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Abstract

Background:

Unintended pregnancy contributes to a high burden of maternal and fetal morbidity in the United States, and pregnancy intention screening offers a key strategy to improve preconception health and reproductive health equity. The One Key Question^© is a pregnancy intention screening tool that asks a single question, “Would you like to become pregnant in the next year?” to all reproductive-age women. This study explored the perspectives of community health workers on using One Key Question in community-based settings.

Objectives:

This study aimed to identify barriers and facilitators to the use of the One Key Question pregnancy intention screening tool by community health workers who serve reproductive-age women in Salt Lake City, Utah.

Design:

Using reproductive justice as a guiding conceptual framework, this study employed a qualitative descriptive design. Participants were asked to identify barriers and facilitators to the One Key Question, with open-ended discussion to explore community health workers’ knowledge and perceptions about pregnancy intention screening.

Methods:

We conducted focus groups with 43 community health workers in Salt Lake City, Utah, from December 2017 through January 2018. Participants were trained on the One Key Question algorithm and asked to identify barriers and facilitators to implementation. All focus groups occurred face-to-face in community settings and used a semi-structured facilitation guide developed by the study Principal Investigator with input from community partners.

Results:

Pregnancy intention screening is perceived positively by community health workers. Barriers identified include traditional cultural beliefs about modesty and sex, lack of trust in health care providers, and female bias in the One Key Question algorithm. Facilitators include the simplicity of the One Key Question algorithm and the flexibility of One Key Question responses.

Conclusion:

One Key Question is an effective pregnancy intention screening tool in primary care settings but is limited in its capacity to reach those outside the health system. Community-based pregnancy intention screening offers an alternative avenue for implementation of One Key Question that could address many of these barriers and reduce disparities for underserved populations.

Keywords

community health workers health equity pregnancy intention screening primary care women’s health

Introduction

Unintended pregnancies, those that are either mistimed or unwanted, account for 35%–42% of the annual pregnancies in the United States.^1,2 and are associated with increased maternal and infant morbidity and mortality.^2
–5 More than 50% of reproductive-age women report at least one preconception risk factor including smoking, alcohol or substance use, obesity, and diabetes, and these risk factors disproportionately impact women of color and women of low socioeconomic status (SES).^1,3,4 Reducing the rate of unintended pregnancies is a key public health objective in the United States, with a focus on increasing use of birth control and family planning services.^6,7 Pregnancy intention screening (PIS) is an approach designed to proactively aid in decision-making about how pregnancy fits into an individual’s life plans.⁸ PIS is used by clinicians to identify a patient’s reproductive health care needs, promote preconception health and minimize preconception risk factors, facilitate appropriate conversations about family planning and pregnancy spacing, and inform counseling about women’s health risks and behaviors.

A simple approach to PIS is the One Key Question^© (OKQ), a tool developed by the Oregon Foundation for Reproductive Health.⁹ It uses a single question, “Would you like to become pregnant in the next year?” and an algorithm that guides clinical counseling with a focus on family planning and/or preconception care.¹⁰ OKQ aims to support women who want to become pregnant and those who do not, with four categories of patient responses: “Yes,” “No,” “OK either way,” and “Unsure.” Because a lack of reproductive life planning contributes to high rates of unintended pregnancy in the United States,^4,9,11 it has been recommended that an approach like the OKQ be used in all clinical encounters with reproductive-age women, regardless of the reason for the care.⁹ A note on language: in this article, we use the term “women” to refer to people who can become pregnant. While we recognize the ongoing shifts in terminology in women’s health to use gender-inclusive language,¹² our study participants used the term “women” in their discussion, and we have chosen to keep their terminology consistent in reporting our data.

Reported data on PIS are limited, but a 2014 survey of federally qualified health centers found that while 90% of their female, reproductive-age patients were not actively planning a pregnancy, 30% of these patients were not using any form of contraception.⁷ There is a need for more research to improve PIS uptake and efficacy both from the perspectives of health care providers and patients. Provider perceptions of PIS and in particular the use of OKQ are mixed. One study of 443 primary care physicians in New York State indicated that only 48% reported routinely performing PIS, although 88% felt that PIS should be integrated into all primary care visits.^13,14 Furthermore, studies indicate a need for further training for health care providers on the basics of contraceptive and preconception clinical care as well as training on reproductive justice and principles of patient autonomy.¹⁵ Other barriers identified in the literature include a lack of knowledge, comfort, and/or training in reproductive health counseling, assumptions about patient pregnancy status and desire, and competing medical issues with limited time during office visits.^14,16 Despite mixed uptake of PIS tools like the OKQ and irregular integration of routine PIS into primary care visits, PIS holds promise for improving unintended pregnancy rates. Patients report overall favorable views of PIS, with up two-thirds reporting that tools like the OKQ are helpful to facilitate communication around reproductive health and family planning.¹⁷ Little is known about how these screening tools might be used by nonclinicians in community settings. Because unintended pregnancy rates are highest within populations that face barriers to health care access, community implementation of PIS by trained community health workers (CHWs) may decrease the rate of unintended pregnancies and improve maternal and infant health outcomes.^1,18

Pregnancy and contraception use are rooted in complex social, economic, and cultural mores.^11,19,20 Furthermore, in recent history, many Black, Indigenous, and People of Color (BIPOC) communities have experienced methods of reproductive coercion (RC) such as emphasis on long-acting highly reversible contraception (LARC) methods²¹ and forced sterilization.²² This can limit community trust of medical providers and reduce the efficacy of the OKQ approach. CHWs could play a key role in PIS in community settings to address these issues. CHWs are members of the communities they serve and can build trust with individuals in a way that might be impossible for outsiders.^23
–26 Despite ample data supporting the effectiveness of CHWs in the United States in promoting preventive health care, CHWs are infrequently included in the field of reproductive health care.²⁷ This contrasts with the use of CHWs in numerous global health settings, where CHW-based reproductive health programs have been effective in increasing contraceptive use and decreasing child mortality.²⁸

Training CHWs in PIS and counseling may be an effective way to facilitate pregnancy intention conversations and make effective referrals for preconception or contraceptive health care. However, little is known about CHW interest and skill in engaging in PIS and counseling activities. Thus, this article will explore the perceptions of CHWs regarding the integration of PIS in general, and the OKQ specifically, into existing community-based services.

Methods

To explore perceptions about PIS among CHWs, we designed a qualitative descriptive study²⁹ and conducted focus groups to understand barriers and facilitators to PIS as perceived by CHWs who received training about PIS and the OKQ approach. The study was reviewed and approved for exemption by the Institutional Review Board (IRB) at the University of Utah on 11 September 2017 (IRB_00104580). The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist guide was followed in the study. We conducted three focus groups with 43 CHW in Salt Lake City who primarily serve BIPOC communities and were recruited from the CHWs Coalition as well as through known CHWs from a prior study of BIPOC women.^30
–33 Snowball sampling was used to reach additional CHWs.

CHWs were provided with a pretraining evaluation form (Appendix 1) to assess knowledge of and confidence in PIS. Limited demographic information was collected at this time, including gender, participant’s role (CHW, outreach worker, and so on), setting of work, length of time in role, and communities served. The majority of CHW study participants identified as serving the Hispanic/Latino/a community (n = 36) and participated in two Spanish-language focus groups. One focus group (n = 7) was conducted in English. Forty-one CHW participants identified as women, and two identified as men. Exclusion criteria included previous training and participation in PIS or formal clinical training in reproductive health services. CHWs were asked to identify the communities they served and share their roles as well as length of service. Communities served included Hispanic/Latino/a, African American, African American Immigrant/Refugee, Other Immigrant/Refugee, Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, Pregnant Women, Caucasians, LGBTQ, and Youth. The term “CHW” was broadly applied to people working to deliver evidence-based health information to their respective communities. Participants also identified their roles within their respective organizations, which ranged from volunteer domestic violence advocates to paid “promotoras” or CHWs embedded in service organizations as doulas and church leaders. Further information regarding the CHW participant characteristics can be found in Table 1.

Table 1.

CHW participant characteristics.

Communities served	% of CHW participants
Hipanic/Latino/a	90.70
Youth	30.23
Pregnant Women	25.58
African Immigrant/Refugee	23.26
Lesbian/Gay/Bisexual/Transgender/Queer & or Questioning	23.26
African American	13.95
Asian	13.95
Native Hawaiian/Pacific Islander	13.95
American Indian/Alaskan Native	13.95
Other Immigrant/Refugee	2.33
Caucasians	2.33
Length of service	Number of participants
<1 year	7
1–3 years	12
4–5 years	4
6–10 years	3
11–15 years	2
16–20 years	4
>20 years	1
Unknown	10

CHW: community health worker.

Focus groups were conducted over the course of 6 weeks from December 2017 through January 2018 in Salt Lake City, Utah. All focus groups occurred face-to-face in a group setting. Participants signed consent documents in Spanish or English and participated in a OKQ training held in local community centers and churches, delivered in Spanish or English (Training PowerPoint slides included in the supplemental material). Participants were then asked, “Are you interested in exploring ways to integrate OKQ into practice?” and results were recorded. Immediately following the training, audio-recorded focus groups were initiated. Each focus group was approximately 60 min long and was conducted using a semi-structured guide developed by the research team (Appendix 1). Two out of three focus groups were conducted in Spanish and were facilitated by CHWs with support from two female researchers, and one focus group was facilitated by the female PI of the research study in English. The PI of the research study has previously worked with various members of the CHW Coalition on several past studies and initiatives and was known to several of the focus group participants. Participants received a meal and a US$25 gift card to compensate them for their time. All focus group discussion was audio-recorded with patient consent. The study was reviewed and approved by the IRB at the University of Utah.

Data analysis

The Spanish-language interviews were translated to English by a professional translator, and all interviews were transcribed verbatim. Inductive codes were developed through a consensus process by three members of the research team (SES, SSC, and SD).³⁴ The transcripts were then coded independently by two members of the research team (SSC and SD) in Dedoose qualitative research software using line-by-line open-coding techniques.³⁵ Coding inconsistencies were reconciled during consensus coding of research team members (SES, SSC, SD, and LC). Content-based categories were identified, and codes were grouped into one or more categories by the entire research team.^29,36 A consensus process was used to review, interpret, and code data, which allowed the research team to share similar and divergent interpretations of the interview dialogue and deepen a shared understanding of the data. Data analysis continued until no new codes occurred in the data either through independent coding by SSC and SD or through group consensus meetings with the research team; that is, data adequacy was achieved.^37,38 As team consensus meetings progressed, we identified exemplary quotes to illustrate the categories. Exemplary quotes illustrate the categories, and the narrative descriptions elaborate on the shared cultural knowledge and nuanced deviations and exceptions within the CHW community.

Results

Of the 43 participants, 41 identified as female and 2 as male. A total of 36 individuals participated in Spanish-language focus groups and 7 participated in an English-language focus group. In total, 86% (n = 37) of focus groups’ participants indicated “Yes” to the question, “Are you interested in exploring ways to integrate OKQ into practice,” 11.63% (n = 5) indicated “Not Sure,” and one participant stated “No.”

During the focus groups, participants explored barriers and facilitators to conversations about reproductive health and pregnancy planning and identified PIS approaches including the OKQ that would enhance trust and improve outcomes in their communities.

The following categories emerged through consensus during data analysis of the focus groups: (1) who is asking the OKQ, and who is the audience; (2) what is the OKQ; (3) why are we asking the OKQ; and (4) how will it be implemented?

See Table 2 for further information on categories and codes generated during data analysis by the research team.

Table 2.

Code tree and exemplary quotes.

Themes	Codes	Exemplary quotes
Who is asking the OKQ? Who is the audience?	Trust	You just don’t go to someone, a stranger and say hey, you know what, are you planning on getting pregnant here soon? So I really think that you have to be sensitive and build that rapport in order for them to build that trust.
	Cultural and generational	Because of culture and generations, this is a subject that is not talked about. I’m going to talk to you about me: five children, three were preemies. So, I would have liked to have gotten that information so I could have healthy children.
	Female bias	“Maybe information on vasectomies, because it’s not only on the woman, you know? Men can also take on some responsibility.”
	Blame	“We tell our boys, ‘When you have sex, you do it for pleasure’ not-in the case of a girl-‘to get pregnant,’ or as well tell him, ‘to ruin your life’.”
	Systemic/Historical oppression	“I’ve worked in the Latino population, for quite some time, and their experiences with different agencies it’s very disappointing. And after that one bad experience they won’t go back.”
	Coercion	“There are women who don’t want to have children but continue having them because the husband doesn’t want to use protection.”
	Religion	“I think most of those people are convinced that regardless of the conversation or the method used if God decides he wants you to get pregnant; you’re going to get pregnant.”
	Social distance	That’s what happened to me when I got pregnant for the sixth time. My doctor scolded me and asked me why I wanted so many children, and that I shouldn’t have anymore and that he wanted me to stop, and I felt bad.
	Women as vessels	“We hear ‘prenatal’ care and we think it’s when we get pregnant. Actually, prenatal care should begin when a girl has her period for the first time.”
	Partner	But at the same time, when someone asks—the most likely, what I have seen, is that doctors always ask them and then they go home and they talk to their partners about the subject. At least, this is the way the conversation starts.
	Abortion	“You can’t tell them, ‘Go to such-and-such place [Planned Parenthood]’, because they’ll say, [whispers] ‘They’re cutting out all the babies over there’.”
What is the OKQ?	Alternative phrasing	“‘Do you want to get pregnant?’ It’s a scientific question. Or, you could say, ‘Do you want to have a child?’”
	Asked too often	“I don’t think they would be open to being asked each time we run into them.”
	Sensitive topic	“Shame is the first barrier we have to break. Even among friend my same age or younger, we feel embarrassed or guilty talking about sex, about how to protect yourself.”
	1 year	“Putting a time limit on it is like asking them, ‘Yes or No?’”
Why are we asking the OKQ?	Program intent	“I don’t think you could expect to come in and tell people do this, or do that, use this, or use that. But rather tell them what the options are and then let them kind of make their own decision.”
Why are we asking the OKQ?	Knowledge	“Those are the most common defects that happen, and they’re 100 percent preventable. It’s sad that we have kids living with these defects when they could’ve been prevented 100 percent”
How will the OKQ be implemented?	Existing resources	“That’s a real barrier in terms of culturally relevant and sensitive material. Even the health department is limited in terms of materials that are culturally relevant and sensitive.”
	Finances	“Many people wouldn’t go to the clinic because they didn’t have a ride, they were embarrassed or they didn’t have any money.”
	Resource needs	“We just hope that they have primary care, that’s what we hope. . .having uninsured clients is a real barrier.”
	Education needs	“We need to know how to engage that conversation. So, like this training we have the tools now so how to communicate with them. I don’t think it will be a big challenge.”

OKQ: One Key Question.

Who is asking the OKQ?

Social distance and trust

Participants discussed the identity of the person conducting the PIS as being critically important. Trust was highlighted as a key aspect for successful engagement with community members: language, race, cultural humility, and SES were noted as factors that influence the willingness of community members to honestly share information about sensitive topics with providers. One participant shared, “women and men of color that approach me can share my experiences. They are able to build that rapport and really value your views.”

While many participants discussed the importance of receiving information from trained health care providers and staff, participants expressed doubts that implementation of PIS in general or OKQ in primary care settings would result in honest conversations.

Many participants expressed an interest in expanding their role to include PIS and preconception/contraceptive health counseling. Participants highlighted their unique relationships with women in their communities as a key facilitator to successful implementation of PIS:

Community health workers have a virtue, and it’s that they gain people’s trust, and they have a personal relationship with the patient. Oftentimes patients tell you things that not even their husbands know about, that not even their parents know. Why? Because you become someone—a resource to that person, and they know the information is confidential, that they’re safe, that you won’t do anything that will affect them.

CHWs were identified by participants as a trusted and accessible source of health information. CHWs themselves and participants felt that they could expand their role to include PIS in underserved populations.

Who is being asked the OKQ?

Cultural and generational considerations

Participants noted that conversations about sex and reproduction are fraught with preconceptions about morality, culture, and religion. Several women highlighted differences in attitudes between generations, with one stating that varied approaches should be used between “younger millennials who have more access to information” and other communities, like “immigrant moms in their 30s and 40s who may have more cultural barriers to talking about [reproductive health].”

Several participants spoke about the culture of shame regarding unintended pregnancies. One woman noted how she was guilty of threatening her own daughter, “if you get pregnant, you get kicked out of the house,” and how she now regrets that approach. Participants also discussed the impact of religion and culture on views of sex and reproduction, with one woman noting how girls in her community are taught that sex is purely for reproductive purposes, “to get pregnant, or as we tell them, to ruin your life.”

Women’s responsibility for reproductive health outcomes

In all four focus groups, participants mentioned the female bias of the OKQ and its exclusive focus on the reproductive health and family planning needs of women. The impact of a woman’s health behaviors on pregnancy outcomes and her perceived responsibility for the health outcomes of her future child was discussed at length. One participant said,

But in reality, to get pregnant you need the man, and they’re not including the men. So, it’s like you’re excluding him, and for them it’s like, “that’s a woman’s thing,” when it isn’t the case. It involves both of them.

Participants identified the lack of corresponding PIS in the male population as a limit to OKQ’s efficacy in reducing rates of unintended pregnancy and noted the double standard of placing the burden of reproductive life planning exclusively on women. One African American male participant shared, “I think that’s our socialization process. It’s that we have not said to men your behavior affects this baby as much as the behavior of the mother does. And we’ve got to say that.”

Participants also noted the absence of nuance regarding reproductive and sexual decision-making: in some cases, participants noted, a woman might not have the choice to decide to get pregnant or have children or might not be able to become pregnant. Conversely, participants also argued that reproductive goals are often decided jointly between women and their spouses or sexual partners. Thus, in many situations, participants noted that the OKQ should involve a conversation with both partners.

What is the OKQ?

The specific verbiage of the OKQ approach was analyzed, with some participants questioning the use of the term “pregnancy” as overly clinical or scientific and suggesting alternative phrasing such as, “Would you like to have a healthy child within the next year?”

Others affirmed the OKQ approach, arguing that the broad use of this question and algorithm could offer women the opportunity to reduce stigma and explore their reproductive and sexual health needs with trusted providers and health care staff. One participant who favored using the OKQ approach indicated that it could help women align their behaviors with their plans and goals:

The question opens the door, and as soon as you open the door you can imagine your future and what the responsibility is by simply having sexual relations. It’s not just getting pregnant or getting a disease.

Participants had mixed opinions on the verbiage of the OKQ, suggesting that alternative phrasing could be explored by those asking the question.

Why are we asking the OKQ?

Throughout the course of our focus groups, participants highlighted the importance of addressing systematic mistrust of the health care system and in particular the intentions of reproductive health providers. Participants described a long history of RC targeting women in their communities including forced sterilization or aggressive use of long-term contraception. Several African American participants noted a lack of trust of reproductive health providers among women in their communities based on this history, stating that there are not culturally sensitive resources for women of color. Specific reproductive health clinics were cited as having a history of targeting communities of color with contraceptive programs and promoting abortions, with one African American participant stating,

“That’s what happens in our cultures sometimes. We’ve heard about getting our tubes tied, and we’ve heard certain things. I heard they’re cutting out all the babies over there.”

Another participant highlighted the disparities in reproductive health outcomes between racial groups and cited the increased risk of fetal demise and miscarriage in African American communities³⁹ as a barrier in the phrasing of OKQ:

“There are some cultures, like ours, where more people lose babies before they are born. I think to have a baby is to not just to be pregnant.”

The intentions of health care providers asking the OKQ are a key driver in facilitation of honest conversations about PIS and require a nuanced approach that addresses the socio-cultural, political, and economic context of the target community.

How do we implement the OKQ?

Multiple participants questioned the idea of PIS occurring exclusively within health care settings. Participants felt that CHWs are well-situated to engage women in their communities about these topics. While participants were supportive of the implementation of OKQ in their communities, some noted its limitation in addressing the issue of health care access. They pointed out that women who have access to primary health care may already be having these conversations with their providers, and OKQ implementation without increasing access to health care for underinsured and uninsured women is unlikely to impact health outcomes. Many members of their communities, they argued, “wouldn’t go to the clinic for [reproductive health services] because they don’t have a ride, they are embarrassed, or they don’t have any money.” They noted that the focus should be on targeting underserved communities for adequate support and resources. One participant noted that even though the OKQ algorithm could be useful, “we just have to hope that they have primary care. That’s what we hope because when we refer them, we don’t give them anywhere specific to go. Having uninsured clients is the real barrier.”

Discussion

The objective of this study was to understand barriers and facilitators to community-based implementation of PIS using the OKQ algorithm by CHWs. Forty-three CHWs primary from Latino/a and African American communities were trained on the OKQ algorithm and provided with a pretest and posttest assessment of their knowledge of reproductive health and PIS. Semi-structured focus groups (see Appendix 1 for guide) were used to elicit feedback from CHWs on their perceptions of PIS, the efficacy of the OKQ, and barriers and facilitators to CHW-led implementation of the OKQ in their communities. Results indicate that CHWs are interested and willing to engage in PIS and feel that their position as trusted community leaders could offer more opportunity for nuanced and culturally appropriate discussions of reproductive health planning.

While the goal of universal PIS is to expand screening to all women accessing primary care services, PIS remains underutilized in the communities most impacted by unwanted or mistimed pregnancies, namely communities of color and of lower SES.^40,41 Studies also suggest that PIS tools such as OKQ delivered in the primary care setting may not address the complexity of reproductive health in these communities.¹¹ However, because of its standardized approach, it may be an effective way to offer consistent screening and counseling by CHWs, who have the existing trust and relationships within the community to guide sensitive reproductive life planning conversations. Focus group discussions highlighted several key barriers to PIS and the OKQ approach in primary care settings, which are situated within relevant existing literature below.

History of RC

A history of oppression, RC, and related mistrust of the health care system was raised in multiple focus groups. RC is defined as “behavior that interferes with women’s autonomous reproductive decision medication” and is strongly correlated with an increased risk of unintended pregnancy.⁴² While RC is often used in the context of intimate partner violence or sexual assault, it can also occur in the context of the health system, where patients are denied appropriate counseling or are not consented prior to decisions that impact their reproductive health. The United States has a long history of policy directives that target women of color and low-income women’s reproductive health choices, including Medicaid “family cap” rules,^43,44 coercive approaches to abortion and long-acting reversible contraception,^45,46 and forced and unwitting sterilization.^44,47 The medical experimentation and abuse in the United States on African American, indigenous, and disabled communities has played a key role in fostering fear and distrust of medicine and of medical professionals in communities of color.^20,47 Given that the predominant community served by CHW participants in this study is the Hispanic/Latino/a community, the history of sterilization racism impacting Latino/a women under programs such as California’s Eugenic Sterilization Program (1920–1945)⁴⁸ and the research trails of Depo-Provera in Puerto Rico and low-income communities of color⁴⁹ cannot be ignored. Indeed, PIS and contraception are invariably linked to the histories of eugenics and racism in the United States. Without addressing these histories, PIS tools used in primary care settings may not foster the trust and honesty required to have fruitful conversations about reproduction, contraception, and health care.

Female bias

Multiple participants highlighted the need for PIS to include discussion with male partners. Women are not the sole arbiters of their reproductive health choices, whether due to consensual joint decision-making in a partnership, or due to a lack of physical or emotional control in an abusive relationship. Furthermore, the exclusion of males in PIS neglects the role that men play in both preconception health and neonatal and infant morbidity and mortality. Despite evidence that paternal use of tobacco, alcohol, and illicit drugs can impact pregnancy outcomes, preconception counseling has been almost solely focused on women’s health and health behaviors.⁵⁰

Critiques of OKQ and PIS highlight that a focus on women’s health behaviors throughout the lifespan and the incorporation of PIS into all primary care visits reduces women to a stage of perpetual “prepregnancy.” This could lead to stigmatization and even criminalization of maternal behaviors that could impact future fetal and maternal wellbeing.^51
–53 PIS tools such as OKQ could serve to remedy these disparities if they offered universal screening, counseling, and related health services to everyone, regardless of gender.⁵⁴

Trust and sociocultural distance

Lack of trust between patients and providers was highlighted as a key barrier in the facilitation of honest dialogue around reproductive health and pregnancy intentions by participants in this study. While a variety of PIS tools are available, there is limited evidence to indicate that these tools facilitate relationship-building between patients and providers, or that they decrease unintended pregnancy rates and improve pregnancy outcomes.¹⁷

Little research has been done to demonstrate the efficacy of PIS tools in BIPOC communities, but hundreds of studies have documented the existence of disparities in medical treatment in the United States.⁵⁵ Particularly relevant in conversations of a sensitive nature like reproductive health and pregnancy intentions is the perception of race-based and SES discrimination in interactions with health care providers.⁵⁶ In fact, one study suggests that even the expectation that a patient will be stereotyped by a health care provider can limit the ability of patients to provide honest and direct information to health care staff.⁵⁷

Expansion into community-based settings

Our results indicate a clear desire by CHWs to expand their existing training and provide preventive reproductive health care in community settings. OKQ offers a direct and simple approach to PIS that could be implemented in community-based settings alongside adequate training and support of community actors such as CHWs.

Strengths and limitations of our study

A strength of this study is the enthusiastic participation of CHWs and community leaders. Pre-existing relationships with CHW communities and community leaders facilitated recruitment of a broad range of individuals working on community settings. All participants received formal training in PIS and the OKQ prior to the focus groups. All facilitators and co-facilitators were known to the participants, supporting honest conversations during the focus groups.

An important limitation of our study is the fact that it occurred within the political and cultural environment of Salt Lake City, Utah. While there are similarities between Utah and other conservative regions of the United States, the findings of our study may be less generalizable in other settings given Utah’s unique religious makeup and cultural mores. Our study included a small number of African American, Indigenous, and Pacific Islander participants, with the majority being Hispanic/Latino/a. Thus, our results are most representative of the views of this group. The study also occurred in an urban area, and results may not apply to health systems and CHWs in rural areas who face different barriers to accessing reproductive health care.

Implications for policy and practice

More research is needed to address the nuances and cultural complexity of pregnancy intention and reproductive life planning. This study provides insight into the perspectives of CHWs that serve predominantly Hispanic/Latino/a communities in an urban context. To understand the efficacy of CHW-driven PIS more fully, there is a need for further research to explore PIS and reproductive health planning in other communities impacted by systemic reproductive oppression, such as sexual and gender minority communities, the disability community, other BIPOC communities not adequately represented in this study, people with substance use and/or mental health disorders, rural communities, and more. There is promise in expanding a CHW-led model of PIS and the OKQ algorithm across diverse communities, but further study is needed to determine the unique cultural needs, messaging, and support and resources required to implement these programs successfully.

Expanded CHW scope into reproductive health and PIS

In conjunction with an appropriately financed and organized primary system, CHWs can contribute to improving and expanding coverage for appropriate reproductive health care, particularly in communities with poor access or connection to primary care. Policy efforts that promote and expand funding and CHW reimbursement, including Medicaid reimbursement, are critical to improving the overall health, and reproductive health, of the diverse communities they serve.

In addition, CHW training and curricula is inconsistent. Further standardization and increased funding for CHW education could improve CHW efficacy and consistency. A coordinated approach to CHW-delivered PIS training, allowing for cultural adaption, may ensure consistent quality and accuracy of information and increase utilization of CHWs.

Finally, the establishment of a robust referral network for trusted reproductive health care is critical for PIS to impact health outcomes. The network must promote access to resources for those who are uninsured or underinsured. While CHWs can be trained to provide PIS and reproductive counseling, utilization of health care for receipt of contraceptives or care before or between pregnancies is necessary.

Conclusion

In conclusion, CHWs are eager to engage community members in PIS and discussions about family planning and preconception care. Cultural values must be considered in the way questions are asked, the timing of questions, and the appropriate person to initiate the conversation. Issues such as distrust of the medical system, social distance and cultural differences, and a lack of resources, may emerge during preconception counseling and are barriers that must be addressed. CHWs are trusted members of the community and could complement primary care-driven PIS by offering patients an opportunity to share reproductive health plans in a more comfortable setting. CHW-delivered PIS holds promise for helping a broader range of women to achieve their reproductive goals and optimize their health. Many of the preconception counseling topics are relevant to all women, regardless of their pregnancy intentions, and could easily be integrated into every conversation. Beyond their role as trusted health care resources, CHWs also offer creative and alternative solutions to healthy inequities that could benefit their communities. During the final focus group of the study, several participants shared their vision of what PIS could look like in their communities: “you know, there’s this push to have these traveling buses. So, you have this fertility bus that goes to each community every twenty-eight days . . . the IUD Bus. The fertility bus.” The authors share this vision and hope that 1 day patients will receive culturally relevant, nuanced, and personalized reproductive health care delivered by trusted health workers in a pink, uterus-themed fertility bus (every 28 days.)

Supplemental Material

sj-docx-1-whe-10.1177_17455057231213735 – Supplemental material for Some key questions: Pregnancy intention screening by community health workers

Supplemental material, sj-docx-1-whe-10.1177_17455057231213735 for Some key questions: Pregnancy intention screening by community health workers by Stephanie St Clair, Susan Dearden, Lauren Clark and Sara E Simonsen in Women’s Health

Supplemental Material

sj-docx-2-whe-10.1177_17455057231213735 – Supplemental material for Some key questions: Pregnancy intention screening by community health workers

Supplemental material, sj-docx-2-whe-10.1177_17455057231213735 for Some key questions: Pregnancy intention screening by community health workers by Stephanie St Clair, Susan Dearden, Lauren Clark and Sara E Simonsen in Women’s Health

Footnotes

Appendix 1 Acknowledgements

The authors would like to recognize the efforts of Jeannette Villalta for her assistance in recruitment for this study.

Declarations

ORCID iD

Stephanie St Clair

Supplemental material

Supplemental material for this article is available online.

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