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Patient-, Provider- and System-Level Factors Impacting Contraceptive Access and Use

Judge-Golden, Colleen (2019) Patient-, Provider- and System-Level Factors Impacting Contraceptive Access and Use. Doctoral Dissertation, University of Pittsburgh. (Unpublished)

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Contraception plays vital roles in promoting women’s health, quality of life and reproductive autonomy. The research described in this dissertation aimed to identify and evaluate factors at the patient, provider, and system levels that contribute to individuals’ abilities to access and use contraceptive methods in concordance with their goals and preferences. We assessed contraceptive preference matching and evaluated system-level policies and provider practices that directly impact access to specific methods, with a particular focus on the medically vulnerable population of women Veterans who use the Veterans Affairs (VA) healthcare system. First, we used a novel measure to investigate the extent to which women Veterans are currently using the contraceptive methods they consider to be “ideal,” and identified characteristics associated with ideal-current method match. Only 58% were currently using their stated ideal method, and match was reduced among non-white women and women with mental health disorders, suggestive of established health care disparities. However, qualitative analysis revealed that the bulk of reasons for ideal method non-use were personal and contextual, rather than resulting from access barriers. Our results underscore the complexity of contraceptive method selection and highlight enduring methodologic challenges of measuring contraceptive preferences. Next, we used decision analysis to estimate financial and reproductive health impacts to the VA healthcare system of a policy change to allow for twelve-month dispensing of oral contraceptive pills. We found that extended dispensing would better enable women Veterans to prevent unintended pregnancies, while also being economically feasible and sustainable for VA. These findings may help to inform evidence-based policy in VA. Finally, we conducted a cross-sectional survey study to evaluate provider-level adherence to best practice guidelines for provision of long-acting reversible contraception (LARC, i.e. intrauterine devices and contraceptive implants) in a single large healthcare system in Western Pennsylvania. We found substantial room for improvement in adherence to best practices, particularly same-day provision of these methods, and identified provider-reported barriers to best practice implementation, which were primarily logistical rather than stemming from knowledge deficits. These results may be used to inform efforts to expand access to LARC methods across this healthcare system.


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Item Type: University of Pittsburgh ETD
Status: Unpublished
CreatorsEmailPitt UsernameORCID
Judge-Golden, Colleencpj6@pitt.educpj60000-0001-9167-9650
ETD Committee:
TitleMemberEmail AddressPitt UsernameORCID
Committee ChairBorrero,
Thesis AdvisorSwitzer,
Date: 24 August 2019
Date Type: Publication
Defense Date: 24 July 2019
Approval Date: 24 August 2019
Submission Date: 29 July 2019
Access Restriction: No restriction; Release the ETD for access worldwide immediately.
Number of Pages: 122
Institution: University of Pittsburgh
Schools and Programs: School of Medicine > Clinical and Translational Science
Degree: PhD - Doctor of Philosophy
Thesis Type: Doctoral Dissertation
Refereed: Yes
Uncontrolled Keywords: Contraception; women's health; health services; women Veterans
Date Deposited: 25 Aug 2019 03:33
Last Modified: 25 Aug 2019 03:33


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