Jennifer Yarger

Black-White Differences in Attitudes Related to Pregnancy among Young Women

In this article, we use newly available data from the Relationship Dynamics and Social Life (RDSL) study to compare a wide range of attitudes related to pregnancy for 961 black and white young women. We also investigate the extent to which race differences are mediated by, or net of, family background, childhood socioeconomic status (SES), adolescent experiences related to pregnancy, and current SES. Compared with white women, black women generally have less positive attitudes toward young nonmarital sex, contraception, and childbearing, and have less desire for sex in the upcoming year. This is largely because black women are more religious than white women and partly because they are more socioeconomically disadvantaged in young adulthood. However, in spite of these less positive attitudes, black women are more likely to expect sex without contraception in the next year and to expect more positive consequences if they were to become pregnant, relative to white women. This is largely because, relative to white women, black women had higher rates of sex without contraception in adolescence and partly because they are more likely to have grown up with a single parent. It is unclear whether attitudes toward contraception and pregnancy preceded or are a consequence of adolescent sex without contraception. Some race differences remain unexplained; net of all potential mediators in our models, black women have less desire for sex in the upcoming year, but they are less willing to refuse to have sex with a partner if they think it would make him angry and they expect more positive personal consequences of a pregnancy, relative to white women. In spite of these differences, black women’s desires to achieve and to prevent pregnancy are very similar to white women’s desires.

Young Women’s Relationships, Contraception and Unintended Pregnancy in the United States

In this chapter, we describe new research to investigate relationships, contraception and unintended pregnancies during the transition to adulthood. The Relationship Dynamics and Social Life (RDSL) study began with a 60-minute in-person interview about family background and current relationship characteristics. At the conclusion of the interview, respondents were enrolled in the journal-based portion of the study, which consisted of a 5-minute survey via web or phone and occurred weekly for 2.5 years. We begin by describing the prevalence and significance of unintended pregnancy in the United States and the limitations of past research on unintended pregnancy as background for our study. Then we describe the specific aims of our study and its design strengths. Next we provide a description of the young women in our sample, their relationships and their pregnancy intentions as of the baseline interview, as well as a summary of any changes across the weekly journals. Finally, we provide a summary of study findings that provide new insights into the contexts producing unintended pregnancies among young women. The results presented throughout the chapter are preliminary as data collection only recently ended in January 2012.

Young Adults Changing Insurance Status: Gaps in Health Insurance Literacy

Half of adults in the United States experience at least one change in insurance eligibility within a year, with 24% changing eligibility twice in a year [1]. Changes or disruptions in insurance coverage—“churning”—often occur due to transitions in employment, income, college status, or family structure [2–4]. As many of these life transitions are associated with young adulthood, young adults are at greater risk of interruptions in health insurance coverage than other age groups [5, 6]. Research conducted before the enactment of the Affordable Care Act (ACA) found that young adults experienced more turnover in nongroup health insurance coverage than older adults; only 21% of adults ages 19–35 maintained continuous nongroup coverage from 2008 to 2011 [7]. Although health care reform expanded health insurance coverage for young adults [8, 9], 39% of adults ages 19–29 reported a gap in their coverage in 2011 [6]. Churning among young adults has the potential to undermine the stability of individual health insurance markets and lead to increases in premiums. Insurers must be able to attract and retain younger, healthier enrollees in order to offset the costs associated with older, sicker enrollees. At the individual level, periods of coverage disruption can affect a young adult’s health care access. Churning can result in fewer doctors’ office visits for preventive care than continuous coverage [10]. Adults and children who switched coverage were found to be more likely to delay care or medication use because of cost or insurance issues and to report lower perceived quality of care than those who did not switch [3, 11–13]. For young adults, these disruptions take place during a critical time in establishing habits and care connections for lifelong health. Though generally a healthy period, young adulthood can involve the onset or peak of reproductive health, behavioral health, and substance abuse problems [5, 14]. Young adults with health insurance have reported greater access to routine health checkups than those without [15]. Insurance coverage affects access to reproductive health services, including access to contraceptive services and cervical cancer screenings [16–19]. Similarly, having health insurance coverage is positively associated with use of behavioral health services and medication, and is negatively associated with an unmet need for behavioral health treatment [20–22]. Research increasingly highlights the importance of health insurance literacy for building strong care connections and maintaining health [23]. The ability to obtain, process and understand health insurance information affects insurance plan choices, use of in-network providers, understanding of rights as a user, and perceived costs of care [24, 25]. These skills are necessary for reading health care notices, understanding insurance cost-sharing designs, and communicating with health care providers [26]. Recent research among young adults found barriers to reproductive health care resulting from confusion and dependence on parental policy-holders [16]. One study showed young adults demonstrating poor health insurance literacy when asked to define common health insurance terms, with 48% incorrectly defining deductible and 78% incorrectly defining coinsurance [27]. Another study found young adults have limited abilities understanding, evaluating and communicating health-related information [28]. Resources aimed at improving health insurance literacy must consider the varied contextual environments of young adults’ lives, such as moving between institutions (e.g., school or jobs) and losing or gaining personal resources that * Lana Tilley Lana.Tilley@gmail.com

The Role of Publicly Funded Family Planning Sites In Health Insurance Enrollment.

CONTEXT Publicly funded family planning providers are well positioned to help uninsured individuals learn about health insurance coverage options and effectively navigate the enrollment process. Understanding how these providers are engaged in enrollment assistance and the challenges they face in providing assistance is important for maximizing their role in health insurance outreach and enrollment. METHODS In 2014, some 684 sites participating in Californias family planning program were surveyed about their involvement in helping clients enroll in health insurance. Weighted univariate and bivariate analyses were conducted to examine enrollment activities and perceived barriers to facilitating enrollment by site characteristics. RESULTS Most family planning program sites provided eligibility screening (68%), enrollment education (77%), on-site enrollment assistance (55%) and referrals for off-site enrollment support (91%). The proportion of sites offering each type of assistance was highest among community clinics (83-96%), primary care and multispecialty sites (65-95%), Title X-funded sites (72-98%), sites with contracts to provide primary care services (64-93%) and sites using only electronic health records (66-94%). Commonly identified barriers to providing assistance were lack of staff time (reported by 52% of sites), lack of funding (47%), lack of physical space (34%) and lack of staff knowledge (33%); only 20% of sites received funding to support enrollment activities. CONCLUSIONS Although there were significant variations among them, publicly funded family planning providers in California are actively engaged in health insurance enrollment. Supporting their vital role in enrollment could help in the achievement of universal health insurance coverage.