Assessing Community Need and Receptiveness to Reproductive Health Literacy Delivered in a Laundromat Setting

Research design

This study employed a CBPR design to explore reproductive health knowledge and community receptiveness to an HL intervention. We selected laundromats as recruitment sites based on prior research indicating they are trusted, frequented spaces within low-income communities—particularly among individuals who may not engage with traditional health care systems.^15,19

As part of our formative work, we established a Community Advisory Board (CAB) of community members, laundromat owners, and reproductive health providers to guide the study from its inception.a The 10-member CAB met quarterly and provided feedback on recruitment strategies, participant incentives, and language for surveys, flyers, and consent forms. CAB discussions also helped identify study areas based on neighborhood-level characteristics (Supplementary Table S1) and perceived barriers to health access.^20,21 Study areas identified included Wards 1, 4, 5, 7, and 8 of DC.

Instruments

Our study was informed by the Paashe-Orlow and Wolf Conceptual Model and focused on patient access and utilization of health care, patient factors of provider–patient interaction, and patient and extrinsic factors contributing to self-care (Fig. 1). ¹⁶ The 80 questions organized into six domains were drawn from validated tools and consultation with content experts (Supplementary Table S2): 1.

Sociodemographic. We captured self-identified variables including age, place of birth, ethnicity/race, and language preference.

Permission to use and translate validated survey tools was sought and granted. The survey was forward and backward translated and pretested with one English- and one Spanish-speaking individual prior to study start; results from pretesting were not included in the analysis.

Participants and recruitment

The principal investigator (PI) visited laundromats (n = 19) in selected areas with the exception of Ward 8, which did not have a laundromat. Of the seven laundromats that met the inclusion criteria (e.g., open to the public, sufficiently large), five agreed to participate in the study. From these, one laundromat from each area was selected as a recruitment site, resulting in four total study sites.

We used quota sampling to recruit laundromat patrons to achieve a representative sample across the four resulting neighborhoods. A literature review did not provide comparable estimates to support a formal power analysis, due to the lack of existing data on this specific population and setting. Additionally, power-based sample size calculations were not required given the descriptive nature of this needs assessment. Instead, to determine our sample size, we followed the “rules of thumb” for pilot studies when there is no prior information upon which to base the sample size and established a minimum sample size of 60 participants.^26,27 Consultation with two biostatisticians further supported this target sample size, which was deemed sufficient to identify meaningful patterns in the data due to the study’s descriptive nature.^28,29 Quotas were then set to ensure a comparable representation from each site (approximately 14–16 participants per location) to reflect neighborhood-level diversity and local context. We did not stratify by demographic characteristics due to the exploratory nature of the study.

Two academic institution research team members, at least one identifying as a Hispanic woman fluent in Spanish/English, held recruitment windows of 2–4 h on different days and times of the week to capture a diversity of patrons and evaluate laundromat patron flow. Recruitment took place between October 2021 and March 2022 and continued until 14–16 participants from each laundromat completed surveys.

Eligibility

Participants were eligible if they met the following: (1) identified as women or persons assigned female at birth (women), (2) over 18 years old, (3) Spanish- and/or English-speaking, and (4) living in DC. In our design, we did not set an age cap, recognizing that in matriarchal, cross-generational communities, older women play a role in passing health knowledge to younger generations. ³⁰ This intergenerational information exchange was stressed by CAB members as essential in fostering widespread understanding of reproductive health.^31–33 The study was limited to languages in which our team had linguistic and cultural expertise. We focused on recruiting local residents to ensure that participants were likely to be engaged with locally based services, which would better capture the experiences of women navigating local health care systems. This ensured cultural relevance and maximized the study’s potential to identify concerns within the communities served by the laundromats.

Data collection

Once consented, participants were verbally offered either an English or Spanish version of the survey. They were also offered the option to complete the survey on paper or electronically via QR code. Study team members were available to read aloud questions or notate responses as needed. Surveys took 30–45 min to complete; participants were incentivized with a $15 gift card. After each recruitment period, team members completed a postrecruitment form to examine procedures, laundromat attendance, data collection procedures, and team member–participant dynamics. We used this information to assess protocol adherence and study reliability. The PI audited data collection procedures to enhance the dependability, confirmability, and credibility of findings. The authors’ university institutional review board approved all procedures.

Data analysis

We conducted descriptive analysis using STATA 17.0. ³⁴ Based on descriptive analysis results, a chi-square test was used to compare reproductive knowledge scores across language groups. We used the HealthMeasures Scoring Service to calculate T-scores and standard errors (SE). ³⁵ The population mean was defined as 50 (standard deviation [SD] = 10). We ran t-tests, with corresponding Shapiro–Wilk and Breusch–Pagan/Cook–Weisberg tests. Due to links shown in the literature between level of education and HL, we also ran t-tests between self-efficacy and level of education (i.e., high school or less versus more than high school). We analyzed intent to seek care scores with the nonparametric equivalent, Kruskal–Wallis.

Team members from the academic institution (R.M.-B., N.D., K.R.) independently read open-ended survey responses, coding responses to create categories in an inductive process. ³⁶ We met regularly to discuss discrepancies and ensure reliability. ³⁷ Once categories were established, team members independently reexamined open-ended responses to assess patterns across surveys. CAB members reviewed final themes prior to finalization.

Sociodemographics

Of 123 patrons approached, 84 expressed interest and were screened for inclusion. After exclusions due to age (n = 3), language (n = 3), and place of residence (n = 12), 66 patrons provided consent (53.7%). Of these, four did not submit electronic surveys, and two did not complete paper surveys due to time constraints. The final sample consisted of 60 participants; 38 participants completed surveys in English and 22 completed surveys in Spanish. Most participants chose paper surveys (n = 54), and several submitted electronic surveys (n = 6). Demographic characteristics by site are found in Table 1. Participants’ ages ranged from 18–71 years, with a mean age of 38.8. Nineteen participants had a college or university degree. Half of participants were from the United States and approximately one-third were from Spanish-speaking countries of Central America and the Caribbean (Table 1).

Health care use/experience

Of the 85% of participants who reported using health care in the past 12 months, most sought care for routine checkups (76.5%) or obstetric/gynecological care (58.8%). There were no differences in health care use and experience between participants attending different laundromats. English-speaking participants were statistically more likely to report health care use in the past 12 months than Spanish-speaking participants (χ²₍₁₎ = 18.29, p = 0.000). Participants most commonly used public transport to travel to health care appointments, with over one-third utilizing this method. Other modes of transportation included taxis/Uber (23.3%), privately owned vehicles (21.7%), walking (21.7%), or having family/friends drive (20.0%). Two participants mentioned having their transportation costs covered by insurance.

The majority of participants reported that their health care experience needed improvement (96.7%). Analysis of open-ended responses revealed an inability to get an appointment or long wait times as the most common areas needing improvement; some also mentioned providers lacking attentiveness or an understanding of patient concerns. One participant wished that providers “were nicer… that they understood people as they were and that they treated us [the patient] well” (60-year-old, English-speaking participant). Another felt that providers were not particularly communicative and that “they should try to evaluate what one says to learn/understand what the patient needs” (38-year-old, Spanish-speaking participant).

The most common sources of information on reproductive health were providers (e.g., midwives, nurses, and physicians; 53.3%), the internet (53.3%), and family (50.0%). Twice as many Spanish than English-language participants mentioned television as a source of information.

Laundromat use

Nearly all participants were repeat laundromat patrons (93.3%). Among repeat patrons, 62.5% visited weekly and 25% visited biweekly. Distance, convenience, or accessibility motivated participants to choose a particular laundromat (41.7%). Half of the participants attended a laundromat within a 10-minute walk of their home, and several participants visited on the same day and time. Downtime was spent scrolling or playing on phones (45.0%), reading (20.0%), or simply waiting/relaxing (16.7%). Observations during recruitment showed most patrons, both participants and non-participants, spent downtime outside of laundry tasks on their phones.

Intervention receptivity

Most participants reported they would be interested in receiving information on reproductive health while waiting at the laundromat (68.3%). There were no significant differences between Spanish and English language speakers in receptivity (χ²₍₃₎ = 4.69, p = 0.196). In open-ended responses, participants explained that having this information delivered while they were at the laundromat would be convenient and important:

A small group of participants stated that their willingness to participate in an intervention would depend on whether privacy was needed (5.0%) and the time/day of the presentation (10.0%). Among the eight participants who shared they would decline to engage with an intervention, “not needing the information” or “a good relationship with [their] physician” were cited as reasons; three of these participants had private insurance and were visiting the laundromat this one time.

Reproductive health knowledge

Participants demonstrated moderate knowledge of reproductive health knowledge-based items drawn from project DC-HOPE (Table 2). There were statistically significant differences between language groups. English-speaking participants were more likely to demonstrate awareness of recommended birth intervals (χ²₍₁₎ = 6.13, p = 0.013), fertility windows (χ²₍₁₎ = 18.37, p = 0.000), recommended initiation for prenatal care (χ²₍₁₎ = 7.18, p = 0.007), and newborn risk when born to a mother with an STI (χ²₍₁₎ = 4.87, p = 0.027) (Table 2). Spanish-speaking participants had a statistically significantly higher chance of knowing the association between pregnancy spacing and fetal weight (χ²₍₁₎ = 7.52, p = 0.006). There were no significant differences between groups for any other knowledge items. Half of the participants knew when fertility windows occurred, and a majority knew prenatal care was needed even in the absence of complications (Table 2). Knowing the reason for taking prenatal vitamins containing folic acid was the area of least awareness (8.3%).

Self-Efficacy and intention to seek care

More than half of the participants expressed self-efficacy to make autonomous reproductive decisions, solve problems, and seek care either fairly often or very often. About one-third of participants shared they would “very often” be able to find a reproductive health care provider if needed, even if it were difficult; 23.7% participants responded they could do so “fairly often.” Similarly, most participants (62.7%) responded that they could “fairly often” and “very often” find a way to procure their desired birth control even if someone disagreed with their decision.

Reproductive health self-efficacy scores were averaged for our sample with a total mean score of 50.0 (SD 1.2) (Table 3). Self-efficacy scores were normally distributed (p = 0.322) and homoscedastic (p = 0.261), meeting t-test assumptions. There were no significant differences in self-efficacy scores between Spanish and English-speaking participants (t₍₅₇₎ = 0.908, p = 0.368), and both groups expressed average self-efficacy (Table 3). Participants with primary or secondary education had significantly lower self-efficacy compared to those with college or higher (t₍₅₅₎ = −2.656, p = 0.010). Participants’ intention to seek care scores also reflected the general population mean with a mean score of 48.9 (SD 1.6) (Table 3). There were no significant differences in intention to seek care scores between Spanish and English-speaking participants (χ²₍₁₎ = .624, p = 0.430) (Table 3).