Safety beliefs, [mis]information sources & contraceptive behavior among young people who can get pregnant in the U.S.: A theory-driven, mixed methods approach Público
Riley, Halley (Fall 2021)
Abstract
Approximately 45% of pregnancies in the U.S. are unintended, meaning that are unwanted or mistimed. Among 15-19-year-olds, 75% are unintended.1-4 Young people, people of color, those with low socioeconomic status, and people in certain regions, such as the Southeast (SE), are at heightened risk of unintended pregnancy (UIP).2, 4-9 People experiencing UIP and subsequent births are at risk of adverse health and socioeconomic outcomes, especially adolescents.10-12 Without contraceptive use, as many as 85% of people who have penile-vaginal sex will become pregnant in one year. With effective contraception, this is as low as 0.05%.13 Methods vary in effectiveness, side effects, and ease of use.14, 15 They are often characterized by method effectiveness tiers by groups like the U.S. Centers for Disease Control and Prevention.16-18 Yet, other factors, including safety, are important to users.19, 20 Clinical research and pharmacovigilance suggest that contraceptive-related serious adverse events (SAEs) are extremely rare,17 but research also shows consistent concerns about safety.17, 21-42 Gaps in the literature surround how beliefs develop and translate to behavior, and data from the SE is lacking. This three-aim mixed methods dissertation sought to address these gaps.
First, I systematically reviewed published literature on contraceptive safety beliefs to characterize this literature and determine which beliefs were prevalent. Across 48 studies, concerns about infertility, adverse pregnancy and fetal outcomes, problems with long-acting reversible contraceptive (LARC) devices, menstrual changes, pain, and weight changes were common. Misconceptions about SAEs appear throughout the literature, which consists largely of low-quality, cross-sectional studies.
In the second study, I used multinomial logistic regression to assess relationships safety and side effect concerns and method use among young people who can get pregnant in Atlanta, GA (n=148). In multivariable models using baseline data, concerns about side effects, pain, bleeding, SAEs and any AE were associated with increased odds of less effective or no method use compared with LARC use. Magnitude and statistical significance of relationships differed by concerns and method use operationalization (ever vs. current use). In longitudinal models, all concerns except bleeding were associated with less effective method use.
Finally, I conducted in-depth-interviews with 29 people who could get pregnant aged 15-24 in GA. Interviews included questions about information sources, interpersonal and social influences, and contraceptive decision-making. We used a grounded theory approach to analyze data. We found three distinct pathways. One group was exposed to negative information about safety and avoided prescription methods. Another enjoyed non-contraceptive and pregnancy preventive benefits of oral contraceptive pills and avoided other methods. A third cycled through methods, using information from peers, providers, and the Internet to make decisions.
Through this research, I characterized common safety concerns, determined how concerns impact behavior among a cohort of young people, and dove deeper into drivers of behavior. Findings highlight the need for better education and counseling to correct misconceptions and empower people to make evidence-based contraceptive decisions.
Table of Contents
Table of Contents
Chapter 1: Introductory Literature Review. 1
Introduction. 1
Unintended pregnancy in the U.S. 1
UIP among adolescents and young people who can get pregnant in the U.S.: 2
Contraceptive use as primary prevention strategy for adolescent UIP in the U.S. 4
Contraceptive use in the U.S. 5
Safety of Contraceptive Methods available in the U.S. 6
Concerns about side effects and AEs as a barrier to contraceptive use. 14
Misinformation about contraceptive safety. 16
The nocebo effect and contraceptive use. 18
Sources of [mis]information about contraceptive safety. 19
Reproductive injustice in the U.S. 24
Gaps in the Research addressed by this dissertation research. 26
Overemphasis on LARC methods in the current literature. 28
Lack of clear theoretical underpinnings of prior research. 28
A dearth of research on young people who can get pregnant in the Southeastern U.S. 29
Theoretical Framework. 29
Health Belief Model 30
The. 30
Social Ecological Model 35
Table 1.1 SAEs and Side Effects Listed in Package Labels of FDA-Approved Contraceptive Methods. 38
Table 1.2. Operationalization of HBM Constructs in Contraceptive Use Literature. 39
Table 1.3. Multi-level influences on contraceptive use. 40
Figure 1.1 Conceptual Model. 43
Chapter 2: Contraceptive Safety Beliefs among People who can get Pregnant in the U.S.: A Systematic Review. 44
Abstract. 44
Introduction. 45
Methods. 49
Results. 51
Overview of included articles: 51
Beliefs about SAEs. 52
Beliefs about side effects. 58
Beliefs about non-contraceptive benefits associated with method use. 64
Discussion. 67
Limitations and Strengths. 69
Conclusion. 70
Figure 2.1. PRISMA 2020 flow diagram for new systematic reviews. 71
Table 2.1. Outcome categorization. 73
Table 2.2. Characteristics of included studies (n= 47). 74
Table 2.3. Studies reporting SAEs (n=30). 100
Table 2.4. Studies reporting side effects (n=27). 105
Table 2.5. Studies reporting beliefs about non-contraceptive benefits (n=20). 110
Figure 2.2. Bar Chart of proportions reporting concerns about infertility. 113
Figure 2.3. Bar Chart of proportions reporting concerns about adverse pregnancy and fetal outcomes. 113
Figure 2.4. Bar Chart of proportions reporting concerns about adverse pregnancy and fetal outcomes. 114
Figure 2.5. Bar Chart of proportions reporting concerns about cancer and blood clots. 114
Figure 2.6. Bar Chart of proportions reporting beliefs about Pain. 115
Figure 2.7. Bar Chart of proportions reporting beliefs about sexual side effects. 116
Figure 2.8. Bar Chart of proportions reporting beliefs about protective effects of methods other than condoms or abstinence on STIs. 116
Figure 2.9. Bar Chart of proportions reporting beliefs about protective effects of OCPs on cancer and benign disease. 117
Figure 2.10. Forest Plot Depicting Relationship Between Race/Ethnicity and Odds of Beliefs. 118
Figure 2.11. Forest Plot Depicting Relationship Between Age and Odds of Beliefs. 119
Appendix 2.A. PRISMA 2020 Checklist. 120
Appendix 2.B. Search Terms. 124
References. 125
Chapter 3: Safety concerns and contraceptive method use among young people who can get pregnant in Atlanta, GA. 132
Abstract. 132
Introduction. 134
Methods. 137
Study Overview.. 137
Measures. 138
Analysis. 141
Results. 143
Baseline Univariate Results: 143
Baseline Bivariate Results. 144
Moderation Assessment 146
Baseline Multivariable Results. 147
Longitudinal Results of Baseline Contraceptive Concerns and Time-varying Method Use. 148
Discussion. 149
Conclusion. 153
Table 3.1. Demographics and reproductive history of YWSS participants who reported ever having sex with a male partner by baseline, n=148. 155
Table 3.2. Bivariate Relationships between Contraceptive Method Use (Dependent Variables) and independent variables, moderators, and covariates, n=148. 157
Table 3.3. Bivariate Relationships between Contraceptive Safety Concerns (Independent Variables) and dependent variables, moderators, and covariates, n=148. 160
Table 3.4 Multivariable Relationships between contraceptive safety concerns and method use, baseline cross-sectional analyses, n=148. 163
Figure 3.1. Forest Plots depicting odds ratios and confidence intervals for models using most effective method ever used as independent variable. 165
Figure 3.2. Forest Plots depicting odds ratios and confidence intervals for models using most effective method currently used as independent variable. 166
Figure 3.3. “Spaghetti” Plot depicting contraceptive use patterns over 11 months, n=78. 167
Table 3.5. Multivariable Relationships between contraceptive safety concerns and monthly method use over 12-months. 168
Appendix 3.A. Goodness of fit statistics for Baseline Multivariable Models. 169
Appendix 3.B. Moderation Assessment, Baseline cross-sectional analyses. 172
Appendix 3.C. Multivariable Relationships between contraceptive safety concerns and method use among Black-identifying participants, baseline cross-sectional analyses, n=60. 174
References. 176
Chapter 4: “I'm not necessarily sure if it's safe”: Perspectives on Contraceptive Safety among young people who can get pregnant in Georgia. 187
Abstract. 187
Introduction. 189
Methods. 192
Sampling and Recruitment 192
Data Collection. 193
Analysis. 195
Results. 196
Contraceptive Use Pathways. 196
Discussion. 208
Interpersonal Implications: 209
Social Implications: 209
Health Systems Implications: 210
Policy Implications: 211
Limitations and Strengths. 212
Conclusion. 213
Figure 4.1. Contraceptive Use Pathways. 215
Table 4.1 State Laws on Sexuality Education in the U.S. Southeast. 216
Appendix 4.A. Interview Guide. 217
References. 222
Chapter 5. Conclusion.. 225
Overview.. 225
Summary of findings. 226
Strengths. 231
Limitations. 232
Implications for research. 233
Implications for Policy and Practice. 234
Dissertation References. 237
About this Dissertation
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