Addressing Administrative and System-Level Challenges to Implementation of Long-Acting Reversible Contraceptives in Adolescent Medicine and Pediatric and Adolescent Gynecology Practices: A Qualitative Study

Study ObjectiveAdolescents use long-acting reversible contraceptive (LARC) methods less than adults. Practices that specialize in adolescent medicine, including Adolescent Medicine (AM) and Pediatric and Adolescent Gynecology (PAG), may be well positioned to help improve adolescent access to these methods. We describe administrative and system-level barriers encountered when implementing LARCs for adolescents and strategies that practices have successfully used to address these barriers.Design/Setting/ParticipantsWe conducted a qualitative study with physicians and staff at AM and PAG practices that provide LARCs to adolescents.InterventionsSemi-structured telephone interviewsMain Outcome MeasuresInterview guides were based on the Consolidated Framework for Implementation Research (CFIR), an implementation science methodology designed to understand the following aspects of settings adopting new practices: innovation characteristics, external environment, institutional and practice settings, the stakeholders involved, and the implementation process.ResultsSeventeen interviews were performed. When examining administrative and system-level challenges encountered by interviewees, the four CFIR constructs identified most frequently were cost, readiness for implementation–available resources, planning, and engaging. Interviewees shared strategies used to overcome these common barriers, including for billing and working with insurance companies, space and equipment needed to introduce LARCs, scheduling and use of telemedicine, and staff training and engagement.ConclusionSites used many strategies to address these common challenges to implementation. Examples could help with implementation of LARC provision in practices serving adolescent populations.     

Barriers and Facilitators to Adolescents' Use of Long-Acting Reversible Contraceptives

Most pregnancies among teenagers are unintended and many can be attributed to contraception misuse or nonuse. The etonogestrel implant and intrauterine devices, referred to as long-acting reversible contraceptives, or LARCs, are the most effective reversible contraceptive methods. These methods are safe for use by adolescents, yet the number of LARC users remains low among adolescents in the United States. In this review we examine recent literature about barriers and facilitators to LARC use among adolescent women. Factors that influence decision-making and provision are organized into 4 categories: (1) cost and clinical operations; (2) adolescent awareness and attitudes; (3) confidentiality, consent, and parental attitudes; and (4) health care provider knowledge, attitudes, and counseling. Knowledge deficits and misconceptions among adolescents and their health care providers are key barriers to adolescent LARC use.     

Insurance Plan Adherence to Mandate for Long-Acting Reversible Contraceptives in a Large Pediatric Hospital Network

Study ObjectiveLong-acting reversible contraceptives (LARCs) are the most effective form of pregnancy prevention for sexually active adolescents, yet usage rates are low. The Affordable Care Act (ACA) mandated insurers cover LARCs without cost-sharing. Compliance with this policy is not well documented. This study assessed LARC coverage by insurers in a large pediatric health system.Design, Setting, Participants, and InterventionsBetween June and August 2016, LARC coverage was assessed through content reviews of insurance Web sites, formularies, and summaries of benefits for all Pennsylvania Medicaid plans and the top 20 commercial insurers for a large pediatric health system.Main Outcome MeasuresThe primary outcome was adherence to the ACA mandate for LARC coverage without cost-sharing.ResultsAmong the 37 plans (17 public, 20 private), 21 (56.8%) were adherent and 16 (43.2%) were nonadherent. Among nonadherent plans, 3 plans covered LARC services but required cost-sharing, whereas 13 did not cover LARC services at all. There was not a statistically significant difference in LARC coverage between public and private plans.ConclusionDespite the landmark ACA mandate, insurance coverage of LARCs in pediatric hospitals is low for young women among private and public insurers. Insurer failure to adhere to the ACA among pediatric patients represents a barrier to LARC access for those at high risk of unintended pregnancy.     

Prevalence and factors predictive of long-acting reversible contraceptive use in a tertiary hospital in urban Ghana

Abstract

Objective To determine the prevalence, socio-demographic and reproductive factors associated with long-acting reversible contraceptive (LARC) use among clients resorting to reversible birth control methods in a tertiary hospital in Ghana.

Methods Retrospective review of records of clients who opted for reversible family planning (FP) methods at Komfo Anokye Teaching Hospital, Kumasi, Ghana, from 1 July 2003 to 30 June 2008. We recorded data on their contraceptive history, and socio-demographic- and reproductive characteristics. Categorical variables were compared using the χ² test and factors associated with LARC uptake examined by binomial regression with a log-link function to estimate relative risks (RRs) and 95% confidence intervals (CIs).

Results Of 5946 clients who opted for reversible contraception, 71% chose LARCs, and the remaining 29% chose shorter-acting contraceptives. LARCs were employed mainly by women with more living children (p trend < 0.001) who had previously used LARCs (adjusted RR: 1.49; 95% CI: 1.39–1.60). Over half of non-contraceptive users started with LARCs while 27% of women switched from shorter-acting contraceptives to LARCs.

Conclusion The prevalence of LARC uptake was much higher than the national average. Significant factors associated with current LARC use were the number of surviving children and previous LARC use.     

Profile of long-acting reversible contraception users in Europe

Objectives?To assess the profile of long-acting reversible contraceptives (LARCs) users in Europe.

Methods?A random sample of women aged 15–49 years in 14 European countries (Germany, France, UK, Spain, Italy, Russian Federation, Estonia, Latvia, Lithuania, Austria, Czech Republic, Denmark, Norway, and Sweden) underwent web-based or computer-aided face-to-face interviews in June 2006. In this paper data pertaining to a subgroup of women using LARCs are presented.

Results?A total of 11,490 women participated in the full study. Of these, 1,188 (10%) women were LARC (hormonal implant, injectables, levonorgestrel-releasing intrauterine system [LNG-IUS], copper intrauterine device [Cu-IUD]) users. The age of the LARC users exceeded 30 years for 57–91% of them. Furthermore, more than half of them found convenience an extremely important factor when selecting the LARC as a contraceptive method. As compared to those wearing a Cu-IUD, women using hormonal LARCs experienced fewer physical and emotional symptoms that appeared or worsened during menstruation.

Conclusions?LARCs have their place in the contraceptive market in Europe. The most popular LARCs among European women were the LNG-IUS and the Cu-IUD; both were mainly used by women who had children and had no wish to have more in the future.     

A Qualitative Study of Factors That Influence Contraceptive Choice among Adolescent School-Based Health Center Patients

Study ObjectiveLong-acting reversible contraceptive (LARC) methods can prevent teen pregnancy yet remain underutilized by adolescents in the United States. Pediatric providers are well positioned to discuss LARCs with adolescents, but little is known about how counseling should occur in pediatric primary care settings. We explored adolescent womens' attitudes and experiences with LARCs to inform the development of adolescent-centered LARC counseling strategies.DesignQualitative analysis of one-on-one interviews.SettingParticipants were recruited from 2 urban school-based, primary care centers.ParticipantsThirty adolescent women aged 14-18 years, diverse in race/ethnicity, and sexual experience.InterventionsInterviews were audio-recorded, transcribed, and coded using inductive and deductive coding.Main Outcome MeasureMajor themes were identified to integrate LARC-specific adolescent preferences into existing counseling approaches.ResultsParticipants (mean age, 16.2 years; range, 14-18 years) represented a diverse range of racial and/or ethnic identities. Half (15/30) were sexually active and 17% (5/30) reported current or past LARC use. Five themes emerged regarding key factors that influence LARC choice, including: (1) strong preferences about device-specific characteristics; (2) previous exposure to information about LARCs from peers, family members, or health counseling sessions; (3) knowledge gaps about LARC methods that affect informed decision-making; (4) personal circumstances or experiences that motivate a desire for effective and/or long-acting contraception; and (5) environmental constraints and supports that might influence adolescent access to LARCs.ConclusionWe identified 5 factors that influence LARC choice among adolescent women and propose a framework for incorporating these factors into contraceptive counseling services in pediatric primary care settings.     

Women's awareness of long-acting,reversible contraceptive methods (LARCs) in community family planning clinics and general practice

Objectives To investigate whether awareness and choice of long-acting reversible contraceptives (LARCs) of women attending a community family planning clinic differ from those of women seeing general practitioners (GPs).

Methods Information was collected from women in their reproductive years about their current contraceptive method, their awareness of LARCs and whether they felt well informed about their options. After additional information was provided the respondents were asked whether they would consider changing their method and if their GP offered this option.

Results Questionnaires were completed by 177 women attending a city-centre contraception and sexual health (CASH) clinic (n = 96) and a GP's surgery in a neighbouring city (n = 81). Forty percent of women in the CASH cohort and 6% in the primary care group were using LARCs. Women attending the CASH service were more aware of their contraceptive options and felt better informed but less than 50% in either group had heard of the levonorgestrel-releasing intrauterine system. At least 50% of women would consider using a LARC yet few knew if their GP fitted/provided these methods.

Conclusion LARC usage was considerably higher in CASH services compared to primary care. Those providing contraceptive care should give up-to-date information covering all methods and referral to local specialist services, as appropriate.     

Barriers to Long-Acting Reversible Contraceptive Uptake Among Homeless Young Women

Study ObjectiveTo identify barriers to long-acting reversible contraception (LARC) uptake among homeless young women.DesignIn this mixed methods study surveys and guided interviews were used to explore women's contraceptive and reproductive experiences, interactions with the health care system, and their histories of homelessness.SettingAll surveys and interviews were conducted at a homeless drop-in center or shelter.ParticipantsFifteen women between 18 and 24 years of age with a past year history of homelessness.InterventionsNone.Main Outcome MeasuresPerceived barriers to contraceptive use, including knowledge and access barriers and interactions with the health care system around reproductive health.ResultsConfusion about the possibility of early termination of LARC, and the perception that providers deliberately withhold selective information about contraceptive options to bias contraceptive decision-making, were 2 key new findings. Women also reported interest in visual aids accompanying verbal contraceptive counseling. Pregnancy attitudes and history of reproductive and sexual coercion also influenced contraceptive decision-making and reported interest in LARC methods.ConclusionComprehensive counseling about all contraceptive options, including LARC, are important for targeting the perceived gaps in contraceptive education and care among homeless young women.     

Does Obesity Influence Body Mass Index Changes in Nulliparous Adolescent Users of Long-Acting Reversible Contraceptives?

ObjectivesTo compare body mass index (BMI) changes in adolescents using long-acting reversible contraceptives (LARCs), specifically, the etonogestrel subdermal implant (ENG-implant), levonorgestrel intrauterine device (LNG-IUD), and copper IUD (Cu-IUD), by initial BMI category from the time of LARC insertion to within 6-18 months after insertion.DesignThis was a single-center retrospective cohort study.Setting and ParticipantsWe reviewed electronic health records from our large health system to identify and follow a cohort of 196 adolescents aged 14-19 years with LARCs inserted from 2010 to 2016. We excluded adolescents with conditions or medications affecting weight, including childbirth.Main Outcome MeasureBMI change from LARC insertion to first BMI documented after 6-18 monthsResultsMean age was 17.2 ± 0.2 years; 59% of the cohort was Hispanic and 29% Black. Mean BMI was 26.4 ± 7.1 kg/m². Of the total cohort of adolescents, 51% were underweight/normal, 24% overweight, and 25% obese. Mean time to first BMI documented after LARC insertion was 10.1 ± 3.2 months. Mean BMI change for the total cohort was +0.73 ± 1.8 kg/m², indicating weight gain. Mean BMI change for the ENG-implant + LNG-IUD users (n = 127) was larger than for Cu-IUD users (n = 69) (+0.92 ± 1.9 kg/m² vs +0.37 ± 1.6 kg/m², respectively, P < .05). Two-way analysis of variance showed that both initial BMI category (P = .001) and type of LARC (P = .011) had an independent significant main effect on BMI change. A significant interaction effect (P = .017) showed that obese adolescents had a larger increase in BMI when they were using a progestin-releasing LARC, either ENG-implant or LNG-IUD, as compared to a Cu-IUD (P < .05).ConclusionAdolescents using progestin-releasing LARCs had a larger increase in BMI within 6-18 months after device insertion than those using Cu-IUDs. The disproportionate increase in BMI with progestin-releasing LARCs was primarily contributed by obese users.     

The effect of mobile video training for healthcare providers on long-acting reversible contraceptive (LARC) use among adolescents and young women

Study ObjectiveTo assess whether improving providers’ education by video training using a mobile phone could affect providers’ knowledge and attitude toward long-acting reversible contraceptives (LARCs), and thus further affect adolescents’ and young nulliparous women's decisions to use LARCs.Design, Setting, Participants, Intervention, and Main Outcome MeasuresThis prospective case-control study was performed between 2019 and 2020. A total of 40 healthcare providers participated, of which 20 received “LARC First” video training, whereas the other 20 served as the control group and received no training. Surveys were conducted of 244 adolescents and young women who were consulted by these 2 groups of healthcare providers before abortion surgery. The data were used to analyze the relationship between providers’ knowledge scores and the percentage of women who received counseling on LARCs decided to use LARCs, and what percentage continued to do so 12 months after surgery.ResultsProviders from the study group scored higher in LARC knowledge than the control group. Compared to the control group, women in the study group reported receiving more counseling on LARCs (81.4% vs 7.9%) and more often chose to use LARCs (24.6% vs 2.4%). Twelve months later, there was no significant difference in contraceptive continuation between study and control groups, but study group participants were more likely to be using LARCs (P < .001).ConclusionVideo training for providers improved both their knowledge and willingness to recommend LARCs and increased the probability of adolescent and young nulliparous women using these methods to reduce unintended pregnancy.     

Barriers and Facilitators to the Implementation of First Trimester Medical Abortion With Mifepristone in the Province of Québec: A Qualitative Investigation

ObjectiveMifepristone became available in Canada in January 2017, but provincial medical policy delayed its use for medical abortion (MA) in Québec for 1 year. The objective of this study was to identify barriers and facilitators experienced by physicians who could potentially provide this newer abortion practice in Québec.MethodsThis study was part of the Canadian Contraception and Abortion Research Team-Mifepristone Implementation Study, an observational, prospective, mixed-methods study. Interviews were conducted with physicians representing all health regions of Québec. Using thematic analysis guided by diffusion of innovation theory, the study identified key barriers and facilitators to implementation.ResultsFrom January 2017 to March 2018, study investigators interviewed 25 family physicians and 12 obstetrician-gynaecologists. Most were women (81%), over 40 years old (65%), with >20 years in practice since residency (49%). Less than half of the sample provided abortion services (41%), and only 8% provided MA with mifepristone. Key barriers to implementation were: (1) uncertainty or confusion about policies regarding MA, (2) lack of human resources or support from colleagues, (3) uncertainty about product distribution, (4) confusion about professional collaboration, and (5) lack of local infrastructure. Key facilitators were: (1) perception of support and influence from colleagues, (2) previous experience with provision of first trimester MA, (3) requests for first trimester MA by patients or other physicians, and (4) knowledge of research on mifepristone MA.ConclusionDespite Health Canada's approval of mifepristone in Canada and supportive federal policies for provision of MA in primary care, physicians in the province of Québec face onerous barriers to the practice of mifepristone MA.     

Study of long-acting reversible contraceptive use in a UK primary care database: Validation of methodology

Abstract

Objectives To develop and validate algorithms to identify new users of long-acting reversible contraceptives (LARCs) in a primary care database, The Health Improvement Network (THIN).

Methods Women in THIN aged 12 to 49 years in 2005 were studied. THIN was searched using Read and MULTILEX codes to identify new users of copper intrauterine devices (Cu-IUDs), the levonorgestrel-releasing intrauterine system (LNG-IUS) and progestogen-only implants. Validation was undertaken for a randomly selected sample of 398 LARC users, in which their primary care physicians were asked to complete a questionnaire detailing LARC use.

Results Questionnaires were received for 379 patients (95%), confirming 316 (83%) as new LARC users. Confirmation rates for Cu-IUDs, the LNG-IUS and progestogen-only implants were 64%, 94% and 89%, respectively. The use of Read codes alone had the lowest confirmation rate, particularly for Cu-IUD users. Confirmation rates increased by using MULTILEX codes when available, or by examination of computerised medical records.

Conclusions Computer algorithms were used to identify new LARC users. While THIN is a useful resource for studying LARC uptake, steps to gather additional information are necessary to ensure the validity of LARC classification.     

Improved access increases postpartum uptake of contraceptive implants among HIV-positive women in Rwanda

Background?Long-acting reversible contraceptives (LARCs) and sterilisation are the most cost-effective methods of contraception but are rarely used in sub-Saharan Africa partly due to limited access.

Study design?HIV-positive pregnant women attending two urban clinics in Rwanda were followed prospectively in a perinatal HIV transmission cohort study. Women attending one clinic were referred to public family planning (FP) services for all contraceptive methods (Site A) and women attending the other clinic (Site B) were offered implants and intrauterine devices (IUDs) on-site.

Results?Fifty three percent of the pregnant women reported an intention to use a LARC or to be sterilised after delivery. The uptake of implants was significantly higher at Site B (38%) than at Site A (6%). The IUD uptake was extremely low at both sites (2%). Twenty-eight of the 39 women at Site B who had intended to start using a LARC actually did so as compared to only one of 23 at Site A.

Conclusion?When access to LARC was provided, a substantial number of HIV-positive women started using hormonal implants, but not IUDs, in the postpartum period. HIV and FP services should consider improving access to implants to reduce the number of unintended pregnancies.     

Postpartum LARC: Best Practices,Policy and Public Health Implications

Purpose of Review

To review current literature highlighting effective strategies and policies in implementation of postpartum long-acting reversible contraception (LARC) as well as outcomes of postpartum LARC use.

Recent Findings

The use of postpartum LARC is highly desired by patients, effective at reducing rates of unintended and short interval pregnancies, and has demonstrated significant health care savings. Despite these positive outcomes associated with postpartum LARC use, availability of immediate postpartum LARC is limited in the majority of US hospitals. Barriers to the provision of postpartum LARC include lack of physician education and comfort in placing postpartum LARC, lack of effective reimbursement structures, lack of streamlined protocols for identifying women who are candidates for postpartum LARC, and lack of structural support for the provision of LARC.

Summary

Providers can eliminate barriers to postpartum LARC access once patients are discharged from the hospital by enhancing efforts to identify patients who are at high risk of no follow-up and by eliminating two-step protocols for LARC insertion. A step-wise strategical approach involving planning, implementation, and sustainability is effective for initiating postpartum LARC programs in hospitals. Enhancing physician education, collaborating among hospital-wide stakeholders, and reforming reimbursement strategies are all key components of successful implementation plans. Future research should continue to demonstrate cost effectiveness of postpartum LARC, and efforts to disseminate this information to other hospitals should be enhanced. Research should also target postpartum LARC insertion techniques to overcome variability of expulsion rate data and elucidate superior postpartum insertion techniques. Lastly, research should target identification strategies for women who desire postpartum LARC; for example, protocol development for streamlining access to patient’s contraceptive preferences from antenatal care to labor and delivery care, or a modified labor and delivery intake form.

     

Patients' and professionals' barriers and facilitators to external cephalic version for breech presentation at term,a qualitative analysis in the Netherlands

Objectiveexternal cephalic version (ECV) is a relatively simple and safe manoeuvre and a proven effective approach in the reduction of breech presentation at term. There is professional consensus that ECV should be offered to all women with a fetus in breech presentation, but only up to 70% of women eligible for ECV undergo an ECV attempt. The aim of the study was to identify barriers and facilitators for ECV among professionals and women with a breech presentation at term.Designqualitative study with semi-structured interviews.SettingDutch hospitals.Participantspregnant women with a breech presentation who had decided on ECV, and midwives and gynaecologists treating women with a breech presentation.Measurementson the basis of national guidelines and expert opinions, we developed topic lists to guide the interviews and discuss barriers and facilitators in order to decide on ECV (pregnant women) or advice on ECV (midwives and gynaecologists).Findingsamong pregnant women the main barriers were fear, the preference to have a planned caesarean section (CS), incomplete information and having witnessed birth complications within the family or among friends. The main facilitators were the wish for a home birth, the wish for a vaginal delivery and confidence of the safety of ECV. Among professionals the main barriers were a lack of knowledge to fully inform and counsel patients on ECV, and the inability to counsel women who preferred a primary CS. The main facilitator was an unambiguous policy on (counselling for) ECV within the region.Conclusionwe identified several barriers and facilitators possibly explaining the suboptimal implementation of ECV for breech presentation in the Netherlands.This knowledge should be taken into account in designing implementation strategies for ECV to improve the uptake of ECV by professionals and patients.     

Development and validation of the global assessment of the evidence implementation environment [GENIE] tool

BackgroundOvercoming the various barriers to evidence implementation is critical to delivering evidence-based health care. Identifying and managing these obstacles is somewhat challenging however, due to interprofessional and interjurisdictional variations in reported barriers. An efficient, systematic, comprehensive and innovative approach to isolating the barriers to evidence implementation is therefore needed.Materials and methodsUsing a mixed methods design, the study aimed to develop, refine and validate a tool to assess the evidence implementation environment for complementary medicine (CM) professions. The tool was developed using a five-stage process, and refined and validated using a two-round e-Delphi technique.ResultsInformed by reviews examining the barriers and enablers to evidence implementation in CM, and shaped by the Behaviour Change Wheel Framework, a preliminary 33-item tool was created (i.e. the Global Assessment of the Evidence Implementation Environment [GENIE] tool). A two-round Delphi technique was used to refine the criteria, with a panel of 23 experts agreeing to the removal of two criteria, and the addition of two items. In the end, the Delphi panel reached consensus on 33 criteria, which were sorted into nine stakeholder groups.ConclusionThis study has for the first time, created an innovative tool to assess the capacity and capability of CM professions to engage in evidence-based practice at an optimal level. By assessing the evidence implementation environment of CM professions, the GENIE tool is able to determine where resources, infrastructure and personnel should be directed in order to optimise the uptake of evidence-based practices within CM professions.     

Young women's attitudes towards,and experiences of,long-acting reversible contraceptives

Abstract

Objectives To identify factors involved in women's decisions to choose particular contraceptive methods and more specifically, incentives and disincentives to use three long-acting reversible contraceptive (LARC) methods: injectables, implants, and intrauterine devices/systems (IUDs/IUSs).

Methods A total of 502 women aged 18 to 30 completed a cross-sectional online questionnaire.

Results The three most important factors in choosing a contraceptive method were: high efficacy at preventing pregnancy, protection against sexually transmitted infections, and non-interference with sexual intercourse. The most common incentives for LARC use were the high efficacy and long duration of action. Disincentives included the possibility of irregular bleeding and concerns about effects on fertility; fear of needles and pain was a particular disincentive for IUD/IUS use. Only 93 (18%) of the participants reported ever having used a LARC.

Conclusions Reported disincentives to LARC use (e.g., concern about effects on future fertility) indicated that many young women hold inaccurate beliefs about these methods. The relatively high proportions of women who held neutral attitudes about LARCs (21–40%, depending on the method) highlight the importance of education and contraceptive counselling to improve knowledge about the advantages of these methods.

Chinese Abstract

摘 要目的 了解女性选择避孕方法的影响因素和应用三种长效可逆避孕方法（LARC）：注射避孕针、埋植剂和宫内节育器/宫内系统(IUDs / IUSs)的有利和不利因素。

方法 502名18～30岁女性完成了横断面在线问卷调查。

结果 在选择避孕方法的三个最重要的影响因素是：防止妊娠的高效性,预防性传播感染和不干扰性交。LARC使用最常见的有利因素是高效和长效性。不利因素包括不规则出血的可能性和对生育影响的担忧;对针和疼痛的恐惧是选用IUDs / IUSs 的不利因素。只有93（18%）的女性曾经使用过LARC。

结论 应用LARC的不利因素（如对将来生育影响的担忧）表示许多年轻女性对这些方法存在错误的观点。对LARCs持有中立态度的女性占相对较高的比例（21–40%）,提示教育和避孕咨询的重要性,以提高对这些方法优点的认识。