Summer L. Martins

Interventions Using New Digital Media to Improve Adolescent Sexual Health: A Systematic Review

New digital media (e.g., the Internet, text messaging, and social networking sites [SNS]) have dramatically altered the communication landscape, especially for youth. These communication platforms present new tools for engaging youth in sexual health promotion and risk reduction. We searched eight public databases across multiple disciplines for all peer-reviewed studies published between January 2000 and May 2011 that empirically evaluated the impact of digital media-based interventions on the sexual health knowledge, attitudes, and/or behaviors of adolescents aged 13-24 years. Of 942 abstracts, 10 met inclusion criteria. Seven studies were conducted in the United States. Eight described Web-based interventions, one used mobile phones, and one was conducted on an SNS. Two studies significantly delayed initiation of sex, and one was successful in encouraging users of an SNS to remove sex references from their public profile. Seven interventions significantly influenced psychosocial outcomes such as condom self-efficacy and abstinence attitudes, but at times the results were in directions unexpected by the study authors. Six studies increased knowledge of HIV, sexually transmitted infections, or pregnancy. This area of research is emerging and rapidly changing. More data from controlled studies with longer (>1 year) follow-up and measurement of behavioral outcomes will provide a more robust evidence base from which to judge the effectiveness of new digital media in changing adolescent sexual behavior.

Pharmacokinetics of the etonogestrel contraceptive implant in obese women.

OBJECTIVE We sought to examine the pharmacokinetics and acceptability of the etonogestrel contraceptive implant in obese women. STUDY DESIGN We developed and validated a plasma etonogestrel concentration assay and enrolled 13 obese (body mass index ≥30) women and 4 normal-weight (body mass index <25) women, who ensured comparability with historical controls. Etonogestrel concentrations were measured at 50-hour intervals through 300 hours postinsertion, then at 3 and 6 months to establish a pharmacokinetic curve. RESULTS All obese participants were African American, while all normal-weight participants were white. Across time, the plasma etonogestrel concentrations in obese women were lower than published values for normal-weight women and 31-63% lower than in the normal-weight study cohort, although these differences were not statistically significant. The implant device was found highly acceptable among obese women. CONCLUSION Obese women have lower plasma etonogestrel concentration than normal-weight women in the first 6 months after implant insertion. These findings should not be interpreted as decreased contraceptive effectiveness without additional considerations.

Use of withdrawal and unintended pregnancy among females 15-24 years of age.

OBJECTIVE: To examine the prevalence of withdrawal (coitus interruptus) use among a cohort of U.S. females aged 15–24 years, to describe characteristics of withdrawal users, and to evaluate whether withdrawal users exhibit a higher risk of unintended pregnancy. METHODS: We analyzed the 2006–2008 National Survey of Family Growth, estimating with a Cox proportional hazards model the risk of an unintended pregnancy over and up to a 47-month retrospective period among females aged 15–24 years who used withdrawal relative to females who used only other methods of contraception. We also examined correlates of withdrawal use using a logit model. RESULTS: During the study period, 31.0% of females in our cohort used withdrawal. Of withdrawal users, 21.4% experienced an unintended pregnancy compared with 13.2% of females who used only other contraceptive methods (adjusted hazard ratio 1.75, 95% confidence interval [CI] 1.23–2.49). Withdrawal users were also 7.5% more likely to have used emergency contraception (adjusted odds ratio [OR] 1.57, 95% CI 1.13–2.20). Married females were 14.8% less likely than single females to use withdrawal (adjusted OR 0.58, 95% CI 0.35–0.96). CONCLUSION: Use of withdrawal as contraception is common and might place females at higher risk of unintended pregnancy. Health care providers should be aware that many patients may use withdrawal, should consider the need for emergency contraception among these females, and should encourage them to use more effective methods of contraception. LEVEL OF EVIDENCE: II

Use of the Intrauterine Device Among Adolescent and Young Adult Women in the United States From 2002 to 2010

PURPOSE Long-acting contraceptives, such as the intrauterine device (IUD), show potential for decreasing the incidence of unintended pregnancy. However, use among adolescent and young adult women remains low. We determined factors associated with IUD use among young women. METHODS We conducted an analysis of nationally representative, cross-sectional data from the 2002 and 2006-2010 National Surveys of Family Growth. We included sexually active women 15-24 years old. We used bivariate analysis to compare proportions of ever-use of any type of IUD in 2002 and in 2006-2010 and multivariable logistic regression to identify correlates of ever-use in 2006-2010. RESULTS We found an increase in IUD use in teens 15-19 years old, from .2% to 2.5% (p < .001), and among women 20-24 years old, 2.0% to 5.4% (p < .001). Use increased among nearly all subgroups of respondents. Compared with nulliparous young women, those with one prior delivery and with two or more deliveries were substantially more likely to have used an IUD (adjusted OR 11.43, 95% CI 3.61-36.16, and adjusted OR 13.60, 95% CI 4-46.48, respectively). Young black women were less likely to report IUD use (adjusted OR .32, 95% CI .16-.66), and women whose mothers received at least a high school education were more likely to report use (adjusted OR 2.56, 95% CI 1.22-5.43). CONCLUSIONS IUD use is increasing among adolescent and young adult women overall and among almost all sociodemographic subgroups. Nonetheless, use remains low, and nulliparous young women are highly unlikely to use the IUD.

Doula support during first-trimester surgical abortion: a randomized controlled trial

OBJECTIVE The objective of the study was to evaluate the impact of doula support on first-trimester abortion care. STUDY DESIGN Women were randomized to receive doula support or routine care during first-trimester surgical abortion. We examined the effect of doula support on pain during abortion using a 100 mm visual analog scale. The study had the statistical power to detect a 20% difference in mean pain scores. Secondary measures included satisfaction, procedure duration, and patient recommendations regarding doula support. RESULTS Two hundred fourteen women completed the study: 106 received doula support, and 108 received routine care. The groups did not differ regarding demographics, gestational age, or medical history. Pain scores in the doula and control groups did not differ at speculum insertion (38.6 [±26.3 mm] vs 43.6 mm [±25.9 mm], P = .18) or procedure completion (68.2 [±28.0 mm] vs 70.6 mm [±23.5 mm], P = .52). Procedure duration (3.39 [±2.83 min] vs 3.18 min [±2.36 min], P = .55) and patient satisfaction (75.2 [±28.6 mm] vs 74.6 mm [±27.4 mm], P = .89) did not differ between the doula and control groups. Among women who received doula support, 96.2% recommended routine doula support for abortion and 60.4% indicated interest in training as doulas. Among women who did not receive doula support, 71.6% of women would have wanted it. Additional clinical staff was needed to provide support for 2.9% of women in the doula group and 14.7% of controls (P < .01). CONCLUSION Although doula support did not have a measurable effect on pain or satisfaction, women overwhelmingly recommended it for routine care. Women receiving doula support were less likely to require additional clinic support resources. Doula support therefore may address patient psychosocial needs.

Correlates of Heterosexual Anal Intercourse among Women in the 2006-2010 National Survey of Family Growth

INTRODUCTION Heterosexual anal intercourse (HAI) is common among U.S. women. Receptive anal intercourse is a known risk factor for HIV, yet there is a paucity of data on HAI frequency and distribution in the United States. Condom use is lower with HAI vs. vaginal intercourse, but little is known regarding of correlates of HAI with and without condoms. AIMS The aims of this study were to describe recent (past 12 months) and lifetime HAI among sexually active reproductive-aged U.S. women, and to characterize women who engage in HAI with and without condoms. METHODS We analyzed a sample of 10,463 heterosexually active women aged 15-44 years for whom anal intercourse data were available in the 2006-2010 National Survey of Family Growth. MAIN OUTCOME MEASURES Weighted bivariate and multivariable analyses were used to determine HAI prevalence and correlates. Primary outcomes were lifetime HAI, recent (last 12 months) HAI, and condom use at last HAI. RESULTS In our sample, 13.2% of women had engaged in recent HAI and 36.3% in lifetime HAI. Women of all racial and ethnic backgrounds and religions reported recent anal intercourse. Condom use was more common at last vaginal intercourse than at last anal intercourse (28% vs. 16.4%, P < 0.001). In multivariable analysis, correlates of recent HAI included: less frequent church attendance, younger age at first intercourse, multiple sexual partners, history of oral intercourse, history of unintended pregnancy, and treatment for sexually transmitted infections (all P < 0.05). Correlates of lifetime HAI were similar, with the addition of older age, higher education, higher income, and history of drug use (all P < 0.05). CONCLUSION Women of all ages and ethnicities engage in HAI, at rates higher than providers might realize. Condom use is significantly lower for HAI vs. vaginal intercourse, putting these women at risk for acquisition of sexually transmitted infections.

Motivational interviewing to improve postabortion contraceptive uptake by young women: development and feasibility of a counseling intervention ☆ ☆☆

OBJECTIVE The objective was to develop and test a postabortal contraception counseling intervention using motivational interviewing (MI) and to determine the feasibility, impact and patient acceptability of the intervention when integrated into an urban academic abortion clinic. STUDY DESIGN A single-session postabortal contraception counseling intervention for young women aged 15-24 years incorporating principles, skills and style of MI was developed. Medical and social work professionals were trained to deliver the intervention, their competency was assessed, and the intervention was integrated into the clinical setting. Feasibility was determined by assessing ability to approach and recruit participants, ability to complete the full intervention without interruption and participant satisfaction with the counseling. RESULTS We approached 90% of eligible patients and 71% agreed to participate (n=20). All participants received the full counseling intervention. The median duration of the intervention was 29 min. Immediately after the intervention and at the 1-month follow-up contact, 95% and 77% of participants reported that the session was helpful, respectively. CONCLUSIONS MI counseling can be tailored to the abortion setting. It is feasible to train professionals to use MI principles, skills and style and to implement an MI-based contraception counseling intervention in an urban academic abortion clinic. The sessions are acceptable to participants. IMPLICATIONS The use of motivational interviewing in contraception counseling may be an appropriate and effective strategy for increasing use of contraception after abortion. This study demonstrates that this patient-centered, directive and collaborative approach can be developed into a counseling intervention that can be integrated into an abortion clinic.

Impact of a theory-based video on initiation of long-acting reversible contraception after abortion

OBJECTIVE Adoption of long-acting reversible contraception (LARC) (ie, the intrauterine device or the contraceptive implant) immediately after abortion is associated with high contraceptive satisfaction and reduced rates of repeat abortion. Theory-based counseling interventions have been demonstrated to improve a variety of health behaviors; data on theory-based counseling interventions for postabortion contraception are lacking. STUDY DESIGN Informed by the transtheoretical model of behavioral change, a video intervention was developed to increase awareness of, and dispel misconceptions about, LARC methods. The intervention was evaluated in a randomized controlled trial among women aged 18-29 years undergoing surgical abortion at a clinic in Chicago, IL. Participants were randomized 1:1 to watch the intervention video or to watch a stress management video (control), both 7 minutes in duration. Contraceptive methods were supplied to all participants free of charge. Rates of LARC initiation immediately after abortion were compared. RESULTS Rates of LARC initiation immediately after abortion were not significantly different between the 2 study arms; 59.6% in the intervention and 51.6% in the control arm chose a LARC method (P = .27). CONCLUSION This study resulted in an unexpectedly high rate of LARC initiation immediately after abortion. High rates of LARC initiation could not be attributed to a theory-based counseling intervention.

A motivational interviewing-based counseling intervention to increase postabortion uptake of contraception: A pilot randomized controlled trial

OBJECTIVE To determine if a counseling intervention using the principles of motivational interviewing (MI) would impact uptake of long-acting reversible contraception (LARC) after abortion. METHODS We conducted a pilot randomized controlled trial comparing an MI-based contraception counseling intervention to only non-standardized counseling. Sixty women 15-29 years-old were randomized. PRIMARY OUTCOME uptake of LARC within four weeks of abortion. SECONDARY OUTCOMES uptake of any effective contraceptive, contraceptive use three months after abortion and satisfaction with counseling. Bivariate analysis was used to compare outcomes. RESULTS In the intervention arm, 65.5% of participants received a long-acting method within four weeks compared to 32.3% in the control arm (p=0.01). Three months after the abortion, differences in LARC use endured (60.0% vs. 30.8%, p=0.05). Uptake and use of any effective method were not statistically different. More women in the intervention arm reported satisfaction with their counseling than women in the control arm (92.0% vs. 65.4%, p=0.04). CONCLUSION Twice as many women in the MI-based contraception counseling intervention initiated and continued to use LARC compared to women who received only non-standardized counseling. PRACTICE IMPLICATIONS A contraception counseling session using the principles and skills of motivational interviewing has the potential to impact LARC use after abortion.

Depot Medroxyprogesterone Acetate Use Is Not Associated With Risk of Incident Sexually Transmitted Infections Among Adolescent Women

PURPOSE To determine whether depot medroxyprogesterone acetate (DMPA) use is associated with an increased risk of acquisition of sexually transmitted infections (STIs) in a cohort of healthy adolescents, for whom prospective evidence is sparse. METHODS Adolescent women aged 14-17 years (n = 342) were recruited from clinical sites in the United States between 1999 and 2005. They returned quarterly for interviews and STI testing. During alternating 3-month periods, participants also completed daily diaries of sexual behaviors and performed weekly vaginal self-obtained swabs to test for STIs. Data collected through 2009 (median follow-up length = 42.2 months) were analyzed. Univariable and multivariable tests of association between STI acquisition during the 3-month diary period and covariates were calculated, using nonlinear mixed-effect logistic regression models to control for repeated measurements. RESULTS In multivariable analysis, there were no significant associations between DMPA use in the current or previous 3-month period and incidence of Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis. The number of total or unprotected sexual events during the diary period was not associated with the risk of STI. Older age was a protective factor for the development of Chlamydia trachomatis (odds ratio = .85; 95% confidence interval = .76-.96). The only factor significantly associated with an increased risk of contracting all three STIs was a greater number of sexual partners during the diary period (odds ratio, range = 1.91-2.62). CONCLUSIONS In this U.S.-based cohort of adolescent women, we found no evidence that DMPA use was associated with increased STI risk. Efforts to curb STI transmission among adolescents should focus on education about the reduced number of sexual partners.