Cara Nikolajski

“It just happens”: a qualitative study exploring low-income women’s perspectives on pregnancy intention and planning☆

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 womens 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 womens 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.

Racial Disparities in Awareness of the Human Papillomavirus

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.

Everything I know I learned from my mother...Or not: perspectives of African-American and white women on decisions about tubal sterilization.

BACKGROUNDAfrican-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.OBJECTIVESThe 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.DESIGNWe 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.PARTICIPANTSThe participants of the study were 24 African-American women and 14 white women.APPROACHTranscripts of the sessions were qualitatively analyzed with particular attention to factors that might be unique to each of the two racial groups.RESULTSPersonal 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.CONCLUSIONSocio-cultural differences may help explain why black and white women choose different contraceptive methods.

Race and reproductive coercion: a qualitative assessment.

BACKGROUND Unintended pregnancy is common and disproportionately occurs among low-income and African-American (AA) women. Male partners may influence womens risk of unintended pregnancy through reproductive coercion, although studies have not assessed whether racial differences in reproductive coercion impact AA womens disparate risk for unintended pregnancy. We sought to describe womens 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 womens 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.

Abortion Stigma Among Low-Income Women Obtaining Abortions in Western Pennsylvania: A Qualitative Assessment.

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 womens 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 Womens reactions to antiabortion attitudes may perpetuate abortion stigma. Further research is needed to inform interventions to address abortion stigma and improve womens abortion experiences.

Using Health Information Technology to Foster Engagement: Patients’ Experiences with an Active Patient Health Record

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.

Informed consent for inguinal herniorrhaphy and cholecystectomy: describing how patients make decisions to have surgery

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 Affairs 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.

Youth Perspectives on Risk and Resiliency A Case Study From Juiz de Fora, Brazil

The present work seeks to contribute to studies of cross-cultural risk and resiliency by presenting results from qualitative research with adolescents attending programs for at-risk youth in Juiz de Fora, Brazil. In 1990, Brazil introduced the Child and Adolescent Act (ECA), a significant piece of legislation that has had a direct impact on how at-risk youth are conceptualized both nationally and locally, through programs that target them. Little, however, is known about how youth in Brazil understand risk behaviors, what factors they believe contribute to risk taking or what they believe promotes resiliency. Furthermore, virtually no qualitative information exists on adolescents who are engaged in programs that use ECA as a prioritizing principle. By examining adolescent perspectives on risk and resiliency in such a context, we highlight the cultural differences in how youth negotiate their daily lives and the implications that continued exclusion of youth has on Brazilian society.

Readiness to Implement an Evidence-Based Psychotherapy: Perspectives of Community Mental Health Clinicians and Administrators

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.