Latina contraceptive decision-making and use: The importance of provider communication and shared decision-making for patient-centered care

Abstract

Background:

Poor patient-provider communication, among other reasons, is a notable barrier to contraceptive decision-making among Latinas. Patient-centered approaches to contraceptive counseling that optimize communication align with shared decision-making (SDM) –which is associated with satisfaction and continued contraceptive use among various populations.

Objective:

To examine associations of patient-provider communication and importance of SDM tenets with consistent contraceptive use among a population of Latinas.

Patient involvement:

Formative work for this study included prior qualitative and quantitative research with Latinas who expressed the importance of patient-provider communication during contraceptive counseling and therefore were instrumental in problem definition.

Methods:

Cross-sectional surveys were administered to Latinas ages 15–29 years. Patient-provider communication, patient-reported importance of specific SDM tenets, and consistent contraception use were measured and analyzed for associations.

Results:

103 Latinas (mean age = 21.4) participated. 33% of participants < 21 years were using contraception consistently vs. 67% for those ≥ 21 (p = 0.003). Among participants ≥ 21, consistent users reported higher communication scores compared to inconsistent users and non-users (p = 0.042). For participants < 21, consistent users were more likely than inconsistent users and non-users to report that 2 SDM tenets (discussion of contraceptive preferences and avoidance of race/ethnic-based judgement) are important (p = 0.052, 0.028, respectively).

Discussion:

Patient-provider communication was especially important for Latinas ≥ 21 while using an SDM approach during counseling was highly valued by those < 21. Patient-centered approaches to contraceptive counseling provide opportunities to optimize healthcare delivery for this vulnerable population.

Practical value:

Results from this research demonstrate that patient-centered communication is highly valued by Latina study participants and is an important consideration in their contraceptive counseling. Clinicians should consider employing techniques such as SDM as they seek to provide patient-centered care during contraceptive counseling for this patient population.

1. Introduction

The ability to control childbearing is vital for the health and wellbeing of women, their families and their communities [1]. Ensuring that all persons have control over their childbearing with respect to contraceptive decision-making, is important for patient-centered, just, equitable care. Latinx¹ folks are the fastest growing racial/ethnic group in the US [2], and in Baltimore, Maryland [3]. Prior studies demonstrate that US Latinas want to use contraception [4,5] but are significantly less likely to do so compared to non-Latina White women [6] and often use inconsistently [7].

In previous studies, some barriers to contraceptive use and use consistency among Latinas have included lack of communication with healthcare providers [4,8], perceptions of coercion by providers to use certain methods [9,10], and a sense of being stereotyped by race/ethnicity [4,9]. Like other groups, Latinos value communication with their healthcare providers while making health-related decisions [11], including decisions about contraceptive choice [4,8].

Better patient-provider communication –a key component of patient-centered care, is associated with improved health, patient satisfaction [12,13] and contraceptive use [8]. Among Latinas, ineffective provider communication impedes care [14] and deters contraceptive use [8,15]. In contrast, patient-centered communication is associated with improved medication adherence and use of preventive health services in general [16], and specifically, contraceptive continuation [8,15,17] and consistent use [8,18]. Communication is also a vital component of shared decision-making [16,19].

Patient-centered communication aligns well with a shared decision-making (SDM) approach to contraceptive counseling in which the provider first elicits patients’ personal preferences, then tailors health education and support to this understanding [19]. Providers focus on understanding patient needs in order to provide desired information. Charles et al.’s framework for SDM has three main tenets: information-exchange (bi-directional communication between patients and providers); deliberation (between patients, providers, and other important persons); and decision-making [19]. Key to achieving SDM is patient-provider communication regarding a patient’s preferences, provision of clear, comprehensive information about the medication/procedure/health intervention being discussed, and avoidance of pre-conceived judgements about patients. SDM in contraceptive counseling and its positive association with patient satisfaction during such counseling and with chosen contraceptive methods [20].

Foundational work by the authors found that Baltimore Latinas value positive communication with healthcare providers, but also report contraceptive counseling is at times coercive [4]. Non-coercive contraceptive decision support is vital given U.S. history of forced sterilization of Black, Indigenous and other people of color [21] and research showing that women of color, including Latinas, experience racial/ethnic discrimination during receipt of contraceptive services [10] and pressure by providers to use contraception [9]. Many Latinas who report negative contraceptive care experiences discontinue their chosen methods and choose not to engage in future care [22]. This reinforces the importance of practicing patient- centered care that focuses on optimizing patient-provider communication and use of SDM during contraceptive counseling.

To what extent positive patient-provider communication, elicitation of patient preferences, and avoidance of race/ethnicity-based pre-judgement (elements of SDM), impact Latinas’ contraceptive decision-making and use, is insufficiently understood. Assessing the importance and impact of these patient-centered SDM values on consistent contraceptive use is key for understanding how providers might positively influence outcomes including patient satisfaction with contraceptive counseling visits and with chosen methods. To that end, the objectives of this study were to assess the association among Baltimore Latinas of 1) patient-provider communication with consistent contraceptive use; and 2) patient-reported importance of SDM tenets with consistent contraceptive use.

2. Methods

2.1. Setting, participants and recruitment procedures

Self-identified Latinas ages 15–29 years of age were recruited from two federally qualified healthcare centers (FQHCs) that deliver full spectrum primary care for children and adults in Baltimore, Maryland. Both healthcare sites serve predominantly low-income, uninsured/underinsured populations with a significant portion of patients identifying as Latinx. At site one, approximately 75% of patients are insured through public assistance and approximately 35% self-report as Latinx. Site 2 serves patients that are primarily insured via public assistance (90%), and 75% of visits are with Latinx folks. Participants in the study were not pregnant or intending to become pregnant at the time of consent. Additional eligibility criteria included women with uteruses who were sexually active and not premenarchal/postmenopausal. Participants who reported tubal ligations were not included in analyses. We did not specifically include transgender, gender non-binary/non-conforming folks. Potential participants were approached in facility waiting rooms by a bilingual research assistant. Informed consent (> 18 years old) or parental consent and assent (< 18 years old) were obtained in participants’ language of choice (English or Spanish). Each participant received a gift card as compensation for their time. This human subjects research was approved by the University of Maryland Institutional Review Board.

2.2. Data collection, instrument, and variables

Surveys were administered by bilingual research assistants. The 50 question survey consisted of items drawn from instruments including the Primary Care Assessment Survey (PCAS) measuring patient-provider communication [13] and the Attitude toward Potential Pregnancy Scale (APPS) [23] measuring pregnancy desire. Other content-validated items measuring additional factors relevant to contraceptive decision-making in the target population including important elements of SDM [24] were included. Contraception use, current method, and consistency were also measured. Detailed descriptions of measures are below.

Patient-provider communication was measured using items adapted from the communication scale of the PCAS [13]. Six items asked about providers’ thoroughness, attention to what the patient says, clarity in explanations/instructions and help in making care decisions. Response options ranged from very poor to excellent on a scale from 1 to 6. Internal reliability of the 6-item communication scale was tested using Cronbach alpha coefficient. Preliminary analysis showed that one item (“How often do you leave your doctor’s office with unanswered questions?”) had low correlation with the total (correlation coefficient 0.15). After removing this question, the Cronbach alpha coefficient for the modified 5-item scale was 0.92. Correlation of each item with the total varied between 0.76 and 0.83. Raw scores from each item were summed and converted to a 100-point score.

When considering some of the tenets of SDM and their relationship to contraceptive decision-making and use, participants were asked about the importance of clinicians recognizing their contraceptive preferences and avoiding patient judgement during counseling. These items were content-validated in a prior study [24] and are as follows:

“I expect that my doctor will ask me about my preferences when we discuss my birth control options.”

“Talking about my preferences with my doctor will help me to use birth control.”

“I can speak with my doctor about birth control without feeling judged.”

“It is important for me to be able to speak with my doctor about birth control without feeling judged.”

Responses for each item were measured on a scale from 1 (agree) to 7 (disagree) and then dichotomized to yes/no (agree/disagree) for congruency with the distribution of responses.

The dependent variable was consistent contraception use. For patients who reported current contraceptive use, methods for determining consistency were modeled from previous research [25]. Use frequency and missing/late doses were considered for short-acting methods (oral contraceptives, contraceptive patch, contraceptive ring, medroxyprogesterone injection). For long-acting methods, including intrauterine devices and contraceptive implants, participants who reported using a device for at least one year or reported a plan to keep the device for at least 1 year, were classified as consistent users. Other methods, including condoms, withdrawal, fertility-based awareness methods, and emergency contraception were also considered. Use of withdrawal or emergency contraception were considered consistent if used during every sexual encounter over the preceding 30 days; use of fertility-based methods was considered consistent if used monthly for the preceding 60 days. For reports of more than one current method, consistent use of at least one of the methods was considered consistent.

For participants who reported not using contraception, we reviewed their responses to items from the Attitude toward Potential Pregnancy Scale (APPS) [23] to determine their reported desire to become pregnant. Four items ask about current desire for pregnancy or avoidance of pregnancy and how worried and upset they would be if pregnant. There are 5 response options for each question ranging from negative to positive reactions to a current pregnancy. Responses were coded so that higher scores corresponded to neutral or positive pregnancy attitudes (scores of 3–5).

Inconsistent contraceptive users and contraceptive non-users who wanted to avoid pregnancy were combined into a single group and compared to the consistent contraceptive users. Inconsistent users and non-users were combined because these groups likely have similarities in terms of reasons for either not using contraception or using it inconsistently. Whether using contraception inconsistently or not at all, these participants all reported wanting to avoid pregnancy but were either not using contraception or not using consistently enough to optimize pregnancy prevention. Contraceptive non-users who did not want to avoid pregnancy or were ambivalent about pregnancy, were excluded from analyses.

2.3. Statistical analysis

We examined relationships between independent and dependent variables and included age. Age was dichotomized at the median (those < 21 years old vs. those ≥ 21), reflecting potential differences in maturity and responsibilities between age groups. About 80% of participants were immigrants, however length of time in the U.S. was not included in the analyses because analyses did not reveal significant associations between length of time in the U.S. (when categorized by quartiles) and the dependent variables, current contraceptive use or consistent contraceptive use. Similarly, there were only 14 participants in the sample who chose to complete a survey in English. When comparing age groups (<age 21 vs. 21 years and older), there was no difference in language distribution by age.

Data were analyzed using SAS version 9.4; statistical significance was set at 2-sided α = 0.05. Associations between and among age group, contraceptive method choice and use consistency were assessed using a chi-square or a 2-sided Fisher exact tests. Associations between communication score and consistency of use were assessed using a non-parametric (Kruskal-Wallis) test. Associations between importance of SDM tenets and consistency of use were assessed using a 2-sided Fisher test.

3. Results

Participants totaled 103 self-identified Latinas. The majority reported countries of origin from Mexico (20%) and Central America (50.5%). (Supplemental Fig. 1). The mean age was 21.4 years, ranging from 15 to 29 years. Consistent contraceptive use was normally distributed by age (data not shown). Sixty-five participants (63%) reported using contraception at the time of data collection, consistent with national data regarding current use. Of the contraceptive users, 55 (85%) reported consistent use of at least one method. Among 38 non-users, 30 (79%) did not desire pregnancy at the time of the survey. See Table 1.

Table 1.

Contraceptive use, consistency and non-use, by age group.

Age	Age < 21	Age ≥ 21	p-value*	Total N = 103
	N = 44	N = 59		Range: 15–29
	Mean: 17.5	Mean: 28.4		Mean: 21.4
Among all participants (N = 103), current contraceptive use, N (%)
Yes	24 (37)	41 (63)	0.120	65 (63)
No	20 (53)	18 (47)		38 (37)
Among current contraceptive users (N = 65), consistent users, N (%)
Yes	18 (33)	37 (67)	0.100	55 (85)
No	6 (60)	4 (40)		10 (15)
Among Non-Users (N = 38), desires pregnancy, N (%)
Yes	1 (13)	7 (87)	0.017 F	8 (21)
No	19 (63)	11 (37)		30 (79)

^*Chi-square test unless indicated otherwise

^F:2-sided Fisher’s exact test.

P values < 0.05 are highlighted in bold.

Fig. 1 displays contraceptive method choice among consistent users by age group. Most consistent users reported using a long-acting reversible method, and among those, most were ≥ 21 years old; p = 0.016. There were no statistically significant differences between age groups among other methods when considering use consistency (Fig. 1).

Fig. 1. Contraceptive method choice among consistent users, by age group.

LARC: Long-acting Reversible Contraceptive (IUD, Implant); SARC: Short-acting Reversible Contraceptive (pill, injection, ring, patch, emergency contraceptive pill); Partner-Dependent (condom, withdrawal); Other non-hormonal: fertility awareness methods; abstinence. The p value corresponds to the chi square test for difference in rates of LARC use between age groups. Differences between age groups for other method categories was non-significant.

Comparing consistent contraceptive users to inconsistent contraceptive users and non-users who wanted to avoid pregnancy, consistent use was highly associated with age. Thirty-three percent of participants < 21 years old were using at least one method consistently compared to 67% of older participants (≥ 21 years old) with p = 0.003 (data not shown). Fig. 2 shows the associations between communication scores and consistent contraceptive use by age group. For younger participants, there was no statistically significant association between communication score and use consistency (Kruskal-Wallis test p = 0.474). For this younger group, median communication score for consistent users was 76 (25th–75th percentile 64–84); median communication score for inconsistent users and non-users was 68 (25th–75th percentile 52–80). In contrast, among older participants, consistent users reported significantly higher communication scores compared to inconsistent users and non-users (Kruskal-Wallis test p = 0.042). For this older group, median communication score for consistent users was 76 (25th–75th percentile 60–84). Median communication scores for inconsistent users and non-users was 62 (25th–75th percentile 52–72). An exploratory analysis showed there was no difference between groups for patient-reported communication when separating inconsistent users and non-users respectively (data not shown).

Fig. 2. Association of patient-provider communication with consistent contraceptive use, by age group.

Communication score was calculated using the modified PCAS communication scale as described in the Methods. Non-consistent use group also included non-users who wanted to avoid pregnancy. Data are presented as box plots. Horizontal lines within the boxes are medians, box frames mark 25th and 75th percentile, whiskers represent 5th and 95th percentile. Numbers on the plot are Kruskal-Wallis test p values.

Associations of the importance of SDM tenants with consistent contraceptive use by age group are shown in Fig. 3. Compared to communication scores, SDM tenets as they relate to contraceptive decision-making, were significant factors for consistent use among the younger group (<21). Younger participants who highly valued the discussion of their preferences during contraceptive counseling, showed a trend toward consistent use compared to those who did not rate such a discussion as highly (2-sided Fisher’s exact test p = 0.052, Fig. 3A). Additionally, provider avoidance of race/ethnic-based judgement during contraceptive counseling was significantly associated with use consistency in this younger group (2-sided Fisher’s exact test p = 0.028, Fig. 3B). For older participants (≥21 years), these SDM tenants were not significantly associated with consistent use.

Fig. 3. Association of Patient-reported Importance of SDM Tenets* with Consistent Contraceptive Use, by Age Group.

High = SDM congruent; Low = SDM non-congruent. Question items were measured using a 7-point Likert scales and dichotomized by median score as described in the Methods. Numbers on the bars are percent of consistent users among responders with high versus low level of perceived SDM in the respective age groups. P values are for 2-sided Fisher’s exact test.

We examined additional variables including insurance coverage and participants’ preferred language. Participants were recruited from FQHCs serving patients with varying degrees of insurance coverage including private/public insurance and those who are uninsured. Survey items included a question asking whether being insured (or having ability to pay for contraception) was an important factor in participants’ ability to use contraception. We found no statistical differences when dichotomizing this variable (‘very important’ vs. all others) with respect to the outcome variable, consistent use (p = 0.245). When considering language preference, participants were asked how language affects their ability to use contraception. We first asked: a) whether the participant thought it was important for the provider to speak her preferred language in order for her to use contraception; we then asked: 2) whether it was important for her to be able to speak her preferred language with the provider in order for her to use contraception. We found no statistical differences when dichotomizing these variables (‘very important’ vs. all others) with respect to the outcome variable, consistent use. P values were 0.434 and 0.685, respectively.

4. Discussion and conclusion

4.1. Discussion

Among this group of predominantly immigrant, self-identified Latinas –an understudied and increasingly vulnerable, underserved population, this study demonstrates the importance of patient- centered contraceptive counseling and decision-making. Results reveal that positive patient-provider communication and SDM are critical for contraceptive decision-making and consistent use among participants. There were notable differences between age groups. High patient-reported provider communication scores were associated with consistency of contraceptive use among participants ≥ 21. In contrast, the importance of discussing contraceptive preferences with providers and as the avoidance of racial/ethnic based judgement from providers during contraceptive counseling, was associated with consistent use for participants < 21 years. Previous research supports the association of patient-centered communication with contraceptive decision-making and use among several populations [4,15,17,26].

The younger group values contraceptive counseling that focuses on their preferences and disfavors racial/ethnic-based prejudgment and/or discrimination. Evidence suggests that perceptions of race/ethnic-based discrimination among adolescents of color negatively impact school performance [27], mental health [28,29], and physical health [29], including participation in risky sexual behaviors [30]. Younger generations are often open to discussing issues of race/ethnicity [31] and therefore may be more acutely aware of its potential for negative consequences. For the younger group, discussion of personal contraceptive preferences and avoidance of racial/ethnic discrimination may equate with positive communication and patient-centered care. Overall, study findings are consistent with previous literature demonstrating the value of patient-provider communication, patient-centered care, and SDM during contraceptive counseling [8].

Some participants placed particular value on provider avoidance of racial/ethnic-based typecasting during contraceptive counseling; this is important because previous studies have demonstrated that women of color, including Latinas, perceive racial/ethnic discrimination during receipt of contraceptive services [10,32]. Moreover, women of color sometimes feel undue pressure by providers to use contraception to limit childbearing [9]. Thus, non-coercive contraceptive decision support is very important and especially crucial given histories of forced/coerced sterilization and unconsented testing of contraceptives among Latinx folks and other non-White groups in the United States [21,33,34]. Moreover, non-coercive contraceptive counseling is consistent with a patient-centered, SDM approach to care. Also reflective of SDM is the notion of eliciting and responding to patient personal preferences during discussion of options, especially among younger participants. Previous recommendations for contraceptive counseling have suggested that providers utilize a tier-effectiveness approach to contraceptive counseling which focuses on the most effective methods preferentially (most to least effective) [35] -which is not necessarily reflective of a patient-centered approach to counseling. Of additional significance is that participants were mostly immigrant Latinas, an especially vulnerable group often affected by sexual health inequities and immigration-related trauma [36] –which is why supporting patient autonomy and personal preference as they relate to reproductive health is a critical part of care. Considering our study findings and those of others supporting preference-focused care, providers might consider framing their approach to contraceptive counseling particularly of young Latinx folks with more attention to personal preferences than to method effectiveness specifically.

4.1.1. Limitations

This study is limited by its lack of generalizability to other groups including other U.S. Latinx populations. The sample population is primarily of Mexican and Central American descent. Preferences may not necessarily reflect those of all self-identified Latinas living in the U.S. as people of Latinx origin hail from many nations across the globe. Another limitation is self-selection of those who chose to participate in the study and/or who sought contraceptive counseling at the healthcare facilities included. Finally, the questions about important tenets of SDM were only contextually related to SDM and not specifically reflective of whether SDM actually occurred during counseling. Notwithstanding, results showed clear clinical and statistical significance by age group with respect to associations of patient-provider communication (≥21) and SDM tenets (<21) with consistent contraceptive use. To our knowledge, there are few/no studies reporting such findings among this demographic.

4.2. Conclusion

As past research shows, it is crucial to apply this counseling approach during contraceptive care provision [26]. It is notably useful for advancing equitable healthcare across populations, particularly the most vulnerable who most often suffer unfavorable social determinants of health and resulting inequity. Future research will work to develop and evaluate an ethnically responsive point-of-care support tool targeted for clinicians in an effort to improve SDM skills during contraceptive counseling with Latinas.

4.3. Practice implications

To provide and promote patient-centered care, clinicians should strongly consider using an SDM approach focused on establishing good communication with patients, eliciting patient contraceptive preferences, and avoiding racial/ethnic-based preconceived judgement during contraceptive counseling with Latinas. The latter two should be especially considered when counseling adolescents.