Patient-centered contraceptive care is key for ensuring that individuals achieve their personal reproductive goals. Despite public health efforts, preventing undesired pregnancies and improving maternal and child health outcomes remains unresolved in the United States (US). In Tennessee (TN), the rate of unintended pregnancies remains higher than the national rate (32.4% vs. 30.3%). Long-acting reversible contraceptives (LARCs) are 99% effective in preventing undesired pregnancies; however, uptake remains low in rural and underserved communities. Previous research has provided some insight into women’s perceptions of LARCs; however, those guided by conceptual frameworks to understand the multiple influences that impact perceptions towards LARCs, especially among rural regions, are scarce. This multimethod qualitative study explored multiple influences that impact northeast Tennessee women’s perceptions and attitudes toward LARCs using the Socio-ecological Model (SEM) as a guiding framework. The qualitative study comprised six focus groups and seven individual interviews of women aged 18-44, not pregnant, and current residents of five Counties in Northeast TN. Participants’ demographics were captured through an anonymous survey administered through REDCap. Qualitative data from these sessions were recorded via Zoom, an online audio/video conferencing platform. Each interview and focus group lasted 60 to 90 minutes. Focus group and interview data were combined, transcribed, and uploaded into NVivo for thematic analysis. A priori list of codes identified from the constructs of the SEM was initially used to deductively code the data. Subsequently, the data were analyzed inductively for new codes and themes that did not apply to the a priori categories. Quotations that were representative of or inconsistent with the codes of interest were identified. Fifteen themes and 20 sub-themes were identified using the SEM; On the intrapersonal level of the SEM, participants’ attitudes towards a method, perception of method features, and perceived side effects were identified as themes that delineate influences on their LARC utilization. On the interpersonal level, perception of partner support, perceived support from peer/social networks, and provider trust were themes that describe influences on participants’ LARC utilization. On the community level, the cost of the method, access to information, perceived accessibility to a method, social services, and cultural norms themes were identified as influences on participants’ use of LARCs. On the organizational level, the availability of preferred methods in a clinic, the need for multiple clinic visits to enable the use of a method, and provider counseling practices were salient themes impacting LARC utilization. On the policy level, insurance, and billing policies, sex education policies were identified as impacting LARC utilization. The study presents multi-layered influences on LARC utilization among Northeast TN women, highlighting the utility of the SEM in understanding factors that influence contraceptive use. Findings are critical for programming as they highlight the areas of influence that can be addressed to increase LARC uptake and enable women in rural and underserved regions of the US to achieve personal reproductive goals.

In Tennessee (TN), the rate of unintended pregnancies remains higher than the national rate (32.4% vs. 30.3%). Although long-acting reversible contraceptives (LARCs) are 99% effective in preventing undesired pregnancies; uptake remains low in rural and underserved communities. Previous research has provided some insight into women’s perceptions of LARCs; however, those guided by conceptual frameworks to understand the multiple influences that impact perceptions towards LARCs, especially among rural regions, are scarce. This multimethod qualitative study explored multiple influences that impact northeast Tennessee women’s perceptions and attitudes toward LARCs using the Socio-ecological Model (SEM) as a guiding framework. The study comprised six focus groups and seven individual interviews of women aged 18-44, not pregnant, and current residents of five counties in Northeast TN. Participants’ demographics were administered through REDCap, while qualitative data from focus groups and interviews were recorded via Zoom. Focus groups and interview data were combined, and an a priori list of codes identified from the constructs of the SEM was initially used to deductively code the data. Subsequently, the data were analyzed inductively for new codes and themes that did not apply to the a priori categories. Seventeen themes and 23 sub-themes were identified using the SEM; On the intrapersonal level of the SEM, participants’ contraception utilization history, attitudes towards a method, perception of method features, and perceived side effects were identified as themes that delineate influences on their LARC utilization. Perception of partner support, perceived support from peer/social networks, and provider trust themes were identified on the interpersonal level. On the community level, the cost of the method, access to information, perceived accessibility to a method, social services, and cultural norms themes were identified. The availability of preferred methods in a clinic, the need for multiple clinic visits to use a method, and provider counseling practices were identified as organizational-level themes. On the policy level, insurance, and billing policies, sex education policies were identified as impacting LARC utilization. Study findings highlight the areas of influence that can be addressed to increase LARC uptake and enable women in rural and underserved regions to achieve their personal reproductive goals.

Using lessor's psychosocial framework of risk behaviour, this study examined the impact of variables within a number of risk domains on condom use at last sex. The sample was 587 sexually active male and female black youth between the ages of 16 and 20 years old from the township areas of Soweto (Johannesburg), Umlazi (Durban) and Khayelitsha (Cape Town). Binary logistic regression models were used in the analysis. Within the biological risk domain, gender was a significant predictor of condom use at last sex. None of the proximate social context variables, viz. parental education, family structure, and parent-adolescent communication, were significant predictors. Health services' promotion of condom use was a significant predictor within the distal social context. Within the perceived environment in relation to the self, perception of risk and perception of barriers were significant predictors of condom use at last sex. None of the variables within the perceived environment in relation to peers domain, viz. perceived peer attitudes to condoms and peers suffering the negative consequences of unprotected sex, were significant. The personality domain contained measures of self-esteem, future time orientation, locus of control and fatalism. Locus of control was the only significant predictor within this domain of condom use at last. Engagement in other risk taking behaviour, such as smoking cigarettes, alcohol and drug use, was a significant predictor within the general behaviour domain. Within the sexual behaviour domain, partner discussion and contraceptive use were significant predictors of condom use at last sex. 2 In the final model, the significant predictors in order of importance, were the perception of risk, the promotion of condom use by a health professional, locus of control, discussion with a partner, the perception of barriers, the use of contraceptives, and risk taking behaviour. The only interaction in the final model of condom use at last sex was between the promotion of condom use by a health professional and concurrent use of other forms of non-barrier contraception. / Thesis (M.A.)- University of Natal, Pietermaritzburg, 2001.