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Lewin A, Skracic I, Brown E, Roy K. "The thing in my arm": Providing contraceptive services for adolescents in primary care. WOMEN'S HEALTH (LONDON, ENGLAND) 2024; 20:17455057241248399. [PMID: 38778774 PMCID: PMC11113018 DOI: 10.1177/17455057241248399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 03/20/2024] [Accepted: 04/02/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND Due to high rates of unintended pregnancies in Delaware, the state launched a public health initiative in 2014 to increase access to contraceptive services. OBJECTIVES This study was designed to assess the practice-level barriers and facilitators to providing contraceptive care, particularly long-acting reversible contraceptives (LARCs), to adolescents in primary care settings. DESIGN This qualitative study was part of a larger process evaluation of the Delaware Contraceptive Access Now (DelCAN) initiative. METHODS In-depth, semi-structured qualitative interviews were conducted with 16 practice administrators at 13 adolescent-serving primary care sites across the state of Delaware. A process of open, axial, and selective coding was used to analyze the data. RESULTS Despite the interest in LARC among their adolescent patients, administrators described numerous barriers to providing LARC for adolescents including confidentiality in patient visits and billing, preceptorship, and provider discomfort and assumptions about the need for contraception among adolescent patients. CONCLUSION Findings from this study reveal substantial barriers to providing contraception to adolescents, even in primary care practices that were committed to comprehensive contraceptive access for their adolescent patients. This study supports the need for contraceptive care to be integrated into training of pediatricians at every stage of their education. Such training must go beyond education about contraceptive options and the clinical skills necessary for LARC insertion and removal, to include counseling skills based in a reproductive justice framework. Additional changes in policies and practices for adolescent patients would further increase access to contraceptive care.
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Affiliation(s)
- Amy Lewin
- Department of Family Science, School of Public Health, University of Maryland, College Park, MD, USA
| | - Izidora Skracic
- Department of Family Science, School of Public Health, University of Maryland, College Park, MD, USA
| | - Ellie Brown
- Department of Family Science, School of Public Health, University of Maryland, College Park, MD, USA
| | - Kevin Roy
- Department of Family Science, School of Public Health, University of Maryland, College Park, MD, USA
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2
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Schulte A, Biggs MA. Association Between Facility and Clinician Characteristics and Family Planning Services Provided During U.S. Outpatient Care Visits. Womens Health Issues 2023; 33:573-581. [PMID: 37543443 DOI: 10.1016/j.whi.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/17/2023] [Accepted: 06/29/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION Recent guidelines from the Centers for Disease Control and Prevention emphasize the importance of access to comprehensive family planning services and recommend patient-centered contraceptive counseling be incorporated into routine primary care visits for reproductive-age individuals. This study aims to describe family planning service provision in outpatient care settings and assess differences by facility and clinician characteristics. METHODS Using National Ambulatory Medical Care Survey data, a nationally representative survey of outpatient care visits, we assessed family planning service provision by facility location, facility type, physician specialty, types of clinicians seen, and whether the patient was seen by their primary care provider. We used random intercept logistic regression with robust standard errors, adjusting for patient characteristics, and state and year fixed effects. RESULTS The analytic sample included 53,489 patient visits with reproductive-age (15-49 years) individuals between 2011 and 2019. Family planning services were provided at 8% of total sampled visits and were more likely to be provided in urban compared with rural areas (adjusted odds ratio, 1.45; p = .02) and at community health centers compared with private physician practices (adjusted odds ratio, 1.74; p = .00). Family planning services were also more likely to be provided when the patient saw a physician assistant or nurse compared with only a physician. After controlling for observed covariates, measures of between-clinician heterogeneity indicate wide variation in which clinicians provided family planning services. CONCLUSIONS Family planning services were more likely to be provided in urban areas, at community health centers, and when patients received team-based care. The wide variation between clinicians suggests a need to better incorporate family planning services into primary care and other outpatient settings to meet patient needs and preferences.
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Affiliation(s)
- Alex Schulte
- Department of Health Policy, School of Public Health, University of California, Berkeley, Berkeley, California.
| | - M Antonia Biggs
- Advancing New Standards in Reproductive Health, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Francisco, Oakland, California
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3
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Smith MG, Beatty KE, Khoury AJ, Gilliam L, de Jong J. Increases in IUD Provision at Alabama Department of Public Health Clinics From 2016 to 2019. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2023; 29:E176-E180. [PMID: 37071028 DOI: 10.1097/phh.0000000000001737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
The Alabama Department of Public Health (ADPH) began allocating Title X funding to intrauterine device (IUD) provision at family planning clinics in 2019, instated more training opportunities, and expanded nurse practitioner scope of practice to include IUD placements. We assessed IUD provision and protocols at ADPH Title X clinics in 2016 and 2019 before and after ADPH policy changes. Generalized binomial regression models assessed differences between years. The proportion of ADPH clinics reporting offering any IUD on-site increased by 61.6 percentage points ( P < .001), stockpiling IUDs on-site increased by 85.9 percentage points ( P < .001), IUD placement/removal training increased by 71.4 percentage points ( P < .001), and same-visit IUD placement trainings increased by 64.1 percentage points ( P < .001). Advanced practice nurses were significantly more likely to place IUDs in 2019 compared with 2016 ( P < .001). These findings highlight the positive impact of policy changes related to Title X funding allocation and scope of practice on provision of a full range of contraceptive methods. These changes in policies and practices at the state and local levels within ADPH have expanded the availability of the full range of contraceptive options across the state of Alabama. This expanded access to contraceptive options is especially important given the rapid changes in reproductive health policies occurring in Alabama and across the United States.
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Affiliation(s)
- Michael G Smith
- College of Public Health, East Tennessee State University, Johnson City, Tennessee (Drs Smith, Beatty, and Khoury and Ms de Jong); and Alabama Department of Public Health, Robertsdale, Alabama (Dr Gilliam)
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Krass P, Sieke EH, Joshi P, Akers AY, Wood SM. Pediatric Resident Perspectives on Long-Acting Reversible Contraception Training: A Cross-Sectional Survey of Accreditation Council for Graduate Medical Education Trainees. J Adolesc Health 2023; 72:964-971. [PMID: 36907801 PMCID: PMC10198905 DOI: 10.1016/j.jadohealth.2023.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 01/07/2023] [Accepted: 01/09/2023] [Indexed: 03/14/2023]
Abstract
PURPOSE Although pediatricians are primary care providers for most adolescents, pediatric residents receive limited training on long-acting reversible contraceptive (LARC) methods. This study aimed to characterize pediatric resident comfort with placing contraceptive implants and intrauterine devices (IUDs) and assess pediatric resident interest in obtaining this training. METHODS Pediatric residents in the United States were invited to participate in a survey assessing comfort with LARC methods and interest in LARC training during pediatric residency. Bivariate comparisons used Chi-square and Wilcoxon rank sum testing. Multivariate logistic regression was used to assess associations between primary outcomes and covariates including geographic region, training level, and career plans. RESULTS Six hundred twenty seven pediatric residents across the United States completed the survey. Participants were predominantly female (68.4%, n = 429), self-identified their race as White (66.1%, n = 412), and anticipated a career in a subspecialty other than Adolescent Medicine (53.0%, n = 326). Most residents were confident counseling patients on the risks and benefits, side effects, and effective use of contraceptive implants (55.6%, n = 344) and both hormonal and nonhormonal IUDs (53.0%, n = 324). Few residents reported comfort with inserting contraceptive implants (13.6%, n = 84) or IUDs (6.3%, n = 39), with most of these respondents having learned these skills as a medical student. Most participants believed that residents should receive training on insertion of contraceptive implants (72.3%, n = 447) and IUDs (62.5%, n = 374). DISCUSSION Although most pediatric residents believe LARC training should be a component of pediatric residency training, few pediatric residents are comfortable with provision of this care.
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Affiliation(s)
- Polina Krass
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Erin H Sieke
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Priyanka Joshi
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Sarah M Wood
- PolicyLab, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Division of Adolescent Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadephia, Pennsylvania
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Bell N, Hopla D, George T, Durham CO, Miller L, Kelley S. Evaluation of a Hands-On Graduate Training Curriculum in Contraception Care. J Nurse Pract 2023. [DOI: 10.1016/j.nurpra.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
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6
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Quinn SM, Goldfarb Terry R, Boock S, Shea JA. Integrating long-acting reversible contraceptives into primary care internal medicine practices: A clinical innovation to reduce wait time. WOMEN'S HEALTH (LONDON, ENGLAND) 2023; 19:17455057231219569. [PMID: 38130094 DOI: 10.1177/17455057231219569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
BACKGROUND Long-acting reversible contraception (LARC) has long been regarded as highly effective and safe. However, access is limited and lengthy when specialty referrals are required. OBJECTIVES To integrate LARC services into an urban internal medicine primary care practice to decrease wait time for LARC procedures. DESIGN/METHODS This pre-post with control group study took place at two large urban academic primary care practices (Practices A and B) and included patients ages 18 to 45 years assigned female sex at birth. Pre-implementation baseline data were collected retrospectively from 2019 to 2020 by identifying subjects who requested LARC insertion or removal via their primary care practice and were referred to Obstetrics and Gynecology (Ob/Gyn) for the procedure. Wait time was noted from time of initial request in the medical record to time of procedure. Practice A developed an integrated primary care LARC program in which one of their LARC-trained providers began offering these procedures within their own practice. All other providers within the practice were educated on how to counsel patients about the devices and procedures. Practice B did not have an in-house LARC provider and continued referring patients to Ob/Gyn. Post-implementation data were collected prospectively 2021-2022. RESULTS Ninety-one patients in Practice A experienced a significant decrease in wait time (87 vs 21 days, p < 0.001) over the observation period, with a majority undergoing procedures on their first visit with the in-house LARC provider. Wait time for the 54 patients in Practice B remained unchanged (57 vs 47 days, p = .59), often requiring multiple specialty visits. CONCLUSION Integrating LARC services into a primary care internal medicine practice can significantly reduce wait times for these procedures with the potential to contribute to increased reproductive and menstrual autonomy.
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Affiliation(s)
- Sheila M Quinn
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Shelby Boock
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Judy A Shea
- Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Moore AL, Hasselbacher L, Tyler CP, Rodriguez-Ortiz AE, Gilliam M. Are Illinois Contraceptive Providers Comfortable Providing Care to Adolescents? Results From a Statewide Provider Needs Assessment. Womens Health Issues 2023; 33:36-44. [PMID: 35961851 DOI: 10.1016/j.whi.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 06/24/2022] [Accepted: 07/15/2022] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Legislation allows adolescents to access comprehensive contraceptive care; however, provider practices remain unclear. We examined predictors of provider knowledge and comfort surrounding the provision of contraceptive care to adolescents. METHODS We mailed a survey to Illinois contraceptive providers (n = 251). Study outcomes include 1) knowledge of adolescent consent laws, 2) comfort asking for time alone with adolescents, 3) comfort providing contraception to adolescents without parental consent, and 4) comfort providing long-acting reversible contraception (LARC) to adolescents without parental consent. Using multivariable logistic regression, we estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs). RESULTS Most providers are knowledgeable of consent laws (90%) and report being comfortable asking for time alone with adolescents (94%) and comfortable providing contraception to adolescents without parental consent (88%). Having a large proportion of patients who are eligible for family planning services was associated with increased comfort asking for time alone with adolescents (aOR, 7.03; 95% CI, 1.58-31.3) and providing contraception to adolescents (aOR, 4.0; 95% CI, 1.4-11.1). Only one-half (54%) were comfortable providing LARC methods to adolescents, with higher comfort among providers who: received more than 2 days of formal family planning training (aOR, 2.77; 95% CI, 1.2-6.2), specialized in obstetrics-gynecology (aOR, 5.64; 95% CI, 2.1-15.1), and had a patient population with more than 50% patients from minoritized racial/ethnic groups (aOR, 2.9; 95% CI, 1.2-6.6). CONCLUSIONS Although knowledge of consent laws was high, gaps remain. Only one-half of our sample indicated comfort with the provision of LARC methods without parental consent. Additional efforts to increase provider comfort with all contraceptive methods and training on adolescent-centered practices may be required to meet the needs of adolescent patients.
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Affiliation(s)
- Amy L Moore
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois
| | - Lee Hasselbacher
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois.
| | - Crystal P Tyler
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois
| | | | - Melissa Gilliam
- Department of Obstetrics and Gynecology, University of Chicago, Chicago, Illinois
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Effectiveness of training primary care internal medicine residents in etonogestrel implants and impact on their future practice: A cross-sectional study. Contraception 2022; 115:31-35. [PMID: 35917931 PMCID: PMC9994633 DOI: 10.1016/j.contraception.2022.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To evaluate the impact of an etonogestrel implant training program within a primary care Internal Medicine residency training program. STUDY DESIGN We surveyed graduates of our primary care Internal Medicine residency program in the Bronx, New York who performed implant procedures though the first 32 months after implementation of a monthly faculty-supervised resident implant clinic. We assessed the number of implants placed and removed per graduate, and surveyed graduates' satisfaction with the implant training program, perceived competence with implant procedures, and intent and ability to perform implant procedures and barriers to performing implant procedures postgraduation. RESULTS Between July 2017 and February 2020, 14 residents placed a total of 34 devices and removed four. All 14 program graduates completed the survey in August 2020. All but one respondent felt this training was valuable and 11 felt competent placing implants without supervision. Although 10 planned to provide implants following graduation, none have been able to, largely because of credentialing and clinic-practice level barriers. CONCLUSIONS The primary care Internal Medicine program graduates we surveyed (n = 14) valued our etonogestrel implant training program and perceived competence, particularly with implant placement. However, even those who intended to provide etonogestrel implants postgraduation were unable to do so. IMPLICATIONS Internal Medicine residents trained to place and remove etonogestrel implants are most comfortable with implant placement. However, these physicians may face barriers related to credentialing and ambulatory practice scope when attempting to provide this care in clinical practice.
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Berlan E, Valenti O, Long W, Toth C, Abenaim A, Maciejewski H, Gowda C. Practice Facilitation Improves Adolescent Reproductive Health Preventive Services in Primary Care. Pediatrics 2022; 149:183863. [PMID: 34972227 DOI: 10.1542/peds.2020-035774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/07/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Provision of reproductive health preventive services to adolescents is critical given their high rates of sexually transmitted infections and unintended pregnancies. Pediatricians are well positioned to provide these services but often face barriers. With this project, we aimed to build quality improvement (QI) capacity within pediatric practices to improve adherence to national guidelines for adolescent reproductive health preventive services. METHODS In 2016, an accountable care organization overseeing health care delivery for low-income children in the Midwestern United States used practice facilitation, a proven approach to improve health care quality, to support pediatric practices in implementing reproductive health QI projects. Interested practices pursued projects aimed at providing (1) sexual risk reduction and contraceptive counseling (reproductive health assessments [RHAs]) or (2) etonogestrel implants. QI specialists helped practices build key driver diagrams and implement interventions. Outcome measures included the proportion of well-care visits with RHAs completed and number of etonogestrel insertions performed monthly. RESULTS Between November 1, 2016, and December 31, 2019, 6 practices serving >7000 adolescents pursued QI projects. Among practices focused on RHAs, the proportion of well-care visits with completed RHAs per month increased from 0% to 65.8% (P < .001) within 18 months. Among practices focused on etonogestrel implant insertions, overall insertions per month increased from 0 to 8.5 (P < .001). CONCLUSIONS Practice facilitation is an effective way to increase adherence to national guidelines for adolescent reproductive health preventive services within primary care practices. Success was driven by practice-specific customization of interventions and ongoing, hands-on support.
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Affiliation(s)
- Elise Berlan
- Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio; and
| | - Olivia Valenti
- Nationwide Children's Hospital, Columbus, Ohio.,Partners For Kids, Columbus, Ohio
| | - William Long
- Nationwide Children's Hospital, Columbus, Ohio.,Partners For Kids, Columbus, Ohio
| | | | | | - Heather Maciejewski
- Nationwide Children's Hospital, Columbus, Ohio.,Partners For Kids, Columbus, Ohio
| | - Charitha Gowda
- Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, College of Medicine, The Ohio State University, Columbus, Ohio; and.,Partners For Kids, Columbus, Ohio
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Matsushita T, Hasegawa T, Noma H, Ota E, Chou VB, Okada Y. Interventions to increase access to long-acting reversible contraceptives. Hippokratia 2021. [DOI: 10.1002/14651858.cd014987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Tomomi Matsushita
- Department of Obstetrics and Gynaecology; Showa University School of Medicine; Tokyo Japan
| | - Takeshi Hasegawa
- Showa University Research Administration Center (SURAC); Showa University; Tokyo Japan
| | - Hisashi Noma
- Department of Data Science; The Institute of Statistical Mathematics; Tokyo Japan
| | - Erika Ota
- Global Health Nursing, Graduate School of Nursing Science; St. Luke's International University; Chuo-ku Japan
| | - Victoria B Chou
- Department of International Health; Johns Hopkins Bloomberg School of Public Health; Baltimore Maryland USA
| | - Yoshiyuki Okada
- Department of Obstetrics and Gynecology; Showa University Northern Yokohama Hospital; Kanagawa Japan
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11
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Contraceptive Procedures in Internal Medicine Clinics and Resident Education: a Qualitative Study of Implementation Methods, Barriers, and Facilitators. J Gen Intern Med 2021; 36:3346-3352. [PMID: 33959883 PMCID: PMC8606354 DOI: 10.1007/s11606-021-06832-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 04/14/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Long-acting reversible contraceptives (LARCs) such as intrauterine devices (IUDs) and implants are highly effective and increasingly popular. Internal Medicine (IM) clinics and residency curricula do not routinely include LARCs, which can limit patient access to these methods. In response, internists are integrating LARCs into IM practices and residency training. OBJECTIVE This study examines the approaches, facilitators, and barriers reported by IM faculty to incorporating LARCs into IM clinics and resident education. DESIGN We interviewed faculty who were prior or current LARC providers and/or teachers in 15 IM departments nationally. Each had implemented or attempted to implement LARC training for residents in their IM practice. Semi-structured interviews were used. PARTICIPANTS Eligible participants were a convenience sample of clinicians identified as key informants at each institution. APPROACH We used inductive thematic coding analysis to identify themes in the transcribed interviews. KEY RESULTS Fourteen respondents currently offered LARCs in their clinic and 12 were teaching these procedures to residents. LARC integration into IM clinics occurred in 3 models: (1) a dedicated procedure or women's health clinic, (2) integration into existing IM clinical sessions, or (3) an interdisciplinary IM and family medicine or gynecology clinic. Balancing clinical and educational priorities was a common theme, with chosen LARC model(s) reflecting the desired priority balance at a given institution. Most programs incorporated a mix of educational modalities, with opportunities based upon resident interest and desired educational goals. Facilitators and barriers related to clinical (equipment, workflow), educational (curriculum, outcomes), or process considerations (procedural volume, credentialing). Participants reported that support from multiple stakeholders including patients, residents, leadership, and other departments was necessary for success. CONCLUSION The model for integration of LARCs into IM clinics and resident education depends upon the clinical resources, patient needs, stakeholder support, and educational goals of the program.
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12
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Dieci M, Wagner Z, Friedman W, Burgess S, Vandermark J, McCoy SI, Shah M, Dow WH. Measuring Family Planning Provider Bias: A Discrete Choice Experiment among Burkinabé, Pakistani, and Tanzanian Providers. Stud Fam Plann 2021; 52:299-320. [PMID: 34472623 DOI: 10.1111/sifp.12170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The unmet need for modern contraception remains high around the world, particularly for youth. While some of this unmet need is driven by limited health infrastructure and method mix availability, many adolescents who visit family planning providers still do not receive methods that fit their needs. This suggests that providers may be biased against youth and that interventions to change provider behavior could help close this gap. However, it is unclear if this bias is a result of age or other characteristics common among young women such as not being married and not having children. We use a discrete choice experiment in Burkina Faso, Pakistan, and Tanzania to disentangle the effects of age on providers' decisions to provide contraception from the effects of other potential confounding factors. We find that, although young women may experience the most bias, age is not the main driver. Rather, marital status and parity seem to influence provider decisions to offer services or counsel on modern methods. These findings suggest that interventions to reduce provider bias should focus on changing behavior towards unmarried and nulliparous women, regardless of their age.
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Affiliation(s)
- Maria Dieci
- Maria Dieci, Sandra I. McCoy, William H. Dow are at the School of Public Health, University of California, Berkeley, Berkeley, CA, 94704, USA
| | - Zachary Wagner
- Zachary Wagner is at the RAND Corporation, Santa Monica, CA, 90401, USA
| | - Willa Friedman
- Willa Friedman is at the Department of Economics, University of Houston, Houston, TX, 77204, USA
| | - Sarah Burgess
- Sarah Burgess, Jessica Vandermark are at the Camber Collective, San Francisco, CA, 94102, USA
| | - Jessica Vandermark
- Sarah Burgess, Jessica Vandermark are at the Camber Collective, San Francisco, CA, 94102, USA
| | - Sandra I McCoy
- Maria Dieci, Sandra I. McCoy, William H. Dow are at the School of Public Health, University of California, Berkeley, Berkeley, CA, 94704, USA
| | - Manisha Shah
- Manisha Shah is at the Luskin School of Public Affairs, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - William H Dow
- Maria Dieci, Sandra I. McCoy, William H. Dow are at the School of Public Health, University of California, Berkeley, Berkeley, CA, 94704, USA
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Skračić I, Lewin AB, Roy KM. Evaluation of the Delaware Contraceptive Access Now (DelCAN) initiative: A qualitative analysis of site leaders' implementation recommendations. Contraception 2021; 104:211-215. [PMID: 33762171 PMCID: PMC8286296 DOI: 10.1016/j.contraception.2021.03.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 03/08/2021] [Accepted: 03/14/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES In 2014, Delaware launched a statewide initiative to reduce the rate of unintended pregnancies and increase access to contraception services. Our study objective was to understand the implementation experiences, barriers, and successes across health care practice settings and to provide recommendations for future, similar initiatives. STUDY DESIGN As part of a larger multicomponent process evaluation, we conducted semistructured interviews with 32 leaders from 26 practice settings implementing the initiative across the state. We analyzed the qualitative data through iterative open, axial, and selective coding using grounded theory methods, employing thematic analysis to identify common themes in implementation experiences. RESULTS Most practices perceived that patient demand for methods of long-acting reversible contraception (LARC) increased. Many practices had to adapt the intervention to fit the needs and constraints of their settings and patient populations. Primary care practices, smaller practices, and practices that served large numbers of adolescents experienced more barriers compared to obstetrics and gynecology or women's health practices. For current and future iterations of the initiative, leaders emphasized: (1) the need for greater implementation flexibility, (2) the importance of inclusive communication at multiple levels, and (3) attending to logistical challenges, particularly around billing. CONCLUSION Varied practice settings required significant flexibility and responsiveness to context in order to implement the initiative. Organizations with greater pre-existing capacity were able to offer the full range of contraceptive care, as the initiative intended, in contrast to practices with less pre-existing capacity for providing methods of LARC and other types of contraception. IMPLICATIONS To meet the specific but heterogenous needs of various practices, it is crucial for future contraceptive access initiatives to conduct a comprehensive pre-implementation assessment. Preceding any training, this assessment should gather input from participants across all roles in a medical practice (e.g., providers, medical assistants, office staff, billing department).
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Affiliation(s)
- Izidora Skračić
- University of Maryland - School of Public Health, College Park, MD, USA.
| | - Amy B Lewin
- University of Maryland - School of Public Health, College Park, MD, USA.
| | - Kevin M Roy
- University of Maryland - School of Public Health, College Park, MD, USA.
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Comfort AB, Rao L, Goodman S, Barney A, Glymph A, Schroeder R, McCulloch C, Harper CC. Improving Capacity at School-based Health Centers to Offer Adolescents Counseling and Access to Comprehensive Contraceptive Services. J Pediatr Adolesc Gynecol 2021; 34:26-32. [PMID: 32730800 PMCID: PMC7385555 DOI: 10.1016/j.jpag.2020.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 07/20/2020] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVES Many pediatric providers serving adolescents are not trained to offer comprehensive contraceptive services, including intrauterine devices (IUDs) and implants, despite high safety and satisfaction among adolescents. This study assessed an initiative to train providers at school-based health centers (SBHCs) to offer students the full range of contraceptive methods. DESIGN Surveys were administered at baseline pre-training and at follow-up 3 months post-training. Data were analyzed using generalized estimating equations for clustered data to examine clinical practice changes. SETTING Eleven contraceptive trainings at SBHCs across the United States from 2016-2019. PARTICIPANTS A total of 260 providers from 158 SBHCs serving 135,800 students. INTERVENTIONS On-site training to strengthen patient-centered counseling and to equip practitioners to integrate IUDs and implants into contraceptive services. MAIN OUTCOME MEASURES The outcomes included counseling experience on IUDs and implants, knowledge of patient eligibility, and clinician method skills. RESULTS At follow-up, providers were significantly more likely to report having enough experience to counsel on IUDs (adjusted odds ratio [aOR], 4.08; 95% confidence interval [CI], 2.62-6.36]) and implants (aOR, 3.06; 95% CI, 2.05-4.57). Provider knowledge about patient eligibility for IUDs, including for adolescents, increased (P < .001). Providers were more likely to offer same-visit IUD (aOR, 2.10; 95% CI, 1.41-3.12) and implant services (aOR, 1.66; 95% CI, 1.44-1.91). Clinicians' skills with contraceptive devices improved, including for a newly available low-cost IUD (aOR, 2.21; 95% CI, 1.45-3.36). CONCLUSIONS Offering evidence-based training is a promising approach to increase counseling and access to comprehensive contraceptive services at SBHCs.
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Affiliation(s)
- Alison B Comfort
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA.
| | - Lavanya Rao
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA
| | - Suzan Goodman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA
| | - Angela Barney
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA
| | | | - Rosalyn Schroeder
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA
| | - Charles McCulloch
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA
| | - Cynthia C Harper
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Francisco, San Francisco, CA
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Lin CJ, Maier J, Nwankwo C, Burley C, deBorja L, Aaraj YA, Lewis E, Rhem M, Nowalk MP, South-Paul J. Awareness and Use of Contraceptive Methods and Perceptions of Long-Acting Reversible Contraception Among White and Non-White Women. J Womens Health (Larchmt) 2020; 30:1313-1320. [PMID: 33297819 DOI: 10.1089/jwh.2020.8642] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Background: Unintended pregnancies continue to account for half of all pregnancies in the United States, primarily due to incorrect or inconsistent use of contraception methods. Long-acting reversible contraception (LARC) methods are safe and highly effective, yet underutilized. Low uptake of LARC may be due to inadequate education, misconceptions, and cultural factors such as race, ethnicity, or religion. This study examined racial differences in contraceptive awareness and use among women seeking care at family health centers. Materials and Methods: Focus groups were used to identify recurrent themes in contraceptive choice of participants and develop a survey, completed by nonpregnant female patients 18-45 years of age from seven family health centers. Results: Among a total of 465 participants, 210 (46.2%) of whom were non-white, awareness of most types of birth control was generally high. Awareness of all types of contraceptives was significantly higher among white than non-white women (p < 0.001). Across most types of contraceptives, use was significantly higher among white women than non-white women with the exception of injectable hormones which were used significantly more often by non-white women (46.0% vs. 28.5%; p < 0.001). Reasons for using LARC did not vary by type nor by race but reasons for not using LARC varied by race and by specific method. Conclusions: Differing patterns of awareness, use, and perceptions of contraceptive methods between white and non-white women were revealed. By understanding factors that influence contraceptive awareness, use, and perceptions, clinicians can better address the contraceptive needs and concerns of their female patients. Clinical Trial # NCT03486743.
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Affiliation(s)
- Chyongchiou J Lin
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - John Maier
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Chidinma Nwankwo
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Cassie Burley
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Leyan deBorja
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Yassmin Al Aaraj
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Elizabeth Lewis
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Marla Rhem
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Mary Patricia Nowalk
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jeannette South-Paul
- Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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16
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Gashaye KT, Tsegaye AT, Abebe SM, Woldetsadik MA, Ayele TA, Gashaw ZM. Determinants of long acting reversible contraception utilization in Northwest Ethiopia: An institution-based case control study. PLoS One 2020; 15:e0240816. [PMID: 33079973 PMCID: PMC7575092 DOI: 10.1371/journal.pone.0240816] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 10/02/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Though long-acting reversible contraceptives (LARCs) are highly effective, have minimal side effects, require minimal follow-up, and are low cost, only 10% of contraceptives used in Ethiopia are LARCs. The reason for this low uptake is not understood at the country or regional level. Therefore, this study identified determinants of LARC utilization in Northwest Ethiopia. METHODS A facility-based unmatched case control study, using LARC users as cases and short- acting reversible contraception (SARC) users as controls, had been conducted at fourteen public health institutions in Northwest Ethiopia. A systematic random sampling technique was used to select participants with a 1:2 case to control ratio (n = 1167). Binary logistic regression analysis was used to identify determinants of LARC utilization among family planning service users. RESULTS Wealth status [AOR:1.87, 95%CI (1.08, 3.24)], history of abortion [AOR:2.69, 95%CI (1.41, 5.12)], limiting family size [AOR: 2.38, 95%CI (1.01, 5.62)], good knowledge about LARCs [AOR: 2.52, 95%CI (1.17, 5.41)], method convenience [AOR: 0.23, 95%CI (0.16, 0.34)], good availability of method [AOR:0.10 (0.05, 0.19)], less frequent visits to health facility [AOR:2.95, 95% CI(1.89, 4.62)], health care providers advice [AOR:10.69, 95%CI (3.27, 34.87)], partner approval [AOR:0.66, 95%CI (0.45, 0.97)], and favorable attitude towards LARCs [AOR:13.0, 95%CI (8.60, 19.72)] were significantly associated with LARC utilization. CONCLUSION Professional support, favorable attitude towards LARC use, high economic status, history of abortion, advantage of less frequent visits, having good knowledge towards LARC and interest of limiting births were significantly associated with LARC Utilization. On the other hand, perceived method convenience, and contraception availability were inversely associated with it. Family planning education about the benefits of LARC should be done by health providers and media. Male involvement in the counselling and decision making about the advantage of using LARC may improve the negative influence of partners on LARC utilization. It is also recommended that, future qualitative research further explore perceptions of LARC use.
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Affiliation(s)
- Kiros Terefe Gashaye
- Department of Obstetrics and Gynecology, College of Medicine and Health Sciences, School of Medicine, University of Gondar, Gondar, Ethiopia
| | - Adino Tesfahun Tsegaye
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Solomon Mekonnen Abebe
- Department of Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Mulat Adefris Woldetsadik
- Department of Obstetrics and Gynecology, College of Medicine and Health Sciences, School of Medicine, University of Gondar, Gondar, Ethiopia
| | - Tadesse Awoke Ayele
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Zelalem Mengistu Gashaw
- Department of Obstetrics and Gynecology, College of Medicine and Health Sciences, School of Medicine, University of Gondar, Gondar, Ethiopia
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Bostick EA, Greenberg KB, Fagnano M, Baldwin CD, Halterman JS, Yussman SM. Adolescent Self-Reported Use of Highly Effective Contraception: Does Provider Counseling Matter? J Pediatr Adolesc Gynecol 2020; 33:529-535. [PMID: 32544517 DOI: 10.1016/j.jpag.2020.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/25/2020] [Accepted: 06/08/2020] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE To examine associations between provider counseling about specific contraceptive methods and method choices reported by adolescents. DESIGN A cross-sectional, secondary analysis of the local 2015 Youth Risk Behavior Survey, to which we added 2 new/modified questions about long-acting reversible contraception (LARC). SETTING Rochester, New York. PARTICIPANTS Female students in 9th-12th grade in the Rochester City School District. INTERVENTIONS An anonymous, standardized survey was administered to collect data. MAIN OUTCOME MEASURES We studied associations between students' reported contraceptive use and counseling (LARC, short-acting contraception [SAC], neither), health care factors, and potential risk/protective factors. Data were analyzed using bivariate and multivariate methods. RESULTS Among 730 sexually active female respondents, 353/730 (49%) were African American and 182/730 (25%) were Other/Mixed race. 416/730 (57%) used no hormonal method at last sex, and 95/730 (13%) used LARC. 210/730 (29%) of participants recalled any LARC-specific counseling, and 265/730 (36%) any counseling on SAC. Recall of LARC and SAC counseling and use were significantly associated with speaking privately with a provider, but were not related to personal risk/protective factors. Multivariate analyses showed that recollection of LARC counseling was significantly associated with higher odds of using either LARC (adjusted odds ratio, 14.3; P < .001) or SAC (adjusted odds ratio, 2.1; P = .007). Recollection of either LARC or SAC counseling was associated with significantly lower odds of using no contraception. CONCLUSION Adolescents' use of LARC was only 13%, but those who recalled contraceptive counseling had higher odds of using some hormonal method. Efforts are needed to improve provider counseling, maintain confidentiality, and identify effective methods to engage adolescents in meaningful, memorable discussions of LARC.
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Affiliation(s)
- Erica A Bostick
- Division of Adolescent Medicine, Department of Pediatrics, University of Rochester Medical Center, Rochester, New York.
| | - Katherine B Greenberg
- Division of Adolescent Medicine, Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Maria Fagnano
- Division of General Pediatrics, Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Constance D Baldwin
- Division of General Pediatrics, Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Jill S Halterman
- Division of General Pediatrics, Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Susan M Yussman
- Division of Adolescent Medicine, Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
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18
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Mitchell M, Stauffenberg C, Vernon V, Mospan CM, Shipman AJ, Rafie S. Opposition to Pharmacist Contraception Services: Evidence for Rebuttal. PHARMACY 2020; 8:E176. [PMID: 32977545 PMCID: PMC7711847 DOI: 10.3390/pharmacy8040176] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 11/16/2022] Open
Abstract
Pharmacist contraception services are growing across the United States. Several states have authorized pharmacists to prescribe contraception, and the interest in other states continues to grow. Opposition to these practices exists and centers on discussions related to safety, training, cost, and fragmentation of care. We review these arguments and provide evidence refuting these concerns. Pharmacist-prescribed contraception increases access to care, and patients express interest in utilizing this service at the pharmacy. Pharmacists follow evidence-based recommendations. Counseling on preventative services and referral to other providers is part of contraception care by pharmacists. Training programs have been developed to equip both pharmacy students and pharmacists with the knowledge, skills, and tools needed to successfully provide these services. This article can serve as a guide for pharmacists and advocates when discussing pharmacist-prescribed contraception with policymakers, patients, and other healthcare professionals.
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Affiliation(s)
- Madeline Mitchell
- College of Pharmacy and Health Sciences, Butler University, Indianapolis, IN 46208, USA; (M.M.); (C.S.)
| | - Courtney Stauffenberg
- College of Pharmacy and Health Sciences, Butler University, Indianapolis, IN 46208, USA; (M.M.); (C.S.)
| | - Veronica Vernon
- Department of Pharmacy Practice, College of Pharmacy and Health Sciences, Butler University, Indianapolis, IN 46208, USA;
| | | | - Allie Jo Shipman
- National Association of State Pharmacy Associations, North Chesterfield, VA 23235, USA;
| | - Sally Rafie
- Birth Control Pharmacist, San Diego, CA 92122, USA
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19
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Racial Disparities in Reproductive Healthcare among Parous and Nulliparous Women in Mississippi. J Racial Ethn Health Disparities 2020; 8:304-314. [PMID: 32495305 DOI: 10.1007/s40615-020-00783-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/16/2020] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Long-standing racial disparities exist in reproductive healthcare and have been associated with negative health outcomes among minority women. This study aimed to analyze the racial disparities in reproductive healthcare among Mississippi women, particularly as it related to contraception access, usage, setting, provider type, and payer. METHODS A two-stage stratified probability design was employed - 95 of the 1500 licensed childcare facilities across the state were randomly selected, and then two to three classrooms were randomly selected within each facility. The children were the means to obtaining a weighted sample of parous women of childbearing age (15-44). Once a parous woman completed the study, she could invite a nulliparous friend of similar age, race, and socioeconomic background to also participate in the study. RESULTS Racial disparities were found in the reproductive healthcare of both the parous and nulliparous groups. Overall, black women were less likely to receive services from an obstetrics and gynecology. Parous and nulliparous black women were more likely to receive their reproductive healthcare at the health department and less likely to use the most effective methods of contraception. CONCLUSION Low use of the most effective methods of contraception, despite high levels of general contraceptive use and high insurance coverage, hints at additional barriers to full access for black women in Mississippi. More equitable access to effective family planning counseling and contraception can have meaningful impact on the lives of black women in our state.
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20
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Congdon JL, Trope LA, Bruce JS, Chung PJ, Dehlendorf C, Chamberlain LJ. Meeting the Needs of Postpartum Women With and Without a Recent Preterm Birth: Perceptions of Maternal Family Planning in Pediatrics. Matern Child Health J 2019; 24:378-388. [PMID: 31875305 DOI: 10.1007/s10995-019-02829-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Women face distinct barriers to meeting their reproductive health needs postpartum, especially women who deliver preterm. Pediatric encounters present unique opportunities to address women's family planning, particularly within 18 months of a prior pregnancy, when pregnancy has an elevated risk of an adverse outcome, such as preterm birth. To ensure maternal family planning initiatives are designed in a patient-centered manner, we explored perspectives on addressing reproductive health in a pediatric setting among women with and without a recent preterm delivery. METHODS We conducted semi-structured, qualitative interviews with 41 women (66% delivered preterm). Women who delivered at any gestational age were interviewed at a pediatric primary care clinic. We also interviewed women whose infants were either in a level II intensive care nursery or attending a high-risk infant follow-up clinic, all of whom had delivered preterm. Data were analyzed using team-based coding and theme analysis. RESULTS While women's preferred timing and setting for addressing peripartum contraception varied, they largely considered pediatric settings to be an acceptable place to discuss family planning. A few women felt family planning fell outside of the pediatric scope or distracted from the child focus. Women discussed various barriers to accessing family planning care postpartum, including circumstances unique to women who delivered preterm. CONCLUSIONS FOR PRACTICE Family planning interventions in pediatric settings were overall an acceptable approach to reducing barriers to care among our sample of women who predominantly delivered preterm. These exploratory findings justify further investigation to assess their generalizability and to develop maternal family planning interventions for pediatric settings.
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Affiliation(s)
- Jayme L Congdon
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, San Francisco, CA, 94158, USA.
| | - Lee A Trope
- Department of Pediatrics, Santa Clara Valley Medical Center, 751 South Bascom Avenue, San Jose, CA, 94128, USA
| | - Janine S Bruce
- Department of Pediatrics, Stanford University, 1265 Welch Road, Palo Alto, CA, 94305, USA
| | - Paul J Chung
- Department of Health Systems Science, Kaiser Permanente School of Medicine, 98 South Los Robles Avenue, Pasadena, CA, 91101, USA
| | - Christine Dehlendorf
- Department of Family and Community Medicine, University of California, San Francisco, 995 Potrero Avenue, San Francisco, CA, 94110, USA
| | - Lisa J Chamberlain
- Department of Pediatrics, Stanford University, 1265 Welch Road, Palo Alto, CA, 94305, USA
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21
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Morgan IA, Zapata LB, Curtis KM, Whiteman MK. Health Care Provider Attitudes about the Safety of "Quick Start" Initiation of Long-Acting Reversible Contraception for Adolescents. J Pediatr Adolesc Gynecol 2019; 32:402-408. [PMID: 30731216 PMCID: PMC6717043 DOI: 10.1016/j.jpag.2019.01.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 12/30/2018] [Accepted: 01/27/2019] [Indexed: 12/14/2022]
Abstract
STUDY OBJECTIVE To identify characteristics associated with provider attitudes on the safety of "Quick Start" initiation of long-acting reversible contraception (LARC) for adolescents. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We conducted a cross-sectional survey of providers in public-sector health centers and office-based physicians (n = 2056) during 2013-2014. RESULTS Overall, the prevalence of considering "Quick Start" initiation of LARC for adolescents as safe was 70.9% for implants and 64.5% for intrauterine devices (IUDs). Among public-sector providers, those not trained in implant or IUD insertion had lower odds of perceiving the practice safe (adjusted odds ratio [aOR], 0.32; 95% confidence interval [CI], 0.25-0.41 for implants; aOR 0.42; 95% CI, 0.32-0.55 for IUDs), whereas those practicing at health centers that did not receive Title X funding had lower odds of perceiving the practice safe for IUDs (aOR, 0.77; 95% CI, 0.61-0.98). Among office-based physicians, lack of training in LARC insertion was associated with lower odds of perceiving "Quick Start" initiation to be safe for IUDs (aOR, 0.31; 95% CI, 0.12-0.77). Those specializing in adolescent medicine had higher odds of reporting "Quick Start" initiation of LARC as safe (implants: aOR, 2.21; 95% CI, 1.23-3.98; IUDs: aOR, 3.37; 95% CI, 1.39-8.21) compared with obstetrician-gynecologists. CONCLUSION Approximately two-thirds of providers considered "Quick Start" initiation of LARC for adolescents safe; however, there were differences according to provider characteristics (eg, Title X funding, training in LARC insertion, specialty). Targeted LARC insertion training and dissemination of evidence-based family planning guidance and implementation into facility and practice-level policies might increase access to "Quick Start" initiation of LARC for adolescents.
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Affiliation(s)
- Isabel A Morgan
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia; Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - Lauren B Zapata
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Kathryn M Curtis
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Maura K Whiteman
- Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia
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22
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Ouyang M, Peng K, Botfield JR, McGeechan K. Intrauterine contraceptive device training and outcomes for healthcare providers in developed countries: A systematic review. PLoS One 2019; 14:e0219746. [PMID: 31306443 PMCID: PMC6629157 DOI: 10.1371/journal.pone.0219746] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/02/2019] [Indexed: 11/19/2022] Open
Abstract
Intrauterine contraceptive devices (IUCD) are a safe and cost-effective contraceptive method for medically eligible women. Despite this, the utilisation rate for IUCDs is relatively low in many high-income countries, including Australia. Provision of education and training regarding IUCDs to healthcare providers, including nurses and midwives, is one approach to overcome some of the barriers that may prevent wider uptake of IUCDs. This study aims to explore the types and impact of IUCD insertion training for healthcare providers. A systematic review was undertaken in January 2017 to determine the effectiveness of IUCD training for healthcare providers in relation to provision of IUCDs to women. The databases MEDLINE, EMBASE, CINAHL, COCHRANE and SCOPUS were searched to identify studies from high-income countries relating to IUCD training for healthcare providers and relevant outcomes. A total of 30 studies were included in the review. IUCD training for healthcare providers contributed to increased knowledge and improved positive attitudes towards IUCDs, high rates of successful insertions, low complication rates, and increased provision of IUCDs. Successful insertions and low complication rates were similar across different healthcare provider types. No notable differences between provider types in terms of knowledge increase or insertion outcomes were observed. Different training programs for healthcare providers were found to be effective in improving knowledge and successful provision of IUCDs. Increasing the number of healthcare providers skilled in IUCD insertions in high-income countries, including nurses and midwives, will enhance access to this method of contraception and allow women greater contraceptive choice.
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Affiliation(s)
- Menglu Ouyang
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- School of Public Health, University of Sydney, Sydney, Australia
| | - Ke Peng
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
- School of Public Health, University of Sydney, Sydney, Australia
| | | | - Kevin McGeechan
- School of Public Health, University of Sydney, Sydney, Australia
- Family Planning NSW, Ashfield, Sydney, Australia
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23
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Arnold Rehring SM, Reifler LM, Seidel JH, Glenn KA, Steiner JF. Implementation of Recommendations for Long-Acting Contraception Among Women Aged 13 to 18 Years in Primary Care. Acad Pediatr 2019; 19:572-580. [PMID: 30959224 DOI: 10.1016/j.acap.2019.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 03/08/2019] [Accepted: 03/31/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Clinical specialty societies recommend long-acting reversible contraceptives (LARCs) as first-line contraception for adolescent women. We evaluated whether a combined educational and process improvement intervention enhanced LARC placement in primary care within an integrated health care system. METHODS The intervention included journal clubs, live continuing education, point-of-care guidelines, and new patient materials. We conducted a retrospective cohort study across 3 time periods: baseline (January 2013-September 2015), early implementation (October 2015-March 2016), and full implementation (April 2016-June 2017). The primary outcome was the proportion of LARCs placed by primary care clinicians among women aged 13 to 18 years compared with gynecology clinicians. RESULTS Kaiser Foundation Health Plan of Colorado cared for approximately 20,000 women aged 13 to 18 years in each calendar quarter between 2013 and 2017. Overall, LARC placement increased from 7.0 per 1000 members per quarter at baseline to 13.0 per 1000 during the full intervention. Primary care clinicians placed 6.2% of all LARCs in 2013, increasing to 32.1% by 2017 (P < .001), including 45.5% of contraceptive implants. Clinicians who attended educational sessions were more likely to adopt LARCs than those who did not (17.9% vs 6.4% respectively, P = .009). Neither overall LARC placement rates (relative risk, 1.9; 95% confidence interval, 0.7-5.6) nor contraceptive implant rates (relative risk, 3.0; 95% confidence interval, 0.9-9.8) increased significantly in clinicians who attended educational activities. CONCLUSIONS This multimodal intervention was associated with increased LARC placement for adolescent women in primary care. The combination of education and process improvement is a promising strategy to promote clinician behavior change.
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Affiliation(s)
- Sharisse M Arnold Rehring
- Department of Medical Education (SM Arnold Rehring, JH Seidel, and JF Steiner); Department of Pediatrics (SM Arnold Rehring); Department of Pediatrics (SM Arnold Rehring)
| | - Liza M Reifler
- Institute for Health Research (LM Reifler, KA Glenn, and JF Steiner), Kaiser Permanente Colorado
| | - Jennifer H Seidel
- Department of Medical Education (SM Arnold Rehring, JH Seidel, and JF Steiner); Department of Women's Health (JH Seidel), Colorado Permanente Medical Group
| | - Karen A Glenn
- Institute for Health Research (LM Reifler, KA Glenn, and JF Steiner), Kaiser Permanente Colorado
| | - John F Steiner
- Department of Medical Education (SM Arnold Rehring, JH Seidel, and JF Steiner); Institute for Health Research (LM Reifler, KA Glenn, and JF Steiner), Kaiser Permanente Colorado; Department of Medicine (JF Steiner), University of Colorado Anschutz Medical Campus, Aurora.
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24
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Norris AH, Pritt NM, Berlan ED. Can Pediatricians Provide Long-Acting Reversible Contraception? J Pediatr Adolesc Gynecol 2019; 32:39-43. [PMID: 30278228 DOI: 10.1016/j.jpag.2018.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 09/17/2018] [Accepted: 09/24/2018] [Indexed: 12/28/2022]
Abstract
STUDY OBJECTIVE In the United States, 40% of high-school students have sex; few use highly effective and safe long-acting reversible contraceptives (LARCs): intrauterine devices and implants. Pediatricians are key health providers for many adolescents, yet few provide LARCs. Our objective was to understand the pragmatics of provision of LARCs (rather than beliefs or attitudes) and identify barriers to and opportunities for LARC provision by community-practicing pediatricians. DESIGN We conducted a qualitative descriptive study using semistructured interviews. Qualitative methods are valuable for generating conceptual models of complex phenomena. SETTING Set in a midsized Midwestern city, our study was community-based. PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES We interviewed 23 pediatricians to understand their views about providing contraception (including LARCs) to adolescents. For analysis, we developed a coding schema and applied it using a priori and open coding. RESULTS Several inter-related themes regarding challenges to provision of LARC emerged: limited motivation for on-site LARC provision or referral streams, low pediatric patient interest in LARC, lack of pediatrician training about LARC provision, and inadequate structural elements for on-site placement of LARCs in pediatric offices. Each challenge could be remedied, because pediatricians were motivated to provide adolescent patients with high-quality care. Improvements in these inter-related conditions could facilitate pediatrician provision of LARC. CONCLUSION Pediatricians and their patients want to prevent pregnancy, but current practice norms limit LARC provision by pediatricians. To increase LARC access in pediatrician offices, we suggest training in LARC provision and patient education for medical students, residents, and pediatricians; communicating about LARC methods with adolescents to increase patient demand; and systemic changes to improve referral processes and/or allow on-site LARC placements.
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Affiliation(s)
- Alison H Norris
- Division of Epidemiology, College of Public Health, Ohio State University, Columbus, Ohio; Department of Internal Medicine, College of Medicine, Ohio State University, Columbus, Ohio.
| | - Nicole M Pritt
- Division of Adolescent Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Elise D Berlan
- Division of Adolescent Medicine, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, College of Medicine, Ohio State University, Columbus, Ohio
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Thompson CM, Broecker J, Dade M, Nottingham K. Influences on Intentions to Place Long-Acting Reversible Contraceptives: A Pilot Study Comparing According to Provider Specialty in Ohio. J Pediatr Adolesc Gynecol 2018; 31:509-515. [PMID: 29580916 DOI: 10.1016/j.jpag.2018.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 03/05/2018] [Accepted: 03/12/2018] [Indexed: 10/17/2022]
Abstract
STUDY OBJECTIVE According to the American Academy of Pediatrics, pediatricians are to counsel and provide long-acting reversible contraceptives (LARCs) as first line of defense contraceptives because they are the most effective. We wanted to explore positive influences on LARC placement for pediatricians, particularly compared with providers in other specialties who care for women. DESIGN Survey methods with data analyzed using analyses of variance and general linear models in statistical software SPSS version 24.0 (IBM Corp). SETTING Online survey. PARTICIPANTS Participants were 224 providers across the state of Ohio who specialize in family medicine (51.8%), obstetrics/gynecology (17.9%), pediatrics (16.5%), and internal medicine (13.8%). Most of the sample was female (50.9%) and Caucasian (74.6%). The most frequent provider types were Doctors of Osteopathic Medicine (42.0%), followed by Doctors of Medicine (37.9%), and Certified Nurse Practitioners (8.5%). INTERVENTIONS None. MAIN OUTCOME MEASURES Attitudes about LARCs, perceived norms about placing LARCs, perceived behavioral control over placing LARCs, intentions to place LARCs. RESULTS Means for all of the variables (attitudes, perceived norms, perceived behavioral control, and intentions to place) differed according to provider specialty. A pattern emerged across these variables in which internal medicine and pediatric practitioners reported lower attitudes, perceived norms, perceived behavioral control, and intentions to place LARCs than family medicine and obstetrics/gynecology practitioners, in that order. CONCLUSION To increase positive attitudes and perceived norms about LARCs, professional organizations should increase communication to providers about the importance and expectations to place, counsel about, and facilitate placement of LARCs, and medical schooling can improve LARC counseling and procedural training to medical students, interns, and residents. Because perceived behavioral control is linked to intentions to place LARCs, perhaps providers would feel more confident to place them if they had more deliberate training. For pediatricians in particular, perhaps encouraging those who do not currently provide LARC methods to begin with training in implant placement would be a way to capitalize on their more favorable attitudes about implants. For pediatricians who do not feel comfortable providing device placement themselves, other strategies should be encouraged to facilitate provision of LARCs.
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Affiliation(s)
- Charee M Thompson
- Ohio University, Scripps College of Communication, School of Communication Studies, Athens, Ohio.
| | - Jane Broecker
- Ohio University, Heritage College of Osteopathic Medicine, Department of Obstetrics and Gynecology, OhioHealth Physician Group, Heritage College Obstetrics and Gynecology, Athens, Ohio
| | - Maggie Dade
- Ohio University, Heritage College of Osteopathic Medicine, Athens, Ohio
| | - Kelly Nottingham
- Ohio University, Heritage College of Osteopathic Medicine, Department of Family Medicine/Primary Care Research, Athens, Ohio
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McClellan K, Temples H, Miller L. The Latest in Teen Pregnancy Prevention: Long-Acting Reversible Contraception. J Pediatr Health Care 2018; 32:e91-e97. [PMID: 30180941 DOI: 10.1016/j.pedhc.2018.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 02/28/2018] [Indexed: 11/16/2022]
Abstract
Teen pregnancy is prevalent in the United States and has a number of potential negative outcomes. The most effective contraceptives available, known as long-acting reversible contraceptives (LARCs), were recently approved for use in adolescents. LARC devices, including the intrauterine device and subdermal implant, are currently recommended as the first-line contraceptive for all women, including adolescents. Despite this recommendation, current LARC use in the adolescent population remains low. A number of barriers to LARC use in adolescents have been identified, including cost, provider knowledge, and patient education. It is important that nurse practitioners providing care to adolescents are knowledgeable of LARC methods and consistently recommend these devices as the first-line contraceptive to all patients desiring contraception because of their high efficacy, safety, and continuation rates. This article discusses LARC benefits, adverse effects, considerations, barriers to access, and implications for nursing practice.
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Trope LA, Congdon JL, Brown L, Zuckerman B. Family Planning in Pediatrics: An Appeal for Enhanced Training. J Pediatr 2018; 200:4-5. [PMID: 30144929 DOI: 10.1016/j.jpeds.2018.06.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 06/01/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Lee A Trope
- Lucile Packard Children's Hospital Stanford, Palo Alto, CA.
| | | | - Lauren Brown
- Boston Children's Hospital and Boston Medical Center, Boston, MA
| | - Barry Zuckerman
- Boston Children's Hospital and Boston Medical Center, Boston, MA
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Moniz MH, Kirch MA, Solway E, Goold SD, Ayanian JZ, Kieffer EC, Clark SJ, Tipirneni R, Kullgren JT, Chang T. Association of Access to Family Planning Services With Medicaid Expansion Among Female Enrollees in Michigan. JAMA Netw Open 2018; 1:e181627. [PMID: 30646135 PMCID: PMC6324283 DOI: 10.1001/jamanetworkopen.2018.1627] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE To date, 32 states and the District of Columbia have expanded Medicaid programs under the Patient Protection and Affordable Care Act. It is vital to understand whether expanded health insurance coverage of low-income individuals improves access to family planning services as a first step toward improving reproductive health outcomes. OBJECTIVE To evaluate the association of Medicaid expansion coverage with access to birth control and family planning services among women of reproductive age enrolled in the Michigan expansion plan. DESIGN, SETTING, AND PARTICIPANTS In a survey study, from January 13 through December 15, 2016, telephone surveys of a stratified sample of enrollees in Michigan's Section 1115 Medicaid Expansion waiver program, the Healthy Michigan Plan (HMP), were conducted. Interviewers completed surveys for 4090 sampled enrollees, of whom 1166 were women aged 19 to 44 years. Surveys were conducted with a computer-assisted telephone interviewing system in English, Arabic, and Spanish. The sample was weighted to 113 565 women. Dates of data analysis were from January 27 through September 18, 2017. MAIN OUTCOMES AND MEASURES Self-reported change in access to birth control and family planning services through HMP (better, worse, about the same, or don't know/doesn't apply), compared with before enrollment. RESULTS Among the 1166 survey respondents aged 19 to 44 years (mean [SD] age, 31.0 [0.3] years) and the weighted sample of 113 565, 74.7% (95% CI, 72.2%-76.9%) lived in very-low-income households (<100% federal poverty level), 64.0% (95% CI, 60.5%-67.3%) reported at least 1 chronic medical condition, 23.5% (95% CI, 20.6%-26.6%) reported fair or poor health, and 17.7% (95% CI, 15.7%-19.9%) lived in rural settings. Overall, 35.5% (95% CI, 32.2%-39.0%) reported increased access to family planning services. After adjusting, those most likely to report increased access were women without health insurance coverage in the year preceding HMP enrollment (adjusted odds ratio [aOR], 2.02; 95% CI, 1.41-2.89) compared with women with health insurance for the full 12 months preceding enrollment; younger women (aOR for 19-24 years, 2.80 [95% CI, 1.75-4.50]; aOR for 25-34 years, 2.35 [95% CI, 1.60-3.45]) compared with women aged 35 to 44 years; and women with a recent visit to a primary care clinician (aOR 1.69; 95% CI, 1.03-2.76) compared with women without a primary care visit in the preceding 12 months. CONCLUSIONS AND RELEVANCE One in 3 women of reproductive age reported better ability to access birth control and family planning services through HMP compared with before enrollment. This finding suggests that Medicaid expansion is associated with improved access to family planning services, which may enable low-income women to maintain optimal reproductive health.
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Affiliation(s)
- Michelle H. Moniz
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Matthias A. Kirch
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Erica Solway
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Susan D. Goold
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- School of Public Health, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor
| | - John Z. Ayanian
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- School of Public Health, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Edith C. Kieffer
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- School of Social Work, University of Michigan, Ann Arbor
| | - Sarah J. Clark
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Pediatrics, University of Michigan, Ann Arbor
| | - Renuka Tipirneni
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Jeffrey T. Kullgren
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Center for Bioethics and Social Sciences in Medicine, University of Michigan, Ann Arbor
- Veterans Affairs Ann Arbor Center for Clinical Management Research, University of Michigan, Ann Arbor
| | - Tammy Chang
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Department of Family Medicine, University of Michigan, Ann Arbor
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Barriers to implementation of long-acting reversible contraception: A systematic review. J Am Assoc Nurse Pract 2018; 30:236-243. [PMID: 29757790 DOI: 10.1097/jxx.0000000000000019] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Long-acting reversible contraception (LARC) is one of the most effective forms of contraception available. The utilization of LARC remains low despite being recommended by major health organizations such as Centers for Disease Control and Prevention, American Congress of Obstetricians and Gynecologists, American Academy of Pediatrics, American Academy of Family Physicians, and the National Committee for Quality Assurance. Health care professionals play an essential role in the potential increased use of LARC. This review aims to highlight key barriers to the utilization of LARC and discuss interventions to address this issue. METHODS A systematic review of 14 peer-reviewed articles focused on LARC utilization rates that help identify barriers to the utilization of LARC in current education and practice. Articles were evaluated for strength of research design using the Johns Hopkins Nursing Evidence-Based Practice Research Evidence Appraisal tool. CONCLUSIONS Three categories affecting LARC utilization emerged: deficits in provider education/competency, lack of hands-on training, and barriers to practice. IMPLICATIONS FOR PRACTICE The importance of including LARC training and education in the advanced practice nursing curriculum and providing opportunities for continuing education with LARC is demonstrated.
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Ho LS, Wheeler E. Using Program Data to Improve Access to Family Planning and Enhance the Method Mix in Conflict-Affected Areas of the Democratic Republic of the Congo. GLOBAL HEALTH: SCIENCE AND PRACTICE 2018; 6:161-177. [PMID: 29602870 PMCID: PMC5878069 DOI: 10.9745/ghsp-d-17-00365] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 01/09/2018] [Indexed: 11/17/2022]
Abstract
Analysis of program data and a formative assessment informed several program changes, including improved coaching and supportive supervision, introduction of postpartum IUDs and the levonorgestrel-releasing intrauterine system, and enhanced behavior change communication. These changes substantially increased family planning adoption, from a monthly average of 14 adopters per facility to 37 per facility. Implants continued to be the most popular method, but the percentage of adopters choosing the IUD increased from 2% in 2012 to 13% in 2016, and it was the most popular method among postabortion care clients. Unmet need for family planning in the conflict-affected area of eastern Democratic Republic of the Congo (DRC) has been reported to be as high as 38%, and women in such conflict settings are often the most at risk for maternal mortality. The International Rescue Committee implements the Family Planning and Post-Abortion Care in Emergencies program in 3 provinces of eastern DRC to provide women and couples access to family planning, including long-acting reversible contraceptives (LARCs). This article presents routine program data from June 2011 through December 2013 from 2 health zones as well as results from a qualitative assessment of family planning clients and of male and female non-users, conducted in 2013. It then describes how these findings were used to make program adjustments to improve access to family planning services and client informed choice and assesses the effects of the program design changes on family planning uptake and method mix using routine program data from January 2014 through December 2016. Between 2011 and 2013, 8,985 clients adopted family planning, with an average 14 clients adopting a method per facility, per month. The method mix remained stable during this period, with implants dominating at 48%. Barriers to uptake identified from the qualitative research were both supply- and demand-related, including misconceptions about certain modern contraceptive methods on the part of providers, users, and other community members. The program implemented several program changes based on the assessment findings, including clinical coaching and supportive supervision to improve provider skills and attitudes, introduction of immediate postpartum insertion of the intrauterine device (IUD) and the levonorgestrel-releasing intrauterine system (LNG-IUS), and behavior change communication campaigns to raise awareness about family planning. After these program changes, the mean number of clients adopting modern family planning per facility, per month increased from 14 to 37 and the percentage of family planning adopters choosing LARCs increased from 50% to 66%. While implants continued to be the most dominant method, reaching 60% of the method mix in 2016, the percentage of clients adopting IUDs increased each year, from 3% in 2014 to 13% in 2016. In total, 39,399 clients started family planning methods during the post-program design change period (2014–2016). Our experience in eastern DRC demonstrates that women and their partners affected by conflict want family planning, and that it is feasible to deliver the full range of modern contraceptive methods when programs are adapted and sensitive to the local context.
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Affiliation(s)
- Lara S Ho
- International Rescue Committee, Washington, DC, USA.
| | - Erin Wheeler
- International Rescue Committee, New York, NY, USA
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Vela VX, Patton EW, Sanghavi D, Wood SF, Shin P, Rosenbaum S. Rethinking Medicaid Coverage and Payment Policy to Promote High Value Care: The Case of Long-Acting Reversible Contraception. Womens Health Issues 2018; 28:137-143. [PMID: 29329988 DOI: 10.1016/j.whi.2017.10.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 10/20/2017] [Accepted: 10/25/2017] [Indexed: 11/16/2022]
Abstract
CONTEXT Long-acting reversible contraception (LARC) is the most effective reversible method to prevent unplanned pregnancies. Variability in state-level policies and the high cost of LARC could create substantial inconsistencies in Medicaid coverage, despite federal guidance aimed at enhancing broad access. This study surveyed state Medicaid payment policies and outreach activities related to LARC to explore the scope of services covered. METHODS Using publicly available information, we performed a content analysis of state Medicaid family planning and LARC payment policies. Purposeful sampling led to a selection of nine states with diverse geographic locations, political climates, Medicaid expansion status, and the number of women covered by Medicaid. RESULTS All nine states' Medicaid programs covered some aspects of LARC. However, only a single state's payment structure incorporated all core aspects of high-quality LARC service delivery, including counseling, device, insertion, removal, and follow-up care. Most states did not explicitly address counseling, device removal, or follow-up care. Some states had strategies to enhance access, including policies to increase device reimbursement, stocking and delivery programs to remove cost barriers, and covering devices and insertion after an abortion. CONCLUSIONS Although Medicaid policy encourages LARC methods, state payment policies frequently fail to address key aspects of care, including counseling, follow-up care, and removal, resulting in highly variable state-level practices. Although some states include payment policy innovations to support LARC access, significant opportunities remain.
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Affiliation(s)
- Veronica X Vela
- Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Center for Health Policy Research, Washington, DC.
| | - Elizabeth W Patton
- Department of Obstetrics and Gynecology, Boston University School of Medicine, Boston, Massachusetts
| | | | - Susan F Wood
- Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Center for Health Policy Research, Washington, DC; Jacobs Institute of Women's Health, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Peter Shin
- Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Center for Health Policy Research, Washington, DC; Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Sara Rosenbaum
- Center for Health Policy Research, Milken Institute School of Public Health, George Washington University, Washington, DC
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Smith AJB, Harney KF, Singh T, Hurwitz AG. Provider and Health System Factors Associated with Usage of Long-Acting Reversible Contraception in Adolescents. J Pediatr Adolesc Gynecol 2017; 30:609-614. [PMID: 28502827 DOI: 10.1016/j.jpag.2017.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Revised: 05/02/2017] [Accepted: 05/05/2017] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE Long-acting reversible contraception (LARC) is recommended as first-line contraception for adolescents. Surveys of primary care providers suggest that physician and clinic factors might influence LARC counseling, but their effect on usage is unknown. Our objective was to explore provider and clinic characteristics associated with LARC usage in adolescents. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We conducted a cross-sectional study of 5363 women ages 15-21 years receiving primary care within a large health system in Massachusetts in 2015. We used data abstracted from electronic medical records to characterize rates of LARC usage. We analyzed the association of provider (specialty, degree, gender, resident status, LARC credentialing) and clinic (Title X funding, onsite LARC provision, onsite obstetrician-gynecologist) factors with adolescents' LARC usage using multivariate logistic regression. RESULTS Overall, 3.4% (95% confidence interval [CI], 2.9-3.9) of adolescents were documented as currently using a LARC method. Older adolescents were significantly more likely to use a LARC method (adjusted odds ratio, 2.41; 95% CI, 1.62-3.58 for women ages 20-21 years compared with ages 15-17 years). Adolescents whose primary care provider was a resident were significantly more likely to use a LARC method (adjusted odds ratio, 1.65; 95% CI, 1.02-2.68). Provider specialty, degree, gender, onsite LARC provision, and onsite obstetrician-gynecologist were not significantly associated with LARC usage in adolescents. CONCLUSION Being older and having a primary care provider early in their training increased the odds of LARC usage among adolescents in a large Massachusetts health system. Across primary care specialties, educating providers about the appropriate uses of LARC methods in nulliparous adolescents might facilitate LARC usage.
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Affiliation(s)
- Anna Jo Bodurtha Smith
- Department of Gynecology and Obstetrics, Johns Hopkins School of Medicine, Baltimore, Maryland.
| | - Kathleen F Harney
- Harvard Medical School, Boston, Massachusetts; Department of Obstetrics and Gynecology, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Tara Singh
- Harvard Medical School, Boston, Massachusetts; Department of Obstetrics and Gynecology, Cambridge Health Alliance, Cambridge, Massachusetts
| | - Anita Gupta Hurwitz
- Harvard Medical School, Boston, Massachusetts; Department of Pediatrics, Cambridge Health Alliance, Cambridge, Massachusetts
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Higgins JA. Pregnancy Ambivalence and Long-Acting Reversible Contraceptive (LARC) Use Among Young Adult Women: A Qualitative Study. PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2017; 49:149-156. [PMID: 28419700 PMCID: PMC5597464 DOI: 10.1363/psrh.12025] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 02/09/2017] [Accepted: 02/17/2017] [Indexed: 05/16/2023]
Abstract
CONTEXT Many young adults are unclear about how much they want to have, or prevent having, a baby. However, pregnancy ambivalence is an underexamined factor in the uptake of long-acting reversible contraceptive (LARC) methods-IUDs and implants-the most effective methods available. METHODS In 2014, investigators conducted six focus groups and 12 interviews with 50 women aged 18-29 in Dane County, Wisconsin; participants were either university students or community residents receiving public assistance. A modified grounded theory approach was used to analyze the data. RESULTS Four themes emerged. First, participants described a pregnancy desire spectrum: Those strongly motivated to avoid pregnancy were most receptive to LARC methods, while those with less clear or mixed desires worried that these methods would prevent "accidental" pregnancies that might not be unwelcome. Second, women within a few years of wanting children perceived LARC methods as too "permanent," despite awareness of their reversibility. Third, age and life stage were important factors: Younger women and those attending school or beginning careers were more likely than others to consider these methods because they had clearer motivations to avoid pregnancy. Finally, relationship stage influenced receptiveness to LARC methods: Women in newer relationships were more receptive than were those in longer term relationships who imagined having a baby with their partner someday. CONCLUSION Effectiveness is not the only factor in women's selection and use of contraceptive methods. Individual preferences will lead some women to choose non-LARC methods even when fully informed of their options.
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Affiliation(s)
- Jenny A Higgins
- associate professor of gender and women's studies, University of Wisconsin-Madison
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O'Rourke-Suchoff DK, Arora KS, Hildebrand VM, Singer ME. Exploring maternal attitudes towards adolescent contraception: implications for use of LARC. Int J Adolesc Med Health 2017; 30:/j/ijamh.ahead-of-print/ijamh-2016-0120/ijamh-2016-0120.xml. [PMID: 28598796 DOI: 10.1515/ijamh-2016-0120] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 12/27/2016] [Indexed: 06/07/2023]
Abstract
Introduction Maternal attitudes have been shown to impact adolescent girls' sexual decision making and attitudes towards contraception. Given the potential for maternal influence on adolescent contraceptive use, we undertook an exploratory study of mothers' perceptions of the maternal role in adolescent contraceptive decision making, and maternal perceptions of long acting reversible contraceptives (LARC) for adolescent girls. Materials and methods We utilized a mixed methods study design. Acceptability of contraceptive methods and attitudes towards adolescent contraceptive use were assessed using a paper survey of 162 mothers of girls aged 11-19 years in Cleveland, Ohio, USA. Seven survey participants completed subsequent semi-structured interviews, which were analyzed using grounded theory methodology. Results Pills, condoms and injections were most frequently selected as acceptable by 55.4%, 55.4%, and 51.6% of women, respectively. One or more LARC methods were selected by 16.6% of the women. Of those (94.4%) agreed or strongly agreed that, "It is expected of me to make sure that my daughter knows about birth control methods." Important themes that emerged during interviews were the responsibility mothers felt to help their daughters navigate contraception options, appreciation of the effectiveness of LARC methods and concerns about the use of those methods by teenagers due to the invasiveness. Conclusion Our data suggest that mothers want to be involved and support adolescent decision making about contraceptives. We also found that mothers viewed LARC as less acceptable than other forms of birth control for adolescents and have specific concerns about LARC. These results suggest directions for future work to better characterize the impact of maternal attitudes on adolescent LARC use.
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Affiliation(s)
- Danielle K O'Rourke-Suchoff
- Case Western Reserve University School of Medicine, 10900 Euclid Ave, Cleveland, OH 44106,USA
- Department of Epidemiology and Biostatistics, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106-4945,USA, Phone: 216-368-3725
| | - Kavita S Arora
- Case Western Reserve University School of Medicine, 10900 Euclid Ave, Cleveland, OH 44106,USA
- Department of Obstetrics and Gynecology, MetroHealth Medical Center, 2500 Metrohealth Dr., Cleveland, OH 44109,USA
- Department of Bioethics, Case Western Reserve University, School of Medicine TA200, 10900 Euclid Ave, Cleveland, OH 44106-4976,USA
| | - Vanessa M Hildebrand
- Department of Anthropology, Case Western Reserve University, Mather Memorial Room 238, 11220 Bellflower Road, Cleveland, OH 44106-7125,USA
| | - Mendel E Singer
- Case Western Reserve University School of Medicine, 10900 Euclid Ave, Cleveland, OH 44106,USA
- Department of Epidemiology and Biostatistics, Case Western Reserve University, 10900 Euclid Ave, Cleveland, OH 44106-4945,USA, Phone: 216-368-3725
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Tomlin K, Bambulas T, Sutton M, Pazdernik V, Coonrod DV. Motivational Interviewing to Promote Long-Acting Reversible Contraception in Postpartum Teenagers. J Pediatr Adolesc Gynecol 2017; 30:383-388. [PMID: 27871919 DOI: 10.1016/j.jpag.2016.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Accepted: 11/04/2016] [Indexed: 11/27/2022]
Abstract
STUDY OBJECTIVE To determine if teenage patients receiving prenatal care in an adolescent-focused clinic, emphasizing long-acting reversible contraception (LARC) using motivational interviewing techniques, had higher rates of uptake of postpartum LARC than a control group. DESIGN AND SETTING Retrospective cohort study comparing young women who received prenatal care in an adolescent-focused setting with those enrolled in standard prenatal care. PARTICIPANTS Adolescents between the ages of 13 and 17 years receiving prenatal care within the Maricopa Integrated Health safety-net system between 2007 and 2014. INTERVENTIONS Motivational interviewing within the context of adolescent-focused prenatal care. MAIN OUTCOME MEASURES Rates of uptake of LARC within 13 postpartum weeks. RESULTS The adjusted rate of LARC for adolescent-focused prenatal care participants by 13 weeks postpartum was 38% (95% confidence interval [CI], 29%-47%) compared with 18% (95% CI, 11%-28%) for standard care participants, with an adjusted odds ratio of LARC use of 2.8 (95% CI, 1.5-5.2). Among patients who received adolescent-focused prenatal care, most (27% vs 12.7%) were using an intrauterine device as opposed to an implantable contraceptive device. CONCLUSION Participation in an adolescent-focused antepartum setting using motivational interviewing to emphasize postpartum LARC resulted in nearly 3 times higher rates of uptake compared with standard prenatal care.
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Affiliation(s)
- Kristl Tomlin
- Department of Obstetrics, Gynecology, and Women's Health, Maricopa Integrated Health System, Phoenix, Arizona.
| | - Tammalynn Bambulas
- Department of Obstetrics, Gynecology, and Women's Health, Maricopa Integrated Health System, Phoenix, Arizona; District Medical Group, Phoenix, Arizona
| | - Maureen Sutton
- Department of Obstetrics, Gynecology, and Women's Health, Maricopa Integrated Health System, Phoenix, Arizona
| | - Vanessa Pazdernik
- Department of Research Support, A.T. Still University, Mesa, Arizona
| | - Dean V Coonrod
- Department of Obstetrics, Gynecology, and Women's Health, Maricopa Integrated Health System, Phoenix, Arizona; District Medical Group, Phoenix, Arizona; Department of Obstetrics and Gynecology, University of Arizona College of Medicine, Phoenix, Arizona
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Hopkins B. Barriers to Health Care Providers' Provision of Long-Acting Reversible Contraception to Adolescent and Nulliparous Young Women. Nurs Womens Health 2017; 21:122-128. [PMID: 28388997 DOI: 10.1016/j.nwh.2017.02.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 12/14/2016] [Indexed: 06/07/2023]
Abstract
Despite recommendations for long-acting reversible contraception (LARC) as a first-line contraceptive method for adolescents and young women, its use in the United States remains low. This integrative review highlights previously unidentified barriers to health care providers' provision of LARC to adolescent and nulliparous young women. Four themes emerged: Appropriateness of Candidates and Contraceptive Safety, Provider Training and Work Setting, Appropriate Resources, and Opportunity. Raising awareness of barriers to LARC use may galvanize providers to find solutions. Nurses and other clinicians can remain aware of new contraceptive options and guidelines to reduce the risk of unintended pregnancy among adolescents.
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Abstract
Long-acting reversible contraception (LARC) is the most effective method of preventing pregnancy in young women and adolescents. The two types of LARC methods are the intrauterine device and the implantable rod device. The success of these methods is demonstrable due to the "perfect use" and "typical use" failure rates being near identical. Pediatricians must be comfortable counseling patients, including adolescents, about LARC methods and how to access them. This primer provides some background about the types of LARC methods, details about their efficacy and side effects, and the role of the primary pediatrician. [Pediatr Ann. 2017;46(3):e79-e82.].
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Pritt NM, Norris AH, Berlan ED. Barriers and Facilitators to Adolescents' Use of Long-Acting Reversible Contraceptives. J Pediatr Adolesc Gynecol 2017; 30:18-22. [PMID: 27477904 DOI: 10.1016/j.jpag.2016.07.002] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 07/15/2016] [Accepted: 07/19/2016] [Indexed: 12/27/2022]
Abstract
Most pregnancies among teenagers are unintended and many can be attributed to contraception misuse or nonuse. The etonogestrel implant and intrauterine devices, referred to as long-acting reversible contraceptives, or LARCs, are the most effective reversible contraceptive methods. These methods are safe for use by adolescents, yet the number of LARC users remains low among adolescents in the United States. In this review we examine recent literature about barriers and facilitators to LARC use among adolescent women. Factors that influence decision-making and provision are organized into 4 categories: (1) cost and clinical operations; (2) adolescent awareness and attitudes; (3) confidentiality, consent, and parental attitudes; and (4) health care provider knowledge, attitudes, and counseling. Knowledge deficits and misconceptions among adolescents and their health care providers are key barriers to adolescent LARC use.
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Affiliation(s)
- Nicole M Pritt
- Division of Adolescent Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Alison H Norris
- Division of Epidemiology, The Ohio State University College of Public Health, Columbus, Ohio; Division of Infectious Diseases, The Ohio State University College of Medicine, Columbus, Ohio
| | - Elise D Berlan
- Division of Adolescent Medicine, Nationwide Children's Hospital, Columbus, Ohio; Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio.
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Long-Acting Reversible Contraception Counseling and Use for Older Adolescents and Nulliparous Women. J Adolesc Health 2016; 59:703-709. [PMID: 27665153 PMCID: PMC6653632 DOI: 10.1016/j.jadohealth.2016.07.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 06/09/2016] [Accepted: 07/12/2016] [Indexed: 11/23/2022]
Abstract
PURPOSE The majority of pregnancies during adolescence are unintended, and few adolescents use long-acting reversible contraception (LARC) due in part to health care providers' misconceptions about nulliparous women's eligibility for the intrauterine device. We examined differences in LARC counseling, selection, and initiation by age and parity in a study with a provider's LARC training intervention. METHODS Sexually active women aged 18-25 years receiving contraceptive counseling (n = 1,500) were enrolled at 20 interventions and 20 control clinics and followed for 12 months. We assessed LARC counseling and selection, by age and parity, with generalized estimated equations with robust standard errors. We assessed LARC use over 1 year with Cox proportional hazards models with shared frailty for clustering. RESULTS Women in the intervention had increased LARC counseling, selection, and initiation, with similar effects among older adolescent and nulliparous women, and among young adult and parous women. Across study arms, older adolescents were as likely as young adults to receive LARC counseling (adjusted odds ratio [aOR] = .85; 95% confidence interval [CI]: .63-1.15), select LARC (aOR = .86; 95% CI: .64-1.17), and use LARC methods (adjusted hazard ratio [aHR] = .94; 95% CI: .69-1.27). Nulliparous women were less likely to receive counseling (aOR = .57; 95% CI: .42-.79) and to select LARC (aOR = .53; 95% CI: .37-.75) than parous women, and they initiated LARC methods at lower rates (aHR = .65; 95% CI: .48-.90). Nulliparous women had similar rates of implant initiation but lower rates of intrauterine device initiation (aHR = .59; 95% CI: .41-.85). CONCLUSIONS Continued efforts should be made to improve counseling and access to LARC methods for nulliparous women of all ages.
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Higgins JA, Kramer RD, Ryder KM. Provider Bias in Long-Acting Reversible Contraception (LARC) Promotion and Removal: Perceptions of Young Adult Women. Am J Public Health 2016; 106:1932-1937. [PMID: 27631741 PMCID: PMC5055778 DOI: 10.2105/ajph.2016.303393] [Citation(s) in RCA: 171] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2016] [Indexed: 11/04/2022]
Abstract
Long-acting reversible contraception (LARC) is effective and acceptable. However, concern exists about potential provider bias in LARC promotion. No study has documented contraceptive users' attitudes toward or experiences with provider influence and bias regarding LARC. We collected qualitative data in 2014 to address this gap. Participants were 50 young adult women with any history of contraceptive use (including LARC) in Dane County, Wisconsin. Women often described providers as a trusted source of contraceptive information. However, several women reported that their preferences regarding contraceptive selection or removal were not honored. Furthermore, many participants believed that providers recommend LARC disproportionately to socially marginalized women. We encourage contraceptive counseling and removal protocols that directly address historical reproductive injustices and that honor patients' wishes.
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Affiliation(s)
- Jenny A Higgins
- Jenny A. Higgins is with the Department of Gender and Women's Studies, University of Wisconsin-Madison. Renee D. Kramer is with the Department of Population Health Sciences, University of Wisconsin-Madison. At the time of the study, Kristin M. Ryder was with the Department of Health Behavior and Health Education, University of Michigan, Ann Arbor
| | - Renee D Kramer
- Jenny A. Higgins is with the Department of Gender and Women's Studies, University of Wisconsin-Madison. Renee D. Kramer is with the Department of Population Health Sciences, University of Wisconsin-Madison. At the time of the study, Kristin M. Ryder was with the Department of Health Behavior and Health Education, University of Michigan, Ann Arbor
| | - Kristin M Ryder
- Jenny A. Higgins is with the Department of Gender and Women's Studies, University of Wisconsin-Madison. Renee D. Kramer is with the Department of Population Health Sciences, University of Wisconsin-Madison. At the time of the study, Kristin M. Ryder was with the Department of Health Behavior and Health Education, University of Michigan, Ann Arbor
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Murphy MK, Stoffel C, Nolan M, Haider S. Interdependent Barriers to Providing Adolescents with Long-Acting Reversible Contraception: Qualitative Insights from Providers. J Pediatr Adolesc Gynecol 2016; 29:436-442. [PMID: 26851537 PMCID: PMC4974172 DOI: 10.1016/j.jpag.2016.01.125] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 01/17/2016] [Accepted: 01/27/2016] [Indexed: 10/22/2022]
Abstract
STUDY OBJECTIVE Long-acting reversible contraceptive (LARC) methods are the most effective form of reversible contraception but are underutilized by adolescents. The purpose of this study was to identify the context-specific barriers to providing adolescents with LARC that are experienced by pediatricians, family medicine physicians, and advanced practice nurses (APNs). DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS Pediatricians, family medicine providers, and APNs (n = 16) who care for adolescents participated in semistructured qualitative interviews. Interview data were analyzed using a modified grounded theory approach. MAIN OUTCOME MEASURES Pediatricians, family medicine physicians, and APNs self-reported attitudes and practices regarding LARC provision to adolescents. RESULTS Provider confidence in LARC, patient-centered counseling on LARC, and instrumental supports for LARC all work interdependently either in support of or in opposition to provision of LARC to adolescents. Low provider confidence in LARC for adolescents was characterized by confusion about LARC eligibility criteria and perceptions of LARC insertion as traumatic for adolescents. Patient-centered counseling on LARC required providers' ability to elicit patient priorities, highlight the advantages of LARC over other methods, and address patients' concerns about these methods. Instrumental support for LARC included provider training on LARC, access to and financial support for LARC devices, and opportunity to practice LARC insertion and counseling skills. CONCLUSION Although none of the identified essential components of LARC provision to adolescents exist in isolation, instrumental support like provider training on LARC and access to LARC devices have the most fundamental effect on the other components and on providers' attitudes and practices regarding LARC for adolescents.
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Affiliation(s)
- Molly K Murphy
- Community Health Sciences Division, School of Public Health, University of Illinois-Chicago, Chicago, Illinois.
| | - Cindy Stoffel
- Department of Obstetrics and Gynecology, University of Illinois-Chicago, Chicago, Illinois
| | - Meghan Nolan
- Department of Obstetrics and Gynecology, University of Illinois-Chicago, Chicago, Illinois
| | - Sadia Haider
- Department of Obstetrics and Gynecology, University of Illinois-Chicago, Chicago, Illinois
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Kumar N, Brown JD. Access Barriers to Long-Acting Reversible Contraceptives for Adolescents. J Adolesc Health 2016; 59:248-253. [PMID: 27247239 DOI: 10.1016/j.jadohealth.2016.03.039] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 03/28/2016] [Accepted: 03/28/2016] [Indexed: 01/08/2023]
Abstract
The United States continues to have the highest adolescent birth rate of any industrialized country. Recently published guidelines by the American Academy of Pediatrics create a new consensus among professional organizations around the suitability of long-acting reversible contraceptives as first-line contraception for adolescents. Through a narrative review of U.S. studies published after 2000, this study seeks to summarize existing access barriers to long-acting reversible contraceptives for adolescents and highlight areas that warrant further intervention so that the recommendations of these professional organizations can be effectively integrated into clinical practice. Existing barriers include costs for institutions providing contraceptive care and for recipients; consent and confidentiality for adolescent patients; providers' attitudes, misconceptions and limited training; and patients' lack of awareness or misconceptions. Systemic policy interventions are required to address cost and confidentiality, such as the Affordable Care Act's mandate that contraceptive coverage be a part of essential health benefits for all insurance providers. Individual-level access barriers such as providers' misconceptions and gaps in technical training as well as patients' lack of awareness can be addressed directly by professional medical organizations, health care training programs, and other interventions.
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Affiliation(s)
- Natasha Kumar
- Warren Alpert Medical School of Brown University, Providence Rhode Island.
| | - Joanna D Brown
- Department of Family Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Chacko MR, Wiemann CM, Buzi RS, Kozinetz CA, Peskin M, Smith PB. Choice of Postpartum Contraception: Factors Predisposing Pregnant Adolescents to Choose Less Effective Methods Over Long-Acting Reversible Contraception. J Adolesc Health 2016; 58:628-35. [PMID: 26852250 DOI: 10.1016/j.jadohealth.2015.12.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 11/02/2015] [Accepted: 12/03/2015] [Indexed: 12/24/2022]
Abstract
PURPOSE The purposes were to determine contraceptive methods pregnant adolescents intend to use postpartum and to understand factors that predispose intention to use less effective birth control than long-acting reversible contraception (LARC). METHODS Participants were 247 pregnant minority adolescents in a prenatal program. Intention was assessed by asking "Which of the following methods of preventing pregnancy do you intend to use after you deliver?" Multinomial logistic regression analysis was used to determine factors associated with intent to use nonhormonal (NH) contraception (male/female condoms, abstinence, withdrawal and no method) or short-/medium-acting hormonal (SMH) contraception (birth control pill, patch, vaginal ring, injectable medroxyprogesterone acetate) compared with LARC (implant and intrauterine device) postpartum. RESULTS Twenty-three percent intended to use LARC, 53% an SMH method, and 24% an NH method. Participants who intended to use NH or SMH contraceptive methods over LARC were significantly more likely to believe that LARC is not effective at preventing pregnancy, to report that they do not make decisions to help reach their goals and that partners are not important when making contraceptive decisions. Other important factors were having a mother who was aged >19 years at first birth and had not graduated from high school, not having experienced a prior pregnancy or talked with parents about birth control options, and the perception of having limited financial resources. CONCLUSIONS Distinct profiles of factors associated with intending to use NH or SMH contraceptive methods over LARC postpartum were identified and may inform future interventions to promote the use of LARC to prevent repeat pregnancy.
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Affiliation(s)
- Mariam R Chacko
- Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston, Texas.
| | - Constance M Wiemann
- Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston, Texas
| | | | - Claudia A Kozinetz
- Baylor College of Medicine, Houston, Texas; Texas Children's Hospital, Houston, Texas
| | - Melissa Peskin
- Center for Health Prevention and Research, The University of Texas School of Public Health, The University of Texas Health Science Center at Houston, Houston, Texas
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Jacobson L, Garbers S, Helmy H, Roobol H, Kohn JE, Kavanaugh ML. IUD services among primary care practices in New York City. Contraception 2016; 93:257-62. [DOI: 10.1016/j.contraception.2015.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 10/28/2015] [Accepted: 11/01/2015] [Indexed: 11/28/2022]
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Shoupe D. LARC methods: entering a new age of contraception and reproductive health. Contracept Reprod Med 2016; 1:4. [PMID: 29201394 PMCID: PMC5675060 DOI: 10.1186/s40834-016-0011-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 12/27/2015] [Indexed: 11/15/2022] Open
Affiliation(s)
- Donna Shoupe
- University of Southern California, Los Angeles, California USA
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Satterwhite CL, Ramaswamy M. Let's talk about sex (again): advancing the conversation around long-acting reversible contraception for teenagers. ACTA ACUST UNITED AC 2015; 11:841-50. [PMID: 26626398 DOI: 10.2217/whe.15.66] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Long-acting reversible contraception (LARC) has incredible potential for decreasing teenage pregnancy rates in the USA, but use among adolescents remains low. LARC methods, including intrauterine devices and implants, are recommended as first-line choices for teenagers by multiple medical professional associations. Barriers at the system, provider and patient level persist, but new demonstration projects, in addition to provisions of the Affordable Care Act, show great promise in facilitating LARC use. A renewed national discourse should acknowledge the reality that many US teenagers have sex, that LARC is safe and effective and that LARC offers an opportunity to prevent teenage pregnancy. By encouraging widespread access and use, a large, positive impact across multiple health and economic sectors can be achieved.
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Affiliation(s)
| | - Megha Ramaswamy
- Department of Preventive Medicine & Public Health, University of Kansas School of Medicine, Kansas City, KS, USA
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A Call to Action: Developing and Strengthening New Strategies to Promote Adolescent Sexual Health. SOCIETIES 2015. [DOI: 10.3390/soc5040686] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Rubin SE, Cohen HW, Santelli JS, McKee MD. Counseling Adolescents About the Intrauterine Contraceptive Device: A Comparison of Primary Care Pediatricians With Family Physicians and Obstetrician-Gynecologists in the Bronx, New York. J Prim Care Community Health 2015; 6:162-9. [PMID: 25628297 PMCID: PMC4466062 DOI: 10.1177/2150131914568460] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The intrauterine device (IUD) is a highly effective contraceptive, yet not all primary care providers (PCPs) counsel adolescents about IUDs. We sought to describe PCPs' frequency of counseling adolescents about IUDs and identify whether different factors are associated with frequent counseling by pediatricians compared with family physicians and gynecologists. METHODS Surveyed PCPs affiliated with a Bronx, New York academic institution. MAIN OUTCOME Frequent counseling of female adolescents about IUDs. RESULTS Frequent counseling was lower in pediatricians compared with family physicians and gynecologists (35.8% and 81.6%, respectively, P < .001). Among all PCP types, frequent counseling was associated with feeling more competent counseling and managing expected IUD side effects (P < .001). Other significant variables included inserting IUDs themselves (P < .001, family physicians and gynecologists) or having access to an inserter in their office (P = .04, pediatricians). CONCLUSIONS Correlates of frequent IUD counseling differed according to PCP specialty. Our results suggest that interventions to increase IUD counseling should focus on improving PCPs' competency around counseling and side effect management as well as increasing access to IUD inserters.
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Affiliation(s)
- Susan E Rubin
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
| | - Hillel W Cohen
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
| | - John S Santelli
- Columbia University Mailman School of Public Health, New York, NY, USA
| | - M Diane McKee
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, USA
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Abstract
In 2013 and 2014, the Centers for Disease Control and Prevention (CDC) publicized its recommendations for the use of long-acting reversible contraception (LARC) (including intrauterine devices and implants) as first-line, highly effective options for pregnancy prevention. The use of LARC by adolescents has had growing support by national health and women's health organizations. Ongoing research is beginning to uncover facilitators and barriers to LARC use in adolescents. The purpose of this column is to highlight two recent U.S.-based studies in which researchers examined perspectives related to and factors associated with LARC use in adolescent and young adult women.
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Providing long-acting reversible contraception services in Seattle school-based health centers: key themes for facilitating implementation. J Adolesc Health 2015; 56:658-65. [PMID: 26003582 DOI: 10.1016/j.jadohealth.2015.02.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 01/31/2015] [Accepted: 02/23/2015] [Indexed: 11/22/2022]
Abstract
PURPOSE The purpose of this study was to describe the implementation of a program that provides long-acting reversible contraception (LARC) services within school-based health centers (SBHCs) and to identify barriers and facilitators to implementation as reported by SBHC clinicians and administrators, public health officials, and community partners. METHODS We conducted 14 semistructured interviews with key informants involved in the implementation of LARC services. Key informants included SBHC clinicians and administrators, public health officials, and community partners. We used a content analysis approach to analyze interview transcripts for themes. We explored barriers to and facilitators of LARC service delivery across and within key informant groups. RESULTS The most cited barriers across key informant groups were as follows: perceived lack of provider procedural skills and bias and negative attitudes about LARC methods. The most common facilitators identified across groups were as follows: clear communication strategies, contraceptive counseling practice changes, provider trainings, and stakeholder engagement. Two additional barriers emerged in specific key informant groups. Technical and logistical barriers to LARC service delivery were cited heavily by SBHC administrative staff, community partners, and public health officials. Expense and billing was a major barrier to SBHC administrative staff. CONCLUSIONS LARC counseling and procedural services can be implemented in an SBHC setting to promote access to effective contraceptive options for adolescent women.
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