Identifying adolescents at risk for noncompliance with contraceptive therapy

ADOLESCENT MEDICINE

W.A. Daniel, Jr.,Editor

Identifying adolescents at risk for noncompliance with contraceptive therapy The sociomedical characteristics of 96 sexually active adolescent females have been studied in order to understand noncompliance with the contraceptive prescription, an important antecedent of adolescent pregnancy. Compliance was found to correlate positively with postmenarchal age, frequency of intercourse, autonomy in making and paying for a clinic appointment specifically for the purpose of obtaining contraception, and acceptance of a method at the time of the initial clinic visit. These .findings serve to alert the pediatrician to the adolescent at risk for noncompliance before the experience of failure, and in so doing to identify those in need of special assistance to ensure the success of contraceptive measures.

Iris F. Litt, M.D.,* Walter R. Cuskey, Ph.D., and Shirley Rudd, R.N., S t a n f o r d , Calif.

FACED with the fact of an epidemic of adolescent pregnancy, 1 many pediatricians have undertaken to provide contraception for this age group. Accordingly, it is becoming routine for the pediatrician to inquire about sexual activity and, if unprotected intercourse is discovered, to discuss and prescribe a contraceptive method. Although the outcome of prescribing contraceptives within family planning and postpartum programs has been reported, 2-6 adolescents receiving such advice from pediatricians have not been previously studied. It is the purpose of this study to elucidate factors which may identify prospectively the adolescent who may have difficulty complying with the contraceptive method prescribed, as well as to identify variables which may assist in designing strategies to improve compliance with contraception. From the Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine. Supported in part by the Robert Wood Johnson Foundation. Presented in part at the meeting of the Society ,for Pediatric Research, Atlanta, May 4, 1979. * Reprint address: Division of Adolescent Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA 94305.

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The Journal o f P E D I A T R I CS Vol. 96, No. 4, pp. 742-745

RESEARCH METHOD The first 100 sexually active female adolescents who presented to the Stanford University Adolescent Clinic of the Department of Pediatrics between September, 1976, and November, 1978, for health maintenance or a medical complaint, were defined as the study sample. Incomplete data in four case records reduced the study sample to 96.

See related article, p. 746. Data isolating the 15 variables selected for study were collected from the medical intake form completed on each patient for each visit, and included information about demographic characteristics, medical history, patterns of sexual activity, physical development, and motivation for clinic attendance. The Figure illustrates the research design and defines the independent and dependent variables used in this investigation. A patient was considered to be compliant if she returned for her one- and threemonth follow-up visits, reported consistent use of the diaphragm, checking IUD string, or n o t missing more than two pills each month, and if she did not become pregnant during the study period. Since the first objective was to ascertain any significant differences between those who failed to comply with the

0022-3476/80/040742+04500.40/0 9 1980 The C. V. Mosby Co.

Volume 96 Number 4

Adolescent noncompliance with contraceptive therapy

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INDEPENDENT V A R I A B L E S I

I DEMOGRAPHICI I I 9 AGE 9 RACE 9 PAYMENT SOURCE

I

~

MEDICAL HISTORY

II

I 9 CHRONIC ILLNESS 9 PAST PREGNANCY 9 VENEREAL DISEASE

DACTIVITY I C~ 1A |

~

9 PARENTAL KNOWLEDGE 9 NUMBER OF PARTNERS 9 DURATION OF RELATIONSHIP

9 AGE AT MENARCHE 9 MENARCHE

L

VISIT

|

9 SOURCE OF APPOINTMENT 9 SOURCE OF AGENDA 9 METHOD CHOSEN

9 FREQUENCY OF INTERCOURSE

I

I

I

I

DEPENDENT V A R I A B L E

! CONTRACEPTIVE COMPLIANCE

]

!

9SELF-REPORT

9 APPOINTMENT KEEPING 9 PREGNANCY

Figure. Design of the study. prescribed contraceptive device from those who complied, a chi square analysis was undertaken. A second technique, stepwise discriminant analysis,7 was used with the same dependent variables in an attempt to isolate potential predictors of compliance. RESULTS

Characteristics of the study group. As Table I illustrates, the mean age of the study group was 15.9 years; slightly more than half were black, having either private or federal insurance and a previous contact with the pediatric health care system. One-third of the group had told their parents of their sexual activity; nearly two-thirds had a single sex partner; the mean duration of the sexual relationship was nearly one year; and more than one-third had intercourse less often than once a week. The mean menarchal age was 12.4 years and mean postmenarchal age was 3.5 years for the entire group. Half the patients had initiated their own ftinic appointment; parents, physicians, or others did so for the remainder. Two-thirds of the patients requested contraception in the course of their initial clinic visit, whereas in the remaining one-third, the pediatrician, upon learning of unprotected intercourse, suggested the need for contraception. Over half of the patients preferred oral contraceptives, with the diaphragm and intrauterine devices being selected less often.

Factors associated with compliance. Of the 96 patients studied, 44.6% were compliant with the contraceptive regimen during the study period. The demographic variables selected for study failed to explain differences in compliance within the study group. Although the dominant source of payment was federally funded insurance ("Medi-Cal") in the compliant group, those adolescents who paid for their own medical care seemed more likely to be compliant. The lack of statistical significance for this variable reflects the small number of subjects in the latter category. Adolescents with a single sex partner and those who were sexually active more often than weekly were more likely to be compliant (Table III). Patients who made their own clinic appointments, regardless of the reason for so doing, were more likely to be compliant than those for whom the appointment had been made by the parent or physician. Also, patients who "set the agenda" for the clinic appointment, that is, came to the clinic themselves desiring birth control, were more likely to follow through with the prescription than those who did not come with that agenda. Finally, although the particular method of birth control prescribed was not related to compliance, acceptance of any kind of method at the time of the initial visit was highly correlated with subsequent compliance. Compliance prediction. Standardized discriminant function coefficients were obtained for six variables:

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Litt, Cuskey, and Rudd

The Journal of Pediatrics April 1980

Table I. Characteristics of Patients at time of admission

Distribution among 96 patients % of total

Attributes

65.2 52.7 48.1 61.2 34.1 60.4

Age (between 16-20 yr) Black Payment source (Medi-Cal) Positive medical history Sexual activity known to parent Single sex partner Duration of sex partner relationship (>6 mo) Frequency of intercourse ( < weekly) Age at menarche (between 10-12 yr) Postmenarchal age (between 1-3 yr) Source of appointment (patient) Source of agenda (patient) Method chosen (pill)

59.4 36.3 57.1 48.8 50.0 65.6 62.2

Table II. Comparison of demographic variables of cornpliant subjects

Basic demographic variables Age Race Payment source

Category

Percent compliant (n = 44)

12-15 16-21 White Black Self Insurance

37.5 62.5 42.9 57.1 15.9 84.1

Significant difference* None None None

*Chi square analysis. computed compliance values, method of payment, method of birth control, frequency of intercourse, appointment source, agenda source. Using these variables, it was possible to correctly assign patients to the compliant or noncompliant group in 72% of the cases. DISCUSSION These data demonstrate that the population studied resembles that reported by other investigators of contraceptive utilization by adolescents, with regard to demography and patterns of sexual activity. Although most physicians are led to believe that adolescents have kept their sexual activity secret from their parents, these data show that it was known to parents in one-third of cases. Also of interest is the observation that one-third of sexually active adolescents had intercourse less frequently than once a month and that most sexual relationships had lasted more than six months, challenging the myth of adolescent promiscuity. The poor rate of compliance once contraception has been prescribed (45%) within a pediatric setting is

Table III. Comparison o f sexual activity and medical visit of complient subjects

Sexual and medical variables Sex activity known to parents Number of sex partners Duration of sex relationship Frequency of intercourse Appointment source Agenda source Method of birth control

Percent compliant (n = 44)

Category Yes No Single Multiple < 12 > 12 > Weekly < Weekly Patient Nonpatient Patient Nonpatient Accepted Nonaccepted

58.3 41.7 92.7 7.3 74.0 26.0 71.1 28.9 77.4 22.6 65.3 34.7 95.9 4.1

Significant difference* None X~ = 5.268 P = <0.05 None X2 = 8.345 P = <0.01 X2 = 8.790 P = <0.01 X2 = 5.941 P = <0.05 X2 = 27.39 P = < 0.001

*Chi square analysis. Table IV. Classification results of contraceptive cornpliance

Predicted group compliance

Actual group

No. of subjects

Noncompliant

Compliant Noncompliant

44 48

27 (61.4%) 9 (18.8%)

1 Compliant 17 (38.6%) 39 (81.3%)

comparable to that reported in previously pregnant adolescents, but higher than that noted for patients self-selected for contraceptive need and attending family planning clinics? The criteria for compliance, namely self-report, continued clinic attendance, and lack of pregnancy, may, however, tend to overestimate noncompliance, as a recent study utilizing telephone calls to adults who failed to keep appointments at a family planning clinic found that the majority were continuing contraception, albeit in a different health care delivery system." The results of this study support previous observations of the lack of relationship between race and age on contraceptive compliance, and the association between frequency of intercourse and adoption of consistent contraception? ~ The lack of a relationship between previous pregnancy and contraceptive compliance disagrees with the findings of Kantner and Zelnik '1 and of Presser, 1~ but is consistent with that of Furstenberg. 13 The association between advanced postmenarchal age, rather than chronologic age alone, and good contraceptive compliance suggests that the youngster who has had a longer period of adjustment to the sexually mature state may better accept her adult role as a sexually active

Volume 96 Number 4 individual. This process may be enhanced by frequent sexual intercourse, another factor found to be associated with better compliance. It had been postulated that previous contact with the pediatric health care system, as manifested by having a positive medical history, may improve use of contraceptives prescribed by a pediatrician in a medical, rather than family planning clinic, setting. As in Korsch et al's TM study of adolescent noncompliance with immunosuppressive therapy, this was found not to be the case. Adolescents may not be receptive to birth control counseling at the time of medical illness or in a setting that they do not associate with birth control prescription. Alternatively, the demonstrated importance of the patient's determining the agenda for the visit may be the critical factor. On the basis of this study, paying for and initiating one's own clinic appointment, as well as setting the agenda for the visit, are clearly associated with adolescent compliance with contraceptive advice. These behaviors may be viewed as reflective of the type of personality reported by others to be predictive of contraceptive utilization, such as "self-sufficient," "high ego-strength," "personality competent," and having an "internal locus of control." On the other hand, they may represent achievement of that stage of development of the sexual relationship in which sexual responsibility is acknowledged, or that cognitive stage in which the adolescent is able to recognize future consequences of present activities. Although it is important for the pediatrician to identify the adolescent at risk for pregnancy, regardless of her reason for seeking health care, these data suggest that it is equally necessary that the youth herself become motivated to use contraception. Passive receipt of a contraceptive prescription is predictive of subsequent noncompliance. The use of the variables found to be associated with noncompliance will provide an opportunity for intervention in advance of failure. The importance of the first utilization of contraceptives should add impetus to the desire to make the initial contraceptive experience a successful one. The role of the primary care physician extends beyond that of identifying sexually active adolescents and pre-

Adolescent noncompliance with contraceptive therapy

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scribing contraception. The adolescent at risk for contraceptive noncompliance should be identified before she is allowed to fail in what is often her first experience of taking responsibility for her own health care. Intervention strategies geared to improving compliance may be directed at increasing the adolescent's responsibility with the medical visit, either through making or paying for the appointment herself or by having a role in setting the agenda. The authors thank Ruth T. Gross, M.D., for her critical review and Lynda Spencer for her typing of the manuscript. REFERENCES

1. McAnarney ER: Adolescent pregnancy a national priority, Am J Dis Child 132:125, 1978. 2. GordisL, Finkelstein R, Fassett JD, and Wright B: Evaluation of a program for preventing adolescent pregnancy, N Engl J Med 282:1078, 1970. 3. SettlageSF, Baroff S, and Cooper D: Sexual experience of younger teenage girls seeking contraceptive assistance for the first time, Fam Plann Perspect 5:223, 1973. 4. JorgensenV: One-year contraceptive follow-up of adolescent patients, Am J Obstet Gynecol 115:484, 1973. 5. Morganthau JE, and Rao PSS: Contraceptive practices in an adolescent health center, NY Sci J Med 76:1311, 1976. 6. Goldsmith S, Gabrielson MO, Gabrielson l, Mathews V, and Potts L: Teenagers, sex and contraception, Fam Plan Perspect 4:32, 1972. 7. CooleyW, and Lohnes P: Multivariate data analysis, New York, 1971, John Wiley & Sons, Inc. 8. Cooke CW: Contraceptive usage among teenagers, JAMWA 28:639, 1973. 9. Cosgrove PS, Penn RL, and Chambers N: Contraceptive practice after clinic discontinuation, Fam Plann Perspect 10:337, 1978. 10. Westoft CF: Coital frequency and contraception, Fam Plann Perspect 6:136, 1974. 11. Kantner JF, and Zelnik M: Sexual experience of young unmarried women in the United States, Fam Plann Perspect 4:9, 1972. 12. Presser H: Early motherhood: Ignorance or bliss? Faro Plann Perpect 6:8, 1974. 13. Furstenberg FF Jr: Unplanned parenthood: The social consequence of teenage childbearing, New York, 1976, Free Press. 14. Korsch BM, Fine RN, and Negrete VF: Noncompliance in children with renal transplants, Pediatrics 61:872, 1978.