Although it’s proven that contraception prevents pregnancy, it’s also clear that many women who don’t want to get pregnant don’t use or don’t have access to contraception.
Christine Dehlendorf, MD, MAS
“There is an implementation failure here. We have evidence, and it’s not being utilized,” said Christine Dehlendorf, MD, MAS, a family physician based at San Francisco General Hospital and Trauma Center, and an assistant professor in residence of family and community medicine at the UCSF School of Medicine.
Through a desire to help women navigate decisions about contraception, Dehlendorf became familiar with implementation science (ImS), which is focused on improving health by translating clinical findings into real-world interventions.
An experienced clinician, Dehlendorf knows that the issues surrounding reproductive decisions are complex, and that contraceptive counseling discussions are intimate and challenging to begin with. “Providers are trying to do this within a medical system that allows very limited time during a clinic visit for any kind of discussion about preventive health,” she said. “Even if providers know the right thing and would like to do it, they aren’t always able to.”
Dehlendorf’s observations conform to a basic tenet of implementation science, said Sara Ackerman, PhD, MPH, a medical anthropologist and program coordinator with the Implementation Science program managed by UCSF’s Clinical and Translational Science Institute (CTSI). “There is increasing awareness that the approach of ‘give people knowledge and they’ll do the right thing’ does not usually bring about a desired change in behavior,” Ackerman said. “Implementation science acknowledges that context always matters, and that behavior is situated within a complex web of influences, many of which we are not in control of or even aware of.”
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Tablet-based Tool Would Help Women Focus on Big Picture
To help women make informed reproductive decisions, Dehlendorf is developing a tablet-based support tool designed to be used online or in a waiting room prior to a contraception counseling visit. “This tool would provide women with some big-picture perspective on the issues they need to consider when thinking about contraception, such as reproductive life goals and their preferences around methods of contraception. It would also help them to narrow down the number of methods they want to talk about,” said Dehlendorf, who is also a CTSI K Scholar.
The tool also would take some of the burden off providers by feeding them information about a woman’s goals and preferences ahead of time, so the conversation during the clinic visit could be more focused, Dehlendorf said. Additionally, it would help to standardize what sort of basic information is exchanged between a clinician and a patient.
However, simply creating a health decision tool is not enough. The question, according to Dehlendorf, is about how to create affordable and lasting solutions that people will actually use. She says training in implementation science has helped her to anticipate these issues and to modify the tool early in the development process to improve the likelihood that it will work, and be useful, in more generalized settings, she said.
Another ImS tenet that Dehlendorf has incorporated into her project involves community engagement.
“My other big research focus is around health disparities,” she said. “Because of past family planning projects in the U.S. that coerced women to use certain contraceptive methods, some communities have an understandable distrust of the health care system, especially in the context of family planning.”
She hopes that her tool can help women in those communities overcome some of that distrust and become more satisfied with family planning counseling. “That satisfaction will not only result in better reproductive health care,” she said, “but will have a positive long-term impact in terms of these women being engaged with the health care system in general.”
Photo by Susan Merrell