Contraception use among individuals with substance use disorder increases tenfold with patient-centered, mobile services: a quasi-experimental study.

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Open Access

Harm Reduction Journal

Contraception use amongindividuals

withsubstance use disorder increases tenfold

withpatient-centered, mobile services:

aquasi-experimental study

Emily A. Hurley

1,2,3*

, Kathy Goggin

1,2,4

, Kimberly Piña‑Brugman

, Janelle R. Noel‑MacDonnell

1,2

, Andrea Allen

Sarah Finocchario‑Kessler

and Melissa K. Miller

2,7

Abstract

Background Individuals with substance use disorders (SUD) have disproportionately high rates of unintended

pregnancy. Reducing harm associated with this risk and its biopsychosocial consequences requires evidence‑based,

non‑coercive interventions that ensure access to contraception for individuals who choose to prevent pregnancy. We

examined feasibility and impact of SexHealth Mobile, a mobile unit‑based intervention that aimed to increase access

to patient‑centered contraceptive care for individuals in SUD recovery programs.

Methods We conducted a quasi‑experimental study (enhanced usual care [EUC] followed by intervention) at three

recovery centers with participants (n = 98) at risk for unintended pregnancy. EUC participants were oﬀered printed

information on community locations where they could access contraception care. SexHealth Mobile participants

were oﬀered same‑day, onsite clinical consultation on a medical mobile unit and contraception if desired. The primary

outcome was use of contraception (hormonal or intrauterine device) at one‑month post‑enrollment. Secondary out‑

comes were at two‑weeks and three‑months. Conﬁdence in preventing unintended pregnancy, reasons for non‑use

of contraception at follow‑up, and intervention feasibility were also assessed.

Results Participants (median age = 31, range 19–40) enrolled in the intervention period were almost 10 times more

likely to be using contraception at one‑month (51.5%) versus the those enrolled in the EUC period (5.4%) (unadjusted

relative risk [URR] = 9.3 [95%CI: 2.3–37.1]; adjusted relative risk [ARR] = 9.8 [95%CI: 2.4–39.2]). Intervention participants

were also more likely to be using contraception at 2‑weeks (38.7% vs. 2.6%; URR = 14.3 [95%CI: 2.0–104.1]) and three‑

months (40.9% vs. 13.9%; URR = 2.9 [95% CI: 1.1–7.4]). EUC participants reported more barriers (cost, time) and less

conﬁdence in preventing unintended pregnancies. Mixed‑methods feasibility data indicated high acceptability and

feasible integration into recovery settings.

Conclusions Mobile contraceptive care based on principles of reproductive justice and harm reduction reduces

access barriers, is feasible to implement in SUD recovery settings, and increases contraception use. Expanding

interventions like SexHealth Mobile may help reduce harm from unintended pregnancies among individuals in SUD

recovery.

*Correspondence:

Emily A. Hurley

[email protected]

Full list of author information is available at the end of the article

Page 2 of 11

Hurleyetal. Harm Reduction Journal (2023) 20:28

Trial Registration NCT04227145.

Keywords Contraception, Reproductive justice, Substance use disorders, Recovery, Sexual health, Mobile unit

Introduction

Ensuring access to contraception is critical for popula-

tions at high risk for unintended pregnancies, particu-

larly those in states with restricted abortion access.

Women with a history of substance use disorders

(SUD) have long suﬀered disproportionately high rates

of unintended pregnancies. A nationally representative

sample of women reported a 70% increased likelihood

of unintended pregnancy among women with precon

ception illicit or recreational drug use, compared to

those with no drug use [1]. In a study of women with

opioid use disorder, nine in ten pregnancies were unin

tended, a rate two to three times higher than in the

general population [2]. Over the last two decades, the

proportion of pregnant women reporting non-pre

scription opioid use has quadrupled and the proportion

reporting methamphetamine use has doubled [3, 4].

Further, overall SUD rates have risen in the U.S. since

the onset of the COVID-19 pandemic [5].

Women with history of SUD often desire contracep

tion but face accessbarriers [6–9]. ey report cost,

insurance and/or transportation challenges, and are

overallless likely to have regular contact with primary

or reproductive health carethan women without SUD

[8, 10]. Women with SUD may also avoid contracep

tion care-seeking due to experienced or anticipated

stigma from providers [6, 8, 9, 11]. Further, theyoften

lack accurate information about contraception options

[7, 8] or may not prioritize seeking contraception

when actively trying to obtain substances [8]. Address

ing these barriers can help individuals with SUD gain

more control over when and if they become pregnant,

and avoid the often devastating health and psychosocial

consequences associated with unintended pregnancies

(e.g., losing childcustody) [12–15].

Entry into recovery services is an opportune time

to help individuals meet unmet contraception desires.

While contraception access is important at all stages of

SUD including recovery, women describe recovery ini

tiation as a time of peak readiness to address broader

health needs. Further, women initiating recovery gen

erally state they prefer to plan pregnancies for a time

when they have reached stable, long-term recovery [8,

16, 17]. Meeting contraception desires with long-acting

reversible contraception (LARC) early in recovery can

also provide longer-term protection for the 40–60% of

women who return to use within one year of beginning

treatment [18].

Although some studies have shown increased contra

ceptive use with SUD recovery-based interventions, they

have had limitations [19]. Few interventions have fully

demonstrated commitment to principals of reproductive

justice (the right to maintain bodily autonomy, includ

ing choice over reproduction) and harm reduction (the

right to access services that reduce harmful eﬀects of

substance use without judgement or pressure to change

behavior) [8, 9, 20]. Some have included the controversial

use of incentives or directive behavior change goals to

encourage contraception use [21, 22]. Further, many have

not been able to provide LARC and have oﬀered only

limited options [23]. Our formative research suggested

women would ﬁnd contraception services valuable and

make use of them without incentives, given that the ser

vices: (1) maximize access to the full range of contracep-

tion options, (2) provide contraception free or at minimal

cost, (3) oﬀer non-judgmental, non-coercive patient-cen

tered care, (4) are delivered by qualiﬁed, trusted provid-

ers, and (5) are supported and promoted by their peers

[9].

We designed an intervention, SexHealth Mobile, to

meet these community-derived priorities for people with

SUD at risk of unintended pregnancy. SexHealth Mobile

featured a medical mobile unit (MMU) equipped with a

range of free contraception options and a reproductive

health care provider who oﬀered counseling and pre

scriptions. e intervention also trained outreach leaders

at recovery centers to support free choice and provid

ing accurate, non-coercive information on contracep-

tion options. is pilot study examines the feasibility of

SexHealth Mobile and its impact on contraception use

among woman in SUD recovery programs in Kansas City,

Missouri.

Methods

We conducted a quasi-experimental study with an inter-

rupted time series design (i.e., enhanced usual care [EUC]

followed by intervention). We compared contraception

use one-month after enrollment among participants

enrolled in the two diﬀerent time periods. e study was

approved by e Institutional Review Board at Children’s

Mercy Kansas City.

Setting andparticipants

SexHealth Mobile was implemented in partnership with

a federally qualiﬁed health center (FHQC) in Kansas

City that was already operating a MMU to provide basic

Page 3 of 11

Hurleyetal. Harm Reduction Journal (2023) 20:28

health services at community locations with high need,

including recovery centers. For this study, we selected

three recovery centers that already partnered with the

FHQC to receive periodic MMU visits for basic health

services (e.g., seasonal vaccination, basic screenings, and

treatment of non-emergency illness and injuries). e

three recovery centers were providing services for clients

with any type of SUD, most commonly polysubstance use

disorders that included use of methamphetamines and/

or opioids. Two centers were residential, serving indi

viduals who had initiated recovery and were expected to

not be using substances other than tobacco while in the

program. e other was outpatient, serving individuals at

various stages of recovery and active substance use. Prior

to our intervention, the FHQC provided contraception

and reproductive health services (free or discounted) at

their main center, but not yet on the MMU.. Recovery

centers did not routinely screen for reproductive health

needs but would informally recommend community clin

ics (including the FHQC partner) for individuals inter-

ested in services.

Recovery center clients were eligible if they were: (1)

aged 18–40; (2) screened positive for a lifetime history

of problematic drinking or drug use according to CAGE-

AID tool [24]; (3) able to become pregnant (assigned

female sex at birth, pre-menopausal, not sterilized or

diagnosed with infertility) but not currently pregnant; (4)

not currently using an intrauterine device or hormonal

contraception (i.e., oral contraceptive pill, transdermal

patch, vaginal ring, injectable, subdermal implant); and

(5) not previously enrolled in either phase of the study.

Procedures

Study staﬀ worked with recovery centers to share infor-

mation about the study and visited each site periodically

for eligibility screening and enrollment. Interested clients

were screened individually by study staﬀ and those eligi

ble provided written informed consent. Site visits con-

tinued until the sample size target for each time period

(n = 46) was reached or exceeded.

All participants completed a 15-min baseline question

naire via REDCap that included demographic, substance

use, and reproductive health history. For the EUC period

(Aug–Nov. 2020), we created a printed information sheet

that listed community locations where each recovery

center would typically recommend clients contact to

access contraception care. By formalizing this contact

sheet and oﬀering it to women after the baseline ques

tionnaire on reproductive health needs, we “enhanced”

recovery centers’ usual care procedures for reproduc

tive health. In the SexHealth Mobile intervention period

(April-Sept. 2021), participants were oﬀered the oppor

tunity to see a reproductive health care provider on the

MMU and, if desired, obtain contraception on-site. Inter

vention period participants not interested in MMU visits

were also oﬀered EUC printed information sheets. Par

ticipants in both time periods completed a 5-min post-

intervention survey as well as 2-week, 1-month, and

3-month follow-up phone assessments. Participants were

compensated $20 for completion of the baseline/post-

intervention survey, $15 each for 2-week and 1-month

follow-ups, and $20 for the 3-month follow-up.

SexHealth mobile intervention

SexHealth Mobile is grounded in formative research

and centered on reproductive justice and harm reduc

tion principles. e intervention featured “SexHealth

Mobile Days” where the MMU, clinical staﬀ, and study

staﬀ would visit each recovery center. In preparation,

we worked with the FHQC leadership and clinical staﬀ

to integrate contraceptive services within the MMU.

is included one nurse practitioner with experience in

patient-centered contraception care for SUD patients,

one care assistant, and materials required for on-site pro

vision of contraceptive medications (e.g., pregnancy tests,

needles, syringes). e nurse practitioner (author AA)

specialized in women’s health, independently placed con

traceptive devices, and hadworked at the partner FHQC

for seven years (including previously providing general

health care on the MMU). We worked with recovery

centers and FHQC staﬀ to ensure services were provided

in a way that was acceptable to potential patients, includ

ing arranging for pregnancy testing with urine collected

by patients themselves within recovery center facilities.

On SexHealth Mobile Days, the provider oﬀered con

traceptive options on the MMU free of charge, includ-

ing hormonal (i.e., pills, transdermal patch, vaginal

ring, injection, subdermal implant) and non-hormonal

(diaphragm, condoms). Participants who chose short-

term hormonal contraception (pills, patch, ring, injec

tion) were given dosage for three months of pregnancy

prevention and instructions for reﬁlls/follow-up at the

main FQHC. e MMU was not outﬁtted with a stand

ard patient exam table that could be used for gynecologi-

cal procedures, thus we could not oﬀer same-day IUDs.

However, participants interested in IUDs could speak

to the provider on the MMU, schedule a facility-based

IUD insertion appointment at the main FHQC with the

same provider, and obtain a bridging method to protect

against pregnancy until IUD insertion. Further, partici

pants interested in sexual and reproductive health ser-

vices beyond contraception were also able to speak with

the MMU provider and schedule appropriate facility-

based FHQC appointments. Study staﬀ also oﬀered free

condoms and home pregnancy tests at the enrollment

table for anyone at the recovery center. We conducted

Page 4 of 11

Hurleyetal. Harm Reduction Journal (2023) 20:28

ten SexHealth Mobile Days before reaching our target

recruitment in intervention period, with four visits at the

larger residential center, two at the smaller residential

center, and four at the outpatient center.

At each recovery center, 2–4 individuals who already

occupied formal roles as trusted resources for clients (7

peer mentors, 3 social workers) were trained as “outreach

leaders” to promote SexHealth Mobile Days and organ

ize interested clients. Training covered basic principles

of reproductive justice and harm reduction, contracep

tion options, needs and challenges faced by individuals

with SUD in preventing unintended pregnancies, and

strategies for using client-centered and trauma-informed

approaches when talking about contraception.

Outreach leaders and study staﬀ stressed that all activi

ties on SexHealth Mobile Days were completely volun-

tary, and people could obtain a clinic referral or meet

with MMU providers and receive free contraception even

if they chose not to enroll in the study, or were not eli

gible due to previous enrollment in the EUC period or

other ineligibility criteria. Individuals could also enroll

in the study and meet with MMU providers even if they

were unsure or not interested in taking up contraception.

Outcome measures

Feasibility

We assessed feasibility of SexHealth Mobile according

to selected Bowen feasibility constructs [25]. Table 1

lists and deﬁnes constructs and measures of assessment,

including participant survey items and study staﬀ ﬁeld

notes.

Primary andsecondary outcomes

e primary outcome was use of IUD or hormonal

contraception (pills, patch, ring, contraception injec

tion, subdermal implant) at one-month post-enroll-

ment. Secondary outcomes were use at two-weeks and

three-months. We also explored group diﬀerences in

conﬁdence in preventing unintended pregnancy at post-

intervention and as a change from baseline to post-inter

vention (reported on a repeated 5-point scale ranging

from “not at all conﬁdent” to “extremely conﬁdent”) as

well as reasons for non-use at one-month (including rea

sons for not attending clinic visits, picking up prescrip-

tions, and/or starting birth control).

Data analysis

Descriptive analysis was carried out for all variables, with

comparisons made between groups with Chi-Square or

Fisher’s Exact tests for categorical variables as appro

priate based on cell values, and two-sided independent

t-test for continuous variables. We compared groups

as intention-to-treat on the primary and secondary

outcomes using Fisher’s Exact test and Poisson regression

with robust standard errors (unadjusted and adjusted).

e adjusted model included demographic factors

known to inﬂuence contraception use or identiﬁed as

having inﬂuence through a series of bivariate associations

with contraception use, including recovery site (residen

tial vs. outpatient), pregnancy intention (trying to avoid/

wouldn’t mind avoiding vs. other), pregnancy history

(ever been pregnant vs. not) and recency of substance

use (deﬁned as use within the three months prior to base

line vs. none). We analyzed the primary outcome again

including participants who had missed the one-month

assessment but reported a contraception injection (which

protects for three months) at post-intervention or two

weeks. Quantitative analyses were completed in SAS Ver

sion 9.4. (SAS Institute, Cary, NC). Field notes were ana-

lyzed with qualitative coding to identify facilitators and

barriers according to Bowen’s feasibility constructs [25].

Results

Baseline demographics

We enrolled 98 participants (48 in EUC period, 50 in

intervention period). An additional 17 were ineligi

ble after screening (Fig.1). Follow-ups were completed

by 70.4% at two-weeks (79.2% EUC, 62.0% interven

tion), 71.4% at one-month (77.1% EUC, 66.0% interven-

tion), and 59.2% at three-months (75.0% EUC, 44.0%

intervention). At baseline, participants in both groups

were similar in age (median = 31, range 19–40), ethnic

ity (92.9% non-Hispanic), educational status (76.5% high

school graduate or higher) and marital status (69.4% sin

gle/never married) (Table 2). Most identiﬁed as white

(79.6%) with more identifying as Black/African American

in EUC (12.5%) versus intervention periods (4.0%). One

participant (in the intervention period) identiﬁed as male

and all others identiﬁed as female. Almost half (46.9%)

were uninsured while most others had public insurance

(35.7%).

EUC and intervention participants were also similar

in substance use and sexual/reproductive health his

tory (p-values > 0.05 unless otherwise noted). Partici-

pants were receiving recoveryservices at the outpatient

(48.0%) or one of two residential (52.0%) centers. Most

participants had used substances other than tobacco

within the past three months, with a greater propor

tion of EUC participants reporting recent substance use

compared to intervention participants (85.4%, 66.0%;

p = 0.026). e majority had used amphetamines (78.6%),

cannabis (80.6%), alcohol (76.5%), opioids (59.2%), and/

or cocaine (60.2%) at some point in their life. Most had

a history of polysubstance use (i.e., use of two or more

substances other than tobacco), with slightly more of the

EUC (58.3%) than the intervention group (42.0%). Most

Page 5 of 11

Hurleyetal. Harm Reduction Journal (2023) 20:28

Table 1 Assessment of SexHealth Mobile feasibility: constructs, indicators, and measures

Intervention participants only;

Intervention participants completing MMU visits only;

Intervention participants who reported interactions with Outreach Leaders only;

Enhanced usual care participants only

Feasibility Construct [25] Indicator Measure

Demand

(To what extent is the intervention likely to be used?)

Proportion of intervention participants interested in an MMU

visit on a SexHealth Mobile Day

Baseline survey item

Proportion of intervention participants completing MMU visits

who received on‑site contraception

Post‑intervention survey item

Number of additional MMU visits among individuals not eligible

for the study (e.g., not within age range, participated in EUC

period, already using contraception but interested in other

methods)

Study staﬀ ﬁeld notes

Number of individuals (participants and non‑participants) who

took free condoms and pregnancy tests; number of study par‑

ticipants reporting taking free condoms at MMU visit

Study staﬀ ﬁeld notes; post‑intervention survey

Acceptability

(How do stakeholders react to the intervention?)

Intervention participants’ ratings of post‑MMU visit satisfaction

and likelihood of recommending to a friend

Post‑intervention survey items

Overall satisfaction: (4‑point scale; range: “not satisﬁed at all” to

“very satisﬁed”)

Likelihood of recommending MMU (5‑point scale from “extremely

unlikely” to “extremely likely”)

Intervention participants’ ratings of patient‑centeredness of

MMU provider

Post‑intervention survey items

Person-Centered Contraceptive Counseling Survey (PCCCS) [26]: using

“top score” (an “excellent” rating on all four items)

Intervention participants’ ratings of outreach leader support Baseline survey item

Level of agreement that outreach leader supported them in mak‑

ing their own decision (4‑point from “strongly disagree” to “strongly

agree)

Recovery center leadership support and cooperation in facilitat‑

ing implementation

Study staﬀ ﬁeld notes

Proportion of EUC participants who reported they would have

used the MMU if it had been available

Post‑intervention survey item

Implementation

(To what extent can the intervention be implemented as planned?)

Outreach leader activity in intervention period Study staﬀ ﬁeld notes

Intervention participants’ self‑reported interactions with out‑

reach leaders

Baseline survey item

Acceptability of patient ﬂow, volume, and wait time for all

stakeholders

Study staﬀ ﬁeld notes

Ability of MMU/provider to meet needs of patients Study staﬀ ﬁeld notes

Integration

(To what extent can the intervention be integrated within an exist-

ing system?)

Overall successes and challenges of integrating recovery and

FHQC service systems, including personnel collaboration,

scheduling, and facilitating pre‑MMU patient procedures (e.g.,

paperwork, urine samples, implant insertion)

Study staﬀ ﬁeld notes

Page 6 of 11

Hurleyetal. Harm Reduction Journal (2023) 20:28

(72.4%) indicated they had received some medical care in

the past 12months and 58.2% said there was a time in the

past 12months they thought they should have accessed

health care but did not.

Most had no (43.9%) or one (44.9%) current male sexual

partner with few reporting they were trying to get preg

nant (2.0%). At last vaginal sex, most reported no preg-

nancy prevention method (48.0%) or withdrawal (24.5%).

Four-ﬁfths had not used a condom at last sex. e major

ity had lifetime experience with contraception, most

commonly the pill (67.3%) and condoms (67.3%). Most

had experienced pregnancy (80.6%) and two reported

previous abortion. Most (72.4%) had at least one living

child and of those with children, and 60.5% reported their

child/children living in foster care or with someone else

at some point.

Intervention feasibility

Table3 summarizes mixed-methods feasibility ﬁndings.

Overall intervention demand was high, as 43 interven

tion participants (86.0%) requested an MMU visit for

contraception counseling. Of the 39 who completed a

visit and post-intervention survey, 22 (56.4%) reported

receiving a form of hormonal contraception on the

Fig. 1 Screening, enrollment, & follow‑up of participants in SexHealth Mobile Intervention

Page 7 of 11

Hurleyetal. Harm Reduction Journal (2023) 20:28

MMU (pills=14, contraception injection=5, subder-

mal implant=1, patches=1,rings=1). Additionally,

two participants (5.1%) were prescribed a diaphragm

and 18 (46.2%) took condoms Acceptability was high, as

most intervention participants who visited the MMU

were “very satisﬁed” with their visit (92.3%) and gave the

provider a top score for person-centeredness (86.8%).

Observations and ﬁeld notes indicated successful imple

mentation and integration of services, with minor chal-

lenges (detailed in Table3).

Contraception use

For our primary outcome, 51.5% (17/33) of participants

in the intervention period were using contraception at

one-month post-baseline compared to 5.4% (2/37) in the

EUC period (Fishers exact test p = 0.001) (unadjusted

relative risk (URR) = 9.3 [95%CI: 2.3–37.1]; p = 0.0016).

Both EUC participants reported contraception injection,

while intervention participants reported pills (n = 11),

contraception injections (n = 3), implant (n = 1), patch

(n = 1) and ring (n = 1). e proportion of interven

tion participants using contraception was also higher

than that in EUC at 2-weeks (38.7% [12/31] vs. 2.6%

[1/38]; p = < 0.0001) (URR = 14.3 [95% CI: 2.0–104.1];

p = 0.0085) and three months (40.9% [9/22] vs. 13.9%

[5/36]; p = 0.020) (URR = 2.9 [95%CI: 1.1–7.4]; p = 0.031).

Likelihood of contraception use at one-month

remained high after adjusting for age, recovery center

type, pregnancy intention, pregnancy history, and

substance use at three-months (adjusted relative risk

(ARR) = 9.8 [95%CI: 2.4–39.2]; p = 0.0013). One addi

tional participant could be assumed to be using con-

traception at one-month despite not completing the

assessment, as she reported receiving a contraception

injection on the post-intervention survey, strengthen

ing the relative risk in the unadjusted (RR = 9.7 [95%CI:

2.5–39.1]; p = 0.0012) and adjusted models (ARR = 10.0

[95%CI: 2.5–40.0]; p = 0.0012).

Table 2 Demographics (including substance use, sexual/repro health history)

Where options do not add to 100%, one or more participants marked “prefer not to answer”

Enhanced Usual Care (EUC)

(n = 48)

SexHealth Mobile Intervention

(n = 50)

p-value

Age in years (Median, [IQR]) 30 (25, 34) 32.5 (28, 35) 0.143

Race (n, %) 0.065

American Indian/Alaska Native 1 (2.1%) 1 (2.0%)

Asian 0 (0.0%) 1 (2.0%)

Black/ African American 6 (12.5%) 2 (4.0%)

White 40 (83.3%) 38 (76.0%)

Other 1 (2.1%) 7 (14.0%)

Ethnicity 1.000

Non‑Hispanic 45 (93.8%) 46 (92.0%)

Hispanic/ Latina 3 (6.3%) 3 (6.0%)

Educational Level 0.110

Less than High School 10 (20.8%) 13 (26.0%)

High school graduate or GED 22 (45.8%) 24 (48.0%)

Post‑high school training/ some college 15 (31.1%) 9 (18.0%)

Undergraduate degree or Higher 1 (2.1%) 4 (8.0%)

Marital status 0.714

Single (never married) 34 (70.8%) 34 (68.0%)

Separated/ Divorced 11 (22.9%) 11 (22.0%)

Married/ domestic partnership 2 (4.2%) 3 (6.0%)

Widowed 1 (2.1%) 2 (4.0%)

Health Insurance Status 0.632

Private 2 (4.2%) 5 (10.0%)

Public (Medicare, Medicaid) 16 (33.3%) 19 (38.0%)

Other 3 (6.3%) 4 (8.0%)

Uninsured 26 (54.2%) 20 (40.0%)

Page 8 of 11

Hurleyetal. Harm Reduction Journal (2023) 20:28

Condence andbarriers

Self-reported conﬁdence in one’s own ability to protect

against unwanted pregnancy (dichotomized as “very/

extremely conﬁdent” and “not conﬁdent/low conﬁdent/

not sure”) was more prevalent in the intervention than

the EUC group in the post-intervention survey (90% vs.

70%; p = < 0.0001). A greater proportion of participants

increased from “not conﬁdent/low conﬁdent/not sure”

at baseline to “very conﬁdent/extremely conﬁdent” post-

interventionin the intervention (28.0% )versus the EUC

group (12.5%; p = < 0.001).

e most frequently cited reason for non-use of contra

ception at one-month among both groups was “decided

did not want/need birth control” (EUC = 27.1%; inter

vention = 16.0%; p = 0.18). Some participants oﬀered

additional explanation for not being interested in contra

ception, including not being sexually active or not having

male partners. A few also expressed ambivalence toward

becomingpregnant. e barrier“not enough time” (to

complete referral appointment, pick up prescription,

and/or start method) was reported more frequently in the

EUC group (22.9%) than the intervention group (6.0%;

p = 0.001). “Insurance/cost” barriers were also reported

Table 3 SexHealth Mobile feasibility: Key ﬁndings

Full description of each construct’s operationalization and measurement is available in Table1

Feasibility Construct

Facilitators ( +) and Barriers (-)

Demand (To what extent is the intervention likely to be used?) 86% of intervention participants indicated interest in an MMU visit on a

SexHealth Mobile Day ( +)

56.4% of intervention participants who visited the MMU received on‑site

contraception ( +)

21 individuals not enrolled in the study had an MMU visit ( +)

42 individuals took free condoms and 30 took free pregnancy tests from

study staﬀ; 18 study participants took free condoms at an MMU visit ( +)

Acceptability (How do stakeholders react to the intervention?) 92.3% of intervention participants who visited the MMU were “very satis‑

ﬁed” with their visit; 97.4% were “likely” or “extremely likely” to recommend

to a friend (+)

86.8% of intervention participants who visited the MMU gave the provider

a top score for patient‑centeredness ( +)

76.6% of intervention participants who spoke to an outreach leader

“agreed” or “strongly agreed” that the leader supported them in making

their own decisions ( +)

Recovery center leadership actively supported implementation at all three

sites ( +)

81.3% of EUC participants reported they would have used the MMU if it

had been available ( +)

Implementation (To what extent can the intervention be implemented as

planned?)

Outreach leaders successfully mobilized attendance for SexHealth Mobile

Days ( +)

60.0% of intervention participants reported having spoken to an outreach

leader about SexHealth Mobile ( +)

Patients with sexual or reproductive health needs beyond available con‑

traception methods were able to have a preliminary consultation on the

MMU and schedule a later appointment at the main FQHC ( +)

Interest in MMU appointments (which were often lengthy) sometimes

exceeded the number of interested individuals (‑)

Some women were asked to wait for a future conﬁrmatory negative preg‑

nancy test before receiving a subdermal implant (‑)

Integration (To what extent can the intervention be integrated within an

existing system?)

Pre‑existing FQHC/recovery center relationships facilitated smooth service

integration and service provision for patients regardless of insurance status

( +)

MMU process were easily adapted to accommodate contraception care

(including implant insertion and self‑collection of urine) and SexHealth

Mobile Days were easily integrated into recovery center activities ( +)

Limited availability of the FQHC MMU and staﬀ created scheduling chal‑

lenges ( +)

Patients not yet registered to receive services with the FQHC faced a high

burden of paperwork (‑)

Page 9 of 11

Hurleyetal. Harm Reduction Journal (2023) 20:28

more frequently in the EUC (14.6%) versus interven-

tion (2.1%; p = 0.023). Less frequently cited barriers

were “transportation” (EUC = 6.3%; intervention = 2.0%,

p = 0.288) and “COVID-19-related” (EUC = 2.1%; inter

vention = 0%, p = 0.305).

Discussion

Participants oﬀered free, autonomy-supportive, mobile

contraceptive services at SUD recovery centers were

over nine times more likely to be using contraception

at one-month post baseline than those exposed to EUC

(51.5% vs. 5.4%). e estimated advantage of the inter

vention over EUC strengthens to tenfold when control-

ling for age, recovery center type, pregnancy intention,

pregnancy history, substance use within three months

of the study and assuming continual protection for the

one lost-to-follow-up participant who received a contra

ception injection during her visit. Participants exposed

to the intervention and not using contraception at one-

month typically reported that this was their preference

(they decided they did not want or did not need contra

ception) indicating that this was not a limit of the inter-

vention, but rather a personal choice. Among those not

using contraception at one-month, EUC participants

reported signiﬁcantly more barriers in terms of time

and cost than intervention participants. Participants

exposed to SexHealth Mobile also reported higher post-

intervention conﬁdence in their ability to protect against

unwanted pregnancy.

Our intervention was designed to address key limi

tations of past interventions aimed at increasing con-

traception access for individuals with SUD. Based on

formative research with our target community (inter

views, focus groups) [9], we carefully designed all aspects

of the intervention to stress reproductive justice (e.g.,

outreach leader role/training stressed a non-coercive

approach, participation/enrollment for all regardless of

contraceptive interest, and provision of all contracep

tion options that could be accommodated on the MMU

free of charge). Prior contraception access interven

tions for individuals with SUD have included behavioral

strategies or incentives [19] and some have drawn con

cern about the potential for coercion from providers

[21, 22]. oughtful recent adaptions have linked ﬁnan

cial incentives to attendance at contraception appoint-

ments instead of to contraception use directly [27, 28],

but thisstrategy was viewed as unnecessary and poten

tially problematic by our community partners. SexHealth

Mobile was highly successful in increasing contracep

tion use without the use of incentives. It also oﬀered

a sustainable intervention model by building oﬀ an

existing FQHC and its trusted partnerships with local

recovery centers. Our work also conﬁrms feasibility of

administering longer-acting contraception (injections

and subdermal implant) via MMU in a U.S. urban setting

[29, 30]. ough MMU-based IUD insertion is possible,

[31] it was not feasible to oﬀer through our intervention,

and more research is needed to determine how to best

integrate IUD provision into scalable MMU programs.

Finally, while MMUs have shown high reach and uptake

for contraception in low and middle-income countries,

their use to among at-risk populations in the U.S. has

not been extensively evaluated [31, 32]. Ours study is the

ﬁrst to estimate the impact of MMU-based contraception

care compared to EUC.

SexHealth Mobile demonstrated high demand and

acceptability, with strengths and limitations in its imple

mentation and integration with existing services. e

vast majority of intervention participants made use of

the MMU, with high ratings of overall satisfaction and

person-centeredness of the provider. Many interven

tion participants chose contraception (56.4%), but others

reported they decided they did not want or did not need

contraception, a strong indicator that they felt reproduc

tive autonomy, and were not coerced toward contracep-

tion even if they elected to visit the MMU. Given our

formative research ﬁndings that LARCs would be highly

desirable option, the low uptake of subdermal implants

on the MMU was surprising. On SexHealth Mobile Days,

many participants were still hesitant or unfamiliar with

subdermal implants and not ready to commit to the pro

cedure. is may have been because many participants

took advantage of MMU visits who had not been reached

by education eﬀorts leading up to SexHealth Mobile

Days (40% reported not having prior conversations about

contraception with an outreach leader) and thus may

not have had adequate time to thoroughly consider new

methods. Many expressed interest interested in learning

about new methods like implants and considering them

for a later date, but on a day-of, walk-in MMU service,

were ultimately most comfortable obtaining familiar

methods (e.g., pills). Another key barrier to implementa

tion was that some participants were told to wait several

weeks to conduct another pregnancy test before getting

a subdermal implant (a standard practice at this FHQC

but inconsistent with evidence-based guidelines) [33]

and were given a bridge method until a later visit. Fur

ther, challenges in scheduling the MMU and paperwork

for new patients sometimes limited the number of MMU

visits oﬀered within on SexHealth Mobile Day.

Limitations

In this quasi-experimental design, participants were

not randomized to conditions. e similarities in both

groups on demographic factors proximally associ

ated with contraception use, and the fact that all were

Page 10 of 11

Hurleyetal. Harm Reduction Journal (2023) 20:28

recruited from the same sites, however, minimizes the

possibility that diﬀerences observed between interven

tion/EUC conditions could be attributed to baseline

participant characteristics. e EUC and intervention

periods also occurred at diﬀerent time points, thus

there may have been inherent beneﬁts to the inter

vention period occurring later (e.g., more exposure at

each site to sexual health information/activities related

to the study). We do not believe that the trajectory of

the COVID-19 pandemic had a signiﬁcant impact on

results, as we did not initiate enrollment in the EUC

period until in-person activities at recovery centers and

referral health centers had resumed. In reporting bar

riers to contraception, just one participant in the EUC

period named a COVID-19 related factor. We alsonote

limitations in diversity in our sample as the majority of

our sample identiﬁed as white and non-Hispanic.

Conclusion

SexHealth Mobile expanded access to patient-centered

contraception options for individuals with SUD, demon

strating meaningful increases in contraception coverage

and conﬁdence to protect against unintended pregnancy,

without the need for incentives or persuasion. Alleviating

barriers to contraception by expanding interventions like

SexHealth Mobile could help empower more individuals

entering substance use recovery to prevent unintended

pregnancy. More research is needed to adapt and imple

ment similar interventions for individuals with SUD who

are not connected to traditional recovery centers.

Acknowledgements

The authors would like to thank all the implementing partners that made this

project possible, especially Rachel Melson, Jennifer Frost, Lori Glenski, Angel

Modersohn, DeAnte Hurd, Amanda Derington, Sarah Knopf‑Amelung, Olivia

Deeken, Mollee Flores, Renee Harris, Erin Hestand, Kelli Hubbard, Bobbi Jo

Reed, Jesse Ibarra, Alex Irvin, Brenda Peters, and Alyssa Ibarra. We would also

like to thank Beth Canipe and Evelyn Donis de Miranda for help with data

collection and manuscript preparation, and all the participants who gave their

time and opinions.

Author contributions

Concept and design: EAH, KG, SFK and MKM. Acquisition, analysis, and/or

interpretation of data: All authors. Drafting of the manuscript: EAH. Critical

revision of the manuscript for important intellectual content: All authors.

Statistical analysis: JNM. Obtained funding: EAH, KG, MKM, SFK. Administrative

and technical support: KPB, AA. Supervision: EAH, MKM. All authors read and

approved the ﬁnal manuscript.

Funding

Research reported in this work was supported by Organon & Co. The content

is solely the responsibility of the authors and does not necessarily represent

the views of Organon & Co. The funding source had no role in the design and

conduct of the study; collection, management, analysis, or interpretation of

the data; preparation, review, or approval of the manuscript.

Availability of data and materials

The datasets used during the current study are available from the correspond‑

ing author on reasonable request.

Declarations

Ethics approval and consent to participate

All participants provided written, informed consent prior to enrollment. The

study protocol was approved by the Institutional Review Board at Children’s

Mercy Kansas City (#1099).

Consent for publication

Not applicable.

Competing interests

EAH and MKM received investigator‑initiated grants from Organon & Co for

studies on contraception access. All other authors declare no competing

interests.

Author details

Division of Health Services and Outcomes Research, Children’s Mercy Kansas

City, 2401 Gillham Rd., Kansas City, MO 64108, USA.

Department of Pediat‑

rics, University of Missouri‑Kansas City School of Medicine, Kansas City, MO,

USA.

Department of Population Health, University of Kansas Medical Center,

Kansas City, KS, USA.

University of Missouri ‑ Kansas City School of Pharmacy,

Kansas City, MO, USA.

Swope Health Services, Kansas City, MO, USA.

Depart‑

ment of Family Medicine, University of Kansas Medical Center, Kansas City, KS,

USA.

Division of Emergency Medicine, Children’s Mercy Kansas City, Kansas

City, MO, USA.

Received: 28 October 2022 Accepted: 24 February 2023

References

1. Shaﬁque S, Umer A, Innes KE, Rudisill TM, Fang W, Cottrell L. Preconcep‑

tion substance use and risk of unintended pregnancy: pregnancy risk

assessment monitoring system 2016–17. J Addict Med. 2021. https:// doi.

org/ 10. 1097/ ADM. 00000 00000 000886.

2. Heil SH, Jones HE, Arria A, et al. Unintended pregnancy in opioid‑abusing

women. J Subst Abus Treat. 2011;40(2):199–202. https:// doi. org/ 10. 1097/

CCM. 0b013 e3182 3e986a.A.

3. Haight SC, Ko JY, Van Tong VT, Bohm MK, Callaghan WM. Opioid use disor‑

der documented at delivery hospitalization—United States, 1999–2014.

Morb Mortal Wkly Rep. 2018;67(31):845–9. https:// doi. org/ 10. 15585/

mmwr. mm673 1a1.

4. Admon LK, Bart G, Kozhimannil KB, Richardson CR, Dalton VK, Winkelman

TNA. Amphetamine‑And opioid‑aﬀected births: incidence, outcomes,

and costs, United States 2004–2015. Am J Public Health. 2019. https:// doi.

org/ 10. 2105/ AJPH. 2018. 304771.

5. Czeisler MÉ, Lane RI, Petrosky E, et al. Mental health, substance use, and

suicidal ideation during the COVID‑19 pandemic—United States, June

24–30, 2020. MMWR Morb Mortal Wkly Rep. 2020. https:// doi. org/ 10.

15585/ mmwr. mm693 2a1

6. MacAfee LK, Harfmann RF, Cannon LM, et al. Substance use treatment

patient and provider perspectives on accessing sexual and reproductive

health services: barriers, facilitators, and the need for integration of care.

Subst Use Misuse. 2020. https:// doi. org/ 10. 1080/ 10826 084. 2019. 16562 55.

7. Fischbein RL, Lanese BG, Falletta L, Hamilton K, King JA, Kenne DR.

Pregnant or recently pregnant opioid users: contraception decisions,

perceptions and preferences. Contracept Reprod Med. 2018. https:// doi.

org/ 10. 1186/ s40834‑ 018‑ 0056‑y.

8. Stancil SL, Miller MK, Duello A, et al. Long‑acting reversible contraceptives

(LARCs) as harm reduction: a qualitative study exploring views of women

with histories of opioid misuse. Harm Reduct J. 2021. https:// doi. org/ 10.

1186/ s12954‑ 021‑ 00532‑1.

9. Hurley EA, Duello A, Finocchario‑Kessler S, et al. Expanding contracep‑

tion access for women with opioid‑use disorder: a qualitative study of

opportunities and challenges. Am J Heal Promot. 2020;34(8):909–18.

10. Drescher‑Burke K. Contraceptive risk‑taking among substance‑using

women. Qual Soc Work. 2014;13(5):636–53. https:// doi. org/ 10. 1177/

14733 25013 498110.

Page 11 of 11

Hurleyetal. Harm Reduction Journal (2023) 20:28

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11. McCartin M, Cannon LM, Harfmann RF, Dalton VK, MacAfee LK, Kusunoki

Y. Stigma and reproductive health service access among women in treat‑

ment for substance use disorder. Women’s Heal Issues. 2022. https:// doi.

org/ 10. 1016/J. WHI. 2022. 06. 003.

12. Lamy S, Laqueille X, Thibaut F. Consequences of tobacco, cocaine and

cannabis consumption during pregnancy on the pregnancy itself, on the

newborn and on child development: a review. Encephale. 2015. https://

doi. org/ 10. 1016/j. encep. 2014. 08. 012.

13. Perez FA, Blythe S, Wouldes T, McNamara K, Black KI, Oei JL. Prenatal meth‑

amphetamine—impact on the mother and child—a review. Addiction.

2022. https:// doi. org/ 10. 1111/ add. 15509.

14. Neonatal KP, Syndrome A. Pediatrics. 2014;134(2):e547–61. https:// doi.

org/ 10. 1542/ peds. 2013‑ 3524.

15. Scott LF, Shieh C, Umoren RA, Conard T. Care Experiences of Women Who

Used Opioids and Experienced Fetal or Infant Loss. JOGNN ‑ J Obstet

Gynecol Neonatal Nurs. 2017;46(6):846–56. https:// doi. org/ 10. 1016/j. jogn.

2017. 08. 006.

16. Olsen A, Banwell C, Madden A. Contraception, punishment and women

who use drugs. BMC Womens Health. 2014. https:// doi. org/ 10. 1186/

1472‑ 6874‑ 14‑5.

17. Hurley EA, Piña K, Cegielski V, Noel‑MacDonnell JR, Miller MK. Recovering

from substance use disorders during the early months of the COVID‑19

pandemic: A mixed‑methods longitudinal study of women in Kansas City.

J Subst Abuse Treat. 2021. https:// doi. org/ 10. 1016/j. jsat. 2021. 108378.

18. McLellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug dependence, a

chronic medical illness implications for treatment, insurance, and out‑

comes evaluation. J Am Med Assoc. 2000. https:// doi. org/ 10. 1001/ jama.

284. 13. 1689.

19. Heil SH, Melbostad HS, Rey CN. Innovative approaches to reduce unin‑

tended pregnancy and improve access to contraception among women

who use opioids. Prev Med. 2019. https:// doi. org/ 10. 1016/j. ypmed. 2019.

105794.

20. Cadena DS, Chaudhri A, Scott C. Contraceptive care using reproductive

justice principles: beyond access. Am J Public Health. 2022;112(S5):S494–

9. https:// doi. org/ 10. 2105/ AJPH. 2022. 306915.

21. Lucke JC, Hall WD. Under what conditions is it ethical to oﬀer incentives

to encourage drug‑using women to use long‑acting forms of contracep‑

tion? Addiction. 2012;107(6):1036–41. https:// doi. org/ 10. 1111/j. 1360‑

0443. 2011. 03699.x.

22. Lyerly AD. Beyond voluntariness—ethics and incentives for contracep‑

tion. JAMA Psychiat. 2021;78(10):1069–70. https:// doi. org/ 10. 1001/ jamap

sychi atry. 2021. 1284.

23. Yermachenko A, Massari V, Azria E, et al. Unintended pregnancy preven‑

tion in women using psychoactive substances: a systematic review.

Addict Behav. 2020. https:// doi. org/ 10. 1016/j. addbeh. 2020. 106393.

24. Brown RL, Rounds LA. Conjoint screening questionnaires for alcohol and

other drug abuse: criterion validity in a primary care practice. Wis Med J.

1995.

25. Bowen DJ, Kreuter M, Spring B, et al. How we design feasibility studies.

Am J Prev Med. 2009. https:// doi. org/ 10. 1016/j. amepre. 2009. 02. 002.

26. Dehlendorf C, Henderson JT, Vittinghoﬀ E, Steinauer J, Hessler D. Devel‑

opment of a patient‑reported measure of the interpersonal quality of

family planning care. Contraception. 2018. https:// doi. org/ 10. 1016/j. contr

acept ion. 2017. 09. 005.

27. Heil SH, Hand DJ, Sigmon SC, Badger MS, Meyer MC, Higgens ST. Using

behavioral economic theory to increase use of eﬀective contraceptives

among opioid‑maintained women at risk of unintended pregnancy. Prev

Med. 2016;92:62–7. https:// doi. org/ 10. 1038/ nn. 3945. Dopam inerg ic.

28. Heil SH, Melbostad HS, Matusiewicz AK, et al. Eﬃcacy and cost‑beneﬁt

of onsite contraceptive services with and without incentives among

women with opioid use disorder at high risk for unintended pregnancy: a

randomized clinical trial. JAMA Psychiat. 2021;78(10):1071–8. https:// doi.

org/ 10. 1001/ JAMAP SYCHI ATRY. 2021. 1715.

29. Martin CE, Han JJ, Serio‑Chapman C, Chaulk P, Terplan M. Injectable

contraceptive continuation among female exotic dancers seeking

mobile reproductive health services. J Health Care Poor Underserved.

2014;25(3):1317–27. https:// doi. org/ 10. 1353/ hpu. 2014. 0134.

30. Nall M, O’Connor S, Hopper T, Peterson H, Mahajan B. Community women

and reproductive autonomy: building an infrastructure for long‑acting

reversible contraception (LARC) services in a mobile health clinic. J

Health Care Poor Underserved. 2019;30(1):47–58. https:// doi. org/ 10. 1353/

hpu. 2019. 0006.

31. Jacobstein R, Curtis C, Spieler J, Radloﬀ S. Meeting the need for modern

contraception: Eﬀective solutions to a pressing global challenge. Int J

Gynecol Obstet. 2013;121:S9–15. https:// doi. org/ 10. 1016/j. ijgo. 2013. 02.

005.

32. Moore E, Han J, Serio‑Chapman C, Mobley C, Watson C, Terplan M. Con‑

traception and clean needles: Feasibility of combining mobile reproduc‑

tive health and needle exchange services for female exotic dancers. Am

J Public Health. 2012;102(10):1833–6. https:// doi. org/ 10. 2105/ AJPH. 2012.

300842.

33. Curtis KM, Jatlaoui TC, Tepper NK, et al. US selected practice recommen‑

dations for contraceptive use, 2016. MMWR Recomm Rep. 2016. https://

doi. org/ 10. 15585/ mmwr. rr650 4a1.

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