Abortion patients' decision making about where to obtain out-of-state care following Texas' 2021 abortion ban.

OBJECTIVE: To assess pregnant Texans' decisions about where to obtain out-of-state abortion care following the September 2021 implementation of Senate Bill 8 (SB8), which prohibited abortions after detectable embryonic cardiac activity. DATA SOURCE: In-depth telephone interviews with Texas residents ≥15 years of age who obtained out-of-state abortion care after SB8's implementation. STUDY DESIGN: This qualitative study explored participants' experiences identifying and contacting abortion facilities and their concerns and considerations about traveling out of state. We used inductive and deductive codes in our thematic analysis describing people's decisions about where to obtain care and how they evaluated available options. DATA COLLECTION: Texas residents self-referred to the study from flyers we provided to abortion facilities in Arkansas, Colorado, Kansas, Louisiana, Mississippi, New Mexico, and Oklahoma. We also enrolled participants from a concurrent online survey of Texans seeking abortion care. PRINCIPAL FINDINGS: Participants (n = 65) frequently obtained referral lists for out-of-state locations from health-care providers, and a few received referrals to specific facilities; however, referrals rarely included the information people needed to decide where to obtain care. More than half of the participants prioritized getting the soonest appointment and often contacted multiple locations and traveled further to do so; others who could not travel further typically waited longer for an appointment. Although the participants rarely cited state abortion restrictions or cost of care as their main reason for choosing a location, they often made sacrifices to lessen the logistical and economic hardships that state restrictions and out-of-state travel costs created. Informative abortion facility websites and compassionate scheduling staff solidified some participants' facility choice. CONCLUSIONS: Pregnant Texans made difficult trade-offs and experienced travel-related burdens to obtain out-of-state abortion care. As abortion bans prohibit more people from obtaining in-state care, efforts to strengthen patient navigation are needed to reduce care-seeking burdens as this will support people's reproductive autonomy.

Abortion assistance fund staff and volunteers as patient navigators following an abortion ban in Texas.

CONTEXT: Abortion assistance funds constitute an important part of the healthcare safety net by covering some of abortion patients' out-of-pocket costs. Few studies have examined the other ways abortion assistance fund staff and volunteers support callers who need help obtaining care. METHODS: Between June and September 2020, we conducted in-depth interviews with 23 staff and volunteers at 11 local abortion assistance funds that helped Texans seeking abortion care following a March 2020 state executive order that prohibited most abortions. Interviewers explored respondents' experiences with callers whose appointments had been canceled or who traveled out of state and subsequent operational changes. We used both inductive and deductive codes in the thematic analysis. RESULTS: Abortion assistance fund staff and volunteers bridged callers' information gaps about the services and financial resources available and helped create plans to secure care that accounted for callers' specific needs. They provided emotional support so callers felt it was possible to overcome logistical hurdles to get an abortion, even if that required out-of-state travel. Respondents described greater collaboration between Texas-based abortion assistance funds and out-of-state organizations to support callers' more complex logistical needs and increased costs. Some callers who encountered multiple barriers to care, including interpersonal violence, were unable to obtain an abortion, even with additional supports. CONCLUSIONS: Local abortion assistance funds worked with Texas callers to co-create person-centered plans for care and expanded inter-organization collaborations. Initiatives that bolster local assistance funds' infrastructure and capacity will be needed as the abortion access landscape becomes further restricted and complex.

Women's Attitudes Towards Abortion in Response to the Zika and COVID-19 Outbreaks in Brazil.

Introduction: Abortion attitudes are influenced by people's socioeconomic and demographic circumstances and can be volatile during times of crisis. Brazil is an interesting case for examining abortion attitudes because of its strict abortion policies, changing religious landscape, high income inequality, and extreme uncertainty generated by the back-to-back Zika and COVID-19 crises. This study seeks to assess Brazilian women's attitudes toward abortion and whether religion and income explain these attitudes in the context of novel infectious disease epidemics. Methods: We used data from a population-based sample of 3996 women ages 18-34 in Pernambuco, Brazil, collected during the onset of the COVID-19 pandemic (May-September 2020). We conducted paired t-tests and multivariate-adjusted logistic regression models with adjusted Odds Ratios (aORs) and 95% CIs to assess differences in support for abortion in the case of fetal congenital Zika syndrome (CZS), maternal Zika infection during pregnancy, and maternal COVID-19 infection during pregnancy. Results: Significantly more women support the right to abortion in the case of fetal CZS (50%) than in the case of maternal Zika infection (40%) and maternal COVID-19 infection (31%). Support for abortion varies by income and religion. Controlling for other demographic characteristics, high-income women have higher odds of supporting abortion in the case of fetal CZS (aOR = 1.92; 95% CI: 1.25-2.94) and maternal Zika infection (aOR = 2.07; 95% CI: 1.33-3.21) than low-income women. Evangelical women have lower odds of supporting abortion in the case of maternal Zika infection (aOR = 0.65; 95% CI: 0.45-0.93) and marginally lower odds of supporting the right to abortion in the case of maternal COVID-19 infection (aOR = 0.69; 95% CI: 0.47-1.00) than women of other religious affiliations. Conclusions and Policy Implications: With increasingly conservative religious groups gaining size in Brazil, we expect to see increasing abortion restrictions. However, this research finds that a sizable portion of women across all incomes and religious affiliations support abortion, particularly in the case of fetal anomalies associated with Zika.

Minors' Experiences Accessing Confidential Contraception in Texas.

PURPOSE: Texas is one of 24 states that restricts minors' ability to obtain contraception without parental consent, unless they access confidential services at federally funded Title X clinics. This study explores Texas minors' reasons for and experiences seeking confidential contraception. METHODS: Between September 2020 and June 2021, we conducted in-depth phone interviews with 28 minors aged 15-17 years. Participants were recruited via the text line and Instagram account of an organization that helps young people navigate Texas' parental consent laws. Interview transcripts were coded and analyzed using inductive and deductive codes in our thematic analysis. RESULTS: Participants wanted to be proactive about preventing pregnancy by using more effective contraceptive methods but faced resistance from adults when they initiated conversations about sex and contraception or tried to obtain consent. In the absence of adult support, they turned to online and social media resources for information about types of contraception but encountered challenges finding accurate information about where to obtain methods in Texas without a parent. Only 10 participants were able to attend an appointment for contraception. Parents' increased monitoring of minors' activities during the COVID-19 pandemic, combined with transportation and appointment-scheduling barriers, made it difficult for minors to attend in-person visits, particularly if clinics were farther away. DISCUSSION: Minors in Texas faced a range of barriers to finding accurate information and obtaining confidential contraceptive services, which were exacerbated by the COVID-19 pandemic. Expanding options for accessible confidential contraception, along with repealing parental consent laws, would better support minors' reproductive autonomy.

A Mixed-Methods Pilot Evaluation of Manhood 2.0, a Program to Reduce Unintended Pregnancy Among Young Men.

One promising though understudied approach to addressing race/ethnic disparities in teen pregnancy rates is through sexual and reproductive health (SRH) programming for young men. This pilot study assessed the feasibility, quality, and preliminary efficacy of Manhood 2.0-a group-based, after-school SRH program for young Black and Latino men, which examines gender norms. This mixed-methods study describes program attendance and quality; participant experiences and engagement in the program; and changes in participant gender norms, knowledge, attitudes, self-efficacy, and social support. Quantitative data from baseline and post-intervention surveys (n = 51) were analyzed using paired t-tests and McNemar's tests. Qualitative data from five post-intervention focus groups (n = 27) were transcribed, coded, and analyzed for themes. At baseline, participants were ages 15 to18 years (M = 16.4 years), 30% were Latino, 66% were Black, 34% ever had sex, and 44% of sexually active participants had sex without any contraceptive method or condom. Quality ratings by program observers were high. The majority of participants (61%) attended at least 75% of sessions, and 96% rated Manhood 2.0 as "very good" or "excellent." Pre-post comparisons showed increases in receipt of SRH information; contraception knowledge; positive attitudes about supporting partners in pregnancy prevention; self-efficacy in partner communication about sex; discussing program content with friends and family; and social competence and support. Focus group participants described benefits from the Manhood 2.0 content (i.e., full range of contraceptive methods, sexual consent, gender norms) and delivery (i.e., reflective discussion, nonjudgmental facilitators). Findings suggest that Manhood 2.0 is a promising SRH program for young men.

Primary Contraceptive Method use and Sexually Transmitted Infections in a Nationally Representative Sample of Young Women.

STUDY OBJECTIVE: Rates of sexually transmitted infections (STIs) in the United States have increased for the sixth consecutive year. Young people ages 15-24 account for over half of all new infections despite comprising only a quarter of the sexually active population. A potential explanation for this is the increased use of long-acting reversible contraceptives, (LARCs) which could result in lower condom use and/or increased sexual risk-taking due to higher pregnancy prevention efficacy. DESIGN: This paper uses the National Survey of Family Growth to examine the relationship between primary contraceptive method use among young women ages 15-24 and STI treatment in the past year, as well as the extent to which this association is mediated by relationship status and frequency of condom use. RESULTS: Findings did not show differences in STI treatment in the past year by primary contraceptive method, indicating that LARC use among young women does not equate to increased STI risk. Findings did show that young women who had been in casual-only relationships or a mix of relationship types in the past year were more likely to have been treated for an STI than young women in serious or dating-only relationships, regardless of the primary method used. Additionally, young women who used condoms "some" of the time were more likely to have been treated for an STI compared with women who used condoms "all" or "most" of the time. This association was mediated by relationship status (P = .05). CONCLUSION: Findings suggest that efforts to address the growing STI burden should be directed at providing comprehensive, gender-equitable sexual health education that enables young people to engage in healthy relationships and consistent condom use.

Examining Partnership Approaches for Engaging Fathers to Address Domestic Violence.

Little is known about partnerships fatherhood programs establish to engage fathers in addressing domestic violence (DV). The study aimed to (a) describe partnership activities between fatherhood programs and organizations that address DV, (b) highlight strategies for productive partnerships, and (c) identify areas in need of improvement for addressing DV. This study discusses findings from qualitative interviews with 27 individuals from 17 fatherhood and DV organizations across the United States including the variety of partnership activities used to prevent and address DV (e.g., conducting trainings or facilitating referrals); strategies for creating productive partnerships; and partnership areas that need further attention.

Impacts of Re:MIX-A School-Based Teen Pregnancy Prevention Program Incorporating Young Parent Coeducators.

BACKGROUND: Latinx adolescents are at increased risk of teen pregnancy. This study evaluates the impact of Re:MIX, a comprehensive sexuality education program cofacilitated by professional health educators paired with young parent educators implemented with primarily Latinx youth in Texas. METHODS: A cluster randomized trial was conducted with students in grades 8-10 in 57 classrooms across three schools. Students completed baseline, post-test, and long-term follow-up surveys to determine the impact of the program on behavioral outcomes-sexual experience and unprotected sex-and on mediating factors including intentions, attitudes, knowledge, and self-efficacy related to sexual activity and contraception. RESULTS: Re:MIX was implemented with fidelity and educators were well-received. At post-test, compared to control students, Re:MIX students were more likely to intend to use hormonal or long-acting contraceptive methods if they had sex, had greater reproductive health knowledge, had more confidence in their ability to ask for and give consent, and were more likely to know where to obtain contraception. Most findings were sustained at the long-term follow-up, but there were no impacts on behaviors. CONCLUSIONS: The implementation and impact findings highlight the promising approach of pairing young parent educators with experienced health educators for teen pregnancy prevention among Latinx students.

Lessons Learned from Replicating a Randomized Control Trial Evaluation of an App-Based Sexual Health Program.

This study presents findings from a randomized control trial replication evaluation of Pulse, an app-based pregnancy prevention program implemented with Black and Latinx women aged 18-20, a population with high rates of unplanned pregnancy. We used social media advertisements to enroll 1013 women online across the U.S. and automatically randomized participants to either the Pulse reproductive health app or a general health control app, stratifying by age and race/Latinx ethnicity. Participants received reminder text messages to view the app as well as text messages with app-related content throughout the intervention. Linear probability models were conducted on the analytic sample of 871 participants who completed the six-week survey and 798 who completed the six-month survey and adjusted for permuted block randomization and multiple hypothesis testing. Compared to the control group, intervention group participants had higher contraceptive knowledge (p = 0.000), which replicates findings from an earlier evaluation. However, these impacts were not sustained at six-month follow-up (p = 0.162). We found no other significant program impacts. This contrasts with an earlier evaluation that found intervention participants were less likely to have had sex without a hormonal or long-acting reversible contraceptive (LARC) method and had greater self-confidence to use contraception consistently than the control group. Different demographic characteristics, lower app usage, and more negative attitudes about and usage of hormonal/LARC contraception in the current sample may help to explain fewer impacts than the earlier evaluation.

Short-Term Impacts of Pulse: An App-Based Teen Pregnancy Prevention Program for Black and Latinx Women.

PURPOSE: Black and Latinx women aged 18-20 years have high rates of unplanned pregnancy. Furthermore, this age group is less likely than school-aged youth to be served by pregnancy prevention programs typically administered in schools. The study's purpose was to assess the effectiveness of a new app-based teen pregnancy prevention program created for this population using an online- and texting-only recruitment and evaluation approach. METHODS: The study design was a randomized controlled trial with individual-level assignment of 1,304 women aged 18-20 years recruited online. Seventy-six percent of participants were black or Latinx. Women were randomized to the Pulse reproductive health app or a general health app and received regular text messages with program content and reminders to view the app. An intention-to-treat approach was used for analyses, and significance tests were adjusted to account for permuted block random assignment and multiple hypothesis testing. Linear probability models controlling for the baseline measure of each outcome, whether the participant reported ever having vaginal sex, age, and race/ethnicity, assessed program impacts for 1,124 participants 6 weeks after randomization. RESULTS: Participants who received the intervention were 7.6 percentage points less likely (p = .001) to report having had sex without a hormonal or long-acting contraceptive method. Intervention participants also scored 7.1 percentage points higher on contraceptive knowledge (p = .000) and were 5.7 percentage points more likely to be confident that they can use birth control during every sexual intercourse (p = .027). CONCLUSIONS: Impacts at 6 weeks are promising, particularly for a self-led intervention with no direct contact with study staff.

Addressing the Adherence-Adaptation Debate: Lessons from the Replication of an Evidence-Based Sexual Health Program in School Settings.

Whether high adherence to programs is necessary to achieve program outcomes is an area of great debate. The objectives of this study were to determine the frequency, type, and rationale of adaptations made in the implementation of an evidence-based program and to determine program outcomes for intervention program participants, as compared to comparison participants, by the level of adaptations. A total of 1608 participants in 45 classrooms participated. Percent adaptations was calculated by classroom. Thematic qualitative analysis was used to categorize types and rationales for adaptations. Program outcomes by level of adaptations were determined using logistic regression analyses and mean differences. Propensity score matching methods were used to create comparability between adaptation subgroup participants and comparison participants. Adaptations ranged from 2 to 97% across classrooms, with mean adaptations of 63%. Thematic analysis revealed that the adaptations made were related to delivery of content, rather than to the content itself and in response to participant needs and setting constraints. Program outcomes did not appear to be reduced for the high-adaptation subgroup. Understanding both rationale (intent) and type of adaptation made is crucial to understanding the complexity of adaptations. These finding support the argument for allowing facilitators some flexibility and autonomy to adapt the delivery of prescribed content to participant needs and setting constraints.

Program implementer perspectives replicating evidence based sexual reproductive health programs.

PURPOSE: Explore factors affecting implementation of evidence based adolescent sexual/reproductive health programs, from the perspectives of program implementers. METHODS: In-depth interviews were conducted with 18 program implementers delivering six sexual/reproductive health programs in New Jersey. Programs were delivered among 2698 primarily African American and Hispanic adolescents in school and community-based settings. Interview transcripts were coded and analyzed iteratively for themes by trained experts. RESULTS: Program implementers reported weaknesses in the program curricula content and design, scheduling constraints with partner sites, and questions from adolescents as factors challenging to implementation. Relationship-building (with adolescents and community partners) and answering adolescent questions were identified as strategies to program implementation. Implementers expressed need for flexibility in the curriculum to tailor the program to participant needs. However, implementers felt restricted in tailoring the program because of a perceived need to adhere to the prescribed program. CONCLUSIONS: Evidence based programs may need to provide more flexibility for implementers to customize programs to student needs. Given the age range of the target audience (ages 10-19), programming should consider the variance of an adolescent's life and assumptions regarding adolescent biology knowledge, modes of communication, and type of sexual relationships. Additionally, facilitators may better meet student needs if they feel less restricted.