Click here to read Dani's study.
Interview with Danielle Van Liefde
Dani is a second-year MCAH/MPH student, passionate about the promotion of equity-centered family health programs and policies that address social and structural determinants of health. She has experience in the development and implementation of programs across multiple domains of maternal, child, and adolescent health in local and global contexts, including contraception, abortion, malnutrition, diabetes, and HIV/AIDS. Before attending Berkeley School of Public Health, she worked in research coordination on the Beyond the Pill team at the UCSF Bixby Center for Global Reproductive Health implementing a state-wide contraception access and education research program, and at Washington University in St. Louis implementing research projects to optimize localized child malnutrition treatment programs in West and Sub-Saharan Africa. She helped launch the new Gestational Diabetes and Postpartum Care Initiative at the California Department of Public Health for her summer practicum and focused on exploring adolescent mental health for her capstone project. She is currently working as a Research Analyst at UCSF Innovating Education in Reproductive Health, supporting an online abortion education program for healthcare providers across the country. Dani believes that the foundation of a healthy society is healthy families, and is passionate about promoting health education, reproductive justice, maternal health equity, and building healthy communities. Dani is originally from south Orange County but has become a full bay-area convert since 2019. In her free time, she teaches pottery classes at a community studio, loves cooking, hiking, good coffee, and the beach, and centers her world around her sweet dog, Mazzi.
Hi Dani! We are so excited to hear about the publication of “Use of telemedicine to obtain contraception among young adults: Inequities by health insurance.” Can you start by providing us with a background of Beyond the Pill and how this project came to be? What motivated you all to conduct this research study on telemedicine and contraception access among young adults?
DVL: Hi all - me too! So the Beyond the Pill (BTP) team at UCSF promotes access and equity in contraceptive health care. Their work includes clinical training programs that provide education about patient-centered contraception care and counseling, and multiple research projects that promote reproductive autonomy and study contraception access, use, and knowledge.
This publication is an analysis of data from our Reproductive Equity and Access in College Health (REACH) Youth Study, a large randomized controlled trial evaluating a digital birth control education intervention to increase contraceptive access and equity among community college students across California and Texas. BTP recognized the need to study this important population, since community college students make up one-third of undergraduates in the US, are predominantly lower income, racial and ethnic minority, immigrant and first-generation students, and typically have lower contraception knowledge and use compared to 4-year university students.
This study has been ongoing since 2018, and throughout the COVID-19 pandemic, we were able to collect additional data about contraception access during this time, including the use of telemedicine services. Telemedicine has since become quite common in our healthcare system, and since our program centers on health equity, we wanted to understand who has access to these services and what kind of barriers they face.
Can you give us an overview of the publication, its key findings, and aspects of this work that inspired the decision to publish?
DVL: The goal of this analysis, led by Jennifer Yarger (UCSF) and Kristine Hopkins (UT Austin), was to explore how often young adults used telemedicine (phone or video appointment with a provider) to get contraception and to see if there were any differences by health insurance. Telemedicine has proven to be a safe and effective way to get birth control and has the potential to decrease barriers to care, particularly for those with time, financial, and transportation constraints. Policies around telemedicine coverage have been rapidly changing since the pandemic, and much is still unknown about how young people access these services. This is a relevant issue to community college students since they are less likely to be insured than 4-year college students.
This study found that from May 2020 to July 2022, telemedicine was used to obtain contraception in only 6% of observations (6,581 surveys from 1,638 participants). Students were significantly less likely to use telemedicine for contraception if they were uninsured or didn’t know their insurance status compared to privately insured students, and Texas students were less likely than California students to use telemedicine for contraception. They found no significant difference in telemedicine use between public and private insurance.
Could you share a little more about your personal experience running the randomized controlled trial (RCT) and working on this research project? What lessons did you learn that you believe would be valuable for other researchers in similar fields?
DVL: As a proud community college graduate myself, I loved working with this population and managing the implementation of this study. I started on this team in 2019 traveling four days per week to recruit students at community colleges all across the state, from rural towns in the Sierra Foothills to urban San Diego. When the pandemic hit, I led the effort to transition our study protocol to an entirely online format, recruiting and enrolling students online and through Zoom instead of in-person. We faced so many challenges that put my adaptability to the test, encouraged me to think creatively, keep up team morale, and get the job done despite the barriers. Researching sexual and reproductive health amidst a constantly changing political landscape, as other researchers may attest to, requires quick thinking and adaptability, which can be difficult in the context of randomized controlled trials. On top of navigating the pandemic organizationally, our study had to consider the changes in access to care and adapt accordingly. This experience highlighted the importance of community-based participatory research, because this work was much more challenging without the insight and guidance from our community college partners, both before and during the pandemic. That element was very impactful to me and will stick with me throughout my career.
Are there any specific aspects of the publication—whether it’s a particular methodology, analysis, or discussion point—that you found particularly interesting or exciting?
DVL: I’ll mention two elements of this study that I find particularly interesting. Experience with contraceptive care hinges on many factors, one of the most important being contraceptive method, which is an area I get excited about. This study found expected differences in telemedicine use by contraceptive method, with participants using methods like the pill, patch, ring and emergency contraception pill more likely to use telemedicine. It gets me thinking about reverse causality - are people more likely to use those methods if they prefer using telemedicine? How might increased reliance on telemedicine impact someone’s choice of method? Thoughts for future research!
I also found it interesting in this study that living with parents was not associated with a student’s use of telemedicine. I also ran a small qualitative study during this time where we talked to college students about their perceptions toward using telemedicine for contraception, and many reported being concerned about privacy living at home. Apparently that wasn’t a barrier for students in this sample, although only a small number of them actually used telemedicine.
How do you envision the future of telemedicine in improving access to contraception for young adults, especially considering the findings of your study?
DVL: Telemedicine adds another layer of complexity to the already unnecessarily complex world of accessing reproductive healthcare. It has the potential to ease access to care, but we must continue to think critically about how it may impact one’s healthcare experience or interact with existing health disparities. In addition to the healthcare system offering telemedicine services, online private birth control delivery companies have also continued to grow (which I believe we ultimately shouldn't need if people are able to get their birth control easily and for free through their providers…but I’ll spare you from my hot takes on that topic). California has more robust telehealth (and contraception coverage) policies compared to other states, ensuring equal coverage to in-person appointments, and other states should follow suit.
Ultimately, the goal is to work towards a world where everyone has the resources to make an informed decision to use any form of birth control they want and need, and to do so without a financial or emotional cost. In my experience working with young adults, it’s clear they have a strong desire for more education and information about how to manage their reproductive health, and they want to be heard, seen, and respected by their healthcare provider. If we can offer them a way to do that from their phones or computers and for free, and make sure everyone has equitable access, we can be on our way to advancing reproductive justice for all.
What are your future aspirations regarding public health practice? Has this experience influenced your academic and career goals moving forward?
DVL: Absolutely! My experience working with Beyond the Pill solidified my passion for public health and encouraged me to pursue graduate school. The opportunity to contribute to manuscripts and publications such as these motivated me to learn more about statistics and data analysis, and exposure to these types of projects before grad school really helped contextualize the skills I learned in the classroom. Moving forward in my career I would love to apply my research skills to local, public programs, and while I have a passion for reproductive health I am equally interested in promoting health equity at all different life stages and family health domains (I have my MCAH education to thank for that)!