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The Contraceptive CHOICE Project

The Contraceptive CHOICE Project. Enter Presenter’s Name Enter Presenter’s Organization Enter Presentation Date. Objectives. Describe the study design and methods Review key findings from Pre-CHOICE surveys Review important findings from CHOICE

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The Contraceptive CHOICE Project

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  1. The Contraceptive CHOICE Project Enter Presenter’s Name Enter Presenter’s Organization Enter Presentation Date

  2. Objectives • Describe the study design and methods • Review key findings from Pre-CHOICE surveys • Review important findings from CHOICE • Discuss dissemination and translation of results into practice

  3. Unintended Pregnancy in the U.S. • Over 3 million unintended pregnancies • 59% mistimed • 39% unwanted • 1.2 million abortions • 367,752 births to teens 15-19 years • Contraception • 52% non-use • 43% incorrect use Finer Contraception 2011; Hamilton NCHS 2012; Frost Guttmacher Inst 2008

  4. Long-acting Reversible Contraception (LARC)

  5. Study Primary Objectives • To increase the acceptance and use of long-acting reversible contraceptive (LARC) methods among women of childbearing age • To measure acceptability, satisfaction, side-effects, and rates of continuation across a variety of reversible contraceptive methods, including long-acting reversible methods

  6. Study Hypotheses • Increase IUD use • Sentinel clinics from <2% to 6% or more • Post-abortion insertion <1% to 10% or more • Increase implant use to 3% or more • Observe higher 12-month continuation rates for LARC vs. other methods • Population outcomes • Teen pregnancy decline by 10% • Repeat abortion decline by 10%

  7. Study Design: Prospective Cohort ELIGIBLE

  8. Study Inclusion Criteria • 14-45 years • Primary residency in STL City or County • Sexually active with male partner (or soon to be) • Does not desire pregnancy during next 12 months • Desires reversible contraception • Willing to try a new contraceptive method

  9. Study Timeline

  10. Screening & Enrollment Introduce study Enroll participant! • Contraceptive Counseling • Informed Consent • Contact Information • Medical Record Authorization • Clinical Forms and Evaluation • Baseline STI • Baseline Survey • Method Allocation Eligibility screen LARC Blurb Eligible Offer participation Agrees

  11. Contraceptive Counseling • P000001 • Development and training included • Counseling Framework • Standard Script • Contraception 101 Lecture • Counseling and Medical History Forms • Testing & Observation • Provided by 53 research staff & volunteers • 37 staff, 14 medical, 1 graduate and 1 undergraduate students • Additional resource for managing patient calls Madden Contraception 2012

  12. Contraceptive “Menu of Options”

  13. Study Recruitment

  14. Study Follow-Up Rates Survey 98% 94% 87% 81% 6 12 24 36

  15. Pre-CHOICE Survey Results

  16. STL Population Survey • Objective: Survey knowledge and attitudes about IUDs among women in St. Louis area • Methods: • 8-page written survey • Mailed to 12,500 randomly selected households • One adult female in household asked to complete survey • 1,665 of 7,722 (22%) deliverable and eligible surveys returned • Measures: • Obstetric & contraceptive history • Knowledge regarding method effectiveness • Knowledge regarding appropriate candidates, side effects, and myths of IUD Hladky ObstetGynecol 2011

  17. STL Population Survey Results • Respondents overall: • Mean age = 31.9 • 57% white • 82% had insurance (83% private) • 70% greater than high school education • 18% history of abortion • 127 (8%) were currently using or had used IUD • Slightly older (mean age = 32.4) • More likely to be parous • More likely to be receiving public assistance Hladky ObstetGynecol 2011

  18. MYTHS Regarding IUDs • 50% of women surveyed believe IUD is SAFE • Common safety concerns: • Pelvic Pain 36% • Infertility 30% • Cancer 14% • STDs 11% • 61% underestimate the effectiveness Hladky ObstetGynecol 2011

  19. Knowledge About IUDs

  20. STL Population Survey Results

  21. STL Provider Survey • Objective: Survey knowledge and attitudes about IUD among providers in St. Louis area • Methods: • Written self-administered survey • Mailed to 250 providers • Medical directories and electronic searches • 137/186 (73.7%) delivered and eligible surveys returned • Measures: • Demographic characteristics • Graduate medical training • Contraceptive patients seen and willingness to insert IUD Madden Contraception 2010

  22. STL Provider Survey Results • 99% physicians • 85% white, 4% black, 10% other • Residency training: • 44% completed before 1989 • 41% 1989-1999 • 16% after 1999 • 56% completed residency at a Catholic institution • Contraceptive patients each week • 35%: 0–25 • 50%: 26-50 • 15%: 50+ Madden Contraception 2010

  23. STL Provider Survey Results • 36% not trained in IUD insertion during residency or clinical training • Discussed IUD with patients • 18% “always” • 75% “most or some of the time” • 66% reported inserted >10 IUD in past year • GC/CT testing prior to IUD insertion • 40% always • 52% sometimes Madden Contraception 2010

  24. STL Provider Survey Results • Appropriate candidates for IUDs • 62% nulliparous • 31% adolescent • 45% STI in past 2 years • 37% PID in past 5 years • 37% non-monogamous relationship • Offer IUD • 98% if 35 y.o., married, with 3 children • 50% if unmarried 17 y.o., monogamous, and one child • 19% if unmarried 17 y.o., never been pregnant Madden Contraception 2010

  25. CHOICE Project Results

  26. CHOICE Study Participants Peipert ObstetGynecol 2012

  27. Baseline Chosen Method 75% Peipert Obstet & Gynecol 2012

  28. Choice of LARC Methods among Adolescents Mestad Contraception 2011

  29. 12-Month Continuation

  30. 12-month Continuation: Adolescents Compared to Older Women Rosenstock ObstetGynecol 2012

  31. Unintended Pregnancy by Contraceptive Method HRadj = 22.3 95% CI 14.0, 35.4 Winner NEJM 2012

  32. Method Failure by Age Winner NEJM 2012

  33. Repeat Abortion in St. Louis Region • Data obtained from MO DHHS • Represents women who reside in Missouri at time of abortion • Repeat abortion measured as ever had a previous abortion • Compared to Kansas City & non-metro MO • KC: One abortion clinic • KC: Similar demographic characteristics to STL

  34. Repeat Abortion 2006 - 2010 Test of Trend 2006-2010: STL, p=.002; KC, p=.003; Non-metro MO, p=.18 Peipert ObstetGynecol 2012

  35. CHOICE Compared to U.S. • Teen birth rate (age 15-19 years) • 6.3 per 1,000 teens (first year use rate) • 16.3 per 1,000 teens (average annual rate) • Compared to 34.3 per 1,000 nationally • Abortion rate (women ages 15-44) • 6.0 per 1,000 women (average annual rate) • Compared to 19.6 per 1,000 nationally • Unintended pregnancy rate • 15.0 per 1,000 women (average annual rate) • Cumulative: 35.0 per 1,000 women • Compared to 52.0 per 1,000 nationally Peipert ObstetGynecol 2012

  36. Main Findings from CHOICE • Women overwhelmingly choose LARC • LARC methods associated with higher continuation & satisfaction than shorter-acting methods • Regardless of age • LARC methods associated with lower rates of unintended pregnancy • Increasing LARC use can decrease unintended pregnancy in the population

  37. Dissemination & Translating Research into Practice

  38. The Secret: 3 Key Ingredients • Education regarding all methods, especially LARC • Reframe the conversation to start with the most effective methods • Access to providers who will offer & provide LARC • Dispel myths and increase the practice of evidence-based medicine • Affordable contraception • Institute of Medicine recommendation, Affordable Care Act, Medicaid Expansion

  39. Successful Implementation of CHOICE Model

  40. 40 Dissemination Strategies • Create online Resource Center to disseminate CHOICE materials LARC First • The Evidence • Contraceptive Counseling • Advanced Practitioner Resources • Patient Management • Effective Staffing & Management • Provide technical assistance to end users • >100 national & international requests • Evaluate how CHOICE materials are adopted and adapted for successful use • PCORI Funding

  41. Online Resource Center

  42. Examples of Dissemination Courtesy of Mary Alexander, Healthy Start Indianapolis

  43. Dissemination Strategies • National forums & grand rounds • Community presentations & festivals/events

  44. Dissemination Strategies • Website transitioned from recruitment to resource guide • Social media • Lay Press • Short videos

  45. Open the Dialog Video http://www.youtube.com/watch?v=VAsdg7f7M7w

  46. Pathway to Choice Video http://www.youtube.com/watch?v=cd46pXtMHOo

  47. What method is right for you? http://www.youtube.com/watch?v=u9SHoy1C3tU

  48. To Learn More Visit www.choiceproject.wustl.edu www.facebook.com/choiceproject http://www.youtube.com/user/WUSTLChoiceProject https://twitter.com/WUSTLChoice

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