Contraceptive Behavior in Appalachia: Exploring Use, Nonuse, and Contraceptive Attitudes.

Very little is known about contraceptive behavior in Appalachia, a large geographic region in the eastern United States where even basic prevalence estimates of contraceptive use/nonuse are lacking. This study characterizes contraceptive behavior among Appalachians, including contraceptive use, reasons for use, and methods used; contraceptive nonuse and reasons for nonuse; and attitudes about contraception, including acceptability. This is a secondary analysis of a subsample of survey data collected on sexual and reproductive health attitudes, behaviors, and needs among reproductive-age women (18-49 years) living in the Appalachian region (n = 332). Results identify rates of contraceptive use (66.6%) and nonuse (33.1%) among Appalachian residents. Methods used most frequently included those that did not require prescription (i.e., external condoms and natural family planning methods) though many reported the use of intrauterine devices (IUDs). Among nonusers, fear of side effects from contraception and ambivalence towards pregnancy were most commonly selected as the most important reason for not using contraception. Contraception was considered acceptable by this sample overall, and these acceptability attitudes were significantly associated with contraceptive behavior.

Mistreatment in health care among women in Appalachia.

Good quality patient care requires health care providers to respect the humanity and autonomy of their patients. However, this is not achieved in all settings. This study used cross-sectional survey data including open-ended text responses to explore negative experiences with health care providers among women in Appalachia. We used the Heath Stigma & Discrimination Framework (HSDF) to identify how stigma is created and perpetuated through interactions with health care providers. Survey data from 628 women collected through purposive sampling identified that two out of three participants had had a bad encounter with a provider that made them not want to return for care. One in six participants had a negative experience specifically while seeking contraception. Using the domains of the HSDF framework, qualitative answers to open-ended questions illuminated how health care providers, influenced by social and cultural norms related to religiosity, patriarchal views, poverty, poor health infrastructure, and the opioid crisis, created and perpetuated stigma through dehumanising treatment, low-quality care, and health care misogyny. Because stigma is a driver of health inequity, these findings highlight the important and sometimes problematic role that health care providers can play when they create a barrier to future care through poor treatment of patients.

An Integrative Review of the Relationship Between Intrauterine Devices and Bacterial Vaginosis.

OBJECTIVE: To examine the relationship between intrauterine devices (IUDs) and bacterial vaginosis (BV) through an integrative review of the current literature. DATA SOURCES: CINAHL, MEDLINE, Health Source, Evidence-Based Medicine's Cochrane Central Registry of Controlled Trials, Embase, and Web of Science databases were searched. STUDY SELECTION: Cross-sectional, case-control, cohort, quasi-experimental, and randomized controlled trials examining copper (Cu-IUD) and levonorgestrel (LNG-IUD) use in reproductive- age users with BV occurrence confirmed with Amsel's criteria or Nugent scoring were included. Articles included were published in the past 10 years. DATA EXTRACTION: Fifteen studies met criteria, after an initial search identified 1,140 potential titles, and two reviewers assessed 62 full-text articles for inclusion. DATA SYNTHESIS: Data were categorized into three groups: retrospective descriptive cross-sectional studies identifying point prevalence of BV among IUD users; prospective analytic studies examining BV incidence and prevalence among Cu-IUD users; and prospective analytic studies examining BV incidence and prevalence among LNG-IUD users. CONCLUSION: Synthesis and comparison of studies were difficult because of disparate study designs, sample sizes, comparator groups, and inclusion criteria for individual studies. Synthesis of data from cross-sectional studies showed that all IUD users combined may have an increased point prevalence of BV compared with non-IUD users. These studies did not delineate LNG-IUDs from Cu-IUDs. Findings from cohort and experimental studies suggest a possible increase in BV occurrence among Cu-IUD users. Evidence is lacking to show an association between LNG-IUD use and BV.

Critiquing the Unintended Pregnancy Framework.

The unintended pregnancy framework, a central tenet of sexual and reproductive health care delivery and research, has been depicted as an adverse outcome that should be prevented. There is growing criticism of the inadequacies of this framework, although little modification in public health guidelines, measurement, or clinical practice has been seen. This article critically reviews the literature on unintended pregnancy to encourage reflection on how this framework has negatively influenced practice and to inspire the advancement of more patient-centered care approaches. We begin by outlining the historical origins of the unintended pregnancy framework and review how this framework mischaracterizes patients' lived experiences, fails to account for structural inequities, contributes to stigma, and is built upon weakly supported claims of a negative impact on health outcomes. We close with a discussion of the relationship between health care provision and unintended pregnancy care and the implications and recommendations for realigning clinical practice, research, and policy goals.

Reproductive Autonomy in Appalachia: An Investigation into Perceived Contraceptive Pressure.

The reproductive autonomy of persons who can give birth can be impeded through forms of interpersonal violence and coercion. Moreover, macro-level factors (e.g., poverty, discrimination, community violence, legislative policies) may impede the reproductive autonomy of entire communities. This study investigates a form of violence we term perceived contraceptive pressure in Appalachia, an understudied region of the Eastern U.S., regarding reproductive health and decision-making. Through targeted Meta advertising, participants (N = 632) residing in Appalachian zip codes completed an online survey on reproductive health. The focus of this study was to investigate the prevalence of perceived contraceptive pressure, who was at increased risk of experiencing pressure, and the source(s) of perceived pressure. Binomial regressions were conducted on three different dependent variables: perceived pressure to be sterilized, perceived pressure to use birth control, and perceived pressure not to use birth control. Approximately half of all respondents (49.5%) reported experiencing at least one type of pressure targeting contraceptive decision-making. The most prevalent source of perceived pressure to use birth control was from the healthcare provider (67.4%), and the most prevalent source of perceived pressure not to use birth control was the respondent's partner (51.1%). Recommendations for providers serving clients in the Appalachian region include pursuing education regarding contraceptive pressure at the individual level and macro-level. In addition, Appalachian residents may benefit from educational programming on reproductive autonomy, healthy relationships, and how to navigate pressure in relationships.

HIV attitudes and beliefs in U.S.-based African refugee women.

ABSTRACTObjective: The Buffalo, New York region is one of the leading refugee resettlement areas in the country, settling 94% of African refugees in 2014. However, little is known about their health beliefs, particularly regarding sexual health and HIV. This study's purpose was to describe HIV attitudes and beliefs in a sample of African refugee women, a population that is increasingly present in the country, yet seldom represented in the literature.Design: A convenience sample of 101 African refugee women were recruited via snowball technique in Buffalo, New York. Data were collected from July 2017-July 2018, via paper-pen survey, and were analyzed using descriptive statistics.Results: Participants had low levels of education, but high HIV screening rates. Inconsistencies between knowledge of HIV acquisition and behaviors relating to HIV positive individuals may indicate HIV stigma among the population.Conclusion: Novel strategies geared towards educational levels and societal norms to educate African refugee women about HIV are urgently needed.

A Review of Unintended Pregnancy in Opioid-Using Women: Implications for Nursing.

BACKGROUND: Opioid use among reproductive-age women has greatly increased, resulting in high rates of opioid-exposed pregnancies, which are associated with negative outcomes, such as neonatal abstinence syndrome. Prevention of unintended pregnancy among opioid users is a critical pathway to reducing opioid-exposed pregnancies; however, little is known about pregnancy intention in this group. This article estimates the prevalence of unintended pregnancy among opioid-using women, thereby supporting efforts to develop interventions to reduce unintended pregnancy. METHODS: A systematic literature search was conducted in PubMed, Web of Science, PsycINFO, and CINAHL, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses framework. Reference lists of articles were searched. Eligibility criteria included reported unintended pregnancy rates within a population of opioid-using women of reproductive age. The search was completed in July 2018 and updated in October 2019. RESULTS: We identified 115 citations, screened 64 titles/abstracts, reviewed 31 full-text articles, and included 12 articles for this review. Rates of unintended pregnancy in opioid users were estimated in two ways, across the lifetime and for a current pregnancy, depending on study samples. Rates for both groups were high, with rates among currently pregnant opioid-using women (85%) compared with 45% among the general population. CONCLUSIONS AND IMPLICATIONS: Unintended pregnancy rates in opioid-using women were strikingly high, indicating a critical need for intervention. Routine inclusion of pregnancy planning in opioid treatment care is indicated. Education regarding contraception and opioid treatment services is essential for nurses in these settings. Family planning and opioid treatment efforts can be optimized by care coordination, with focus on nurse training for screening and patient education.

Validation of the short-form reproductive coercion scale with Appalachian women.

OBJECTIVE: The purpose of this study was to investigate the psychometric properties of the short-form Reproductive Coercion Scale among a sample of Appalachian women. STUDY DESIGN: We recruited a purposive sample of Appalachian women, using targeted Facebook ads to collect data via an online survey in fall 2019. We randomly split our sample into two independent samples and used exploratory factor analysis on sample 1 (N = 314) and confirmatory factor analysis on sample 2 (N = 314) in order to cross-validate our findings. RESULTS: Findings indicated that the short-form Reproductive Coercion Scale is a valid and reliable instrument to assess reproductive coercion among this sample of Appalachian women. Our findings indicated that, in this Appalachian sample, the reduced, five-item Reproductive Coercion Scale measured a unidimensional construct and was not comprised of the multiple dimensions of pregnancy coercion and condom manipulation. As expected, intimate partner violence and pregnancy fatalism were significantly and positively associated with reproductive coercion while religious affiliation and insurance status were not significantly associated with reproductive coercion. These findings help build construct validity for the short-form Reproductive Coercion Scale with this sample. CONCLUSION: While pregnancy coercion and condom manipulation are often considered independent reproductive coercion factors, the current study indicates that, in this Appalachian sample, the short-form Reproductive Coercion Scale measures a single latent reproductive coercion factor. IMPLICATIONS: While pregnancy coercion and condom manipulation are often considered independent reproductive coercion factors, the current study indicates that, in this Appalachian sample, the short-form Reproductive Coercion Scale measures a single latent reproductive coercion factor. Additional research may be needed to confirm the factor structure of the short-form Reproductive Coercion Scale across populations and geographic conditions.

The Experience of Participating in an 8-Week Mindfulness Based Stress Reduction plus Sleep Retraining Course among Women Living with Multiple Sclerosis.

Adult women with multiple sclerosis (MS) can benefit from innovative mindfulness-based interventions designed and structured with understanding and consideration of the multifaceted challenges these women face on a daily basis. The purpose of this qualitative descriptive study was to explore the experience of participating in an online or traditional onsite 8-week, once a week, Mind Body Stress Reduction combined with Sleep Retraining course among women living with MS to establish online course acceptability. Braun and Clarke's Reflexive Thematic Analysis method was used to analyze focus group interview data. Time and length for both courses was found acceptable, camaraderie and interconnectedness were essential, having choice regarding course delivery format was important, and being provided with organized learning materials at the course start in a binder or packet was considered imperative. Acceptability was established for both the online and onsite formats.

Improving Sleep among Adults with Multiple Sclerosis using Mindfulness plus Sleep Education.

We explored the feasibility of a mindfulness plus sleep education intervention, SleepWell!, delivered via videoconference compared to onsite among adults with MS. A non-randomized wait-list control design was used. Participants wore actigraphy watches and kept sleep diaries for seven days pre- and post intervention. Questionnaires were completed pre-intervention, post-intervention, and three months post-intervention. One group was conducted onsite. Three groups participated via videoconference. Attrition among videoconference groups was 23% compared to 57% in the onsite group. Within group analysis showed moderate-to-large effect sizes on sleep efficiency (d=0.78) and total sleep time (d=0.54) in the videoconference groups. One-way repeated measures ANOVA post-hoc analysis suggested small-to-medium effect over three months on sleep quality (ηp2 =0.28), physical health quality of life (ηp2 =0.42), mental health quality of life (ηp2 =0.13), and mindfulness (ηp2 =0.29). Results indicate feasibility of providing our intervention via videoconferencing. Preliminary analysis suggests that SleepWell! improves sleep and mindfulness among adults with MS.

Family planning trends among community-dwelling African refugee women.

PURPOSE: From 2009 to 2019, more than 175,000 refugees were admitted into the United States from African countries. What is known about sexual and reproductive health in this population is focused on perinatal outcomes; beliefs and attitudes towards family planning and related behaviors, which can impact perinatal health, have not been explored. Understanding these beliefs and attitudes can guide future work with this population. STUDY DESIGN: A cross-sectional, convenience survey of 100 community-dwelling African refugee women was conducted. RESULTS: The following research questions guided analysis: What are African refugee women's family planning attitudes (pregnancy intention, desired timing, perceived fecundity)? What are African refugee women's family planning behaviors (use vs. non-use of methods, type of methods used)? and What socio-demographic factors and family planning attitudes are related to family panning behaviors (use or non-use of methods)? Almost 49% of participants reported ever using a method of family planning and 35% reported current use. Reasons for non-use included desire for more children (28.8%), infrequent intercourse (22.0%), and fear of side effects (16.9%). Nearly two thirds expressed a desire for a future pregnancy (63.4%), but the majority reported wanting to become pregnant in two or more years (25.7%) or "when God wants" (24.8%). No significant relationship was found between family planning method use and future pregnancy intention, desired timing of future pregnancy, perceived fecundity, marital status, religious affiliation, number of years in the US. Having had any formal schooling decreased the likelihood of using a family planning method. IMPLICATIONS FOR PRACTICE AND RESEARCH: Low family planning method use rates among African refugee women are not completely explained by desires for future pregnancy, perceived fecundity, marital status, or other sociodemographic factors. Concern for future fertility and fear of side effects were identified as potentially modifiable reasons appropriate for community based culturally congruent educational interventions on family planning use.

Family Planning Practices in Appalachia: Focus Group Perspectives on Service Needs in the Context of Regional Substance Abuse.

Reproductive health disparities in the Appalachian region may be driven by barriers to healthcare access. However, the barriers specific to accessing family planning services in Appalachia have not yet been identified from the perspectives of Appalachian community members. Moreover, it is unclear how community members might perceive elevated levels of opioid use in the region to impact family planning practices. To fill this gap in knowledge, the current qualitative study explored community perspectives about family planning in Appalachia in the context of the opioid epidemic for the purpose of developing a survey instrument based on these responses. We conducted three video call focus group interviews with community stakeholders, those who live, work and are invested in Appalachia (N = 16), and analyzed the responses using Levesque, Harris, and Russell's (2013) five pillars of healthcare access as a framework to categorize family planning practices and perceptions of service needs in the context of regional substance abuse: (1) approachability, (2) acceptability, (3) availability and accommodation, (4) affordability, and (5) appropriateness. Subthemes within each of these five categories were also identified. Our findings highlight stakeholder concerns around a lack of knowledge about and access to family planning services in Appalachia. Community members also expressed concern around the lack of availability of substance use treatment services, which may negatively impact family planning use and access in the region.

Reproductive Health Outcomes in African Refugee Women: A Comparative Study.

Background: African refugee women in the United States are at risk of poor reproductive health outcomes; however, examination of reproductive health outcomes in this population remains inadequate. We compared: (1) prepregnancy health and prenatal behavior; (2) prenatal history and prenatal care utilization; and (3) labor and birth outcomes between African refugee women and U.S.-born Black and White women. Methods: A secondary data analysis of enhanced electronic birth certificate data was used. Univariate comparisons using chi-squared tests for dichotomous variables and analysis of variance and/or Kruskal-Wallis tests for continuous variables were conducted for Refugee versus Black versus White women. A p-value <0.05 was considered statistically significant. Results: From 2007 to 2016, 789 African refugee, 17,487 Black, and 59,615 White women in our population gave birth. African refugees experienced more favorable health outcomes than U.S.-born groups on variables examined. Compared to U.S.-born women, African refugee women had fewer prepregnancy health risks (p < 0.001), fewer preterm births (p < 0.001), fewer low birth weight infants (p < 0.001), and higher rates of vaginal deliveries (p < 0.001). These favorable outcomes occurred despite later initiation of prenatal care (p < 0.001) and lower scores of prenatal care adequacy among refugee women compared to U.S.-born groups (p < 0.001). Conclusions: The healthy immigrant effect appears to extend to reproductive health outcomes in our studied population of African refugee women. However, based on our data, targeted, culturally-congruent education surrounding family planning and prenatal care is recommended. Insight from reproductive health care experiences of African refugee women can provide understanding of the protective factors contributing to the healthy immigrant effect in reproductive health outcomes, and knowledge gained can be utilized to improve outcomes in other at-risk groups.