Improving Capacity at School-based Health Centers to Offer Adolescents Counseling and Access to Comprehensive Contraceptive Services

Effectiveness of interventions to support person-centered contraceptive care for adolescents and young adults: a systematic review

OBJECTIVE

To investigate the association between interventions to support adolescent and young adult person-centered contraceptive counseling and the delivery of person-centered contraceptive counseling, and their impact on clinician and patient outcomes.

DATA SOURCES

PubMed, Cumulative Index to Nursing and Allied Health Literature via EBSCO, Embase.com, PsycInfo via EBSCO, and Scopus searched on March 31, 2024.

STUDY ELIGIBILITY CRITERIA

Published from March 2011 to present, included patients assigned female at birth and <25 years, studied interventions that operationalized aspects of person-centered contraceptive counseling, and had patient or clinician outcomes related to person-centered contraceptive counseling (eg, direct measurement of person-centered contraceptive counseling, knowledge, confidence, and contraceptive decision-making). All study designs with primary data collection were included except case studies/series.

STUDY APPRAISAL AND SYNTHESIS METHODS

Search results were downloaded to EndNote, and duplicates were removed. References were uploaded to Covidence Systematic Review software. Two authors independently screened the studies using the eligibility criteria by title and abstract then full-text review. Relevant information was extracted independently by 2 authors. Discrepancies were resolved through consensus discussion. Data included study sample demographic characteristics, methodological characteristics, intervention and comparator descriptions, and outcome measures. We then determined risk of bias for individual studies and strength of evidence by included outcomes.

RESULTS

Of 5611 unique titles and abstracts, 12 studies met eligibility criteria. Four were pre/post studies, 2 were randomized controlled trials, and 6 were observational. These studies evaluated interventions including contraceptive coaching, decision aids, and clinician counseling prompts. No studies directly assessed person-centered contraceptive counseling using validated measures. All studies reported improvements in contraception-related secondary patient and clinician outcomes in the short and medium term. Patient outcomes included the following: continuation, choice, knowledge, perceived benefits, quality of care, and self-efficacy. Clinician outcomes included the following: comfort, knowledge, quality of care, and perceived benefits. Most studies had a high risk of bias.

CONCLUSION

While interventions to support person-centered contraceptive counseling may improve patient and clinician outcomes, none of the studies directly measured person-centered contraceptive counseling or assessed preferred method use or reproductive autonomy as outcomes. The results were integrated into a Socioecological Model of Person-Centered Contraceptive Counseling and Care to diagram relationships between interventions, delivery of person-centered contraceptive counseling, and secondary outcomes.

Single-Visit Long-Acting Reversible Contraception Initiation Among Adolescents Before and During COVID-19

PURPOSE

Single-visit long-acting reversible contraception (LARC) is cost-effective and convenient. Our objective was to compare incidence of single-visit LARC placement and associated factors during the year before the COVID-19 pandemic (March 15, 2020) and the first year of the pandemic.

METHODS

This retrospective cohort study analyzed electronic health records from a large healthcare system. Eligible adolescents were aged 10-19 years and received outpatient LARC from March 15, 2019 to March 14, 2021. Logistic regression models determined the relationship of patient and provider characteristics on single-visit LARC before and during COVID-19.

RESULTS

One thousand six adolescents initiated LARC during the study period. Fewer adolescents received single-visit LARC during COVID-19 (289/506, 57.1%) compared to before (315/500, 63.0%), although changes in odds of single-visit LARC were not statistically significant. Concordance between county of patient residence and the location of the LARC placement facility was associated with single-visit LARC before (adjusted odds ratio [aOR] = 2.75) and during (aOR = 1.74) the pandemic (both p < .05). During the pandemic, a few factors were associated with reduced odds of single-visit LARC: (1) public insurance (aOR = 0.49, p < .01), (2) nonobstetricians/nongynecologists providers (pediatrics [aOR = 0.35, p < .01], family medicine [aOR = 0.53, p < .01], or internal medicine [aOR = 0.14, p < .05]), and (3) advanced practice practitioners (aOR = 0.49, p < .01).

DISCUSSION

Incidence of single-visit LARC was similar before and during the pandemic. Certain factors were associated with lower odds of single-visit LARC insertion, suggesting differential access during the pandemic for subgroups of adolescents. Our findings may guide policy and programmatic interventions to improve access to single-visit LARC for all adolescent populations.

Recap of the sixth international symposium on intrauterine devices and systems for women's health

Due to the COVID-19 pandemic, the Sixth International Symposium on Intrauterine Devices and Systems for Women's Health was held as a series of seven 2-hour webinars between May 28, 2020, and June 22, 2021. This Symposium featured 48 different presenters and moderators covering a wide range of topics to highlight new IUD issues and update general IUD knowledge, just as it was done in previous symposia dating back to 1962 [1-5]. A total of 1346 people attended remotely to observe the events live. In this article, we share summaries of the presentations from the sixth symposium. These summaries, provided by the presenters, are meant to archive the symposium. This article gives the reader an overview of the topics and identifies the sessions' moderators and speakers charged with providing the content. Those interested in further detail, references, and information about the speakers can find more information on the conference website: www.iud2020.com. After the summaries, we share ideas for future IUD research and programmatic needs, as provided by Symposium's presenters and organizers. The authors' summaries are personal opinions and do not necessarily reflect the perspectives of the Symposium's organizers or the medical community at large. The Symposium was recorded and the sessions are available for viewing free of charge at the website, www.iud2020.comor on YouTube. As of July 2022, approximately 1700 visitors have viewed the recordings.

Relationships between Penile-Vaginal Intercourse Frequency and Condom/Contraceptive Use from 2009 to 2018: Findings from the National Survey of Sexual Health and Behavior

Objectives

To examine changes over time in event-level condom/contraceptive use and the association between past year penile-vaginal intercourse frequency and event-level condom/contraceptive use.

Methods

Data were from the 2009 and 2018 National Survey of Sexual Health and Behavior, an online probability survey of U.S. adolescents and adults.

Results

Use of condoms and highly effective hormonal contraceptives decreased while long-acting reversible contraceptive use increased from 2009 to 2018 among adults. Increased penile-vaginal intercourse frequency was associated with decreased use of most contraceptive methods but an increase in condom use for adolescents.

Conclusions

Sexual frequency should be considered when assessing condom/contraceptive use.

Access to Contraceptives in School-Based Health Centers: Progress and Opportunities

INTRODUCTION

The U.S. has a higher adolescent pregnancy rate than other industrialized countries. School-based health centers can improve access to contraceptives among youth, which can prevent unplanned pregnancies. This cross-sectional study examines the characteristics and predictors of contraceptive provision at school-based health centers in 2016-2017 and changes in and barriers to provision between 2001 and 2017.

METHODS

In 2020-2021, the authors conducted analyses of the National School-Based Health Care Census data collected from 2001 to 2017. The primary outcome of interest was whether adolescent-serving school-based health centers dispense contraceptives, and a secondary outcome of interest was the policies that prohibit school-based health centers from dispensing contraceptives. A multivariate regression analysis examined the associations between contraceptive provision and various covariates, including geographic region, years of operation, and provider team composition.

RESULTS

Less than half of adolescent-serving school-based health centers reported providing contraceptives on site. Those that provided contraceptives were more likely located in the Western and Northeastern regions of the U.S., older in terms of years of operation, and staffed by a wide variety of health provider types. Among school-based health centers that experienced policy barriers to providing access to contraceptive methods, most attributed the source to the school or school district where the school-based health center was located.

CONCLUSIONS

School-based health centers are an evidence-based model for providing contraceptives to adolescents but not enough are providing direct access. Understanding the predictors, characteristics, and barriers influencing the provision of contraceptives at school-based health centers may help to expand the number doing so.

Addressing long-acting reversible contraception access, bias, and coercion: supporting adolescent and young adult reproductive autonomy

PURPOSE OF REVIEW

Long-acting reversible contraception (LARC) is comprised of highly effective methods (the subdermal implant and intrauterine devices) available to adolescents and young adults (AYAs). Professional medical societies endorse LARC use in AYAs and, more recently, have emphasized the importance of using a reproductive justice framework when providing LARC. This article reviews reproductive justice, discusses contraceptive coercion, examines bias, and highlights interventions that promote equitable reproductive healthcare.

RECENT FINDINGS

Research indicates that both bias and patient characteristics influence provider LARC practices. AYA access to comprehensive LARC services is limited, as counseling, provision, management, and removal are not offered at all sites providing reproductive healthcare to AYAs. Interventions aimed at addressing provider bias and knowledge, clinic policies, confidentiality concerns, insurance reimbursement, and systems of oppression can improve AYA access to equitable, comprehensive contraceptive care. Additionally, the COVID-19 pandemic has exacerbated inequities in reproductive healthcare, as well as provided unique innovations to decrease barriers, including telemedicine LARC services.

SUMMARY

Clinicians who care for AYAs should honor reproductive autonomy by approaching contraceptive services with a reproductive justice lens. This includes implementing patient-centered contraceptive counseling, increasing access to LARC, eliminating barriers to LARC removal, and committing to systemic changes to address healthcare inequities.

Racial and Ethnic Disparities in Receipt of Sexual Health Care and Education Among A Nationally Representative Sample of Adolescent Females

OBJECTIVE(S)

The USA has a high rate of adolescent pregnancy, with non-Hispanic (NH) Black and Hispanic women disproportionately affected. We sought to investigate the presence of racial/ethnic disparities in the receipt of sexual health (SRH) care and education and whether such disparities contribute to differences in sexual health outcomes for youth.

STUDY DESIGN

We conducted a cross-sectional study of females aged 15-21 years who participated in the National Survey of Family Growth from 2008 to 2015. Multivariable logistic regression was used to measure the association between race/ethnicity and SRH outcomes after adjustment for potential confounders. Models were developed to measure whether receipt of SRH care and education served as an effect modifier on SRH outcomes.

RESULTS

The sample included 4316 participants, representing 33.5 million females. Almost half (47.2%) received birth control services in the last 12 months; NH-Blacks (aOR 0.7 [0.5, 0.9]) and Hispanics (aOR 0.6 [0.5, 0.8]) were less likely to have obtained birth control services than NH-whites. Hispanics (aOR 1.5 [1.2, 1.9]) had a higher likelihood of receipt of condom education than NH-whites. We found that disparities in SRH outcomes were slightly mitigated after adjustment for access to SRH care and education.

CONCLUSIONS

We identified racial/ethnic disparities in sexual health outcomes and in SRH and education; however, SRH care and education can mitigate some of these differences in sexual behaviors and outcomes. Racial/ethnic differences in sexual health outcomes may be at least partially related to the differential receipt of sexual health care and education and deserve further investigation.

Provision of contraceptive implants in school-based health centers: A cost-effectiveness analysis

OBJECTIVE

To evaluate the cost-effectiveness of providing contraceptive implants in school-based health centers (SBHCs) compared to the practice of referring adolescents to non-SBHCs in New York City.

STUDY DESIGN

We developed a microsimulation model of teen pregnancy to estimate the cost-effectiveness of immediate provision of contraceptive implants at SBHCs over a 3-year time horizon. Model parameters were derived from both a retrospective chart review of patient data and published literature. The model projected the number of pregnancies as well as the total costs for each intervention scenario. The incremental cost-effectiveness ratio was calculated using the public payer perspective, using direct costs only.

RESULTS

The health care cost of immediate provision of contraceptive implants at SBHCs was projected to be $13,719 per person compared to $13,567 per person for delayed provision at the referral appointment over 3 years. However, immediate provision would prevent 78 more pregnancies per 1000 adolescents over 3 years. The incremental cost-effectiveness ratio for implementing in-school provision was $1940 per additional pregnancy prevented, which was less than the $4206.41 willingness-to-pay threshold. Sensitivity analyses showed that the cost-effectiveness conclusion was robust over a wide range of key model inputs.

CONCLUSION

Provision of contraceptive implants in SBHCs compared to non-SBHCs is cost-effective for preventing unintended teen pregnancy. Health care providers and policymakers should consider expanding this model of patient-centered health care delivery to other locations.

Perspectives on Adolescent Pregnancy Prevention Strategies in the United States: Looking Back, Looking Forward

Attempts to solve the "problem of adolescent pregnancy" have long been a  focus of national, state, and local efforts in the United States. This review article summarizes trends and strategies around adolescent pregnancy prevention, provides lessons learned and best practices, and presents ideas for future directions. Over the past decades, a wide variety of policy and programmatic interventions have been implemented - including educational efforts, clinical health services, and community-wide coalitions - accompanied by a growing consensus regarding viable solutions. While notable reductions in adolescent pregnancy and childbearing have occurred across all sociodemographic groups, racial/ethnic, geographic, and socioeconomic disparities persist. Many adolescents who most need sexual health information and services are underserved by current programs and policies. A growing understanding of the role of social determinants of health, the impacts of structural racism, and the need for equity and inclusion must inform the next set of interventions and societal commitments to not only ameliorate the occurrence of unintended adolescent pregnancy but also foster healthy adolescent development. Recommendations for future efforts include improving the content, quality, and sustainability of education programs; actively engaging youth in the design of policies, programs, and clinical services; using technology thoughtfully to improve health literacy; expanding access to services through telehealth and other delivery options; and designing programs and policies that recognize and address structural racism, health equity, and inclusion.