








key: cord-312232-ktlrc5gx
authors: Comfort, Alison B.; Rao, Lavanya; Goodman, Suzan; Barney, Angela; Glymph, Angela; Schroeder, Rosalyn; McCulloch, Charles; Harper, Cynthia C.
title: Improving capacity at school-based health centers to offer adolescents counseling and access to comprehensive contraceptive services
date: 2020-07-28
journal: J Pediatr Adolesc Gynecol
DOI: 10.1016/j.jpag.2020.07.010
sha: 
doc_id: 312232
cord_uid: ktlrc5gx

Abstract Study Objectives Many pediatric providers serving adolescents are not trained to offer comprehensive contraceptive services, including intrauterine devices (IUDs) and implants, despite high safety and satisfaction among adolescents. This study assessed an initiative to train providers at school-based health centers (SBHCs) to offer students the full range of contraceptive methods. Design Surveys were administered at baseline pre-training and at follow-up three months post-training. Data were analyzed using generalized estimating equations for clustered data to examine clinical practice changes. Setting Eleven contraceptive trainings across the US from 2016-2019 Participants Two hundred-sixty providers from 158 SBHCs serving 135,800 students Interventions On-site training to strengthen patient-centered counseling and equip practitioners to integrate IUDs and implants into contraceptive services. Main Outcome Measures The outcomes included counseling experience on IUDs and implants, knowledge of patient eligibility, and clinician method skills. Results At follow-up, providers were significantly more likely to report having enough experience to counsel on IUDs (adjusted odds ratio [aOR]: 4.08; 95% confidence interval [CI], 2.62—6.36]) and implants (aOR: 3.06; 95% CI, 2.05 – 4.57). Provider knowledge about patient eligibility for IUDs, including for adolescents, increased (p<0.001). Providers were more likely to offer same-visit IUD (aOR: 2.10; 95% CI, 1.41 – 3.12) and implant services (aOR: 1.66; 95% CI, 1.44 – 1.91). Clinicians’ skills with contraceptive devices improved, including for a newly available low-cost IUD (aOR:2.21; 95% CI, 1.45-3.36). Conclusions Offering an evidence-based training is a promising approach to increase counseling and access to comprehensive contraceptive services at SBHCs.

Providing adolescents with access to comprehensive contraceptive services can empower them to select their preferred method if they want to prevent pregnancy. Many pediatric providers serving adolescents are not trained to offer patients a full range of contraceptives, including IUDs and the implant, 1,2 despite high safety and acceptability for these methods among adolescents 3, 4 and high satisfaction and continuation rates. [5] [6] [7] National survey data of contraceptive providers show that many providers hesitate to offer the IUD to adolescents due to providers' outdated views on patient eligibility. 8, 9 Primary care providers, as compared to obstetricians and gynecologists, are less likely to have received training in IUDs and implants. 10 The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics both recommend that providers include these contraceptive methods in contraceptive counseling for adolescents, alongside other reversible methods. 11, 12 The Centers for Disease Control and Prevention also state that IUDs and implants are appropriate for adolescent and nulliparous women. 13 However, knowledge of contraceptives is incomplete among adolescents, and particularly low for the IUD and implant. 14 Access barriers represent one among several factors which may limit adolescents' ability to use their contraceptive method of choice. 15 Other barriers to access that may be exacerbated for adolescents include high upfront costs and waiting periods where patients are asked to return for multiple clinic visits to obtain these methods. 16, 17 Access to comprehensive services for adolescents is especially challenging during a time when there is emphasis in federal policies to support abstinence-only education and to restrict contraceptive funding for adolescent health education. 18 

Adolescence is an important time to learn accurate reproductive health information. In 2017, 40% of adolescents aged 15-19 reported having had sexual intercourse, with 20% of students by 9 th grade having had sexual intercourse compared to more than half of students (57%) by 12 th grade. 19 One promising approach to increase adolescent contraceptive education, counseling and access to services is through school-based health centers (SBHCs). Indeed, a systematic review of studies on the impact of providing reproductive health services through SBHCs on adolescents' sexual and reproductive health identified some positive effects on condom use and hormonal contraceptive use among the more rigorous evaluations. 20 However, SBHCs vary in terms of the reproductive and sexual health services they offer, which can include contraceptive counseling, pregnancy testing, vaccination against the human papillomavirus, and on-site diagnosis and treatment of STIs. 21 However, currently less than 40% of SBHCs nationwide provide contraceptive methods onsite, 22 and fewer still offer implants (6%) and IUDs (5% ) onsite. [21] [22] While half of all SBHCs are prohibited from dispensing contraceptives, most commonly due to school district policy, there are many schools with potential to offer high-quality care. 21 Training providers at SBHCs on patient-centered counseling and full contraceptive services could be an effective strategy to ensure adolescents have access to their method of choice. Offering contraceptive counseling and services on school campuses could be helpful for adolescents who wish to prevent pregnancy and/or STIs. Notably, a majority of adolescents and young adults report that they trust a clinician or a health care provider for birth control information. 23 In addition, SBHCs are considered a highly effective strategy for providing preventive and comprehensive health services to young people, especially for those who are uninsured, low-income, or underserved by other health care settings. 20, 22 SBHCs often represent the first point of contact with the health care system for many adolescents. 24 Providing health services, including contraception through SBHCs, can increase access to comprehensive and non-stigmatizing health services for adolescents, provide links between schools and communities, and reduce transportation costs. 20 Furthermore, in light of the COVID-19 pandemic, there are increasing concerns about ensuring access to contraceptive services 25 especially for adolescents who may have limited privacy for telehealth services from home.

SBHCs may become even more important in delivering health services, 26 

In prior research, we developed and tested a provider contraceptive training intervention in a cluster randomized-controlled trial among adolescents and young adults. 28 The trial demonstrated significant effects of the training on provider knowledge and clinical practice change. Specifically, we saw increased counseling on the full range of methods and greater capacity to offer patients IUDs and implants, without compromising patient autonomy in contraceptive decision-making, or other contraceptive and STI prevention outcomes. 28 Adolescents, along with young adults, were more likely to know about and choose IUDs and implants after being counseled on the full range of contraceptive methods. 4 Providers demonstrated sustained improvements one year post-training in knowledge, attitudes and practice. 29 Following the randomized trial, we adapted and scaled the provider training intervention to different practice settings, including SBHCs, in an implementation science phase. As part of the scale-up, we drew on a leading theory in clinical practice change, the Diffusion of Innovation, 30 by starting with the experts in specialized care or 'early adopters', and expanding out to the 'early majority' or those providers willing to adopt evidence-based practice changes. Following the principles of implementation science research, 30 we adapted the training to the needs of the practice setting, which in this study were SBHCs interested in strengthening their contraceptive services. Specifically, the training we offered to SBHCs focused on patient-centered counseling for adolescents. The intervention addressed adolescents' access to the full range of contraceptive methods, helping overcome barriers on the provider side, including a lack of training in counseling and provision of IUDs and implants. This study evaluates the scaling of the provider training intervention to SBHCs to test whether it contributed to enhanced provider capacity to provide full contraceptive services.

Our study assessed the effect of an evidence-based provider training on contraceptive counseling and access to the full range of contraceptive services including IUDs and implants on providers' knowledge, skills, counseling and provision practices ( Figure 1 ). We implemented the training throughout the U.S. among providers and health educators at SBHCs and local community referral clinics. A total of 11 trainings were implemented between 2016 and 2019, with 260 health care providers trained from 158

SBHCs that served approximately 135,800 students across Albuquerque, Chicago, Los Angeles, Minneapolis, New York, Portland, San Francisco Bay Area, Seattle, and Washington D.C. This SBHC sample was part of a larger implementation science initiative among a variety of practice settings. 31 We offered the training to SBHCs meeting the following conditions: They were open to learning new skills and techniques, following our theoretical framework; they were part of networks of SBHCs interested in contraceptive care; and they had the support of their school systems. 30 Most of the sites provided contraceptives on-site. Data available from 2017 onwards showed that 68% offered IUDs and implants on-site. The training was offered to providers and staff at SBHCs with patient care responsibility; these included physicians, nurse practitioners, and counselors/health educators, as well as support staff, such as medical assistants and social workers. For cost efficiency, the trainings typically included several SBHCs operating within a geographic area, through public health departments and/or school districts. To measure training impact on provider knowledge and clinical practice change, we collected data from providers on socio-demographic characteristics, provider type, and contraceptive knowledge, counseling and provision practices. We collected baseline data prior to the training and follow-up data 3 months after the training.

The provider training, a Continuing Education-accredited course from the University of California, San Francisco School of Medicine, involved an on-site training to equip participants to use patient-centered counseling, and provide the full range of contraceptive methods, including condoms for STI prevention.

The training adopted an all-staff approach to ensure clinic-wide changes in culture and practices, which is particularly important in high turnover settings and low resource clinics. The trainings also included local referral clinics in order to strengthen the SBHCs' referral networks, because not all SBHCs were able to offer contraceptive devices on-site. The course was informed by a rights and equity framework 32 focusing on ethical issues specific to IUDs and implants, with discussions on the importance of upholding patients' reproductive autonomy, issues around coercion and provider bias, and the importance of method removal upon patient request. The training also covered updated evidence on all methods, including medical eligibility for IUDs and implants. Clinicians were offered a hands-on practicum to practice IUD placement and removal with uterine models, while health educators and other staff were offered an interactive contraceptive counseling session. An important component of the training was to address clinic flow and systems issues including reimbursement to be able to offer same-day services, and the strengthening of referral networks to promote the continuum of care. 15 This evaluation was approved by the University of California, San Francisco Institutional Review Board.

We evaluated the quality of the training using data from the formal Continuing Medical Education (CME) course evaluation. We assessed training quality, educational content, and faculty quality, with responses on a 5-point Likert scale (poor, fair, good, very good, excellent). We asked whether issues of cultural and linguistic competency in diverse populations were adequately addressed (yes/no) and whether attendees intended to change their practice (not at all, unlikely, somewhat likely, highly likely, definitely likely).

Study outcomes included provider knowledge, counseling skills, and provision practices at follow-up. We assessed provider knowledge with a 6-item scale that has been validated and adapted from prior research. 8 To measure changes in provider counseling skills, we collected data from participants on whether they felt they had enough experience to counsel on IUDs and implants (strongly agree, agree, disagree, strongly disagree). We created dichotomized variables that take a value of 1 if the provider "strongly agrees" or "agrees" and 0 for "disagrees" or "strongly disagrees". We assessed changes in clinic practice by asking whether the clinic offered same-day services, as an access measure. 33 Among clinicians, we assessed whether they had acquired the skills to feel comfortable inserting an IUD (including levonorgestrel devices, Mirena®, Skyla®, Liletta®, and the copper IUD) and the implant (Nexplanon®).

We used Likert scales (strongly agree, agree, disagree, strongly disagree) and coded the outcome 1 for "strongly agrees" or "agrees" and 0 for "disagrees" or "strongly disagrees". We included a covariate for provider type (clinician/non-clinician) and year of training.

The analytic sample included all clinic staff who received the training and had patient care responsibilities (N=260). To examine training impact on clinical practice outcomes, we used a repeated cross-sections approach, including data from all providers completing a baseline or follow-up survey. 34 This approach is the most appropriate for the study design, allowing us to account for differences in clinical practice pre-and post-training, and for any staff turnover. We used generalized estimating equations (GEE) to assess changes in study outcomes from baseline to follow-up. We used multivariable regressions to assess changes in provider knowledge, counseling skills and provision practices, adjusting for provider type (clinicians versus non-clinician) and training year. Observations were clustered by training and within health centers, as trainings were hosted by an organizing agency and included all affiliated SBHCs. We used GEE to account for correlation within trainings and by extension within clinics.

For the continuous outcome, the provider knowledge scale, we used an identity link with a Gaussian distribution. For dichotomous outcomes for counseling and provision skills, we used a logit link with a binomial distribution. We used cluster robust standard errors at the training level. We used the Stata option "nmp" to adjust the standard errors for the number of predictors in the model given the relatively small number of trainings (n=11). We conducted an attrition analysis to assess whether there were differences in key baseline characteristics, including age, gender, race, provider type (clinician), and level of education, between respondents and non-respondents at follow-up. Analyses were conducted in Stata 16 (Stata Corp, College Station, TX), and significance levels reported at p ≤ 0.05.

Among the 260 clinic staff participating in the trainings, 238 (92%) completed the baseline survey. The response rate at follow-up was 67% (173/260). Results from the attrition analysis showed that there were no significant differences in characteristics between respondents and non-respondents at followup for age, gender, race/ethnicity, or educational level. However, we found that clinicians were less likely to respond at follow-up compared to non-clinicians. The sample of participants trained included the full care team: 10% were physicians, 9% physician assistants, 32% nurse practitioners, 5% registered nurses, 7% medical assistants, 14% counselors/health educators and 7% social workers (Table 1) . On average, the clinic staff were 38 years old and 93% identified as female. About half identified as White (54%), 14% as Black, 11% as Hispanic/Latinx, 9% as Asian/Pacific Islander, and 12% as other race/ethnicity. The majority of participants (72%) had a graduate or professional degree.

Almost all (96%) believed that students should have access to the full range of contraceptive methods through SBHCs (Figure 2) . Likewise, almost all SBHC providers (95%) reported routinely counseling on condom use, both at baseline and follow-up. Almost all clinic staff (81%) believed that students had misperceptions about birth control and only about a third believed that students were knowledgeable about IUDs (30%) and implants (34%).

Participant had high ratings of overall quality of the training intervention, the faculty, and educational content (4.5, 4.6, and 4.5 respectively out of a scale of 1 to 5). Ninety-one percent reported that issues of cultural and linguistic competency in diverse populations were adequately addressed in the course, and 97% reported an intention to change practice.

Provider knowledge about the range of patients who are eligible for IUDs increased significantly. The knowledge scale measuring patient eligibility for IUDs, including adolescents and nulliparous women, increased from 0.85 at baseline to 0.91 at follow-up (p ≤ 0.001) ( Table 2 ).

This evaluation identified significant improvements among providers at SBHCs in knowledge, counseling skills and provision practices, with increased capacity to offer adolescents interested in IUDs or the implant with these methods. The training improved knowledge about these methods and led providers to feel experienced in counseling on these methods. Among the clinicians, the hands-on training practicum also led them to feel more comfortable providing different methods. In particular, there were substantial increases in skills providing the newly available low-cost levonorgestrel IUD, Liletta®, from 16% of clinicians at baseline to 27% at follow-up reporting they felt comfortable providing this method.

The training also led providers to be more likely to offer same-day IUD and implant services upon patient request, a component to improving access to these methods.

These results showed that this training intervention can be scaled and adapted to different health provider contexts, specifically SBHCs. These positive impacts within SBHCs highlight that the training intervention is an effective way to enable providers that serve adolescents to integrate IUDs and implants into their counseling and contraceptive services.

Adolescents are increasingly more likely to use a contraceptive method at last intercourse. 35 The most common methods used by sexually active women aged 15-19 is condoms (55%), followed by the pill (27%), and withdrawal (26%). In contrast, only 7% of sexually active women ages 15-19 have used the intrauterine device (IUD) and subdermal implant. 36 However, method choice is not necessarily a reliable measure of adolescents' preference because it assumes that the method was freely chosen over other methods without considering barriers to access. 37 Studies on method preference among adolescents find that while there are relatively low rates of use of long-acting reversible contraceptives, up to 61-69% of adolescents would prefer using these methods. 3 Increasing access to preferred methods is an important component of contraceptive care that respects patient reproductive autonomy. 37 Barriers to contraceptive access may play an especially important role in limiting adolescents' ability to access the full range of contraceptive methods and choose their preferred method. 38 Emphasizing patient preferences and voluntary method choice is essential for all age groups, including adolescents.

It is also important to highlight that the training focuses on counseling about IUDs and implants together with condoms, given potential concerns with STI rates. Our randomized controlled trial confirmed that the training intervention did not compromise condom use nor did it result in increased STI rates, 39 in contrast to concerns about increasing access to IUDs and implants among young people. 40 While our results highlight that the provider training was effective in improving SBHC providers' knowledge, counseling skills and provision practices, there remain significant challenges in working with SBHCs to ensure adolescents' access to comprehensive services. Since so many SBHCs face limitations in offering contraceptive services as a result of restrictions at the state, school district, and school level, 21 training referral clinics is also relevant, as was done in our intervention. While SBHCs reach an important adolescent population, youth-friendly clinics outside of schools remain essential points of care, especially in regions where contraceptive services available at SBHCs are restricted.

Our evaluation focuses on specific provider-related barriers to access for contraceptive services. Sameday provision and provider competency are important aspects of access that our intervention targets.

Nonetheless, there is also a need to more broadly address other aspects of the continuum of contraceptive care, from community outreach and trust building to follow-up support and identifying interventions that address structural and social contexts. 15

While our sample included trainings across different regional contexts in the US, it comprised sites supportive of contraceptive education and access, with most providing contraceptives on-site.

Implementing the intervention with SBHCs across different geographic regions and school districts requires substantial programmatic effort, as each district has its own requirements and permissions.

The sample size for this study was relatively small to measure intervention impact for the clinician-only measures. We cannot rule out external factors that may account for the changes measured in this implementation science scale up to a new practice setting. Nevertheless, the results were similar to the data in our randomized trial showing clinical practice changes. 29 This study reflects the counseling practices and clinician skills at the SBHC itself, but we did not collect data on referrals. Although SBHCs often provide referrals for contraceptive services off-site, referrals do not guarantee that adolescents will follow through on referrals, either due to confidentiality concerns, transportation issues, costs, or capacity to schedule a visit amidst other competing priorities. 22 Understanding changes in referral patterns after the training, however, could help us to understand the impact of the intervention on SBHCs that work in restrictive environments.

This study demonstrated the impact of adapting a provider training intervention post-randomized trial to the context of SBHCs. Our findings highlighted that offering provider training to SBHCs is an effective way to improve adolescents' access to full contraceptive services. This is especially important in the current policy environment, which is increasingly restrictive of contraceptive services and sexual education for adolescents, 18 and with access to clinic services further challenged by the COVID-19

pandemic. 25 These results show that this provider training is an effective approach that can be scaled and replicated across SBHCs to enable adolescents to have access to the full range of contraceptive methods.

The authors do not have any conflicts of interest to disclose. 

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Factors associated with provision of long-acting reversible contraception among adolescent health care providers

Acceptance of long-acting reversible contraceptive methods by adolescent participants in the Contraceptive CHOICE Project

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This scale has 6-items asking providers if they would consider a patient eligible for an IUD if: nulliparous, adolescent, immediately post-abortion, HIV positive, or with a history of STI or PID in the last 2 years

Robust standard errors clustered at training level. Coef= Coefficient, aOR=adjusted odds ratio, CI = confidence interval. Models adjusted for provider type and training year

We would like to thank participants in our training intervention, including collaborating organizations such as Peer Health Exchange which helped bring together SBHCs. We would also like to acknowledge our expert clinician and health educator teams and staff, including Connie Folse, Nina Pine, Maya Blum, Janelli Vallin, Lauren Coy, and Caitlin Quade.

We are grateful to The JPB Foundation for supporting this work (grant number 1088).

