change, intervention champions, and integration of intervention processes into daily workflows. Despite common barriers, CMHP staff identified several elements related to successful BHH implementation, including the CMHP-wide cultural shift to comprehensively address health/wellness that benefitted service users and staff alike.
Collapse
Affiliation(s)
- Cara Nikolajski
- UPMC Center for High-Value Health Care, UPMC Insurance Services Division, 600 Grant Street, 40thFloor, Pittsburgh, PA, 15219, USA.
| | - Kelly Williams
- UPMC Center for High-Value Health Care, UPMC Insurance Services Division, 600 Grant Street, 40thFloor, Pittsburgh, PA, 15219, USA
| | - Patricia Schake
- Community Care Behavioral Health Organization, 339 Sixth Avenue #1300, Pittsburgh, PA, 15222, USA
| | - Tracy Carney
- Community Care Behavioral Health Organization, 339 Sixth Avenue #1300, Pittsburgh, PA, 15222, USA
| | - Megan Hamm
- Qualitative, Evaluation And Stakeholder Engagement Research Services, Center for Research On Health Care, University of Pittsburgh, 200 Meyren Ave, Suite 200, Pittsburgh, PA, 15213, USA
| | - James Schuster
- UPMC Insurance Services Division, 600 Grant Street, 55th Floor, Pittsburgh, PA, 15219, USA
| |
Collapse
|
5
|
Brar JS, Maise AA, Schake P, Bills LJ, Washington L, Nikolajski C, Herschell AD. Correction to: Implementing a Learning Collaborative for Population-Based Physical and Behavioral Health Integration. Community Ment Health J 2021; 57:1374. [PMID: 33905018 DOI: 10.1007/s10597-021-00826-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Jaspreet S Brar
- Community Care Behavioral Health, UPMC Insurance Services Division, 339 Sixth Ave., Suite 1300, Pittsburgh, PA, 15222, USA.
| | - Amanda A Maise
- Community Care Behavioral Health, UPMC Insurance Services Division, 339 Sixth Ave., Suite 1300, Pittsburgh, PA, 15222, USA
| | - Patricia Schake
- Community Care Behavioral Health, UPMC Insurance Services Division, 339 Sixth Ave., Suite 1300, Pittsburgh, PA, 15222, USA
| | - Lyndra J Bills
- Community Care Behavioral Health, UPMC Insurance Services Division, 339 Sixth Ave., Suite 1300, Pittsburgh, PA, 15222, USA
| | - Leslie Washington
- Community Care Behavioral Health, UPMC Insurance Services Division, 339 Sixth Ave., Suite 1300, Pittsburgh, PA, 15222, USA
| | - Cara Nikolajski
- UPMC Center for High-Value Health Care, 600 Grant Street, 40th fl, Pittsburgh, PA, 15219, USA
| | - Amy D Herschell
- Community Care Behavioral Health, UPMC Insurance Services Division, 339 Sixth Ave., Suite 1300, Pittsburgh, PA, 15222, USA
| |
Collapse
|
6
|
Brar JS, Maise AA, Schake P, Bills LJ, Washington L, Nikolajski C, Herschell AD. Implementing a Learning Collaborative for Population-Based Physical and Behavioral Health Integration. Community Ment Health J 2021; 57:1361-1373. [PMID: 33452948 DOI: 10.1007/s10597-020-00769-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 12/29/2020] [Indexed: 11/26/2022]
Abstract
Behavioral health home models are increasingly being utilized to provide physical-behavioral health integration for individuals with mental illness. The Behavioral Health Home Plus model (BHHP) is a phased approach designed to instill a culture of wellness, provide wellness coaching, and offer care coordination for individuals with serious mental illness. The present study utilized a 12-month Learning Collaborative to implement scaling of BHHP in two cohorts totaling 24 community mental health provider organizations in Pennsylvania to include population-wide screening and intervention for tobacco use and hypertension. Providers reported increases in screening rates and wellness goals related to tobacco use and hypertension, as well as reductions in tobacco use and blood pressure readings among participating individuals. Evidence presented indicates that a Learning Collaborative of community mental health providers is a feasible quality improvement approach to scale integration of physical and behavioral health care for individuals with serious mental illness.
Collapse
Affiliation(s)
- Jaspreet S Brar
- Community Care Behavioral Health, UPMC Insurance Services Division, 339 Sixth Ave., Suite 1300, Pittsburgh, PA, 15222, USA.
| | - Amanda A Maise
- Community Care Behavioral Health, UPMC Insurance Services Division, 339 Sixth Ave., Suite 1300, Pittsburgh, PA, 15222, USA
| | - Patricia Schake
- Community Care Behavioral Health, UPMC Insurance Services Division, 339 Sixth Ave., Suite 1300, Pittsburgh, PA, 15222, USA
| | - Lyndra J Bills
- Community Care Behavioral Health, UPMC Insurance Services Division, 339 Sixth Ave., Suite 1300, Pittsburgh, PA, 15222, USA
| | - Leslie Washington
- Community Care Behavioral Health, UPMC Insurance Services Division, 339 Sixth Ave., Suite 1300, Pittsburgh, PA, 15222, USA
| | - Cara Nikolajski
- UPMC Center for High-Value Health Care, 600 Grant Street, 40th fl, Pittsburgh, PA, 15219, USA
| | - Amy D Herschell
- Community Care Behavioral Health, UPMC Insurance Services Division, 339 Sixth Ave., Suite 1300, Pittsburgh, PA, 15222, USA
| |
Collapse
|
7
|
Silfee V, Williams K, Leber B, Kogan J, Nikolajski C, Szigethy E, Serio C. Health Care Provider Perspectives on the Use of a Digital Behavioral Health App to Support Patients: Qualitative Study. JMIR Form Res 2021; 5:e28538. [PMID: 34529583 PMCID: PMC8512194 DOI: 10.2196/28538] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 08/13/2021] [Accepted: 09/13/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Despite the growing evidence indicating the efficacy of digital cognitive behavioral interventions (dCBIs) for behavioral health (BH) treatment, broad and consistent use of such interventions has been limited by knowledge obtained in real-world settings, including factors that impact provider uptake/referral. Engaging providers early in the implementation process offers an opportunity to explore their needs and behaviors, integrate interventions into workflows, and better understand provider setting capabilities. OBJECTIVE This study assessed providers' views on the feasibility and acceptability of delivering a cognitive behavioral therapy (CBT)-based mobile app in multiple care settings. METHODS Participating providers included BH and physical health (PH) providers from a women's health center, an outpatient BH clinic, and both rural/urban primary care settings. All participating providers cocreated workflows through facilitated workshops, including establishing feedback loops between the project team and providers and identifying clinical champions at each site. Over a 12-week period, the providers referred adult patients experiencing anxiety or depression to a mobile app-based dCBI, RxWell, and provided other indicated treatments as part of usual care. Referrals were completed by the providers through the electronic medical record. To better understand facilitators of and challenges in integrating RxWell into routine practice and perceptions of sustainability, a series of qualitative interviews was conducted. Interview data were analyzed to identify major themes using an inductive content analysis approach. RESULTS A total of 19 provider interviews were conducted to discover motivators and barriers for referring RxWell. The providers benefited from a focused discussion on how to incorporate the referral process into their workflow, and knowing the app content was rooted in evidence. Although the providers believed engaging in experiential learning was important, they indicated that more education on the digital health coach role and how to monitor patient progress is needed. The providers thought patient engagement may be impacted by motivation, a lack of comfort using a smartphone, or preference for in-person therapy. The providers also expressed enthusiasm in continuing to refer the app. They liked the ability to provide patients with support between sessions, to have an extra treatment option that teaches BH exercises, and to have a CBT treatment option that overcomes barriers (eg, wait times, copays, travel) to traditional therapy modalities. CONCLUSIONS Digital intervention success in health care settings relies heavily on engagement of key stakeholders, such as providers, in both design and implementation of the intervention and focused evaluation within intended care setting(s). Scaling digital interventions to meet the mental health needs of patients in usual care settings leans on thoughtfully constructed and streamlined workflows to enable seamless referral of patients by providers. Our findings strongly suggest that providers are supportive of digital tool integration to support the mental health of patients and endorse its use within their routine workflow.
Collapse
Affiliation(s)
| | - Kelly Williams
- UPMC Center for High-Value Health Care, Pittsburgh, PA, United States
| | - Brett Leber
- UPMC Health Plan, Pittsburgh, PA, United States
| | - Jane Kogan
- UPMC Center for High-Value Health Care, Pittsburgh, PA, United States
| | - Cara Nikolajski
- UPMC Center for High-Value Health Care, Pittsburgh, PA, United States
| | - Eva Szigethy
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, United States
| | | |
Collapse
|
8
|
Kearney SM, Williams K, Nikolajski C, Park MJ, Kraemer KL, Landsittel D, Kang C, Malito A, Schuster J. Stakeholder impact on the implementation of integrated care: Opportunities to consider for patient-centered outcomes research. Contemp Clin Trials 2020; 101:106256. [PMID: 33383229 DOI: 10.1016/j.cct.2020.106256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 12/02/2020] [Accepted: 12/22/2020] [Indexed: 12/21/2022]
Abstract
Nearly half of Americans live with chronic disease. Many have multiple chronic conditions that often present as a combination of physical and mental health conditions. Aligning stakeholder-driven, patient-centered outcomes research with population health strategies such as innovative ways to deliver care management can reduce the burden of multiple chronic conditions. In addition, successfully creating meaningful, inclusive research requires actively engaging stakeholders throughout the lifecycle of a study. This study integrates stakeholder engagement, using a large health plan in western Pennsylvania, to conduct a randomized controlled trial. Three care management strategies, High-Touch, High-Tech, and Usual Care, are compared for effectiveness among members with multiple chronic conditions. Care strategies are delivered via the Community Team, a multidisciplinary community-based team, offering in-person (High-Touch) and digital (High-Tech) care management in 14 counties across Pennsylvania. Participants are followed for 12months, with repeated measurements of self-reported health status and activation in care, while tracking administrative measurements of primary and specialty health service utilization. Quality of life, care satisfaction, engagement in care, and service utilization will be compared using generalized mixed models. Additionally, semi-structured interviews are conducted for both participants and care managers over the course of the study to evaluate feasibility. This manuscript presents implementation strategies, while noting that the implementation of patient-centered outcomes research in a real-world setting requires rapid evaluation, redesign of workflow, and tailored approaches for success.
Collapse
Affiliation(s)
- Shannon M Kearney
- UPMC Insurance Services Division, UPMC Center for High-Value Health Care, Pittsburgh, PA, USA
| | - Kelly Williams
- UPMC Insurance Services Division, UPMC Center for High-Value Health Care, Pittsburgh, PA, USA.
| | - Cara Nikolajski
- UPMC Insurance Services Division, UPMC Center for High-Value Health Care, Pittsburgh, PA, USA
| | | | - Kevin L Kraemer
- Medicine and Clinical & Translational Science, Section of Treatment, Research, and Education in Addiction Medicine, GIM Clinician-Researcher Fellowship Program, General Internal Medicine Center for Opioid Recovery, Clinical and Translational Science Fellowship, NRSA for Primary Medical Care, Department of Medicine, University of Pittsburgh, USA
| | - Doug Landsittel
- Biomedical Informatics, Biostatistics, and Clinical and Translational Science, Biostatistics, Starzl Transplant Institute, Expanding National Capacity in PCOR through Training, Comparative Effectiveness Research Center; Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Chaeryon Kang
- Biostatistics, Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Adelina Malito
- UPMC Insurance Services Division, UPMC Center for High-Value Health Care, Pittsburgh, PA, USA
| | - James Schuster
- Medical and Behavioral Services, UPMC Insurance Services Division, Psychiatry, University of Pittsburgh, Pittsburgh, PA, UPMC, USA
| |
Collapse
|
9
|
Abstract
OBJECTIVE This study evaluated the impact of two behavioral health home (BHH) approaches, provider-supported care and self-directed care, on health care utilization and cost outcomes among adult Medicaid recipients with serious mental illness. METHODS Eleven community mental health provider sites were randomly assigned to one of the BHH approaches, which each site implemented over a 2-year period. In both approaches, staff were trained in wellness coaching to support patients' progress toward general health and wellness goals. Provider-supported sites employed a full-time on-site registered nurse, who provided consultation to patients and wellness coaches. Each approach had a consistently enrolled treatment group (combined N=859) with a matched comparison cohort that was identified for analysis. Approaches were compared with each other and with baseline, and differences between each approach and its comparison cohort were examined by using analysis of covariance to determine impact on total health care cost, prescription costs, and use and cost of general medical and behavioral health services. RESULTS Relative to its comparison cohort, each approach achieved significant reductions in total cost (15% for provider-supported care and 26% for self-directed care) and increases in use of outpatient general medical services (43% for provider-supported care and 29% for self-directed care). Compared with self-directed care, provider-supported care resulted in approximately 28% lower use of general medical inpatient services and 26% lower related costs. CONCLUSIONS BHH approaches in community mental health settings can produce health care savings and decrease use of inpatient health care.
Collapse
Affiliation(s)
- James Highland
- BerryDunn, Portland, Maine (Highland), Phoenix (Ji), and Honolulu (Kukla); UPMC Center for High-Value Health Care (Nikolajski, Kogan) and Community Care Behavioral Health Organization (Schuster), UPMC Insurance Services Division, Pittsburgh
| | - Cara Nikolajski
- BerryDunn, Portland, Maine (Highland), Phoenix (Ji), and Honolulu (Kukla); UPMC Center for High-Value Health Care (Nikolajski, Kogan) and Community Care Behavioral Health Organization (Schuster), UPMC Insurance Services Division, Pittsburgh
| | - Jane Kogan
- BerryDunn, Portland, Maine (Highland), Phoenix (Ji), and Honolulu (Kukla); UPMC Center for High-Value Health Care (Nikolajski, Kogan) and Community Care Behavioral Health Organization (Schuster), UPMC Insurance Services Division, Pittsburgh
| | - Yang Ji
- BerryDunn, Portland, Maine (Highland), Phoenix (Ji), and Honolulu (Kukla); UPMC Center for High-Value Health Care (Nikolajski, Kogan) and Community Care Behavioral Health Organization (Schuster), UPMC Insurance Services Division, Pittsburgh
| | - Matt Kukla
- BerryDunn, Portland, Maine (Highland), Phoenix (Ji), and Honolulu (Kukla); UPMC Center for High-Value Health Care (Nikolajski, Kogan) and Community Care Behavioral Health Organization (Schuster), UPMC Insurance Services Division, Pittsburgh
| | - James Schuster
- BerryDunn, Portland, Maine (Highland), Phoenix (Ji), and Honolulu (Kukla); UPMC Center for High-Value Health Care (Nikolajski, Kogan) and Community Care Behavioral Health Organization (Schuster), UPMC Insurance Services Division, Pittsburgh
| |
Collapse
|
10
|
Schuster J, Nikolajski C, Kogan J, Kang C, Schake P, Carney T, Morton SC, Reynolds CF. A Payer-Guided Approach To Widespread Diffusion Of Behavioral Health Homes In Real-World Settings. Health Aff (Millwood) 2018; 37:248-256. [DOI: 10.1377/hlthaff.2017.1115] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- James Schuster
- James Schuster is chief medical officer for Medicaid, Special Needs, and Behavioral Services and vice president of behavioral integration, both at UPMC Insurance Services Division, and a senior faculty member at the UPMC Center for High-Value Health Care, all in Pittsburgh, Pennsylvania
| | - Cara Nikolajski
- Cara Nikolajski is a senior program administrator at the UPMC Center for High-Value Health Care
| | - Jane Kogan
- Jane Kogan is senior director of the UPMC Center for High-Value Health Care
| | - Chaeryon Kang
- Chaeryon Kang is an assistant professor of biostatistics at the University of Pittsburgh, in Pennsylvania
| | - Patricia Schake
- Patricia Schake is senior director of program innovation, Community Care Behavioral Health Organization, in Pittsburgh
| | - Tracy Carney
- Tracy Carney is a senior recovery and resiliency specialist, Community Care Behavioral Health Organization
| | - Sally C. Morton
- Sally C. Morton is dean of the College of Science, Virginia Tech, in Blacksburg
| | - Charles F. Reynolds
- Charles F. Reynolds III is a distinguished professor of psychiatry emeritus at the University of Pittsburgh School of Medicine
| |
Collapse
|
11
|
Johnson-Kwochka A, Carpenter-Song E, Griesemer I, Nikolajski C, Parrotta N, MacDonald-Wilson KL. First-Person Perspectives on Prescriber-Service User Relationships in Community Mental Health Centers. Psychiatr Serv 2017; 68:947-951. [PMID: 28566021 DOI: 10.1176/appi.ps.201600325] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Because of changes in health care, there is a greater focus on brief medication management visits as the primary method of providing psychiatric care in community mental health settings. Research on the first-person perspectives of service users and prescribers in these settings is limited. The objective of this study was to describe first-person perspectives on medication management visits and the service user-prescriber relationship. METHODS Researchers conducted qualitative interviews as part of a larger comparative effectiveness trial at 15 community mental health centers, researchers interviewed service users (N=44) and prescribers (N=25) about their perspectives on the typical elements of a medication management visit and asked service users about their relationship with their prescriber. RESULTS Both service users and prescribers described medication management visits as very brief encounters focused on medication and symptoms. Most service users reflected on the service user-prescriber relationship in positive or neutral terms; they did not describe the development of a strong therapeutic relationship or a meaningful clinical encounter with prescribing clinicians. CONCLUSIONS Service users described the service user-prescriber relationship and medication management visit as largely transactional. Despite the transactional nature of these encounters, most service users described relationships with prescribing clinicians in positive or neutral terms. Their satisfaction with the visit did not necessarily mean that they were receiving high-quality care. Satisfaction may instead suggest service users' disengagement from care. They may need more support to fully participate in their own care.
Collapse
Affiliation(s)
- Annalee Johnson-Kwochka
- Ms. Johnson-Kwochka is with the IPS Employment Center, Westat, Lebanon, New Hampshire. Dr. Carpenter-Song is with the Department of Anthropology, Dartmouth College, Hanover, New Hampshire. Ms. Griesemer is with the Department of Health Behavior, University of North Carolina at Chapel Hill. Ms. Nikolajski is with the University of Pittsburgh Medical Center (UPMC), Center for High-Value Health Care, Pittsburgh. Ms. Parotta and Dr. MacDonald-Wilson are with Community Care Behavioral Health, UPMC Insurance Services Division, Pittsburgh
| | - Elizabeth Carpenter-Song
- Ms. Johnson-Kwochka is with the IPS Employment Center, Westat, Lebanon, New Hampshire. Dr. Carpenter-Song is with the Department of Anthropology, Dartmouth College, Hanover, New Hampshire. Ms. Griesemer is with the Department of Health Behavior, University of North Carolina at Chapel Hill. Ms. Nikolajski is with the University of Pittsburgh Medical Center (UPMC), Center for High-Value Health Care, Pittsburgh. Ms. Parotta and Dr. MacDonald-Wilson are with Community Care Behavioral Health, UPMC Insurance Services Division, Pittsburgh
| | - Ida Griesemer
- Ms. Johnson-Kwochka is with the IPS Employment Center, Westat, Lebanon, New Hampshire. Dr. Carpenter-Song is with the Department of Anthropology, Dartmouth College, Hanover, New Hampshire. Ms. Griesemer is with the Department of Health Behavior, University of North Carolina at Chapel Hill. Ms. Nikolajski is with the University of Pittsburgh Medical Center (UPMC), Center for High-Value Health Care, Pittsburgh. Ms. Parotta and Dr. MacDonald-Wilson are with Community Care Behavioral Health, UPMC Insurance Services Division, Pittsburgh
| | - Cara Nikolajski
- Ms. Johnson-Kwochka is with the IPS Employment Center, Westat, Lebanon, New Hampshire. Dr. Carpenter-Song is with the Department of Anthropology, Dartmouth College, Hanover, New Hampshire. Ms. Griesemer is with the Department of Health Behavior, University of North Carolina at Chapel Hill. Ms. Nikolajski is with the University of Pittsburgh Medical Center (UPMC), Center for High-Value Health Care, Pittsburgh. Ms. Parotta and Dr. MacDonald-Wilson are with Community Care Behavioral Health, UPMC Insurance Services Division, Pittsburgh
| | - Nancy Parrotta
- Ms. Johnson-Kwochka is with the IPS Employment Center, Westat, Lebanon, New Hampshire. Dr. Carpenter-Song is with the Department of Anthropology, Dartmouth College, Hanover, New Hampshire. Ms. Griesemer is with the Department of Health Behavior, University of North Carolina at Chapel Hill. Ms. Nikolajski is with the University of Pittsburgh Medical Center (UPMC), Center for High-Value Health Care, Pittsburgh. Ms. Parotta and Dr. MacDonald-Wilson are with Community Care Behavioral Health, UPMC Insurance Services Division, Pittsburgh
| | - Kim L MacDonald-Wilson
- Ms. Johnson-Kwochka is with the IPS Employment Center, Westat, Lebanon, New Hampshire. Dr. Carpenter-Song is with the Department of Anthropology, Dartmouth College, Hanover, New Hampshire. Ms. Griesemer is with the Department of Health Behavior, University of North Carolina at Chapel Hill. Ms. Nikolajski is with the University of Pittsburgh Medical Center (UPMC), Center for High-Value Health Care, Pittsburgh. Ms. Parotta and Dr. MacDonald-Wilson are with Community Care Behavioral Health, UPMC Insurance Services Division, Pittsburgh
| |
Collapse
|
12
|
Gelman A, Rosenfeld EA, Nikolajski C, Freedman LR, Steinberg JR, Borrero S. Abortion Stigma Among Low-Income Women Obtaining Abortions in Western Pennsylvania: A Qualitative Assessment. Perspect Sex Reprod Health 2017; 49:29-36. [PMID: 27984674 PMCID: PMC5572656 DOI: 10.1363/psrh.12014] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 10/07/2016] [Accepted: 10/14/2016] [Indexed: 06/06/2023]
Abstract
CONTEXT Abortion stigma may cause psychological distress in women who are considering having an abortion or have had one. This phenomenon has been relatively underexplored in low-income women, who may already be at an increased risk for poor abortion-related outcomes because of difficulties accessing timely and safe abortion services. METHODS A qualitative study conducted between 2010 and 2013 used semistructured interviews to explore pregnancy intentions among low-income women recruited from six reproductive health clinics in Western Pennsylvania. Transcripts from interviews with 19 participants who were planning to terminate a pregnancy or had had an abortion in the last two weeks were examined through content analysis to identify the range of attitudes they encountered that could contribute to or reflect abortion stigma, the sources of these attitudes and women's responses to them. RESULTS Women commonly reported that partners, family members and they themselves held antiabortion attitudes. Such attitudes communicated that abortion is morally reprehensible, a rejection of motherhood, rare and thus potentially deviant, detrimental to future fertility and an irresponsible choice. Women reacted to external and internal negative attitudes by distinguishing themselves from other women who obtain abortions, experiencing negative emotions, and concealing or delaying their abortions. CONCLUSIONS Women's reactions to antiabortion attitudes may perpetuate abortion stigma. Further research is needed to inform interventions to address abortion stigma and improve women's abortion experiences.
Collapse
Affiliation(s)
- Amanda Gelman
- Resident in internal medicine, University of Colorado, Aurora
| | - Elian A Rosenfeld
- Postdoctoral fellow of women's health, VA Pittsburgh Healthcare System
| | - Cara Nikolajski
- Research coordinator, Center for Research on Health Care, Department of General Internal Medicine, University of Pittsburgh School of Medicine
| | - Lori R Freedman
- Assistant professor, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco
| | - Julia R Steinberg
- Assistant professor, Department of Family Science, School of Public Health, University of Maryland, College Park
| | - Sonya Borrero
- Associate professor of medicine and clinical and translational science, University of Pittsburgh School of Medicine
| |
Collapse
|
13
|
Rief JJ, Hamm ME, Zickmund SL, Nikolajski C, Lesky D, Hess R, Fischer GS, Weimer M, Clark S, Zieth C, Roberts MS. Using Health Information Technology to Foster Engagement: Patients' Experiences with an Active Patient Health Record. Health Commun 2017; 32:310-319. [PMID: 27223684 DOI: 10.1080/10410236.2016.1138378] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Personal health records (PHRs) typically employ "passive" communication strategies, such as non-personalized medical text, rather than direct patient engagement in care. Currently there is a call for more active PHRs that directly engage patients in an effort to improve their health by offering elements such as personalized medical information, health coaches, and secure messaging with primary care providers. As part of a randomized clinical trial comparing "passive" with "active" PHRs, we explore patients' experiences with using an "active" PHR known as HealthTrak. The "passive" elements of this PHR included problem lists, medication lists, information about patient allergies and immunizations, medical and surgical histories, lab test results, health reminders, and secure messaging. The active arm included all of these elements and added personalized alerts delivered through the secure messaging platform to patients for services coming due based on various demographic features (including age and sex) and chronic medical conditions. Our participants were part of the larger clinical trial and were eligible if they had been randomized to the active PHR arm, one that included regular personalized alerts. We conducted focus group discussions on the benefits of this active PHR for patients who are at risk for cardiovascular disease. Forty-one patients agreed to participate and were organized into five separate focus group sessions. Three main themes emerged from the qualitatively analyzed focus groups: participants reported that the active PHR promoted better communication with providers; enabled them to more effectively partner with their providers; and helped them become more proactive about tracking their health information. In conclusion, patients reported improved communication, partnership with their providers, and a sense of self-management, thus adding insights for PHR designers hoping to address low adoption rates and other patient barriers to the development and use of the technology.
Collapse
Affiliation(s)
- John J Rief
- a Department of Communication and Rhetorical Studies , Duquesne University
| | - Megan E Hamm
- b Qualitative, Evaluation and Stakeholder Engagement Services, Center for Research on Health Care , University of Pittsburgh
| | - Susan L Zickmund
- c Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Division of General Internal Medicine, Department of Medicine , University of Pittsburgh School of Medicine, University of Pittsburgh
| | - Cara Nikolajski
- d Center for Research on Health Care , University of Pittsburgh
| | - Dan Lesky
- e University of Pittsburgh School of Medicine , University of Pittsburgh
| | - Rachel Hess
- f Departments of Population Health Sciences and Internal Medicine , University of Utah
| | - Gary S Fischer
- g Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine , University of Pittsburgh
| | - Melissa Weimer
- d Center for Research on Health Care , University of Pittsburgh
| | - Sunday Clark
- h Department of Emergency Medicine , Weill Cornell Medical College
| | - Caroline Zieth
- d Center for Research on Health Care , University of Pittsburgh
| | - Mark S Roberts
- g Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine , University of Pittsburgh
- i Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health , University of Pittsburgh
| |
Collapse
|
14
|
Cluss P, Lorigan D, Kinsky S, Nikolajski C, McDermott A, Bhat KB. School-Based Health Promotion Initiative Increases Children's Physical Activity. American Journal of Health Education 2016. [DOI: 10.1080/19325037.2016.1219287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | - Devin Lorigan
- Armstrong School District, West Hills Primary School
| | | | | | | | - Kiran B. Bhat
- University of Pittsburgh, School of Medicine, Children's Community Pediatrics-Armstrong
| |
Collapse
|
15
|
Schuster JM, Kinsky SM, Kim JY, Kogan JN, Hamblin A, Nikolajski C, Lovelace J. Connected Care: improving outcomes for adults with serious mental illness. Am J Manag Care 2016; 22:678-682. [PMID: 28557515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To evaluate the effectiveness of Connected Care-a care coordination effort of physical and behavioral health managed care partners in Pennsylvania-on acute service use among adult Medicaid beneficiaries with serious mental illness (SMI). STUDY DESIGN We examined changes in service utilization using a difference-in-differences model, comparing study group with a comparison group, and conducted key informant interviews to better understand aspects of program implementation. METHODS We compared the difference in service use rates between baseline year and 2-year intervention period for the Connected Care group (n = 8633) with the difference in rates for the comparison group (n = 10,514), confirming results using a regression adjustment. RESULTS Mental health hospitalizations (per 1000 members per month) decreased for the Connected Care group from 41.1 to 39.6, while increasing for the comparison group from 33.8 to 37.2 (P = .04). All-cause readmissions within 30 days decreased nearly 10% for Connected Care while increasing slightly for the comparison group (P < .01), with a similar pattern observed for 60- and 90-day all-cause readmissions. No differences were observed in physical health hospitalizations, drug and alcohol admissions, or ED use. Data from qualitative stakeholder interviews illuminated facilitators and barriers of implementing Connected Care. CONCLUSIONS Payer-level healthcare information sharing can help identify members who could benefit from care coordination services, inform care management activities, and assist with pharmacy management. Results can inform state, health plan, and provider efforts around integration of care for individuals with SMI and improve care efficiencies and quality, which is especially important in this time of Medicaid expansion.
Collapse
Affiliation(s)
| | | | | | - Jane N Kogan
- UPMC Center for High-Value Health, UPMC Insurance Services Division, 600 Grant St, 40th Fl, Pittsburgh PA, 15219. E-mail:
| | | | | | | |
Collapse
|
16
|
Kogan JN, Schuster J, Nikolajski C, Schake P, Carney T, Morton SC, Kang C, Reynolds CF. Challenges encountered in the conduct of Optimal Health: A patient-centered comparative effectiveness study of interventions for adults with serious mental illness. Clin Trials 2016; 14:5-16. [PMID: 27681658 DOI: 10.1177/1740774516670895] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The aim of patient-centered comparative effectiveness research is to conduct stakeholder-driven investigations that identify which interventions are most effective for which patients under specific circumstances. Conducting this research in real-world settings comes with unique experiences and challenges. We provide the study design, challenges confronted, and the solutions we devised for Optimal Health, a stakeholder-informed patient-centered comparative effectiveness study focused on the needs of seriously mentally ill individuals receiving case management services in community mental health centers across Pennsylvania. METHODS Optimal Health, supported by the Patient-Centered Outcomes Research Institute, is a cluster-randomized trial of two evidence-based interventions for improving health and wellness across 11 provider sites. Participants were followed for 18-24 months, with repeated measurements of self-reported health status and activation in care and administrative measurements of primary and specialty health service utilization. Health-related quality of life, engagement in care, and service utilization are to be compared via random effects mixed models. Stakeholders were, and continue to be, engaged via focus groups, interviews, and stakeholder advisory board meetings. A learning collaborative model was used to support shared learning and implementation fidelity across provider sites. RESULTS From 1 November 2013 through 15 July 2014, we recruited 1229 adults with serious mental illness, representing 85.1% of those eligible for study participation. Of these, 713 are in the Provider-Supported arm of the study and 516 in Patient Self-Directed Care. Across five data collection time points, we retained 86% and 83% of the participants in the Provider-Supported and Self-Directed arms, respectively. LESSONS LEARNED Lessons learned relate to estimation of the size of our study population, the value of multiple data sources, and intervention training and implementation. The use of historical claims data can lead to an overestimation of eligible participants and, subsequently, a reduced study sample and an imbalance between intervention arms. Disruptions in continuity of care in real-world settings can pose challenges to on-site self-report data collection, although the inclusion of multiple data sources in study design can improve data completeness. Geographic dispersion of rural provider sites and staff turnover can lead to training and intervention fidelity challenges that can be overcome with the use of a "train-the-trainer" model, "wellness champions," and the use of a Learning Collaborative approach. Stakeholder engagement in mitigating these challenges proved to be critical to study progress. CONCLUSION Conducting real-world patient-centered comparative effectiveness research in healthcare systems that care for seriously mentally ill persons is an important yet challenging undertaking, one which requires flexibility in identifying potential adaptations within all major study phases. Advice from a wide range of stakeholders is critical in development of successful strategies.
Collapse
Affiliation(s)
- Jane N Kogan
- 1 UPMC Center for High-Value Health Care, Pittsburgh, PA, USA.,2 Community Care Behavioral Health, UPMC Insurance Services Division, Pittsburgh, PA, USA
| | - James Schuster
- 1 UPMC Center for High-Value Health Care, Pittsburgh, PA, USA.,2 Community Care Behavioral Health, UPMC Insurance Services Division, Pittsburgh, PA, USA
| | - Cara Nikolajski
- 1 UPMC Center for High-Value Health Care, Pittsburgh, PA, USA
| | - Patricia Schake
- 2 Community Care Behavioral Health, UPMC Insurance Services Division, Pittsburgh, PA, USA
| | - Tracy Carney
- 2 Community Care Behavioral Health, UPMC Insurance Services Division, Pittsburgh, PA, USA.,3 Columbia Montour Snyder Union Counties of Central Pennsylvania Service System, Danville, PA, USA
| | - Sally C Morton
- 4 Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Chaeryon Kang
- 4 Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Charles F Reynolds
- 5 School of Medicine and Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
17
|
Hamm M, Williams K, Nikolajski C, Celedonia KL, Frank E, Swartz HA, Zickmund SL, Stein BD. Readiness to Implement an Evidence-Based Psychotherapy: Perspectives of Community Mental Health Clinicians and Administrators. Psychiatr Serv 2015; 66:1109-12. [PMID: 26030318 PMCID: PMC4591082 DOI: 10.1176/appi.ps.201400424] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Using evidence-based psychotherapies in community mental health clinics could significantly improve patient functioning. This study explored perceived facilitators and barriers related to implementing interpersonal and social rhythm therapy (IPSRT), an evidence-based psychotherapy for bipolar disorder. METHODS The authors conducted 30-minute semistructured interviews with clinic administrators, supervisors, and clinicians from five community mental health clinics focusing on anticipated barriers and facilitators related to implementing IPSRT. RESULTS Seventeen participants (four administrators, three supervisors, and ten clinicians) completed the interviews. Important barriers to effective implementation included frequent client no-shows, difficulties transitioning from training to practice, and time constraints. Facilitators included support from supervisors and other clinicians, decreased productivity requirements or compensation for time spent while learning IPSRT, and reference materials. CONCLUSIONS Administrators and clinicians expressed similar beliefs about facilitators and barriers related to implementing IPSRT. The challenge of high no-show rates was not identified as a barrier in previous research.
Collapse
Affiliation(s)
- Megan Hamm
- Dr. Hamm and Ms. Williams are with the Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania. Ms. Nikolajski is with the Center for High-Value Health Care, University of Pittsburgh Medical Center, Pittsburgh. Ms. Celedonia and Dr. Stein are with RAND Corporation, Pittsburgh. Dr. Stein is also with the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, where Dr. Frank and Dr. Swartz are affiliated. Dr. Zickmund is with the Center for Health Equity Research and Promotion, U.S. Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh. Send correspondence to Dr. Stein (e-mail: )
| | - Kelly Williams
- Dr. Hamm and Ms. Williams are with the Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania. Ms. Nikolajski is with the Center for High-Value Health Care, University of Pittsburgh Medical Center, Pittsburgh. Ms. Celedonia and Dr. Stein are with RAND Corporation, Pittsburgh. Dr. Stein is also with the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, where Dr. Frank and Dr. Swartz are affiliated. Dr. Zickmund is with the Center for Health Equity Research and Promotion, U.S. Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh. Send correspondence to Dr. Stein (e-mail: )
| | - Cara Nikolajski
- Dr. Hamm and Ms. Williams are with the Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania. Ms. Nikolajski is with the Center for High-Value Health Care, University of Pittsburgh Medical Center, Pittsburgh. Ms. Celedonia and Dr. Stein are with RAND Corporation, Pittsburgh. Dr. Stein is also with the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, where Dr. Frank and Dr. Swartz are affiliated. Dr. Zickmund is with the Center for Health Equity Research and Promotion, U.S. Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh. Send correspondence to Dr. Stein (e-mail: )
| | - Karen L Celedonia
- Dr. Hamm and Ms. Williams are with the Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania. Ms. Nikolajski is with the Center for High-Value Health Care, University of Pittsburgh Medical Center, Pittsburgh. Ms. Celedonia and Dr. Stein are with RAND Corporation, Pittsburgh. Dr. Stein is also with the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, where Dr. Frank and Dr. Swartz are affiliated. Dr. Zickmund is with the Center for Health Equity Research and Promotion, U.S. Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh. Send correspondence to Dr. Stein (e-mail: )
| | - Ellen Frank
- Dr. Hamm and Ms. Williams are with the Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania. Ms. Nikolajski is with the Center for High-Value Health Care, University of Pittsburgh Medical Center, Pittsburgh. Ms. Celedonia and Dr. Stein are with RAND Corporation, Pittsburgh. Dr. Stein is also with the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, where Dr. Frank and Dr. Swartz are affiliated. Dr. Zickmund is with the Center for Health Equity Research and Promotion, U.S. Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh. Send correspondence to Dr. Stein (e-mail: )
| | - Holly A Swartz
- Dr. Hamm and Ms. Williams are with the Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania. Ms. Nikolajski is with the Center for High-Value Health Care, University of Pittsburgh Medical Center, Pittsburgh. Ms. Celedonia and Dr. Stein are with RAND Corporation, Pittsburgh. Dr. Stein is also with the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, where Dr. Frank and Dr. Swartz are affiliated. Dr. Zickmund is with the Center for Health Equity Research and Promotion, U.S. Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh. Send correspondence to Dr. Stein (e-mail: )
| | - Susan L Zickmund
- Dr. Hamm and Ms. Williams are with the Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania. Ms. Nikolajski is with the Center for High-Value Health Care, University of Pittsburgh Medical Center, Pittsburgh. Ms. Celedonia and Dr. Stein are with RAND Corporation, Pittsburgh. Dr. Stein is also with the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, where Dr. Frank and Dr. Swartz are affiliated. Dr. Zickmund is with the Center for Health Equity Research and Promotion, U.S. Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh. Send correspondence to Dr. Stein (e-mail: )
| | - Bradley D Stein
- Dr. Hamm and Ms. Williams are with the Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, Pennsylvania. Ms. Nikolajski is with the Center for High-Value Health Care, University of Pittsburgh Medical Center, Pittsburgh. Ms. Celedonia and Dr. Stein are with RAND Corporation, Pittsburgh. Dr. Stein is also with the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, where Dr. Frank and Dr. Swartz are affiliated. Dr. Zickmund is with the Center for Health Equity Research and Promotion, U.S. Department of Veterans Affairs Pittsburgh Healthcare System, Pittsburgh. Send correspondence to Dr. Stein (e-mail: )
| |
Collapse
|
18
|
Nikolajski C, Miller E, McCauley HL, Akers A, Schwarz EB, Freedman L, Steinberg J, Ibrahim S, Borrero S. Race and reproductive coercion: a qualitative assessment. Womens Health Issues 2015; 25:216-23. [PMID: 25748823 DOI: 10.1016/j.whi.2014.12.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 12/09/2014] [Accepted: 12/09/2014] [Indexed: 10/23/2022]
Abstract
BACKGROUND Unintended pregnancy is common and disproportionately occurs among low-income and African-American (AA) women. Male partners may influence women's risk of unintended pregnancy through reproductive coercion, although studies have not assessed whether racial differences in reproductive coercion impact AA women's disparate risk for unintended pregnancy. We sought to describe women's experiences with pregnancy-promoting behaviors by male partners and explore differences in such experiences by race. METHODS Semistructured interviews were conducted with low-income, AA and White women aged 18 to 45 years recruited from reproductive health clinics in Western Pennsylvania to explore contextual factors that shape women's contraceptive behaviors. Narratives were analyzed using content analysis and the constant comparison method. FINDINGS Among the 66 participants (36 AA and 30 White), 25 (38%) described experiences with male partner reproductive coercion. Narratives provided accounts of contraceptive sabotage, verbal pressure to promote pregnancy and specific pregnancy outcomes, and potential motives behind these behaviors. AA women in the sample reported experiences of reproductive coercion more often than White women (53% and 20%, respectively). AA women were also more likely than White women to attribute a current or prior pregnancy to reproductive coercion. AA women identified relationship transiency and impending incarceration as potential motivations for men to secure a connection with a female partner via pregnancy. CONCLUSIONS Our findings suggest that reproductive coercion may be a factor contributing to disparities in unintended pregnancy. More research, including population-level studies, is needed to determine the impact of reproductive coercion on unintended pregnancy and to understand the social and structural factors associated with pregnancy-promoting behaviors.
Collapse
Affiliation(s)
- Cara Nikolajski
- Department of Medicine, University of Pittsburgh Center for Research on Health Care, Pittsburgh, Pennsylvania
| | - Elizabeth Miller
- Division of Adolescent Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh and University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Heather L McCauley
- Division of Adolescent Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh and University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Aletha Akers
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee Womens Hospital and University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eleanor Bimla Schwarz
- Department of Medicine, University of Pittsburgh Center for Research on Health Care, Pittsburgh, Pennsylvania; Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee Womens Hospital and University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lori Freedman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, Oakland, California
| | - Julia Steinberg
- Department of Psychiatry, University of California San Francisco, San Francisco, California
| | - Said Ibrahim
- Center for Health Equity, Research, and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania; Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Sonya Borrero
- Department of Medicine, University of Pittsburgh Center for Research on Health Care, Pittsburgh, Pennsylvania; Center for Health Equity, Research, and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.
| |
Collapse
|
19
|
Borrero S, Nikolajski C, Steinberg JR, Freedman L, Akers AY, Ibrahim S, Schwarz EB. "It just happens": a qualitative study exploring low-income women's perspectives on pregnancy intention and planning. Contraception 2015; 91:150-6. [PMID: 25477272 PMCID: PMC4303515 DOI: 10.1016/j.contraception.2014.09.014] [Citation(s) in RCA: 172] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Revised: 09/18/2014] [Accepted: 09/22/2014] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Unintended pregnancy is common and disproportionately occurs among low-income women. We conducted a qualitative study with low-income women to better typologize pregnancy intention, understand the relationship between pregnancy intention and contraceptive use, and identify the contextual factors that shape pregnancy intention and contraceptive behavior. STUDY DESIGN Semistructured interviews were conducted with low-income, African-American and white women aged 18-45 recruited from reproductive health clinics in Pittsburgh, PA, to explore factors that influence women's pregnancy-related behaviors. Narratives were analyzed using content analysis and the constant comparison method. RESULTS Among the 66 participants (36 African-American and 30 white), we identified several factors that may impede our public health goal of increasing the proportion of pregnancies that are consciously desired and planned. First, women do not always perceive that they have reproductive control and therefore do not necessarily formulate clear pregnancy intentions. Second, the benefits of a planned pregnancy may not be evident. Third, because preconception intention and planning do not necessarily occur, decisions about the acceptability of a pregnancy are often determined after the pregnancy has already occurred. Finally, even when women express a desire to avoid pregnancy, their contraceptive behaviors are not necessarily congruent with their desires. We also identified several clinically relevant and potentially modifiable factors that help to explain this intention-behavior discrepancy, including women's perceptions of low fecundity and their experiences with male partner contraceptive sabotage. CONCLUSION Our findings suggest that the current conceptual framework that views pregnancy-related behaviors from a strict planned behavior perspective may be limited, particularly among low-income populations. IMPLICATIONS This study identified several cognitive and interpersonal pathways to unintended pregnancy among low-income women in Pittsburgh, PA, including perceptions of low reproductive control, perceptions of low fecundity and male partner reproductive coercion.
Collapse
Affiliation(s)
- Sonya Borrero
- Center for Research on Health Care, Department of Medicine, University of Pittsburgh, Pittsburgh, PA; VA Center for Health Equity, Research, and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.
| | - Cara Nikolajski
- Center for Research on Health Care, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Julia R Steinberg
- Department of Psychiatry, University of California San Francisco, San Francisco, CA
| | - Lori Freedman
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, San Francisco, CA
| | - Aletha Y Akers
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee Womens Hospital and University of Pittsburgh, Pittsburgh, PA
| | - Said Ibrahim
- VA Center for Health Equity, Research, and Promotion, Philadelphia VA Medical Center, Philadelphia, PA; Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Eleanor Bimla Schwarz
- Department of Medicine, University of California, Davis School of Medicine, Sacramento, CA
| |
Collapse
|
20
|
Hall D, Morrison P, Nikolajski C, Arnold R, Fine M, Zickmund S. Informed Consent to Inguinal Herniorrhaphy and Cholecystectomy: Differences Between What Surgeons Say They Discuss and What They Actually Do Discuss. J Surg Res 2013. [DOI: 10.1016/j.jss.2012.10.751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
|
21
|
Hall DE, Morrison P, Nikolajski C, Fine M, Arnold R, Zickmund SL. Informed consent for inguinal herniorrhaphy and cholecystectomy: describing how patients make decisions to have surgery. Am J Surg 2012; 204:619-25. [PMID: 22944389 PMCID: PMC7224355 DOI: 10.1016/j.amjsurg.2012.07.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Revised: 07/10/2012] [Accepted: 07/10/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND We describe how patients perceive the process of informed consent and its influence on decision making for elective surgery. METHODS A cohort of 38 patients documented consent for cholecystectomy or inguinal herniorrhaphy using the Veterans Affair's computer-based tool for documenting informed consent for clinical treatment. Participants completed semistructured telephone interviews exploring their attitudes about informed consent, iMed, and the decision-making process. We used qualitative methods to code and analyze the data. RESULTS Sixty-nine percent of patients decided to have surgery before meeting their surgeon, and 47% stated that the surgeon did not influence their decision. Although the surgeon was an important source of information for most patients (81%), patients frequently described using information gathered before meeting the surgeon, such as other health care providers (81%) or family members (58%). Most (68%) patients perceived iMed as a legal formality with little influence on decision making. CONCLUSIONS Future research should examine whether patient decision making regarding elective surgery becomes better informed if nonsurgeon clinicians connect patients to educational resources such as iMed closer to the time of initial diagnosis and before meeting the surgeon.
Collapse
Affiliation(s)
- Daniel E Hall
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA 15206, USA.
| | | | | | | | | | | |
Collapse
|
22
|
Abstract
BACKGROUND Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States yet is one of the least recognized among the general public. HPV awareness may be relatively low among minority women. Because HPV awareness is associated with uptake of the HPV vaccine, it is critical to assess HPV awareness in the population and identify any racial/ethnic gaps. METHODS This study used nationally representative data collected by the National Survey of Family Growth between July 2007 and December 2008. A multivariable logistic regression model was used to determine the independent effect of race/ethnicity on HPV awareness while controlling for sociodemographic and clinical confounders in a sample of 4088 women. Stratified multivariable analysis was also conducted to assess the relationship between race/ethnicity and HPV awareness among women in different age groups. RESULTS After adjusting for confounders, Hispanic and black women overall were significantly less likely to have heard of HPV compared to white women (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.29-0.54 and OR 0.39, 95% CI 0.29-0.54, respectively). Black women aged 15-18 and Hispanic women aged 19-26 had particularly low rates of HPV awareness (OR 0.17, 95% CI 0.07-0.43 and OR 0.18, 95% CI 0.11-0.30, respectively) compared to white women of the same ages. CONCLUSIONS Hispanic and black women have significantly lower levels of HPV awareness than white women. Targeted educational efforts will be important to improve HPV awareness and associated preventive health measures to avoid HPV-related morbidity and mortality.
Collapse
Affiliation(s)
- Amanda Gelman
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | | | | |
Collapse
|
23
|
Mattocks KM, Nikolajski C, Haskell S, Brandt C, McCall-Hosenfeld J, Yano E, Pham T, Borrero S. Women Veterans’ Reproductive Health Preferences and Experiences: A Focus Group Analysis. Womens Health Issues 2011; 21:124-9. [DOI: 10.1016/j.whi.2010.11.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Revised: 09/10/2010] [Accepted: 11/08/2010] [Indexed: 11/25/2022]
|
24
|
Borrero S, Abebe K, Dehlendorf C, Schwarz EB, Creinin MD, Nikolajski C, Ibrahim S. Racial variation in tubal sterilization rates: role of patient-level factors. Fertil Steril 2011; 95:17-22. [PMID: 20579640 PMCID: PMC2970690 DOI: 10.1016/j.fertnstert.2010.05.031] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Revised: 04/23/2010] [Accepted: 05/03/2010] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess racial differences in attitudes and knowledge about sterilization. DESIGN Cross-sectional survey. SETTING Questionnaires were mailed to participants' home addresses. PATIENT(S) One hundred ninety-three women, aged 18-45, who had undergone tubal sterilization. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Attitudes and knowledge about tubal sterilization and awareness of contraceptive alternatives. RESULT(S) We received 193 completed surveys (64% response rate). African American (AA) woman were more likely to have a family member who had undergone tubal sterilization, to report that their mothers influenced their sterilization decisions, and to report that prior unintended pregnancy and desire to avoid insertion of a foreign object were very important factors in their decision to choose sterilization over other methods. Compared with white women, AA women more often thought that sterilization reversal could easily restore fertility (62% vs. 36%); that a woman's sterilization would reverse itself after 5 years (60% vs. 23%); and that a man cannot ejaculate after vasectomy (38% vs. 13%). Fewer AA women had ever heard of intrauterine contraception (90% vs. 98%). Racial differences in knowledge remained statistically significant after adjusting for socioeconomic confounders. CONCLUSION(S) Misinformation about sterilization and limited awareness of contraceptive alternatives among AA women may contribute to racial disparities in tubal sterilization rates.
Collapse
Affiliation(s)
- Sonya Borrero
- Divison of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15213, USA.
| | | | | | | | | | | | | |
Collapse
|
25
|
Schwarz EB, Santucci A, Borrero S, Akers AY, Nikolajski C, Gold MA. Perspectives of primary care clinicians on teratogenic risk counseling. ACTA ACUST UNITED AC 2009; 85:858-63. [PMID: 19591115 DOI: 10.1002/bdra.20599] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Women of childbearing age are commonly prescribed medications by primary care providers (PCPs) that may cause birth defects if used during pregnancy. METHODS To identify what PCPs perceive as barriers to and potential facilitators of providing counseling to women of childbearing age when teratogenic medications are prescribed, we conducted eight focus groups with 48 PCPs recruited from four clinical settings in Pittsburgh, Pennsylvania. We explored PCPs' experiences counseling women about teratogenic medications. Each focus group was audio-recorded, transcribed, and coded using a grounded theory approach by three independent coders. RESULTS PCPs feel responsible for counseling women when they prescribe medications that may cause birth defects, but note difficulties identifying clinically relevant sources of information on teratogenicity. Other barriers to providing counseling include limited visit times and lack of reimbursement for preconception or teratogenic risk counseling. PCPs find it challenging to identify patients who may become pregnant and who therefore need contraceptive and/or teratogenic risk counseling. PCPs expressed a desire for online resources that could be used when explaining medication risks to patients. PCPs feel that the development of patient information materials, electronic decision support tools, clinical care systems that routinely assess patients' pregnancy risk, and changes in the reimbursement structure may facilitate counseling patients about teratogenic risks. CONCLUSIONS PCPs perceive themselves as playing an important role in providing their patients information on risk of medication-induced birth defects. To ensure safe prescription of teratogenic medications, PCPs suggest interventions at both the clinic and healthcare system levels.
Collapse
Affiliation(s)
- Eleanor Bimla Schwarz
- Center for Research on Health Care, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
| | | | | | | | | | | |
Collapse
|
26
|
Borrero S, Lin Y, Dehlendorf C, Schwarz E, Creinin M, Nikolajski C, Ibrahim S. Differences in knowledge may contribute to racial variation in tubal sterilization rates. Contraception 2009. [DOI: 10.1016/j.contraception.2009.05.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
27
|
Borrero S, Nikolajski C, Rodriguez KL, Creinin MD, Arnold RM, Ibrahim SA. "Everything I know I learned from my mother...Or not": perspectives of African-American and white women on decisions about tubal sterilization. J Gen Intern Med 2009; 24:312-9. [PMID: 19107540 PMCID: PMC2642577 DOI: 10.1007/s11606-008-0887-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2008] [Revised: 11/18/2008] [Accepted: 11/25/2008] [Indexed: 12/01/2022]
Abstract
BACKGROUND African-American women have had higher rates of female sterilization compared to white women since its emergence as a contraceptive method. The reasons underlying this observed racial difference are unknown. OBJECTIVES The goals of this study were to (1) explore what factors shape black and white women's decisions about tubal sterilization as a contraceptive method and (2) generate hypotheses about the relationship of race to the decision-making process. DESIGN We conducted six focus groups stratified by tubal sterilization status and race. During each of the audio-recorded sessions, participants were asked to discuss reasons that women choose sterilization as a contraceptive method. PARTICIPANTS The participants of the study were 24 African-American women and 14 white women. APPROACH Transcripts of the sessions were qualitatively analyzed with particular attention to factors that might be unique to each of the two racial groups. RESULTS Personal factors shaped black and white women's decisions regarding tubal sterilization. Preference for a convenient, highly effective contraceptive method was the main reason to get a tubal sterilization for women of both racial groups. We also identified socio-cultural differences that might explain why black women are more likely than white women to choose tubal sterilization over other contraceptive methods. An unanticipated, but clinically important, finding was that women often reported feeling that their doctors and the health-care system served as barriers to obtaining the desired procedure. CONCLUSION Socio-cultural differences may help explain why black and white women choose different contraceptive methods.
Collapse
Affiliation(s)
- Sonya Borrero
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | | | | | | | | | | |
Collapse
|