Exploring Multiple Influences on Equity: A Mixed Methods Study of Low-income Women’s Access to Family Planning Services in the South Open Access
Newton-Levinson, Anna (Summer 2020)
Abstract
Background
Achieving equity in sexual and reproductive health (SRH) requires eliminating socially unjust and systematic health disparities in outcomes and access to SRH services. A female-bodied individual’s ability to make decisions related to her sexual and reproductive health (SRH) is critical to her overall well-being and the well-being of her family. Disparities persist in poor SRH related outcomes and in access to SRH services among individuals who are lower socioeconomic status, people of color, and among those living in the Southern US.
Objective
To inform how equitable access can be measured and how it can be achieved, the studies included in this dissertation attempted to develop a complex understanding of what equity in access to SRH care means for low-income female individuals. Using a mixed methods approach, the studies included in this work explore multiple dimensions of access and how the care-seeking processes of low-income women in Southern states are influenced by: 1) individual access factors (e.g. insurance status, access to transportation), 2) the health care system (e.g. clinic location, cost of services), and 3) elements of their social context.
Results
We found that low-income women have different priorities in seeking SRH care and are likely influenced by complex combinations of demographic and individual access factors. Those seeking care at Planned Parenthoods often do so because the services are fast, trusted, and confidential. These studies demonstrate that “good access” is determined by alignment of individual and health system factors that met individual’s needs in a particular moment.
A mismatch of these factors often produced inequities in access and contraceptive outcomes. Finally, social and structural forces including those related to systems of discrimination, economics, and health policy influenced both individuals and health systems and ultimately access.
Conclusion
These studies contribute to a broadened understanding of what “access” to SRH care is as well as the factors that influence the ability of low-income women in the Southern US to achieve it. Taken together these studies suggest that access may be understood as multi-dimensional, multilevel, interactive, fluid over time, and as a process.
Table of Contents
TABLE OF CONTENTS
Chapter 1: Introduction and Literature Review 1
INTRODUCTION 1
Literature Review 5
Summary of Gaps and Remaining Challenges in Literature on Access to FP Services 24
Expected Contribution of the Research Aims 36
REFERENCES 38
Chapter 2 : Influences on women’s care-seeking at Planned Parenthood health centers in the South 48
ABSTRACT 48
INTRODUCTION 49
METHODS 51
RESULTS 54
DISCUSSION 58
CH.2 TABLES 63
REFERENCES 69
Chapter 3 : “I probably have access, but I can’t afford it”: Expanding definitions of affordability in access to contraceptive services among low-income women in a state without Medicaid Expansion 71
INTRODUCTION 71
METHODS 73
RESULTS 76
DISCUSSION 90
CONCLUSION 93
CH.3 TABLES 95
REFERENCES 98
Chapter 4 How low-income women in Georgia understand “access” to appropriate sexual and reproductive health care: A life history analysis 100
INTRODUCTION 100
METHODS 102
RESULTS 107
DISCUSSION 138
REFERENCES 143
APPENDIX 145
Chapter 5 : Summary & Conclusion 147
5.1 Summary of Findings 147
5.2 Broadening understandings of ‘equitable access’ 150
5.3 Strengths & Limitations 153
5.4 Future Research 154
5.5 Implications for Public Health Practice & Policy 154
5.6 Conclusion 163
REFERENCES 165
About this Dissertation
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