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The Hoekelman Center, Golisano Children's Hospital, the Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY
The Hoekelman Center, Golisano Children's Hospital, the Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NY
The Hoekelman Center, Golisano Children's Hospital, the Department of Pediatrics, University of Rochester School of Medicine and Dentistry, Rochester, NYDepartment of Obstetrics & Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, NY
Preventing unintended teen pregnancy is a national public health priority, and increasing access to long-acting reversible contraception is part of the recommended strategy for the achievement of this goal. Nevertheless, adolescent long-acting reversible contraceptive use across the nation has remained low, even after national and state-level programs increased coverage for no-cost contraception. One persistent barrier is misinformation about the safety, efficacy, and availability of long-acting reversible contraception for teens. To overcome this barrier, the Hoekelman Center, in collaboration with multiple partners, designed and implemented a community health intervention. The Greater Rochester LARC Initiative disseminated accurate information about contraceptive options with a focus on long-acting reversible methods by delivering interactive lunch-and-learn talks throughout the Greater Rochester, NY area. Audiences included both healthcare providers and adults who work with adolescents in nonmedical community-based organizations.
Objective
The primary purpose of this study was to evaluate the community-level impact of the Greater Rochester LARC Initiative on adolescent long-acting reversible contraception use.
Study Design
Our evaluation design was pre-post with a nonrandomized control group. We used publicly available Youth Risk Behavior Surveillance System data from the years 2013, 2015, and 2017 for our intervention site of Rochester, NY, New York City, New York State, and the United States overall. These years cover the time before and after the intervention began in 2014. We used z-statistics in investigating the hypothesis that long-acting reversible contraception use increased more in Rochester than in the comparison populations.
Results
Between 2013 and 2017, long-acting reversible contraception use in Rochester rose from 4–24% of sexually active female high school students (P<.0001). Over the same period, long-acting reversible contraception use in New York State rose from 1.5–4.8%, and in New York City long-acting reversible contraception use rose from 2.7–5.3%. In the United States overall, long-acting reversible contraception use rose from 1.8–5.3%. Thus, the increase in long-acting reversible contraception use in Rochester was larger than the secular trend in the control groups (P<.0001).
Conclusion
Adolescent long-acting reversible contraceptive use increased significantly more in Rochester than in the nation as a whole. This finding is consistent with a substantial positive impact of the Greater Rochester LARC Initiative, which implies that similar interventions could be useful complements to unintended teen pregnancy prevention programs elsewhere and might be helpful more generally for the diffusion of evidence-based health-improvement practices.
Despite guidelines recommending that long-acting reversible contraception be considered a “first-line” contraceptive option for adolescents, its use remains low in the United States. The Greater Rochester LARC Initiative is an intervention that disseminated accurate information about contraceptive methods through discussions with adults who work with adolescents. This study was conducted to evaluate whether the intervention was successful in its goal of increasing adolescent long-acting reversible contraceptive use.
Key findings
Adolescent long-acting reversible contraceptive use in Rochester, NY, increased from 4% before the intervention to 24% after. This increase was significantly greater than the rise that occurred in the nation overall.
What does this add to what is known?
Dissemination, in both community organizations and medical settings, of accurate information about contraception can help to increase community-level uptake of highly effective contraception by adolescents.
According to the Centers for Disease Control and Prevention, reducing teen pregnancy is a national public health priority and long-acting reversible contraception (LARC) is a key strategy for this “winnable battle.”
LARC methods, which include the intrauterine device and the contraceptive implant, are “set it and forget it” approaches that can function for years after insertion and are therefore much more effective than methods that require repeated action by the user. In fact, LARC is 40 times more effective than oral contraception for the prevention of unintended pregnancy in adolescents.
American College of Obstetricians and Gynecologists ACOG Committee Opinion No. 735: adolescents and long-acting reversible contraception: implants and intrauterine devices.
Numerous studies indicate that, when sexually active women are offered medically accurate counseling about all contraceptive methods and access to no-cost family planning services, the proportion who choose LARC is much higher than 2%.
In Colorado, a state-wide foundation-funded program (LARC for Colorado: LARC4CO) that provided advertising, clinician training, and no-cost family planning services led to teen LARC use of >20%.
In the Contraceptive CHOICE Project, 72% of adolescent study participants chose LARC when offered evidence-based counseling and easy, cost-free access to all contraceptive methods.
In 1 study of family planning providers, which is a group likely to have information and access, 42% of contraceptive-using female participants reported using LARC methods themselves.
The optimal level of LARC use in any given population cannot be defined. Even when it should not be close to 0%, that does not mean that one should aim for a level of 100%; the goal should be to empower individuals to decide what is right for them in a context of social and reproductive justice.
There is a history of reproductive coercion in the United States that included forced sterilization of women of color; therefore, it is critical that LARC methods not be imposed on any particular group. On the other hand, LARC should not be withheld deliberately from adolescents who want it, because this is another form of injustice.
It is thus plausible, according to Diffusion of Innovations theory, that dissemination of accurate information among the local population could increase community-level LARC use.
In 2014, with support from the Greater Rochester Health Foundation, the Hoekelman Center in the University of Rochester Department of Pediatrics launched the Greater Rochester LARC Initiative. This intervention delivered interactive lunch-and-learn talks to adults who work with teens in both youth-serving community-based organizations and in medical settings. In community settings, these adults included health teachers, caseworkers, and staff from home visiting, after-school programs, positive youth development, recreation, and other programs. In medical settings, these adults included pediatricians, family medicine physicians, nurses, residents, medical students, and front desk and administrative staff.
The talks covered the safety, efficacy, and local availability of confidential, no-cost LARC services for teens. New York State provides a public health insurance program called the Family Planning Benefit Program with Presumptive Eligibility (FPBP/PE), which offers free, confidential, and same-day family planning services to people of reproductive age.
FPBP/PE is an important option for adolescents without health insurance and for those with insurance who need confidential services. The Initiative’s talks highlighted this resource. A team of 1 physician and 1 certified health educator codelivered each 1-hour talk. Physician speakers were local experts in providing evidence-based contraception for teens; health educators were local experts in how and where to obtain free and confidential services. Given concerns that providing LARC could increase sexually transmitted infections (STIs) because highly effective birth control might lead to less condom use, dual-method use (i.e. using condoms to prevent STIs and another method of contraception) was highlighted in the Initiative’s talks and in related materials.
The talks included time for discussion to address adequately a variety of questions from the audience.
A project coordinator prepared all materials and scheduled these talks, most of which were arranged by referral through our network of contacts. The talks, although concentrated in Rochester, have also reached audiences in numerous suburban locations throughout Monroe County, where Rochester is located. We use the term “community detailing” to describe the design of the intervention because it was an innovative hybrid of academic detailing and community health education.
In academic detailing, professional educators deliver unbiased medical education while using the format of commercial detailing practiced by pharmaceutical industry representatives (eg, providing brief slide shows over the lunch hour with free food and handouts).
The Initiative went beyond its core function of community detailing to include facilitating participation in the FPBP/PE program for qualified clinics, facilitating contraceptive implant insertion training for many primary care physicians in the region, and inspiring another Hoekelman Center project that led to the institutionalization of contraceptive implant insertion training for all pediatrics residents in Rochester. A more detailed description of the intervention is beyond the scope of this evaluation report.
The primary objective of this study was to evaluate the community-level impact of the Greater Rochester LARC Initiative on adolescent LARC use among sexually active female adolescents in Rochester, NY.
Materials and Methods
Setting
Located in Upstate New York, Rochester is a mid-sized city (population approximately 200,000).
In 2010, Rochester had 6 of the top 10 ZIP codes in New York State for teen pregnancy with an overall teen birth rate of 66 per 1000, which is almost double the national average.
Fortunately, Rochester is blessed with a wealth of community-based organizations. Initial core partners for the LARC Initiative included the Metro Council for Teen Potential, an umbrella agency for positive youth development and sexual education programs, and 2 family planning agencies, each with 1 urban and 1 suburban FPBP/PE site: Highland Family Planning, which provided health educators for the talks, and Planned Parenthood of Central and Western New York, whose medical director was our original physician speaker and slide show creator. The Hoekelman Center functioned as a connector for these and other partners.
In preparation for the LARC Initiative, interviews with local adolescents and community-based organization staff and a survey of local primary care pediatricians helped to establish the feasibility and acceptability of the intervention’s approach in Rochester.
Guide to evaluating the effectiveness of strategies for preventing work injuries: how to show whether a safety intervention really works.
Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health,
Cincinnati (OH)2001
The main control group was the United States as a whole. We also included data for New York State, where Rochester is located. In addition, we specifically included data for New York City because this is a location within New York State that implemented a LARC-awareness campaign.
Our primary outcome was LARC use among sexually active female high school students as reported by the Youth Risk Behavior Surveillance System (YRBS), a nationwide biennial serial cross-sectional survey sponsored by the Centers for Disease Control and Prevention.
The YRBS is administered locally by the Rochester City School District and the Monroe County Department of Public Health. LARC use is an intermediate outcome with respect to unintended pregnancy; however, because of its availability, the National Quality Forum recommends it as the metric for the assessment of progress in the prevention of unintended pregnancy.
We examined publicly available YRBS data for the years 2013, 2015, and 2017 to cover the time period before and after the start of the LARC Initiative. We used z-statistics (GraphPad QuickCalcs; GraphPad Software Inc, La Jolla, CA) to analyze the change in LARC use over time in Rochester vs the United States. To address concerns that increased LARC use could increase STIs, we examined the item in YRBS that asks about dual-method use. We examined the percentage of sexually active high school female students who reported failure to practice dual-method use in 2017. The Research Subjects Review Board at the University of Rochester approved this evaluation analysis.
For 2013, the Rochester City School District YRBS did not have a specific question for LARC use. Instead, LARC was included in a category of “other” contraceptives that totaled 6% and also included other methods such as the patch, ring, diaphragm, fertility awareness. We used 4% as a conservative overestimate of LARC use in Rochester at that time. Even if one assumes that all of the 6% in the “other” category was LARC use, the probability values reported later remain well below .05.
Results
Process measures
Between July 2014 and June 2017, LARC Initiative presenters gave 81 educational talks on birth control to >1300 people, which included 50 talks in medical settings (703 attendees) and 31 talks in community-based organizations (662 attendees).
LARC use
The 2013, 2015, and 2017 local YRBS included approximately 1100–2200 (of a total population of approximately 4000 each year) female high school students in Rochester (Table 1).
From 2013–2017, LARC use in Rochester among sexually active female high school students rose from 4–24%; this increase over time was statistically significant (P<.0001). Over the same time period, LARC use rose from 1.8–5.3% in the nation overall, from 1.5–4.8% in New York State, and from 2.7–5.3% in New York City (Figure). The difference between the increase in Rochester as compared with the secular trend in the control groups was statistically significant (P<.0001).
Table 1Demographic characteristics of high school students surveyed in the Youth Risk Behavior Survey, Rochester, NY, New York City, New York State, and the United States, 2013 and 2017
The diagram shows the percentage of long-acting reversible contraception use among sexually active female high school students in Rochester, NY, the United States, New York State, and New York City from 2013–2017. The intervention began in 2014. The asterisk indicates a probability value of <.0001 for the difference between groups with respect to increase in long-acting reversible contraception use.
LARC, long-acting reversible contraception.
Aligne et al. Impact of the Rochester LARC Initiative. Am J Obstet Gynecol 2020.
Failure to practice dual-method use (Table 2) was lower in 2017 in Rochester than in New York City, New York State, or in the United States as a whole: 78% vs 93%, 85%, and 91%, respectively.
Table 2Percentage of sexually active high school female students who self-reported failure to use both a condom and another method of pregnancy prevention (intrauterine device, implant, pills, patch, ring, or shot) at last sexual intercourse: 2017
Location
Failure to practice dual-method use, %
Rochester, NY
78
New York, NY
93
New York State
85
United States
91
Aligne et al. Impact of the Rochester LARC Initiative. Am J Obstet Gynecol 2020.
Compared with the period before the intervention, there was a significant increase (from 4–24%) in LARC use among sexually active female high school students in Rochester, NY. This increase was significantly greater than the increases occurring in the control groups of New York City, New York State, or the nation as a whole. This quasi-experimental community-level evaluation provides evidence that the Greater Rochester LARC Initiative was successful in its goal of increasing adolescent LARC use.
Other results
Given the relatively high LARC use in Rochester, if LARC use increased the risk for STIs by diminishing condom use, one would expect to see low dual-method use in Rochester relative to the control groups. However, we failed to observe such an effect. These results are consistent with the evidence from the most rigorous study (a multisite randomized trial of an intervention to increase LARC use) to date that examined this question.
The strengths of this evaluation include the use of data from YRBS. These “found data” are collected in a standardized fashion over time and across the country and allowed us to use the study design of pre-post with a nonrandomized control group. This is a relatively rigorous evaluation method for community prevention projects because it reduces several of the threats to internal validity that are associated with other designs.
Guide to evaluating the effectiveness of strategies for preventing work injuries: how to show whether a safety intervention really works.
Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health,
Cincinnati (OH)2001
Comparing the change in Rochester with the secular trend at the state and national levels allows us to make inferences about our local observations that would not be possible otherwise. Another advantage of using publicly available official statistics collected by the Centers for Disease Control and Prevention and local agencies is that this can enhance credibility and facilitate community engagement.
Limitations
There are limitations to this kind of evaluation. It was not a randomized trial. However, given the existing evidence and official recommendations that support LARC use, randomizing some populations to have LARC information withheld from them would be impractical and perhaps unethical. In such circumstances, quasi-experimental designs can provide useful evidence regarding causality.
Guide to evaluating the effectiveness of strategies for preventing work injuries: how to show whether a safety intervention really works.
Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health,
Cincinnati (OH)2001
The lack of randomization means that one must consider potential confounders. Theoretically, it is possible that another factor operating in Rochester at the same time as our intervention is the explanation for the observed rise in adolescent LARC use. However, we partnered with or spoke at all the major agencies that are engaged in evidence-based teen pregnancy prevention in Rochester. As far as we are aware, the LARC Initiative was the only program connecting all of them around the specific goal of increasing awareness about LARC. Another potential confounder would be some factor operating in New York State but not in the rest of the nation. For example, New York State’s FPBP/PE program greatly facilitated the availability of LARC.
However, when compared with New York State as a whole, and even the more rigorous comparison group of New York City, there was still a significantly larger increase in LARC use in Rochester. These findings further support the hypothesis that the observed rise in LARC use in Rochester was specifically related to our intervention.
There are also limitations to the data source. YRBS consists of self-reported information, and excludes students who drop out of high school. However, this potential bias applies to all of the locations in the comparisons. Because we are examining publicly available YRBS data summaries, we do not have access to individual-level information on respondents. The LARC Initiative itself was a population-level community health intervention, not an individual-level clinical research study; we therefore do not have access to any individual-level information on the adults who attended the talks, let alone the adolescents who were the eventual recipients of the disseminated information. Feedback was collected from talk audiences; however, this was for quality improvement purposes, and we did not seek permission from survey respondents to share their answers.
Public health implications
Our main finding of increased LARC use is consistent with the literature and demonstrates that many sexually active young women, including adolescents, will choose LARC if they are given access not only to birth control itself, but also to accurate information about various contraceptive methods.
Colorado Department of Public Health and Environment Taking the unintended out of pregnancy: Colorado’s success with long-acting reversible contraception.
In contrast to previously successful interventions like LARC4CO and the Contraceptive CHOICE Project, the Greater Rochester LARC Initiative relied on existing resources to a great extent. For example, the LARC Initiative did not pay for LARC, because this was already covered by FPBP/PE in New York State and the Affordable Care Act. Nor was it necessary to invest in training family planning specialists; the local Title X clinics that were FPBP/PE enrollment sites were ready to provide evidence-based same-day LARC. Later in the Initiative, as primary care pediatricians became interested in providing LARC, they were able to obtain the Food and Drug Administration–mandated training for contraceptive implant insertion for free via the manufacturer. The LARC Initiative collaborated with the implant manufacturer to give talks before insertion trainings to include information on the importance of counseling about and offering access to all methods. The Contraceptive CHOICE Project occurred in a population of volunteers and patients who were referred to a family planning research study. CHOICE used dedicated counselors who provided a structured contraceptive script where contraceptive methods were presented in order from most to least effective.
In these ways, the LARC Initiative is more generalizable for disseminating community-level adoption of LARC than some earlier interventions.
The LARC Initiative has the potential to be scaled up to other communities. As of January 2020, 26 of 50 states have approval from the US federal government to extend Medicaid eligibility for family planning services to those who qualify.
Several of these states are among the most populous in the country, such as California and New York; collectively, these states include most of the US population.
In addition, the national Affordable Care Act mandated insurance coverage for contraception. Even though easy LARC access is far from universal, there are vast areas of the nation where cost need not be seen as an insurmountable barrier.
Although US adolescent pregnancy rates have been declining, overall rates are still higher than in many other countries, and large racial and socioeconomic disparities remain. Increasing LARC use is 1 way to contribute to declining unintended adolescent pregnancy rates.
Although teen birth rates are affected by multiple factors other than LARC, LARC methods are so effective at the prevention of pregnancy that one would expect a significant increase in LARC use to have an effect on teen birth rates. Indeed, over the duration of the LARC Initiative, teen birth rates have been declining faster in Rochester than in New York State or the nation.
To the best of our knowledge, the LARC Initiative is the only unintended adolescent pregnancy prevention program in the United States that uses community detailing. Our results suggest that this approach is both feasible and effective.
Research implications
Future studies could help to characterize which aspects of this intervention are necessary for success. Exploration of various interventions in other localities would shed light on common elements of success. Studies could be done that would use multisite all-claims data for LARC insertions and removals, which would allow measurement of actual (as opposed to self-reported) LARC use and more rigorous study designs, such as interrupted time series or difference in differences analysis.
Conclusions
YRBS data reveal a significant increase in LARC use among adolescents in Rochester, NY, relative to the secular trends in the nation or in New York State. Although it is possible that there are unknown confounders, the most likely explanation for these observed results is that the Greater Rochester LARC Initiative succeeded in its goal. The community detailing approach could be a useful complement to programs for the prevention of unintended adolescent pregnancy. Furthermore, it could be applied more generally to the dissemination of evidence-based practices, thereby having a broad impact on population health.
Acknowledgments
We do not have the space to acknowledge all the individuals and organizations that contributed to carrying out the Greater Rochester LARC Initiative. With respect to this evaluation, we gratefully acknowledge the Bloom Family Trust for assistance with publication, Anne Huber, MD (self-employed) and Kelly McDermott, MA, for reviewing the manuscript, and Michael Chen, PhD, for reviewing our statistical methods (both from the Division of General Pediatrics, Department of Pediatrics, University of Rochester).
References
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Ethier K.
Schuchat A.
Improving the health of the United States with a winnable battles” initiative.
Guide to evaluating the effectiveness of strategies for preventing work injuries: how to show whether a safety intervention really works.
Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health,
Cincinnati (OH)2001
Supported by a grant from the Greater Rochester Health Foundation.
The Foundation encourages evaluation of its funded projects; otherwise, it had no direct role in the preparation of this article.
C.A.A.’s spouse receives financial compensation as an instructor for the FDA-mandated physician training for contraceptive implant insertion. R.P. and K.B.G. receive financial compensation as instructors for the Food and Drug Administration–mandated physician training for contraceptive implant insertion. The remaining authors report no conflicts of interest.
Cite this article as: Aligne CA, Phelps R, VanScott JL, et al. Impact of the Rochester LARC Initiative on adolescents’ utilization of long-acting reversible contraception. Am J Obstet Gynecol 2020;222:S890.e1-6.
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