Susan E. Rubin

Determinants of intrauterine contraception provision among US family physicians: a national survey of knowledge, attitudes and practice

BACKGROUND Poor contraception adherence contributes to unintended pregnancy. Intrauterine contraception (IUC) is user-independent thus adherence is not an issue, yet few US women use IUC. We compared family physicians (FPs) who do and do not insert IUC in order to ascertain determinants of inserting IUC. STUDY DESIGN We surveyed 3500 US FPs. The primary outcome variable was whether a physician inserts IUC in their current clinical practice. We also sought to describe their clinical practice with IUC insertions. RESULTS FPs who insert IUC had better knowledge about IUC (adjusted OR 1.85, 95% CI 1.32-2.60), more comfort discussing IUC (adjusted OR 2.35, 95% CI 1.30-4.27), and were more likely to believe their patients are receptive to discussing IUC (adjusted OR 2.96, 95% CI 2.03-4.32). The more IUC inserted during residency, the more likely to insert currently (adjusted OR 1.44, 95% CI 1.12-1.84). Only 24% of respondents inserted IUC in the prior 12 months. CONCLUSIONS US FPs have training and knowledge gaps, as well as attitudes, that result in missed opportunities to discuss and provide IUC for all eligible patients.

New york city physicians' views of providing long-acting reversible contraception to adolescents.

PURPOSE Although the US adolescent pregnancy rate is high, use of the most effective reversible contraceptives—intrauterine devices (IUDs) and implantable contraception—is low. Increasing use of long-acting reversible contraception (LARC) could decrease adolescent pregnancy rates. We explored New York City primary care physicians’ experiences, attitudes, and beliefs about counseling and provision of LARC to adolescents. METHODS We conducted in-depth telephone interviews with 28 family physicians, pediatricians, and obstetrician-gynecologists using an interview guide based on an implementation science theoretical framework. After an iterative coding and analytic process, findings were interpreted using the capability (knowledge and skills), opportunity (environmental factors), and motivation (attitudes and beliefs) conceptual model of behavior change. RESULTS Enablers to IUD counseling and provision include knowledge that nulliparous adolescents are appropriate IUD candidates (capability) and opportunity factors, such as (1) a clinical environment supportive of adolescent contraception, (2) IUD availability in clinic, and (3) the ability to insert IUDs or easy access to an someone who can. Factors enabling motivation include belief in the overall positive consequences of IUD use; this is particularly influenced by a physicians’ perception of adolescents’ risk of pregnancy and sexually transmitted disease. Physicians rarely counsel about implantable contraception because of knowledge gaps (capability) and limited access to the device (opportunity). CONCLUSION Knowledge, skills, clinical environment, and physician attitudes, all influence the likelihood a physician will counsel or insert LARC for adolescents. Interventions to increase adolescents’ access to LARC in primary care must be tailored to individual clinical practice sites and practicing physicians, the methods must be made more affordable, and residency programs should offer up-to-date, evidence-based teaching.

Challenges of providing confidential care to adolescents in urban primary care: Clinician perspectives

PURPOSE Clinician time alone with an adolescent has a major impact on disclosure of risk behavior. This study sought to describe primary care clinicians’ patterns of delivering time alone, decision making about introducing time alone to adolescents and their parents, and experiences delivering confidential services. METHODS We undertook qualitative interviews with 18 primary care clinicians in urban health centers staffed by specialists in pediatrics, family medicine, and adolescent medicine. RESULTS The annual preventive care visit is the primary context for provision of time alone with adolescents; clinicians consider the parent-child dynamic and the nature of the chief complaint for including time alone during visits for other than preventive care. Time constraints are a major barrier to offering time alone more frequently. Clinicians perceive that parental discomfort with time alone is rare. Many clinicians wrestle with internal conflict about providing confidential services to adolescents with serious health threats and regard their role as facilitating adolescent-parent communication. Health systems factors can interfere with delivery of confidential services, such as inconsistent procedures for determining whether unaccompanied youth would be seen. CONCLUSION Despite competing time demands, clinicians report commitment to offering time alone during preventive care visits and infrequently offer it at other times. Experienced clinicians can gain skills in the art of managing complex relationships between adolescents and their parents. Office systems should be developed that enhance the consistency of delivery of confidential services.

Urban female family medicine patients perceptions about intrauterine contraception.

AIMS Improper and inconsistent contraceptive use contributes to the unintended pregnancy rate. The intrauterine device (IUD) is an effective, safe method of contraception that cannot be used improperly or inconsistently. However, it is relatively underused in the United States. We developed a qualitative study to better understand patient beliefs and attitudes that may act as a barrier to acceptance or use of an IUD. METHODS We conducted semistructured interviews with a convenience sample of 40 reproductive aged women from two Bronx, New York, family medicine practices. Self-report of having heard of the IUD was the main eligibility criterion. We used an iterative process of data collection and analysis. RESULTS Although respondents appreciate the advantages of an IUD, they express a number of conceptual concerns and fears about the device. These are primarily related to voluntarily placing a device inside the body for a prolonged period of time and to a knowledge gap about internal female reproductive anatomy. The IUD is viewed as a contraception option to use when other methods have failed or after childbearing. Additionally, respondents report a lack of discussion and information about the IUD from healthcare providers, the media, and informal networks. CONCLUSIONS Directly addressing patient reservations that might otherwise be left unsaid could potentially increase acceptance of the IUD. The issues elucidated in this study begin to shed light on specific patient concerns that providers or public health messages may address during IUD contraception counseling. Given the high efficacy and safety of IUDs, increasing use could impact rates of unplanned pregnancy.

Primary Care Physicians’ Concerns May Affect Adolescents’ Access to Intrauterine Contraception

Purpose: Although the intrauterine device (IUD) may be safely used in adolescents, few US adolescents use IUDs. Increasing IUD use in adolescents can decrease pregnancy rates. Primary care providers’ clinical practices many be one of the many barriers to increasing adolescents access to IUDs. We explored primary care physicians’ (PCPs) approaches to contraception counseling with adolescents, focusing on their views about who would be appropriate IUD candidates. Methods: Phone interviews were conducted with 28 urban family physicians, pediatricians, and obstetrician-gynecologists. Using standard qualitative techniques, we developed coding template and applied codes. Results: Most respondents have a patient-centered general contraceptive counseling approach. However, when considering IUDs many PCPs describe more paternalistic counseling. For example, although many respondents believe adolescents’ primary concern is pregnancy prevention, many PCPs prioritize sexually transmitted infection (STI) prevention and thus would not offer an IUD. Attributes PCPs associate with an appropriate IUD candidate include responsibility, reliability, maturity, and monogamy. Conclusion: Our findings suggest that when considering IUDs for adolescents some PCPs’ subjective assessment of adolescent sexual behavior, attitudes about STI risk factors and use of overly restrictive IUD eligibility criteria impede adolescent’s IUD access. Education around best practices may be insufficient to counterbalance attitudes concerning adolescent sexuality and STI risk; there is also a need to identify and discuss PCPs potential biases or assumptions affecting contraception counseling.

Primary care providers' reports of time alone and the provision of sexual health services to urban adolescent patients: results of a prospective card study.

Confidential care is an essential element of quality adolescent primary care. Twenty-one primary care providers tracked provision of confidential care (time alone with adolescent) and sexual health services in clinics serving low-income, primarily minority communities. Over 144 visits attended by a parent, 68% involved time alone with the adolescent. Time alone was 18 times higher for physicals than same day or walk-in visits, and 3 times higher if teen presented a sex complaint. Provision of sexual health services was 3 times higher for those who had time alone with the provider, especially among girls. The results indicate some missed opportunities to deliver needed services to at-risk populations, especially among boys.

Intrauterine Devices at Six Months: Does Patient Age Matter? Results from an Urban Family Medicine Federally Qualified Health Center (FQHC) Network

Background: Federally qualified health centers (FQHCs) can address high rates of unintended pregnancy among adolescents in the United States by increasing access to intrauterine devices (IUDs) in underserved settings. Despite national guidelines endorsing adolescent use of IUDs, some physicians remain concerned about IUD tolerance and safety in adolescents. Therefore we compared adolescents and adults in a family physician staffed FQHC network with regard to (1) IUD postinsertion experience, (2) device discontinuation, and (3) sexually transmitted infection (STI) rates. Methods: We conducted a retrospective cohort study among women <36 years old who had an IUD inserted in 2011 at a New York City FQHC staffed by family physicians. Results: We included 684 women (27% adolescents, 73% adults). During the 6-month postinsertion period, 59% of adolescents and 43% of adults initiated IUD-related clinical contact after insertion, most commonly for bleeding changes and pelvic or abdominal pain. There were no significant differences between groups in IUD expulsion or removal or STI rates. Conclusions: Urban FQHC providers may anticipate that, compared with their adult IUD users, adolescents will initiate more clinical follow-up visits after insertion. Both groups will, however, have similar clinical concerns about, reasons for, and rate of device discontinuation and low STI rates.

US family physicians' intrauterine and implantable contraception provision: Results from a national survey

OBJECTIVE Establish a current cross-sectional national picture of intrauterine device (IUD) and implant provision by US family physicians and ascertain individual, clinical site and scope of practice level associations with provision. STUDY DESIGN Secondary analysis of data from 2329 family physicians recertifying with the American Board of Family Medicine in 2014. RESULTS Overall, 19.7% of respondents regularly inserted IUDs, and 11.3% regularly inserted and/or removed implants. Family physicians provided these services in a wide range of clinical settings. In bivariate analysis, almost all of the individual, clinical site and scope of practice characteristics we examined were associated with provision of both methods. In multivariate analysis, the scope of practice characteristics showed the strongest association with both IUD and implant provision. For IUDs, this included providing prenatal care with [adjusted odds ratio (aOR) 3.26, 95% confidence interval (95% CI)=1.93-5.49] or without (aOR=3.38, 95% CI=1.88-6.06) delivery, performance of endometrial biopsies (aOR=16.51, 95% CI=11.97-22.79) and implant insertion and removal (aOR=8.78, 95% CI=5.79-13.33). For implants, it was providing prenatal care and delivery (aOR=1.77, 95% CI=1.15-2.74), office skin procedures (aOR=3.07, 95% CI=1.47-6.42), endometrial biopsies (aOR=3.67, 95% CI=2.41-5.59) and IUD insertion (aOR=8.58, 95% CI=5.70-12.91). CONCLUSIONS While a minority of family physicians regularly provided IUDs and/or implants, those who provided did so in a broad range of outpatient settings. Individual and clinical site characteristics were not largely predictive of provision. This connotes potential for family physicians to increase IUD and implant access in a variety of settings. Provision of both methods was strongly associated with scope of practice variables including performance of certain office procedures as well as prenatal and/or obstetrical care. IMPLICATIONS These data provide a baseline from which to analyze change in IUD and implant provision in family medicine, identify gaps in care and ascertain potential leverage points for interventions to increase long-acting reversible contraceptive provision by family physicians. Interventions may be more successful if they first focus on sites and/or family physicians who already provide prenatal care, obstetrical care, skin procedures and/or endometrial biopsies.

Counseling Adolescents About the Intrauterine Contraceptive Device: A Comparison of Primary Care Pediatricians With Family Physicians and Obstetrician-Gynecologists in the Bronx, New York.

Background: The intrauterine device (IUD) is a highly effective contraceptive, yet not all primary care providers (PCPs) counsel adolescents about IUDs. We sought to describe PCPs’ frequency of counseling adolescents about IUDs and identify whether different factors are associated with frequent counseling by pediatricians compared with family physicians and gynecologists. Methods: Surveyed PCPs affiliated with a Bronx, New York academic institution. Main Outcome: Frequent counseling of female adolescents about IUDs. Results: Frequent counseling was lower in pediatricians compared with family physicians and gynecologists (35.8% and 81.6%, respectively, P < .001). Among all PCP types, frequent counseling was associated with feeling more competent counseling and managing expected IUD side effects (P < .001). Other significant variables included inserting IUDs themselves (P < .001, family physicians and gynecologists) or having access to an inserter in their office (P = .04, pediatricians). Conclusions: Correlates of frequent IUD counseling differed according to PCP specialty. Our results suggest that interventions to increase IUD counseling should focus on improving PCPs’ competency around counseling and side effect management as well as increasing access to IUD inserters.

Testing Adolescents for Sexually Transmitted Infections in Urban Primary Care Practices: Results From a Baseline Study

Objective: Sexually active urban adolescents experience a high burden of sexually transmitted infections (STI). Adolescents often access medical care through general primary care providers; their time alone with a provider increases the likelihood that youth will disclose risky behavior, which may result in STI testing. Our goals were to assess the association (if any) between the provision of time alone and STI testing, and describe the rates of STI testing among sexually active adolescents in urban primary care. Methods: Youth (aged 12-19 years) presenting for care at 4 urban health centers were invited to complete post-visit surveys of their experience. Sexually transmitted infection screening rates were obtained from the clinical information systems (CIS); CIS data were linked to survey responses. Results: We received 101 surveys. Surveyed youth experienced time alone in 69% of all visits. Time alone varied by age (older teens experienced more time alone), and it occurred more frequently in preventive visits (71%) versus nonpreventive visits (33%). It did not vary by gender. Forty-two of the 46 sexually active youth experienced time alone. Screening rates for sexually active females, either at the index visit or within 6 months prior to the index visit, were 17.9% for human immunodeficiency virus and 32.1% for gonorrhea/Chlamydia. No sexually active surveyed males were tested. Overall screening rates varied widely across practices (human immunodeficiency virus 0%-29%; gonorrhea/Chlamydia 7%-29%). There was no difference in screening rates among youth with and without time alone. Conclusion: STI testing for adolescents is being conducted in this primary care urban population, especially for sexually active females. However, clinicians in this setting are not screening females consistently enough and rarely screen males. We were unable to test our hypothesis that provision of time alone was associated with a higher rate of STI testing. Site differences suggest substantial variation in clinician practices that should be addressed in quality improvement interventions.