Identifying adolescents at risk for noncompliance with contraceptive therapy

Initiation of oral contraceptives--start now!

PURPOSE

Conventional practice for initiating oral contraceptive (OC) pills involves waiting to start the pills with the next menstrual period. We investigated whether immediate initiation of OCs would lead to improved continuation rates and therefore decreased pregnancy rates in adolescents aged 12-17 years.

METHODS

Study subjects were recruited from adolescent women presenting to 2 inner city clinics requesting OCs. A total of 539 adolescents between 12 and 17 years old were randomized to conventional initiation of the OC pill (Conventional Start [CS]) versus immediate, directly observed OC pill ingestion in the clinic (Quick Start [QS]). At 3 and 6 months the participants completed interviews that questioned them about their OC continuation and pregnancies.

RESULTS

In all, 86% of our adolescents completed follow-up interviews at 3 months, and 77% at 6 months. There were 45 pregnancies during the study period. QS was associated with continuing OCs to a second pack (adjusted OR 1.8, 95% CI 1.1-3.3). There was no difference in OC continuation rates at 3 or 6 months. Only 26% of adolescents continued OCs at 6 months and we identified 45 pregnancies during follow-up.

CONCLUSION

We conclude that directly observed, immediate initiation of oral contraceptives (QS) with adolescents briefly improves continuation although overall continuation rates are discouraging low. Health care providers could use this simple strategy to start adolescents on OCs at the initial visit. The low 6-month OC continuation rates highlight the need to seek novel ways to provide adolescents with the necessary tools to be successful at contraception.

Increasing adherence to cystic fibrosis treatment: a systematic review of behavioral techniques

Cystic fibrosis is a fatal chronic illness that primarily affects the respiratory and pancreatic systems. Treatment includes daily medications, enzyme and vitamin supplements, a high-calorie diet, and airway clearance sessions (e.g., chest physiotherapy, exercise). Although this regimen is essential to longevity, families have difficulty adhering to the multiple treatment components. Adherence is especially problematic with diet, chest physiotherapy, and exercise. Studies utilizing behavioral techniques to increase adherence to cystic fibrosis treatment components have been conducted with varying results. In this paper, a critical review of these treatment studies and suggestions for future work are presented.

Drug compliance in adolescents: assessing and managing modifiable risk factors

Many studies have found that adolescence represents a problem in compliance with prescribed drug regimens. Multiple factors contribute to this problem, including the developmental evolution taking place in the adolescent physique and psyche. Health belief and patient demographic factors, inherent disease and regimen factors, as well as the dynamics between patient and provider may also contribute to problems with compliance to treatment. Simple interventions such as working with the teen to construct a tolerable treatment regimen, assessing anticipated compliance, discussing potential adverse effects, and establishing cues from the adolescent's daily routine can positively impact treatment compliance. Healthcare providers should recognize the fact that psychosocial changes in an adolescent's life can impact upon compliance with medications and enlist the help of their patients in constructing treatment regimens taking into account the individual's lifestyle that may impact upon compliance. In particular, the healthcare provider should ask the adolescents what they anticipate their success with compliance to treatment might be, adverse effects they are concerned about and what cues could best aid the treatment plan. The healthcare provider should then synthesize this information to create the best treatment plan for that patient.

Adolescent compliance and side effects with Quick Start initiation of oral contraceptive pills

Adolescents' compliance with use of oral contraceptive pills has been described in the literature. The purpose of this study was to compare traditional Sunday Start to a same day (Quick Start) approach. A retrospective study of patients 22 years of age and younger was performed comparing compliance at 3 months and 12 months and side effects. The groups were divided into Quick Start (N = 77, 40%) and Sunday Start (N = 116, 60%). One hundred twenty-five (65%) patients were compliant at 3 months; 68 patients (35%) were compliant at 12 months. Quick Start users were more likely to comply at 3 months (72% vs. 56%, p = 0.059), especially if they were Caucasian (80% vs. 65%, p = 0.007), with dysmenorrhea (86% vs. 62%, p = 0.006), nulligravid (77% vs. 58%, p = 0.008), or nulliparous (73% vs. 59%, p = 0.038). There was no difference in side effects. There was no significant difference at 1 year in compliance or side effects. Findings suggest better compliance in adolescents at 3 months with the Quick Start approach while maintaining side effect profile.

Will the pill make me sterile? Addressing reproductive health concerns and strategies to improve adherence to hormonal contraceptive regimens in adolescent girls

PAPER OBJECTIVE: This paper is designed to help clinicians understand the relationship between hormonal contraceptive side effects and the potential development of general and reproductive health concerns that can impact on adherence to hormonal contraception. By understanding the concerns raised by young women, we can then make our counseling more specific to the factors that affect compliance in this population.

DESIGN

Studies that specifically addressed hormonal contraceptive compliance, side effects, and method selection in adolescents and young women were chosen for this paper. All articles were from peer-reviewed journals. Medline-Ovid articles from 1980-2000 were used with the following search keywords: Contraception, Patient Compliance, Hormonal Contraception, Oral Contraceptive Pills, Norplant, Depo Provera, and Adolescents.

DATA SYNTHESIS

The general public has many concerns about the safety of hormonal contraception. The development of side effects, especially those that are menstrual-related, seem to cause adolescents and young women to feel that their general and reproductive health is being threatened.

CONCLUSIONS

Hormonal contraceptive counseling should include 1) explaining, in a nontechnical manner, how these methods work; 2) addressing negative information the patient has heard about the methods; 3) providing factual information about cancer risks, blood clots, and other general health concerns; 4) discussing the potential side effects and what each means to her health; 5) asking specifically about possible reproductive health worries, especially in light of the menstrual irregularities that may occur; and 6) assuring the patient that she should always feel free to share her concerns and worries with you, the provider.

Contraceptive dispensing and selection in school-based health centers

PURPOSE

To determine whether initiation of on-site dispensing of hormonal contraceptives (oral contraceptive pill, Depo-provera, and Norplant) in six urban school-based health centers reduced time to initial selection, and increased their consistent use among sexually active females.

METHODS

Participants were sexually active females who received family planning care in a school year before (1994-1995 cohort) or after (1996-1997 cohort) the initiation of on-site dispensing. Data on contraception and sexual behavior were collected at each family planning visit. Cohorts were compared using Student's t-tests and Chi-square tests, analysis of covariance, and logistic regression.

RESULTS

About 59% of the 1994-1995 cohort selected hormonal contraceptives at the first or second visit; this increased to 72% of the 1996-1997 cohort (chi(2) = 11.3; p <.001). After adjustment for cohort differences, the 1996-1997 cohort consistently selected hormonal contraceptives a longer period of time, although the difference did not reach statistical significance (adjusted means: 1994-1995 cohort = 73 days, 1996-1997 cohort = 81 days; t = 1.6, p <.10).

CONCLUSION

Sexually active females receiving family planning care select methods of hormonal contraception sooner and somewhat more consistently when the clinics in their high schools can dispense contraceptives on-site.

Adolescent contraception

Adolescent pregnancy rates have declined modestly, most likely because of the increased use of condoms, especially at first intercourse. Condom distribution in schools appears to be effective in promoting condom use without increasing sexual activity. Although, to date, no contraceptive has been as effective as Norplant in reducing teen pregnancy, use of the method has declined dramatically. Depo-Provera use is increasing, but continuation rates are disappointing and the impact on teen pregnancy rates is as yet unknown. Emergency contraception remains underutilized, and interventions to improve oral contraceptive compliance are beginning to be explored. School-based programs that provide contraception without adding a strong educational component fail to improve contraceptive use or reduce pregnancy rates. Use of any contraceptive by teens is cost effective.

[Factors associated with follow-up visit non-compliance after induced abortion]

Non-compliance to follow-up after an induced abortion is associated with poor compliance to contraception. This study was undertaken to determine which factors are associated with follow-up visit compliance after an induced abortion among 1,661 women who had the operation at the Clinique de Planification des Naissances du Centre Hospitalier de I'Université Laval. Factors associated with non-compliance to follow-up include young age, smoking, previous induced abortion, a single sexual partner during the previous year, the use of oral contraceptives and advanced gestational age at the time of the procedure. Careful screening of these women might improve compliance with follow-up visits and contraception, which could in turn help to prevent repeat abortions.

Drug compliance in pediatrics. Clinical and research issues

Noncompliance with therapy is widespread in children, with potentially important implications in clinical practice and the research setting. Compliance with therapy is a critical element in the success of therapy, that is, for an efficacious medication to be effective, it must be taken. Demonstration of patterns of drug adherence and the association between compliance and outcome in clinical practice have been facilitated by the recent introduction of electronic monitoring of medication compliance. Determinants of drug compliance, optimal measurement of compliance, and strategies to improve compliance remain to be further explored in children. Given the prevalence of and the potential consequence of noncompliance, pediatricians must have a high index of suspicion of noncompliance to provide the best possible care to their patients.

Compliance and oral contraceptives: a review

Compliance difficulties are more common among oral contraceptive (OC) users than generally appreciated by clinicians, in part because unintended pregnancy is a relatively infrequent consequence and in part because more common manifestations such as spotting and bleeding may not be recognized as resulting from poor compliance. While improving compliance is a shared responsibility of patients, clinicians, and manufacturers, the clinician is the focal point for these efforts. Counseling must be individualized, which requires knowledge of factors that predict compliance and an understanding of the patient's decision-making process as it relates to medications. Most OC compliance research has focused on adolescents, where predictors of poor compliance include multiple sex partners, low evaluation of personal health, degree of concern about pregnancy, and previous abortion. Good compliance has been linked with patient satisfaction with the clinician, the absence of certain side effects, establishing a regular daily routine to take OCs, and reading information distributed with OC packaging.

Adolescent girls' attitudes toward contraceptive subdermal implants

Norplant, which has been shown to be a highly effective and acceptable contraceptive for adult women, may also be a very useful contraceptive for adolescents. This study is designed to determine the level of interest in Norplant for adolescent girls with and without children, their attitudes toward various features of Norplant, and the demographic and psychosocial factors predictive of their interest. A self-administered questionnaire was given to 112 adolescents attending our pediatric or adolescent clinic. Data from 28 adolescent mothers and 79 nulliparous adolescents were analyzed. Fifty-six percent of the subjects had heard of Norplant prior to the survey. The overall level of interest in Norplant was high; 70% of the adolescents without children, and 79% of the adolescent mothers were interested. In comparison to oral contraceptives, 73% of those without children and 89% of those with children thought Norplant would be a better contraceptive. The specific features of Norplant liked by 87% and 81% of the subjects, respectively, were not needing to take pills every day and its effectiveness in preventing pregnancy. The characteristics seen as most undesirable related to potential side effects with acne being mentioned by 87% of the subjects. Recursive partitioning analysis demonstrates that more than one prior pregnancy was the main characteristic predictive of very high levels of interest. In summary, this study demonstrates high levels of interest in Norplant by adolescents and suggests that it should be offered as a contraceptive option, especially to those girls who have previously been pregnant.

Adherence to recommended medical regimens in childhood and adolescence

OBJECTIVE

Factors that appear to influence treatment adherence among adults have been the focus of considerable research in recent years. However, less research has focused on children's treatment adherence. This paper reviews current knowledge about factors that appear to influence adherence among children and adolescents.

METHODOLOGY

Factors associated with adherence to medical regimens reviewed here include: (i) the psychosocial characteristics of children and their parents; (ii) the nature of the treatment regimen; and (iii) the relationship between health practitioners, parents and paediatric patients.

CONCLUSIONS

Issues for future research include: (i) the adherence of both children and their parents to children's treatment, and the allocation of responsibility for treatment adherence; (ii) the wide range of behaviours involved in regimen adherence should be acknowledge; patients' adherence to one aspect of their regimen should not be considered indicative of their overall adherence; and (iii) longitudinal studies are required to examine the causal relations between patient adherence and its antecedents.

Use of levonorgestrel implants versus oral contraceptives in adolescence: a case-control study

OBJECTIVE

We compared continuation rates, effectiveness, satisfaction with method, side effects, and condom practices among adolescents using levonorgestrel implants (Norplant, Wyeth-Ayerst Laboratories, Philadelphia) as compared with oral contraceptives.

STUDY DESIGN

We conducted a case-control study comparing 94 adolescents < or = 18 years old who received Norplant between March 1, 1992, and Nov. 1, 1993 (cases), with 94 age-matched controls who selected oral contraceptives during this same time period. By use of a structured questionnaire, information was obtained on pregnancy status, duration of use, patient satisfaction, side effects, and condom practices 6 months after initiation. Objective measures included weight on Norplant and oral contraceptive users and hematocrit on implant patients.

RESULTS

Forty (43%) oral contraceptive patients compared with no Norplant patients discontinued their selected method before the 6-month interview (p = 0.00). Six patients prescribed oral contraceptives became pregnant. Ninety-three percent of Norplant users expressed overall satisfaction despite experiencing menstrual irregularity and cramping, amenorrhea, nervousness, abnormal hair growth or loss, rashes, and an increase in appetite more often than oral contraceptive users. Although Norplant patients also reported an increase in the duration of menstrual flow and number of days of spotting more often than oral contraceptive users, evaluation of hematocrits in these patients demonstrated a significant increase over the 6-month period (p = 0.00). Assessment of condom practices since initiation demonstrated that Norplant patients used condoms less often than oral contraceptive users (p = 0.00).

CONCLUSION

Use of levonorgestrel implants may cause more side effects than oral contraceptives in the early months after initiation but provide superior protection against unintended pregnancy. We concluded that Norplant is a reasonable alternative for adolescents, especially when compliance is an issue.

The relationship between female adolescents' oral contraceptive adherence and autonomy

This exploratory study examines the relation between female adolescents' emotional autonomy and oral contraceptive adherence. The participants were 51 single female adolescents (16, 17, and 18 years old) who had never been pregnant. At the 3-month follow-up, 39 of the subjects (77%) completed the study. Subjects completed the Emotional Autonomy Scale (Steinberg & Silverberg, 1986) initially and at the 3-month follow-up. Oral contraceptive adherence was assessed at the 3-month follow-up. Subjects had relatively high oral contraceptive adherence and autonomy. Oral contraceptive adherence was not associated with autonomy (r = .22, p = .21). Autonomy may be more influential on adolescents' seeking oral contraceptives rather than to adhering to their use.

Female adolescents' perceptions of benefits of and barriers to using oral contraceptives

A study was conducted to describe 12 female adolescents' oral contraceptive perceptions that were considered first independently and then after facilitation by a nurse. A self-administered decisional balance sheet elicited 44 descriptions of oral contraceptive perceptions, and a structured interview elicited 31 additional descriptions. The data were content-analyzed for common elements. The majority of participants perceived oral contraceptive benefits related to pregnancy prevention and others' approval and barriers related to side effects and others' disapproval. Participants considered additional oral contraceptive perceptions upon facilitation by a nurse after the opportunity for independent consideration. Facilitation of female adolescents' consideration of oral contraceptive perceptions may be an appropriate nursing intervention.

Adolescent Sexuality: Part 2. Contraception

The United States has the highest rate of teen pregnancy in the Western world. Although abstinence may be the ideal solution for the prevention of this problem, one half of adolescents in the United States are sexually active. This article reviews the epidemiology of contraception among adolescents, barriers to effective use of contraception, and ways to improve efficacy. Major methods of contraception, including oral contraceptive pills, Norplant, Depo-Provera, condoms, spermicide, sponge, intrauterine device (IUD), diaphragm, and rhythm/periodic abstinence, are discussed along with method-specific issues related to adolescents.

Contraceptive compliance with a levonorgestrel triphasic and a norethindrone monophasic oral contraceptive in adolescent patients

OBJECTIVE

This study was undertaken to assess the impact of two low-dose oral contraceptive pills on compliance and side effects in adolescent patients.

STUDY DESIGN

The use of a levonorgestrel-containing triphasic pill (N = 114) was compared with that of a monophasic (1 + 35) norethindrone-containing pill (N = 110) at two different sociodemographic sites.

RESULTS

No significant difference in compliance or pill satisfaction was observed between the pills. Socioeconomic factors were the overriding predictors of compliance. At 3 and 12 months of follow-up, there were significantly fewer complaints of overall side effects (p less than 0.001 and p = 0.004, respectively), breakthrough bleeding (p = 0.017 and p = 0.018), and pill amenorrhea (p = 0.002 and p less than 0.001) among users of the triphasic pill. Mean weight change at 12 months was +1.1 kg for the monophasic pill and -0.1 kg for the triphasic pill. All known pregnancies occurred among noncompliant city clinic patients.

CONCLUSIONS

Adolescents experienced fewer side effects with the triphasic pill than with the monophasic one, but compliance was the same.

Return for follow-up care and contraceptive continuation among adolescents

Family planning service providers have noted a greater than 50% nonreturn rate among adolescent clients. Those who fail to return to the clinic are likely to discontinue their use of contraceptives and be at riskfor an unintendedpregnancy. Case record reviews of a random sample of adolescent oral contraceptive users were used to investigate variables correlated with nonreturn for follow-up care. Compared to adolescents who returned to the clinic, those least likely to return had a sexually transmitted disease, had irregular menstrual periods, had a pap smear over a year prior to the initial clinic visit, reported more general health problems, were referred for additional tests, and had waited longer since first coitus to obtain birth control. Implications for the development of a method to screen adolescents for risk of contraceptive discontinuation are drawn.

Contraceptive behavior among sexually active Hispanic adolescents

The purpose of this study was to examine those factors associated with the contraceptive behavior of a national representative sample of Hispanic female adolescents. The subjects included all (n = 85) unmarried, sexually active Hispanic women, aged 15 to 19, from the 1982 National Survey of Family Growth. Contraceptive behavior was measured on a normalized scale, ranging from oral contraceptives to no contraception. Mexican/American and Central/South American background females were more likely (p less than 0.031) to use effective birth control than Puerto Rican, Cuban, and other Hispanic background subjects. Twenty additional social, behavioral, and demographic variables were found to be significantly associated (p less than 0.05) with contraceptive behavior. Based on multiple regression analysis, seven of these variables were found to explain 62% (p less than 0.0001) of the variation in the contraceptive behavior of this sample. Poorer contraceptive behavior was associated with noncompliance with the initial birth control method used (33.8%), lower coital frequency (8.3%), older postmenarchial age (5.7%), failure to use birth control at first coitus (4.6%), fewer years dating (4.0%), lower frequency of church attendance (3.3%), and never having experienced a pregnancy scare (2.0%). These findings suggest that the contraceptive behavior of Hispanic female adolescents is a dynamic process that can be understood in the context of previous sexual and contraceptive behavior.

Incentives and their influence on appointment compliance in a teenage family-planning clinic

The purpose of this study was to ascertain whether or not the family-planning compliance patterns of indigent adolescents could be influenced by various types of incentives. From February 1988 through January 1989, 534 postpartum inner city teenagers, aged 12-19, who delivered at a large city-county public hospital, participated. Teens were randomly assigned to two treatment groups that either offered a coupon for milk for the infant or a gift for the teenage mother if they returned for their postpartum visit 4-6 weeks after delivery. A third group, which used no incentive for appointment keeping, acted as a control. Although overall compliance was low, a significant relationship was found between type of program incentive and compliance outcome. The program using milk coupons as an incentive had the best compliance rate. This incentive appeared to be most effective with black adolescents. Such incentive programs, although not without controversy, offer a potential way to enhance postpartum contraceptive appointment-keeping compliance in a high-risk population.

Contraceptive and sexual behavior of black female adolescents. A test of a social-psychological theoretical model

To test a previous theoretical model, we studied the relationships between social, attitude, and psychological factors and adolescent contraceptive behavior over a 6-month period. A pretested questionnaire was administered to a random sample of 115 black females aged 12 to 18 years from a low socioeconomic population. Six months after the initial interview 113 of the subjects were administered a second questionnaire assessing their sexual and contraceptive behavior. Based on regression analysis, previous pregnancy and coital frequency explained 12.7% (p less than or equal to 0.0001) of the variation in engaging in unprotected coitus. When controlling for sexual activity, birth control knowledge and previous broken appointments explained an additional 5.5% of variation in the regression model (total R2 = 0.185). Coital frequency of the subjects was positively associated with Tanner stage, length of the relationship, effectiveness of previous contraceptive method(s), and degree of birth control knowledge. Coital frequency was inversely associated with a negative attitude toward pregnancy and negative parental attitudes toward adolescent pregnancy. The perceived risk of pregnancy was positively correlated with coital frequency and previous pregnancy. These findings support our model, but suggest that among low socioeconomic black female adolescents the interpretation of several model components depends on the subjects' attitude toward pregnancy and her perception of her parent's attitude toward adolescent pregnancy.

Adolescent contraceptive behavior: an assessment of decision processes

The utility of a rational model of contraceptive use in adolescents was evaluated in a cohort of 325 sexually active adolescents aged 14 to 19 years. Adolescents were interviewed regarding their beliefs about the consequences of using each of four methods of contraception, evaluation of those consequences, perception of the wishes of others regarding use of each method, motivation to comply with those wishes, general attitude toward using the method, view of general social expectations regarding their use of the method, and their intention to use the method during the next year. They were reinterviewed 1 year later to determine actual use. The results support the utility of this model for understanding adolescent behavior. Significant associations were found between intentions to use contraceptive methods and their actual use. Intentions were significantly related to adolescents' attitudes toward using the methods and their perception of social expectations regarding use. General attitudes were significantly related to a summary score reflecting the adolescents' beliefs about specific consequences of use weighted by their evaluations of them. General social perceptions were significantly related to a summary score of perceived desires of specific individuals multiplied by the adolescent's desire to comply with those desires. These findings indicate that physicians can be more effective in clinical practice by querying adolescents about their beliefs and intentions and about their perceptions of significant individuals in their lives.

Risk of contraceptive discontinuation among adolescents

This prospective study assesses a sample of adolescent oral contraceptive users for correlates of continued use of birth control. Data were collected by interview at both an initial family planning clinic visit and 3 months later. Half of the sample did not return to the clinic for follow-up. Among those contacted by phone, all had discontinued the use of a contraceptive, and 69% were at risk for an unintended pregnancy. Least likely to continue to use the pill were adolescents who perceived substantial health-related problems associated with oral contraceptive use, felt their own risk of pregnancy was less than that of other teenagers, and had poor problem-solving skills. Among the most common problems experienced were the side effects associated with oral contraceptive use and difficulty remembering to take a pill every day. Suggested interventions aimed at supporting continued and effective use of birth control are provided.

Female adolescents' compliance with contraceptive regimens

Although today's adolescents have access to a variety of contraceptive options, they remain inconsistent and suboptimal users of these methods. A particularly frustrating problem for those caring for adolescents is the issue of noncompliance with contraceptives, which is an important antecedent of adolescent pregnancy. In the future, new fertility-related developments such as subdermal hormonal implants may reduce the likelihood of noncompliance. For the present, however, systematic monitoring rather than only when noncompliance is suspected is essential in enhancing adolescents' contraceptive compliance.

Sexual behavior and contraceptive risk taking among sexually active adolescent females

Drawing on DeLamater's conceptual model of premarital contraceptive activity, this study assessed the relationships between various social, developmental, and behavioral variables and contraceptive risk taking by sexually active adolescent females. The hypotheses were tested on a national random sample of unmarried sexually active adolescent females (n = 1512) ages 15-20 years from Cycle III of the National Survey of Family Growth. The number of years the subjects had been sexually active was the strongest predictor of their frequency of sexual intercourse, followed by their frequency of attendance at religious services. The inverse relationship between religious attendance and coital frequency was much stronger among whites than blacks. When the influence of these variables on contraceptive risk taking was assessed, coital frequency explained 7.2% of the variation in contraceptive risk taking, with the number of years the adolescent had been dating explaining a small amount of additional variation. Our data support not only the first stage of DeLamater's conceptual model of premarital contraceptive activity, but also aspects of Jessor's more general theory of adolescent risk taking and problem behavior.

Analysis of contraceptive behavior of sexually active female adolescents in the United States

Drawing on a theoretical model of adolescent contraceptive behavior, we examined the relationships between various social and behavioral variables and contraceptive use by sexually active female adolescents. Hypotheses were tested with the use of a national random sample of sexually active female adolescents (n = 1426), aged 15 to 20 years, from Cycle III of the National Survey of Family Growth. The data were analyzed with Pearson correlation coefficients and multiple regression analysis. Noncompliance with the initial birth control method was the strongest predictor of the adolescents' contraceptive behavior at the time of the interview. Not acquiring birth control at the initial family planning visit and the frequency of family planning visits during the previous 12 months were the second and third best predictors of subjects' contraceptive use. Coital frequency and the length of time between first coitus and the initiation of birth control each explained a small amount of additional variation in the regression model. When combined, these five variables explained 40% of the variation in the contraceptive behavior of this representative sample of sexually active female adolescents. The findings could be useful for clinicians in providing more effective birth control counseling to adolescent patients.

Use and misuse of oral contraceptives by adolescents attending a free-standing clinic

A total of 216 adolescents attending a free-standing clinic completed a questionnaire on oral contraceptive use. Over 80% knew the brand name of their pill and took it correctly from cycle to cycle. About a third had missed at least one pill in the previous three months. Those who took their pills irregularly were more likely to miss them. In the event of missing a pill only 25% would use additional contraceptive measures such as condoms. Over half thought that not menstruating was harmful. The pill-taking pattern in this group of adolescents does not appear to differ significantly from that in adults. Oral contraceptive packs containing 28 tablets (including placebos) appear to produce fewer cycle-to-cycle problems than packs containing 21 active tablets.

Comparative analysis of the effectiveness of the diaphragm and birth control pill during the first year of use among suburban adolescents

Little attention has been paid to the diaphragm as a contraceptive option for adolescents. To compare diaphragm and birth control pill use by adolescents, 124 females (aged 13-20 years) in a suburban-based adolescent health service were interviewed at least one year after receiving a contraceptive prescription. The 73 diaphragm choosers did not differ from the 51 pill choosers in age, race, or reason for their original visit to the health service. Diaphragm choosers, however, were better students, of higher socioeconomic status, and had had fewer prior pregnancies. In the year following prescription, continuous use for 12 months was reported by 43% of diaphragm choosers and 45% of pill choosers, with significantly more pill (26%) than diaphragm (8%) choosers reporting discontinued use for at least one month while remaining sexually active. Regular use (diaphragm every intercourse, missing less than or equal to 1 pill/month) was reported by 36% of diaphragm choosers compared to 88% of pill choosers; and at least one pregnancy during the year was reported by 15% of diaphragm choosers and 18% of pill choosers. At follow-up interviews, diaphragm subjects disliked the immediate annoyances of the diaphragm, and pill users expressed concern about the potential side effects of the pill. No single factor or set of factors correlated with continuous and regular use of either method. Because both methods present specific problems for certain patients, we suggest that in addition to the pill, the diaphragm should receive serious consideration as a contraceptive option for adolescents.

Follow-up of adolescents previously studied for contraceptive compliance

Identification of adolescents at risk for contraception noncompliance and consequent pregnancy presents an important challenge to physicians caring for this age group. The present study examines the relationship between psychosocial information found in earlier studies to predict short-term contraceptive compliance to compliance one to three years later. Of the 31 patients located, 45% had become pregnant, of whom more than half had undergone therapeutic abortions. Three subscales of the Piers-Harris Self-Concept Scale had been significantly lower at baseline in the group that subsequently became pregnant. Those who chose to abort their pregnancies had higher baseline self-image. Low baseline scores on self-image and reproductive knowledge differentiated the group that became pregnant and kept their babies from those who had not become pregnant. There was excellent concordance between contraceptive compliance four months after prescription and compliance one to three years later. Accordingly, adolescent females who are using prescribed contraception at six months are likely to continue to do so subsequently. This suggests that follow-up should be frequent during this six-month period to maximize the likelihood of compliance.

Promoting adolescents' compliance with therapeutic regimens

Noncompliance in the adolescent is a difficult problem that can be prevented or improved. It is best identified early by nonjudgmental questioning about current or previous regimen behavior. An appreciation of the relevant psychological and social issues can suggest to the clinician which adolescents are at high risk for noncompliance. Intervention techniques based on educational and psychological principles can be successfully applied by the physician to improve compliance and can improve the teenager's sense of mastery. Personal characteristics of the physician, however, may determine whether he or she can work productively with the noncompliant adolescent.

What is the relationship between postpartum withdrawal from school and repeat pregnancy among adolescent mothers?

An association between the failure of teenage mothers to return to school postpartum and rapid repeat pregnancy (recidivism) has been described. We report the postpartum education pursuits and contraceptive practices of 29 teenage mothers. Our data, together with the literature, suggest that with close postpartum follow-up, young mothers who are not motivated to return to school following delivery can effectively postpone pregnancy.

Compliance with anticonvulsant therapy by epileptic youth. Relationships to psychosocial aspects of adolescent development

Independence in daily life, family harmony as perceived by youths and their parents, and self-esteem were investigated in relation to anticonvulsant medication compliance in 25 epileptics aged 9-17 years. Medication compliance was assessed by monthly home saliva sampling for phenobarbital concentrations. Psychosocial issues were assessed by standardized instruments. Each psychosocial issue was highly correlated with compliance. Partial correlation analysis reveals that these findings are not explained by the subject's demographic or clinical characteristics. Medication noncompliance appears to be associated with a restriction of independence in daily life, lack of harmony in family relations, and low self-esteem in teenage epileptics. Clinicians should observe for these conditions and initiate patient and family counseling in order to maximize medication compliance and seizure control.

Birth control use by teenagers. One and two years postabortion

A prospective study was undertaken of the contraceptive behavior of adolescent women following a first-trimester abortion. Each women had an individual counseling session, including birth-control counseling. Effective birth control was used by 77% of the 182 respondents one year postabortion. Two years after abortion, 79% of those who remained in the study group continued to use reliable birth control methods. The repeat abortion rate for all respondents was 7% in the first year and 11% in the second year. These results suggest that teenagers who obtain abortions do not rely on the procedure as a method of contraception. Instead, they are more likely to be using reliable methods of birth control postabortion than they were before the unplanned pregnancy.

Satisfaction with health care. A predictor of adolescents' appointment keeping

Adolescents are assuming greater responsibility for their own health care, yet have a high rate of broken appointments. The importance of satisfaction with their health care in determining appointment compliance has been demonstrated for adult patients. The purpose of the present study was to explore patient satisfaction among teenagers and its relationship to appointment keeping. A short, reliable instrument was developed to assess adolescent patients' satisfaction with their clinic care. The patient's satisfaction was highly correlated with subsequent compliance in coming for appointments. Satisfaction, hence, appointment keeping, was higher in females, older adolescents, those making their own initial clinic appointment, those with a positive body image, and those scoring high on a test of personal freedom.

Influence of psychosocial factors on adolescent compliance with oral contraceptives

This paper prospectively tests the influence of a variety of sociomedical and psychosocial factors on compliance with oral contraceptives among adolescent females from a population at high risk for pregnancy. Fifty-six females aged 14-19 yr from a lower socioeconomic background received a battery of pretest measurements and were then given Ortho-Novum 1/35 combined with riboflavin during an initial visit and 1-, 2-, and 4-month follow-ups. Compliance was measured at each follow-up using a Guttman scale consisting of: (1) avoidance of pregnancy, (2) appointment adherence, (3) pill count, and (4) urinary fluorescence for riboflavin. Six factors were found to be significantly associated with noncompliance: (1) multiple sexual partners, (2) appointment being made by the adolescent, (3) low evaluation of personal health, (4) feelings of hopelessness, (5) worry about becoming pregnant, and (6) previous abortion. These findings suggest that certain indicators of sexual activity and social psychological status may help predict noncompliance in some adolescent females.

Lowering broken appointment rates at a teenage health center

In an attempt to increase physician efficiency by lowering the "no show" rate of adolescents in a teenage health center, the possible variables related to broken appointments were explored. A new triage system was implemented. While most of the variables studied did not differ between the "show" and "no show" adolescents, there were significant differences based on the chief complaint. Those teenagers seen for well adolescent care had a 55% "no show" rate, those with noncosmetic problems had a 37% "no show" rate, and those with cosmetic complaints had a zero "no show" rate. With the implementation of a new triage system which required parent/adolescent involvement, the "no show" rate fell by 50%, thus dramatically decreasing the waiting time for initial appointment and improving the utilization of physician and nurse time.

Appointment-keeping behavior in adolescents

Adolescent appointment-keeping behavior was investigated prospectively in 245 first-scheduled appointments in a general youth clinic within a pediatric ambulatory setting, to determine if older adolescents were more compliant when they made their appointments and less compliant when their appointments were made by their parents. Among single variables (age, sex, and who made the appointment), rates of kept appointments varied considerably. The highest rates of compliance were found in males, under the age of 15, whose parents made the appointment. The lowest rates were found in females, over the age of 15, who made their own appointment. A multiple regression analysis was used to determine which of the variables was most important in predicting compliance. The most important factor was appointment source. Whether parents make the appointment for their sons and daughters (irrespective of age) was the most important predictor of compliance, emphasizing the importance of parental involvement in scheduling appointments.

The amount of sex information learning obtained during early adolescence

This study reports the findings of a survey on sources of sex information among 1152 students. They were asked to identify their initial sources of information on twelve sexual concepts. In addition, they indicated the age when they first learned these concepts and wrote a definition for each of the twelve terms. Results indicate that 99 percent of initial sex infor-mation is learned in the early adolescent years or earlier. Females tended to learn from more reliable sources than males although both learned more from peers than any other source. The overall accuracy in under-standing sexual concepts was high which is interpreted within this study as a positive indicator of early adolescents learning about sex.