Women’s Health Reports

Volume 3.1, 2022

DOI: 10.1089/whr.2021.0128
Accepted April 7, 2022

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ORIGINAL ARTICLE Open Access

Multilevel Influences on Providers’

Delivery of Contraceptive Services:
A Qualitative Thematic Analysis
Abbey K. Mann,1,*,{ Amal Khoury,2 Paezha McCartt,2 Michael G. Smith,2
Nathan Hale,2 Kate Beatty,2 and Leigh Johnson1

Abstract
Introduction: Access to a full range of contraceptive services is essential for quality health care. Contraceptive
provision practices of primary care providers play an important role in patients’ decision-making about their
reproductive health care. Understanding the multilevel factors influencing contraceptive care delivery in pri-
mary care settings is critical for advancing quality care. This study offers an in-depth examination of influences
on providers’ delivery of contraceptive services across multiple primary care specialties and practice settings to
identify issues and strategies to improve care.
Materials and Methods: Twenty-four in-depth face-to-face interviews were conducted in 2017 with primary
care providers, including family physicians, gynecologists, pediatricians, and nurse practitioners from academic
settings, private practices, and health centers. Interviews were transcribed and analyzed thematically.
Results: Providers described a complex set of influences on their provision of contraception across multiple eco-
logical contexts. Seven major themes emerged from the qualitative analysis, including six types of influence on
provision of contraception: organizational, individual provider-related, structural and policy, individual patient-
related, community, and the lack of influences or barriers. Providers also discussed the sources they access for
information about evidence-based contraception counseling.
Conclusions: A diverse set of providers described a complex system in which multiple concentric ecological
contexts both positively and negatively influence the ways in which they provide contraceptive services to
their patients. To close the gaps in contraceptive service delivery, it is important to recognize that both barri-
ers and facilitators to patient-centered contraceptive counseling exist simultaneously across multiple ecological
contexts.
Keywords: contraceptive behavior; qualitative research; primary care

1
Department of Family Medicine, Quillen College of Medicine, and 2Department of Health Services Management and Policy, College of Public Health, East Tennessee State
University, Johnson City, Tennessee, USA.
{
Current affiliation: Psychology Department, Lafayette College, Easton, Pennsylvania, USA.

*Address correspondence to: Abbey K. Mann, PhD, Psychology Department, Lafayette College, 350 Hamilton Street, Easton, PA 18042, USA, E-mail: mannak@lafayette.edu

ª Abbey K. Mann et al., 2022; Published by Mary Ann Liebert, Inc. This Open Access article is distributed under the terms of the Creative Commons
License [CC-BY] (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided
the original work is properly cited.

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Introduction women in SC do not use any contraception.23 Pro-

Reproductive health care, including access to the full viders and patients in SC face a challenging socio-
range of contraceptive services, is fundamental to pa- demographic landspace. SC experiences a higher
tients’ health and well-being. Modern contraception poverty rate than the national average and 25 of the
is safe and effective, allowing reproductive life planning state’s 46 counties are rural.24
and preventing unintended pregnancy.1–4 Primary care It is estimated that more than 300,000 women in need
providers play a key role in contraceptive counseling in SC live in contraceptive deserts—counties where the
and provision.5–7 Provider practices and quality of number of health centers offering the full range of meth-
care are a major driver of contraceptive use in the ods is not enough to meet the needs of the county’s
population and ultimately of reproductive health number of women eligible for publicly funded contra-
outcomes.8,9 ception.25 The legislative and political environment in
Researchers have noted gaps in the delivery of the state also presents barriers to contraceptive provi-
evidence-based contraceptive counseling and the full sion and access. SC did not expand Medicaid under
range of contraceptive methods.10–17 Studies identify the Affordable Care Act,26 and nearly 16% of reproduc-
individual provider characteristics associated with con- tive aged women in SC remain uninsured.25
traceptive provision, including provider type/specialty,15,18 Sex education in SC schools is limited by restrictive
provider training (knowledge, skills), and attitudes/ requirements,27 and the state does not perform favorably
beliefs,11,12,16–19 but much of the literature focuses on reprodutive health and reprodutive rights policy.28
on specific specialties such as emergency medicine or As such, examining factors impacting contraceptive de-
pediatrics.19,20 livery in SC is important for advancing patient-centered
Little is known about influences on providers’ con- care and reproductive autonomy in this historically un-
traceptive practices beyond their individual character- derserved state while contributing to the national discus-
istics, such as policy, community, and organizational sion around accessible, quality family planning. In
factors, and whether these influences vary or not across addition, to the extent that the health policies and orga-
primary care specialties. In addition, much of the liter- nizational climates that affect contraceptive access and
ature has focused on specific contraceptive methods use are similar across the U.S. South,22,28 this study find-
such as emergency contraception or long-acting reversible ings could have implications for advocacy and program-
contraception (LARC),19,21 and there is limited research matic efforts in other southern states.
about influences on contraceptive counseling.
This study adds to the literature in a meaningful
way by offering an in-depth examination of multilevel Materials and Methods
influences on providers’ contraceptive counseling and Design and eligibility
provision, including policy, community, and organiza- This study is a cross-sectional qualitative study in which
tional factors. This study is novel in assessing both we conducted 24 in-depth, face-to-face interviews
positive and negative influences across multiple pri- in 2017. Interviewees represented diverse primary care
mary care specialties (family physicians, pediatricians, specialties, practice settings, and geographic regions of
obstetricians/gynecologists [obs/gyns], nurse practi- SC. To be eligible for this study, providers had to meet all
tioners) and practice settings (private practices, pub- three eligibility criteria: (1) office-based family physician,
licly funded clinics, academic settings) to identify the ob/gyn, pediatrician providing adolescent care, or nurse
most salient issues and strategies to improve care. practitioner (women’s health nurse practitioner or fam-
Understanding the multilevel factors influencing con- ily nurse practitioner); (2) major professional activity
traceptive care in primary care settings is critical for in primary care (i.e., provider spent most of the
informing health policy and clinical practice and ad- time in outpatient patient care, not in administra-
vancing accessible high-quality care. tion, teaching, research, or other activity); and (3)
In addition, our study focuses on providers in South provided contraceptive and/or HIV/sexually trans-
Carolina (SC), a population that has not been studied mitted infection services.
in this context before. Examining contraceptive provi- We focused on these medical specialties because they
sion in SC is important given that the state has one of provide the majority of reproductive health care to pa-
the lowest rates of ‘‘wanted-then-or-sooner’’ pregnan- tients. Study procedures were approved by the East
cies,22 and more than one in four reproductive aged Tennessee State University Institutional Review Board.
Mann, et al.; Women’s Health Reports 2022, 3.1 493
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Sample identification and recruitment Variables of interest

Eligible providers were identified using purposive and Analysis for this study focused on seven interview
snowball sampling. A ‘‘maximum variation’’ purposive questions (see Appendix A1 for a complete list of
sampling approach maximized heterogeneity of partic- questions) designed to elicit information from provid-
ipants across four criteria (medical specialty, practice ers regarding factors that influence the ways in which
setting, geographic location across the four regions they counsel about and prescribe contraception.
of the state, and rurality) and captured a wide range These questions included an explicit focus on informa-
of provider perspectives related to contraceptive atti- tion that helps providers stay up-to-date on contracep-
tudes and practices. Recruitment strategies included tive prescribing guidelines, how similar or different a
(1) nominations for interviewees from women’s health provider’s practice is compared with peers, organiza-
leaders at public and private agencies in SC, (2) recruit- tion, policy and community influences, and patients’
ing providers from the SC Rural Health Association unmet needs.
conference, and (3) asking interviewees for recommen-
dations of potential participants. Analysis
Study staff sent invitation letters to a total of 39 pro- Using a thematic analysis approach,29 the first and
viders. Providers who did not respond within 1 week third authors, read through the transcribed data
received a reminder email and telephone follow-up to and identified an initial list of codes through open
clarify the purpose of the study and answer questions. coding. The authors then applied the initial codes
A total of 24 providers accepted the invitation (62% to a section of the data independently, after which
participation rate). Interviews were scheduled at a we collaboratively organized the codes into themes,
time and place convenient to the providers, typically revised the codes, and applied the codes to additional
at their practice location. data. We repeated this process until all data were
coded and we were in agreement about the applica-
Data collection tools tion of codes and themes to the whole data set. The
We collected data using a semistructured discussion second author, was given the codebook and a set of
guide and a brief demographic survey. The guide, con- responses to which she applied these codes without
sisting of a series of open-ended questions with probes, knowledge of how the data were coded by the first
was informed by an extensive literature review and col- two authors.
lected data about contraceptive practices and sources of This process resulted in 80% agreement between
influence on contraceptive care delivery. The demo- codes applied by the first two authors and the ad-
graphic sheet collected data about provider’s age, gen- ditional coder. Minor revisions were made to the
der, race/ethnicity, clinical degree, medical specialty, codebook and application of codes, and the resulting
years in practice, practice setting, zip code, board certi- agreement regarding coding of the data was 100%.
fication, faculty status, time allocated for patient care, Analysis was performed with NVivo 1.0.30
and patient volume. The interview guide and demo-
graphic survey were piloted with a small sample of pro- Results
viders, including physicians and nurse practitioners, Description of the sample
revised and finalized. We conducted interviews with a diverse sample of 24
providers, including 8 nurse practitioners, 5 pediatri-
Data collection cians, 4 family physicians, and 7 ob/gyns (see Table 1
We conducted interviews in the fall of 2017. Two mem- for participant characteristics). In terms of practice set-
bers of the research team traveled to the providers’ offices, tings, 9 providers were in private medical practice, 7 in
with the project leader consenting the providers and con- academic settings (university or hospital clinic), and 8
ducting the interviews and the research assistant taking practiced at health centers. Of the 24 providers, 9 prac-
field notes. Interviews typically lasted 45–60 minutes ticed in rural areas. Collectively, participating providers
each, and we sent providers a $100 remuneration for saw diverse clients including adolescents and adults
their time. Data saturation was achieved with 24 partici- with varied racial and ethnic backgrounds across mul-
pants, and data collection was concluded in December tiple income levels, insurance status (privately insured,
2017. We audio recorded and transcribed interviews, publicly insured, uninsured), and geographic locations
and we appended field notes appended to the transcripts. (rural and urban/suburban).
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Table 1. Participant and Clinic Characteristics visits at their clinic, noting that patients might want
(n = 24 Interviews) birth control 1 day but could change their mind if
Participant characteristics No. of participants (%) they have to wait 2 weeks for an appointment.
Gender More same day visits. If somebody calls and says, ‘‘I want birth
Male 5 (21) control’’ they want birth control’, they want it then. In two
Female 19 (79) weeks they may change their mind.—Family nurse practi-
Age tioner, college campus
Range 30–74
Mean 47.48 Another provider talked about access, in terms of
Standard deviation 11.15 clinic location, walk-in visits, and same-day service
Race/ethnicity provision, as an organizational facilitator of contra-
White 18 (75)
Black/African American 4 (17) ceptive care.
Mixed race 2 (8)
. you can walk in and get those services without having to
Provider specialty go see someone, potentially go home, go again to get whatever
Family physician 4 (17)
it is contraception that you want to get. .That model where
Obstetrician/gynecologist 7 (29)
Pediatrician 5 (21) you don’t have to have an appointment and you can get
Nurse practitioner 8 (33) the contraceptive services that you need that day, I think is
ideal. if the contraceptives are free but you can’t get there
Years in practice
Less than 5 years 3 (12.5) and you can’t get to it, then it doesn’t matter.—OBGYN, pri-
5–10 years 6 (25) vate practice, urban area
10–15 years 3 (12.5)
15–20 years 3 (12.5) Providers also mentioned challenges related to the
20 or more years 9 (37.5) need for clinic profitability, with some noting that
Clinic characteristics No. of clinics (%)
they wish they could offer care for free or for less
than what they currently charge to increase access for
Geography patients. A related concern raised by some providers
Rural 9 (38)
Urban 15 (62) was the expense of having LARC devices in stock and
Region of the state the delay in care that having to order devices on a
Upstate 5 (21) case-by-case basis creates.
Midlands 6 (25)
Pee Dee 7 (29) A few providers discussed supportive organizational
Low country 6 (25) policies. For example, a couple of providers specifically
Primary practice settinga mentioned that their organization’s policies are sup-
Academic (university or hospital clinic) 7 (29)
Private office practice 9 (38) portive of them offering contraception to pediatric pa-
Health centerb 8 (33) tients. One provider mentioned the negative influence
a
Of the 24 interviews, 5 were at rural health clinics, including 4 private of some organizational policies, including a previous
offices and 1 health center.
b
policy in the organization against providing contracep-
Of the 8 health centers, 6 were federally qualified health centers 1
was a college health center, and 1 was a hospital-affiliated center. tion or supporting provider training for contraceptive
practices. Another provider, a pediatrician in an aca-
demic setting, mentioned that his or her organization is
Findings ‘‘not restrictive’’ and ‘‘fairly forward-thinking’’ when it
Authors identified seven major themes that emerged comes to providing contraception to adolescents.
from the analysis of providers’ responses: organiza-
tional, provider-related, structural and policy, patient- Provider-related. Most (20) participants brought up
related, community, absence of barriers or influences, provider-related influences on contraceptive provision.
and sources of information about contraception. Participants indicated that provider experience, train-
ing, and educational background influence the ways
Organizational. Of the 24 providers interviewed, 21 in which they practice.
mentioned organization-related barriers and facilita- I think that we as providers may not have as much knowledge,
tors to contraceptive provision. Specifically, about primary care may be behind the times in what we’re throwing
half of the providers mentioned difficulty of getting ap- out there, and what we are offering.—Family Nurse Practi-
tioner, health center, rural area
pointments and lack of available providers as organization-
related barriers to contraceptive care. For example, one Participants also mentioned that they or other pro-
provider expressed a desire for patients to get same-day viders have individual preferences or varying comfort
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with procedures or practices that guide the way they to their patients and their inability to provide lower
provide contraception, including some participants, fees or participate in government pricing.
most of whom were not pediatricians, who mentioned . the health departments get 340B pricing, it’s government
that pediatricians might be less comfortable than other pricing so they can get their pills and stuff cheap. I know
primary care providers addressing reproductive health when I was there we paid like a penny a cycle for pills. But I
can’t get that even though we’re a state supported agency.
issues with patients. Some participants expressed their I don’t want to charge for my services to be able to. I like
and others’ discomfort in prescribing intrauterine de- not charging and them being able to come see me without pay-
vices (IUDs) to teens. ing a fee.—Nurse, college campus

.probably half of the pediatricians didn’t even want to mess Beyond financial barriers, several providers men-
with birth control. They talked to their patients right in front tioned it can be difficult for patients to get transporta-
of their parents. ‘‘You’re not having sex right?’’ Yes, because
you’re going to wait until you’re married and all this stuff.I tion to their clinic, and while there are efforts in some
get to meet pediatricians from all over the country. I find that communities to improve access through transporta-
almost none of them screen their patients for HIV. .The tion, these efforts do not help enough people.
Nexplanon or IUD, I don’t know a single pediatrician that
does that. Now listen, medicine is a different story. A general Transportation is an issue because a lot of patients come from
pediatrician, I’ve not met one that does that.—Pediatrician, rural areas; some of them, up to 50 miles away. I’m always
health center impressed, when they tell me they do that. I’m like, ‘‘Wow.
Thanks. Nice to know’’ It makes access a little bit of an issue
Some other participants cited other providers’ reli- for them.—Pediatrician, health center
gious beliefs as influencing whether or how they pro- Some providers also mentioned efforts to increase
vide contraception for patients. access via transportation that had been successful,
We do have quite a few in this particular practice that are such as one who described a program that takes girls
adverse [to providing contraception] for their own religious
beliefs. They tend to refer them to some of us who are com-
from school to the clinic and back.
fortable with doing contraceptive care. I’d say that probably We also have the transportation that helps bring the patients
there’s a greater group than I would have expected to see that in and out. If there’s any kids that need these types of
are not willing to prescribe or use any kind of contraception things, that parents have agreed.they can transport them
for their patients—Family nurse practictioner, health center during school hours.They’ll be seen and then brought
back to school so they can finish the rest of the day,.They’ll
Notably, most participants talked about provider transport them to wherever they need to go to a specialized.—
preference or experiences, about half talked about pro- Family nurse practitioner, private practice
vider training and education as a barrier or facilitator, A few providers commented on specific laws related
and a quarter mentioned that provider beliefs play a to contraceptive care provision, such as the law that
role. All three subcategories were mentioned by provid- prevents them from providing contraceptive care in
ers from each specialty represented in the sample. school settings.
.we can’t do school based clinics and provide contraception
Structural and policy. Nineteen providers identified in schools. That’s illegal in our state, but having clinics that are
issues beyond the organization at the structural or pol- in locations that are more accessible to teens would be really
helpful.—OB/Gyn, academic setting
icy level that influenced their care, primarily insurance
coverage, billing and reimbursement issues related to While some providers only discussed their frus-
insurance, specific policies/laws, cost of contraceptives tration with certain laws and policies, others described
to clinics, and transportation. Half of the participants ways in which they had worked around such issues to
mentioned that uninsurance or underinsurance poses connect with patients despite these barriers.
a barrier to their ability to provide care that best
meets the contraceptive needs of their patients and Patient-related. Many providers (17) brought up
talked about challenges related to billing and reim- patient-specific issues that influenced their provision
bursement for the services they provide. of contraception. Provider talked about patients’ lack
I do have several patients that have decided just to go with the of knowledge or misconceptions about reproductive
OCPs because that’s what they can afford. Because they can’t health in general and contraception options specifically,
afford $600, $700 for the placement of an IUD or $800 for as well as limited awareness of the availability of family
Nexplanon.—OBGYN, private practice, rural area
planning clinics as barriers to their ability to prescribe
Relatedly, several providers talked about the barriers contraception. Potential patients might not know what
that the general cost of getting contraceptive care poses their options are or where they can go to get care.
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. I think there’s a lot of people out there who aren’t aware community reaching organizations. A few providers
that they can get some of those services through a place like
[clinic name], through a federally qualified health center.
described generally good relationships with the sur-
So I think the awareness of the availability is probably the rounding communities and community-based groups.
biggest.—Nurse, health center, suburban area .the community at large is largely receptive to the provision
Several providers talked about the importance of of contraceptive services.—OB/Gyn, private practice
listening to patients’ preferences about their contracep-
Sources of information. Providers noted a range of dif-
tion options, and several providers also mentioned the
ferent sources of information about contraceptive care.
role that parents sometimes play in the process of get-
Most providers pointed to more than one source of in-
ting contraception, particularly for pediatric patients,
formation. The most frequent responses were other pro-
but also for older teenagers including those starting col-
viders, conferences, peer-reviewed literature, and formal
lege. Parents’ role can be supportive of contraception or
guidelines, such as American College of Obstetricians
not, with some parents encouraging their sexually ac-
and Gynecologists, or online resources such as UpTo-
tive teens to use contraception, including long-acting
Date. Notably, five providers said that they do not follow
methods, and accompanying them to their appoint-
a specific set of guidelines or that they do not find them
ments, while other parents seeming to ignore or deny
helpful. For example, one ob/gyn in a private practice
sexual activity.
responded ‘‘I don’t think I follow any formal guidelines.’’
A few providers noted that patient compliance influ-
A couple of providers stated that providers have
ences the choices providers make about providing con-
freedom to practice based on their preferences, rather
traception. Providers discussed why they may be more
than following specific guidelines, and one mentioned
likely to recommend LARCs for patients whom they
that they felt guidelines were not nuanced enough to
suspect will not comply with user-dependent methods,
be helpful in their contraceptive provision pratices.
but even there, patients may not show up to their
LARC appointment.
Discussion
Then there’s the patient compliance issue. You set aside 30 or
45 minutes for a contraceptive counseling session, a postpar-
This study used in-depth interviews to closely examine
tum visit and the patient is alleged to want an IUD. You’ve got multiple levels of influence on provider counseling
it, or you’ve requisitioned it from the pharmacy. The patient about and provision of contraception. Our findings il-
doesn’t show up. Unfortunately, that happens much more fre-
quently than we need for it to.—OB/gyn, academic setting
lustrate similarities in influences across providers with
multiple specialties. Providers discussed structural/
Community. Half of the providers interviewed (12) policy, organizational, community, patient, and per-
mentioned community-situated influences on their sonal influences on their contraception provision, in
ability to provide contraception. These influences can addition to formal sources of information. The major-
be negative or positive. ity of providers cited community factors and the ma-
Several providers mentioned predominant religious jority of providers cited all other factors , illustrating
beliefs and stigma in the community as negative influ- how common and widespread these influences are on
ences on contraception provision, such that conser- contraceptive delivery. Responses add depth to our un-
vative religious beliefs and negative attitudes about derstanding of the complex network of interrelated fac-
contraception could pose as barriers to care. tors affecting contraception counseling and provision.
In contrast with much of the previous research,
I think it’s still a little bit of a taboo to talk about contracep-
tion. For a long time I think the only form of contraception which examined influences on clinical decision-
was abstinence, so to even suggest that there was something making,31–35 the current findings extend our knowl-
to do, to use to prevent pregnancy other than abstinence edge by identifying contextual influences on care, in
was just unheard of. . That still we shouldn’t be talking
about those things and you shouldn’t need to worry about addition to organizational and individual factors, across
contraception because you’re not going to have sex until multiple provider specialties and practice settings.
you’re married ..- Family Physician, academic setting, sub- Across organization types, providers identified
urban area
organization-related factors that echo previous findings,
On the contrary, a few participants shared exam- such as the ability to make same-day appointments, and
ples of community acceptance and support of their availability of long-acting contraception.36,37 They also
practices, making it easier to connect patients with discussed organization-related issues not previously
contraception, and highlighted the positive role of noted in the literature, such as the need for clinic
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profitability and the role of organizational leadership programs to raise patients’ awareness of their options
and policies. This may be because these issues were be- and for provider training that emphasizes a patient-
yond the scope of previous research, but their identifi- centered approach to contraception counseling.
cation here indicates that a focus on the role of the There may be an opportunity for providers to fur-
organization is a complex one that is recognized by a ther acknowledge their role and responsibility in coun-
range of providers. seling and informing their patients, as well as an
Much of the previous literature on provider-related opportunity for training programs to prepare providers
influences on contraception provision focused on to better address patients’ misperceptions about con-
specific specialties and on particular methods of traception. Providers in this study also dicussed the
contraception.19–21 role of patients’ parents in the process of contraception
In this study, providers from a mix of specialties counseling. Parents’ own beliefs and experiences may
noted provider-related factors—specifically their prefer- influence those of their children. This warrants addi-
ences or previous experiences with contraception provi- tional study, particularly when adolescent patients are
sion, their training or education, and their beliefs—play the population of interest.
an important role in how they counsel about and pre- Little of the previous literature focuses on community-
scribe contraception. These factors were not all de- related factors that influence contraceptive provision.
scribed as barriers, as some providers noted that their Only one study mentions the role of religion but
high degree of knowledge and experience facilitates does so in the context of individual patients.36
care. Nevertheless, lack of experience, confidence, and Participants in this study noted that religion, com-
comfort in counseling about and providing the full munity acceptance or support, and stigma from com-
range of contraceptive methods emerged as a common munity members play a role in their provision of
theme. This highlights the need for training of providers contraception. These findings point to the need for ad-
while in medical school and residency and also as a part ditional close examination of the ways in which reli-
of continuing medical education. gious communities, community support, and stigma
Previous researchers have identified providers’ affect providers’ perceptions and practices, particularly
perceptions of cost as a barrier to contraception,19,38 al- given the omnipresence of evangelical religious beliefs
though the structural barriers, such as limited insurance and practices in this region.41 In addition, these find-
reimbursement or the high cost to clinics of obtaining ings point to an opportunity to promote models of col-
IUDs, raised in this study have received less attention. laboration with faith-based organizations to help raise
Although previous work has focused on the cost and community support for contraceptive care.
lack of insurance as barriers,39,40 there is less evidence Interestingly, there was little consensus among pro-
on providers’ perspectives on these significant barri- viders as to where they get their information about con-
ers.36 Moreover, providers in this study recognized traceptive guidelines and evidence-based practices.
the role of specific policy issues, lack of patients’ access Providers mentioned a range of sources of information
to transportation, and legal impediments to contracep- including some that may not be highly reliable.
tion provision. These findings indicate that providers rec- This study has some limitations including that its
ognize that the factors influencing their contraception intent is not to serve as a representation of all contra-
provision are complex and work simultaneously across ception providers, but rather to closely examine the in-
multiple ecological conctexts They also recognize fluences on this sample in this context. The study also
that some of these factors extend beyond the walls only included providers who prescribe contraception.
of the clinic and may be largely beyond their control. We may be underestimating or missing some barriers
Some providers recognized patient preferences as im- or influences that would have been voiced by providers
portant factors to consider during the counseling process who do not provide contraception. In addition, given
to facilitate shared decision-making and patient-centered that more providers in the sample were white than
care. Other providers talked about the limited knowledge non-white, female than male, and more practiced in
of their patients and, as highlighted in the results, a pos- urban areas than in rural areas, we may have picked
sibility for patients to ‘‘change their mind’’ about wanting up on a wider range of themes related to the experi-
contraception, as negatively affecting their preferences ences of those providers than we would have if we
and awareness of their contraceptive options. This high- had included more providers of color, more male pro-
lights the need for community outreach and education viders, and more providers in rural areas.
Mann, et al.; Women’s Health Reports 2022, 3.1 498
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Author Disclosure Statement 19. Miller MK, Plantz DM, Denise Dowd M, et al. Pediatric emergency health
No competing financial interests exist. care providers’ knowledge, attitudes, and experiences regarding emer-
gency contraception. Acad Emerg Med 2011;18:605–612.
20. Kaskowitz A, Quint E, Zochowski M, Caldwell A, Vinekar K, Dalton VK.
Funding Information Contraception delivery in pediatric and specialist pediatric practices.
J Pediatr Adolesc Gynecol 2017;30:184–187.
This study was funded by a private philanthropic 21. Swanson KJ, Gossett DR, Fournier M. Pediatricians’ beliefs and prescribing
foundation. The funder had no involvement in the patterns of adolescent contraception: a provider survey. J Pediatr Adolesc
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22. Guttmacher Institute, Kost K, Maddow-Zimet I, Kochhar S. Pregnancy
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Appendix

Appendix A1. Interview Guide 5. How would you say your community and/or so-
cial environment impact your delivery of contra-
1. How do you remain up-to-date on cur- ceptive services to your patients?
rent recommendations for contraceptive pre- 6. Do you see an unmet need for contraceptive ser-
scribing? vices in your community?
a. What guidelines do you follow to determine 7. Is there anything else about this topic that you
if the patient is eligible for one contraceptive feel is important to discuss?
method over another?
2. In your opinion, how useful are clinical guidelines
in contraceptive care delivery? Publish in Women’s Health Reports
a. Which sets of guidelines do you find the most
helpful? - Immediate, unrestricted online access
b. What are the barriers you face in utilizing - Rigorous peer review
- Compliance with open access mandates
those guidelines?
- Authors retain copyright
3. To what extent is your approach to contraceptive
- Highly indexed
delivery similar or different from the approach of
- Targeted email marketing
your colleagues/peers?
4. In what ways does your organizational culture
of policies impact your delivery of contraceptive
services to your patients? liebertpub.com/whr