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21/576 HSDR Improving choice, access and uptake of contraception for women - commissioning brief

Contents

Closing date: 1pm on 21 January 2022

Scope

Research is needed to understand the impact of the pandemic on women’s, including transgender and non-binary people's, choices, access and their attitudes and preferences towards contraception, especially towards long-acting reversible contraceptives.  It is also important to understand their experiences of initial access to contraception in both general practice and sexual and reproductive health services. We are also interested in research that explores women’s, including transgender and non-binary people's, experiences of using these services, and the extent to which their care is fragmented or well-coordinated, and what this indicates in terms of how service provision may need to change to meet future needs. Research into understanding women’s experiences of these services in the context of rapid changes to services from face-to-face to remote during the COVID-19 pandemic is also of interest.

The Health and Social Care Delivery Research (HSDR) Programme is interested in receiving applications for high quality, mixed methods research with strong theoretical grounding, to generate robust national learning and strengthen the evidence base for the development of the new Sexual and Reproductive Health Strategy for England. Research in this area will help to understand women’s attitudes and preferences towards contraception, issues related to accessing contraception, including medium and long-term impact on wellbeing (both physical and psychological), and in what way access to contraception through multiple providers (both specialist and non-specialist) can be improved to meet the needs of women. Interim findings should be made available to support the implementation phase of the sexual and reproductive health strategy and further policy and service development.

Research comparing women’s experiences and attitudes towards contraception and services from Wales and Northern Ireland are of interest and, although applicants from Scotland are only eligible as co-applicants, not lead applicants, the programme would welcome using Scotland as a comparator, thereby extending generalisability of the findings.

Identified research need

Women have multiple and changing reproductive health needs throughout their lives, from puberty, through to menopause, and beyond. Sexual and reproductive health for women plays an important role in shaping their overall wellbeing. The stigma surrounding reproductive issues can result in significant barriers to accessing contraception. Therefore, providing equitable access to the full range of contraception is a major challenge, and an important priority for the provision of equitable local health services.

Prescriptions for long acting reversible contraceptives dropped by 11% in general practice between 2014-2016 and contraception-related attendance dropped by 13% in specialist services between 2014/15 to 2017/18. Overall, there was a 3% decline in long acting reversible contraceptives prescriptions across general practices and sexual and reproductive health clinics pre-pandemic and this issue has been exacerbated during the pandemic. Both general practice and sexual and reproductive health services have been adversely affected by the impact of the pandemic and particularly with respect to the fitting and removal of long acting reversible contraceptives due to face-to-face appointments only being possible for urgent cases. A 37% fall in contraception-related contacts with sexual and reproductive health services was observed during April to September 2020. Uptake of long acting reversible contraceptives fell from 46% in 2019/20 to 43% in 2020/21. Prior to this, long acting reversible contraceptives uptake had been steadily increasing. Similarly, in general practice after a period of generally steady volumes, there has been a large fall in the number of long acting reversible contraceptives fitted. In 2020 there were 1.03 million prescriptions, which is 17% lower than in 2019 when 1.24 million were dispensed.

The significant drop in long acting reversible contraceptives provision and limited resources during the pandemic leading to pressures on all services, were being managed by offering “bridging” alternatives such as progesterone-only pills to women however, some of these methods remain less effective. The unmet demand of long acting reversible contraceptives provision during the pandemic is likely to have a cumulative effect on unplanned pregnancies, along with potentially poor maternal and child outcomes and an increased demand on maternity and abortion services. Although there is increased convenience of remote health advice services as highlighted during the COVID-19 pandemic, digital exclusion could be a barrier in accessing contraception for women from lower socio-economic groups and ethnic minorities. Also, some procedures such as fitting coils and injections require in person appointments. Little is known about how women in the UK perceive their reproductive health and what factors influence the choice they make in relation to their reproductive health.

To improve access and uptake of contraceptive services for marginalised groups, research exploring the way in which women’s identity and life circumstances, as well as other socio-economic, educational, and cultural factors, affect their ability to access contraceptive care is needed. Also, of note is that the needs of marginalised and ethnic minority groups are likely to vary and therefore should be considered.  

The Department of Health and Social Care (DHSC) in March 2021 launched a 14 week call for evidence on women’s health to form the basis for the development of the government’s Women’s Health Strategy for England, published in due course. Research into understanding women’s attitudes and experiences of contraception and sexual and reproductive health services would thus help in the development of both the Sexual and Reproductive Health Strategy and the Women’s Health Strategy, including informing public health messaging, efforts to increase access to services via new care pathways, and reviewing information sources available and accessible to a diverse range of women.

Areas of interest

The HSDR Programme is not prescriptive about the form of evaluation, but elements may include large- scale mixed methods, qualitative or longitudinal research to understand the experiences of demographically diverse women, including trends and impact of changes to sexual and reproductive health services over time. It is anticipated that the areas mentioned below will be the sequential stages of a single overarching study.

Attitudes and experiences

  • To explore women’s attitudes and preferences about different methods of contraception (including influencing factors for choice, such as partners) with a specific focus on long acting reversible contraceptives, across different socio-demographics and context, priority groups including younger and older women, marginalised groups of women, such as from different ethnic backgrounds, and to explore whether these are changing over time, and specifically due to the pandemic.
  • To explore women’s attitudes and preferences about the provision of sexual and reproductive health services using different methods (e.g., remote- or tele-consultations or face-to-face).
  • To explore women’s experiences of different types of sexual and reproductive health service providers (e.g., primary care or specialist sexual and reproductive health clinics or pharmacy).
  • To explore the attitudes of staff, including barriers to and facilitators of the delivery of contraceptive and other sexual and reproductive health services in different settings (GP practice, specialist clinics).
  • To understand women’s experiences of accessing different forms of contraception from specialist sexual health clinics, general practice and other NHS services and their pathways to care – including the choice women are given when accessing contraception methods in general practice.

Sexual and reproductive health service mapping, trends, and impact

  • Mapping current service provision and identifying the characteristics of services where contraception is provided, including the nature of the workforce, and the approach taken to enable access to services, for instance developments undertaken by primary care networks. This would include system level approaches to coordinating care across different providers and agencies.
  • To examine the impact of changes to sexual health services and NHS services specifically during the pandemic – including the impact of shift to online service provision on contraception provision.
  • To understand the short and long-term impact on women’s wellbeing (physical and psychological) because of their experiences accessing reproductive healthcare and contraception, particularly during the pandemic.
  • To understand the impacts of reduced access to contraception and long acting reversible contraceptives in general practice and sexual and reproductive health services on widening inequalities.

Co-designing sexual and reproductive health services

  • Participative research to develop and test access pathways and configurations and build consensus [subject to forthcoming sexual and reproductive health strategy and policy development].

General guidance

The NIHR Health and Social Care Delivery Research programme supports applied research with the aim of improving health and social care services across the UK and is open to any methodology, or combination of methods, which is appropriate to answer the proposed research question(s), and this must be fully explained and justified. In order to enhance the success of a proposal a clear theory of change and pathway to impact with links into the NHS and social care is required. It is useful to consider in your study design how outcomes could be scaled up to maximise impact and value for money across the NHS and social care – the focus is on applied research with tangible impact on systems that improve the quality, accessibility and organisation of health and social care services. This also includes stakeholder engagement and the development of processes, tools, and guidelines to strengthen workforce capacity. 

Research proposals should be co-produced with national organisations and professional bodies, health and social care service professionals, and service users. Links with health and social care planners, commissioners and professional bodies is encouraged to facilitate the impact and scaling up of research findings to benefit the wider health and social care system. Applicants may wish to consult the NIHR INVOLVE guidance on co-producing research.

The COVID-19 outbreak is having a significant impact across health and social care. As this research may be conducted during the COVID-19 response and recovery stage, the research should consider how the impact of COVID-19 response and recovery may affect your ability to conduct your research. Mitigating steps need to be set out to reassure as to the deliverability and feasibility of the proposed work.

The NIHR is committed to actively and openly supporting and promoting equality, diversity, and inclusion (EDI). All NIHR applications need to demonstrate they have met the requirements of the Equality Act (2010) by embedding EDI throughout the research proposal, ensuring there is no discrimination across the following domains; age; disability; race, including colour, nationality, ethnic or national origin; religion or belief; sex; sexual orientation; gender reassignment; being married or in a civil partnership; being pregnant or on maternity leave. Applicants are expected to pay attention to populations in locations with greatest need, socioeconomic disadvantage, which have disproportionately less access to health and social care services and are of an under researched area.