{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,28]],"date-time":"2026-08-28T02:46:02Z","timestamp":1787885162001,"version":"build-2784847793"},"reference-count":85,"publisher":"Wiley","issue":"2","license":[{"start":{"date-parts":[[2023,1,30]],"date-time":"2023-01-30T00:00:00Z","timestamp":1675036800000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"funder":[{"DOI":"10.13039\/100007746","name":"W.K. Kellogg Foundation","doi-asserted-by":"publisher","award":["P\u2010P3039147\u20102020"],"award-info":[{"award-number":["P\u2010P3039147\u20102020"]}],"id":[{"id":"10.13039\/100007746","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["onlinelibrary.wiley.com"],"crossmark-restriction":true},"short-container-title":["Health Services Research"],"published-print":{"date-parts":[[2023,4]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Objective (Study Question)<\/jats:title>\n                    <jats:p>To use systems thinking with diverse system actors to (a) characterize current problems at the intersection of chronic conditions (CCs) and reproductive health (RH) care and their determinants, (b) determine necessary system actors for change, and (c) document cross\u2010system actions that can improve identified problems in the United States.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Data Sources\/Study Setting<\/jats:title>\n                    <jats:p>Data were collected from six groups of system actors via online focus groups.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Study Design<\/jats:title>\n                    <jats:p>This is a qualitative multilevel study using the iceberg systems thinking framework.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Data Collection\/Extraction Methods<\/jats:title>\n                    <jats:p>Data were collected by note\u2010taking and recording six focus groups; analysis incorporated perspective triangulation using the systems thinking iceberg and system mapping to visualize interconnected system challenges, actors, and action ideas.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Principal Findings<\/jats:title>\n                    <jats:p>Participants described eight necessary system actors: health care institutions, medical leaders, medical providers, patient advocates and foundations, patients and families, payors, policy makers, and research funders. Forty pain points were identified, spread across each of the four levels of the systems thinking iceberg: undesirable outcomes (6), concerning trends (9), system structure flaws (15), and problematic mental models (10). In response to these pain points, a set of 46 action ideas was generated by participants and mapped into nine action themes: (1) adjust QI metrics, incentives, and reimbursement, (2) bolster RH medical education and training, (3) break down medical silos, (4) enrich patient education, (5) expand the health care team, (6) improve holistic health care, (7) modify research and programmatic funding to prioritize RH and CC, (8) spur innovation for patient visits, and (9) support professional champions and leaders.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>By embracing system complexity, creating visual maps, and pushing participants to identify actionable strategies for improvement, this study generates a set of specific actions that can be used to address pain points across the multiple system levels that make improving reproductive care for people with CCs so challenging.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1111\/1475-6773.14131","type":"journal-article","created":{"date-parts":[[2023,1,12]],"date-time":"2023-01-12T02:24:19Z","timestamp":1673490259000},"page":"521-533","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Supporting reproductive health among birthing persons with chronic conditions in the\n                    <scp>United States<\/scp>\n                    : A qualitative multilevel study using systems thinking to inform action"],"prefix":"10.1111","volume":"58","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-9723-891X","authenticated-orcid":false,"given":"Cambray","family":"Smith","sequence":"first","affiliation":[{"name":"Department of Health Policy and Management University of North Carolina at Chapel Hill  Chapel Hill North Carolina USA"},{"name":"School of Medicine University of North Carolina at Chapel Hill  Chapel Hill North Carolina USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1172-0081","authenticated-orcid":false,"given":"Hiba","family":"Fatima","sequence":"additional","affiliation":[{"name":"Department of Maternal and Child Health University of North Carolina at Chapel Hill  Chapel Hill North Carolina USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2521-4342","authenticated-orcid":false,"given":"Erin","family":"McClain","sequence":"additional","affiliation":[{"name":"Collaborative for Maternal and Infant Health, School of Medicine University of North Carolina at Chapel Hill  Chapel Hill North Carolina USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5047-3824","authenticated-orcid":false,"given":"Katherine","family":"Bryant","sequence":"additional","affiliation":[{"name":"Collaborative for Maternal and Infant Health, School of Medicine University of North Carolina at Chapel Hill  Chapel Hill North Carolina USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2491-1170","authenticated-orcid":false,"given":"Sarah","family":"Verbiest","sequence":"additional","affiliation":[{"name":"Collaborative for Maternal and Infant Health, School of Medicine University of North Carolina at Chapel Hill  Chapel Hill North Carolina USA"},{"name":"Jordan Institute for Families, School of Social Work University of North Carolina at Chapel Hill  Chapel Hill North Carolina USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3311-4202","authenticated-orcid":false,"given":"Kristen","family":"Hassmiller Lich","sequence":"additional","affiliation":[{"name":"Department of Health Policy and Management University of North Carolina at Chapel Hill  Chapel Hill North Carolina USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"311","published-online":{"date-parts":[[2023,1,30]]},"reference":[{"key":"e_1_2_7_2_1","doi-asserted-by":"publisher","DOI":"10.5888\/pcd17.200130"},{"key":"e_1_2_7_3_1","doi-asserted-by":"publisher","DOI":"10.1002\/acr2.11114"},{"key":"e_1_2_7_4_1","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0160264"},{"key":"e_1_2_7_5_1","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2020.0734"},{"key":"e_1_2_7_6_1","unstructured":"Prevention CfDCa.Chronic disease indicators (CDI) data. 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