Unmet Reproductive Health Needs of Transgender and Gender Diverse People in Hawai'i: A Qualitative Needs Assessment.

The purpose of this study was to assess the reproductive health experiences of transgender and gender diverse people in Hawai'i, identify reproductive health needs that were unmet, and explore opportunities for addressing those needs. This was a qualitative, semi-structured individual interview study. Adults who identified as transgender or gender diverse were interviewed about their experiences accessing reproductive health services, their needs, and their ideas about clinical settings in which to receive reproductive health care services. Interviews were conducted until thematic saturation was reached. Six trans men, 6 trans women, and 4 people who identified as non-binary or genderqueer were interviewed. Negative experiences in health care settings, particularly when seeking reproductive health care services, were common. Participants often had multiple providers and gender-affirming care was often accessed separately from other health care services. Desires for fertility and pregnancy varied widely between participants but were often not addressed at the initiation of gender-affirming care. Finding trans-friendly providers was notably difficult and participants often relied on friends and other members of the transgender community for guidance. Obstetrics and gynecology clinics present a potential opportunity for access to reproductive health services although their gendered environment was concerning for some participants. Transgender and gender diverse people in Hawai'i have access to some reproductive health services but experience stigma in certain settings. There is a need for ongoing improvement in reproductive health care services in Hawai'i to improve access for transgender and gender nonconforming people in Hawai'i.

Patient Barriers to Discontinuing Long-Acting Reversible Contraception.

OBJECTIVES: To describe how frequently a national sample of patients with experience discontinuing or desiring discontinuation of long-acting reversible contraception (LARC) experienced barriers to discontinuation. METHODS: We conducted an online survey of individuals ages 18 to 50 in the United States who had previously used and discontinued or attempted to discontinue LARC. We recruited respondents using the Amazon platform MTurk. Respondents provided demographic information and answered questions regarding their experience discontinuing LARC, including reasons removal was deferred or denied. We analyzed frequency of types of barriers encountered and compared these by demographic factors. RESULTS: Of the 376 surveys analyzed, 99 (26%) described experiencing at least one barrier to removal. Barriers were disproportionately reported by those who had public health insurance, a history of abortion, and a history of birth compared to those who did not report barriers to removal. They also more frequently identified as Latinx, Asian, or Middle Eastern. Most barriers were provider-driven and potentially modifiable. CONCLUSIONS FOR PRACTICE: Barriers to LARC discontinuation are common and may be provider- or systems-driven. Providers should be mindful of biases in their counseling and practices to avoid contributing to these barriers.

Roots, Leaves, and Flowers: A Narrative Review of Herbs and Botanicals Used for Self-Managed Abortion in Asia and the Pacific.

Abortion has existed throughout history, often outside of formal health care systems. This type of care, now called self-managed abortion, has historically been achieved in part through botanicals and traditional medicines. Their use continues into the modern day, especially in Asia, Hawai'i, and other Pacific Islands, where indigenous medicine traditions practice alongside allopathic medicine. Many of these botanicals, such as papaya leaves, hibiscus flowers, and young ki, and traditional medicines, such as tianhuafen, yuanhua, and Shenghua Decoction, have undergone scientific and clinical investigation of their potential abortifacient and antifertility action. The incidence of self-managed abortion with such abortifacients in countries with severe abortion restrictions are only estimates, leading to the possibility that legal rulings and societal pressures may cause underreporting. The Asian American, Native Hawaiian, and Pacific Islander communities in the United States also suffer from a lack of abortion access in addition to unique health disparities and barriers to reproductive health care. As difficulties in abortion access increases due to the Supreme Court decision in Dobbs v. Jackson Women's Health Organization, some may seek or even prefer self-managed abortion through traditional methods that have been passed down in their communities. Midwives and other health care providers may then be contacted during this process. This narrative review provides an overview of the literature on the use of botanicals, herbs, and traditional medicines used for self-managed abortion, specifically in Asia, Hawai‧i, and other Pacific Islands. Their implications for practice for providers in the United States and further opportunities for research are also presented.

Data Equity for Asian American and Native Hawaiian and Other Pacific Islander People in Reproductive Health Research.

Though racial and ethnic disparities in sexual and reproductive health outcomes are receiving greater interest and research funding, the experiences of Asian American and Native Hawaiian and Other Pacific Islander (NHPI) people are often combined with those of other racial and ethnic minority groups or excluded from data collection altogether. Such treatment is often rationalized because Asian American and NHPI groups comprise a smaller demographic proportion than other racial or ethnic groups, and the model minority stereotype assumes that these groups have minimal sexual and reproductive health needs. However, Asian American and NHPI people represent the fastest-growing racial-ethnic groups in the United States, and they face disparities in sexual and reproductive health access, quality of care, and outcomes compared with those of other races and ethnicities. Disaggregating further by ethnicity, people from certain Asian American and NHPI subgroups face disproportionately poor reproductive health outcomes that suggest the need for culturally targeted exploration of the unique drivers of these inequities. This commentary highlights the evidence for sexual and reproductive health disparities both in and between Asian American and NHPI groups. We also examine the failures of national data sets and clinical studies to recruit Asian American and NHPI people in proportion to their share of the U.S. population or to consider how the cultural and experiential diversity of Asian American and NHPI people influence sexual and reproductive health. Lastly, we provide recommendations for the equitable inclusion of Asian American and NHPI people to promote and systematize the study and reporting of sexual and reproductive health behaviors and outcomes in these culturally, religiously, and historically diverse groups.

"It was close enough, but it wasn't close enough": A qualitative exploration of the impact of direct-to-patient telemedicine abortion on access to abortion care.

OBJECTIVE: To understand how obtaining a medication abortion by mail with telemedicine counseling versus traditional in-clinic care impacted participants' access to care. STUDY DESIGN: We conducted a qualitative study with semi-structured telephone interviews with individuals who completed a medication abortion by mail through the TelAbortion study. We asked participants how they learned about telemedicine abortion, reasons for choosing it, what their alternative would have been, and about their experience. We transcribed, coded, and performed qualitative content analysis of the interviews and are presenting a subset of themes related to access to care when the restrictions on clinic dispensing of mifepristone are removed. RESULTS: We interviewed 45 people from January to July 2020. Direct-to-patient telemedicine abortion was more convenient and accessible than in-clinic abortion care when considering the burdens of travel, clinic availability, logistics, and cost that were associated with in-clinic abortion. Stigma led to a prioritization of privacy, and by going to a clinic, participants feared a loss of privacy whereas obtaining a medication abortion by mail made it easier to maintain confidentiality. Faced with these barriers, 13% of participants stated they would have continued their pregnancy if TelAbortion had not been an option. Participants found direct-to-patient telemedicine abortion to be acceptable and recommended it to others. Benefits of telemedicine were amplified during the COVID-19 pandemic due to concerns around infection exposure with in-clinic care. CONCLUSION: Going to a clinic was a burden for participants, to the point where some would not have otherwise been able to get an abortion. Medication abortion by mail with telemedicine counseling was a highly acceptable alternative. IMPLICATIONS: Medication abortion by mail can increase access to abortion with the added benefits of increased perceived privacy and decreased logistical burdens. Removing the in-person dispensing requirement for mifepristone would allow direct-to-patient telemedicine abortion to be implemented outside of a research setting without compromising the patient experience.

Highly-Effective Contraception Use More Likely Among Native Hawaiian Women than Non-Native Hawaiian Women at Title X Clinics in Hawai'i.

Differences in contraceptive method use have been noted among women of different races, but studies describing contraceptive method use among Native Hawaiian women have not been published. To examine method choice in this group, the authors conducted a database review of the Hawai'i State Department of Health Title X program. Reviewed were client visit records (CVRs) that health care providers completed for women who were ages 15-44 years, avoiding pregnancy, not currently pregnant, and using a contraceptive method (N=54 513). Because a patient could have had several visits during the study period, the contraceptive method chosen at the last visit was selected for analysis. Statistical analyses included descriptive statistics, bivariate analyses, and logistic regression. The proportion of Native Hawaiian women who selected a highly-effective method of contraception (HEC), defined as an intrauterine device, implant, or permanent contraception, was higher than the proportion of non-Native Hawaiian women who selected an HEC. Overall, 15.4% of Native Hawaiian women during the study period chose HEC, compared to 8.8% of non-Native Hawaiian women. In a logistic regression analysis, Native Hawaiian women ages 15-29 were 1.46 times more likely to use HEC (95% CI: 1.35-1.58) than non-Native Hawaiian women ages 15-29, and Native Hawaiian women ages 30-44 were 1.69 times more likely to use HEC (95% CI: 1.53-1.87) than non-Native Hawaiian women in the same age group. Because Native Hawaiian women are reported to have higher rates of unintended pregnancy in the state compared to other racial groups, additional research exploring contraceptive non-use and pregnancy intention are needed.

Recommendations for Contraception: Examining the Role of Patients' Age and Race.

The literature suggests that women of different races are more or less likely to use certain contraceptive methods and patient race can influence which contraceptive recommendations a provider makes. To explore whether health care providers treat individuals of different races differently, we conducted a preliminary investigation on whether medical students recommended different contraceptive methods for hypothetical patients presenting with the same clinical features who only varied by race. Third- and fourth-year medical students (n=103) at the University of Hawai'i completed an online survey. Students read case studies about a 23-year-old and 36-year-old patient and then made contraceptive recommendations. All students reviewed the same scenarios, with the exception of the patient's name which was randomly assigned to represent one of five racial/ethnic groups (White, Chinese, Filipina, Native Hawaiian, and Micronesian). Recommendations were analyzed using χ2 tests and bivariate logistic regressions. For the younger patient, students were most likely to recommend intrauterine devices (IUDs), followed by the contraceptive pill and Etonogestrel implant; recommendations did not differ by race/ethnicity (P = .91). For the older patient, students were most likely to recommend IUDs or sterilization, and Micronesian women were more likely to receive sterilization recommendations compared to White women (60% versus 27%, P = .04). In summary, contraceptive recommendations, specifically the frequency of recommending sterilization varied by race. Our findings add to the literature exploring the role of a patient's race/ethnicity on recommendations for contraception and highlights the need for more studies exploring the etiology of health care disparities.

Promoting and Providing HPV Vaccination in Hawaii: Barriers Faced by Health Providers.

Despite the availability of HPV prophylactic vaccines, uptake has been suboptimal in the US. In the state of Hawaii, HPV vaccine coverage has decreased among females and remains low among males aged 13-17. The reasons for low uptake are unknown and may indicate the existence of critical barriers to HPV vaccination. The purpose of this investigation was to identify policy, system and environmental barriers and promoters of pediatric HPV vaccination in Hawaii. An online 86-item survey addressing knowledge, attitudes, beliefs, practices, and barriers to HPV vaccination was distributed to practicing physicians in Hawaii specializing in Pediatrics, Family Medicine, and Obstetrics-Gynecology. Survey responses were received from a total of 120 physicians. Private practice physicians reported more concerns with vaccine ordering and stocking costs (p < 0.0001), reimbursement levels (p < 0.0001), and insurance coverage (p < 0.0001) compared to physicians in large group practices. Eighty-three percent of providers cited lack of parent knowledge and understanding of HPV infection as a barrier. Over half of physicians (58 %) reported that completion of the 3-dose schedule was a barrier. Most physicians did not use tracking or reminder systems to ensure dose completion. A majority (58 %) of providers cited the lack of school-based vaccination requirements as a barrier. Uptake of HPV vaccination in Hawaii may be impeded by physician perception of parent knowledge and attitudes. Cost-related system barriers are particular barriers among those in private practice. Completion of the 3-dose schedule also remains a challenge.

Unintended Pregnancy in the Native Hawaiian Community: Key Informants' Perspectives.

CONTEXT: Native Hawaiians experience the highest reported rate of unintended pregnancy of any ethnic group in Hawaii. Understanding the context in which they make decisions that influence pregnancy and pregnancy planning is essential to reducing this rate. METHODS: A qualitative study was carried out in partnership with a community health center serving a large Native Hawaiian population to explore how Native Hawaiians conceptualize pregnancy and pregnancy planning. Between August and October 2013, semistructured interviews were conducted with 10 diverse key informants from the Hawaiian community. Content analysis was used to identify themes and patterns that emerged from the interviews. RESULTS: Core Hawaiian values of children and family strongly affect how Native Hawaiians view pregnancy, pregnancy planning and unintended pregnancies. 'Ohana (families) are large and characterized by tremendous support, which is perceived to lessen the burden of an unintended pregnancy. Pregnancies, whether planned or not, are seen as blessings because children are highly valued. Because of these concepts, there is an expectation for women to continue unplanned pregnancies. Although Hawaiians ascribe value to planning pregnancies and hope that children are born under what they identify as ideal circumstances, they acknowledge that these circumstances are not necessary and often do not occur. CONCLUSION: The concepts of family and children serve as core values to Native Hawaiians and are linked to the ways in which they view pregnancy and pregnancy planning.

Contraceptive Coverage and the Affordable Care Act.

A major goal of the Patient Protection and Affordable Care Act is reducing healthcare spending by shifting the focus of healthcare toward preventive care. Preventive services, including all FDA-approved contraception, must be provided to patients without cost-sharing under the ACA. No-cost contraception has been shown to increase uptake of highly effective birth control methods and reduce unintended pregnancy and abortion; however, some institutions and corporations argue that providing contraceptive coverage infringes on their religious beliefs. The contraceptive coverage mandate is evolving due to legal challenges, but it has already demonstrated success in reducing costs and improving access to contraception.

A Survey of Physicians' Attitudes and Practices about the Human Papillomavirus (HPV) Vaccine in Hawai'i.

The human papillomavirus (HPV) vaccine has the potential to decrease the incidence of several cancers that affect women and men. Despite recommendations by the medical and public health community, and the incorporation of the vaccine into the adolescent immunization schedule, uptake of the vaccine remains well below target goals. To understand potential physician barriers to recommendation and provision of the vaccine, a cross-sectional survey was administered to Hawai'i pediatricians and family physicians from July 2012 to September 2012 on their attitudes, practices, and perceived barriers regarding HPV vaccination. Surveys were mailed to 465 members of the local pediatrics and family medicine professional chapters, and 87 responses were received for a response rate of 19%. After excluding 14 responses, 73 surveys were included in the analysis. Although almost all of the respondents reported stocking and administering the HPV vaccine in their offices, only 71% reported strongly recommending the HPV vaccine to girls 11-12 years, and only 57% strongly recommend the vaccine to boys 11-12 years old. Lack of insurance coverage and other financial considerations were barriers to provision of the vaccine by physicians. Physicians who felt it is necessary to discuss sexuality with patients prior to recommending the vaccine were significantly less likely to strongly recommend the vaccine to boys 11-12 years old. Public health efforts should focus on addressing the financial barriers and encouraging physicians to recommend the HPV vaccine according to the guidelines.