Body Mapping and Story Circles in Sexual Health Research With Youth of Color: Methodological Insights and Study Findings From Adolescent X, an Art-Based Research Project.

We describe the implementation and select findings from Adolescent X, an arts-based research project that used story circles and body mapping to elucidate how young people understand the relationship between their social contexts and their sexual and reproductive health, with a particular focus on youth's understandings of gender, sexuality, and the body as sites of possibility and power. A community-based sample of N = 24 youth of color was recruited from the South and West Sides of Chicago to participate in 3-day workshops. In addition to story circles and body mapping, data were collected via brief surveys with N = 24 youth, debriefing groups (n = 10 youth), and focus groups (n = 14 youth). Study data consisted of (1) body map visuals, that is, legends, mini-, and full-body maps; (2) written body map narratives; and (3) audio recordings of the story circles, body mapping activities, debriefing groups, and focus groups. All audio recordings were transcribed, deidentified, and uploaded in Dedoose for qualitative thematic analysis. Data analysis was conducted by a team of independent coders. Across all sources of data, three major themes were identified: (1) strong feelings of unsafety related to how young people's bodies are gendered, sexualized, and racialized in different social settings; (2) the extent to which adults and institutions foster youth safety; and (3) sources of young people's coping and resilience. Implications for public health research, practice, and policy are discussed.

Contraception.

Contraception counseling and provision are vital components of comprehensive health care. Unplanned pregnancy can be devastating to any woman but is particularly dangerous for those with chronic illness. Internal medicine providers are in a unique position to provide contraception, as they often intersect with women at the moment of a new medical diagnosis or throughout care for a chronic problem. A shared decision-making approach can engage patients and ensure that they choose a contraceptive method that aligns with their reproductive plans and medical needs.

Development of a Framework and Tool to Facilitate Cost-of-Care Conversations With Patients During Prenatal Care.

Background: Studies show that patients want to engage in cost-of-care conversations and factor costs into the formulation of care plans. Low-income patients are particularly likely to defer care because of costs, suggesting that cost-of-care conversations may be an important factor in health equity. Little guidance is available to clinicians and health systems for how to integrate effective cost-of-care conversations into clinical practice or to address specific cost needs of low-income patients. Objective: To develop a framework and tool to assist cost-of-care conversations with low-income patients during prenatal care. Design: A qualitative study using human-centered design methods. Setting: University medical center-based obstetrics-gynecology (ob-gyn) practice. Participants: 20 pregnant or recently postpartum women, 16 clinicians, and 8 support and executive staff. Results: Pregnant women accumulate substantial indirect costs that interfere with treatment adherence and stress patients and their relationships. Frequency and duration of appointments are primary drivers of indirect costs; the burden is exacerbated by not knowing these costs in advance and disproportionately affects low-income patients. Working with ob-gyn clinicians, staff, and patients, a paper-based tool was developed to help patients forecast treatment demands and indirect costs, and to help clinicians introduce and standardize cost conversations. Limitations: Data were collected from a small number of stakeholders in a single clinical setting that may not be generalizable to other settings. The tool has not been tested for effects on adherence or clinical outcomes. Conclusion: A communication tool that helps pregnant patients understand their care plan and anticipate indirect costs can promote cost-of-care conversations between clinicians and low-income patients. Primary Funding Source: Robert Wood Johnson Foundation.

A Novel Lay Health Worker Training to Help Women Engage in Postabortion Contraception and Well-Woman Care.

Young women, low-income women, and women of color make up a disproportionate share of abortion patients and experience higher rates of unintended pregnancy, maternal morbidity and mortality, and infant mortality. Furthermore, these individuals are also less likely to have access to preventive gynecologic care. Whereas lay health worker interventions have been developed to help link individuals to care in other fields, the use of such interventions to link individuals to preventive care after abortion is novel. This article describes a training protocol and curriculum that provided nonmedically trained individuals with knowledge, skills, and competency to conduct a behavioral theory-based counseling intervention to help individuals achieve self-identified goals regarding obtaining postabortion reproductive health care and contraception. When piloted with 60 patients presenting for abortion who lacked a regular health care provider and desired to delay pregnancy for at least 6 months, participants found the lay health worker skills and the counseling session highly acceptable. Specifically, participants reported feeling comfortable speaking to lay health workers about contraception and reproductive health care. These findings indicate that lay health worker interventions may present an important opportunity to help individuals address their postabortion preventive and contraceptive health care needs.

Understanding young women's experiences of gender inequality in Lucknow, Uttar Pradesh through story circles.

Gender inequality poses grave consequences for young women's health and wellbeing. The aim of this study was to understand how gender influences the lives of young women living in urban slums of Lucknow, Uttar Pradesh, India using story circles as a research methodology. Narrative-based participatory methods like story circles (which involves sharing individual stories in a group circle on a given topic) can provide the nuance and detail needed to understand young people's experiences, build trust between participants and researchers, and offer spaces to speak about culturally sensitive subjects. Six story circle sessions were conducted with 50 young women (aged 15-24) in Lucknow. Sessions were audio-recorded, transcribed, and coded. Transcriptions were analysed to identify the following salient themes, all of which act as mechanisms of gender inequality: mobility restrictions, rampant sexual harassment in the community, limited educational and work opportunities, and the utmost prioritization of marriage for young women.

Factors Shaping Women's Pre-abortion Communication with Members of Their Social Network.

To understand women's pre-abortion conversations with members of their social network about their abortion decision. Semi-structured interviews were conducted with women presenting for first-trimester surgical abortion at a high volume, hospital-based abortion clinic. Women were asked their reasons for discussing or not discussing abortion and responses received after disclosing their abortion decision. Interviews were transcribed and computer-assisted content analysis was performed. Salient themes are presented. Thirty women who obtained an abortion were interviewed. All but three spoke to at least one member of their social network about their abortion decision making. However, women were very selective about whom they spoke to regarding this decision. Reasons not to discuss their abortion decision included: concerns about judgment, desiring to maintain privacy, and certainty about their decision. Reasons to discuss their abortion decision included: seeking information about the procedure, needing guidance about their decision, wanting support for their decision to proceed with abortion. While many were concerned about being judged, most women who spoke about their decision experienced a positive response. Though most women in this study had at least one person to turn to for assistance with abortion decision making, many participants avoided confiding in some or all members of their social network about their abortion decision due to concerns of judgment and stigma.

Is LARC for Everyone? A Qualitative Study of Sociocultural Perceptions of Family Planning and Contraception Among Refugees in Ethiopia.

Objective Ethiopia is home to an increasingly large refugee population. Reproductive health care is a critical issue for these groups because refugee women are at high risk for unmet family planning needs. Efforts to expand contraceptive use, particularly long acting reversible contraceptive (LARC) methods are currently underway in several Ethiopian refugee camps. Despite availability of LARC methods, few refugee women opt to use them. The purpose of this study was to explore how culture influences contraceptive attitudes and behaviors, particularly towards LARC methods, among Ethiopia's refugee populations. Methods Focus group discussions and individual interviews were conducted with Eritrean and Somali refugees living in Ethiopia. The qualitative data was analyzed to identify important themes highlighting the relationship between cultural values and contraceptive attitudes and behaviors. Results Childbearing was highly valued among participants in both study groups. Eritreans reported desire to limit family size and attributed this to constraints related to refugee status. Somalis used cultural and religious faith to deal with economic scarcity and were less likely to feel the need to adapt contraceptive behaviors to reduce family size. Participants held overall positive views of the contraceptive implant. Attitudes toward the intrauterine device (IUD) were overwhelmingly negative due to its long-acting nature. Conclusions Culture, religion and refugee status form a complex interplay with family planning attitudes and behaviors among Eritrean and Somali refugees. For these populations, the three-year implant appears to be a more acceptable contraceptive method than the longer-acting IUD because it is in line with their reproductive plans.

Doula support during first-trimester surgical abortion: a randomized controlled trial.

OBJECTIVE: The objective of the study was to evaluate the impact of doula support on first-trimester abortion care. STUDY DESIGN: Women were randomized to receive doula support or routine care during first-trimester surgical abortion. We examined the effect of doula support on pain during abortion using a 100 mm visual analog scale. The study had the statistical power to detect a 20% difference in mean pain scores. Secondary measures included satisfaction, procedure duration, and patient recommendations regarding doula support. RESULTS: Two hundred fourteen women completed the study: 106 received doula support, and 108 received routine care. The groups did not differ regarding demographics, gestational age, or medical history. Pain scores in the doula and control groups did not differ at speculum insertion (38.6 [±26.3 mm] vs 43.6 mm [±25.9 mm], P = .18) or procedure completion (68.2 [±28.0 mm] vs 70.6 mm [±23.5 mm], P = .52). Procedure duration (3.39 [±2.83 min] vs 3.18 min [±2.36 min], P = .55) and patient satisfaction (75.2 [±28.6 mm] vs 74.6 mm [±27.4 mm], P = .89) did not differ between the doula and control groups. Among women who received doula support, 96.2% recommended routine doula support for abortion and 60.4% indicated interest in training as doulas. Among women who did not receive doula support, 71.6% of women would have wanted it. Additional clinical staff was needed to provide support for 2.9% of women in the doula group and 14.7% of controls (P < .01). CONCLUSION: Although doula support did not have a measurable effect on pain or satisfaction, women overwhelmingly recommended it for routine care. Women receiving doula support were less likely to require additional clinic support resources. Doula support therefore may address patient psychosocial needs.

Impact of a theory-based video on initiation of long-acting reversible contraception after abortion.

OBJECTIVE: Adoption of long-acting reversible contraception (LARC) (ie, the intrauterine device or the contraceptive implant) immediately after abortion is associated with high contraceptive satisfaction and reduced rates of repeat abortion. Theory-based counseling interventions have been demonstrated to improve a variety of health behaviors; data on theory-based counseling interventions for postabortion contraception are lacking. STUDY DESIGN: Informed by the transtheoretical model of behavioral change, a video intervention was developed to increase awareness of, and dispel misconceptions about, LARC methods. The intervention was evaluated in a randomized controlled trial among women aged 18-29 years undergoing surgical abortion at a clinic in Chicago, IL. Participants were randomized 1:1 to watch the intervention video or to watch a stress management video (control), both 7 minutes in duration. Contraceptive methods were supplied to all participants free of charge. Rates of LARC initiation immediately after abortion were compared. RESULTS: Rates of LARC initiation immediately after abortion were not significantly different between the 2 study arms; 59.6% in the intervention and 51.6% in the control arm chose a LARC method (P = .27). CONCLUSION: This study resulted in an unexpectedly high rate of LARC initiation immediately after abortion. High rates of LARC initiation could not be attributed to a theory-based counseling intervention.

Development and testing of an iOS waiting room "app" for contraceptive counseling in a Title X family planning clinic.

OBJECTIVE: Long-acting reversible contraceptive (LARC) methods, such as the intrauterine device and implant, are highly effective but used by less than 10% of US women. The objective of our study was to improve LARC interest by enhancing clinic counseling. STUDY DESIGN: A quality improvement methodology was used to evaluate intrauterine device service delivery in 3 Chicago Title X clinics. To address identified barriers, we developed a theory-based iOS application (app) for patients to use in the clinic waiting room using human-centered design. The final prototype was tested in a randomized controlled trial in a Title X clinic with sexually active females (79% African American) under age 30 years. Our sample of 60 was chosen to detect an increase from 10% (baseline) to 45% (app intervention) in the proportion of patients expressing interest in discussing a LARC method during their clinic visit with 80% power and two-sided α = 0.05. After completing demographic and baseline knowledge questionnaires, participants were randomized 1:1 to intervention (app) or standard care arms. App users also completed a posttest. Our primary outcome was expressed interest in discussing a LARC method during the clinic visit. Secondary outcomes were contraceptive knowledge and LARC selection. RESULTS: App testers (n = 17) preferred interactive, visually appealing design and video testimonials. In the pilot randomized controlled trial (n = 52), app users had a significantly higher knowledge of contraceptive effectiveness (P = .0001) and increased interest in the implant (7.1-32.1%, P = .02) after the intervention. Users were highly satisfied with the app. Staff reported no problems using the app in the clinic. CONCLUSION: Use of a theory-based counseling app offers a novel method to optimize wait time while minimizing clinic flow disruption. Preliminary data demonstrate that app use was associated with improvements in patients' contraceptive knowledge and interest in the implant.

Factors influencing parental involvement among minors seeking an abortion: a qualitative study.

OBJECTIVES: We explored factors that influenced whether minors involved or excluded a parent when seeking an abortion. METHODS: In the summer of 2010, we conducted interviews with 30 minors who sought an abortion in a state that did not require parental involvement at the time. Interviews were coded and analyzed following the principles of the grounded theory method. RESULTS: The majority of minors involved a parent. Commonly cited factors were close or supportive parental relationships, a sense that disclosure was inevitable, a need for practical assistance, and compelled disclosure. Motivations for not wanting to involve a parent, although some minors ultimately did, included preservation of the parent-daughter relationship, fear or detachment, and preservation of autonomy. CONCLUSIONS: Minors were motivated to involve parents and other adults who were engaged in their lives at the time of the pregnancy, particularly those who supported them in obtaining an abortion. Motivations to exclude a parent were often based on particular family circumstances or experiences that suggested that involvement would not be helpful, might be harmful, or might restrict a minor's ability to obtain an abortion.

Digital media and sexually transmitted infections.

PURPOSE OF REVIEW: Digital media, including the Internet, social networking sites, text messaging, and mobile applications, are ubiquitous among adolescents and young adults. These platforms enable users to obtain important information on a multitude of health topics, they may facilitate risk-taking behaviors, and they can be key components of health interventions. The purpose of this article is to review the recent literature on digital media and sexually transmitted infections, discussing their role in potentiating and reducing risk. RECENT FINDINGS: This review demonstrates adolescents' use of digital media to gather information on health topics and discusses significant privacy concerns regarding using media to explore sexual health information. Although several studies demonstrate an association between social media and increased sexual risk-taking behaviors, this relationship is not fully understood. Digital media-based interventions are increasingly being developed to either reduce risk or improve management of sexually transmitted infections. SUMMARY: As greater numbers of adolescents use digital media, the potential for these platforms to influence sexual risk-taking behaviors is significant. Additional research is needed to better understand the impact of digital media on sexually transmitted infection risk and to develop social media-based interventions to improve sexually transmitted infection outcomes.

Minor histocompatibility antigens are expressed in syncytiotrophoblast and trophoblast debris: implications for maternal alloreactivity to the fetus.

The fetal semi-allograft can induce expansion and tolerance of antigen-specific maternal T and B cells through paternally inherited major histocompatibility complex and minor histocompatibility antigens (mHAgs). The effects of these antigens have important consequences on the maternal immune system both during and long after pregnancy. Herein, we investigate the possibility that the placental syncytiotrophoblast and deported trophoblastic debris serve as sources of fetal mHAgs. We mapped the expression of four mHAgs (human mHAg 1, pumilio domain-containing protein KIAA0020, B-cell lymphoma 2-related protein A1, and ribosomal protein S4, Y linked) in the placenta. Each of these proteins was expressed in several placental cell types, including the syncytiotrophoblast. These antigens and two additional Y chromosome-encoded antigens [DEAD box polypeptide 3, Y linked (DDX3Y), and lysine demethylase5D] were also identified by RT-PCR in the placenta, purified trophoblast cells, and cord blood cells. Finally, we used a proteomic approach to investigate the presence of mHAgs in the syncytiotrophoblast and trophoblast debris shed from first-trimester placenta. By this method, four antigens (DDX3Y; ribosomal protein S4, Y linked; solute carrier 1A5; and signal sequence receptor 1) were found in the syncytiotrophoblast, and one antigen (DDX3Y) was found in shed trophoblast debris. The finding of mHAgs in the placenta and in trophoblast debris provides the first direct evidence that fetal antigens are present in debris shed from the human placenta. The data, thus, suggest a mechanism by which the maternal immune system is exposed to fetal alloantigens, possibly explaining the relationship between parity and graft-versus-host disease.

Are Illinois Contraceptive Providers Comfortable Providing Care to Adolescents? Results From a Statewide Provider Needs Assessment.

OBJECTIVES: Legislation allows adolescents to access comprehensive contraceptive care; however, provider practices remain unclear. We examined predictors of provider knowledge and comfort surrounding the provision of contraceptive care to adolescents. METHODS: We mailed a survey to Illinois contraceptive providers (n = 251). Study outcomes include 1) knowledge of adolescent consent laws, 2) comfort asking for time alone with adolescents, 3) comfort providing contraception to adolescents without parental consent, and 4) comfort providing long-acting reversible contraception (LARC) to adolescents without parental consent. Using multivariable logistic regression, we estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS: Most providers are knowledgeable of consent laws (90%) and report being comfortable asking for time alone with adolescents (94%) and comfortable providing contraception to adolescents without parental consent (88%). Having a large proportion of patients who are eligible for family planning services was associated with increased comfort asking for time alone with adolescents (aOR, 7.03; 95% CI, 1.58-31.3) and providing contraception to adolescents (aOR, 4.0; 95% CI, 1.4-11.1). Only one-half (54%) were comfortable providing LARC methods to adolescents, with higher comfort among providers who: received more than 2 days of formal family planning training (aOR, 2.77; 95% CI, 1.2-6.2), specialized in obstetrics-gynecology (aOR, 5.64; 95% CI, 2.1-15.1), and had a patient population with more than 50% patients from minoritized racial/ethnic groups (aOR, 2.9; 95% CI, 1.2-6.6). CONCLUSIONS: Although knowledge of consent laws was high, gaps remain. Only one-half of our sample indicated comfort with the provision of LARC methods without parental consent. Additional efforts to increase provider comfort with all contraceptive methods and training on adolescent-centered practices may be required to meet the needs of adolescent patients.

Factors influencing uptake of intrauterine devices among postpartum adolescents: a qualitative study.

OBJECTIVE: We assessed barriers and facilitators to uptake of the intrauterine device (IUD) among primiparous African American adolescent mothers. STUDY DESIGN: Twenty participants who expressed IUD desire completed 4-5 qualitative interviews during the first postpartum year as part of a larger longitudinal study. Transcripts were analyzed for salient themes using a grounded theory approach to content analysis. RESULTS: Twelve participants did not obtain IUDs and instead used condoms, used no method, or intermittently used hormonal methods, resulting in 3 repeat pregnancies. Outdated IUD eligibility requirements, long wait times, lack of insurance coverage, and fear of IUD-related side effects precluded or delayed uptake. Facilitators to IUD uptake included strong recommendations from providers or family members, planning for IUD during pregnancy, and perceived reproductive autonomy. CONCLUSION: Postpartum adolescents may reduce their risk of rapid repeat pregnancy by using IUDs. Providers and members of adolescents' support networks can be instrumental in method adoption.

Pharmacokinetics of the etonogestrel contraceptive implant in obese women.

OBJECTIVE: We sought to examine the pharmacokinetics and acceptability of the etonogestrel contraceptive implant in obese women. STUDY DESIGN: We developed and validated a plasma etonogestrel concentration assay and enrolled 13 obese (body mass index ≥30) women and 4 normal-weight (body mass index <25) women, who ensured comparability with historical controls. Etonogestrel concentrations were measured at 50-hour intervals through 300 hours postinsertion, then at 3 and 6 months to establish a pharmacokinetic curve. RESULTS: All obese participants were African American, while all normal-weight participants were white. Across time, the plasma etonogestrel concentrations in obese women were lower than published values for normal-weight women and 31-63% lower than in the normal-weight study cohort, although these differences were not statistically significant. The implant device was found highly acceptable among obese women. CONCLUSION: Obese women have lower plasma etonogestrel concentration than normal-weight women in the first 6 months after implant insertion. These findings should not be interpreted as decreased contraceptive effectiveness without additional considerations.

From intervention to invitation: reshaping adolescent sexual health through story telling and games.

The University of Chicago and the University of Ibadan in Nigeria have partnered to exchange innovative insights into the sexual and reproductive health of disadvantaged populations in Chicago and Nigeria. Youth in both Chicago and Nigeria face disproportionately high rates of mortality and morbidity due to poor sexual and reproductive health. Traditional models have fallen short of the needs of these youth, so the University of Chicago is seeking to reframe and retool adolescent sexual health education. Game Changer Chicago is an initiative that incorporates digital storytelling, new media, and game design to conduct workshops with youth around issues of sexuality and emotional health. Based on the success of storytelling and digital media programs in Nigeria and the success of Game Changer Chicago, we believe this model holds promise for implementation in Nigeria and other sub-Saharan countries

Exploring Illinois contraceptive providers' interest in medication abortion training.

OBJECTIVES: To explore Illinois contraceptive providers' interest in medication abortion training. STUDY DESIGN: We surveyed Illinois contraceptive providers to explore associations between interest in medication abortion training and provider, practice, and patient variables. RESULTS: Of 1040 reachable, eligible contacts, 251 responded to the survey (24% response rate) and more than half (56%) expressed interest in medication abortion training. Providers with the highest interest in medication abortion training were those with <2 days' formal contraceptive training (n = 31; 76%) and those who received Title X funding (n = 32; 81%). CONCLUSION: Findings suggest interest in medication abortion training among Illinois contraceptive providers. IMPLICATIONS: Our findings suggest some contraceptive providers may be interested in training opportunities around medication abortion. More research is needed to understand whether additional training could increase the number of providers able to counsel, refer, and provide medication abortion.

Community Violence Exposure and Adolescent Pregnancy in Chicago.

This study examined the association between community violence exposure (CVE), sex without contraception, and adolescent pregnancy in Chicago. A self-administered, online survey was conducted among 15- to 19-year-old girls from the South and West sides of Chicago from October to March 2018. Participants were recruited via community organization partnerships and social media advertising. The survey included questions about CVE, sexual behaviors, and covariates that are known to contribute to sexual risk taking. CVE was measured via a validated index of seven questions that measured individual experiences with violence. Multivariable and logistic regression analyses were performed to examine the association between CVE, penile-vaginal intercourse without contraception, and ever being pregnant. The final sample included 644 girls. Levels of CVE were high: 62.87% of girls reported that a close friend or relative died because of violence and 41.60% were a victim of violence. Nearly half (48.69%) of girls had penile-vaginal intercourse and 6.01% had been pregnant. For each standard deviation increase in CVE score, the odds of penile-vaginal intercourse without contraception (odds ratio [OR] = 1.69, 95% confidence interval [CI] = [1.27, 2.25]) and the odds of ever being pregnant (OR = 1.87, 95% CI = [1.36, 2.57]) increased. These results remained significant when adjusting for demographic, psychosocial, institutional, and interpersonal factors. Findings suggest that girls in Chicago who are exposed to higher levels of community violence have an increased likelihood of experiencing penile-vaginal intercourse without contraception and teenage pregnancy, even when adjusting for other predictors to teenage pregnancy.

Effect of a narrative intervention on individual-level abortion stigma: a randomised controlled trial.

OBJECTIVE: To evaluate the effect of a narrative intervention on individual-level abortion stigma in patients undergoing abortion. STUDY DESIGN: This randomised controlled trial examined individual-level abortion stigma and psychological distress among patients undergoing outpatient abortion. Patients were randomised to a narrative intervention verus usual care. The intervention consisted of viewing a digital narrative and responding to a writing prompt. Abortion stigma was measured using the Individual Level Abortion Stigma Scale (ILAS) and psychological distress was assessed with a modified Profile of Mood States-Short Form (POMS-SF) at baseline and after 2 weeks. The primary outcome compared change in ILAS score from baseline to follow-up between groups. The secondary outcome compared change in the modified POMS-SF score. RESULTS: We randomised 215 participants. Baseline characteristics were similar between groups. Overall baseline stigma scores were low. The study groups did not differ significantly in the primary ILAS outcome (mean change=0.07 in both groups with score range 0 to 3.5, 95% CI -0.11 to 0.11, p=0.98). There was also no significant difference in the secondary modified POMS-SF outcome (mean change -0.64 for the intervention group and -0.65 for the control group with score range -8 to 8, 95% CI -1.10 to 1.12, p=0.98). Black participants, comprising the majority, demonstrated lower levels of individual-level abortion stigma and psychological distress at baseline than participants identifying with any other race (mean baseline ILAS score of 0.70 vs 1.00 and mean modified POMS-SF score of -3.00 vs -1.45, 95% CI 0.12 to 0.46 and 95% CI 0.28 to 2.01, p=0.001 and p=0.02, respectively). CONCLUSIONS: Patients who participated in a narrative intervention did not score lower on an individual-level abortion stigma scale compared with a control group at 2-week follow-up. Demographic characteristics may predict levels of individual-level abortion stigma and psychological distress among patients seeking abortion.