The impact of an IUD and implant intervention on dual method use among young women: Results from a cluster randomized trial

Long-acting reversible contraception and condom use: A cohort study of female adolescents and young adults in New York City

OBJECTIVES

This study aimed to determine whether condom use varied between adolescents and young women using long-acting reversible contraception (LARC) vs non-LARC hormonal methods and assess if the initiation of LARC was associated with lower condom use.

STUDY DESIGN

This study used data from a large longitudinal study of sexually active females aged 13-25 years. Questionnaires assessed contraception, condom use, sexual history, and partner characteristics at the baseline visit and every 6 months. Log-binomial regression analyses examined associations between hormonal contraceptive methods and condom use, and the moderating effects of age and number of sexual partners. Exploratory analyses compared condom use based on partner characteristics.

RESULTS

Of 1512 participants, 1116 reported LARC or non-LARC hormonal method use during any study visit. Among baseline and new LARC users, 75.7% and 84.7% reported intrauterine device (IUD) use, respectively. Condom use at baseline among hormonal non-LARC users (37.5%) was significantly higher (p < 0.01) than LARC users (23.5%). Condom use among LARC vs non-LARC users was moderated by age in that LARC was associated with lower condom use among participants aged 13-18 years, but not those aged 19-25 years. Number of sexual partners was not a significant moderator. Among participants with increased sexually transmitted infection (STI) risk based on partner characteristics, LARC users had lower condom use compared to non-LARC users.

CONCLUSIONS

Condom discontinuation was common following initiation of LARC and hormonal non-LARC methods. However, condom use was lower in LARC users at baseline, among younger adolescents, and if partners had risk factors for STIs.

IMPLICATIONS

Condom discontinuation following initiation of highly effective contraception increases the risk of STI. Young women using LARC may be at greater risk than non-LARC users given lower condom use despite having partners with risk factors for STIs. Condom use counseling for STI protection is critical for adolescents.

Dual Protection Messaging for Adolescents and Young Adults in the Setting of Over-the-Counter Hormonal Contraception: A Human-Centered Design Approach

STUDY OBJECTIVE

To use human-centered design approaches to engage adolescents and young adults in the creation of messages focused on dual method use in the setting of over-the-counter hormonal contraception access DESIGN: Baseline survey and self-directed workbooks with human-centered design activities were completed. The workbooks were transcribed and analyzed using qualitative methods to determine elements of the communication model, including sender, receiver, message, media, and environment.

SETTING

Indiana and Georgia PARTICIPANTS: People aged 14-21 years in Indiana and Georgia INTERVENTIONS: Self-directed workbooks MAIN OUTCOME MEASURES: Elements of the communication model, including sender, receiver, message, media, and environment RESULTS: We analyzed 54 workbooks, with approximately half from each state. Stakeholders self-identified as female (60.5%), white (50.9%), Hispanic (10.0%), sexually active (69.8%), and heterosexual (79.2%), with a mean age of 18 years. Most strongly agreed (75.5%) that they knew how to get condoms, but only 30.2% expressed the same sentiment about hormonal contraception. Exploration of the elements of the communication model indicated the importance of crafting tailored messages to intended receivers. Alternative terminology for dual protection, such as "Condom+____," was created.

CONCLUSION

There is a need for multiple and diverse messaging strategies about dual method use in the context of over-the-counter hormonal contraception to address the various pertinent audiences as this discussion transitions outside of traditional clinical encounters. Human-centered design approaches can be used for novel message development.

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.

Primary Contraceptive Method use and Sexually Transmitted Infections in a Nationally Representative Sample of Young Women

STUDY OBJECTIVE

Rates of sexually transmitted infections (STIs) in the United States have increased for the sixth consecutive year. Young people ages 15-24 account for over half of all new infections despite comprising only a quarter of the sexually active population. A potential explanation for this is the increased use of long-acting reversible contraceptives, (LARCs) which could result in lower condom use and/or increased sexual risk-taking due to higher pregnancy prevention efficacy.

DESIGN

This paper uses the National Survey of Family Growth to examine the relationship between primary contraceptive method use among young women ages 15-24 and STI treatment in the past year, as well as the extent to which this association is mediated by relationship status and frequency of condom use.

RESULTS

Findings did not show differences in STI treatment in the past year by primary contraceptive method, indicating that LARC use among young women does not equate to increased STI risk. Findings did show that young women who had been in casual-only relationships or a mix of relationship types in the past year were more likely to have been treated for an STI than young women in serious or dating-only relationships, regardless of the primary method used. Additionally, young women who used condoms "some" of the time were more likely to have been treated for an STI compared with women who used condoms "all" or "most" of the time. This association was mediated by relationship status (P = .05).

CONCLUSION

Findings suggest that efforts to address the growing STI burden should be directed at providing comprehensive, gender-equitable sexual health education that enables young people to engage in healthy relationships and consistent condom use.

Are LARC Users Less Likely to Use Condoms? An Analysis of U.S. Women Initiating LARC in 2008-2018

INTRODUCTION

Public health professionals have raised concern that increased use of long-acting reversible contraceptives (LARC) could raise women's risk for sexually transmitted infections (STIs), because LARC's superior pregnancy protection may decrease women's motivation to use a barrier method for supplemental pregnancy prevention. This study uses population-based data to examine whether condom use is lower, particularly among young women who are at increased STI risk, after initiating LARC versus moderately effective methods.

METHODS

With the 2011-2019 data files of the National Survey of Family Growth, we examine the percent of sexually active months with condom use in the year after LARC or moderately effective method initiation for a nationally representative sample of 2,018 women aged 15-44 years. Multinomial logistic models regressed condom use on method type and age group, as well as their interaction, while adjusting for key confounders.

RESULTS

The unadjusted likelihood of any condom use is substantially lower among women who initiated LARC versus moderately effective methods (12% vs. 37%), and this difference is greater among younger versus older women. After accounting for differences in women's reproductive and sociodemographic profiles, however, a statistically significant difference in condom use by method initiated remains only for those aged 20-34 years.

CONCLUSIONS

Crude estimates suggest that condom use is lower after initiating LARC versus moderately effective methods, especially among young women. After accounting for the confounding effects of LARC users' distinct profiles-particularly in terms of parity and teenage childbearing-the difference is decreased overall and no longer significant for adolescent women. Overall results indicate a need for new STI prevention strategies and policies that emphasize the importance of dual prevention for LARC users at risk of STIs.

Effectiveness and Harms of Contraceptive Counseling and Provision Interventions for Women : A Systematic Review and Meta-analysis

BACKGROUND

The effectiveness and harms of contraceptive counseling and provision interventions are unclear.

PURPOSE

To evaluate evidence of the effectiveness of contraceptive counseling and provision interventions for women to increase use of contraceptives and reduce unintended pregnancy, as well as evidence of their potential harms.

DATA SOURCES

English-language searches of Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, PsycINFO, SocINDEX, and MEDLINE (1 January 2000 to 3 February 2022) and reference lists of key studies and systematic reviews.

STUDY SELECTION

Randomized controlled trials of interventions providing enhanced contraceptive counseling, contraceptives, or both versus usual care or an active control.

DATA EXTRACTION

Dual extraction and quality assessment of studies; results combined using a profile likelihood random-effects model.

DATA SYNTHESIS

A total of 38 trials (43 articles [25 472 participants]) met inclusion criteria. Contraceptive use was higher with various counseling interventions (risk ratio [RR], 1.39 [95% CI, 1.16 to 1.72]; I ² = 85.3%; 10 trials), provision of emergency contraception in advance of use (RR, 2.12 [CI, 1.79 to 2.36]; I ² = 0.0%; 8 trials), and counseling or provision postpartum (RR, 1.15 [CI, 1.01 to 1.52]; I ² = 6.6%; 5 trials) or at the time of abortion (RR, 1.19 [CI, 1.09 to 1.32]; I ² = 0.0%; 5 trials) than with usual care or active controls in multiple clinical settings. Pregnancy rates were generally lower with interventions, although most trials were underpowered and did not distinguish pregnancy intention. Interventions did not increase risk for sexually transmitted infections (STIs) (RR, 1.05 [CI, 0.87 to 1.25]; I ² = 0.0%; 5 trials) or reduce condom use (RR, 1.03 [CI, 0.94 to 1.13]; I ² = 0.0%; 6 trials).

LIMITATION

Interventions varied; few trials were adequately designed to determine unintended pregnancy outcomes.

CONCLUSION

Contraceptive counseling and provision interventions that provide services beyond usual care increase contraceptive use without increasing STIs or reducing condom use. Contraceptive care in clinical practice could be improved by implementing enhanced contraceptive counseling, provision, and follow-up; providing emergency contraception in advance; and delivering contraceptive services immediately postpartum or at the time of abortion.

PRIMARY FUNDING SOURCE

Resources Legacy Fund. (PROSPERO: CRD42020192981).

Long-Acting Reversible Contraception, Condom Use, and Sexually Transmitted Infections: A Systematic Review and Meta-analysis

INTRODUCTION

Given mixed findings regarding the relationship between long-acting reversible contraception and condom use, this systematic review and meta-analysis synthesizes studies comparing sexually transmitted infection‒related outcomes between users of long-acting reversible contraception (intrauterine devices, implants) and users of moderately effective contraceptive methods (oral contraceptives, injectables, patches, rings).

METHODS

MEDLINE, Embase, PsycINFO, Global Health, CINAHL, Cochrane Library, and Scopus were searched for articles published between January 1990 and July 2018. Eligible studies included those that (1) were published in the English language, (2) were published in a peer-reviewed journal, (3) reported empirical, quantitative analyses, and (4) compared at least 1 outcome of interest (condom use, sexual behaviors other than condom use, sexually transmitted infection‒related service receipt, or sexually transmitted infections/HIV) between users of long-acting reversible contraception and users of moderately effective methods. In 2020, pooled ORs were calculated for condom use, chlamydia/gonorrhea infection, and trichomoniasis infection; findings for other outcomes were synthesized qualitatively. The protocol is registered on the International Prospective Register of Systematic Reviews (CRD42018109489).

RESULTS

A total of 33 studies were included. Long-acting reversible contraception users had decreased odds of using condoms compared with oral contraceptive users (OR=0.43, 95% CI=0.30, 0.63) and injectable, patch, or ring users (OR=0.58, 95% CI=0.48, 0.71); this association remained when limited to adolescents and young adults only. Findings related to multiple sex partners were mixed, and only 2 studies examined sexually transmitted infection testing, reporting mainly null findings. Pooled estimates for chlamydia and/or gonorrhea were null, but long-acting reversible contraception users had increased odds of trichomoniasis infection compared with oral contraceptive users (OR=2.01, 95% CI=1.11, 3.62).

DISCUSSION

Promoting condom use specifically for sexually transmitted infection prevention may be particularly important among long-acting reversible contraception users at risk for sexually transmitted infections, including adolescents and young adults.

Condom use in young women using long-acting reversible contraception (LARC): a qualitative study

Young women in Australia disproportionately experience unintended pregnancy and sexually transmissible infections (STIs). As the promotion of highly effective pregnancy prevention methods such as long-acting reversible contraception (LARC) increases, concurrent use of condoms with LARC remains optimal for pregnancy and STI prevention. There is little data exploring condom use behaviour in young Australian women using LARC. In this qualitative study we interviewed twenty women using LARC about their experiences of making decisions regarding condom use. We used inductive thematic analysis to identify factors influencing participant decision-making. We found that while LARC had an impact on condom use and sexual practices, decisions regarding condom use were influenced by multiple factors including mood, menstrual changes related to LARC, and relationship dynamics. Participants' views of 'safe sex' extended beyond pregnancy and STI protection, to include desired outcomes such as pleasure, consent and communication. Access to STI testing and treatment was key to how participants managed STI risk. Findings highlight the need for a more comprehensive approach to safer sex health promotion, and the importance of ensuring STI testing and treatment services continue to be available and accessible to all young people.

Intrauterine Devices and Sexually Transmitted Infection among Older Adolescents and Young Adults in a Cluster Randomized Trial

STUDY OBJECTIVE

Provider misconceptions regarding intrauterine device (IUD) safety for adolescents and young women can unnecessarily limit contraceptive options offered; we sought to evaluate rates of Neisseria gonorrhoeae or Chlamydia trachomatis (GC/CT) diagnoses among young women who adopted IUDs.

DESIGN

Secondary analysis of a cluster-randomized provider educational trial.

SETTING

Forty US-based reproductive health centers.

PARTICIPANTS

We followed 1350 participants for 12 months aged 18-25 years who sought contraceptive care.

INTERVENTIONS

The parent study assessed the effect of provider training on evidence-based contraceptive counseling.

MAIN OUTCOME MEASURES

We assessed incidence of GC/CT diagnoses according to IUD use and sexually transmitted infection risk factors using Cox regression modeling and generalized estimating equations.

RESULTS

Two hundred four participants had GC/CT history at baseline; 103 received a new GC/CT diagnosis over the 12-month follow-up period. IUDs were initiated by 194 participants. Incidence of GC/CT diagnosis was 10.0 per 100 person-years during IUD use vs 8.0 otherwise. In adjusted models, IUD use (adjusted hazard ratio [aHR], 1.31; 95% confidence interval [CI], 0.71-2.40), adolescent age (aHR, 1.28; 95% CI, 0.72-2.27), history of GC/CT (aHR, 1.23; 95% CI, 0.75-2.00), and intervention status (aHR, 1.12; 95% CI, 0.74-1.71) were not associated with GC/CT diagnosis; however, new GC/CT diagnosis rates were significantly higher among individuals who reported multiple partners at baseline (aHR, 2.0; 95% CI, 1.34-2.98).

CONCLUSION

In this young study population with GC/CT history, this use of IUDs was safe and did not lead to increased GC/CT diagnoses. However, results highlighted the importance of dual sexually transmitted infection and pregnancy protection for participants with multiple partners.

The Association Between Nonbarrier Contraceptive Use and Condom Use Among Sexually Active Latina Adolescents

PURPOSE

This study aimed to determine the association between use of highly effective methods of nonbarrier contraception and condom use in a sample of Latina adolescents and whether the change to a more effective method of nonbarrier contraception is associated with a change in condom use.

METHODS

As part of a larger study, 442 sexually active Latina adolescents aged 14-18 years were surveyed immediately before an appointment with a medical care provider at a school-based health center and 3 months later. Ordinal logistic and linear regression were used in the analysis of cross-sectional and longitudinal data to assess the relationship between patterns of nonbarrier contraception and condom use.

RESULTS

The use of all types of nonbarrier methods of contraception was significantly associated with decreased condom use. Change over time from a less effective to a more effective nonbarrier method of contraception was also associated with a decrease in condom use. Greater number of sexual encounters was associated with lower the frequency of condom use.

CONCLUSIONS

The use of highly effective methods of nonbarrier contraception was associated with reduced frequency of condom use. This highlights the need to promote condom use concurrently with nonbarrier methods of contraception to improve protection against both pregnancy and STIs.

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

STUDY OBJECTIVES

Many pediatric providers serving adolescents are not trained to offer comprehensive contraceptive services, including intrauterine devices (IUDs) and implants, despite high safety and satisfaction among adolescents. This study assessed an initiative to train providers at school-based health centers (SBHCs) to offer students the full range of contraceptive methods.

DESIGN

Surveys were administered at baseline pre-training and at follow-up 3 months post-training. Data were analyzed using generalized estimating equations for clustered data to examine clinical practice changes.

SETTING

Eleven contraceptive trainings at SBHCs across the United States from 2016-2019.

PARTICIPANTS

A total of 260 providers from 158 SBHCs serving 135,800 students.

INTERVENTIONS

On-site training to strengthen patient-centered counseling and to equip practitioners to integrate IUDs and implants into contraceptive services.

MAIN OUTCOME MEASURES

The outcomes included counseling experience on IUDs and implants, knowledge of patient eligibility, and clinician method skills.

RESULTS

At follow-up, providers were significantly more likely to report having enough experience to counsel on IUDs (adjusted odds ratio [aOR], 4.08; 95% confidence interval [CI], 2.62-6.36]) and implants (aOR, 3.06; 95% CI, 2.05-4.57). Provider knowledge about patient eligibility for IUDs, including for adolescents, increased (P < .001). Providers were more likely to offer same-visit IUD (aOR, 2.10; 95% CI, 1.41-3.12) and implant services (aOR, 1.66; 95% CI, 1.44-1.91). Clinicians' skills with contraceptive devices improved, including for a newly available low-cost IUD (aOR, 2.21; 95% CI, 1.45-3.36).

CONCLUSIONS

Offering evidence-based training is a promising approach to increase counseling and access to comprehensive contraceptive services at SBHCs.

Identifying Missed Opportunities for Human Immunodeficiency Virus Pre-exposure Prophylaxis During Preventive Care and Reproductive Visits in Adolescents in the Deep South

BACKGROUND

Pre-exposure prophylaxis (PrEP) for individuals at significant risk for Human Immunodeficiency Virus acquisition is approved for individuals weighing at least 35 kg by the Food and Drug Administration. This cross-sectional study analyzed indications for PrEP in a clinical setting.

METHODS

There were 429 charts reviewed from adolescents between 15 and 21 years old seen for preventive care visits at an adolescent primary care center in the Deep South during a 1-year timeframe. Univariate and multivariable regression analyses were completed to identify factors associated with indications for PrEP.

RESULTS

Forty-four percent of 429 adolescents (between 15 and 21 years) had a PrEP indication; 77% were women and 95% heterosexual. Significant factors associated with an indication for PrEP included living with a nonparent or nonrelative and polysubstance use. No adolescents with an indication for PrEP were prescribed PrEP. A sensitivity analysis comparing indications for PrEP between the 2014 and 2017 The Centers for Disease Control and Prevention Guidelines revealed no significant differences in percent with an indication (44.5% vs. 42.8%) or factors associated with indications.

CONCLUSIONS

Pre-exposure prophylaxis as a biomedical tool for adolescents and young adults (AYAs) may remain underutilized. A key factor in improving utilization involves providers being able to recognize AYAs who may have an indication for PrEP with a specific focus on those AYAs who do not live in households with parents or a surrogate family member and those who are polysubstance users.

Implementation science: Scaling a training intervention to include IUDs and implants in contraceptive services in primary care

Building capacity for contraceptive services in primary care settings, including for intrauterine devices (IUDs) and implants, can help to broaden contraceptive access across the US. Following a randomized trial in family planning clinics, we brought a provider training intervention to other clinical settings including primary care in all regions. This implementation science study evaluates a national scale-up of a contraceptive training intervention to varied practice settings from 2013 to 2019 among 3216 clinic staff serving an estimated 1.6 million annual contraceptive patients. We measured providers' knowledge and clinical practice changes regarding IUDs and implants using survey data. We estimated the overall intervention effect, and its relative effectiveness in primary care settings, with generalized estimating equations for clustered data. Patient-centered counseling improved, along with comfort with method provision and removal. Provider knowledge increased (p < 0.001), as did evidence-based counseling for IUDs (aOR 3.3 95% CI 2.8-3.9) and implants (aOR 3.5, 95% CI 3.0-4.1), and clinician competency in copper and levonorgestrel IUDs (aORs 1.8-2.6 95% CIs 1.5-3.2) and implants (aOR 2.4 95% CI 2.0-2.9). While proficiency was lower initially in primary care, gains were significant and at times greater than in Planned Parenthood health clinics. This intervention was effectively scaled, including in primary care settings with limited prior experience with these methods. Recent changes to Title X family planning funding rules exclude several large family planning providers, shifting greater responsibility to primary care and other settings. Scaling effective contraceptive interventions is one way to ensure capacity to offer patients full contraceptive services.

Condom use among young women in Australia using long-acting reversible contraceptives or other hormonal contraceptives

Background Dual condom and long-acting reversible contraceptive (LARC) or non-LARC hormonal contraceptive use is the most effective way to protect against unwanted pregnancy and sexually transmissible infections (STIs). This study aimed to determine whether condom use varied between users of LARC and non-LARC hormonal contraceptives and explore their motivations for condom use.

METHODS

Women aged 16-24 years attending a sexual and reproductive health centre in Melbourne, Australia, completed a survey about contraceptives and sexual practices. The proportion of LARC and non-LARC hormonal contraceptive users using condoms was calculated and logistic regression compared condom use between the two groups. Condom use was based on frequency of use and coded as a binary variable 'never, not usually or sometimes' versus 'usually or always'.

RESULTS

In all, 294 (97%) women participated in the study; 23.8% (95% confidence interval (CI) 19.0-29.1%) used LARC and 41.7% (95% CI 36.0-47.6%) used non-LARC hormonal contraceptives. Condom use was reported by 26.1% (95% CI 16.3-38.1%) of LARC users and by 27.8% (95% CI 19.9-37.0%) of non-LARC hormonal contraceptive users. There was no difference in condom use between groups (odds ratio (OR) 0.9; 95% CI 0.4-1.9). Condom use reduced with increasing relationship length (≥6 months vs no relationship: OR 0.2; 95% CI 0.1-0.6). Non-LARC hormonal contraceptive users were more motivated to use condoms if worried about pregnancy than LARC users (62.8% vs 47.8%; P = 0.04).

CONCLUSION

Condom use was low and similar between users of LARC and non-LARC hormonal contraceptives, and was associated with the length of the relationship. These results highlight the need to promote condom use when prescribing LARCs and non-LARC hormonal contraceptives to reduce the risk of STIs.

Positive Deviance for Dual-Method Promotion among Women in Uganda: A Qualitative Study

Dual-method use is the most reliable form of protection against unintended pregnancies and human immunodeficiency virus/sexually transmitted infections (HIV/STIs). Although dual-method use remains uncommon among women in stable relationships, some women do practice it. In this study, we explored the barriers that make dual-method use rare and the behaviors of women who practice dual-method use using a positive deviance framework in Uganda. We screened 150 women using highly effective contraceptives at five health facilities. We identified nine women who practiced dual-method use and 141 women who did not. In a qualitative study, we conducted in-depth interviews with all nine women practicing dual-method use and 10 women randomly selected out of the 141 who did not. We performed a thematic analysis using the positive deviance framework. Regardless of practicing dual-method use or not, women faced perceived barriers against dual-method use, such as partner’s objection, distrust, shyness about introducing condoms into marital relationships, and limited access to condoms. However, women practicing dual-method use had higher levels of risk perception about unintended pregnancies and HIV/STIs. They also engaged in unique behaviors, such as influencing their partners’ condom use by initiating discussions, educating their partners on sexual risks and condom use, and obtaining condoms by themselves. These findings will be useful in developing effective community-led and peer-based interventions promoting dual-method use to reduce the dual burden of unintended pregnancies and HIV/STIs among women in Uganda.

Impact of the Rochester LARC Initiative on adolescents' utilization of long-acting reversible contraception

BACKGROUND

Preventing unintended teen pregnancy is a national public health priority, and increasing access to long-acting reversible contraception is part of the recommended strategy for the achievement of this goal. Nevertheless, adolescent long-acting reversible contraceptive use across the nation has remained low, even after national and state-level programs increased coverage for no-cost contraception. One persistent barrier is misinformation about the safety, efficacy, and availability of long-acting reversible contraception for teens. To overcome this barrier, the Hoekelman Center, in collaboration with multiple partners, designed and implemented a community health intervention. The Greater Rochester LARC Initiative disseminated accurate information about contraceptive options with a focus on long-acting reversible methods by delivering interactive lunch-and-learn talks throughout the Greater Rochester, NY area. Audiences included both healthcare providers and adults who work with adolescents in nonmedical community-based organizations.

OBJECTIVE

The primary purpose of this study was to evaluate the community-level impact of the Greater Rochester LARC Initiative on adolescent long-acting reversible contraception use.

STUDY DESIGN

Our evaluation design was pre-post with a nonrandomized control group. We used publicly available Youth Risk Behavior Surveillance System data from the years 2013, 2015, and 2017 for our intervention site of Rochester, NY, New York City, New York State, and the United States overall. These years cover the time before and after the intervention began in 2014. We used z-statistics in investigating the hypothesis that long-acting reversible contraception use increased more in Rochester than in the comparison populations.

RESULTS

Between 2013 and 2017, long-acting reversible contraception use in Rochester rose from 4-24% of sexually active female high school students (P<.0001). Over the same period, long-acting reversible contraception use in New York State rose from 1.5-4.8%, and in New York City long-acting reversible contraception use rose from 2.7-5.3%. In the United States overall, long-acting reversible contraception use rose from 1.8-5.3%. Thus, the increase in long-acting reversible contraception use in Rochester was larger than the secular trend in the control groups (P<.0001).

CONCLUSION

Adolescent long-acting reversible contraceptive use increased significantly more in Rochester than in the nation as a whole. This finding is consistent with a substantial positive impact of the Greater Rochester LARC Initiative, which implies that similar interventions could be useful complements to unintended teen pregnancy prevention programs elsewhere and might be helpful more generally for the diffusion of evidence-based health-improvement practices.

Positive deviance for dual-method promotion among women in Uganda: study protocol for a cluster randomized controlled trial

Background

Dual-method use is known as the most reliable protection against unintended pregnancies and sexually transmitted infections, including HIV. However, it is not commonly used in sub-Sharan Africa, especially among women using highly effective contraceptives. This article describes a protocol to evaluate the effect of an intervention formulated under the positive deviance approach for promoting dual-method use in Uganda.

Methods

A total of 150 women will be interviewed using a structured questionnaire to find those practicing dual-method use. In-depth interviews will then be conducted with all women using the dual method and 10 women using only highly effective contraceptives to identify their unique practice. Then, a cluster randomized controlled trial will be conducted to examine the effect of an intervention formulated under the positive deviance approach on dual-method uptake and adherence. Twenty health facilities will be randomized to an intervention or control arm and 480 women will be enrolled in each group. The participants will be followed up for 8 months.

Discussion

This trial focuses on women who already adapted dual-method use and identifies their unique solutions to promote dual-method use. This trial could tackle barriers for dual-method use, which expert outsiders may fail to recognize, by analyzing and promulgating their unique behaviors. This study could provide evidence that the positive deviance approach can address unintended pregnancies and sexually transmitted infections as well as other health problems which usual approaches have failed to address.

Trial registration

UMIN-CTR Clinical Trial, UMIN000037065. Registered on 14 June 2019.

Condom use and incident sexually transmitted infection after initiation of long-acting reversible contraception

BACKGROUND

Use of more effective contraception may lead to less condom use and increased incidence of sexually transmitted infection.

OBJECTIVE

The objective of this study was to compare changes in condom use and incidence of sexually transmitted infection acquisition among new initiators of long-acting reversible contraceptives to those initiating non-long-acting reversible contraceptive methods.

STUDY DESIGN

This is a secondary analysis of the Contraceptive CHOICE Project. We included 2 sample populations of 12-month continuous contraceptive users. The first included users with complete condom data (baseline, and 3, 6, and 12 months) (long-acting reversible contraceptive users: N = 2371; other methods: N = 575). The second included users with 12-month sexually transmitted infection data (long-acting reversible contraceptive users: N = 2102; other methods: N = 592). Self-reported condom use was assessed at baseline and at 3, 6, and 12 months following enrollment. Changes in condom use and incident sexually transmitted infection rates were compared using χ² tests. Risk factors for sexually transmitted infection acquisition were identified using multivariable logistic regression.

RESULTS

Few participants in either group reported consistent condom use across all survey time points and with all partners (long-acting reversible contraceptive users: 5.2%; other methods: 11.3%; P < .001). There was no difference in change of condom use at 3, 6, and 12 months compared to baseline condom use regardless of method type (P = .65). A total of 94 incident sexually transmitted infections were documented, with long-acting reversible contraceptive users accounting for a higher proportion (3.9% vs 2.0%; P = .03). Initiation of a long-acting reversible contraceptive method was associated with increased sexually transmitted infection incidence (odds ratio, 2.0; 95% confidence ratio, 1.07-3.72).

CONCLUSION

Long-acting reversible contraceptive initiators reported lower rates of consistent condom use, but did not demonstrate a change in condom use when compared to preinitiation behaviors. Long-acting reversible contraceptive users were more likely to acquire a sexually transmitted infection in the 12 months following initiation.