Technology holds the key — Help young women pick prevention options
November 1, 2013
Technology holds the key Help young women pick prevention options
Use digital technology to reduce unintended pregnancy, STIs
Technology might help providers effectively reach teens and young adults with effective messages on birth control and prevention of sexually transmitted infections (STIs).
• Among youth ages 12-17, 93% are online, 75% have a mobile phone, and 97% play video games. Such digital technologies provide youth with anonymous avenues for seeking sexual health information. Social media tools can effectively deliver such messages.
• The Adolescent Pregnancy Prevention Campaign of North Carolina launched its BrdsNBz Text Message Warm Line in 2009 to provide confidential, factually accurate answers to sexual health questions via text message to young people ages 14-19 in North Carolina. It now works with other agencies across the United States in offering similar services.
In a 2013 national online survey of young women, more than half (58%) said they did not use contraception all the time.1(Read more about the survey; see story below.) Technology might help providers effectively reach teens and young adults with effective messages on birth control and prevention of sexually transmitted infections (STIs).
The Centers for Disease Control and Prevention (CDC) estimate that nearly 20 million new STIs occur every year in this country, with half among young people ages 15-24, notes Rachel Kachur, MPH, a health scientist in the CDC's Division of STD Prevention. The CDC recently published a white paper for practitioners and others who work with adolescents to provide insight into how digital technology can be used to improve the sexual health of this population.2
"With younger Americans at higher risk for infection, it is critical to reach them with information about STIs and how to protect themselves," says Kachur. "Digital technology is helping CDC and its public health partners, including healthcare providers, to do just that."
Whether it is the internet, mobile phones, or gaming, technology is increasingly influencing the lives of youth and has changed the way they interact and access information, notes Kachur. Among youth ages 12-17,
93% are online, 75% have a mobile phone, and 97% play video games.3,4
In addition to providing new ways for teens and young adults to communicate, these digital technologies also provide youth with anonymous avenues for seeking health information in general and sexual health, in particular, observes Kachur. Social media tools can effectively get them the information they need, she states.
"CDC is using social media vehicles like Facebook, Twitter, YouTube and Flickr to provide our public health partners with resources they can use to help raise awareness about STIs," states Kachur.
In addition to Twitter, the CDC offers several educational podcasts and webinars for providers. Go to http://1.usa.gov/17PWEUv to access them. Kachur also points to the recently released STD Tx Guide, a mobile application that helps healthcare providers identify and treat patients for STIs.
The mobile application is an easy-to-use reference that helps healthcare providers identify and treat patients for STIs. It combines information from the most current STD Treatment Guidelines as well as updates from the CDC's Morbidity and Mortality Weekly Report. It features a streamlined interface so providers can access treatment and diagnostic information. The free app is available for Apple and Android devices. Go to http://1.usa.gov/11YXyMw and click on the appropriate download link for your device.
Providers who are interested in using social media in their practice or for their organization might want to take a look at the CDC's social media guidelines, available at http://1.usa.gov/VEFAu1. The guidelines have been developed to provide critical information on lessons learned, best practices, clearance information, and security requirements. Use the agency's Social Media Toolkit, available on that web page, for a free downloadable document, to develop blogs, video-sharing sites, mobile applications, and Rich Site Summary (RSS) feeds for your practice.
NC agency goes digital
The Durham, NC-based Adolescent Pregnancy Prevention Campaign of North Carolina has embraced digital technology to reach at-risk teens and young adults. It launched its BrdsNBz Text Message Warm Line in 2009 to provide confidential, factually accurate answers to sexual health questions via text message to young people ages 14-19 in North Carolina. A young person simply texts a question, and a trained health educator responds within 24 hours.
The agency, in partnership with Houston-based OneSeventeen Media, operates BrdsNBz text lines in North Carolina, Texas, Indiana, and New Mexico, as well as two pilot parent text lines, says Elizabeth Hundley Finley, director of strategic communications for the agency. Some of the organizations that have launched BrdsNBz Text Lines include nonprofit agencies, hospitals, and state and local health departments, says Finley. More information on the program, as well as contact information, is available at http://bit.ly/Kzgmpc.
How much does it cost the agency and its contract partners to run BrdsNBz? BrdsNBz is implemented on a sliding scale based on the size of the target population and the type of organization that wants to buy a BrdsNBz license, says Finley. License fees are determined on a case-by-case basis, and the agency also factors in how much intensive help a site needs, she notes.
"For example, they may only need help developing protocols and implementing the technology, or they may also need a full-on marketing plan," Finley states.
Check "The Playbook"
The North Carolina agency also has recently launched a comprehensive social marketing campaign, "The Playbook: Your Guide to Safer, Sexier Choices," to connect sexually active 18-19 year-olds in Gaston County to clinical services. (To take a look at the online site, go to http://bit.ly/VyYEuG.)
"The Playbook" is the latest tactic of the agency's Gaston Youth Connected initiative, a five-year project funded by the CDC. The initiative is primarily focused on improving clinical services, implementing prevention programs for middle- and high-school-aged youth, and rallying community support for teen pregnancy prevention. In 2011, Gaston County recorded a teen pregnancy rate among girls ages 15-19 of 48.8 per 1,000; the national rate was 31.3 births for every 1,000 adolescent females ages 15-19.5,6
Why is "The Playbook" needed? Almost 75% of Gaston County's teen pregnancies occur in in teens ages 18-19, according to the agency. Additional research indicates 78% of these teens have been sexually active before, yet only a small proportion of them are using the county's clinics to access family planning services. A secondary focus of the campaign is designed to increase knowledge about contraceptive use, especially use of long-acting reversible contraception (LARC), and elevate the intention to use contraceptives, says Finley.
Reception to the program has been "great," says Finley. Online social marketing presents many evaluation challenges, since pre-and post-tests cannot be easily implemented as with more traditional interventions, notes Finley. Agency staffers are following such online analytics as website visits and social media engagement, however, and have seen a steady increase in use, says Finley.
To further track program use, the agency is conducting periodic in-clinic referral surveys. Its most recently completed clinic referral survey was held in May 2013, just three months after the launch of the program. More than 12% of clinic patients who completed the survey identified "The Playbook" as a referral source, says Finley. The leading referrers continue to be family, friends, and other healthcare providers, she states.
Adult reception of the program also has been positive, reports Finley. The agency held a mini-launch tour with community adults prior to the official launch of "The Playbook" site in an attempt to head off any potential controversy, says Finley. Program organizers were clear with adults that the site's target audience is sexually active teens ages 18-19.
"We told them point blank, 'You will not like it. It's not designed for you to like it.'" states Finley. "Those measures seemed to have allayed any pushback in the community."
How can providers promote effective use?
In a 2013 national online survey of young women, more than half (58%) said they did not use contraception all the time The survey polled more than 1,000 unmarried women, ages 18-29, none of whom have had children, all of whom have had sex, and none of whom are trying to get pregnant.
• More than three-quarters (77%) of women surveyed say effectiveness is the most important factor in choosing a contraceptive.
• With this in mind, providers should start counseling messages with the most effective long-acting reversible contraceptives: the intrauterine device and implant.
Your last patient of the day is a 19-year old college student. She leaves your office with a prescription for a low-dose oral contraceptive (OC). What are the chances that she will continue to use her chosen method?
If the results of a new national online survey are any indication, there's a more than 50% chance there will be inconsistency in her use of the contraceptive.1The survey, a joint project of the Washington, DC-based National Campaign to Prevent Teen and Unplanned Pregnancy and Cosmopolitan magazine, was administered in March 2013 to more than 1,000 unmarried women, ages 18-29, none of whom have had children, all of whom have had sex, and none of whom are trying to get pregnant.
What did these young women say? Examine the following results:
• Even though more than eight in 10 say they would be upset if they got pregnant, nearly half (48%) say it is at least a little bit likely they will have unprotected sex in the next year. One in five says it is very likely.
• One in four (24%) have let a partner talk them out of using contraception.
• More than eight in 10 (82%) of those who have had a pregnancy scare say that experience made them more careful about using protection and more than half (54%) say it made them switch to a more reliable method of birth control.
• One in three (30%) have used emergency contraception.
Given all of these inconsistencies in contraceptive use, though, 78% of women surveyed say they are totally satisfied with their current method of contraception.1 What can providers do to help women achieve successful, consistent use?
Women need to hear that "most of the time" isn't good enough when it comes to such methods as the Pill, condoms, and other user-dependent methods, says Sarah Brown, chief executive officer of the campaign.
"Healthcare providers have a real opportunity to educate young women, introduce them to new methods, and support them as they keep trying different types of birth control until they find the one that best suits them," says Brown. "Doctors and nurse practitioners are already a trusted source for this information and are well-positioned to set the tone for open, informative conversations."
Many young women might assume incorrectly that they are subfertile, or infertile, because they have had unprotected sex in the past and have not become pregnant, says Brown. Clinicians need to emphasize that risk of pregnancy is real, especially for women who do not choose a top-tier method.
Make effectiveness no. 1 priority
When talking with young women about contraception, routinely ask them if they want to get pregnant in the next year, says Brown.
"This is turning out to be the sentinel question not the next five years, or this week, but the next year and if they say no, then have a discussion that begins with the most effective method," states Brown. "This is different from the old way where [providers] would say in essence, 'let me tell you about all of your options, the pluses and minuses, and you make the decision.'"
Based on the survey results, 77% of women say effectiveness is the most important factor in choosing a contraceptive, says Brown. With this in mind, providers should start with the most effective long-acting reversible contraceptives (LARCs): the intrauterine device (IUD) and implant, she states. Using language such as "if for some reason, those you don't care for them or they are not right for you," providers then can move to lower-tier methods. (See resources below)
The effectiveness of LARC methods is the first message provided to women in the St. Louis Contraceptive CHOICE project, where 75% of 9,256 women who entered into the study chose to use a LARC method, says Robert Hatcher, MD, MPH, professor emeritus of gynecology and obstetrics at Emory University School of Medicine in Atlanta (To read more the CHOICE project, see the Contraceptive Technology Update articles, "What avenues will raise LARC method awareness," August 2013, p. 91," "More women moving to LARC methods Will your facility follow the trend?" April 2013, p. 37, and "The 'Get It and Forget It' methods are here: Remove obstacles to use," April 2012, p. 37.)
Effectiveness is the most important message and the first message in the two clinics offered LARC methods in the capital city of Rwanda, Hatcher says. In a study conducted by Emory University's Susan Allen, MD, MPH, and members of the Rwanda Zambia HIV Research Group, IUD and implant use rose from zero to 36-38% in the two-clinic study.2
Hatcher points to a third program that has emphasized contraceptive effectiveness. In the Northeast Health District of Georgia, a 10-county district surrounding Athens, GA, district health director Claude Burnett, MD, MPH, has presented failure rates in a fascinating method, says Hatcher. A brightly colored page of numbers presented to visitors to district clinics list the pregnancy rates from a range of contraceptives in an innovative manner. There are no decimal points. For example, the failure rate for the contraceptive implant is expressed as five per 10,000 typical women; for female sterilization, it is as 10 times as high, or 50 per 10,000 women. The failure rate for birth control pills is listed as 900 per 10,000 typical women. There has been a remarkable increase in implant and IUD use in this health district, says Hatcher.
"In a presentation to the family planning staff at Emory University, Dr. Susan Allen made an important point: Patients can really absorb one or two messages per visit," says Hatcher. "The first words out of the mouth of family planning programs should stress the effectiveness of the implants and IUDs now offered by a program."
Talk about side effects
Talking about side effects is crucial to successful use of birth control. One in four (25%) women surveyed say that fear of long-term side effects is a key reason for their decision not to use a particular method, survey results show.1One in five (19%) say they are afraid of more immediate possible side effects, such as weight gain.
It is important that clinicians say contraception options are good and healthy choices. The word "healthy" seems to have a particular resonance with young women, says Brown. If a patient says "I'm worried about X," providers should reply with such wording as "that risk is there for a certain number of women, but let me also tell you what that risk is if you get pregnant," says Brown.
"That's what we are managing against with contraception; it's pregnancy." states Brown. "We're not managing against measles."
Get up to speed
What can clinicians do to help young women successfully use contraception to protect themselves against unintended pregnancy? Get training for inserting intrauterine devices and implants, become educated on same-day insertion of these methods, and build a support system among staff to effectively manage any side effects that might stem from LARC use, says Brown.
Know that today's intrauterine devices are different from those of 25 years ago, states Brown. Keep IUDs and implants in stock so women don't have to return to the office for a separate insertion visit, she notes.
With the Affordable Care Act, insurance plans must cover all Food and Drug Administration-approved contraceptive methods with no out-of-pocket expenses. Women without insurance might qualify for Medicaid or Title X services, says Brown.
"Depending on the insurance status of the young woman, it's very important that they understand that even the best methods now for them come with no copay," states Brown.
1. The National Campaign to Prevent Teen and Unplanned Pregnancy, Cosmopolitan magazine. Contraception calling: Why aren't more young women listening? Accessed at http://bit.ly/19H7CyW.
2. Khu NH, Vwalika B, Karita E, et al. Fertility goal-based counseling increases contraceptive implant and IUD use in HIV-discordant couples in Rwanda and Zambia. Contraception 2013; 88(1):74-82.
• Download a free diagram, "Effectiveness of Family Planning Methods," from the Centers for Disease Control and Prevention to help illustrate your counseling message. Go to http://1.usa.gov/1e37WsX.
• Use free material from the St. Louis-based Contraceptive CHOICE Project Resource Center to develop your own "LARC First" practice. Go to http://bit.ly/1e3edEM.
• Visit the American College of Obstetricians and Gynecologists' LARC web page, http://bit.ly/MpQ63R, for a wide range of provider and patient resources. To sign up for free LARC e-newsletters, go to http://bit.ly/15X4wyQ.
• Direct your patients to www.bedsider.org, an online birth control support network for women ages 18-29 that is operated by the National Campaign to Prevent Teen and Unplanned Pregnancy.
1. The National Campaign to Prevent Teen and Unplanned Pregnancy, Cosmopolitan magazine. Contraception Calling: Why Aren't More Young Women Listening? Accessed at http://bit.ly/19H7CyW.
2. Kachur R, Mesnick J, Liddon N, et. Adolescents, Technology and Reducing Risk for HIV, STDs and Pregnancy. Atlanta: Centers for Disease Control and Prevention. 2013. Accessed at http://1.usa.gov/14J5Oy0.
3. Lenhart A, Ling R, Campbell S, et al. Teens and Mobile Phones. Washington, DC: Pew Internet & American Life Project; 2010.
4. Lenhart A, Kahne J, Middaugh E, et al. Teens, Video Games, and Civics. Washington, DC: Pew Internet & American Life Project; 2008.
5. Adolescent Pregnancy Prevention Campaign of North Carolina. Gaston County, NC. Accessed at http://bit.ly/1845iih.
6. Martin JA, Hamilton BE, Ventura SJ, et al. Births: Final Data for 2011. Hyattsville, MD: National Center for Health Statistics; 2013.
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