美国女性避孕选择

G R p a ’ ra Ch ng Kir OB fou ma the ST dem vid ges RE tra h so tus e in ono ce/ kely con 5% cio m tion c st ve c ont Cite h K, ptio rac yne D isparities in health outcomes by sta ma viders in contributing to these disparities ers treat patients differently depending on patients’ race/ethnicity4-6 and SES.7,8 Fro do Gr s-D Me ia, Sch ep Sci al R He Pre soc Re Re Re This project was supported by the Fellowship in Family Planning and by NIH/NCRR/OD UCSF- CT Its view 000 Research www.AJOG.org ment being highly dependent on pa- tients’ personal preferences. In addition, the discussion of sexual behavior and contraception use in a clinical encounter is a culturally and socially complex area of medicine in which providers’ subcon- scious biases or assumptions might play an important role. The limited data analyzing potential disparities in providers’ decision making in this context suggest that providers SI Grant no. KL2 RR024130. contents are solely the responsibility of the authors and do not necessarily represent the official s of the National Institutes of Health. 2-9378/free • © 2010 Mosby, Inc. All rights reserved. • doi: 10.1016/j.ajog.2010.05.009 For Editors’ Commentary, see Table of Contents See related editorial, page 293 m the Departments of Family and Community Medicine (Drs Dehlen umbach), Epidemiology and Biostatistics (Drs Vittinghoff and Bibbin dicine (Drs Bibbins-Domingo and Schillinger), University of Californ ool of Medicine; and the Department of Obstetrics, Gynecology and R ences (Drs Dehlendorf, Ruskin, and Steinauer), Bixby Center for Glob alth, University of California San Francisco, San Francisco, CA. sented in preliminary form (data in article) at the Annual Meeting of the As productive Health Professionals, Los Angeles, CA, Oct. 1-3, 2009. ceived Nov. 10, 2009; revised Feb. 25, 2010; accepted May 5, 2010. prints not available from the authors. See Journal Club, page 411 ries is widespread even among those who self-identify as nondiscriminatory.9 Previous research on the effect of pa- tient race/ethnicity and SES on provid- ers’ clinical behavior has focused on provider-patient interactions around discrete medical decisions for which there is general consensus about appro- priate treatment.4,5,10 Contraceptive de- cision making, in contrast, involves the consideration of multiple clinically ap- propriate options, with the best treat- rf and omingo), and San Francisco, roductive eproductive iation of race/ethnicity and socioeconomic tus (SES) are well documented in ny areas.1 The role of health care pro- is an area of growing research,2,3 with multiple studies suggesting that provid- These findings are consistent with social psychology research indicating that sub- conscious stereotyping by social catego- ENERAL GYNECOLOGY ecommendations fo randomized trial of ce/ethnicity and soc ristine Dehlendorf, MD, MAS; Rachel Ru sten Bibbins-Domingo, MD, PhD; Dean JECTIVE: Recommendations by health care nd to vary by patient race/ethnicity and socio y contribute to health disparities. This study inv se factors on recommendations for contracep UDY DESIGN: One of 18 videos depicting pati ographic characteristics was shown to each o ers. Providers indicated whether they would trel intrauterine contraception to the patient sh SULTS: Low socioeconomic status whites were uterine contraception recommended than hig whites (odds ratio [OR], 0.20; 95% confidenc this article as: Dehlendorf C, Ruskin R, Grumbac e/ethnicity and socioeconomic status. Am J Obstet G ntrauterine contrace e effects of patients oeconomic status in, MD; Kevin Grumbach, MD; Eric Vitti hillinger, MD; Jody Steinauer, MD, MAS viders have been nomic status and igated the effect of . s of varying socio- 4 health care pro- ommend levonor- n in the video. s likely to have in- cioeconomic sta- terval [CI], 0.06– 0.69); whereas, socioec Latinas and blacks. By ra and blacks were more li mended than low socioe 1.1–10.2 and OR, 3.1; 9 race/ethnicity for high so CONCLUSION: Providers ception or make assump nicity and socioeconomi Key words: contracepti disparities, intrauterine c et al. Recommendations for intrauterine contrace col 2010;203:319.e1-8. ma OCTOBER 2010 American tion: hoff, PhD; mic status had no significant effect among ethnicity, low socioeconomic status Latinas to have intrauterine contraception recom- omic status whites (OR, 3.4; and 95% CI, CI, 1.0–9.6, respectively), with no effect of economic status patients. ay have biases about intrauterine contra- s about its use based on patient race/eth- atus. ounseling, family planning, health raception n: a randomized trial of the effects of patients’ r i th i sk Sc pro eco est tion ent f 52 rec ow les y be susceptible to different influ- Journal of Obstetrics& Gynecology 319.e1 en on ges lik fec cou com mi Un ten tra hig sys do the rai no tra the T pro ute ula effi cou tio lik Alt cer pe cre fec cli con wh tio lik co no use as na sta rec SE dif IU T eth me we om da nic M Sta W sta ab var or cla wi his [ST ina ma wo mi wa for rec as an by nic tha no ha Ch tes in she at the pro ha ha thi cei da or get for gra sho I he var scr wi the iza tio act wa con Stu W he Pra at fam ne be the tra lec of ab tio of �3 Ag me ing co ord od eff ing car me the lev eff Un qu pa the lik an gen wo aw reg nic da O wh vid can ba co IU of thi can len of Research General Gynecology www.AJOG.org 31 ces on their recommendations. From e perspective, several studies have sug- ted that providers may be especially ely to encourage the use of highly ef- tive contraceptive methods and dis- rage fertility in minority and low-in- e populations.11-13 In contrast, nority and low-income women in the ited States have higher rates of unin- ded pregnancy and lower use of con- ceptive methods than do white and her-income women.14,15 Although tem and patient-related factors un- ubtedly contribute to these statistics, presence of these disparities also ses the possibility that clinicians may t, in fact, be promoting effective con- ceptive methods among patients from se sociodemographic groups. he effect of patient characteristics on vider recommendations for intra- rine contraception (IUC) is of partic- r interest due to this method’s high cacy,16 as any tendency toward dis- raging the fertility of specific popula- ns could be manifested in a greater elihood of recommending this method. ernatively, as many providers are con- ned that the use of IUC could result in lvic infections among women at in- ased risk for sexually transmitted in- tions,17,18 although well-designed nical studies have indicated that these cerns are misplaced,19,20 clinicians o make race- and class-based assump- ns about sexual behaviors may be less ely to consider IUC as an appropriate ntraceptive method for poor and mi- rity women. As an expansion in the of IUC is currently being advocated a means to decrease unintended preg- ncy,18,21,22 it is important to under- nd whether differences in provider ommendations by race/ethnicity and S exist and, if so, consider how these ferences may affect efforts to promote C in different demographic groups. o determine whether patient race/ nicity and SES affect provider recom- ndations for the levonorgestrel IUC, conducted a study of providers’ rec- mendations using videos of stan- rdized patients of different race/eth- ities and SES. con 9.e2 American Journal of Obstetrics& Gynecology ATERIALS AND METHODS ndardized patient videos e produced 18 videos portraying a ndardized patient requesting advice out contraception, with the patient ying by race/ethnicity (white, black, Latina), SES (low- or upper-middle ss), and gynecologic history (a woman th a history of a vaginal delivery and no tory of sexually transmitted infections Is]; a woman with a history of a vag- l delivery and history of pelvic inflam- tory disease [PID]; or a nulliparous men with no history of sexually trans- tted infections). The low SES patient s portrayed as a housekeeper studying her GED and the high SES patient as a ent business school graduate working a bank manager. Both the high SES d the low SES patients were portrayed the same actor within each racial/eth- category. The providers were told t the patient was 27 years old, had rmal blood pressure, and had recently d a negative test for Gonorrhea and lamydia and a normal Papanicolaou t. Each patient indicated that she was a monogamous relationship and that did not want to become pregnant for least a few years. For the purpose of se analyses, the primary gynecologic file of interest was the woman who d previously had a vaginal delivery and d no history of STIs, as women with s history have historically been per- ved as ideal IUC candidates. The stan- rdized patients who were nulliparous had a history of PID were grouped to- her as having perceived risk factors complications related to IUC. Photo- phs of the standardized patients are wn in Figure 1, A-F. n each video, the patient presented r history as a monologue, with the only iation being the study factors. The ipts used in the videos were pretested th a sample of 15 providers to ensure maximal level of realism. Standard- tion of verbal factors, such as inflec- n and tone, were practiced with the 3 ors. Five health care providers tched all 18 videos to verify overall sistency of nonverbal and verbal tent. dif OCTOBER 2010 dy design e recruited a convenience sample of alth care providers (MDs, DOs, Nurse ctitioners, and Physician Assistants) meetings of professional societies of ily medicine and obstetrics and gy- cology. Eligibility criteria consisted of ing a practicing health care provider in United States who had completed ining. After observing 1 video, se- ted using randomly permuted blocks 18, the providers completed a survey out their contraceptive recommenda- ns for the patient shown, ranking each 6 methods on a scale of�3 to�3, with indicating “Strongly Recommend ainst”, 0 indicating “Neither Recom- nd for nor Against” and �3 indicat- “Strongly Recommend For.” The mputerized survey randomized the er in which the contraceptive meth- s were displayed to avoid any sequence ect. The subjects were informed dur- the survey that the patient’s health e insurance covered all contraceptive thods. Our outcome of interest was recommendation regarding the onorgestrel IUC, as this is the more ective of the 2 IUCs offered in the ited States.23 Providers also answered estions about their perceptions of the tient in the video, indicating whether y felt the patient was more or less ely to experience specific outcomes d whether she was more or less intelli- t and knowledgeable than an average man her age. The providers were not are of the primary study hypothesis arding the effect of patient race/eth- ity and SES on provider recommen- tions for IUC. ur primary research question was ether the recommendations of pro- ers for IUC differ for African Ameri- , Latina and White patients. We sed our sample size on a binary out- me of willingness to recommend an C. We hypothesized that a difference 15 percentage points in prevalence of s outcome would be clinically signifi- t in populations where overall preva- ce of the outcome is 30%. Our sample 524 provided 84% power to detect a ference of this magnitude in separate com La Sta W ou for Fis pri wa spo the fac an be rac jec pa RE Th tw reg Am Gy of Ph he stu gyn pa vid rac ble sta act we ma pa mo tie La ers Re lev Sig rac (P log wi lev no int str nic wo ha SE Bla lik pa P� rec wh A pa wa cen str A s F S A, pat SES Deh www.AJOG.org General Gynecology Research parisons of African American and tina women to white women. tistical analysis e performed bivariate analysis of the tcome variable of recommendation the levonorgestrel IUC using �2 tests, her’s exact tests, and t tests as appro- ate. Multivariate logistic regression s performed using a dichotomized re- nse variable of�1 or�0. Because of complicated interplay between social tors in other studies,24 prespecified alyses included analysis of interactions tween the patient characteristics of IGURE 1 tandardized patients Low SES white patient. B, High SES white patie ient. E, Low SES Latina patient. F, High SES Lat , socioeconomic status. lendorf. Recommendation for intrauterine contraception. Am e/ethnicity, SES, and gynecologic his- cis y. For the multivariate model, we pre- cified the following provider-level iables to be included in the model: , sex, race/ethnicity, specialty, and vision of IUC. For all other variables, used backward selection and in- ded any variables that changed any of coefficients of interest by�10%. The jects’ perceptions of the patients were alyzed in the same manner. All analy- were performed using Stata Version (Stata Corp, College Station, TX). he Committee of Human Research at University of California, San Fran- , Low SES black patient. D, High SES black patient. bstet Gynecol 2010. co approved this study, and all sub- hig OCTOBER 2010 American ts provided informed consent before rticipation. SULTS e videos were shown at 4 meetings be- een September 2007 and May 2008; 2 ional and 1 national meeting of the erican College of Obstetricians and necologists, and the national meeting the American Academy of Family ysicians. Five hundred twenty-four alth care providers completed the dy, and the race/ethnicity, SES, and ecologic profile of the standardized tients were balanced between all pro- er characteristics except provider e/ethnicity in the overall sample (Ta- 1). Within each strata defined by the ndardized patients’ gynecologic char- eristics, the provider characteristics re balanced, with the exception that le providers assigned to standardized tients with perceived risk factors were re likely to be assigned the black pa- nt and less likely to be assigned the tina patient than were female provid- (P� .02). commendations for onorgestrel IUC nificant interactions between patient e/ethnicity and gynecologic history � .05) and patient SES and gyneco- ic history (P � .04) were identified th respect to recommendations for the onorgestrel IUC. As the woman with perceived risk factors was of primary erest, we focused our analysis on this atum (n � 173). Analyzing race/eth- ity and SES separately, low SES men were significantly less likely to ve IUC recommended than were high S women (57% vs 75%; P � .01). ck women were significantly more ely to have IUC recommended com- red with white women (75% vs 57%; .04) while there was no difference in ommendations between Latina and ite women (66% vs 57%; P� .31). s an additional interaction between tient race/ethnicity and SES (P� .02) s identified, Figure 2 presents the per- t of providers recommending IUC atified by both race/ethnicity and SES. ignificant difference between low and tor spe var age pro we clu the sub an ses 9.2 T the nt. C ina J O h SES white women (P� .01) and low Journal of Obstetrics& Gynecology 319.e3 T C C s M . R . A . S . P . P . F c . B . P r . A . H . P . D Research General Gynecology www.AJOG.org 31 ABLE 1 haracteristics of study subjects, by standardized patient characteristics haracteristics of study ubjects Standardized patient characteristics All subjects White n � 179 Black n � 172 Latina n � 173 P value High SES n � 262 Low SES n � 262 P value No risk factors n � 173 Perceived risk factors n � 351 P value ale sex, % 53.6 52.5 59.3 49.1 .16 50.8 56.5 .19 52.0 54.4 .61 ............................................................................................................................................................................................................................................................................................................................................................................... ace/ethnicity, % .96 .38 .008 ....................................................................................................................................................................................................................................................................................................................................................................... White 76.9 79.9 75.0 75.7 78.2 75.6 84.4 73.2 ....................................................................................................................................................................................................................................................................................................................................................................... Black 7.8 7.3 7.6 8.7 6.1 9.5 2.3 10.5 ....................................................................................................................................................................................................................................................................................................................................................................... Latina 3.8 2.8 4.1 4.6 5.0 2.7 3.5 4.0 ....................................................................................................................................................................................................................................................................................................................................................................... Asian 9.2 7.8 11.1 8.7 8.4 9.9 6.9 10.3 ....................................................................................................................................................................................................................................................................................................................................................................... Other 2.3 2.2 2.3 2.3 2.3 2.3 2.9 2.0 ............................................................................................................................................................................................................................................................................................................................................................................... ge, y (mean/SD) 45.9 (10.5) 44.9 (9.7) 46.9 (11.3) 45.8 (10.4) .22 44.6 (10.0) 47.2 (10.8) .10 45.5 (10.9) 46.0 (10.3) .47 ............................................................................................................................................................................................................................................................................................................................................................................... pecialty, % .94 .80 .57 ....................................................................................................................................................................................................................................................................................................................................................................... Obstetrics/Gynecology 59.0 59.8 59.9 57.2 58.0 59.9 59.5 58.7 ....................................................................................................................................................................................................................................................................................................................................................................... Family Medicine 38.7 38.6 37.8 39.9 39.3 38.2 39.3 38.5 ....................................................................................................................................................................................................................................................................................................