Where do women and men in Britain obtain contraception? Findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)

Understanding barriers to using long-acting reversible contraceptives (LARCs) in primary care: a qualitative evidence synthesis

BACKGROUND

Long-acting reversible contraceptives (LARCs) are highly effective. In primary care, LARCs are prescribed less frequently than user-dependent contraceptives despite higher efficacy rates. Unplanned pregnancies are rising in the UK, and LARCs may have a role in reducing these through and redressing inequitable contraceptive access. To provide contraceptive services that offer maximal choice and patient benefit, we must understand what contraception users and healthcare professionals (HCPs) think about LARCs and uncover barriers to their use.

METHODS

A systematic search using CINAHL, MEDLINE via Ovid, PsycINFO, Web of Science and EMBASE identified research about LARC use for pregnancy prevention in primary care. The approach adhered to the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' methodology, critically appraised the literature, and used NVivo software to organise data and perform thematic analysis to determine key themes.

RESULTS

Sixteen studies met our inclusion criteria. Three themes were identified: (1) trustworthiness (where and from whom participants obtained information regarding LARCs), (2) control (whether LARCs detract from personal autonomy) and (3) systems (how HCPs influenced LARC access). Misgivings about LARCs frequently arose from social networks and fears of surrendering control over fertility were prominent. HCPs perceived access issues and lack of familiarity or training as the main barriers to prescribing LARCs.

CONCLUSIONS

Primary care plays a key role in improving access to LARC but barriers need to be addressed especially those involving misconception and misinformation. Access to LARC removal services are key to empower choice and prevent coercion. Facilitating trust within patient-centred contraceptive consult is essential.

Barriers and facilitators to HIV Pre-Exposure Prophylaxis (PrEP) in Specialist Sexual Health Services in the United Kingdom: A systematic review using the PrEP Care Continuum

OBJECTIVES

HIV pre-exposure prophylaxis (PrEP) delivery in the UK is inequitable; over 95% of PrEP users were men who have sex with men (MSM) despite making up less than 50% of new HIV diagnoses. We conducted a systematic review to identify modifiable barriers and facilitators to PrEP delivery in the UK among underserved populations.

METHODS

We searched bibliographic/conference databases using the terms HIV, PrEP, barriers, facilitators, underserved populations, and UK. Modifiable factors were mapped along the PrEP Care Continuum (PCC) to identify targets for interventions.

RESULTS

In total, 44 studies were eligible: 29 quantitative, 12 qualitative and three mixed-methods studies. Over half (n = 24 [54.5%]) exclusively recruited MSM, whereas 11 were in mixed populations (all included MSM as a sub-population) and the other nine were in other underserved populations (gender and ethnicity minorities, women, and people who inject drugs). Of the 15 modifiable factors identified, two-thirds were at the PrEP contemplation and PrEParation steps of the PCC. The most reported barriers were lack of PrEP awareness (n = 16), knowledge (n = 19), willingness (n = 16), and access to a PrEP provider (n = 16), whereas the more reported facilitators were prior HIV testing (n = 8), agency and self-care (n = 8). All but three identified factors were at the patient rather than provider or structural level.

CONCLUSIONS

This review highlights that the bulk of the scientific literature focuses on MSM and on patient-level factors. Future research needs to ensure underserved populations are included and prioritized (e.g. ethnicity and gender minorities, people who inject drugs) and provider and structural factors are investigated.

Patterns of use of emergency and oral contraceptives from an online service in the United Kingdom during the COVID-19 pandemic: A quantitative study of routinely collected data

OBJECTIVES

Our study aimed to describe users of a free online contraception service, compare online emergency contraceptive pill (ECP) users with online oral contraceptive (OC) users, and describe patterns of use of online ECP and OC over time, including transition from ECP to more effective forms of contraception.

STUDY DESIGN

Analysis of routinely collected, anonymized data from a large, publicly funded, online contraceptive service in the United Kingdom from April 1, 2019 to October 31, 2021.

RESULTS

The online service provided 77,447 prescriptions during the study period. About 84% for OC and 16% for ECP, of which 89% were ulipristal acetate. ECP users were younger, lived in more deprived areas, and were less likely to be of white ethnicity than OC users. About 53% ordered OC only, but 37% ordered both ECP and OC. Among those prescribed both OC and ECP (n = 1306), 40% had one method as dominant, 25% appeared to move from one method to the other (11% ECP to OC, 14% OC to ECP), and 35% continued to use both methods.

CONCLUSIONS

Online services are accessible to diverse young populations. While the majority of users order OC only, our study suggests that where there is free, online access to both OC and ECP, and those ordering ECP are always offered free OC, transition to more effective ongoing forms of contraception is uncommon. Further research is needed to understand whether online access to ECP increases its attractiveness and reduces likelihood of transition to OC.

IMPLICATIONS

This study demonstrates that free, online contraceptive services are accessible to ethnically and socioeconomically diverse users. It identifies a subgroup of contraceptive users who combine use of OC and ECPs over time, and suggests that improved access to ECP may alter contraceptive choices.

Profiles of copper intrauterine devices and levonorgestrel intrauterine systems users in France in 2019: A national observational population-based study

OBJECTIVE

To assess the user profiles of copper intrauterine devices (Cu-IUD) and levonorgestrel intrauterine systems (LNG-IUS) in France in 2019 and the rates of continuation 1 year later.

METHODS

A population-based study was conducted of all French women aged 13-49 years for whom an IUD was dispensed in 2019. Information was collected from the French National Health Data System about their characteristics at the time of dispensation and indicators of continued use 1 year later. Associations between these characteristics and the type of IUD were analyzed using multivariate regressions.

RESULTS

A total of 477 705 Cu-IUDs and 355 242 LNG-IUSs (mean age 32.5 ± 7.3 and 36.4 ± 7.7 years, respectively) were dispensed in 2019. After adjustment, having a LNG-IUS rather than a Cu-IUD was associated with being aged 35-44 years compared to 25-35 years (odds ratio [OR_35-44 ] 2.03, 95% confidence interval [CI] 2.01-2.05), having a prescription by a gynecologist rather than a general practitioner (OR_35-44 1.09, 95% CI 1.08-1.11), and having a gynecological history (OR_35-44 2.28, 95% CI 2.20-2.36). The continuation rates 1 year after dispensation were 86.4% for Cu-IUD versus 85.7% for LNG-IUS. A Cu-IUD dispensation rather than a LNG-IUS one was associated with a higher chance of continued use 1 year later.

CONCLUSION

Two different patterns of use of Cu-IUDs and LNG-IUSs in France are highlighted.

Factors affecting contraceptive choice in women over 40: a qualitative study

OBJECTIVE

To explore the views of women over 40 years in choosing and using contraception, and to inform how contraceptive counselling for this age group could be improved.

DESIGN, SETTING AND PARTICIPANTS

Fourteen women aged 40-52 years were recruited through social media platforms to take part in online, semistructured, in-depth interviews. Transcripts were analysed using a qualitative thematic approach.

RESULTS

(1) Participants were anxious about unplanned pregnancy, and still highly motivated to avoid this. (2) Changes of contraceptive method over the lifecourse were occasionally precipitated by emergent health conditions, but healthcare providers often recommended a change in method on the basis of age alone. (3) Participants were experiencing perimenopausal symptoms but were largely unaware of how hormonal contraception could be used to treat these symptoms. (4) Prior negative experiences with contraceptive methods, coercive experiences with healthcare providers, and traumatic life events all contributed to a narrowing of contraceptive preference in later life.

CONCLUSION

Women over 40 years may be highly motivated to avoid pregnancy. This age group may have complex contraceptive histories with emerging perimenopausal symptoms. Women over 40 years may have accumulated adverse experiences which impact their contraceptive choices. These factors need to be explored by clinicians, to facilitate shared decision-making.

Ethnic inequalities in mental and physical multimorbidity in women of reproductive age: a data linkage cohort study

OBJECTIVES

Explore inequalities in risk factors, mental and physical health morbidity in non-pregnant women of reproductive age in contact with mental health services and how these vary per ethnicity.

DESIGN

Retrospective cohort study.

SETTING

Data from Lambeth DataNet, anonymised primary care records of this ethnically diverse London borough, linked to anonymised electronic mental health records ('CRIS secondary care database').

PARTICIPANTS

Women aged 15-40 years with an episode of secondary mental health care between January 2008 and December 2018 and no antenatal or postnatal Read codes (n=3817) and a 4:1 age-matched comparison cohort (n=14 532).

MAIN OUTCOME MEASURES

Preconception risk factors including low/high body mass index, smoking, alcohol, substance misuse, micronutrient deficiencies and physical diagnoses.

RESULTS

Women in contact with mental health services (whether with or without severe mental illness (SMI)) had a higher prevalence of all risk factors and physical health diagnoses studied. Women from minority ethnic groups were less likely to be diagnosed with depression in primary care compared with white British women (adjusted OR 0.66 (0.55-0.79) p<0.001), and black women were more likely to have a SMI (adjusted OR 2.79 (2.13-3.64) p<0.001). Black and Asian women were less likely to smoke or misuse substances and more likely to be vitamin D deficient. Black women were significantly more likely to be overweight (adjusted OR 3.47 (3.00-4.01) p<0.001), be diagnosed with hypertension (adjusted OR 3.95 (2.67-5.85) p<0.00) and have two or more physical health conditions (adj OR 1.94 (1.41-2.68) p<0.001) than white British women.

CONCLUSIONS

Our results challenge the perspective that regular monitoring of physical health in primary care should be exclusively encouraged in people with a l diagnosis. The striking differences in multimorbidity for women in contact with mental health services and those of ethnic minority groups emphasise a need of integrative models of care.

Experiences of access and use of contraceptive care during COVID-19 lockdown in the UK: a web-based survey

BACKGROUND

The first wave of lockdown measures to control the covid-19 pandemic in the United Kingdom (UK) resulted in suspension of "non-essential" services including contraception.

AIM

To examine women's perceptions and experiences of contraceptive care in the UK during the first lockdown.

DESIGN & SETTING

Cross-sectional survey during lockdown period from March to June 2020.

METHOD

We designed an online questionnaire asking women aged 16-54 their experiences of contraceptive care during lockdown. Questions were based on Maxwell's evaluation framework on access, acceptability, relevance, and equity. It was promoted on social media from 27^th May to ninth June 2020. We conducted descriptive analysis of quantitative data and thematic analysis of free text data.

RESULTS

214 responses were analysed. General practice was the source of contraception for 43% and 52% of respondents before and during the lockdown respectively. 55% (118/214) of respondents including regular and new users were uncertain where or how to get contraception during the pandemic. Respondents reported reduced access to contraception during lockdown, some thought sexual health clinics and general practices were closed.Remote consultations and electronic prescriptions facilitated contraceptive access for some respondents. Long-acting reversible contraception (LARC) was unavailable in some areas due to restrictions, alternatives were not acceptable to those who used methods for non-contraceptive benefits to treat medical conditions e.g., menorrhagia.

CONCLUSIONS

Our study highlighted the need for better information and signposting for contraception during lockdown. Contraception including LARC should be reframed as an essential service with robust signposting for pandemic planning and beyond.

Contraception in Person-Contraception Online (CiP-CO) cohort study

BACKGROUND

Online contraception services increasingly provide information, clinical assessment and home-delivered oral contraceptives (OCs). Evidence is lacking on the effects of online contraceptive service use on short-term contraceptive continuation.

METHODS

Cohort study comparing contraceptive continuation between new users of a free-to-access online OC service in South East London with those from other, face-to-face services in the same area. Online questionnaires collected data on participants' sociodemographic characteristics, motivations for OC access, service ratings, OC knowledge and contraceptive use. Contraceptive use in the 4-month study period was measured using health service records. Unadjusted and multivariable logistic regression models compared outcomes between the online service group and those using other services.

RESULTS

Online service-users (n=138) were more likely to experience short-term continuation of OCs compared with participants using other services (n=98) after adjusting for sociodemographic and other characteristics (adjusted OR 2.94, 95% CI 1.52 to 5.70). Online service-users rated their service more highly (mean 25.22, SD 3.77) than the other services group (mean 22.70, SD 4.35; p<0.001), valuing convenience and speed of access. Among progestogen-only pill users, knowledge scores were higher for the online group (mean 4.83, SD 1.90) than the other services group (mean 3.87, SD 1.73; p=0.007). Among combined oral contraceptive users, knowledge scores were similar between groups.

CONCLUSIONS

Free-to-access, online contraception has the potential to improve short-term continuation of OCs. Further research using a larger study population and analysis of longer-term outcomes are required to understand the impact of online services on unintended pregnancy.

Complex contraception provision during the COVID-19 pandemic, how did sexual health services fare?

Background

This study evaluated whether sexual health services (SHS) across the UK could meet the Faculty of Sexual and Reproductive Health (FSRH) standard for access by being able to offer an appointment for a long-acting reversible contraception (LARC) fitting within 2 weeks of initial contact.

Methods

SHSs offering LARCs were identified using the British Association for Sexual Health and HIV (BASHH) clinic database. During October 2020, all clinics open for more than 1 day a week were contacted by telephone. The researcher posed as a 20-year-old woman in a regular heterosexual relationship who was using condoms and requesting a contraceptive implant. Data collected included the time to wait to appointment and whether clinics offered bridging methods of contraception during any delay in appointment. It was also noted whether a local COVID-19 restriction was in place at the time of the call. The information collected was coded, and data was analysed using chi-square tests in SPSSv27.

Results

Of the 218 contactable clinics, 51.4% (n = 112) of clinics offered the patient an appointment within two weeks, and 66.1% (n = 144) of clinics could offer appointments within four weeks. 7.3% (n = 16) of clinics offered the patient adjunct bridging oral contraception until the time of appointment. Comparing the devolved nations, 11/17 (64.7%) clinics in Scotland, 8/13 (61.5%) clinics in Wales, 0/4 (0.0%) clinics in Northern Ireland and 93/182 (51.1%) clinics in England offered an appointment within two weeks with significant regional variation across England (p = .005). No statistically significant difference was demonstrated in access between clinics with or without high-level COVID-19 restrictions (p = .056).

Conclusion

The 2-week standard was met in just over half of the occasions, with significant variation across regions across the UK. The development of a national target for access may improve access to LARCs.

Awareness of the link between human papillomavirus and oral cancer in UK university students

Awareness of the link between human papillomavirus (HPV) and oral cancer varies across populations. Levels of awareness and factors may impact HPV vaccine uptake in women and the intent to obtain the vaccine in men if it becomes available. A cross-sectional survey of 1415 UK university students (495 men and 920 women) aged 18-25 years was conducted. Women who had and had not received the HPV vaccine were included. Vaccination was not available for men at the time of the survey. Seventy percent of participants had heard of oral cancer but only 25% were aware of the link between HPV and oral cancer. Women who ever engaged in sexual activity (adjusted odds ratio, aOR = 1.74; 95% CI: 1.12-2.72) or had at least one dose of the HPV vaccine (aOR = 1.71; 95% CI: 1.24-2.37) were more likely to be aware. Men who intend to receive the HPV vaccine in the future were more likely to be aware (aOR = 1.62; 95% CI: 1.04-2.53). Non-white women were less likely to be vaccinated (aOR = 0.56; 95% CI: 0.41-0.77). However, being aware was associated with HPV vaccine uptake in women (aOR = 1.65; 95% CI: 1.19-2.28) and borderline associated with the intent to obtain the HPV vaccine in men (aOR = 1.52; 95% CI: 0.99-2.35). Non-heterosexual men were more willing than heterosexuals to receive the vaccine. Following the UK gender-neutral HPV vaccination programme, there is an opportunity to increase awareness about the link between HPV and oral cancers aside from the cervical cancer link to influence HPV vaccine uptake.

Uptake and User Characteristics for Pharmacy-Based Contraception and Chlamydia Treatment: A Quantitative Retrospective Study from the UK

The health provider Umbrella delivers several SRHS through more than 120 pharmacies in Birmingham (England). Umbrella pharmacy data collected between August 2015 and August 2018 were used to descriptively analyse the uptake and user characteristics for emergency contraception, short-acting oral contraception, condoms and chlamydia treatment. In total, 54,309 pharmacy visits were analysed. A total of 30,473 females presented for emergency contraception. Most were supplied with an emergency contraceptive pill (98.6%, 30,052 out of 30,473), which was levonorgestrel in 57.4% of cases (17,255 out of 30,052). Of those females who attended for short-acting oral contraception, 54.3% (1764 out of 3247) were provided with the progesterone-only pill. Of those who were given chlamydia treatment, the majority received doxycycline (76.8%, 454 out of 591). A total of 74% (14,888 out of 19,998) of those who requested condoms were not provided with specific instructions on their use. Pharmacies have the potential to make a substantial contribution to the delivery of an integrated sexual health service including rapid access to emergency contraception, convenient delivery of short-acting hormonal contraception and treatment of chlamydia. Appropriate education, support and audit is required to ensure the delivery of high-quality care.

Modern contraceptive use among unmarried girls aged 15-19 years in South Western Nigeria: results from a cross-sectional baseline survey for the Adolescent 360 (A360) impact evaluation

PURPOSE

Adolescents 360 (A360) is an initiative being rolled out across Nigeria with the aim of increasing voluntary modern contraception use among women aged 15 to 19 years. Using evaluation study baseline data, we identified sexuality, fertility and contraceptive use characteristics of young unmarried girls in South Western Nigeria.

METHODS

A cross-sectional baseline survey of unmarried girls aged 15 to 19 years was conducted in Ogun state, Nigeria in August 2017. A clustered sampling design was used. We identified determinants of modern contraceptive use in this subpopulation using logistic regression.

RESULTS

Of 12,024 women interviewed, 15.3% reported sexual intercourse in the past year. The majority of respondents (79.6%, 9525/11,967) had heard of contraception. 45.3% of sexually active respondents were using a modern contraceptive method. Of those using any method of contraception, male condoms (50.3%) were the most widely used modern method followed by the emergency contraceptive pill (16.7%). Following adjustment for socio-demographic characteristics, there was evidence that the use of modern contraception was positively associated with having never given birth, living in an urban area, current enrolment in education, high level of education, high socioeconomic status, exposure to information about contraception, perceived social support for contraception, and self-efficacy for contraception.

CONCLUSIONS

In South Western Nigeria, unmarried sexually active adolescent girls have relatively low levels of modern contraceptive use. Programmes should aim to increase access to modern contraception and to increase social support and acceptability of contraceptive use.

An interactive website to aid young women's choice of contraception: feasibility and efficacy RCT

BACKGROUND

Effective use of contraception can reduce numbers of unintended pregnancies, but misunderstandings and concerns about contraception abound. Increasingly, women seek health-care information online.

OBJECTIVES

To develop an interactive website to aid informed choice of contraceptive method, including long-acting reversible contraception (Phase I), and test its effectiveness in a parallel, single-blind randomised trial (Phase II). Approval came from London - Camden & King's Cross Research Ethics Committee (reference 17/LO/0112).

SETTING AND PARTICIPANTS

For both phases, women aged 15-30 years were recruited from general practice, sexual health services, maternity services, community pharmacies and an abortion service.

DESIGN

In Phase I, we conducted three systematic literature reviews, a review of YouTube (YouTube, LLC, San Bruno, CA, USA) videos about contraception, and focus groups and interviews with young women to explore barriers to and concerns and misperceptions about contraception. We then iteratively co-designed an interactive website, Contraception Choices [URL: www.contraceptionchoices.org (accessed June 2020)], with young women and a software company. In Phase II, we evaluated the website through a randomised trial that began as a feasibility trial. Early demand for Contraception Choices stimulated a design change from a feasibility to an efficacy trial, with follow-up for clinical outcomes at 3 and 6 months. A randomisation list was incorporated into the trial software program to allocate participants to the intervention (website) or control group (standard care).

INTERVENTION

Contraception Choices is a co-designed, evidence-based, interactive website to aid informed choice of contraception. It provides information about different methods, addresses common concerns and offers tailored contraceptive options in response to individual preferences.

MAIN OUTCOME MEASURES

Qualitative - participant views and experience of the intervention, assessed through qualitative interviews. Quantitative primary outcomes - follow-up rate at 6 months in the initial feasibility trial, using a long-acting reversible contraception method, and satisfaction with contraceptive method at 6 months in the efficacy trial.

RESULTS

A total of 927 women were randomised online to the website (n = 464) or control group (n = 463), of whom 739 (80%) provided follow-up data at 6 months [786 women (85%) provided data at 3 and/or 6 months that were included in the analysis of primary outcomes]. There was little difference between groups in the proportion using long-acting reversible contraception at 6 months [30.4% intervention vs. 31.0% control, adjusted odds ratio after imputation 0.87 (95% confidence interval 0.60 to 1.27)] or in satisfaction with contraceptive method [proportion being 'satisfied' or 'very satisfied', 82.6% intervention vs. 82.1% control, adjusted odds ratio 0.93 (95% confidence interval 0.69 to 1.25)]. Qualitative evaluation indicated highly positive views about the website and increased knowledge of contraceptive methods that could dispel misperceptions. Women appreciated having information tailored to their specific needs and felt better prepared before consultations.

LIMITATIONS

We did not include intermediate measures, such as knowledge of contraceptive methods, intention to change method or confidence in discussing contraception with a health-care professional, which may have indicated other benefits of using the website. In future, the website should be studied in different settings (e.g. schools and in routine practice) to see whether or not it improves the quality or efficiency of contraceptive consultations.

CONCLUSIONS

Our systematic review indicated wide-ranging influences on women's use of contraception globally. The website, Contraception Choices, was very popular with young women and contraception service providers. It was not associated with statistically significant differences in use of long-acting reversible contraception or satisfaction with contraceptive method at 6 months.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN13247829.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 56. See the NIHR Journals Library website for further project information.

A cohort study of the service-users of online contraception

BACKGROUND

In January 2017, the first free service providing oral contraceptive pills (OCPs) ordered online and posted home became available in the London boroughs of Lambeth and Southwark - ethnically and socioeconomically diverse areas with high rates of unplanned pregnancy. There are concerns that online services can increase health inequalities; therefore, we aimed to describe service-users according to age, ethnicity and Index of Multiple Deprivation (IMD) quintile of area of residence and to examine the association of these with repeated use.

METHODS

We analysed routinely collected data from January 2017 to April 2018 and described service-users using available sociodemographic factors and information on patterns of use. Logistic regression analysis examined factors associated with repeat ordering of OCPs.

RESULTS

The service was accessed by 726 individuals; most aged between 20 and 29 years (72.5%); self-identified as being of white ethnic group (58.8%); and residents of the first and second most deprived IMD quintiles (79.2%). Compared with those of white ethnic group, those of black ethnic group were significantly less likely to make repeat orders (adjusted OR 0.53, 95% CI 0.31 to 0.89; p=0.001), as were those of Asian and mixed ethnic groups.

CONCLUSIONS

These are the first empirical findings on free, online contraception and suggest that early adopters broadly reflect the population of the local area in terms of ethnic diversity and deprivation as measured by IMD. Ongoing service development should prioritise the identification and removal of barriers which may inhibit repeat use for black and minority ethnic groups.

Changes in the prevalence and profile of users of contraception in Britain 2000-2010: evidence from two National Surveys of Sexual Attitudes and Lifestyles

AIM

To describe prevalence and trends in contraceptive method use in Britain through a comparison of the second and third National Surveys of Sexual Attitudes and Lifestyles (Natsal-2 and Natsal-3).

METHODS

Cross-sectional probability sample surveys. General population sample of women aged 16-44 years, resident in Britain, with ever-experience of vaginal sex and, for analysis by sociodemographic characteristics, vaginal sex in the last year. Main outcome measure was current contraceptive method use ('usual these days'), categorised by effectiveness.

RESULTS

Prevalence of current contraceptive use among women who had ever had vaginal sex declined between Natsal-2 and Natsal-3, 83.5% (95% CI 82.4 to 84.5) and 76.4% (95% CI 75.0 to 77.7), respectively. The condom and oral contraceptive pill remain the most commonly used methods. One in five women reported use of a most effective method. While no difference was found between surveys in use of most effective methods, a decline in sterilisation use was compensated by an increase in long-acting reversible contraceptive (LARC) use. Increased LARC use was particularly evident among under-25s compared with women aged 40-44 years (OR 11.35, 95% CI 3.23 to 39.87) and a decline was observed among those with two or more children relative to those with none (OR 0.21, 95% CI 0.13 to 0.35).

CONCLUSIONS

Strategies to improve access to LARC methods have been particularly successful in increasing uptake among young people in the first decade of the 21st century. Whether this trajectory is maintained given changing sociodemographic characteristics and more recent financial cuts to sexual health service provision will warrant investigation.

An interactive website for informed contraception choice: randomised evaluation of Contraception Choices

OBJECTIVE

Improving use of effective contraception to prevent unintended pregnancy is a global priority, but misperceptions and concerns about contraception are common. Our objective was to evaluate an interactive website to aid informed choice of contraception.

METHODS

The Contraception Choices website is an interactive digital intervention which offers tailored advice to aid contraception decision-making (www.contraceptionchoices.org). In a parallel single-blind trial, we randomised 927 women aged 15-30 years from six clinic settings to access the intervention website (n = 464) or to a waiting-list control group (n = 463). The study was initially a feasibility trial, evolving into an evaluation of efficacy, with two primary outcomes at six months: long-acting reversible contraception (LARC) use, and satisfaction with contraceptive method. Secondary outcomes included self-reported pregnancy and sexually transmitted infection diagnoses. Free-text comments on the 3 and 6 month outcome surveys were analysed thematically.

FINDINGS

There was no significant difference between intervention and control groups in the proportion of women using LARC [30.4% intervention versus 31.0% control; adjusted odds ratio 0.87 (95% confidence interval 0.60 to 1.28)]; satisfaction with contraceptive method [82.6% versus 82.1%; adjusted ordinal odds ratio 0.93 (95% CI 0.69 to 1.25)]; self-reported pregnancy [3.3% versus 4.1%; adjusted odds ratio 0.90 (95% CI 0.45 to 1.79)] nor sexually transmitted infection [5.3% versus 4.7%; adjusted odds ratio 0.72 (95% CI 0.55 to 2.36)]. Highly positive free-text comments from intervention participants indicated that the website facilitates contraception choice and can help women feel better prepared before consultation with healthcare providers.

INTERPRETATION

The Contraception Choices website was popular for its design, trustworthy information and decision aids but it was not associated with significant differences in use of LARC or satisfaction with contraceptive method. An interactive website can aid contraception choice, but interventions that address factors beyond women's control, such as access to services, and partner, family or community influences are needed to complement this approach.

RESEARCH IN CONTEXT

Preventing unintended pregnancy through effective use of contraception is essential for women's health, but choosing between different contraceptive methods can be challenging, and the opportunity for adequate discussion during routine consultations is often constrained.

EVIDENCE BEFORE THIS STUDY

We conducted two systematic literature reviews: 1) Factors influencing contraception choice, uptake and use: a meta-synthesis of systematic reviews; and 2) Effectiveness of interactive digital interventions (IDI) for contraception choice, uptake and use. For the first review we searched PubMed, CDSR, Epistemonikos, DoPHER, DARE, NHS Economic Evaluation Database, Campbell Library, NIHR Health Technology Assessment, and Health Evidence Canada databases for systematic reviews which addressed contraceptive choice, uptake or use, from 2000 to 2017. PROSPERO registration number: CRD42017081521 https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=81521. We synthesised the findings of 18 systematic reviews of mostly moderate or high quality. They highlighted the importance of women's knowledge, beliefs, perceptions of side effects and health risks, as well as relationship status, social network, economic and healthcare factors on contraception choice and use. For the second review, we searched 23 electronic databases, trials registers and reference lists for randomised controlled trials of IDI for contraception, including CENTRAL, MEDLINE, EMBASE, CINAHL, ERIC, ASSIA and PsycINFO, from start date to June 2017. PROSPERO registration number: CRD42017081636. We found only five randomised trials of IDI, all from the USA. Risk of bias prevented synthesis of results. www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=81636.

ADDED VALUE OF THIS STUDY

Women's common concerns about contraception - fear of hormones, weight gain, cancer, infertility, mood changes, breaks from contraception and changes in bleeding patterns - underpinned development of a new interactive website (www.contraceptionchoices.org). Contraception Choices addresses women's concerns through succinct text; Q and A format (Frequently Asked Questions, Did you Know?; videos of women and health professionals); an effectiveness infographic, and an interactive decision aid (What's right for me?).In an online randomised trial with 927 women attending clinics, we found no association of the Contraception Choices intervention with the primary outcomes - satisfaction with contraceptive method and uptake of long-acting reversible methods at 6 months. Nor did we find an association with secondary adverse outcomes - sexually transmitted infections or pregnancy. Comments from women indicated that the website can meet young women's need for information on the benefits and drawbacks of contraception, help them to make informed decisions, and feel better prepared before healthcare consultations. Contraception Choices is now available on the NHS website: www.nhs.uk/conditions/contraception/which-method-suits-me.

IMPLICATIONS OF ALL THE AVAILABLE EVIDENCE

Interactive digital interventions (websites) can aid contraception choice, but other intervention research is needed to address wider influences on unintended pregnancy, including partner views, friends, family, the media, wider society and experiences with healthcare professionals. Future research could examine the impact of the website in different settings, e.g. schools or different countries. We hypothesise that use of the website during contraceptive consultations might improve the efficiency or quality of consultation, for both patients and healthcare providers. Appropriate methodology and time-scale for evaluating digital health interventions remains a key question.

In everybody's interest but no one's assigned responsibility: midwives' thoughts and experiences of preventive work for men's sexual and reproductive health and rights within primary care

Background

Sexual and reproductive health and rights (SRHR) have historically been regarded as a woman’s issue. It is likely that these gender norms also hinder health care providers from perceiving boys and men as health care recipients, especially within the area of SRHR. The aim of this study was to explore midwives’ thoughts and experiences regarding preventive work for men’s sexual and reproductive health and rights in the primary care setting.

Methods

An exploratory qualitative study. Five focus group interviews, including 4–5 participants in each group, were conducted with 22 midwives aged 31–64, who worked with reproductive, perinatal and sexual health within primary care. Data were analysed by latent content analysis.

Results

One overall theme emerged, in everybody’s interest, but no one’s assigned responsibility, and three sub-themes: (i) organisational aspects create obstacles, (ii) mixed views on the midwife’s role and responsibility, and (iii) beliefs about men and women: same, but different.

Conclusions

Midwives believed that preventive work for men’s sexual and reproductive health and rights was in everybody’s interest, but no one’s assigned responsibility. To improve men’s access to sexual and reproductive health care, actions are needed from the state, the health care system and health care providers.

A 5-year evaluation of the emergency contraception enhanced community pharmacy service provided in Wales

BACKGROUND

Access to emergency contraception (EC) has been a core component of attempts to address high teenage pregnancy rates in Wales. A national service was commissioned in 2011, allowing supply of EC free of charge from community pharmacies (CPs). This study investigated 5 years of the EC service, to describe its use and investigate changes in the pattern of use over time.

METHODS

Secondary analyses of data from all National Health Service funded CP EC consultations in Wales between 1 August 2012 and 31 July 2017 (n=181 359). Data comprised standardised clinical and demographic information, in the form of predefined service user responses, submitted for reimbursement by CPs.

RESULTS

Overall service provision remained relatively consistent over the study period, with women aged between 13 and 59 years accessing the service. An association was observed between the time since unprotected sexual intercourse and the day on which the service was accessed (Χ2(18)=16 292.327, p<0.001). Almost half (47.9%) of requests were because no contraception had been used, with a strong and positive association for teenagers and women aged 40+ years. A statistically significant and increasing percentage of consultations were accompanied by further sexual health advice (r=0.7, p<0.01).

CONCLUSIONS

Access to EC through CPs is contributing to reducing teenage conceptions and termination rates. However, action is needed to increase contraception use in all age groups. Reduced availability of CP services on Sundays is a barrier to timely EC access. Findings support an expanded role for community pharmacists in provision of regular contraception.

Pharmacy-based sexual health services: a systematic review of experiences and attitudes of pharmacy users and pharmacy staff

BACKGROUND

Pharmacies are increasingly providing services related to contraception and STIs. Identifying pharmacy staff' and users' experiences and attitudes relating to sexual health services is critical to understand users' needs and examining how pharmacy staff can most effectively contribute to patient-centred care. This systematic review aimed to examine pharmacy staff and pharmacy users' experiences and attitudes towards the delivery of a large range of sexual health services.

METHODS

Seven electronic databases and the reference lists of all included studies were searched in September 2018. Studies giving insight into pharmacy users' and pharmacy staff's experiences and attitudes towards the delivery of services related to contraception and STIs were included. The Mixed Methods Appraisal Tool was used to assess the quality of included studies and a narrative synthesis applied to analyse evidence.

RESULTS

Nineteen studies were included. Eleven studies looked at pharmacy staff, four at users and four at both groups. Users found services accessible and convenient and staff found service provision feasible. However, several barriers to service delivery were identified including lack of privacy for delivering services, lack of trained staff available to provide services and subjective judgements being made on who should be provided or offered a service.

DISCUSSION

Barriers to service delivery need to be addressed to allow pharmacies to deliver their full potential. Future research on pharmacy-based gonorrhoea and syphilis screening, and hepatitis B vaccination is needed.

PROSPERO REGISTRATION NUMBER

CRD42018106807.

Sexual and reproductive healthcare providers' opinions on expansion of pharmacy-led provision of contraception

INTRODUCTION

Reduced funding to contraceptive services in the UK is resulting in restricted access for women. Pharmacists are already embedded in sexual and reproductive health (SRH) care in the UK and could provide an alternative way for women to access contraception. The aim of this study was to determine the views of UK contraception providers about community pharmacist-led contraception provision.

METHODS

An anonymous questionnaire was distributed to healthcare professionals at two UK SRH events, asking respondents about: (1) the use of patient group directions (PGDs) for pharmacist provision of oral contraception (OC); (2) the sale of OC as a pharmacy medicine or general sales list medicine; (3) the perceived impact of pharmacy provision of OC on broader SRH outcomes; and (4) if other contraceptive methods should be provided in pharmacies.

RESULTS

Of 240 questionnaires distributed, 174 (72.5%) were returned. Respondents largely supported pharmacy-led provision of all non-uterine methods of contraception, excluding the contraceptive implant. Provision of the progestogen-only pill by PGD was most strongly supported (78% supported initiation). Respondents felt that the use of bridging (temporary) contraception would improve (103/144, 71.5%), use of effective contraception would increase (81/141, 57.4%), and unintended pregnancies would decline (71/130, 54.6%); but that use of long-acting reversible contraception would decrease (86/143, 60.1%). Perceived barriers included pharmacists' capacity and competency to provide a full contraception consultation, safeguarding concerns, and women having to pay for contraception.

CONCLUSIONS

UK SRH providers were largely supportive of community pharmacy-led provision of contraception, with training and referral pathways being required to support contraception delivery by pharmacists.