A Second Look
Title BYLINE
Long-Acting Reversible Contraception for Adolescents
A Photo © B-C Designs / thinkstockphotos.com
Approximately 50 percent of women in the United States experience an unplanned pregnancy (Finer & Zolna, 2011). Of this group, adolescents and young adults under the age of 25 have the highest rate of unintended pregnancy compared with women of all other reproductive ages (Finer, 2010; Finer & Zolna, 2011). Unintended pregnancy has been associated with a low level of contraceptive knowledge and use, fear of side effects, as well as ambivalence regarding
HOLLY B. FONTENOT HEIDI COLLINS FANTASIA
pregnancy and mistrust of government-supported family planning services (Frost, Lindberg, & Finer, 2012; Zolna & Lindberg, 2012). Currently, the Centers for Disease Control and Prevention (CDC) recommends counseling patients on the use of long-acting reversible contraception (LARC), including intrauterine devices (IUDs) and implants, as a first-line, highly effective
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. DOI: 10.1111/1751-486X.12207 Keywords adolescents | birth control | IUD | long-acting reversible contraception | LARC
http://nwh.awhonn.org
© 2015, AWHONN
253
A Second Look Holly B. Fontenot, PhD, RN, WHNP-BC, is an assistant professor at W. F. Connell School of Nursing at Boston College in Chestnut Hill, MA, and a women’s health nurse practitioner at the Sidney Borum Jr. Health Center in Boston, MA. Heidi Collins Fantasia, PhD, RN, WHNP-BC, is an assistant professor in the College of Health Sciences, School of Nursing at the University of Massachusetts in Lowell, MA, and a women’s health nurse practitioner at Health Quarters in Beverly, MA. Dr. Fontenot reports no conflicts of interest or relevant financial relationships. Dr. Fantasia is a member of the women’s health advisory board for Actavis Pharma, for which she receives financial consideration. Actavis Pharma had no involvement in the creation of this article. Address correspondence to: [email protected].
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option for pregnancy prevention (CDC, 2013, 2014). Use of LARC in adolescents is supported by national organizations (American College of Obstetricians and Gynecologists [ACOG], 2012; CDC, 2013, 2014). LARC refers to contraceptive methods that are nondaily, not intercourse-dependent and have efficacy that is not dependent on correct use or intervention on the part of the user. Currently, LARC includes IUDs and the progestin implant (Hatcher et al., 2011). Length of contraceptive benefit ranges from 3 years with the implant to 3 to 10 years depending on IUD type. Effectiveness is similar to or better than sterilization for both the implant and IUDs, and fertility returns quickly upon removal (Hatcher et al., 2011). These characteristics make LARC an ideal option for adolescents who are seeking a highly effective method while they delay pregnancy for many years. This column takes a second look at two recent studies that examine factors associated with LARC use among adolescent and young adult women. This column provides women’s health nurses an opportunity to stay up to date on emerging contraceptive science and highlights potential areas for reflection on and improvement of current practice and clinical education. In the first study, Kavanaugh, Frohwirth, Jerman, Popkins, and Ethier (2013) describe both provider and patient perspectives about LARC.
Nursing for Women’s Health
In the second study, Greenberg, Makino and Coles (2013) report on adolescent health provider and practice characteristics that are associated with the provision of LARC. Both of these studies provide level III evidence (see Box 1).
First Study The purpose of the study by Kavanaugh et al. (2013) was to explore and compare provider and patient perspectives about LARC use among adolescent and young adult women, as well as to identify strategies to facilitate the provision of LARC for young women.
Design, Sample and Data Analysis Kavanaugh et al. (2013) utilized a qualitative design that included both direct interviews as well as focus groups to achieve the study aims. This study was conducted at several national Title X family planning health centers. Title X is a federal grant program dedicated to providing comprehensive family planning and related health services to low income women and men. This program funds approximately 4,400 health centers nationally, which include government health departments, community health centers, Planned Parenthood centers and hospital, school, private or faith-based health centers (U.S. Department of Health & Human Services, Office of Population Affairs, 2014). Sample and data collection was as follows:
Box 1.
Levels of Evidence The quality of evidence for a study is based on a grading system that evaluates the scientific rigor of a design, as developed by the U.S. Preventive Services Task Force. The levels are as follows: I:
Evidence obtained from at least one properly randomized controlled trial.
II-1:
Evidence obtained from well-designed controlled trials without randomization.
II-2:
Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
II-3:
Evidence obtained from multiple time series with or without intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.
III:
Opinions of respected authorities are based on clinical experience, descriptive studies and case reports or reports of expert committees. Source: United States Preventive Services Task Force (1996).
Volume 19
Issue 3
Photo © Valentina Petrova / thinkstockphotos.com
(1) individual telephone interviews (1 hour) with 20 health center directors, (2) 48 individual patient interviews (1 hour) across six health centers and (3) six focus group discussions (90minute) each with five to eight participants who were staff (clinicians, educators, medical assistants and receptionists) across six health centers. The patients interviewed were between the ages of 16 and 24, with 22 of the 48 interviews completed with those ages 16 to 19. Approval was granted from an Intuitional Review Board (IRB) and all necessary assents and/or consents were obtained prior to data collection. The qualitative data were analyzed and common themes emerged across groups (Kavanaugh et al., 2013).
Findings Demographics of the participants included 46 percent teens (n = 22, ages 16 to 19) and 54 percent young adult women (n = 26, ages 20 to 24). Fortysix percent were below 100 percent of the poverty level and nearly the rest (35
June | July 2015
percent) had low income (defined by 100 percent to 199 percent of the poverty level). The race and ethnicity of the sample were as follows: 40 percent white non-Hispanic, 19 percent black
effectiveness. Themes from the data reflected both patients’ and staff members’ perspectives on advantages and disadvantages for LARCs. The advantage most commonly voiced by the young women was how LARC methods were forgettable. Other advantages voiced included method effectiveness, long lasting and beneficial side effects (in descending order). The staff also reported the forgettable nature of LARC as the most common advantage, followed by long lasting, beneficial side effects and lastly provider-controlled. Perceived disadvantages reported by the two groups were reported similarly. The young women’s reported disadvantages, in descending order, were foreign object, possible pain with insertion or removal, side effects and others could feel implant. For the staff the disadvantages, in descending order, were side effects, possible pain with insertion or removal, reduced condom use and cost. Additional data from the focus groups with the staff were coupled with data from interviews with health center directors. These merged data were examined, and strategies to address the identified challenges to providing
Kavanaugh et al.’s (2013) findings highlighted differing perceptions on advantages and disadvantages among adolescent and young adult women and their contraceptive health providers non-Hispanic, 35 percent Hispanic, 8 percent mixed or other and 2 percent not identified. One teen and 10 young adult women reported one or more past births. Race, ethnicity and other demographics were not provided for the health center directors or staff (Kavanaugh et al., 2013). According to Kavanaugh et al. (2013), among the young women who participated, the majority had some knowledge about IUDs and implants and they knew about side effects, insertion locations, method duration and
LARC were reported. These strategies included addressing cost-related challenges (time pressures and reimbursement issues), improving and supplementing patient counseling to reduce time constraints (clear counseling resources, such as pamphlets, websites and videos), incorporating revised guidelines into practice (including guidelines from ACOG, Contraceptive Technology, World Health Organization and CDC) and improving provider buy-in to address staff resistance (Kavanaugh et al., 2013).
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A Second Look
Study Conclusions Kavanaugh et al.’s (2013) findings highlighted differing perceptions on advantages and disadvantages among adolescent and young adult women and their contraceptive health providers. Even though they both primarily believed the ease of LARC methods as “forgettable” (not having to remember to take daily pills or change patches or rings weekly/monthly) was the top advantage, the remaining advantages and disadvantages differed in extent and content. These differences influence what is emphasized during contraceptive counseling and thereby may not make the counseling as effective as it could be. Kavanaugh et al. (2013) discussed the need for providers to employ open-ended counseling styles and not make assumptions regarding what an adolescent woman may perceive as desirable or not desirable about a method. Finally, future research is necessary to explore the best strategies for combatting facility level challenges. This includes improved contraceptive counseling for women, broader contraceptive training for staff and maintaining updated and evidence-based contraceptive guidelines in health care facilities.
Second Study The purpose of the study conducted by Greenberg et al. (2013) was to identify adolescent health provider and practice characteristics that maybe associated with the provision of LARC in their patient populations.
Design, Sample and Data Analysis Greenberg et al. (2013) utilized a quantitative online survey design to achieve the study aims. The survey invitation was e-mailed to members of the Society for Adolescent Health and Medicine who reported offering any contraceptive services during their regular practice. Society members excluded in the analysis were nurse practitioners, physicians whose training was in psychiatry or emergency medicine and any provider who denied offering contraceptive services to their patients. Nurse practitioners were excluded because the researchers did not have data on procedural women’s health training during formal nurse practitioner education for this group. Chi-square analyses were used to examine provider characteristics (those whose training includes procedural women’s health care and
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those whose did not) and practice characteristics (location [i.e., urban, suburban and rural] and primary clinical site [i.e., private practice, academic medical center, hospital-based clinic or other]). Multivariate logistic regression analyses were used to uncover any variables that predicted LARC provision, and sensitivity analyses were used to assess for associations of LARC provision if the providers residency was before or after the 2006 Implanon® approval by the U.S. Food and Drug Administration. The study was approved by a university IRB (Greenberg et al., 2013).
Findings According to Greenberg et al. (2013), final data were reported on 430 adolescent health providers. Of these providers, approximately 68 percent were female, their ages were evenly distributed (29 percent ages 24 to 39, 26 percent ages 40 to 49, and 31 percent ages 50 to 59 with the rest older than 60 years), 79 percent identified as white, 9 percent black, 7 percent Asian, 3 percent other and 4 percent Hispanic. The sample was overwhelmingly trained in pediatrics (77 percent), and 5 percent were trained in internal medicine (IM), 10 percent in family medicine (FM) and 2 percent in obstetrics and gynecology (OB). In the OB and FM group, 88 percent reported providing some form of LARC for patients as compared to only 26 percent of the pediatric and IM group. Specifically, 47 percent of the OB- and FM-trained providers placed implants as compared to 24 percent of the pediatric and IM-trained providers. The OB and FM providers had an increased odds of placing both IUDs (OR = 83.83; CI 15.3 to 458.9; p < .001) and implants (OR = 4.45; CI 1.72 to 11.54; p < .05) as compared to the pediatric and IM providers. The strongest predictor of LARC provision for both contraceptive implants and IUDs was exposure to procedural women’s health training. Practice location was also significantly associated with LARC provision; providers located in suburban and rural setting had greater odds of providing LARC methods than urban providers. Practice clinical site was not statistically significant. Finally, LARC provision was not associated with timing of residency completion (as related to 2006 Implanon® approval; Greenberg et al., 2013).
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Study Conclusions According to Greenberg et al. (2013), only 32 percent of these adolescent health providers reported providing either implants or IUDs for their patients. Rates of LARC provision were much higher for those who had presumptively obtained procedural women’s health training during their residencies (identified as OB or FM) and rates for IUDs in particular were highest in this group, which is likely a reflection of the skills and equipment necessary to insert IUDs. The rate of implant provision was lower than expected by Greenberg et al. (2013), suggesting underutilization of this contraceptive method. The results of this study suggest that having women’s health procedural training is a key factor for LARC provision and any increase in LARC trainings, provisions and access for adolescents would be an improvement in current practice and help to prevent unintended pregnancies (Greenberg et al., 2013).
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Discussion of These Two Studies These two U.S.-based studies highlighted both qualitatively and quantitatively different aspects related to LARC perspectives and provisions for adolescent and young adult women. Strengths of Kavanaugh et al.’s (2013) study included use of a national and diverse sample uncovering multiple (patient, health staff and health center director) perspectives on LARC use for adolescents. The authors were able to draw comparisons between the patient and health staff perspectives as well as identify system challenges expressed at the staff and health center director level. These different aspects of the study strengthen the work and provide opportunities for research to be expanded at the patient/ provider communication level as well as the systems health center level. Kavanaugh et al.’s (2013) work was not without limitations. The ability to generalize to larger populations of family planning clients and health centers was
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The studies discussed in this column highlight the importance of understanding patients’ perspectives related to contraceptive decision-making
limited by: (1) the qualitative nature of the design and (2) the use of LARC was more common in this sample as compared to national estimates for adolescent and young adult women (Finer, Jerman, & Kavanaugh, 2012; Kavanaugh et al., 2013). Greenberg et al.’s (2013) study was strengthened by the collection of data from a national sample of providers who specialize in adolescent health. These authors were able to highlight the importance of specific women’s health training in formal education. Their study’s limitations included (1) lack of generalizability to providers who are not members of the Society of Adolescent Health and Medicine and (2) analyses were limited by the small sample size of OB/FM providers and the use of residency type to reflect procedural women’s health training (Greenberg et al., 2013).
It’s clear that additional research is necessary to fully explore emerging trends in contraceptive practices, especially LARC use for adolescents and young adult women. Unmistakably, future research is needed to explore nurses’ roles (RN as well as advanced practice levels) in contraceptive and LARC counseling as well as a greater understanding of facilitators and barriers for young women to obtain LARC. The studies discussed in this column highlight the importance of understanding patients’ perspectives related to contraceptive decision-making and report on the value of contraceptive and procedural women’s health training in all health providers formal education, as well as ensuring opportunities for ongoing professional educational (Greenberg et al., 2013; Kavanaugh et al., 2013).
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reproductive-age women are poised to provide comprehensive education and counseling on all contraceptive methods
Implications for Nursing Practice Despite national recommendations for an increased use of LARC, barriers continue to exist. As highlighted in these research studies, use of LARC is underutilized by health care providers who care for adolescents, and there are some disconnects to patient and provider perspectives on the advantages and disadvantages of LARC use, which could lead to less effective contraceptive counseling (Greenberg et al., 2013; Kavanaugh et al., 2013). Adolescents who are unfamiliar with LARC methods might not consider LARC as a first choice, and providers who feel they lack the necessary training and resources may be hesitant to prescribe LARC. Nurses who work with reproductive-age women are poised to provide comprehensive
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education and counseling on all contraceptive methods (see Box 2). Adolescents will benefit from individualized contraceptive counseling that addresses their specific concerns and reproductive life planning. LARC is medically appropriate for most women, including adolescent and nulliparous women (CDC, 2010, 2013). Increasing awareness of these highly effective methods is the first step in effective long-term prevention of unwanted pregnancies for adolescent patients. Concern about the potential lack of condom use was expressed by health care providers in one study (Kavanaugh et al., 2013). Comprehensive contraceptive counseling must stress that LARC doesn’t protect against sexually transmitted infections and, therefore, condoms must also be used as part of safer sexual practices. A review of side effects is important. Women who use contraceptive implants and IUDs may experience a change in bleeding patterns. While this is expected, women who are unaware of this change may be less prepared to manage irregular bleeding and seek discontinuation of the method (Hatcher et al., 2011). Additionally, all counseling with adolescents related to contraception and sexual health should also include a discussion of abstinence, sexual decision-making,
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Issue 3
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A Second Look
Nurses who work with
Box 2.
Additional Evidence-Based Resources From CDC Providing Quality Family Planning Services www.cdc.gov/mmwr/pdf/rr/rr6304.pdf
U.S. Medical Eligibility Criteria for Contraception www.cdc.gov/mmwr/pdf/rr/rr5904.pdf
U.S. Selected Practice Recommendations for Contraceptive Use www.cdc.gov/mmwr/pdf/rr/rr6205.pdf
healthy relationships and sexual violence and coercion.
Conclusion This column described two recent U.S.-based studies examining LARC and adolescent and young women. It’s evident that barriers to provision of LARC exist at the contraceptive counseling, training/education and systems levels. Future research is needed to continue to explore patient perspectives as well as barriers for providers and health centers. Nurses need to keep up to date on the latest advances in contraceptive technology and be able to effectively counsel women on all options for contraception. Nurses are positioned to be leaders in contraceptive counseling, which may bring about direct reductions in the rates of unintended pregnancies, particularly among adolescents. NWH
References American College of Obstetricians and Gynecologists (ACOG). (2012). Adolescents and long acting reversible contraception: Implants and intrauterine devices. Committee Opinion No. 539. Retrieved from www.acog.org/ Resources-And-Publications/ Committee-Opinions/Committee-onAdolescent-Health-Care/Adolescentsand-Long-Acting-ReversibleContraception
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Centers for Disease Control and Prevention (CDC). (2010). U.S. medical eligibility criteria for contraceptive use, 2010. Morbidity and Mortality Weekly Report, 59(RR-4), 1–85. Centers for Disease Control and Prevention (CDC). (2013). U.S. selected practice recommendations for contraceptive use, 2013. Morbidity and Mortality weekly Report, 62(5), 1–60. Centers for Disease Control and Prevention (CDC). (2014). Providing quality family planning services: Recommendations of CDC and U.S. Office of Population Affairs. Morbidity and Mortality weekly Report, 63(4), 1–54. Finer, L. B. (2010). Unintended pregnancy among U.S. adolescents: Accounting for sexual activity. Journal of Adolescent Health, 47(3), 312–314. doi:10.1016/ j.jadohealth.2010.02.002 Finer, L. B., Jerman, J., & Kavanaugh, M. (2012). Changes in use of long-acting contraceptive methods in the United States, 2007–2009. Contraception, 98, 893–897.
Greenberg, K., Makino, K., & Coles, M. (2013). Factors associated with provision of long-acting reversible contraception among adolescent health care providers. Journal of Adolescent Health, 52, 372–374. doi:10.1016/j. jadohealth.2012.11.003 Hatcher, R. A., Trussell, J., Nelson, A. L., Cates, W., Kowal, D., & Policar, M. S. (2011). Contraceptive technology (20th ed.). New York, NY: Ardent Media. Kavanaugh, M., Frohwirth, L., Jerman, J., Popkins, R., & Ethier, K. (2013). Longacting reversible contraception for adolescents and young adults: Patient and provider perspectives. Journal of Pediatric and Adolescent Gynecology, 26, 86–95. doi:10.1016/j.jpag.2012.10.006 United States Department of Health and Human Services, Office of Population Affairs (2014). Title X: The National Family Planning Program. Retrieved from www.hhs.gov/opa/title-s-familyplanning-overview.pdf United States Preventive Services Task Force. (1996). Guide to Clinical Preventive Services. Report of the U.S. Preventive Services Task Force (2nd ed.). Washington, DC: Office of Disease Prevention and Health Promotion, U.S. Government Printing office. Zolna, M., & Lindberg, L. (2012). Unintended pregnancy: Incidence and outcomes among young adult unmarried women in the United States, 2001 and 2008. New York: Guttmacher Institute. Retrieved from www.guttmacher. org/pubs/unintended-pregnancyUS-2001-2008.pdf
Finer, L. B., & Zolna, M. R. (2011). Unintended pregnancy in the United States: Incidence and disparities, 2006. Contraception, 84(5), 478–485. doi:10/1016/ j.contraception.2011.07.013 Frost, J. J., Lindberg, L. D., & Finer, L. B. (2012). Young adults’ contraceptive knowledge, norms and attitudes: Associations with risk of unintended pregnancy. Perspectives on Sexual and Reproductive Health, 44(2), 107–116.
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Title BYLINE
Long-Acting Reversible Contraception for Adolescents
A Photo © B-C Designs / thinkstockphotos.com
Approximately 50 percent of women in the United States experience an unplanned pregnancy (Finer & Zolna, 2011). Of this group, adolescents and young adults under the age of 25 have the highest rate of unintended pregnancy compared with women of all other reproductive ages (Finer, 2010; Finer & Zolna, 2011). Unintended pregnancy has been associated with a low level of contraceptive knowledge and use, fear of side effects, as well as ambivalence regarding
HOLLY B. FONTENOT HEIDI COLLINS FANTASIA
pregnancy and mistrust of government-supported family planning services (Frost, Lindberg, & Finer, 2012; Zolna & Lindberg, 2012). Currently, the Centers for Disease Control and Prevention (CDC) recommends counseling patients on the use of long-acting reversible contraception (LARC), including intrauterine devices (IUDs) and implants, as a first-line, highly effective
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. DOI: 10.1111/1751-486X.12207 Keywords adolescents | birth control | IUD | long-acting reversible contraception | LARC
http://nwh.awhonn.org
© 2015, AWHONN
253
A Second Look Holly B. Fontenot, PhD, RN, WHNP-BC, is an assistant professor at W. F. Connell School of Nursing at Boston College in Chestnut Hill, MA, and a women’s health nurse practitioner at the Sidney Borum Jr. Health Center in Boston, MA. Heidi Collins Fantasia, PhD, RN, WHNP-BC, is an assistant professor in the College of Health Sciences, School of Nursing at the University of Massachusetts in Lowell, MA, and a women’s health nurse practitioner at Health Quarters in Beverly, MA. Dr. Fontenot reports no conflicts of interest or relevant financial relationships. Dr. Fantasia is a member of the women’s health advisory board for Actavis Pharma, for which she receives financial consideration. Actavis Pharma had no involvement in the creation of this article. Address correspondence to: [email protected].
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option for pregnancy prevention (CDC, 2013, 2014). Use of LARC in adolescents is supported by national organizations (American College of Obstetricians and Gynecologists [ACOG], 2012; CDC, 2013, 2014). LARC refers to contraceptive methods that are nondaily, not intercourse-dependent and have efficacy that is not dependent on correct use or intervention on the part of the user. Currently, LARC includes IUDs and the progestin implant (Hatcher et al., 2011). Length of contraceptive benefit ranges from 3 years with the implant to 3 to 10 years depending on IUD type. Effectiveness is similar to or better than sterilization for both the implant and IUDs, and fertility returns quickly upon removal (Hatcher et al., 2011). These characteristics make LARC an ideal option for adolescents who are seeking a highly effective method while they delay pregnancy for many years. This column takes a second look at two recent studies that examine factors associated with LARC use among adolescent and young adult women. This column provides women’s health nurses an opportunity to stay up to date on emerging contraceptive science and highlights potential areas for reflection on and improvement of current practice and clinical education. In the first study, Kavanaugh, Frohwirth, Jerman, Popkins, and Ethier (2013) describe both provider and patient perspectives about LARC.
Nursing for Women’s Health
In the second study, Greenberg, Makino and Coles (2013) report on adolescent health provider and practice characteristics that are associated with the provision of LARC. Both of these studies provide level III evidence (see Box 1).
First Study The purpose of the study by Kavanaugh et al. (2013) was to explore and compare provider and patient perspectives about LARC use among adolescent and young adult women, as well as to identify strategies to facilitate the provision of LARC for young women.
Design, Sample and Data Analysis Kavanaugh et al. (2013) utilized a qualitative design that included both direct interviews as well as focus groups to achieve the study aims. This study was conducted at several national Title X family planning health centers. Title X is a federal grant program dedicated to providing comprehensive family planning and related health services to low income women and men. This program funds approximately 4,400 health centers nationally, which include government health departments, community health centers, Planned Parenthood centers and hospital, school, private or faith-based health centers (U.S. Department of Health & Human Services, Office of Population Affairs, 2014). Sample and data collection was as follows:
Box 1.
Levels of Evidence The quality of evidence for a study is based on a grading system that evaluates the scientific rigor of a design, as developed by the U.S. Preventive Services Task Force. The levels are as follows: I:
Evidence obtained from at least one properly randomized controlled trial.
II-1:
Evidence obtained from well-designed controlled trials without randomization.
II-2:
Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group.
II-3:
Evidence obtained from multiple time series with or without intervention. Dramatic results in uncontrolled experiments (such as the results of the introduction of penicillin treatment in the 1940s) could also be regarded as this type of evidence.
III:
Opinions of respected authorities are based on clinical experience, descriptive studies and case reports or reports of expert committees. Source: United States Preventive Services Task Force (1996).
Volume 19
Issue 3
Photo © Valentina Petrova / thinkstockphotos.com
(1) individual telephone interviews (1 hour) with 20 health center directors, (2) 48 individual patient interviews (1 hour) across six health centers and (3) six focus group discussions (90minute) each with five to eight participants who were staff (clinicians, educators, medical assistants and receptionists) across six health centers. The patients interviewed were between the ages of 16 and 24, with 22 of the 48 interviews completed with those ages 16 to 19. Approval was granted from an Intuitional Review Board (IRB) and all necessary assents and/or consents were obtained prior to data collection. The qualitative data were analyzed and common themes emerged across groups (Kavanaugh et al., 2013).
Findings Demographics of the participants included 46 percent teens (n = 22, ages 16 to 19) and 54 percent young adult women (n = 26, ages 20 to 24). Fortysix percent were below 100 percent of the poverty level and nearly the rest (35
June | July 2015
percent) had low income (defined by 100 percent to 199 percent of the poverty level). The race and ethnicity of the sample were as follows: 40 percent white non-Hispanic, 19 percent black
effectiveness. Themes from the data reflected both patients’ and staff members’ perspectives on advantages and disadvantages for LARCs. The advantage most commonly voiced by the young women was how LARC methods were forgettable. Other advantages voiced included method effectiveness, long lasting and beneficial side effects (in descending order). The staff also reported the forgettable nature of LARC as the most common advantage, followed by long lasting, beneficial side effects and lastly provider-controlled. Perceived disadvantages reported by the two groups were reported similarly. The young women’s reported disadvantages, in descending order, were foreign object, possible pain with insertion or removal, side effects and others could feel implant. For the staff the disadvantages, in descending order, were side effects, possible pain with insertion or removal, reduced condom use and cost. Additional data from the focus groups with the staff were coupled with data from interviews with health center directors. These merged data were examined, and strategies to address the identified challenges to providing
Kavanaugh et al.’s (2013) findings highlighted differing perceptions on advantages and disadvantages among adolescent and young adult women and their contraceptive health providers non-Hispanic, 35 percent Hispanic, 8 percent mixed or other and 2 percent not identified. One teen and 10 young adult women reported one or more past births. Race, ethnicity and other demographics were not provided for the health center directors or staff (Kavanaugh et al., 2013). According to Kavanaugh et al. (2013), among the young women who participated, the majority had some knowledge about IUDs and implants and they knew about side effects, insertion locations, method duration and
LARC were reported. These strategies included addressing cost-related challenges (time pressures and reimbursement issues), improving and supplementing patient counseling to reduce time constraints (clear counseling resources, such as pamphlets, websites and videos), incorporating revised guidelines into practice (including guidelines from ACOG, Contraceptive Technology, World Health Organization and CDC) and improving provider buy-in to address staff resistance (Kavanaugh et al., 2013).
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A Second Look
Study Conclusions Kavanaugh et al.’s (2013) findings highlighted differing perceptions on advantages and disadvantages among adolescent and young adult women and their contraceptive health providers. Even though they both primarily believed the ease of LARC methods as “forgettable” (not having to remember to take daily pills or change patches or rings weekly/monthly) was the top advantage, the remaining advantages and disadvantages differed in extent and content. These differences influence what is emphasized during contraceptive counseling and thereby may not make the counseling as effective as it could be. Kavanaugh et al. (2013) discussed the need for providers to employ open-ended counseling styles and not make assumptions regarding what an adolescent woman may perceive as desirable or not desirable about a method. Finally, future research is necessary to explore the best strategies for combatting facility level challenges. This includes improved contraceptive counseling for women, broader contraceptive training for staff and maintaining updated and evidence-based contraceptive guidelines in health care facilities.
Second Study The purpose of the study conducted by Greenberg et al. (2013) was to identify adolescent health provider and practice characteristics that maybe associated with the provision of LARC in their patient populations.
Design, Sample and Data Analysis Greenberg et al. (2013) utilized a quantitative online survey design to achieve the study aims. The survey invitation was e-mailed to members of the Society for Adolescent Health and Medicine who reported offering any contraceptive services during their regular practice. Society members excluded in the analysis were nurse practitioners, physicians whose training was in psychiatry or emergency medicine and any provider who denied offering contraceptive services to their patients. Nurse practitioners were excluded because the researchers did not have data on procedural women’s health training during formal nurse practitioner education for this group. Chi-square analyses were used to examine provider characteristics (those whose training includes procedural women’s health care and
256
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those whose did not) and practice characteristics (location [i.e., urban, suburban and rural] and primary clinical site [i.e., private practice, academic medical center, hospital-based clinic or other]). Multivariate logistic regression analyses were used to uncover any variables that predicted LARC provision, and sensitivity analyses were used to assess for associations of LARC provision if the providers residency was before or after the 2006 Implanon® approval by the U.S. Food and Drug Administration. The study was approved by a university IRB (Greenberg et al., 2013).
Findings According to Greenberg et al. (2013), final data were reported on 430 adolescent health providers. Of these providers, approximately 68 percent were female, their ages were evenly distributed (29 percent ages 24 to 39, 26 percent ages 40 to 49, and 31 percent ages 50 to 59 with the rest older than 60 years), 79 percent identified as white, 9 percent black, 7 percent Asian, 3 percent other and 4 percent Hispanic. The sample was overwhelmingly trained in pediatrics (77 percent), and 5 percent were trained in internal medicine (IM), 10 percent in family medicine (FM) and 2 percent in obstetrics and gynecology (OB). In the OB and FM group, 88 percent reported providing some form of LARC for patients as compared to only 26 percent of the pediatric and IM group. Specifically, 47 percent of the OB- and FM-trained providers placed implants as compared to 24 percent of the pediatric and IM-trained providers. The OB and FM providers had an increased odds of placing both IUDs (OR = 83.83; CI 15.3 to 458.9; p < .001) and implants (OR = 4.45; CI 1.72 to 11.54; p < .05) as compared to the pediatric and IM providers. The strongest predictor of LARC provision for both contraceptive implants and IUDs was exposure to procedural women’s health training. Practice location was also significantly associated with LARC provision; providers located in suburban and rural setting had greater odds of providing LARC methods than urban providers. Practice clinical site was not statistically significant. Finally, LARC provision was not associated with timing of residency completion (as related to 2006 Implanon® approval; Greenberg et al., 2013).
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Study Conclusions According to Greenberg et al. (2013), only 32 percent of these adolescent health providers reported providing either implants or IUDs for their patients. Rates of LARC provision were much higher for those who had presumptively obtained procedural women’s health training during their residencies (identified as OB or FM) and rates for IUDs in particular were highest in this group, which is likely a reflection of the skills and equipment necessary to insert IUDs. The rate of implant provision was lower than expected by Greenberg et al. (2013), suggesting underutilization of this contraceptive method. The results of this study suggest that having women’s health procedural training is a key factor for LARC provision and any increase in LARC trainings, provisions and access for adolescents would be an improvement in current practice and help to prevent unintended pregnancies (Greenberg et al., 2013).
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Discussion of These Two Studies These two U.S.-based studies highlighted both qualitatively and quantitatively different aspects related to LARC perspectives and provisions for adolescent and young adult women. Strengths of Kavanaugh et al.’s (2013) study included use of a national and diverse sample uncovering multiple (patient, health staff and health center director) perspectives on LARC use for adolescents. The authors were able to draw comparisons between the patient and health staff perspectives as well as identify system challenges expressed at the staff and health center director level. These different aspects of the study strengthen the work and provide opportunities for research to be expanded at the patient/ provider communication level as well as the systems health center level. Kavanaugh et al.’s (2013) work was not without limitations. The ability to generalize to larger populations of family planning clients and health centers was
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The studies discussed in this column highlight the importance of understanding patients’ perspectives related to contraceptive decision-making
limited by: (1) the qualitative nature of the design and (2) the use of LARC was more common in this sample as compared to national estimates for adolescent and young adult women (Finer, Jerman, & Kavanaugh, 2012; Kavanaugh et al., 2013). Greenberg et al.’s (2013) study was strengthened by the collection of data from a national sample of providers who specialize in adolescent health. These authors were able to highlight the importance of specific women’s health training in formal education. Their study’s limitations included (1) lack of generalizability to providers who are not members of the Society of Adolescent Health and Medicine and (2) analyses were limited by the small sample size of OB/FM providers and the use of residency type to reflect procedural women’s health training (Greenberg et al., 2013).
It’s clear that additional research is necessary to fully explore emerging trends in contraceptive practices, especially LARC use for adolescents and young adult women. Unmistakably, future research is needed to explore nurses’ roles (RN as well as advanced practice levels) in contraceptive and LARC counseling as well as a greater understanding of facilitators and barriers for young women to obtain LARC. The studies discussed in this column highlight the importance of understanding patients’ perspectives related to contraceptive decision-making and report on the value of contraceptive and procedural women’s health training in all health providers formal education, as well as ensuring opportunities for ongoing professional educational (Greenberg et al., 2013; Kavanaugh et al., 2013).
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reproductive-age women are poised to provide comprehensive education and counseling on all contraceptive methods
Implications for Nursing Practice Despite national recommendations for an increased use of LARC, barriers continue to exist. As highlighted in these research studies, use of LARC is underutilized by health care providers who care for adolescents, and there are some disconnects to patient and provider perspectives on the advantages and disadvantages of LARC use, which could lead to less effective contraceptive counseling (Greenberg et al., 2013; Kavanaugh et al., 2013). Adolescents who are unfamiliar with LARC methods might not consider LARC as a first choice, and providers who feel they lack the necessary training and resources may be hesitant to prescribe LARC. Nurses who work with reproductive-age women are poised to provide comprehensive
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education and counseling on all contraceptive methods (see Box 2). Adolescents will benefit from individualized contraceptive counseling that addresses their specific concerns and reproductive life planning. LARC is medically appropriate for most women, including adolescent and nulliparous women (CDC, 2010, 2013). Increasing awareness of these highly effective methods is the first step in effective long-term prevention of unwanted pregnancies for adolescent patients. Concern about the potential lack of condom use was expressed by health care providers in one study (Kavanaugh et al., 2013). Comprehensive contraceptive counseling must stress that LARC doesn’t protect against sexually transmitted infections and, therefore, condoms must also be used as part of safer sexual practices. A review of side effects is important. Women who use contraceptive implants and IUDs may experience a change in bleeding patterns. While this is expected, women who are unaware of this change may be less prepared to manage irregular bleeding and seek discontinuation of the method (Hatcher et al., 2011). Additionally, all counseling with adolescents related to contraception and sexual health should also include a discussion of abstinence, sexual decision-making,
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A Second Look
Nurses who work with
Box 2.
Additional Evidence-Based Resources From CDC Providing Quality Family Planning Services www.cdc.gov/mmwr/pdf/rr/rr6304.pdf
U.S. Medical Eligibility Criteria for Contraception www.cdc.gov/mmwr/pdf/rr/rr5904.pdf
U.S. Selected Practice Recommendations for Contraceptive Use www.cdc.gov/mmwr/pdf/rr/rr6205.pdf
healthy relationships and sexual violence and coercion.
Conclusion This column described two recent U.S.-based studies examining LARC and adolescent and young women. It’s evident that barriers to provision of LARC exist at the contraceptive counseling, training/education and systems levels. Future research is needed to continue to explore patient perspectives as well as barriers for providers and health centers. Nurses need to keep up to date on the latest advances in contraceptive technology and be able to effectively counsel women on all options for contraception. Nurses are positioned to be leaders in contraceptive counseling, which may bring about direct reductions in the rates of unintended pregnancies, particularly among adolescents. NWH
References American College of Obstetricians and Gynecologists (ACOG). (2012). Adolescents and long acting reversible contraception: Implants and intrauterine devices. Committee Opinion No. 539. Retrieved from www.acog.org/ Resources-And-Publications/ Committee-Opinions/Committee-onAdolescent-Health-Care/Adolescentsand-Long-Acting-ReversibleContraception
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Centers for Disease Control and Prevention (CDC). (2010). U.S. medical eligibility criteria for contraceptive use, 2010. Morbidity and Mortality Weekly Report, 59(RR-4), 1–85. Centers for Disease Control and Prevention (CDC). (2013). U.S. selected practice recommendations for contraceptive use, 2013. Morbidity and Mortality weekly Report, 62(5), 1–60. Centers for Disease Control and Prevention (CDC). (2014). Providing quality family planning services: Recommendations of CDC and U.S. Office of Population Affairs. Morbidity and Mortality weekly Report, 63(4), 1–54. Finer, L. B. (2010). Unintended pregnancy among U.S. adolescents: Accounting for sexual activity. Journal of Adolescent Health, 47(3), 312–314. doi:10.1016/ j.jadohealth.2010.02.002 Finer, L. B., Jerman, J., & Kavanaugh, M. (2012). Changes in use of long-acting contraceptive methods in the United States, 2007–2009. Contraception, 98, 893–897.
Greenberg, K., Makino, K., & Coles, M. (2013). Factors associated with provision of long-acting reversible contraception among adolescent health care providers. Journal of Adolescent Health, 52, 372–374. doi:10.1016/j. jadohealth.2012.11.003 Hatcher, R. A., Trussell, J., Nelson, A. L., Cates, W., Kowal, D., & Policar, M. S. (2011). Contraceptive technology (20th ed.). New York, NY: Ardent Media. Kavanaugh, M., Frohwirth, L., Jerman, J., Popkins, R., & Ethier, K. (2013). Longacting reversible contraception for adolescents and young adults: Patient and provider perspectives. Journal of Pediatric and Adolescent Gynecology, 26, 86–95. doi:10.1016/j.jpag.2012.10.006 United States Department of Health and Human Services, Office of Population Affairs (2014). Title X: The National Family Planning Program. Retrieved from www.hhs.gov/opa/title-s-familyplanning-overview.pdf United States Preventive Services Task Force. (1996). Guide to Clinical Preventive Services. Report of the U.S. Preventive Services Task Force (2nd ed.). Washington, DC: Office of Disease Prevention and Health Promotion, U.S. Government Printing office. Zolna, M., & Lindberg, L. (2012). Unintended pregnancy: Incidence and outcomes among young adult unmarried women in the United States, 2001 and 2008. New York: Guttmacher Institute. Retrieved from www.guttmacher. org/pubs/unintended-pregnancyUS-2001-2008.pdf
Finer, L. B., & Zolna, M. R. (2011). Unintended pregnancy in the United States: Incidence and disparities, 2006. Contraception, 84(5), 478–485. doi:10/1016/ j.contraception.2011.07.013 Frost, J. J., Lindberg, L. D., & Finer, L. B. (2012). Young adults’ contraceptive knowledge, norms and attitudes: Associations with risk of unintended pregnancy. Perspectives on Sexual and Reproductive Health, 44(2), 107–116.
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