Title: Does access to no-cost contraception change method selection among individuals who
report difficulty paying for health-related care?
Version: 2 Date: 02 Mar 2022
Reviewer:  Isabel Morgan
Reviewer's report:
Thank you for the opportunity to review this manuscript.
The manuscript reports data from a study on the effects of eliminating out-of-pocket expenses
affects contraceptive method choice and examines satisfaction of method choice among
individuals reporting difficulty paying for healthcare in the previous year.
I’ve included comments below organized by section for authors to consider to clarify and
strengthen the manuscript.
Title
If the character count allows, consider using consistent language in: Does access to no-cost
contraception change method selection among individuals who report **difficulty** paying for
health-related care?
Abstract
Abstract is clear, concise, and presents the highlights of the key results
Background
The first paragraph notes that there is unmet need for family planning among women in Utah
and that contraceptive access initiatives that remove consumer costs increases utilization of
LARC. If data are available, considering citing a source that indicates patient/client preference
for contraceptive methods (including LARC) in Utah relative to method utilization.
I appreciate the footnote describing why gendered language was employed in the text and
how the authors perceive the gender identity (or presentation) of study participants. Should the
footnote be provided for the description of the study population (in the first sentence of the
methods section) instead of the reference to another data source in the background section?
Methods
Study Population
Consider describing the patient-centered counseling protocol that PPAU staff were trained in.
It may be helpful to provide this additional information to help the readers contextualize the
results on method selection and method satisfaction. Additionally, it will address concerns that
have been raised regarding coercive contraceptive method counseling practices and critiques of
the tiered effectiveness contraceptive counseling techniques.
Statistical Methods & Analyses
Consider specifying how racial categories were collapsed for the multivariable analyses. It isn’t
clear until viewing Table 3 that all participants who did not identify as White were collapsed
into one category.
In describing the model building techniques, it is noted that a cut-off of 0.3 was used to determine
which variables were to be included in the final models. Consider specifying why a cut-off of
0.3 was selected to finalize the models.
Covariate selection was informed by previous literature on factors associated with method
selection. It is suggested that health center enrollment site, ever-use of LARC, and hx of abortion
were additional variables controlled for in the analyses and perhaps not shown to be associated
with method selection previously. Consider describing the rationale for why these additional
variables were identified and included in the model. (May suffice to reference studies that have
suggested these variables should be examined in future research.)
Results
Table 1.
For the reporting of race and ethnicity, are the data presented in a strategic order? (For example,
age is an ordinal variable and the data are presented as such.) The rationale for the order of
data presented by race is unclear. (Upon viewing the tables presenting data for the logistic
regression models, White non-Latinx was selected as the referent group.) Listing White, non-
Latinx first (with no apparent order) may be interpreted as centering Whiteness (or viewing
White as default).
See References:
Johfre SS, Freese J. Reconsidering the Reference Category. Sociological Methodology.
2021;51(2):253-269. doi:10.1177/0081175020982632
https://libguides.umn.edu/antiracismlens
Predictors of Method Selection
Consider moving the sentence “results from all adjusted models are presented in table 3” to
the start the second paragraph of the predictors of method selection section (prior to describing
results from the adjusted models).
Discussion
The discussion thoughtfully highlights and contextualizes the results on method selection. One
the study aims was to examine method satisfaction among participants who continued a method
for at least one year, yet the discussion does not highlight these results. Consider describing and
providing additional context to these results in the discussion section. Additionally, the results
section notes that the highest continuation rates were observed for LARC users. Consider noting
that these methods are intended for long-acting use and provide context to the options provided
to patients/clients that may have desired to remove these methods.