Contraception use among individuals with substance use disorder increases 10-fold with patient-centered, mobile services: a quasi- experimental study

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Hurley, Kathy Goggin, Kimberly Piña-Brugman, Janelle R. Noel-MacDonnell, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2214464/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Mar, 2023 Read the published version in Harm Reduction Journal → Version 1 posted 9 You are reading this latest preprint version 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 aimed to examine feasibility and impact of SexHealth Mobile, a mobile unit-based intervention aiming 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 hormonal contraception/IUD at one-month post-enrollment. Secondary outcomes were use 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 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. Following the overturning of Roe v. Wade, expanding interventions like SexHealth Mobile may help reduce harm from unintended pregnancies among individuals in SUD recovery. Trial Registration: NCT04227145 contraception reproductive justice substance use disorders recovery sexual health mobile unit Figures Figure 1 Introduction Ensuring access to contraception is more critical than ever, especially among those at high risk for unintended pregnancies in states where the overturning of Roe v. Wade has 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 preconception 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 unintended, a rate 2 to 3 times higher than in the general population. 2 The number of individuals impacted is growing as rates of non-prescription opioid use have quadrupled and rates of methamphetamines have doubled among pregnant women in the last two decades. 3 , 4 SUD rates have continued to rise among all since the onset of the COVID-19 epidemic. 5 Women with a SUD history report high unmet desire for contraception but face barriers. 6 – 9 They are less likely to have regular contact with primary or reproductive health care and report cost, insurance, and/or transportation challenges. 8 , 10 They may also avoid contraception care-seeking due to experienced or anticipated stigma from providers. 6 , 8 , 9 , 11 Women often lack accurate information about contraception options 7 , 8 or may not prioritize seeking contraception when actively trying to obtain substances. 8 Addressing these barriers can help individuals with SUD to have 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 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 initiation as a time of peak readiness to address broader health needs. Contraception is highly desired, as women initiating recovery generally 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 provider longer-term protection for the 40–60% of women who relapse within one year of beginning treatment. 18 Although some studies have shown increased contraceptive use with SUD recovery-based interventions, they have had limitations. 19 Few interventions fully demonstrate commitment to principals of reproductive justice (the right to maintain bodily autonomy, including choice over reproduction) and harm reduction (the right to access services that reduce harmful effects of substance use without judgement or pressure to change SUD behavior). 8 , 9 , 20 Some include 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 services: (1) maximize access to the full range of contraception options, (2) provide contraception free or at minimal cost, (3) offer non-judgmental, non-coercive patient-centered care (4) are delivered by qualitied, trusted provider advisors, and (5) are supported and promoted by their peers. 9 SexHealth Mobile is an intervention designed to meet these community-derived priorities for people with SUD at risk of unintended pregnancy. It features a medical mobile unit (MMU) equipped with a range of free contraception options as well as peer outreach leaders trained to support free choice and provide accurate, non-coercive information on contraception options. This 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 interrupted time series design (i.e., enhanced usual care [EUC] followed by intervention). We aimed to compare contraception use one-month after enrollment among participants enrolled in the two different time periods. The study was approved by The 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 health services at high-risk community locations, including recovery centers. For this study, we selected three recovery centers that already partnered with the FHQC to receive MMU visits. These centers (two residential, one outpatient) were providing services for clients with any type of SUD, most commonly polysubstance use disorders that included use of methamphetamines and/or opioids. Recovery center clients were eligible if they were: (1) aged 18–40; (2) screened positive for 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 hormonal contraception (i.e., oral contraceptive pill, transdermal patch, vaginal ring, injectable, subdermal implant, or intrauterine device); and (5) not previously enrolled in either phase of the study. Procedures Study staff worked with recovery centers to share information about the study and visited each site periodically for eligibility screening and enrollment. Interested clients were screened individually by study staff and those eligible provided informed consent. Site visits continued until the sample size target for each time period (n = 46) was reached or exceeded. Participants completed a 15-minute baseline questionnaire via REDCap that included demographic, substance use, and reproductive health history. In the EUC period (Aug-Nov. 2020), participants were then offered a printed information sheet that listed community locations where they could access contraception care. In the SexHealth Mobile intervention period (April-Sept. 2021), participants were offered the opportunity to see a reproductive health care provider on the MMU and, if desired, obtain contraception on-site. Intervention period participants not interested in an MMU visit were offered EUC printed information sheets. Participants in both time periods completed a 5-minute 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 reduction principals. The 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. This included a provider with experience in patient-centered contraception care for SUD patients, a care assistant, and materials required for on-site provision of contraceptive medications (e.g., pregnancy tests, needles, syringes). We worked with recovery centers and FHQC staff to ensure services were provided in a way that was acceptable to potential patients, including arranging for pregnancy testing with urine collected by patients themselves within recovery center facilities. On SexHealth Mobile Days, the provider offered contraceptive options on the MMU free of charge, including hormonal (i.e., pills, transdermal patch, vaginal ring, injection, subdermal implant) and non-hormonal (diaphragm, condoms). Participants choosing short-term hormonal contraception (pills, path, ring, injection) received enough for three months of pregnancy prevention and instructions for refills/follow-up. The MMU was not outfitted with a standard patient exam table that could be used for gynecological procedures, thus we could not offer IUDs. Participants interested in IUD or other health services not available on the MMU could obtain referral for a facility-based appointment. Study staff also offered free condoms and home pregnancy tests at the enrollment table for anyone at the recovery center. At each recovery center, 2–4 individuals who already occupied formal roles as trusted resources for clients (e.g., peer mentor, social worker) were trained as “outreach leaders” to promote SexHealth Mobile Days and organize interested clients. Training covered basic principles of reproductive justice and harm reduction, contraception options, needs and challenges of women with SUD in preventing unintended pregnancies, and strategies for using client-centered and trauma-informed approaches when talking contraception. Outreach leaders and study staff stressed that all activities on SexHealth Mobile Days were completely voluntary, and women could obtain a clinic referral or meet with MMU providers and receive free contraception without enrolling in the study or 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. Table 1 Assessment of SexHealth Mobile feasibility: constructs, indicators, and measures 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 1 Proportion of intervention participants completing MMU visits who received on-site contraception Post-intervention survey item 2 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 participants reporting taking free condoms at MMU visit Study staff field notes; post-intervention survey 1 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 2 - 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 2 - Person-Centered Contraceptive Counseling Survey (PCCCS) 34 : using “top score” (an “excellent” rating on all four items) Intervention participants’ ratings of outreach leader support Baseline survey item 3 - Level of agreement that outreach leader supported them in making their own decision (4-point from “strongly disagree” to “strongly agree) Recovery center leadership support and cooperation in facilitating 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 4 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 outreach leaders Baseline survey item 1 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 existing 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 Notes: 1 Intervention participants only; 2 Intervention participants completing MMU visits only; 3 Intervention participants who reported interactions with Outreach Leaders only; 4 Enhanced usual care participants only Primary and secondary outcomes Use of hormonal contraception/IUD (pills, patch, ring, depo shot, subdermal implant or IUD) at one-month post-enrollment was the primary outcome and continued use at two-weeks and three-months were the secondary outcomes. We also explored confidence in preventing unintended pregnancy at post-intervention and as a change from baseline to post-intervention (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 reasons for not attending clinic visits, picking up prescriptions, 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 appropriate 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). The adjusted model included demographic factors known to influence contraception use or identified as having influence through a series of bivariate associations, including recovery site (residential 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 substance use in the three months prior to baseline vs. none). We analyzed the primary outcome again including participants who had missed the one-month assessment but reported a Depo shot (which protects for three months) at post-intervention or two weeks. Quantitative analyses were completed in SAS Version 9.4. (SAS Institute, Cary, NC). Field notes were analyzed with qualitative coding according to Bowen’s constructs 25 and major findings are presented within the overall feasibility assessment. Results Baseline demographics We enrolled 98 participants (48 in EUC period, 50 in intervention period). An additional 17 were ineligible after screening (Fig. 1 ). Follow-ups were completed by 70.4% at two-weeks (79.2% EUC, 62.0% intervention), 71.4% at one-month (77.1% EUC, 66.0% intervention), 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), ethnicity (92.9% non-Hispanic), educational status (76.5% high school graduate or higher) and marital status (69.4% single/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 reported identifying as male, with all others identifying as female. Almost half (46.9%) were uninsured while most others had public insurance (35.7%). Table 2 Demographics (including substance use, sexual/repro health history) Enhanced Usual Care (EUC) (n = 48) SexHealth Mobile Intervention (n = 50) Age in years (Median, [IQR]) 30 (25, 34) 32.5 (28, 35) Race (f, %) 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 Non-Hispanic 45 (93.8%) 46 (92.0%) Hispanic/ Latina 3 (6.3%) 3 (6.0%) Educational Level 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 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 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%) *p < 0.05 difference between groups according to Chi-Square, Fisher’s Exact or independent t-test Note: Where options do not add to 100%, one or more participants marked “prefer not to answer” EUC and intervention participants were also similar in substance use and sexual/reproductive health history. Participants were receiving services at an outpatient (48.0%) or one of two residential (52.0%) recovery centers. Most participants had recently initiated recovery, with more EUC participants reporting recent substance use (within the past three months, other than tobacco) compared to intervention participants (85.4%, 66.0%; p = 0.026). The 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%). In the past 12 months, 72.4% had not received any medical services and 58.2% said there was a time 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 pregnant (2.0%). At last vaginal sex, most reported no pregnancy prevention method (48.0%) or withdrawal (24.5%) and 20.4% used a condom. The majority had used some type of contraception in the past, 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, 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 (86.0%) intervention participants decided to visit the MMU to speak with a healthcare provider about contraception. Of the 39 who completed a visit and post-intervention survey, 22 (56.4%) reported receiving a form of hormonal contraception on the MMU (14 pills, 5 Depo shot, 1 subdermal implant, 1 patch, 1 ring) and 2 (5.1%) were prescribed a diaphragm. Acceptability was also high, as most intervention participants who had 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 implementation and integration of services, with minor challenges (detailed in Table 3 ). Table 3 SexHealth Mobile feasibility: Key findings Feasibility construct Key findings Demand (To what extent is the intervention likely to be used?) 86% of intervention participants interested in an MMU visit on a SexHealth Mobile Day 56.4% of intervention participants completing MMU visits received on-site contraception 21 individuals not eligible for 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 MMU visit Acceptability (How do stakeholders react to the intervention?) 92.3% of intervention participants who visited the MMU were “very satisfied” 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 women to attend SexHealth Mobile Days 60.0% of intervention participants reported having spoken to an outreach leader about SexHealth Mobile Interest in MMU appointments (which were often lengthy) sometimes exceeded the number of interested individuals MMU patients sometimes arranged a “warm handoff to the main FQHC;” for patients with sexual or reproductive health needs beyond available contraception methods Some women were asked to wait to receive a subdermal implant until a future confirmatory negative pregnancy test Integration (To what extent can the intervention be integrated within an existing system?) Pre-existing FQHC/recovery center relationships facilitated smooth service integration (e.g., processes already existed to facilitate FQHC service provision for recovery center clients, regardless of insurance status) MMU process were easily adapted to accommodate contraception care (including implant insertion and self-collection of urine) and SexHealth Mobile Day activities were well integrated into recovery center schedules Challenges included FQHC scheduling (due to limited availability of the MMU and staff) and high burden of paperwork for women not yet registered to receive services with the FQHC 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). The proportion of intervention 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 additional participant could be assumed to be using contraception at one-month despite not completing the assessment, as she reported receiving a Depo shot at on the post-intervention survey, strengthening 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). Confidence 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 intervention participants increased from “not confident/low confident/not sure” in baseline to “very confident/extremely confident” post-intervention (28.0% vs. 12.5% in EUC; p = < 0.001). The most frequently cited reason for non-use of contraception at one-month among both groups was “decided did not want/need birth control” (EUC = 27.1%; intervention = 16.0%; p = 0.18). “Not enough time” (to complete referral appointment, pick up prescription, and/or start method) was frequently reported in the EUC group (22.9%) but was rare in the intervention group (6.0%; p = 0.001). “Insurance/cost” barriers were also reported more frequently in the EUC (14.6%) versus intervention (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%; intervention = 0%, p = 0.305). Discussion Participants offered free, autonomy-supportive, mobile contraceptive services at SUD recovery centers were over 9 times more likely to be using contraception at one-month post baseline than those exposed to EUC (51.5% vs. 5.4%). The estimated advantage of the intervention over EUC strengthens to 10-fold when controlling 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 Depo shot 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 contraception) indicating that this was not a limit of the intervention, 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, which was related to contraception use. Our intervention was designed to address key limitations of past interventions aimed at increasing contraception access for individuals with SUD. Listening to guidance from our target community, 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 contraception options that could be accommodated on the MMU free of charge). Prior interventions have included behavioral strategies, incentives, or used peer leaders to “make contraception a higher priority” 19 and have drawn concern about the potential for coercion. Thoughtful recent adaptions of these interventions have shifted financial incentives from contraception use to attendance at follow-up contraception appointments 26 , 27 but this was viewed as unnecessary and potentially problematic by our community partners. SexHealth Mobile was highly successful without the use of incentives and provides a highly sustainable intervention that builds off an existing FQHC model of care and partnerships with local recovery centers. Our intervention also moves the field forward by targeting all individuals as they enter recovery reaching many more than prior studies that have historically targeted only those in the postpartum period. 28 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, and few have included LARC. 29 – 32 Our study is the first to estimate the impact of MMU-based contraception care compared to EUC. SexHealth Mobile demonstrated high feasibility in terms of demand and acceptability, with strengths and limitations in its implementation and integration with existing services. The vast majority of intervention participants made use of the MMU, with high ratings of overall satisfaction and person-centeredness of the provider. Many intervention participants chose contraception (56.4%), but others reported they decided they didn’t want or didn’t need contraception, a strong indicator that they felt reproductive autonomy, and were not coerced toward contraception even if they elected to visit the MMU. Given our formative research findings that LARCs would be a highly desirable option, the low uptake of subdermal implants on the MMU was surprising. Many participants were still hesitant or unfamiliar with subdermal implants and not ready to commit to the procedure on enrollment day. A few as well indicated they 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 took pills as a bridge method until a later clinic visit. Further, challenges in scheduling the MMU and paperwork for new patients sometimes limited the number of MMU visits offered. In this quasi-experimental design, participants were not randomized to conditions. The similar demographic makeup of both groups and the fact that all were recruited from the same sites, however, minimizes the possibility that differences observed between intervention/EUC conditions could be attributed to baseline participant characteristics. The EUC and intervention period also occurred at different time points, thus there may have been inherent benefits to the intervention 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 report of barriers to contraception, just one woman in the EUC period named a COVID-19 related factor. We note limitations in diversity in our sample as the majority of our sample identified as white and non-Hispanic. SexHealth Mobile expanded access to patient-centered contraception options for individuals with substance use disorder, demonstrating meaningful increases in contraception coverage and confidence to protect against unintended pregnancy, without the need for incentives or persuasion. 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 Availability of data and materials : The datasets used during the current study are available from the corresponding author on reasonable request. Competing interests : EAH and MKM received investigator-initiated grants from Organon & Co for studies on contraception access. All other authors declare no competing interests. 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. Authors' contributions : Concept and design: EAH, KG, SFK and MKM. Acquisition, analysis, 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 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, Dante Hurd, Amanda Derington, Sara Knopf-Amelung, Olivia Deeken, Mollee Flores, Renee Harris, Jamila Edwards, 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. References Shafique S, Umer A, Innes KE, Rudisill TM, Fang W, Cottrell L. Preconception Substance Use and Risk of Unintended Pregnancy: Pregnancy Risk Assessment Monitoring System 2016-17. J Addict Med . 2022; 16(3):278-285. Heil SH, Jones HE, Arria A, et al. Unintended Pregnancy in Opioid-abusing Women. 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Subst Use Misuse . 2020;55(1). doi:10.1080/10826084.2019.1656255 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;3(1). doi:10.1186/s40834-018-0056-y 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;18(1). doi:10.1186/s12954-021-00532-1 Hurley EA, Duello A, Finocchario-Kessler S, et al. Expanding contraception access for women with opioid-use disorder: A qualitative study of opportunities and challenges. Am J Heal Promot . 2020;34(8):909-918. Drescher-Burke K. Contraceptive risk-taking among substance-using women. Qual Soc Work . 2014;13(5):636-653. doi:10.1177/1473325013498110 McCartin M, Cannon LM, Harfmann RF, Dalton VK, MacAfee LK, Kusunoki Y. Stigma and Reproductive Health Service Access Among Women in Treatment for Substance Use Disorder. Women’s Heal Issues . Published online July 9, 2022. doi:10.1016/J.WHI.2022.06.003 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;41(S1). doi:10.1016/j.encep.2014.08.012 Perez FA, Blythe S, Wouldes T, McNamara K, Black KI, Oei JL. Prenatal methamphetamine—impact on the mother and child—a review. Addiction . 2022;117(1). doi:10.1111/add.15509 Kocherlakota P. Neonatal Abstinence Syndrome. Pediatrics . 2014;134(2):e547-e561. doi:10.1542/peds.2013-3524 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):846-856. doi:10.1016/j.jogn.2017.08.006 Olsen A, Banwell C, Madden A. Contraception, punishment and women who use drugs. BMC Womens Health . 2014;14(1). doi:10.1186/1472-6874-14-5 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;129. doi:10.1016/j.jsat.2021.108378 McLellan AT, Lewis DC, O’Brien CP, Kleber HD. Drug dependence, a chronic medical illness implications for treatment, insurance, and outcomes evaluation. J Am Med Assoc . 2000;284(13). doi:10.1001/jama.284.13.1689 Heil SH, Melbostad HS, Rey CN. Innovative approaches to reduce unintended pregnancy and improve access to contraception among women who use opioids. Prev Med (Baltim) . Published online 2019. doi:10.1016/j.ypmed.2019.105794 Cadena DS, Chaudhri A, Scott C. Contraceptive Care Using Reproductive Justice Principles: Beyond Access. Am J Public Health . 2022;112(S5):S494-S499. doi:10.2105/AJPH.2022.306915 Lucke JC, Hall WD. Under what conditions is it ethical to offer incentives to encourage drug-using women to use long-acting forms of contraception? Addiction . 2012;107(6):1036-1041. doi:10.1111/j.1360-0443.2011.03699.x Lyerly AD. Beyond Voluntariness—Ethics and Incentives for Contraception. JAMA Psychiatry . 2021;78(10):1069-1070. doi:10.1001/jamapsychiatry.2021.1284 Yermachenko A, Massari V, Azria E, et al. Unintended pregnancy prevention in women using psychoactive substances: A systematic review. Addict Behav . 2020;107. doi:10.1016/j.addbeh.2020.106393 Brown RL, Rounds LA. Conjoint screening questionnaires for alcohol and other drug abuse: Criterion validity in a primary care practice. Wis Med J . Published online 1995. Bowen DJ, Kreuter M, Spring B, et al. How We Design Feasibility Studies. Am J Prev Med . Published online 2009. doi:10.1016/j.amepre.2009.02.002 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 (Baltim) . 2016;92:62-67. doi:10.1038/nn.3945.Dopaminergic 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 Psychiatry . 2021;78(10):1071-1078. doi:10.1001/JAMAPSYCHIATRY.2021.1715 Elko A, Jansson LM. Contraception in Drug-Dependent Women: A Novel Approach. Soc Work Ment Health . 2011;9(6):445-455. doi:10.1080/15332985.2011.575723 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-S15. doi:10.1016/j.ijgo.2013.02.005 Moore E, Han J, Serio-Chapman C, Mobley C, Watson C, Terplan M. Contraception and clean needles: Feasibility of combining mobile reproductive health and needle exchange services for female exotic dancers. Am J Public Health . 2012;102(10):1833-1836. doi:10.2105/AJPH.2012.300842 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):1317-1327. doi:10.1353/hpu.2014.0134 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. doi:10.1353/hpu.2019.0006 Curtis KM, Jatlaoui TC, Tepper NK, et al. U.S. selected practice recommendations for contraceptive use, 2016. MMWR Recomm Reports . 2016;65(4). doi:10.15585/mmwr.rr6504a1 Dehlendorf C, Henderson JT, Vittinghoff E, Steinauer J, Hessler D. Development of a patient-reported measure of the interpersonal quality of family planning care. Contraception . 2018;97(1). doi:10.1016/j.contraception.2017.09.005 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 06 Mar, 2023 Read the published version in Harm Reduction Journal → Version 1 posted Editorial decision: Major revision 31 Jan, 2023 Reviews received at journal 29 Jan, 2023 Reviews received at journal 21 Jan, 2023 Reviewers agreed at journal 15 Jan, 2023 Reviewers agreed at journal 22 Nov, 2022 Reviewers invited by journal 03 Nov, 2022 Editor assigned by journal 31 Oct, 2022 Submission checks completed at journal 31 Oct, 2022 First submitted to journal 28 Oct, 2022 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2214464","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":148232794,"identity":"5c5b8ea7-0ec6-4da8-813e-279db4f83c8a","order_by":0,"name":"Emily A. Hurley","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAxElEQVRIiWNgGAWjYFACHiAuYGDgZ2BgA7KYidViwMAg2UCyFoMDxGrhZz97TLrCwCZx8/HTaQ8YKqwTGwhpkezJS5M8Y5CWuO1M7nYDhjPphLUYHMgxk2wwOJy47QbvNgnGtsOEtdiffwPS8j9x8wyQln9EaDGQANtyIHGDBEhLAxFaJG68MbZsMEg2nnEmd5tEwrF0Y4Ja+PtzDG82VNjJ9ref3SbxocZalqAWGHAEq0wgVjkI2JOieBSMglEwCkYYAADQnD0JgSpVxwAAAABJRU5ErkJggg==","orcid":"","institution":"Children’s Mercy Kansas City","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Emily","middleName":"A.","lastName":"Hurley","suffix":""},{"id":148232795,"identity":"6da556c9-8855-42b6-94c4-4b0ebd9a542c","order_by":1,"name":"Kathy Goggin","email":"","orcid":"","institution":"Children’s Mercy Kansas City","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kathy","middleName":"","lastName":"Goggin","suffix":""},{"id":148232796,"identity":"b46eedf7-0a37-48fb-8ca7-02d7ce0e0cea","order_by":2,"name":"Kimberly Piña-Brugman","email":"","orcid":"","institution":"Children’s Mercy Kansas City","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kimberly","middleName":"","lastName":"Piña-Brugman","suffix":""},{"id":148232797,"identity":"c375736a-ef1d-4e05-af9e-9a52d564389d","order_by":3,"name":"Janelle R. Noel-MacDonnell","email":"","orcid":"","institution":"Children’s Mercy Kansas City","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Janelle","middleName":"R.","lastName":"Noel-MacDonnell","suffix":""},{"id":148232798,"identity":"f55e0a8d-caa3-4097-87a1-be9baef207bc","order_by":4,"name":"Andrea Allen","email":"","orcid":"","institution":"Swope Health Services","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Andrea","middleName":"","lastName":"Allen","suffix":""},{"id":148232799,"identity":"b16283e3-b93c-487e-b6c7-8a227a4e3d36","order_by":5,"name":"Sarah Finocchario-Kessler","email":"","orcid":"","institution":"University of Kansas Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Finocchario-Kessler","suffix":""},{"id":148232800,"identity":"20f83f14-f5f9-48ed-8730-4c11df25093b","order_by":6,"name":"Melissa K. Miller","email":"","orcid":"","institution":"University of Missouri-Kansas City School of Medicine","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Melissa","middleName":"K.","lastName":"Miller","suffix":""}],"badges":[],"createdAt":"2022-10-28 19:14:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2214464/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2214464/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12954-023-00760-7","type":"published","date":"2023-03-06T19:32:01+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":28580049,"identity":"27a2bbeb-e41b-4cb9-873f-72449ed5aa63","added_by":"auto","created_at":"2022-11-02 19:42:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":35144,"visible":true,"origin":"","legend":"\u003cp\u003eScreening, enrollment, \u0026amp; follow-up of participants in SexHealth Mobile Intervention\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-2214464/v1/3f6c447998173582c181ba82.png"},{"id":44721788,"identity":"10ca61e2-24ad-4245-9b26-1d574c781eb3","added_by":"auto","created_at":"2023-10-16 19:39:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":432687,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2214464/v1/f14ae5e2-4d44-4eff-86b3-81aa3625cde7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Contraception use among individuals with substance use disorder increases 10-fold with patient-centered, mobile services: a quasi- experimental study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEnsuring access to contraception is more critical than ever, especially among those at high risk for unintended pregnancies in states where the overturning of \u003cem\u003eRoe v. Wade\u003c/em\u003e has 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 preconception illicit or recreational drug use, compared to those with no drug use .\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e In a study of women with opioid use disorder, nine in ten pregnancies were unintended, a rate 2 to 3 times higher than in the general population.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e The number of individuals impacted is growing as rates of non-prescription opioid use have quadrupled and rates of methamphetamines have doubled among pregnant women in the last two decades.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e SUD rates have continued to rise among all since the onset of the COVID-19 epidemic.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWomen with a SUD history report high unmet desire for contraception but face barriers.\u003csup\u003e\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e They are less likely to have regular contact with primary or reproductive health care and report cost, insurance, and/or transportation challenges.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e They may also avoid contraception care-seeking due to experienced or anticipated stigma from providers.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Women often lack accurate information about contraception options\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e or may not prioritize seeking contraception when actively trying to obtain substances.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Addressing these barriers can help individuals with SUD to have 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 custody).\u003csup\u003e\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eEntry 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 initiation as a time of peak readiness to address broader health needs. Contraception is highly desired, as women initiating recovery generally state they prefer to plan pregnancies for a time when they have reached stable, long-term recovery.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Meeting contraception desires with long-acting reversible contraception (LARC) early in recovery can also provider longer-term protection for the 40\u0026ndash;60% of women who relapse within one year of beginning treatment.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlthough some studies have shown increased contraceptive use with SUD recovery-based interventions, they have had limitations.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Few interventions fully demonstrate commitment to principals of \u003cem\u003ereproductive justice\u003c/em\u003e (the right to maintain bodily autonomy, including choice over reproduction) and \u003cem\u003eharm reduction\u003c/em\u003e (the right to access services that reduce harmful effects of substance use without judgement or pressure to change SUD behavior).\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Some include the controversial use of incentives or directive behavior change goals to encourage contraception use.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e Further, many have not been able to provide LARC and have offered only limited options.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Our formative research suggested women would find contraception services valuable and make use of them without incentives, given that the services: (1) maximize access to the full range of contraception options, (2) provide contraception free or at minimal cost, (3) offer non-judgmental, non-coercive patient-centered care (4) are delivered by qualitied, trusted provider advisors, and (5) are supported and promoted by their peers.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eSexHealth Mobile\u003c/em\u003e is an intervention designed to meet these community-derived priorities for people with SUD at risk of unintended pregnancy. It features a medical mobile unit (MMU) equipped with a range of free contraception options as well as peer outreach leaders trained to support free choice and provide accurate, non-coercive information on contraception options. This pilot study examines the feasibility of \u003cem\u003eSexHealth Mobile\u003c/em\u003e and its impact on contraception use among woman in SUD recovery programs in Kansas City, Missouri.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe conducted a quasi-experimental study with an interrupted time series design (i.e., enhanced usual care [EUC] followed by intervention). We aimed to compare contraception use one-month after enrollment among participants enrolled in the two different time periods. The study was approved by The Institutional Review Board at Children\u0026rsquo;s Mercy Kansas City.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSetting and Participants\u003c/h2\u003e \u003cp\u003e \u003cem\u003eSexHealth Mobile\u003c/em\u003e was implemented in partnership with a federally qualified health center (FHQC) in Kansas City that was already operating a MMU to provide basic health services at high-risk community locations, including recovery centers. For this study, we selected three recovery centers that already partnered with the FHQC to receive MMU visits. These centers (two residential, one outpatient) were providing services for clients with any type of SUD, most commonly polysubstance use disorders that included use of methamphetamines and/or opioids.\u003c/p\u003e \u003cp\u003eRecovery center clients were eligible if they were: (1) aged 18\u0026ndash;40; (2) screened positive for problematic drinking or drug use according to CAGE-AID tool;\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e (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 hormonal contraception (i.e., oral contraceptive pill, transdermal patch, vaginal ring, injectable, subdermal implant, or intrauterine device); and (5) not previously enrolled in either phase of the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eProcedures\u003c/h2\u003e \u003cp\u003eStudy staff worked with recovery centers to share information about the study and visited each site periodically for eligibility screening and enrollment. Interested clients were screened individually by study staff and those eligible provided informed consent. Site visits continued until the sample size target for each time period (n\u0026thinsp;=\u0026thinsp;46) was reached or exceeded.\u003c/p\u003e \u003cp\u003eParticipants completed a 15-minute baseline questionnaire via REDCap that included demographic, substance use, and reproductive health history. In the EUC period (Aug-Nov. 2020), participants were then offered a printed information sheet that listed community locations where they could access contraception care. In the \u003cem\u003eSexHealth Mobile\u003c/em\u003e intervention period (April-Sept. 2021), participants were offered the opportunity to see a reproductive health care provider on the MMU and, if desired, obtain contraception on-site. Intervention period participants not interested in an MMU visit were offered EUC printed information sheets. Participants in both time periods completed a 5-minute post-intervention survey as well as 2-week, 1-month, and 3-month follow-up phone assessments. Participants were compensated \u003cspan\u003e$\u003c/span\u003e20 for completion of the baseline/post-intervention survey, \u003cspan\u003e$\u003c/span\u003e15 each for 2-week and 1-month follow-ups, and \u003cspan\u003e$\u003c/span\u003e20 for the 3-month follow-up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSexHealth Mobile Intervention\u003c/h2\u003e \u003cp\u003e \u003cem\u003eSexHealth Mobile\u003c/em\u003e is grounded in formative research and centered on reproductive justice and harm reduction principals. The intervention featured \u0026ldquo;SexHealth Mobile Days\u0026rdquo; 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. This included a provider with experience in patient-centered contraception care for SUD patients, a care assistant, and materials required for on-site provision of contraceptive medications (e.g., pregnancy tests, needles, syringes). We worked with recovery centers and FHQC staff to ensure services were provided in a way that was acceptable to potential patients, including arranging for pregnancy testing with urine collected by patients themselves within recovery center facilities.\u003c/p\u003e \u003cp\u003eOn SexHealth Mobile Days, the provider offered contraceptive options on the MMU free of charge, including hormonal (i.e., pills, transdermal patch, vaginal ring, injection, subdermal implant) and non-hormonal (diaphragm, condoms). Participants choosing short-term hormonal contraception (pills, path, ring, injection) received enough for three months of pregnancy prevention and instructions for refills/follow-up. The MMU was not outfitted with a standard patient exam table that could be used for gynecological procedures, thus we could not offer IUDs. Participants interested in IUD or other health services not available on the MMU could obtain referral for a facility-based appointment. Study staff also offered free condoms and home pregnancy tests at the enrollment table for anyone at the recovery center.\u003c/p\u003e \u003cp\u003eAt each recovery center, 2\u0026ndash;4 individuals who already occupied formal roles as trusted resources for clients (e.g., peer mentor, social worker) were trained as \u0026ldquo;outreach leaders\u0026rdquo; to promote SexHealth Mobile Days and organize interested clients. Training covered basic principles of reproductive justice and harm reduction, contraception options, needs and challenges of women with SUD in preventing unintended pregnancies, and strategies for using client-centered and trauma-informed approaches when talking contraception.\u003c/p\u003e \u003cp\u003eOutreach leaders and study staff stressed that all activities on SexHealth Mobile Days were completely voluntary, and women could obtain a clinic referral or meet with MMU providers and receive free contraception without enrolling in the study or enroll in the study and meet with MMU providers even if they were unsure or not interested in taking up contraception.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eOutcome Measures\u003c/h2\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003eFeasibility\u003c/h2\u003e \u003cp\u003eWe assessed feasibility of \u003cem\u003eSexHealth Mobile\u003c/em\u003e according to selected Bowen feasibility constructs.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e lists and defines constructs and measures of assessment, including participant survey items and study staff field notes.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssessment of \u003cem\u003eSexHealth Mobile\u003c/em\u003e feasibility: constructs, indicators, and measures\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeasibility Construct\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndicator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMeasure\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cem\u003eDemand\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(To what extent is the intervention likely to be used?)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProportion of intervention participants interested in an MMU visit on a SexHealth Mobile Day\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBaseline survey item\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProportion of intervention participants completing MMU visits who received on-site contraception\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-intervention survey item\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber 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).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudy staff field notes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of individuals (participants and non-participants) who took free condoms and pregnancy tests; number of study participants reporting taking free condoms at MMU visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudy staff field notes; post-intervention survey\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cem\u003eAcceptability\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(How do stakeholders react to the intervention?)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention participants\u0026rsquo; ratings of post-MMU visit satisfaction and likelihood of recommending to a friend\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-intervention survey items\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e- Overall satisfaction: (4-point scale; range: \u0026ldquo;not satisfied at all\u0026rdquo; to \u0026ldquo;very satisfied\u0026rdquo;)\u003c/p\u003e \u003cp\u003e- Likelihood of recommending MMU (5-point scale from \u0026ldquo;extremely unlikely\u0026rdquo; to \u0026ldquo;extremely likely\u0026rdquo;)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention participants\u0026rsquo; ratings of patient-centeredness of MMU provider\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-intervention survey items\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e- \u003cem\u003ePerson-Centered Contraceptive Counseling Survey\u003c/em\u003e (PCCCS)\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e : using \u0026ldquo;top score\u0026rdquo; (an \u0026ldquo;excellent\u0026rdquo; rating on all four items)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention participants\u0026rsquo; ratings of outreach leader support\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBaseline survey item\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e- Level of agreement that outreach leader supported them in making their own decision (4-point from \u0026ldquo;strongly disagree\u0026rdquo; to \u0026ldquo;strongly agree)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecovery center leadership support and cooperation in facilitating implementation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudy staff field notes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProportion of EUC participants who reported they would have used the MMU if it had been available\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-intervention survey item\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cem\u003eImplementation\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(To what extent can the intervention be implemented as planned?)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOutreach leader activity in intervention period\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudy staff field notes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIntervention participants\u0026rsquo; self-reported interactions with outreach leaders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBaseline survey item\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAcceptability of patient flow, volume, and wait time for all stakeholders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudy staff field notes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbility of MMU/provider to meet needs of patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudy staff field notes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eIntegration\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(To what extent can the intervention be integrated within an existing system?)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall 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)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStudy staff field notes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eNotes: \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Intervention participants only; \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Intervention participants completing MMU visits only; \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Intervention participants who reported interactions with Outreach Leaders only; \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Enhanced usual care participants only\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003ePrimary and secondary outcomes\u003c/h2\u003e \u003cp\u003eUse of hormonal contraception/IUD (pills, patch, ring, depo shot, subdermal implant or IUD) at one-month post-enrollment was the primary outcome and continued use at two-weeks and three-months were the secondary outcomes. We also explored confidence in preventing unintended pregnancy at post-intervention and as a change from baseline to post-intervention (reported on a repeated 5-point scale ranging from \u0026ldquo;not at all confident\u0026rdquo; to \u0026ldquo;extremely confident\u0026rdquo;) as well as reasons for non-use at one-month (including reasons for not attending clinic visits, picking up prescriptions, and/or starting birth control).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eDescriptive analysis was carried out for all variables, with comparisons made between groups with Chi-Square or Fisher\u0026rsquo;s Exact tests for categorical variables as appropriate 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\u0026rsquo;s Exact test and Poisson regression with robust standard errors (unadjusted and adjusted). The adjusted model included demographic factors known to influence contraception use or identified as having influence through a series of bivariate associations, including recovery site (residential vs. outpatient), pregnancy intention (trying to avoid/wouldn\u0026rsquo;t mind avoiding vs. other), pregnancy history (ever been pregnant vs. not) and recency of substance use substance use in the three months prior to baseline vs. none). We analyzed the primary outcome again including participants who had missed the one-month assessment but reported a Depo shot (which protects for three months) at post-intervention or two weeks. Quantitative analyses were completed in SAS Version 9.4. (SAS Institute, Cary, NC). Field notes were analyzed with qualitative coding according to Bowen\u0026rsquo;s constructs\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e and major findings are presented within the overall feasibility assessment.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eBaseline demographics\u003c/h2\u003e \u003cp\u003eWe enrolled 98 participants (48 in EUC period, 50 in intervention period). An additional 17 were ineligible after screening (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Follow-ups were completed by 70.4% at two-weeks (79.2% EUC, 62.0% intervention), 71.4% at one-month (77.1% EUC, 66.0% intervention), and 59.2% at three-months (75.0% EUC, 44.0% intervention). At baseline, participants in both groups were similar in age (median\u0026thinsp;=\u0026thinsp;31, range 19\u0026ndash;40), ethnicity (92.9% non-Hispanic), educational status (76.5% high school graduate or higher) and marital status (69.4% single/never married) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). 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 reported identifying as male, with all others identifying as female. Almost half (46.9%) were uninsured while most others had public insurance (35.7%).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics (including substance use, sexual/repro health history)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEnhanced Usual Care (EUC)\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;48)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSexHealth Mobile Intervention (n\u0026thinsp;=\u0026thinsp;50)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge in years (Median, [IQR])\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (25, 34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.5 (28, 35)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace (f, %)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmerican Indian/Alaska Native\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (2.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack/ African American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (12.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (4.0%)*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40 (83.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38 (76.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (14.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Hispanic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (93.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (92.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic/ Latina\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (6.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (6.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducational Level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLess than High School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (20.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (26.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school graduate or GED\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (45.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (48.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-high school training/ some college\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (31.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (18.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndergraduate degree or Higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (8.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle (never married)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (70.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (68.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeparated/ Divorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (22.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (22.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried/ domestic partnership\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (6.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (4.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth Insurance Status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic (Medicare, Medicaid)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (33.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (38.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (6.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (8.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUninsured\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (54.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (40.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 difference between groups according to Chi-Square, Fisher\u0026rsquo;s Exact or independent t-test\u003c/p\u003e \u003cp\u003eNote: Where options do not add to 100%, one or more participants marked \u0026ldquo;prefer not to answer\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eEUC and intervention participants were also similar in substance use and sexual/reproductive health history. Participants were receiving services at an outpatient (48.0%) or one of two residential (52.0%) recovery centers. Most participants had recently initiated recovery, with more EUC participants reporting recent substance use (within the past three months, other than tobacco) compared to intervention participants (85.4%, 66.0%; p\u0026thinsp;=\u0026thinsp;0.026). The 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%). In the past 12 months, 72.4% had not received any medical services and 58.2% said there was a time they thought they should have accessed health care but did not.\u003c/p\u003e \u003cp\u003eMost had no (43.9%) or one (44.9%) current male sexual partner with few reporting they were trying to get pregnant (2.0%). At last vaginal sex, most reported no pregnancy prevention method (48.0%) or withdrawal (24.5%) and 20.4% used a condom. The majority had used some type of contraception in the past, 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, 60.5% reported their child/children living in foster care or with someone else at some point.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eIntervention feasibility\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes mixed-methods feasibility findings. Overall intervention \u003cem\u003edemand\u003c/em\u003e was high, as 43 (86.0%) intervention participants decided to visit the MMU to speak with a healthcare provider about contraception. Of the 39 who completed a visit and post-intervention survey, 22 (56.4%) reported receiving a form of hormonal contraception on the MMU (14 pills, 5 Depo shot, 1 subdermal implant, 1 patch, 1 ring) and 2 (5.1%) were prescribed a diaphragm. \u003cem\u003eAcceptability\u003c/em\u003e was also high, as most intervention participants who had visited the MMU were \u0026ldquo;very satisfied\u0026rdquo; with their visit (92.3%) and gave the provider a top score for person-centeredness (86.8%). Observations and field notes indicated successful implementation and integration of services, with minor challenges (detailed in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eSexHealth Mobile\u003c/em\u003e feasibility: Key findings\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeasibility construct\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKey findings\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cem\u003eDemand\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(To what extent is the intervention likely to be used?)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86% of intervention participants interested in an MMU visit on a SexHealth Mobile Day\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56.4% of intervention participants completing MMU visits received on-site contraception\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 individuals not eligible for the study had an MMU visit\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 individuals took free condoms and 30 took free pregnancy tests from study staff; 18 study participants took free condoms at MMU visit\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cem\u003eAcceptability\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(How do stakeholders react to the intervention?)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92.3% of intervention participants who visited the MMU were \u0026ldquo;very satisfied\u0026rdquo; with their visit; 97.4% were \u0026ldquo;likely\u0026rdquo; or \u0026ldquo;extremely likely\u0026rdquo; to recommend to a friend\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86.8% of intervention participants who visited the MMU gave the provider a top score for patient-centeredness\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e76.6% of intervention participants who spoke to an outreach leader \u0026ldquo;agreed\u0026rdquo; or \u0026ldquo;strongly agreed\u0026rdquo; that the leader supported them in making their own decisions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecovery center leadership actively supported implementation at all three sites\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81.3% of EUC participants reported they would have used the MMU if it had been available\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cem\u003eImplementation\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(To what extent can the intervention be implemented as planned?)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOutreach leaders successfully mobilized women to attend SexHealth Mobile Days\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60.0% of intervention participants reported having spoken to an outreach leader about SexHealth Mobile\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInterest in MMU appointments (which were often lengthy) sometimes exceeded the number of interested individuals\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMMU patients sometimes arranged a \u0026ldquo;warm handoff to the main FQHC;\u0026rdquo; for patients with sexual or reproductive health needs beyond available contraception methods\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSome women were asked to wait to receive a subdermal implant until a future confirmatory negative pregnancy test\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cem\u003eIntegration\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003e(To what extent can the intervention be integrated within an existing system?)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-existing FQHC/recovery center relationships facilitated smooth service integration (e.g., processes already existed to facilitate FQHC service provision for recovery center clients, regardless of insurance status)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMMU process were easily adapted to accommodate contraception care (including implant insertion and self-collection of urine) and SexHealth Mobile Day activities were well integrated into recovery center schedules\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChallenges included FQHC scheduling (due to limited availability of the MMU and staff) and high burden of paperwork for women not yet registered to receive services with the FQHC\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eContraception use\u003c/h2\u003e \u003cp\u003eFor 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\u0026thinsp;=\u0026thinsp;0.001) (unadjusted relative risk (URR)\u0026thinsp;=\u0026thinsp;9.3 [95%CI: 2.3\u0026ndash;37.1]; p\u0026thinsp;=\u0026thinsp;0.0016). The proportion of intervention participants using contraception was also higher than that in EUC at 2-weeks (38.7% [12/31] vs. 2.6% [1/38]; p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) (URR\u0026thinsp;=\u0026thinsp;14.3 [95% CI: 2.0-104.1]; p\u0026thinsp;=\u0026thinsp;0.0085) and three months (40.9% [9/22] vs. 13.9% [5/36]; p\u0026thinsp;=\u0026thinsp;0.020) (URR\u0026thinsp;=\u0026thinsp;2.9 [95%CI: 1.1\u0026ndash;7.4]; p\u0026thinsp;=\u0026thinsp;0.031).\u003c/p\u003e \u003cp\u003eLikelihood 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)\u0026thinsp;=\u0026thinsp;9.8 [95%CI: 2.4\u0026ndash;39.2]; p\u0026thinsp;=\u0026thinsp;0.0013). One additional participant could be assumed to be using contraception at one-month despite not completing the assessment, as she reported receiving a Depo shot at on the post-intervention survey, strengthening the relative risk in the unadjusted (RR\u0026thinsp;=\u0026thinsp;9.7 [95%CI: 2.5\u0026ndash;39.1]; p\u0026thinsp;=\u0026thinsp;0.0012) and adjusted models (ARR\u0026thinsp;=\u0026thinsp;10.0 [95%CI: 2.5\u0026ndash;40.0]; p\u0026thinsp;=\u0026thinsp;0.0012).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eConfidence and barriers\u003c/h2\u003e \u003cp\u003eSelf-reported confidence in one\u0026rsquo;s own ability to protect against unwanted pregnancy (dichotomized as \u0026ldquo;very/extremely confident\u0026rdquo; and \u0026ldquo;not confident/low confident/not sure\u0026rdquo;) was more prevalent in the intervention than the EUC group in the post-intervention survey (90% vs. 70%; p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). A greater proportion of intervention participants increased from \u0026ldquo;not confident/low confident/not sure\u0026rdquo; in baseline to \u0026ldquo;very confident/extremely confident\u0026rdquo; post-intervention (28.0% vs. 12.5% in EUC; p\u0026thinsp;=\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eThe most frequently cited reason for non-use of contraception at one-month among both groups was \u0026ldquo;decided did not want/need birth control\u0026rdquo; (EUC\u0026thinsp;=\u0026thinsp;27.1%; intervention\u0026thinsp;=\u0026thinsp;16.0%; p\u0026thinsp;=\u0026thinsp;0.18). \u0026ldquo;Not enough time\u0026rdquo; (to complete referral appointment, pick up prescription, and/or start method) was frequently reported in the EUC group (22.9%) but was rare in the intervention group (6.0%; p\u0026thinsp;=\u0026thinsp;0.001). \u0026ldquo;Insurance/cost\u0026rdquo; barriers were also reported more frequently in the EUC (14.6%) versus intervention (2.1%; p\u0026thinsp;=\u0026thinsp;0.023). Less frequently cited barriers were \u0026ldquo;transportation\u0026rdquo; (EUC\u0026thinsp;=\u0026thinsp;6.3%; intervention\u0026thinsp;=\u0026thinsp;2.0%, p\u0026thinsp;=\u0026thinsp;0.288) and \u0026ldquo;COVID-19 related\u0026rdquo; (EUC\u0026thinsp;=\u0026thinsp;2.1%; intervention\u0026thinsp;=\u0026thinsp;0%, p\u0026thinsp;=\u0026thinsp;0.305).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eParticipants offered free, autonomy-supportive, mobile contraceptive services at SUD recovery centers were over 9 times more likely to be using contraception at one-month post baseline than those exposed to EUC (51.5% vs. 5.4%). The estimated advantage of the intervention over EUC strengthens to 10-fold when controlling 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 Depo shot 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 contraception) indicating that this was not a limit of the intervention, 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 \u003cem\u003eSexHealth Mobile\u003c/em\u003e also reported higher post-intervention confidence in their ability to protect against unwanted pregnancy, which was related to contraception use.\u003c/p\u003e \u003cp\u003eOur intervention was designed to address key limitations of past interventions aimed at increasing contraception access for individuals with SUD. Listening to guidance from our target community, 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 contraception options that could be accommodated on the MMU free of charge). Prior interventions have included behavioral strategies, incentives, or used peer leaders to \u0026ldquo;make contraception a higher priority\u0026rdquo;\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e and have drawn concern about the potential for coercion. Thoughtful recent adaptions of these interventions have shifted financial incentives from contraception use to attendance at follow-up contraception appointments\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e but this was viewed as unnecessary and potentially problematic by our community partners. \u003cem\u003eSexHealth Mobile\u003c/em\u003e was highly successful without the use of incentives and provides a highly sustainable intervention that builds off an existing FQHC model of care and partnerships with local recovery centers. Our intervention also moves the field forward by targeting all individuals as they enter recovery reaching many more than prior studies that have historically targeted only those in the postpartum period.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e 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, and few have included LARC.\u003csup\u003e\u003cspan additionalcitationids=\"CR30 CR31\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Our study is the first to estimate the impact of MMU-based contraception care compared to EUC.\u003c/p\u003e \u003cp\u003e\u003cem\u003eSexHealth Mobile\u003c/em\u003e demonstrated high feasibility in terms of demand and acceptability, with strengths and limitations in its implementation and integration with existing services. The vast majority of intervention participants made use of the MMU, with high ratings of overall satisfaction and person-centeredness of the provider. Many intervention participants chose contraception (56.4%), but others reported they decided they didn\u0026rsquo;t want or didn\u0026rsquo;t need contraception, a strong indicator that they felt reproductive autonomy, and were not coerced toward contraception even if they elected to visit the MMU. Given our formative research findings that LARCs would be a highly desirable option, the low uptake of subdermal implants on the MMU was surprising. Many participants were still hesitant or unfamiliar with subdermal implants and not ready to commit to the procedure on enrollment day. A few as well indicated they 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\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e and took pills as a bridge method until a later clinic visit. Further, challenges in scheduling the MMU and paperwork for new patients sometimes limited the number of MMU visits offered.\u003c/p\u003e \u003cp\u003eIn this quasi-experimental design, participants were not randomized to conditions. The similar demographic makeup of both groups and the fact that all were recruited from the same sites, however, minimizes the possibility that differences observed between intervention/EUC conditions could be attributed to baseline participant characteristics. The EUC and intervention period also occurred at different time points, thus there may have been inherent benefits to the intervention 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 report of barriers to contraception, just one woman in the EUC period named a COVID-19 related factor. We note limitations in diversity in our sample as the majority of our sample identified as white and non-Hispanic.\u003c/p\u003e \u003cp\u003e \u003cem\u003eSexHealth Mobile\u003c/em\u003e expanded access to patient-centered contraception options for individuals with substance use disorder, demonstrating meaningful increases in contraception coverage and confidence to protect against unintended pregnancy, without the need for incentives or persuasion.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eAll participants provided written, informed consent prior to enrollment. The study protocol was approved by the Institutional Review Board at Children\u0026rsquo;s Mercy Kansas City (#1099).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: The datasets used during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003cem\u003e:\u0026nbsp;\u003c/em\u003eEAH and MKM received investigator-initiated grants from Organon \u0026amp; Co for studies on contraception access. All other authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: Research reported in this work was supported by Organon \u0026amp; Co. The content is solely the responsibility of the authors and does not necessarily represent the views of Organon \u0026amp; 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.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e:\u0026nbsp;Concept and design: EAH, KG, SFK and MKM. Acquisition, analysis, 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\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: The authors would like to thank all the implementing partners that made this project possible, especially Rachel Melson, Jennifer Frost, Lori Glenski, Angel Modersohn, Dante Hurd, Amanda Derington, Sara Knopf-Amelung, Olivia Deeken, Mollee Flores, Renee Harris, Jamila Edwards, 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.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eShafique S, Umer A, Innes KE, Rudisill TM, Fang W, Cottrell L. 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Conjoint screening questionnaires for alcohol and other drug abuse: Criterion validity in a primary care practice. \u003cem\u003eWis Med J\u003c/em\u003e. Published online 1995.\u003c/li\u003e\n\u003cli\u003eBowen DJ, Kreuter M, Spring B, et al. How We Design Feasibility Studies. \u003cem\u003eAm J Prev Med\u003c/em\u003e. Published online 2009. doi:10.1016/j.amepre.2009.02.002\u003c/li\u003e\n\u003cli\u003eHeil 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. \u003cem\u003ePrev Med (Baltim)\u003c/em\u003e. 2016;92:62-67. doi:10.1038/nn.3945.Dopaminergic\u003c/li\u003e\n\u003cli\u003eHeil 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. \u003cem\u003eJAMA Psychiatry\u003c/em\u003e. 2021;78(10):1071-1078. doi:10.1001/JAMAPSYCHIATRY.2021.1715\u003c/li\u003e\n\u003cli\u003eElko A, Jansson LM. Contraception in Drug-Dependent Women: A Novel Approach. \u003cem\u003eSoc Work Ment Health\u003c/em\u003e. 2011;9(6):445-455. doi:10.1080/15332985.2011.575723\u003c/li\u003e\n\u003cli\u003eJacobstein R, Curtis C, Spieler J, Radloff S. Meeting the need for modern contraception: Effective solutions to a pressing global challenge. \u003cem\u003eInt J Gynecol Obstet\u003c/em\u003e. 2013;121:S9-S15. doi:10.1016/j.ijgo.2013.02.005\u003c/li\u003e\n\u003cli\u003eMoore E, Han J, Serio-Chapman C, Mobley C, Watson C, Terplan M. Contraception and clean needles: Feasibility of combining mobile reproductive health and needle exchange services for female exotic dancers. \u003cem\u003eAm J Public Health\u003c/em\u003e. 2012;102(10):1833-1836. doi:10.2105/AJPH.2012.300842\u003c/li\u003e\n\u003cli\u003eMartin CE, Han JJ, Serio-Chapman C, Chaulk P, Terplan M. Injectable contraceptive continuation among female exotic dancers seeking mobile reproductive health services. \u003cem\u003eJ Health Care Poor Underserved\u003c/em\u003e. 2014;25(3):1317-1327. doi:10.1353/hpu.2014.0134\u003c/li\u003e\n\u003cli\u003eNall M, O\u0026rsquo;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. \u003cem\u003eJ Health Care Poor Underserved\u003c/em\u003e. 2019;30(1):47-58. doi:10.1353/hpu.2019.0006\u003c/li\u003e\n\u003cli\u003eCurtis KM, Jatlaoui TC, Tepper NK, et al. U.S. selected practice recommendations for contraceptive use, 2016. \u003cem\u003eMMWR Recomm Reports\u003c/em\u003e. 2016;65(4). doi:10.15585/mmwr.rr6504a1\u003c/li\u003e\n\u003cli\u003eDehlendorf C, Henderson JT, Vittinghoff E, Steinauer J, Hessler D. Development of a patient-reported measure of the interpersonal quality of family planning care. \u003cem\u003eContraception\u003c/em\u003e. 2018;97(1). doi:10.1016/j.contraception.2017.09.005\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"contraception, reproductive justice, substance use disorders, recovery, sexual health, mobile unit","lastPublishedDoi":"10.21203/rs.3.rs-2214464/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2214464/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\n\u003cp\u003eIndividuals 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 aimed to examine feasibility and impact of SexHealth Mobile, a mobile unit-based intervention aiming to increase access to patient-centered contraceptive care for individuals in SUD recovery programs.\u003c/p\u003e\n\u003ch2\u003eMethods\u003c/h2\u003e\n\u003cp\u003eWe 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 hormonal contraception/IUD at one-month post-enrollment. Secondary outcomes were use 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.\u003c/p\u003e\n\u003ch2\u003eResults\u003c/h2\u003e\n\u003cp\u003eParticipants (median age = 31, range 19–40) enrolled in the intervention 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.\u003c/p\u003e\n\u003ch2\u003eConclusions\u003c/h2\u003e\n\u003cp\u003eMobile 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. Following the overturning of Roe v. Wade, expanding interventions like SexHealth Mobile may help reduce harm from unintended pregnancies among individuals in SUD recovery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration: \u003c/strong\u003eNCT04227145\u003c/p\u003e","manuscriptTitle":"Contraception use among individuals with substance use disorder increases 10-fold with patient-centered, mobile services: a quasi- experimental study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-11-02 19:42:39","doi":"10.21203/rs.3.rs-2214464/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-01-31T10:40:34+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-01-30T03:00:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-01-21T20:09:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"9a7bea9f-32ec-4f67-9869-fa9b04e3af6c","date":"2023-01-15T18:35:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"189d53fd-14fb-4885-810f-8a7256dccaa8","date":"2022-11-22T15:19:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2022-11-03T05:46:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2022-10-31T10:35:03+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2022-10-31T10:35:01+00:00","index":"","fulltext":""},{"type":"submitted","content":"Harm Reduction Journal","date":"2022-10-28T19:10:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e95938b4-43eb-496d-92b1-08c5c338e770","owner":[],"postedDate":"November 2nd, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T19:37:04+00:00","versionOfRecord":{"articleIdentity":"rs-2214464","link":"https://doi.org/10.1186/s12954-023-00760-7","journal":{"identity":"harm-reduction-journal","isVorOnly":false,"title":"Harm Reduction Journal"},"publishedOn":"2023-03-06 19:32:01","publishedOnDateReadable":"March 6th, 2023"},"versionCreatedAt":"2022-11-02 19:42:39","video":"","vorDoi":"10.1186/s12954-023-00760-7","vorDoiUrl":"https://doi.org/10.1186/s12954-023-00760-7","workflowStages":[]},"version":"v1","identity":"rs-2214464","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2214464","identity":"rs-2214464","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}