Evidence: Contraceptive CHOICE Project
modification date: June 20, 2013
content: Facilitator Notes—CHOICE Overview & Key Findings Slide Set
Overview
The slide set titled CHOICE Overview & Key Findings details the Contraceptive CHOICE Project in St.
Louis, MO. Specifically, it focuses upon 4 key areas: 1) study design and methodology; 2) provider
knowledge and attitudes; 3) key research findings; and 4) moving from research to practice. The
presentation can be tailored toward diverse audiences, including clinic staff, board members, policy
advocates, community organizations, or potential funders. These notes can also be found in the “Notes”
on the bottom of the PowerPoint presentation, and are available in audio, as presented by Dr. Gina
Secura, Project Director of the Contraceptive CHOICE Project.
*Please note that you can elect to only present a subset of the 4 key areas. If you decide to reduce the
presentation, be sure to edit Slide 2 and delete the slides you are not going to present.
Slide 1: The Contraceptive CHOICE Project
Enter the presenter, organization, and presentation date in the lower
text box.
SAY:
Hello, my name is [enter name here]. I'm the [title and/or role in
organization]. It's great to share information about the Contraceptive
CHOICE Project with you today.
Slide 2: Objectives
SAY:
This presentation will focus on four areas. First I'm going to describe
the study design and methodology of the CHOICE project. Second, I
want to tell you about two surveys conducted by CHOICE prior to
launching the project in 2007. We'll then discuss and review the
important findings from the CHOICE cohort. And finally, I want to tell
you about the work currently being done regarding dissemination
and translation of research results into practice.
Slide 3: Unintended Pregnancy in the U.S.
SAY:
First let's talk a little bit about what unintended pregnancy looks like
in the United States. We experience over three million unintended
pregnancies every year. The majority of those pregnancies are
actually mis-timed: she wanted to be pregnant at a later time. Only
about 40% are truly unwanted pregnancies. Of those three million
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unintended pregnancies, nearly 1.2 million result in abortion. We also experience over 350,000 birth to
teens aged 15-19 every year. One of the questions we think about when we think about unintended
pregnancy is contraceptive use. Of those unintended pregnancies, about half are due to non-use. So she
was not using a contraceptive method at the time she experienced that unintended pregnancy.
However, notice about 43% are due to incorrect use. What that means is that she didn't use her pill
every day, she didn't swap out her patch every week, she didn't return to the clinic every three months
for a birth control shot. And about 5% are truly a method failure.
Slide 4: Long-acting Reversible Contraception (LARC)
SAY:
But we actually have a great solution of non-adherence. Longacting reversible contraception, otherwise known as LARC, allows
a woman to make a one-time decision and have protection for up
to ten years -- depending on what method she chooses. There are
two intrauterine devices -- also known as IUDs, and a subdermal
implant. The first two pictures show IUDs, the first one is a
hormonal IUD. It's 99% effective and it delivers levonorgestrel
every day and can last up to five years. The second IUD is made of copper. It does not contain any
hormone. It too is up to 99% effective and this method can last up to ten years although she can have it
removed sooner if she wants to get pregnant. And the last method is the arm implant. This one is also
99% effective, delivers etonogestrel every day and can last up to three years.
Slide 5: Study Primary Objectives
SAY:
Let's talk about the Contraceptive CHOICE project. The objective
was to increase the acceptance and use of long-acting reversible
methods among women of child-bearing age. When the CHOICE
Project launched in 2007, the national average of LARC use was
less than 5% in the country. They also looked at what a woman
chose – or acceptability -- how satisfied she was with her method,
side effects that she experienced, and how long she used the
method. Finally, they wanted to compare LARC methods to other commonly used methods.
Slide 6: Study Hypotheses
SAY:
The researchers at the CHOICE Project had a number of
hypotheses. Given the low rate of LARC use in the country, they
hypothesized that they could increase IUD use from around the
current standard in 2007 of about 2% to about 6% or more and
possibly up to 10% in abortion settings. Because implant use was
nearly non-existent at the time they launched the CHOICE
Project, they thought they could raise that rate to about 3%. The
researchers also believed that they would see greater 12-month continuation rates for LARC methods
compared to women using other methods. And finally, they believed that they could make a population
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impact—they thought they could see a reduction in teen pregnancy by 10% and also repeat abortion by
10%. CHOICE researchers chose these two outcomes because they are actually measurable. These are
data that are collected in vital statistics.
Slide 7: Study Design: Prospective Cohort
SAY:
The CHOICE project is a prospective cohort study. Eligible women - and I'll tell you about eligibility in the next slide – are provided
with contraceptive methods at no cost. She gets to choose what
she uses and here's the list of the methods that were offered in
the CHOICE project. This list is based upon what could be
purchased at the time they launched the CHOICE project. So
although there are other methods such as the cervical cap, it was
nearly impossible to purchase that. She's then followed for two to three years -- depending on when she
entered the study. The first 5,000 were followed for 3 years and the second 5,000 followed for 2 years.
Slide 8: Study Inclusion Criteria
SAY:
The researchers at CHOICE looked at a number of outcomes over
time: unintended pregnancy, teen pregnancy, abortion,
continuation, and satisfaction. They also looked at STIs, or sexually
transmitted infections, at the time she enrolled and over time.
Women were eligible to participate in the Contraceptive CHOICE
Project if they were between the ages of 14 and 45 years. Minors
were enrolled in the CHOICE project, and parental consent was
required for minors. Although in the state of Missouri minors can obtain STI testing and contraception
without parental consent, this was a research project. CHOICE researchers wanted the parents involved.
She needed to be a resident of the St. Louis city and county. Remember one of the main objectives is to
look at a population impact so she needed to be a resident of that area. She needed to be sexually active
with a male partner or soon to be in the next six months. They wanted her to not want a pregnancy
during the next 12 months but didn't hold her to that -- that was just a simple question during the
eligibility screening. The project only provided reversible contraception so if she wanted permanent
sterilization, she was not eligible. And she needed to be willing to try a new contraceptive method and
let me talk about this for a second. Because they were looking at continuation and satisfaction, they
wanted everybody to be starting a new method. If those young girls who absolutely loved their
NuvaRing were allowed to come in and continue to use that NuvaRing, it would be very difficult to
compare their experience with a new IUD or implant user.
Slide 9: Study Timeline
SAY:
This is the study timeline. So you can see -- a couple of things
happened. She was interviewed at enrollment, so month 0, and
then at three and six months and every six months after that for
the duration of her follow-up. The first survey was done in
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person: face-to-face administered by a staff person. And then the follow-up surveys were done by
telephone. She also underwent STI screening. At enrollment, she did this herself: chlamydia and
gonorrhea through self-collection of a vaginal swab and then through a mailed STI kit at 12 months, 24
and 36 months. Again, she self-collected and sent it back to the project.
Slide 10: Screening & Enrollment
SAY:
A number of things happened during the screening and
enrollment process. During screening, she was introduced to the
study and she underwent an eligibility screen. Every person who
was screened heard what is called the "LARC Blurb". This is an
abbreviated script that discusses the three LARC methods.
Regardless of whether she enrolled or not or she was eligible,
everybody heard about the three LARC methods. If she was
deemed eligible, she was then offered participation. She could have been screened by telephone, by
calling the research clinic, or she could have been screened in person out at the community partner
clinics that CHOICE partnered with in the St. Louis area. Once she agreed, she was either enrolled
immediately at that time or she made an appointment and enrolled at a later time. The enrollment
process took about an hour and a half to two hours, depending on where the enrollment happened.
During enrollment, a number of things happened. First, she underwent contraceptive counseling and I'll
tell you a little bit about that in a moment. That was a standardized counseling session that was
developed by the project. She then underwent informed consent. Research staff obtained contact
information from her and two contacts that would know about her whereabouts for the next two to
three years. They collected a medical record authorization release form, evaluated some clinical
indicators, and conducted her baseline STI testing. She then did her baseline survey and the project
distributed her contraceptive method. Everybody for the most part left with a contraceptive method
that day. If she wasn't eligible for the method she desired, she was bridged with another method until
she could come back and get the method she wanted.
Slide 11: Contraceptive Counseling
SAY:
All right, so contraceptive counseling. CHOICE researchers were
under the assumption that most --well every woman-- would
come in after she had a conversation with her provider about
what method she wanted and the project would just provide that
method at no cost. In fact, participant number one -- that's what
P00001 stands for -- came in to enroll and Jenny Mullersman, the
nurse coordinator who enrolled her, went running upstairs and
said to the Project Director, "Gina, she knows nothing about contraception. What do we do?" and Gina
said, "Jenny, talk to her." Thankfully, Jenny came from Labor and Delivery so basically sat down and had
an on-the-spot contraceptive counseling session with this young woman and she was then able to make
an informed decision about what method she truly wanted. So what that meant was that researchers
were completely wrong in their assumption about what women knew about contraception. In fact, most
women don't know a lot about contraception or they only know about one method. So they decided
they needed to develop a contraceptive counseling standardized system and needed to train staff to be
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able to administer that. Most of the care to the CHOICE project participants was delivered by a nurse
practitioner. Stacy could not administer contraceptive counseling to 10,000 women so that meant
somebody else had to do it. And in fact, they trained research assistants. They identified a counseling
framework--the GATHER Process, and developed a standardized script that talked about all of the
methods. Those methods are discussed in order of effectiveness from most to least. That's different
than what the typical counseling session looked like when the project was launched. They also created
didactic training. CHOICE providers delivered a lecture about the basic information about each
contraceptive method and then trained staff how to properly counsel a person, how to be empathetic,
how to gather sensitive information, how to engage that person and how to collect a medical history.
Research assistants also collected the medical history. Finally they underwent testing: three testing
experiences and quarterly observation by the quality assurance person -- so that they could ensure that
every research participant experienced the exact same counseling session. They trained 53 research
assistants and volunteers which included 37 staff members who had predominantly no medical
experience prior to joining the CHOICE project. And then volunteers who were first year medical
students, a graduate student and an undergraduate student. The great thing about this that was
unexpected was that they now had 53 people who could also provide additional services to participants.
So when a participant called and complained, "I'm still having irregular bleeding" that first person who
answered the phone could have a conversation with her. She didn't have to go directly to the nurse
practitioner or the medical provider which was really fantastic because they could respond to
participants much sooner than if she had to wait for a callback from the actual provider.
Slide 12: Contraceptive “Menu of Options”
SAY:
This is the contraceptive menu of options. So this is a tool that
CHOICE developed for the counselor and the participant. This
tool is actually laminated and it's put in front of the participant
so that she can follow along as the counselor is providing that
script basically. And you can see it's listed in order of
effectiveness -- the two IUDs and then the implant and then the
injection and down the list down to condoms and emergency
contraception. Although condoms are not that effective in
terms of preventing pregnancy because that requires action at the point of every sexual encounter,
condoms were discussed with every participant for STI protection.
Slide 13: Study Recruitment
SAY:
9,256 women in the St. Louis area were enrolled in the CHOICE
Project. CHOICE partnered with a number of clinics. They
partnered with two abortion clinics in the area and recruited
17% of participants from those clinics. CHOICE also partnered
with eight community clinics -- about 14% of the cohort were
recruited at those clinics. That included Planned Parenthood, a
teen focused clinic called The Spot and federally qualified health
centers. The majority of the research participants actually
enrolled at the university research clinic. Most of that happened through word of mouth. This research
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clinic was only set up for the CHOICE project. So people heard from another participant or a family
member and through provider referrals. About 250 St. Louis area providers referred their patients to
CHOICE. Through this process, researchers started to get a sense of provider bias around LARC methods.
Although docs or nurse practitioners believed in those as being good methods for their patients, they
didn't feel comfortable or skilled enough to provide those methods. And so they referred their patients
to CHOICE who provided the method, did the insertion and then sent patients back to their providers.
The CHOICE Project did not provide any other gynecological care, so it was actually a nice way to
facilitate back and forth that relationship. The graph on the right shows the recruitment process;
CHOICE launched August 1, 2007 and finished in September 2011. They enrolled 200 women every
single month for four years.
Slide 14: Study Follow-up Rates
SAY:
This shows study follow-up rates. The reason why I bring this up is
one because these are impressive rates. They still have an 80%
retention rate at 36 months. It also gives you a sense that they've
kept the cohort together which means the study results that I'll be
showing you in a minute are really really powerful.
Slide 15: Pre-CHOICE Survey Results
SAY:
Let's briefly talk about the two surveys CHOICE did before they
launched the project.
Slide 16: STL Population Survey
SAY:
The first one was a population-based survey and what CHOICE
researchers wanted to understand was what do women in the St.
Louis area know and how to do they feel about IUDs? They
wanted to get a sense of what was going on in the area. This was
an 8-page survey that we mailed to about 12,000 randomly
selected households in the area. Of those, 22% came back to use
for analysis. They looked at a number of things. Women were
asked questions about their obstetric and contraceptive history, what they knew about method
effectiveness across a number of methods and did they think particular women were appropriate
candidates for IUDs and what they could expect in terms of side effects and myths around IUD use.
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Slide 17: STL Population Survey Results
SAY:
If we look at who responded: the average age was about 32 years.
They were predominantly white. And notice how many had
insurance. Seventy percent had greater than a high school education
and only 18% reported a history of abortion. Eight percent said that
they were either currently using or had used an IUD. This is not
surprising given the current rate at this time of IUD use nationally
was only about 5%. Women who said they were either using an IUD
right now or had in the past were a little bit older than the overall cohort of this sample, and more likely
to be receiving public assistance.
Slide 18: MYTHS Regarding IUDs
SAY:
When asked about myths: 50% of women believe that an IUD is safe
-- only 50% thought the IUD was safe. One in three are concerned
about pelvic pain, 30% were concerned about the relationship
between an IUD and infertility, about 15% were concerned that
there was some kind of relationship between IUD and cancer. And
then about 11% were concerned about STDs with IUDs. What is
striking is that 61% -- almost two in three women -- underestimated
the effectiveness of an IUD.
Slide 19: Knowledge about IUDs
SAY:
If we look at what they actually knew about IUDs, what is most
interesting to me about this slide is not the blue bar which shows
they correctly answered these questions on the left but look at all of
that purple. Purple meant she didn't know, she didn't know how to
answer that question. And so what this says to us is that women
really just don't know enough. They were asked a number of
questions and they just couldn't even answer what they knew about
the IUD. So that gave CHOICE a hint that they had some work to do in terms of educating women and
actually dispelling myths around IUDs.
Slide 20: STL Population Survey Results
SAY:
Women were asked how effective methods are; not only LARC
methods, but compared to the commonly used pill, ring, shot,
condoms… This first one is sterilization. You see that they were
overwhelmingly correct in terms of the effectiveness of sterilization.
And then you start to see some interesting things around the more
commonly used methods-- look at all that red. Red signifies over
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estimate. Women think these methods are actually more effective at preventing pregnancy than they
really are. And they underestimate -- in green -- how effective the IUD and the implant are. So let's
move on to the next survey CHOICE did. They surveyed women in general and then wanted to get a
sense of what was going on with the providers in the area.
Slide 21: STL Provider Survey
SAY:
Again, a similar survey looking at the knowledge and attitudes
about IUDs among providers in the St. Louis area. This too was a
written, self-administered survey mailed to about 250 providers in
the area. Seventy-three percent were returned. And again,
CHOICE researchers looked at similar questions in terms of
contraceptive patients seen and willingness to insert an IUD, but
they also looked at their demographic characteristics and
graduate medical training.
Slide 22: STL Provider Survey Results
SAY:
Ninety-nine percent were physicians; a few were nurse
practitioners. They were overwhelmingly white. The majority -over 80% -- had completed residency before 2000. And 56% had
completed residency at a Catholic institution. This is not that
surprising, there's a predominance of Catholic institutions in the
St. Louis area. And if you look to see how many actual
contraceptive patients they see each week, the majority saw
about less than 50 and very few saw more than 50 patients each week.
Slide 23: STL Provider Survey Results
SAY:
In terms of their training around IUDs: 36% were not trained in
IUD insertion either during their residency or clinical training -- a
fairly large gap in terms of access. When asked how often you
discuss IUDs with your patients, only 18% said "always". Again this
is back in 2007 but still. So only 18% said, "I always do." Seventyfive percent said "most" or "some of the time". Sixty-six percent
reported inserting about or more than ten IUDs in the past year.
And when asked about who requires chlamydia and gonorrhea screening prior to IUD insertion: 40%
said "always" and about 52% said "sometimes".
Slide 24: STL Provider Survey Results
SAY:
When asked who was an appropriate candidate for IUDs. Okay
this first one: 62% said a nulliparous woman is appropriate. But
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look at that -- that means over 30% said, "No, she wasn't." Only 31% said an adolescent was an
appropriate candidate for IUDs. And then 37% said women in a non-monogamous relationship were a
candidate. And what is striking to me about this is if we're really trying to prevent unintended
pregnancy, we're excluding a lot of women who are really good candidates for IUDs. Women were also
asked a number of scenarios: "If you had a 35 year old patient, she was married with three children.
Would you offer her an IUD?" Okay, no brainer. Overwhelmingly "yes". She's a good candidate. She's
probably done with her childbearing. Next, "Well, what if she's unmarried a 17 year old in a
monogamous relationship and she already has one child?" Only 50% said they would offer her an IUD.
And, “How about an unmarried 17 year old, never been pregnant and wants to avoid pregnancy?” Less
than 28% said they'd offer her an IUD. CHOICE had their work cut out for them-- women don't know
about IUDs, and providers were reluctant to provide those methods. And with that, the CHOICE Project
was launched.
Slide 25: CHOICE Project Results
SAY:
Let’s talk about the main findings from the CHOICE Project.
Slide 26: CHOICE Study Participants
SAY:
Let’s talk about who participated in the CHOICE Project—
remember, nearly 10,000 women enrolled. If you look at the age
distribution, about 500 minors enrolled and predominantly the
women in the cohort were 21-25 years old. A sliver of 35-45 year
old women enrolled. The average age is actually 25. If we look at
race, you see 50% were black, about 43% white and 7% other.
What is really nice is that this represents the demographics of
the St. Louis area. In terms of education, you actually see that almost half have some college. And so
when people think that this is cohort of poor women, this is not the case. This cohort actually represents
a wide distribution of women in terms of a number of characteristics which is fantastic because that
means that it's generalizable across a number of different settings.
Slide 27: Baseline Chosen Method
SAY:
Look what happens when women have access to and education
about all contraceptive methods and they're provided at no
cost. Seventy-five percent of the cohort chose a long-acting
reversible contraceptive method. Remember, at the time the
CHOICE project was launched, the national average was 5%. In
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this cohort, women overwhelmingly chose the hormonal IUD but about 12% chose the copper and
about 17% chose the implant. And then you can see the other methods and the percent that chose
them at baseline.
Slide 28: Choice of LARC Methods among Adolescents
SAY:
Looking at adolescents; 72% of CHOICE adolescents chose a
long-acting method. This shows you what it looks like if the
category between younger adolescents or teens -- 14 to 17 -and then 18 to 20 is split. And you see 25% of 14 to 17 year olds
actually chose an IUD in blue: 25%. That is fantastic. They liked
the implant better -- 50% chose an implant. But that is
phenomenal. And then you look at older teens and you see it
flip. Almost 50% of those age girls chose an IUD and about 25% chose the implant.
Slide 29: 12-Month Continuation
SAY:
Let's look at what women were using at one year. Remember
they were followed with telephone surveys. This represents they
started with this method on the left and who was still using it
one year later. Look at these rates. It's by method but if you look
at any LARC method -- that first circled number -- 86% of LARC
users were still using her method at one year. Now compare that
to the women using a non-LARC method. It drops to about 55% - she is much more likely to discontinue a non-LARC method by one year.
Slide 30: 12-Month Continuation: Adolescents Compared to Older Women
SAY:
Let's look at continuation by age. Lots of folks in the community
are worried about providing LARC methods to younger girls
because they think they're going to have them taken out the
next week, and this slide shows that is not the case. Let's look at
the top three methods which are the LARC methods. Here in the
green you see 14 to 17 year olds. In red you see 20 to 25 year
olds. And in blue, older than 25. And look at that -- if you look at
the 80% mark at the bottom, almost -- regardless of age -they're all still using their method. You start to see differences in
age with the shorter acting methods. Look at the bottom two sets of graphs with the circles. If we look
at any LARC method by age, you see that there is no difference in 12-month continuation rates. If you
look at non-LARC methods, the green bar is much shorter and in fact teens -- the 14 to 19 year olds -are 30% more likely to discontinue their non-LARC method than any other age groups.
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Slide 31: Unintended Pregnancy by Contraceptive Method
SAY:
Let's look at unintended pregnancy. This represents the women
who reported experiencing an unintended pregnancy in the
cohort. The left of the slide looks at the percent of women that
experience the failure. It is split between three groups: the LARC
methods in blue, the injection in orange and the pill/patch/ring
combined in green. It was looked at after one year of use, two
years of use and three years of use. What's important to note
here is that the green bar is tall regardless of year. And that blue bar is really low regardless of year and
in fact, women using the pill/patch/ring are 22 times more likely to experience an unintended pregnancy
than women using a LARC method: 22 times more likely. So let's think about this: if there was a heart
medication out there that was 22 times less effective -- is that the method we'd start with? Why are we
starting with the pill? We should be starting with a LARC method.
Slide 32: Method Failure by Age
SAY:
This looks at unintended pregnancy but it’s flipped. What this is
looking at is the probability or the chance that she is going to
avoid an unintended pregnancy. We want the lines to be really
high. It’s grouped between LARC and pill/patch/ring and split by
age. Those first two lines in red and blue are women using a
LARC method and it’s split by women who are 21 and older and
women who are less than 21. Those lines are identical. There's
no difference in the chance of her experiencing an unintended pregnancy if she's using a LARC method
by age. It works just as well in a young girl as an older woman. Okay, not an older woman -- someone
older than 21. Let's look at the bottom two lines, all right? That's when you start to see a difference.
Those two lines in orange and green represent women using pill/patch/ring. And you see the lines drop.
These are the women who are experiencing an unintended pregnancy. And in fact, look at the lowest
line -- that's the youngest girls using pill/patch/ring. They are two times more likely to experience an
unintended pregnancy using a pill/patch/ring compared to older women using the pill/patch/ring. These
methods work regardless of age in terms of LARC methods.
Slide 33: Repeat Abortion in St. Louis Region
SAY:
All right so that was data representing women in the CHOICE
cohort. Now let's move out to the population. This is data
obtained from the Missouri Department of Health and Human
Services. This represents all women who are residents of
Missouri. This is vital statistics data to look at the percent of
abortions that were repeat in every year. What that means is
you look at all of the abortions in that year and what percent
happened in a woman who had a history of abortion. That's the measure we're looking at. This is
necessary to compare St. Louis to two other areas: Kansas City and then the rest of Missouri. Kansas City
is similar to St. Louis in a number of respects. They have one abortion clinic, St. Louis has two.
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Demographic characteristics of the women in that area are very similar to the women in St. Louis so that
was a fair comparison to make.
Slide 34: Repeat Abortion 2006-2010
SAY:
This graph looks at the percent of abortions that are repeat every
year. The CHOICE Project started in 2007, okay? So you can see
on that left bar that in the rest of Missouri, it hovers around 35%.
So 35% of abortions each year happened to a woman who
experienced abortion in the past. Look at the top two lines: that's
St. Louis city and county compared to Kansas City. And what do
you see? You actually see that they started at the same place in
2007 and St. Louis is going down whereas Kansas City is going up. And in fact, in 2010, there was a
statistically significant difference in those rates. They’re experiencing a decline in St. Louis and Kansas
City is experiencing an increase in the percent. We can't say definitively it's due to the CHOICE project
but we think it might have had something to do with it.
Slide 35: CHOICE Compared to U.S.
SAY:
The next comparison made is the CHOICE cohort compared to
the national rates that are generated from the National Survey of
Family Growth worked on by the Guttmacher Institute and the
Centers for Disease Control. Let's look at the teen birth rate-that's the birth rate among teens 15 to 19. If we look at the
CHOICE cohort, just within the cohort of teens, we see a first year
rate of 6.3. If we look at all contraceptive use, we see an average
annual rate of 16.3 compared to the national rate of 34.3. That's a 52% reduction in teen birth in the
CHOICE cohort compared to the national average. If we look at the abortion rate and expand that to all
the women in the cohort, 15 to 44. In the CHOICE cohort the rate was 6.0 per thousand women and we
compare that to the national rate of about 20. And that again is a substantial reduction in the CHOICE
cohort compared to the national average. And then finally if we look at the unintended pregnancy rate
in the CHOICE cohort, it's about 15 per one thousand women and we compare that to the national rate
of 52 per thousand women. Again a substantial reduction in the unintended pregnancy rate in CHOICE
compared to the national average.
Slide 36: Main Findings from CHOICE
SAY:
In summary, women including teens overwhelmingly choose
LARC methods if they're told about those methods. LARC
methods are associated with higher continuation at one year
and satisfaction compared to the shorter acting methods that
are commonly used across the nation. And this is true
regardless of age. Remember those slides -- regardless of age.
LARC methods are associated with lower rates of unintended
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pregnancy within the CHOICE cohort and increasing LARC use can decrease unintended pregnancy in the
population.
Slide 37: Dissemination & Translating Research into Practice
SAY:
Let's move on to some really interesting work that’s currently
being done. It wouldn't be great to just publish in peer-reviewed
journals. So CHOICE has spent the last two years -- there's a team
working on the project -- who are really trying to think about
how to share these results and translate them into actual clinical
practice. So let's talk about what’s been done lately.
Slide 38: The Secret: 3 Key Ingredients
SAY:
CHOICE believes its success is due to three key ingredients. The
first is education regarding all methods including, especially LARC
methods. We need to flip or reframe the conversation to start
with the most effective methods. No longer are we going to start
contraceptive counseling with "What have you used in the past?
What has your mom used? What has your sister used? What do
you not like about that method?" And then slowly go up -- I call
the pill which everybody starts with even though it's so much easier to give a prescription for the pill -the gateway contraceptive drug. Right? No, we're going to flip it like in the CHOICE project and we're at
least going to start with the LARC methods. And that doesn't mean to say that everybody should have a
LARC method but it means that everybody should at least hear about those methods. And it might not
be the method she wants today but it could be the method she wants in two years from now. Second
thing is access to providers who will offer and provide LARC methods. Remember those early surveys?
There are a lot of providers who are reluctant to provide LARC methods. So that means dispelling myths
and increasing the practice of evidenced-based medicine. So educating women, educating providers,
and getting them skilled and more comfortable with these LARC methods. And then the last piece is cost
or what we can call affordable contraception. In the CHOICE project, women were provided their
method for free and they could actually switch methods over the course of the study. We're hopeful
with the Institute of Medicine recommendation and the Affordable Care Act and Medicaid expansion
that what was experienced in CHOICE will actually be rolled out nationally -- or at least to a greater
degree than what some of the current limitations are in terms of cost and LARC methods being
prohibitive for a lot of women.
Slide 39: Successful Implementation of CHOICE Model
SAY: CHOICE dissemination work has been built around those
three key areas. So when we talk to people who call us, we get
them to think about those three buckets. These are often some
of the things that we hear when people call us and we say, "Well
try this, try that." And this is often the response that we hear.
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And then we try to help them facilitate ways in which they can implement the CHOICE model. So for
example: first line. When we say, "You need to counsel and talk about all the methods." And they say,
"We don't have time for that. We only have ten minutes to see each patient." And so remember if you
have limited time for contraceptive counseling during the appointment, how about using our model
where we train or you train ancillary staff in the clinic to provide that service? Not only can they provide
the counseling but they also can provide that follow-up when she calls back and has a complaint or side
effect that she wants to discuss.
In terms of access, we often hear that the providers in the community who don't think that certain folks
are good candidates for LARC methods, especially teens. And what we've identified is working is that
finding a local champion, a clinician who believes in these methods. And they can talk face-to-face or on
the phone with your clinician. It needs to be somebody who's done it themselves and who's proficient
and trusted and can actually dispel those myths. And then the last piece is cost. We know that
reimbursement for some of the methods is low, or maybe removal isn't paid for. One of the things that
we're hearing from clinics is that they're starting to figure out how to best manage cost through
effective payer mixes and billing. So providing that sheet that says, "This is how to properly code so that
you get properly reimbursed" -- I know there are communities out there and clinics who are doing that
and we can share that information with you. The other piece is the up-front cost of stocking LARC
methods for same-day insertions. We want to make sure that if she wants that method that day and if
there are no contra-indications, she should get that method. That can be a problem. Those methods are
expensive. It's hard to have $30,000 of method sitting on the shelf waiting for somebody to come in and
use them. And so we're hearing from clinics who are finding other resources and private funders in the
community actually who are willing to buy that up-front stock, have that on the shelf and then you can
pull from that stock, bill the insurance company, replenish the stock. So we're starting to see some really
innovative things happening in terms of replicating what’s been done in CHOICE.
Slide 40: Dissemination Strategies
SAY: The thing we're really working on which we're really
excited about is our Resource Center. So as we received more
and more calls and questions, we realized that what we need to
do is catalog every thing we know so that we can share it -every thing that we've developed, everything that we've
created, practiced, perfected. And so what we will do -hopefully, soon -- is launch the LARC FIRST website. There are
five modules. And I'll talk about those modules in a second.
We’ve provided technical assistance to over 100 national and international folks in a number of different
settings: health departments, private physicians, public clinics. And we are always looking to evaluate
how the materials that we provide are used and adopted and changed actually in clinics. And now we
have funding to actually evaluate that in two different locations.
Slide 41: Online Resource Center
SAY: This is the online resource center. And like I said, there are
five modules. So the first module is the evidence module where
we provide you actually with this slide set -- as you know -- and
also information so that you can build the case for how
important it is to provide LARC methods to your patients in your
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clinic. The second one is the contraceptive counseling. That module will contain everything you need to
know about our contraceptive counseling and how to train contraceptive counselors. That includes
videos of our actual contraceptive counseling sessions and the script -- lots of information. And the
quality assurance needed to ensure consistent contraceptive counseling. Our advanced practitioner
resources is for the practitioner: guidelines, commonly asked questions, how to respond to those
commonly asked questions, how to troubleshoot difficult cases. Patient management refers to how we
manage 10,000 contraceptive users -- most of whom were LARC patients. So we developed a clinician
call-back system, who can answer what questions, our entire staff is engaged in this process. It's not just
the advanced practitioner who's interacting with the patient. And then finally effective staffing and
management. The success of the CHOICE project is due to the staff. This staff is unbelievable,
empowered and out of this world talented. So we created an environment where people who worked
on this project could excel. And so this is all about how we hire really great people. There is an interview
question bank of how the process in which we interviewed, how we motivate them, how do we keep
them engaged and then how to be really good managers. Our philosophy is the patient comes first and
we want it to be LARC friendly. And we all believe in that mission and this is the way in which we did it.
This will all be available for your use.
Slide 42: Examples of Dissemination
SAY:
So let me just quickly share a couple of examples. So Mary
Alexander of Healthy Start in Indianapolis, heard about us and
she asked if she could take our menu of options that I showed
earlier -- that ugly green menu of options. And look what she
did with it? On the left side, she took that, created a really
beautiful purple color scheme and then listed -- notice she put
most effective, moderately effective all the way down on the
left side -- which I think is just fantastic. And then she added the logos at the bottom. We love this
example. So when we say we want to know how you change what we've developed -- because we don't
think it's perfect. We just want to know how you did it so we can share it with others. She then took
information that we provided on our website and said, "Can I make a flip chart?" So this is actually
something she put together that her staff uses when they go out and do educational sessions with
clients. And it goes through every single method and it's just a little bit more detailed in terms of the
advantages and disadvantages of every method.
Slide 43: Dissemination Strategies
SAY:
Here's our staff -- we send our staff out to do all sorts of things
because like I said the success of the CHOICE project is due to
the staff. And so that is Kay Kerwin. She runs our front desk and
she's out at one of our community presentations. And then Jen
Wade is one of our managers -- again at a community
presentation. And so what we've learned is being out in the
community is really valuable. So our participants come up to the
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table and talk to us about it. But also our counselors do a lot of on-the-spot contraceptive counseling
out in the community. So we've been everywhere from Gay Pride, Dad's Day in the Park, Healthy Start,
Nurses For Newborns -- you name it, we'll go. And I would encourage you to do the same.
Slide 44: Dissemination Strategies
SAY:
We used to have a website that was more focused on
recruitment. And then once we stopped, we transitioned it as a
resource guide. So it was rebuilt and then Ragini on our staff
manages this website. This is where we post our videos that we
develop, information about all of our recent publications on our
big publication page and information about methods. And
there's a methods tab and you can learn more information
about it.We also launched a social media campaign. Ragini manages all that which has been a huge
undertaking. We have been cited in the Lay Press over 500 times which is fantastic. We get a lot of
coverage through that. And then like I said, we've produced a number of short videos. So I would
encourage you to look at these videos.
Slide 45: Open the Dialog Video
SAY:
This first one is called Open The Dialogue. This is actually
CHOICE participants talking about what it meant to them to
have access to all methods of contraception for free.
Slide 46: Pathway to CHOICE Video
SAY:
Pathway To Choice is an animated video that we worked on to
be able to share our research results in a way that resonated
with a number of different audiences. We worked with a graphic
artist. It's about three minutes and it's a really compelling short
video that shows what could happen if we rolled out CHOICE
nationally in terms of unintended pregnancy and abortion.
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Slide 47: What Method is Right for You?
SAY:
And then finally what method is right for you. We got lots of
questions around, "What does that contraceptive counseling
script look like?" And so this is actually done in English and
Spanish and it's our contraceptive counselors delivering this
script. And we actually have now clinics who are showing this
video in their waiting room. So this is how they're using this
educational piece in their own clinic.
Slide 48: To Learn More Visit
SAY:
So that's it. If you want to learn more about CHOICE or have any
questions, please feel free to check out their website, Facebook
page, YouTube channel, or follow them on Twitter. They are
happy to answer any questions, and can be reached at 314-7470800. Thanks so much for listening. Have a great day.
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