Improving LARC Access for Urban Adolescents and Young Adults in the Pediatric Primary Care Setting

"The thing in my arm": Providing contraceptive services for adolescents in primary care

BACKGROUND

Due to high rates of unintended pregnancies in Delaware, the state launched a public health initiative in 2014 to increase access to contraceptive services.

OBJECTIVES

This study was designed to assess the practice-level barriers and facilitators to providing contraceptive care, particularly long-acting reversible contraceptives (LARCs), to adolescents in primary care settings.

DESIGN

This qualitative study was part of a larger process evaluation of the Delaware Contraceptive Access Now (DelCAN) initiative.

METHODS

In-depth, semi-structured qualitative interviews were conducted with 16 practice administrators at 13 adolescent-serving primary care sites across the state of Delaware. A process of open, axial, and selective coding was used to analyze the data.

RESULTS

Despite the interest in LARC among their adolescent patients, administrators described numerous barriers to providing LARC for adolescents including confidentiality in patient visits and billing, preceptorship, and provider discomfort and assumptions about the need for contraception among adolescent patients.

CONCLUSION

Findings from this study reveal substantial barriers to providing contraception to adolescents, even in primary care practices that were committed to comprehensive contraceptive access for their adolescent patients. This study supports the need for contraceptive care to be integrated into training of pediatricians at every stage of their education. Such training must go beyond education about contraceptive options and the clinical skills necessary for LARC insertion and removal, to include counseling skills based in a reproductive justice framework. Additional changes in policies and practices for adolescent patients would further increase access to contraceptive care.

How Can We Address What We Do Not Measure? A Systematic Scoping Review of the Measurement and Operationalization of Social Determinants of Health Research on Long-Acting Reversible Contraceptive among Adolescents in the US

Teen pregnancy is often considered an adverse health outcome that accentuates gender inequities, diminishes opportunities, and jeopardizes the safety of adolescent and young adult birthing people. Long-Acting Reversible Contraceptives (LARC) have been hailed as a panacea for teen pregnancy. However, adolescents and emerging adults intersect with multiple assaults on their health and well-being due to gender inequity and racism. To establish equitable care, it is imperative to discern all barriers that influence their reproductive autonomy. This study evaluates the measurement, operationalization, and quality of research conducted on adolescents and emerging adults that analyzed the use of LARC within the social determinant of health framework (SDOH) in the US. SDOH were assessed using the Dahlgren and Whitehead model, and reports were analyzed using a modified version of the Joanna Briggs Institute (JBI) Critical Appraisal tools. Nineteen articles were included in this study. Researchers found the insufficient measurement of race, ethnicity, sexuality, and gender among studies on LARC and SDOH in adolescents and emerging adults. Future studies must measure a full range of identities in data collection to generate knowledge on the impact of SDOH and LARC use among diverse populations.

Pediatric Resident Perspectives on Long-Acting Reversible Contraception Training: A Cross-Sectional Survey of Accreditation Council for Graduate Medical Education Trainees

PURPOSE

Although pediatricians are primary care providers for most adolescents, pediatric residents receive limited training on long-acting reversible contraceptive (LARC) methods. This study aimed to characterize pediatric resident comfort with placing contraceptive implants and intrauterine devices (IUDs) and assess pediatric resident interest in obtaining this training.

METHODS

Pediatric residents in the United States were invited to participate in a survey assessing comfort with LARC methods and interest in LARC training during pediatric residency. Bivariate comparisons used Chi-square and Wilcoxon rank sum testing. Multivariate logistic regression was used to assess associations between primary outcomes and covariates including geographic region, training level, and career plans.

RESULTS

Six hundred twenty seven pediatric residents across the United States completed the survey. Participants were predominantly female (68.4%, n = 429), self-identified their race as White (66.1%, n = 412), and anticipated a career in a subspecialty other than Adolescent Medicine (53.0%, n = 326). Most residents were confident counseling patients on the risks and benefits, side effects, and effective use of contraceptive implants (55.6%, n = 344) and both hormonal and nonhormonal IUDs (53.0%, n = 324). Few residents reported comfort with inserting contraceptive implants (13.6%, n = 84) or IUDs (6.3%, n = 39), with most of these respondents having learned these skills as a medical student. Most participants believed that residents should receive training on insertion of contraceptive implants (72.3%, n = 447) and IUDs (62.5%, n = 374).

DISCUSSION

Although most pediatric residents believe LARC training should be a component of pediatric residency training, few pediatric residents are comfortable with provision of this care.

Sexual Health and Relationship Abuse Interventions in Pediatric Primary Care: A Systematic Review

PURPOSE

Supporting adolescents in developing healthy relationships and promoting sexual and reproductive health (SRH) is an important responsibility of pediatric primary care providers. Less is known about evidence-based interventions in pediatric settings focused on healthy relationships and SRH.

METHODS

We conducted a systematic review to describe SRH and healthy relationship/adolescent relationship abuse (ARA) interventions for pediatric primary care over the past 20 years. Eligible articles were original research on an SRH-focused or ARA-focused intervention, conducted in-person within pediatric primary care or school-based health centers specifically for middle or high school-aged adolescents. Data abstracted from included articles included intervention description, content, delivery, evaluation design, and effectiveness of primary outcomes. Heterogeneous outcomes and evidence levels made conducting a meta-analysis infeasible.

RESULTS

Nineteen studies described 17 interventions targeting a variety of SRH and ARA topics (e.g., sexually transmitted infections, contraception, ARA). Interventions largely focused on screening/counseling adolescents (89%). Interventions generally were reported as being effective in changing adolescent health or practice-level outcomes.

DISCUSSION

This review provides preliminary evidence that SRH and ARA interventions in pediatric primary care settings can be effective in promoting adolescent health. Future work should consider ARA-specific prevention interventions, including parents in interventions, and strategies for implementation, dissemination, and scaling.

Are Illinois Contraceptive Providers Comfortable Providing Care to Adolescents? Results From a Statewide Provider Needs Assessment

OBJECTIVES

Legislation allows adolescents to access comprehensive contraceptive care; however, provider practices remain unclear. We examined predictors of provider knowledge and comfort surrounding the provision of contraceptive care to adolescents.

METHODS

We mailed a survey to Illinois contraceptive providers (n = 251). Study outcomes include 1) knowledge of adolescent consent laws, 2) comfort asking for time alone with adolescents, 3) comfort providing contraception to adolescents without parental consent, and 4) comfort providing long-acting reversible contraception (LARC) to adolescents without parental consent. Using multivariable logistic regression, we estimated adjusted odds ratios (aORs) and 95% confidence intervals (CIs).

RESULTS

Most providers are knowledgeable of consent laws (90%) and report being comfortable asking for time alone with adolescents (94%) and comfortable providing contraception to adolescents without parental consent (88%). Having a large proportion of patients who are eligible for family planning services was associated with increased comfort asking for time alone with adolescents (aOR, 7.03; 95% CI, 1.58-31.3) and providing contraception to adolescents (aOR, 4.0; 95% CI, 1.4-11.1). Only one-half (54%) were comfortable providing LARC methods to adolescents, with higher comfort among providers who: received more than 2 days of formal family planning training (aOR, 2.77; 95% CI, 1.2-6.2), specialized in obstetrics-gynecology (aOR, 5.64; 95% CI, 2.1-15.1), and had a patient population with more than 50% patients from minoritized racial/ethnic groups (aOR, 2.9; 95% CI, 1.2-6.6).

CONCLUSIONS

Although knowledge of consent laws was high, gaps remain. Only one-half of our sample indicated comfort with the provision of LARC methods without parental consent. Additional efforts to increase provider comfort with all contraceptive methods and training on adolescent-centered practices may be required to meet the needs of adolescent patients.

Pediatric Practice Transformation and Long-Acting Reversible Contraception (LARC) Use in Adolescents

OBJECTIVE

Long acting reversible contraceptives (LARCs) are recommended as highly effective for adolescents. Although the uptake of LARCs has increased, overall use remains low due to barriers for both providers and patients. We evaluate whether pediatric medical home transformation, including implant placement in pediatrics, may increase LARC use or decrease adolescent pregnancy rates.

METHODS

Retrospective interrupted time-series analysis of adolescents ages 11 to 19 years at 2 pediatric practices in academically affiliated community health centers during 2005-2015. The intervention practice underwent medical home transformation including team-based care with family planning and health coaching, youth-friendly policies, and contraceptive implant placement. The control practice continued usual care. Differential changes in population event rates were evaluated using a segmented longitudinal regression model.

RESULTS

The study population included 4946 adolescent females at the intervention practice and 1992 at the control practice. Following practice transformation, LARC use increased significantly more at the intervention practice compared to the control (1.73 versus 0.28 events per 1000 patients quarterly P = 0.004). Pregnancy rate declined at both practices without temporal correlation to the LARC intervention. During the medical home transformation period, the intervention practice showed a greater decline in pregnancy rate, though this difference did not reach statistical significance (2.01 versus 0.81 events per 1000 patients quarterly P = 0.090).

CONCLUSIONS

Adolescents had higher LARC use where implant placement was offered within the pediatric practice as part of medical home transformation. Although LARC did not impact pregnancy rate, the process of practice transformation may have accelerated its decline through heightened adolescent health focus.

What Does He Think? Male Knowledge and Attitudes Regarding Long-Acting Reversible Contraception

STUDY OBJECTIVE

Contraceptive counseling, especially regarding long-acting reversible contraception (LARC), has generally been directed at women. However, male partners and peers may influence contraceptive decision making. As there were no published studies examining male perceptions of LARC in the United States, this study investigated male knowledge and attitudes regarding LARC.

DESIGN

An anonymous electronic cross-sectional survey collecting qualitative and quantitative data was administered from May to September 2018.

SETTING

Participants were recruited via university e-mail listservs and in-person at a campus student organization fair at the University of Illinois at Chicago in Chicago (UIC), Illinois.

PARTICIPANTS

University students identifying as male and 18-24 years of age.

INTERVENTIONS

None.

MAIN OUTCOMES MEASURED

Knowledge of LARC, perceptions of LARC, interest in learning about LARC.

RESULTS

Participants (n = 97) were predominantly heterosexual (83.5%) men. Of those who were sexually active (63.9%), 98.4% reported female partners trying to avoid pregnancy. The most commonly used methods of contraception were oral contraceptive pills (48.4%) and/or condoms (80.6%). The majority (76.3%) of participants had not heard of LARC. Absence of prior LARC use by a partner was associated with knowledge deficits about LARC (odds ratio = 0.26, 95% confidence interval = 0.70-1.00); however, this association was not seen with other contraceptive methods. Participants familiar with LARC were generally neutral to very supportive of LARC (87.0%). Additionally, 80.4% of participants were interested in learning more about LARC.

CONCLUSION

Males 18-24 years of age had limited knowledge of LARC, with an interest in learning more about LARC. This information could shape interventions to bridge knowledge gaps, ultimately helping women to make supported contraceptive choices.

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.

Association of rural location and long acting reversible contraceptive use among Oregon Medicaid recipients

OBJECTIVE

To evaluate whether the use of long-acting, reversible contraception (LARC) is equitably accessible to Medicaid recipients in rural and urban areas. We also determined whether women's health specialists' availability was associated with the type of LARC used.

STUDY DESIGN

We used claims data for 242,057 adult women who were continuously enrolled in Oregon Medicaid for at least one year and at risk of pregnancy from January 1, 2015, through December 31, 2017 to assess the association between LARC utilization and (1) rurality and (2) provider supply. Our primary analysis included 430,918 person-years. Regression models adjusted for patient age, whether the patient was newly eligible for Medicaid due to Medicaid expansion, and health status. We also examined differences in the caseload of implants and IUD by provider type (women's health specialist vs other).

RESULTS

Among all women, 11.6% had at least one claim indicating LARC use. There was no significant difference in overall LARC use by location (urban residence +0.66%, 95% CI [-0.12%, 1.43%]), although urban residents were slightly more likely to have an IUD (+0.72%, 95% CI [0.11%, 1.33%]). An increase of one women's health specialty provider per 10,000 women was associated with a 0.14 percentage point increase in the rate of IUD utilization (95% CI: 0.02, 0.26). Compared to other providers, women's health specialty providers supplied 62% of all IUDs and 43% of all implants.

CONCLUSION

Among Oregon's Medicaid enrollees, LARC is equitably used in rural areas; however, IUD use is slightly more frequent in urban areas.

Long-acting reversible contraception side effect management

PURPOSE OF REVIEW

Long-acting reversible contraception (LARC) is increasingly used by adolescents and young adults (AYAs). Subsequent to LARC insertion, AYAs are presenting to their primary care providers with LARC concerns. This article seeks to equip primary care clinicians with the tools necessary to assess and manage common LARC-associated side effects.

RECENT FINDINGS

Side effects are common with progestin-only LARC, and can precipitate early discontinuation of an otherwise effective, low-maintenance form of contraception. Abnormal uterine bleeding, pelvic pain, acne, and weight change are often cited as progestin-only LARC side effects, yet the causes are poorly understood despite extensive research. While most side effects improve with time, therapeutic interventions are available for patients with undesirable side effects that prefer medical management. Research emphasizes the importance of proper patient counseling and clinical follow-up.

SUMMARY

Counseling remains essential in the management of LARC-associated side effects. However, options are available to temporarily mitigate such side effects and increase LARC satisfaction. While these therapeutic options are prescribed based on expert opinion, such regimens remain inadequately studied in AYA populations.

Chlamydia Infection Among Adolescent Long-Acting Reversible Contraceptive and Shorter-Acting Hormonal Contraceptive Users Receiving Services at New York City School-Based Health Centers

STUDY OBJECTIVE

One concern regarding long-acting reversible contraceptive (LARC) use among female adolescents is the potential for sexually transmitted infection acquisition. Few studies investigate chlamydia infection among adolescent LARC users compared with other hormonal contraceptive method (non-LARC) users. We hypothesized that incident chlamydia infection would be similar in these 2 groups and that it would not be associated with adolescent LARC use.

DESIGN, SETTING, AND PARTICIPANTS

Secondary data analysis of electronic health records of adolescents who started using LARC (n = 152) and non-LARC methods (n = 297) at 6 New York City school-based health centers between March 2015 and March 2017.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Demographic characteristics, sexual risk factors, and occurrence of chlamydia infection over a period of 1 year were compared in the 2 groups using χ² tests and t tests. Multivariable logistic regression was used to test the association between LARC use and chlamydia infection adjusting for relevant covariates.

RESULTS

Among 422 adolescent patients tested the year after method initiation, 48 (11.4%) had at least 1 positive chlamydia test. The proportions of LARC users and non-LARC users with chlamydia infection were not statistically significantly different (10.9% vs 11.6%; P = .82). Multivariable analysis showed that LARC use was not associated with greater chlamydia risk (adjusted odds ratio, 0.84; 95% confidence interval, 0.41-1.43).

CONCLUSION

Adolescent LARC users did not have significantly higher chlamydia infection occurrence compared with non-LARC users the year after method initiation. Concern for chlamydial infection should prompt recommending condom use but should not be a barrier to recommending adolescent LARC use.