Report is concomitant with Master in Public Health capstone requirements for the Community- Oriented Public Health Practice Program at the University

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2 Report is concomitant with Master in Public Health capstone requirements for the Community- Oriented Public Health Practice Program at the University of Washington. Report generated June 1 st, Please direct inquiries to Kelly Gilmore kellyg18@uw.edu or Janet Cady Janetc@neighborcare.org.

3 ACKNOWLEDGEMENTS I would like to express my deep gratitude to the many people involved in this project for their support and guidance, but most of all, for their dedication to adolescent health. I am particularly grateful to Janet Cady, MN, ARNP, my capstone supervisor, for her support, thoughtful critiques, and for introducing me to Neighborcare Health s amazing school- based health program. A special thanks to Ann Vander- Stoep, PhD, my faculty advisor, for her steady guidance, support, and unfailingly good advice throughout this project. I would like to thank fellow student Annie Hoopes, MD, for her assistance and support with data analysis and collection, as well as her delightful companionship. My grateful thanks are also extended to the entire Neighborcare school- based staff for their support and for the amazing work they do for Seattle area teens specifically: Katie Acker, Colin Walker, Auky Van- Beek, Lib Montgomery, Lisa Krogman, Helen Weems, Beth Upton, Krista Eknes, and Nadia Novotny. I would also like to thank James Phillips and Maya Berkowitz from Neighborcare for their assistance. Thank you to staff from Public Health Seattle and King County for their technical assistance including: Kari Kessler, Jessica Knaster, Diana Vihn, and Eva Wong. I would like to thank the following people for contributing their expertise to this project: Deborah Oyer, MD, Anne Shields, Sarah Prager, MD and Anne- Marie Amies Oelschalger, MD. Thank you to Aaron Lyon, PhD and James Pfieffer, PhD for guidance on qualitative research methods. And a very special thank you to Valerie Tarico, PhD for her vision and for making this project possible.

4 EXECUTIVE SUMMARY The United States has the highest teen pregnancy rate in the developed world. The majority (82%), of teen pregnancies in the United States every year are unintended. Over 700,000 teenagers in the U.S. give birth every year. Teen girls and their children suffer from developmental and behavioral problems, struggle academically, and will earn less over their lifetime than their peers. Racial disparities in teen births persist nation-wide and in Seattle. Teens of color, particularly Black and Hispanic/Latina teens, are disproportionately affected by early unintentional childbearing. In the city of Seattle there are more births to teenagers of color who live in low- income neighborhoods. Teens in the Delridge neighborhood, in the Chief Sealth High School attendance area, give birth at a rate 14 times higher than in the Fremont, Greenlake neighborhood. Teens in the West Seattle neighborhood, in the West Seattle attendance area, give birth less than the city- wide average, but nearly all of the teen births in this neighborhood are among Black and Latina girls. LARCs are highly effective and safe contraceptive methods for adolescents. Long- Acting Reversible Contraceptive (LARC) methods are over 99% effective at preventing unintentional pregnancy and are safe for adolescents and women who have never been pregnant. LARC methods are 20 times more effective at preventing pregnancy in teens than the pill, patch or ring. Comprehensive provider training is crucial for delivering LARC methods in School- Based Health Centers (SBHCs) SBHC providers cited hands- on LARC insertion training, shadowing with an experienced clinician, and having a trusted physician in the community deliver information on LARC safety and efficacy, as the most important factors in their ability to provide LARC methods. Neighborcare Health has successfully provided over 250 LARC methods at six SBHCs since Over 90% of teens surveyed at Neighborcare SBHCs said they were very satisfied with the services they received at the SBHC. Over 40% of teens surveyed said they would feel comfortable getting a LARC method placed at the SBHC. LARC insertions have increased at West Seattle and Chief Sealth SBHCs 105% in the last two years. Health education at West Seattle and Chief Sealth High Schools has been associated with increased LARC knowledge among teens. Teens who interacted with the health educator in a classroom or 1:1 setting were significantly more likely to be aware of LARC methods than teens who had never interacted with the health educator. In the school year the health educator increased the opportunities for teen contraceptive counseling by 22%.

5 I. ABSTRACT AIMS: Evaluate an intervention that provides Long- Acting Reversible Contraception (LARC) and health education about LARC on- site in a school- based setting. Specifically, identify barriers and facilitators to LARC delivery implementation; evaluate teen acceptability and uptake of LARC methods and teen s use and acceptability of the school- based health center (SBHC) as a place to go for reproductive healthcare. Document the activities of the reproductive health educator and trends in teen LARC uptake. SETTING: Neighborcare SBHCs in West Seattle High School and Chief Sealth International High Schools in Seattle, WA. METHODS: To address the aims of this project, I used four different research approaches and data sources. I also conducted literature reviews on LARC method efficacy, safety, and recommendations for adolescents. I interviewed fourteen experts involved in the development and implementation of LARC services in the SBHCs, their positions ranging from school- based health providers to public health officials. I analyzed interview transcripts for themes using a priori codes and ATLAS.ti qualitative software. I conducted an online survey of 107 female students who were registered to use the school based health center about LARC knowledge and attitudes. I collected secondary data from Seattle Public Schools (SPS) school- wide records and SBHC electronic medical records. LARC uptake data and teen survey data were analyzed and summarized using STATA statistical software. I analyzed self- reported data from the health educator regarding the individual contraceptive counseling sessions and classroom education sessions she provided in the school year at both schools. RESULTS: Key themes for implementation included: a respected individual to champion LARC services, clear communication about risks and benefits of LARC in adolescents, establishment of public and private community partnerships, and comprehensive provider trainings. Barriers for implementation included: Mid- level provider discomfort with procedures, LARC device cost and staff training costs, and providers misperceptions about LARC safety and efficacy for adolescents. Teens reported high levels of satisfaction with the school- based health center as a place for reproductive health information and services, as well as general interest in obtaining a LARC method at the SBHC. In student survey responses, teens who met the health educator were significantly more aware of LARC methods than their peers who had not met the health educator in student survey responses (X2= 5.26, df=1, p = 0.022). Between the school year and May 16 th, 2014, LARC insertions had increased by 107% at both schools. While Hispanic and Latino teens attend West Seattle and Chief Sealth in high numbers as compared to the SPS district average, no Hispanic or Latino teens received a LARC method in the school year. White teens, especially at West Seattle High, chose LARC methods more often than teens of color. CONCLUSION: LARC counseling and device placement can be implemented in a school setting with individual and community support and comprehensive provider trainings. Adolescent girls reported the school- based health center as a trusted source of reproductive health information and services. Health education at Chief Sealth and West Seattle has increased teen awareness of LARC methods among teens. LARC device insertions continue to grow year to year at both schools. Health education should continue to focus on racial disparities in teen pregnancy and LARC use at both schools.

6 DEFINITIONS OF TERMS AND ACRONYMS ACOG- The American College of Obstetricians and Gynecologists ATLAS.ti- Qualitative analysis software CDC- The Centers for Disease Control and Prevention The Contraceptive CHOICE Project- A longitudinal study in St. Louis Missouri. EHR- Electronic Health Record HRA- Health Reporting Area: Geographical areas in King County, WA for health data collection. IUD- Intra- Uterine Device LARC- Long- Acting Reversible Contraception. A category of contraceptives that includes Intra- Uterine Devices and arm implants. MIrena IUD- Intra- Uterine Device containing progesterone, FDA approved for use for 5 years. MEC- Medical Eligibility Criteria Nexplanon- A progesterone containing LARC method the size of a matchstick that is inserted into the arm and is FDA approved for use for 3 years. Paragard IUD- A non- hormonal Intra- Uterine Device made from copper that is FDA approved for use for 10 years. PHSKC Public Health Seattle and King County SBHC- School- Based Health Center Skyla IUD- A progesterone containing Intra- Uterine Device that is specifically approved by the FDA for use in adolescents and nulliparous women and lasts for 2 years. SPS- Seattle Public Schools SPR- Selected Practice Recommendations STATA- Statistical analysis software WHO- The World Health Organization

7 TABLE OF CONTENTS INTRODUCTION 1 PROBLEM STATEMENT 1 SUMMARY OF SCIENTIFIC KNOWLEDGE AND EVIDENCE 3 A BRIEF HISTORY OF LARC METHODS IN THE UNITED STATES 3 THIS IS NOT YOUR GRANDMA S IUD- IT S THE BEST METHOD AVAILABLE FOR ADOLESCENTS 5 THE CHOICE PROJECT: GROUNDBREAKING LARC RESEARCH 5 THE SCHOOL-BASED CLINIC AS AN IMPORTANT POINT OF CARE FOR ADOLESCENTS 6 LOCAL BACKGROUND 6 THE SEATTLE EXPERIENCE: IMPLEMENTING LARC SERVICE DELIVERY AT NEIGHBORCARE HEALTH 6 THE NEIGHBORCARE LARC INTERVENTION 5 NEIGHBORCARE HEALTH 7 WASHINGTON STATE LAW 9 METHODS 9 PRIMARY OBJECTIVES 9 THEORY OF CHANGE 10 QUALITATIVE AND QUANTITATIVE DATA METHODS 11 IMPLEMENTATION FACILITATORS AND BARRIERS 14 LARC USERS VS. SBHC USERS 14 LARC UPTAKE AND ACCEPTABILITY- SURVEY DATA 15 LARC UPTAKE AND ACCEPTABILITY- EHR DATA 15 SBHC USE AND ACCEPTABILITY 16 HEALTH EDUCATOR IMPACT 16 RESULTS 17 IMPLEMENTATION FACILITATORS AND BARRIERS 17 BARRIERS 19 FACILITATORS 21 LARC USERS VS. SBHC USERS 23 LARC UPTAKE AND ACCEPTABILITY- SURVEY DATA 25 LARC UPTAKE AND ACCEPTABILITY- EHR DATA 26 SBHC USE AND ACCEPTABILITY 27 HEALTH EDUCATOR IMPACT 28 CONCLUSIONS 29 RECOMMENDATIONS FOR NEIGHBORCARE HEALTH 30 IMPLICATIONS FOR PUBLIC HEALTH 31 LIMITATIONS 32

8 WORKS CITED 33 APPENDICES 36 SEATTLE PUBLIC SCHOOLS HIGH SCHOOL ATTENDANCE AREA MAP SCHOOL YEAR 36 KING COUNTY HEALTH REPORTING AREAS 37 QUANTITATIVE DATA SOURCES TABLE 37 INTERVIEW QUESTIONNAIRES FOR KEY INFORMANTS 39 FINAL QUALITATIVE INTERVIEW CODE LIST 41 HEY LARC SURVEY QUESTIONNAIRE 43 HEY LARC SURVEY RECRUTIMENT FLYERS 50 INFOGRAPHIC 52

9 II. INTRODUCTION Specific Aims Evaluate the Neighborcare LARC intervention in West Seattle and Chief Sealth High Schools on uptake and acceptability of LARC methods among teen girls. Evaluate the use and acceptability of the school- based health center as a place for reproductive health information and services. Evaluate the health educator intervention as an opportunity for teen engagement and education on LARC methods. Describe key themes for facilitation and barriers to implementation of the LARC intervention. Identify any trends among teens choosing LARC methods based on race, and/or school. I developed the following Problem Statement and Summary of Scientific Knowledge and Evidence by conducting an extensive literature review on LARC method efficacy, safety, and recommendations for adolescents. Problem Statement Teen pregnancy is a significant public health problem in the United States, causing academic, developmental, and financial hardships for teen mothers and their children 1,2. While many of the risk factors associated with teen pregnancy (low socio- economic status) exist before pregnancy or birth, early childbearing is independently associated with a number of negative outcomes for mothers and their children 3,4. Low educational attainment among teen mothers and their children lead to negative consequences throughout the life course. Even when controlling for income and occupation, education continues to be one of the strongest predictors of human health 5. Pregnancy is the primary reason girls aged drop out of high school 1,5. While the economic consequences for teen mothers is still a subject of debate, children of teen mothers have been shown to suffer financially as compared to their peers 1,3. Children of teen mothers are less likely to finish high school and more likely to suffer from developmental hardships related to behavior and literacy 4,6. In the United States nearly seven percent of teens girls will become pregnant before age twenty 7. Among sexually active teens the pregnancy rate doubles. Fifteen percent of sexually active year olds and 16.2% of sexually active year olds experience pregnancy every year 8. That is twice the rate of teen pregnancy in Canada and three times that of most Western European countries; over eighty percent of these pregnancies are unintentional 7. Like the rest of the United States, Seattle and King County have seen declines in teen pregnancy rates since their peak in the 1990s; however racial and geographic disparities persist. Seattle has higher rates of teen pregnancies, live births, and abortions than King County or the State of Washington. The most recent examination of county and citywide pregnancy data ( ) revealed the city of Seattle has seen a 65% reduction in teen pregnancy rates since 1990 to 1

10 43.7/1000 of teen girls aged An examination of recent live birth data for teens aged from in the city of Seattle, found disparities in teen live births in the Health Reporting Areas (HRA) that coincide with SPS attendance areas for Chief Sealth and West Seattle Highs. Teens in the Delridge HRA, (Delridge HRA represents part of the Chief Sealth High attendance area) have a live birth rate 14 times higher than teens in the Greenlake/Fremont HRA 1. Within the West Seattle and Chief Sealth school attendance areas teen live births vary significantly by HRA, from the high at Delridge of 28/1000 (95%CI 23-33) teens, to a low in West Seattle of 9/1000 (95%CI 6-12) teens 10. Figure teen live birth rate per 1000 teens aged by Health Reporting Area in Seattle, 1 See appendix for Public Health Seattle and King County Health Reporting Area maps and Seattle Public Schools Attendance Area maps. 2

11 Teens of color in the United States are disproportionately affected by early unintentional childbearing and high school dropout as a result of pregnancy 2,5. Disparities in teen birth rates by race exist within the city of Seattle and in the HRAs that are the primary school attendance boundaries for Chief Sealth and West Seattle High schools (West Seattle HRA and Delridge HRA). The city live birth rate for year olds of Black non- Hispanic origin is 31/1000 (95% CI 27-35), for Hispanic teens the live birth rate is 34/1000 (95%CI 30-39), and for Pacific Islander non- Hispanic teens the live birth rate is 41/1000 (95%CI 26-62). Within the Delridge HRA the teen live birth rate among Hispanic teens is 57/1000 (95% CI 40-78). While the variation in this sample is large, and the sample size is small, there is a difference between this rate and the overall Delridge HRA rate of 28/1000 (95% CI 23-33). In the West Seattle HRA there is a marked difference between the reporting area overall live birth rate of 9/1000 (95%CI 6-12) and live births in Black teens (42/1000 (95%CI 19-78)) and Hispanic teens (38/1000 (95%CI 19-67)) 10. While LARC methods offer the potential to dramatically reduce unintended pregnancy in the United States, many providers, teachers, parents and teens continue to harbor misconceptions about the safety of LARC methods, particularly IUDs 11,12. Despite recommendations from the World Health Organizations, Centers for Disease Control and Prevention, and the American College of Obstetricians and Gynecologists for the use of LARC in adolescents, only a handful of school- based health providers administer LARC methods on- site as part of their contraceptive services 13,14. III. SUMMARY OF SCIENTIFIC KNOWLEDGE AND EVIDENCE A Brief History of LARC Methods in the United States The first generation of LARC methods introduced in the United States in the 1970s were plagued with horrific side- effects and, in some cases, were introduced in highly unethical circumstances- leading to LARC methods bad reputation and low utilization today 11. The Dalkon Shield intrauterine device continues to play a large role in provider and patient resistance to the IUD. The Dalkon Shield was introduced to the US market in the 1970s when it enjoyed much popularity with nearly 10% of US women using the method 11. Septic maternal shock, and infertility from Pelvic Inflammatory Disease (PID) infections were tragic consequences of the Dalkon Shield and led to its eventual ban from the US market 11. In 1981 the National Women s Health Study published results from a case- control analysis of women with IUDs who were admitted to the emergency room for Pelvic Inflammatory Disease (PID) 15. The study falsely linked the Dalkon Shield (the approved IUD in the US as the time) to PID, when the reality is more complicated. The Dalkon Shield contained a braided string that hung below the cervix into the vagina for removal, creating a pathway for harmful bacteria into the uterus, including the Sexually Transmitted Infections (STI) Chlamydia and Gonorrhea 16. PID is caused by untreated Chlamydia or Gonorrhea infection in women and can cause uterine scarring and/or infertility. Women in the 1970s were not routinely screened for Chlamydia and 3

12 Gonorrhea infections prior to IUD insertion. With the Dalkon Shield, the risk of developing PID among women with an active Chlamydia or Gonorrhea infection was very high at or close to the time of IUD insertion 17. As a result many women developed PID from the procedure 11. This led to a long public debate which ended in the Dalkon Shield being recalled from the US market 11. While routine Chlamydia and Gonorrhea screening, as well as sterile technique and the redesign of the devices themselves, have virtually eliminated PID as an outcome for IUD users, the reputation has never fully recovered 11, Norplant, the first subdermal arm implant LARC method approved for use in the United States in the early 1990s, was introduced under unethical circumstances and was eventually litigated off the US market due to side effects 19,20. Norplant appeared to be a solution to the problems presented by the Dalkon Shield. Because it is inserted in the arm, it has no impact on fertility or uterine health. Norplant is effective for up to 5 years and is still very popular and accepted by women in the developing world 19. Within a few years of Norplant s introduction to the US market, policy makers in Kansas, Tennessee, and Louisiana developed campaigns to reduce the welfare roles and the number of African American women having children by either requiring Norplant implantation as a condition of receiving state assistance or paying women on state assistance one time or ongoing sums for using the device 20. This caused an outcry from the African American community, particularly after reports that black mothers on state assistance were unable to get the devices removed even though they were experiencing unwanted side- effects 20. Norplant, like the next generation of arm implant available today (Nexplanon and Implanon), can cause irregular and unpredictable bleeding that differs widely woman to woman 21. While Norplant is still endorsed by the Food and Drug Administration and the World Health Organization as a safe and effective LARC method, the manufacturer pulled the product from US shelves in Today a single rod subdermal option known as Implanon or Nexplanon is available; the implant lasts for 3 years Since the political fallout from the Dalkon Shield and Norplant, providers have continued to harbor negative attitudes towards LARC methods. Misconceptions among providers about LARC are ubiquitous, the most common being that IUDs are not appropriate for nulliparous women or women who plan to have more children Despite the extensive evidence documenting the modern IUDs safety, since the introduction of the Mirena and Paragard IUDs to the US market over ten years ago, many providers still refuse to perform an IUD insertion on a woman or teen who has never given birth 19. Over the past ten years international and domestic authorities validating the safety and efficacy of the new LARC devices have handed down a number of recommendations. In 2004 the World Health Organization s Department of Reproductive Health and Research released its first Select Practice Recommendation (SPR) document 27. The SPR clearly outlined LARC methods as safe and highly effective means of contraception that are suitable for women who have never been pregnant 27. In 2007 the American College of Obstetricians and Gynecologist (ACOG) reviewed 4

13 the research and found that LARC methods, including IUDs, were safe and that the data support their use in most women including adolescents 13. In 2010 the Centers for Disease Control and Prevention released updated Medical Eligibility Criteria (MEC) for contraceptives, a guide for providers, which shows there are very few contraindications for the use of LARC in women of all ages 28. In October of 2012 ACOG released a landmark committee opinion stating that LARC methods should be a first- line contraceptive method for most women and teens and discussed at every adolescent health visit 29. In May of 2014 the Centers for Disease Control and Prevention in conjunction with the U.S. Office of Population Affairs reiterated the ACOG recommendations with the release of Providing Quality Family Planning Services where they state LARC methods are safe and appropriate for teens, and that tiered counseling methods (presenting contraceptive methods in order of efficacy) should be used for all women and teens 30. This is Not Your Grandma s IUD- It s the Best Method Available for Adolescents LARC devices have emerged as highly effective and safe means of contraception for adolescents, with the potential to significantly reduce adolescent pregnancy 12,31. Decreased rates of teen pregnancy in the United States and Seattle have been attributed to teens increased use of the most effective contraception available and delaying the onset of sexual activity, much like teens in Western Europe 7,9,32. However, US teens are still at much higher risk for unintended pregnancy than their peers in the developed world who have higher rates of LARC method utilization. LARC methods, which are used widely in Europe, are actually more suitable for adolescents than more commonly prescribed methods like the pill. The efficacy of LARC comes from the user s ability to forgo daily, weekly, or monthly maintenance and medication adherence 33. Nine out of 100 women who use the pill, patch, or ring will become unintentionally pregnant in the United States every year. An adolescent s risk for unintended pregnancy while using the pill, patch, or ring is double that of a woman over 21 years of age. That s a 20% increase in risk for adolescents as compared the general population. These methods are less effective in this population, while the efficacy of LARC methods remain high regardless of age 34. Only 2-6/1000 women who use the Mirena IUD, Paragard IUD, or Nexplanon arm implant become unintentionally pregnant each year 34. The Choice Project: Groundbreaking LARC Research The Neighborcare SBHC LARC intervention has been adapted from a project still underway in St. Louis, Missouri conducted by Washington University. The Choice Project began in 2007 and enrolled a cohort of 9,256 women ages Participants were offered any method of contraception free of cost 35. Each participant received a one- on- one contraceptive counseling session with a health educator where all of the available methods were presented in order of efficacy (a technique often referred to as tiered counseling ) 35. LARC methods were presented first, as they are over 99% effective at preventing pregnancy 35. Over 50% of teenagers aged chose a LARC method in the project 35. 5

14 The Choice Project results are incredible when compared to national averages of LARC utilization among all ages. Between LARC method utilization among women of all ages in the United States was dramatically lower than the St. Louis Choice Project s 50% but doubled from 3.7%- 8.5% 36. LARC utilization among teens nationwide tripled during this same period from 1.5% - 4.5% among those aged (although the majority of this increase was observed among teens aged 18-19) 36. Even with the increasing popularity of LARC, the United States is still far behind many countries in LARC utilization. For instance, 17%- 27% of women in France, Denmark, Sweden and Norway use an intrauterine contraceptive 33. The School- Based Clinic as an Important Point of Care for Adolescents School- based clinics are uniquely positioned to reach adolescents at risk for unplanned pregnancy, yet few school- based health centers in the United States offer LARC methods on- site or actively encourage LARC use in teens 2,14,37. Use of school- based health services has been correlated with increased academic performance and lower drop out rates in high- risk groups 38,39. School based health centers represent an innovative strategy to provide comprehensive primary care and adolescent health specialty services to a hard- to- reach population- i.e., adolescents, where they are- i.e., at school 37. The school based health center model was developed in the 1970s as a response to concern over skyrocketing teen pregnancy rates 37. While in the beginning, reproductive health care was a part of every school based health center, now only 85% of school based health centers provide some form of reproductive health care services. Nearly 70% of school based health centers report at least one restriction on the reproductive health services they are allowed to offer 14. Few school based health centers are able to offer contraception and even fewer offer emergency contraception to teens 14. In 1989 City of Seattle voters passed the Families and Education Levy that supported the creation of school- based health centers in SPS. Voters approved the levy again in 1997, 2004, and The 2011 levy provides $44 million to mental, physical and dental health services in schools. PHSKC is contracted through the city of Seattle to solicit community- based agencies to sponsor SBHCs in SPS, where Neighborcare Health is one of five SBHC providers 40. IV. LOCAL BACKGROUND The Seattle Experience: Implementing LARC Service Delivery at Neighborcare Health In 2009 Public Health Seattle and King County received a grant from the National Campaign to Prevent Teen and Unplanned Pregnancy to increase LARC usage among local teens. The county began by conducting a needs assessment, which found provider misconceptions about IUD safety as the primary barrier to adolescent uptake of LARC methods 41. PHSKC asked school- based health center sponsors if their providers would be willing to undergo LARC training and offer LARC methods on- site with support from the county. Neighborcare Health was the only 6

15 school- based health sponsor who agreed to try LARC service delivery under the leadership of Janet Cady, MN, ARNP, Assistant Medical Director of Neighborcare s school- based health program. Neighborcare school- based health providers (all mid- level providers) attended an attitude- shifting training led by Deborah Oyer MD, Medical Director of Aurora Medical Services in Seattle. The training focused on updated guidelines for the use of LARC in adolescents and research on the safety and efficacy of IUDs for adolescents and nulliparous women. Dr. Oyer, a highly respected doctor and provider of reproductive health care services in the Seattle area, provided credibility to the idea that LARC is acceptable and recommended for adolescents. A pre/post survey conducted by Public Health found the training was highly satisfying for providers and effective in changing their attitudes about the safety of LARC for adolescents 42. Neighborcare went ahead with provider insertion and removal trainings with support from Public Health including on- site shadowing from their staff and sharing of equipment lists and medical standards and guidelines for LARC method delivery and monitoring. LARC service delivery in Seattle Public School SBHC s began in the spring of LARC services in Neighborcare SBHCS were designed after the Contraceptive CHOICE project by offering tiered counseling to patients and updating contraceptive method materials in the SBHC to reflect LARC as the most effective and recommended method for teens. A private donor in the Seattle area approached Neighborcare in 2012 and asked what they would need to bring LARC service delivery to the next level of dissemination in their school- based health program. Neighborcare asked for funding for a health educator to spread the word about LARC in the larger school population and assist clinicians in delivering contraceptive counseling for teens in the school- based health center and in the broader school community. The health educator position was funded as a three- year pilot program in time to begin the school year. The Neighborcare LARC Intervention All providers in Neighborcare school- based high school and middle school clinics are trained to counsel patients about and insert and remove LARC methods on- site. High school sites include: Chief Sealth, West Seattle, Roosevelt. Middle school sites include: Mercer, Denny, Madison. Contraception education materials in middle and high schools are taken from Public Health Seattle and King County and the National Campaign to Prevent Teen and Unplanned Pregnancy, which reflect LARC methods as the most effective and recommended methods for teens. SBHC providers use tiered contraceptive counseling methods when counseling students about contraception. A health educator was hired for the school year to focus on providing additional contraceptive counseling sessions and doing health outreach in the larger school population at Chief Sealth and West Seattle High Schools. 7

16 Figure 2. The Neighborcare LARC Intervention * SBHC provider training was completed in LARC insertions began at all Neighborcare Middle and High School SBHCs in the spring of The Health Educator was hired for Chief Sealth and West Seattle High Schools only for the school year. Neighborcare Health Neighborcare Health is Seattle s largest not- for- profit primary and dental care provider that focuses on serving low- income communities, immigrants, and those who have difficulty accessing health care. Neighborcare Health is one of five contracted primary care providers that run school based health centers throughout the Seattle area. Neighborcare is contracted with Seattle Public Schools to provide services at eight schools in the district, three of which are high schools. Neighborcare clinicians are trained in LARC insertion and follow the evidence- based clinical guidelines released by ACOG. Neighborcare s school based health centers are staffed by licensed providers, ARNPS and RNs, they also provide mental health and dental services 43,44. 8

17 Washington State Law In Washington State teens may consent to reproductive health care without a parent s consent including accessing contraception and abortion services 45. The State of Washington participates in a Medicaid waiver program called Take Charge! The Take Charge! program covers the cost of any contraceptive method for women and teens of any age whose income is below 250% of the federal poverty level. The Take Charge! program provides confidential coverage for teens 18 years and younger who cannot bill their family health insurance for reproductive health services and for victims of domestic violence or sexual abuse 46. Washington State law and social services make it relatively easy for Neighborcare s school based health centers to offer all forms of contraception, including LARC, in the schools free of charge and without parental consent if necessary. Despite the removal of cost, provider, parental consent and transportation barriers, LARC methods are still underutilized by sexually active teens in the high schools where they are available. This intervention was intended to expand the breadth of reproductive health services offered in Neighborcare SBHCs in a way that is consistent with ACOG guidance on contraceptive recommendations for adolescents. This project was also intended to model the success of the Contraceptive CHOICE project in increasing adolescent uptake of LARC methods through tiered- contraceptive counseling. V. METHODS Primary Objectives: Identify barriers and facilitating factors to LARC service delivery in the school- based health setting. Determine whether LARC uptake increased at Chief Sealth and West Seattle over the three school years of implementation. Determine whether the introduction of the health educator increased uptake of LARC at the school- based health center and/or utilization of the school- based health center. Describe what characteristics define teen girls who have chosen LARC methods at the school- based health center and/or report LARC methods as something they would be interested in obtaining at the SBHC. Determine whether the school- based health center is considered by teens to be a trusted source for reproductive health information. To address these Primary Objectives, I used four different research approaches and data sources. I conducted fourteen key informant interviews with experts involved in the development and implementation of LARC services, their positions ranging from school- based health providers to public health officials. I analyzed interview transcripts for themes using a 9

18 priori codes and ATLAS.ti qualitative software. I conducted an online survey of female students who were school based health center users about LARC knowledge and attitudes. I collected secondary data from SPS school- wide records and SBHC electronic medical records. LARC uptake data and teen survey data were analyzed and summarized using STATA statistical software. I analyzed self- reported data from the health educator regarding the individual contraceptive counseling sessions and classroom education sessions she provided in the school year at both schools. Figure 3. Program Evaluation Aims with Data Sources. 2 Theory of Change By removing barriers to LARC method acquisition among teens and providing accurate and updated information on LARC methods from trusted adults, we hypothesize teens will choose LARC methods more often thereby reducing unintended adolescent pregnancy. 2 See appendix for comprehensive table of data sources. 10

19 Figure 4. Logic Model: Theory of Change for LARC Intervention Qualitative and Quantitative Data Methods IMPLEMENTATION FACILITATORS AND BARRIERS Qualitative Interviews with Key Informants Semi- structured, in- depth interviews were conducted from a convenience sample of 14 key informants. Key informants were recruited via snowball sampling. Neighborcare Health staff and key informants helped identify people involved in LARC service implementation in the SBHCs for interviews. Interviews lasted from 15 minutes to 1 hour. I conducted all of the interviews and developed interview questionnaires 3. Interview questions were tailored to the various groups (Neighborcare school- based health providers, Neighborcare administrative and executive staff, public health officials, and community partners). Interviews were further tailored to individual respondents based on their unique role in implementing LARC service delivery. Interview questions focused on the history of the LARC service implementation in schools, changing attitudes about LARC methods as appropriate for adolescents, implementation challenges and how they were overcome, implementation successes, and communication strategies for engaging key stakeholders. Out of seventeen key informants invited to interview, fourteen accepted the invitation. (93% female, 7% male). All participants were directly involved in the implementation of LARC service delivery at Neighborcare Health s school- based health clinics. 3 See appendix for interview questionnaire. 11

20 Table 1. Characteristics of Key Informant Positions. Position Description n School- based clinic sponsor Clinic sponsor school- based 3 administrative staff program staff involved in implementing this intervention or providing logistical support to the intervention. School- based clinic provider ARNPs, and PAs providing 5 LARC services in clinic sponsored school- based health centers. Public health official Public health workers who 3 were involved in acquiring grant funding for the intervention, and redesigning Seattle Public Schools sex ed. curriculum to reflect LARC service delivery as appropriate for adolescents. Community partners Individuals involved in training school- based clinic providers, fundraising for the intervention, and school staff. 3 I conducted and transcribed interviews from audio recordings and handwritten notes. Data were analyzed qualitatively through the use of systematic coding. A priori codes were developed from a review of the literature and conversations with Neighborcare and Public Health staff involved in the intervention. A priori codes were applied to the interviews by two independent coders using ATLAS.ti qualitative software. Dr. Andrea Hoopes MPHc, assisted as a second independent coder for all fourteen interviews. Sixty- eight a priori codes were initially developed. Coders added twenty- six new codes during the coding process. Codes were reconciled through a consensus process before the final analysis. Transcripts were analyzed using a content analysis approach. Transcripts were grouped into: school- based health providers, administrators, public health officials, and community partners. Codes were then compared between groups. Barriers and Facilitators that were cited by all groups were pulled out for further analysis. All quotations from these most commonly cited barriers and facilitating factors were analyzed to determine more specifics. For example if every group cited the barrier bias and negative attitudes about LARC, we then explored the quotations to understand if they expressed bias about LARC because of a perceived risk of infection, or because of concerns about minors ability to consent to a procedure. 12

21 Table 2. Code Descriptions for Facilitators and Barriers Cited by All Participant Groups In Hierarchical Order. Codes BARRIERS Clinical Barriers Keeping up LARC skills with low LARC volumes Midlevel provider discomfort with procedures Staffing and equipment needs Expense and Billing Barriers Billing systems LARC device expense Medicaid reimbursement Private pay confidentiality issues Training and staff support costs Provider Fear of Complications Emergency situations Pain management Bias and Negative Attitudes About LARC IUD infection risk IUD perforation risk Teens too young for LARC LARC inappropriate for nulliparous women LARC inappropriate for teens Teens unable to consent FACILITATORS ACOG Contraceptive Updates Clear Communication Strategies Communication to parents Communication to teens Tips for parents and teens to talk about sex Community Partnerships Funding Training and staff support Implementation support Contraceptive Counseling Practice Changes Tiered counseling General patient education Patient education on pain management/adjustment period Teen reactions to new contraceptive counseling information Provider Trainings LARC attitude shifting trainings Insertion trainings On- site shadowing and training Stakeholder Engagement The Scientific Evidence Efficacy of LARC for teens LARC safety evidence for nulliparous women and adolescents Trusted Information Source for Teens Peers 13

22 Trusted adults LARC USERS VS. SBHC USERS Demographic Data From Neighborcare EHR And Seattle Public Schools Trends in the likelihood of choosing a LARC method by teens ethnicity were examined. Demographic information for SBHC users and LARC users was compared to SPS October 2013 enrollment data for Chief Sealth and West Seattle High Schools to determine if students enrolled in the SBHC differ from the overall population of students enrolled in these schools. SPS enrollment data are not broken down by sex so the total populations of boys and girls were compared between the school and the SBHC users (users are unique students who have had at least one visit in the SBHC in the given school year). Ethnicity data for SBHC users who had a LARC device inserted over the three year period were then compared to the ethnicity data for all female SBHC users at each school to determine if the ethnic composition of LARC users differed from that of the general SBHC user population. LARC UPTAKE AND ACCEPTABILITY SBHC User Survey Data (HEY LARC Survey) A survey questionnaire was developed in tandem with another qualitative study conducted by adolescent health researchers from the Seattle Children s Research Institute: Health Education for Youth on Long- Acting Reversible Contraception (HEY LARC). Survey questions added for this evaluation include demographic information, teen s knowledge of and acceptability of LARC methods, teen s interactions with the health educator, and perceptions of the school- based health center as a trusted source for reproductive health information and services 4. Surveys were approved by the University of Washington s Human Subjects Division in late November of Surveys were then available online for teens to fill out anonymously in exchange for a $5 gift card. Participants were recruited through flyers I created and by the school- based health center staff 5. Kindle Fires were available in the clinic for teens to use to fill out the survey. Teens collected their gift cards from the school- based health center. 107 surveys were collected by January The HEY LARC survey will be administered again in June of 2014 to test for any increase in LARC knowledge and acceptability over the course of the school year. Eligibility requirements to complete the survey included female sex, enrolled as a student at Chief Sealth International High School or West Seattle High School and registered to use the school- based health center. Representation of the total female SBHC user population was consistent across schools. Of the 563 female school- based health center users (both schools combined) in 2013, 107 responded to the survey, resulting in a 19% response rate among eligible students. 340 females used Chief Sealth SBHC in 2013, and 223 females used West Seattle s SBHC in Twenty percent of eligible students from West Seattle High participated 4 See appendix for survey questions. 5 See appendix for recruitment flyers. 14

23 in the survey, while 18% of eligible students at Chief Sealth participated in the survey. The HEY LARC survey will be re- administered in June 2014 to the same participants electronically to compare the affects of the health educator throughout the school year. Table 3. Survey respondents self- reported characteristics race, Hispanic origin, and free and reduced lunch eligibility. Race/Ethnicity Categories N=107 Race N(%) Alaska Native/Native American 0 Asian 6(6%)) Black 19(18%) White 32(30%) Hawaiian/Pacific Islander 2(2%) Multiracial 21(20%) Other 20(20%) Non response = 7 Hispanic Origin N(%) Hispanic 30(28%) Non- Hispanic 73(68%) Non response = 4 Income Category Qualify for Free and Reduced Lunch N(%) Yes 64(60%) No 37(35%) Non response= 6 School of Attendance N(%) West Seattle High School 45(42%) Chief Sealth International High School 62(58%) Non response = 0 LARC UPTAKE AND ACCEPTABILITY Quantitative Data From Neighborcare EHR Secondary data on LARC method insertions and removals were collected from Neighborcare s NextGen electronic medical records database. Student health record data were de- identified by Neighborcare IT staff, removing all protected health information before analysis. Electronic health record data from the spring of 2010, the beginning of LARC service delivery, until May 16 th, 2014 (the school year ends June 19 th, 2014) were analyzed. Data included LARC insertions and removals by school and device. Total number of contraceptive visits for each school year by school was reported in this data set, as well. 15

24 SBHC USE AND ACCEPTABILITY SBHC User Survey Data, HEY LARC Survey, Neighborcare HER SBHC use was evaluated using Neighborcare EHR data for total contraceptive visits by diagnosis code, visits where a LARC method was discussed by diagnosis code, and total unique SBHC users within a given year. HEY LARC survey questions addressed SBHC acceptability as a place for LARC method delivery by asking How comfortable would you be getting an IUD/Nexplanon at the SBHC? Possible responses included: Not very comfortable at all, somewhat uncomfortable, neutral, somewhat comfortable, and very comfortable. The HEY LARC survey also asked respondents level of satisfaction with services and care they have received at the SBHC. Possible responses included: Very satisfied, somewhat satisfied, neutral, somewhat unsatisfied, not satisfied. HEALTH EDUCATOR IMPACT Quantitative Data From Health Educator Tracking, HEY LARC Survey Data The health educator recorded data on the individual contraceptive counseling sessions she provided and the classroom presentations she gave about contraceptives, the SBHC services, and teen pregnancy at both schools. In contraceptive counseling sessions the health educator recorded the month counseling was provided, the grade of the student, the primary reason for counseling request, the students current sexual activity, current birth control method, contraceptive choice after the counseling session, clinician referral if any, and if a friend or partner was present in the room for counseling. The health educator recorded raw numbers for students present at in- classroom sessions, but no demographic or identifying data. Health educator data from September 4 th, 2013 to May 19 th, 2014 were incorporated into this report. This data were used to look at the number of opportunities the health educator provided for updated contraceptive information regarding LARC and use of tiered counseling methods. No identifying information was collected that could link students in counseling sessions or classroom sessions to clinic visits. I evaluated the number of students reached through health educator counseling as compared to the number of contraceptive visits provided by SBHC providers in both schools. I calculated the percent increase in opportunities for contraceptive counseling with the health educator counseling sessions versus just the number of contraceptive visits with SBHC providers at both schools. HEY LARC survey questions asked respondents if they had ever interacted with the health educator and under what circumstance (classroom presentation, individual counseling, other, or never interacted with the health educator). The survey also asked for those who had interacted with the health educator if they would recommend her services to a friend. HEY LARC results were analyzed and summarized using STATA statistical software. I conducted chi- squared tests to determine whether awareness of LARC methods differed for young women who had been exposed to the health educator and those who had not. 16

25 VI. RESULTS IMPLEMENTATION FACILITATORS AND BARRIERS Qualitative Interviews with Key Informants Eight facilitating factors and four barriers were commonly cited by all key informant groups. The facilitating factors identified were: ACOG contraceptive updates, clear communication strategies, community partnerships, contraceptive counseling practice changes, provider trainings, stakeholder engagement, the scientific evidence, and a trusted source of information for teens. The barriers cited were: clinical, expense and billing, provider fears of complications, bias and negative attitudes about LARC methods. Each barrier is described in greater detail below. Table 3 depicts actual quotes from key informants about the role of specific facilitators and barriers. Table 4. Descriptive Quotations From Most Cited Facilitators and Barriers Code Quotations BARRIERS Clinical Barriers I was theoretically behind it but nervous about getting up to speed with my own skills. Expense and Billing Barriers Provider Fear of Complications Bias and Negative Attitudes about LARC You can train em up all you want, but if they are not practicing weekly, their skills get rusty. Billing for services in school- based environments is really complicated. If we billed [a private insurance company] for that confidential visit they would still send an [explanation of benefits] home that breaches that confidentiality. Really it s the most hesitant ones who need the most support. I hear a lot of anxiety around how do we handle complications? A slow supportive training process is going to make all the difference. It s still scary to begin putting them in. Scary meaning that, we know the biggest complication risk come with the least experienced providers. So how do you take that leap and just go for it? I had this opinion that the IUDs were highly invasive. The shocking thing I hear from providers is that it is not safe for teens. FACILITATORS ACOG Contraceptive Updates It s hard when you are talking to a kid and they say I went to my OB/GYN or my doctor, and they said it s not a good choice for me. We clearly had ACOG guidance around 2009 for LARC in adolescents. 17