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Emerging statistical modeling approaches that go beyond standard aggregate analyses helped identify three groups of women's health nurse practitioners. By considering their diverse perceptions of potential obstacles to diaphragm use, strategies aimed at changing provider behaviors may be developed to reverse declining prescribing rates and retain the diaphragm as a viable reproductive healthcare option for women.

Background and methodology Women have used the contraceptive diaphragm for decades. Although use has recently declined, the diaphragm may find a new role in STI/HIV and dual-prevention programmes when microbicides become available. We developed a questionnaire to examine seven provider issues identified as possible barriers to diaphragm use among advanced practice nurses (APNs) specialising in women's health. The perceived degree to which each issue represented a barrier was examined. Non-parametric correlations were calculated between diaphragm fitting history, demographic and practice characteristics, and the response ratings for each issue. ResultsResponses were analysed for 204 APNs who averaged 15 years' experience in women's health care; 87% had fitted a diaphragm at least once, but 40% had not prescribed one in the past year. The degree to which each issue was perceived as a barrier varied. Based on respondents' ratings of a 'more than moderate barrier,' 79 IntroductionHigh rates of unintended pregnancies and sexually transmitted infections (STIs) underscore the urgent need to improve barrier contraceptive options and use. Femalecontrolled methods are particularly vital because women suffer disproportionately from these twin burdens and cannot control condom use. Diaphragms, long used for contraception, are now being reconsidered for dual-method use and specifically as an intervention for limiting sexual transmission of bacterial STIs and HIV, especially when used with a microbicide. [1][2][3][4][5][6] However, diaphragm use has fallen and, along with all other vaginal barrier methods, now accounts for less than 1% of all contraceptive use globally. 7 Many clinicians appear unwilling to recommend the diaphragm, despite its excellent safety profile and high acceptability reported by current method users in multiple countries. [8][9][10][11][12][13][14] This study assesses potential barriers to diaphragm use as perceived by providers. Such barriers must be identified and better non-promotion by women's health providers, effectiveness doubts, unfamiliarity and lack of access to educational materials were more often perceived as impeding diaphragm use. Other results indicated that APNs with recent diaphragm fitting history perceived five of the seven issues to be less of a barrier: non-promotion by women's health providers, lack of access to educational materials and to a fitting set, unfamiliarity, and inadequate reimbursement. Barriers to diaphragm use: the views of advanced practice nursesDiscussion and conclusions Formulation of successful strategies to reintroduce the diaphragm will depend on better identification and understanding of providerperceived barriers. This paper offers new insights about such barriers and guidance for the development of strategies for diaphragm reintroduction.