The Health Belief Model can guide modern contraceptive behavior research and practice

Knowledge and Use of Emergency Contraception Among Female College Students in Ghana

OBJECTIVE

To assess the knowledge and use of emergency contraception (EC) and to identify factors associated with the perceptions of EC use among female college students in Ghana.

DESIGN

A descriptive cross-sectional study.

SETTING

Nursing-midwifery and teacher-training colleges in Ghana.

PARTICIPANTS

A convenience sample of 400 female college students.

METHODS

Data were collected using a four-part structured questionnaire. Descriptive statistics, chi-square tests, and univariable and multivariable regression analyses were performed.

RESULTS

Most participants (n = 352; 88.0%) reported hearing about EC. However, only 10.0% (n = 40) knew about the copper-bearing intrauterine device as an EC. Friends (n = 216; 54.0%) were reportedly the primary source of information about EC. Concerns about serious adverse effects were the top reason for not using EC (n = 354; 88.5%). In contrast, facilitators for use included availability, easy access, partner agreement, affordability, and family discussions. Teacher-training college students who were single were more likely to have negative perceptions of EC use than nursing-midwifery students who were married or living with a partner.

CONCLUSION

Although the results highlight the limited knowledge and use of EC among female college students in Ghana, they also point to the potential for more effective education to improve knowledge and use of EC.

Fertility intention and its correlates with reproductive-aged married women in Ethiopia: an adapted theory of planned behavior (TPB)

BACKGROUND

In Ethiopia, despite different attempts to manage rapid population growth and reduce the average number of births per woman, the expected changes outlined in the National Health Sector Transformation Plan (HSTP II) and Reproductive health (RH 2015 2020) strategies have not been fully realized over the past decade. The population continues to grow at a rate of 2.7 and fertility rates remain at 4.6. Fertility is one of the three key aspects in shaping population dynamics, as women's fertility intention for children play a significant role in determining actual fertility rates. In addition, it can be an instructive tool for discovering more about overall fertility patterns, which is important for understanding future reproductive behaviors. In women, fertility intention refers to their preferences regarding the number of children they wish to have in the future, considering factors such as the costs and benefits associated with childbearing.

METHODS

This study used cross-sectional data from Performance Monitoring for Action Ethiopia (PMA-ET) 2020.The hypothesis tested in this analysis was adapted and used TPB constructs as a guiding behavioral theoretical model. The study included 3916 women aged 15-49 years who were not pregnant. Frequencies and percentages were commuted to characterize women. Chi-square tests were conducted to evaluate associations and assess sample cell size adequacy across categories. Multilevel binary logistic regression statistical modeling was employed to identify important factors influencing women's fertility intention. The findings were reported in terms of percentages and odds ratios, with 95% confidence intervals. Statistical significance was established at a significance level of 0.05.

RESULTS

Three-quarters 74.9% (95% CI; 72.5%-77.1%) of married reproductive-aged women in Ethiopia intended to have a/another child. Women who reported having a forced pregnancy by partner, Muslim and Protestant religion, 19 years and above old at first sex, and secondary or higher education were found to increase the likelihood of fertility intention to have a child. However, women who reported 30 years of age or older, had three or more live births, had a family size of five or more members, had a moderate family planning (FP) knowledge, positive subjective social norm towards FP and living in Addis and Dire Dawa were found to have lower odds of women's fertility intention.

CONCLUSION

The prevailing strong intention for high fertility in Ethiopia delays efforts to quickly decrease fertility and calls for implementation of multifaceted strategies that maintain high fertility intention rates. Accordingly, demographic and socio-physiological factors were found to affect women's intention to have children. Awareness of these influencing factors is crucial for designing fertility programs and policies tailored to demographics strategies. Specifically, these strategies should be sufficiently diverse to create a positive social norm toward FP use, which can lead to information sharing, reduced stigma, and community support that can play significant importance in shaping individuals' fertility intention and reproductive behaviors.

What emerging adults say about the appropriateness of sexual and reproductive health programmes: evidence from a suburb in Accra, Ghana

Introduction

Young people's access to appropriate health information in Ghana has been marginal, hence their utilisation of existing services remains poor. Most sexual and reproductive health (SRH) policies and outreach programmes target adolescents, neglecting emerging adults who are equally vulnerable to SRH risks. This study seeks to elicit emerging adults' knowledge and experiences with SRH programmes, and their recommendations to improve the services for their needs.

Methods

Using data from 30 in-depth interviews and 10 focus group discussions with youth aged 18-24 years in a suburb of Accra, we provide insights on emerging adults' experiences with SRH programmes and their recommendations for their improvement, as well as young men's perspectives on SRH programmes, in particular.

Results

The participants were in three socio-economic groups: tertiary students, informal workers and apprentices. The main SRH education that the emerging adults had received was from their earlier formal education in Junior and Senior High Schools but not in their current places of school or work. However, they indicate that the SRH education programmes and information they received earlier in life were inadequate to tackle pragmatic issues that contemporary youth face. Furthermore, SRH programmes operate in unfriendly environments with negative messages that cause them to lack vital information.

Discussion

For the success of SRH programmes, the youth should be targeted with diverse contemporary approaches specific for their SRH needs. Key recommendations comprised making available SRH education tailored for emerging adults' current demographic and socio-economic groups, and providing appropriate SRH content and youth-friendly community centres.

Determinants of teenage pregnancy and knowledge about contraception, sexually transmitted diseases among pregnant women: A case-control study in Eastern India

Context

Each year, about 21 million girls aged 15-19 in developing regions experience pregnancy, posing significant challenges for their health, well-being, and economic stability due to its vast impact.

Aim

To identify the risk factors contributing to teenage pregnancy as compared to Pregnancy in pregnant women in the rural area of the Khordha district with the assessment of their knowledge and, health-seeking behaviour (Contraception and STDs) among teenage and adult pregnant women in the study area.

Settings and Design

Hospital-based case-control study conducted at Bhubaneswar's Community Health Centre.

Material and Methods

The study, conducted from April to July 2022, recruited 138 participants using consecutive sampling and interviewed them using a pretested semi-structured questionnaire.

Statistical Analysis

Chi-square and logistic regression assessed association and strength.

Results

Factors contributing to teenage pregnancy include education below high school (AOR = 2.46; 95%CI 0.89-6.79), SC and ST caste (AOR = 2.34; 95%CI 0.94-5.82), having more than three siblings (AOR = 4.45; 95%CI 1.53-12.96), and lack of communication about sexual issues (AOR = 2.84; 95%CI 1.25-6.39). Awareness of contraceptive methods was 34.8% among cases and 56.5% among controls (p = 0.02). Regarding STD awareness and symptoms, 15.2% of cases and 42.4% of controls were knowledgeable and experienced symptoms (p < 0.01).

Conclusions

This study suggests that factors such as lower education, minority caste, having more than three siblings, and lack of communication about sexual issues contribute to early pregnancy. These findings could enhance existing ARSH platforms by integrating regular engagement and sensitization efforts.

Abortion pill marketing and sourcing on twitter following Dobbs v. Jackson supreme court ruling

OBJECTIVE

This study examines abortion-related discourse on Twitter (X) pre-and post-Dobbs v. Jackson ruling, which eliminated the constitutional right to abortion.

STUDY DESIGN

We used a custom data collection tool to collect tweets directly from Twitter using abortion-related keywords. We used the BERTopic language model and examined the top 30 retweeted and top 30 textually similar tweets from relevant topic clusters using an inductive coding approach. We also conducted statistical testing to assess potential associations between abortion themes.

RESULTS

166,799 unique tweets were collected from December 2020-December 2022. 464 unique tweets were coded for abortion-related themes with 154 identified as relevant. Of these, 66 tweets marketed abortion pills, 17 tweets were identified as offering consultations, and 91 tweets were relevant to self-managed abortion. All marketing and consultation tweets were posted post-Dobbs decision and 7 (7.69%) of self-managed tweets were posted pre-Dobbs versus 84 (92.30%) posted post-Dobbs. A positive association was found between tweets offering a medical consultation with tweets marketing abortion pills and discussing self-managed abortion.

CONCLUSION

This study detected online marketing of abortion pills, consultations and discussions about self-managed abortion following the Dobbs v. Jackson ruling. These results provide more context to the type of abortion-related information that is available online.

Facilitators and barriers to contraception access and use for Hispanic American adolescent women: An integrative literature review

STATEMENT OF THE PROBLEM

Hispanic American adolescents experience high rates of pregnancy with profound consequences. Compared with White teens, Hispanic teens use contraception less frequently and often choose less effective forms of contraception. Access to contraception is a primary barrier to use which contributes to relatively high and disparate rates of pregnancy in Hispanic teens. This integrative review identifies facilitators and barriers of contraception access and use for Hispanic women, 13-17 years of age, living in the U.S.

METHODOLOGY

Following the Whittemore and Knafl (2005) methodology and PRISMA guidelines, peer reviewed studies were retrieved from PUBMED, CINAHL and EMBASE. The Mixed Methods Appraisal Tool was used to assess the study quality and thematic analysis was used to categorize barriers and facilitators.

FINDINGS

Of 131 studies retrieved, 16 met inclusion criteria. Individual, interpersonal and healthcare provider factors were identified as primary categories of barriers and facilitators with structural issues comprising an additional barrier category. Individual level barriers were disproportionately represented and further categorized into themes: beliefs/misconceptions, dislike of contraception, pregnancy risk perception, lack of knowledge, and lack of control. Barriers related to cultural and religious influences were identified in individual, interpersonal and structural levels. The most frequently reported facilitators were perceived parent comfort discussing sexual health and past experience of pregnancy.

DISCUSSION

Limitations in this review may stem from heterogeneity in the acculturation and geography of participants and analysis by a single reviewer. Implications include considering the range of information sources and the influence they have on risk perception and risk mitigation for this population.

CONCLUSION & SIGNIFICANCE

Adolescents describe many modifiable influences on contraception access and use. Misperceptions related to contraception, stemming from beliefs and perceptions, can be corrected through increased access to reliable sources of sex education, parental support, and direct access to nurses and healthcare providers. Awareness of these influences can inform further research and intervention development to address these health disparities.

Education and reproductive health: evidence from schooling expansion in Turkey

We investigate the role of additional years of schooling mandated by a compulsory schooling expansion law in affecting reproductive preferences and safe reproductive health behaviors in Turkey-a middle-to-high-income country with gender inequity in education but overall high levels of safe reproductive health practices at the time of passing the law. Using a fuzzy regression discontinuity design, we find that the additional schooling improved several health behaviors. However, the effects on some outcomes commonly analyzed in the existing literature, such as contraceptive use or fertility, were either weak or insignificant. Overall, our findings complement the current literature on the marginal health benefits of schooling expansion and suggest that policymakers consider the institutional and cultural factors while evaluating the scope and potential non-educational benefits of such expansions.

An empirical analysis of the demand for family planning satisfied by modern methods among married or in-union women in Nigeria: Application of multilevel binomial logistic modelling technique

BACKGROUND

Given the health and economic benefits of family planning (FP), Nigeria's very low demand for FP satisfied by modern methods (mDFPS) of less than 50% is therefore a major public health concern, especially considering the global target aimed at achieving an mDFPS of at least 75% by year 2030 for all countries. In view of this, together with recognising the possible contextual nature of health outcomes, this study aimed to empirically analyse the mDFPS among married or in-union women of reproductive age (WRA) in Nigeria.

MATERIALS AND METHODS

A multilevel binomial logistic model with two levels of analysis was used: individual and community levels. Secondary cross-sectional data were obtained from the 2018 Nigeria Demographic and Health Survey, and analyses were performed using Stata 15.0. The analytical sample size was 9,122 WRA nested in a total of 1,072 communities.

RESULTS

The mDFPS was approximately 31.0%. The median odds ratio (MOR) estimated from the final multilevel model was 2.245, which was greater than the adjusted odds ratio (aOR) for most of the individual-level variables, suggesting that the unexplained/residual between-community variation in terms of the odds of women having their mDFPS was more relevant than the regression effect of most of the individual-level variables. This was with the exception of the regression effects of the following individual-level variables: women's husbands that had higher education level in comparison to their counterparts who had husbands with no formal education (aOR = 2.539; 95% CI = 1.896 to 3.399; p<0.001); and women from the Yoruba ethnic group in comparison to their counterparts from the Hausa/Fulani/Kanuri ethnic group (aOR = 2.484; 95% CI = 1.654 to 3.731; p value<0.001). However, other individual-level variables with positive statistically significant regression effects on mDFPS were: women who mentioned that money for accessing health care was not a problem; women's empowerment in relation to the visitation of family and relatives; and women being exposed to FP messages through various media sources, all in comparison to their respective counterparts. On the other hand, at the community level, women in communities where a high percentage of them had at least a secondary education had statistically significant greater odds of having mDFPS than women in communities with lower education levels (aOR = 1.584; 95% CI = 1.259 to 1.991; p<0.001). We found similar findings regarding women residing in communities with exposure to FP messages through various media sources. However, using the 80% interval ORs (80% IORs) as a supplemental statistical measure for further understanding the regression effects of community-level variables showed that all of the 80% IORs had a value of '1', signifying considerable uncertainty in the regression effects of all community-level variables due to the substantial residual variation existing between communities.

CONCLUSIONS

Our study showed that to achieve the dire increase in mDFPS in Nigeria, policy interventions aimed at improving the education level of both females and males, especially beyond the secondary school level, should be implemented. Additionally, all of the various media sources should be extensively utilised, both at the individual and the community level, by the Nigerian government to spread information on the importance of women having their mDFPS.

The Use of the Health Belief Model in the Context of Heatwaves Research: A Rapid Review

As heatwaves increase and intensify worldwide, so has the research aimed at outlining strategies to protect individuals from their impact. Interventions that promote adaptive measures to heatwaves are encouraged, but evidence on how to develop such interventions is still scarce. Although the Health Belief Model is one of the leading frameworks guiding behavioral change interventions, the evidence of its use in heatwave research is limited. This rapid review aims to identify and describe the main themes and key findings in the literature regarding the use of the Health Belief Model in heatwaves research. It also highlights important research gaps and future research priorities. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, 10 articles were included, with a geographic distribution as follows: United States (n = 1), Australia (n = 1), Pakistan (n = 1), and China (n = 1), as well as Malaysia (n = 2), Germany (n = 1), and Austria (n = 1). Results showed a lack of research using the Health Belief Model to study heatwaves induced by climate change. Half of the studies assessed heatwave risk perception, with the 2 most frequently used constructs being Perceived Susceptibility and Perceived Severity. The Self-efficacy construct was instead used less often. Most of the research was conducted in urban communities. This review underscores the need for further research using the Health Belief Model.

Promotion of an Algorithm-Based Tool for Pregnancy Prevention by Instagram Influencers

Objective: Despite growing concerns that some digital algorithm-reliant fertility awareness-based methods of pregnancy prevention are marketed in an inaccurate, opaque, and potentially harmful manner online, there has been limited systematic examination of such marketing practices. This article therefore provides an empirical examination of how social media influencers have promoted the fertility tracking tool Daysy on Instagram. We investigate: (1) how the tool is framed in relation to pregnancy prevention using Health Belief Model (HBM) constructs, and (2) the promotional and disclosure practices adopted by influencers. Materials and Methods: We collected Instagram posts mentioning Daysy made between June 2018 and May 2022 using the tool CrowdTangle. Using a qualitative content analysis approach, we coded a random sample of 400 Daysy posts. This yielded 122 Instagram influencer posts promoting Daysy for pregnancy prevention that we coded for promotional content and HBM constructs. Results: Posts originated primarily from Europe (n = 62, 50.82%) and the United States (n = 37, 30.33%). Findings indicate that barriers to use (n = 18, 15.57%) and the severity of risks from unplanned pregnancy (n = 8, 6.56%) were rarely conveyed, whereas benefits of use (n = 122, 100%) and the severity of risks of hormonal contraception (n = 31, 25.41%) were covered more extensively. Only about one third of posts disclosed any formal relationship to the brand Daysy. Conclusions: With many posts emphasizing benefits and obscuring potential limitations, we argue that accurate and transparent information about the effectiveness and limitations of fertility tracking technologies is critical for supporting informed decision-making and, as such, should remain a public health priority.

The determinants of postpartum contraceptive use in Nigeria

Introduction

Postpartum contraception is vital for maternal and child health, and reduces the risk of infant mortality. The Health Belief Model (HBM) is a widely accepted framework for exploring health behaviors, such as contraceptive use. Therefore, this study aimed to investigate the factors influencing postpartum contraceptive use in Nigeria and to contextualize the findings within the framework of the HBM.

Methods

This study was a secondary analysis of cross-sectional data collected from the Demographic Health Survey conducted in Nigeria (NDHS). In total, 28,041 women were included in this study. Self-reported contraceptive use was the outcome, while the explanatory variables included maternal age, place of residence, region of residence, religion, marital status, educational level, household wealth quintiles, knowledge of the ovulatory cycle, decision-maker for health care, and distance to health care facilities. Descriptive statistics and multivariate logistic regression were used to summarize and identify factors influencing postpartum contraceptive use. The HBM was used to discuss the main findings.

Results

The prevalence of postpartum contraceptive use in Nigeria is 27%. Our findings showed that the odds of using contraceptives during the postpartum period were higher among women who knew their ovulation cycles, lived in urban areas in the southern region, had no distance barriers to health care, and were 25-49 years old. Education, wealth, and marital status also increase the odds of contraceptive use. However, women who lived in the northeast and northwest regions or shared decision-making with their partners had lower odds.

Conclusion

This study highlights the need for region-specific and age-focused interventions to increase contraceptive use in Nigeria. Additionally, increasing accessibility and affordability of contraceptives for younger and economically disadvantaged women, along with promoting women's autonomy in decision-making, can further enhance contraceptive use across Nigeria.

Reproductive decision making in women with medical comorbidities: a qualitative study

BACKGROUND

A growing number of reproductive-age women in the U.S. have chronic medical conditions, increasing their risk of perinatal morbidity and mortality. Still, they experience unintended pregnancies at similar rates to low-risk mothers. We have limited understanding of how these individuals consider decisions about pregnancy and contraceptive use. The purpose of this study was to understand factors that influence reproductive decision-making among pregnant women with chronic medical conditions.

METHODS

We conducted 28 semi-structured interviews with pregnant women with pre-existing medical conditions admitted to a tertiary maternal hospital to examine factors influencing reproductive decision making. Maternal demographic characteristics, medical history, and pregnancy outcome data were obtained through participant surveys and abstraction from electronic health records. Interview transcripts were coded and analyzed using Dedoose® with both deductive and inductive content analysis.

RESULTS

Out of 33 eligible participants, 30 consented to participate and 28 completed interviews. The majority of participants identified as black, Christian, made less than $23,000 yearly, and had a variety of preexisting medical conditions. Overarching themes included: 1) Perceived risks-benefits of pregnancy, 2) Perceived risks-benefits of birth control, 3) Determinants of contraceptive utilization, and 4) Perceived reproductive self-agency. Contraception was viewed as acceptable, but with concerning physical and psychological side effects. Although some considered pregnancy as a health threat, more experienced pregnancy as positive and empowering. Few planned their pregnancies.

CONCLUSIONS

Preexisting health conditions did not significantly influence reproductive decision-making. Barriers to birth control use were generally based in patient value-systems instead of external factors. Interventions to improve uptake and use of birth control in this cohort should focus on improving care for chronic health conditions and influencing patient knowledge and attitudes toward contraception.

Oh Baby! A Content Analysis of Contraception Pins on Pinterest

BACKGROUND

Social media platforms have become a popular source for health information despite concerns about the quality of content shared. We examined how oral contraceptive pills and intrauterine devices are framed on the platform Pinterest using the Health Belief Model (HBM), as well as how fertility awareness methods are portrayed as an alternative to hormonal contraception.

METHODS

We collected pins in February 2021 using searches for birth control, oral contraceptives, and intrauterine devices. After excluding paid ads and pins not relevant to contraceptive use, we conducted a content analysis of 404 pins using a coding framework grounded in the HBM. We carried out descriptive statistics for all variables in the final sample.

RESULTS

Following coding, we found that 54.7% of pins mentioned oral contraceptive pills, 41.58% mentioned intrauterine devices, and 11.63% mentioned fertility awareness methods. Fertility awareness pins had the highest percentage of benefits conveyed (70.21%), followed by intrauterine devices (44.05%), then oral contraceptive pills (38.91%). Pill pins had the highest percentage of barriers conveyed (52.94%) and fertility awareness had the least (25.53%). Side effects were the most mentioned barrier among pill (37.10%) and intrauterine device pins (23.21%). Very few pins were made by (2.48%) or originated with medical institutions (5.45%).

CONCLUSIONS

Oral contraceptive pills are often negatively framed on Pinterest, whereas intrauterine devices and fertility awareness methods are more positively framed. This suggests a need for clear communication from clinicians regarding all contraceptive options and their relative merits and risks.

Postpartum family planning attitudes among Turkish women: development of a reliable and valid scale

AIM

The aim of this study was to develop a scale based on the Health Belief Model (HBM) to assess the family planning (FP) attitudes of postpartum women with 0- to 12-month-old infants residing in eight neighbourhoods of the Bornova province, Izmir, Turkey.

INTRODUCTION

Family planning is an integral component of maternal and infant health during the postpartum period and is a fundamental aspect of healthcare services in the prenatal and postnatal period.

METHODS

The Postpartum Family Planning Attitude Scale (PFPAS) was developed in four stages: item pool development, content validity evaluation, pilot study, and reliability and validity assessment. The PFPAS was administered to 292 women. The developed scale comprised 27 items and six sub-dimensions. Cronbach's alpha coefficient was used to evaluate the reliability of the scale. Construct validity was evaluated using confirmatory factor analysis.

FINDINGS

Cronbach's alpha coefficient was 0.88, indicating good reliability. Confirmatory factor analysis validated the structural validity of the scale, with a chi-square/degree of freedom ratio of 2.24, an RMSEA value of 0.068, and a CFI value of 0.95. The lowest and highest possible scores for the PFPAS were 27 and 135, respectively, with a mean total score of 105.32 ± 11.91.

Perception of risk of relapse among patients with first episode and recurrent schizophrenia: a descriptive phenomenological study

BACKGROUND

Patients suffering from schizophrenia are at a higher risk of relapse. The perception of the risk of relapse in patients is critical for relapse prevention. In the field of psychiatry, the study of risk perception of relapse has been neglected.

METHODS

We carried out a qualitative study using a descriptive phenomenological approach. Data were collected at two psychiatric hospitals in China. In total, 22 patients with schizophrenia were recruited through purposive sampling. Face to face semi-structured in-depth interviews were conducted. Interview recordings were transcribed by the research team, and transcripts were analysed by two independent coders with Colaizzi's descriptive analysis framework. The consolidated criteria for reporting qualitative research checklist were used for reporting.

RESULTS

The data of first-episode patients yielded three themes: (i) lack of knowledge about disease recognition and medical treatment; (ii) overoptimistic estimation of the risk of relapse; (iii) perceived importance of treatment. For first-relapse patients : (i) initial awareness of relapse warning signs; (ii) lack of systematic and accurate assessment of disease information; (iii) the perception that drug withdrawal is related to relapse. Patients with multiple relapses: (i) susceptibility to relapse: confusion and powerlessness; (ii) the severity of relapse: suicidal thoughts and behavior; (iii) effects of perceived benefits and barriers of medication behaviour.

CONCLUSIONS

In schizophrenic patients with first-episode, first-relapse, and multiple relapses, there were dynamic changes in the perception of disease relapse risk and medication behaviour. Medical workers must improve risk awareness education. They should provide patients with scientific, accurate, and timely communication channels, and dynamically assess and manage the risk of relapse in various patients.

Characterizing Twitter Content About HIV Pre-exposure Prophylaxis (PrEP) for Women: Qualitative Content Analysis

BACKGROUND

HIV remains a persistent health problem in the United States, especially among women. Approved in 2012, HIV pre-exposure prophylaxis (PrEP) is a daily pill or bimonthly injection that can be taken by individuals at increased risk of contracting HIV to reduce their risk of new infection. Women who are at risk of HIV face numerous barriers to HIV services and information, underscoring the critical need for strategies to increase awareness of evidence-based HIV prevention methods, such as HIV PrEP, among women.

OBJECTIVE

We aimed to identify historical trends in the use of Twitter hashtags specific to women and HIV PrEP and explore content about women and PrEP shared through Twitter.

METHODS

This was a qualitative descriptive study using a purposive sample of tweets containing hashtags related to women and HIV PrEP from 2009 to 2022. Tweets were collected via Twitter's API. Each Twitter user profile, tweet, and related links were coded using content analysis, guided by the framework of the Health Belief Model (HBM) to generate results. We used a factor analysis to identify salient clusters of tweets.

RESULTS

A total of 1256 tweets from 396 unique users were relevant to our study focus of content about PrEP specifically for women (1256/2908, 43.2% of eligible tweets). We found that this sample of tweets was posted mostly by organizations. The 2 largest groups of individual users were activists and advocates (61/396, 15.4%) and personal users (54/396, 13.6%). Among individual users, most were female (100/166, 60%) and American (256/396, 64.6%). The earliest relevant tweet in our sample was posted in mid-2014 and the number of tweets significantly decreased after 2018. We found that 61% (496/820) of relevant tweets contained links to informational websites intended to provide guidance and resources or promote access to PrEP. Most tweets specifically targeted people of color, including through the use of imagery and symbolism. In addition to inclusive imagery, our factor analysis indicated that more than a third of tweets were intended to share information and promote PrEP to people of color. Less than half of tweets contained any HBM concepts, and only a few contained cues to action. Lastly, while our sample included only tweets relevant to women, we found that the tweets directed to lesbian, gay, bisexual, transgender, queer (LGBTQ) audiences received the highest levels of audience engagement.

CONCLUSIONS

These findings point to several areas for improvement in future social media campaigns directed at women about PrEP. First, future posts would benefit from including more theoretical constructs, such as self-efficacy and cues to action. Second, organizations posting on Twitter should continue to broaden their audience and followers to reach more people. Lastly, tweets should leverage the momentum and strategies used by the LGBTQ community to reach broader audiences and destigmatize PrEP use across all communities.

The impact of depression at preconception on pregnancy planning and unmet need for contraception in the first postpartum year: a cohort study from rural Malawi

BACKGROUND

The impact of depression on women's use of contraception and degree of pregnancy planning in low-income settings has been poorly researched. Our study aims to explore if symptoms of depression at preconception are associated with unplanned pregnancy and nonuse of contraception at the point of conception and in the postpartum period.

METHODS

Population-based cohort of 4244 pregnant women in rural Malawi were recruited in 2013 and were followed up at 28 days, 6 months and 12 months postpartum. Women were asked about symptoms of depression in the year before pregnancy and assessed for depression symptoms at antenatal interview using the Self-Reporting Questionnaire-20, degree of pregnancy planning using the London Measure of Unplanned Pregnancy and use of contraception at conception and the three time points postpartum.

RESULTS

Of the 3986 women who completed the antenatal interview, 553 (13.9%) reported depressive symptoms in the year before pregnancy and 907 (22.8%) showed current high depression symptoms. History of depression in the year before pregnancy was associated with inconsistent use of contraception at the time of conception [adjusted relative risk (adjRR) 1.52; 95% confidence interval (1.24-1.86)] and higher risk of unplanned [adjRR 2.18 (1.73-2.76)] or ambivalent [adj RR 1.75 (1.36-2.26)] pregnancy. At 28 days post-partum it was also associated with no use of contraception despite no desire for a further pregnancy [adjRR 1.49 (1.13-1.97)] as well as reduced use of modern contraceptives [adj RR 0.74 (0.58-0.96)]. These results remained significant after adjusting for socio-demographic factors known to impact on women's access and use of family planning services, high depression symptoms at antenatal interview as well as disclosure of interpersonal violence. Although directions and magnitudes of effect were similar at six and 12 months, these relationships were not statistically significant.

CONCLUSIONS

Depression in the year before pregnancy impacts on women's use of contraception at conception and in the early postpartum period. This places these women at risk of unplanned pregnancies in this high fertility, high unmet need for contraception cohort of women in rural Malawi. Our results call for higher integration of mental health care into family planning services and for a focus on early postnatal contraception.

Effect of Educational Intervention Based on Theory of Planned Behavior (TPB) on Doing Breast Self-examination in a Sample of Iranian Women

BACKGROUND

Breast self-examination (BSE) is an important part of health care for all women in every stage of life. This study aimed to investigate the effect of theory of planned behavior (TPB) on doing BSE in a sample of Iranian women.

METHODS

A cross-sectional study was carried out to examine the factors affecting the BSE in 400 women. Then, a quasi-experimental study was conducted on 200 subjects (100 in experimental group and 100 in control group). The educational intervention for the experimental group consisted of 8 training sessions. A questionnaire including demographic characteristics, knowledge, and constructs of TPB was used to measure BSE performance before and 6 months after the intervention. Constructs of attitude, subjective norms, and perceived behavioral control predicted the intention to do the BSE.

RESULTS

The mean age of the subjects was 31.65 ± 7.59 years. The studied variables predicted 38.7% of behavioral intention (P < .001, odds ratio = 0.387). Six months after the intervention, the experimental group showed a significant increase in the knowledge, attitude, perceived behavioral control, subjective norms, intention, and BSE performance compared with the control group (P < .001).

CONCLUSIONS

This study showed that educational intervention based on the TPB was effective in promoting breast cancer screening behavior such as BSE. Therefore, it is suggested that health educators and health care planners use educational texts based on these constructs of TPB to increase their influence on individuals via screening behavior for breast cancer.

Assessment of content, behavior change techniques, and quality of unintended pregnancy apps in Spain: Systematic search on app stores

Objective

Unintended pregnancies are a public health problem that represents 48% of global pregnancies. Despite the proliferation of smartphones there is limited data on the app's features on unintended pregnancy. The purpose of this research was to identify free apps available in Spanish, in the iOS Store and Google Play, which can be recommended to prevent unintended pregnancies in adolescents.

Methods

A systematic search to identify apps was performed in the iOS App Store and in Google Play aiming to replicate the way a patient might access an "unintended pregnancy prevention" app. Additionally, the quality, using the Mobile Application Rating Scale, and content were assessed.

Results

A total of 4614 apps were identified, of which 8 were retrieved for assessment (0.17%). The mean for objective and subject quality was 3.39 (standard deviation (SD) = 0.694) and 1.84 (SD = 0.626), respectively. A total of 16 thematic categories were identified. The mean of topics covered in the apps was 5.38 (SD = 2.925) being those related to contraception the more frequent.

Conclusion

The results of the present study suggest that only a small percentage of free pregnancy prevention apps in Spanish should be recommended. The contents of the apps retrieved meet the potential necessities of adolescents.

How young Australian women explain their use of condoms, withdrawal and fertility awareness: a qualitative analysis of free-text comments from the CUPID study

Rates of oral contraceptive pill use have declined over the past decade in Australia. While some women use highly effective methods, others rely on less effective methods such as condoms, withdrawal and fertility awareness. We aimed to understand motivations for relying on these methods among young women in Australia. Women aged 18-23 years who reported using less effective methods and participated in the Contraceptive Use, Pregnancy Intention and Decisions (CUPID) study formed the sample for this analysis. Using thematic analysis, we analysed 140 free-text comments. Findings suggest that less effective methods were used when they were assessed as being best suited to current reproductive needs. These methods were perceived as offering benefits that hormonal and more invasive methods did not, and participants were largely satisfied with them. By contrast, some less effective method use was driven by a lack of choice or alternative options, previous bad experiences with hormonal methods, a lack of appropriate information about alternatives and difficulty accessing other methods. It is therefore essential to move beyond 'LARC-first' contraceptive counselling approaches to ensure young women are provided with accurate information regarding all contraceptive options available (including how to negotiate their use) and how to use them to their greatest efficacy.

Pediatric hematology providers' contraceptive practices for female adolescents and young adults with sickle cell disease: A national survey

BACKGROUND

Adolescent and young adult (AYA) women with sickle cell disease (SCD) have increased pregnancy-related health risks and are prescribed potentially teratogenic medications, yet limited data are available regarding pediatric SCD provider contraceptive practices. We aimed to assess pediatric hematology providers' beliefs, practices, motivators, and barriers for providing contraceptive care to female AYAs with SCD.

METHODS

Guided by the Health Belief Model (HBM), we developed a 25-question, web-based survey to assess practices. Survey links were distributed nationwide to pediatric SCD and/or general hematology providers through their publicly available emails and by request to directors of U.S.-accredited Pediatric Hematology-Oncology fellowship programs for distribution to their SCD providers. Data analysis included descriptive statistics, chi-square analysis, and logistic regression.

RESULTS

Of 177 respondents, 160 surveys meeting inclusion criteria were analyzed. Most providers reported counseling (77.5%) and referring female AYA patients for contraception (90.8%), but fewer reported prescribing contraception (41.8%). Proportionally fewer trainees provided counseling compared with established providers (54% vs. 85%, p < .001), with a similar trend for prescribing (p = .05). Prescription practices did not differ significantly by provider beliefs regarding potential teratogenicity of hydroxyurea. Key motivators included patient request and disclosure of sexual activity. Key barriers included inadequate provider training, limited visit time, and perceived patient/parent interest.

CONCLUSION

Provider contraceptive practices for female AYAs with SCD varied, especially by provider status. Health beliefs regarding teratogenic potential of hydroxyurea did not correlate with contraceptive practices. Clinical guidelines, provider training, and patient/parent decision-making tools may be tested to assess whether provider contraceptive practices could be improved.

Contraceptive decision making among Chinese international students in Melbourne: findings from a qualitative investigation

Compared to their non-Chinese peers in Australia, Chinese international students have very low rates of effective contraceptive use and this combined with other factors impacts unintended pregnancy rates. There is limited research exploring Chinese international students in Australia's decision-making with respect to contraceptive choices. In early 2020, 26 individual semi-structured interviews were conducted with 18-25-year-old Chinese international students to explore factors influencing their contraceptive choices. Using both deductive and inductive analysis, seven primary themes were identified. Of note was the identification of the strongly expressed cultural value of (ài xī, cherishing). Cherishing was used to describe the promotion of self-protection and the protection of loved ones from any negative outcomes related to contraceptive methods. Findings suggest that cherishing has an important role to play in Chinese students' decision-making around contraception. In particular, notions of cherishing may make it difficult for Chinese international students to accept and trust the advantages of hormonal contraceptives. Moreover, the confusing and inconsistent terminology students use to describe contraceptive options may hamper their ability to access effective forms of contraception in Australia.

Understanding contraceptive failure: an analysis of qualitative narratives

Most American women wanting to avoid pregnancy use contraception, yet contraceptive failures are common. Guided by the Health Belief Model (HBM), we conducted a secondary qualitative analysis of interviews with women who described experiencing a contraceptive failure (n=69) to examine why and how this outcome occurs. We found three primary drivers of contraceptive failures (health literacy and beliefs, partners and relationships, and structural barriers), and we identified pathways through which these drivers led to contraceptive failures that resulted in pregnancy. These findings have implications for how individuals can be better supported to select their preferred contraception during clinical contraceptive discussions.

Contraceptive decisions among individuals with medical conditions in Michigan, USA: A qualitative explanatory model informed by the Health Belief Model and the principle of respect for patient autonomy

OBJECTIVE

We aimed to qualitatively describe the contraceptive experiences of individuals with medical conditions and develop an explanatory model of contraceptive decision-making in this context.

STUDY DESIGN

We conducted 41 interviews with pre-menopausal patients with a range of medical conditions from Michigan, USA. We identified themes through open coding and comparative analysis until we reached theoretical saturation. We analyzed the themes in the context of the Health Belief Model constructs and patient autonomy. To develop the explanatory model, we qualitatively mapped out relationships between constructs and how they informed contraceptive-decision making.

RESULTS

The model posits that contraceptive decisions are affected by the perceived impact of chronic disease on pregnancy, parenting, and contraceptive options. These perceptions were strongly affected by others, particularly health care providers (HCPs). Most worried that pregnancy could threaten their health, fetal health, or ability to parent. Active symptoms of chronic disease (e.g., pain, fatigue) amplified this perceived threat. Patients appreciated when their HCPs acknowledged, rather than dismissed, their concerns about contraceptive side effects that affected their chronic disease symptoms and management (e.g., headaches, worsening mood). Patients with medical contraindications to hormonal contraception and preferred to use coital-dependent methods (e.g. condoms) did not feel supported to do so by their HCPs. Patients who were Black, young, living on low-incomes, or considered medically "high risk" felt discriminated against by HCPs who limited or coerced their contraceptive decisions.

CONCLUSIONS

This explanatory model synthesizes factors that underlie, constrain, or promote reproductive and contraceptive decisions and autonomy for individuals with medical conditions.

IMPLICATIONS

This new explanatory model can guide the development and evaluation of interventions that support the contraceptive decisions and autonomy of individuals with medical conditions.

Perspectives among women receiving medications for opioid use disorder: Implications for development of a peer navigation intervention to improve access to family planning services

Background Studies have consistently found high rates of unintended pregnancy among women with opioid use disorder (OUD). Few interventions have been developed to specifically engage and address the family planning (FP) needs of women in substance use disorder treatment. Objectives: Our goal was to collect formative qualitative data to identify the FP experiences, needs and service preferences of women receiving medications for OUD and to use these data to develop a FP education and navigation intervention that could be tested in diverse, resource-limited treatment settings. Methods: From August 2016 to April 2017, we conducted 21 guided qualitative interviews with women from two outpatient treatment clinics in Denver, Colorado. We recorded, transcribed, and coded all interviews. We then facilitated three focus groups (n = 16) from May to July 2017 to verify or challenge interview themes and to further inform the development of the FP intervention. Results: Most participants expressed ambivalence or low perceived risk regarding unintended pregnancy and desired more information about contraceptive methods. Many participants described mistrust or lack of engagement in the medical system and histories of trauma were a common barrier to seeking services. Focus group participants endorsed a peer-led FP navigation intervention and provided feedback to tailor existing FP educational materials to fit the specific needs of women in recovery. Conclusions/Importance: Results from this qualitative study suggest that women in recovery from OUD have unique, unmet FP education and service needs. These findings provide important information for the development of feasible and acceptable FP service delivery within diverse, resource-limited treatment settings and informed the development of a trauma-informed, peer-led FP education and navigation intervention that would be implemented in a subsequent phase of the study.

Knowledge and Information Exposure About Family Planning Among Women of Reproductive Age in Informal Settlements of Kira Municipality, Wakiso District, Uganda

Introduction: A high unmet need for family planning (FP) prevails in sub-Saharan Africa. Knowledge, awareness creation, and ensuring accessibility are frequently used to increase FP uptake. However, evidence on knowledge or information dissemination about FP among marginalized populations in urban settings in Africa is limited. This study explored the knowledge of FP methods, media exposure, and contact with FP providers among women from an informal settlement in Uganda.

Methods: Using a cross-sectional study design, we interviewed 626 women aged 15–49 years living in informal settlements of Kira municipality, selected through multistage sampling. Using a standard questionnaire, data was collected on socioeconomic characteristics, knowledge of FP methods, and access to media FP messages among others. Binomial log-linear regression was used to assess disparities in exposure to media FP messages or provider information. Data were analyzed using STATA version 14, at a 5% level of statistical significance.

Results: Nearly all women in the survey were aware of FP methods (99.7%). On average, each woman was aware of 10 FP methods. The most commonly known methods were male condoms (98.2%), injectables (97.4%), and the oral contraceptive pill (95.2%). Use of any contraceptive was found among 42.7% of respondents. Exposure to media was found in 70.6% of the respondents, mostly through television (58.5%) and radio (58.3%). Discussing FP with a provider was significantly associated with media exposure (aPR 1.4, 95% CI: 1.24–1.56). Less than 50% of women who were not using FP had contact with an FP provider. Women in union (aPR 1.6, 95% CI: 1.01–2.68) and those with access to media messages (aPR 2.5, 95% CI: 1.37–4.54) were more likely to have contact with a provider to discuss FP.

Conclusion: There is high general awareness about FP methods and media exposure, but method use was low. Further exploration of women's understanding of FP methods and the fit between existing education programs and FP knowledge needs in this urban setting should be conducted. The potential for mobile health solutions in this urban population should be explored. Future studies should focus on the knowledge and understanding of FP among unmarried and nulliparous women and those with no access to media information.

A Qualitative Exploration of Factors Explaining Non-Uptake of Hormonal Contraceptives Among Adolescent Girls in Rural Ghana: The Adolescent Girls' Perspective

BACKGROUND

Adolescent pregnancy remains a public health concern globally. The use of hormonal contraceptive methods are proven ways of preventing pregnancies and in turn unsafe abortions. However, research shows that use of hormonal contraceptive methods is rather low among African adolescent girls, of which Ghana is no exception.

OBJECTIVE

This manuscript uses the socio-ecological model to guide our understanding of the factors associated with non-use of hormonal contraceptives among adolescent girls in Ghana.

METHODS

An explorative study was done using qualitative data collection methods. Two focus group discussions and sixteen in-depth interviews were conducted among adolescent girls aged 15-19 years (N = 38) in the Kintampo area of Ghana to determine factors affecting uptake of hormonal contraceptives.

RESULTS

Adolescents showed a lack of in-depth knowledge related to the different hormonal contraceptive types. Negative attitudes towards adolescent hormonal contraceptive use, fear of real and perceived side effects of hormonal contraceptives, lack of self-efficacy to use contraceptives, fear of disclosure of use and fear of societal stigma related to sexual intercourse and its related issues among adolescents may explain why adolescent girls in this context do not use hormonal contraceptive methods.

CONCLUSION

To promote hormonal contraceptives among adolescent girls, a combination of multifaceted social-psychological, personal and community level interventions are needed.

Adherence to Oral Contraception in Young Women: Beliefs, Locus of Control, and Psychological Reactance

Background: There is a high dropout rate of oral contraceptive pills (OCP), mainly due to a lack of adherence to treatment. The aim of this study was to identify the psychological processes and attitudes toward medication involved in adherence to OCP, depending on the prescription, to avoid unintended pregnancies (AUP) or gynecological problems (GP). Methods: This cross-sectional study was conducted by asking 689 young women in the fertile period, mean age 23.41 (SD = 5.90), to complete questionnaires related to attitudes, beliefs, psychological reactance, locus of control, and adherence to contraceptive medication. Descriptive analyses and a binary logistic regression were performed. Results: The results confirmed that different beliefs and psychological processes were involved in adherence to oral contraception, based on women’s reasons for taking contraceptive medication. More psychological processes were involved in non-adherence in the AUP group than in the GP group. Psychological reactance contributed most to explaining non-adherence in women who used the OCP to prevent unintended pregnancies. Conversely, women with gynecological problems reported difficulties in adherence, mainly due to their beliefs about contraceptive pills. Conclusions: These findings indicate that attitudes toward medication and psychological processes can play an important role in adherence to OCP, including reasons for using the pill. Identifying the psychological factors and beliefs linked with contraception could guide health professionals to provide counseling to women, thus increasing their adherence to medication and maximizing their health and well-being.

Perceptions of recurrence risk and behavioural changes among first-ever and recurrent stroke survivors: A qualitative analysis

Background

Among stroke survivors, the risk of stroke recurrence is high, and stroke survivors' perception of the risk of recurrence is crucial to promote healthy behaviours.

Objectives

This study aimed to explore the perceptions of stroke survivors about their risk of recurrence and healthy behavioural modifications.

Design

A qualitative interview study was carried out.

Results

We interviewed 19 stroke survivors from 3 hospitals. Thematic analysis showed that the perceptions of recurrence risk and healthy behavioural changes differed between first‐ever and recurrent stroke survivors. Three themes were generated from the data of first‐ever stroke survivors: indifference to and unawareness of the risk of stroke recurrence, the need for professional information support and different awareness of the importance of different healthy behaviours. For first‐relapse stroke patients: worry but feel powerlessness towards recurrent event, accurate information is still warranted, regret of unhealthy behaviour patterns. For the survivors suffered two or more times recurrences: perceived severity of recurrences, increased psychological care need, incorrect perceptions of healthy behaviour.

Discussion and Conclusion

Stroke survivors with or without recurrence hold different perceptions towards the risk of recurrence and behavioural changes. The need for information related to warning signs, recurrence risk and risk factors remained consistently unmet. The benefits of healthy behaviours could be a double‐edged sword for the prevention of stroke recurrence if the survivors fail to understand these accurately. It is strongly recommended that a specific recurrence risk communication tool and related health education plan be explored on the basis of the number of times patients have experienced stroke recurrence to inform secondary prevention of stroke in the future.

Patient/Public Contribution

The patients were involved in the formulation of interview questions and conduct of this study. No public was involved in this study.

Increasing access to family planning services among women receiving medications for opioid use disorder: A pilot randomized trial examining a peer-led navigation intervention

OBJECTIVE

High rates of unintended pregnancy occur among women with opioid use disorder (OUD). OUD treatment settings may provide an ideal opportunity to address the family planning needs of patients. However, few studies have rigorously evaluated interventions designed to address family planning needs in the OUD treatment setting. This study assessed the feasibility, acceptability, and preliminary efficacy of a peer-led navigation intervention designed to educate and link women receiving medications for OUD to family planning services.

METHODS

The study recruited women from four OUD treatment programs in Denver, Colorado, to participate in a pilot randomized controlled trial from March 2018 to February 2019. Eligible participants were English-speaking adult females who were neither pregnant nor desiring a pregnancy and who were not using a long-acting reversible contraceptive (LARC) method. Participants completed a baseline survey, and the study randomized them to receive a two-session, peer-led family planning navigation intervention or usual care. The study assessed feasibility by participant engagement in the intervention. The study used follow-up self-report surveys and electronic health record data to assess intervention acceptability and intervention efficacy for the primary outcomes of a family planning visit and use of a LARC method.

RESULTS

The study enrolled 119 women who were randomized to the Sexual Health Initiative for Navigation and Empowerment (SHINE) peer-led navigation intervention (n = 56) or usual care (n = 63). The average age was 32 (SD = 6.4); 76% were receiving methadone, 24% were receiving buprenorphine and 19% reported a treatment provider had ever discussed family planning with them. Most had a previous pregnancy (82%) and of these, 93% reported an unplanned pregnancy. Among intervention participants, 93% completed the first navigation session, 90% felt that intervention topics were important, 76% indicated that the information was new, and 82% found working with a peer helpful. At six months postbaseline, significantly more (p = 0.01) intervention participants (36%) received a family planning visit compared to control participants (14%). There was no between-group difference on use of LARC methods.

CONCLUSIONS

A peer-led family planning navigation intervention was feasible to implement, acceptable to participants, and showed evidence of preliminary efficacy. This model may be an effective and potentially sustainable approach to support the family planning needs of women in treatment for OUD.

Perspectives on preconception health among formerly incarcerated women with substance use disorders

INTRODUCTION

Women involved in the criminal justice system have high rates of substance use disorders (SUD) placing them at increased risk for unintended pregnancy and adverse pregnancy outcomes. Little is known about the factors that influence the decision-making of formerly incarcerated women with SUD prior to becoming pregnant, in the preconception period. The goal of this study is to understand formerly incarcerated women's perceptions of changing substance use behaviors before pregnancy.

METHODS

We analyzed 33 semi-structured interviews with formerly incarcerated women in Saint Louis, Missouri. We asked questions about factors that influenced decision-making related to substance use and pregnancy. Interviews were recorded and transcribed verbatim. Transcripts were coded and analyzed using a grounded theoretical approach with ATLAS.ti software.

RESULTS

Four main themes emerged: (1) participants' understanding of preconception behavior change was influenced by their experiences with unplanned pregnancies and lack of control over outcomes; (2) substance use created challenges for women in considering their reproductive wishes; (3) while pregnant, participants weighed the medical and legal risks in their decision-making about their substance use; and (4) participants described how the internal motivation necessary to stop substance use during pregnancy was influenced by factors such as hitting rock bottom and witnessing negative outcomes experienced by others.

CONCLUSIONS

Preconception health services must be provided to women with SUD during opportunistic times such as during incarceration or while in SUD treatment. Services need to be non-judgmental and supportive rather than penalizing and should increase internal motivation to adopt behavior change.

Choosing intrauterine device of mothers in rural area, Indonesia: Based on Health Belief Model Theory

This study aimed to identify the correlation between perceived susceptibility, perceived seriousness, perceived benefit, self-efficacy, perceived barrier, cues to action, and the choice of using the intrauterine device. A cross-sectional study was carried out to 109 mothers in Ngudikan Village. Data were collected using questionnaires. The data was analyzed using the Spearman Rank correlation with a level of significance α=0.05. The result show that there is a correlation between perceived susceptibility (p=0.000; r=0.436), perceived seriousness (p=0.000; r=0.402), perceived benefits (p=0.033; r=0.204), perceived barriers (p=0.00, r=-0.614), perceived self-efficacy (p=0.008; r=0.253) and cues to action (p=0.006; r=0.261) had a correlation with the choice of intrauterine device in Nganjuk, Indonesia. Perceived susceptibility, perceived seriousness, perceived benefits, self -efficacy, and cues to action will affect the decision of mothers in choosing an intrauterine device. This study recommended further research on a transcultural nursing approach to follow up on the result of this study.

A theoretical model of contraceptive decision-making and behaviour in diabetes: A qualitative application of the Health Belief Model

AIM

People with diabetes have contraceptive needs that have been inadequately addressed. The aim of this qualitative study was to develop a theoretical model that reflects contraceptive decision-making and behaviour in the setting of diabetes mellitus.

METHODS

We conducted semi-structured, qualitative interviews of 17 women with type 1 or type 2 diabetes from Michigan, USA. Participants were recruited from a diabetes registry and local clinics. We adapted domains from the Health Belief Model (HBM) and applied reproductive justice principles to inform the qualitative data collection and analysis. Using an iterative coding template, we advanced from descriptive to theoretical codes, compared codes across characteristics of interest (e.g. diabetes type), and synthesized the theoretical codes and their relationships in an explanatory model.

RESULTS

The final model included the following constructs and themes: perceived barriers and benefits to contraceptive use (effects on blood sugar, risk of diabetes-related complications, improved quality of life); perceived seriousness of pregnancy (harm to self, harm to foetus or baby); perceived susceptibility to pregnancy risks (diabetes is a 'high risk' state); external cues to action (one-size-fits-all/anxiety-provoking counselling vs. personalized/trust-based counselling); internal cues to action (self-perceived 'sickness'); self-efficacy (reproductive self-efficacy, contraceptive self-efficacy); and modifying factors (perceptions of biased counselling based upon one's age, race or severity of disease).

CONCLUSIONS

This novel adaptation of the HBM highlights the need for condition-specific and person-centred contraceptive counselling for those with diabetes.

Infertility, Perceived Certainty of Pregnancy, and Contraceptive Use in Malawi

Infertility and unintended pregnancy are dual burdens in Malawi, where 41% of pregnancies are unintended and approximately 20% of people report infertility. Although preventing unintended pregnancy has been a focus in public health, infertility has rarely been explored as a factor that may be associated with contraceptive use. Using cross-sectional survey data (2017-2018; N = 749), we report on the prevalence of and sociodemographic characteristics associated with infertility and certainty of becoming pregnant among women in Malawi. We conducted multivariable logistic regressions examining the relationship between infertility, certainty of becoming pregnant, and contraceptive use. Approximately 16% of women experienced infertility, and three-quarters (78%) were certain they could become pregnant within one year. Women who experienced infertility had lower odds of contraceptive use than women who did not (Adjusted Odds Ratio [AOR]: 0.56; 95% Conficence Interval [CI]: 0.39-0.83). Women who said there was "no chance" or they were "unlikely" to become pregnant also had lower odds of contraceptive use compared to women who were certain they would become pregnant (AOR: 0.30; 95% CI: 0.10-0.92). Our findings indicate that experiences and perceptions surrounding fertility are associated with contraceptive use, underscoring their importance in understanding how people manage their fertility to reach their reproductive goals.

Perceived likelihood of becoming pregnant and contraceptive use: Findings from population-based surveys in Côte d'Ivoire, Nigeria, and Rajasthan, India

OBJECTIVE

Advancing reproductive autonomy requires targeted strategies and interventions that address barriers to contraceptive use. The primary objective of this study is to investigate whether perceptions of low pregnancy likelihood are associated with lower likelihood of using contraception among presumably fecund, sexually active women.

STUDY DESIGN

We used population-based survey data of reproductive age women at risk of pregnancy collected in 2018 from Côte d'Ivoire (N = 1447), Nigeria (N = 4110), and Rajasthan, India (N = 1994). To assess one's perceived biological likelihood of pregnancy, we used 2 measures: likelihood following a single act of sex without contraception and likelihood following 1 year of regular sex without contraception. Response options included: definitely yes, maybe yes, maybe no, definitely no, and do not know. We conducted multivariable logistic regression to assess the relationship between each perception measure with odds of contraceptive use separately by country.

RESULTS

Perceived chance of definitely or maybe becoming pregnant after one act of sex without contraception ranged from 54.0% to 55.0% in Nigeria and Rajasthan to 80.0% in Côte d'Ivoire, while it was higher for regular sex without contraception (76.0%-85.1%). Multivariable results indicate that perceptions of pregnancy likelihood were associated with contraceptive use among presumably fecund women, with a stronger relationship observed in relation to cumulative likelihood (odds ratio 0.1-0.6) than likelihood after one act (odds ratio 0.4-0.8) and a dose-response pattern by strength of perceived chance.

CONCLUSIONS

Results indicate that women's use of contraception in low-resource settings is associated with their perceived likelihood of becoming pregnant after unprotected sex.

IMPLICATIONS

Findings suggest that understanding women's perceived likelihood of pregnancy may aid in the development of interventions to help women achieve their reproductive goals.

Youth Preferences for HIV Testing in South Africa: Findings from the Youth Action for Health (YA4H) Study Using a Discrete Choice Experiment

We conducted a discrete choice experiment (DCE) and quantified preferences for HIV testing among South African youth (Nov 2018 to Mar 2019). Six attributes and levels were identified through qualitative methods: source of HIV information; incentive amount and type; social support; testing method; and location. Each participant chose one of two options that comprised six attributes across 18 questions. Conditional logistic regression estimated the degree of preference [β]. Of 130 participants, median age was 21 years (interquartile range 19-23 years), majority female (58%), and 85% previously tested for HIV. Testing alone over accompanied by a friend (β = 0.22 vs. - 0.35; p < 0.01); SMS text over paper brochures (β = 0.13 vs. - 0.10; p < 0.01); higher incentive values (R50) over no incentive (β = 0.09 vs. - 0.07; p = 0.01); and food vouchers over cash (β = 0.06 vs. β =  - 0.08; p = 0.01) were preferred. Testing at a clinic or home and family encouragement were important. Tailoring HTS to youth preferences may increase HIV testing.

Revisiting the Association between Race, Ethnicity, and Beliefs about Pregnancy

Objective

Black and Latinx individuals are often the focus of health educational efforts to 'correct' perceived flawed beliefs about pregnancy, in order to increase contraceptive use and reduce unintended pregnancies. We sought to revisit the association between race, ethnicity, and beliefs about pregnancy.

Methods

We administered a web-based survey to 2,099 heterosexual men and women aged 21-44 years, using non-probability quota sampling. We analyzed a subset who were not currently pregnant (n=1,884) and conducted chi-square tests to examine the association between race/ethnicity and beliefs about avoiding pregnancy (can be avoided, determined by fate/God, 'just happens,' and is a natural process). We then performed a two-stage multinomial logistic regression, modeling the belief that pregnancy can be avoided. The first model included sociodemographic characteristics and the second model added feelings about pregnancy.

Results

Bivariate analyses revealed that, compared with Whites, those who identified as Black/African American or Latinx were significantly more likely to believe that pregnancy was determined by fate/God (15%,13% vs 9%, respectively) or a natural process (13%,13% vs 9%, respectively) and less likely to report that it can be avoided (57%,56% vs 67%, respectively; P=.001). In the first regression model, these differences persisted. However, in the second model, being Black/African American or Latinx was not significantly associated with beliefs about avoiding pregnancy.

Conclusions

Our findings suggest that once more nuanced beliefs about pregnancy prevention are considered, Black and Latinx individuals do not hold strongly different beliefs than Whites. Efforts that exclusively focus on people of color to change beliefs about pregnancy appear unwarranted.

Mental health impact on the unmet need for family planning and fertility rate in rural Ethiopia: a population-based cohort study

AIMS

Although much research has focused on socio-demographic determinants of uptake of contraception, few have studied the impact of poor mental health on women's reproductive behaviours. The aim of this study was to examine the impact of poor mental health on women's unmet need for contraception and fertility rate in a low-income country setting.

METHODS

A population-based cohort of 1026 women recruited in their third trimester of pregnancy in the Butajira district in rural Ethiopia was assessed for symptoms of antenatal common mental disorders (CMDs; depression and anxiety) using Self-Reporting Questionnaire-20. Women were followed up regularly until 6.5 years postnatal (between 2005 and 2012). We calculated unmet need for contraception at 1 year (n = 999), 2.5 (n = 971) and 3.5 years (n = 951) post-delivery of index child and number of pregnancies during study period. We tested the association between CMD symptoms, unmet need for contraception and fertility rate.

RESULTS

Less than one-third of women reported current use of contraception at each time point. Unmet need for birth spacing was higher at 1 year postnatal, with over half of women (53.8%) not using contraception wanting to wait 2 or more years before becoming pregnant. Higher CMD symptoms 1 year post-index pregnancy were associated with unmet need for contraception at 2.5 years postnatal in the unadjusted [odds ratio (OR) 1.09; 95% confidence interval (CI) 1.04-1.15] and fully adjusted model [OR 1.06; 95% CI 1.01-1.12]. During the 6.5 year cohort follow-up period, the mean number of pregnancies per woman was 2.4 (s.d. 0.98). There was no prospective association between maternal CMD and number of pregnancies in the follow-up period.

CONCLUSIONS

CMD symptoms are associated with increased unmet need for family planning in this cohort of women with high fertility and low contraceptive use in rural Ethiopia. There is a lack of models of care promoting integration of mental and physical health in the family planning setting and further research is necessary to study the burden of preconception mental health conditions and how these can be best addressed.

Contraceptive use among sexually active women living with HIV in western Ethiopia

Introduction

Contraception can help to meet family planning goals for women living with HIV (WLHIV) as well as to support the prevention of mother to child transmission of HIV (PMTCT). However, there is little research into the contraceptive practice among sexually active WLHIV in Ethiopia. Therefore, we aimed to examine contraceptive practice among sexually active WLHIV in western Ethiopia and identify the factors that influenced such practice using the Health Belief Model (HBM).

Methods

A facility-based cross-sectional survey of 360 sexually active WLHIV was conducted from 19^th March to 22^nd June 2018 in western Ethiopia. The eligible participants were WLHIV aged between 18 and 49 years who reported being fecund and sexually active within the previous six months but were not pregnant and not wanting to have another child within two years. Modified Poisson regression analyses were conducted to identify factors that influenced contraceptive practice among sexually active WLHIV in western Ethiopia.

Results

Among sexually active WLHIV (n = 360), 75% used contraception with 25% having unmet needs. Of the contraceptive users, 44.8% used injectables, 37.4% used condoms and 28.5% used implants. Among 152 recorded births in the last five years, 17.8% were reported as mistimed and 25.7% as unwanted. Compared to WLHIV having no child after HIV diagnosis, having two or more children after HIV diagnosis (Adjusted Prevalence Ratio [APR] = 1.31; 95%CI 1.09–1.58) was associated with increased risk of contraceptive practice. However, sexually active unmarried WLHIV (APR = 0.69; 95%CI 0.50–0.95) were less likely to use any contraception compared to their sexually active married counterparts. Importantly, high perceived susceptibility (APR = 1.49; 95%CI 1.20–1.86) and medium perceived susceptibility (APR = 1.55; 95%CI 1.28–1.87) towards unintended pregnancy were associated with higher risk of contraceptive use than WLHIV with low perceived susceptibility.

Conclusions

Although contraceptive use amongst sexually active WLHIV was found to be high, our findings highlight the need for strengthening family planning services given the high rate of unintended pregnancies, the high rate of unmet needs for contraception, as well as the lower efficacy with some of the methods. Our findings also suggest that the HBM would be a valuable framework for healthcare providers, programme planners and policymakers to develop guidelines and policies for contraceptive counselling and choices.

Acceptability and Efficacy of a Sexual Health Texting Intervention Designed to Support Adolescent Females

OBJECTIVE

To evaluate the feasibility, acceptability, and initial efficacy of a pilot texting intervention ("t4she") in primary care designed to increase sexual health knowledge and promote dual protection strategies to reduce unintended pregnancies and sexually transmitted infections among adolescent females.

METHODS

Participants were recruited from 2 federally qualified health centers. Eligibility included: being 13 to 18 years of age; assigned female at birth; English-speaking; not currently pregnant and/or intending to become pregnant; and having texting capabilities. A randomized controlled trial assessed between-group differences at 3 and 6 months on knowledge, Health Belief Model constructs, and sexual behaviors. Input on intervention acceptability was obtained at 3 months.

RESULTS

Among 244 participants enrolled and randomized, the average age was 16 (±1.6), 80% were Hispanic/Latina, 53% had ever had vaginal sex, and 50% had used prescription birth control with 24% currently using a long-acting reversible method. Among those sexually active, 29% reported consistent condom use and 24% reported engaging in dual protection behaviors at last sex. Among participants with all follow-up data (N = 136), intervention participants had significant increases in sexual health knowledge and reported more prescription birth control use at follow-up than control participants. No significant outcome differences were found for condom use or dual protection behaviors. Intervention participants reported receiving messages, being introduced to new information, and reading and sharing the messages.

CONCLUSIONS

The pilot t4she sexual health intervention significantly improved knowledge and use of short-acting prescription birth control among young females in primary care and was acceptable by youth and feasible to implement.

Promoting drug abuse preventive behaviors in adolescent students based on the health belief model

Background Nowadays, drug abuse is one of the most important health problems that can affect the quality of life of people in mental, psychological, physical, and social dimensions. Theory-based education can help the adolescents to promote their drug abuse preventive behaviors. Objectives The aim of this study was to determine the effectiveness of education based on the health belief model (HBM) on drug abuse preventive behaviors in adolescent students. Methods This study was an interventional quasi-experimental study with a pre-test/post-test design conducted in two high schools in the southeast of Iran. A two-step cluster sampling method was used and 120 students were randomly selected and categorized into the control (n = 60) and intervention (n = 60) groups. The intervention group participated in an education program based on the HBM in four 75-min sessions. Data were collected using demographic and drug abuse preventive behavior questionnaires based on the HBM. Results In the pre-test stage, the mean scores of drug abuse preventive behaviors and its dimensions were not significantly different between the intervention and control groups (t = -2.597 p = 0.641). In the post-test stage, the mean scores of the intervention and control groups were significantly different; the drug abuse preventive behaviors and its dimensions improved in the intervention group (t = 14.57, p < 0.001). Conclusion The findings showed that education based on the HBM had a significant effect on drug abuse preventive behaviors and its dimensions. Therefore, educational packages based on the HBM are recommended to improve these behaviors in adolescents.

Examining Women's and Men's Ideal Criteria Before Forming Families

In the United States, family formation decision-making is more complex than the predominant models that have been used to capture this phenomenon. Understanding the context in which a pregnancy occurs requires a more nuanced examination. In-depth interviews were conducted with 60 men and women, aged 18-35, who had children or were pregnant. Using grounded theory analysis, themes emerged that revealed participants' ideal criteria desired before pregnancy. We stratified by those who met and did not meet these criteria. Almost universally, participants shared ideal criteria: to graduate, gain financial stability, establish a relationship, and then become pregnant. Many participants did not accomplish these goals. Those who had not met their criteria had experienced traumatic childhoods and suffered economic concerns. For this group, having children prompted positive changes within their control, but financial stability remained limited. Efforts should focus on improving circumstances for all individuals to fulfill their criteria before pregnancy.

A qualitative assessment of perspectives on getting pregnant: the Social Position and Family Formation study

BACKGROUND

Intentions-oriented approaches to measuring pregnancy do not necessarily align with how people view and approach pregnancy. Our objective was to obtain an in-depth understanding of the notions women and men hold regarding pregnancy.

METHODS

We conducted semi-structured in-depth interviews with 176 heterosexual women and men ages 18-35, in the United States. Data were analyzed using grounded theory methodology.

RESULTS

Participants described notions of getting pregnant in one of three ways. One group of participants used language that solely described pregnancy as a deliberate process, either premeditated or actively avoided. Another described pregnancy as a predetermined phenomenon, due to fate or something that 'just happens.' The third group represented a blending of both notions.

CONCLUSIONS

Our findings underscore the need to shift the current paradigm of deliberate intentions to one that recognizes that pregnancy can also be viewed as predetermined. These findings can be used to improve measurement, health services, and better direct public health resources.

Study Protocol: 6th National Survey of Australian Secondary Students and Adolescent Sexual Health, 2018

Introduction: Since 1992 the Australian Government has funded a periodic national survey of HIV and Sexually Transmissible Infection (STI) knowledge and sexual risk behavior among secondary school students. Adolescents continue to be a priority population in public health efforts to reduce rates of STIs in Australia. The purpose of the survey is to inform progress on national strategic sexual health priorities. The results are used by federal and state/territory government agencies, youth-serving community organizations and health educators to improve knowledge, promote healthy sexual behaviors and target educational efforts aimed at communicating public health messages to young people.

Materials and Equipment: The 6th survey entitled the “National Survey of Secondary Students and Adolescent Sexual Health” was conducted online in 2018 among 14–18 year olds living in Australia. The anonymous self-complete survey contained up to 286 items assessing three primary domains of knowledge, behaviors and education experiences. Factual knowledge measures covered HIV transmission and STI knowledge around transmission and prevention covering gonorrhea, Chlamydia, syphilis, hepatitis, herpes, and HPV. Behavioral measures examined perceived susceptibility, peer norms, protective behaviors, age of onset for various behaviors, reasons for not being sexually active yet, and/or sexual histories with additional detail on most recent sexual event. The 6th survey was completed by 8,400 Australian adolescents a represents a broad cross-section by age, gender, year in school, type of school (e.g., government, Catholic), and state/territory which closely matched census data on these strata. The one-of-a-kind survey instrument, grounded in public health theories, may prove valuable for public health researchers.

Expected Impact of the Study on Public Health: Findings from the 6th National Survey of Secondary Students and Adolescent Sexual Health will contribute important insights into current knowledge, behaviors and educational experiences of young people. Results, similar to previous iterations of the survey, will inform public health practitioners, policymakers, educators, and advocates for the sexual health and well-being of young Australians. Results may assist sexual health services to align with broader public health goals articulated in the national HIV and STI strategies aimed to reduce the burden of disease and improve the quality of sexual lives of young Australians.

Psychological factors associated with protected sex among indirect female sex workers in Denpasar, Bali, Indonesia

A cross-sectional study was conducted among indirect FSWs (a type of FSWs who provide sex services under the cover of entertainment or recreational enterprises) in Denpasar, Bali from August to October 2017 to investigate factors associated with protected sex with clients using the Health Belief Model (HBM) framework. The protected sex as a dependent variable was identified through self-reported consistency in using condoms with clients in the last month. Independent variables consisted of six HBM constructs and three main groups of modifying factors (personal, sex work, and interventional factors). Binary logistic regression was employed to identify the determinants. The prevalence of protected sex with clients in last month was 50.17% (95%CI = 41.50-80.83). Indirect FSWs were more likely to use condoms consistently if they completed senior high school or higher. Meanwhile, those working in a karaoke lounge, bar, or café were less likely to have protected sex than those in a massage parlour, spa, or beauty salon. Based on HBM, an increase of one-score of these following constructs increased likelihood of protected sex: perceived susceptibility, self-efficacy, and cues to action. Low protected sex among indirect FSWs indicates the need for public health interventions at individual, interpersonal, and institutional level.

Acceptability, feasibility and utility of a Mobile health family planning decision aid for postpartum women in Kenya

BACKGROUND

Unmet need for contraception is high during the postpartum period, increasing the risk of unintended subsequent pregnancy. We developed a client facing mobile phone-based family planning (FP) decision aid and assessed acceptability, feasibility, and utility of the tool among health care providers and postpartum women.

METHODS

Semi-structured in-depth interviews (IDIs) were conducted among postpartum women (n = 25) and FP providers (n = 17) at 4 Kenyan maternal and child health clinics, 2 in the Nyanza region (Kisumu and Siaya Counties) and 2 in Nairobi. Stratified purposive sampling was used to enroll postpartum women and FP providers. Data were analyzed using an inductive content analysis approach by 3 independent coders, with consensual validation.

RESULTS

FP providers stated that the Interactive Mobile Application for Contraceptive Choice (iMACC) tool contained the necessary information about contraceptive methods for postpartum women and believed that it would be a useful tool to help women make informed, voluntary decisions. Most women valued the decision aid content, and described it as being useful in helping to dispel myths and misconceptions, setting realistic expectations about potential side effects and maintaining confidentiality. Both women and providers expressed concerns about literacy and lack of familiarity with smart phones or tablets and suggested inclusion of interactive multimedia such as audio or videos to optimize the effectiveness of the tool.

CONCLUSIONS

The iMACC decision aid was perceived to be an acceptable tool to deliver client-centered FP counseling by both women and providers. Counseling tools that can support FP providers to help postpartum women make informed and individualized FP decisions in resource-limited settings may help improve FP counseling and contraceptive use in the postpartum period.