Heike Thiel de Bocanegra

Challenges in Translating Evidence to Practice: The Provision of Intrauterine Contraception

OBJECTIVE: Intrauterine contraception is used by many women worldwide, however, it is rarely used in the United States. Although available at no cost from the state family planning program for low-income women in California, only 1.3% of female patients obtain intrauterine contraceptives annually. This study assessed knowledge and practice patterns of practitioners regarding intrauterine contraception. METHODS: We conducted a survey among physicians, nurse practitioners, and physician assistants (n=1,246) serving more than 100 contraceptive patients per year in the California State family planning program. The response rate was 65% (N=816). We used multiple logistic regression to measure the association of knowledge with clinical practice among different provider types. RESULTS: Forty percent of providers did not offer intrauterine contraception to contraceptive patients, and 36% infrequently provided counseling, although 92% thought their patients were receptive to learning about the method. Regression analyses showed younger physicians and those trained in residency were more likely to offer insertions. Fewer than half of clinicians considered nulliparous women (46%) and postabortion women (39%) to be appropriate candidates. Evidence-based views of the types of patients who could be safely provided with intrauterine contraception were associated with more counseling and method provision, as well as with knowledge of bleeding patterns for the levonorgestrel-releasing intrauterine system and copper devices. CONCLUSION: Prescribing practices reflected the erroneous belief that intrauterine contraceptives are appropriate only for a restricted set of women. The scientific literature shows intrauterine contraceptives can be used safely by many women, including postabortion patients. Results revealed a need for training on updated insertion guidelines and method-specific side effects, including differences between hormonal and nonhormonal devices. LEVEL OF EVIDENCE: III

Number of oral contraceptive pill packages dispensed, method continuation, and costs.

OBJECTIVE: To estimate the effect of the number of cycles of oral contraceptive pills (OCPs) dispensed per visit on method continuation, pill wastage, use of services, and health care costs. METHODS: We used paid claims data for 82,319 women dispensed OCPs through the California Family PACT (Planning, Access, Care, and Treatment) Program in January 2003 to examine contraceptive continuation and service use. RESULTS: Women who received 13 cycles at their first visit in January 2003 received 14.5 cycles over the course of 2003 compared with 9.0 cycles among women receiving three cycles at first visit. When client characteristics are controlled, women who received 13 cycles were 28% more likely to have OCPs on hand and twice as likely to have sufficient OCP cycles for 15 months of continuous use compared with women who received three cycles. Oral contraceptive pill wastage was higher among women initially dispensed 13 cycles (6.5% of the cycles dispensed) than among women who received three cycles (2% of cycles). Despite having one fewer clinician visit, women dispensed 13 cycles were more likely to receive Pap and Chlamydia tests and less likely to have a pregnancy test than women initially dispensed fewer cycles. Over the course of the year, Family PACT paid

Interpregnancy intervals: impact of postpartum contraceptive effectiveness and coverage

99 more for women who received three cycles and

Birth Control Sabotage and Forced Sex: Experiences Reported by Women in Domestic Violence Shelters:

44 more for women who received only one cycle than it did for women who received 13 cycles at their first visits of 2003. CONCLUSION: Dispensing a year’s supply of OCP cycles to women is associated with higher method continuation and lower costs than dispensing fewer cycles per visit. LEVEL OF EVIDENCE: II-2

Race, Ethnicity and Differences in Contraception Among Low-Income Women: Methods Received By Family PACT Clients, California, 2001–2007

OBJECTIVE The purpose of this study was to determine the use of contraceptive methods, which was defined by effectiveness, length of coverage, and their association with short interpregnancy intervals, when controlling for provider type and client demographics. STUDY DESIGN We identified a cohort of 117,644 women from the 2008 California Birth Statistical Master file with second or higher order birth and at least 1 Medicaid (Family Planning, Access, Care, and Treatment [Family PACT] program or Medi-Cal) claim within 18 months after index birth. We explored the effect of contraceptive method provision on the odds of having an optimal interpregnancy interval and controlled for covariates. RESULTS The average length of contraceptive coverage was 3.81 months (SD = 4.84). Most women received user-dependent hormonal contraceptives as their most effective contraceptive method (55%; n = 65,103 women) and one-third (33%; n = 39,090 women) had no contraceptive claim. Women who used long-acting reversible contraceptive methods had 3.89 times the odds and women who used user-dependent hormonal methods had 1.89 times the odds of achieving an optimal birth interval compared with women who used barrier methods only; women with no method had 0.66 times the odds. When user-dependent methods are considered, the odds of having an optimal birth interval increased for each additional month of contraceptive coverage by 8% (odds ratio, 1.08; 95% confidence interval, 1.08-1.09). Women who were seen by Family PACT or by both Family PACT and Medi-Cal providers had significantly higher odds of optimal birth intervals compared with women who were served by Medi-Cal only. CONCLUSION To achieve optimal birth spacing and ultimately to improve birth outcomes, attention should be given to contraceptive counseling and access to contraceptive methods in the postpartum period.

Barriers to Adolescents' Getting Emergency Contraception Through Pharmacy Access in California: Differences by Language and Region

Women who experience intimate partner violence often experience birth control sabotage, forced sex, and partner’s unwillingness to use condoms. We interviewed 53 women at four domestic violence shelters. Participants reported that their abusive partners frequently refused to use condoms, impeded them from accessing health care, and subjected them to birth control sabotage, infidelity, and forced sex. However, women also reported strategies to counteract these actions, particularly against birth control sabotage and attempts to force them to abort or continue a pregnancy. Domestic violence counselors can focus on these successful strategies to validate coping skills and build self-esteem.

Cancer patients?? interest in group support programs

CONTEXT The extent to which racial and ethnic differences in method choice are associated with financial barriers is unclear. Understanding these associations may provide insight into how to address racial and ethnic disparities in unintended pregnancy. METHODS Claims data from the California Family PACT program, which provides free family planning services to low-income residents, were used to determine the proportions of women receiving each type of contraceptive method in 2001-2007. Bivariate and multivariate analyses were performed to identify associations between womens race and ethnicity and the primary contraceptive method they received in 2007. RESULTS Compared with white women, blacks and Latinas were less likely to receive oral contraceptives (odds ratios, 0.4 and 0.6, respectively) and the contraceptive ring (0.7 and 0.5), and more likely to receive the injectable (1.6 and 1.4) and the patch (1.6 and 2.3). Black women were less likely than whites to receive the IUD (0.5), but more likely to receive barrier methods and emergency contraceptive pills (2.6); associations were similar, though weaker, for Latinas. Racial and ethnic disparities in receipt of effective methods declined between 2001 and 2005, largely because receipt of the patch (which was introduced in 2002) was higher among minority than white women. CONCLUSION Although Family PACT eliminates financial barriers to method choice, the methods women received differed substantially by race and ethnicity in this low-income population. The reduction in racial and ethnic disparities following introduction of the patch suggests that methods with novel characteristics may increase acceptability of contraceptives among minority women.

Breast-Feeding in Immigrant Women: The Role of Social Support and Acculturation.

CONTEXT In California, emergency contraception is available without a prescription to females younger than 18 through pharmacy access. Timely access to the method is critical to reduce the rate of unintended pregnancy among adolescents, particularly Latinas. METHODS In 2005-2006, researchers posing as English- and Spanish-speaking females-who said they either were 15 and had had unprotected intercourse last night or were 18 and had had unprotected sex four days ago-called 115 pharmacy-access pharmacies in California. Each pharmacy received one call using each scenario; a call was considered successful if the caller was told she could come in to obtain the method. Chi-square tests were used to assess differences between subgroups. In-depth interviews with 22 providers and pharmacists were also conducted, and emergent themes were identified. RESULTS Thirty-six percent of all calls were successful. Spanish speakers were less successful than English speakers (24% vs. 48%), and callers to rural pharmacies were less successful than callers to urban ones (27% vs. 44%). Although rural pharmacies were more likely to offer Spanish-language services, Spanish-speaking callers to these pharmacies were the least successful of all callers (17%). Spanish speakers were also less successful than English speakers when calling urban pharmacies (30% vs. 57%). Interviews suggested that little cooperation existed between pharmacists and clinicians and that dispensing the method at clinics was a favorable option for adolescents. CONCLUSIONS Adolescents face significant barriers to obtaining emergency contraception, but the expansion of Spanish-language services at pharmacies and greater collaboration between providers and pharmacists could improve access.

Intrauterine contraception: impact of provider training on participant knowledge and provision.

Extended periods of remission from cancer have led to an increasing number of patients coping with problems in day-to-day living. Attendance at group support programs that address these problems has been low, however, and only certain subgroups of cancer patients seem to be attracted to them. This study consisted of gathering qualitative and quantitative information from 73 cancer patients concerning factors that might influence participation in group support programs. Only 25% of the patients expressed an interest in group programs. The main reason for interest was the opportunity for mutual support and exchange of experiences. On the other hand, the most common reasons for lack of interest among the 75% who were not interested in group programs were doubts about the usefulness of patient groups and/or the impression that other kinds of support were more important. The ratio 1:3 (one person interested versus three persons not interested) was distributed across most of the analyzed sociodemographic and cancer-related variables. A logistic regression analysis showed that patients indicated significantly more interest in group programs when they had been diagnosed within the previous 14 weeks (p < 0.033). Less-educated individuals were more likely to be interested in groups (p < 0.055). Implications of the study findings are discussed with regard to the future design of support group programs.

Mexican Immigrant Male Knowledge and Support Toward Breast and Cervical Cancer Screening

This study assessed the influence of social support and acculturation on breast-feeding in 962 low-income immigrant women in New York Women completed a questionnaire during their postpartum visit. ...