Melissa Kottke

Randomized controlled trial of a computer-based module to improve contraceptive method choice.

BACKGROUND Unintended pregnancy is common in the United States, and interventions are needed to improve contraceptive use among women at higher risk of unintended pregnancy, including Latinas and women with low educational attainment. STUDY DESIGN A three-arm randomized controlled trial was conducted at two family planning sites serving low-income, predominantly Latina populations. The trial tested the efficacy of a computer-based contraceptive assessment module in increasing the proportion of patients choosing an effective method of contraception (<10 pregnancies/100 women per year, typical use). Participants were randomized to complete the module and receive tailored health materials, to complete the module and receive generic health materials, or to a control condition. RESULTS In intent-to-treat analyses adjusted for recruitment site (n=2231), family planning patients who used the module were significantly more likely to choose an effective contraceptive method: 75% among those who received tailored materials [odds ratio (OR)=1.56; 95% confidence interval (CI): 1.23-1.98] and 78% among those who received generic materials (OR=1.74; 95% CI: 1.35-2.25), compared to 65% among control arm participants. CONCLUSIONS The findings support prior research suggesting that patient-centered interventions can positively influence contraceptive method choice.

Age Differences in STDs, Sexual Behaviors, and Correlates of Risky Sex Among Sexually Experienced Adolescent African-American Females

OBJECTIVE To explore age differences in factors associated with positive sexually transmitted diseases (STD) status among a sample of African-American adolescent females. METHODS Data were collected via ACASI from 701 African-American adolescent females (14-20 years) seeking services at reproductive health clinics. Adolescents provided self-collected vaginal swabs assayed using NAAT to assess the prevalence of three STDs. RESULTS Younger adolescents (14-17 years) had significantly higher rates of STDs than older adolescents (18-20 years), but older adolescents had significantly higher levels of STD-associated risk behavior. In controlled analysis, having a casual sex partner was the only variable significantly associated with a positive STD test for younger adolescents, and prior history of STD and higher impulsivity were significantly associated with testing STD positive among older adolescents. CONCLUSIONS These findings suggest that developmentally tailored STD/HIV prevention interventions are needed for younger and older subgroups of adolescent females to help reduce their risk of infection.

Tailored health messaging improves contraceptive continuation and adherence: results from a randomized controlled trial

BACKGROUND Discontinuation and incorrect use of contraceptive methods may contribute to as many as 1 million unintended pregnancies annually in the United States. Interventions to improve contraceptive method continuation and adherence are needed. STUDY DESIGN A three-arm randomized controlled trial was conducted at two family planning sites testing the efficacy of a computer-based contraceptive assessment module in increasing the proportion of patients who continued use of their chosen contraceptive method 4 months after the family planning visit (n=224). RESULTS In analyses adjusting for clinical site of recruitment, family planning patients who used the module and received individually tailored health materials (n=78), compared to those in the control group (n=70), were significantly more likely to continue use of their chosen contraceptive method [95% compared to 77%; odds ratio (OR)=5.48; 95% confidence interval (CI): 1.72-17.42] and to adhere to their method (86% compared to 69%; OR=2.74; 95% CI: 1.21-6.21). No significant differences in these outcomes were found for participants who used the module but did not receive tailored materials (n=76), compared to the control group. CONCLUSIONS Tailored health materials significantly improved contraceptive method continuation and adherence. Additional research on the impact of the intervention on continuation and adherence in a larger sample and over a longer follow-up period is merited.

In Their Own Words: Romantic Relationships and the Sexual Health of Young African American Women

Objective. We assessed young African American womens understanding of “dual protection” (DP) (i.e., strategies that simultaneously protect against unintended pregnancies and sexually transmitted diseases [STDs]) and how relationship factors influence their use of DP methods. Methods. We conducted 10 focus groups with African American women (n=51) aged 15–24 years in Atlanta, Georgia, to identify barriers to and facilitators of their DP use. Focus group participants also completed a brief self-administered questionnaire that assessed demographics and sexual behaviors. We analyzed focus group data by theme: relationships, planning for sex, pregnancy intentions, STD worries, the trade-off between pregnancy and STDs, attitudes toward condoms and contraceptives, and understanding of DP. Results. From the questionnaire, 51% of participants reported that an STD would be the “worst thing that could happen,” and 26% reported that being pregnant would be “terrible.” Focus group data suggested that most participants understood what DP was but thought it was not always feasible. Relationship factors (e.g., trust, intimacy, length of relationship, and centrality) affected pregnancy intentions, STD concerns, and use of DP. Social influences (e.g., parents) and pregnancy and STD history also affected attitudes about pregnancy, STDs, and relationships. Conclusions. Although participants identified risks associated with sex, a complex web of social and relationship factors influenced the extent to which they engaged in protective behavior The extent to which relationship factors influence DP may reflect developmental tasks of adolescence and should be considered in any program promoting sexual health among young African American women.

Dual Protection Use to Prevent STIs and Unintended Pregnancy

This editorial provides a brief summary of eight research papers concerning dual protection strategies as designed to enhance prevention of both unintended pregnancy and STI/HIV and to better understand factors influencing their use. The papers present findings on dual protection use among adolescents and adults in the United States dual protection use among HIV-positive individuals in Zambia and India biomedical approaches to dual protection the potential impact of multiple risk messaging on condom use among women and biological strategies to enhance the measurement of dual protection.

Contraceptive history unintended pregnancy and contraceptive method choice among urban low-income women.

BACKGROUND Nearly half of pregnancies in the United States are unintended, a proportion that has remained constant in the last decade. Half of unintended pregnancies occur among women not using any contraception, but little is known about how contraceptive history and contraceptive priorities predict contraceptive method choice. METHODS Among 1454 women not currently seeking pregnancy who completed a computer-based contraceptive assessment module at an urban reproductive health center, factors associated with not obtaining a contraceptive method were assessed. RESULTS The 1454 participants were low-income (98% had incomes <200% federal poverty level), predominantly Hispanic (71%), and foreign-born (76%). None were seeking to become pregnant, but 15% did not obtain a method of contraception. In adjusted analyses, women who had ever had an unintended pregnancy-41% of the sample-were significantly more likely to leave their visit without receiving a method (adjusted odds ratio [AOR]=1.67, 95% confidence interval [CI]: 1.21-2.30), as were women who were not using contraception at the start of their visit (AOR=3.82, 95% CI: 2.73-5.35). In an adjusted model, prioritizing no hormones or the preference of not wanting to interrupt sex to use a method was not a significant predictor of obtaining a method. CONCLUSIONS Analyses revealed that women at higher risk of unintended pregnancy identified by their contraceptive histories were significantly more likely to leave their healthcare visit without a method of contraception. Additional research is needed on ways to help women obtain effective, medically indicated contraceptive methods that fit their reproductive life goals, priorities, and preferences.

Over-the-Counter Access to Oral Contraceptives for Adolescents

Oral contraceptives (OCs) are used by millions of women in the U.S. The requirement to obtain OCs by prescription from a clinician may serve as a barrier to contraceptive initiation and continuation for women, in particular adolescents. Over-the-counter (OTC) availability would reduce this barrier and could further reduce unintended pregnancy rates. This review explores the scientific issues and regulatory processes involved in switching OCs to OTC status for minor adolescents. We review: (1) the regulatory criteria for switching a drug to OTC status; (2) risk of pregnancy and safety during use of OCs including combined oral contraceptives and progestin-only pills for adolescents; (3) the ability of adolescents to use OCs consistently and correctly; (4) OTC access to OCs and potential effect on sexual risk behaviors; and (5) the potential for reduced opportunities for clinicians to counsel and provide recommended reproductive health care to adolescents. We find strong scientific rationale for including adolescents in any regulatory change to switch OCs to OTC status. OCs are safe and highly effective among adolescents; contraindications are rarer among adolescents compared to adult women. Ready access to OCs, condoms, and emergency contraception increases their use without increasing sexual risk behaviors.

Use of Dual Methods for Protection from Unintended Pregnancy and Sexually Transmitted Diseases in Adolescent African American Women

STUDY OBJECTIVE To characterize factors associated with dual method contraceptive use in a sample of adolescent women. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We conducted a cross-sectional survey of sexually active African American women aged 14-19 years who attended an urban Title X clinic in Georgia in 2012 (N = 350). Participants completed a computerized survey to assess contraceptive and condom use during the past 2 sexual encounters with their most recent partner. Dual method use was defined as use of a hormonal contraceptive or intrauterine device and a condom. We applied multinomial logistic regression, using generalized estimating equations, to examine the adjusted association between dual method use (vs use of no methods or less effective methods alone; eg, withdrawal) and select characteristics. RESULTS Dual methods were used by 20.6% of participants at last sexual intercourse and 23.6% at next to last sexual intercourse. Having a previous sexually transmitted disease (adjusted odds ratio [aOR], 2.30; 95% confidence interval [CI], 1.26-4.18), negative attitude toward pregnancy (aOR, 2.25; 95% CI, 1.19-4.28), and a mother who gave birth as a teen (aOR, 2.34; 95% CI, 1.21-4.52) were associated with higher odds of dual method use. Having no health insurance (aOR, 0.39; 95% CI, 0.18-0.82), 4 or more lifetime sexual partners (aOR, 0.42; 95% CI, 0.22-0.78), sex at least weekly (aOR, 0.54; 95% CI, 0.29-0.99), and agreeing to monogamy with the most recent partner (aOR, 0.40; 95% CI, 0.16-0.96) were associated with decreased odds of dual method use. CONCLUSION Dual method use was uncommon in our sample. Efforts to increase use of dual methods should address individual and relationship factors.

Clinically Significant Depressive Symptoms in African American Adolescent Females in an Urban Reproductive Health Clinic

Adolescent depression is a major public health concern. Depression and depressive symptoms are more prevalent in adolescent females and are associated with high-risk sexual behavior. Only one third of adolescents receive professional help for their depression, although about 90% visit their primary care providers on average 2–3 times per year. It is imperative that health professionals seek additional methods in the identification and treatment of depressive symptoms. This paper presents findings of the presence of clinically significant depressive symptoms in African American female adolescents receiving routine health care services within an adolescent primary care reproductive health clinic. Results revealed higher rates of depressive symptoms in this subsample of African American adolescent females when compared to the national sample, suggesting that primary care reproductive health clinics are a viable setting for the identification of depressive symptoms among low income, African American female adolescents. Psychosocial interventions and recommendations for the integration of primary care reproductive health, and behavioral health consultation services are presented.

Nondaily Contraceptive Options User Benefits, Potential for High Continuation, and Counseling Issues

Advances in contraception over the past decade have included an increasing number of methods that do not require daily or coital administration. Currently available reversible nondaily options include the transdermal patch, vaginal ring, contraceptive progestin injection, subdermal etonogestrel implant, levonorgestrel intrauterine system (LNG IUS), and copper intrauterine device (IUD). These methods have the attributes of convenience, high efficacy, ease of use, noncontraceptive benefits, and reversibility. Each method offers reliable contraception, with its own adverse effects and benefit-risk profile. Clinicians should be well-versed in the available reversible contraceptive methods to adequately counsel their patients. This is particularly pertinent when counseling women about female and male permanent sterilization (tubal ligation or vasectomy). Counseling before tubal ligation or vasectomy should include a review of the benefits of permanent sterilization and the risks unique to these procedures, such as the risks associated with minor surgery, anesthesia, or sedation. Counseling before permanent sterilization should also include the possible loss of noncontraceptive benefits related to hormonal contraception, the permanence of the procedure, risk of regret, and a review of all available contraceptive alternatives. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to summarize information about non-daily contraceptive options to allow patients to make well-informed decisions, distinguish differences between non-daily contraceptive choices to guide recommendations for care, and generate counseling plans and materials for contraceptive patients.