Contraceptive and family planning experiences, priorities, and preferences of women with serious mental illness

Over three million women of reproductive age residing in the United States are living with a serious mental illness (SMI). Compared to the general population, women with SMI have lower rates of contraceptive use, receive suboptimal reproductive care, and are at increased risk for unintended pregnancy. Few studies examine the factors associated with contraceptive nonuse/misuse and unintended pregnancy among this population or what women with SMI identify as important contraceptive and family planning counseling topics. A systematic literature review was conducted in Study 1 to understand the current state of research regarding the contraceptive experiences, knowledge, and attitudes of women with SMI. Research quality, outcomes assessed, and findings varied, but many studies confirmed that women with SMI have disproportionately poorer contraceptive experiences. In Study 2, qualitative interviews were facilitated with women with SMI to understand factors influencing their contraceptive use/nonuse. Findings revealed that pregnancy intentions did not always align with contraceptive behaviors. Contributing factors to contraceptive nonuse/misuse included the influence of SMI symptoms, knowledge of and attitudes toward contraception, reproductive coercion, and sexual violence. Study 3 examined women’s reproductive counseling preferences and priorities, which included consideration of SMI symptoms when making contraceptive decisions, SMI medication contraindications and teratogenicity, SMI symptom changes during pregnancy/post-partum, and provider sensitivity. Additionally, these studies uncovered a more robust understanding of the differential reproductive experiences of women with bipolar, major depressive, and schizophrenia/schizoaffective disorders. Primary differences included variations in SMI symptoms and their influence on contraceptive use, with bipolar mania contributing to nonuse and fear of exacerbations in depressive symptoms impacting contraceptive method choice. Further, a higher proportion of women with schizophrenia/schizoaffective disorder experienced reproductive coercion, increasing their risk for unintended pregnancy. This dissertation provides important information that can enhance the way reproductive services are delivered to women with SMI. All women deserve the opportunity to express their sexuality and realize their family planning goals, however they may be defined. To promote the reproductive health and rights of this population, it is of significant public health importance to ensure that women with SMI can safely and effectively prevent or experience pregnancy and achieve optimal fertility-related outcomes

YOUTH AND COMMUNITY BASED PARTICIPATORY RESEARCH: SUGGESTIONS FOR FUTURE DIRECTIONS

Community Based Participatory Research (CBPR) is becoming popular in the field of public health. While many studies focus on including adults in the CBPR process, far fewer have utilized the input and expertise of children and adolescents. Successful CBPR projects are important to the field of public health due to their ability to open the doorway to the health needs and experiences of youth. This review paper first provides relevant background information regarding the health of youth living in the United States, the importance of adopting a life course approach to public health interventions, and the field of Community Based Participatory Research. It then explains the review methodology utilized and presents the results of the literature review. Specific attention is paid to summarizing CBPR work conducted with youth and the key issues related to such work. This review concludes by providing suggestions for future successful applications of CBPR with youth populations, and discusses the benefits and challenges of conducting this type of research. Results from this review contribute to a better understanding of the importance of utilizing ideas and insights of young people in order to create programming and policy changes that effectively address their needs

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

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

Health Care Provider Perspectives on the Use of a Digital Behavioral Health App to Support Patients: Qualitative Study

BackgroundDespite 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. ObjectiveThis study assessed providers’ views on the feasibility and acceptability of delivering a cognitive behavioral therapy (CBT)-based mobile app in multiple care settings. MethodsParticipating 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. ResultsA 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. ConclusionsDigital 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

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

ObjectiveUnintended 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 designSemistructured 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.ResultsAmong 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.ConclusionOur 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.ImplicationsThis 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

Race and Reproductive Coercion: A Qualitative Assessment

BackgroundUnintended 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.MethodsSemistructured 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.FindingsAmong 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.ConclusionsOur 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

Women veterans\u27 reproductive health preferences and experiences: a focus group analysis

OBJECTIVE: Although women veterans are seeking care at the Veterans Administration (VA) in record numbers, there is little information regarding women veterans\u27 experiences and preferences for reproductive health care services. We sought to characterize women veterans\u27 experiences with, and preferences for, reproductive health services in the VA. METHODS: We conducted five focus groups with a total of 25 participants using a semistructured interview guide to elicit women veterans\u27 experiences and preferences with reproductive health care. Women veterans\u27 utilizing VA health care at two VA facilities who responded to advertisements were selected on a first-come basis to participate in the study. We analyzed transcripts of these audio-recorded sessions using the constant comparative method of grounded theory. RESULTS: Five main themes emerged from the focus group discussions: 1) Women veterans prefer VA women\u27s clinics for comprehensive medical care; 2) Women veterans have had both positive and negative reproductive health experiences in the VA; 3) Women veterans experience knowledge gaps regarding VA coverage for reproductive health services; 4) Women veterans believe the VA should provide additional coverage for advanced infertility care and for newborns; and 5) Perceived gender discrimination shapes how women veterans view the VA. CONCLUSION: As the VA continues to tailor its services to women veterans, attention should be given to women\u27s reproductive health care needs. All rights reserved

The effect of an adapted digital mental health intervention for sickle cell disease on engagement: a pilot randomized controlled trial

Abstract Introduction Despite promising outcomes, lack of engagement and poor adherence are barriers to treating mental health using digital CBT, particularly in minority groups. After conducting guided focus groups, a current mental health app was adapted to be more inclusive for minorities living with SCD. Methods Patients between the ages of 16–35 with SCD who reported experiencing anxiety or depression symptoms were eligible for this study. Once enrolled, participants were randomly assigned to receive one of two versions of a mental health app: 1) the current version designed for the general population or 2) the adapted version. Baseline measures for depression, anxiety, pain, and self-efficacy were completed at the start of the study and again at post-intervention (minimum 4 weeks). Results Compared to baseline, mean scores for pain decreased an average of 3.29 (p = 0.03) on a 10-point scale, self-efficacy improved 3.86 points (p = 0.007) and depression symptoms decreased 5.75 points (p = 0.016) for the group that received the adapted app. On average, control participants engaged with the app 5.64 times while the participants in the experimental group engaged 8.50 times (p = 0.40). Regardless of group assignment, a positive relationship (r = 0.47) was shown between app engagement and a change in depression symptoms (p = 0.042). Discussion Target enrollment for this study sought to enroll 40 participants. However, after difficulties locating qualified participants, enrollment criteria were adjusted to expand the population pool. Regardless of these efforts, the sample size for this study was still smaller than anticipated (n = 21). Additionally, irrespective of group approximately 40% of participants did not engage with the app. However, despite a small sample size and poor engagement, this study 1) demonstrated the feasibility of implementing socially relevant changes into a mental health app and 2) indicated that participants in the intervention group displayed better outcomes and showed trends for greater app interaction. Conclusion These promising results should encourage future researchers to continue exploring ideal adaptations for implementing digital CBT in minority populations. Future studies should also consider implementing post-intervention surveys to help identify common factors relating to a lack of engagement. Trial registration This trial (NCT04587661) was registered on August 12th, 2020