- Email: [email protected]
Contraceptive decisional balance, self-efficiency and stage of change measures among women presenting for induced abortion
Abstracts / Contraception 88 (2013) 433–473 implant, the levonorgestrel intrauterine system and the copper intrauterine device — have differ in terms of duration of use, insertion techniques and side effect profiles. Given these differences, the objective of our study was to review the characteristics of women who choose the contraceptive implant compared with intrauterine contraception (IUC). Methods: A cross-sectional study was performed that investigated all women who initiated LARCs for contraceptive use at the Ohio State University obstetrics and gynecology house staff clinic in 2007–2012. Clinical and demographic data were compared among those who initiated the contraceptive implant and those initiating either IUC. Comparisons were analyzed using logistic regression. Results: We studied 1262 women who initiated LARC: 279 (22.1%) who initiated the implant and 983 (77.9%) who initiated IUC. Women who initiated the implant were younger than those who initiated IUC (23.5 vs. 25.4 years, pb.001). Nulligravid status was associated with decreased odds of choosing IUC (OR 0.20, pb.01). Postpartum women had increased likelihood of initiating IUC (OR 2.08, pb.05). A greater proportion of implant users than IUC users had a history of STIs (OR 0.43, pb.01 and OR 0.88, pb.05, respectively). Conclusions: Our study indicates that patient factors, including age, gravidity, postpartum status and history of STIs, differ among women who choose the contraceptive implant versus IUC. Patient-centered contraceptive counseling should be performed when making LARC use recommendations.
P79 WHAT IS THE EFFECT OF A SELF-ADMINISTERED REPRODUCTIVE LIFE PLAN (RLP) ON PRECONCEPTION AND CONTRACEPTIVE COUNSELING? Bello Kottenstette J University of Chicago, Chicago, IL, USA Adkins K, Stulberg D, Rao G Objectives: The Centers for Disease Control and Prevention recommends incorporating reproductive life plans (RLPs) into each clinical encounter for women of reproductive age. However, there have been no studies examining the effect of a self-administered RLP designed as a patient-empowerment tool in the primary care setting. This study used a qualitative design in a clinic serving low-income AfricanAmerican women to examine patient and provider perceptions of the effect of a novel format of RLP on reproductive health counseling, as well as factors that influence reproductive health counseling in primary care. Methods: Every 18–44-year-old woman was eligible to receive an RLP between July 2 and October 19, 2012. Semi-structured interviews were performed with 22 patients who were non-pregnant, more than 12 months postpartum and not permanently sterilized, and whose reason for visiting the clinic was not family planning. Similar interviews with 15 providers, who had been educated on recommendations for incorporating RLPs into primary care. Transcripts were thematically analyzed using a grounded theoretical approach. Results: Patients and providers had generally positive perceptions of the RLP, including that it was presented in an effective format with thought-provoking material that facilitated reproductive health counseling. Patients and providers identified multiple factors that influenced their experiences with reproductive health counseling, including the patient-provider relationship, attitudes and assumptions about pregnancy, and whether the patient or the provider initiates the counseling. Conclusions: A self-administered RLP is acceptable and useful to patients and providers in the primary care setting. This novel RLP, with a patient-empowering format, has the potential to improve the quality of reproductive health counseling by increasing patient knowledge and promoting patient-driven counseling.
461
P80 KNOWLEDGE OF LONG-ACTING REVERSIBLE CONTRACEPTION AMONG WOMEN PRESENTING FOR INDUCED ABORTION Bhardwaj N University of Chicago, Chicago, IL, USA Davidson A, Martins S, Whitaker A Objectives: Scant quantitative data exist on contraceptive knowledge among women obtaining an abortion. We sought to determine contraceptive knowledge in this population. Methods: We surveyed women presenting for induced abortion to an urban academic medical center, using a 15–30-min self-administered written survey. We reviewed medical records to determine choice of contraceptive method postabortion. In addition to descriptive statistics, we performed bivariate analysis to determine correlates of awareness of long-acting reversible (LARC) methods. Results: We surveyed 167 women from March 2012 to March 2013. The median age was 27 years (range 15–42), 73.9% were black and 71.1% were parous. Although 71.9% (120/167) had heard of the IUD and 64.2% (106/165) had heard of the implant, only 13.2% and 1.8% had used them, respectively. Parous women were more likely to have heard of the IUD than nulliparous women (83.1% vs. 43.8%, pb.001), and there was a similar trend for the implant (68.1% vs. 54.2%, p=.09). Of those who had heard of the IUD, only 49.2% (59/ 120) and 36.7% (44/120) perceived the levonorgestrel IUD and copper IUD to be effective, respectively. Assessment of the implant was even poorer, with only 34.0% (36/106) of those who had heard of it perceiving it to be effective. Approximately half (51.5%) of the participants planned to use a LARC method after their abortion. Conclusions: Although the majority of women had heard of LARC methods, knowledge about their efficacy was low, and a minority had used them. By learning women's current knowledge about contraceptive methods, contraceptive counseling interventions can be better directed.
P81 CONTRACEPTIVE DECISIONAL BALANCE, SELFEFFICIENCY AND STAGE OF CHANGE MEASURES AMONG WOMEN PRESENTING FOR INDUCED ABORTION Whitaker A University of Chicago, Chicago, IL, USA Martins S, Tomlinson A, Woodhams E, Gilliam M, Quinn M Objectives: The transtheoretical model (TTM) has been studied as a potent behavioral theory for understanding general contraceptive use but not in the context of induced abortion. We surveyed women presenting for induced abortion to assess three key constructs of TTM: decisional balance, selfefficacy and stage of change. Methods: As part of a parent survey assessing contraceptive knowledge and attitudes among women presenting for induced abortion, we included validated questions to assess decisional balance and self-efficacy and an algorithm to assess stage of change (maintenance, action, preparation, contemplation and pre-contemplation) for contraceptive use. We converted raw decisional balance and self-efficacy scores to T-scores and then conducted one-way analysis of variance with decisional balance and selfefficacy as dependent variables and stage as the independent variable. Results: We recruited 122 women from July 2012 through March 2013. Median age of participants was 27 (range 16–42). The majority were nonHispanic black (73.0%); single, non-cohabitating (67.2%); and parous (72.1%). Consistent with TTM, for women in the pre-contemplation and contemplation stages (PC/C), perceived drawbacks of effective contraceptive use exceeded perceived benefits, but for women in action and maintenance, perceived
462
Abstracts / Contraception 88 (2013) 433–473
benefits exceeded perceived drawbacks. T-scores for contraceptive drawbacks were lower (p=.03) and for contraceptive benefits higher (p=.04) in preparation, compared with PC/C. In addition, compared with PC/C, self-efficacy scores were higher in preparation (p=.02), action (p=.06) and maintenance (p=.008). Conclusions: Our findings suggest that key constructs of TTM (decisional balance, self-efficacy and stage of change) provide a useful model for understanding contraceptive use among women presenting for induced abortion.
P82 DEVELOPMENT AND PILOT TESTING OF A THEORY-BASED COUNSELING INTERVENTION TO IMPROVE POSTABORTION CONTRACEPTIVE UPTAKE BY YOUNG WOMEN Whitaker A University of Chicago, Chicago, IL, USA Tomlinson A, Woodhams E, Quinn M, Martins S, Gilliam M Objectives: Motivational interviewing (MI), a theory-based counseling technique, holds promise for contraceptive counseling. We trained counselors, then developed and pilot-tested an MI-based intervention to improve uptake of highly effective contraception by young women presenting for induced abortion. Methods: We trained counselors by using lecture-based instruction and skill practice through role-plays. After training, we utilized standardized patients and videotaped MI-based counseling sessions to test for minimal MI competence. Two investigators reviewed videos and rated fidelity to principles of MI. Counselors meeting an established benchmark were approved to deliver the intervention. We then pilot tested the counseling intervention with 20 English-speaking women aged 15–24 years presenting for induced abortion. Results: All counselors (3/3) passed the competency assessments. Inter-rater agreement between reviewers of the videotaped sessions was 68% (kappa 0.30). The counseling intervention lasted a median of 29 min (range 15–50 min). Our formative data suggest that all participants found the intervention helpful, and 95% (19/20) would recommend it. Most (12/20, 60%) chose long-acting reversible contraception (LARC). Fifteen percent (3/20) were considering a less effective method but switched to LARC. At the 1-month follow-up contact, most (12/13, 92.3%) reported the session as helpful, and all would recommend it. Most (12/13, 92.3%) were comfortable with participating in research while waiting for the abortion, and none felt pressured to participate. Conclusions: It is feasible to train counselors in MI-based contraceptive counseling and to integrate this brief intervention into a busy clinic. These data suggest that women are willing to use LARC methods after participating in the intervention.
P83 IMPACT OF A REVISED APPOINTMENT-SCHEDULING SCRIPT ON IUD SERVICE DELIVERY IN THREE TITLE X FAMILY PLANNING CLINICS Mistretta S University of Chicago, Department of Obstetrics and Gynecology, Chicago, IL, USA Martins S, Betham B, Holl J, Gilliam M Objectives: The appointment-scheduling call represents a first-line opportunity for improving clinical service delivery. We evaluated the impact of a revised standardized script for IUD appointment scheduling on both patient and administrative outcomes at three Title X clinics in Chicago. Methods: As part of a larger study evaluating IUD service delivery to young women in Chicago Title X clinics, we performed a systematic risk assessment that identified several “high-risk” areas preventing planned IUD insertion: unprotected sex, lack of awareness of clinic policies and missed appointments. We revised the call center’s script for IUD appointment scheduling to target
these problem areas. We piloted the new script over a 1-month period in November 2012 and assessed its impact on rates of appointment attendance, IUD eligibility (i.e., adherence to unprotected sex instructions) and completed IUD insertions using a pre-/post-study design with 3-week blocks of data collection before and after the intervention (n=99 appointments). Results: The revised script decreased no-show rates for appointments overall (40.4% vs. 23.8% before the script, p=.08), with significant differences for patients aged 25 and younger (n=51; 46.9% vs. 15.8%, p=.04). Among patients who attended their appointment, there were no pre/post differences in the proportions of IUD-eligible patients (97.1% vs. 90.3%, NS) or completed insertions (79.4% vs. 78.1%, NS). Conclusions: Use of a standardized scheduling script that emphasizes clinical and administrative policies for IUD visits may positively impact appointment outcomes. This simple, scalable intervention can increase the efficient use of clinic resources, thereby improving IUD service delivery and administrative outcomes.
P84 DEVELOPMENT OF AN IPAD WAITING ROOM APP FOR CONTRACEPTIVE COUNSELING IN TITLE X CLINICS Martins S University of Chicago, Department of Obstetrics and Gynecology, Chicago, IL, USA Gilliam M, Dudley J, Yan S, Holl J Objectives: To describe our process of developing a contraceptive counseling iPad application (“app”) for Title X patients to use in the clinic waiting room prior to their visit. Methods: In a larger study of three Chicago-based Title X clinics, we identified barriers to IUD uptake, including limited time for contraceptive counseling and patients’ misconceptions of long-acting reversible contraception (LARC). To address these barriers, we developed a contraceptive counseling iPad app, grounded in behavioral theory and the principles of human-centered design (HCD), for patients to use in the waiting room prior to their visit. HCD brings the designer and end-users together early in the development process to ensure the product is engineered to meet users’ needs. Design solutions are created with users through iterative, low-fidelity prototyping. We created an initial app prototype based on the findings of the parent study, in-depth interviews with patients and the extant literature. We conducted usability testing with 18 adult women from August 2012 to March 2013 to gain feedback on app content, design and navigation. Results: All app prototypes featured a graphical depiction of contraceptive effectiveness by method; theory-based video testimonials from LARC users; and self-navigated, method-specific informational pages containing illustrations, pictures and text. Users preferred contraceptive effectiveness conveyed in absolute numbers versus percentages or categories. Users wanted method-specific information for the following categories: “How does it work?” “What can I expect?” and “What will he think?” Patient testimonials were received favorably. Conclusions: Digital technology and HCD provide useful platforms for creating patient-centered, low-cost, replicable interventions.
P85 A SYSTEMS-BASED APPROACH TO EVALUATING AND IMPROVING IUD SERVICE DELIVERY TO YOUNG WOMEN IN THE TITLE X SETTING Gilliam M University of Chicago, Department of Obstetrics and Gynecology, Chicago, IL, USA Martins S, Mistretta S, Holl J
P79 WHAT IS THE EFFECT OF A SELF-ADMINISTERED REPRODUCTIVE LIFE PLAN (RLP) ON PRECONCEPTION AND CONTRACEPTIVE COUNSELING? Bello Kottenstette J University of Chicago, Chicago, IL, USA Adkins K, Stulberg D, Rao G Objectives: The Centers for Disease Control and Prevention recommends incorporating reproductive life plans (RLPs) into each clinical encounter for women of reproductive age. However, there have been no studies examining the effect of a self-administered RLP designed as a patient-empowerment tool in the primary care setting. This study used a qualitative design in a clinic serving low-income AfricanAmerican women to examine patient and provider perceptions of the effect of a novel format of RLP on reproductive health counseling, as well as factors that influence reproductive health counseling in primary care. Methods: Every 18–44-year-old woman was eligible to receive an RLP between July 2 and October 19, 2012. Semi-structured interviews were performed with 22 patients who were non-pregnant, more than 12 months postpartum and not permanently sterilized, and whose reason for visiting the clinic was not family planning. Similar interviews with 15 providers, who had been educated on recommendations for incorporating RLPs into primary care. Transcripts were thematically analyzed using a grounded theoretical approach. Results: Patients and providers had generally positive perceptions of the RLP, including that it was presented in an effective format with thought-provoking material that facilitated reproductive health counseling. Patients and providers identified multiple factors that influenced their experiences with reproductive health counseling, including the patient-provider relationship, attitudes and assumptions about pregnancy, and whether the patient or the provider initiates the counseling. Conclusions: A self-administered RLP is acceptable and useful to patients and providers in the primary care setting. This novel RLP, with a patient-empowering format, has the potential to improve the quality of reproductive health counseling by increasing patient knowledge and promoting patient-driven counseling.
461
P80 KNOWLEDGE OF LONG-ACTING REVERSIBLE CONTRACEPTION AMONG WOMEN PRESENTING FOR INDUCED ABORTION Bhardwaj N University of Chicago, Chicago, IL, USA Davidson A, Martins S, Whitaker A Objectives: Scant quantitative data exist on contraceptive knowledge among women obtaining an abortion. We sought to determine contraceptive knowledge in this population. Methods: We surveyed women presenting for induced abortion to an urban academic medical center, using a 15–30-min self-administered written survey. We reviewed medical records to determine choice of contraceptive method postabortion. In addition to descriptive statistics, we performed bivariate analysis to determine correlates of awareness of long-acting reversible (LARC) methods. Results: We surveyed 167 women from March 2012 to March 2013. The median age was 27 years (range 15–42), 73.9% were black and 71.1% were parous. Although 71.9% (120/167) had heard of the IUD and 64.2% (106/165) had heard of the implant, only 13.2% and 1.8% had used them, respectively. Parous women were more likely to have heard of the IUD than nulliparous women (83.1% vs. 43.8%, pb.001), and there was a similar trend for the implant (68.1% vs. 54.2%, p=.09). Of those who had heard of the IUD, only 49.2% (59/ 120) and 36.7% (44/120) perceived the levonorgestrel IUD and copper IUD to be effective, respectively. Assessment of the implant was even poorer, with only 34.0% (36/106) of those who had heard of it perceiving it to be effective. Approximately half (51.5%) of the participants planned to use a LARC method after their abortion. Conclusions: Although the majority of women had heard of LARC methods, knowledge about their efficacy was low, and a minority had used them. By learning women's current knowledge about contraceptive methods, contraceptive counseling interventions can be better directed.
P81 CONTRACEPTIVE DECISIONAL BALANCE, SELFEFFICIENCY AND STAGE OF CHANGE MEASURES AMONG WOMEN PRESENTING FOR INDUCED ABORTION Whitaker A University of Chicago, Chicago, IL, USA Martins S, Tomlinson A, Woodhams E, Gilliam M, Quinn M Objectives: The transtheoretical model (TTM) has been studied as a potent behavioral theory for understanding general contraceptive use but not in the context of induced abortion. We surveyed women presenting for induced abortion to assess three key constructs of TTM: decisional balance, selfefficacy and stage of change. Methods: As part of a parent survey assessing contraceptive knowledge and attitudes among women presenting for induced abortion, we included validated questions to assess decisional balance and self-efficacy and an algorithm to assess stage of change (maintenance, action, preparation, contemplation and pre-contemplation) for contraceptive use. We converted raw decisional balance and self-efficacy scores to T-scores and then conducted one-way analysis of variance with decisional balance and selfefficacy as dependent variables and stage as the independent variable. Results: We recruited 122 women from July 2012 through March 2013. Median age of participants was 27 (range 16–42). The majority were nonHispanic black (73.0%); single, non-cohabitating (67.2%); and parous (72.1%). Consistent with TTM, for women in the pre-contemplation and contemplation stages (PC/C), perceived drawbacks of effective contraceptive use exceeded perceived benefits, but for women in action and maintenance, perceived
462
Abstracts / Contraception 88 (2013) 433–473
benefits exceeded perceived drawbacks. T-scores for contraceptive drawbacks were lower (p=.03) and for contraceptive benefits higher (p=.04) in preparation, compared with PC/C. In addition, compared with PC/C, self-efficacy scores were higher in preparation (p=.02), action (p=.06) and maintenance (p=.008). Conclusions: Our findings suggest that key constructs of TTM (decisional balance, self-efficacy and stage of change) provide a useful model for understanding contraceptive use among women presenting for induced abortion.
P82 DEVELOPMENT AND PILOT TESTING OF A THEORY-BASED COUNSELING INTERVENTION TO IMPROVE POSTABORTION CONTRACEPTIVE UPTAKE BY YOUNG WOMEN Whitaker A University of Chicago, Chicago, IL, USA Tomlinson A, Woodhams E, Quinn M, Martins S, Gilliam M Objectives: Motivational interviewing (MI), a theory-based counseling technique, holds promise for contraceptive counseling. We trained counselors, then developed and pilot-tested an MI-based intervention to improve uptake of highly effective contraception by young women presenting for induced abortion. Methods: We trained counselors by using lecture-based instruction and skill practice through role-plays. After training, we utilized standardized patients and videotaped MI-based counseling sessions to test for minimal MI competence. Two investigators reviewed videos and rated fidelity to principles of MI. Counselors meeting an established benchmark were approved to deliver the intervention. We then pilot tested the counseling intervention with 20 English-speaking women aged 15–24 years presenting for induced abortion. Results: All counselors (3/3) passed the competency assessments. Inter-rater agreement between reviewers of the videotaped sessions was 68% (kappa 0.30). The counseling intervention lasted a median of 29 min (range 15–50 min). Our formative data suggest that all participants found the intervention helpful, and 95% (19/20) would recommend it. Most (12/20, 60%) chose long-acting reversible contraception (LARC). Fifteen percent (3/20) were considering a less effective method but switched to LARC. At the 1-month follow-up contact, most (12/13, 92.3%) reported the session as helpful, and all would recommend it. Most (12/13, 92.3%) were comfortable with participating in research while waiting for the abortion, and none felt pressured to participate. Conclusions: It is feasible to train counselors in MI-based contraceptive counseling and to integrate this brief intervention into a busy clinic. These data suggest that women are willing to use LARC methods after participating in the intervention.
P83 IMPACT OF A REVISED APPOINTMENT-SCHEDULING SCRIPT ON IUD SERVICE DELIVERY IN THREE TITLE X FAMILY PLANNING CLINICS Mistretta S University of Chicago, Department of Obstetrics and Gynecology, Chicago, IL, USA Martins S, Betham B, Holl J, Gilliam M Objectives: The appointment-scheduling call represents a first-line opportunity for improving clinical service delivery. We evaluated the impact of a revised standardized script for IUD appointment scheduling on both patient and administrative outcomes at three Title X clinics in Chicago. Methods: As part of a larger study evaluating IUD service delivery to young women in Chicago Title X clinics, we performed a systematic risk assessment that identified several “high-risk” areas preventing planned IUD insertion: unprotected sex, lack of awareness of clinic policies and missed appointments. We revised the call center’s script for IUD appointment scheduling to target
these problem areas. We piloted the new script over a 1-month period in November 2012 and assessed its impact on rates of appointment attendance, IUD eligibility (i.e., adherence to unprotected sex instructions) and completed IUD insertions using a pre-/post-study design with 3-week blocks of data collection before and after the intervention (n=99 appointments). Results: The revised script decreased no-show rates for appointments overall (40.4% vs. 23.8% before the script, p=.08), with significant differences for patients aged 25 and younger (n=51; 46.9% vs. 15.8%, p=.04). Among patients who attended their appointment, there were no pre/post differences in the proportions of IUD-eligible patients (97.1% vs. 90.3%, NS) or completed insertions (79.4% vs. 78.1%, NS). Conclusions: Use of a standardized scheduling script that emphasizes clinical and administrative policies for IUD visits may positively impact appointment outcomes. This simple, scalable intervention can increase the efficient use of clinic resources, thereby improving IUD service delivery and administrative outcomes.
P84 DEVELOPMENT OF AN IPAD WAITING ROOM APP FOR CONTRACEPTIVE COUNSELING IN TITLE X CLINICS Martins S University of Chicago, Department of Obstetrics and Gynecology, Chicago, IL, USA Gilliam M, Dudley J, Yan S, Holl J Objectives: To describe our process of developing a contraceptive counseling iPad application (“app”) for Title X patients to use in the clinic waiting room prior to their visit. Methods: In a larger study of three Chicago-based Title X clinics, we identified barriers to IUD uptake, including limited time for contraceptive counseling and patients’ misconceptions of long-acting reversible contraception (LARC). To address these barriers, we developed a contraceptive counseling iPad app, grounded in behavioral theory and the principles of human-centered design (HCD), for patients to use in the waiting room prior to their visit. HCD brings the designer and end-users together early in the development process to ensure the product is engineered to meet users’ needs. Design solutions are created with users through iterative, low-fidelity prototyping. We created an initial app prototype based on the findings of the parent study, in-depth interviews with patients and the extant literature. We conducted usability testing with 18 adult women from August 2012 to March 2013 to gain feedback on app content, design and navigation. Results: All app prototypes featured a graphical depiction of contraceptive effectiveness by method; theory-based video testimonials from LARC users; and self-navigated, method-specific informational pages containing illustrations, pictures and text. Users preferred contraceptive effectiveness conveyed in absolute numbers versus percentages or categories. Users wanted method-specific information for the following categories: “How does it work?” “What can I expect?” and “What will he think?” Patient testimonials were received favorably. Conclusions: Digital technology and HCD provide useful platforms for creating patient-centered, low-cost, replicable interventions.
P85 A SYSTEMS-BASED APPROACH TO EVALUATING AND IMPROVING IUD SERVICE DELIVERY TO YOUNG WOMEN IN THE TITLE X SETTING Gilliam M University of Chicago, Department of Obstetrics and Gynecology, Chicago, IL, USA Martins S, Mistretta S, Holl J