The development of facility standards for common outpatient procedures and implications for the context of abortion.

BackgroundIn recent years, an increasing number of states have enacted laws that impose specific requirements for facilities in which abortions are performed. In this study, we sought to understand the processes used to develop facility standards in the context of other, less politically charged areas of health care and consider implications for the context of abortion.MethodsWe conducted key informant interviews with 20 clinicians and accreditation professionals involved in facility standards development for common outpatient procedures (endoscopy, gynecology, oral surgery, plastic surgery). We examined the motivations for and processes used in facility standards development, use of scientific evidence in standards development, and decision-making in the absence of evidence. Interview data were thematically coded and analyzed using an iterative approach.ResultsIn contrast to U.S. state laws that target abortion facilities, standards for other outpatient procedures are commonly set by committees of clinicians organized by professional associations or accreditation organizations. These committees seek to establish standards that ensure patient safety without placing unnecessary burden on clinicians in practice. They aim to create evidence-based standards but can be hampered by lack of relevant research. In the absence of research evidence, committees rely on their clinical expertise and sense of best practices in decision-making. According to respondents, considerations of potential harm (e.g., deeper levels of sedation, invasiveness), rather than the specific procedure, should prompt additional requirements.ConclusionsIf facility standards in the context of abortion were developed through processes similar to other outpatient procedures, 1) professionals who perform the procedure would be involved in standards development and 2) in the absence of clear research evidence, the expertise of clinicians, and the guidelines and standards of other organizations, are used to describe a best practice standard of care

Complex situations: Economic insecurity, mental health, and substance use among pregnant women who consider - but do not have - abortions.

We examine characteristics and experiences of women who considered, but did not have, an abortion for this pregnancy. Participants were recruited at prenatal care clinics in Louisiana and Maryland for a mixed-methods study (N = 589). On self-administered surveys and structured interviews, participants were asked if they had considered abortion for this pregnancy and, if so, reasons they did not obtain one. A subset (n = 83), including participants who considered abortion for this pregnancy, completed in-depth phone interviews. Multivariable logistic regression analyses examined characteristics associated with having considered abortion and experiencing a policy-related barrier to having an abortion; analyses focused on economic insecurity and of mental health/substance use as main predictors of interest. Louisiana interviews (n = 43) were analyzed using modified grounded theory to understand concrete experiences of policy-related factors. In regression analyses, women who reported greater economic insecurity (aOR 1.21 [95% CI 1.17, 1.26]) and more mental health diagnoses/substance use (aOR 1.29 [1.16, 1.45] had higher odds of having considered abortion. Those who reported greater economic insecurity (aOR 1.50 [1.09, 2.08]) and more mental health diagnoses/substance use (aOR 1.45 [95% CI 1.03, 2.05] had higher odds of reporting policy-related barriers. Interviewees who considered abortion and were subject to multiple restrictions on abortion identified material and instrumental impacts of policies that, collectively, contributed to them not having an abortion. Many described simultaneously navigating economic insecurity, mental health disorders, substance use, and interpersonal opposition to abortion from family and the man involved in the pregnancy. Current restrictive abortion policies appear to have more of an impact on women who report greater economic insecurity and more mental health diagnoses/substance use. These policies work in concert with each other, with people's individual complex situations-including economic insecurity, mental health, and substance use-and with anti-abortion attitudes of other people to make abortion care impossible for some pregnant women to access

Conceptualizing and Measuring a Rights-Based Approach to Sexuality Education

For more than a century, the question of how adolescents should be taught about their emerging sexuality and sexual health has been debated in schools, within communities, and across the public sphere. Today, most efforts to provide formal sexuality education fall under two models: abstinence-only programs, which promote the benefits of restraint from sexual activity, or abstinence-plus programs, which encourage abstinence and offer lessons on safer sexual practices. The lack of consistent, compelling evidence for these widely used approaches has reinforced the need, among some leaders in the field, to reconsider the paradigm as a whole. They advocate for a shift from a narrow emphasis on reducing the risks of adolescent sexual activity toward a positive, holistic emphasis on the healthy sexual development of young people. The term "rights-based" has become increasingly linked to this concept of a more comprehensive approach to sexuality education. Discussions of a rights-based approach to sexuality education have become increasingly common in both international and U.S. contexts over the past decade. Among a small but growing group of program developers, funders, health educators, and scholars, the idea of addressing contextual factors such as gender norms, power differentials, and sexual rights within sexuality education has gained enthusiastic backing. While preliminary evidence from basic science and theoretical guidance lend support to this interest, there is little direct evidence for concluding that that this new approach is preferable to existing models. This dissertation was developed to offer a critical exploration of this new paradigm for sexuality education. In the first paper, "A Rights-Based Approach to Sexuality Education: Conceptualization, Clarification and Challenges," I present a conceptual definition for a rights-based approach to sexuality education that is consistent with and gives structure for understanding the guidelines, curricula, research, and theory that have been cited as informing the approach. Based on in-depth qualitative interviews with experts, I propose a rights-based approach as the intersection of four elements: 1) an underlying principle guiding the provision of sexuality education to youth as holders of sexual rights and responsibilities; 2) an expansion of programmatic goals beyond reducing unintended pregnancy and sexually transmitted infections; 3) a broadening of curriculum content to include issues such as gender norms, sexual orientation, sexual expression and pleasure, violence, and individual rights and responsibilities in relationships; and 4) a participatory teaching strategy that engages youth in critical thinking about their sexuality and sexual choices. In the second and third papers, I focus on one construct - adolescents' underlying attitudes about their sexual rights in relationships - of particular importance for the development, implementation, and evaluation of future rights-based sexuality education programs. In "Adolescents' Attitudes about Rights in Sexual Relationships: Measure Development and Psychometric Assessment," I describe the development of self-report survey measures that address adolescents' attitudes about their rights in steady and casual sexual relationships, and assess their psychometric properties using both classical test theory (CTT) and item response modeling (IRM) approaches. The final measures show evidence of psychometric soundness, including reliability and validity, which encourages their use in both epidemiological studies of adolescent sexual behavior and evaluations of rights-based sexuality education programs.In the third paper, "Understanding Adolescents' Attitudes about Rights in Sexual Relationships," I examine how adolescents' attitudes about their sexual relationship rights vary by demographic and behavioral characteristics, in contexts with a steady or casual sexual partner, and across the different dimensions of sexual relationship rights. Adolescents report strong support for sexual relationship rights across complex hypothetical situations, with some notable differences by individual characteristics and relationship contexts. I also investigate a theorized causal connection between attitudes about their sexual relationship rights and communication with sexual partners using a series of regression models. These analyses support a causal relationship between attitudes about rights to express sexual engagement needs and partner communication, net of plausible alternative explanations and partially mediated by comfort communicating with sexual partners. In contrast, there was no evidence to support an association between adolescents' attitudes about their rights to refuse sexual activity or rights to establish relationship autonomy and their communication with sexual partners.As a whole, this dissertation provides a critical examination of the rights-based approach to sexuality education, asking research questions not previously addressed in the literature and suggesting a number of avenues for future sexual health promotion efforts