University Students’ Gynecology Care Experiences in the US and Canada: Implications for Equitable Access to Person-Centered Care

Introduction: The United States (US) and Canada (CA) have differing healthcare systems that play a central role in how reproductive care is accessed and delivered. Yet, their shared patriarchal history and culture contribute to the underdevelopment of medical reproductive knowledge and appropriate healthcare for uterus-having individuals of various intersecting identities. Medical literature lacks uterus-having individuals’ lived experiences of navigating reproductive services, and perspectives on how social factors, healthcare structure, and clinical practice can better support equitable access to person-centered reproductive care within both countries. As university students reflect diverse individuals transitioning to autonomous roles and changing reproductive health needs, their voices are critical to uncovering social and structural influences of person-centered access. The overall goal of this research was to identify what the US and CA system stakeholders can learn from uterus-having university students to improve reproductive healthcare delivery. I investigated how university students navigate gynecology care within divergent healthcare delivery models to address the following aims. \nAim 1: Identify university students’ barriers to accessing gynecology care. \nAim 2: Document factors influencing students’ person-centered gynecology care experiences. \n \nMethodology: This study was operationalized from the transformative-intersectional perspective that knowledge is created through individual experiences of reality, power, and oppression. Twenty-two university students who have used reproductive health services (CA: n = 11, US: n = 11) participated in semi-structured interviews and surveys (Nov 2019 – Jan 2021). Five reproductive health experts (CA: n = 3, US: n = 2) were interviewed to further situate students’ experiences within existing policy and practice standards. Student data collection tools were guided by intersectionality theory, the equitable access model (EAM), person-centered care frameworks, and American College of Gynecology clinical recommendations. \nQualitative analysis occurred in three coding steps: inductive, identity, and deductive, allowing a broad look at raw data, intersectional identity discovery, and equitable healthcare access framework application. To supplement qualitative clinical-level findings, I analyzed surveys to show descriptive frequencies of students’ reported experiences of person-centered care indicators. I used abduction to connect qualitative and descriptive findings to existing concepts (e.g., theories, models, literature), identifying themes within and beyond existing knowledge and standards. To conclude my analysis, I used retroductive reasoning to extend the EAM model as it applies to gynecology care, illustrating social, policy, and practice opportunities to promote accessible person-centered care in both health systems. \n \nResults: Each participant self-reported uniquely intersecting identities (e.g., races, ethnicities, genders, sexualities, socioeconomic statuses, and cultures), which contributed to specific reproductive needs that played a role in their healthcare navigation and clinical experiences. These reports determined the scope of my thematic investigation, establishing a focus on access to and quality of preventive gynecology care and treatment for chronic reproductive issues in CA and the US. \nAim 1: University students’ gynecology care access was determined by intersecting influences of structural health system nuances and personal cues to accessing reproductive care. CA’s health system provided students in this study with simplified reproductive healthcare navigation, but it limited reproductive health options and prolonged waits to specialist services. The US health system theoretically provided participants with reproductive care choices, but access to these choices was logistically complicated by healthcare fragmentation. Healthcare structure shaped the clinical setting, determining protocols and care provisions that students identified as negatively impacting care options and experiences such as inaccessible preferred contraception methods, short appointment durations, and a narrowed scope of health services. Students reported the importance of providers’ health system knowledge and clinical strategies to mitigate negative impacts of their respective health models. Personal influences to seeking care existed at various steps, including identifying when to seek care, knowing how to access care, preparing for clinical interactions, and physically attending appointments. Personal influences of how and when to access care stemmed from participants’ life experience and social networks, which they developed over time. Students reported that universities’ social and built environments further shaped reproductive health efficacy by providing proximate support, resources, and confidential services. \nAim 2: I noted discrepancies between current reproductive care standards, participants’ clinical experiences, and students’ perceptions and values of what person-centered care means. Students reported frustration with the wording, intention, and interpretation of some standard clinical screening questions. Most students were not asked questions related to sexuality, mental health, and abuse. With participants’ frequent reference to the relationship between mental, sexual, and reproductive wellbeing, failure to ask these questions sometimes limited providers’ ability to address students’ needs. While most students were offered STI testing and reported STI services as a key reproductive health value, students infrequently reported blood tests, possibly indicating incomplete or insufficient STI testing. Students’ discussions about clinical experiences focused on perceived quality of provider interactions. While most survey responses showed satisfaction with providers’ shared decision-making approach, interviews revealed nuanced experiences of students feeling unengaged in their care, reporting providers did not offer adequate support to enable them to make informed, autonomous decisions. \n \nConclusion: Students in both countries expressed the need for reproductive service navigation support within systems that provided timely options to care that centered on their specific intersectional identities and health needs. In addition to policy and practice mitigation opportunities for identified structural barriers within health systems, I found that comprehensive education policy and social support may improve students’ access to person-centered reproductive care, allowing for knowledge and skills to identify reproductive needs, navigate health systems, self-advocate, and ultimately make informed decisions. These findings suggest that providers can play a crucial clinical role in mitigating some structural and personal barriers to person-centered care by maintaining and applying proficiencies in reproductive health literature, health policy, and cultural safety as it relates to their patient populations. Overall, this work situates reproductive healthcare access within the EAM, extends this framework to better integrate person-centeredness as a care quality mediator, and connects concepts identified in this study to opportunities for improvement.

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