Physician engagement in reproductive health advocacy: findings from a mixed methods evaluation of a leadership and advocacy program

BACKGROUND

Medical curricula include advocacy competencies, but how much physicians engage in advocacy and what enables this engagement is not well characterized. The authors assessed facilitators and barriers to advocacy identified by physician alumni of a reproductive health advocacy training program.

METHODS

The authors present secondary results from a mixed methods program evaluation from 2018 to 2020, using alumni data from a cross-sectional survey (n = 231) and in-depth interviews (IDIs, n = 36). The survey measured engagement in policy, media, professional organization, and medical education advocacy and the value placed on the community fostered by the program (eight questions, Cronbach's alpha = 0.81). The authors estimated the association of community value score with advocacy engagement using multivariable Poisson regression to estimate prevalence ratios and analyzed IDI data inductively.

RESULTS

Over one third of alumni were highly engaged in legislative policy (n = 90, 39%), professional organizations (n = 98, 42%), or medical education (n = 89, 39%), with fewer highly active in media-based advocacy (n = 54, 23%) in the year prior to the survey. Survey and IDI data demonstrated that passion, sense of urgency, confidence in skills, and the program's emphasis on different forms of advocacy facilitated engagement in advocacy, while insufficient time, safety concerns, and sense of effort redundancies were barriers. The program community was also an important facilitator, especially for "out loud" efforts and for those working in environments perceived as hostile to abortion care (e.g., alumni in hostile environments with high community value scores were 1.8 times [95% CI 1.3, 2.6] as likely to report medium/high levels of media advocacy compared to those with low scores after adjusting for age, gender, and clinical specialty).

CONCLUSION

Physician advocacy training curricula should include both skills- and community-building and identify a full range of forms of advocacy. Community-building is especially important for physician advocacy for reproductive health services such as abortion care.

Parenting Students and Indicators of Financial Stability, Health, and Academic Success: Findings from a Population-Based Sample of Public Urban University Students

Parenting students constitute a significant portion of the college population, with 22% of undergraduate students nationwide managing the dual responsibilities of parenthood and education. Single-parenting students face disproportionate challenges to achieving academic success. This study examines the health, financial, and academic aspects of parenting students attending a large, urban public university, specifically comparing single parents to their married or cohabiting counterparts and non-parenting students in New York City. We collected data from 2104 participants, including 142 single parents and 119 married or cohabiting parents, through a cross-sectional survey. Using adjusted regression models, we evaluated the associations between parenting status and financial, health, and academic factors. Our findings reveal that, in comparison to non-parents, single parents are significantly more likely to carry debt (adjusted odds ratio [aOR] 1.81), rely on food assistance (aOR 5.03), and achieve slightly lower GPAs (β - 0.11). Single parents also work more hours (aOR 1.66) and have an increased likelihood of facing debt (aOR 2.66), housing difficulties (aOR 2.80), food insecurity (aOR 2.21), and lower GPAs (β - 0.22) compared to their married or cohabiting peers. The disaggregation of single and married or cohabiting parents reveals significant disparities, emphasizing the vulnerability of single-parenting students in higher education. Targeted interventions addressing issues like food security and housing are essential to support the academic success of single parents.

Sexual and Reproductive Health Advocacy Successes, Failures, and Needs in the United States: Perspectives From Key Stakeholders

Physician advocates for sexual and reproductive health (SRH) care have been active in the United States for decades. Despite such activism, access to SRH services has been fraught with persistent restrictions, particularly for abortion care. We sought the perspectives of key stakeholders on what makes for an effective SRH physician advocate and thoughts about the successes, failures, and needs of the abortion advocacy movement. We interviewed 15 SRH key informants (KIs) in sectors with expertise in organizational policy and advocacy (n = 6); clinical leadership and education (n = 3), media (n = 3), and reproductive justice (n = 3). The analytic team coded repeating ideas and conducted a thematic analysis, organizing findings within KI perspectives on the role of physician advocates in the field of abortion and contraception; successes, failures, and needs in abortion and contraception advocacy; and recommendations on the composition and components of an ideal clinician advocacy training program. KIs relayed that skill building related to communication, developing relationships with changemakers, and understanding political systems was critical for effective advocacy. They felt clinician advocacy training programs should include providers other than physicians and be designed for trainees to build relationships with one another over time. KI perspectives can be valuable in informing advocacy training programs and for contributing strategic approaches to increasing equitable and widespread access to SRH services.

Delays in Obtaining Abortion and Miscarriage Care Among Pregnant Persons in New York State During the COVID-19 Pandemic: The CAP Study

Background

We sought to investigate delays obtaining abortion and miscarriage care during the COVID-19 pandemic, compared with before the pandemic, among pregnant persons in New York State (NYS).

Methods

We administered a cross-sectional survey in June-July 2020 to NYS residents aged 18-44 years who identified as female or transgender male (N = 1,525). This analysis focused on a subsample who had an abortion or miscarriage during COVID-19, were seeking an abortion at the time of the survey, or had an abortion or miscarriage before COVID-19 (n = 116). We conducted bivariate analyses to determine differences in delays to seeking or obtaining an abortion or miscarriage during versus before the pandemic, as well as consideration of abortion among those pregnant during versus before the pandemic. We also asked open-ended questions about miscarriage and abortion experiences.

Main Findings

Of the 21 respondents who sought or were seeking an abortion during the COVID-19 pandemic, 76.2% (n = 16) reported experiencing a delay in obtaining abortion care, compared with 18.2% (n = 4) of those who experienced a delay before the pandemic (p < 0.001). A significantly higher proportion of respondents who were pregnant during the pandemic considered abortion, compared with those who gave birth before the pandemic (39.1% vs. 7.6%; p < 0.001). Of the 39 respondents who miscarried during the pandemic, 35.9% (n = 14) delayed care, compared with 5.9% (n = 2) before the pandemic (p < 0.01). Some respondents also commented on the difficulty of accessing miscarriage services during COVID-19 in open-ended responses.

Principal Conclusions

Those who sought abortion or miscarriage care during the COVID-19 pandemic experienced significant delays in getting care. These are essential services that must be available during public health emergencies, and yet access to these services is now severely limited in many states due to the Dobbs vs. Jackson Women's Health Organization decision.

Assessing comprehension of the Parenting/Pregnancy Attitudes, Timing, and How Important (PATH) questions through cognitive interviewing

OBJECTIVES

PATH, "Parenting/Pregnancy Attitudes, Timing, and How Important," is a method for providers to engage in a person-centered discussion about reproductive desires. This study sought to assess patient understanding of and receptivity to PATH questions.

STUDY DESIGN

Cognitive interviews were conducted with young adult (aged 18-29 years) patients at a federally qualified health center in New York (n = 10).

RESULTS

Participants demonstrated clear comprehension and comfort with the PATH questions.

IMPLICATIONS

These data provide needed person-driven support for the Centers for Disease Control and Prevention and the Society of Family Planning's recommendation to implement PATH questions as a patient-centered method for discussing an individual's reproductive desires.

How do childcare and pregnancy affect the academic success of college students?

OBJECTIVE

We examined socioeconomic, academic, and health-related factors associated with respondent reports that childcare interfered with academics.

PARTICIPANTS

176 undergraduate student parents.

METHODS

We administered a cross-sectional survey to a representative sample of students at a public university in New York City. Using a sub-set of those who reported being parents/guardians (n = 176), we conducted bivariate analyses to assess factors associated with childcare problems interfering with school.

RESULTS

About 30% of the sample reported that childcare interfered with school somewhat/moderately/a lot in the last year. Compared to those with no/little perceived interference, they were significantly more likely to need mental health treatment (30% vs. 13%; p < 0.01), worry that they would run out of food sometimes/often (32% vs. 16%; p < 0.01), and experience housing problems (26% vs. 9%; p < 0.01).

CONCLUSIONS

Offering mental healthcare and services addressing food and housing insecurity can help college students to navigate challenges inherent to being a student parent.

Physician perspectives of abortion advocacy: findings from a mixed-methods study

OBJECTIVE

Our aim was to assess physicians' perspectives of what constitutes abortion advocacy and the skills needed to be effective in their efforts to safeguard legal abortion.

METHODS

Alumni from a physician training programme for sexual and reproductive health advocacy completed a cross-sectional survey including questions on perceived skills needed for effective advocacy. The research team conducted in-depth interviews (IDIs) with alumni, based on their level of engagement in advocacy. We present descriptive statistics for survey data and themes identified in the interview data using techniques informed by grounded theory.

RESULTS

Of the survey respondents (n=231), almost a third (28.6%; n=66) felt the most important media skill they learnt was the ability to stay on message. The most important policy skill was communicating effectively with policymakers (47.0%; n=108), followed by distilling evidence for policymakers and laypeople (13.0%; n=30). In the IDIs (n=36), participants reported activities such as media interviews as clear examples of advocacy, but also considered implementing institutional policies and abortion provision to be advocacy. They discussed how individual comfort and capacity for advocacy activities may change over time, given personal and professional considerations. Regardless of the type of activity, physicians valued strategic communication and relationship-building skills.

CONCLUSIONS

Based on our findings, training programmes that seek to mobilise physician advocates to advance sexual and reproductive health and rights should work with trainees to create a tailored advocacy plan that fits their personal and professional lives and goals. Regardless of the types of advocacy activities physicians focus on, strategic communication may be central in skills-based training.

The primacy of meeting public university students' essential needs in the wake of COVID-19: An overdue higher education priority

OBJECTIVES

We investigated the holistic experiences of university students during the pandemic.

PARTICIPANTS

Thirty-eight students in a public university system in New York City (NYC) purposively selected from neighborhoods highly affected by the pandemic based on level of self-reported impact.

METHODS

We conducted virtual in-depth interviews from May to August 2021 and analyzed data using thematic coding and constant comparison techniques informed by grounded theory.

RESULTS

Financial and social support systems, such as governmental and school resources, were critical to addressing essential needs and allowing students to persist. For those whose essential needs were met, faculty members' flexibility and students' experience with online learning were central to their academic success.

CONCLUSIONS

Institutions of higher education should strengthen financial and social support systems to meet students' essential needs. Academic policies to bolster online pedagogy and faculty's flexibility can facilitate student retention and completion.

The Role of COVID-19, Race and Social Factors in Pregnancy Experiences in New York State: The CAP Study

Given that New York State's (NYS) was the first epicenter of the COVID-19 pandemic in the United States (US), we were interested in potential racial/ethnic differences in pregnancy-related experiences among women pregnant during versus prior to the pandemic. We surveyed 1,525 women (18-44 years) proportionate to geographic and sociodemographic distribution between June 9, 20 and July 21, 20. We carried out bivariate analysis of various social and pregnancy-related factors by racial/ethnic identity (White, Black, Hispanic) and binary logistic and linear regression assessing the association between race/ethnicity, pregnancy prior to/during the pandemic, demographic characteristics, health and social wellbeing, and employment as an essential worker with pregnancy-related healthcare delays and changes. Overall, Black and Hispanic women were significantly more likely to experience a host of negative prenatal and postpartum experiences. In general, multivariate analyses revealed that individuals who were pregnant during the pandemic, lived in NYC, participated in social welfare programs, lacked health insurance, and/or were essential workers were more likely to report delays in prenatal and postpartum care and/or more changes/negative experiences. In light of previous evidence of racial disparities in birth experiences, the higher rates of negative pregnancy/birth-care and postpartum/newborn-care experiences among Black and Hispanic women in bivariate analysis warrant further inspection given that their aggregation for multivariate analysis may have obscured differences at the level of individual events. Findings support continued efforts for universal health insurance and improved social welfare programs. Guidelines are needed to protect essential workers' access to health services, particularly related to pregnancy given the time-sensitive nature of this care.Supplemental data for this article is available online at https://doi.org/10.1080/08964289.2021.1997893 .

Factors related to delays in obtaining contraception among pregnancy-capable adults in New York State during the COVID-19 pandemic: The CAP study

Objectives

To investigate factors associated with delays to obtaining contraception during the COVID-19 pandemic among pregnancy-capable adults in New York State.

Study Design

We administered a cross-sectional survey in June-July 2020 to female/transgender male New York State residents aged 18–44 years (n = 1,525). This analysis focused on respondents who were not pregnant and sought contraception (n = 953). We conducted bivariate and multinomial logistic regression analyses to assess sociodemographic, social, and health characteristics, by the outcome of delays to obtaining birth control (delayed due to COVID-19, delayed due to other reasons, no delay). We also analyzed a sub-sample who reported COVID-19 as a reason for delays (n = 317) and report the frequencies of type of contraceptive methods/procedures delayed and availability of telemedicine visits.

Results

Half of respondents had no contraceptive delays, 39% reported delays due to COVID-19, and 11% reported delays due to reasons other than COVID-19. In adjusted analyses, those who missed a rent/mortgage payment during the pandemic (aOR: 2.23; CI: 1.55, 3.22), participated in a supplemental government program in 2019 (aOR: 1.88; CI: 1.36, 2.60), and themselves/household member had COVID-19 (aOR: 1.48; CI: 1.04, 2.12) were more likely to report delays to contraception due to COVID-19 (versus no delays). In the sub-sample, 63% reported available virtual contraceptive visits, 28% unavailable, and 9% not sure. The most frequently (42%) reported delays were new prescriptions for the pill, patch, or ring.

Conclusions

Reducing financial barriers that help individuals maintain their housing and living necessities, and promoting telemedicine visits, may help increase access to contraception.

The Impact of the COVID-19 Pandemic on College Students' Health and Financial Stability in New York City: Findings from a Population-Based Sample of City University of New York (CUNY) Students

Understanding the effect of the coronavirus disease 2019 (COVID-19) pandemic on students' health and financial stability is important to establish effective interventions to mitigate these effects, which may have long-term consequences on their health and well-being. Public universities in urban centers represent a substantial proportion of college students in the USA. We implemented a cross-sectional population-based online survey of 2282 students in a large, public university in New York City in April 2020. We created weights to account for non-response and used Poisson regression with robust standard errors to estimate adjusted prevalence ratios (aPR) for factors associated with mental health outcomes. Students experienced high rates of anxiety/depression and financial instability due to the pandemic. Half of the students reported anxiety/depression (54.5%) and an increased need for mental health services (49.0%) as a result of the COVID-19 pandemic. The majority (81.1%) reported loss of household income, and half (49.8%) reported worries about losing housing. High levels of food (aPR  = 1.4, 95% CI 1.2, 1.6) and housing (aPR = 1.3, 95% CI 1.2, 1.4) insecurity were the strongest predictors of anxiety/depression. Household and personal experiences with possible COVID-19 symptoms were also associated with anxiety/depression or the need for increased mental health services. Addressing student needs at public urban universities requires an integrated holistic approach that targets urgent mental health and economic needs related to the impact of COVID-19. Students who become infected need mental health services as well as health monitoring.

Primary care patients' preferences for reproductive health service needs assessment and service availability in New York Federally Qualified Health Centers

OBJECTIVES

Expanding reproductive health services in primary care could increase access to preconception and contraceptive services. We assessed patients' preferences around wording, frequency and staffing for reproductive health service needs assessment and availability of a range of reproductive health services in primary care.

STUDY DESIGN

We implemented a cross-sectional anonymous survey of adults in the waiting rooms of four Federally Qualified Health Centers (FQHCs) in New York State in 2017. We present descriptive findings on preferences, including preferences among four questions on reproductive health needs assessment, and differences by socio-demographic characteristics.

RESULTS

We had an 89.4% response rate. Of 1,071 respondents, 68.8% self-reported gender as female, 26.5% male and 4.1% transgender/other, while 40.8% self-identified as black non-Hispanic, 32.2% white non-Hispanic, 17.6% Hispanic and 9.4% other. A third had no preferred reproductive health needs assessment question (34.5%), while another third preferred, "Can I help you with any reproductive health services today such as birth control or planning a healthy pregnancy?" (31.5%). Respondents wanted to be asked by a doctor (43.9%) or nurse/medical assistant (21.1%). Females wanted to be asked at every visit (52.9%) more than males (43.9%) and transgender/other individuals (34.1%, p < 0.01). The majority would like to be able to access contraception (59.0%) and sexually transmitted infection (STI) testing (55.4%) at their FQHC.

CONCLUSIONS

Most patients supported inclusion of reproductive health discussions and contraception and STI services at these FQHCs. Among those with a preference, patients preferred to be asked about reproductive health service needs rather than pregnancy intentions or desires.

IMPLICATIONS

Primary care settings should consider routine inclusion of reproductive health needs assessments over screening for pregnancy intentions or desires. Primary care settings which do not currently provide contraception and sexually transmitted infection testing should consider making these services available.

Understanding racial disparities in treatment intensification for hypertension management

BACKGROUND

Disparities in blood pressure (BP) control may be a function of disparities in treatment intensification (TI).

OBJECTIVE

To examine racial differences in TI, understand modifiable factors that may mediate this relationship, and explore the relative effects of TI and race on blood pressure.

DESIGN

Prospective cohort study.

PARTICIPANTS

Participants were 819 black and white patients with hypertension from an urban, safety-net hospital

MAIN MEASURES

We sequentially explored the effects of patient race, sociodemographic and clinical characteristics, beliefs about BP/medications, perceptions of provider/discrimination, sodium intake, medication adherence, and provider counseling on TI, performing a series of random effects analyses. To assess the effects of race and TI on BP, we performed linear regressions, using systolic BP (SBP) as the outcome.

KEY RESULTS

Unadjusted analyses and those including sociodemographic and clinical characteristics revealed that black patients had less TI than whites (-0.31 vs.-0.24, p < 0.001), but adjustment for patient beliefs and experiences eliminated the effects of race (beta =-0.02, p = 0.5). Increased patient concerns about BP medications were related to lower TI, as was more provider counseling (beta =-0.06, p = 0.02 and beta = -0.01, p = 0.001, respectively). In the unadjusted analysis, black race was a significant predictor of SBP (134 mm/Hg for blacks vs. 131 mm/Hg for whites, p = 0.009), but when both race and TI were included in the model, TI was a significant predictor of SBP (final SBP 2.0 mm/Hg lower for each additional therapy increase per 10 visits, p < 0.001), while race was not (Blacks 1.6 mm/Hg higher than whites, p = 0.17).

CONCLUSIONS

Improved patient-provider communication targeted towards addressing patient concerns about medications may have the potential to reduce racial disparities in TI and ultimately, BP control.

Self-reported willingness to have cancer screening and the effects of sociodemographic factors

BACKGROUND

The relative effects of race/ethnicity and other sociodemographic factors, compared to those of attitudes and beliefs on willingness to have cancer screening, are not well understood.

METHODS

We conducted telephone interviews with 1148 adults (22% Hispanic, 31% African American, and 46% white) [corrected] from 3 cities in mainland United States and Puerto Rico. Respondents reported their sociodemographic characteristics, attitudes about barriers and facilitators of cancer screening, and willingness to have cancer screening under 4 scenarios: when done in the community vs one's doctor's office, and whether or not one had symptoms.

RESULTS

Racial/ethnic minority status, age, and lower income were frequently associated with increased willingness to have cancer screening, even after including attitudes and beliefs about screening. Having screening nearby was important for community screening, and anticipation of embarrassment from screening for when there were no cancer symptoms. Associations varied across 4 screening scenarios, with the fewest predictors for screening by one's doctor when there were symptoms.

CONCLUSIONS

Sociodemographic characteristics not only were related to willingness to have cancer screenings in almost all cases, but were generally much stronger factors than attitudinal barriers and facilitators. Cancer screening campaigns should affect attitudinal change where possible, but should also recognize that targeting screening to specific population groups may be necessary.

Understanding contributors to racial disparities in blood pressure control

BACKGROUND

Racial disparities in blood pressure (BP) control are well documented but poorly understood; prior studies have only included a limited range of potential explanatory factors. We examined a comprehensive set of putative factors related to blood pressure control, including patient clinical and sociodemographic characteristics, beliefs about BP and BP medications, medication adherence, and experiences of discrimination, to determine if the impact of race on BP control remains after accounting for such factors.

METHODS AND RESULTS

We recruited 806 white and black patients with hypertension from an urban safety-net hospital. From a questionnaire administered to patients after their clinic visits, electronic medical record and BP data, we assessed an array of patient factors. We then examined the association of patient factors with BP control by modeling it as a function of the covariates using random-effects logistic regression. Blacks indicated worse medication adherence, more discrimination, and more concerns about high BP and BP medications, compared with whites. After accounting for all factors, race was no longer a significant predictor of BP control.

CONCLUSIONS

Results suggest that equalizing patients' health beliefs, medication adherence, and experiences with care could ameliorate disparities in BP control. Additional attention must focus on the factors associated with race to identify, and ultimately intervene on, the causes of racial disparities in BP outcomes.

Intensifying therapy for hypertension despite suboptimal adherence

More intensive management can improve control blood pressure (BP) in hypertensive patients. However, many would posit that treatment intensification (TI) is not beneficial in the face of suboptimal adherence. We investigated whether the effect of TI on BP varies by adherence. We enrolled 819 patients with hypertension, managed in primary care at an academically-affiliated inner-city hospital. We used the following formula to characterize TI: (visits with a medication change-visits with elevated BP)/total visits. Adherence was characterized using electronic monitoring devices ("MEMS caps"). Patients who returned their MEMS caps (671) were divided into quartiles of adherence, whereas patients who did not return their MEMS caps (148) had "missing" adherence. We examined the relationship between TI and the final systolic blood pressure (SBP), controlling for patient-level covariates. In the entire sample, each additional therapy increase per 10 visits predicted a 2.0 mm Hg decrease in final SBP (P<0.001). After stratifying by adherence, in the "best" adherence quartile each therapy increase predicted a 2.1-mm Hg decrease in final SBP, followed by 1.8 for the "next-best" adherence quartile, 2.3 in the third quartile, and 2.4 in the "worst" adherence quartile. The effect size for patients with "missing" adherence was 1.6 mm Hg. The differences between the group with "best" adherence and the other 4 groups were not statistically significant. In this observational study, treatment intensification was associated with similar BP improvement regardless of the patient's level of adherence. A randomized trial could further examine optimal management of patients with suboptimal adherence.

Comparing methods of measuring treatment intensification in hypertension care

BACKGROUND

Greater treatment intensification (TI) improves hypertension control. However, we do not know the ideal way to measure TI for research and quality improvement efforts. We compared the ability of different TI measures to predict blood pressure (BP) control.

METHODS AND RESULTS

We enrolled 819 hypertensive outpatients from an urban academic hospital. Each patient was assigned 3 scores to characterize TI. The any/none score divides patients into those who had any therapy increases during the study versus none. The norm-based method models the chance of a medication increase at each visit, then scores each patient based on whether they received more or fewer medication increases than predicted. The standard-based method is similar to the norm-based method but expects a medication increase whenever the blood pressure is uncontrolled. We compared the ability of these scores to predict the final systolic blood pressure (SBP). The any/none score showed a paradoxical result: any therapy increase was associated with SBP 4.6 mm Hg higher than no increase (P<0.001). The norm-based method score did not predict SBP in a linear fashion (P=0.18); further investigation revealed a U-shaped relationship between the norm-based method score and SBP. However, the standard-based method score was a strong linear predictor of SBP (2.1 mm Hg lower for each additional therapy increase per 10 visits, P<0.001). Similarly, the standard-based method predicted dichotomized blood pressure control, as measured by SBP <140 mm Hg (odds ratio, 1.30; P<0.001).

CONCLUSIONS

Our results suggest that standard-based method is the preferred measure of treatment intensity for hypertension care.

Perceptions of race/ethnicity-based discrimination: a review of measures and evaluation of their usefulness for the health care setting

BACKGROUND

To assess discrimination in health care, reliable, valid, and comprehensive measures of racism/discrimination are needed.

OBJECTIVE

To review literature on measures of perceived race/ethnicity-based discrimination and evaluate their characteristics and usefulness in assessing discrimination from health care providers.

METHODS

Literature review of measures of perceived race/ethnicity-based discrimination (1966-2007), using MEDLINE, PsycINFO, and Social Science Citation Index.

RESULTS

We identified 34 measures of racism/discrimination; 16 specifically assessed dynamics in the health care setting. Few measures were theoretically based; most assessed only general dimensions of racism and focused specifically on the experiences of African American patients. Acceptable psychometric properties were documented for about half of the instruments.

CONCLUSIONS

Additional measures are needed for detailed assessments of perceived discrimination in the health care setting; they should be relevant for a wide variety of racial/ethnic groups, and they must assess how racism/discrimination affects health care decision making and treatments offered.