 Patient and provider perspectives on Bedsider.org in a low income, racially diverse clinic population Gregory M. Gressel MD PGY-2 Department of Obstetrics, Gynecology and Reproductive Sciences

Disclosure  This speaker has no conflicts of interest to disclose relative to the contents of this presentation.

Objectives At the end of this presentation, participants should be able to:  Discuss the opinion of year old women in a low- income, racially-diverse clinic population of Bedsider.org.  Discuss the viewpoint of physicians, midwives, nurse practitioners and support staff exposed to Bedsider.org.  Describe the efficacy of Bedsider.org in improving patient contraceptive knowledge and intention to use long-acting reversible contraception (LARC) methods.

Yale New Haven Hospital Women’s Center  19,000 visits annually  60% Medicaid, 40% free care  45% Hispanic, 37% black, 13% white, 1% asian, 4% “other”

Study Aims and Objectives:  Aim 1: To expose year old women in a low-income, racially diverse clinic population to Bedsider  Aim 2: To expose clinic physicians, midwives, nurse practitioners and support staff to Bedsider  Aim 3: To assess patient contraceptive knowledge and birth control intention before and after exposure to Bedsider

Methodology  Mixed methods study  Focus groups  Patients  Clinicians and clinic staff  Yale New Haven Hospital’s Women’s Center  Urban, Medicaid-based clinic  Cares for an at-risk population of diverse, young women.  Patients completed surveys  To assess contraceptive knowledge and intention  Before and after exposure to Bedsider

Eligibility Criteria  Patient Participants  years of age  Seeking contraception, heterosexually active  Not planning new pregnancy in next 12 months  Could be pregnant at time of focus group  English or Spanish speaking  LARC naive  Women without a history of sterilization or hysterectomy  Provider Participants  MDs, midwives, NPs, nurses, medical assistants, office staff

Participant Enrollment GroupNumber of participants EligibleIneligibleReason for ineligibility Bedsider Patient Focus Group 15123All 3 pts w hx LARC use (Analysis based on 15) Bedsider Resident/Staff Focus Group 34 0(Quantitative analysis based on n=32 due to missing intake forms)

Patient Demographics Race Black8 (53.3%) Hispanic6 (40.0%) White1 (6.7%) Age Mean23.5 yrs (SD3.5) Education High school diploma or less4 (26.7%) Some College11 (73.3%) College/Grad degree0% Marital Status Never Married9 (60%) Married2 (6.7%) Living w partner, not married3 (20%) Separated/divorced/widowed2 (13.3%) # living children 04 (26.7%) 17 (46.7%) 24 (26.7%)

Intention to use birth control methods PRE-QUESTIONNAIREPOST-QUESTIONNAIRE Likely to very likely n (%) Likely to very likely n (%) LNG-IUD 3 (20.0%)6 (46.2%) Copper IUD 1 (6.7%)1 (7.1%) Implant 2 (13.3%)3 (20.0%) Female sterilization 2 (13.4%)2 (13.3%) Vasectomy 0 (0.0%)

Assessment of pre-vs. post- exposure knowledge of birth control efficacy < 1%1-5%6-10%> 10%Don’t know n (%) PrePostPrePostPrePostPrePostPrePost LNG- IUD 5 (33.3) 11 (73.3) 5 (33.3) 2 (13.3) 3 (20.0) 001 (6.7) 2 (13.3) 1 (6.7) Copper IUD 6 (40.0) 10 (66.7) 5 (33.3) 2 (13.3) 0001 (6.7) 4 (26.7) 2 (13.3) Implant8 (53.3) 3 (20.0) 5 (33.3) (26.7) 2 (13.3) Female steriliz. 10 (66.7) 11 (73.3) 2 (13.3) 001 (6.7) 02 (13.3) Male steriliz. 11 (73.3) 01 (6.7) 001 (6.7) 03 (20.0)

PatientsProviders Overall Impression and Attitudes + Legitimacy Accessibility Empowerment Applicability Helpful Share- everyone Easy Clinic integration Quick, convenient Pertinent for men & women Helpful Share- their own friends Easy Clinic integration Relatable Modern Diverse patients represented -Unknown Marketing Name unclear Legitimacy Accessibility Empowerment Applicability Marketing Name unclear Difficult to navigate Too complex, sophisticated Racy, smutty, ↑ promiscuity Disrespectful, inappropriate Unprofessional Intention unclear

PatientsProviders Information + Avoids medical terms Comprehensive Cost info Men included Detail-oriented, specific Up to date Understandable Others’ experiences Avoids medical terms Comprehensive Cost info Men included Interesting FAQs accurate - Not in Spanish Too much information Inaccurate Promotes less effective methods “Perfect use”

PatientsProviders Presentation and Format + Interactive Side x side method comparison Private Variety: written, videos, pictures Internet access Easy to use Flexible (use at home, clinic) Reminder section Interactive Side x side method comparison Private Variety: pictures, videos Speaks at level of audience Eye catching, appealing, chic - Internet access Language: slang, unclear terms, vocabulary Too busy, distracting Does not promote LARC Pictures: size, unclear (cork) Assumes wild sex Incongruent w MD counseling styles

PatientsProviders Recommendations and Future General Spanish Change name Patients and providers use together Availability: clinic waiting room, exam rooms, PP, maybe in high schools Market website more Distribute website info on cards Increase web exposure Information STI info for gay/lesbian couples Rapidity of fertility return Where to purchase female condoms Use younger patients for videos, pictures Update comment sections General Spanish Change name Patients and providers use together Simplify site Incorporate choice, self-esteem Information Remove “perfect use” “For Guys” section Most ob/gyns choose for themselves Define terms (“do me now”) in chart Better distinction between IUDs Unify years of LARC use w FDA approval Explain menses and amenorrhea Category for methods affecting menses Mechanism of action for methods Presentation and Format Integrate reproductive planning Group methods by effectiveness Promote LARC Identify which methods MDs recommend Highlight methods more (colors) Eliminate testimonials Have option of text being read Remove racy side bars

Quotes on Accessibility  Patients:  “Everything was perfect. Everything was in order, very easy to use. I thought it was going to be difficult... I mean, for people like us, it’s awesome. Other people don’t really know how to use computers… Yeah navigating was perfect.”  Providers:  “It’s just a ton of information just feels like where do we go next. It’s just a lot. So a lot of our population may not have desktop or laptop they may have it just on phones, so it may be harder to navigate where they’re going. If it was a little bit cleaner.”  “It needs to be simpler for our patients”

Quotes on Empowerment  Patients:  “I didn’t know a lot about all the different types of birth control…now I know that there (are) many different varieties I can choose from.”  “It opened me to a couple of methods of birth control that I wouldn’t have considered using before.”  Providers:  “I feel like, that’s like, it’s almost like smutty.”  “I think it is borderline pornographic.”  “ The fact is we’re trying to empower women to use this, and I feel that its sending the wrong message that um it’s ok to be trashy ”

Quotes on Legitimacy  Patients:  “They had actual women who had IUDs and the Mirena and they were talking about it so I thought it was really good.”  “The videos helped a lot. Where you could hear somebody talk about it instead of just reading it.”  Providers:  “There’s some concerning information that I don’t think is accurate or should be promoted to young patients.”  “But I think if they’re going to get their information online, this is definitely better than some of the information that is floating out around there. And as far as medical facts go, it’s not quite as accurate as what I’m telling my patients, but it's certainly closer than a lot of information out there on some seemingly formal- looking websites.”

Strengths & Limitations  Strengths  New insights  Thematic saturation  Limitations  Did not meet our enrollment goals  Unable to interview Spanish speaking patients

Conclusions  Patients like Bedsider  Even in a low-income patient population with limited resources, patients find Bedsider accessible, easy to use and informative.  Translating Bedsider into other languages and marketing it more broadly may make it available to a wider audience.  Bedsider may improve knowledge about birth control options and increase intention to use more effective contraceptive methods.  We, as providers, may be out of touch with our patient population and may need to re-think how to approach contraceptive education.

Special Thanks:  Aileen Gariepy MD, MPH  Lisbet Lundsberg PhD  Jessica Illuzzi MD  Cheryl Danton RN