Clinician Attitudes and Practices

Surrounding Long-Acting Reversible

Contraceptive Use by Adolescents
Rachel Soles
University of Detroit Mercy

Adolescent Pregnancy and

Contraceptive Use
There

are approximately 750,000 adolescent

pregnancies yearly in the United States, at least
80% of these are unintended pregnancies. (Finer &
Zolna, 2011; Sheeder, Tocce, Stevens-Simon, 2008)
Approximately 35% of women either do not use
contraception or use it inconsistently or incorrectly
Guttmacher Institute, 2013).
Teens are more likely to use contraceptive methods
which require adherence, including condoms and
oral contraceptives, despite significantly lower
efficacy with usual use than long-acting methods
such as intrauterine devices (IUD) and implanted
contraceptives (Kohn, Hacker, Rouselle, & Gold,
2012; Rubin, Davis & McKee, 2013).

Recommendations
In

2012, the American College of

Obstetricians and Gynecologists issued a
position statement recommending that
clinicians consider long-acting reversible
contraceptives (LARCs) as first-line for
adolescents.
In 2014, the American Academy of
Pediatrics followed suit and also
recommended that clinicians counsel and
recommend contraceptives to
adolescents in order of efficacy, with
LARCs recommended first.

Clinician Attitudes
Studies

have demonstrated that clinicians

have negative attitudes towards the
provision of LARCs, particularly IUDs, to
adolescents (Biggs, Harper, Malvin &
Brandis, 2014; Kohn et al., 2012; Madden,
Allsworth, Hladky, Secura & Peipert, 2010;
Vaaler, Kalanges, Fonseca & Castrucci,
2012).
Clinicians have demonstrated:
Age-based clinical decision making
Lack of knowledge about true contraindications
Lack of knowledge about adverse effects

Purpose
Development

of an intervention
model to address clinician
knowledge, attitudes, and
intentions surrounding provision
of LARCs to adolescents may
result in declines in the
adolescent pregnancy rate as
teens choose more effective
methods of contraception.

Empiric Knowing
"Empirics as a pattern of knowing is grounded in
science and other empirically based methodologies"
(Chinn & Kramer, 2011, p 11)
In order to develop a model which will effectively
address clinician attitudes and behaviors
regarding long-acting reversible contraceptives for
adolescents, it is essential to understand:
How adolescent pregnancy impact teens individually
and collectively.
Current state of clinician attitudes and knowledge levels.
Benefits and risks of long-acting reversible
contraceptive method use for adolescents.
Factors that influence teen contraceptive decisionmaking.
Effective strategies for clinician behavior change
interventions.

Aesthetic Knowing
"Aesthetic knowing makes it possible to
move beyond the surface to sense the
meaning of the moment and to connect
with human experiences that are unique
for each person" (Chinn & Kramer, 2011,
p 9)
It is essential to consider how this
intervention will impact clinicians and
their patients.
Clinician practice environments are not
homogenous: how will this intervention
impact the clinician in his or her
practice environment and community?

Ethical Knowing
"Ethical knowing...involves clarifying
conflicting values and exploring
alternative interests, principles, and
actions" (Chinn & Kramer, 2011, p 7)
It is essential to recognize that clinicians
may have personal beliefs that conflict
with the intention of the intervention: to
increase use of LARCs in teens.
Clinicians may also work in practice
environments or communities where
LARCs would not be welcomed or would
cause community friction.

Personal Knowing
Personal knowing encompasses knowing
ones own Self as well as the Self in relation
to others (Chinn & Kramer, 2011, p 8).
A clinician intervention should consider how
opinions, beliefs, and habits influence
practices in contraceptive counseling.
Clinician recommendation is one of the
most important predictors of adolescent
contraceptive choice, but how does the
relationship between clinician and
adolescent impact this? How can a strong
relationship be fostered?

Emancipatory Knowing
Emancipatory knowing begins with
awareness of social problems such as
injustices and questions why they exist
(Chinn & Kramer, 2011, p 6).
It is essential to maintain a focus on why the
issue of adolescent pregnancy is important.
Consider how access and financial barriers
may impact use of LARCs in low-income
areas.
Minority adolescents have
disproportionately higher rates of
pregnancy.

Theory Support of
Intervention
The

Integrated Behavior Model (IBM)

describes intention to act (which is influenced
by beliefs, attitudes, and norms) as the most
influential predictor of behavior. The model
also includes additional factors which
influence behavior, including environmental
constraints, knowledge, salience, and habit
(Montano & Kaspryzk, 2008). The model was
developed as an extension of the Theory of
Reasoned Action and the Theory of Planned
Behavior, both of which also describe
intention as the most significant predictor of
behavior.

Integrated Behavior Model

Feelings about
behavior

Experiential
attitude

Attitude
Behavioral beliefs

O
t
h
e
r

F
a
c
t
o
r
s

Instrumental
attitude

Knowledge and
skills to perform
the behavior

Salience of the
Behavior
Normative beliefs
Others
expectations

Injunctive
norm

Perceived
Norm
Normative beliefs
Others behavior

Intention or
Decision to
Perform the
Behavior

Descriptive
norm
Environmental
Constraints

Control
beliefs

Perceived
control

Personal
Agency
Efficacy
beliefs

Selfefficacy

Habit

Behavior

Phenomenon Integrated with

Theory: Attitudes
Attitudes

influence intention.

Experiential attitudes are the emotional

responses to a behavior or the idea of
performing a behavior. Clinicians develop
feelings about counseling and providing LARCs
to adolescents based on actual experience as
well as beliefs about the behavior.
Instrumental attitudes are determined by
beliefs about outcomes of a behavior and are
influenced by knowledge and cognition.
Clinician beliefs about the outcomes of
provision of LARCs are based on knowledge of
methods as well as knowledge of patients and
circumstances impacting contraception choice.

Phenomenon Integrated with

Theory: Perceived Norms
Perceived

norms (the pressure a clinician feels

to perform or not perform the behavior)
influence intention.
Injunctive norms are beliefs about what a clinician
is expected to do by others and the clinicians
motivation to comply. Clinicians working in an
organization or certain setting may feel that they
are expected to counsel adolescents about LARCs
and be motivated to act partly because of this.
Descriptive norms are the perception about what
others are doing. Clinicians who perceive that
others in similar roles or in their network of peers
are counseling adolescents about LARCs may be
more likely to act.

Phenomenon Integrated with

Theory: Personal Agency
Personal

agency is the clinicians ability

to act for a purpose.
Perceived control is the clinicians perceived
control over the behavior (counseling and
providing LARCs) and is primarily influenced
by how easy or difficult the behavior is
based on environmental factors.
Self-efficacy is the clinicians beliefs about
effectiveness in performing counseling for
LARCs (or provision of LARCs) as well as
actual abilities to perform these behaviors.

Phenomenon Integrated with

Theory: Additional Factors
Knowledge

and skills to perform the behavior: clinician

knowledge about LARCs, skill in counseling as well as
actual LARC insertion procedures.
Salience: clinician belief or understanding of the
importance of counseling for LARCs as a contraceptive
option for teens.
Environmental constraints are factors which make
action difficult: use of LARCs by adolescents is
constrained by insurance restrictions, access difficulty,
limited number of clinicians capable of performing
insertions, privacy concerns, among others.
Habit: habits surrounding counseling for contraception
may be deeply ingrained for some clinicians, oral
contraceptives have historically been the first option,
despite problems with adherence.

Intervention Strategy
No

single theory has been demonstrated

to be more effective than others in
effecting change in clinician behavior, but
the most successful strategies are
comprehensive rather than narrow in
focus (Robertson & Jochelson, 2006).
A designed intervention utilizing the IBM
will focus on specific areas to both
influence clinician intention to act as well
as address the additional factors which
contribute to behavior.

Focus Areas
Instrumental

attitudes are sensitive to knowledge.

Clinician training focused on enhancing
understanding of LARCs, with a focus on identified
deficiencies (e.g. knowledge of contraindications,
knowledge of adverse effects) may impact attitude
towards the provision of LARCs.
Descriptive norms are impacted by clinician beliefs
about what other clinician peers are doing.
Providing a training intervention about LARCs in
groups of clinicians which is also clinician-led can
influence the normative beliefs about LARCs.
Self-efficacy may be influenced by a training
session designed to enhance skills in counseling
about LARCs as well as practical training for LARC
insertion.

Focus Areas (continued)

Knowledge

and skills will be addressed through

the intervention as describe.
Salience: understanding the importance of the
behavior can be partially impacted through
knowledge, although the clinician still must have
personal belief in the importance of the behavior.
Environmental constraints will be addressed
through a comprehensive intervention strategy by
providing information and practical support in
overcoming insurance and other financial barriers,
access barriers, dealing with confidentiality
concerns, and patient education materials.
Interventions to address environmental
constraints may secondarily impact perceived
control and also positively impact intention.

Modified Intervention Model

Training to
enhance skills
in counseling
about LARCs
and in LARC
insertions.

Educational
Training to
address
identified
knowledge
deficits.

Instrumental
attitude

Clinician-led
trainingamong
peers.

Descriptive
norm

Selfefficacy

Knowledge and
skills to
perform the
behavior

Intention or
Decision to
Perform the
Behavior

Environmental
Constraints

Targetedtrainingto
addressaccess
barriers,financial
barriers,insurance
barriers.Patient
educationmaterials

Behavior

Questions Raised by
Implementation Model
What

is the impact of clinician behavioral change

(increasing recommendation for LARCs) on desired
outcomes: increasing adolescent use of LARCs and
decreasing adolescent pregnancy rate?
How much does habit (which is not addressed in the
modified intervention model) impact clinician behavior?
Can a primarily educational intervention overcome
clinician resistance based on past misinformation,
outdated recommendations, etc?
Environmental constraints are addressed with an
educational and supportive intervention, but what if
environmental constraints are particularly difficult to
overcome in a clinicians service area?
What impact does emphasis on LARCs have on education
about barrier methods which reduce sexually transmitted
infection incidence and abstinence teaching?

Limitations of Model Application

to Phenomenon
This

model comprehensively addresses clinician

behavior and attempts to address the
environmental constraints which impact clinician
behavior however the ultimate outcome of
adolescent pregnancy may not be significantly
impacted due to the number of variables besides
clinician counseling that impact adolescent
decision-making regarding contraception.
Some areas of the IBM are not addressed in the
modified model because they require change in
processes or clinic environment (injunctive norms)
or require actual experience and outcomes
(experiential attitudes).

Strengths of Model Application to

Phenomenon
Comprehensive

intervention
strategy has the potential to
impact multiple variables which
impact behavior according to the
IBM.
Clinician recommendation is an
important factor in adolescent
decision-making about
contraception.

Potential Measurement
Clinician

attitudes and practices will be

assessed in a pre-intervention survey as well
as a post-intervention survey. Survey will be
re-administered at 6 month intervals.
LARC use as a percent of total contraceptive
use will be measured pre-intervention and at
6 month intervals following intervention.
Clinician experiences with LARC counseling
and provision will be assessed and repeat
clinician trainings organized based on needs
assessment.

References
American Academy of Pediatrics. (2014). Policy statement: Contraception for adolescents. Pediatrics, 134,
1244-1256, doi: 10.1542/peds.2014.2299
American College of Obstetricians and Gynecologists. (2012). ACOG committee opinion- Adolescents and
long-acting reversible contraception: Implants and intrauterine devices. Washington, D.C.: American College
of Obstetricians and Gynecologists, retrieved from http://www.acog.org/Resources-AndPublications/Committee-Opinions
Biggs, M.A., Harper, C.C., Malvin, J., & Brandis, C.D. (2014). Factors influencing the provision of long-acting
reversible contraception in California. Obstetrics and Gynecology, 123, 593-602, doi:
10.1097/AOG.0000000000000137
Chinn, P.L. & Kramer, M.K. (2011). Integrated theory and knowledge development in nursing. (8 th ed.). St.
Louis, MO: Mosby/Elsevier
Finer, LB, & Zolna, MR. (2011). Unintended pregnancy in the United States: Incidence and disparities.
Contraception, 84(5), 478-485, doi: 10.10.1016/j.contraception.2011.07.013
Kohn, J.E., Hacker, J.G., Rousselle, M.A., & Gold, M. (2012). Knowledge of and likelihood to recommend
intrauterine devices for adolescents among school based health center providers. Journal of Adolescent
Health, 51(4), 319-324, doi: 10.1016/j.j.adohealth.2011.12.024
Madden, T., Allsworth, J.E., Hladky, K.J., Secura, G.M. & Peipert, J.F. (2011). Intrauterine contraception in Saint
Louis: A survey of obstetrician-gynecologists knowledge and attitudes. Contraception, 81(2), 112-116, doi:
10.1016/j.contraception.2009.08.002
Montano, D. & Kasprzyk, D. (2008). Theory of reasoned action, theory of planned behavior, and the integrated
behavioral model. In K. Glanz, B., Rimer, & K. Viswanath (Eds.) Health behavior and health education: Theory,
research, and practice. Retrieved from: http://www.med.upenn.edu/hbhe4/part2-ch4-integrated-behaviormodel.shtml
Robertson, R. & Jochelson, K. (2006). Interventions that change clinician behavior: Mapping the literature.
National Institute for Health and Clinical Excellence, 1-37, retrieved from:
http://www.kingsfund.org.uk/publications/articles/interventions-change-clinician-behaviour-mapping-literature
Sheeder, J., Tocce, K., Stevens-Simon, C. (2008). Reasons for ineffective contraceptive use antedating
pregnancies part 1: An indicator of gaps in family planning. Maternal Child Health Journal, 13(3), 295-305, doi:
10.1007/s10995-008-0360-2
Vaaler, M., Kalanges, L., Fonseca, V., & Castrucci, B. (2012). Urban-rural differences in attitudes and practices
toward long-acting reversible contraceptives among family