Abortion After Pregnancy Occurrence with Contraceptive Use Among Veterans.

Objective: Many people report becoming pregnant while using contraception. Understanding more about this phenomenon may provide insight into pregnant people's responses to and healthcare needs for these pregnancies. This study explores the outcome (e.g., birth, miscarriage, abortion) of pregnancies among Veterans in which conception occurred in the month of contraceptive use. Study Design: We used data from the Examining Contraceptive Use and Unmet Need Study, a telephone-based survey conducted in 2014-2016 of women Veterans (n = 2302) ages 18-44 receiving primary care from the Veterans Health Administration. For each pregnancy, we estimated the relationship between occurrence in the month of contraceptive use and the outcome of the pregnancy using multinomial logistic regression, controlling for relevant demographic, clinical, and military factors and clustering of pregnancies from the same Veteran. Results: The study included 4436 pregnancies from 1689 Veterans. Most participants were ≥30 years of age (n = 1445, 85.6%), identified as non-Hispanic white (n = 824, 51.6%), and lived in the Southern United States (n = 994, 55.6%). Nearly 60% (n = 1007) of Veterans who had ever been pregnant reported experiencing a pregnancy in the month of contraceptive use; a majority of those pregnancies (n = 1354, 80.9%) were described as unintended. In adjusted models, pregnancies occurring in the month of contraceptive use were significantly more likely to end in abortion (aOR: 1.76, 95% CI: 1.42-2.18) than live birth. Conclusions: Pregnancy while using contraception is common among Veterans; these pregnancies are more likely to end in abortion than live birth. Given widespread restrictions to reproductive health services across much of the United States, ensuring Veterans' access to comprehensive care, including abortion, is critical to supporting reproductive autonomy and whole health.

A systematic review of experimentally tested implementation strategies across health and human service settings: evidence from 2010-2022.

BACKGROUND: Studies of implementation strategies range in rigor, design, and evaluated outcomes, presenting interpretation challenges for practitioners and researchers. This systematic review aimed to describe the body of research evidence testing implementation strategies across diverse settings and domains, using the Expert Recommendations for Implementing Change (ERIC) taxonomy to classify strategies and the Reach Effectiveness Adoption Implementation and Maintenance (RE-AIM) framework to classify outcomes. METHODS: We conducted a systematic review of studies examining implementation strategies from 2010-2022 and registered with PROSPERO (CRD42021235592). We searched databases using terms "implementation strategy", "intervention", "bundle", "support", and their variants. We also solicited study recommendations from implementation science experts and mined existing systematic reviews. We included studies that quantitatively assessed the impact of at least one implementation strategy to improve health or health care using an outcome that could be mapped to the five evaluation dimensions of RE-AIM. Only studies meeting prespecified methodologic standards were included. We described the characteristics of studies and frequency of implementation strategy use across study arms. We also examined common strategy pairings and cooccurrence with significant outcomes. FINDINGS: Our search resulted in 16,605 studies; 129 met inclusion criteria. Studies tested an average of 6.73 strategies (0-20 range). The most assessed outcomes were Effectiveness (n=82; 64%) and Implementation (n=73; 56%). The implementation strategies most frequently occurring in the experimental arm were Distribute Educational Materials (n=99), Conduct Educational Meetings (n=96), Audit and Provide Feedback (n=76), and External Facilitation (n=59). These strategies were often used in combination. Nineteen implementation strategies were frequently tested and associated with significantly improved outcomes. However, many strategies were not tested sufficiently to draw conclusions. CONCLUSION: This review of 129 methodologically rigorous studies built upon prior implementation science data syntheses to identify implementation strategies that had been experimentally tested and summarized their impact on outcomes across diverse outcomes and clinical settings. We present recommendations for improving future similar efforts.

Contraceptive Use Among Traditional Medicare And Medicare Advantage Enrollees.

Medicare is the primary source of health insurance coverage for reproductive-age people with Social Security Disability Insurance. However, Medicare does not require contraceptive coverage for pregnancy prevention, and little is known about contraceptive use in traditional Medicare and Medicare Advantage. We analyzed Medicare and Optum data to assess variations in contraceptive use and methods used by traditional Medicare and Medicare Advantage enrollees, as well as among enrollees with and without noncontraceptive clinical indications. Clinically indicated contraceptives are used for reasons other than pregnancy prevention, including menstrual regulation or to treat acne, menorrhagia, and endometriosis. Contraceptive use was higher among Medicare Advantage enrollees than traditional Medicare enrollees, but use in both populations was low compared with contraceptive use among Medicaid enrollees. We found significant variation by Medicare type with respect to contraceptive methods used. Relative to traditional Medicare, the probability of long-acting reversible contraception was more than three times higher in Medicare Advantage, and the probability of tubal sterilization was more than ten times higher. Overall, Medicare enrollees with noncontraceptive clinical indications had twice the probability of contraceptive use as those without them. Medicare coverage of all contraceptive methods without cost sharing would help address financial barriers to contraceptives and support the reproductive autonomy of disabled enrollees.

The role of gender and veteran status in healthcare access among a national sample of U.S. adults with unhealthy alcohol use.

Background: Routine healthcare access is critical to reduce drinking and its effects, yet little is known about Veteran and gender differences in routine healthcare access among unhealthy drinkers. The current study examined differences in routine healthcare access, stratified by Veteran status and gender, among a national sample of adults endorsing unhealthy drinking. Method: Using data from the Centers for Disease Control and Prevention's 2019 Behavioral Risk Factor Surveillance System National Survey, we identified adults who endorsed unhealthy drinking over the past month (N = 58,816; 41.4% female; 2.7% female Veterans). Bivariate and multivariable analyses modeled associations between gender, Veteran status, and their interaction in predicting routine healthcare access. All multivariable models adjusted for sociodemographic characteristics. Results: Veterans with unhealthy alcohol use reported high rates of routine healthcare access (e.g., >86% sought care in the past 2 years) and were less likely to experience a cost barrier to care (aOR = 0.75, 95% CI = 0.62-0.92). Females were more likely than males to report better access to care but also to experience a cost barrier (aOR = 1.2, 95% CI = 1.10-1.37). The interaction between Veteran status and gender was non-significant. Conclusions: Overall, healthcare access was better for Veterans and females with unhealthy alcohol use compared to civilians and males with unhealthy alcohol use. However, given that females were more likely to report a cost barrier, future implementation research aiming to improve equity in care may want to explore reasons for cost barriers and develop strategies to help reduce these barriers in order to eliminate gender disparities in primary care-based alcohol-related care.

Reproductive health services: A missed opportunity in VA primary care?

OBJECTIVE: Integration of reproductive health services into comprehensive primary care is increasingly viewed as a strategy to address service gaps and improve patient-centered care. We assess receipt of contraceptive and prepregnancy health counseling among pregnancy-capable Veterans within Veterans Affairs (VA) primary care. STUDY DESIGN: Data are from 1076 participants in a nationally representative, cross-sectional survey of women Veterans ages 18 to 45 with an overall survey response rate of 28%. Descriptive analyses and chi square tests of association were performed. RESULTS: Only 44% of pregnancy-capable Veterans reported receiving any contraceptive and/or prepregnancy care from a VA primary care provider in the past year. CONCLUSIONS: Although VA guidelines include reproductive services as a core component of primary care, additional efforts may be needed to promote routine provision of this care in practice.

Recent and Frequent Mental Distress Among Women with a History of Military Service, 2003-2019.

Examining women veterans' self-reported mental health is critical to understanding their unique mental and physical health needs. This study describes self-reported mental distress over a 17-year period among cross-sectional nationally representative samples of women in the USA using data from the Behavioral Risk Factor Surveillance System (BRFSS) core national surveys from 2003 to 2019. Nationally representative prevalence estimates of self-reported mental distress were compared between women veterans and their (1) men veteran and (2) women civilian counterparts. In each year examined, women veterans report significantly more days of recent mental distress and significantly higher prevalence of frequent mental distress than their men veteran counterparts. In several years, women veterans also report greater levels of recent and frequent mental distress than women civilians. These findings highlight the long-standing high prevalence of self-reported poor mental health among women veterans and suggest that specific efforts to address mental health among women veterans as a unique population may be warranted.

Veteran-Reported Receipt of Prepregnancy Care: Data from the Examining Contraceptive Use and Unmet Need (ECUUN) Study.

OBJECTIVES: To identify the prevalence of women Veterans reporting receipt of counseling about health optimization prior to pregnancy, topics most frequently discussed, and factors associated with receipt of this care. METHODS: We analyzed data from a nationally representative, cross-sectional telephone survey of women Veterans (n = 2302) ages 18-45 who used VA for primary care in the previous year. Our sample included women who were (1) currently pregnant or trying to become pregnant, (2) not currently trying but planning for pregnancy in the future, or (3) unsure of pregnancy intention. Multivariable logistic regression was used to examine adjusted associations of patient- and provider-level factors with receipt of any counseling about health optimization prior to pregnancy (prepregnancy counseling) and with counseling on specific topics. RESULTS: Among 512 women who were considering or unsure about pregnancy, fewer than half (49%) reported receiving any prepregnancy counseling from a VA provider in the past year. For those who did, the most frequently discussed topics included healthy weight (29%), medication safety (27%), smoking (27%), and folic acid use before pregnancy (27%). Factors positively associated with receipt of prepregnancy counseling include history of mental health conditions (aOR = 1.96, 95% CI: 1.28, 3.00) and receipt of primary care within a dedicated women's health clinic (aOR = 2.07, 95% CI: 1.35, 3.18), whereas factors negatively associated include far-future and unsure pregnancy intentions (aOR = 0.35, 95% CI: 0.17, 0.71 and aOR = 0.33, 95% CI: 0.16, 0.70, respectively). CONCLUSIONS FOR PRACTICE: Routine assessment of pregnancy preferences in primary care could identify individuals to whom counseling about health optimization prior to pregnancy can be offered to promote patient-centered family planning care.

Measuring Female Veterans' Prepregnancy Wellness Using Department of Veterans Affairs' Health Record Data.

OBJECTIVE: To estimate the feasibility of using measures developed by the Clinical Workgroup of the National Preconception Health and Health Care Initiative to assess women's prepregnancy wellness in a large health care system. METHODS: We examined Department of Veterans Affairs' (VA) national administrative data, including inpatient, outpatient, fee-basis, laboratory, pharmacy, and screening data for female veterans aged 18-45 who had at least one pregnancy outcome (ectopic pregnancy, spontaneous abortion, stillbirth, and live birth) during fiscal years 2010-2015 and a VA primary care visit within 1 year before last menstrual period (LMP). LMP was estimated from gestational age at the time of pregnancy outcome, then used as a reference point to assess eight prepregnancy indicators from the Workgroup consensus measures (eg, 3 or 12 months before LMP). RESULTS: We identified 19,839 pregnancy outcomes from 16,034 female veterans. Most (74.9%) pregnancies ended in live birth; 22.6% resulted in spontaneous abortion or ectopic pregnancy, and 0.5% in stillbirth. More than one third (39.2%) of pregnancies had no documentation of prenatal care within 14 weeks of LMP. Nearly one third (31.2%) of pregnancies occurred in women with obesity. Among pregnancies with a recent relevant screening, 29.2% were positive for smoking and 28.4% for depression. More than half (57.4%) of pregnancies in women with preexisting diabetes did not have documentation of optimal glycemic control. Absence of sexually transmitted infection screening in the year before or within 3 months of LMP was high. Documentation of prenatal folic acid use was also high. Exposure in the same timeframe to six classes of teratogenic medications was low. CONCLUSION: Despite limitations of administrative data, monitoring measures of prepregnancy wellness can provide benchmarks for improving women's health across health care systems and communities. Areas for intervention to improve female veterans' prepregnancy wellness include healthy weight, optimizing control of diabetes before pregnancy, and improved use and documentation of key prepregnancy health screenings.

Strategies for effective dissemination of research to United States policymakers: a systematic review.

BACKGROUND: Research has the potential to influence US social policy; however, existing research in this area lacks a coherent message. The Model for Dissemination of Research provides a framework through which to synthesize lessons learned from research to date on the process of translating research to US policymakers. METHODS: The peer-reviewed and grey literature was systematically reviewed to understand common strategies for disseminating social policy research to policymakers in the United States. We searched Academic Search Premier, PolicyFile, SocINDEX, Social Work Abstracts, and Web of Science from January 1980 through December 2019. Articles were independently reviewed and thematically analyzed by two investigators and organized using the Model for Dissemination of Research. RESULTS: The search resulted in 5225 titles and abstracts for inclusion consideration. 303 full-text articles were reviewed with 27 meeting inclusion criteria. Common sources of research dissemination included government, academic researchers, the peer reviewed literature, and independent organizations. The most frequently disseminated research topics were health-related, and legislators and executive branch administrators were the most common target audience. Print materials and personal communication were the most common channels for disseminating research to policymakers. There was variation in dissemination channels by level of government (e.g., a more formal legislative process at the federal level compared with other levesl). Findings from this work suggest that dissemination is most effective when it starts early, galvanizes support, uses champions and brokers, considers contextual factors, is timely, relevant, and accessible, and knows the players and process. CONCLUSIONS: Effective dissemination of research to US policymakers exists; yet, rigorous quantitative evaluation is rare. A number of cross-cutting strategies appear to enhance the translation of research evidence into policy. REGISTRATION: Not registered.

History of unintended pregnancy and patterns of contraceptive use among racial and ethnic minority women veterans.

BACKGROUND: Nearly half of all pregnancies in the United States each year are unintended, with the highest rates observed among non-Hispanic black and Hispanic women. Little is known about whether variations in unintended pregnancy and contraceptive use across racial and ethnic groups persist among women veteran Veterans Affairs users who have more universal access than other populations to health care and contraceptive services. OBJECTIVES: The objectives of this study were to identify a history of unintended pregnancy and describe patterns of contraceptive use across racial and ethnic groups among women veterans accessing Veterans Affairs primary care. STUDY DESIGN: Cross-sectional data from a national random sample of women veterans (n = 2302) aged 18-44 years who had accessed Veterans Affairs primary care in the previous 12 month were used to assess a history of unintended pregnancy (pregnancies reported as either unwanted or having occurred too soon). Any contraceptive use at last sex (both prescription and nonprescription methods) and prescription contraceptive use at last sex were assessed in the subset of women (n = 1341) identified as being at risk for unintended pregnancy. Prescription contraceptive methods include long-acting reversible contraceptive methods (intrauterine devices and subdermal implants), hormonal methods (pill, patch, ring, and injection), and female or male sterilization; nonprescription methods include barrier methods (eg, condoms, diaphragm), fertility-awareness methods, and withdrawal. Multivariable logistic regression models were used to examine the relationship between race/ethnicity with unintended pregnancy and contraceptive use at last sex. RESULTS: Overall, 94.4% of women veterans at risk of unintended pregnancy used any method of contraception at last sex. Intrauterine devices (18.9%), female surgical sterilization (16.9%), and birth control pills (15.9%) were the 3 most frequently used methods across the sample. Intrauterine devices were the most frequently used method for Hispanic, non-Hispanic white, and other non-Hispanic women, while female surgical sterilization was the most frequently used method among non-Hispanic black women. In adjusted models, Hispanic women (adjusted odds ratio, 1.60, 95% confidence interval, 1.15-2.21) and non-Hispanic black women (adjusted odds ratio, 1.84, 95% confidence interval, 1.44-2.36) were significantly more likely than non-Hispanic white women to report any history of unintended pregnancy. In the subcohort of 1341 women at risk of unintended pregnancy, there were no significant racial/ethnic differences in use of any contraception at last sex. However, significant differences were observed in the use of prescription methods at last sex. Hispanic women (adjusted odds ratio, 0.51, 95% confidence interval, 0.35-0.75) and non-Hispanic black women (adjusted odds ratio, 0.69, 95% confidence interval, 0.51-0.95) were significantly less likely than non-Hispanic white women to have used prescription contraception at last sex. CONCLUSION: Significant racial and ethnic differences exist in unintended pregnancy and contraceptive use among women veterans using Veterans Affairs care, suggesting the need for interventions to address potential disparities. Improving access to and delivery of patient-centered reproductive goals assessment and contraceptive counseling that can address knowledge gaps while respectfully considering individual patient preferences is needed to support women veterans' decision making and ensure equitable reproductive health services across Veterans Affairs.

Family factors associated with emerging adults' human papillomavirus vaccine behavior.

Objective: The current study examined the role of family influences on the vaccine behavior of emerging adults. Participants: In Spring 2017, we conducted anonymous online surveys of undergraduate students (n = 608) at a large, public university in the mid-Atlantic. Methods: Logistic regression was used to examine associations between family factors and students' awareness of the HPV vaccine, vaccine receipt, and vaccine intentions. Family factors included sex communication, religiosity, parental monitoring, family structure, and parents' birthplace. Results: More comprehensive family sex communication is associated with less uncertainty regarding HPV vaccine receipt and greater likelihood of being already vaccinated. More frequent family religiosity and more parental monitoring are associated with greater likelihood of having decided against vaccination rather than already being vaccinated. Significant gender and racial disparities exist. Conclusion: Further research, policy, and programmatic intervention are needed to reduce disparities and to improve emerging adults' compliance with HPV vaccine recommendations.

A Primary Care Intervention to Prevent Repeat Pregnancy Among Teen Mothers.

INTRODUCTION: The purpose of this study is to determine the effectiveness of a patient-centered medical home intervention for teen parent families in reducing rates of unintended repeat pregnancy in the first 2 years postpartum. METHODS: A prospective quasi-experimental evaluation was conducted with 98 African American, low-income, teen mother (aged <20 years) participants who received either the intervention or standard pediatric primary care. All participants completed structured interviews at baseline (child aged 2 months) and at follow-ups 12 and 24 months later. Data were collected from 2011 to 2015. Participants reported number of pregnancies, contraception used at last intercourse, depressive symptoms, and romantic status of the relationship with the baby's father. Analyses were conducted from 2015 to 2017. RESULTS: Logistic regression showed that mothers in the intervention group were half as likely as mothers who received standard pediatric primary care to have a repeat pregnancy within 2 years (OR=0.55, p=0.16). The main effect of the intervention on lower rates of repeat pregnancy was mediated by higher rates of contraceptive use. Depression was associated with higher odds of repeat pregnancy, but did not appear to mediate the intervention effect. CONCLUSIONS: This comprehensive and integrated model of care for teen parents may be an effective method to prevent rapid repeat pregnancies in this vulnerable population.

Contrast-enhanced ultrasound of the kidney: a single-institution experience.

BACKGROUND: Focal renal masses are typically evaluated by means of triphasic contrast-enhanced CT or MRI scan but use of iodinated contrast or gadolinium is unsuitable for some patients. Contrast-enhanced ultrasound (CEUS) is an imaging alternative in this scenario but has limited availability in Ireland. AIM: The aim of the study was to retrospectively evaluate experience with selective use of CEUS for non-invasive characterization of focal renal masses in a tertiary referral institution in Ireland, with a particular focus on cystic renal lesions and the influence of CEUS on final Bosniak classification and treatment outcomes. METHODS: All cases of renal CEUS between 2009 and 2017 were identified. Imaging history, patient records, histopathology reports, urology conference notes, clinical follow-up details, details of lesion progression or stability on surveillance, biopsy and/or resection details and pre- and post-CEUS Bosniak scores were recorded. RESULTS: Thirty-one patients underwent renal CEUS (7 solid renal lesions, 21 cystic renal lesions and 3 'indeterminate' renal lesions). After CEUS, the CEUS-modified Bosniak score was upgraded in nine patients and downgraded in two patients. All three lesions upgraded from Bosniak III to IV were renal cell carcinomas. One of two lesions downgraded from Bosniak IV to III was resected (cystic nephroma) and the other showed no progression after 19 months of surveillance. CONCLUSION: CEUS is a valuable alternative to CT in assessing complex cystic or solid renal lesions where iodinated CT contrast or gadolinium is inappropriate. CEUS can also refine the Bosniak category of atypical cystic renal lesions and help facilitate treatment decisions.

The Role of Teen Mothers' Support Relationships in Maintenance of Contraceptive Use.

STUDY OBJECTIVE: To explore interpersonal factors associated with maintaining contraceptive use over time among urban, African American teen mothers. DESIGN: Longitudinal study, 2011-2015. SETTING: Six pediatric primary care sites in the same city, all of which primarily serve urban, low-income, African American families. PARTICIPANTS: Teen mothers accessing health services for their child at one of the six study sites. INTERVENTIONS: The current study was a secondary data analysis of data that were collected as part of a patient-centered medical home model intervention, that compared a group of teen mothers and their children who were participants in the intervention with mother-child dyads who were enrolled in standard community-based pediatric primary care. Structured interviews were conducted with teen mothers at baseline/enrollment, when their children were, on average, 3 months old, and again 12 months later. MAIN OUTCOME MEASURES: Maintenance of contraceptive use over time. RESULTS: Teen mothers who perceived any tangible support from their own mothers were significantly less likely to maintain contraceptive use over time (adjusted odds ratio [AOR] = .27). However, teens who perceived any emotional support from their own mothers were nearly four times more likely to maintain contraceptive use (AOR = 3.74). Teens who lived with their own mothers were more than 5 times more likely to maintain contraceptive use over time (AOR = 5.49). CONCLUSION: To better understand contraceptive discontinuation and thus to prevent repeat pregnancies among teen mothers, it might be necessary to further examine the role of support relationships in teen mothers' contraceptive decision-making. Secondary pregnancy prevention programs should include key support persons.