Assessing research impact: A framework and an evaluation of the Society of Family Planning Research Fund's grantmaking (2007-2017).

The Society of Family Planning Research Fund (SFPRF) provides grants for research on abortion and contraception. In 2017, SFPRF conducted a retrospective evaluation of its investment in family planning research. Using a developmental evaluation approach, we created a framework for assessing research impact in family planning and applied it to an analysis of our grantmaking between 2007 and 2017. Our framework consists of 30 indicators of research impact, which span nine impact categories from building researchers' capacity to influencing individuals, communities, and systems. Through application of this framework to our grantmaking, we learned that our grantmaking has helped build the research capacity of emerging and established family planning scholars and advance the field of family planning by supporting the creation of a robust scholarly evidence base. At the same time, we identified less evidence of impact on policy and practice. The results of this analysis directed SFPRF to move towards more focused funding opportunities, including longer-term and larger investments, and to prioritize partnerships between researchers and knowledge brokers.

Investigation of factors influencing the implementation of two shared decision-making interventions in contraceptive care: a qualitative interview study among clinical and administrative staff.

BACKGROUND: There is limited evidence on how to implement shared decision-making (SDM) interventions in routine practice. We conducted a qualitative study, embedded within a 2 × 2 factorial cluster randomized controlled trial, to assess the acceptability and feasibility of two interventions for facilitating SDM about contraceptive methods in primary care and family planning clinics. The two SDM interventions comprised a patient-targeted intervention (video and prompt card) and a provider-targeted intervention (encounter decision aids and training). METHODS: Participants were clinical and administrative staff aged 18 years or older who worked in one of the 12 clinics in the intervention arm, had email access, and consented to being audio-recorded. Semi-structured telephone interviews were conducted upon completion of the trial. Audio recordings were transcribed verbatim. Data collection and thematic analysis were informed by the 14 domains of the Theoretical Domains Framework, which are relevant to the successful implementation of provider behaviour change interventions. RESULTS: Interviews (n = 29) indicated that the interventions were not systematically implemented in the majority of clinics. Participants felt the interventions were aligned with their role and they had confidence in their skills to use the decision aids. However, the novelty of the interventions, especially a need to modify workflows and change behavior to use them with patients, were implementation challenges. The interventions were not deeply embedded in clinic routines and their use was threatened by lack of understanding of their purpose and effect, and staff absence or turnover. Participants from clinics that had an enthusiastic study champion or team-based organizational culture found these social supports had a positive role in implementing the interventions. CONCLUSIONS: Variation in capabilities and motivation among clinical and administrative staff, coupled with inconsistent use of the interventions in routine workflow contributed to suboptimal implementation of the interventions. Future trials may benefit by using implementation strategies that embed SDM in the organizational culture of clinical settings.

Right For Me: protocol for a cluster randomised trial of two interventions for facilitating shared decision-making about contraceptive methods.

INTRODUCTION: Despite the observed and theoretical advantages of shared decision-making in a range of clinical contexts, including contraceptive care, there remains a paucity of evidence on how to facilitate its adoption. This paper describes the protocol for a study to assess the comparative effectiveness of patient-targeted and provider-targeted interventions for facilitating shared decision-making about contraceptive methods. METHODS AND ANALYSIS: We will conduct a 2×2 factorial cluster randomised controlled trial with four arms: (1) video+prompt card, (2) decision aids+training, (3) video+prompt card and decision aids+training and (4) usual care. The clusters will be clinics in USA that deliver contraceptive care. The participants will be people who have completed a healthcare visit at a participating clinic, were assigned female sex at birth, are aged 15-49 years, are able to read and write English or Spanish and have not previously participated in the study. The primary outcome will be shared decision-making about contraceptive methods. Secondary outcomes will be the occurrence of a conversation about contraception in the healthcare visit, satisfaction with the conversation about contraception, intended contraceptive method(s), intention to use a highly effective method, values concordance of the intended method(s), decision regret, contraceptive method(s) used, use of a highly effective method, use of the intended method(s), adherence, satisfaction with the method(s) used, unintended pregnancy and unwelcome pregnancy. We will collect study data via longitudinal patient surveys administered immediately after the healthcare visit, four weeks later and six months later. ETHICS AND DISSEMINATION: We will disseminate results via presentations at scientific and professional conferences, papers published in peer-reviewed, open-access journals and scientific and lay reports. We will also make an anonymised copy of the final participant-level dataset available to others for research purposes. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT02759939.

A Survey of Teenagers' Attitudes Toward Moving Oral Contraceptives Over the Counter.

CONTEXT: Evidence suggests that over-the-counter access to oral contraceptives may help expand use among adult women. Teenagers may particularly benefit from this approach, as they experience disproportionately high rates of unintended pregnancy and face unique challenges accessing contraceptives. However, limited research has explored teenagers' attitudes toward over-the-counter access. METHODS: In 2014, a sample of 348 females aged 14-17, recruited via Facebook advertisements, participated in an online survey assessing teenagers' attitudes toward over-the-counter access and their understanding of how to use oral contraceptives after reading a prototype over-the-counter product label. Differences by participants' characteristics were assessed in bivariate analyses (Pearson chi-square and Fisher's exact tests for categorical measures, and independent t tests and one-way analyses of variance for continuous measures). RESULTS: Seventy-three percent of participants supported over-the-counter access, and 61% reported that they would likely use oral contraceptives available through this approach. Few subgroup differences were found. Notably, sexually experienced participants were significantly more likely than others both to support this approach (85% vs. 63%) and to be interested in obtaining oral contraceptives this way (77% vs. 48%). Participants understood an average of 7.1 of eight key concepts that the prototype product label was intended to convey; no significant differences were found among subgroups. CONCLUSIONS: Over-the-counter access may be a promising approach for providing oral contraceptives to teenagers. Additional research is needed to evaluate whether teenagers can screen themselves for contraindications to oral contraceptive use and correctly use oral contraceptives obtained over the counter.

A Qualitative Exploration of Low-Income Women's Experiences Accessing Abortion in Massachusetts.

BACKGROUND: At a time when most states are working to restrict abortion, Massachusetts stands out as one of the few states with multiple state-level policies in place that support abortion access for low-income women. In 2006, Massachusetts passed health care reform, which resulted in almost all residents having insurance. Also, almost all state-level public and subsidized insurance programs cover abortion and there are fewer restrictions on abortion in Massachusetts compared with other states. METHODS: We explored low-income women's experiences accessing abortion in Massachusetts through 27 in-depth telephone interviews with a racially diverse sample of low-income women who obtained abortions. Interviews were digitally recorded, transcribed, coded, and analyzed thematically. RESULTS: Most women described having access to timely, conveniently located, affordable, and highly acceptable abortion care. However, a sizable minority of women had difficulty enrolling in or staying on insurance, making abortion expensive. A small minority of women said their abortion care could be improved by increasing emotional support and privacy, and decreasing appointment times. Some limited data also suggest that young women and immigrant women face specific barriers to care. CONCLUSION: This study provides important, novel information about the need for state-level policies that support access to health insurance and comprehensive abortion coverage. Such policies, along with a well-functioning health care environment, help to ensure that low-income women have access to abortion. However, not all abortion access challenges have been resolved in Massachusetts. More work is needed to ensure that all women can access affordable, confidential care that is responsive to their specific needs and preferences.

Does medicaid coverage matter?: A qualitative multi-state study of abortion affordability for low-income women.

Medicaid is designed to ensure low-income populations can afford health care. However, not all health services are covered by the program. Most state Medicaid programs restrict abortion coverage, though a small number of state programs offer such coverage. Little is known about how low-income women are affected by differing Medicaid coverage policies regarding abortion. We conducted in depth interviews with 98 low-income women who had abortions. We found that women's impressions about abortion costs and the availability of Medicaid coverage are generally accurate and that women rely predominantly on abortion facilities for confirmatory cost and coverage information. Additionally, when abortion is out of financial reach, women and the people in their lives experience numerous emotional and financial harms. Policies that aim to ensure abortion is affordable largely prevent these harms, though the availability of Medicaid coverage does not always guarantee access to affordable care. Findings can help advance evidence-based policies

A qualitative investigation of low-income abortion clients' attitudes toward public funding for abortion.

We explored how low-income abortion clients in states where public funding was and was not available perceived the role of public funding for abortion. From October 2010 through February 2011, we conducted 71 semi-structured in-depth telephone interviews with low-income abortion clients in Arizona, Florida, New York, and Oregon. Women reported weighing numerous factors when determining which circumstances warranted public funding. Though most women generally supported coverage, they deviated from their initial support when asked about particular circumstances. Respondents felt most strongly that abortion should not be covered when a woman could not afford another child or was pregnant outside of a romantic relationship. Participants used disparaging language to describe the presumed behavior of women faced with unintended pregnancies. In seeking to discredit "other" women's abortions, women revealed the complex nature of abortion stigma. We propose that women's abortion experiences and subsequent opinions on coverage indicated three distinct manifestations of abortion stigma: women (1) resisted the prominent discourse that marks women who have had abortions as selfish and irresponsible; (2) internalized societal norms that stereotype women based on the circumstances surrounding the abortion; and (3) reproduced stigma by distancing themselves from the negative stereotypes associated with women who have had abortions.

A mixed-methods exploration of the contraceptive experiences of female teens with epilepsy.

PURPOSE: We explored the contraceptive experiences of female teens with epilepsy, including their knowledge and perceptions of interactions between antiepileptic drugs and hormonal contraception and contraceptive decision-making processes. METHOD: From November 2012 to May 2013, we conducted one online survey (n=114) and 12 online focus group discussions (n=26) with female teens with epilepsy about their contraceptive experiences and unmet needs. Survey data were analyzed using descriptive statistics and focus group transcripts were analyzed thematically using modified grounded theory methods. RESULTS: Both survey and focus group participants reported believing that interactions between epilepsy medications and hormonal contraceptives could lead to reductions in contraceptive efficacy and seizure control. However, their knowledge about these types of medication interactions was often incomplete. Many study participants viewed contraceptive decision making as a difficult process, and some participants reported avoiding hormonal contraceptives because of potential interactions with antiepileptic drugs. Study participants reported relying on health care providers and parents for contraceptive decision-making support. Focus group participants also reported they wanted health care providers to provide more in-depth and comprehensive counseling about contraception, and that they desired peer support with contraceptive decisions. CONCLUSION: The ability to make informed contraceptive decisions is important for teens with epilepsy as interactions between anti-epileptic drugs and hormonal contraceptives can impact seizure occurrence and lead to an increased risk of unplanned pregnancy. Guidance for providers offering contraceptive care to this population is needed, as well as a contraceptive support tool that empowers teens with epilepsy to advocate for desired health care.

Reproductive health access among deployed U.S. servicewomen: a qualitative study.

Servicewomen's reproductive health experiences during deployment are important given that the majority of women in the U.S. military are of reproductive age and that this population experiences a disproportionately high rate of unintended pregnancy. Few studies have explored women's reproductive health experiences and their perceived barriers and facilitators to health care access during deployment. From May 2011 to January 2012, we conducted 22 in-depth interviews with women in the U.S. military about their reproductive health experiences during deployment, including their access to health services. Participants identified a range of barriers to accessing medical care in deployment settings, including confidentiality concerns, lack of female providers, and health-seeking stigma, which were reported to disproportionately impact reproductive health access. Some participants experienced challenges obtaining contraceptive refills and specific contraceptive methods during deployment, and only a few participants received predeployment counseling on contraception, despite interest in both menstruation suppression and pregnancy prevention. These findings highlight several policy and practice changes that could be implemented to increase contraceptive access and reduce unintended pregnancy during deployment, including mandated screening for servicewomen's contraceptive needs before operational duty and at least annually, and increasing the number of female providers in deployed settings.

Military sexual trauma among US servicewomen during deployment: a qualitative study.

OBJECTIVES: We explored qualitatively US servicewomen's experiences with and perceptions of military sexual trauma (MST), reporting, and related services. METHODS: From May 2011 to January 2012, we conducted 22 telephone interviews with US servicewomen deployed overseas between 2002 and 2011. We analyzed data thematically with modified grounded theory methods. RESULTS: Factors identified as contributing to MST included deployment dynamics, military culture, and lack of consequences for perpetrators. Participants attributed low MST reporting to negative reactions and blame from peers and supervisors, concerns about confidentiality, and stigma. Unit cohesion was cited as both a facilitator and a barrier to reporting. Availability and awareness of MST services during deployment varied. Barriers to care seeking were similar to reporting barriers and included confidentiality concerns and stigma. We identified several avenues to address MST, including strengthening consequences for perpetrators. CONCLUSIONS: We identified barriers to MST reporting and services. Better understanding of these issues will allow policymakers to improve MST prevention and services.

Bolstering the Evidence Base for Integrating Abortion and HIV Care: A Literature Review.

HIV-positive women have abortions at similar rates to their HIV-negative counterparts, yet little is known about clinical outcomes of abortion for HIV-positive women or the best practices for abortion provision. To fill that gap, we conducted a literature review of clinical outcomes of surgical and medication abortion among HIV-positive women. We identified three studies on clinical outcomes of surgical abortion among HIV-positive women; none showed significant differences in infectious complications by HIV status. A review of seven articles on similar gynecological procedures found no differences in complications by HIV status. No studies evaluated medication abortion among HIV-positive women. However, we did find that previously expressed concerns regarding blood loss and vomiting related to medication abortion for HIV-positive women are unwarranted based on our review of data showing that significant blood loss and vomiting are rare and short lived among women. We conclude that although there is limited research that addresses clinical outcomes of abortion for HIV-positive women, existing data suggest that medication and surgical abortion are safe and appropriate. Sexual and reproductive health and HIV integration efforts must include both options to prevent maternal mortality and morbidity and to ensure that HIV-positive women and women at risk of HIV can make informed reproductive decisions.