Building Capacity for Research on Community Doula Care: A Stakeholder-Engaged Process in California.

PURPOSE: In an effort to address persistent inequities in maternal and infant health, policymakers and advocates have pushed to expand access to doula care. Several states, including California, now cover doula services through Medicaid. As coverage expands, research on the impact of doula care will likely increase. To develop best practices for research, it is critical to engage community doulas, clients, and other key stakeholders. DESCRIPTION: Our overarching goal was to build capacity for future doula- and client-centered research on community doula care. First, we established a Steering Committee with members from seven relevant stakeholder groups: community doulas, former or potential doula clients, clinicians, payers, advocates, researchers, and public health professionals. Second, we conducted a needs assessment to identify and understand stakeholders' needs and values for research on community doula care. Findings from the needs assessment informed our third step, conducting a research prioritization to develop a shared research agenda related to community doula care with the Steering Committee. We adapted the Research Prioritization by Affected Communities protocol to guide this process, which resulted in a final list of 21 priority research questions. Lastly, we offered a training to increase capacity among community doulas to engage in research on community doula care. ASSESSMENT: Our findings provide direction for those interested in conducting research on doula care, as well as policymakers and funders. CONCLUSION: The findings of our stakeholder-engaged process provide a roadmap that will lead to equity-oriented research centering clients, doulas, and their communities.

'We tend to prioritise others and forget ourselves': How women's caregiving responsibilities can facilitate or impede diabetes self-management.

AIM: The objective of the parent study was to examine attitudes and experiences regarding counselling about preconception care among Black and/or Latina women in the United States with type 2 diabetes (T2DM). Here, we present emergent findings from a secondary analysis of caregiving. METHODS: In this qualitative descriptive study, we used conventional content analysis to identify themes from semi-structured interviews with 32 Black and/or Latina women ages 18-40 who have T2DM in the United States recruited from online platforms and snowball sampling. RESULTS: Caregiving responsibilities both motivate and disrupt diabetes self-management behaviours. Caregiving largely meant taking care of children, but women also had responsibilities to adult family members and romantic partners. Women were motivated to manage their diabetes in order to prevent negative health effects on their children and to stay healthy so they could fulfil caregiving responsibilities. However, caregiving competed for time, energy and money with self-management. Struggling to balance caregiving and self-management caused stress that women felt was intrinsically unhealthy and undermined self-management. CONCLUSIONS: Young adult women with T2DM identified different ways that the roles and responsibilities in the family could affect their diabetes self-management. Providers and policymakers should develop health-promoting interventions that accommodate caregiving responsibilities.

A Randomized Encouragement Trial to Increase Mail Order Pharmacy Use and Medication Adherence in Patients with Diabetes.

BACKGROUND: Mail order pharmacy (MOP) use has been linked to improved medication adherence and health outcomes among patients with diabetes. However, no large-scale intervention studies have assessed the effect of encouraging MOP use on medication adherence. OBJECTIVE: To assess an intervention to encourage MOP services to increase its use and medication adherence. DESIGN: Randomized encouragement trial. PATIENTS: 63,012 diabetes patients from three health care systems: Kaiser Permanente Northern California (KPNC), Kaiser Permanente Hawaii (KPHI), and Harvard Pilgrim Health Care (HPHC) who were poorly adherent to at least one class of cardiometabolic medications and had not used MOP in the prior 12 months. INTERVENTION: Patients were randomized to receive either usual care (control arm) or outreach encouraging MOP use consisting of a mailed letter, secure email message, and automated telephone call outlining the potential benefits of MOP use (intervention arm). HPHC intervention patients received the letter only. MEASUREMENTS: We compared the percentages of patients that began using MOP and that became adherent to cardiometabolic medication classes during a 12-month follow-up period. We also conducted a race/ethnicity-stratified analysis. RESULTS: During follow-up, 10.6% of intervention patients began using MOP vs. 9.3% of controls (p < 0.01); the percent of cardiometabolic medication delivered via mail was 42.1% vs. 39.8% (p < 0.01). Metformin adherence improved in the intervention arm relative to control at the two KP sites (52% vs. 49%, p < 0.01). Stratified analyses suggested a significant positive effect of the intervention in White (RR: 1.12, 95% CI: 1.03, 1.22) and Asian (RR: 1.30, 95% CI: 1.17, 1.45) patients. CONCLUSION: This pragmatic trial showed that simple outreach to encourage MOP modestly increased its use and improved adherence measured by refills to a key class of diabetes medications in some settings. Given its minimal cost, clinicians and health systems should consider outreach interventions to actively promote MOP use among diabetes patients. TRIAL REGISTRATION: ClinicalTrials.gov registration number: NCT02621476.

Opportunities to encourage mail order pharmacy delivery service use for diabetes prescriptions: a qualitative study.

BACKGROUND: Medication non-adherence is a major contributor to poor outcomes in diabetes. Previous research has shown an association between use of mail order pharmacy delivery and better medication adherence, but little is known about the barriers and facilitators to mail order pharmacy use in diabetes patients. This qualitative study examined factors related to mail order pharmacy use versus traditional "brick and mortar" pharmacies to refill prescriptions. METHODS: We conducted four 90-min focus groups in 2016 among 28 diabetes patients in the Hawaii and Northern California regions of Kaiser Permanente, a large integrated health care delivery system. We queried participants on their preferred mode for refilling prescriptions and perceived barriers and facilitators of mail order pharmacy use. One researcher independently coded each focus group transcript, with two of these transcripts double-coded by a second researcher to promote reliability. We employed thematic analysis guided by the Capability, Opportunity, Motivation, and Behavior (COM-B) framework using NVivo 11 software. RESULTS: A total of 28 diabetes patients participated. Participants' average age was 64.1 years; 57% were female; and racial/ethnic backgrounds included Asian/Native Hawaiian/Pacific Islander (36%), Black/African-American (21%) Hispanic/Latino (7%), and non-Hispanic White (36%). Analysis uncovered 26 themes related to the decision to use mail order pharmacy, with each theme representing a barrier or facilitator mapped to the COM-B framework. Most themes (20/26) fell into the COM-B category of 'Opportunity.' Opportunity barriers to mail order pharmacy use included unpredictability of medication delivery date, concerns about mail security, and difficulty coordinating refill orders for multiple prescriptions. In contrast, facilitators included greater access and convenience (e.g., no need to wait in line or arrange transportation) compared to traditional pharmacies. Motivational facilitators to mail order pharmacy use included receiving a pharmacy benefit plan incentive of a free one-month supply of prescriptions. CONCLUSIONS: This study found that while patients with diabetes may benefit from mail order pharmacy use, they perceive numerous barriers to using the service. These findings will inform the design of interventions and quality improvement initiatives to increase mail order pharmacy use, which in turn may improve medication adherence and outcomes in diabetes patients, across health care systems.

Experiences of Preconception Counseling among Pregnant Women with Preexisting Diabetes: Opportunities to Improve Patient-Centered Care.

Available research suggests that patients with diabetes do not regularly receive preconception counseling, but information on patients' experiences of counseling is scant. We conducted a qualitative study involving semi-structured interviews with 22 patients between October 2020 and February 2021. Pregnant patients with preexisting diabetes were recruited from a specialty diabetes and pregnancy clinic at a large academic medical center in Northern California. Interviews were transcribed, coded, and analyzed using an inductive and deductive content analysis approach. A total of 27% reported they did not have any pregnancy-related discussions with a health care provider before pregnancy. Of those that did, many sought out counseling; this was often connected to how "planned" the pregnancy was. Few participants, nearly all with type 1 diabetes, reported having a formal preconception care visit. Participants described receiving information mostly about the risks associated with diabetes and pregnancy. While participants who sought out counseling generally reported their providers were supportive of their desire for pregnancy, there were a few exceptions, notably all among patients with type 2 diabetes. The varied experiences of participants indicate gaps in the delivery of pre-pregnancy counseling to patients with diabetes and suggest counseling may vary based on diabetes type. There are opportunities to improve the patient-centeredness of counseling.

"A patient should not have to ask": Women's experiences of patient education about preconception care for type 2 diabetes.

OBJECTIVES: To characterize perspectives and experiences regarding preconception care (PCC) patient education among women with type 2 diabetes. METHOD: Descriptive, qualitative research design. Thirty-two English-speaking women with type 2 diabetes identifying as Black and/or Latina, ages 18-40 years old, participated. We conducted semi-structured interviews about PCC perspectives and experiences which we analyzed with conventional content analysis. To enhance rigor, we collected freelisting data from which we calculated salience scores. We triangulated our qualitative findings with salience scores. RESULTS: We identified three themes. Our first theme concerned mismatch between women's desires for PCC counseling to be frequent in contrast with their experiences of its infrequency. Our second theme captured how women felt responsible for initiating care in the clinical encounter but uncertain about what they "should" be asking for. Our third theme characterized women's perspectives on receiving information about PCC and pregnancy planning. CONCLUSIONS: Young adult women with type 2 diabetes who are Black and/or Latina welcome more education about how PCC can prevent obstetrical complications associated with diabetes, which disproportionately affect their communities. PRACTICE IMPLICATIONS: Our findings provide actionable suggestions for improving acceptability and accessibility of PCC patient education in the United States where PCC awareness and uptake are low.

The association between depression and contraceptive behaviors in a diverse sample of new prescription contraception users.

OBJECTIVE: Among women initiating new prescription contraception, we investigated the relationship between recent depression and a range of contraceptive behaviors. STUDY DESIGN: We used medical and pharmacy records of 52,325 women ages 19 to 29 who initiated prescription contraception (pills, patches or rings, injectables, and long-acting reversible contraceptives) in 2014-2016 at a large integrated healthcare system in Northern California. Women had continuous enrollment for a year before and after initiating, and no records of prescription contraceptive use in the year before initiating. Depression in the year prior to initiation was dichotomized into (1) no depression indicator (reference group) or (2) depression diagnosis or redeemed antidepressant. Multinomial logistic regression models examined the associations between depression and method type initiated, and contraceptive patterns, timing of discontinuation, inconsistent use, and switching methods over a year after initiating, adjusting for sociodemographics and testing for interactions between depression and having a recent birth or abortion. RESULTS: Women with recent depression were more likely to initiate methods other than the pill, and the association was stronger for patches or rings vs pills among those with a recent birth compared to those without. Among women initiating all methods and the pill, those with depression were more likely to discontinue their method, use it inconsistently, and switch from it than use it continuously for a year. CONCLUSION: Women with recent depression were less likely to initiate the pill; and when the pill was initiated, those with depression were more likely to discontinue use, use it inconsistently, and switch from it. IMPLICATIONS: Women with recent depression indicators should be followed closely to ensure they have the support they need to meet their reproductive goals. Those who wish to avoid pregnancy may benefit from methods that do not require daily use.

All in the Family: A Qualitative Study of the Early Experiences of Adults with Younger Onset Type 2 Diabetes.

OBJECTIVE: Adults with type 2 diabetes diagnosed at a younger age are at increased risk for poor outcomes. We examined life stage-related facilitators and barriers to early self-management among younger adults with newly diagnosed type 2 diabetes. RESEARCH DESIGN AND METHODS: We conducted 6 focus groups that each met twice between November 2017 and May 2018. Participants (n = 41) were aged 21 to 44 years and diagnosed with type 2 diabetes during the prior 2 years. Transcripts were coded using thematic analysis and themes were mapped to the Capability-Opportunity-Motivation-Behavior framework. RESULTS: Participants were 38.4 (±5.8) years old; 10 self-identified as Latinx, 12 as Black, 12 as White, and 7 as multiple or other races. We identified 9 themes that fell into 2 categories: (1) the impact of having an adult family member with diabetes, and (2) the role of nonadult children. Family members with diabetes served as both positive and negative role models, and, for some, personal familiarity with the disease made adjusting to the diagnosis easier. Children facilitated their parents' self-management by supporting self-management activities and motivating their parents to remain healthy. However, the stress and time demands resulting from parental responsibilities and the tendency to prioritize children's needs were perceived as barriers to self-management. CONCLUSIONS: Our results highlight how the life position of younger-onset individuals with type 2 diabetes influences their early experiences. Proactively addressing perceived barriers to and facilitators of self-management in the context of family history and parenthood may aid in efforts to support these high-risk, younger patients.

Prepregnancy Counseling Among U.S. Women With Diabetes and Hypertension, 2016-2018.

INTRODUCTION: Individuals who have diabetes or hypertension established before pregnancy are at increased risk for maternal and infant health complications. Guidelines recommend that providers deliver prepregnancy counseling, but little is known about the receipt of those services among patients with chronic conditions. METHODS: Data from the 2016-2018 Pregnancy Risk Assessment Monitoring System, a population-based survey among women with recent live births, were used. Self-reported receipt of prepregnancy counseling on folic acid supplementation, pregnancy desire, contraceptive use, and improving health before pregnancy was examined overall and by diabetes and hypertension status. Multivariable logistic regression examined the association between diabetes and hypertension status and the 4 prepregnancy counseling outcomes. Analyses were conducted in 2020. RESULTS: Overall, 2.1% of women reported having both diabetes and hypertension, 1.3% reported having diabetes alone, and 3.1% reported having hypertension alone. Less than half of the sample reported receiving each prepregnancy counseling outcome. In adjusted models, women with hypertension alone were more likely to report each counseling outcome than women without diabetes or hypertension. Women with diabetes alone were only more likely to report receiving counseling about improving health, and women with both conditions were not more likely to report the receipt of any counseling outcome under study. CONCLUSIONS: Women with prepregnancy diabetes, hypertension, or both reported low levels of the recommended prepregnancy counseling, suggesting an evidence-practice gap that should be addressed to optimize maternal and infant health outcomes. There is a need for evidence-based and patient-centered models of prepregnancy counseling for those with diabetes and hypertension.

"My 9 to 5 Job Is Birth Work": A Case Study of Two Compensation Approaches for Community Doula Care.

With the increased policy emphasis on promoting doula care to advance birth equity in the United States, there is a vital need to identify sustainable and equitable approaches for compensation of community doulas, who serve clients experiencing the greatest barriers to optimal pregnancy-related outcomes. This case study explores two different approaches for compensating doulas (contractor versus hourly employment with benefits) utilized by SisterWeb San Francisco Community Doula Network in San Francisco, California. We conducted qualitative interviews with SisterWeb doulas in 2020 and 2021 and organizational leaders in 2020. Overall, leaders and doulas reported that the contractor approach, in which doulas were paid a flat fee per client, did not adequately compensate doulas, who regularly attend trainings and provide additional support for their clients (e.g., referrals to promote housing and food security). Additionally, this approach did not provide doulas with healthcare benefits, which was especially concerning during the COVID-19 pandemic. As hourly, benefited employees, doulas experienced a greater sense of financial security and wellbeing from receiving consistent pay, compensation for all time worked, and benefits such as health insurance and sick leave, allowing some to dedicate themselves to birth work. Our study suggests that efforts to promote community doula care must integrate structural solutions to provide appropriate compensation and benefits to doulas, simultaneously advancing birth equity and equitable labor conditions for community doulas.

Racial and Ethnic Disparities in Diabetes Care Quality among Women of Reproductive Age in an Integrated Delivery System.

BACKGROUND: Diabetes is increasingly prevalent among women of reproductive age, yet little is known about quality of diabetes care for this population at increased risk of diabetes complications and poor maternal and infant health outcomes. Previous studies have identified racial/ethnic disparities in diabetes care, but patterns among women of reproductive age have not been examined. METHODS: This retrospective cohort study analyzed 2016 data from Kaiser Permanente Northern California, a large integrated delivery system. Outcomes were quality of diabetes care measures-glycemic testing, glycemic control, and medication adherence-among women ages 18 to 44 with type 1 or type 2 diabetes (N = 9,923). Poisson regression was used to estimate the association between patient race/ethnicity and each outcome, adjusting for other patient characteristics and health care use. RESULTS: In this cohort, 83% of participants had type 2 diabetes; 31% and 36% of women with type 2 and type 1 diabetes, respectively, had poor glycemic control (hemoglobin A1c of ≥9%), and approximately one-third of women with type 2 diabetes exhibited nonadherence to diabetes medications. Compared with non-Hispanic White women with type 2 diabetes, non-Hispanic Black women (adjusted risk ratio, 1.2; 95% confidence interval, 1.1-1.3) and Hispanic women (adjusted risk ratio, 1.2; 95% confidence interval, 1.1-1.3) were more likely to have poor control. Findings among women with type 1 diabetes were similar. CONCLUSIONS: Our findings indicate opportunities to decrease disparities and improve quality of diabetes care for reproductive-aged women. Elucidating the contributing factors to poor glycemic control and medication adherence in this population, particularly among Black, Hispanic, and Asian women, should be a high research and practice priority.

Using Neighborhood-Level Census Data to Predict Diabetes Progression in Patients with Laboratory-Defined Prediabetes.

CONTEXT: Research on predictors of clinical outcomes usually focuses on the impact of individual patient factors, despite known relationships between neighborhood environment and health. OBJECTIVE: To determine whether US census information on where a patient resides is associated with diabetes development among patients with prediabetes. DESIGN: Retrospective cohort study of all 157,752 patients aged 18 years or older from Kaiser Permanente Northern California with laboratory-defined prediabetes (fasting plasma glucose, 100 mg/dL-125 mg/dL, and/or glycated hemoglobin, 5.7%-6.4%). We assessed whether census data on education, income, and percentage of households receiving benefits through the US Department of Agriculture's Supplemental Nutrition Assistance Program (SNAP) was associated with diabetes development using logistic regression controlling for age, sex, race/ethnicity, blood glucose levels, and body mass index. MAIN OUTCOME MEASURE: Progression to diabetes within 36 months. RESULTS: Patients were more likely to progress to diabetes if they lived in an area where less than 16% of adults had obtained a bachelor's degree or higher (odds ratio [OR] =1.22, 95% confidence interval [CI] = 1.09-1.36), where median annual income was below $79,999 (OR = 1.16 95% CI = 1.03-1.31), or where SNAP benefits were received by 10% or more of households (OR = 1.24, 95% CI = 1.1-1.4). CONCLUSION: Area-level socioeconomic and food assistance data predict the development of diabetes, even after adjusting for traditional individual demographic and clinical factors. Clinical interventions should take these factors into account, and health care systems should consider addressing social needs and community resources as a path to improving health outcomes.

Young men's awareness and knowledge of intrauterine devices in the United States.

OBJECTIVE: Increasing use of long-acting methods of contraception, such as intrauterine devices (IUDs), has been recognized as a promising strategy to reduce the incidence of unintended pregnancy. While men may play an important role in promoting or discouraging contraceptive use, very little research has examined men's knowledge of and attitudes toward IUDs. STUDY DESIGN: We used data from the 903 men included in the 2009 National Survey of Reproductive and Contraceptive Knowledge to examine their awareness and knowledge of IUDs and other contraceptive methods by several individual-level characteristics. RESULTS: Men's awareness and perceived knowledge of IUDs is low in comparison to condoms and birth control pills. Men's perceived knowledge of IUDs was lower than their objective knowledge, as measured by true/false questions about IUDs, suggesting that men may be more knowledgeable of IUDs than they perceive. In the multivariate models, men who were uninsured [adjusted odds ratio (AOR), 0.4; 95% confidence interval (CI), 0.2-0.6], identified as Christian (AOR, 0.6; 95% CI, 0.3-1.0) and who had never had a sexual health visit (AOR, 0.6; 95% CI, 0.4-1.0) were less likely to have heard of IUDs. Among men who had heard of the method, Hispanic men were less likely (AOR, 0.2; 95% CI, 0.1-0.5) to be more knowledgeable of the method. CONCLUSION: Young men report low awareness of IUDs in comparison to other methods, and this varies by demographic characteristics including health insurance status. Family planning programs should consider targeted knowledge promotion for young men, with a focus on contraceptive methods besides condoms and oral contraception. IMPLICATIONS: Male partners are influential in contraceptive use, yet little research has examined their IUD knowledge. Our findings indicate that healthcare providers may play important role in increasing young men's knowledge of contraceptive methods, including IUDs. This study highlights the need to better incorporate young men into contraception research and programs.